Good morning, and welcome to the 22nd meeting of the Health and Sport Committee of 2018. Can I ask everyone to please ensure that mobile phones are switched off or to silent? You're very welcome to tweet or do other things of that sort, but please don't record or film the session that is done by the Parliament for us. Can I start today with a declaration of interests and in accordance with section 3 of the Code of Conduct? I will invite Keith Brown, as a new member, to declare any interests relevant to the remit of the committee. I don't think that this was about a list of your health conditions, but I have no interest to declare. Thank you very much. We'll take that as no interest to declare, rather than as a medical testament. Welcome, Keith Brown. As a new member to the committee, we will have another new member next week, but can I take this opportunity to thank Ash Denham, Kate Forbes, Ivan McKee and Alison Johnstone for their work while members of the committee, and congratulate those who have gone from here to ministerial office. Clearly the work of the Health and Sport Committee provides many opportunities to address issues and take those forward. The work of all those four members has been much appreciated by me and by the committee as a whole. Can I now move to the second item on the agenda, which is to choose a new deputy convener? The Parliament has agreed that members of the Scottish National Party are eligible for nomination as deputy convener of the committee. Given that, may I invite nominations for the post of deputy convener? I nominate Emma Harper as deputy convener. Thank you very much. There being one nomination, I am pleased to ask the committee to agree that Emma Harper will be chosen as deputy convener of the committee. Are we all agreed? Thank you very much. Congratulations to Emma Harper. I am very much looking forward to working with her as deputy convener in the months and years ahead and contributing as she has done so much already to the work of this committee. We move on now to agenda item 3, which is subordinate legislation. We have in front of us one negative instrument, the National Health Service General Ophthalmic Services Scotland amendment regulations 2018. There has been no motion to annul and the Delegated Powers and Law Reform Committee has not made any comments on the instrument. Are there any comments from members of the committee on this instrument? If not, does the committee agree to make no recommendations? That is agreed. Thank you very much. I move swiftly on to agenda item 4, which is to take evidence on the health and care staffing Scotland bill. We have two evidence sessions this morning. I anticipate that we will both last roughly an hour each and an opportunity for members to ask our witnesses about aspects of the bill. I welcome to the committee Dr Sally Gosling, the Assistant Director of Practice and Development with the Chartered Society of Physiotherapy, Kim Hartley-Keane, head of the Royal College of Speech and Language Therapists in Scotland, representing the Allied Health Professions Federation Scotland, and Patricia Cassidy, chief officer of the Falkirk Health and Social Care Partnership, representing the chief officer's group and for health and social care Scotland. We will go straight to questions and I ask each of them witnesses to kick us off to outline briefly main concerns and considerations in relation to the bill's proposals. Who would like to start? Sally Gosling. I am happy to start. Thank you very much. If you could just give me a wee second to sort out my paper, it was not expecting to do that. First of all, just thanks for the opportunity to speak to the committee this morning. I am representing 12 Allied Health Professional bodies, so real value for the committee this morning. You are getting 12 for the price of one. It is music therapists, art therapists, drama therapists, occupational therapists, dieticians, prosthists, orthotists, orthoptics, physios, physiotherapists, paramedics, speech and language therapists, dietists and radiographers. That is quite a lot of different professions that I am here representing. I am going to have to sort out my notes here. We account for more than 11,500 members of staff. That is 8.3 per cent of the workforce, which compares quite well with 8.9 per cent of the workforce that is made up of medics and dentists. We work in health and social care, OTs are employed by social services, birth from birth to palliative care, public health prevention, primary, secondary and community care. It would be pretty challenging to find a care group for whom HPs do not work. I have five key points that I wish to get over and I will do it as quickly as possible. First of all, we do not believe that the bill achieves its objectives. It is not future focused. We have several fears, significant fears about the bill. None of the professional bodies that I am representing all 12 can support the bill as it stands, but we offer some solutions. First of all, it will not achieve its objectives. Only the right staffing team can provide the highest quality of care, leading to the very best outcomes. In that sense, legislating for the right staffing presents a really great opportunity. In principle, we like the bill, but it is not outcomes focused. Instead, it is focused on a very restricted range of inputs, which is its big challenge. It is not future focused. The bill plays to an old unidisciplinary siloed model of health and social care, which seems to go against the grain of modern models of health and social care, those that are promoted in the GP contract, the national clinical strategy and most recently in the workforce plan part 3. HPs work in all of the 11 types of healthcare listed. It does not reflect the reality of the most disciplinary working. In fact, some parts of the bill seem to specifically exclude HPs. The parts 1-1-C, which talks about the list of employees, are identified as registered nurses, midwives and medical practitioners, along with those working under the supervision of those staff groups. Allied professions do not work under the supervision of any of those staff groups, and for 40 years we have been autonomous clinicians. The bill does not cover that. It says that it is multidisciplinary, but the financial guidance is pretty disheartening. It seems to indicate that it will be up to 10 years plus until we see any multidisciplinary tools. It is not needs-based. People need HPs, too, and this is all about doctors and nurses. Our fears are shared by the GP directors. Those are the people who are working out there in the service already trying to run HPs. It will create unintended consequences, and that will skew the resources away from the dire financial distribution now. Directors are likely to say, sorry, we can see what you mean about needing more HPs or multidisciplinary teams, but my hands are tied by this legislation. Our fears are grounded in reality. If you compare the central government funding for nurses and doctors, say, for example, the 500 million plus, no-one says that that should not have happened for primary care, but that compares to the 3 million announced for HPs in 2015. We have not heard any more about any other money for HPs since then. There is a sense that that has been forgotten. If you look at the process of the bill writing, we were excluded from that. That is indicative of organisational habits. There is one reference to us in the bill on page 93 of the policy memorandum, and I am sure that everyone can remember what that says. The Scottish Government nursing director itself says, the potential for resources to be diverted to nursing and midwifery to meet the mandatory requirement could be the detriment of other professionals contributing to the care, so it seems that it is recognised, but it is a problem. As I said, none of the professional bodies that I am here representing can support the bill as it is now. What we would like to see is an outcome that is focused on the general principles, but to create a general presumption that quality and safety are best supported by multidisciplinary teams, and to replace the list of tools in section 121C with a section that establishes a statutory duty on, for example, HIS, which would be equivalent to CISWIS, to annually review and improve the common staffing method, including tools, to reflect the developing evidence base of multidisciplinary staffing, and for that same body to make annual or again biannual recommendations to the minister on improving the tools. That is all that I wanted to say. That is very comprehensive. I would like to add to much of what Kim has already said. As Kim has said, the CSP is part of the HPE Federation for Scotland. If I briefly outline some additional issues that relate to our concerns about the legislation that is currently couched, I think that the first point to make is that we believe very strongly that a multidisciplinary team approach has to be taken to staffing levels. We believe that that has risks for the quality of patient care both in terms of experience and outcomes unless a multidisciplinary team approach is taken. It also has risks for staffing and risks focusing staff level legislation on one part of the workforce and potentially depleting other parts of the workforce, potentially adding to staff workload in ways that are obviously unhelpful and unintended. We also think that the staffing levels legislation assumes that looking at staffing levels in isolation will make a difference to the quality of patient care both in terms of experience and outcomes. We strongly believe that just looking at staffing levels in isolation cannot address the need. It risks a very partial approach being taken. It risks not looking at the outcomes for patients and it risks at best avoiding negative outcomes for patients or negative incidents. We think that it has a risk of building in rigidity and inflexibility when, as Kim has said, there is a need to focus on future service delivery models and ensuring that staffing is responsive to and unable to meet those future or current and future staffing service delivery models rather than being grounded in historical models. The legislation risks being a distraction and it risks creating a bureaucracy, so investing staff time for those staffing groups that would come under the legislation in gathering data about activity but without a real focus on what the benefit for that will be. I think that the Parliamentary Information Centre undertook recently and seemed to affirm that, at least in terms of how the tools are currently used, there is a lot of activity invested, a lot of time invested in using them, but not a clear sense of what impact that has in terms of analysis being taken forward of staffing issues or their being accountability for making decisions and acting on what that usage of the tools may indicate. On that basis, we do think that the existing nurse staffing level tools, the workload management tools, etc., are an odd place to start with legislation and, certainly to embed them in the legislation, seems to again build in rigidity, inflexibility and a lack of responsiveness to changing the population patiently but also service delivery models. That seems to be borne out by the survey feedback that has been obtained where nurses using the tools were reflecting that already they do not capture how they are working, how they are contributing to patient care. I think that that risks grounding it in historical issues. I think that we are also concerned that the tools are not in a public domain, so we are not able to see, as I understand you, what the tools are at the moment but also we do not understand they have been evaluated. We have some concerns on that front. We believe strongly that a whole systems approach must be taken to staffing levels, so, again, reflecting changing models of delivery, moving care closer to home, obviously integrating health and social care and delivering the Scottish health and social care delivery plan, we feel that the grounding of the legislation at the moment could actually work against delivery of Scottish health and social care policy, including by only taking a partial approach to staffing. We then think that it does generate the risk of unintended consequences and creating perverse incentives, perverse unintended activity. That, again, is grounded partly in the singular approach to one, obviously very significant, but one staff group. It could obviously distract resources to meeting the needs of the legislation but not actually meeting service delivery needs or patient needs. We would have strong concerns about the perverse activities. I think that that is borne out by some evidence around where legislation has been introduced, particularly for nursing and perhaps in individual states, where the impact of the legislation has not been what was intended. I think that we have concerns that that is a risk. Lastly, we recognise absolutely the spurious in which the legislation has been introduced and we recognise that it is intended to enhance patient care and, obviously, to address issues of staff wellbeing, but we do not believe that, as it is couched, it will currently do that. We think that it needs to be much more responsive to changing population patient needs, much more in line with health and social care policy, and to be much more focused on being integrated into that. I suppose that in terms of what we will be looking for is legislation that is much more strategic in its approach, much more integrated, so not sitting in isolation and also introduces a much longer sense of accountability. It is not just accountability for demonstrating use of the tools. We need to see accountability for integrating a strategic approach to workforce planning, workforce deployment, etc. I would like to prefix my comments by remembering the focus of everything that we do. It is around person-centred care and to ensure that that is flexible, responsive and safe, as well as high quality. I am representing the 31 chief officers for health and social care across all of the integration authorities in Scotland. Our initial response to consultation in July 2017 made it clear that we did not support safe staffing tools, which protected only one element of the health and social care workforce. However, conversely, it did not infer that we were in favour of tools being extended to other parts of the workforce. We responded to the second consultation and this restated that, while we understand both the political and public desire to ensure that our health and social care services are a appropriate resource in terms of staffing, our position remained the same that we would be cautious about supporting a legislative approach for several key reasons. There is potentially a significant additional layer of administrative bureaucracy being added to existing systems. Our challenge in the whole system currently is to ensure that, if people do not need to be in an acute hospital, we have sufficient health and social care provision in the community to keep them out of hospital. If they are in hospital, we need to be sure that we can receive them back into the community and support them to be re-abled in the community. That requires us servicing community hospitals across Scotland and being able to be very quick and responsive to anticipating needs and anticipating the volume of care that we need to provide ourselves or to commission from other providers. We would be very concerned if the legislative process did impede that, as opposed to adding benefit and impact on our ability to respond to that need. There is a risk that the legislative requirement to use particular tools could stifle innovation. We are in a very exciting policy landscape in health and social care in Scotland, where there is big transformation in developing community-based