Health and Sport Committee
Meeting date: Tuesday, September 19, 2017
Official Report 586KB pdf
Agenda: Subordinate Legislation, NHS Governance, Draft Budget Scrutiny 2018-19
- Subordinate Legislation
- NHS Governance
- Draft Budget Scrutiny 2018-19
Agenda item 2 is national health service governance. We will look specifically at staff governance. We have about an hour for the session.
I welcome to the committee George Doherty, who is director of human resources at NHS Tayside; Jennifer Porteous, who is director of human resources and workforce development at NHS Western Isles; Elaine Mead, who is chief executive of NHS Highland; and Kenneth Small, who is director of human resources at NHS Lanarkshire.
We will move directly to questions.
I want to ask a couple of questions about the NHS staff survey. Much of the evidence that the committee has received so far suggests that the results of the survey, even when they highlight staff concerns, are largely ignored. The perception is that very little action is taken as a result of it. Is that a fair criticism in witnesses’ health board areas?
We have to look at what has happened as a progression. The annual staff survey, as was, is no longer. We ran a staff survey for many years, and there were a number of areas of frustration with it, but I do not think that one of the frustrations was to do with responses to the messages that came from it. The biggest frustration for me and NHS Lanarkshire—colleagues from other boards can speak for themselves—was to do with the inability to get significant numbers of staff to complete the survey, despite the power of partnership working with our trade union, managerial and clinical colleagues on encouraging staff to complete it. Over the years in which we ran a staff survey in Lanarkshire, I think that we managed to move our staff’s participation in it from the low 20 per cents to the mid 30 per cents. Despite significant effort, the figure went no higher than that.
Our collegiate approach to the staff survey was always that we ran it and then got its results from the national engine room that developed and organised it. Our response to those results was to develop an annual action plan—again, in partnership with trade union colleagues and all the staff. The staff survey action plan would draw down the particular challenges, as well as the positives, that came from the survey results. We prioritised action against those results.
The staff survey action plan was an integral part of my governance framework and was regularly considered at the staff governance committee, which includes non-executive directors, trade union and managerial colleagues, and human resources professional colleagues. The actions were reported and, where appropriate, a redefinition of priorities was agreed for the next period.
I do not agree that the staff surveys’ results were ignored. They were used to inform priorities for action and improvement.
I echo everything that Kenny Small has highlighted. NHS Tayside’s experience of responses from individuals to the survey was similar: our best-ever response rate was about 35 per cent.
With iMatter, which is a tool that talks more to individuals’ experience of the day-to-day workplace and their team, and to their views of the organisation, we have a response rate of 68 per cent. The level of engagement is much higher, which I think is because the exercise is much more meaningful for individuals.
The board still takes the key messages as a summation and receives a global report that is based on the totality of responses. However, the key differences are made day-to-day and are related to experiences of working within a team. The discussions happen there, led by the team. Where they can enact changes, they do. Through our area partnership forum with our staff side, the global action plan that we used to develop using the staff survey is now done using iMatter. NHS Tayside’s board monitors our response to common themes that emerge across the organisation and which need action globally, as opposed those on which teams individually take self-leadership.
NHS Highland’s experience of the response rate to the survey was similar. We are pleased with the response now, using iMatter. I echo George Doherty’s view that the fact that action plans are developed with and by local teams results in a lot more engagement, and in people taking a lot more responsibility. That is a real change in the approach to staff governance across NHS Scotland.
NHS Western Isles has the same arrangements. We had, following the survey, action plans that were embedded in the staff governance action plan. Now that we have implemented iMatter, we are pleased that we have an employee engagement index of 76 per cent. We now focus on the team action plans that address the staff’s issues directly at team level.
It is important to recognise that iMatter, as the replacement for the main components of the NHS staff survey in Scotland, now achieves a level of response that ranges between 60 per cent and 70 per cent, compared to the staff survey average of about 35 per cent.
Participation does not tell us what staff are saying; it just says that they are saying something. If panellists find that iMatter is more effective, can they give me an example from their health boards of a tangible change that they have made as a result of feedback from staff using iMatter?
I am happy to pick that issue up. NHS Tayside’s written submission includes some of the key domains that are being reported back on and which give a sense of individuals’ involvement. A strong response for us was about the extent to which individuals felt that they were involved in local day-to-day decision making within their teams.
An area that was identified through iMatter as being one that we needed to strengthen with our staff was the degree to which individual employees felt that they had a voice in the board’s overall strategy. As a consequence, one step that we have taken is to move beyond area partnership forums and to put in place local partnership forums. Joint staff forums with our trade unions and line managers ensure that local plans, budgets, strategies and workforce issues are considered within their service. That is a clear example of where iMatter outcomes have created a strong position in terms of local governance. The staff survey did not do that.
Are there examples from the other health boards?
One concern in NHS Highland staff’s responses from iMatter was about the visibility of our management. As a direct response, our actions have included encouragement and support, particularly to middle managers, to be out in what we call the gemba—the place where work happens. They are out daily with teams and are buddied with wards, in some areas. The visibility of senior and middle managers is now much higher, so staff can regularly see them.
