1. The First Minister announced the Scottish Government's intention to enshrine safe staffing in law at the Royal College of Nursing Congress in Glasgow in 2016. In its Programme for Government 2017/18 the Scottish Government committed to "deliver" on the commitment to enshrine in law the principles of safe staffing in the NHS, starting with the nursing and midwifery workforce planning tools'.

2. These commitments resulted in the Health and Care (Staffing) (Scotland) Bill (“the Bill”) being produced to enable safe and high quality care by making the provision of appropriate staffing in health and care statutory, resulting in better outcomes for services users. The Bill was introduced into the Scottish Parliament on 23 May 2018 by Shona Robison, then Cabinet Secretary for Health and Sport. The Bill was referred to us on 28 May 2018.

3. Safe staffing is an issue that has been considered across the UK. The Francis Report (looking at care quality at Mid Staffordshire NHS Foundation Trust) explicitly stated inadequate staffing levels led to poor quality care. Staffing levels in England are not set in law and whilst this Bill aims to ensure safe and high quality care through the provision of appropriate staffing, it does not set staffing levels in law.

4. Following introduction of the Bill, we issued a call for evidence, which ran from 6 June 2018 to 1 August 2018. We received 70 submissions.

5. In an effort to engage with as many front line staff as possible we attended the NHS Scotland Event at the SEC, Glasgow on 18 and 19 June. At the event we ran a parallel session which used the Bill as a test case, inviting attendees to think like a Committee member and consider how they would scrutinise the Bill. In doing so we gathered the views of the NHS staff in attendance on the Bill and identified areas where they thought scrutiny was required.

6. We also issued a survey which sought views on the current nursing and midwifery workforce tools and as such was specifically aimed at those who use the tools. The survey ran from 29 June 2018 until 1 August 2018 and 195 responses were received. SPICe produced a summary of the responses received and a report covering the full survey responses.

7. We held an informal evidence session on 11 September with nursing and midwifery staff to discuss with them their experience of how workforce planning is managed in their work settings.

8. We took formal evidence on the Bill at our meetings on 11 September, 18 September, 25 September and 2 October 2018. These sessions looked at the Bill in relation to integration and multi-disciplinary teams, staff groups already covered by workforce and workload tools, the impact of the Bill on the care home sector and the development of new workload tools.

9. We thank everyone who provided written and oral evidence, or engaged with us as part of our consideration of the general principles of the Bill. Their input has greatly assisted our deliberations.

10. A full list of witnesses and written submissions can be found at Annexe A

11. The Bill covers both health and social care services, with the aim of ensuring more integrated workload and staff planning. This broader approach is noted as seeking to ensure there will be appropriate staffing to deliver high quality care whatever the setting.

12. The Policy Memorandum notes "high quality care requires the right people, in the right place, with the right skills at the right time to ensure the best health and care outcomes for service users and people experiencing care".

13. It is important to be clear the Bill does not focus on national workforce planning. The Bill includes a focus on the development and application of workload planning tools aiming to ensure health and social care providers (those registered and inspected by the Care Inspectorate) are providing adequate numbers of suitably qualified staff to provide safe and high quality services.

14. The Bill sets out principles which must be taken into account when considering staffing requirements across health boards and by those providing care services. The Policy Memorandum states the Bill "creates a coherent overall legislative framework for appropriate staffing across the health and care services landscape".

15. The Policy Memorandum also notes the policy intention of the Scottish Ministers is to "enable a rigorous, evidence based approach to decision making relating to staffing requirements". The overall aim of the Bill is to ensure safe and appropriate care staffing levels based on clear, evidence-based methodologies, regardless of setting.

16. The Policy Memorandum states:

    The legislation is not intended to set out or prescribe minimum staffing levels or fixed ratios; this would be at odds with the Scottish Government's established policy approach and could potentially undermine innovation in service provision. Rather, the legislation will support local decision-making, flexibility and the ability to redesign and innovate across multi-disciplinary and multi-agency settings.

17. The Bill is structured in four parts:

    • Part 1 sets out the guiding principles for health and care staffing and sets out duties in relation to these principles in health care and care services, including in the planning and securing of such services;

    • Part 2 relates to staffing in the NHS;

    • Part 3 relates to staffing in care services;

    • Part 4 contain what are described as standard provisions, an ancillary power to make regulations, commencement powers and the Bills' short title.

18. Part 1 of the Bill sets out the guiding principles for both health and care staffing with duties including the planning and securing of health and care services. The principles in the Bill combine:

    • outcome focus;

    • transparency in decision making for service users and staff and;

    • the value of the importance of staff wellbeing.ⁱPolicy Memorandum paragraph 98

19. The guiding principles will apply to health boards, NHS National Services Scotland and those special health boards with a clinical facing role, as well as all care service providers. Health boards will have to consider the guiding principles when commissioning care services from other providers and commissioning authorities will have to consider them and the duties placed on care providers when commissioning care services.

20. The principles intend to ensure equity and parity in decision making for staffing requirements across all staff groups and they note that the primary purpose of staffing health and care services is to provide safe and high-quality services.

21. Part 2 of the Bill sets out staffing duties on the NHS. Every health board in Scotland has a duty to workforce plan and to ensure the provision of high quality care. The Bill would place further duties and guiding principles on health boards to ensure staffing requirements are appropriate for the patients in their care, in all locations and specialities.

22. A set of 12 workforce planning tools were developed for nursing and midwifery following the work of the Nursing and Midwifery Workload and Workforce Planning Programme (the Programme) and these have been mandated by the Scottish Government for use in health boards since 2013. They form part of a methodology for health boards to determine on an annual basis what the establishment should be for each nursing setting.ⁱThere are currently tools for the following nursing settings: Adult inpatient, neonatal, SCAMPS (paediatrics), clinical nurse specialist/community children's and specialist community nurse, mental health, small wards, maternity, emergency medicine/medicine, peri-operative and professional judgement

23. For areas where one of the 12 staffing tools currently exit, the Bill will make it explicit that health boards are expected to:

    • apply the common staffing method (further details of this can be found in the next section);

    • use the output from the tools along with professional judgement, local context and quality measures to underpin and inform decisions about staffing requirements;

    • make sure a consistent approach is taken to identification and lessening of risk, take account of appropriate clinical advice and consider whether services can be redesigned;

    • ensure staff are properly trained to apply the common staffing method and tools, engage with the process and understand the decisions made in relation to staffing decisions;

    • monitor and report on how they have achieved all the above and provide assurance regarding safe and effective staffing.

24. The tools noted above are based on an average workload for each speciality across Scotland, and are supplemented by considering the specifics of local context - for example, the age profile of staff, local recruitment challenges; quality indicators and professional judgement. The Scottish Government describe this as a triangulated approach. Figure 1 is produced by NHS Scotland to show the 'triangulated' process used as part of the staffing methodology.

NHS Scotland

25. In the SPICe Bill briefing they have taken figure 1 and shown it in linear format. Figure 2 below shows our linear description of the approach.

Scottish Parliament Information Centre (SPICe)

26. Although it has been mandatory for health boards to use the tools and methodology since 2013 the Policy Memorandum notes there have been "inconsistencies in the way in which tools are applied and the extent to which the existing methodology is utilised to make informed decisions about staffing requirements".

27. An updated common staffing method is proposed in the Bill and detailed below. The diagram illustrates the common staffing method and identifies which aspects relate to the existing triangulation process (the base of the pyramid) and which are additional duties under this Bill (shown in the middle section). All leading to the proposed new common staffing method as show in figure 3.

Health and Care (Staffing) (Scotland) Bill, Policy Memorandum

28. An equivalent linear description of the approach shown in figure 3 has been prepared by SPICe and is shown below in figure 4.

Scottish Parliament Information Centre (SPICe)

29. Part 3 of the Bill sets out staffing duties in care services. It is currently the responsibility of every provider of care services to engage properly qualified and competent people working in appropriate numbers to ensure the health, welfare and safety of service users. Providers are also required to ensure their employees receive appropriate training to carry out their duties and are given time for further training.

