 Welcome to the 24th meeting of the Health and Sport Committee in 2018. Can I ask everyone please to ensure that mobile phones are set to silent? If you are using electronic devices for social media purposes, please do not film or record proceedings. We heard that the Parliament will do that for us. Apologies have been received this morning from Miles Briggs and David Torrance. We will move swiftly on to the first item of business on our agenda, which is a further evidence session on the health and care staffing Scotland bill in today's session, focusing on those who regulate, register and oversee the training of social care staff in Scotland. Can I welcome to the committee Gordon Patterson, the chief inspector of adult services with the care inspectorate, Philip Gillespie, director of development and innovation with the Scottish Social Services Council, Ann Gow, who is the director of nursing, midwifery and allied health professionals at Healthcare and Proven Scotland, and Joy Atterbury, who is a member of the health and medical law subcommittee of the Law Society of Scotland. Welcome to you all. I begin with a general question about the bill and some of the evidence that we have heard so far. Clearly, the bill covers both healthcare and social care, which have different cultures and different regulatory arrangements of which you are all, in one way or another, very aware. I wonder if I can ask whether the witnesses accept the view put forward in the policy memorandum that the bill has the potential to help to bring the regulation of these two sectors closer together. If it does, does it also make it easier to promote the integration of the two sectors, as is laid out in wider policy objectives? Who would like to start on those general points about drawing care and health and care? Thank you very much for the opportunity to come today and provide evidence. The care inspectorate is acutely aware that the quality of care services is critically influenced by high-quality staffing. As the bill has evolved, we have taken a very clear position of support for what it seeks to achieve and we believe that it will achieve its policy objectives. We think that, because the social care sector is regulated, the bill, as it stands, will enhance and strengthen our existing powers. We believe that it will bring greater focus to how providers are able to determine the optimum skills mix and numbers of staff to deliver high-quality care. We are very content with the proposition that this should begin with care homes for adults and, as the policy and financial memorandum indicate, with care homes for older people in the first instance. We are content, too, that the bill has moved to a position where it seeks to adopt a very enabling approach to enable the care inspectorate to work in collaboration with the sector and with people who experience care. We think that it will bring greater transparency and consistency to the way that care providers determine the optimum staffing mix for the delivery of high-quality care. In terms of its contribution towards levelling, some of the distinctions that exist between health and social care, the fact that it is based around a general set of principles that apply to health and registered care services is important. The fact that it brings what we understand to be regulation 15 of the Public Services Reform Act, the condition that providers should have in place adequate numbers of suitably qualified staff applies that equally to the health services as currently applies to social care. We see it as providing an adding value to that development. Thank you for the opportunity to give evidence this morning. We believe that there is an effective link between sustainable staffing levels and quality of care, and we believe that the bill will offer the opportunity to ensure that staff are appropriately skilled and deployed in the right places at the right time. The bill also supports the continued progress towards health and social care scrutiny that is outcome-focused, and this is enhanced, we believe, by the health and social care standards and the new care inspectorate methodology. We welcome the bill's policy, intention and collaborative work across the health and social care system, and the approach to enable a more rigorous evidence-based approach to staffing requirements for employers. Ultimately, the bill takes account of the needs of service users and is inclusive to that effect. It relies on professional judgment and creates a safer environment for service users and staff. We welcome the initial focus on care homes, and this provides a consistent approach that can be applied across integration with new-changing service models and multidisciplinary teams. As a workforce regulator, we welcome the prominence given to workforce planning. We publish data around the workforce in terms of skills, qualifications and workforce data that can enhance and support workforce planning more generally. Health Care Improvement Scotland welcomes the bill and the guiding principle of providing safe and high-quality services. We welcome the focus on transparency and the needs of both service users and staff. We specifically welcome the duty to ensure that people are qualified staff at all times. Although we acknowledge that the common staffing method that is laid out in the bill does not entirely support that, we are working with the policy team at the moment to look at how we ensure in the next iteration of the bill that there is a response to the dynamic staffing needs day-to-day within the NHS. We acknowledge and fully support the use of a triangulated approach in the common staffing method, not just the use of a tool. Having watched previous sessions, I think that there has been a lot of focus on the tool and the number, but on that triangulation with quality outcomes, with the views of patients and staff, and then coming to a decision on what staff are needed for a specific service with specific local needs at the end of that and the governance that boards would have to put in around that. Having previously been a senior nurse out in territorial boards, I have used the tool to do that and found it very successful for nursing. I think that we can use a similar method in terms of assuring and improving services across the NHS. We welcome the pivotal role for healthcare improvement Scotland in implementing this key piece of legislation, and we believe that it will be a key driver and assuring safe, effective and person-centred care for both service users and staff across both sectors. Our roles outline more in the policy and financial memoranda, but we have been given similar powers to the care inspectorate, in which the two should mirror each other, and we believe that that mirroring of roles will provide that vital piece of regulation that will allow us to work better together across both health and social care sectors. We also believe that that is important from the patients and service users and staff point of view, because it really should not matter where you are looked after across the social sector. You should be entitled to good care, good quality outcomes and to assurance that the right level of staff will be there to look after you. Overall, it welcomes the legislation, it feels that it fits with its functions, and indeed it will support our functions, and it will provide real benefits for both staff and patients alike. You used an interesting phrase there, which I would just like to come back on, when you were talking about the further work that you felt was necessary with the common staffing methodology. You said that you were looking forward to the next iteration of the bill. Do you think that there is significant change in the bill that is required in order to achieve that objective, or do you look to secondary legislation? I suppose that I will leave it to the policy team and legal colleagues to decide what needs to be in the bill and what needs to be in the guidance. However, the common staffing method, as I understand it, is outlined in the bill. It will give us an establishment. If you have a 25 to 30-patients award, it might tell you that you need 28 to 30 nurses, which is where it has been up until now. What it does not do is tell you how to deploy those nurses or give you assurance around how those nurses are deployed, and that will extend into other staff groups. I think that it would be within either the bill or the guidance. We are working with the policy team at the moment, so it is not just to ensure that you have sufficient people on the roster, but that you have sufficient people at all times who are adequately trained to look after or provide care within the social sector. Thank you very much. Good morning. The Law Society of Scotland is very grateful for the opportunity to be here. Can I just advise the committee that my substantive role is the head of litigation at the NHS Central Legal Office, but I am here today as a member of the Law Society's Health and Medical Law sub-committee. It is our remit to look at developments in law and policy in the health and medical law field, in the interests of both the public and the profession. You have already heard from the bodies that represent health professionals, and they have given you evidence about that. As a committee of the Law Society, what we have really looked at are the potential legal effects of the bill. The aim of the act is clearly to provide a statutory basis for appropriate staffing and health and care settings. The guiding principles are set out, however, they are very general, they are very multifactorial, and they recognise the need for a balancing of competing priorities. The real point of the bill is to pave the way for the later introduction of regulations that are going to set out how appropriate staffing is to be achieved, specify the frequency with which it is to use and create this model. The policy memorandum refers to a policy intention of enabling rigorous evidence-based approach to decision making relating to staffing requirements, but the bill does not really show us what that model is going to look at. I think that because of that, our feeling was that the bill raises a series of questions that may be regarded as significant for consideration during this period of scrutiny in taking the view on what we absolutely accept as a very laudable policy objective, whether that will be achieved. Those include issues relating to bureaucratic burden, financial resource implications, whether a single tool could deal with geographic and cultural variation across Scotland, what is the impact on training needs both locally and using the tool, but also nationally in terms of availability of training places for the trained staff who are going to be required to meet the requirements of the bill. We considered what the proposed mechanisms for oversight might be proposed to be. Is this going to be restricted to the reporting mechanisms contained in section 121e, or is it intended that there are going to be sanctions in event of non-compliance? Is it intended that any perceived failure to comply with the guiding principles should form basis for challenge by way of judicial review or provide support for allegations of breach of duty within civil litigation? The bill obviously is going to standard fall by the efficacy and robustness of the tools that are going to be imposed as the consequence of the power set out in it. I think that there is a danger of inflexibility if the tools cannot adapt to changing our unusual circumstances. I think that our conclusion having considered the bill was without sight of the regulations effective scrutiny of this bill by the effective professionals and the public by the committee is going to be extremely challenging. We think that there will be considerable merit in more detailed scrutiny and further consultation once the regulations are in place. I am interested to look at the whole overall aspects of the bill to use evidence-based workforce planning tools so that we can have an overarching bill that will allow us to build and develop and that the whole evolution of healthcare is happening all the time. It will be interesting to hear the positives about the bill and then what is missing then if we need to be adding other information. We would like to start with that one. On the workforce planning tools and the evidence base, I think that it starts from a very positive place. Of course, I have got a bias being a nurse, but based on some of the work that has happened in nursing over the last 10 to 12 years, having chaired the development of the community nursing tool, I have fairly intimately seen how those have been developed. They are based on current workload, which is based on the needs of the patient population that the nurses and midwives who have used those tools are looking after and taking into effect the whole workload. The triangulation, as I said earlier, with quality outcome is very positive and allows the boards and IGBs to be flexible in terms of how they use that tool and use the numbers. We think that all that is very positive. The gaps, as I said earlier, are really around that dynamic day-to-day management. When you come on shift, for instance, and you have a couple of people off sick, what do you do if you have a very busy middle of the winter period in