The Scottish Government's Response to the Vale of Leven Hospital Inquiry Report

Chapter 4 Professional practice

Issues around professional practice - staffing levels, standards of nursing and medical care, how staff communicate with patients and families, the quality of their record-keeping, lines of reporting and accountability mechanisms in the Vale of Leven Hospital (VOLH) and at NHS board level, and education and training of professionals - all figure large in the report. Failures in each contributed to the tragic circumstances that occurred in the hospital, and the report sets out recommendations that when enacted will help to ensure there is no recurrence anywhere else in NHSScotland.

In this chapter, we focus on some of these key elements of professional practice, specifically in relation to professional standards, practice and behaviour, communication, record-keeping and reporting, and education and training, highlighting progress that has been made in Scotland since 2007.

4.1 Professional standards, practice and behaviour

This section focuses on workforce and professional regulation issues, specific elements of nursing care highlighted in the report and measures to govern Do Not Attempt Cardiopulmonary Resuscitation orders and death certification. It relates to report recommendations: 18, 19, 20, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 36, 37, 39, 44, 50, 68, 70 and 71.

What the report tells us

The report finds deficiencies in nursing care at basic and specialist levels and sets out 21 recommendations that specifically address nursing issues.

The professional expert witnesses engaged by the Inquiry were critical of the lack of proper care-planning at the VOLH, which the report addresses in recommendations 18, 19 and 24 (the last specifically in relation to tissue viability nurses).

Much activity related to assessing, monitoring and recording key elements of patients' care was found to be unsatisfactory, with the report providing specific recommendations on assessing, monitoring and recording patients' stools (recommendation 20), wounds and pressure damage (25 and 26), need for positional changes (27), nutritional status and intake (28), weight (29) and fluid intake and output (30). Evidence of poor complaint management by nursing teams was identified by the Inquiry, and this forms the substance of recommendation 33.

Delays in diagnosing, reporting and treating C. diff infection were described as significant problems in patient management and are addressed in recommendation 37.

The report acknowledges the importance of adequate staffing levels to ensuring good standards of care. The Inquiry's investigations concluded that while staffing ratios on the wards were acceptable, they did not necessarily take account of a situation in which a number of patients became unwell and additional nursing input was required. As the report puts it: "The staffing levels at the VOLH were in accordance with nationally approved standards in 2007 and 2008 but that does not mean that staffing levels were safe." Accordingly, it addresses staffing levels and skill-mix in recommendation 31 and procedures for nurses to report staffing concerns in recommendation 32. The need to provide appropriate levels of medical staff (recommendation 36) and ensure 24‑hour cover by infection prevention and control staff (recommendation 50) are also addressed.

Appraisal of performance is a central part of ensuring that professionals are functioning safely and effectively. Evidence was found, however, of significant lapses in appraisal compliance within the infection prevention and control structure at the VOLH. This shortcoming is addressed in recommendation 44, with an emphasis on infection control doctors.

The clinically and ethically difficult challenges posed by Do Not Attempt Cardiopulmonary Resuscitation orders is the focus of recommendation 39, which sets out precise standards for decision-making, involvement, communication and recording. The need for consultant involvement in completion of death certificates of patients who die in hospital and for whom HAI is a contributory cause of death is emphasised in recommendation 68, with responsibilities for the Crown Office andamp; Procurator Fiscal Service and Scottish Government described in recommendations 70 and 71.

Our current position

The NHSScotland workforce

Pay, terms and conditions

Over 160,000 people work for NHSScotland. We recognise that when staff are valued and supported, they are motivated to deliver better-quality care for patients. That is why we have worked to ensure we have fair pay, terms and conditions in place by, for example, implementing recommendations of the NHS Pay Review Body^[15] and the Review Body on Doctors' and Dentists' Remuneration, offering additional support to those on low salaries, guaranteeing the Scottish Living Wage across the NHS and committing to the No Compulsory Redundancies policy for public sector workers.

We see this as an investment in people and the skills they bring. By having fair and clearly understood pay, terms and conditions, we can not only provide NHSScotland with a well-motivated and engaged workforce, but can also recruit and retain high-quality staff to the service in the future.

Regulation

Nurses and midwives practising in the UK are regulated by the Nursing andamp; Midwifery Council (NMC) and must abide by the NMC's Code of Conduct and Standards. Doctors must be registered with the General Medical Council (GMC) and hold a current licence to practise medicine in the UK. Registered doctors must adhere to the ethical standards and guidance set out by the GMC.

The NMC revised its professional code in March 2015. The code provides the foundation for good nursing and midwifery practice and is a key tool in safeguarding the health and wellbeing of the public. Any nurse or midwife whose practice does not meet the expectations of the code is liable to be investigated by the NMC and may face sanctions that include suspension or removal from the professional register.

The GMC controls entry to the medical register and is responsible for determining the principles and values that underpin good medical practice. Like the NMC, it takes action against practitioners who fail to meet its standards.

Allied health professionals in the UK are regulated by the Health andamp; Care Professions Council (HCPC), which has similar powers of sanction over registered practitioners to other UK professional regulatory bodies, such as the NMC and GMC.

Healthcare support workers^[16] are not subject to formal legal regulation by an independent statutory body like the NMC, GMC or HCPC, but Scotland has led the way on employer-led regulation by introducing mandatory induction standards and a code of conduct for new healthcare support workers joining NHSScotland from December 2010. These measures apply to a wide group of NHSScotland staff, not just workers who have direct patient-care roles, and place protection of the public first, with patient experience and safety prominent.

We began a detailed review of the healthcare support worker induction standards and code of conduct scheme in December 2012. Since then, we have been working with key strategic partners and interested parties to develop robust proposals for improvement and expansion of the existing scheme: we expect to begin work on implementation later in 2015, following further consultation.

