Health and Sport Committee

Meeting date: Tuesday, May 30, 2017

Official Report 529KB pdf

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NHS Governance

The second item on our agenda is our first evidence session in our inquiry on NHS governance. Today, we will look at staff governance.

I welcome to the committee Donald Harley, who is deputy Scottish secretary of the British Medical Association; Ros Shaw, who is a senior officer with the Royal College of Nursing Scotland; Kenryck Lloyd-Jones, who is public affairs and policy manager for Scotland for the Chartered Society of Physiotherapy, and is a representative of the Allied Health Professions Federation Scotland; Matt McLaughlin, who is secretary to the health committee of Unison Scotland; and Claire Pullar, who is the national officer for Managers in Partnership. We sought a representative from Unite the union, but it was unable to put someone forward.

I declare an interest as a member of Unite the union.

We will move directly to questions, the first of which will be asked by Colin Smyth.

Good morning, panel. What role does staff governance play in delivering an effective workforce? How would you rate the NHS’s performance on staff governance?

Who would like to go first?

I am happy to do so.

I put on the record that we are fully committed to the staff governance arrangements in Scotland and that the ideals that underpin them are very good, but there are definitely functional areas and probably board areas in which there are marked differences between the practical reality on the ground and the ideals in the standard.

We want to flag up three main areas. First, Scotland has a proud record on engagement and involvement. A recent study by the University of Nottingham gave Scotland high marks for its arrangements but, in practice, engagement oftentimes does not fulfil the function that it ought to fulfil. There is an element of rubber stamping in that fully formed ideas are brought to be validated rather than staff being involved from the bottom up.

Medical staff, whom I am representing today, find it particularly hard to be released for engagement, because it is not easy to provide cover for them. That is a long-standing issue. As finances become tighter in the NHS, it becomes even harder to release medical staff, and it requires planning and foresight. Typically, six weeks’ notice is required to release a consultant, and somebody must cover for them.

Monday is the busiest day in practice, particularly for general practitioners, but also in clinics in hospitals, yet all too often we see joint arrangements being organised for Mondays, which effectively—unintentionally or otherwise—excludes medical involvement in engagement. We thereby lose that practical front-line experience and the chance to improve services from that perspective.

The second area that I want to highlight is the raising of concerns. You will have read a lot of stuff in the written evidence about how effective the arrangements are for raising concerns in general. I will not rehearse that, but I flag up that there is a particular unique situation with regard to junior doctors. Their training programmes are controlled by NHS Education for Scotland, which therefore exercises considerable power over their access to—

We will discuss the concerns that are being raised across the piece, so you could maybe hold fire on that for now. Is that okay?

Okay—I am happy to do that.

Thank you.

The staff governance standard is a clear ideology that was developed through partnership between trade unions, the employer and the Government of the day, and a lot of people invest a lot of time and effort to try to make sure that that continues, but that ideology or principle is starting to feel the strain, partly because some of the people who crafted it have retired or left the service, but also because of continuing budget pressure, which does not help.

It is easy to do partnership working in staff governance in a period of growth, because there are good things to say to people, but it is much harder to do it in a period of retraction and change. That is affecting current performance, particularly as middle managers feel squeezed to deliver. We hear lots of stuff about ticking boxes and consuming your own smoke. That kind of mantra starts to feed through; in the past, people were much more inclined to try to engage and talk positively, and they had the time, energy and space to listen.

In their submissions, colleagues have discussed the need for training of middle managers. That is a good thing to identify and focus on, because it is a key issue.

A more recent analysis was undertaken by the Pennsylvania State University—I think that it is in the system somewhere. It speaks highly of partnership and, in particular, the staff governance model, which is unique to Scotland’s NHS. The interaction and interfaces in work in the integration joint boards are challenging that partnership agenda because another big complex beast is involved in the joint boards, and it does not necessarily have at its heart that commitment to staff governance. That needs to be worked through a bit more.

However, generally speaking, the report card would say that things are ticking along nicely, but a bit of focus is needed.

I agree. The staff governance standard in Scotland is strong. The tripartite agreement between the Scottish Government, the employers and the trade unions works well at national level, but we would question how aware of it staff on the ground floor are. They become aware when something happens, such as when there will be an organisational change in their area and they suddenly have to become aware, but all three partners in the tripartite agreement struggle to ensure that they get the positive messages out. Some really good work is done in staff governance and engaging with the trade unions, but that message does not always get out to staff.