an acute hospital? What do you do in night shift if someone goes off? How do you provide that cover? How do you provide that assurance 24 hours a day, seven days a week in health and care services, to make sure that people have got adequately trained staff to look after them? We are doing a bit of work with the policy team at the moment ourselves in a wider group. In the billage that you have in front of you in the guidance, I think that there is a recognised gap. The other gaps, of course, are in tools for the care sector and wider tools within the health sector, so multidisciplinary tools and tools that cover non-nursing and wiffery disciplines. In the policy memorandum, it talks about the fact that in nursing we have had the tools for 10 years, so they have been implemented and that is a great place to start. There are more health employees or nurses than allied health professionals, but the whole process will allow other tools to be developed for other allied health professionals. As part of the process of moving forward in sub-regulation, we would include other tools as they are in development. Wouldn't that be how we would manage it? I think that the inclusion of other tools is in the bill as it stands at the moment. I suppose that having listened to previous sessions, there is perhaps an over-emphasis on the tools that are there at the moment and an over-emphasis on the methodology today, which might change depending on evidence base. We might need a bit more flexibility around that. There is mention of nurses and doctors, but we might need a bit more strong mention within the NHS about other disciplines in other groups, such as AHPs, for instance, or pharmacists, who are also critical to both the safety and the quality of care of people in our sector. I think that what the tools do, particularly in social services, is quite a diverse sector. Lots of different employers, lots of different sizes of organisations help to start to align them to their national health and social care standards because they are absolutely about what matters to the individual. I think that, from our perspective, they fit nicely with our codes of practice in terms of the values and behaviours and skills and competencies that workers are required to in terms of delivering care. There is good alignment between the bill, development of tools, the standards and our codes of practice. We have to be absolutely flexible in our sector about the different types of tools that are required for different settings, given the diversity of the sector. It needs to be sector-led and driven by the sector's needs and supported by ourselves and the care and spectrum. I'll go hand in a brief supplementary. Just a very brief supplementary. Thank you, convener. Good morning to the panel. Ann Gow, you talked both in your opening remarks and in your answer to Emma Harper there about the skills mix. Indeed, there might be a gap in the legislation here. We are very good in terms of defining the tools, defining the appropriate optimum staff capacity number. Do we need to amend the bill to ensure that there is an appropriate blend of training within the staff cohort? Yes. I think that the wording could be amended slightly to make it more overt. The tools came from a very specific place 12 years ago. They were developed because of some of the things that had happened and were found in large-scale reviews. In mid-staffershire, for instance, there was a strong link between harm to patients and nursing numbers. We have evidence that we are nursing numbers, in particular, or low. There is more harm to patients, so mortality and morbidity goes up. People fall more. You do not recognise that they are getting sicker. That is where the tools came from. It was very much about harm prevention. The bill takes it a step beyond that and to look at quality of care overall and the general well-being of staff and patients. That requires a much more multidisciplinary approach. Having listened to what other people have said about the bill, I think that the bill possibly does not describe that in the way that it should. I think that it could be reworded, although I will leave that to my colleagues. To supplement that and respond to Ms Harper's question, it is important to recognise that our view is that the bill articulates the need for safe and high-quality services. It is not just about how we keep people safe and how we prescribe the minimum numbers of staff. High-quality services for us should be defined and are defined by the new health and care standards, as Philip indicated. When we work with the sector to look at the development of tools, we will not merely be asking what is the minimum number of staff to keep people safe. It will be what are the mixes of staff doing what roles deployed to do what tasks with what objectives. Those objectives should be about the ambition of the health and care standards. They should be about ensuring that people who are using care services have good lives, not just good services, and are not defined by what they lack, but are seen as people with assets, with gifts, with experience, with ambition. When we describe high-quality services, what we are talking about for care home population are people who should have community connectedness, should be included in their local communities, should be supported to have good lives. We very much welcome the fact that the bill talks about high-quality services and makes links in its provisions to the health and care standards. Thank you very much. Thank you, convener. I thank the panel for their contributions to date. Most of my questions are about healthcare improvement Scotland, so I am afraid that Ann Gaus is in the hot seat, but I welcome the contributions from any other panel members. Ann Gaus, can you explain and amplify his role in monitoring staffing levels? Our role today has been via our inspection regime. The tools and use of the common staffing method will add for us an ability as we develop our approach to assurance and scrutiny, an ability both within our quality of care approach, which I know you heard a bit about when you were doing the work on clinical governance, to look generally at the outcomes within a border system and align those quality outcomes to the use of the common staffing method and triangulate some of that with the views of staff and patients, mirroring what happens in development of the tools and what happens in the service. Then, to come up with some sort of conclusion that we can publish and make publicly available on the balance between staffing, skill mix, quality outcomes and the outcomes and views of patients and staff, in a very general sense. The other thing that it allows us to do, if we have to do specific thematic inspections, is to do a much deeper dive into staffing and the effect that staffing might have on a particular area, whether that is S-E-Rs, sorry, adverse event reviews for those who are not aware of that, or maternity services or cancer services that will allow us to align workforce numbers. If we get the tools right, workforce skill mix and quality outcomes and give us an extra part of that jigsaw so that we can provide that open and transparent public assurance. Can I move on then to an issue that you have touched on already, which is looking at staffing tools? As you know, you have looked at our previous evidence. We have had a lot of evidence about tools. One of the issues that has come up, both in oral evidence and written evidence, is the difficulty in trying to get a tool or tools that both work for Great Glasgow and Clyde and Western Isles. Is that fair comment in terms of previous evidence that we have taken? The staffing method, the tools themselves, because they are based on current workload and they have an aspect of professional judgment to them. In my view, having worked with them, they should be variable enough to be able to use in Greater Glasgow and in Orkney. If you are looking just at the number, which I think that a lot of people have been focusing on, then the number on its own would not give you that variability. The professional judgment part of it and the quality outcome part of the triangulated method allows you to put some local variability in. For instance, in areas that I have had a professional oversight of in the past, for instance, a cancer ward, chemotherapy ward, where they have also got an outpatients department, the tool would give you an average number for a ward of that size. However, because you are running an outpatients department in that room at the same time, the professional judgment part of it allows you to say, we need an extra five staff because in the mornings that week we have outpatients coming in. That should allow for the variability across different population groups. Wards certainly vary in size and, as do community teams, in size and quality. The triangulated method should allow for the variability across. It remains to be seen whether or not that same method will work if we are doing joint and integrated tools, but that is a piece of work that we can do in the future. In your view, am I right in thinking that you are the main organisation for developing and scrutinising the various types of tools that are available across Scotland? We will be, at some point, in the future. I will be right in the future, but I am not right currently. At the moment, for scrutinising, workforce is part of the overall approach to quality. Development of the tool sits with the workforce team at the moment who sits with CNOD. Apart from health boards, who else are your stakeholders in the development of tools? In the development of tools, health boards are obviously other employers and managers—IGBs, for instance, staff, patients, staff groups, unions and, I suppose, in future, a care inspector with their duty to co-operate with care inspectors around joint development of tools in an integrated space. I understand that you are a key scrutiny body for healthcare. How can the public be reassured in the broadcast that staffing is adequate across Scotland? Secondly, what consultation has there been particularly on the type of tools that we are using across Scotland? In terms of consultation on the tools that we have across Scotland at the moment, that is probably more of a question for the existing team, because I could not give you a detailed answer on that. In terms of transparency for the public on the work of Healthcare Improvement Scotland and what we would hope to do in future in scrutinising the tools, we publish our reports, asking service users about the quality of their service as part of our quality of care reviews, and we would do in our OPA inspections and our HCI and other inspections as well. I believe in the bill. There is either in the bill or the policy memorandum, I cannot remember which, but there is an obligation on boards to annually report on whether or not they have used the tools. Again, we believe that that will give us more public scrutiny on whether staffing levels are right and whether there has been adequate attention paid to them. I said that just a second ago, but finally. Obviously, the public are very interested in that, but to rephrase that, my understanding of the case work that I would have in my region is that many constituents will not be that interested in management tools. If I go to a care home, is it adequately staffed? If my granny or my auntie or my uncles in a care home or in a hospital setting, what is staffing? That has certainly been an issue that I am sure for all members here in terms of case work. It complains about staffing, and we all know the wider picture. Is that a reasonable observation that you have observed in your role in his? Yes, it is a reasonable observation. I think that, certainly in my role in his and previously, as a nurse out in the system, what people look at first is the outcome and the quality of care that they have received. If that is not right, they will start to unpick that and ask whether there have been enough staff looking after them or whether they are relative. Certainly in other systems, and in some units within the NHS in Scotland, staffing numbers are published on ward doors, what you can expect to do, what there is to do. That is not in the Bill and we have not looked at that, but under some of the other work that we are doing with excellence in care, the public availability of what you should have and what you do have is an option, and some boards are working towards that. I am interested in what the current situation is. For example, how do the care inspector at currently assess whether the provider has appropriate staffing and what support would you give to staff planning with providers? That also links to Mr Stewart's question about our role in monitoring staffing methods. There are approximately 832 care homes for older people in Scotland and we inspect them every year, at least once, often twice and in some situations three or four times. When we inspect, we inspect for outcomes, so we are concerned about how people's lives and wellbeing are being enhanced by the experience of living in that service. We recognise that this Bill and its tools are not about outcomes, but we are sensitive to the relationship between inputs, processes, resources, outputs and outcomes. We see the tools as being an input, we