needs. The health and social care partnerships are not solely about NHS boards and the councils, though they are important partners. Our key partners are communities, the individuals themselves and the third sector. We would be very concerned that we became preoccupied with a tool where there is existing legislative framework and inspection framework in place and the new health and social care standards that may preclude our innovation and development at locality level to work with families, communities and third sector partners to develop a whole range of supports in communities to enhance people's wellbeing. It is not just about providing care and support and the main issue in Scotland is around isolation. We need to work with other providers and communities to provide solutions for that. We are concerned that any tool that is developed needs to be sufficiently flexible and dynamic to allow for the developments that we will be leading in the next few years to meet local need. It is very much about local need. We are talking about diverse communities, geographies and landscapes across Scotland. I know that colleagues in the islands and rural areas are very concerned about any restriction to their ability to respond to local need. I must emphasise that safety and quality of service are absolutely at its heart. We are concerned that legislation is still quite restrictive, and colleagues from allied health professionals have laid out their concerns, and we would be equally concerned. In the health and care service at the moment, there is quite a lot of development of advanced roles to support general practice and the delivery of hours and other services. We would like to continue looking at that and looking at nothing as dropping off the other end of these nursing and other roles. What is the workforce that we need? Is it a blended workforce? Is it a baseline workforce that we can create pathways into a variety of health and social care professions by having a ground-level opportunity? We are all facing significant recruitment and retention issues across every element of health and social care. There is a demographic challenge facing us all, and we need to be able to develop services that respond to that reduction, perhaps in the availability of employees and recruitment opportunities, to develop quite innovative solutions, to attract people in, to retain them and, actually, to develop them into perhaps more senior or sophisticated roles to meet need across the whole system. Finally, just to sum up, legislation should not create rigid compliance framework that undermines the new integrated environment for health and social care. Each partnership is expected to work at a locality level, identify local needs and then meet those needs, so we would need to be very, very responsive. Part 2, which is focused on staffing in the NHS, does not take a licence of the significant overlap of governance responsibilities between health boards, integration joint boards and local authority, so would require clear guidance. There is a tremendous diversity in the workforce and health and social care across providing care at home, providing care home provision and intermediate care. The one-size-all approach to workforce planning simply will not work. It is a case of a potential legislative framework, but it needs to be contextualised in that much broader national workforce plan that is happening nationally across all the professions. We are also looking forward, with our colleagues in schools, colleges and university, as to what could be quite innovative health and care careers that we could feed people into through various pathways and then perhaps into the professions. I thank you very much for the opportunity to give an input. I am happy to take any questions. Thank you very much to all three witnesses for laying out in some detail the concerns that you have. Don't feel the questions and answers henceforth will be through the chair. Don't feel that you have to respond to each question, but please do respond where it's something on which you wish to comment. Can I start with Sandra White? Thank you very much, chair. Welcome and thank you very much. A number of the questions I was going to ask, obviously about integration and health and social care, you've actually given me some answers, but I could just maybe pull it a wee bit more out. The bill is, hopefully, meant to enhance the work that is going on with health and social care and integration, but obviously behind your replies. Thank you for that as well. I just want to touch on one of them and ask you about the bill as itself. Through the bill proposals, I want to ask you—you've already mentioned about what effect it will have in great detail, but what effect do you think it will have if it is passed without any due care and diligence in looking at the integration of health and social care? What do you think will happen if we do not change the bill to take a nice sense of what you've been saying today? Patricia Cassidy. Thank you. I think that it could drive resource to focus on being compliant with the requirements of the bill, which potentially could add more administration, potentially divert resources from front-line care. On a day-to-day basis, for social care, we will receive referrals from emergency departments directly, from the hospital discharge team, from GPs, from families, from social workers. That can be quite a significant volume of work. We need to flex our system to make an assessment, to provide that care, to link with allied health professionals, to provide a rounded package of care, provide equipment and do that across a range of several thousand people on a daily basis. It may require us then to commission additional provision if we can't meet it internally to go to one of our providers. We would need to be assured through a commissioning process that that provider was also compliant and we'd need assurance in that regard. The whole thrust of outcome-based care is assessing with the service user and their family and identifying what their personal outcomes are and then agreeing a way that we will jointly work towards those outcomes. It is adding that we already have checks and balances in place, as you would expect, to ensure that we are commissioning and employing sufficiently registered and high-quality and trained staff and that there is coverage across the people receiving care, but that would bring in another dimension. Our central fear is the outcomes for service users. That skewing resources towards the professions that are covered by the tools. Already significant cuts have happened for service users. There is a quote from my radiography colleagues that said, At present, radiography departments are running with gaps and rota due to unfilled vacancies, maternity and sick leave, which are treated differently in the HPs than they are in other professions, leading to delays in examinations, reporting of results, radiotherapy treatment, as well as increasing stress on radiographers. Again, another professional body will mean less HPs on all those different care pathways, for example with disciplinary teams delivering rehab in the community settings, preventing hospital admissions and readmissions, reducing length of stay, restoring function, and increasing people's independence. All those things would be in jeopardy. They are the new models about prevention and self-management, enabling people to live in the homeless settings. That is the issue and that is what is at threat. I think that it does risk the issues that Patricia highlighted around skill mix and job role reconfiguration across health and social care not being addressed. It also risks the assurance being given to the public that staffing level issues are being addressed when, in reality, the legislation, as it stands, would not address increasing workforce supply or addressing workforce needs in line with population, patient and service demand. It risks appearing to provide a solution when it would not do that and it would distract attention away from more strategic approaches in line with policy.  Basically, what you are saying is that a set of workforce planning tools for nursing is put on a statutory footing that would have the effect that you are talking about just now would have an adverse effect on health and social care? If you are a director, you might see that there is a need for a multidisciplinary team planning. If only one member of that team is staturally protected in terms of the needs of the service users of nursing and the service users, the interests of those who are using those other members of the multidisciplinary team have not got the same legislative protection that you are obviously going to make sure that you have the staff for nursing first, rather than looking at what is the skill mix that we need. I think that it was precisely that I mentioned the IJBs, and we know that they do not have a statutory duty to produce a workforce plan at the moment, and they are not employees either. How do you see that working for the integration authorities? As you mentioned, you work with them. Do they need flexibility? Do they need to be involved in the plan, the bill that is coming out? The integration board is required to produce a workforce plan. It is part of the integration schemes. We are working on that. We work closely with colleagues in the council and in the health service that those employees remain their employees, but we have to jointly create a workforce plan. I apologise for that. I missed up a bit about that particular bit. As the bill stands, do you think that the integration authority, the IJBs, either have less authority or more through this bill? I do not think that the bill adds or detracts from that authority. I do not think that it adds any significance in that way. We are cited in the bill and we are key stakeholders in the bill, but we have to work and we will always work with our colleagues in the NHS and in the councils. I have some experience working in education previously, and I would be concerned that, as my colleague described, that perhaps one profession or one and two or two professions have legislative protection in terms of numbers. We have seen that in education where, because of teacher numbers, it can often mean that classroom assistants, busses, squads, etc., are subject to cuts against the backdrop of protecting the pupil-teacher ratio and the teacher numbers in schools. I would not like us to not learn from that and to recognise that there is a complexity of skills that are required to meet need. Each of those skills is valid, but we need to be considerate using professional judgment what combination of those staff members or skills that you would need. However, that is much more subtle than perhaps a legislative tool could allow. Just one last question that you were talking about workforce as well. Whose responsibility would it be or is it to ensure adequate supply of workforce if the bill goes through without people having it? I think that I would need to bow to colleagues who have more detailed knowledge of the legislation to be able to answer that, I am afraid, but certainly the integration joint boards and the health boards and councils work very closely together and at this time share that responsibility. I am not aware of that. At the moment, it is not clear that the legislation would address the workforce planning issue. For the allied health professions, there is not a workforce planning process yet in place in Scotland. I think that what is important, which fits very well and strongly with the integration agenda, is looking at workforce needs across the whole system. Not just looking at NHS workforce need, but looking at workforce need where it comes from whatever part of delivering care to patients as well as leadership management, education research capacity as well. The legislation as planned does not address that, but we would see that it is an imperative above beyond the legislation that is presented that a much more strategic approach is given to what workforce is needed and how is that best delivered and produced and how is investment appropriately made if the workforce is developed to meet changing population and patient needs. That can only really be done in a multidisciplinary way to meet the blended skill mix approach that is required. I thank our three panellists for the excellent contributions that they have made. I would like to focus and drill down in a bit more detail on looking at staff planning outwith nursery and midwifery. We hear frequently in this committee about major problems in Scotland about recruitment and retention. To what extent will the bill aid your problems in dealing with recruitment and retention? I am not clear that the legislation as planned would help address those issues. I do not think that it is premised on those issues. It is looking at staffing levels for the staffing body that is already there within one profession. We are certainly keen that the broader issues around workforce planning, development and investment are looked at such that recruitment and retention are addressed across all staff groups. Again, for AHPs, there is not at the moment a strategic process such that those issues cannot currently be addressed. There is not possibly sufficient data on which to understand the recruitment and retention issues. There is one example of just from a workforce supply perspective. For many or a number of the AHPs, workforce is produced through postgraduate pre-registration education routes, and those are very well established and have existed in physiotherapy in Scotland for well over 20 years. Those are not funded, so the students going through those routes are self-funded, but that could be a very useful way of expediting workforce supply if that route was funded. It is the mixed economy approach at the moment and the lack of data that makes addressing that issue difficult, but I do not think that the legislation that we are considering here really touches on those issues, but it needs to be integrated into a more strategic approach. I think that your question touches on just the clash between other policy and this legislation as well. We have talked previously about the first fall in terms of the recruitment. Workforce plan 3 talks about considering increasing or controlling the numbers into some of the AHP professions and increasing the number of paramedics in training, but there is nothing in the bill that will enable there to be jobs created in order to make that for those people to have, they are needed for jobs for those people to go to. In terms of retention, again, because it is very focused on one discipline, that investment in CPD in the continuing professional development and the career structure for others is in doubt. If you look at the workforce data that is available across the professions, there has been a very small growth in AHPs and they have primarily been at band 5, which is where you go when you are a new graduate. There is nowhere to go. The bill does nothing to address that. To be fair to the bill, it does not purport to be the workforce plan. There is nothing there that I would say gives assurance or opportunity that it would contribute or improve the situation around recruitment and retention at this stage. Can we move on into the second area that Sandra White touched on briefly? That is the issue of planning tools. That is a big element, particularly within nursing and midwifery, but looking out with that area, when do you see multidisciplinary tools being created, for example, the social care sector? If you do see them being created in the future, can you give some sort of timescale when that would be a practical use to those in the industry, and particularly to clients who are getting the service across Scotland? The only clue to