It is often extremely difficult for nursing staff to engage actively because they are under immense pressure. We all know how busy the clinical areas are in the hospitals and in the community. There are huge vacancy levels in the community and hospitals, which puts incredible pressure on staff. In addition, the complexities of patients are so huge that it is difficult to get staff to become actively involved. Therefore, I question whether staff governance is working as well on the ground floor.

I echo some of those last points. We are pleased that the partnership agreement in Scotland is a good and positive model that has worked. Obviously, it will feel greater strains when budgets are tight.

I will add something from the perspective of allied health professionals. AHPs feel a little more disadvantaged in that, traditionally, there is at local level no backfill for them to take on roles that do not directly deal with patients. Therefore, in order to engage, they often have to cancel appointments. That is the reality, but it is not the case in other areas, where cover is arranged. In addition, continuing professional development courses have to be paid for by allied health professionals themselves. Funding is not often made available for CPD, and their ability to be released for it is restricted.

In many ways, the allied health professions feel somewhat disadvantaged in the overall picture.

I agree with my colleagues that the tripartite agreement is good and strong, but it is not always delivered to all the employers and it does not cascade down through them. The work that is done at the tripartite level therefore does not always reach the people who work in the NHS.

I agree that governance is time consuming. That relates not just to reorganisational change, but to grievances being raised and to complaints and disputes between colleagues, which can take years to sort out. When we go through governance, we should ask what we want to achieve by using that framework. If we use a framework for reorganisational change, for example, we know why we are doing it: we know that there will be a change, that there is a business model to consult on, and that we need to take on board staff and stakeholder views to ensure that the right end point is reached.

However, in staff governance, when I represent a senior manager, I will often ask somebody who has raised a complaint, “Has anybody asked you what you want to get out of this?” More often than not, the answer is no. I will say, “Well, what do you want to get out of this?” and they will say, “I’d like an apology, and I’d like it not to happen again, but I don’t want the senior manager to be suspended for 18 months while somebody else does an investigation and I have to bring all my colleagues through as witnesses.”

Because we have good staff governance and we work well together, it would be useful sometimes to stop and take stock, review what we are doing, and ask whether it is time to evolve what we are doing, whether there are other things that we can put to one side, and how we can reintroduce skills that have been lost, such as talking to one another, rather than putting in a grievance when we feel a bit ticked off with one of our managers.

11:00  

I am sure that colleagues have met constituents who work in the health service and have a particular issue. They often come to us because they cannot work through the system. My perception is that the person on the ground floor will have been completely unaware of an arrangement or a deal that was struck or whatever at the level of the tripartite arrangement, and they will have asked, “Who agreed this? Who told us about this?” They will then have gone to their MSP for representation. They might have gone through their staff representative or union to try to get a solution, but they will have been unaware that somebody up there has agreed a course of action. I certainly find that in my constituency casework.

You have hit on a fairly significant challenge in the partnership arrangements. I smiled when you mentioned it, because I remember having a long discussion with Clare Haughey when she was a Unison shop steward—let us bear in mind that shop stewards are part-time volunteers who do a professional job as well—about getting sucked into the machinery of meetings.

I am sure that all members appreciate that meetings can become their own industry and that, in those circumstances, it can be difficult—when you have political directions from chief officials, local chief officers and local managers, who all tell you that we need to make a change—to make a space and place for the shop steward to have what we called in the old days a shop meeting: to go into a workplace and have a chat with colleagues. Now, a lot more is done electronically and through bulletins and flyers. As politicians, you will know that, in your profession, you can write to people until your hands fall off but, if they do not read or comprehend what you have written to them because they are busy with real life, that can be a major challenge.

We also need to recognise that, when we have localised change agendas, a space needs to be made for that interaction and a commitment needs to be made to that. There are a couple of things that challenge that a wee bit, and we are seeing more of that. Staff governance does not mean we cannot disagree. Again, I recall the conversations that Clare Haughey and I had when she was a shop steward. You can go into a meeting about an arrangement and say, “I’m sorry, but we don’t agree with that,” and then work through a mechanism to try to reach agreement, but people still have the natural traditional industrial methodologies available to them if we cannot get that consensus.