The UK statutory regulator for dentists and dental care professionals^[17] is the General Dental Council (GDC). The GDC keeps up‑to‑date registers of these professionals. Applicants to join the registers need to meet professional standards set by the GDC, and anyone who wants to work in the UK as a dentist or dental care professional must be registered with the GDC.

Promoting staff welfare and dignity

NHSScotland staff are key to delivering services and it is essential that everyone feels supported to carry out their role. Our aim is to ensure that all staff have a good experience in their work and are fully engaged with their job, their team and their organisation. This has a positive impact on organisational performance and quality of service provision and is also an important component of treating all employees with dignity.

The NHSScotland Staff Governance Standard, now in its fourth edition, sets out what NHSScotland employers must achieve to manage staff fairly and effectively. All NHS boards must be able to show that staff are well informed, appropriately trained and supported, involved in decisions, treated fairly and consistently, and provided with a continuously improving and safe working environment. NHS boards monitor their progress towards meeting the standard, submitting an annual return to the Scottish Government that provides assurance and evidence of progress made and defines priorities for the coming year.

NHSScotland Staff Governance Standard

The fourth edition of the Staff Governance Standard was published in June 2012 to reflect developments such as implementation of the Healthcare Quality Strategy for NHSScotland and its Quality Ambitions, the Patient Rights (Scotland) Act 2011 and our 2020 Vision. It emphasises the importance of a motivated and engaged workforce with the necessary knowledge and skills to deliver high-quality, person-centred, safe and effective patient care and describes employer and employee responsibilities. Employee responsibilities include a commitment to keep themselves up to date with developments relevant to their job, undertake continuous personal and professional development, treat all staff and patients with dignity and respect while valuing diversity, and ensure that their actions maintain and promote the health, safety and wellbeing of all staff, patients and carers.

Other initiatives we have introduced to promote staff welfare and dignity include:

• an occupational health and safety strategic framework, Safe and Well at Work, and policies to support the health, safety and wellbeing of the workforce
• a national dress code, which requires staff to dress in a professional manner to inspire public confidence and minimise the risks of infection, and an NHSScotland national uniform.

NHSScotland Staff Survey

The NHSScotland Staff Survey enables workers to give their views on their job and other aspects of working in NHSScotland. The information is used to improve the working lives of staff to promote better care for patients and assess NHS board performance against the NHSScotland Staff Governance Standard.

The survey asks for staff members' views on communications, training, decision-making, how they are treated as employees, health and safety, and their perceptions of the job and organisation. Getting feedback on these issues help boards to see where they are doing well and where further changes need to be made to improve ways of working.

Key findings from the NHSScotland Staff Survey

The national staff survey was last conducted in 2014 with just over 55,000 responses, an increase of 7% from the previous year. The survey showed that: 90% of participating staff were happy to "go the extra mile" at work, an increase of 3% from the 2013 survey 79% stated that they could get the help and support they need from colleagues, up by 3% 67% felt care of patients was their NHS board's top priority, up by 12% 61% would recommend their NHS board as a good place to work, up by 10%. We remain committed to working in partnership with NHS boards to make improvements based on the survey results and are now collaborating with them on the 2015 survey.

The survey is only one of the ways in which we can ask employees for their views.

We are currently implementing a new team-based framework for measuring staff experience. The iMatter Staff Experience Continuous Improvement Model will provide meaningful information on staff experience and a more effective framework for addressing issues of concern and making improvements. Improved staff experience should ultimately benefit patient care. iMatter is currently being rolled out across all NHS boards, with implementation due to be completed by the end of 2017.

Workforce planning

The NHS workforce is planned to reflect service changes that are designed to enhance quality and increase efficiency. Quality of care for Scotland's people will always come first: we are fully committed to planning an NHS workforce that provides high-quality, world-leading services, and the structures and guidance to ensure informed and effective workforce planning are in place.

There are 10,450 more whole-time equivalent^[18] (WTE) staff working in NHSScotland (excluding GPs and dentists) than in September 2006 - an increase of 8.2% WTE. As of December 2014, there were 137,511.9 WTE staff in the service, up from 127,061.9 in September 2006.^[19]

Nursing and medical staff (WTE)

The number of qualified nurses and midwives (including interns19) in NHSScotland is now at a record high, up by 2,315.7 WTE from September 2006 to 43,341.9 WTE in December 2014. NHS consultant (medical and dental) numbers are also at a record high, up by 37.1% (or 1,348.1 WTE) from 3,636.5 WTE in September 2006 to 4,984.7 WTE in December 2014. This includes a 170.6% increase in accident andamp; emergency consultants, 32.8% rise in consultants in medicine for older people, and a 73.9% increase in paediatric specialties.

The NMC stipulates that every registered nurse (and midwife) must act without delay if they believe there is a risk to patient safety or public protection; this includes a requirement to escalate concerns in relation to the level of care people are receiving. To support this, Scotland is leading the UK in developing a series of ground-breaking nursing and midwifery workload and workforce planning tools. The tools, used as part of a broader approach that also incorporates nurses' professional judgement and quality measures, help to determine the number of nurses or midwives needed by measuring the actual workload in clinical areas.

Use of the tools to inform local nursing and midwifery workforce planning is now mandatory for all NHS boards. Boards develop action plans to support use of the tools and make arrangements for communicating and reporting outcomes, including how information about recommended and actual staffing levels is communicated to patients, families and frontline staff.

Nursing workforce and workload planning tools

To date, we have a nationally agreed professional judgement tool and workload measurement tools in the following services: adult inpatient; mental health and learning disability; paediatrics; neonatal; community children's nursing; community nursing; clinical nurse specialists; small wards; maternity; emergency departments/emergency medicine; and theatres. This ensures coverage of 98% of service areas.