answer that question in the bill is around the financial memorandum. It implies that it details how the development of tools for the next five years is already planned and that the tools take a minimum of three years to develop, and they will be focused on nursing. We believe that there is a risk that we will not see any multidisciplinary tools for up to 10 years if we followed the financial memorandum, which means that there will be 10 years behind a policy that is current. That is a long time. That is 10 years for people waiting for adequate EHP services and for us to establish the vision that we share in terms of prevention, self-management and enabling people to stay at home and cared for at home. That is just totally against the grain of what we are trying to do. I would agree that it seems unclear at what time, or it seems a long timescale through which they could be developed. One issue that it may be helpful to raise is the EHP professional bodies. We do have quite a lot that we could contribute to the development of multidisciplinary tools. A number of us have done quite a lot of work around safe and effective staffing levels, taking a more nuanced approach to the complexity of issues that are bound up with that. We have work that we could contribute to developing something that was much more multidisciplinary in its approach. I thank you a lot that a lot of the professional bodies have something there. It would be inaccurate. It is important to point out that there already are multidisciplinary tools out there that are being used by EHPs. They are not at the same level of publicity, I suppose, or knowledge as the level of investment, certainly, as the tools that are in the current bill. There is something called the six steps methodology. There is something called the balance system that has recently been piloted by the Scottish Government looking at EHP provision in children's services. There is something to build on. To say that the bill, as it stands, would take 10 years, but it does not have to be like that, I suppose. I was just to say that the Government and COSLA have co-produced a national health and social care workforce plan part 2 in 2017. One of the recommendations proposes the development of multidisciplinary workforce planning tools. I am not sure what the timeframe for that is, but that is work that I understand is under way. The development of what is called a dependency tool, which is looking at the acuity of need in the care sector, and that work will help to inform staffing models and the national care home contract. I think that Patricia Casse has covered partially my next point, but just to be totally clear, currently, when we are talking about multidisciplinary teams in hospitals and in the community, in reality how staffing is calculated is quite a complex and dynamic issue trying to calculate staffing. There are some tools that can be used. Can you say a little bit more about that? Certainly—well, not as a practitioner myself, but the tools that people are using, for example, the balance system, is that your—just to be clear on your question. One of the things that they have done is that children and young people need services at several levels. They need a universal provision so that we are developing all children's capacities. We need targeted for those children who are—targeted level provision for those children at risk of having poor outcomes. We need specialist provision for those children who have identified disabilities, identified additional support needs, and the balance system is a way of looking at the workforce and the assets that are available in the school, in the family and in the community, as well as among all the HPs to see together how many HPs do we need in order—within that context, within that population, that particular population would be Ayrshire, Lothian, whatever—the system that we need. It is really coming back to the point that Patricia made. It is about looking at population need and starting there with your workforce planning, not with how many we have got and how many we need. I just want to make a general simplistic point, but it would be useful to hear your views on that. Some have said to me—and certainly as it is through the contributions that we have received to the committee—that why do you need less isolation to have workplace tools? Good management would normally involve that anyway. You do not need less isolation for that. That is probably a simplistic overall view, but I would certainly be useful to hear what the three of your views are on that particular general point about the bill. I will reiterate what our response has said. We feel that there are existing tools in place and that we do not see the need for legislation in that regard. However, we do embrace the need to have good workforce planning for multidisciplinary teams. From my perspective, it is about introducing some consistency in the intelligence that you need in order to be able to produce your staffing complement for your particular community. If it were more multidisciplinary, it would provide support to the delivery of that new model by reflecting all those difficulties. There are a lot of good things in the bill about the things that people have to take into account in the common staffing methodology. It is very complex and difficult to reach perfection, but we want to move a wee bit away from wetfinger in the wind to make the decision on what their knowledge is and move to something that is reassuring the public that the services that they and might need in the future are being planned for and are not down to some random decision making. To add to what colleagues have said, it is a valid question as to whether legislation is what is needed or what can achieve what is in the spirit of the bill. I think that what seems to be missing from the bill at its count is accountability, but if there is going to be stronger accountability for ensuring safe, effective staffing levels to deliver safe, effective care to patients, then that has to be predicated on approaches that are robust and integrated in their approach, strategic in their approach, and about the whole system, not about one part of the workforce. It is multi-lead in terms of whether it is the right thing to be doing. Alice Cole-Hampton I would like to pick up on the discussion about the impact that this has on integration. We did a lot of work as a committee on the integration agenda and we had an inquiry in that in the last year. I have always had a niggle since the bill was introduced that this was going to fly in the face of the good work that we have been doing through integration, that it creates a silo, that primary care somehow gets a different set of rules and is considered in a more focused way than the national health service, social care and all the other arms of integration. Can you just explore whether we could remedy that in this bill by the inclusion of the national health service and social care provision within its pages or do we just need to tear this up and start again? It is a very good question. Who would like to answer? Is this bill providing a platform or is it going in the wrong direction? Kim Hartleke Thank you for the question. I think that the general principles, if they were extended to cover outcomes, but I think that it could create a foundation. I would remove that list of tools and set up, as Sally has been talking about, a strategic way of continuously improving the way that we are planning for staff in a way that reflects the evidence base and new models. It is a foundation, but it needs to be radically changed. Hearing what my colleague Patricia is saying about not having legislation at all, I think that the bill could be significantly improved, rather than chucking it out altogether. I think that it is helpful to think of the origin of the bill. It was around nursing, a uniprofessional model, and it is to be lauded for that. It aims to secure safe staffing across all care groups in the NHS. My colleague nurse director in NHS Forth Valley is a real supporter of the bill. It was a train that started on a journey and integration has happened. We have joined that journey. The tool began being developed about 10 years ago, which was before the current integration and current health and social care policy. In an ideal world, we would be starting from the other end of the telescope and visioning what our workforce needs, what services we want to provide across health and social care, and what is the skill mix that we need across low-level to very high-end level to provide a balance across that system. Then we look at how we move from where we are now to a point where we have that blended multidisciplinary workforce. Obviously, we are not in an ideal world, but that would be one way of coming at this solution, but not at the cost of nursing colleagues who have worked long and hard on this tool, and it just feels because it is extended that it is raising a whole race of questions at this committee today. To add to what colleagues have said, I would agree that it feels an odd place to start, or it seems an odd contribution to delivering on Scottish health and social care policy to introduce this bill as it is framed. It would be helpful to perhaps take stock of the available evidence around what does work and what may have an impact that possibly is not intended when legislation in good faith is introduced. Some of the perverse impacts of other legislation should be very carefully evaluated, taking account of what will be about other different types of healthcare system. The case that I highlighted in my introduction showed that the introduction of that legislation led to more reliance on nurse agency staff rather than increasing nurse capacity. It reduced opportunities for nurse staff to exercise professional judgment and making decisions, and it led to some services simply deciding to incur the penalty fee for not complying with the legislation, none of which was intended by the legislation's introduction. Taking very strong account of what the unintended consequences of the legislation could be would be important to look at, as well as the changed context of what is trying to be achieved and whether the legislation contribute to it, recognising everything that has been done, specifically in nursing, but the risks are that that model is outdated as nursing staff have seen to reflect in the survey results. It needs a thorough review to make sure that it is not going in the wrong direction. Your professions all work cheap by jowl with the nursing profession in terms of integration and what you do in and around hospitals and other care settings. Taking in isolation, does the bill achieve what it set out to do and is it needed? On the back of our last set of questions, you may be able to give very brief answers to this one. If you have a tiny follow-up, I like this is the moment for it. We learned this morning about a horrific case in NHS Highland about a gentleman who's had his social care package removed and being paralysed from the neck down. He's been waiting for that for months. That's symptomatic of problems right across the health service. Should we be using our legislative time to tinker with something that isn't badly broken already in terms of the nursing profession, or should we be bringing legislation that overhauls our approach to social care? It's not actually a little question, is it? If any of the witnesses wish to respond to that very broad question, feel free. My answer to your question is that it is broken at the moment, so we need massive improvement in the way that we are planning our workforce. I suppose that the 1, 2 and 3 workforce plans would indicate that there's quite a lot of work to be done. I think that it is needed. Thank you, convener. Good morning. The panel has certainly a lot of information flowing in this general direction, and we need to try and gather together at it. I specifically wanted to talk about multidisciplinary working, which seems to be a theme that consistently comes up in every time that we take events this idea of multidisciplinary working, and how that bill could impact positively or negatively on that. If we could drill down further into the role of allied healthcare professionals within multidisciplinary groups, specifically our only distinctive role of AHPs in health and social care and, crucially, perhaps bridging the role between those two sectors, I think that I'm really interested in the preventive agenda and how AHPs play into that preventable agenda, for example, ensuring that there's much less unnecessary emissions into hospitals, for example. I can talk in detail about the profession that I, my own profession, which is speech and language therapy, and I hope that the HPE colleagues that I'm representing will forgive me for talking in detail, because that's what I know most about, and I'm sure that Sally will talk about physiotherapists. Everybody who has dementia or a third of people who have had a stroke, but let's talk about people with dementia, everyone there will have an eating, drinking, swallowing difficulty at some stage in the progress of their disease. That's one of the earliest things that happen, if you have dementia, is that your ability to swallow safely is impaired.  What speech and language therapists do is to work with the individual, with the spouse, with the home care staff, wherever the person is, to assess where the swallow is going wrong. Again, in partnership with radiographers and doctors and the screening and monitoring that is done by our nursing colleagues as well, I will make recommendations about how to safely eat and swallow so that the person is not choking and aspirating and not needing to be admitted to hospital. That's one example from speech and language therapy, which would prevent people from being undernourished, having unpleasant traumatic experiences every time they try to eat and drink, and being admitted to hospital and having to have a little medication. To add to that a key development in physiotherapy at the moment across the UK is physiotherapists playing a much stronger role in delivering care within primary care or general practice settings, particularly to address musculoskeletal disorders. The growing evidence around that is that that front line first point of contact role is really helping to ensure more timely care for individuals to avoid issues becoming worse before the individual gains any treatment and reducing both unnecessary referrals to hospital but also admission to hospital, etc., or unnecessary tests and medications. I think that there's real and also very much developing and supporting patient self-management. I think that there's lots of potential, as Kim said, within each of the allied health professions to really build on that prevention, more timely, closer to home care for patients that keeps people out of hospital where they don't need to be in hospital. Those kinds of service delivery, service improvement models are at risk of not being progressed through this kind of legislation because the risk, as we've talked about, is that it's predicated on all models of service delivery and obviously isn't capturing the multidisciplinary team. What we need to be doing is looking more at, in this instance, how primary care teams genuinely work collaboratively in patients' best interests and service interests as well, but also how workforce development is progressed to meet those changing service delivery model needs. I think that those kinds of issues of integration and a more strategic approach to meeting changing population patient needs are at risk of not being addressed by, as Patricia Hallow did at the start, quite rigid approaches. Just to build on the theme around dementia. If we have a person at home with dementia working with speech and language