With the committee’s agreement, we will change the order of the agenda. We will take item 3 now and take item 2 when we find our witnesses for that item. Is that agreed?
Members indicated agreement.
National Assistance (Assessment of Resources) Amendment (Scotland) (No 2) Regulations 2016 (SSI 2016/80)
Agenda item 3 is on subordinate legislation. We have five negative instruments to dispose of. There has been no motion to annul the first instrument and the Delegated Powers and Law Reform Committee has made no comments on it. As no committee members have any comments, do we agree to make no recommendation?
Members indicated agreement.
National Assistance (Sums for Personal Requirements) (Scotland) (No 2) Regulations 2016 (SSI 2016/87)
There has been no motion to annul the second instrument and the Delegated Powers and Law Reform Committee has made no comments on it. As no committee members have any comments, do we agree to make no recommendations?
Members indicated agreement.
Country of Origin of Certain Meats (Scotland) Regulations 2016 (SSI 2016/84)
There has been no motion to annul the third instrument. However, the Delegated Powers and Law Reform Committee has commented on it. That committee has drawn the Parliament’s attention to the regulations on the general reporting ground that some of the terms that are defined in the instrument are superfluous, as they are not used elsewhere in the instrument, so they should have been omitted. It must be said that the Scottish Government has advised that, although the words have no effect, they will be removed at the next convenient legislative opportunity.
As no members have any comments, does the committee agree to make no recommendation?
Members indicated agreement.
National Health Service Pension Scheme (Scotland) Amendment Regulations 2016 (SSI 2016/97)
The fourth instrument is the National Health Service Pension Scheme (Scotland) Amendment Regulations 2016. I see people in the public gallery bristling and sitting up straight at the mention of the pension scheme, but I had better push on with the formalities.
There has been no motion to annul and the Delegated Powers and Law Reform Committee made no comments on the instrument. As no members have any comments, does the committee agree to make no recommendations?
Members indicated agreement.
National Health Service Superannuation Scheme (Miscellaneous Amendments) (Scotland) Regulations 2016 (SSI 2016/98)
There has been no motion to annul the fifth instrument and the Delegated Powers and Law Reform Committee has made no comments on it. As no members have any comments, does the committee agree to make no recommendations?
Members indicated agreement.
Thank you for that; we have made some progress.
Healthcare Improvement Scotland (Delegation of Functions) Order 2016 (SSI 2016/86)
We move to agenda item 2, which is oral evidence on one negative instrument. The instrument gives Healthcare Improvement Scotland the power to direct health boards to close hospital wards to new admissions when there is a serious risk to life, health or wellbeing.
I welcome—again—Maureen Watt, Minister for Public Health. I also welcome from the Scottish Government Elizabeth Sadler, head of the planning and quality division, and Ailsa Garland, principal legal officer, and from Healthcare Improvement Scotland we have Robbie Pearson, interim chief executive, and Jacqui Macrae, head of quality of care.
I invite the minister to make a short opening statement. Thereafter, we will move to questions.
Thank you for providing me with the opportunity to explain the rationale behind the Healthcare Improvement Scotland (Delegation of Functions) Order 2016. Tackling and reducing healthcare associated infection and containing antimicrobial resistance remain a key priority for ministers and the Scottish Government. Latest figures show that, since 2007, cases of Clostridium difficile in patients who are aged 65 years or over have reduced by 84 per cent and cases of methicillin-resistant staphylococcus aureus—MRSA—have reduced by 88 per cent. Although that demonstrates significant progress, the challenge is to look at ways to continue the reduction in order to drive down HAI rates.
The incidence of key HAIs has plateaued over the past two years. We need to work even harder to ensure that those figures move in the right direction as we strive to make appropriate and updated advice accessible to all who deal with infection prevention and control.