We should look at the number of employment tribunals that are lodged against NHS employers in Scotland, if we strip out equal pay. They compare favourably with those in every other industry, including local government, the voluntary sector and the private sector. There is a reason for that. Albeit that the machinery moves at a pace that we sometimes would not recognise as progress, there is always an opportunity to get through the staff governance and partnership routes to solutions to problems. We collectively use that with the employers and colleagues in Government to our maximum benefit. That is a key measure of where we are.

How easy is it to raise concerns or to whistleblow if you have concerns about a colleague’s practice? I worked for 20 years as a clinical pharmacist in a psychiatric hospital. My perception is that over the course of those 20 years, from the mid-1990s until recently, there was a transformational change in how easy it was to raise concerns about other people’s practice or about other practices that we witnessed in the hospital. Does that reflect a national trend, or is that just my experience?

Claire Pullar is shaking her head vigorously.

Yes—I am shaking my head. My organisation does not have reps; we have link members, so I have people I can contact directly to answer questions for me. I have some evidence with me from senior managers who say that they have never had anybody raise concerns through whistleblowing, and that it has not had a particularly devastating impact on them personally, either in their career or in their relationships with colleagues.

Whistleblowing is a vital part of staff governance and of how we safeguard our interactions, but judging from what our members say, senior managers think that there is still blame attachment when someone has the temerity to raise concerns through whistleblowing. The attitude is, “How dare you?” There are other routes to use, and whistleblowing is viewed as an undignified way of doing things. However, we need whistleblowing and we need people to feel safe in whistleblowing. I do not think that they do.

In the medical field, raising concerns about a colleague is both a professional and a personal issue. For a doctor, professional reputation is all, so a slight to that is a real wound: it is felt. People tend to react against that. A toxic reaction can often be seen when a person’s practice is held up to question.

In the medical field, it is not necessarily a matter of raising concerns, as people might understand it in terms of whistleblowing; it might be that the person is referred to the General Medical Council, and it would be for the GMC to take appropriate action. You then get into a tit-for-tat thing. The person might react by saying, “How can they accuse me? They’re not exactly blameless, themselves,” and so on.

I am not sure whether this is the time to mention this. You said, convener, that you were going to discuss raising concerns in more depth.

Please carry on—it is fine.

In their day-to-day practice in the health service, medical and clinical professionals see things that they are not comfortable with, but it is always tricky if they want to raise concerns. If the concern is about their employer, they have protections at law, but, as we have seen and as the committee will have read in the testimony of various individuals, those protections sometimes do not amount to much. Relationships and careers can still be destroyed even with those protections in place.

As I was starting to explain earlier, junior doctors are in a unique position, in that they are in a power relationship with NHS Education for Scotland, which controls access to and retention on its training programme. If the relationship with NES goes wrong and a junior doctor falls out of its training programme, that person has de facto lost their job and career, too. They have no protection against the actions of NES. That is not to say that NES is a bad organisation. Clearly, it is not—it is a very good and important organisation—but such things happen from time to time and from place to place. Arrangements have recently been put in place so that Health Education England provides those protections for trainee doctors within their training relationship. So far, however, NES has not been willing to pursue similar arrangements here, so junior doctors are probably even more reticent to raise concerns if their doing so would put their training relationship in jeopardy.

There is a big difference between raising concerns and whistleblowing. Our members come to us daily to raise concerns, usually about staffing levels, but it is early days with regard to seeing how the legislation on whistleblowing is going to work. I was at the Lothian area partnership forum yesterday, and it reported to us that it has had nine cases go through the whistleblowing policy since September last year. It has investigated those. A number of them were anonymous, which makes it difficult to feed back and get further information. People are now very aware of the whistleblowing legislation and the policy. A lot of work has been done with regard to that—certainly in the health boards that I cover.

It is always difficult for a person to put their head above the parapet and raise a concern. However, as with the BMA and our AHP colleagues, our members are in a regulated profession, so they are bound by their own code of conduct. If they see anything that puts patient care at risk, they have an obligation to raise it, and we always support and encourage our members to do that because we are about patient safety and quality.

Clinicians have a duty of care and must look to that and to their code of conduct if they have serious concerns. The difficulty is, as we have said, that whistleblowing is about revealing something that has perhaps been hidden, whereas people’s concerns are sometimes about whether the quality of a service is suffering. At what point does that become whistleblowing? At what point does a service become unsafe? That is not always clear. The various professional bodies of the allied health professions are there to support and advise members on that but, of course, that relates to particular circumstances.