see the application of those tools as being a process and we see the determination that they bring about being an output in terms of how many staff are working to do what tasks, at what levels and with what skills. The bill itself will not guarantee outcomes, but it will contribute towards that chain, which is probably as strong as its weakest link. We see the outcomes in relation to how people experience care that we pick up through our inspection activity. We know that having large numbers of staff does not guarantee outcomes, but not having any staff guarantees poor outcomes. There are balances and judgments to be made about what makes a difference and what contributes to good care. We think that the bill and the validated tools that do not currently exist in the care home sector will add value and will contribute something to improve outcomes. We see it as working very closely with some of the other developments that are under way. For example, there is work being done that we are involved in with Scottish Care and COSLA around a dependency tool, a means of assessing the level of independence that people living in care homes have, but that does not lend itself to making determinations about how many staff are needed to meet the aggregated needs of a care home population. We see it as being part of a package of our after-measures that will contribute towards improved outcomes for people. I think that we all agree that the most important thing that you highlighted there was positive outcomes. When the care inspector goes in and says that they are looking at outcomes, if they are not up-to-standard, they will work their way back. I am interested in how you feel the bill and the way that you assess it will enhance and improve that process. We think that the tools that are once developed will bring consistency and transparency. We think that they will add something to the measures that are available to care home providers to ensure that they are providing good quality care. Where we identify that there are failings, under section 44 of the Public Services Reform Act, the care inspector has a statutory duty to further improve. We do not take a view that we are only led by compliance. We think about how we can support improvement, how we can provide improvement, how we can advise, coordinate the improvement activities of others in order that the quality of care improves. We have that commitment and obligation, and we very much see our inspection activity as providing a diagnostic. Beyond that, we see our responsibilities around ensuring that improvement is provided either by ourselves and we have improvement support team or by the IJB, the provider or those who commission the services. It would only be in extreme circumstances that we would take ultimate sanctions in relation to proposing to cancel a care home's registration. Our initial steps would always be about how we can make a situation better, even if it is a highly performing service. How can we showcase what is working well so that the rest of the sector can benefit and learn from that in order to improve their services? We also have enforcement action that involves making requirements where there has been a breach of a regulation or potentially applying for an improvement notice, which gives a care provider notice that we may seek to withdraw the registration if they do not achieve improvements within a set timescale. There is a raft of measures that are available to us, and what we intend in relation to the bill would be that we would commend a tool that would add value to care providers and would enable them to better understand what the needs of their residents are and how they might be best met through a combination of different methods of skills mixing staff in. In terms of getting a spectrum at role and that sort of continuous improvement, the question for me then is legislation required to get to that end goal? The proposed legislation would strengthen and enhance that role. We think that it gives greater focus to the importance of having appropriate staffing. We think that the tools that are once developed will be an enabler. We are very keen that the bill is now framed in a way that does not necessarily talk about prescribing. We think that the tool, like any tool, should be fit to do the job that is required to do and can add value when used and deployed by people who have the competence and skills to use it. We are very keen that it will be seen as something that is going to support the sector in terms of developing effective staffing models. I would like to follow on from Brian Whittle's line of questioning to the Care Inspectorate. I have a broader question for the rest of the panel. It is fair to say, Gordon, that your organisation has been on a bit of a journey with the bill. In your original response to the Scottish Government consultation, you talked about the anxieties that your organisation has had about a further statutory requirement on the care sector, but it seems that that position has moved a bit. With your joint submission with the SSSC, you say that you now welcome the bill. Can I just ask what has changed to bring you on board? Our position has evolved as the proposals for consideration in the bill have evolved. The original consultation talked about the application of existing tools to social care. By that, we understood that the nursing tools would be imposed on a social care sector. We were not confident that the definitions or the understanding of the complexity and the divergence of social care were recognised in the consultation exercise. We have become content with where the bill settled and, so far as care services are already regulated, but that enhances that regulatory power. We see enormous potential in the narrowing of that care service definition down to care homes for adults and older people. We have revised our position as the Scottish Government has developed its proposition. Thank you for that. In the broader question, I alluded to, we have great concerns on this committee and have done since this Parliament sat after the election about the pressures on the integration agenda and the fact that there are still very much silos in our care landscape. Are you content that this bill does nothing to compound that sort of siloed culture? Will it offer an opportunity to break down those walls further? I welcome the opportunity. I said earlier that models of care are changing, they are becoming more integrated and that lends itself well to multidisciplinary teams. The nature of care systems is changing and that offers a more consistent approach. If the tone of the bill is right, it is about involving employers and organisations in developing the tools that work for them and the local variation. I think that the focus on care homes for me is really important because there are huge dependency levels in care homes and that is variable. I think that what the tools will do will offer flexibility but understanding what the levels of need are within care homes and then responding to that accordingly, I think that the public would expect that as well in terms of safety. I think that the key really is in the close working relationship between the care inspector and ourselves and both organisations' implicit understanding of the health and social care sector. I think that to give the development of the tools entirely to either one or the other of us, given Gordon's feedback on earlier iterations of the bill and some of the wording and the language that was used in that, because it was written from very much from an NHS perspective, it gives us a bit of insight into how important it is to people who understand the culture, the language used in the background within each of those agencies and then to bring it together in the front line and make sure that we get the right numbers and the right skill mix of staff. I do think that the bill will enhance that, will enhance care and will, if we get it right, and we make sure that it is focused on good quality care, which is the term that we generally use in the NHS, and good outcomes, which is the focus in social care, then it will enable much more and much better front line working. Can I just pick up on Ann's point there? I see that you are also responsible for AAHPs within his, isn't that right? Can you send a slight absence from the inclusion within the bill? I think not just AAHPs, but we need to start to talk about multidisciplinary teams within the NHS, as well as multidisciplinary multi-sector teams when we get out into IGBs and care sectors and elsewhere. I can see where it has come from, because again, referring back to one of our early answers, the tools that initially came from areas where it was safety critical to get minimum numbers of nurses and, of course, the next thing is doctors to reduce harm. If we are talking about quality of care and quality outcomes and wellbeing for staff and patients, then not just AAHPs, but all staff groups need to be considered within both the NHS and that integrated context. I think that that is one of the changes that we might need in the bill, is to have wording that reflects that and gives us the flexibility to make sure that we get that right skill mix of staff, depending on which setting that we are working in. You think that the bill can be amended to cover the concerns of AAHPs and multidisciplinary workforce that you described? Yes, yes. I look forward to working with you on that. Can I ask Joy Atterbury from the Law Society's point? You talked at the beginning about the need to know what was going to be in regulations in order to have full scrutiny. What is your view of the bill? Clearly, there is scope for amendment. How much amendment do you think it requires in order to be fit for scrutiny, quite apart from fit for purpose? I think that our difficulty was that the bill is a stand alone. I am not aware of this ever happening. If we had a set of regulations going along with it at this stage, it would be much easier to have answered the questions that were raised with us. Most of those questions have been reflected by colleagues on the panel. Certainly, the whole issue of competing priorities and any implications for multidisciplinary teams and professionals allied to health was one that had particularly occurred to us. If there is an opportunity to introduce that into the bill, then a number of the concerns that are expressed by colleagues could be resolved. We would not have a continuing gap in understanding that would exist until the regulations are drafted. That is very helpful, thank you very much. Can I ask Philip Gillespie about the role of SSC currently, but also how far you anticipate our role in the development of workforce tools as they are applied to the social care sector? Yes, thank you. Currently, at the minute, we hold a lot of workforce intelligence around the sector in terms of social services. Over 100,000 workers are registered with us, so we hold a whole range of information about skills competencies and where they are and where they are employed. Our role in the national workforce plan is to support that in terms of providing data for planners at local level that they can do integrated planning. We also publish official statistics on numbers of mental health officers and workforce skills within Scotland. We have a rich library of information that we can lend to support workforce planning more generally, and we are doing work under the national workforce plan that is going in tandem with this. With the development of tools for the care sector, how far do you see an active role in that process? Certainly, we would want to be a key partner working alongside the care inspector with that, and that was outlined in our submission. We see a key role for us in terms of that. Thank you very much, convener. Good morning, everyone. Thank you for your evidence so far. I just wanted to pick up with Philip Gillespie. You have put forward and have read in the committee about wanting to be a key worker in a role alongside the care inspectorate. Unfortunately, the Scottish Social Services Council is not really mentioned in the bill. Is that an oversight or should that be changed considering what you have just said about the fact that you are starting to work together to ensure that staffing is safe and appropriate? I think that what it does welcomes the prominence around workforce plan and workload plan is a key role. That needs to be enhanced within the bill. We already have powers under the Regulation of Care Act for workforce planning that are there. We would like to see those enhanced, because we are a key contributor to workforce planning and workload planning to support employers and work with the care inspectorate. I see Mr Paterson nodding his head, so I assume that you are in agreement with that. We have made representations to the bill team that we think that the SSC should be explicitly referenced in the body of the bill as among the partners with whom we would collaborate in the development of tools. If that does not feature through amendment, it may well be articulated through the regulations and guidance that follow. I will go further on how the bill could work and hopefully will work. It is for the SSC as well. How would the bill help to balance the duties of the SSC in regulation, registration