The Government will continue to drive forward improvements across NHS Scotland as we work closely with Healthcare Improvement Scotland, Health Protection Scotland and the Scottish antimicrobial and healthcare associated infection strategy group to reduce infection rates further. We will also support health boards to deliver further improvements for the safety of healthcare staff, patients and the public.
I turn to the specific measures that the order contains. The Scottish Government fully accepted all the recommendations that were made in the Vale of Leven hospital inquiry report. Recommendation 1 in Lord MacLean’s report was that the
“Scottish Government should ensure that the Healthcare Environment Inspectorate (HEI) has the power to close a ward to new admissions if the HEI concludes that there is a real risk to the safety of patients. In the event of such closure, an urgent action plan should be devised with the Infection Prevention and Control Team and management.”
The order implements that recommendation by giving HIS the powers to direct a board to close a hospital ward to new admissions when HIS considers that, without the direction to close, there would be a serious risk to life, health or wellbeing. The powers will not be limited to closure for reasons of cleanliness and will apply for other safety reasons, such as staffing levels and other non-medical reasons. The powers are designed to ensure patient safety and it is therefore right that they should cover all circumstances in which there is a serious risk to life, health or wellbeing.
In conjunction with the Scottish Government and other interested stakeholders, HIS has developed an escalation procedure that includes arrangements on the powers to direct the closure of wards to new admissions. The draft procedure was shared with health boards on 3 March for their views and I have asked for a copy of the final paper to be sent to the committee for its information.
I should stress that closing a ward to new admissions is intended to be an option of last resort and that we hope that it is never needed. I assure the committee that HIS will work with NHS boards—particularly chief executives and medical directors—to address any concerns that are raised as a result of an inspection of any hospital. My officials have confirmed that the escalation procedure will provide a clear, transparent and consistent process to manage the identification and escalation of serious issues that might be facing NHS service delivery, quality, safety of care and organisational effectiveness.
The escalation process will ensure clear communication paths across all stakeholders, clarity over roles and responsibilities, and an explicit record of actions that have been undertaken in partnership with boards to secure a timely resolution. Consistent and effective communication between HIS and board officials will be crucial to achieving that resolution.
The order meets our commitment to implementing recommendation 1 of the Vale of Leven hospital inquiry report. It gives HIS the power to direct NHS boards to close a hospital ward to new admissions when HIS considers that there is a serious risk to life, health or weIlbeing. The draft escalation process that HIS has published makes it clear that the power will be used only very rarely and as a measure of last resort. It is, however, an important additional tool to safeguard patient safety. I am happy to answer any questions that members have.
Thank you, minister.
The minister has said that she does not believe that the power will be used often. In what circumstances does she see it being used? What will the process be? We know that health boards can close wards to new admissions at the moment, so what will be the process if HIS does that rather than the health board?
The powers will be used only in unusual situations. There are powers in the National Health Service (Scotland) Act 1978 for ministers to take action when certain bodies, including health boards, are failing to carry out their functions. We do not envisage a situation where those powers would be used, given the close understanding and co-operation that there is between ministers and boards. The situation would have to be very unusual.
Does any of the team want to add anything?
11:00
We are clear that Healthcare Improvement Scotland’s role sits within a broader escalation framework. That framework is in place ahead of the powers and is used in our inspections when a cause for concern is found—that might be about ward staffing levels or infection control.
The key part of the existing escalation process is local resolution of concerns. In my experience as director of scrutiny and assurance for four years, in the vast majority of instances those issues are addressed and resolved at local level, with the intervention of our inspectors, who work closely with staff on the ground.
If the powers were to be applied, that would be a last resort, as the minister described. Using the powers would require escalation to Healthcare Improvement Scotland’s chief executive and discussion about the concerns with the chief executive of the health board involved as the accountable officer. The chief executive of that health organisation would be asked to take steps to prevent admissions to the affected ward.