Whistleblowing is often seen as relating to headlines and scandals rather than as a run-of-the-mill way in which people can raise concerns where the quality of a service is being diminished.

I will be brief, convener, as I appreciate that you are busy. Whistleblowing is an emerging issue, but Unison’s position is clear: we believe that the NHS has the machinery to deal with it. The Datix system that exists across the NHS in Scotland is a very good and principled system. What people do not get is feedback when they make a referral or a report at local level when there is something that they are not happy about. Colleagues have spoken about the need for professionals to reflect on things, which is also key.

At senior level, the NHS can be quite defensive and risk averse. A hierarchical macho culture exists in some places—almost right from the top, I have to say—and it quashes any ability for the service to properly reflect on and deal with genuine concerns in a sensitive and sensible way, so we get conflict and differing positions, which do not help. However, it is important to say that the machinery is there. It is about people investing in that.

Some of us who were here when the Lothian waiting times scandal emerged saw exactly that culture.

I ask Claire Pullar to be brief, because we need to move on. We do not have a lot of time this morning, so I ask people to keep their answers pretty snappy.

Employees in the NHS are aware that, following the Francis report, they have a duty of candour to raise concerns, which will not always lead to whistleblowing. As we have pointed out, they are two different things. The question is how to balance that in a system that is often risk averse.

I want to ask about an issue that is frequently raised with me when I am out meeting folk who work in the health service—the quality that is provided by locum and temporary staff. There is probably a much better system in place for managing people who are employed by the NHS. Is the system robust enough to manage people working in the NHS who are not permanently employed by it?

In the interest of keeping it snappy, I say simply that any organisation or system that relies on bank or temporary workers will have difficulty driving staff governance and quality; we have a lot of areas in which we are wholly reliant on bank or temporary workers. We would be absolutely delighted to work with the committee to resolve that.

11:15  

I am glad that Maree Todd mentioned raising concerns. She described her experience as a clinical pharmacist. I am sure that the environment for raising concerns has transformed because there are far more concerns to raise, not least on workforce planning, delays and blockage, particularly at the social care end of the spectrum, which leads to interruptions in flow throughout the NHS.

We are talking about two different things. It is okay for staff to raise concerns at the macro level—we see that and I get doctors in my surgery all the time raising concerns about the macro level—but whistleblowing is an intensely personal thing. We have seen from staff surveys across the workforce that staff have no faith in current whistleblowing structures. They are not convinced that they will be believed, that action will follow and that there will be no recriminations. How do we change that? If there is bad practice in the NHS, we need to root it out. If there are individuals at any tier who are responsible for bad practice, we need to address it, but if there is no belief in the system, we can never do that.

What we need to do goes wider than staff governance. We need to ensure that the culture that is set by the people up at the top is supportive and enabling. Unless we have that throughout the health service, staff will not feel confident that they would be supported if they raised a legitimate concern.

We have to enable people to understand that there will be no blame. We have to emphasise the fact that they not only have a duty of candour; they also need to be mindful of emotional intelligence and ask themselves how best to raise an issue.

Many senior managers have clinical or professional backgrounds and are aware that, in that part of their identity, raising concerns would be considered to be a slight, as Donald Harley mentioned. Therefore, we need to reset how we talk to one another in the NHS so that we do not accuse one another of doing things or blame one another, and so that we certainly do not blame people for raising concerns or for whistleblowing. Things usually get to the whistleblowing level only when people who have tried to raise concerns have not been listened to. We need to reset from the top down; that is, from the political level all the way through to everybody who has any interaction with the NHS. How do we take national pride in working together, put blame to one side and seek understanding? That is the way forward.

In the governance arrangements, we set great store by a constructive approach being taken to resolving concerns that are raised and working within teams in boards. As has been expressed here, and as was shown in the most recent staff survey, there is a significant lack of trust that concerns will be acted upon. It is not possible just to wave a wand and make people trust in arrangements when they perceive that there is a vested interest in bad news stories not being exposed and reflecting badly on the organisation.