and so on? You mentioned yourself before about the diverse workforce that you have and the motivation that some people wish to expand their career. The workforce is sometimes about 45 and older at times. As the bill is proposed at the moment, how do you think that will affect what you are doing just now? Will it enhance or should there be some changes? I think that it will complement the work that is going on around national workforce planning. We are leading on the development of career pathways for social services so that people can plot a career in care and also a career potentially into health as well. They are not trying to integrate some of those pathways. Our role is well that we investigate, as part of our function, fitness practice cases as well, whether there are potential staff issues or we share that intelligence with the care and spectrum. We have a body of evidence that will be helpful to employers, but ultimately the data that we hold around the workforce and the diversity of the workforce will support workforce planners and IJBs at a local level. You will go further on in that particular point. If you are a stakeholder in the face of the bill or in the legislation of the bill, I am assuming that others—yourself, Scow and others—would be working towards, including training and so on. One of the things is the development of the social care workforce. How will it help to do that? Do you believe that it will be helpful in that respect? I think that what it will do is, for employers, it will give them an overview of the skills that people have, the qualifications that people are working to. As you know, people that are registered either have a qualification or they are working towards a qualification. That intelligence will be helpful to employers about what they need to do, what they need to plan to ensure that they have the right people with the right qualifications and skills to carry out the job. We have the information that we can share with employers on the workforce planning. I am sorry that I kept on myself, Mr Gillespie, on that respect. Brexit is looming on the horizon and we are looking at the potential, perhaps, shortages in social care staff. What do you think that the outcome will be in regard to Brexit? Do you have the bill? Any thoughts on that? The work of a debate in Brexit, but if there are aspects of the bill that are affected by that, then feel free to comment. Anybody? It is important that we recognise the significant staffing crisis that is impacting on social care at the moment, which will be no doubt compounded by Brexit when, if it happens. The section 80 of the financial memorandum outlines that this legislation is not intended to address the wider recruitment challenges. That does not mean that those are not important, but, as Philip said, there is work going on elsewhere in relation to the national health and social care workforce plan that should seek to address some of those challenges or mitigate the risks of them. For us, the bill will potentially identify what the challenge is. It will potentially identify that there is a shortage in some aspects of the areas of the workforce, but it may not. It may identify that there are more effective ways of using the staff that we have at the moment to work to grade, to work at a different level and to deliver good care through different configurations and different arrangements. The committee may be interested in the work that we did with 40 care providers in Scotland a couple of years ago, where they were struggling to recruit nurses and they were over-relying on agency nurses, which was costing significant amounts of money and not providing a good quality continuity of care. We worked with 40 care homes who were looking to reconfigure their staffing approach by reducing nursing, by bringing in peripathetic nursing, by bringing in nursing assistants, by upscaling senior carers, by reconfiguring how they provided nursing overnight and by looking at how community nurses could enrich and they might not necessarily be provided by those care homes themselves. We worked with them and tried to enable that type of innovation, recognising that we have to maintain safety and good quality of care, and they were able to reconfigure. We required them to have in place arrangements to discuss their proposals with the local commissioners, quality indicators and measures to determine whether that was effective. A year later, we went back to inspect these 40 care homes and we identified that four of them, their grades were lower after we inspected, nine were improved, so their grades had improved and 27 remained the same. Four out of any 40 care services grades would change over the course of a year and would deteriorate. However, what that did was enable the care providers to look differently at how they configured their existing staff to be innovative, to bring forward solutions, to engage with partners and to develop an approach that enabled a recognition of the importance of nursing, but also a recognition of how scarce that resource was to ensure that it was being used only on nursing tasks that needed to be done by a nurse. That was only for the care homes that looked to do that with us. We would like to create the conditions for all care homes to have a tool to be able to do that in a more consistent way and to deliver outputs about what sort of numbers they need, but also outcomes about how we can make sure that people are getting good care. Do you think that the bill will include that and would enhance that innovation then? By designing, co-producing, collaborating with Scottish Care, with COSLA, with the sector, with care providers, with SSCC, and with his, as we did jointly with his, we developed the care standards on behalf of the Government. A real collaborative approach, we think that we will be able to develop a tool that will add value and that people will feel is something that they want to use. By using a validated tool, greater consistency and transparency will be brought. We will be clearer about where the staff and pressures are to link back to your question about workforce planning. That work can be taken elsewhere in relation to the workforce developments nationally. The bill, as it stands at the moment, does not compel employers to have a specific staff number, but it does encourage them to do some of the redesign work to ensure that services are safe and are of high quality. If we get the workforce tools right across that whole multidisciplinary sector, it should give us the information and a deep dive into work loads that will allow us to make sure that we have the right people, with the right skills in the right place, and to make the most of our workforce going forward. Whether that is impacted by Brexit or it is impacted by our population changes as people get older, and we have fewer and fewer young people coming into each of the sectors, it should allow us to become more efficient in terms of the use of our workforce, as it stands. Emma Harper and Keith Brown Just to reiterate in the policy memorandum, it says that the words multi-agency working across a range of professionals and staff groups, as mentioned, and the ability to redesign and legislate using multidisciplinary and multi-agency teams. It is all in the policy memorandum to specifically look at the emergence of local multidisciplinary teams so that both health and social care backgrounds are enabled to develop tools together. I am aware that different urban A&Es and different urban med surge units and even care homes might apply different staff to do different things. Some A&E units have more nurses than others or more doctors than others. Would the staffing bill not have a standardised approach and an evidence-based way to look at staffing so that it can also be flexible between urban and rural, so that we can look at a proper base for developing guidance on staffing so that we can have safe staffing? I think that it will enhance some of the multidisciplinary issues that the IGBs, for instance, are dealing with at the moment and which we have dealt with in both sectors. Again, it is about developing the tools in the right way. If we are developing a multidisciplinary tool, it is about looking at that multidisciplinary team in terms of safety and quality of outcome for the people who are using the service. What can only a social worker under the regulation that they use do? What can only a nurse do? What can only a doctor do? What are the bits that you can blur around the edges? What can support services do? It should not matter whether you live in a rural area or whether you live in an urban area. Your right to that safe care should be the same, but the key will be in the flexibility locally and making sure that you are using the small number of very highly qualified staff that you have to do the bits that only they can do. I thank the panel for their contribution. It has been really useful to hear general support, but also to hear whether you are not happy or content with how things are and to construct the suggestions that should be made. A lot of the panellists that we have had before have mentioned the interests of patients, but I think that for the first time I think that Ann Gaus mentioned the views of patients. I just wondered how that can be taken into account, the views of patients, either in the development of the tools or the implementation of the bill. Again, as I said, we have not been responsible for tools up to now, but certainly it would be our intent within healthcare improvements Scotland. We have got the Scottish Health Council, and we have a network of external advisers who come from various patient groups. It would be our intent, as we are developing tools, to ensure that both patients and staff are involved in the development of the tools and that we consult people within services as we are out providing assurance and improvement of how those tools are used. To reiterate what I said earlier, Andrew Strong, who gave evidence to the committee last week from the Health and Social Care Alliance, commended the work that the Care Inspectorate and Healthcare Improvement Scotland had done in developing the national health and care standards. We very much see that that same approach could be brought to collaborate on the development of staffing methodologies. That is about a high-level stakeholder group, and that is about engaging with the sector. That is about organisations that represent people who experience care and use services, as well as those people themselves, collectively coming together to determine what is needed and how it can best be brought to effect. We would very much take that collaborative approach that we did in the context of developing the care and health standards with Healthcare Improvement Scotland, which has been commended. There are other such examples. One of the criticisms that the committee has heard or one of the cautions that the committee has been asked to consider is the extent to which a regulator would be marking its own homework if it was to design tools and then inspect against them. We have done that. We do that all the time. We do not think that it is a conflict of interest. We think that it is about our interest in ensuring that care is good. We have developed national guidance about safer recruitment, about how to recruit in a way that ensures that people are going through the disclosure process, the recruitment process and how the balances and checks can be built in. We have brought that to the market and it is now universally used and accepted as a good practice guide. When we come and inspect, we say that if you are not aware of good practice, here is a guide, and maybe you need to think about that moving forward and improving your services. We do not see that conflict. Can I take you back to Keith Brown's question? How would you ensure that the views of those who use services are included in the development of tools? We would do that through the tool development process by engaging with people directly, by involving those who represent them. We do that all the time when we go in to inspect services. We speak to people who use services and we speak to carers. We have recently developed a new methodology that is about inspecting through the lines of the new care and health standards. That significantly shifts the focus of our activity towards people's experience of care rather than policies and procedures. Thank you very much. I thank you to our witnesses for their evidence this morning. That has been much appreciated. We will take a short break to allow a change of panel. No doubt we will hear from you all again as the process goes forward. Thank you very much. We are now able to resume our session and welcome to the committee our second panel this morning. I welcome Karen Wilson, the director of nursing, midwifery and allied health professionals at NHS education for Scotland. Joyce Thompson, who is chair of the British Dietetics Association Scotland board and dietetic consultant in public health nutrition at NHS Tayside. Dr Tony Axon, national officer Scotland with the Society and College of Radiographers and Tracy Dalling, regional organiser for local government Scotland with Unison Scotland. Welcome to you all this morning. Can I start with the question with which I