If the chief executive of HIS and the chief executive of the health organisation failed to reach agreement that preventing admissions was the most appropriate action, the steps under the powers would be for HIS to instruct that health board to stop all new admissions to the ward. It is important for the committee to understand that the escalation algorithm is at the pinnacle of an escalation process and needs to be seen in that context.
Closing a ward to new admissions makes sense if it is for infection control purposes. Those who might already have been infected would be isolated and not moved to the rest of the hospital.
However, if the concern is about patient safety and staffing numbers, surely the patients who are left in the ward are still in danger. What steps will you take to deal with the dangers if the issue is not the more easily understood one of infection control?
If the concern was about ward staffing levels, a reduction in the number of admissions to that ward would clearly be beneficial, as the cohort of available staff would be managing a much reduced number of patients. That would be an immediate action.
The important point for the committee is that boards already take action when there are concerns about, for example, staffing levels or infection control. In a norovirus outbreak, for example, boards take action to prevent admissions to wards if there are concerns about patient safety or a risk to life or wellbeing.
Closing a ward to admissions is an important step in relation to staffing levels, but the committee will be aware that there is a range of scenarios in which such steps might have to be taken.
We are not necessarily aware of the range of areas that fall into the category of a serious risk to life, health or wellbeing. We have established that there are a few areas—they involve infection control, staffing levels and the staffing mix—where remedies are already in place. What other scenarios would you include in the list for potential use of the powers?
An example would be a theatre in which someone notices that cleanliness is not up to standard. Do you want other examples?
So we have theatre situations, staffing levels and mix, and infection.
One example would be extreme pressure at the front of a hospital from the number of A and E attendances and patients requiring to be seen in an assessment unit. That might have an impact on safety and demand in the hospital overall and on how patients are managed within the flow of that hospital.
Jacqui Macrae may wish to add other examples.
That is the only other example that I can think of.
I reiterate that our general experience is that boards take immediate action to resolve such issues and take into account the safety of patients in the whole system rather than just at the individual point of concern.
The issue is the power that the order gives HIS. I can see a ward being closed to new admissions when there is an infection. I can see a decision to close A and E when a major accident has occurred and emergency planning is coming into place such that people are being sent to other hospitals in an immediate area. We know that that happens and we know that infection happens; we read and hear about such situations.
What powers does the order give HIS or the Scottish Government that we do not already have? What will your role be in such a decision? When will the decision be yours? Who will decide that a health board has failed to act in the face of a risk to the life, health or wellbeing of its patients? I have difficulty in seeing where the order will be relevant and what additional powers it gives us that we do not already have.
The order has been made because one of Lord MacLean’s recommendations in the Vale of Leven inquiry report was that the Scottish Government should ensure that Healthcare Improvement Scotland had such a power and that the power was not left just to health boards. He felt that there might be a gap. The order comes specifically from his recommendation in that report.
A wider point is about whether Healthcare Improvement Scotland is a regulator or a part of the health service. Was Lord MacLean getting at that?
A broader consideration of Lord MacLean as chair of the inquiry was that additional powers were not needed, beyond those in the first recommendation. The inquiry report made it clear that there is sufficient independence and separation at present in Healthcare Improvement Scotland’s role.
I am not totally satisfied with the answer to my previous question about staffing numbers being seen as unsafe for patients. Closing a ward to new admissions means that the safety pressures do not escalate, but it does nothing to remove them, unless the hospital suddenly starts to discharge patients. However, we cannot assume that patients will be discharged, because we do not know what the nature of the ward will be—patients could be there for the long term. How will you deal with the safety risk for existing patients in the ward?
Hospitals already deal with that issue. As we have stated, a norovirus outbreak can affect not only patients but staff. That is why a ward would be closed to new admissions and why staff would be moved from other parts of the hospital, to make sure that the patients who were already in the ward and who were not fit to be discharged were looked after.
What powers does the order provide to increase staffing levels, rather than just stop admissions, to deal with patient safety concerns?