Although there is a responsibility on all of us to do what we can to support the existing constructive internal arrangements, there needs ultimately to be an impartial appeal arrangement that can oversee that. It was always likely that people would see the flaw in the helpline that always refers people back to the internal arrangements, so there is no escape from the inward-looking way of addressing things. There has to be a degree of proportionality about that so that people do not always escalate matters. There needs to be a mechanism to judge whether it is right and proper that there should be an appeal, when it is safe to leave an issue where it is and when it is appropriate to have somebody who is impartial cast a second eye over the matter to say whether the issue is not best practice.

You said that there is a need for “an impartial appeal arrangement”. You are probably aware that a petition has been submitted to Parliament that calls for the establishment of a new national whistleblower hotline. Do you think that such an independent organisation would be beneficial? I see Matt McLaughlin shaking his head.

Our evidence on that matter is fairly well established. We do not support the view that money should be given to the private sector to develop a call-centre hotline on such issues. There are problems with governance, and the idea of a whistleblowing ombudsman is much more sensible and constructive, and would deal with the appeals issues. The ombudsman approach has worked in other sectors; it would work better than just handing money to a call centre somewhere.

Is that view shared by the rest of the panel?

Yes.

Yes.

I am not sure what evidence there is that the availability of a hotline would mean that people would have a motive to call it. I wonder about the circumstances in which that would happen.

My next question is directed at Ros Shaw and Matt McLaughlin. In its submission, the RCN highlighted that integration authorities do not operate the same partnership model as is operated between the NHS, the Government and the unions. Unison noted that integration means that

“health services and workers find themselves managed on a daily and strategic basis by non-health professionals. As a result there is a need ... to ensure that there is no dilution of the standards for affected NHS workers.”

Could you expand on how staff governance has been affected by integration?

It is early days, in that the structures are just beginning to be set up and developed.

In the integration authorities, our members from the NHS are still employed by the NHS, so although they might have a manager from the council, which will have a very different culture of working with the trade unions, it would be fair to say that our members would always be able to go back through their professional structures, because they have professional accountability to the NHS. However, we are keeping a very close eye on the issue, because we have concerns that the same partnership arrangements are not in place for our members.

I have three quick points to make. There is significant potential for confusion when someone who understands and is steeped in one culture and one set of rules of engagement is managing a group of people who have a different culture and different rules of engagement.

I will give two quick examples. In recent months, the IJB leads in the NHS Greater Glasgow and Clyde area have decided that it would be a good idea to slash the school nursing budget by more than 50 per cent, without having referred to the staff side at a high level, let alone at a local level. That runs contrary to the work that we are doing with the Scottish Government in a host of areas on getting it right for every child. There is a major issue there in respect of the big staff governance picture. We are having to fight a rearguard action on that.

Last week, I met a group of workers who had been transferred from Parkhead hospital to Stobhill hospital. They had a clear set of shift patterns and clear contractual entitlements. A colleague from another organisation who sits above them in the hierarchy structure decided that they should be issued with a 90-day notice of change for their hours of work, their place of work and their working arrangements. That is just not how we do things in the NHS. That generates hours of work for poor old me over a long weekend because people are rightly upset.

We are not getting it right at that level. Because of the nature and construction of IJBs, the potential exists for there to be a wee bit of a culture clash. We could do with some guidance from the Government and the health department on how things should work.

I agree with Matt McLaughlin and Ros Shaw. In Managers in Partnership, we have members who are expert managers in health. They have MScs and PhDs, and they have got to where they are in the profession because they have the knowledge, the credibility and the ability to do very difficult jobs.

They are then line managed by someone from the local authority who does not understand that part of what they do and who thinks, “Can I save money through, say, organisational change or spending your money in a different way?” If one of our members tries to explain the risk to their non-NHS manager, their explanation is not seen as credible and is not understood. We then find that the framework of governance—which we have all spent a lot of time establishing, which sets out the correct steps and which gives us a core point of understanding that we can go to and say, “That’s our starting point: that’s what we follow”—gets put to one side, and we end up with a bit of a mess that a lot of people have to spend a lot of time sorting out.

That sounds frustrating.

Presumably, that could be a two-way situation.

I imagine that someone from a local authority would say the same thing.

Absolutely. Do you want to come in here, Donald?