Evidence from NHS boards suggests that information generated from the tools has resulted in more effective use of nurses and further investment in nursing, including £6.7 million in NHS Greater Glasgow andamp; Clyde.

Whistleblowing

Whistleblowing is about a worker raising a concern over suspected wrongdoing at work. More formally, it is referred to as "making a disclosure in the public interest". Whistleblowing concerns generally relate to a risk, malpractice or wrongdoing that affects patients, the public, other staff or the organisation itself.

The VOLH Inquiry is one of a number carried out in the UK in recent years that have investigated tragic incidents in the NHS. These investigations often reveal that in some cases, staff had concerns about what was happening but were unsure whether or how to raise their worries, or had raised them only to be ignored. Removing barriers and encouraging a culture that supports whistleblowing in health care is therefore vital.

It is also crucial that NHS workers feel they can raise concerns about patient safety and malpractice without fear of repercussions. Our whistleblowing policy encourages employees to raise any valid concerns and guarantees that they will be taken seriously and investigated appropriately. NHS boards are required to have a local policy that meets or exceeds the terms of the national policy: they have a big part to play in building trust and confidence across their organisation to support whistleblowing.

National whistleblowing policy and legislation

Our policy, Implementing andamp; Reviewing Whistleblowing Arrangements in NHSScotland, is designed to improve and standardise whistleblowing arrangements. It gives NHS boards the ability to show to staff, patients and others that high standards of clinical care and governance are at the heart of their work. The policy sets out staff rights in relation to whistleblowing, particularly on protection from victimisation as a result of raising a concern. It specifies that anyone victimising a whistleblower will be subject to disciplinary action, as is anyone who maliciously makes a false whistleblowing allegation. Whistleblowers also have legal protections. The Public Interest Disclosure Act 1998 made amendments to the Employment Rights Act 1996 to protect individuals from suffering at the hands of their employer following a genuine whistleblowing concern.

Whistleblowing is often interlinked with bullying and harassment, particularly when staff say they have been bullied and/or harassed for raising a whistleblowing concern. A bullying/harassment concern differs from a whistleblowing concern, however, as it is a personal complaint regarding an individual's employment situation. We therefore have a different policy in place - Preventing and Dealing with Bullying and Harassment in NHSScotland - to deal with this.

NHSScotland Confidential Alert Line

The NHSScotland Confidential Alert Line, launched in April 2013, is a dedicated freephone service for NHSScotland staff. Its principal purpose is to provide additional support to staff should they feel unsure about how (or whether) to report concerns about patient safety or malpractice, or if they have reported their concerns but have exhausted the existing procedures. Advice is provided by legally trained staff. The alert line also provides an alternative route for staff who feel they may be bullied as a result of whistleblowing. Where appropriate, concerns can be passed to the appropriate NHS board or professional regulatory body on behalf of the caller, giving staff the confidence to whistleblow without fear of recrimination. Following a successful pilot period, we announced in March 2014 that the service is to continue for a further two years.

Public concern has been raised recently about confidentiality clauses - so-called "gagging clauses"^[20] - in settlement agreements. People fear that these might prevent staff from disclosing concerns about service issues on leaving employment, and the Scottish Parliament was petitioned to ban them.

We carefully considered the position on the use of confidentiality clauses in settlement agreements in NHSScotland and decided to make it absolutely clear that staff should not be gagged. A new standard agreement is being drafted, removing the automatic inclusion of confidentiality clauses and sanctioning their use only where there is explicit agreement between employer and employee.

We wrote to all NHS boards in February 2014 to set out the new arrangements and to confirm that the presumption must be against the use of confidentiality clauses unless there are clear and transparent reasons for inclusion. The new agreement will be finalised later in 2015.

Nursing care

The report criticises specific elements of nursing care at the VOLH, finding "a catalogue of failures" in fundamental aspects of the care provided.

While unreservedly accepting in full the report's recommendations relating to nursing care and recognising the system and individual failures it identifies, we feel it is right to acknowledge the generally very high standards of nursing care delivered day-in, day-out throughout NHSScotland. We have high confidence in our NHS nursing workforce, a confidence we have demonstrated (and continue to demonstrate) through the support initiatives for nursing we have introduced in recent years. Some of those with particular relevance to the findings in the report are now described.

Prevention and management of pressure ulcers (tissue viability)

The report stresses that patients who have C. diff infection with profuse diarrhoea are particularly vulnerable to skin damage. Protection of patients from the risks of skin damage and pressure ulcers - widely known as "tissue viability" - is a fundamental aspect of nursing practice that is continuing to develop as the evidence base for effective interventions expands.

Healthcare Improvement Scotland published a Best Practice Statement - Prevention and Management of Pressure Ulcers in 2009 and the national Tissue Viability Programme commenced in the same year, completing its work in 2011. The programme provided a coherent and coordinated approach throughout Scotland to reducing the incidence of pressure ulcers. It reviewed practice statements, developed a national standardised definition, grading system and prevalence methodology, and introduced tissue viability "care bundles" (for more on care bundles, see Chapter 2).

Education and support for tissue viability

NHS Education for Scotland, in partnership with Healthcare Improvement Scotland and key stakeholders, has developed educational resources for tissue viability as part of an integrated development approach. The resources, first developed in 2009, were updated in 2013 and are currently being reviewed in light of advice from the European Pressure Ulcer Advisory Panel, with the National Association of Tissue Viability Nurse Specialists (Scotland) actively participating in the review. A tissue viability "toolkit", managed by Healthcare Improvement Scotland, sets this integrated programme of work in context.