That would be discussed with all the partners who are involved because, as we have said, the decision would be taken not by HIS alone but by HIS in conjunction with the health board, the senior management and, if necessary, ministers.
The order is restricted to simply giving HIS the power to give the direction to close a ward. I understand that the escalation procedure involves discussing measures to improve the situation in hand. What to do about the situation that led to the direction to close a ward would be part of a wider procedure.
Mr Pearson, will the order give you greater power in your relationship with health boards to get quicker action? Will it help in that discussion or negotiation?
Yes. The order allows us a degree of direction, formality and legal power that we do not have at present. The important point is that that does not take away from or disturb the accountability of health board chief executives for delivering safe services to their populations. They remain accountable for the safety and wellbeing of patients who are in their care and for the mix of services that are provided, which includes the workforce and staffing levels.
Mike MacKenzie has a supplementary question.
Mr Pearson, you mentioned that an algorithm would be used in the decision-making process. That thought fills me with concern. Will the decision be made by a human being or by a computer? I am sure that you could understand public concern about that if it is a case of, “Computer says no.” I am interested in finding out a wee bit more about the algorithm, so will you share that information with the committee, perhaps in writing? Will the algorithm take into account geographical circumstances and capacity issues that might be found in places such as Orkney, Shetland or the Western Isles? Will it take into account the prevailing weather conditions, which might mean that it is impossible to evacuate patients to alternative facilities on the mainland?
I assure the committee that the algorithm is not some remote computer-generated yes/no answer. It will be informed by clinical and professional judgment on the ground and by senior inspectors working with staff in delivering those services. It is about professional judgment and about the appropriate management of risk. I emphasise that the algorithm can only guide. It is not fixed—it guides and influences. It has a number of steps but, at each step, there is a professional judgment to be made about risk and the impact on the quality of care for patients.
On the operating context, I think that Mr MacKenzie makes a general point about remote areas and rurality. Those issues would be part of the risk assessment in assessing the situation on the ground. Obviously, the delivery and pattern of health services vary vastly across Scotland. It is key that we take into account the operating context and understand the distribution and mix of services. For instance, the responses might be different when dealing with a hospital environment that has a large number of single rooms and when dealing with an open-plan ward environment.
Mr Pearson has just pre-empted my question, but I seek clarity with regard to single rooms. A ward may be comprised of a number of single rooms. Rather than close the ward, you may wish to isolate individual rooms. Can you give us greater clarity on that?
That is an important point. In new hospitals such as the Queen Elizabeth university hospital, which has single rooms, the response is different from the response in more traditional, open-plan, Nightingale ward environments. Again, it comes down to a careful assessment of risk for individual patients and how that is mitigated on the day to ensure that new admissions can be made to the ward as quickly as possible.
Jacqui Macrae might wish to add more detail on that.
It is very much about the individual context. We should bear in mind the timescales within which things might happen and how the decisions would be taken to reopen areas. Mr Robertson is right that, with a ward area that has predominantly single rooms, it might, for example, be possible to isolate a specific area and deep clean it so that the impact on the service that is being provided is minimal. However, in a completely different context, such as a Florence Nightingale-type ward with longer-term admissions, if the issue is around staffing levels, it might take longer before things can be put in place so that we have assurance that the situation is safe enough again to open the ward to patients. It is context specific.
I was just looking for a degree of clarification that, in some of the new hospitals in particular, single rooms could be isolated and you would not have to close a ward per se. Where there is a mix of single rooms and Nightingale wards, there is the potential to move a patient into a single room, where they can be isolated. I wanted to tease out from you that there is that flexibility. I acknowledge that closure to new admissions would be a last resort.
11:15
My question is in the same vein, given that we have been talking about staffing levels and concerns about closing wards. In its submission on the order, the Royal College of Nursing Scotland said:
“Closing a ward may be necessary because of a systemic failing in a service. It also may be the result of a health board trying to meet a Scottish Government-set HEAT standard that applies to one part of the service and has unintended consequences on another part of the service ... The RCN would not want to see a situation where individual staff members working on wards are penalised because of a systemic failing or from the unintended consequences of a health board’s effort to meet a HEAT standard.”