We already had an arrangement through which the executive team went out, which was over and above the walk-arounds that we do for things such as our Scottish patient safety programme work. It is about getting back to the place where work happens. I hope that that action will improve the result on that next year, in our iMatter survey.
Obviously, we have not yet seen detailed results from iMatter because it is still being implemented. Are you saying that there will be, when we see those results, a substantial improvement in staff satisfaction ratings on a range of things, compared to the results of the staff survey?
The difficulty with that is that you are talking about two different systems that will be challenging to compare and contrast. Giving iMatter absolute corporate commitment across NHS Scotland will, in time, allow us to look at trends in boards, and to look right down within boards into departments and clinical areas, but it will also allow us to look corporately at the NHS in Scotland.
iMatter, as a tool, has the potential to do that, provided that we give it longevity. That is one of the issues: let us give it a chance to work properly and to build confidence in looking at trends. iMatter has the potential to allow us to drill down much more readily than we ever could with the old staff survey.
Would there be any benefit in independent scrutiny of the work that you do around iMatter and the staff satisfaction survey?
I suppose that it depends, but I see no reason why it would not be of benefit, because we should be absolutely confident that what we are doing is the right thing and that it has the potential to make a difference. The old survey and iMatter already get independent scrutiny, because we take the results, including the action plans, to our staff governance committees, on which we have non-executive directors. In NHS Lanarkshire, our chair and our employee director are an integral part of that arrangement. They look, from a governance perspective, at the results, at what we are doing about them and at what difference that is making.
Committee members will have met constituents who have experience of whistleblowing, who always raise the fact that there is no independent investigation; investigation is internal. Given your experience, what are your views on how that could be improved? With the establishment of an independent whistleblowing hotline, which has been suggested, could investigations be independent of the health board?
I am thankful that I have limited experience of whistleblowing. In the past three years in Lanarkshire, our whistleblowing occurrence has been nil. My involvement in relation to whistleblowing in the NHS in Scotland is as chair of the national human resources directors group. In that role, I was asked to support another board with the investigation and response to a whistleblowing case. I was seen as an independent contributor, which was accepted by the whistleblower and the board. There are benefits in having a level of objectivity that can sometimes be difficult to achieve within a board. However, in most whistleblowing situations, it is important to engage locally as well as having that level of objectivity because, arguably, you get a better result that way.
This might well have been presented in evidence to the committee previously, but all boards have a non-executive director who is appointed independently to act as a whistleblowing champion. In my board, that person is the vice-chair of the staff governance committee. The staff governance committee is co-chaired by a non-executive board member and an employee director, who is the staff-side chair, as elected by the trade unions. We bring a report to that committee every six months on all whistleblowing issues that have been raised. The whistleblowing champion has two roles: to give assurance that due process has been followed in our handling of cases, and to ensure that concerns are escalated, whether that be to the chairman or, beyond that, to the Scottish Government.
I agree that it is important that individuals have confidence that, when they raise concerns under the banner of whistleblowing—not just about wrongdoing, but in relation to risk—they will be dealt with appropriately. That is an ethos in all the boards, each of which has been asked to identify and appoint a whistleblowing champion.09:45
That person does not investigate the incident; their responsibility is to oversee the investigation.
The champion does not directly investigate.
So who investigates?
The champion’s responsibility is to ensure that an investigatory process is progressed and that matters that are raised are addressed. Their accountability is to the board, in order to assure the board that any matter that is brought forward under the whistleblowing policy has been addressed appropriately.
By whom would such matters be investigated?
That would depend on the nature of the issue. For a clinical issue, it would be for an officer from the clinical governance line—for example, the medical director or nursing director—to take forward an investigation. For individual cases in which wrongdoing is raised, investigation would be through an appropriate policy person.
We also have fraud liaison officers who work with NHS counter-fraud services. Where there is an issue of wrongdoing, matters can be escalated to counter-fraud services through the fraud liaison office.
So, the investigation is not independent.
Counter-fraud services is an independent body.
Previously, you referred to how clinical or other issues are investigated. They would be investigated by someone within the organisation.
Such matters would be investigated in line with our policies that have been agreed with our trade unions. The role of—
Let me be clear on that point. Such matters would be investigated by someone within your organisation—for example, a senior manager, or the manager in the department.
Investigation would not be done by an individual who was connected to the case. It would be taken forward in accordance with the policy to ensure independent investigation. That is one of matters on which the whistleblowing champion provides assurance to the board.
It is not an independent investigation if it is done by someone within the organisation.
It is an independent investigation under the terms of our policy to ensure appropriate due process.
Okay. Miles Briggs has a question—
I would like to add to that. The committee has, I presume, taken evidence on the existence of a national PIN—partnership information network—policy on whistleblowing. The policy was built up nationally by a partnership of the NHS boards, the Scottish Government and the trade unions. That is the policy that George Doherty is talking about, and it is the policy that we apply corporately. It depends on one’s definition of “independent”.
It is that policy that people have raised concerns about.
I apologise for the delay, Miles.
How many people are on permanent gardening leave within the panel’s organisations? Do you have, or could you provide, those figures? How many have not returned to the health boards after the investigations?