began our previous session, which is broadly speaking the bill proposes that the measures in it or the policy memorandum proposes that the bill can help bring closer together the different regulatory systems that apply to health and social care and across some of those bridges. I would be interested in the view of witnesses as to whether they believe that that is right and whether they believe that the changes in the regulatory regime in which the bill implies can also help with the process of integration of health and social care. I am speaking on behalf of NHS education for Scotland. We are a national health board with a crucial role in the education training and development of Scotland's healthcare staff. Nes has been involved in supporting the nursing and midwifery workforce planning since 2008 with the co-production and publication of the first edition of the nursing and midwifery workload and workforce planning toolkit, and I have the learning toolkit here with me today. We are currently contributing to the national programme through membership of the steering group and sharing of the education and training subgroup. Nes, although it is NHS education for Scotland, has been working very closely with SSSWC and other care providers out with the NHS to ensure that, when we produce educational materials or development materials, they are suitable for any of the health and care professionals. We would be producing anything to support the bill in terms of making sure that it is suitable for health and care. I am here on behalf of the British Dietetics Association Scotland Board. For those who are less familiar, you may also say a couple of words in relation to dietetics, because it is one of the allied health professions. We are unusually one of the nutrition bodies that are statutory regulated. Our role and function is to translate everything to do with food and nutrition into practical guidance for people. As an autonomous practitioner, we are able to assess, diagnose and treat nutrition and diet problems, both from an individual point of view and from a population point of view. In relation to your question, the BDA, just as we put in our written response, does welcome the bill's aim to provide safe and high-quality services. Like the previous panel, we also highlight that we are one of the allied health professions. Therefore, we very much would promote that. There will be consideration to the development of tools and the application of these methodologies in relation to professions beyond nursing. The site of college radiographers are mainly hospital-based. It is slightly difficult to answer that question, because we are not really in the social care sphere so much. However, similar to my colleagues, we would be keen to see the development of the tools to be also to work with radiographers and other allied health professionals. We would support that and we support the principles of the bill. As my contribution spans largely all of the workforce, no matter where or what setting, we are delivering care specifically in relation to your question about bringing together the different regulatory systems. Unless the bill will do that, if I am honest, the regulatory systems are the regulatory systems. We still have a whole number of the workforce that are not covered by the regulatory system and will not be until 2020, specifically the home care, which is the personal care that is delivered within individuals' houses. In terms of that whole fitness to practice for individuals, each regulatory body will have its own arrangements for the assessment of that. The integration element is probably critical to this in terms of service delivery and the contract compliance. We already know from our own experience of workers out there delivering social care in a home setting that the contract compliance is threadbare. I would probably say both in relation to pay for the individuals but also in relation to some of the practices of 15-minute visits and a lack of general equipment and time in order to deliver the service. I am not sure that the bill in itself will address some of those issues, particularly since most of that falls in part 3 and it is not prescriptive really at this stage, but it is certainly a move in the right direction. Okay, thank you very much. Brian Whittle. Yeah, good morning to the panel I think. Kind of in the last panel I wanted to kind of look at what's currently in play and I wonder if in terms of training and sort of continuing professional development what considerations are currently given and what you're cutting on covering patient safety. So certainly in relation to the implementation of the workload and workforce planning tools, as I say, there's a learning toolkit for people who are actively using that methodology. So within the current nursing and midwifery workforce that would largely be the senior charge nurses and the equivalent out in the community for the community tools. So there's a development process there for people who are going to be using the tools. We recognise that in the case of nursing and midwifery, the senior charge nurses and their equivalent are the kind of linch pins for delivering safe and effective care to patients. So again, we're considering how we can refresh the previous process we had, which was called leading better care, which is specifically around ensuring safe and quality care for patients in clinical settings. And again, as I've said, we intend to make sure that all of our educational resources are suitable for health and care. So as the tools develop, we will produce materials that help to support staff to understand and use the methodologies effectively. Does the bill enhance that process? I think that what I asked the question earlier on in the previous panel is, is legislation required to enhance the process that you're currently going through, or are you already on that journey? Well, to a certain extent, I think that we are already on that journey. But I think, as has been said in various fora, that the application is a bit patchy. And I think that's where the bill comes in, the legislation supports consistency. And I think that's the key strength of it, as far as I'm concerned. I think that, finally, if I could, it's the implementation of the bill in terms of having access to training. How will the bill change that? Will that put more pressure on the training element? Yes, and there is already an infrastructure being introduced to support the implementation of the bill. So I think that we're already seeing that there's a stronger infrastructure to support the training and development of staff. And it is about giving people the space and time to actually undertake the training. I think that the training's there. It's available, and it is the prioritisation that this kind of legislation process brings to bear that is an added strength for us. Okay, thank you. Thanks very much. We heard from the previous, yes, Tony Akson, please. The radiographers, they are degree-level staff, but they need to be trained in hospitals to get a bit greater expertise and move up the system. But they're also regulated by the HSPC and so required to take out so much CPD every year to carry on that regulation. The issue that we often see is that the time for training is often not, it's the thing that's quite often not able to do that because you've got all the pressures on delivering the rotor and delivering the weight-in list. So we see the bill as being adding in that time because if these tools are applied to our staff, they're much more likely to have that time to do the training. Ryan. Things that I did want to ask, as I forgot to tell you on, I think that this idea of want constitutes safety and risk across professions because it seems to vary a little bit. I wonder if there are different views on that and does the bill account for these different definitions? I think on safety, this is part of the reason we want to see an extension of the tools to our practitioners because we are dealing with radiation, we're dealing with giving radiation to members of the public and making sure that our staff are not overworked and are on rotas that are not too long. I mean, there's still rotas at the moment in a hospital of 16 hours and making sure that we see the extension of these tools as helping with safety because it's making sure that staff aren't working too long and are getting proper rest. I think there's a whole variety of measurement tools out there and that's fine if that's all you want to do is measure it for statistical purposes but if you want to ensure compliance, then we're back into that regulatory framework about who is responsible for compliance and we still have a large chunk of the social care workforce that are not governed by any form of regulation just now so it's going to be largely down to the employer to undertake that role and that will vary. I mean, 32 local authorities will have different continuing professional development tools, measures, there will theoretically be thousands amongst the private care providers. Our experience would say that that theory can't be proven and that there is very very little there by way of continuing professional development and staff training. As my colleague said, here it's often the thing that costs the most and is dispensed with when there are other funding pressures so I'm not sure that the bill builds in that compliance element. It may well have the framework for it but I'm not sure that it's there on compliance. In relation to your question, particularly about safety, just reflect to you again that this bill is also about high-quality services and certainly don't want to lose sight of that. But I think that this is another reason why it would be good if it was extended specifically to other professions but also took a multidisciplinary or a multi-agency approach. Dietetics historically has been a very demand-led service and the reality of that is that continuing on that premise there are more people in need of dietetic intervention than there ever will be capacity to deliver. In order to truly get upstream, not just from a preventative point of view but from an early intervention perspective, what that is currently meaning is that dietitians amongst other professions are working in partnership with others in order to truly redesign pathways that stretch across systems. My reason for bringing this up as an example is that within that, that also provides the opportunity and the need for professions to extend their scope of practice. That reflects the need to specifically look at safety and enhances the need for a very multidisciplinary approach to that. Elevating you on to some greatness. Thank you very much, convener, in that respect. Thank you for your evidence as well and good morning, too. I was pleased to hear you say, Karen Wilson, in regard to learning toolkits because we had in previous submissions the fact that people weren't trained up and educated enough in using the tools. As the bill goes forward, giving more training to staff could perhaps more accurately assess where staff are needed more in that pattern parcel of the bill, with more training and more education. Do you use the tools properly? Absolutely. The more we prepare, as I said, senior charge nurses and the equivalent in the community to understand the importance of safe staffing, the better the service will be. As I said, there is an infrastructure now being put in place because of that. I think that one of the problems before was that if areas use the tools that they use them once a year, you cannot remain competent in something if you only do it once a year. Having an infrastructure there and running the tools regularly over the whole of the health system will mean that expertise will build and people will become much more confident in the methodology and the information behind it. Can I perhaps ask, Tracy, that you mentioned the fact about the workforce and the non-compliance and the different local authorities and different practice. Will they be getting trained in the tools as well, or will it be the management level? I imagine that it would be the management level. It is hard to say at this stage, but at the moment that is what I would anticipate. I will take it a bit further. You mentioned various professions being involved because obviously it is not just coming from the top, it is going right out into the communities. I was just going to ask what body are bodies when we are developing the tools and the new mythologies should be involved in this. Should it be the professions, the sectors, the regulators, should it be everyone who is involved in this, or would you need to stop at some level of involvement for new tools and new mythologies? My knowledge about the development of the workload tools is that when you are actually developing a new tool, you work with the people who are working with the clients or the patients, and I think that that is really important. At that point, it is ground level staff. It is the people who are in direct contact, who are providing the evidence of what the workload is. Because nobody else knows the workload apart from the people who are actually delivering, so I think that it is important to involve the right staff for the right kind of levels of decision making and being involved. I