30. The Policy Memorandum notes the purpose of including care services in the legislation is to allow the sector to build on and strengthen existing mechanisms. This is achieved by placing Regulation 15 of the Social Care and Social Work Improvement (Scotland) Regulations 2011 in the Bill to create a single legislative framework in this area across health and care settings. By having parity in the legislation the expectation is that it will allow, and support, innovative approaches to workload and workforce planning which take into account the role of the range of staff groups employed across multiple organisations delivering care.

31. The Bill builds on existing legislative functions by providing:

    • A power for the Care Inspectorate (CI) to work in consultation with the care sector to develop staffing methods (workforce planning tools) for application in specific settings, where a need has been identified. Initially this will only be for care homes for adults. Other powers include:

    • A regulation-making power for the Scottish Ministers to enable the CI to develop tools for other care settings in the future, if required;

    • A regulation-making power for the Scottish Ministers to require the use of staffing methods developed by the CI;

    • The ability for Scottish Ministers to issue guidance to care service providers setting out further detail around the duties contained within the Bill.

32. The CI's statutory function requires them to work with the relevant sector to examine if a tool is appropriate. If there is agreement it would be up to the CI to facilitate the development and validation of a tool, in collaboration with the sector.

33. Care homes for older people will be the first setting for which a tool is developed. This will build on existing work by the sector to produce a dependency tool for use in care homes. By initially focussing on only care homes for adults the Scottish Government believe this will provide an opportunity to test and evaluate an approach and its impact on quality of care as well as service users' experiences.

34. Part 4 of the Bill includes general provisions falling into three sections:

    • Section 12 sets out the scope of the regulation power available to Scottish Ministers under the Bill, including power to amend other Acts (only by affirmative instrument).

    • Section 13 provides that Scottish Ministers may by regulations commence the provisions of the Bill on such dates as they determine.

    • Section 14 gives the Bill its short title as the Health and Care (Staffing) (Scotland) Bill.

35. Each of these provisions are of a standard nature found in most legislation. The Delegated Powers and Law Reform Committee have scrutinised the regulation-making powers and we report their conclusion later in this report. Beyond that we have nothing to add in relation to section 4.

36. This report considers the evidence we have received and uses it to examine the general principles of the Bill.

37. We examined the general principles of Part 1 of the Bill as set out in paragraphs 18-20 as they apply in territorial health boards, service providers and others. Our primary purpose was to understand the breadth of the provisions in this part and the extent, if at all, to which they would achieve their primary purposes.

38. Most submissions to the Committee's call for views were supportive of the guiding principles of the Bill. Scottish Borders Council/Integration Joint Board stated:

    The guiding principles for staffing are laudable. No-one is likely to take issue with a main purpose aimed at providing "safe and high quality services"

39. However the Law Society summarised initial thoughts of a number of witnesses when they stated:

    the guiding principles are unobjectionable, but so general and multi-factorial as to leave plenty of scope for subjective judgement and the inevitable juggling of competing priorities....It is difficult to assess from the face of the Bill whether the main policy objective of appropriate staffing will be met, as the Bill is largely a vehicle for more legislation to come.

40. We therefore determined to look at the individual components making up the general principles in turn.

41. The integration of health and social care is discussed later in the report. However it is noted that the integration agenda is very focused on providing better outcomes for individuals.

42. Some submissions highlighted the Bill was very process focused rather than focussing on outcomes. Some stakeholders were concerned the Bill could undermine individuals by focussing on process and narrowly defined settings, rather than the outcomes for service users.

43. COSLA indicated they "see the Bill as focussing on inputs rather than outcomes"Health and Sport Committee Official Report 25 Sept 2018, COL 2. This was supported by Glasgow City IJB who felt it was significant that the Public Bodies (Joint Working) (Scotland) Act 2014 is explicitly about outcomes for individuals and communities whereas they saw the Bill as very process-oriented. They believe "there is real potential that this Bill will mitigate against the delivery of those outcomes"Health and Sport Committee Official Report 18 Sept 2018, COL 20.

44. The Scottish Council for Voluntary Organisations (SCVO) saw "no particular benefit coming from the bill; it has no focus on outcomes, which is how the sector thinks at the moment."Health and Sport Committee Official Report 18 Sept, COL 4 By contrast, the Scottish Social Services Council (SSSC) believe the Bill "supports continued progress towards outcome focused health and social care scrutiny..."Health and Sport Committee Official Report 25 Sept 2018, COL 2

45. The Allied Health Professions Federation Scotland (AHPFS) advised they would like the General Principles to have an outcomes focus, noting Part 1 of the Bill should be "underpinned by an additional principle relating to optimising outcomes for patients and service users".Health and Sport Committee Official Report 11 Sept 2018, COL 06

46. The Policy Memorandum notes that responses to the Scottish Government's consultation highlighted a "focus on achieving better outcomes for service users should be at the heart of the legislation..."Health and Care (Staffing) (Scotland) Bill Policy memorandum - page 13

47. The Cabinet Secretary for Health and Sport advised the Bill doesn't explicitly mention outcomes believing it shouldn't. Noting health and care standards and quality measures already define the outcomes the Scottish Government wants to see. The Cabinet Secretary advised the Bill "will put in place a framework to support the systematic identification of the workload needed to improve outcomes and deliver high-quality care".Health and Sport Committee Official Report 2 Oct 2018

50. The Policy Memorandum notes the Bill places a general duty to ensure appropriate staffing on health boards and care service providers. It states it will be health boards, commissioners and providers - that is organisations rather than individuals- who will be accountable.

51. Concerns were raised with us that there needs to be greater clarity on where accountability sits. If no-one is named as an accountable officer, there is a risk responsibility is felt at the level of people who are running the tools at ward level (senior charge nurses and team leaders), and it is they who become exposed if there is an adverse event arising as a result of short staffing.

52. The Chartered Society of Physiotherapy noted "what seems to be missing from the bill as it is couched is accountability". Whilst the Royal College of Surgeons of Edinburgh advised:

    Responsibility for implementation and approach to safe staffing should be organisational with non-delegable responsibility for compliance being jointly shared between the commissioning bodies and the institutions and cannot flow into the senior staff on any operational or governing committees. There is a danger that individuals are held accountable for not being able to provide “safe” levels despite circumstances being out of their control.Royal College of Surgeons of Edinburgh written submission

53. Those in the care sector have similar concerns over lack of clarity around accountability. We heard of confusion about whether accountability will be with the provider or with the commissioner. UNISON Scotland advised if something is put in place and is to be adhered to then people need to know who is responsible for that adherence.Health and Sport Committee Official Report 25 Sept 2018, COL 35

54. UNISON Scotland also highlight the potential difficulties inherent in commissioning services where lines of responsibility are not clear cut:

    Given the fragmentation of delivery of care services the question of who the designated person with responsibility for ensuring safe staffing levels – and how they are reported is a serious one. This is particularly the case when rather than being provided directly, care provision is commissioned from a third party. Who would be responsible for measurement – the private care provider or the IJB/ Council commissioning the care?UNISON Scotland written submission

55. The Scottish Partnership for Palliative care raised a similar issue, "it ends up being very difficult if there is an expectation on the part of the regulator that the provider will meet a certain set of workforce requirements but there is not adequate resource to meet that in the commissioning process. The comeback in that position is often at the level of the provider, who may suffer because of poor ratings from the regulator".Health and Sport Committee Official Report 18 Sept 2018, COL 13

56. The Coalition of Care and Support Providers in Scotland (CCPS) noted it was a huge concern for their members that there is no duty placed on commissioners.Health and Sport Committee Official Report 18 Sept 2018, COL 13 The ALLIANCE advised the procurement of care services should require commissioners to bear some responsibility for ensuring that providers are adequately supported and funded to meet safe staffing obligations.The ALLIANCE written submission

59. Whilst this Bill is not about the rights of individuals, but about putting staffing tools and methodologies on a statutory footing, the guiding principles and overall purpose is about providing assurance and reassurance that someone in hospital or social care is receiving both safe and high quality care.