An updated grading tool for measuring the severity of pressure ulcers was issued to NHS boards in February 2015 to support nurses and other professionals. Healthcare Improvement Scotland and other key stakeholders are now working on developing a clinical standard for the prevention and management of pressure ulcers, with publication expected in 2016.

Tissue viability nurse specialists in NHS boards across the country ensure standards are driven up. They are central to promoting use of the national grading tool and providing clear guidance on appropriate prevention and treatment, including referral to specialists. All registered nurses are expected to have an awareness and knowledge of pressure ulcers and wound management, but tissue viability nurse specialists possess high-level expertise.

Nutritional care and hydration

National standards for food, fluid and nutritional care, originally developed in September 2003, were refreshed in October 2014 by Healthcare Improvement Scotland (supported by the National Nutritional Care Advisory Board). The standards are used to assess performance on the provision of food, fluid and nutritional care in NHS boards through, for example, inspections related to the Older People in Acute Care improvement programme.

Improving care for older people in acute care

With the number of older people increasing in our population, we need to ensure they receive appropriate care in our healthcare system. Healthcare Improvement Scotland's Older People in Acute Care improvement programme, now in its third year, focuses on two key areas: care coordination, particularly around identifying and caring for people who are frail cognitive impairment, identifying and providing immediate management for people with delirium, which is the sudden onset of confusion and restlessness in older people caused by acute illness. Healthcare Improvement Scotland supports this work by assessing the standard of care provided for older people in acute hospitals in Scotland. Their inspection reports highlight hospitals' strengths and areas for improvement, particularly in relation to: treating older people with compassion, dignity and respect caring for people with dementia and cognitive impairment preventing and managing falls providing adequate nutritional care and hydration preventing and effectively managing pressure ulcers.

We have committed over £2 million since 2008 to support and improve nutritional care in NHS boards, promoting initiatives such as malnutrition screening of all patients when they come into hospital and introducing protected meal times (enforced by senior charge nurses) to make sure patients who need help with eating are properly supported.

The national Improving Nutrition Care Programme was introduced in 2008 to enhance nutritional care for people in hospitals and address issues in relation to patients who are nutritionally vulnerable. The programme created a related development and education programme and a monitoring tool incorporating patient experience and ran in parallel with the development of a national catering and nutrition specification for food in hospitals. While the programme ended in 2012, its work continues at NHS board level.

A "toolkit" for improving nutritional care was published in 2012, providing guidance on good practice and educational resources for staff. NHS Education for Scotland is integrating all nutritional education components on one website, which will serve as an access point for healthcare professionals and others.

National approach to assuring nursing and midwifery care

Following publication of the report, we announced that the Chief Nursing Officer would work with nurse directors to roll out care assurance programmes covering nursing and midwifery in all hospitals and community services. National standards for nursing documentation and care planning will also be developed and monitored as part of the care assurance programmes. We stated that information from the programmes should be made easily accessible to patients and the public.

Rolling out a care assurance process for nursing and midwifery is central to delivering a service that is more transparent, accountable and focused on improvement. There are benefits in taking a national approach to care assurance to ensure consistency of measurement and reporting, reduce duplication and enable a clearer national picture of nurses' and midwives' contribution to achieving the Quality Ambitions.

A stakeholder event to consider the first phase of the national approach to assuring nursing and midwifery care took place in May 2015, with a particular focus on acute adult in-patient, in-patient maternity and in-patient specialist dementia care.

Do Not Attempt Cardiopulmonary Resuscitation and death certification

Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions

Cardiopulmonary resuscitation (CPR) is life-saving, but can also be invasive, seemingly aggressive and undignified, and may cause the staff involved and those observing (particularly family members) distress. It is therefore an intervention that needs to be targeted on individuals it would benefit and for whom it would have some likelihood of success.

Scotland has a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) Integrated Adult Policy that was developed in 2010. The policy and associated children and young persons acute deteriorating management policy for those under 16 years help ensure DNACPR decisions are transparent and open to examination. They aim to prevent inappropriate, futile and/or unwanted attempts at CPR that may cause distress to patients and families and are intended to represent a positive step in helping a person's wishes to be honoured at the end of life. The policies are currently being reviewed, with conclusions expected in summer 2015.

A letter from the Chief Medical Officer and Chief Nursing Officer issued in June 2014 confirmed that if a DNACPR decision is made on the clear clinical grounds that CPR would not be successful, there should be a presumption in favour of informing the patient of the decision and explaining the reason for it. A decision can be made not to inform the patient at the time only if it is judged that the conversation would cause him or her physical or psychological harm. This must be clearly documented, along with a plan to review the patient's ability to engage with the conversation.

Subject to appropriate respect for confidentiality, those close to the patient should also be informed and offered an explanation. Regrettably, the report found that relatives at the VOLH perceived a lack of proper discussion with them on DNACPR decisions.

There has been increasing awareness since 2010 that DNACPR decisions are part of those relating to wider emergency anticipatory care planning. Sensitive and explicit consultation with patients and families about all decisions and wider planning, including DNACPR decisions, is required. The review of the Scottish policies will address the immediate need to reflect good practice guidance published by the British Medical Association, the Royal College of Nursing and the Resuscitation Council (UK) in autumn 2014.

There has been some variation in implementation of the DNACPR policy throughout Scotland. Good practice examples have nevertheless emerged and learning from the safety improvement programmes has informed new approaches to support reliable and consistent implementation across the country. This has been complemented by activity to raise awareness of the policy through public meetings and in clinical settings with patients, and targeting senior medical staff and consultants with specific DNACPR-related communication training.