completely agree. It needs to be from the ground up. Those tools are a long time in development because they have to be evidence-based, so you are going to have to involve the people who are using it. I think that one of my concerns is the procurement element of this, that when you are procuring the service, who do you involve in terms of developing that? Some of those services are well established, but there are a whole range of social care services that are procured every day of the week based on particular needs. Whoever is involved in this is going to have to be able to cover that entire social care setting, particularly in homes. I am not necessarily on the face of the bill, but that should be in some guidance then in regards to the bill. My concern would be that, once you have got the management level and the professionals, it does not filter down to the workforce on the ground. I do not know how you would work that, and I do not know if there should be a timing taken into consideration, adequate timing to look at these new tools being developed or not. Do you think that that would be some form of guidance then, a timescale and also the fact that you have got to include all of the workforce? I think that a timescale would be very helpful, as you will note from some of the comments that I have made so far, although it is very supportive that we have concerns about particularly some of the smaller professions around that. History dictates that frequently work focuses on bigger professions, and it takes a long time for the smaller professions to be addressed. I would like to see something that would ensure that there was almost parallel work streams going forward in addition to a multidisciplinary approach. As I said before, we certainly support the information of tools to other professions. The advantage of the tools is that it is not just looking at numbers of people you are treating, which is what tends to be happening at the moment. It is also looking at the professional voice on that, so it has to involve the professionals on the ground to do that. That means that those decisions then on running the tools are done at a reasonably low level, so not at a departmental level. On timescales, there has been some talk about how long it is taking for some of the tools to be developed, but a lot of those tools are already sitting there. It is just a matter of revising those tools to fit in with other professions or making multidisciplinary tools, but I think that it would be useful to have some of that on the face of the bill or certainly in the guidance. Can I just add that those tools are there in that kind of acute or building setting, where it is much easier to manage a workforce planning within a building? That is why I would say that that does helpfully suggest that the social care element starts within care homes, where it becomes far more complex is when it is out in the community-based in people's homes. I am sorry, but I have a very small add-on to that in regards to the timescales, and I absolutely agree that it should be timescale for everyone. That then should have a timescale for reviewing those tools as they come in to make sure that they fit for purpose as well? Absolutely. I think that it is an opportunity to review those existing tools before we then extend anything beyond what we have already got, but, yes, that is in itself therein lies the problem. The provision of care has changed. Are those tools that we have currently got still fit for purpose? They may be, but that needs to be tested. Thank you very much. Emma Harper. Good morning, everybody, and thanks for being here with us this morning. I welcome this morning's generally positive approach to the health and care staff in Bill. I am aware that the existing tools that are currently in place are under review right now as we move forward and see other tools being developed. I am aware that we are talking about training and continuous professional development. There is a lot of cross-over work between physios radiographers, for instance, where they might perform similar tasks that nurses do. There is a standardised approach out there that I believe can be assigned to different job descriptions, whereas, if radiographers are putting in cannulas, it is the same cannula training that the nurses undergo, or say, hand-washing infection control measures. Those are national learn pro or e-learning modules that are put out there. As we move this training out, I think that if all the local authorities have access to community learn pro, acute care learn pro, there is a standard approach that can be accessed. I am assuming that that would be the way to move forward so that we are not reinventing the wheel. I take on Tracey's issue that we have got to start somewhere with the bill and, yes, let's look at health and the care setting, and then the individual workers and social care. I would be interested in further thoughts about training and development and how do we assure a standard approach across the setting? Yes. We are certainly looking at how we can modernise the toolkit and make it available for every day. For example, learn pro is one of the platforms that we have also now in Nesgot Turas Learn, which we are working with social care to implement across the whole sector, making things available via social media apps, all that sort of thing, to make it easier for people, especially the workforce that we are talking about here, who could be in somebody's home, how do they get access to learning resources? We are working on putting the same resource in place, but it is available for everyone. I completely agree that it would be great to have a single platform in that everybody had access to it. It does not exist in local government. There is no single training platform. There are a whole range of variations on that theme that various local authorities have either bought themselves or have bought into as part of a consortium, but to the best of my knowledge, COSLA could probably tell you better than me, but I do not think that there is a single platform within the local authority element, but that does not mean that that cannot be part of the broader integration discussion that needs to take place. Okay, okay. Thanks very much, Emma. Okay, no, that's good. Thanks. Excellent. Brian Whittle. Thank you, convener. I think that if we look at the complexity of the health and social care landscape, I wonder how that sort of workforce planning would be best to be approached to achieve a whole system viability, given the multidisciplinary needs within the sector. Does the bill enable that? Will the bill enable that kind of thinking and that sort of planning? I think that's a very good question, and that probably reflects some of the concerns that we come from as a professional body in that currently perhaps that needs to be strengthened if it truly does apply that whole system approach. Within the dietetic profession, I think that we are increasingly trying to address nutrition issues from a whole system perspective, and the example that I use frequently is that if you take the Scottish population then almost half of the Scottish population has an issue with nutrition, be it over nutrition or under nutrition or some sort of condition that requires therapeutic dietetic intervention, for example, a food allergy. As I said earlier, historically, as a profession, we're very demand-led, so that means that whoever manages to get through our door actually gets our support, but the reality is that it's a much, much bigger population out there that requires that support. We have got examples to date in Scotland where we have taken that whole system approach. One example of that is the issue of celiac disease, which affects a significant proportion of the population, and it requires an assessment of symptoms, a diagnosis, and dietetic intervention, a gluten-free diet is the primary intervention. Over a period of time, we have tested and subsequently completely redesigned that approach on a Scotland-wide basis, whereby now there is greater assurance that people who are experiencing the symptoms are assessed, that they are diagnosed, that they do receive dietetic intervention and that they also get access to a gluten-free diet and prescribe gluten-free products in a much more cost-effective way. That's required, that whole system approach, so that means that it's involved dieticians, but it's also involved general practitioners, it's involved consultant gastroenterologists, specialist nurses, community pharmacists, and it's not until we sat down with all those disciplines and individuals experiencing that condition that we could look back and reflect on a much better way of doing it, which is that whole system approach. If you applied a workforce tool specifically to dietetics, that wouldn't answer the question as to what number of dieticians, what expertise of dietetics, which level of experience of dietetics is required in order to address that area of nutrition need unless you took that whole system multidisciplinary approach. Tony Orton. I mean, obviously, workforce planning takes place at the moment. I think what the bill might, hopefully what the bill would do was to make that, put that into legislation so that it's done better and staffing and safe staffing is increased. I think what might be a slight problem with the bill is if it does just only apply to nurses and midwives, and there's too much emphasis on that, and their numbers are funded because they applied the tools, and that's why we think that the tools need to be applied across the system, and with diagnostics, it doesn't matter how many nurses you're going to have if you don't know how, what's wrong with the patient. So the diagnosis is absolutely crucial to the journey for a patient, and also in treatment and counselling, radiotherapy, and that's obviously crucial as well, that we have the right numbers to make sure you get through the waiting lists, and plus have enough people around in accidents and emergencies to make sure those diagnosis is taken through. I think it's one of the benefits of the integration joint boards that we are able to take a more holistic look at workforce planning across the whole of the social care setting, rather than just in a local authority centre or in an NHS centre, because one of the things that I'd be keen that the bill does deliver is that multidisciplinary approach, and we don't continue to do things in silos because I don't think it's serving as well. It would be remiss of me not to say, although the bill can't provide for it, well, maybe it could if you wanted to, but unless we address pay in the social care setting, then we're never going to have enough staff in the social care setting. The recruitment and retention staff is a huge problem, it's one of the things that has been thrown up time and time again when we do look at workforce planning. We do do an analysis about the ageing workforce, particularly in social care, in the rural communities. We know how many people live and work within that local authority setting, particularly in social care. The percentages are enormous. People don't travel well to provide that kind of service, they want to do it in their own community. As the age, as Tesco's open is a new store and pays more than what they're paying home care workers, and as career pathways seem limited to them, those are issues that are not going to go away simply because we've got a tool to measure it. All it will do is throw it into a sharper focus. On a more general note, there's no doubt that consistent application of a common staffing method will improve workforce planning. If that common staffing method is interdisciplinary, multi-disciplinary or even, as it is at the moment in most cases, unidisciplinary, it does improve workforce planning. It gives you more data on which to base your workforce planning, so going forward it is the right direction of travel. I think that there's this sort of dilemma within the bill. I think that it's a reasonable lack of prescriptiveness, if that's a word. I wonder if that in itself would be useful in terms of developing an integrated way of developing the workforce, or does it need to be more prescriptive than it currently is? I don't think so. I think that the strength of the current methodology is, as Angaw said, about the professional judgment and the quality issues, because you can have a slightly different staffing level or you could have a better staffing level in poorer quality. There is definitely something about leaving it loose enough to have professional judgment and look at quality and not define a ratio or a number or get too tight. For me, that is important. Tony Axel. When I looked at the bill, I was a little bit surprised to see how prescriptive that particular table is. I would have thought that it was something that you would normally see in a schedule. I realise that in part 3 it says that there are many new regulations to change that, but it does seem quite prescriptive that it mentions something that is at the same time saying that multidisciplinary tools apply to the professions. It is quite a prescriptive table on sitting on the bill. I was slightly surprised by that. Thank you very much. One obvious question would be if Karen Wilson is right and you need to have that resort