Health and Sport Committee

Meeting date: Tuesday, November 8, 2016

Official Report 600KB pdf

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Recruitment and Retention

Item 2 is our final evidence-taking session on recruitment and retention in the health service. I welcome back Shona Robison, the Cabinet Secretary for Health and Sport. She is accompanied by two officials from the Scottish Government: Shirley Rogers, the director of health workforce and strategic change, and Fiona McQueen, the chief nursing officer. Welcome to the committee. I invite the cabinet secretary to make an opening statement.

Thank you for the invitation to speak again to the committee. We are all aware that demand for health and social care services is changing, as is the way in which those services are delivered. In response, the Scottish Government has a programme of transformational change to take us towards the 2020 vision and beyond. However, we cannot deliver that without a sustainable workforce.

Our approach to delivering that workforce is described in “Everyone Matters—2020 Workforce Vision”. In short, we need to ensure that the right people are available to deliver the right care in the right place at the right time.

Key to our ability to recruit and retain our staff is our attractiveness and inclusiveness as an employer. Through our work on the staff governance standard, NHS Scotland has made significant progress in recent years. We have worked closely with our staff-side partners and health board colleagues to develop high-quality and supportive policies and terms and conditions for our staff that also recognise the highest standards of equality and diversity and help us to deliver on our vision for NHS Scotland to be an exemplar employer. I was delighted that NHS Scotland’s good work was recognised in practice when the Golden Jubilee national hospital was recently voted employer of the year at the 2016 awards.

Under this Government, staff numbers have increased by more than 11,000, which includes over 5 per cent more qualified nurses and midwives and over 25 per cent more doctors. We have a record number of consultants—the number has gone up by 43 per cent during the Government’s term. However, we are not complacent and we recognise that challenges remain. We need to improve the long-term sustainability of our workforce, particularly in remote and rural settings.

We are growing our medical workforce. In addition to increasing specialty training places by 124 in the past three years, we have increased undergraduate medical school places by 50 from this year, and those places are focusing on widening-access criteria. The Scottish graduate entry medical programme—ScotGEM—will add a further 40 places from 2018 and will focus on general practice and rurality.

We signalled our intention that the ScotGEM programme will have an element of bonding, by which I mean an arrangement whereby, in return for the reimbursement of the cost of their education, an individual commits to a period of employment in the NHS. I am aware of the evidence that was given to the committee last week and I realise that there is a range of views on such arrangements. We are developing our policy on bonding and I welcome the opportunity to discuss it further with the committee and the wider stakeholder community.

We are committed to developing a national and regional workforce plan by spring next year. The plan will seek to address capacity issues consistently in the right places and at the right levels in our workforce to help to deliver the transformation agenda that is envisaged in our national clinical strategy. We recognise the need to strengthen workforce planning to ensure that the workforce is able to deploy and manage its huge range of knowledge and skills to best effect, not just by having the right numbers but by ensuring that people are in the right places at the right times.

I recognise that those initiatives will not produce instant results. We are therefore also looking at actions that will address the challenges that we face now. A number of key actions are under way to reduce the use of costly agency staff, including the use of a staff bank system and a long-standing framework contract. We accept that we need to do more and, with NHS National Services Scotland, we have launched a nationally co-ordinated programme to ensure the effective management of all temporary staffing and help boards to reduce the reliance on agency staff.

We are well aware that some parts of the country, including rural areas, have particular challenges in relation to recruitment. We have invested £2 million in GP recruitment and retention measures, which include the Scottish rural collaborative and support for deep-end practices. We are also working with universities to increase meaningful exposure to remote and rural placements at undergraduate level. Additionally, we are encouraging those who have trained and worked in NHS Scotland to return and work here in the health service.

Finally, I have to highlight that, in the context of a highly competitive international recruitment and retention market, there is a risk that because of Brexit we will lose many valued individuals if we cannot offer reassurances on free movement and future career opportunities.

I am committed to building a sustainable health and social care workforce for the future and I welcome the opportunity to discuss the issues further.

Thank you. We are extremely short of time, so I would appreciate brief questions and answers from people.

Last week, we heard evidence from people in the midwifery profession and the nursing profession that, five or six years ago, the Scottish Government cut back training in the midwifery profession in a move that equated to a loss of roughly more than half the training places. They also told us that they are talking about a crisis in recruitment because of retirement.

Workforce planning in the NHS focuses on a five-year period. Will the workforce plan that you are talking about for next year take account of the Audit Scotland report that—rightly—points out that we need to stare much further into the future, in the recognition that it takes up to seven to 10 years to train some primary care professionals? Will the plan that you bring forward reflect that?