therapists, physiotherapists, community psychiatric nurses, we can really improve the level of care that we are able to provide and the consistency of that care through joint planning and joint communication. Also, if we have someone who's been cared for in a care home, it's really important that staff in that care home are really aware of the level of care that is required. Again, community psychiatry can be really helpful in coming in and giving training to how to cope with that particular patients or service users' manifestation of their illness and how to de-escalate situations and work around and retain the consistency that that individual may require. It's very much about looking at how we can blend and work together instead of having layers of services going in to meet needs. I've actually been really clear and agreed what is the need that that person has at this point in time and who's best to co-ordinate that but who's best to deliver it. People will come in and out of that care delivery package, but there will be a joint and shared assessment and multidisciplinary discussions about that patient's progress or otherwise. It's really key that we're able to keep people in care homes or at home if that's where they want to be and to avoid unnecessary hospital admissions. For example, if colleagues provide in care homes a really challenge about providing nursing care, how can we go in through district nurses and others to provide that care to keep that person in the care home if they're at the end of life if that's where they want to be and what they ought to be in a home setting of their choice? It's very much about blending and planning around the person but doing that not in a siloed way in a shared space. Just to point out that occupational therapists are the group of allied professionals who are currently directly employed in social care as well as in the healthcare setting. Felly, following on from that, where we should be starting then is quality of care into quality of life. If I look at the idea then that who should be leading in this methodology, who should be involved in the development of the bill? It currently stands just now at the bill that states that care inspectorate will lead on the development of new methodologies for social care and that healthcare improvement Scotland will lead on any new healthcare tools. To my mind, there's a danger of a divergence of the development in this bill. Is that something you would share? I would be concerned about that because in the integration space and provided integrated care, it's about how we plan that together and how we plan the workforce together. It's key to our success in cutting across. People care that they are getting high quality responsive services. They don't necessarily care that someone is wearing a uniform from an external provider or the council or whoever they want to know that the team working with them is working together and are able to meet their needs. You don't get a situation where there's no conversation of district nurses and carers going in that they are speaking together and they're planning the care and that's what integration can provide through having integrated teams where they're speaking to each other on a daily basis, they're working together, they're jointly planning and assessing and adjusting that care when it's required. I'm pulling in other professionals if that's required as well because previously care workers and social workers quite often the GP is the point of entry, so you'd have to go back and refer to a GP to get access to a service. That takes up a lot of GP time and actually when we establish that shared understanding of professionals and limitations and responsibilities it can take a lot of the obstacles out of the way of delivering really responsive care in a timely manner. In our submission, the HP Federation were suggesting that his was given equivalent role to SCISWIS, excuse that acronym, and we felt that that would offer the potential for consistency of integrated planning across health and social care. There's something about that equivalence in making sure that they're working together as Patricia described, being innovative and transformative in the way that across those two agencies we're planning services and beyond those statutory sectors as well. The integrated joint boards obviously have clear relationships with service user forums and the third sector, so it would offer opportunities for much better integration. That would be good to use for the bill to enable and facilitate that joint working. Thank you very much. Emma Harper. Thank you, convener. Good morning everybody. It's been really interesting hearing all the discussions so far and a lot of it has focused around allied health professionals. The Welsh bill that was passed focused only on acute care, medical and surgical, so this bill proposes to take that even further to go to the community as well. For me, as my background is 30 years on nursing and when we look at the guiding principles that are actually stated in the bill, it says that the main purpose of staffing for health and care services is to provide safe and high quality services. That is so far consistent with the main purpose staffing for health care and care services to be arranged. It goes on to talk about service users and needs and abilities and all that. Yesterday I had a conversation about an upside down triangle and the top, the broad part was the health and social care, it was the care provided in the community and the pointy bit at the bottom was acute care, which is where some of the care is delivered, but most of the care should be delivered in the community. I think that the bill really needs to be really good at focusing on the differences in community, which requires allied health professional input. I agree that we should not be working in silos that the health and social care or the bill has come about after 10 years of implementing tools. We are seeing a patchy approach to the way that the tools are accessed and used all across the whole healthcare in the NHS. Does not the bill support a better training and enablement of the use of tools and the professional judgment tool and the quality tool would be used as part of that to feed in to allied health professionals' contribution to whatever we look at as the best way to staff and plan our workload? In the short answers, no, it does not feel like that is going to happen. If we look at what is happening already around attention to the needs of the service users, we would not be confident that there would be some kind of hoped-for trickle-down effect. If that is what you are meaning, I think that what is really important to point out is that HPs work in all those services in both acute and community provision. I think that it will allow the bill, as it stands, to allow training and enabling use of tools to those specific tools for those specific staff groups. I suppose that the survey that has been published on how they are used and the patchy use might indicate that there is a lack of training, which is one of the best use, but it might also indicate that the tools are not any good. We all know that we all have a kitchen drawer full of bits and pieces of tools, but we only use the ones that work. I do not mean to be flippant here, but those are the right tools, and Sally's made it clear that there is not the evaluation of those tools. In fact, none of us can tell how good those tools are, because they are not publicly available to anyone. CSPs have worked hard to try to find them and get hold of them, and we can.  I think that, as you say, it is possible to see the Scottish bill as progress from the Welsh legislation from the point of view that it is not just focused on nursing in acute adult inpatient wards. As you would expect, we did have and we continue to have concerns about the impact of that in terms of, again, the risks of staffing resources being focused on meeting the legislation and, again, not in line with the direction of health and social care policy. It is progress from that point of view, but I think that the tools that we understand underpin the legislation are predominantly acute focused. The feedback that was gained through the survey results was that nurses who are currently using them found them particularly limited for those who were relating to community-based service delivery and did not seem to have a huge amount of confidence in them. However, as I say, we are not aware that an evaluation has been undertaken of them. I think that, as Kim said, we would want to, if the legislation were to be progressed, we would want to have some direct involvement as AHP professional bodies in how that is done, given the work that we have done around safe and effective staffing levels, and quite a thorough appraisal of different approaches. We feel that we have got a lot to add to how it could be done differently that would be in line with a whole system approach and could add, certainly, to a multidisciplinary approach. I think that we would be sceptical at the moment about the starting points as we have captured in the legislation. Patricia Caster here. I just add that, for the avoidance of doubt, there is no evidence base that the tools will work across health and social care. There is no evidence base that is applied to other professions, such as social work and social care provision, that it will work. We need a more thorough evaluation of the success and the evidence base for it within nursing. We also need to be sure that the impact of any legislative tool is to improve outcomes for people who require our care and support services. I want to finish on that. I think that, as far as I am aware, the tools are being revised because they have been used or not used, and there needs to be further education to implement their use. The tools have been developed by the specialty clinicians involved in the specialty areas, such as community and mental health maternity. I agree that evidence is where the basis of any formation of legislation needs to be the number one priority. I look forward to clearer evidence, if it is not out there, to make sure that, if we are supporting any legislation or changing it—for me, including allied health professionals, especially out there in the community—needs to be part of the legislation going forward. We are seeing that the allied health professional teams are working together with nurses in the community and need to be considered as part of the legislation going forward. I see a scent from all the witnesses. Evidence first, I think, is what is being said. Finally, Miles Briggs. I wanted to carry on the point that Emma Harper has just made and Brian Whittle's point about capturing quality, because I think that that is one thing that we have kind of lost. I wondered at this point in time how, without the tools, are you doing that, especially in a community care setting? We are being told that the idea is to have two speeds for the bill, so I wonder in terms of your work at this moment in time to capture quality and outcomes and then that impact, where you are doing that without tools at this moment in time. No, we are not doing it without tools. It has been left up to the professional bodies. Obviously, we are here for people that use our services and want to provide the best provision possible. I know that my own professional body and a number of the other health professional bodies will, like us, have developed outcome measurement tools that have been tested across the UK. We have set up a platform where speech and language therapy services can record and report the outcomes that they deliver, therapy outcome measures or common tool that people use and we have adapted those in order for all our speech and language services to report. One of the things that, obviously rightly, all the HP leaders have to do is to make the case for investment in HP services and they will be using the data developed through those outcome measurement tools to make that case. That is one of the main drivers that we need to create a case based on outcomes. There are outcomes there, I do not know if you will do that. To add to that, we have said throughout our key focuses on the quality of patient outcomes. As Kim said, HBs use tools to appraise, evaluate and demonstrate the quality of their outcomes for patients. As we are going back to the example that I cited earlier around physio roles in primary care relating to musculoskeletal conditions, we are undertaking, with other key stakeholders, a thorough evaluation of the impact of that new model of first contact practitioners. It is a very strong focus for professional bodies in taking forward service improvements for patients in terms of demonstrating their value and impact. For me it comes back to, as currently couched, the legislation is focused much more on issues of input and activity of staff rather than a focus on quality of outcomes or quality of experience potentially for patients. We are talking about different aspects of quality and it is how we seek to ensure that the legislation is focused on quality of patient experience and outcomes, not on inputs and activity, which I think traditionally staffing level tools have tended to do. Again, we have done work to shift that to focus much more on patient outcomes, not on inputs, tasks, activity etc. The current legislative framework for social care comes under regulation 15 of the social care and social work improvement Scotland 2011. That has regulations and a scrutiny framework. The care inspectorate inspect all the services that are provided and the new health and social care standards that came in this year are a key focus of that inspection and very much focus on outcomes, particularly outcome 3. I have confidence with the people who are providing my support and care. Care homes began to be inspected against the health and social care standards in July of this year, so that is a whole new filter through which it is very much about looking at outcomes focused at a more local level across multidisciplinary teams. There are a range of outcome measures. People's person-centred plans are developed on their personal outcomes and, with their carers, were required under the carers act to do planning with carers as well. There is a whole range of checks and balances that are in place to measure outcomes and safety and quality across the services. Thank you very much. I thank all of our witnesses on this panel for very informative contributions and for answering a wide range of questions and, of course, for your initial written submissions. We will now take a short break and resume at 11.50pm with our second witness panel. We will resume our evidence session on the health and care staffing Scotland Bill with our second evidence witness panel. I welcome to the committee Rachel Cackett, the policy adviser of the Royal College of Nursing Scotland, Dr Mary Ross Davie, director Scotland of the Royal College of Midwives, Dr David Chung, vice-president of the Royal College of Emergency Medicine in Scotland, Professor Alman Macman, executive nurse director NHS Lothian, representing the Scottish Executive Nurse Directors Group and David MacArthur, director of nursing midwifery and allied health professionals NHS Orgney. Welcome to you all to the committee this morning. As you may know, we have heard already some extensive formal evidence in relation to health and social care and in relation to allied health professionals and we have also taken informal evidence from many of those responsible for the tools that are a focal part of the bill. Could I perhaps ask each of the witnesses to comment briefly on your overall view of the bill and what it brings to the objectives in health and in social care, perhaps starting with Rachel Cackett? Happy and thank you for the opportunity. It's