A DNACPR indicator was developed in 2013 to help NHS boards embed the national policy. Healthcare Improvement Scotland is now progressing work with three pilot NHS boards to develop a measurement plan so that we know people are being cared for in line with the policy.

Caring for people in the last days and hours of life

We issued new guidance on Caring for People in the Last Days and Hours of Life in December 2014, emphasising the importance of informative, timely and sensitive communication with patients and families. The guidance noted that significant decisions about a person's care, including the diagnosis of dying, should be made on the basis of multi-disciplinary discussion. Each person's physical, psychological, social and spiritual needs should be recognised and addressed as far as is possible, with consideration also being given to the wellbeing of families and carers.

Death certification

We produced national guidance following the VOLH outbreak to ensure that deaths in which HAI played a part were accurately certified by medical staff. The guidance was distributed to NHS boards in September 2009, with an updated version issued in October 2014.^[21] The updated guidance asks NHS boards to:

• have systems in place to ensure the infection control manager is informed when HAI is recorded on a death certificate
• ensure consistent and reliable systems are in place to identify, as a minimum, C. diff and MRSA-associated deaths
• conduct rapid event investigation, as a minimum, for all deaths where C. diff or Staphylococcus aureus bacteraemia contributed to the death
• develop processes to ensure weekly and quarterly death data from National Records of Scotland^[22] for C. diff and MRSA (as a minimum) are reported to the infection control manager
• establish liaison with the Procurator Fiscal to ensure more coordinated action
• ensure all certifying doctors are appropriately trained in completing death certificates.

We are working with NHS Education for Scotland to ensure that certifying doctors are trained appropriately to complete death certificates and to provide relevant information for non-certifying staff and the public. We have also worked with Healthcare Improvement Scotland, National Records of Scotland and NHS Education for Scotland to develop a robust review system that randomly selects and reviews death certificates for accuracy and quality and provides feedback on the outcome to all relevant parties. This information is used for multiple purposes, including ongoing education and training for certifying doctors.

4.2 Communication, record-keeping and reporting

This section focuses on statutory, national and local initiatives that support good practice in communication, record-keeping and reporting. It relates to report recommendations: 10, 11, 12, 14, 15, 16, 19, 21, 22, 38, 47, 48, 51, 55, 56, 57, 58, 59, 69 and 73.

What the report tells us

The report cites communication with nurses and doctors as one of the two main areas of concern for the patients and families, with relatives describing "serious deficiencies" in communication, particularly in relation to aspects of C. diff infection. It calls for NHS boards to ensure staff inform patients and relatives not only about a diagnosis of C. diff infection, but also that the condition can be life-threatening (recommendations 10 and 11). Clear and proper advice on infection control precautions is identified as particularly important (recommendation 12).

Some family members found it difficult to get information from nurses during visiting times to the ward, as these periods coincided with nursing shift changes and formal handovers. While acknowledging the importance of ward handovers, the report believes it is reasonable to expect that a member of nursing staff should be available at these times to respond to relatives' queries (recommendation 21). It also recommends that relevant discussions be recorded in patients' notes (recommendation 22).

Information is crucial for relatives at all stages of their loved one's care and treatment, including when the person dies. In accordance with national guidance on death certification related to HAI, the report recommends that relatives are provided with clear explanations of the role played by C. diff in the death (recommendation 69).

Criticism was levelled at record-keeping practices, with the report finding a "culture" in which record-keeping was not considered a priority. Recommendations 14, 15, 19 and 38 relate to record-keeping, the last specifically to records maintained by medical staff.

The report acknowledges the significant changes made following the VOLH outbreak to monitoring, accountability and reporting arrangements for HAI in NHS Greater Glasgow andamp; Clyde. It nevertheless makes specific recommendations on measures to ensure effective reporting by infection control managers to chief executives (recommendation 47) and boards (48). The structure and functioning of infection prevention and control teams and committees is addressed in recommendations 51 (clarifying communication lines and meeting schedules), 56 (reporting structures), 57 (detail and reporting of meeting minutes), 58 (lay representation on committees) and 59 (prioritisation of attendance at meetings across the infection prevention and control structure).

Mechanisms must also be in place in NHS boards, the report states, to ensure reporting of numbers and rates of C. diff infection to chief executives (recommendation 55) and ward outbreaks of C. diff infection to infection prevention and control teams (recommendation 16). Outbreak control teams' reports should provide sufficient detail to allow effective auditing (recommendation 73).

Our current position

Patient, family, carer and public participation in services

We set out in Chapter 2 some of the policies and legislation introduced and actions we have taken to ensure the patient, family, carer and public voice is heard in NHSScotland and is the key driver of improvement. One of the actions mentioned was the introduction of the Participation Standard, and we return to this here.

The Scottish Health Council uses the Participation Standard to monitor progress and drive improvement in how people are involved in the NHS. It enables the collection of information on good practice from across Scotland and measurement of how well NHS boards focus on the patient, involve the public and take responsibility for ensuring their participation.

The latest assessment against the standard, in March 2013, showed 20 of Scotland's 22 NHS boards had improved on the levels of the previous assessment in 2011, providing robust evidence of genuine improvement in participation processes and practices. The performance of the two boards that did not show progress stayed the same. All boards are now working with improvement plans agreed with the Scottish Health Council. The next round of assessments will take place in summer 2015, focusing on how NHS boards use feedback and complaints to improve services.

Participation contributes positively to making services person-centred by improving communication and developing a mutually beneficial partnership among patients, the public and services. The last 10 years have seen a culture change in attitudes and behaviours across NHSScotland towards involving people and increased levels of involvement are reflected in higher levels of public satisfaction with local health services. Activity is now underway to embed and spread best practice and drive improvement in participation practice through, for example, national improvement support for person-centred care and the Stronger Voice initiative, which aims to ensure that the voices of citizens are heard at every level in health and social care.