I will come in briefly, convener. Although we support the idea of integration, we have a number of concerns about how it is applied. For example, as far as medical staff are concerned, employee involvement and engagement are just not happening. They are barely happening for primary care staff and general practitioners, and not happening at all for secondary care doctors. People might say, “Oh, we speak to medical directors and others at that level”, but they are not talking to operational doctors who deliver the services. In planning services and doing what integration is meant to do, which is to link things up and have smooth systems across health and social care, they are not involving the doctors who are doing the delivery, so they could be setting themselves up to fail at an early stage.

In 2014, we lobbied to have a nurse board member on every integration authority. We have recently done a bit on work on some of the decisions that are being made on community nursing, and unfortunately we have found that some of them are being made without the involvement of the nurse member on the board. That is extremely concerning for us. The Government’s 2020 vision is all about transferring care into the community and ensuring that we have the right number of nurses and other healthcare professionals out there. However, we have a massive number of vacancies in the community at the moment, especially in district nursing and, as Matt McLaughlin has pointed out, school nursing—in fact, we are aware of the example that he referred to. I know of another example in, I believe, the Glasgow area of band 8A senior managers being stripped out of clinical decision making without there having been a great deal of consultation, and those are the people whom the nurses on the front line—the healthcare support workers, community staff nurses, district nurses and health visitors—go to for professional support and advice.

I will add that we did not get legislative specification that allied health professions be represented on IJBs. Of course, an allied health profession representative would represent 12 professions; the specific things that those professions have expertise in and knowledge of will not be well understood, so even that has to be co-ordinated by the AHP representing all of them. Cutting that out from IJB decision making and lacking an understanding of the contributions that are made by those services can lead to significant gaps or less good—and sometimes bad—decision making.

On Donald Harley’s point about doctors’ voices not being heard at IJB level, does the BMA feed into staff-side representation on the IJBs? Are you speaking from a trade union or a professional point of view?

It is both, essentially. I will say, at the risk of repeating myself, that we had hoped that people who are involved in clinical decision making at local level would be engaged by the IJBs, but our members say that that is not happening.

Why is that not happening? Should professional points of view not be fed through the medical director, and should trade union points of view not be fed through the staff-side representative who sits on the IJB?

11:30  

It is more complicated than that, to be honest.

I do not understand the point that you are making.

I am not sure that we have the time today to go into detail.

Maybe you could write to the committee to provide the detail.

Yes, I could do that.

That would be fine.

We have held informal sessions with front-line staff and with middle managers in the NHS. The themes that came across were that the system is under massive pressure and people are feeling the heat from their managers and the managers above them—and ultimately from, I presume, the Government and Parliament, where targets are demanded and budgets are placed under huge pressure. We have had a debate about budgets this morning.

That seems to be creating a culture within the system in which people are afraid and intimidated. They feel unable to raise concerns or are frustrated about what happens when there are concerns. Is that a reflection of the system that you are working in at the moment, or is that an exaggeration?

NHS workers are no different from any other group—

I suppose that I am asking whether the pressures are now greater than they have ever been.

Yes, they are.

The pressures are being felt more keenly than they have ever been. Some of the issues that you have heard about—staffing levels, the culture and people having to do more for less—feed into that, particularly given that we have an ageing workforce and an ageing community in which the demands on people have become greater.

However, that argument can sometimes be overstated a bit. People need to take some responsibility for their own lives globally. In my view, everybody should be a political activist and a trade union activist. People can certainly work more positively with their trade union colleagues. If they are unhappy, I would encourage them to be active rather than passive trade union members, because that is how we will get the message through to your good selves and to others. It is tough, though. It is hard, and people are feeling the pressure.

I agree. It is tougher than it has ever been, and the budget pressures are immense. It would be remiss of me not to mention the fact that healthcare professionals and nursing staff have had a loss of earnings, which has impacted severely on the numbers in the wards. Members are coming to us and saying that they are demoralised and lacking motivation because they have had a pay cut of 9 to 14 per cent in real terms. That is significant, and the situation is the same across the whole public sector. It is also coupled with absolutely massive workloads that are leading to stress and fatigue. People are taking on extra hours, through bank and agency work, in order to make ends meet. All that means that people have their heads down—they are working—and it is hard for them to engage.

I agree with Matt McLaughlin that it would be great if all our members were active members. However, when someone is exhausted through working extra hours but relies on their unsocial hours payments to make ends meet, it is really tough. It is a really difficult situation at the moment.