Fiona McQueen can say more but, over the past three years, we have increased nursing and midwifery numbers. We have also increased the numbers of those who are in advanced training, and we have increased the number of advanced nurse practitioner posts by 500. We are aware that that workforce is critical not only in our hospital sector but in our primary care sector. We have been working closely with NHS Education for Scotland to develop opportunities for the advanced nursing practice career route, because we know that, whether in emergency medicine or primary care, the roles of advanced nurses will be critical in delivering the new models.

That is absolutely the case. The person from the RCM who spoke to the committee last week recognised that, when undergraduate numbers were reduced, there were hundreds of unemployed midwives and nurses. We had 800 nurses on return-to-practice schemes and we had nurses and midwives who were qualifying and unable to get jobs.

We have a planning process that looks at retiral rates, and people now have the choice of retiring from 55 onwards. There is a challenge, because overproduction is not helpful either, as it stops good people coming into the profession.

Over the past three years, we have increased the numbers. The number of midwives in training has been increasing.

Who signs off the annual intake?

There is a process. Ultimately, the cabinet secretary agrees to the position.

That is fine.

There is a process of negotiation in the professions.

The trade unions are involved and the care home sector is now involved.

I would like to get my head round some of the vacancy rates. The figures for June that ISD published put the vacancy rate for nursing and midwifery at 4.2 per cent and for other AHPs at 4.4 per cent. What do you see as a usual percentage for vacancies? We will not have every post filled all the time.

One of the challenges is that the more posts we create, the higher the vacancy rates are, particularly in areas where recruitment is harder. The ISD figures are national, but vacancy rates vary across the boards.

Recruitment takes time. If we look at industry norms, 4 per cent is a moderate figure. The position depends on the post. If the post is that of a staff nurse who delivers care all the time, that person needs to be replaced right away, and the situation is similar for our support workers. In that case, it is easier to have a recruitment line. Along with workforce colleagues, the nursing and workforce directors on boards look at how to efficiently fill posts because, although someone might give four weeks’ notice, the recruitment process takes longer than that. A number of boards anticipate situations by looking at their turnover and bringing people in so that there is almost no vacancy for the post that is being left.

More specialist posts take time to recruit for. Even if there is no difficulty in recruiting, if someone gives one month’s notice and people have to be pulled in, the recruitment process will take longer than that month, so there will be a period of vacancy.

The figures vary depending on the area that a person is in and how long they are leaving their post for, but 4 per cent does not seem unreasonable. Vacancies that last for more than three months might be indicators of where it is trickier to recruit. Shirley Rogers can add to that.

It is difficult to give a global answer. Some specialties are harder to recruit for. The committee might find it helpful to understand more about the workforce planning that takes place. I recognise the time constraints, convener, but I would like to say a few words on that.

Mr Cameron asked earlier about the prospective nature of workforce planning. Over the past couple of years, we have put in place arrangements that allow us to see the existing trained workforce and the supply, through specialty doctors, that is coming through the training process. We can see the consultant workforce as we have it and all the people who are emerging from medical school, who we can track through training. That is the case across all the 56 major specialties in the health service.

Those arrangements enable us to make intelligent decisions that are based on projections of retirement ages, for example. The committee has heard evidence about the impact of UK pension changes. The arrangements allow us to see what would happen if the consultant workforce decided to retire a bit earlier, stay on a bit longer or whatever it is.

The approach over the past couple of years has used the six-step workforce planning methodology, which is an international industry standard that does not pertain just to the health service. It is used by a number of big employers around the globe to look at short, medium and long-term recruitment needs and at how to nuance them depending on the circumstances and the individual choices that people make.

The methodology has been shared across the health service and is now a requirement for how every board in Scotland does workforce planning. That is a relatively recent development. Perhaps more important in the space of health and social care integration is that we are busy sharing the methodology with colleagues in local authorities to make sure that they use a similar methodology. Indeed, we have invited any other employer that is operating in that space to use a similar methodology. That should enable us to address as best we can the issues that exist now and, more important, to deal with the medium and longer term.

I thought that it might be helpful to give the committee that context on the workforce planning methodology.

10:45  

I will come back on something that is a bit more specific about nurse retention. I declare an interest because I am a registrant with the Nursing and Midwifery Council and I am going through the revalidation process.

My question is about registration and revalidation. Has any work been done on how many nurses and midwives are leaving the profession because of the revalidation process, which is quite complex, and on nurses and midwives who fall off the register because of late payment of their registration fees and the excessive time that it takes the NMC to get people back on to the register—up to three months—which leaves those nurses and midwives without a source of income? They are often women who work part time and are sole parents. I am keen to hear what the Scottish Government is doing to support that part of the workforce.