A Stronger Voice for citizens in health and social care

We are working in partnership with the Scottish Health Council, Healthcare Improvement Scotland Public Partners, the Health and Social Care Alliance Scotland (The ALLIANCE) and the Convention of Scottish Local Authorities through a process of open engagement with stakeholders and members of the public to develop a framework to support a stronger voice for citizens in health and social care. This new framework is based on a vision in which: "People who use health and care services, carers and the public will be enabled to engage purposefully with health and social care providers to continuously improve and transform services. People will be provided with feedback on the impact of their engagement, or a demonstration of how their views have been considered." Further information about this developing framework is available online at www.scottishhealthcouncil.org/strongervoice.aspx

Person-centred care

The Person-centred Health and Care Collaborative was launched in November 2012 with the aim of ensuring that 90% of people who use services have a positive experience and achieve the outcomes of care they expect. It was taken forward by Healthcare Improvement Scotland, working in partnership with NHS boards and with support from The ALLIANCE and NHS Education for Scotland.

The collaborative successfully provided support to teams across NHSScotland, including:

• developing the five "Must Do with Me" elements of person-centred care
• providing a measurement framework to support teams to gather real-time feedback from people who use services
• delivering improvement support to NHS boards through team visits, improvement skills development courses and national events.

There is good evidence that the profile of person-centred care has been raised considerably through the collaborative and that related concepts and principles have spread widely. An example is the "Must Do with Me" elements of care, which are based on five key issues for patients:

• what matters to you?
• who matters to you?
• what information do you need?
• "nothing about me without me", meaning people are involved in decisions and their care at the level they choose
• personalised contact, with services organised as far as possible around people's needs.

Health literacy

A key aim of the Person-centred Health and Care Portfolio is to enable people to have sufficient knowledge, understanding, confidence and skills to cope with the complex demands of modern health care. Meeting people's health literacy needs and communicating in meaningful ways is key to delivering person-centred care. It also improves the safety and effectiveness of care, and helps address health inequalities. Health literacy is recognised globally as a priority health issue, and Scotland is at the vanguard in its promotion. We published Making it Easy - a Health Literacy Action Plan for Scotland in May 2014 and have also established a national Clinical Lead for Health Literacy.

Healthcare Improvement Scotland is now refocusing national quality improvement support for person-centred care to build on progress since 2012. The new model will incorporate three main strands:

• supporting NHS boards to further develop real-time feedback systems and methods to capture care experience
• ensuring person-centred care is integral to other national quality improvement programmes
• sharing best practice examples and person-centred evidence across NHSScotland through a variety of methods, including networking, social media, WebEx and video streaming technologies.

Record-keeping

Regulation and codes

The report highlights the potential dangers of inadequate record-keeping. Registered health professionals, such as nurses and doctors, must meet professional standards on record-keeping established by their regulatory bodies - the Nursing andamp; Midwifery Council (NMC) and the General Medical Council (GMC).

Professional regulation of record-keeping

The revised NMC code (effective from March 2015) that all nurses and midwives must follow provides specific guidance on record-keeping and requires that clear and accurate records be maintained. It stipulates that nurses and midwives must: complete all records at the time or as soon as possible after an event identify any risks or problems and the steps taken to deal with them so colleagues who use the records have all the information they need complete all records accurately and without any falsification sign, date and time any entries they make (in paper or electronic records) not include unnecessary abbreviations, jargon or speculation take all steps to make sure that all records are kept securely. The GMC requires doctors to: keep clear, accurate and legible records make records at the time the events happen or as soon as possible afterwards record concerns, including any minor concerns, and the details of any action taken, information shared and decisions made relating to those concerns make sure information that may be relevant to keeping a child or young person safe is available to other clinicians providing care to them.

We have developed our own Scottish Government Records Management: NHS code of practice (Scotland) as a guide to the required standards of practice for those who work in, or under contract to, NHSScotland. An update was published in January 2012 based on current legal requirements and professional best practice. The update takes into account the Public Records (Scotland) Act 2011, which seeks to improve records management across Scottish public authorities, including NHS boards.

Improving record-keeping through eHealth

eHealth is the use of information, computers and telecommunications to support health.

NHSScotland records are more joined up now than they have ever been, with investment in modern information technology systems providing the building blocks for better record-keeping. Our national eHealth Strategy 2014-2017 uses these modern systems to support NHS boards to help people communicate with NHSScotland, manage their own health and wellbeing and become more active participants in the care and services they receive. It also improves the availability of appropriate information for healthcare workers and provides tools to enable them to communicate more effectively.

We have allocated £770 million to eHealth since 2008, including £38 million to ensure general practice records provide comprehensive life-long health data, £44 million in patient management systems and £5 million on measures to improve hospital bed management and reduce length of stay.

We are now at a pivotal point in relation to the possibilities presented by electronic health records. We believe further developments in this area will bring significant benefits to how patients and healthcare workers interact, and will also support research and development.

Technological developments at the Vale of Leven Hospital

In common with all acute facilities in NHS Greater Glasgow andamp; Clyde, the VOLH has benefited from the introduction of technology that allows images such as X-rays and scans to be stored electronically and viewed on video screens, enabling healthcare workers to access the information and compare it with previous images at the touch of a button. The hospital now uses the TrakCare patient management system, which provides an electronic record for patients attending hospital from referral or unscheduled admission through their inpatient and outpatient care to discharge. The information can be shared securely with hospital staff and general practitioners. In addition, the VOLH has consolidated its laboratory systems on a single platform and introduced an online clinical portal that enables clinical information, including correspondence, results and diagnoses, to be shared securely. The consequence of these developments is greater traceability of patients and the ability to track the flow of individual patients wherever they are situated. Healthcare workers' access to information technology has been enhanced, giving them the ability to order and report diagnostic tests electronically and share results across the clinical community.