60. Healthcare Improvement Scotland (HIS) noted there were some gaps around dynamic day-to-day management and how someone reacts when they come on shift and a couple of people are off sick or how cover is provided if someone on a night shift goes off. They raised the question of how they can provide assurance that people will have adequately trained staff to look after them 24 hours a day, seven days a week, in health and care services.Health and Sport Committee Official Report 25 Sept 2018, COL 6

61. HIS further advised that although not in the Bill, they have as part of their excellence-in-care approach, been working to make available to the public information on expected staffing levels and actual staffing levels on a ward, and advised some boards are working towards that.Health and Sport Committee Official Report 25 Sept 2018, COL 10

62. The Scottish Government accepted there were issues around staff and members of the public raising concerns with staffing levels. They advised:

    staff will tell us that they are not quite sure what to do, or else they put something into the incident reporting system and either nothing happens or something happens three months later. It is something that we would work on with stakeholders, the colleges, HIS and staff. For patients and service users, we would want to work with people to get something that is meaningful and practical and makes a difference

63. A further area we considered where clarity may be required is around assurance. The Policy Memorandum states "The key aims of placing the existing tools and methodology on a statutory basis include providing assurance, for both staff and service users, that appropriate staffing is in place to enable the provision of high quality care." (para 146)

64. We sought more information on how staff on the ground and patients (and their families) can be sure staffing is adequate.

65. The ALLIANCE noted they "are concerned that the principles outlined in section 1(1b) are reliant on a perceived consistency with the purpose of health and care staffing…We believe that a clearer explanation is required ….of ‘safe’ and ‘high quality’ services [in section 1(1)(a)] from the perspective of people who use support."The ALLIANCE written submission

66. The CI noted "the bill's contribution to levelling some of the distinctions that currently exist between health and social care" adding they though "the fact that it is based on a general set of principles that apply to both health and registered care services is important." Before explaining the current statutory condition applying to providers in social care and contrasting that with health services:

    Regulation 15 of the Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011 sets out the condition that providers should have in place adequate numbers of “suitably qualified” staff. We understand that the bill applies that to health services as it currently applies to social care. We see the bill as providing and adding value through that development.Health and Sport Official Report 25 Sept 2018, COL 2

67. The Policy Memorandum places "public assurance that the goal of sufficient staff to ensure safe and high quality care across all health care settings is at the heart of the Bill".

68. We asked the Cabinet Secretary to provide detail on how the public can access information on the existing tools. In response she advised information could be found on the Information Services Division Scotland (ISD) website which directs users to the Scottish Standard Time System (SSTS) website which includes video clips on how to use the tools. She added the information resource and associated learning packages are currently being reviewed.

72. The guiding principles of health and care staffing are to provide safe and high quality services, helpfully, the Policy Memorandum notes whilst doing this staff wellbeing also has to be assured.

73. The Royal College of Nursing Scotland (RCN) notes the duty to ensure appropriate staffing is set out in the Bill however they would like to see the health, safety and wellbeing of staff included in the duty.RCN Scotland written submission

74. Marie Curie believe ensuring staff safety and wellbeing is paramount to ensuring safe and high quality care can be delivered. They welcome the provisions in the Bill which focus on an open and honest culture but believe further work needs to be undertaken across health and social care to ensure staff are valued, recognised and have the time needed to provide care and support.Marie Curie written submission

77. The need for the role and input of professional judgment to be more prominent in the Bill was noted by numerous witnesses. It was felt professionals had to be involved in the process, with views taken at a local level i.e. below executive and senior management level.

78. At present, while professional judgment is part of the new common staffing method it is not included in the Bill. The Policy Memorandum notes the Programme for Government states "The Bill will ensure nationally agreed, evidence based workload and workforce planning tools are applied, and ensure key principles relating to professional judgment, local context and quality measures underpin workload and workforce planning."

79. Currently professional judgment is mentioned only in relation to the consideration of the results from the common staffing method. We wanted to understand the adequacy of this in light of the commitment given.

80. The concern seems to stem from the fact the tools within the common staffing method are often only run once a year. This means on a day-to-day basis staff have to use their professional judgment when factoring in skills mix, absence levels and acuity of patients. NHS Orkney advised sensitivity is not built into the tools for them to make day-to-day changes and the tools do not facilitate the piece of work that needs to be done on the skills mix and risk.Health and Sport Committee Official Report 11 Sept 2018, COL 45

81. We heard the Bill does not adequately cover the day to day, dynamic staffing of health settings. The existing tools assist only in setting staffing establishments in nursing and midwifery settings, not how staff are deployed. It is the deployment of staff that determines whether or not staffing is safe and this is carried out through professional judgment, on the ward, on a daily basis.

82. The RCN believe it is essential this legislation enables and empowers nurses, from Nursing Directors to ward level, to use their knowledge, skills and experience in order to exercise their professional judgment. The RCN also noted:

    Without nurses of appropriate seniority (i.e. those ranging from directors of nursing and integration authority nurse board members to senior charge nurses and community team leaders) exercising their professional judgment through each and every step of the process, safe staffing establishments cannot be set; care assurance cannot be monitored; risk assessment cannot be undertaken; local resolution cannot be sought; and effective exception reporting cannot be completed. Royal College of Nursing written submission

83. NHS Forth Valley noted the Bill encourages all levels of staff to be involved in reviewing safer staffing levels and be given adequate time to do this.NHS Forth Valley written submission

84. COSLA observed professional responsibility was not reflected in the Bill, suggesting this should be an area for attention when looking at improvements to the Bill.Health and Sport Committee Official Report 18 Sept 2018, COL 24 Glasgow City Health and Social Care Partnership felt professional judgment had to be at the heart of the Bill rather than a mechanistic tick box exercise.Health and Sport Committee Official Report 18 Sept 2018, COL 24

85. The BDA Scotland Board advised determination of staffing must consider the mix of professions needed as well as the skill mix within each profession. They were concerned the Bill could well result in uneasiness and affect staff morale, noting staff will need to be properly supported and their wellbeing taken into account.BDA Scotland Board written submission

86. The Chief Nursing Officer (CNO) when supporting the Cabinet Secretary advised:

    I absolutely expect there to be a professional judgment element. The grass-roots staff know best how to deliver most effectively, and professional judgement should support that.Health and Sport Committee Official Report 2 Oct 2018, COL 8

87. The Cabinet Secretary was clear in evidence to us "The approach in the bill is more transparent and allows for better decision making because it is evidence-based, with application of professional judgment."Health and Sport Committee Official Report 2 Oct 2018, Col 11 The Cabinet Secretary agreed the bill provides a tool that will help providers and commissioners of health and care services to recognise when there is a need for increased staffing "when we have a consistent methodology that produces evidence on the workload, to which professional judgment is applied, and that process takes place on a statutory basis".Health and Sport Committee Official Report 2 Oct 2018, Col 21

90. We received considerable evidence on the impact they Bill could have on the integration agenda. The Scottish Government advised the Bill will support the increased integration of health and social care services by providing a consistent framework for staff planning across the sectors, and more specifically across the organisations entailed in integration: health boards, local authorities and integration authorities.

91. Integration Joint Boards (IJBs) are not currently employers themselves and the Bill, in effect, requires health boards and local authorities to put in place a workforce development/organisational development plan for those parts of the workforce providing services. They also require to ensure arrangements are in place to develop and support staff in the delivery of those integration services.

92. Participants at the NHS Scotland Event Session and a large number of submissions to the Committee's Call for ViewsⁱAberdeenshire IJB, NHS Ayrshire and Arran, Borders IJB, Royal Blind, SPDS, East Ayrshire IJB as well as witnesses we heard from all suggested the Bill could undermine or stall integration. It was suggested that rather than integrate services the Bill separates out health from social care and misses the important role of allied health professionals (AHPs) and other staff groups.

93. Scottish Borders Council and Scottish Borders Integration Joint Board noted restricting the application of the proposed duty to care homes reinforces a perception that different expectations continue to apply to different parts of a system, which should be seen as a whole.Scottish Borders Council and Scottish Borders IJB written submission

94. The Chief Officers Group Health and Social Care Scotland believe the development of tools considering one professional group (or a limited number of groups) in isolation may be detrimental to the development of integrated services across health and social care.Chief Officers Group Health and Social Care Scotland written submission

95. The Law Society of Scotland believe the Bill does not particularly take account of integration of health and social care other than the imposition on them of a similar list of principles and duties in regard to staffing.