I am happy to answer and equally happy to give you granular information on a month-by-month basis about revalidation and people’s registration lapsing or not. We have found that there is little difference in the number of people who are remaining on the register. September was going to be our crunch month, as we had a lot of registrants who qualified in September and revalidation is three yearly from then.

We have found that, in the care home sector and across the NHS in Scotland, there has been little difference since revalidation came in; we have watched that closely. We have invested money over the past two years to support each board. We gave boards resource to support practitioners with revalidation and we worked closely with the NMC to get the statistics and data on that.

Other committee members might not know that nurses have a system of submitting for revalidation every three years but we have to pay an annual fee. Until quite recently, if someone missed paying the annual fee by a few days, that did not matter, but now the NMC says that re-registering will take between two and eight weeks. We continue to encourage the NMC to be as quick as it can in its processes, as we fully recognise the financial challenge that registrants have and the issue of care delivery. Someone who has not paid cannot deliver care as a registered nurse during that time.

We are continuing to work closely with the NMC on the issue and we are looking at ways that we can flag to boards for them to remind nurses that they have an annual fee to pay. The NMC reminds people quite regularly about what needs to be done. Any time that we hear of anyone having that struggle, we direct them to someone in their board who can help them, to make sure that they are paying.

The NMC has introduced a way to spread fees by paying instalments by direct debit rather than paying £120 a year all at once, so the NMC is doing its best to support registrants to maintain their registration.

I believe that it takes on average five to seven years to train a doctor. I was surprised when I last met the BMA that once a doctor has trained they can just go away, anywhere in the world. The cabinet secretary said something earlier about bonding, which is a new word to me. Why do we not tie doctors down to a contract that says that if they trained in Scotland, they should live and work in Scotland? Should they not pay back to Scotland before they leave? I hate using the word “leave”.

Shirley Rogers will say a bit more about this in a moment, but obviously we want people to remain here and train and work here. A lot of the evidence shows that if they have had a good training experience and good experiences in their placements that is a big encourager for doctors to want to stay here in Scotland. There is an international market and we have looked at how we can encourage, with financial incentives or in other ways, the keeping of people here in the NHS.

The graduate programme lends itself well to bonding because it leads to a second degree and, therefore, the fees are not automatically paid. That means that there is an opportunity to offer any payment of fees through the graduate programme with a commitment to the NHS in Scotland. That would be more challenging to do in the undergraduate programme. It is not that it is not being explored and we will keep an open mind on what more we can do.

From a widening access point of view, you will be interested to know that, because we felt that it was important that medical students were drawn from a wider socioeconomic base, we linked to the widening access criteria the 50 new places from this year that we have agreed with the medical schools. The more that we draw people from a wider variety of backgrounds, the greater the chance we will have of them staying in Scotland to work in the NHS.

Scotland has five of the most highly regarded medical schools in the world. It attracts and draws candidates from all over the world. That is one of the things that it should be proud of. Scotland has a long history of medical academia and medical research that is very attractive in an international marketplace. We operate in an international marketplace for medics and it is right that we do that. We are extremely innovative but we are not the only innovative place.

However, there is evidence that strongly suggests that Scotland-domiciled students who attend Scottish medical schools are more likely to practise in Scotland immediately or come back to practise in Scotland—they may go somewhere else to gain experience and then return to Scotland later. We are trying to create a space in which NHS Scotland is internationally recognised as an attractive place to practise medicine. An enormous amount of work is being done to improve working lives throughout the NHS and specifically for junior doctors, for example. That recognition is starting to accrue.

As the cabinet secretary said, we have focused a particular endeavour on the introduction of a first for Scotland: it is the first time that we will have a graduate medical school. We have done that because we recognise that, generally speaking, people who are doing second degrees are a little bit older, are a little bit more settled in the environment in which they want to live and have perhaps already made some domestic decisions and life choices that would more readily site them in Scotland. Therefore, if we can support those individuals to make those choices, it seems that the options for us to be able to have some payback for that investment are before us.

As the cabinet secretary indicated, we are in the foothills of that consideration. Committee members may be aware that that model has been used in the military for a number of years and is used in some parts of the world. There are a number of models, but we are ensuring that we have a balance of people who really want to work in Scotland and to make their medical careers and their lives here. We will be able to do that.

How much is the funding or bonding on offer?

We have not reached that stage yet. I guess that we would be looking at an arrangement such as, if we paid a year’s fees, we would expect a year’s commitment to the NHS. That would be an obvious way of doing it, but we need to work through the detail before the programme starts.