What are your views on that comment, minister?
I do not think that that would ever happen. It is not the intention that particular members of staff would be penalised. That is perhaps rather a negative view from the royal college. As I said, there is collective responsibility. The order is not about penalising staff, nor is it about meeting the health improvement, efficiency and governance, access and treatment targets; it is about ensuring that the wellbeing and safety of everyone involved—staff, patients and the public—are paramount.
Thank you. I just wanted to have that comment on the record.
The order is a response to a recommendation in the Vale of Leven hospital inquiry report. Given that that is the context in which we are considering the order, I want to put on record that my family had recourse to the Vale of Leven hospital in recent months, when my mother received palliative care there. The hospital provided an outstanding service and did very well by my mother and my family.
The witnesses have got the short straw, to some extent, because you have been urged to think of cataclysmic scenarios in which HIS would use these proposed powers of last resort, and when you could not quite come up with such scenarios members have raised issues around that. We did not foresee what happened at the Vale of Leven, and we never know when the powers might be needed—I get that.
Given that we do not always know what tomorrow will bring and that we might need to use the powers in circumstances that are currently unforeseen, I suppose that speed is the issue. I will not ask for a scenario, but I want to explore the speed of the chain of events whereby HIS’s attention would be drawn to a significant issue, by whatever mechanism. I imagine that the escalation process in the health board and in HIS could take quite a bit of time and be quite bureaucratic, and I am looking for reassurance that that would not be the case if there was a significant issue.
Thank you for your comments about the Vale of Leven hospital. Lord MacLean’s report contained 75 recommendations, of which 65 were for the NHS, nine were for the Scottish Government and one was for the Crown Office and Procurator Fiscal Service. All the recommendations were accepted and are being implemented.
Your question takes us back to Mr MacKenzie’s question about the algorithm, which is a framework that provides a brief description of the roles and responsibilities of each national group and the people involved. By having that, we can speed up the process, as you suggest that we would need to do. I do not know whether anyone else wants to come in on that.
Speed is of the essence in such a situation. Our current escalation process is extremely fast—I am only a phone call away from Jacqui Macrae and others in the senior inspection team, and decisions are made on the ground in real time to ensure that patient care is not compromised. The escalation algorithm cannot be a bureaucratic process: if it is a continuation of the existing algorithm, it must have the same degree of speed. We need to ensure that decisions are made as swiftly as possible.
I am glad that there is some reassurance in that answer. I do not want to explore the algorithm—I will leave that to Mike MacKenzie. I want to look at the human-touch aspect, which involves people picking up the phone and speaking to the most senior person at the health board. I am talking about people phoning to say, “Who is the chief executive? Clear her diary and let’s have that meeting. We have to chat. We have enforcement powers if they need to be used.” That is what I was looking for. Somewhere in those answers I got that message, but I also heard about the algorithm, which I will not explore any further. I am reassured by Robbie Pearson’s answer, which was in effect, “We’ll pick up the phone and chat immediately.” That is what I hoped to hear.
We have a wonderful NHS, but you never know when things will go wrong in such a vast organisation. There will always be a situation in which a health board, without enforcement powers, may decide to close a ward to new admissions because of unforeseen events. I would like to think that contingency planning takes place in NHS boards anyway.
I have explored the area of speed and received some reassurance in that respect. We never know where the need to use those powers may manifest itself, and I would like to think that health boards already have in place contingency planning for what they would do if something happened. It could be a fire alarm going off or a health and safety issue, or it could be to do with the fabric of the building. There does not necessarily have to be a clinical incident to bring about a situation in which wards cannot be used.
Does HIS have a role in ensuring that boards have effective contingency planning in place, or do boards make such plans anyway? What mechanisms are in place for that?