4.3 Education, training and development^[23]

This section focuses on national education initiatives that aim to drive up standards before turning to approaches to undergraduate and postgraduate education for nurses and doctors.23 It relates to report recommendations: 23, 42, 43, 54, 60 and 67.

What the report tells us

The report makes specific reference to the need for ongoing education initiatives in particular aspects of HAI-related work. It calls for mandatory infection prevention and control training (including training on C. diff infection) for all people working in a healthcare setting (recommendation 42), targeted education for infection control nurses and doctors (recommendation 43), specific training for link nurses in boards that employ this system as part of the infection prevention and control structure (recommendation 67), and appropriate training at postgraduate level for those appointed as tissue viability nurses (recommendation 23).

It also emphasises the need for immediate implementation of initiatives such as the Cleanliness Champion Programme that are designed to improve staff knowledge of infection prevention and control practice, with protected time for staff undertaking the programmes (recommendation 60), and training for staff using surveillance systems to ensure they are fully aware of how to use and respond to the data available (recommendation 54).

Our current position

National education and training initiatives

Education and training plays an essential part in preparing and supporting the NHSScotland workforce to face current and future challenges. This section briefly describes some of the national education initiatives launched since 2007 that have relevance to issues highlighted in the report.

HAI Taskforce support for education

The HAI Taskforce delivery plan (April 2008 to March 2011) recognised the crucial role education plays in the fight against HAI. It promoted a range of education initiatives that remain in place today, including:

• a strategy to ensure all healthcare workers receive appropriate education and training related to HAI
• an education framework for specialists working in infection prevention and control
• support for the Cleanliness Champions Programme in undergraduate nursing and medical courses and extension of the programme to a range of healthcare staff.

Cleanliness Champions Programme

The Cleanliness Champions Programme was introduced in September 2003, with over 18,000 NHSScotland staff now having completed it. The aim is to prepare staff to promote and maintain a healthcare culture in which patient safety related to infection prevention and control is of the highest importance. The programme focuses on two key themes: promoting safe practice; and ensuring a safe patient environment. Cleanliness champions play a key role in promoting good practice and raising awareness about infection prevention and control in NHSScotland settings.

Scottish Patient Safety Fellowship

The Scottish Patient Safety Fellowship was introduced to develop and strengthen clinical leadership and improvement capability as part of the Scottish Patient Safety Programme. NHS Education for Scotland currently leads delivery of the programme in collaboration with Healthcare Improvement Scotland. Over 100 fellows have now been trained.

Learning and development plan for person-centred care

As part of the Person-centred Health and Care Collaborative, NHS Education for Scotland was commissioned to develop a learning and development plan to support the Person-centred Health and Care Portfolio, building on a range of learning opportunities at all levels that embed a person-centred approach.

National learning sessions on person-centred care

Five national learning events at which NHSScotland staff learned from international experts and peers how care can be made reliably person-centred for every person, every time have been held since 2012 as part of the Person-centred Health and Care Collaborative. Learning has continued between events, with regular conference calls, online dialogue and on-site mentoring visits.

Nursing education

Scotland is rightly proud of its undergraduate and postgraduate nursing education. Now embedded in 13 universities (including the Open University), our education system and quality have long been admired throughout the world.

Quality education and training is vital at all steps of nurses' careers, beginning with undergraduate preparation (which leads to registration with the NMC) through to ongoing professional development and advanced or specialist training.

We recognise that a highly-skilled and motivated nursing workforce with good access to educational opportunities is crucial to delivering person-centred, safe and effective care. That is why we worked with partners to develop Setting the Direction for Nursing and Midwifery Education in Scotland. Launched in February 2014, this action plan provides a clear direction for effective, efficient and sustainable nursing and midwifery education to meet the demands and expectations of the public. It is informed by the work of the Chief Nursing Officer's education review and is a key strand of our 2020 workforce vision implementation plan.

Setting the Direction for Nursing and Midwifery Education in Scotland

The action plan identifies six strategic aims: 1. develop a sustainable national approach to postgraduate education and continuing professional development 2. embed NHSScotland values and professionalism in all aspects of nursing and midwifery education, research and practice 3. deliver dynamic undergraduate nursing and midwifery education 4. enhance the quality of the practice learning environment for staff and students 5. strengthen clinical-academic collaboration to ensure that research and evidence underpins and drives improvements in quality 6. develop an infrastructure to deliver efficient, responsive, flexible and sustainable education. A delivery plan identifying priorities for action over 2015/16 is being developed with stakeholders.

Undergraduate nursing education

We commission and fund all undergraduate nursing and midwifery education programmes in Scotland and recommend intake numbers annually based on assessments of service needs for registered nurses. All programmes must meet specified NMC standards that ensure nurses are equipped with the skills and qualities to deliver person-centred, safe and effective practice when they qualify, with NHS Education for Scotland undertaking performance management reviews of provider universities on our behalf.

Information collected by NHS Education for Scotland suggests a sustained improvement in the number of students completing their courses. This improvement, coupled with an increase in applications for places on undergraduate nursing programmes, means that universities are able to focus on improving selection techniques. As a result, an even greater proportion and number of students are now completing their programmes and are available to enter the workforce as registered nurses.

Nursing student, mentor and charge nurse annual survey

NHS Education for Scotland annually surveys students, mentors (who are assigned individually to students in practice areas to provide support and guidance and help them achieve their objectives) and charge nurses to capture unique feedback on the education experience in university and healthcare settings. Analysis of data produced over the last five years shows that mentors and charge nurses rate newly qualified nurses emerging from the undergraduate programmes highly for their professional attitude and behaviour, caring and compassionate approach, and motivation. Student nurses give top ranking to their education programmes for promoting holistic care, practising ethically and managing HAI.