been an interesting morning. I'm sure there'll be a lot to build on from the discussions that we've already heard. The Royal College of Nursing has put extensive evidence in and been working on trying to develop this bill with the Government and now through the parliamentary process for the past 12 months plus. The first thing I guess I would say, and we heard a little bit this morning, is how far the bill has moved from where it began, which was simply to legislate, to put tools on to legislation and that was going to be it. I think it's important to note how far this has gone and how complex the bill is now and how there is still work to be done. The six areas that the RCN is particularly keen to see this bill improve around. The first, and we've heard a lot about this already this morning, is that the bill must be rooted in positive outcomes for patients and for staff, because if we have an overstretched staff workforce, then simply those members of staff who go the extra mile every single day will struggle. That is the situation that we are in now and I guess coming back to the question that was asked to the first round of people giving evidence was why do we need this bill? That's certainly the reason. There is clear evidence about the link between patient outcomes and nursing staff, and we would certainly be happy to provide some of that to the committee if that would help. There is work to be done in the bill to increase the level of a strong professional voice, and I do use the word professional voice. I'm here speaking for the Royal College of Nursing and our remit and mandate is for nursing. It is important for us that nursing has a voice right through all elements of this bill as we would hope to see it by the time it completes its parliamentary passage. That does not mean that we are trying to exclude other professions, that is the mandate that we have to speak to. It's important that decision making around staffing is informed, and that does mean using the best available evidence that we have and the best available data. Obviously, the bill at the moment in terms of the common staffing method limits itself to emergency medicine as the one multidisciplinary tool in nursing and midwifery. The RCN is clear that we have spent a lot of time in Scotland developing a series of tools for a workforce that is the largest workforce in the NHS, delivering 24x7 clinical care, often high-risk clinical care, and I think that we have to be aware of the patient's safety elements that this bill affords us the opportunity to address. However, that doesn't mean that those tools are anaspic. They really aren't set anaspic and it's never been our position. There was mention made at the end of the last session that those tools are being reviewed at this time, and even for us, not all elements of nursing are currently included in the available tools. Prison nursing, for example, an area that we've done a lot of work, does not currently have a tool attached to it. We would like to see that starting point that evidence developed, both for nursing and for others, but we certainly would not wish to see what we have dropped, because that would be a retrograde step. I think that Kim used a very helpful phrase of not wanting to put a wet finger in the air, and I think that what the tools give us is a starting point for a significant part of the workforce to do that, with the opportunity to learn and develop more. I think that the bill would have been helped, had those provisions for how those methodologies would be developed in the future appeared clearly on the face of the bill, and we would certainly seek for that to be the case, and had the financial memorandum made a greater timed commitment to the extension of those tools, both for nursing and for our colleagues. We want to see responsibility, accountability, real-time action and long-term planning apart of the bill. I think that the paper that we shared last night from the Government was helpful, and I think that it clearly sets out where there are areas for development. The common staffing method, as it stands in our view, is a means for setting establishment, and it goes beyond the tools as they currently stand to include far more data around how professional judgment will inform that establishment. What it doesn't do, and what our members need to see it to do, and what patients should be expecting to see it do, is deal with real-time risk. You turn up on shift and you do not have enough staff to deliver all the right staff to deliver the care that is required. What then happens? We've provided in our evidence a schematic for how we think that that could be better dealt with, and my understanding is that the Government's thinking is that that will go forward linked to the general GT, and we must remember that the general GT to provide appropriate staffing is for all staff, and not just for nursing, midwifery and emergency medicine. There is no scrutiny and sanction on the face of the bill, and we would like to see that added. We don't want another 12-week referral to treatment target put into legislation where you can breach it as many times as you like, and it makes no difference whatsoever. This has to have teeth. This is a crucial patient safety issue, and we need to make sure that there is accountability in the right place. One of the issues in the bill is that at the moment where we're talking about part 2, focused on the NHS, there is accountability put on to boards for delivering the general duty, and that is important, but it needs to be linked to a scrutiny methodology, and there's a great opportunity that his and our are reviewing how they do that to include that, but there also needs to be the opportunity for public scrutiny, either where things are repeatedly going wrong or where something very serious has happened. We need to make sure that staff on the ground are enabled to do that in real time, and that Parliament and others have a role in doing that over the longer term. Finally, we need to make sure that there are enough staff to care. Senior charge nurses—I know that you've been speaking to many this morning—are crucial to this as a process. They are there to set the culture for their team, to supervise the work of their team, to set staffing to deal with risk. If we do not free up our senior charge nurses and their equivalents in the community, this bill cannot do what we expect it to do. It's utterly important, and it comes back from your survey, that they do not currently have the time to do what they need to do, and so we are seeking that this bill makes senior charge nurses and their equivalents in the community non-caseload holding, so that they are freed up from direct patient care to be able to supervise the work of their teams and ensure that that is safe. But we also need to make sure that there is supply dealt with, and this doesn't deal with supply. We cannot tie the hands of boards to put a duty on them to provide appropriate staffing if actually the supply, which is held by Scottish Government, doesn't come through, so we would like to see that added. We appreciate part three is complex because of the landscape it's working in, but our interest in that is for our clinical nurses providing clinical care in the care home sector and our stances that you shouldn't expect any different in terms of the clinical care you receive, whether that's in a care home, in your own home or in a hospital, and that's why we have supported part three. Thank you. The Royal College of Midwives believe that this legislation may be helpful in establishing a consistent strategic focus on the staffing of maternity services. We've been grateful for the great focus that our sister organisation, Royal College of Nursing, have given to this legislation, and we've been working alongside them to affect change in the nature of the bill and also to support the developments that are needed to ensure that the planning tools are fit for purpose. I'm sure you'll have heard from some of my colleagues this morning that the midwifery planning tool that's in existent at the moment does have some weaknesses, and there are some issues in terms of how effectively they have been implemented. That is a bit patchy, but what we recognise is that through the preparations that have been under way for the introduction of the bill, that has led to greater focus on the need to amend and develop the midwifery workforce planning tool and also to increase the support being provided in health boards to successfully run the tools. The bill is just part of a much wider picture in ensuring that we have safe staffing levels and that we have midwives in all parts of Scotland. We have particular challenges in recruiting and retaining midwives, particularly in the north of Scotland and in more remote and rural areas, and there are a whole raft of other supports and changes that are needed in addition to the bill. You'll know from the SPICE survey undertaken earlier this year and also from our consultations with our members that there are a range of problems with the current midwifery workforce planning tool. I apologise for not having tabled a paper before today, but I have copies for you today that just summarise some of those challenges that have been identified. There are some areas in Scotland that have invested significant time and energy into providing dedicated time for completion of the tool and training, and in those areas, there have been instances where a staff shortfall has been identified and then business case was able to be made for more midwifery staff. We acknowledge the significant amount of national activity that is now under way to ensure that state staff are trained to use the tool effectively and giving on-going support. Thank you very much. Royal College of Medicine is broadly supportive of the principles behind the bill, so the speakers have said that it is quite important to have some oversight and an integrated planning of the health and social care system within Scotland. The bill acknowledges that. It is quite important because what we are looking at is that we have an unofficial motto, which is that if it is right for the patient, it is right for the emergency department. Many of the things that we see are the interface between different parts of social care and primary care, secondary care and health. We get to see things quite quickly and we get to see where the issues become manifest in us more acutely than other areas. Most of the things where we feel that patients might be getting a raw deal, such as if they are waiting for a long time in trolleys in a department trying to get into a bed or to go somewhere to be rapidly processed and to have their needs met, whether it be clinics or whatever, due to the fact that there may well be staffing issues elsewhere in the system. So, whilst we welcome that there is an emphasis on multidisciplinary care within emergency medicine, it is also quite important that there is an emphasis on care outwith the emergency department because staffing levels there need to be adequate for the whole process to run smoothly. We, as I have often said before, are the sort of the canary in the mine or for younger people who cannot remember that indicator light on a dashboard until you have a problem in your engine. That in itself is good. As other people have said, I think that we need to accept that the concept of the bill, while it sounds, needs to be accepted. It is going to be an iterative process and there needs to be feedback available from clinicians of all stripes to say if they find that the bits of the bill are not workable or the actual tools are not providing or there is a weakness. There is an ability and capacity to rectify that as soon as you can. It is the same with any sort of process, whether it be health, social care or industry. If people feel that it is making a mistake, we need to be able to correct that because there is no point in doing the same thing incorrectly just because it has been set in legislation. I think that one of the things that we would say is that it is important that, in terms of data recording or things that are transparent, it is quite important that when the bill comes in and various organisations are going to be showing how they have implemented the tools and reached levels of staffing, that that entire process should be in the public domain, which I am not sure if the bill makes quite explicit, but I think that it would be important because, at the end of the day, it is the taxpayer's money but it has also been able to be transparent and it is open to scrutiny. In short, I can answer another direct question, but we would be broadly supportive. Again, it should be something that helps speed and provide greater impetus to true integration of health and social care, which, whilst we are making some steps, could perhaps start to be progressing at a slightly more faster pace than it is just now. As long as we are mindful of that, it has definitely got the potential to benefit patients and staff and improve the human experience of everybody working in health and social care. Thank you very much. I will make one. Just building on some of the comments that colleagues have made, all of which I think that I would probably agree with. I do not think that anyone would disagree with the principles of the legislation that has been proposed, or indeed the aspirations around it in terms of patient safety, but also looking to ensure that we look after the staff that we employ going forward. I think that most people would probably agree that the tools as they stand are not perfect, but there is a process of how we review those tools and the implementation of those tools. That also means to bear the infrastructure that we previously did not have in the past. It would support the running of the tools, the analysis of the tools and the implementation of the finding of the tools. Those are things that we want to address with the Government and others going forward. I think that the principle of this is also about how we work in partnership between health boards, councils and integration joint bodies. There is a process already in place around workforce planning. We need to build on that planning process to ensure, not just from a nursing perspective. As I sit here, I am also responsible for AHPs and Lodian. I have a duty at the executive level to ensure that the voice of AHPs is heard at the workforce planning level and the professional level as well. I want to see the tools as they progress becoming much more multidisciplinary because we need to ensure that patients get access to the right staff across the spectrum, not just within the nursing perspective as well. I guess that the other point that I would make is that, in terms of process around escalation, it is important to look at that from a public scrutiny point of view, but it must not become bureaucratic and interfere with day-to-day business within health boards. It may be worthwhile to give an outline of the scale of NHS Orkney as the smallest health board in Scotland. In terms of headcount of AHPs, we have a princely sum of 40. Our community nurse headcount in whole-tim equivalence is 62. Our hospital nursing headcount in WTE is 135. Although we are not talking about huge numbers here, when we start to apply the staffing tools, we do commit to challenges in terms of our lack of resilience. Our bank, for example, is wholly employed by our bank within the board already. There is no spare capacity. We tend to staff up in terms of working towards worst-case scenarios. The tools, in fact, will be helpful for us in as much as they will provide transparency. They will, hopefully, support that in that view, especially in terms of the professional judgment tool. I would support entirely what my colleagues have said already. That is about