We do not have a direct role in health board contingency planning. Health boards have a role in ensuring that they have robust disaster recovery and contingency planning arrangements in place. Chief executives, as the accountable officers, will test those plans and ensure that they are robust and effective.
When we carry out inspections, we look at how those plans are understood by staff and how they would be deployed in certain situations. Examples include healthcare environment inspections, in which we look at the plans for certain incidents, and inspections of older people’s care, in which we look at the arrangements for staff levels. Although boards have responsibility and accountability for those arrangements, we take an interest in the robustness and effectiveness of those plans.
That is right. If there were issues around fire regulations, for example, we would test staff on their knowledge of how they would evacuate a building in the event of fire. These issues come up periodically across our inspection programmes.
I accept that contingency planning is a matter for the health boards. However, let us say that you needed to have immediate and speedy conversations, although we hope that you do not have to have such conversations, with a health board chief executive to say, “If this doesn’t get sorted, we will instruct you to take this action”—closing a ward to new admissions, for example. Would you at that point expect to say, “Although we don’t want this to happen, we might do it in the next few days, so what are your contingency plans?”?
Absolutely—that is an important point. We expect the boards as of now to respond to concerns that we identify in inspections, even without these powers in place. In my experience, boards respond very swiftly, and we have follow-up mechanisms to ensure that arrangements are in place and are effective.
It is probably the lack of brevity in my questions that means that I am not clear on the answers.
Brevity?
I know, Mr Robertson—I am not renowned for it. I hope that the process of escalation is quicker than my questions.
On the first occasion that HIS has that conversation with the health board and says, “We might use these powers”, do you at that point say, “We must see your contingency plans”?
Absolutely. That is the point of the powers—they are there in reserve and boards know that we have them, which informs how they respond.
There is a much more difficult area, in a practical sense, than what we are puzzling about just now. If the place goes on fire or there is disease, it is fairly obvious: there is a smell of smoke and bells are ringing, or there are people being sick. However, a controversial area—it has been controversial in some of our discussions, and has been mentioned this morning—is the question of staff mix and staffing levels. What is your role in such situations, and how do you escalate issues quickly?
You are not there when the staffing levels on two or three shifts have dipped because of sickness, pressure or whatever; you are not there when there is only one senior nurse for a ward full of 20-odd people. How do you intervene reasonably in that situation, wag your finger and say, “If you do not get that sorted out, you are potentially at risk of having that facility closed down because you are not staffing it properly and the staff mix is not right”?
Your relationship up to now with the health boards, Mr Pearson, has been to seek improvement—not conflict, with the imposition of rules from outside. You give people lots of time—weeks or months—to deal with some of the issues that you identify in inspections. Sometimes, you trust them to tell you that they have dealt with the issue and you do not go back to inspect them again for some time.
How do you deal with issues as complex as the staff mix and staffing levels?
There are a number of levels to consider. First, we take an interest in staffing levels—increasingly so in our inspections of older people’s care, for instance. We ask to see staffing rotas not just for the day of the inspection but for the previous weeks as well as the projected staff rotas over the next period of time. That is an area of increasing interest.
On the timetable for a response, we have a fairly swift escalation of concerns within our existing algorithm, but we also set in place requirements—for example, in the Healthcare Environment Inspectorate, we set a timetable for NHS boards to respond to those requirements based on our concerns. We can say that our expectation is that our requirements will be in place when we come back the next week or the following day, so there can be a swifter turnaround.
On a broader issue, we consulted last year and are taking forward work under the quality of care reviews to look at more comprehensive assessments of healthcare and the things that impact on healthcare. Workforce and leadership are fundamental components in that regard. We have had bigger and broader reviews around that, such as in NHS Grampian, at Aberdeen royal infirmary. The intention is that we will use that much more systematic and comprehensive assessment of workforce effectiveness and leadership in the future, which will enable us to get into those more complex issues.