to professional judgment, and that professional judgment might produce a different outcome from simply applying the tool. Is the tool necessary at all? It gives you a basic methodology that, again, if it is consistently applied and regularly applied, then it gives you a much more sound basis for why you are doing things. Otherwise, it is just professional judgment, which might work, but we have had professional judgment for a long time and we feel that the workload measurement tools are an improvement because there is a rationale and evidence base behind them. I think that it is the merging of both that is the strength of it rather than one or the other. If that is the case, is there a risk that, because the bill is coming in at a point when we have workforce tools in a number of areas, mostly in nursing and midwifery, is there a risk that that skews the allocation of resources, the allocation of time and effort, away from other sectors into those sectors where the tools already are there? Joyce Thompson. I think that there is a risk of that unless due regard is given to the other groups within the NHS. Tracy Darling. The bill is designed to go beyond the NHS, so we need to extend beyond that. We have staffing tools that prescribe staff ratios, particularly in the early years setting. We know absolutely how many early years practitioners we have to X number of children. It is arguable that you could be prescriptive. The difficulty is going to be coming up with something that allows that to happen without losing the very real professional view about what is appropriate and we get wedded to something that is simply about numbers and not about quality. I think that it is a very difficult one to answer, but it can be done. At the moment, we are obviously not using the tools in our profession. It does tend to come down about numbers and the advantage of the tools is that that professional view is added into that. A scan does not take so many minutes for each person who comes through that door, so knowing that you need to allow extra times. For example, in a children's department, it takes longer to scan someone who is a child because they will not stand still in front of the machine or not be happy on the table. It tends to be easier maybe on an adult situation, so knowing those different positions is useful, but also allowing for in some areas, in rural and satellite settings quite often, it is small numbers of staff there, but then you need to allow for the fact that if somebody goes off, it is a great proportion of the staff, so you need to allow for that. Having that professional view rather than just the numbers do not only require so many. At the moment, I spend a lot of time arguing about how many staff you need on routers because of that. You mentioned earlier in answer to a previous question the issue of where responsibility would lie within a team for running the tools. Do panel members see any risks with the way that the tools are currently applied and may be applied under the bill, that responsibility for quite significant staffing issues is seen to rest with somebody in a relatively junior and over a supervisor, be a charge nurse or equivalent post rather than management for staffing levels that may have wider consequences and implications? I think it is less about who is running the tool than about whether it is being run using an ideal standard or whether it is being run using the reality of the situation, and that will come down to frequency. You might have an ideal standard of operating across the year and then you hit a real winter pressure, for example, or a flu epidemic or something like that. Are we then launching those tools back into that setting to re-establish what is the reality, or re-establish staffing levels based on the reality? Is that reactionary? Is it planned? I am not sure if the people who are operating the tools understand them and are perfectly capable and competent in their job, I think that it is less about them and more about at what stage do we do it, how frequently do we do it and is it about realities, or is it about some kind of ideal standard that we are trying to deliver? I believe that it is important to empower the front line person in charge to operate the measurement tools and be responsible for that. We think that there is enough evidence to suggest that the culture of the clinical area in our case is dictated by that person and that therefore giving them the more power, giving them more education and allowing them to be in charge and be the linchpin is vitally important. We think that it sits at the right level. There is obviously then a discussion up the hierarchy, so we do see the clinical managers being important as well in relation to making sure that they completely understand the tools and how to apply them etc. I think that there is a hierarchical thing, but I think that it is important that front-line leaders are given that leadership role. I ask about it to say very similar things, that you need to be down enough that the professional view can be implemented, but the bill puts the emphasis on the health board in the end, so it has to be a management level and a hierarchy as well to look at that. Are there for witnesses any unintended potential consequences of the bill that we have not yet touched on, that you think committee members should be aware of? I just wanted to mention that this might have been part of what Brian was trying to get at about making sure that the tools themselves have enough in them to allow people time to do CPD, so the predictable absence in the case of the current tools, whether that is enough time and whether it gets eaten away by other things like sickness absence etc. It is really important that we get that right for staff. I would agree with that point and echo that point. Likewise, I point out that professions like dietetics, while they have a very important direct patient-facing role, because of the magnitude of the issue of nutrition, it means that dietitians have also got a very important role supporting others in the delivery of care at the earliest point in order to ensure that the right person gets the right nutrition intervention at the right time and in the right place. I think that one would just want to raise caution to ensure that any workforce planning tool did not specifically or only look at areas where it was only patient-facing activity. Certainly, it is the concern that has been imagined earlier about taking resources away from the other areas. If it is just the tools applied to nursing and midwifery, and certainly that seems to happen to some extent in Wales when the bill was introduced there, so that is a concern. Also, another concern might be if the tools are said, if not correctly done, so that they were seen almost as a maximum for the numbers of staff setting an idea of how many staff there should be. I think that possibly the escalation and the enforcement element of it is perhaps not there in the sense that we would like to see it. I do not think that it is clear at all about where that responsibility lies. Is it with the integrated joint board? Is it with individual employers? Where does the buck stop? Very good question. Brian Whittle. I just picked up, as I thought I had there, was around this idea of resource management and where you think the bills and the tools currently sit. To your point, who is ultimately responsible? Who has the ultimate responsibility of that? What is the repercussions of perhaps not hitting or falling short of what the tool suggests is safe staffing? Where exactly does that lead us down a dark path? We have the care commission at the moment, so individuals are free to report to the care commission and the care commission are free to inspect and take whatever enforcement action they feel necessary, but I do think that there is a critical question to be answered about that. If there is a problem, the care commission will come in and recommend a whole range of measures. They will continue to monitor that to make sure that it is safe, but if we have a bill around staffing, who picks that up? Is it the integrated joint board on the social care setting? Is it the health board in an acute setting? From a unison point of view, we have thousands of people working for very small employers. Does the responsibility sit with them or does it sit back with the integrated joint board because they commissioned that employer to deliver that service? I do not think that that is clear at all. Very much at the moment we see that staff levels can get driven by how much finances there are, so there is an interesting question about resource management. The duty is going to be on the board, but it is up to how much money comes from the Government whether they can meet the right staffing levels. There is an issue with the financial notes on this one that it is talking about, introducing the tools and how much money that might cost, but it is not talking necessarily about how many more staff you might need if these tools are applied appropriately. I think that it is clear for the NHS that the buck stops at the board. I think that there is an important issue about resource versus quality. It is important to put as much emphasis on the quality of care as on the number of staff. I think that it has made that clear this morning that it is about the bigger picture of safety, quality and number of staff. My questions around accountability and responsibility are mainly towards unison, and I could just draw on members' attention to the fact that I am a member of unison. Tracey Dahlding, in your submission, you made an interesting suggestion that the staffing bill might be ignored, and the general points on a paraphrase to your lines are concerned about shortage of staff, lack of enforcement and constrained resources. Will the bill resolve any of those factors? I think that we are back to the compliance point. We know from our own experience perhaps a good example of it that the Scottish living wage being applied in the social care setting was money released by the Scottish Government, came to integrated joint boards and was then released to various providers of services. However, we are still pursuing those providers of the services to pay the employees. The money is sitting with them and has not been passed on appropriately. If that is a parallel, it worries me that we have another piece of legislation that we have the Health and Safety at Work Act and we have had it for decades, and we have employers that ignore it. It is about compliance. If you are going to put something in place and you are looking for adherence, we need to know who is responsible for that adherence. Frankly, what the penalties are if you do not? In a simplistic level, everyone in this room wants to see better staffing levels and better care. What is your assessment of what the post-act world will look like in terms of care provision and staffing provision? I am not sure that it will look any different than it does just now, if I am really honest. I do not think that this is any kind of panacea. We are desperately short of staff who are not well paid. They are low paid workers, they live in their local communities. I am not sure where we are going to get them from to continue to work in this area. Perhaps if it was a safer environment, there were more people providing that service who were better paid and better supported and trained, and they knew that when things went wrong that there was a degree of enforcement, then perhaps if we piece all of those parts of the puzzle together, it will look better. This in itself—sorry, no—I cannot see it making an enormous change, not in the social care setting and not at this stage. Americans have a line about where is the beef. I am trying to verify whether there is a real substance here. Is there some elements of that? Certainly, some of our witnesses suggested that we do not need legislation to have workforce tools. Those are internal management issues. I would agree. I am never going to say, do not legislate for something that I firmly believe is the right thing to do, provided that it comes with an element of enforcement. The legislation might give us that if it is couched in that way, but colleagues are absolutely correct. You do not need legislation to introduce workforce planning tools. Obviously, there are existing provisions across all the public sector and beyond for whistleblowing. Again, everyone would support that. If you have scenarios in the future where staff who work in care sectors are very upset with the current staffing rate wrote us just to give you an example. Is there anything that the bill will do that will add to the provision of staff and the power of staff to come forward to the appropriate ages and say that this is not good enough and that this is putting patients at risk? Has it currently written? No. The enforcement is not there. The degree of comfort around doing that is not there. Thank you. Good morning to the panel. I would like to pick up on David Stewart's line of questioning around the impact on staff, because when we introduce tools, that is us telling staff that this is how things ought to be done. I am concerned that that flow only goes in one direction. Are colleagues on the panel confident that this bill will build in mechanisms