So if somebody commits to stay five years, we will pay their five years’ fees.

That is an option. We need to work through the detail.

As a representative for the Highlands and Islands, I am keen to ask about rural recruitment. We have heard time and again that people from the Highlands and Islands are keen to get back and I know that from personal experience. Will the widening access scheme cover people who grow up in rural areas, who might face challenges in getting the right qualifications to enter medical school because of the limited options that are available at the high schools in rural areas in the Highlands and Islands?

We have three further members who wish to ask questions and we are short of time, so I ask you to be brief, please, cabinet secretary.

The ScotGEM—Scottish graduate entry medicine—system will partner with NHS Highland on rural placements and rural opportunities, plus there are existing programmes through the Scottish rural medicine collaborative to encourage and retain staff who work in rural areas. The graduate scheme has the ability to give people a very positive experience of working in a rural area and it will have a bias towards general practice, too.

I meant specifically with regard to getting access to medical school.

It is one of a number of things that we hope will do that. We are working with schools to look at the triangulation of qualification, medical school applicant and the chances that there are for study opportunities. We are working with education colleagues to ensure that the necessary curriculum is available—that would probably be the biggest win, if we can achieve that. There is no doubt that the postgraduate entry requirements lend themselves better to students who have not been able to study, for example, higher chemistry in rural parts of Scotland.

In her opening remarks, the cabinet secretary mentioned rural bursaries, which are terribly advantageous for recruiting in rural parts of Scotland. It is a totality of things as opposed to just a thing, but that totality ought to achieve the objective. Again, there is very strong evidence that people from those communities who can practise in those communities will stay in those communities.

Absolutely. To broaden the question beyond medical staff, we have heard from all the professions—particularly midwives, nurses and allied health professionals—that they are struggling to offer opportunities for work experience in rural areas and that there might be additional costs for people who want to work in rural areas during their training period, either as undergraduates or as postgraduate students. Will the Government do anything to tackle that? I welcome the strategies that you have already put in place to tackle the issues.

We provide 300 pre-registration nursing places through the University of Stirling and the University of the Highlands and Islands, and a further 60 nursing students from seven boards that cover remote and rural areas study a pre-registration nursing programme through the Open University. Those are good options for people who are from the Highlands and Islands, and the Western Isles has a particularly good programme. It is about home-growing our workforce from school right through to qualification.

We are also reviewing the financial support that we give to other undergraduates, such as AHP undergraduates—nurses already get travel and accommodation expenses when they are on placement. We are looking at more rural placements for our undergraduates.

I want to comment quickly on the workforce planning tool. I was glad to hear the comment that Shirley Rogers made because, in previous evidence sessions, people have told us that workforce planning is difficult—to the point of being too difficult—and that we should not expect them to deliver anything coherent on that. I am glad to hear that you are on top of that.

I have done workforce planning in the past and my experience is that it is 90 per cent science. It is about getting the right variables, understanding how those are trending and making adjustments based on that. More importantly, although you will get it wrong, it is about knowing what to go back and look at when that happens. You can then understand whether the decisions that you made were coherent and based on the data. Would it be possible to have a wee look at the planning? I would be interested to see what the tool is capable of doing, although I do not know whether other members would be interested.

I am happy to share the six-step methodology with the committee.

Brilliant. Thanks very much.

What action has been taken to ensure that those working in the professions have access to a suitable level of on-going professional development? Jill Vickerman said that that issue is not making medicine as attractive as it might be in Scotland.

Also, what specific action is being undertaken to recruit in our deep-end practices?

In part, it is about ensuring that people have the time—and that backfilling is in place—to be able to take on professional development opportunities. We also need to ensure that there is equality of access to those opportunities. There are issues in some areas where that is more difficult but, without a doubt, CPD is hugely important for career development and for opportunities.

11:00  

I am the individual who is leading the work to develop the transformational strategic change plan, which we have mentioned a number of times in the meeting. We recognise in that plan that education and reskilling, upskilling and maintaining skills are a fundamental part of transformation. Opportunities for people to be able to do that—we have dealt with the testing of new models of care—are critical to that work. We are configuring to do that in a range of ways.

We always talk about doctors and nurses, so I will give an example that goes a little bit beyond their remit. A quiet success of the past couple of years has been the development of the educational framework for healthcare support workers. That extends way beyond health into all the social care provision and gives an educationally based career framework that allows people to join at a relatively modest level of skill, to use the framework to develop their skills and, of course, to enhance their careers. We are taking that approach and methodology throughout.

The cabinet secretary mentioned deep-end practices. We are exploring the benefits of a rural bursary, and we are starting to give consideration to whether a bursary around deep-end practice would be effective.