Across the NHS in Scotland, I do not think that we have anyone on what is deemed to be gardening leave. There will be times when an employee is suspended from duty, without prejudice and on full pay, for a reason that they are made aware of. There are support mechanisms and regular reviews of the suspension built in to our normal policy approach. The reason for suspension is almost invariably disciplinary action. Very rarely will it be for health reasons: someone with health issues would be off work on sickness absence and there is a separate policy for that.
The answer to the question in relation to NHS Lanarkshire is that we have four members of staff who are suspended from employment. All are subject to active disciplinary investigatory processes, and are kept well informed of and engaged in that process. To my knowledge, we have never had anyone who was permanently on what you would deem to be gardening leave, because that would be a misuse of public resources.
Does anyone else want to come in on that point?
NHS Western Isles does not have any staff on gardening leave. We have the same arrangement as that which Kenneth Small outlined.
But you may have staff who are suspended on a long-term basis, pending investigation?
We have no staff suspended on a long-term basis. Where we have staff suspended, it is as a consequence of an investigation into a potential disciplinary matter.
It is the same for NHS Highland. We follow our policies and procedures and have people suspended as necessary.
I do not want to give the impression that suspensions are not occasionally quite long. I am the old man of the panel; I have been in the NHS for 40-odd years. In that time, probably the longest suspension that has taken place was approaching two years duration. Again, that was not because we had forgotten about that individual.
Quite often, particularly when we are dealing with senior clinical staff, the act of investigation is complex. With any such investigation, you invariably end up in areas that you had not predicted that you would end up in. Some suspensions can be for long periods, but we seek actively and proactively to manage the situation in order to keep suspensions to the minimum, while balancing the need for suspension with an appropriately comprehensive investigation. The norm is nothing like two years; suspensions are for a matter of weeks, or sometimes months.
I welcome the panel to the meeting. First of all, I seek some clarification on the evidence that we have just heard. I should say that I am coming at this issue as someone who was on the staff side in the NHS, so I want to get some clarity for other committee members who might not be as familiar with NHS policies and procedures.
Is it the case in all the NHS boards represented today that if a member of staff is suspended, that suspension will happen under policies that are underpinned by the PIN guidelines, which are agreed in partnership with the trade unions?
Moreover, is it the case in all your NHS boards that a staff member’s suspension is not a punishment and that, instead, it protects them and the integrity of the investigation?
Exactly. Is that staff member supported throughout the time that they are off? Do they have a contact person in your HR department?
And do they have access to a trade union representative if they are a member of that trade union?
Yes, and in addition, they can also directly contact our occupational health services in case they require other support.
I want to return to the independence of the whistleblowing champion, which is a concern that has been raised in some of the written submissions. In previous evidence, Sir Robert Francis said:
“The concern that some people have expressed and which I think we have to look at is that a non-executive director has a corporate responsibility to the running of the organisation”.—[Official Report, Health and Sport Committee, 13 June 2017; c 60.]
Can you clarify whether you are allowed to appoint someone who is not a non-executive director as whistleblowing champion?
As we have said, we are required to adopt and are expected to apply a national whistleblowing PIN policy—I think that we will be talking about PIN a lot today—and it sets out the investigation and decision-making arrangements for any case of whistleblowing. As it stands, though, it does not provide for what I think you have in mind with regard to independence; instead, it provides for an individual or panel to carry out an investigation within their current employment or connection arrangements, and that would include non-executives of a health board.
Can you see, though, why some people might have concerns about a lack of independence?
Absolutely. I can see why that might be the case, and what I would seek to do with such an individual is to convince them, if I can, that the arrangements that we would put in place would be sufficiently distant from those concerned with or involved in the subject of the whistleblowing case. I hope that that would give them confidence and a level of reassurance about objectivity.
Would it be possible to improve the process and policy to ensure that no one was left in any doubt whatever about the independence of the individual who is appointed as whistleblowing champion?
We would be foolish and naive to think that we could not improve on a lot of things. I would not disagree with you that in this case there is potential to build and sustain greater confidence.
Have any of your organisations discussed the possibility of making this process much more robust and independent by appointing someone who does not come from those organisations?
That has not been discussed in Lanarkshire.
Perhaps you could go back and make that suggestion, Mr Small.
I could well do.
I should point out that the whistleblowing champion is agreed in partnership. In 2015, I think, the Scottish Government wrote to boards about appointing a non-executive whistleblowing champion. As Kenny Small has said, we can always improve and feed into opportunities for improvement, but when these things are agreed in partnership at Scottish partnership level, our role is to ensure that we implement the PIN policies.
Speaking from my experience of being a non-executive director on a board, I think that the situation could be improved if the whistleblowing champion were absolutely independent of the board, because board members have certain responsibilities and they want to see that board performing well. My view is that that is a concern that we need to consider further.
I want to go on to the issue of blacklisting. We received written submissions from two doctors who detailed their experiences of whistleblowing and their consequent difficulties when they applied for jobs later on. Whistleblowers are not legally protected from the actions of a future employer. Does the NHS operate a blacklist?