for staff who know their onions in their day-to-day work to inform and suggest meaningful changes to how those tools operate on the ground? Certainly when we first introduced the tools to nursing in Medwifery, it did empower charged nurses. It gave them information that they did not have before, it gave them a methodology that they did not have before, and it gave them a language to talk to the clinical nurse managers and beyond up to the nurse directors. To that extent, having consistent tools can help? If I can add as a corollary, how responsive will this strat of tools be to upward suggestion for change from the ground? Again, at the moment in the nursing, I am sorry to go on about nursing in Medwifery to my colleagues, but the nurse directors are really interested in the outcome of running the tools. It matters to the quality and safety of clinical care delivery, so where they are available, they are used. You contend that there is a feedback loop built into the legislation that will allow that to be nuanced and changed based on practice and the application of the tools on the ground? Again, I am with colleagues here that I am not sure that the bill does have the teeth that it needs. I think that it comes to governance and there are different arrangements with different employers in terms of staff engagement. The question has been asked about how low level will staff engagement be around using those tools. In a social care setting, I am not convinced that we will go right down in which case we are potentially missing a trick there because we will not have that level of engagement. The bill encourages employers to seek views. I think that it needs to be stronger than that. There needs to be absolute engagement at all levels of the organisation, particularly out there in terms of front-line delivery staff. They know their onions and should be engaged in the process. Even if they are not using the tool, there should be a mechanism by which their view of what is currently happening can be elicited and they can engage in the process. I agree with those comments. I think that one of the key learnings over the last few years is that you cannot do too, you have to do with, and that means irrespective of what your profession, your grade or whomever you sit alongside. From that perspective, engagement both in terms of development but also in the testing and the application of the tools is absolutely essential. I am just reflecting that, for example, when you look at a dietic service, not all dietic services consist of services that contain nothing other than dieticians, and not all dieticians are in a dietic service. There are different examples of where dieticians will sit in organisations. That places different types of pressures on the individuals, so it is important that that is taken into consideration as well. The point about the tools is that there is a professional element to them, not just about the numbers, but I would add that in the sections in here about training, consultation of staff etc., it would be helpful if the professional body were included in the face of the bill. I am just interested in the unison's approach. I noticed in the written submission that they were unable to identify any strengths in the bill, either in part 2 or part 3, although I have raised a number of other issues of concern, including pay, which you have discussed a fair, but here today I should say I speak as the next shop-shoot and branch officer for unison as well. On the pay issue, I am not sure how the Scottish Government could have enforced compliance on a living wage, but it does not have that legal power to do that. On the point that you made, Trace Eilor-Organ, when you said that one of the things that would happen with the implementation of the bill that you feared would be that it would throw into sharper focus the issue of pay, I think that it is in relation to recruitment in particular. Is that not a good thing? If the bill does do that, if the various tools set out a particular standard and professional judgment backs that up, that demonstrates a short fall in the staffing that is there, would that not be a pressure on the system to enforce higher levels of pay, greater recruitment and adequate staffing? Absolutely, it would, but I am not sure where you are going to get the bodies from, where the money is coming from, in order to address those issues. It is linked largely with the workforce planning. We are seriously short of people who see care, but we are not nursing care as a career. Young people are not coming into that profession, they do not see it as a profession, they do not see it as a career and they certainly see that they are never going to make more than living wage as things currently stand, or they are about in terms of salary. There is a whole cultural aspect to this that I think that the bill and its provisions and the staffing tools may well throw that into sharp focus and we will see it in its really stark terms rather than perhaps anecdotally, as we see it just now, but there is a whole range of things that are going to have to happen in order to address the problems that I think that this will throw up. Tony Jackson I think that retention is absolutely crucial at the moment. We have got, we have got, for radiographers, a vacancy rate of about 4 per cent at the moment, which varies from year to year, but we have got also a cap on the number of people that can be trained because you have got to go through the hospital system to be trained, so there is a limited number of spaces in there. I think that in the hospital setting and the NHS setting, obviously, we just had a change to the pay scales. I was heavily involved in developing the new pay scales and I think that that might help in retention. What certainly will help in retention is if there is not so much pressure on staff to cover for other people. At the moment, there is a lot of people going off sick because they are through stress, because of the pressures on them to cover routers and having to do weekend work and overnight work, and if we manage to increase the number of staff and make that a better workplace, that will help in keeping people in post. A quick supplementary question. I do not think that you should apologise for nursing tools because they have been in existence for 10 years. It is what we have right now, and it is what we can build on. I would be interested to see how the panel can engage in the future development of tools that would apply to the multidisciplinary teams, whether it is community, care in the home or acute care, because you are all articulating very well about the need for a multidisciplinary approach. I am seeking to know whether you would be engaging in the development of tools for your own disciplines, whether they are pitch and hold or whether they are a multidisciplinary team approach? The simple answer to that would be, yes, we would be looking to do that. I have already spoken to my colleagues in RCA, etc., that are using those tools and looking at how they could be moved across. For radiographers, it is possibly slightly easier because they tend to be employed in hospitals in the main, dealing with waiting lists or dealing with A&E departments, which are quite similar to nursing roles anyway. As you said earlier, some of the training modules would apply to radiographers. There is maybe an easier gain on that one. For some more of the colleagues in RCA, it might be more difficult. I would say that we would definitely be looking to engage in the development of those tools. I would say that we would welcome the opportunity very much, particularly from a multidisciplinary perspective. In order to do so, that means that it has to be made an explicit priority. There also needs to be appropriate resource to support the development of them. I thank our witnesses once again this morning for another very useful session. We will suspend very briefly to allow witnesses. For the moment, to deal with agenda item number two, which is in relation to the European Union Withdrawal Act 2018. This is our first consideration of a proposal by the Scottish Government to consent to the UK Government legislating using the powers under the European Union Withdrawal Act 2018 in relation to a UK statutory instrument. That statutory instrument is the tobacco products and nicotine inhaling products amendment EU exit regulations of 2018. Colleagues, we will have seen the paper from the clerks, which sets out the protocol that is in place between the Scottish Parliament and the Scottish Government on obtaining the approval of the Parliament to the exercise of powers by UK ministers under the Withdrawal Act in relation to proposals that fall within the legislative competence of the Scottish Parliament. Provisions in these regulations, to the extent that they are within devolved competence, are considered by ministers to fall within category A, as described in the protocol. In other words, they are relatively minor and largely technical in detail. What is exceptional here is that the UK Government wished to propose to lay those regulations on 10 October. They are keen to do so in order to provide sufficient lead-in time for all concerned. Therefore, with our October recess starting on 6 October, the Scottish Government, as an exception, is seeking approval to proceed within a shorter timescale than the 28 days outlined in our protocol. The paper that members will have seen invites you to consider the notification from the Government and for us to decide if we are content for the Scottish Government to give consent to UK ministers in the way that it is described. Do members have any views on that matter that they wish to raise at this stage? I think that, therefore, we will… Can I ask a question first of all in relation to the timing? First of all, I am more than willing to accept that the UK Government wants to do this to give us much lead-in time, a bit more concerned by two more than two years since the referendum. This is how long it is taking to do it and we are having to do it in a truncated process. The point is that the Scottish Government has to ensure that the UK Government is aware of Scottish Parliament recess periods. Can you just check that? That is a fairly obvious question. That has been done. The UK Government is aware of our recess periods, and it has taken this long for it to come to… I think that that is less than satisfactory to do it. I do not know enough about this employment. Maybe the only smoker here at enough, but it does mention at page five about the one thing that can be affected by this is decreasing the maximum emission levels. That seems to be more than technical. Presumably that could have an impact on stakeholders and producers. I should say one interest. I declare that I have a company in my constituency that produces the filters and packaging for cigarettes, which is its only business, but that would seem to be more than… I do not know, I am just asking the question, whether that is more than a technical or minor possible change. Do you understand the stuff about the advertising and the packaging and so on, but the maximum emission level seems to be a bit different? In the sense of substituting for existing regulations, then minor and technical would apply, but certainly that is… We have enough time to take evidence next week, if you would wish us to do that in order to get to the bottom of that and be clear on whether this is a change in substance. It depends on how they come in. If maybe the questions can be answered now, the one other thing that I was wondering is if this is agreed and for whatever reason Brexit does not happen, or at least happen at the schedule, what happens to these powers? They just do not get used, is that right? Yes. My reading of it is that they have come in at such a point as the EU regulations still apply. That is my understanding of this. I have to say that if you think that this one is late, this is actually the first. Be aware that we may have quite a lot of these regulations coming through over the next few months. The decisions that we make, clearly the decision that we make about this, which is the only one that we will see before the October release, is a standalone decision, but we will have to think carefully about how closely we wish to interrogate other matters that come before us, because after October there could be quite a lot of them coming forward quite quickly. Do other members feel the need to explore this further before giving a cent? We can certainly do that if you are keen. Are you happy with that? In that case, we will indicate to the Scottish Government that we are content for them to do so. I think that we should put in the record that we take the assurance that, of this truncated timescale, we will expect them to hold to their commitment that this is exceptional and will not be standard. We do want to see these things in enough time to take evidence should we so wish. That, in terms of what comes before this committee, is the responsibility of the Scottish Government, although clearly there are backstories to all of that as well. If we are agreed and we will therefore notify the Scottish Government accordingly and let them know that we are content that they should proceed as described. We will now move into private session.