96. Concerns were expressed the Bill focusses on inputs rather than outcomes. Glasgow City Health and Social Care Partnership told us:

    ’The Public Bodies (Joint Working) Scotland Act 2014 clearly sets out nine national health and wellbeing outcomes that integration authorities are expected to work towards achieving. It is significant that that legislation is explicitly about outcomes for individuals and communities. There is real potential that this Bill will militate against the delivery of those outcomes because….it is very process-oriented.’Health and Sport Committee Official Report 18 Sept 2018, COL 20

97. However the SSSC welcome the Bill's policy intention on collaborative working across the health and social care system and feel the Bill takes account of the needs of service users and ultimately creates a safer environment for service users and staff.Health and Sport Committee Official Report 25 Sept 2018 COL 2

98. Multi-disciplinary working is essential for positive service user outcomes (in both health and social care environments). The integration of health and social care relies on multi-disciplinary working and as indicated above the lack of reference to AHPs in the Bill is a major concern for many witnesses.

99. AHPs work across health and social care, as independent professionals covered by their own professional bodies and regulation. AHPs are involved throughout a persons lifetime from birth to end of life palliative care, they work in public health preventive services and in primary, secondary and community care. AHPs account for more than 11,500 staff, 8.3 per cent of the NHS workforce. They are increasingly central to bridging the gap between health and social care. They are key to keeping people out of hospital.

100. The AHPFS suggested the Bill does not reflect the reality of multi-disciplinary working, and some parts of the Bill seem specifically to exclude AHPs.Health and Sport Committee Official Report 11 Sept 2018, COL 5

101. Concerns were also raised the Bill could create an unbalanced approach to staffing, with a focus only on nursing and midwifery staff. Integrated services utilise skills across a multi-disciplinary team and it was unclear to witnesses how an integrated environment could be viewed as being safely staffed when only one part of this team is represented in that assessment.

102. Similar concerns that this approach risked skewing resources from multi-disciplinary teams to ensure the resource requirements on nursing and midwifery would be met were raised with the Scottish Government as part of their earlier consultation.

103. Paragraph 93 of the Policy Memorandum suggests that a general duty to ensure appropriate staff covers all appropriate staff:

     For health boards, this general duty to ensure appropriate staffing would be required in addition to a health board‘s existing duty in the 1978 Act, to put and keep in place arrangements for the purposes of workforce planning...This general appropriate staffing duty will apply to health boards in relation to all their employees who deliver care, including but not limited to nurses, midwives, doctors, allied health professionals.

104. The Policy Memorandum at paragraph 18 acknowledges the emergence of multi-disciplinary teams:

     "the emergence of local multi-disciplinary teams comprising staff from both health and social care backgrounds is becoming more widespread. The Scottish Government considers that it is therefore important that approaches to staffing, including the development of workload tools, enable seamless, joined up services, support - rather than constrain - service innovation and redesign and ensure an evidence-based approach can be taken when considering staffing requirements.

105. AHPs work in all 11 types of health care listed in proposed new section 12IC of the NHS (Scotland) Act 1978, which would be inserted by section 4 of the Bill. The list of employees in section 12IC, however, identifies only registered nurses, midwives and medical practitioners, along with other people providing care for patients who work under the supervision of those staff groups. As AHPs do not work under the supervision of any of those staff groups they do not appear to fall within the ambit of the Bill.

106. The Chartered Society of Physiotherapists noted the Bill will result in risks to the quality of patient care, in terms of experience and outcomes, unless a multi-disciplinary team approach is taken.

107. AHPFS advised the Bill will create unintended consequences and will skew resources from the current financial distribution. With the likelihood Directors are likely to say: “Sorry, we can see what you mean about needing more AHPs or multi-disciplinary teams, but my hands are tied by the legislation.”Health and Sport Committee Official Report 11 Sept 2018, COL 5 And the Society and College of Radiographers stated there would be a problem if the Bill only applied to nurses and midwives, noting if there was too much emphasis on them only their numbers could be funded because the tools applied only to them.Health and Sport Committee Official Report 25 Sept 2018, COL 29

108. The Policy Memorandum responds to the criticisms that resources could be skewed by noting the Bill applies a general duty to all staff groups. Adding this will require health boards to take account of the impact of staffing decisions across all staff and prevent diversion of resources to one staff group. The Memorandum also notes the general duty which applies to all staff groups provides a framework for the use of multi-disciplinary tools, should they be developed, in the future.Health and Care (Staffing) (Scotland) Bill, Policy Memorandum - Para 157 The Financial Memorandum seems to indicate that it will be 10 years plus before any multi-disciplinary tools are available for use.

109. In their response to the Delegated Powers and Law Reform Committee (DPLR), the Scottish Government acknowledge that the creation of multi-disciplinary tools is new territory, let alone tools that can function across health and social care settings and services:

     In particular, since multi-disciplinary tools, with the exception of the emergency care tool, have not yet been developed, there is currently no body of evidence or experience to call upon to determine what type of changes, if any, might be necessary to improve the common staffing method in the future in light of the experience of developing and operating further multi-disciplinary staffing level tools.

110. The British Dietetic Association (BDA) Scotland Board recognises the Bill permits the creation of new tools where necessary and sets a mechanism to develop new tools. However, they are concerned there is no commitment to develop such tools for AHPs and also a complete lack of timescales for development and implementation.BDA written submission

111. The Scottish Government advised during evidence:

     ...as consideration is given to what the right skills mix is for the workload, allied health professionals will turn out to be the very people who have the skills that are required to meet that need...the Care Inspectorate will enable work to be done to review the current tools and to look at how they need to be modified and applied to a care home setting. We expect a degree of AHPs’ expertise to be involved in that work to develop the tools that would be appropriate for a care home setting.Health and Sport Committee Official Report 2 Oct 2018, COL 20-21

112. There is also a concern in the social care sector that resources could be skewed towards the nursing sector. The Policy Memorandum advised "some social care bodies were also worried that a focus on NHS settings could skew resourcing decisions and lead to an under-resourcing of social care with a concern that integration authorities will have to prioritise resources to nursing and midwifery over the rest of the health and social care workforce."

113. This was an issue reiterated by some of our witnesses. Scottish Care noted:

     If the health aspect of the bill is implemented first, resource will go first into getting people employed in that sector. That means that we are likely to lose staff.Health and Sport Committee Official Report 18 Sept 2018, COL 13

114. Those working in the care sector also raised a concern other care services outwith care homes would then become third in line for services, making them very difficult to resource. The SCVO were concerned they would have to divert staff from one service to focus on care homes.Health and Sport Committee Official Report 18 Sept 2018, COL 14 CCPS noted a similar concern, highlighting a very small proportion of their members have care homes and if resources initially go to health and then to care homes, services that deliver community support will become under resourced.

115. The Cabinet Secretary addressed these issues on 2 October indicating:

     I am keen not only that we should break down some of the current barriers, but that we should not create additional barriers. I understand the concerns that he [Alex Cole-Hamilton] raises.

     When the developed tool is worked through in social care settings, it will include the skill sets that come from AHPs in many cases, so it is not entirely accurate to say that they are excluded. As one applies the assessment of workload and then considers the skill sets that are required to deliver against the detail of that workload, AHPs in particular will have a critical role to play. They are covered in that way.

122. Part 2 relates to staffing in the NHS and we examined the general principles set out in paragraphs 21-27 as they apply in territorial health boards.

123. Every health board and the Common Services Agency for the Scottish Health Service has a duty to workforce plan and to ensure the provision of high quality care. The Bill would place further duties and guiding principles to ensure staffing requirements are appropriate for the patients in their care.

124. As part of wider measures to ensure a sustainable health workforce a set of 12 workforce planning tools were developed for nursing and midwifery. Over a period of years from 2004, the tools were developed following the work of the Programme and have been mandated by the Scottish Government since 2013. These form part of a methodology for health boards to decide on an annual basis what the establishment should be for each nursing setting.

125. For areas where one of the 12 staffing tools currently exist, section 106 of the Policy Memorandum explains that the Bill will make it explicit that health boards are expected to:

     • apply the common staffing method (further details of this can be found later in this report);

     • use the output from the tools along with, professional judgement, local context and quality measures to underpin and inform decisions about staffing requirements;

     • make sure a consistent approach is taken to identification and lessening of risk, take account of appropriate clinical advice and consider whether services can be redesigned;

     • ensure staff and properly trained to apply the common staffing method and tools, engage with the process and understand the decisions made in relation to staffing decisions;

     • monitor and report on how they have done all the above and provide assurance regarding safe and effective staffing.