In that case, why do you think that two of the written submissions that we have from doctors suggest that they have suffered consequences as a result of their whistleblowing? The Employment Rights Act 1966 protects people from suffering a detriment as a result of making a public interest disclosure. However, we have the written submissions that I mentioned, and I have met people who believe that they have suffered as a result of making such disclosures and who say that they have found it incredibly difficult, if not impossible, to gain employment again in the NHS.
That is a difficult question to answer. People’s perceptions are a reality, but we must accept that that is different from the position that an NHS board would take as an employer. It might sometimes be difficult to rationalise those two positions and bring them together in a way that enables people to come to a common agreement. I can only repeat that, to my knowledge, which is based on working in many health boards north and south of the border, there is no such thing as blacklisting. I would play no part in that, personally or professionally.
I agree entirely with that position.
Is that view shared by the other witnesses?
Yes. We have robust recruitment procedures that would preclude blacklisting.
I do not think that there is a blacklist, but there is only a small number of boards and it only takes a few calls between human resources staff, directors, senior managers or whoever to say, “Don’t touch her,” or, “Don’t touch him.” Does that happen?
Like Kenny Small, I have worked in a number of boards across NHS Scotland as a director in NHS Scotland, and I have never encountered that. It is not something that I would sanction in my team. It has not been my experience.
As chief executive, I have not had any experience of that happening. Certainly, my HR directors would give me clear advice about not being able to do that, and we would not want to in any case. We want to appoint people on their merit. Recently, when I was appointing a director, I had no knowledge of who the candidates were, because we redact all their personal information before the information is circulated for the shortlist. Even though it might be frustrating, we have no idea who people are when we shortlist them for appointment.
That is interesting. I do not want to identify the person, but I know of one case in which a person who raised serious concerns about clinical practice was suspended for five years. They had a previously unblemished record but, when they applied for one of 12 vacancies in the health board area, all the vacancies disappeared shortly after they submitted their application—the jobs were no longer presented. That person has never worked in Scotland again. That might be a conspiracy theory, but it seems a bit of a coincidence in the case of that individual.
When a petition on whistleblowing was brought to the Public Petitions Committee, we took a lot of oral evidence on the issue. It seems that there is a perception among NHS staff that whistleblowing will not be effective and that the whistleblower will not be able to effect change, and there is also a perception that being a whistleblower will be a blot on their copybook.
We have looked at the policies as they stand, whether they are good or bad. Should you be doing more to encourage NHS staff to come forward? As you say, very few of them do so, which raises a flag for me.10:00
If I were sitting where you are, I would see the world in that way—that is my immediate reaction. However, I do not see it in that way because I see whistleblowing as a failure. If a member of staff gets to the stage of having to resort to a whistleblowing arrangement, it means that our staff engagement processes—and their openness and honesty—have failed. In Lanarkshire, we have very solid and effective arrangements for staff engagement at a variety of levels—corporately through our operating divisions, right down to clinical teams and individual wards. That has a number of strands, which are driven through our approach to staff governance.
The starting point is our highly constructive and open relationship with our staff-side colleagues. Staff-side members are an integral part of our board and corporate management team. They work with us in an open-book environment such that if we have a financial or a clinical governance problem, the staff side is aware of that to the same degree as managers are. We do everything that we can to pass that message down through the organisation. Our non-executive and executive directors are out on the wards and the departments every week, conducting patient safety reviews and visits. An integral part of that is to promote their profile and so enable access. That means that, if staff have an issue, they know the relevant people by name and not just from a picture on a website.
We also go to the lengths of having HR surgeries, which go out to the organisation. I have a separate email address, which is called uMatter, to link it to the iMatter concept. Any staff member in Lanarkshire can email me at my uMatter account any time of day or night and they will get a response in 48 hours. They can ask me anything—and they often do. That is why I see whistleblowing as a failure. People who have issues or concerns have numerous routes and opportunities to raise issues, in the confidence—I hope—that they will be responded to.
I look at whistleblowing slightly differently. Although I do not like the term “whistleblowing”, I would consider it an opportunity to re-examine the systems that are in place and see how they can be improved.
For me, if someone has to whistleblow, it is because other systems—the routine, embedded ones—have failed. People should feel confident and free to raise an issue as locally as possible—sometimes that fails locally and it is orchestrated up the organisation, but that should rarely result in a whistleblowing situation.
I concur totally with Kenny Small. In the Western Isles we have several methods for staff to raise complaints. We have Datix systems; staff can enter complaints, issues and concerns confidentially and then receive a response. We have normal complaints procedures, a grievance policy and a dignity at work policy. As Kenny Small says, the use of whistleblowing is a last resort. Those formal processes are supported by the patient safety walk-arounds, the chief executive open meetings and the availability of directors to receive comments. We also work in partnership with the staff side through iMatter and the various HR forums across the Western Isles.
Whistleblowing is a last resort. We work closely with staff to ensure that any concerns are raised as locally as possible so that the issue can be resolved as locally as possible.