We have agreed with the BMA a full review of all aspects of GP pay and expenses. That will take place next year and will inform options from 2018. The Scottish allocation formula will be part of those discussions.

I have said before that we need to get that work right. Our support for deep-end practices is important, but we need to look beyond that and at how we ensure that GPs working in more deprived areas get the support that they require. We also have, for example, the 250 link workers to support practices in deprived areas. The issue of support is very much a focus of our discussions as we take forward the new contract.

Between 2006 and 2013, the number of student nurse placements was cut by a quarter. Was that the wrong decision? The number of places for Scotland-domiciled students at Scottish universities is capped. What impact is that having, especially given that just 52 per cent of students going to our medical schools are Scotland-domiciled students, which is a historical low?

Fiona McQueen can come in on the nursing numbers, although she answered in some detail the point about the oversupply and the need to adjust the workforce requirements. Requirements change over time, and it is quite difficult to land that 100 per cent accurately.

Over the past three years, we have seen an increase in the number of undergraduate places. That will filter through into the workforce. It is important to have advanced nurse training, as well as undergraduate training.

It might be of interest to the committee to look at the overall numbers of medical students in Scotland. As Shirley Rogers said, we have five medical schools. That is a high number for a country with a population of 5.3 million. The total number of medical students across the UK is just over 40,000. If we were to take a population share of that number, Scotland’s figure would be just short of 3,500. However, we have more than 1,400 medical students above our share. In essence, we are providing far more places and producing far more medical graduates than our population share. You have to see the percentage of Scotland-domiciled students in that context. If we are to sustain five medical schools—as we want to—they must be able to draw their undergraduates from a wider source, whether that is from the rest of the UK or internationally. As I say, we produce far more medical graduates than our population share or any other part of the UK per head of population. That is a good thing. Our five medical schools are internationally recognised, but in order to sustain them we have to draw from a wider pool than just Scotland.

Is that a financing issue, in that international students can be charged up to £30,000 to study at Scottish universities, whereas Scotland-domiciled students are not?

We discuss the issue with universities and the Scottish Further and Higher Education Funding Council. Our medical schools have always drawn people from a wide variety of backgrounds and places, which I suppose is part of the richness of those schools. A number of international students study medicine in Scotland, as well as a large number of students from the rest of the UK. We want them to stay and work here in Scotland and we encourage them to do so through the mechanisms that Shirley Rogers outlined.

Do you want to add anything, Shirley?

No—that covers it. The reality is that universities survive by having a mixture of students—Scotland-domiciled students, those from international backgrounds and those from the rest of the UK. We have a close relationship with the Scottish Board for Academic Medicine, which represents the medical schools in Scotland, and I meet it regularly.

To return to Ms Todd’s question, the medical schools are very keen to work collaboratively to provide placement opportunities in, for example, remote and rural locations or deep-end practices. Those relationships are very good. As the workforce director for the NHS in Scotland, I endeavour to have a sustainable world-class workforce.

Within that, we of course want more Scotland-based students, which is why we are widening the number of undergraduate medical places even further, by 50. That will be 250 more places over a five-year period, plus the places in the graduate medical school. It is not that we do not recognise the need to expand the number of Scotland-based students, but it is important—

But the figure for Scotland-domiciled students going to the universities is capped. My question, which has not really been answered, is: what impact is that having?

I was going to come back to that question, because I do not recognise the point that you are making about the cap.

When this Parliament was reconvened, 64 per cent of those going to medical schools were Scots, but the figure is now down to 52 per cent because of the cap.

Yes, but if you look at the overall numbers, we produce a huge number of medical graduates beyond our population share. If we only produced the number of medical graduates as a percentage of the 40,000 across the UK—

But Ms Rogers has said that it is important that people who are domiciled in a country can study there, and we are reducing that number in Scotland. If we had more Scotland-domiciled people studying, that would surely help to tackle the shortage. That is where the cap is not helping.

We have just increased the number of places by 50, and we have linked those places to widening access, which means that people from poorer backgrounds will get into medicine who would not previously have done so. There are 250 more medical places over the course of five years. Plus, we think that the graduate school will draw mainly from Scotland-domiciled students because, as Shirley Rogers said, the students in that school will be a bit older and more settled. Therefore, we are expanding the number of Scotland-domiciled students, and that is in the context of a large pool of medical places in Scotland, which is sustained in part by drawing people from elsewhere.

Okay—I am not getting very far with this.

Thank you very much.

I suspend the meeting briefly to allow the panels to change.

11:08 Meeting suspended.  

11:11 On resuming—