126. Although this Bill is not linked to national workforce planning, the National Health and Social Care Workforce Plan (the Plan) is mentioned throughout the Policy Memorandum and relates to duties on health boards, and providers of care services and service providers to ensure appropriate staffing. We discuss wider recruitment and retention issues and their links to the Bill later in this report.

127. The Plan was published by the Scottish Government in three parts and lays the foundations for improved national workforce planning across integrated health and social care services. Part 1 of the Plan covers NHS Scotland, Part 2 covers social care and Part 3 covers primary care.

128. The Scottish Government believe the Bill will enable further improvements in workforce planning by:

     • strengthening and enhancing arrangements already in place to support transparency in staffing and employment practice; and

     • supporting consideration of service delivery models and service redesign.Health and Care (Staffing) (Scotland) Bill - Policy Memorandum

129. As mentioned above, there is a set of 12 workforce planning tools for nursing and midwifery which were developed following the work of the Programme. We have been advised the tools have not been evaluated or modified since they were created.

130. Given the absence of any evaluation carried out on the tools we issued a survey to nursing and midwifery staff at various levels across all health boards who are responsible for using or completing workforce planning tools. We sought to determine the extent of current usage and whether the tools remained fit for purpose. We received 195 responses from staff across eight of the 14 territorial health boards.

131. The full summary of responses can be read here. However, some of the main observations from the survey were:

     • Some respondents were explicit about problems with specific tools. For example, the Community Nursing Tool, the Midwifery Tool in community settings, the Mental Health and Learning Disability Tool were stated to be not helpful in community settings. The perioperative tool duplicated other methods and some tools were very time-consuming to carry out.

     • A range of other methods (eg. SafeCare, Shelford, Risk assessment and staff 'huddles') were used by staff to try to ensure their ward or area had adequate staff of the right skill mix, on a day to day basis

     • Many respondents were unsure how the tools contributed to ensuring staffing was safe for patients.

132. The issues noted above were also discussed and confirmed during our informal session with frontline staff.

133. In a letter dated 10 September 2018 the CNO provided us with a breakdown of the number of wards/teams/departments in each NHS board area who have applied each of the workload tools during the financial years 2016/17 and 2017/18 .

134. The letter also notes "We do not currently hold validated data on how many wards/teams in each Board should apply each of the tools. In the absence of this information we are unable to ascertain the number of wards who should be applying each tool and, therefore, what 100% compliance looks like." The CNO went on to advise work was underway that will enable them to report on the percentage of wards who are applying the tools as required.

135. The letter from the CNO allowed us to identify discrepancies in the running of the tools. We wrote to the relevant boards' seeking clarification on these discrepancies. The letters and the responses can all be viewed here.

136. The reasons for not using the tools provided by NHS boards vary and provide a basic understanding of some of the issues with the tools as they currently stand. Some boards had good reasons for not running certain tools such as service reconfiguration and ward changes. Other reasons are listed below:

     • the repeated use of the children's community nursing and specialist nurse tool is extremely time consuming to apply and does not currently provide a useful output to enable a decision about staffing levels.

     • In the professional opinion of the Nurse Director, using the clinical nurse specialist tool during 2017-18 was not a priority when compared with the need to use limited resources to run other more complex tools.

     • use of Trakcare used as a source of gathering patient and acuity and dependency information, in preference to the manual collation required to run the tools.

     • lack of capacity within the workforce - significant additional support required to run tool.

     • attempted to run the tools but were unable to interpret the data and were therefore unable to run reports.

137. It is clear services provided by nurses and midwives are very different from those 10-12 years ago. As such we were pleased to learn from witnesses that the Scottish Government set up a working group to review the tools.Health and Sport Committee Official Report 11 Sept 2018

138. In a letter dated 20 September 2018 the Cabinet Secretary for Health and Sport advised the newly established Nursing and Midwifery Tool and Maintenance sub-group of the Programme steering group met for the first time on 4 September 2018.

139. The role and remit of the group includes providing assurance that existing workload tools remain contemporary by overseeing regular review and updating of existing tools as necessary and to oversee the development of new tools.

140. The creation of the working group was welcomed by witnesses. The RCN noted it is encouraging the Scottish Government has put in place a process to review the tools.

144. The Scottish Standard Time System (SSTS) is the software platform on which the tools are located. This platform is used by all health boards to run the tools as well as its prime purpose of holding their payroll and time recording information.

145. Several responses from NHS boards noted issues with SSTS. NHS Shetland advised there was no requirement to upload results onto the SSTS platform so they used the 'offline' version. This has been largely due to technical difficulties in accessing the SSTS platform. NHS Tayside advised there is currently no facility to capture school nursing workforce activity on SSTS.

146. The National Waiting Times Centre advised they are co-hosted by another board which has resulted in challenges with accessing the tools via the SSTS platform over a sustained period.Responses from NHS Boards

147. The Scottish Executive Nurse Directors Group noted SSTS is not necessarily fit for purpose, because it involves the entry of lots of old data/information requiring duplication of effort by staff to triangulate information.Health and Sport Committee Official Report 11 Sept 2018, COL 35

148. Witnesses, including the Cabinet Secretary for Health and Sport advised NHS National Services Scotland (NSS) are undertaking a procurement exercise for a new platform to replace SSTS.

149. The Scottish Government advised:

     We are looking at the e-rostering platform, after which we will take a decision about whether to stay on the present site or to transfer over to that. As part of the procurement exercise, we will be asking about the ability of the platform to feed into our workload tools platform. Health and Sport Committee Official Report 2 Oct 2018 COL 20

150. The Financial Memorandum does not note any costs in relation to procuring a new platform to replace SSTS. The CNO, in her letter dated 10 September 2018 advised these costs were not included "because the need for, and procurement of, the new platform is not due to the requirements of the Bill, but rather the need to significantly enhance the functionality available to manage and monitor the deployment of staff on a real-time basis."

153. One of the issues highlighted by our survey was that around a third of respondents had not received training on how to use the tools, or had only received ad hoc training from a colleague. There was no consistency in how training was delivered. This issue was also noted in the responses we received from NHS boards.

154. NHS Western Isles advised they had not received training on certain tools so were unable to run them. NHS Orkney advised the on-line training packages are not user friendly and are difficult to understand, lacking depth of explanation. They also noted they had lost a number of personnel who were skilled in operating the tools with little training available to replace those who were lost.

155. The Scottish Executive Nurse Directors Group advised "when the tools were first established, there was a huge training effort to support them. That cohort of trained people has changed and moved out. We have not kept as up to date as we should have on the tools".Health and Sport Committee Official Report 11 Sept 2018 COL 35 They further noted more education and training needs to be undertaken.

156. It was advised assessment was required to understand where staff need more training and education to use the tools properly. UNISON believe the more prepared senior charge nurses and their equivalents in the community are to understand the importance of safe staffing, the better the service will be.Health and Sport Committee Official Report 25 Sept 2018 COL 25

157. We heard many just didn't have the time to undertake training; and Audit Scotland advised there was a risk the time needed to train affected staff would put additional workload pressures on staff and services.Audit Scotland on behalf of the Auditor General for Scotland written submission

158. NHS Education for Scotland stated people being given the time and space to undertake training was important. They advised training was available, and the legislative process could bring a greater prioritisation to it.Health and Sport Committee Official Report 25 Sept 2018 COL 24

159. The Bill's Financial Memorandum (FM) details the training costs of implementing the Bill. The cost per year for 2019-2021 is given as £332,215. Section 4 (at proposed new 12ID) of the Bill states that NHS Boards must ensure that those employees affected receive adequate time to use the common staffing method, and understand the results and processes.