We had a session with middle managers in the NHS and they were very frank about the pressures that they felt under and the way in which the pressure from above to meet performance targets was driving everything. They said that innovation and concerns that were raised by their staff in the ward were often set aside because the target-driven culture is everything. They were very open and frank about that in our off-the-record session with them. Do you agree that that target culture is driving behaviours in the NHS that might end up being negative behaviours and might impact on front-line staff?
It is all about the culture of the organisation. We are there to deliver on the targets and the objectives that the Government sets for us but, importantly, we are also there to serve local people and protect our patients and clients. All staff in our organisations have the responsibility to say something if they see something, and we encourage that. Part of our local NHS Highland quality approach is to encourage staff to be open, and to work with integrity as part of a team. We triangulate what we are hearing in the boardroom by being—as I have already described—out on the shop floor and talking to staff. It is about accessibility.
I do not doubt that middle managers feel that they are under pressure in the system. However, they know that the most important thing is to protect the people whom we serve.
Their argument was that they are not doing that. They were saying that they have ideas about innovation in their wards or whatever service they provide that are being stifled by the target culture and pressure from the top on them as individuals. They were very frustrated by that.
I am sure that they could feel frustrated by that, but we need to encourage staff to take responsibility for their own work and make the changes in their own workplace, and we in NHS Highland are doing that.
That takes time, but we are certainly encouraging local staff to take every opportunity they can to do their job and to change their job for the better. In fact, they feel more empowered and more engaged to do that. I come back to my point about that being an issue of the culture in the organisation. We have to live it as well as saying it. It is really important for the staff to know that they will be listened to and that they can influence the way in which their jobs are working and how their services are run and organised.
One third responded positively to the statement that staff are always consulted about changes at work but 41 per cent would not recommend the NHS as a place to work. Significant numbers mention bullying—15 per cent talk about bullying and harassment at work. That is the kind of thing that those managers were getting across to us. Is that something that you recognise?
Like Elaine Mead, I recognise that the life of the middle manager in the NHS and in any organisation is always a pressured one, because they have pressures coming from the staff they manage as well as from the staff who manage them. That is the life of a middle manager.
I echo Elaine Mead’s thought that there are lots of pressures in the NHS. There are clinical pressures, public expectations and financial pressures, and these things come together to make the role demanding.
I do not recognise the statements that you are making either, convener. Middle managers are doing a good job in a challenging environment during difficult times. Speaking for NHS Lanarkshire, I can say that my middle managers are motivated, committed and good staff.
Those are not my statements; they are comments made by people who were giving evidence to us.
I agree completely with Kenneth Small. One of the differences between the staff survey and iMatter is the sense in which everybody belongs to a team, and that includes our professional middle managers.
NHS Tayside is driving a values-based process of cultural development that has empowerment leadership at its heart. In the iMatter outcomes, what corporately starts at about 76 per cent for to the extent to which individuals are treated with dignity and respect increases into the 80 per cent range when we look at the environment in which they work as a team every day—and that includes our middle managers. I completely agree with Elaine Mead that, as with any organisation, we are required to deliver outcomes and, in our case, those outcomes are throughput in terms of treatment. However, underpinning all that is the overall responsibility that we all have for the quality of care that is delivered and the clinical outcomes that sit alongside that. It does not matter whether someone is a chief executive, or a nurse, an allied health professional or a domestic—we all have a similar responsibility and a similar goal to ensure that those are delivered.
Jenny Porteous referred to the Datix system with regard to risk. That system is there to do exactly that at any level in the organisation; it allows any individual to report where they believe there is an emerging risk, so that it can be addressed in the organisation. At every level of NHS Tayside, the Datix results are scrutinised and reported transparently to our board to ensure that if, in any case, a team feels that the pressures on it exceed its ability to deliver, we are able to take action.
My question follows on from that. A recent poll in the British Medical Journal found that 91 per cent of doctors who responded believed that healthcare managers should be regulated in the same way as doctors are, and George Doherty has just said that healthcare managers take the same level of responsibility. The poll was accompanied by an editorial that quoted Sir Robert Francis and which said:
“When we look at what really goes on in a hospital, in the engine room, we’ve got consultants and, alongside them, managers. Together they are meant to manage a service and yet one side is subject to a regulator, and could be in jeopardy for any decision that they make, whereas the other side is not.”
I am interested to know whether any of the panel thinks that it might make a difference to the career of a manager or the quality of management in the health service if there was a regulated profession. If that would not make a difference, what would?
Maybe I could start—I think that my colleagues are looking at me.
I am very interested in that idea. There is a real opportunity for the validation of management in the NHS. I maintain a personal development plan to show that I keep up to date in what I do, which could be looked at by anybody, internal or external to the organisation. We all have to be able to evidence what we do. As Maree Todd says, validation is not there for managers at the moment, but my experience is that most managers continually learn. We are not subject to external validation but, personally, I would welcome it. A lot of managers would be very happy to subject themselves to the same scrutiny faced by our clinical colleagues, both nurses and doctors.
And pharmacists and AHPs.
And pharmacists and AHPs. I used to be an AHP, as you know.