transparency. It is about being able to demonstrate that we are doing the right thing and that we have the appropriate amount of staff. Within the bill that gives me some degree of concern is the lack of specificity in terms of the impact on that remote and rural area. It goes back to one of the earlier comments about the Scottish Government being holding that supply. We need that supply coming on to the islands. We need that flexibility in workforce. In support of my HPE colleagues, I would say that we also need to build that very strong multidisciplinary workforce that can perhaps work across barriers and work across professional boundaries. I think that any caveats that we have on the bill and workforce tools, I see the bill as a huge opportunity. It is an opportunity that we can utilise to build that multidisciplinary workforce. It gives us an opportunity to ensure that the workforce tools are utilised properly. One of the issues that we have with the workforce tools is that there is a lack of knowledge in their application. We need to ensure that that educational piece is out there and whether the tools are not working for us as professionals. We need to put our hands up and say that, but we also provide an answer to those questions. I thank you for your presentations as well. Certainly, things have changed, as has already been mentioned by others. It has certainly moved on. From what you are saying, I think that you would like to see it move on and maybe a wee bit more tools on it. I would put this particular question to you, which was raised by the previous panel. It mentioned the fact that the bill and the tools are acute service-based. Now, it can be a quick yes or a no. I do not agree. If you wish to expand, I will just mention one or two. Certainly, I will talk from the Midwifery perspective. The original research to develop the Midwifery workforce planning tool, some of the observations were undertaken in community settings and not just in acute labour ward settings. However, when we speak to colleagues out in the service, they are very clear that they feel that the tool is more effective in the acute setting, in a labour ward setting or the antenatal and postnatal ward, and less so out in community settings. One of the key problems that has arisen is that the community elements of the tool only allow for community care to be provided in working hours. Obviously, not all babies are born out in the community between nine to five, Monday to Friday. We have a significant number of home births and births in midwife-led units all over the country. There have been real issues in acknowledging that care that is being provided and making sure that it is recorded correctly. That is a key element that is currently not well covered in the Midwifery workforce planning tool. We are hoping that the look at this is going to improve on that. We are particularly concerned because the direction that maternity services are going over the next five years with the best start review recommendations is definitely towards a more community-based service, where many midwives will move out from working in hospital settings into the community. We need to make sure that the tool is robust and fit for purpose for ensuring that we have safe staffing levels out in the community, particularly in remote and rural areas where midwives are having to sometimes drive for four hours to undertake their and back for one postnatal visit. That all needs to be taken into account. Colleagues in remote areas have certainly said that they feel that that is not done effectively at the moment. Many of those tools were developed at a point in time when many of the services that we deliver were not being delivered by healthcare professionals. For example, prisons have been mentioned, police custody is another area that has been mentioned. Only recently, we have delegated to the responsibility to IGBs for community mental health, disability and substance specialist services. From the point of view of as time is progressing, there is a greater need to look at how we are providing that care to people in different settings and what the workforce requirements are around those. There is much more scrutiny now around that, so we need to rebalance as it were some of the tools to ensure that we are taking cognisance of the community elements just as much as we are the acute bit. For me, it is the point about the pathway that patients are not quite linear, so they are going to one bit of a system. They have covered many pathways, so it is making sure that there is that synergy and connectedness. They include community tools. They are not comprehensive. They do not cover all areas of community nursing at this point in time, but they are there. Clearly, there is more that sits within specialties within the acute sector, but it is not that they are only for the acute sector. That has to be welcomed. One of the areas, as we are looking at the review of those tools that has begun—the Scottish Government has begun that review—is that the type of services that nursing is providing in the community is now very different than it would have been 10 or 12 years ago. The sorts of things that you have gone into hospital for, you will now be receiving in the community as we change the way in which we deliver services and new options come online. Certainly, that needs work, and there are areas of the community that are not covered. Perhaps one of the things that I would pick up on that is linked to what was being discussed with you earlier this morning is the idea of multidisciplinary. What does that look like, particularly in the community? We have to pick that apart a little bit. I think that there is not a single person around this table that would not be absolutely promoting the need for multidisciplinary teams where that is exactly what is required by patients or service users, whether that is in the community or in the acute sector. The team has to be multidisciplinary where that is the right thing to do. However, in that team, when you come down to setting your establishment and understanding your workforce planning, you still have to know how many of each individual profession you require to meet the needs of individual patients. You need to know how many paramedics are needed in the back of an ambulance to run an ambulance service that may or may not be done on a multidisciplinary basis. You need to know how many district nurses—we were talking this morning about what those changes might look like in the care home sector—you need to know how many district nurses you need to deliver your multidisciplinary community service. I think that it is really important that we bear in mind that when you are setting establishments, particularly when you are thinking whether that is the number of bodies that you have on the ground on one day or the supply that you are planning for at Scottish Government level, you need to know how many nurses you need. That does not mean that you do not then apply that to a multidisciplinary setting. Often, one tool may not be appropriate. If you are running a 24-7 nursing service that may have seasonal input from our HPE colleagues, for example, I would be surprised if you were using exactly the same tool to try and work out how you have enough physios or OTs compared to enough nurses, but you would be putting that into a multidisciplinary workforce planning process. I think that we have to bear that in mind that the bill is not necessarily trying to do everything that is being described. I think that it is important to try and lose, in some ways, the distinctions between community and acute. That is part of the problem. There may well be a need for more staff in the community, which will ameliorate negative effects on the acute care and vice versa. We would hope that, as those tools become better developed with the sort of feedback, it will then be decided that what might the outcome measures be, how can you tell if it is working or not, and if community is only looking to within community or what average level is, and it is a mistake to use average to plan capacity in anything because it is going to be not enough half of the time. It should be those kind of measures that we are saying in support of the principle, but this is what we want to see happening, so we can see right, okay, as a community tool going to take into account, it is going to enable, let us say, all of the delayed discharges not to occur. It is going to enable people, more importantly, to have assessments at home like they do in East Asia and not even get anywhere near a hospital, which is good for them. Is it also going to mean that, let us say, there is enough for acute staff that, let us say, if there are things that patients do need to come to hospital, they are going to stay there for the amount of time they need to, as opposed to perhaps go out to the community, then the two sides are not going to constantly be created. Many go around for patients, which they do not need because their capacity is not right in either, so I really would emphasise whatever tools they cannot really afford in the next five to ten years to be seen themselves as I am a community tool, I am an acute tool, you are all an integrated tool and that is how the system should be developed. We mentioned earlier on the particular challenges in Midwifery, where we are in the position at the moment of supporting home births from our central base in Kikwell out to Papawestra. It is either a helicopter or it can be a couple of our boat ride to get out and do that. That means that, while we are waiting for Midwifery to arrive and we are waiting for that work and for the team to get there, there needs to be an ability to provide care. That is where our multidisciplinary piece really needs to come in. The workforce tool, I would agree, needs to be very much based across that holistic view, that continuity and continuum of care. Otherwise, we will end up siloed and we will lose the ability to flex. In addition, that also allows the IGB, for example, to commission appropriately and to make sure that it is providing the correct services. Thank you for that answer. It appears to me that the tools that stand at the moment do not seem to be fit for purpose if you are looking to the future. I wonder if you would perhaps maybe not agree with me about saying something about that, but they are all based on SSTS, which is the pay and staffing as well. Therefore, when you are looking at that, it is quite difficult to look beyond the triangle in the opposite way that was described by my colleague Emma Harper. How do we fix that? I think that everyone wants to see the bill work and obviously for the community as well, but it seems that the tools are not fit for purpose based on the SST3. How do we get around that to include other issues? For the SSTS, it is simply a system that is built on its e payroll. It is not necessarily fit for purpose because there is a lot of entry and duplication of effort for staff to try and triangulate information from that system back into a workforce planning perspective. There is a piece of work that the Scottish Government is leading with the NSS to review that and what would a better platform be, an information system be, to support that going forward. I think that there is that one element of it. I think that the other elements have been the education, the training, the awareness of the tools and the implementation of the outputs from those tools, be that from a desktop exercise, albeit through the actual running it through the e-system. More laterally, the expert capacity in the system to be able to work with people like myself and others to make sure that the outputs from those tools are being interrogated, analysed and then turned into quite robust plans. All those elements are being addressed. If we get those right, at the point of becoming legislation and then enacted, that would certainly put us in a better playing field to begin with. I would like to emphasise that, when the tools were first established, there was a huge training effort that went into supporting that. We have seen that cohort of people change and have moved out. We have not perhaps kept ourselves up to date as we should have done with the tools, but the tools, as they stand at the moment, provide us with a start point. The direction of travel is absolutely correct in the way that the tools are coming in. We also need to be very cognisant of the fact that that is also recognised by CNO's office, who has provided us with an extra resource, an expert resource, both from within our office and locally within the boards, yet to be recruited, who will provide that continuity and that additional input for us. As I said earlier, no one wants to see tools that are set in ASPIC because the world moves on. It is encouraging that the Government has now put in a process to review the tools that we have. That should be an on-going review process. We cannot let the dust settle on these tools at any point—they have to be fit for purpose. I think that that is why the bill should be amended to include that as a duty within the bill so that that on-going method of review is in place. We need to be able to say when a tool has come to the end of its life. We need to be able to say when we need a new tool and we need to keep what we have up to date. That is a really important process that is currently missing. In the social care section, the responsibility as it currently stands for developing new methodologies does not go far enough by saying that they need to be able to keep those up-to-date on the process for doing that. Those are really important things that we need to look at to make the bill fit more for purpose. I go back to the point of the survey and the discussions that we have been having with our members, which is that when you are wanting to run these, you need the education and the time and the expertise to do that. Those things also really matter and have to be in place. We need to look at where the levers are within the legislation to get that right. Thank you, convener. It is probably an appropriate time to mention my register of interests here that I am a close family member who is a midwife. I also wanted to follow on from Sandra White's line of questioning in terms of the technology. If the bill is going to succeed, it is fundamental that the technology that underpins it supports the tools that are required. We heard again in evidence this morning that the wide variety of tools that seem to be used by midwives and nurses who did not recognise some of the names of the tools that other areas were using. The SSTS platform is not built for purpose and never fit for purpose. Are we suggesting that, before the bill can go anywhere near a platform that is developed specifically to deliver on that and a better regulation of the tools across the profession? I am currently looking to procure a new system and I believe that they would hope to have that by the end of the calendar year. Then there is an issue about how that can be then developed and implemented. One would hope that it could work at the pace at which legislation is going forward. That might be in place. From that perspective, it is not just about having a system in place. It is about having people trained and educated and able to use that system. There is a lot of work to be done from that point of view. There is also testing out of systems. I guess not to have a new system in place and then to introduce it after we have introduced the bill, which causes more confusion and work for people. I am not saying that one should stop the other progressing, but it would be in the ideal world if they were both coming in at the same time. Anyone else? Maybe Ross David? I think that the introduction of the bill has in itself focused people's minds on what is not