Health and Sport Committee

Meeting date: Tuesday, March 28, 2017

Official Report 570KB pdf

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NHS Governance

The third item on our agenda is NHS governance. We had an informal evidence session with NHS staff this morning. I put on record my thanks to the staff for coming in and speaking to us candidly. Does anyone want to reflect on what we heard this morning?

I found it a really interesting session and I would like to thank the staff who gave their time to come along and talk to us. One of the things that I picked up was that staff are keen on having an NHS Scotland-wide governance strategy or guidance. Although each health board has its own governance, the staff felt that, given that we are a small nation, it should be an easy win to have a national framework.

Are there any other issues that members want to put on record?

Everyone that I spoke to this morning kept coming back to the word “communication”. They were quite clear that communication in our health service has taken many steps backwards—that is from whistleblowing right through to people wanting to feed their concerns to management but not feeling confident to do so or that those concerns would be acted on. Some of the specific points were about the increasing levels of long-term sickness and management not ever linking in with staff. A key issue was that it is not only that people who have problems do not even know who the management are and so do not know to whom to take those problems, but also that there is a need for senior management to shadow staff and see what they are dealing with, so that they are not just looking after the beans but understand what people are facing on the front line. It was disappointing to learn that that problem is widespread across the health service.

I got an impression of an organisation under a great deal of stress. I learned that they were working at 100 per cent capacity all the time with probably around 85 per cent of the staff that they need and that that lack of communication often came from a lack of time—managers simply do not have time to manage properly and develop their own skills and expertise in management.

I also heard about a culture of under-reporting incidents because of fear of the potential implications. I was also told about a lack of consultation, even about something as simple as decisions on uniforms: a move to a one-uniform-fits-all policy had led some to feel faceless, as if they were numbers, not people. I also picked up that people felt that they thought that they had entered a profession, but that it had been turned into an incredibly hard job.

12:15  

I echo what Alison Johnstone has said. I sensed a lot of strain and stress in what people were saying. I was also struck by the use of the phrase “defensive culture” with regard to the NHS, and the sense that everyone felt very defensive about what they were doing. That is something that we need to address.

I picked up a number of things, but one thing that I noted was that, at the end of the discussion, everyone asked us to ensure that our work makes some kind of difference. The majority of people said that the pressure that they were under was unlike any pressure that they had felt before in their career in the NHS. All of them were able to highlight the camaraderie and the solidarity that they have with each other in providing healthcare; however, they said that although they got great support from their colleagues and that they often received letters, cards or whatever from patients who had been provided with very good care, they were rarely told “Thank you” with any sincerity by people up the tree in the management system. That was a general theme that emerged from quite a few people.

In fact, a number of people told us that they did not know the senior managers in the system—they did not even know the name of the site director of a particular hospital. I find that quite remarkable. I am not talking about one or two people who might have had a grievance or problem; it seemed to be a general theme.

I wrote down a number of concerns or issues, but I really want to highlight the issue of long hours, on the basis of its being in the media both yesterday and today. A junior doctor told me that she had just come off five shifts of seven days on, two days off, working for 11 hours each day. To me, that does not sound healthy either for her patients or for her. She also mentioned that a number of her junior doctor colleagues had already left either the country or the profession, because of the pressure that they were under. I found that quite concerning, given what is in the media.

A whole range of other issues, including staff appraisals, sickness absence and continuing professional development were also raised, and we will ensure that those and everyone else’s points are captured in our report. To that end, I ask that people forward such issues as soon as possible.

The stress associated with having to work at 100 per cent all the time was undoubtedly raised with us, and it was certainly made clear that there was a culture of working overtime and that many of the staff found that difficult. However, I want to highlight some of the positives that were highlighted; indeed, one of the people in our group commented once or twice that we seemed to be talking entirely about the negatives without mentioning the positives.

One of the positives that was mentioned and which we should get on record was the fact that there is now much better multidisciplinary team working than there has been in the past, and that is considered to be a real strength in terms of governance. Moreover, despite the risk of CPD time being lost and the fact that it is the first thing to go if the system is under pressure, there was a perception that the situation was slightly better than it had been a couple of years ago. People felt that there might have been a slight improvement, with CPD being given a higher profile than it had a couple of years ago.

A couple of people said that if sickness absence went up, it ate into the CPD budget. I could not quite understand the link between those two things—we can look into it—but according to those people, if sickness absence goes up and up, the CPD budget goes down and down. That seems like quite a strange way to operate. Did you hear that, too, Miles?

Yes, and I have to say that I was not sure how that was budgeted for.

I also want to mention targets. Obviously work is going on in that respect, but some of the people to whom I spoke said openly that targets were constantly being fiddled. A lot of that was about being asked to say that you had met targets that, in many cases, people thought were completely unachievable. I was concerned by what seemed to be a culture of fiddling to chase a target instead of looking at the patient experience. Moreover, I got the sense that we had this incredible resource of people who had worked in the health service for, in some cases, 30 years but who felt that they were not being listened to at all.

On your point about management, convener, when I asked the folk who worked in acute hospitals what the management structure above them looked like, they sort of laughed at me. They could not begin to describe, say, how many levels there were, who was responsible for what or who was in charge. I therefore echo your point that there seems to be a lack of clarity and transparency around who is responsible and who is managing things.

To be fair—and many of the people to whom we spoke this morning were fair—I should say that those who made that point did not particularly blame the people at management level, because they know that they are under immense pressure to deliver whatever they have been told to deliver. The whole issue is the tension between the pressures that are on the system and the fact that things are being driven from the top without consultation with the people at the bottom about how they should be implemented. The people we spoke to said that they had many ideas about how to implement change but they just did not know how a change that came from the top down rather than the bottom up could ever be implemented. They said that they were able to implement some change in their ward or section, but when they saw the bigger changes that needed to happen, they found it very difficult to influence what was happening at the top. That is what I picked up from the discussion.

Our group raised the issue of the system not having enough room at the moment to test change. Clinicians are naturally very cautious about changing procedures, because they do not want to move from what they know is an effective system to something that is new and which might be less effective. There was therefore a concern about it not being possible to test change because the system is running at such capacity.

The issue of targets also came up in our group, but no one mentioned anything about fiddling. Instead, we heard that targets were being adhered to almost without any possibility for clinical judgment to be made. With a target that might have been plucked out of the air—say, 12 weeks for a certain operation, or something like that—there was no room for a clinician treating a patient to make a clinical judgment as to whether the patient could wait longer or whether they needed the treatment sooner. The target was driving when care was to be delivered, instead of the matter being left to individual clinical judgment.

One point that was made quite strongly by a couple of people was the reliance on or promotion of fixed-term contracts and the offering of part-time posts to new graduates. If those people came in for a few hours and were then asked to stay on for the rest of the day, they would be paid just time, not overtime, and it was felt that the use of fixed-term contracts and part-time posts was all about avoiding having to offer permanent contracts with more expensive terms and conditions. The committee was also asked to look at and further investigate the number of locum consultants who would not accept permanent posts but, instead, worked in a way that was incredibly expensive.

If there are any other issues that members picked up on, they should feed them back to the committee clerks, and we will try to cover them all.

As agreed at a previous meeting, we will now go into private session.

12:24 Meeting continued in private until 13:00.