I agree entirely with Elaine Mead. I also point out that much depends on the definition of “manager”. Many of our managers are already members of regulatory bodies—whether they are ward managers from a nursing background, who are regulated through the Nursing and Midwifery Council, AHPs, or human resources practitioners such as us, who have a chartered institute, as do our financial colleagues. All the managers whom I have worked with are intensely keen on on-going professional development in their own practice. Looking at my colleagues, I suggest that that is an area in which all boards are active.
It is also important to recognise that the vast majority of managers in the NHS—whether they are clinical or generic managers—operate under a performance management cycle, so they held accountable, their performance is regularly and routinely scrutinised, and they have objectives set for them against which their performance is measured. On occasions, those objectives are numerical, but they are also qualitative and about personal style. To come back to the subject of today’s meeting, they are also about how they lead and manage staff under the terms of the legislative staff governance standard. We adopt a very disciplined and robust approach to the standard, which I think does a good job.
Does the career structure attract the brightest and best, or could more be done to improve it? I know that that is a hard question.10:15
It is a difficult question. The answer, in part, is that we could do better.
Shirley Rogers, the director of health workforce in the Scottish Government, is leading an initiative that is looking back at our performance on leadership development, succession and talent management and questioning robustly whether we have got that right in the past and whether we have it right at present. There is a recognition that we could do better, and some thoughts are developing around that. There is a meeting on Thursday this week at St Andrew’s house to look further at how we bring together a series of initiatives on that front that will, if they are accepted by chief executives and so on, put us in a better place to answer your question more confidently.
I have a couple of questions on different issues. This one is for Elaine Mead in particular. NHS Highland operates the lead agency model, which is different from all the other boards. One of the advantages of the model, as it has been described to me, is that it has clear governance lines. Can you expand on that? Perhaps your colleagues can comment on how governance is different in other health boards.
It is a model that is unique in Scotland and, inevitably, I am biased about it. The clarity that we have around single management, single budget and single governance over the continuum of health and social care makes it very easy for me to be the accountable officer for the whole system. I can speak only for my system, but the challenges that we thought that we might have in transferring the employment of staff from the local authority to the NHS were in fact very easy to resolve with staff partnership support. We now find people working as genuinely integrated teams. The work of those teams has been even more beneficial to the patients and clients whom we serve than we anticipated.
The integration of health and social care can work in many different ways. As you are aware, there is an integration joint board model in NHS Argyll and Bute. However, we have been able to fundamentally change the whole culture of the organisation, with one team working in one organisation, as opposed to two different groups of staff working under different terms and conditions and with different policies that make it more difficult to take a single approach. As I said, I accept that I am biased about the lead agency approach, but it has been beneficial for us in NHS Highland.
Does anyone else have a comment?
We have a different arrangement in Tayside, as has been highlighted. I would describe it as our being on a journey. It is about partnership and partners coming together. Integration for us is about mutual learning. We recognise that we are two different systems. In governance terms, as a health board we are very clear about where our accountabilities and responsibilities lie, whether those are clinical or, given today’s agenda, about staff.
On governance for NHS employees, all our actions and reporting cover the members of our team who work in the health and social care partnership as much as they cover anyone who is based on the acute side. However, there is learning on both sides. I think that everybody recognises that we cannot impose one organisation’s culture on another. There are examples of good practice, such as in the Dundee health and social care partnership. Although it still operates as the NHS and the local authority, people are coming together and acting as single teams, and they see themselves in such teams.
The iMatter tool is being applied across our health and social care partners, who are as keen as we are to understand the experience. The local authority wants to understand how the day-to-day experience of its social care staff in working alongside their health colleagues can be more effective so that we act as a single system. There will always be purse-string issues in some of that, but from a governance perspective—particularly a staff governance perspective—we have a quite strong story.
My final question is aimed mainly at Elaine Mead and Jennifer Porteous. As well as purse-string strains, there are real challenges with recruitment in the Highlands and Islands. One of the ways in which we have tackled that is by using targeted campaigns in Europe to recruit European health professionals. Given that we have you here today and that recruitment challenges are definitely a huge underlying cause of staff stress, I would like to hear your thoughts on how we are going to manage the situation post-Brexit.
In NHS Western Isles, we were pleased a couple of years ago to lead on a northern periphery project on recruitment and retention, which included the Arctic countries. We were the only health board in Scotland that was involved, and we worked in close liaison with Greenland, Iceland and Norway. We think that we are remote, but experiencing the healthcare structures in those countries makes us rethink that.
We got some very good learning from that experience. The main outcome was identifying that there are twin key challenges in remote and rural areas: social isolation and professional isolation. We cannot address one without addressing the other. If we focus only on one, we do so at a cost for the other, and the change is not sustainable. For example, a campaign for particular career opportunities or learning and development opportunities comes at a cost for social isolation. Likewise, a focus on social issues such as housing or schools will not be a professionally sustainable solution.
We have been looking at taking a twin-track approach. With the medical director and the nursing director, we have been looking at opportunities with my colleagues in the north, particularly in NHS Grampian and NHS Highland, for staff to be professionally supported by the bigger boards for periods of time. We are working with Shirley Rogers and her team in the Scottish Government to look at ways to implement such best practice across Scotland.