working. That has certainly been the case for the midwifery workforce planning tool. Then views were sought from the heads midwifery around how effective the tool was. It was clear that it was really quite patchy. At least half of the health boards were feeling that the tool was not reflecting what they needed. I think that the bill in itself, its introduction, helps to move things. The work is well progressed, I understand, with the new platform. I think that it helps in tandem, if you like. I think that what we are hearing and the information that you got back from the survey shows that it is not a uniform picture. There are clearly areas where things are working more fluidly than perhaps they are in others. I think that that is part of the work that the Government is now doing with its additional support. I certainly focus minds within boards and elsewhere to rethink how that is implemented. I would certainly be reluctant to say, let's hold off till everything is perfect, because what we were saying earlier, this is an ongoing improvement process. It will never stop, nor should it. That is what the health service is built on, is an improvement focus, as is our social care service. There are other platforms as well that we are looking around the care assurance system that the CNO is developing through excellence in care, which will give really important indicators to ask about the quality of care being provided and the outcomes for people. That is being developed in tandem with this bill, which is a really important point that we shouldn't forget, that there are other indicators out there in other platforms. We have to remember that the common staffing method is not just the tools. We lobbied from the RCN very hard for that to be the case, and the Government listened. In terms of setting an establishment, it gives those with professional judgment a whole variety of other means to then come up with what that establishment should be. It is not limited to the tool alone. You will be looking at other things. One of the things that we would like to see added, for example, is professional guidance from royal colleges or peer reviewed international evidence that could be brought in by those who have the professional judgment to make on what an appropriate staffing level would be for any particular setting. Ideally, we would see both come together, and that would be the perfect solution. However, from our previous employment, it was made very clear to me on many occasions that we perhaps need to go with the best current solution that we have, rather than hold up the plan, because we will never get quite the perfect plan. Is it going to survive first contact? Rachael Seng, I guess that it is a potential to run with systems that are not all necessarily collecting the same data and are not all defined in the same way. We start to select things as we want to from bits to try to make the argument, but what we really need here is a like for apples and apples situation, not situations that we might have had in the past about depending on which day of the week you run it or depending on which question you ask, where you get a different output. That needs absolute clarity and consistency. Thank you very much. Thank you, convener. Good morning to the panel. I have one quite large narrative question about this, and then a couple of detailed questions, perhaps more for those dealing with the nursing profession on a day-to-day basis. Dr Chung, I was struck by your canary in the mind reference at the start. We have met personally, and you have described in very coherent detail as to how the problem in social care is actually causing an interruption in flow, which is manifest in accident emergency, but you cannot release people into the wider hospital because there are no beds to receive them. Are we missing a trick by not including aspects of social care within this? Does that cause us problems for the whole integration experiment? It is very much siloed and focused on primary care. I would say that you have summed up quite nicely the points that I was making. It is essential that social care is involved in this, because that is where a lot of the capacity is. Again, a lot of this is aimed at what is best for the patient, and it will also turn out to be what is best for the staff if the patient is getting the right care. The two have to go hand in hand. As I have already indicated, it needs to totally account for integration and the fact that the different parts of the system cannot afford to plan in isolation from one another. They are going to have to work together because there will be effects, hopefully positive, but they could be negative if one bit does not get it right. Therefore, whatever tools are developed must ensure that the effects of whatever planning occurs in one particular area. Just now, there is a broader scope and some overview to see whether that will have a negative unintended consequence somewhere else. All sorts of planning is littered with this. Again, if we make the system that it can be rapidly assessed and updated and changed, if that appears to be the case, then we can change the tool to ensure that that does not happen. I agree that your analysis is correct. It is imperative that all the parts of the system within health and social care is called emergency medicine, but a lot of it is actually social medicine in some ways as well. People come to us because there are issues within their lives. We are available, we are there. We are very often not the best place to solve the problems. Increasingly, we have seen some very good work in Scotland about how we are using other staff groups to help to reconcile those people to the right place. You have got, let us say, the navigators in the big hospitals now, including Arun Eishor. You have got other things like community connectors, adult support protection. All those are very integrated groups. Those can get very much to the route of the problem moving into the likes of paediatrics and adverse child events that are solving the problem for the next 20 years. If you can get to grips with early childhood stuff, we are going to have less work to do. It is quite important. It is very difficult to nail this down to the way the tool is just now because it is very easy to look at a defined group. However, as it develops, it needs to become sophisticated to reflect all those to see where does the system need to get most bang for its buck for the patient's benefit and for the value of money for the taxpayer. Thank you very much for that. That is great. The second is a bit more detailed. It is about obviously within the toolkit and the other provisions in the bill. It is clear that this is about better workforce planning. However, in our background briefing, I have been struck by the focus on things such as headcount and being sure that we have capacity, but it is not always necessarily clear whether that is the right capacity. Should we be specifying the need for appropriate skills mix within the staffing that we are planning for? We will take Rachel first, then David, then Alex. A few things to answer to that. First is that the duty to provide appropriate staffing is very clear that they need to be competent and qualified to do that. I think that that is the way in which the bill is attempting to deal with the issue of skills mix. Within the nursing tools, as they currently stand, the tool itself is not going to give you a skill mix. It will give you a number, and it is for the average workload. It gives you a baseline, and the professional judgment is then applied to work out what that should look like. The bill is currently drafted because of the way that the common staffing method is written. It goes back to an earlier point, which gives you essentially a focus on a number for that average workload based on a certain set of assumptions, such as bed occupancy, which may be well off where bed occupancy is in the current situation for the NHS in Scotland. What it does not do is deal with risk. That is the big bit that is missing in the bill for us, along with some of the other things that I set out earlier. However, the risk management process, you can have a number, you can have a skill mix, but if you have a sudden outbreak of flu that is affecting both your staff group and the acuity of the patients coming to you, you need to be able to adjust that and do an ongoing risk assessment. I think that only part of this is about an evidence-based number, which you need for workforce planning, and you need to get your finance right. You need to have the professional judgment in place with the support for that to be consistently every single day adjusting that according to patient need, whether that is in the community or in the acute sector. Is there sufficient provision for that within the bill? No, it needs to be added. I know that the Government is obviously looking at work to do that, and we will not see exactly what that looks like for a while yet, but there are discussions going on. However, we have obviously put forward proposals as well as to how that could look. I think that, in terms of our members, that would address many of their concerns, which is about finding a number and getting your budget right for your establishment. That is an important process, and it needs to be based on the best available evidence, which is why we need the tools as part of that. However, you need to be able to deal with risk in real-time. Like all issues, it tends to get more complex the more you look at it, which is one of those things that is life, isn't it? I would say that the points that are made about using an average to plan capacity is a fool's errand because, by the law of averages, you are not going to have enough half of the time.  The perfectionist would say, we need to be able to cope with having enough reserve to plan for 95 per cent of what there is. That is probably not far off, or maybe 85 per cent is perhaps a minimum. However, I would certainly say that using the averages is going to cause problems because it is then not going to work. People are going to be unhappy half the time and you are going to lose engagement. There needs to be some modification around that. Again, headcount in as of itself is a wee bit too crude because there are differences in skill mix. The differences in time of day, days of the week, seasons of the year, all of these may create different pressures. The way things are, most tools and most workforce planning appears to have said, well, historically, the viewpoint is mainly, if we have got this amount of staff, how can we divide them up to put them where we need to be? Perhaps it needs to be some work about how many staff do we actually need and the Royal College can certainly give some help with that. If you look at national benchmarks, you should be saying, well, what kind of health service model are we aiming for? If you look at, let's say, someone like Australia, they've got about, maybe not quite double, but certainly 78 per cent more beds, more doctors, probably more nurses as well, or we are currently at about the same level as the US, compared to our European neighbours. We're less than all these and I've got the figures here because I remember I mentioned this last time and I was asked, but I've got them to hand. You could say, is your tool going to reflect the fact that you're going to need a certain amount of different staff, let's say, on a Monday evening, which is the busiest time in the most department, compared to a less busy time, which might be Saturday morning. If you're in a paediatric assessment area, do you need a different amount of staff when it's a middle of bronch season versus another time? Every area will have different peaks and troughs, and there will be different advantages to having different levels of staff. It may just be a volume thing and a certain level can do stuff. You may have the benefit by having more senior people who can move from one task to another, and therefore, whilst appearing to be more expensive, it might be more efficient.  We need to have some thought about whether tools are and how they can adapt to give a more detailed and reflect some of the complexities, which may again vary from area to area as a time of day, day of the week, season of the year, all these sort of things, and also unexpected pressures. We've done a lot of work to create a very, very efficient system, and by international measures, the NHS in the UK and in Scotland is very efficient, but there's an increasing body of thought starting to be about, by evidence, not just in healthcare, more to do with industrial processes, that if you get very efficient, you're going to become more fragile. I think that this might be what we're seeing when we're squeezed with periods like so-called winter or whenever you get other pressures upon the system. We have to decide whether balance is going to lie when we're doing our workforce planning. At the moment, it's very much amongst efficiency. Maybe we do need to think where's our reserve, what kind of level we're going to plan for, but, again, for the third time, average is the one way to do it. I have to remember that these tools are best to run once a year, so they give you a snapshot at a point in time. What they don't do, as Rachel has said, is give you that skill mix or that risk element. On a day-to-day basis, we would be doing that in a ward or a community. We would often start a day with, are we safe to start? There would be a huddle, there would be a discussion around patient safety, staff safety, and none of that should be taken away, but there are elements of how we plan that into process around the tools and the frequency of running those tools as well. It's married up from a day-to-day and into an annual process if that's the way that we decide to go with those things. Within many of the submissions, you would see the support for banned citizens being made supervisory. I think that that's an important conversation that we should be having, so it shouldn't just be that everything falls to them, but they've got a key role to play in that day-to-day staff safety and patient safety perspective, but they also become experts in the running of the tools and the education and training of others in the tools as well. I think that it's really important to stress that we do look at risk on a day-to-day basis and probably our to our basis in some departments, but in terms of the process overall, it's a key element that needs to be built in more rigorously. We would support those thoughts really around risk and around the use of averages. Certainly, we find in maternity that we have very specific peaks, often nine months from Christmas, but that we can't necessarily plan for and where you are seeking to create a workforce that is based on averages, as has been said really clearly, you're going to have a lot of the time where you are midwiser running short. I think our other problem, midwifery workforce planning tools, were actually some of the first workforce planning tools that were developed, and I think that's for a reason in order to try and cope with this peaks and troughs that we see. The rest of the UK uses a workforce planning tool called Birth Rate Plus, but around 2010 it was felt in Scotland that that wasn't appropriate in the Scottish context because it really didn't take into account some of our really remote and rural issues. What we're seeing, where they're trying to evolve that tool down south now and looking at new models of care around continuity, is that they're having issues and realising that that tool needs to develop to reflect the new ways of working. As Rachael's clearly said, that is something that we're going to need to continue to do as service changes to make sure that the tools reflect new practice. We don't know yet what that's going