160. NHS Lothian, NHS Greater Glasgow and Clyde and the Scottish Executive Nurse Directors Group all felt training costs had not been worked through and may bring an additional cost to bear.Written submissions to the Finance and Constitution Committee

161. The RCN expressed training requirements and costs set out in the Memorandum were insufficient. They also noted serious concerns about the training need as identified in the Financial Memorandum, believing it was much higher than stated. They also questioned the Financial Memorandum's statement that training could be completed as part of the continuous professional development which is included in current nursing and midwifery establishments, noting, at present, nursing staff getting time to complete even mandatory training such as moving and handling and infection control can be a challenge.Royal College of Nursing written submission to the Finance and Constitution Committee

162. The Cabinet Secretary addressed training with us stating

     The role of Healthcare Improvement Scotland is critical in that regard, as is the role of NHS Education for Scotland, the education body, to ensure that we have a consistent planned programme of roll-out and training and that training is continuous so that as new staff come on board we are able to meet their training needs, too. Should the bill be passed, that will be covered in the guidance on the bill and in the programme of work that is carried out by the chief nursing officer and colleagues".

168. The Bill at section 4 (proposed new 121E) requires annual reports by health boards and the Common Services Agency to be made to the Scottish Government. The reports are required to cover how duties have been carried out ensuring appropriate staffing, use of the common staffing method and the training of staff. No specific sanction for failure to comply with the provisions of the Bill are stated although it is understood existing powers contained in the 1978 Act allow Scottish Ministers to take action.

169. The Policy Memorandum advises that in practice reporting will be done through existing annual reporting mechanisms (para 124) and through existing local and national reporting and regulatory mechanisms and HIS and the CI scrutiny processes. (para 89)

170. HIS advised us they were to be given new powers, similar to those of the CIⁱThe Care Inspectorate discussed these powers and sanctions with us on 25 September. See the Official Report for that date., and their roles should mirror each other. Social Care providers are assessed by the CI to ensure appropriate staffing of services.

171. The Cabinet Secretary for Health and Sport advised us the Scottish Government will expect boards to report not only on the application of the tools but on the outcomes, and HIS will look at that in its inspections.Health and Sport Committee Official Report 2 Oct 2018, COL 23

172. NHS Forth Valley noted there is no mention of what the national monitoring processes will be to ensure consistency across all boards.NHS Forth Valley written submission As mentioned above there is a lack of detail in the Bill around sanctions should the statutory requirements not be fulfilled by health boards. It is not clear what will happen to health boards if they do not adhere to the results of the common staffing method.

173. This issue was raised by many witnesses. NHS Orkney advised clarity must also be established regarding the scrutiny methodology and consequences of failure to comply.NHS Orkney written submission The Royal College of Physicians of Edinburgh raised various questions around escalation and would welcome strengthening in this area of the Bill to allow for greater scrutiny and transparency, to ensure the confidence of healthcare professionals and the public is maintained.Royal College of Physicians of Edinburgh written submission The Scottish Executive Nurse Directors Group noted a need for clarity in the process of escalation.Health and Sport Committee Official Report 11 Sept 2018, COL 47

174. When asked if HIS will have powers and the ultimate sanctions in parallel with those available to the CI, the Cabinet Secretary for Health and Sport advised:

     In its inspection role, HIS has a number of powers, which it will continue to have. It also has an important improvement function so, when standards are not being met and duties are not being complied with, it has a responsibility to offer support to allow people to improve and meet standards or fulfil duties. If improvement does not happen, other steps can be taken.

175. The enforcement issue was raised by the Delegated Powers and Law Reform Committee in their Stage 1 report. In response to that report the Scottish Government stated the Bill inserts the provisions relating to health boards into the National Health Service (Scotland) Act 1978, noting:

     the existing powers contained in the 1978 Act for Scottish Ministers to take action where there are issues about discharge of health board duties will apply to the duties placed on health boards by this Bill. For example, there is a power of direction in section 2(5) of the 1978 Act which can be used generally or for specific matters (which could involve directing a particular board). There are also powers in section 78A where there has been failure in provision of a service.

176. The Scottish Government further advised if following improvement support and intervention there are still areas of non-compliance this can ultimately lead to the powers of intervention in the 1978 Act detailed above being applied. This was reiterated by the Cabinet Secretary for Health and Sport.Health and Sport Committee Official Report 2 Oct 2018, COL 14

179. Part 3 relates to staffing duties in care services and we examined the general principles set out in paragraphs 28-33 as they may be developed and applied to care services in the future.

180. Regulation 15 of the Social care and Social Work Improvement (Scotland) Regulations 2011 makes clear the responsibility of every provider of care services to ensure suitably qualified and competent people are working in appropriate numbers to ensure the health, welfare and safety of service users. Providers are also required under that regulation to ensure their employees receive appropriate training to carry out their work and time off work for further training. Section 6 of the Bill repeats the above regulation.

181. The Policy Memorandum at paragraph 128 notes the purpose of including care services in the legislation is to allow the sector to build on and strengthen existing mechanisms, thereby creating a cohesive legislative framework across health and care settings. By having parity in the legislation the expectation is stated that it will allow, and support, innovative approaches to workload and workforce planning which take into account the roles of the range of staff groups employed across multiple organisations in the delivery of care.

182. In addition the Bill provides a power at section 10 for Social Care and Social Work Improvement Scotland (SCSWIS) better known as the Care Inspectorate to work in consultation with the care sector to develop staffing methods (workforce planning tools) for application in care settings, where a need has been identified. Initially this will only be for care homes for older adults.

183. The Policy Memorandum at paragraph 133 states the CI is required to work with the relevant sector to examine if a tool is appropriate (although this requirement is not included in the Bill). The Bill does however require the CI in section 10 to collaborate with a range of interested parties in the development and validation of a tool.

184. The Policy Memorandum makes clear care homes for older people will be the only setting for which a tool is developed within the first five years. It is indicated this will build on existing work by the sector to produce a dependency tool for use in care homes. By focussing on only care homes for adults the Scottish Government believe this will provide an opportunity to test out and evaluate an approach and its impact on quality of care and service user's experiences.

185. Registered care services across Scotland are regulated by the CI who are also the scrutiny and improvement body for social work. The CI inspects care services and social work services. The CI website states:

     The Care Inspectorate is a scrutiny body which supports improvement. That means we look at the quality of care in Scotland to ensure it meets high standards. Where we find that improvement is needed, we support services to make positive changes.Care Inspectorate website - about us

186. The Health and Social Care Standards have been in place since 2018 and are used by the CI (and HIS) in their scrutiny and improvement work. The Standards note individuals should have the following outcomes:

     • experience high quality care and support that is right for them;

     • fully involved in all decisions about their care and support;

     • have confidence in the people who support and care for them;

     • have confidence in the organisation providing their care and support; and

     • experience a high quality environment if the organisations provides the premises.

187. The Policy Memorandum notes the purpose of including care services in the legislation is to enable the sector to build on and strengthen existing mechanisms by placing Regulation 15 into primary legislation and creating a cohesive legislative framework across health and care settings.

188. The Scottish Government undertook two consultations on proposals for this Bill. The first consultation sought views on the proposals to enshrine safe staffing in law, starting with the nursing and midwifery workload and workforce planning tools. The second consultation included refreshed legislative proposals, in particular detailed proposals for care services.

189. A majority of respondents to the Scottish Government second consultation agreed the requirements of the Bill should extend across health and social care settings - thus reflecting the importance of an integrated approach to planning and delivery of services. However, some respondents (mostly Health and Social Care Partnerships and public bodies) felt it was unnecessary to expand to care settings. They believe the current statutory frameworks were sufficient to ensure safe staffing in the sector.

190. Our witnesses were generally unsure whether Part 3 of the Bill was required. The majority of witnesses we heard from felt there was already a clear statutory requirement for ensuring appropriate staffing in the care sector and the Bill was not needed for this purpose.