It is no easy solution. I have worked in various health boards during campaigns in eastern European countries for professions such as dentistry. Such campaigns might work initially, but unless the infrastructure is in place to give long-term support, they are not effective.
Where is the recruitment campaign in Scotland? When I worked in schools, no one from the NHS ever came in and said to kids, “This is your career.” I have never seen a television campaign that says, “Come and work for the NHS,” or a newspaper campaign that says, “This is the career of the future”. Do such campaigns happen?
I am happy to pick that up. In the Western Isles, we have a placement scheme for school pupils to taste jobs in the NHS, ranging from catering to nursing. We are also starting a medicine for schoolchildren programme, to encourage young people who are interested in going to medical school—we have 90 places a year for that. We do local careers fairs in schools and across the islands, including Uist and Barra.
There are also national careers fairs; I think that one is currently going on in Liverpool. On Friday, we met and spoke to general practitioners who represent the health service there about the material they are going to use that focuses on remote and rural areas.
Again, we have a two-pronged approach. We have on-going placements for our local schools and colleges to support people in understanding the kind of jobs that there are in the health service, with a focus on encouraging people into jobs that they might not think they would be interested in, such as engineering and so on. We also have the national campaigns.
The recruitment campaigns do not appear to be very “in your face.” There are private sector employers who very obviously use all sorts of methods to recruit people into posts, but the NHS, which is the biggest employer in the country, is well below par at doing that.
I support everything that Jenny Porteous has just described. There is a similar story in Tayside, although it is not as picturesque as Uist and Barra. Our engagement also starts at school.
My board has a very active modern apprenticeship programme; the cabinet secretary was in Tayside earlier this year, celebrating that programme. We have pioneering apprenticeships in social care, payroll, hospitality and healthcare and we are very active in promoting them locally across Tayside and beyond. We receive about 500 applicants per place, such is the demand to work in the NHS.
The point about opening up an understanding of the wide range of roles and professions that exist in the NHS has been well made. We can always be better—collectively and individually—at doing that, but we are extremely active in our communities, and we tend to take a high-profile approach to the issue.
I want to go back to the discussion about the iMatter survey and how it compares with the staff survey. The iMatter survey is described as a continuous improvement tool, which I think is great—I have experience of such tools in previous work. It is valuable that you are moving in that direction.
The staff survey provides some clear metrics on whether the NHS is a good place to work and whether staff are consulted. Kenneth Small mentioned that iMatter is different and is not directly comparable with the staff survey. Will direct questions be asked at a top level that will allow us to make sure that the continuous improvement stuff is working and to take a view on how the whole system is performing?
The iMatter approach is embedded locally, but it also has a corporate structure to it. Every health board will ultimately—by that, I mean by the end of this year—have a staff engagement score, which will be built up from a pyramid of contributions from the local action plans and local participation by staff. As to whether it will explicitly say how good a health board is at staff engagement, it will not give the board a score for that, but it will give a feeling for general staff wellbeing on the basis of an arithmetical score.
However, as the HR director of my board, I can look at as many of the action plans—and their focus—as I wish to. An administrative approach is taken that will allow me to do so. There is nothing to stop individual boards picking and choosing certain things through the staff governance action plan, because we are not doing away with staff governance action plans. We will have corporate, divisional and local staff governance action plans that we will feed messages and priorities down through. If I perceive, as a result of being out and about and listening to people, or receiving uMatter emails, that staff are unhappy or aggrieved, I will say, in 2018-19, that I want a series of actions and proposals on staff engagement, enhanced staff training and development or whatever the priority topic of that year might be to be embedded in the action plans. It is a case of listening, but it is also a question of feeding in and informing.
Right, but there will not be a dashboard that will allow the committee to say, next year or the year after, that NHS Western Isles scored X per cent on this question and NHS Greater Glasgow and Clyde scored Y per cent on that question in the way that we can at the moment. Is it correct to say that we will lose that ability?
I think that we are gaining rather than losing—
We are gaining something else, but we are losing that ability.
It is something different, but that something different is embedded in greater participation and a greater feeling of being informed and being able to respond to what the staff are saying.
There is one other point that I should make, as we have not mentioned this yet. As part of a national exercise, we have looked at what iMatter covers. It is a series of questions that are largely what was in the previous staff survey, but they are embedded in an iMatter wellbeing quotient or score. However, there were elements of the previous staff survey that were not caught in the iMatter questionnaire. I am talking about areas of interest to the committee and to me that were largely to do with harder-edged—if I can use that term—issues such as bullying and harassment and health and safety.
Therefore, at the end of this calendar year, we will carry out a supplementary survey. We have managed the process as carefully as we can, because we do not want to confuse staff and make them think that we are just running another partial staff survey alongside iMatter. There is a gap in the current staff engagement on issues such as bullying, harassment and violence—whether verbal or physical—at work. We will conduct a supplementary survey on some of those harder-edged issues, which will be agreed with the Scottish Government as a corporate process across the NHS. That will feed into its own action plan, which will be aligned with and supplementary to the iMatter work.