to look like because that model of care has never been done at scale. It's only been done in small research projects, randomised control trials, so the tools can't replace risk management on a day-to-day basis. I would only support that view and also pick up on the skill mix piece. In an acute ward in NHS Auckland in the Balfour hospital, we have 23 beds. Any one time they can be accommodating acute surgery, acute medicine, renal, gynaecology, ENT and the list goes on, including orthopedics. We're really very much in the business of being the specialist generalist. What we need to make sure is that any skill mix package, and I wholly support the approach, takes due cognisance of that. Not only do we need to be able to provide those specialist generalist people, but we also don't have the critical mass to call on for example, when I was theatre manager at Glasgow Royal Infirmary, I could call on colleagues from ITU, I could call on colleagues from any one of the 27 operating theatres we had. I think that we lack that critical mass in remote and rural. Not only is it a question of skill mix and assessing skill mix and managing that risk, but there is also that knock-on training element for us and perhaps a training margin, which should be increased in that case as well. Thank you, convener. Welcome to everybody for our second panel this morning. I'm interested in the one comment that Alec McMahon made was about not another level of bureaucracy where senior charge nurses are going to say, no way, this is just going to impact my clinical supervision ability, so I would support no further pieces of paper that would reflect just additional workload. In our submission from Fiona McQueen, their chief nursing officer, NHS Lothian's documentation about the number of rosters that have applied the tool, and the number of staff that have applied the tool has looked pretty successful. Can you tell us about the success of applying the tool and what have you done? Training is key to engaging the staff to take on board something like this workforce tool? With any data, there are always more questions that you want to ask than there are answers to, so that was in place that came late last evening, I think, from the CNO's department. I've been very fortunate in, I've only been in this post for two years, but I have a deputy director who has steeped in these tools and was involved with them right from the beginning, so someone who's very expert working with associate nurse directors and clinical nurse managers and charge nurses across the system, that doesn't negate the fact that there's still more education training to be done. We recently did an internal audit of our own processes and yes, although it feels like we do it and we do it well, actually I don't think we're as good as we could be about the implementation sometimes of the outputs from the tool, so it's closing the circle sometimes on that piece. Again, for me, very much about using what we have, but building on that, because one of the things that my deputy director would say that the current system that picks up the issue about the SSTS is actually, it makes it much more clunky and cumbersome, and she has spent a lot of time working with others to try and get the data out of the system, so we might want to do it more often, but actually a lot of the things that are in our way are about the infrastructure, the time, the expertise to be able to do it, so having said that, I do welcome the commitment that the Scottish Government have given around the advisory posts, which will help her and work with us, and build up that awareness, that education and that training, but I think we're probably all in slightly different places. I think some people in some areas do do them, but they might do them on a tabletop exercise, or it might be that the reporting systems out with them, what's being reported there, so I guess I just thought and thought, there's more questions in there than we probably know just now some of the answers to. Okay, it's just that e-rostoring is one of the things that was picked up earlier about how that can pick up the competence or skills required, because depending on who's on shift, you need somebody who's central line trained, IV trained, catheter trained, the list goes on to be able to give like competent care wherever it is, because IVs are delivered in the community now as well, so that's part of this development process. Absolutely, so from that point of view, NHSLudian has almost completely run out the e-rostring system, so an electronic rostring system, so not even without its challenges, you know, bearing in new systems always creates some challenges, but actually what it does do is it allows you to see what the QT of your patients are and what the skill mix is that you would require for any particular shift. It doesn't mean that you can necessarily always respond to that as effectively as you would, but it gives a charge nurse and others the absolute ability to be able to see it on a day-to-day basis, and does their staffing and a skill mix actually meet the needs of the patients that they're actually looking for at a point in time? So that's called safe care, the bit that sits behind that is called safe care. So again, as we've talked about earlier, there are different systems out there, but certainly with the Ludian that's the one that we're using and it's proving to be successful, but not without some challenge. Thank you very much, David Stewart. Thank you, convener. I can also thank you all for your contributions. I'm particularly interested in looking at the issues of rural, remote and island, so I want to address some marks, particularly Mr MacArthur. In your statement, Mr MacArthur, your conclusion is pretty stark for your say that you don't think the philosophy behind the island bill, now that the island act is fully reflected in the staffing bill as we see it now. Could you say a little bit more about that? Yeah, I think in terms of the bill's statement in having regard to the distinct and geographical cultural awareness of the islands, is it a whole new reflector in there? I think a very stark reference would be very useful. I reflect the opinion of my IGB and council colleagues in that as well. This is a very crucial element for us as we start to roll out. We're moving to a new hospital, as you're probably aware, and the philosophy behind that is that we will roll out more and more into our community to ensure that we're using all the facilities that we can use out there of attend anywhere and the various other video systems. From our perspective, it's about having that due recognition that there are some things that are going to be different. We're not asking for allowances to be made, we're just looking for that recognition so that we can test and adjust. For example, although our staffing tool may tell us that staffing is x for a given period, so that because we don't have that same resilience, perhaps it should be x plus one, and it's that type of view that I would take on it. The philosophy behind the islands bill is that there would be an island proofing. In other words, every piece of legislation needs to be conscious of islands. For example, you're seeing in your submission that you felt the tool wasn't sufficient for use within small hospitals, so is that a lack of island proofing then? Sorry, that was a mis-taping. I meant in terms of small wards rather than small hospitals. From that point of view, the tool is a national tool. It's applicable right across the country, and I wholly support the views in the bill. However, for that remote and rural element, we really need to be looking at something slightly different. If we look at CNO's letter that came out last night, there are areas of non-compliance, not just within the islands. You will look at Shetland. We only applied the tools this year, sorry late last year, when I came on staff there. However, we also look at remote and rural areas. We look at the borders, and it's non-compliance there as well. I think that there is an issue where there is a view being taken that it doesn't really meet the need and doesn't really apply to us. I would counter that by saying that some of that is a lack of understanding and a lack of training, but equally, in very small units, it is a difficult concept to apply. I think that without being flippant, there is a famous quote from the military context, which says that every plan collapses with the first contact with the enemy. Are you suggesting in some senses that the plan isn't really sensitive enough when it comes to dealing with rural and remote areas? I think that the quote is, no plan survives first contact. For a remote and rural element, it can be made to work. As I said earlier on, we're not at the perfect point within the tools, so we need to make this work. We can make it work by giving people the appropriate education, the appropriate training. We've got support from the Scottish Government in this. Bear in mind that my submission predated the additional support that was being made available. I think that I'm quite confident that we can make it work for us, but it needs to be nuanced. Is the issue of the tension between the tool as a financial workforce predictor and as a safe staffing predictor? That's quite an interesting point. Can you say a little bit more about that? Yes, it goes back to the issue of risk and skill mix. The way that the tool was used, I don't think, produced that skill mix sensitivity. I'm not quite really pointing out that it happens once or twice a year. The sensitivity isn't built in to be able to for us to make those day-to-day changes in terms of the tool. Equally, we have our hurdle every morning. It's probably easier in some ways for us because there's half a dozen people around the table saying whether we're safe or not. Equally, it's very challenging because we don't have that critical master of people to move about, but I think that the tool doesn't facilitate that piece of work in terms of skill mix and risk. Thank you very much. Finally, and very briefly, clearly we haven't had time to cover every aspect of the building detail. I wonder if witnesses have any brief comments regarding the financial memorandum and in particular the absence of funding for any additional staffing and whether there is adequate funding for full implementation of the tools as they currently exist across health boards. Finally, is there a risk of a perverse incentive that running the tools may demonstrate that you don't have adequate staffing and the way to balance the tool may be to reduce the number of beds? Is that a live or real risk in the context of Rachel? In our evidence to the finance committee, and I know that this committee is now considering the financial elements of this bill, we were critical of the assumption that we read into the financial memorandum that this bill would not necessarily result in more staffing. We are certainly seeing our members under extreme pressure at this time, so set aside the vacancy rate that we are now holding, we have new models of care arriving, greater demand from the public and the assumption that this won't result in any change to that seems an interesting place to start given that this is meant to be about improving the safety and quality of services to people. From our point of view, where that is delivered by nursing care across health and social care, I would be deeply surprised if that were to be the result of the bill. I think that the submission that we received last night seemed to address some of that by talking about the need for any additional staffing to go into the annual uplifts and for that to be a discussion within the budget process. If that is where we are going with this, I think that that is a helpful process, but whether that will be sufficient for the boards to be able to do what they need to do, I do not yet know. In terms of the perverse incentive, I guess one of the things that we need to say, and maybe it has not been said clearly enough, is that nurses go into work to do a really good job. That is what they go into do. That is why they join the profession. It does not matter to me whether that is a healthcare support worker or a director of nursing. Their aim is to go and do a good job and to make sure that the safety and quality of the care that nursing is provided wherever it is provided is good. I would hope that what this bill does is that it provides an important balance to the financial positions that boards are under and that goes back to the governance discussions that we were having around this table some time ago. I think that that is crucially important, but the idea that it would be gamed in that, I would certainly hope not. From a nursing perspective, that is certainly not why nurses go into the profession. Thank you very much. I look well, man. I guess that we have not really touched on workforce and workforce supply, and although the numbers, certainly for student nurses and midwives, have increased this year and will increase possibly next year as well, they will not be out for the next three or four years, so there is no overlap with this legislation coming into effect. From that point of view, there are vacancies and there will continue to be vacancies, particularly in areas such as David's, where it is incredibly difficult to recruit staff. From that point of view, more of the same will not do it. That is why we do need to look at skill mix, and that is not to denude or put down nursing. That is about how we grow workforce that can better meet needs in different areas. We often look to advanced nurse practitioners as a solution to many of those problems, but we are probably going to pay Paul sometimes around that, because we take them from one area and we cannot replace them. There are also areas of medicine that are difficult to recruit into, and sometimes the answer to that is nursing. We need to, from a workforce and a skill mix perspective, look at this in the longer term, because that should not distract us from the principles and aspirations around us, but it is a reality. On the unintended consequences, I think that that would be where, in terms of clarity around the process of escalation, that if we have done everything that we can to ensure that things are as safe from a staffing point of view but we cannot because we have to then look to put two words into one word or do it, then actually that has to be supported because we are doing everything that we can. It is not because we are trying to fudge around it or not, it is because actually there is nothing else left available to people, so it is about looking after patients, it is about looking after staff. I would agree entirely with that. The currency that we have, if we look at beds in terms of currency, the only variable that we have got certainly in Orkney, and it is reflected throughout the health service, is the availability of beds and how we do things safely. We need to be very careful, and we have not hit that issue yet, but we are looking forward to the future. If we were to run out of—if we did not have enough staff, would we then need to close beds and then we would then need to start moving our patients to the mainland? I am not saying that that is going to happen and that sounds quite scaremongering, but this is where I think that the island bill comes in and the island proofing comes in, because we need to be able to attract those outputs from students to the island. We do have issues with affordable housing, transport infrastructure and broadband. That provides broadband peace for young people, which is very important in terms of communications. I would agree a whole heartily with Alex, but I would put that island's bill and that remote rural spin on it. I think that there is a fear amongst many people who are looking at this thinki