The order would help HIS to make progress in that area of establishing—
It is an important power for us to have but the broader question is how we take forward that deeper consideration of the factors that impact on the quality of care.
We know that the Care Inspectorate, in inspecting residential facilities, focuses on elements such as staff changes, which can sometimes cause failure. I will return to that point later and to some of the committee’s recommendations about HIS and the Care Inspectorate working together and learning from each other on some of those issues.
HIS does not have the power at present to direct health boards to close wards, but does it have the power to direct boards in relation to each of the other steps in the escalation process?
For those steps that are about co-operation between HIS and the NHS boards and, ultimately, the chief executives of the boards, HIS has sufficient power at present. The final power to close a ward is informed by that co-operative relationship in the escalation all the way up to the use of that ultimate power. There is not a series of subsidiary powers underlying that. The legal directorate might be able to confirm that I am using the correct language.
I agree with Robbie Pearson.
Some people might ask why HIS is not being given a wider power; other people say that HIS should not be given this power. However, it could be argued that, if it is a process of steps, why is HIS only being given the power for the ultimate sanction rather than having a directive power over the other areas as well?
11:30
I feel that the powers that the order will give us and the ultimate sanction are sufficient without a whole series of other separate powers, which might lead to a more bureaucratic debate and discussion at each of those steps. The key point is about the speed of the response at the moment of concern. That is what is critical, rather than a series of subsidiary pieces of legislation or powers underlying the overall sanction.
During the four years that you have been director of scrutiny, can you think of occasions—without naming the place—when you would have found that power useful?
In all honesty, I believe that boards have responded without our having that power, but it is still an important power to have in a context where there may be serious and significant service failings. We have carried out 535 reviews and inspections since the establishment of Healthcare Improvement Scotland, and we have formally escalated matters of concern to the Scottish Government on five occasions. That reflects a number of things. The main thing is about the quality of care, but it is also about the fact that, where we have escalated cases, whether informally at local level or more formally to the chief executive, the boards have responded.
I do not know whether this question is for you or for the minister. Given that the cabinet secretary already has the power to direct health boards, why do you need this power specifically, rather than just going to the cabinet secretary and saying what requires to be done?
The important point is about the overall shape of accountability in Scotland. There is quite a shallow hierarchy in the health service in Scotland and there is a short escalation between the chair of a health board and ministers and the cabinet secretary, so it is important to think about that Scottish context. The other point to make is that the powers also sit in a broader context of powers for ministers in the ladder of escalation and of the powers that ministers have to intervene in a health board more generally.
The cabinet secretary would be involved at all stages. The information flow is quick for such things.
That relates to some of the questions that were raised by the RCN about political interference. If you feel that you have to escalate a case, but it is the wrong time of year or the wrong time in the political cycle, and you are proposing the closure of a high-profile facility six weeks away from an election, the cabinet secretary—whoever he or she may be—could say, “No, I don’t want that bad news at this time.”
Patient safety is paramount.
That is right. Patient safety is the most important thing. The powers are intended as a backstop, to be used when all else has failed. Giving the power to HIS to ask the board to close the ward removes ministers from that direct decision. Of course, ministers will be kept informed, because it is of wider interest to them given their responsibilities, but the responsibility rests with HIS and it would be for HIS to take that decision in partnership with the health board.
You said that HIS would inform the cabinet secretary, rather than discussing with him or her whether to take that decision. You would take a decision at HIS that, in your view and based on all the information that you had received, a facility would have to close because of consistently low staffing levels or a poor mix, and you would inform the cabinet secretary of your decision, rather than having a discussion with the cabinet secretary before making that decision.
That is correct, and the important point is about the powers that are vested in Healthcare Improvement Scotland to make those decisions.
I wanted to explore different aspects of the issue. I think that it is a good power for HIS to have, just in case anyone misunderstood me.
Does anyone want to respond to Malcolm Chisholm?
I was just making a comment.