191. COSLA advised through discussions with all of its partners they:

     found a common thread, that neither COSLA nor its partners can see where the Bill adds value to the social care workforce, as safe and high-quality services are already assured through existing legislation, the inspection regime, current policy and the Health and Social Care Standards.COSLA written submission

192. The Scottish Partnership for Palliative Care noted the main issues of having the right people, in the right place at the right time was not primarily caused by problems with local workforce planning or by inadequacies in legislative or regulatory frameworks. They believe major workforce issues are caused by factors including national workforce planning, affordability for commissioners and wider issues that affect recruitment and retention.Health and Sport Committee Official Report 18 Sept 2018, COL 3

193. However, not all witnesses were against Part 3 of the Bill. The SSSC felt the Bill was positive, advising "The tools can help to start to align them to the national health and social care standards...From our perspective, the tools fit nicely with our codes of practice on the values, behaviours, skills and competencies that workers are required to have in delivering care."Health and Sport Committee Official Report 25 Sept 2018, COL 6

197. The Bill provides a new statutory function for the CI: to work in consultation with the care sector to develop staffing methods. Initially this function is only for care homes for adults, however, a regulation-making power enable the powers of the CI to be extended to other care settings in the future. The Public Services Reform (Scotland) Act 2010 at section 47(1) defines "care service" as covering:

     (a) a support service,

     (b) a care home service,

     (c) a school care accommodation service,

     (d) a nurse agency,

     (e) a child care agency,

     (f ) a secure accommodation service,

     (g) an offender accommodation service,

     (h) an adoption service,

     (i) a fostering service,

     (j) an adult placement service,

     (k) child minding,

     (l) day care of children,

     (m) a housing support service.ⁱhttp://www.legislation.gov.uk/asp/2010/8/section/15

198. The Policy Memorandum notes throughout the process of agreeing on a need for a tool and its development the CI would be required to work collaboratively with commissioning authorities, providers, recipients of services, partnership organisations, trade unions and professional bodies. Although we observe again the Bill only covers development of a tool and does not cover, as presently drafted, agreement of the need for a tool within section 10.

199. We heard some concerns about the CI having lead responsibility for producing such tools and many of the witnesses worried the Bill only noted a need for the CI to collaborate, not for co-production. Witnesses believe for any future tools for care services to be developed correctly they must be co-produced, specifically with providers and recipients of services.

200. Scottish Care highlighted collaboration is not the same as co-production and if tools are to be produced, the CI can lead, but they must be co-produced. They also advised any tool would need to be developed for the sector and co-produced by those who work in the sector. Health and Sport Committee Official Report 18 Sept 2018, COL 15 and 18

201. The ALLIANCE advised:

     The national care standards were developed in co-production with providers, people who use the services and other bodies. The Care Inspectorate should see the value of doing that...We would be supportive of that, but with the caveat...that it is done in co-production, particularly with people who receive support and use services and with providers.Health and Sport Committee Official Report 18 Sept 2018, COL 16

202. COSLA noted they had received assurances from the Scottish Government the tools will be co-produced with the CI.Health and Sport Committee Official Report 18 Sept 2018, COL 25

205. As mentioned previously, this Bill is about staffing and workload planning, and does not cover wider workforce planning designed to ensure an adequate supply of staff to meet future requirements in health and social care.

206. The majority of witnesses raised concerns that the Bill was being introduced into a workforce context under pressure from general recruitment and retention problems nationally. Lack of availability of staff, high levels of predicted retirements is leading to short supply in many health professions, as well as the social care sector. These factors together with Brexit uncertainties mean that it is challenging to meet the existing requirements and staffing establishments currently set by health boards and social care providers.

207. Audit Scotland noted concerns associated with the risk of increasing vacancies, and over what measures health boards and social care providers should take if the rise continues. The National Health Workforce Plan acknowledges that for the next few years the numbers of student nurses and midwives entering the workforce will not be enough to meet demand.

208. Concerns were indicated about how providers could meet the requirements under the Bill and ensure sufficient staff given there are national shortages. The RCN stated:

     We also need to ensure that supply is dealt with, but the bill does not do that. We cannot tie the hands of boards and put a duty on them to provide appropriate staffing if the supply, which is held by the Scottish Government, does not come through. We would like that to be added.Health and Sport Committee Official Report 11 Sept 2018, COL 27

209. Cancer Research UK noted the workforce issues are not primarily caused by deficiencies in workforce planning at local level or by inadequacies in legislative or regulatory frameworks. They saw the problem as being primarily driven by factors including national workforce planning.Cancer Research UK written submission

210. Scottish Borders Council and Scottish Borders Integration Joint Board advised placing workforce planning tools on a statutory footing does nothing to address recruitment and resourcing issues in the health and social care service and among providers.Scottish Borders Council and Scottish Borders Integration Joint Board written submission

211. The Scottish Government have not included national workforce planning in the Bill. They believe the application of a methodology and tools will provide evidence on workload demand and that the Bill provides a tool to help providers and commissioners of health and care services recognise when there is a need for increased staffing.Health and Sport Committee Official Report 2 Oct 2018

212. In evidence to us the Cabinet Secretary was confident that the Bill "will contribute significantly to robust workforce planning across health and social care." Later noting the link between local planning requirements and the national position:

     It is important that the approach will also contribute to increased robustness in workforce planning at local level. If local plans are more robust and evidence based, we will be able to collate more robust evidence-based data at national level to help us to work on national workforce planning with increasing acuity.Health and Sport Committee Official Report 2 Oct 2018, COL 3 and 9

215. The Finance Committee issued a call for views on the Financial Memorandum of the Bill and received 11 responses. The issues raised included lack of training costs, costs associated with reviewing the staffing tool and costs to other social care providers. Following this they advised us they did not need to undertake any further work on the Bill. We have throughout this report addressed financial issues as appropriate.

216. The Delegated Powers and Law Reform Committee considered the Bill at its meetings on 19 June and 18 and 25 September. The Committee published its report on the Bill on the 25 September and we have nothing further to add to their report.

18th Meeting, 2018 (Session 5) Tuesday 5 June 2018

11. Health and Care (Staffing) (Scotland) Bill (in private): The Committee considered and agreed its approach to the scrutiny of the Bill at Stage 1.

22nd Meeting, 2018 (Session 5) Tuesday 11 September 2018

4. Health and Care (Staffing) (Scotland) Bill: The Committee took evidence on the Bill at Stage 1 from—

• Dr Sally Gosling, Assistant Director, Practice and Development, Chartered Society of Physiotherapy;

• Kim Hartley Kean, Head of the Royal College of Speech and Language Therapists Scotland, representing the Allied Health Professions Federation Scotland; and

• Patricia Cassidy, Chief Officer, Falkirk Health and Social Care Partnership, representing the Chief Officers Group Health and Social Care Scotland

and then from—

• Rachel Cackett, Policy Adviser, Royal College of Nursing Scotland;

• Dr Mary Ross-Davie, Director, Scotland, The Royal College of Midwives;

• Dr David Chung, Vice President, The Royal College of Emergency Medicine (Scotland);

• Professor Alex McMahon, Executive Nurse Director, NHS Lothian, representing the Scottish Executive Nurse Directors Group; and

• David McArthur, Director of Nursing, Midwifery and Allied Health Professionals, NHS Orkney.

Brian Whittle declared a relevant interest. Full details of which can be found in the Official Report of the meeting.

5. Health and Care (Staffing) (Scotland) Bill (in private): The Committee considered the evidence heard earlier in the meeting.

23rd Meeting, 2018 (Session 5) Tuesday 18 September 2018

2. Health and Care (Staffing) (Scotland) Bill: The Committee took evidence on the Bill at Stage 1 from—

• Karen Hedge, National Director, Scottish Care;

• Alison Christie, Policy and Development Officer (Workforce), Coalition of Care and Support Providers in Scotland;

• Andrew Strong, Assistant Director (Policy and Communications), Health and Social Care Alliance Scotland;

• Mark Hazelwood, Chief Executive, Scottish Partnership for Palliative Care; and

• Katherine Wainwright, Head of Human Resources, Turning Point Scotland, representing the Scottish Council for Voluntary Organisations;

and then from—

• John Wood, Chief Officer, Health and Social Care, COSLA;

• Stuart Bain, HR Business Partner (Health and Social Care Partnership), Fife Council, representing the Society of Personnel and Development Scotland;

• Dr Jane Kellock, Head of Social Work Strategy and Development, Social Work Scotland;

• David Williams, Chief Officer, Glasgow City Health and Social Care Partnership; and

• Eddie Fraser, Director, East Ayrshire Health and Social Care Partnership.

5. Health and Care (Staffing) (Scotland) Bill (in private): The Committee considered the evidence heard earlier in the meeting.