The reality for many front-line members is that they just do not feel empowered to change the situation; they are told, “This is the situation,” and they have to suck it up.

I agree with my colleagues—especially with what Matt McLaughlin said about people needing to take more responsibility. Often, when people raise concerns with me or when I represent one of our members, people will say that such and such a person tried to make them feel a certain way. I ask what makes them think that the person would want them to feel as bad as that and whether we could have a sensible conversation about what happened. Do we have to go down a grievance or a complaint route whereby witnesses are brought in and everyone is upset? That approach adds to the pressure, and there is a lot of pressure in the system at the moment.

Ros Shaw referred to members having to use unsocial hours payments to make up their pay. Our members do not have that option but are absorbing more and more stress. When I recently engaged with members, I asked, “What do you want me to do for you?” and they said, “Just protect our time, because we’re exhausted.” Many middle-management roles have been stripped out, which puts the interface between senior managers and junior managers between a rock and a hard place. There is no give or support, but there is a lot of blame. People feel that they cannot say no, so some members are in the workplace before 7 o’clock and leave after 10 o’clock. They work three or four hours on Saturday and Sunday, to the detriment of family lives and their physical and mental health. They are giving more and more, yet they are getting more and more blame.

We talk a lot about front-line services but not about our members. When a new hospital or clinic opens, a politician stands with people in uniform, but those who manage the laundries and the catering and those who project manage new builds and keep within budget are nowhere to be seen. They are personae non gratae because they do not wear a uniform. We have a direct discrimination system in which people do not feel valued.

Returning to the subject of rumours, there are loads of them. They start from the top and spread down, beyond the NHS, including to think tanks. On Friday, I got an email from a member that is relevant to the point that Alex Cole-Hamilton made at the beginning of the evidence session. It said, “Can you please tell me that the rumours that all the alcohol and drug partnerships are being binned are not true? It is my job—the service that I deliver through integration with the local authority.” At 4 o’clock on a Friday afternoon, an entire team thought that they would have no jobs in three or four months’ time, and the people who receive support from that group had a weekend with the rumours and no access to support.

There is greater pressure and less money. People are in a pressured system and need to be able to ask why someone is trying to upset them, if that is what they think, how to reality check their perceptions and who is part of the team. People such as non-uniform-wearing staff feel left out. We must cut down on gossip and rumours, because they are profoundly unhealthy.

Section h on page 2 of Claire Pullar’s submission says:

“There is widespread belief that NHS will crumble without the ongoing contribution of its international staff. As one member told us: ‘The anti-immigrant culture in the UK at the moment is hugely embarrassing and personally hurtful.’”

I ask the panel to comment on the pressures that the current situation in the United Kingdom around Brexit is causing for our NHS staff.

I imagine that all the panellists will have something to say on that. The situation is unpleasant, and there is a spike in people seeking support. They feel that decisions are being made against them because they are not seen as part of the future team or workforce. Naturally, it is assumed that they will not be here. They are asked, “Why are you still here?” and told, “You should see the writing on the wall—you are not wanted,” although they are also told, “We want you to work here,” and, “If you were British, it would be fine.” Those attitudes are permeating, and newer casework is presenting for me.

Does anyone else want to comment briefly? We do not have a lot of time left.

In physiotherapy, we have international students who have studied in the Scottish system, have qualified as physiotherapists and now work in the NHS, where they can work for two years following graduation. After that, they have to work above a certain threshold or they can no longer work in the NHS. At the moment, that threshold is set at about £35,000, which means that a band 6 physiotherapist does not qualify.

We have a few situations in which consideration is being given to ways in which such staff members can be kept on, but they simply cannot be kept on, because the rules say that it is not possible. That is at a time when we are having trouble filling vacancies in many areas, and the biggest impact is often in the rural areas and the small teams. We have concerns, which we have voiced, about the current arrangements for non-European Union people—for example, I know of a case involving a Canadian-born person. There is a large question mark over where we will be with EU workers in the future. If that approach were to be applied to EU workers in the NHS, the impact would be significant.

You may already know this, but a not insignificant proportion of doctors are EU graduates. Scotland already struggles to recruit and retain enough doctors overall to meet the operational commitments that we set. In the worst-case scenario, if we were to lose EU graduates, we would have another significant hole in the medical cover that we provide in Scotland. Obviously, we all hope that that is not going to happen, but there is no certainty of that. We hear many anecdotes about people making arrangements to look for employment elsewhere in the EU rather than take a chance that there will be an appropriate settlement here, because something adverse may happen.