Postgraduate nursing education

Once nurses are registered, they are obliged to keep themselves up to date by taking part in ongoing education and development activities.

Nursing revalidation

The NMC is committed to implementing an effective system of revalidation for nurses and midwives. A pilot process is underway across the UK to test the proposed model with a view to full implementation later in 2015, with the first nurses revalidating in April 2016. Revalidation will require nurses to confirm that they: continue to remain fit to practise by meeting the principles of the revised NMC code have completed the required hours of practice and learning activity through continuing professional development have used feedback to review and improve the way they work have received confirmation from someone well placed to comment on their continuing fitness to practise.

NHSScotland nurses at all levels can now access a wide range of education and development experiences through online and classroom-based programmes and formal courses in universities and colleges, but the local workplace has also become increasingly recognised as a core setting in which learning takes place.

There are many resources through which nurses can update their knowledge and skills in work settings, including accessing journals and online education materials through NHS Education for Scotland resources, meeting and discussing issues with colleagues, in-service training activities, reviews of significant incidents, "shadowing" colleagues in different departments and the almost unlimited opportunities for learning presented by working with patients and families on a regular basis.

Examples of education and development initiatives developed by NHS Education for Scotland for nurses in Scotland include:

• Flying Start NHS®, the national development programme for all newly qualified nurses, midwives and allied health professionals to help them consolidate clinical practice, facilitate learning and develop team-working skills
• Early Clinical Career Fellowships, which support highly enthusiastic and motivated nurses at an early stage in their careers to develop personally, professionally and academically through access to master's-level education, mentorship, one-to-one clinical coaching and masterclasses
• The Effective Practitioner, an online resource to develop clinical practice, learning, teaching and supervision, leadership and management
• The Senior Charge Nurse Educational Development Framework, building from the Leading Better Care review (see Chapter 2) to support senior charge nurses' education and professional development
• Advanced Nursing Practice Toolkit, a repository for resources to support nurses in advanced practice roles
• Clinical Education Career Pathways, which aim to enhance clinical education career opportunities and positively contribute to staff development, retention and the practice education experience of all staff
• Promoting Excellence, a resource to support nurses and other staff working with people with dementia.

Postgraduate (specialist) nursing education

A variety of accredited education programmes for specialist and advanced practice roles are available to nurses. These are provided by universities, with nurses' places usually funded by NHS boards.

We provided £1 million in March 2012 to support increased postgraduate education for the existing workforce and will ensure education programmes for specialist and advanced practice roles continue to be available and accessible across Scotland through our Setting the Direction action plan.

Medical education

As is the case for nursing, Scottish medical education and practice is admired throughout the world and NHSScotland remains a popular employment choice for doctors. We are determined to do all we can to ensure Scotland sustains and enhances its reputation for world-leading medical education, services, research and innovation. This starts with enabling trainee doctors to get the right preparation for practising medicine safely and competently, and supporting postgraduate trainees to access appropriate education and development activities to ensure their ongoing fitness for practice.

Undergraduate medical education

Medical students are subject to ongoing supervision throughout their GMC-approved undergraduate learning. They undertake clinical placements during their final years of study designed to ensure they have the knowledge and aptitude to practice medicine. Scotland's medical schools, working with NHS Education for Scotland, oversee this process and take corrective action where medical students are experiencing difficulties.

Postgraduate medical education

Postgraduate medical education and training operates within a UK-wide framework, with programme curricula and standards approved and overseen by the GMC and quality-assured by NHS Education for Scotland, working with NHS boards.

The GMC has recently concluded a review of its arrangements for quality-assuring medical education and training in the UK and is considering how best to take forward the recommendations. A key recommendation is that quality assurance reports should provide explicit judgements (with supporting evidence) about whether standards have been met, accompanied by an organisation's action plans for addressing any that are unmet.

Professor David Greenaway's independent review of the future shape of medical training, Securing the Future of Excellent Patient Care, reported to UK ministers in October 2013. After consideration, all four UK nations have given their broad endorsement to its main recommendations and have approved implementation activities on a phased basis. The review recommends that medical training needs to be adapted to better meet the needs of patients and service providers within integrated care settings, with more emphasis on developing generic skills and competencies. It also suggests that training places should be limited to organisations and locations that provide high-quality training and supervision opportunities, as approved and quality-assured by the GMC.

Revalidation for doctors

Revalidation is the process by which doctors have to demonstrate to the GMC, normally every five years, that they are up to date, fit to practise and are complying with relevant professional standards. The information required for revalidation is drawn from doctors' practice, feedback from patients and colleagues, and participation in ongoing professional development activity. Revalidation across the UK began in December 2012, with an agreed roll-out programme in place to ensure that all doctors are revalidated by the end of 2015. The process of revalidation for the first cohort of doctors in Scotland commenced in 2013. Healthcare Improvement Scotland reports that we are on track to meet our commitments. The agreed roll-out plan for revalidation is overseen and supported by our Revalidation Delivery Board.

The early action we took to ensure Scotland's readiness for the introduction of medical revalidation means the key systems and tools to ensure NHS boards and individual doctors can meet the GMC's statutory requirements are in place.

Revalidation is supported by a system of appraisal. We have revised appraisal guidance for NHSScotland, funded the development of the Scottish online appraisal resource system and training for some 700 appraisers, and are continuing to provide training for the network of "responsible officers", whose key roles are to ensure that all doctors comply with the revalidation requirements and make recommendations to the GMC on their fitness to practise.