24th Meeting, 2018 (Session 5) Tuesday 25 September 2018

1. Health and Care (Staffing) (Scotland) Bill : The Committee took evidence on the Bill at Stage 1 from—

• Gordon Paterson, Chief Inspector Adult Services, Care Inspectorate;

• Phillip Gillespie, Director of Development and Innovation, Scottish Social Services Council;

• Ann Gow, Director of Nursing, Midwifery and Allied Health Professionals, Healthcare Improvement Scotland; and

• Joy Atterbury, Member of the Health and Medical Law Sub-Committee, Law Society of Scotland;

and then from—

• Karen Wilson, Director of Nursing, Midwifery and Allied Health Professions, NHS Education for Scotland;

• Joyce Thompson, Chair of the British Dietetic Association Scotland Board, and Dietetic Consultant in Public Health Nutrition, NHS Tayside;

• Dr Tony Axon, National Officer Scotland, The Society and College of Radiographers; and

• Tracey Dalling, Regional Organiser - Local Government Scotland, UNISON Scotland.

3. Health and Care (Staffing) (Scotland) Bill (in private): The Committee considered the evidence heard earlier in the meeting.

25th Meeting, 2018 (Session 5) Tuesday 2 October 2018

1. Health and Care (Staffing) (Scotland) Bill: The Committee took evidence on the Bill at Stage 1 from—

• Jeane Freeman, Cabinet Secretary for Health and Sport,

• Fiona McQueen, Chief Nursing Officer, Diane Murray, Associate Chief Nursing Officer,

• Louise Kay, Safe Staffing Bill Team Leader, Programme and Stakeholder Engagement, and

• Ailsa Garland, Principal Legal Officer, Scottish Government.

Brian Whittle declared a relevant interest. Full details of which can be found in the Official Report of the meeting.

3. Health and Care (Staffing) (Scotland) Bill (in private): The Committee considered the evidence heard earlier in the meeting.

29th Meeting, 2018 (Session 5) Tuesday 13 November 2018

5. Health and Care (Staffing) (Scotland) Bill (in private): The Committee considered a draft Stage 1 report and agreed to continue consideration at its next meeting.

30th Meeting, 2018 (Session 5) Tuesday 20 November 2018

5. Health and Care (Staffing) (Scotland) Bill (in private): The Committee continued its consideration and agreed a draft Stage 1 report.

• HS/S5/18/HCSS/1 - Scottish Borders Council and Scottish Borders Integrated Joint Board for Health and Social Care

• HS/S5/18/HCSS/2 - Scotland Excel

• HS/S5/18/HCSS/3 - Scottish Partnership for Palliative Care

• HS/S5/18/HCSS/4 - MND Scotland

• HS/S5/18/HCSS/5 - Society of Personnel and Development Scotland (SPDS)

• HS/S5/18/HCSS/6 - Law Society of Scotland

• HS/S5/18/HCSS/7 - NHS Orkney

• HS/S5/18/HCSS/8 - Royal College of Nursing

• HS/S5/18/HCSS/9 - Royal Blind

• HS/S5/18/HCSS/10 - MS Society Scotland

• HS/S5/18/HCSS/11 - Social Work Scotland

• HS/S5/18/HCSS/12 - Chief Officers Group Health and Social Care Scotland

• HS/S5/18/HCSS/13 - Royal College of Psychiatrists in Scotland

• HS/S5/18/HCSS/14 - South Lanarkshire Health and Social Care Partnership

• HS/S5/18/HCSS/15 - Coalition of Care and Support Providers in Scotland (CCPS)

• HS/S5/18/HCSS/16 - Chest Heart and Stroke Scotland

• HS/S5/18/HCSS/17 - Marie Curie

• HS/S5/18/HCSS/18 - Care Inspectorate and Scottish Social Services Council

• HS/S5/18/HCSS/19 - Audit Scotland on behalf of the Auditor General for Scotland

• HS/S5/18/HCSS/20 - NHS Forth Valley

• HS/S5/18/HCSS/21 - Royal College of Emergency Medicine

• HS/S5/18/HCSS/22 - East Ayrshire Health and Social Care Partnership

• HS/S5/18/HCSS/23 - NHS Lothian

• HS/S5/18/HCSS/24 - Scottish Executive Nurse Directors Group

• HS/S5/18/HCSS/25 - Cancer Research UK

• HS/S5/18/HCSS/26 - Scottish Independent Advocacy Alliance (SIAA)

• HS/S5/18/HCSS/27 - NHS Tayside

• HS/S5/18/HCSS/28 - The Association of Anaesthetists

• HS/S5/18/HCSS/29 - Clackmannanshire and Stirling Health and Social Care Partnership

• HS/S5/18/HCSS/30 - Royal College of Physicians of Edinburgh

• HS/S5/18/HCSS/31 - NHS Health Scotland

• HS/S5/18/HCSS/32 - Bliss Scotland

• HS/S5/18/HCSS/33 - NHS Ayrshire and Arran

• HS/S5/18/HCSS/34 - Aberdeen City Health & Social Care Partnership and Aberdeen City Council

• HS/S5/18/HCSS/35 - The Brain Tumour Charity

• HS/S5/18/HCSS/36 - Aberdeenshire Integration Joint Board

• HS/S5/18/HCSS/37 - NHS National Services Scotland

• HS/S5/18/HCSS/38 - Health and Social Care Alliance Scotland (the ALLIANCE)

• HS/S5/18/HCSS/39 - BDA The Association of UK Dietitians, Scotland Board

• HS/S5/18/HCSS/40 - NHS Western Isles

• HS/S5/18/HCSS/41 - Royal College of Anaesthetists

• HS/S5/18/HCSS/42 - Royal College of Nursing Scottish Inflammatory Bowel Disease Nurses Network

• HS/S5/18/HCSS/43 - Healthcare Improvement Scotland

• HS/S5/18/HCSS/44 - The Royal College of Speech and Language Therapists

• HS/S5/18/HCSS/45 - COSLA

• HS/S5/18/HCSS/46 - Allied Health Professions Federation Scotland

• HS/S5/18/HCSS/47 - The College of Podiatry

• HS/S5/18/HCSS/48 - The Royal College of Surgeons of Edinburgh

• HS/S5/18/HCSS/49 - Scottish Council for Voluntary Organisations (SCVO)

• HS/S5/18/HCSS/50 - The State Hospitals Board for Scotland

• HS/S5/18/HCSS/51 - Scottish Care

• HS/S5/18/HCSS/52 - NHS Greater Glasgow and Clyde

• HS/S5/18/HCSS/53 - Chartered Society of Physiotherapy

• HS/S5/18/HCSS/54 - General Medical Council

• HS/S5/18/HCSS/55 - North Ayrshire Health and Social Care Partnership

• HS/S5/18/HCSS/56 - Falkirk Health and Social Care Partnership

• HS/S5/18/HCSS/57 - AHP Directors Scotland Group (ADSG)

• HS/S5/18/HCSS/58 - Royal College of Occupational Therapist's (RCOT)

• HS/S5/18/HCSS/59 - NHS Education for Scotland

• HS/S5/18/HCSS/60 - British Healthcare Trades Association (Scotland)

• HS/S5/18/HCSS/61 - The Society and College of Radiographers

• HS/S5/18/HCSS/62 - Catherine Hughes

• HS/S5/18/HCSS/63 - Irene Barkby, Executive Director of Nursing, NHS Lanarkshire

• HS/S5/18/HCSS/64 - NHS Grampian

• HS/S5/18/HCSS/65 - BMA Scotland

• HS/S5/18/HCSS/66 - Inclusion Scotland

• HS/S5/18/HCSS/67 - Glasgow City Health and Social Care Partnership

• HS/S5/18/HCSS/68 - NHS Borders

• HS/S5/18/HCSS/69 - UNISON Scotland

• HS/S5/18/HCSS/70 - Royal College of General Practitioners Scotland

• HS/S5/18/HCSS/71 - The Royal College of Midwives

Following our formal evidence session on 18 September, we received further written evidence from the Scottish Partnership for Palliative Care and Scottish Care:

• Scottish Partnership for Palliative Care

• Scottish Care

The Committee issued a survey which sought views on the current nursing and midwifery workforce tools and as such was specifically aimed at those who use the tools.

• Full survey responses

• Summary of survey responses

• Tuesday 11 September 2018 - evidence from stakeholders

• Tuesday 18 September 2018 - evidence from stakeholders

• Tuesday 25 September 2018 - evidence from stakeholders

• Tuesday 2 October 2018 - evidence from the Scottish Government