I agree. We cannot afford to lose EU nursing staff, either. We have a significant number of vacancies at the moment. At the end of December, we had 1,800 hospital vacancies and more than 600 community nursing vacancies just in the NHS. I appreciate that the discussion is about the NHS, but the situation is even worse in the independent sector, which relies heavily on EU nationals.

Constant constitutional confusion does not help anyone, particularly people who need a bit of confidence that, if they come here to work, they can stay here and invest in their futures. The issue goes beyond professional grades. In many areas, support staff are heavily made up of EU colleagues and colleagues from further afield. It would be really helpful if we could get beyond the constitutional spin and into the delivery of service. Stuff like workforce planning will help.

I want to ask briefly about iMatter, which has replaced the annual staff survey. What are your comments on iMatter and how effective it has been? What has been your experience of it?

Please be brief.

I will be dead brief. If people act on what they are told, it will be a raging success; if they do what they did with the existing staff survey, which was to completely ignore it, it will just be the same again.

The new approach has the potential to be really helpful, because it drills down to the team level. As Matt McLaughlin says, provided that people get the opportunity and space to work in their team and put an action plan in place, it could have a lot of influence.

As Ros Shaw says, there is a real gain in employee engagement at team, department and board levels and in driving local solutions. The slight concern is that the new system does not cover all the areas that the old staff survey covered. I understand that the plan is to have flash surveys to cover issues such as how grievances or concerns about discrimination are dealt with. It is important that those flash surveys take place and that there is no gap in what we ask the workforce.

Overall, a lot of work needs to be done to get more people to engage. For example, my rough calculations show that only 25 per cent of doctors completed the survey. That is a relatively low figure, and it might reflect a degree of cynicism about how valuable the process is. I guess that, if people see the same figures year after year and action does not generate significant improvements in areas of concern, it becomes a harder sell to get people to take part.

11:45  

Our members think that iMatter is useful, but people must be allowed to ring fence time for it, otherwise it is just more paperwork for people and they do not matter—only the paperwork matters. We need to think about why we are asking people to take part, why we are saying that it matters and why it is important. Staff must have time to prioritise iMatter, and they are allowed to prioritise it.

I have a specific question on junior doctor hours for Donald Harley. A few years ago, Dr Lauren Connelly tragically died following an extended period of consecutive long shifts. After that, there were supposed to be changes to rotas for junior doctors and the like. The BMA has raised the issue of protection for junior doctors for whistleblowing, and it might want to raise the issue of extended periods of long shifts that leave them extremely tired. Some of them also have to travel long distances to their work, and we saw the tragic consequences of that in the case of Dr Connelly.

Has the situation changed? Is the position for junior doctors better in relation to not just the official hours that the rota says that they work but the actual hours that they work? If junior doctors in Scotland do not have the same protection as they have in England, what negotiations with the Scottish Government is the BMA involved in to advance the position so that they have protection on issues that, in many ways, are a matter of life and death?

It is a complicated issue. The Scottish Government has taken action to address the concerns that we and Dr Connelly’s father raised. Because of the tragic circumstances of that case, there has been a degree of emotion and sensitivity around the matter and the things that are being done are not necessarily what would have the best impact on junior doctors’ quality of life. The number of days that a junior doctor works back to back is one issue that has been tackled, but we must consider the whole arrangement for employing juniors. For example, we could limit the number of such days, but that might mean that a junior doctor gets only one weekend away in a month because they end up covering alternate weekends in a complex shift pattern, meaning that their quality of life and family connections deteriorate.

Ultimately, when we seek to improve the arrangements, there must be some flexing of all those things. In the aftermath of the Connelly tragedy, there was a rush to do something rather than a decision to take a holistic approach to a constrained solution. We encourage the Scottish Government to have further dialogue with the Scottish junior doctors committee.

Is the system better, the same or worse?

It is better, but there is more to do.

Are there negotiations on the legal protection for whistleblowers in Scotland that your submission says is missing?

I understand that NES was not receptive to that suggestion.

I thank the witnesses for their evidence and suspend the meeting briefly to allow them to leave.

11:49 Meeting suspended.  

11:51 On resuming—