Okay. So, in summary, we are gaining a lot, but we will not have the hard numbers that we as a committee can look at and say, “This is the score”, and identify how it compares with last year’s score and how, at the top level, different health boards’ scores compare.10:30
I go back to what Kenny Small described in relation to the iMatter outcomes at the board level. There is the staff governance action plan and, in Tayside, we have the people matter strategy, which is built on top of that. All of that is published and is in the public domain, so any member of the committee can look at our position from year to year, what we are doing and what, for us, are the key issues. We do that through our staff governance committee in open business.
I am still not sure. Does that mean that we will have charts of data to look at?
You will be able to track my board’s progress.
At the moment, I can sit here and see that NHS Western Isles is the best on a particular question and compare, by health board, what happened in 2013 with what happened in 2015 across Scotland. Will we still be able to do that?
It is a matter for the Scottish Government to determine how it wishes to use the data but, as Kenny Small has already explained, each board has an overall staff engagement score, and that score is and will be published. The outcomes of the pulse survey that will be brought forward at the end of this year will be commonly reported across all the boards.
In the art of the possible, that ability to examine could happen but, as George Doherty said, the Scottish Government would need to be the parent body that analysed and interrogated and then created that report. The individual boards have their scores and build action plans corporately and locally in relation to those scores, but somebody else would need to aggregate all of that. To my knowledge, that is not routinely in the planned system.
In its submission, NHS Highland said:
“The Staff Governance Standard was implemented at a time of growth and relative prosperity, when the financial challenges in the NHS were not as significant as they are today. Engaging staff in times of austerity where there are real budget and staff pressures and the requirement for significant organisational and service change to ensure that services are sustainable, is more difficult.”
Is that the nub of where we are at the moment? In our constituency caseloads, many of us—maybe most of us—have lots of NHS staff telling us that they are under pressure that they have never felt before. We have heard that in evidence, too. People not being released for things such as training and events has been mentioned. My wife works in the NHS and in a 12-hour shift last week she walked 10 miles and had two 15-minute breaks. That is not unusual. People routinely do not get things such as breaks. That kind of thing is going on, and staff are feeling real pressure. There are not enough staff to do the job and there is reliance on bank staff, for example. Do you recognise that? Are staff saying to you, “We really are feeling the heat here”?
I absolutely recognise that.
I asked the question because that has not come over in your evidence today. It came over in your written evidence, which is really good, but the general feeling that I get from the panel today is that, in answering our questions, you are putting a very positive gloss on everything. Of course, it is your job to do that, but there has not been a recognition of the massive pressures that people feel on a day-to-day basis. Will you comment on that?
I am very happy to comment on that and, of course, to thank our staff, who do a fantastic job every day. It is important to do that in valuing our staff.
The NHS has to change. The current models of care are no longer sustainable, and we increasingly understand and accept that. This is a time of great change, and change causes uncertainty for staff, so we need to engage the staff in that process of change. As we transition from the old way of working to what will need to be a new way of working with potentially different models, that will sometimes feel very uncomfortable for staff. That means that the staff governance arrangements and our partnership working are more important than ever before.
I do not think that any of us has pretended anything other than that the NHS is a pressured environment for all at the moment, and it probably has been for many years.
Is there more pressure now than ever before?
There is a different pressure. Increasingly, we see an opportunity through the national delivery plan to create, with a fair wind, a light at the end of that tunnel. Lanarkshire has a history of being fairly pragmatic and sometimes brave. At the moment, we are having a fairly challenging but, I hope, constructive conversation with Government on budget, budget capacity and capacity to deliver targets, care and health improvement in the way that we would like to. We are saying to Government that some of the targets that it has set will not be met because we do not have sufficient resource or capacity to do that, and we are having an adult conversation with Government about the art of the possible within that capacity.
Our calculations take into account the demands that we put on staff and our ability to recruit, retain and provide staff in certain areas. The islands are not unique—there are vacancies all over Scotland in general practice, primary care and community care. One of the approaches that we have taken to our ability to maintain capacity has been to engage with the very staff you are talking about, who are enduring the pressure, and to ask them, “What would you do?” We want to get their ideas on where we can make efficiencies, improve performance and reduce costs, based on their knowledge and experience of the front line, which is where it matters.
We have a rigorous approach of staff engagement, which goes down from our employee director through staff-side colleagues into wards and departments, to build ideas on the initiation of cash-releasing efficiency savings and other efficiency savings, but the reality is that we will never have enough money. It will almost never be affordable to meet public demand and expectation as well as clinical expectation on modernisation, new models, the use of robots and all the other things that people would like to do in their clinical worlds. Therefore, we need to make the best of what we have. For my board in the west of Scotland, that is about how we make more sense of our joint capacity. How can we use the scale and complexity of the health service in the west of Scotland to improve our ability to deliver? That will bring challenges back to politicians and to the public, because services in people’s back yards are possibly no longer affordable, so we need to aggregate and create economies of scale, through which people will get better care, but not necessarily in the same geography.
Okay, folks, we are out of time. Thank you very much for your evidence. I suspend the meeting briefly to allow us to change the panel.10:37 Meeting suspended.
10:42 On resuming—