The RCN has suggested that the new power could give you a conflict of interests, given your dual role of scrutiny and improvement. Do you agree with that comment, or would you like to say anything about that?
I do not agree with that comment. The important thing is how we utilise the mix and blend of expertise, skills and capabilities within Healthcare Improvement Scotland.
The King’s Fund recently published a paper about improving the quality of healthcare in England. It encourages people in England to study what is happening to improve quality in Scotland, the work of Healthcare Improvement Scotland and the mix of things that we have in our organisation, such as the Scottish health council, our evidence base, scrutiny and improvement. We need to make sure that, when we scrutinise, we are seen to be independent, we act independently and we provide recommendations without fear or favour. The bigger opportunity for us is in how we use the range of things in our organisation to make us more efficient and effective than we would be if we had to transact with a range of bodies.
Thank you.
I will try to tie this up. HIS is going to get an extra power, which it may or may not use; do you have sufficient staffing levels to cope with it?
I think that our staffing levels are not directly related to the power. We have an excellent group of inspectors in the team, who come with a clinical background, for example those who carry out our inspections of older people’s care. An increasingly important point about our workforce is that we will never have all the skills and expertise in Healthcare Improvement Scotland and we will be increasingly reliant on the skills and expertise of professionals coming to join us and work with us in all parts of our organisation, including inspections. There will be an increasing demand on health boards to provide clinical experts, for instance, to carry out inspections.
Thank you.
As there are no other questions from members, I just want to touch on the context in which Healthcare Improvement Scotland and the Care Inspectorate operate. I refer back to the committee’s inquiry into the regulation of care for older people, which reported in 2011. At that time, there was a big focus on national care standards and there was agreement that we would have in place a set of national care standards that everyone would work to. That report included recommendations on staffing levels, staff mix and so on, particularly in residential settings and the community.
Are we all working on the development of national care standards in the context that regulators work under? Do we now recognise that there are very similar arrangements as a result of the integration of health and social care? That is a pathway and a journey for people. How much are all the agencies that work in this field learning from one another? Are we working closely together to develop good practice across those agencies, if not bringing them all together?
The short answer is yes. I will leave Mr Pearson to give you the fuller version.
We have been working on several levels. First, there has been an excellent consultation on the national care standards, and a set of principles has been agreed that is very much human rights based. Jointly with the Care Inspectorate, we are now carrying out work to take forward more detailed national care standards that will be fundamental in supporting more integrated health and social care in communities and care settings. That is the first thing to say; that is happening now.
Can you make any of that information public? We are working on our legacy paper and that important recommendation was made way back. How old are the Russell care standards now? When were they last reviewed? Was it 15 years ago?
I think that it would have been in about 2002. Work is now under way to take forward those new standards.
How much information can be shared with the committee at this stage?
We are very happy to share with the committee the work on the national care standards and the principles that have been agreed.
Thank you.
One of the key things arising from the committee’s review concerned joint working more generally with the Care Inspectorate. We have been carrying out joint inspections with the Care Inspectorate for the care of older adults. We have now done quite a number of inspections across Scotland—probably eight or nine—and they have been really informative in looking at the different models of care and sharing good practice. You made a point about that, convener.
We are now undertaking a review of that methodology and ensuring that it is fit for purpose in the context of health and social care partnerships. That work is being led by two non-executives from Healthcare Improvement Scotland and the Care Inspectorate, John Glennie and David Wiseman. The fact that we are taking forward that piece of work jointly emphasises again the importance of the Care Inspectorate and Healthcare Improvement Scotland going with the grain in respect of service delivery in individuals’ communities.
That is good to hear. We look forward to the additional information being provided to the committee.
As committee members have no further questions, I express our gratitude and appreciation to the minister and her colleagues, who have been here for quite a while this morning, and colleagues from Healthcare Improvement Scotland. Thank you to you all.
11:40 Meeting suspended.Next
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