Health and Care (Staffing) (Scotland) Act 2019: statutory guidance

3. Guiding Principles in Health Care

3.1 Which sections of the Act is this chapter about?

This chapter provides further detail on the following sections of the Act:

• section 1: Guiding principles for health and care staffing (as these principles apply to staffing for health care); and
• section 2: Guiding principles etc. in health care staffing and planning.

There are other links to useful information embedded in this chapter; these are denoted in blue text.

3.2 Who does this chapter apply to?

The following organisations must comply with the requirements contained in this chapter:

• All geographical Health Boards;
• NHS National Services Scotland (referred to in the Act as the “Agency”); and
• Special Health Boards who deliver direct patient care, i.e., NHS 24, the Scottish Ambulance Service Board, the State Hospitals Board for Scotland and the National Waiting Times Centre Board.

These are referred to as “relevant organisations” in this chapter.

This chapter of the guidance relates to the guiding principles as far as they apply to staffing for health care. The guiding principles apply equally to the provision of care services and care service providers must take these into account when arranging staffing. Guidance on the application of the guiding principles to care services can be found in chapter 14.

3.3 In what settings and to which staff does this chapter apply?

These sections apply to all NHS functions provided by all professional disciplines (chapter 2, introduction provides more details on professional disciplines covered by the Act). They are not limited to the types of health care listed in section 12IK of the Act in relation to the section 12IJ Duty to follow the common staffing method.

Accountability for the obligations imposed in sections 1 and 2 of the Act remains with the relevant organisation and not with individuals who may be charged with carrying out certain actions.

3.4 What is this chapter about?

This chapter covers the requirements on relevant organisations to have regard to the guiding principles when carrying out the section 12IA duty to ensure appropriate staffing in health care, and when planning or securing the provision of health care from another person under a contract, agreement or arrangement made under or by virtue of the 1978 Act. It should be read in tandem with chapter 5 which covers the section 12IA duty to ensure appropriate staffing. Further details about planning or securing health care from others can be found in chapter 4.

The principles, alongside the section 12IA duty to ensure appropriate staffing in health care, underpin the outcomes that the Act is seeking to deliver. They explain what people using health care and those who work there can expect; the requirements on relevant organisations; and actions required of those who are involved in making decisions about staffing

The guiding principles have been developed to ensure that decisions made in relation to staffing are aligned with wider health and care policy.

3.5 What are the guiding principles in section 1 of the Act?

The Act states that the main purposes of staffing for health care and care services are:

• to provide safe and high-quality services; and
• to ensure the best health care or (as the case may be) care outcomes for service users.

The Act then lists principles to be met, in so far as they are consistent with the main purposes, when relevant organisations are arranging staffing.

3.6 What is meant by “safe”?

When judging whether or not a service is “safe”, safe does not mean “no-risk”. Depending on the service, safe may not even mean low risk; risks are an inevitable part of all health care services. Risk must be managed to have safe systems. In many services, for example where an enablement approach is taken, a level of risk is required and needs to be managed by both service users and staff to support people to achieve outcomes. Positive risks, as defined in the Health and Social Care Standards (paragraphs 2.24 and 2.25), mean making balanced decisions about risks and benefits, recognising that risks to safety are inevitable and can sometimes result in benefits.

However, the Act requires relevant organisations to have appropriate staffing in place to enable provision of safe and high-quality services, and so reduce risk to service users. Patients / service users should not be put at unnecessary risk as a result of staffing which fails to provide high-quality health care services.

It is important to note that while the guiding principles are focused on outcomes for service users and the reference to “safe” is drafted with service users in mind, this cannot be separated from the wellbeing of staff themselves. An unsafe staffing environment can create unsafe services. Conversely, improving the wellbeing of staff can improve the safety, quality of care and experience of service users and so the two are inextricably linked. See also 3.13 about the wellbeing of staff below.

3.7 What is meant by “high-quality”?

The provision of high-quality care that is right for the individual service user is one of the headline outcomes under the Health and Social Care Standards and as such the guiding principles of the Act should be read alongside these standards. As the Standards make clear, care can only be “high-quality” if it provides support or services that are right for the individual, taking into account their own particular characteristics.

High quality care, as detailed in the Health and Social Care Standards should include

• consideration of the dignity and respect of service users, and their carers and representatives where appropriate;
• respect for and promotion of their human rights;
• compassionate care and support;
• empowering and enabling individuals to be fully involved in all decisions about their care and support;
• responsive care which adapts to the needs of the service user;
• care which improves wellbeing; and
• care which highlights and supports personal outcomes.

3.8 What principles need to be met in arranging staffing?

The principles to be met are:

• improving standards and outcomes for service users;
• taking account of the particular needs, abilities, characteristics and circumstances of different service users;
• respecting the dignity and rights of service users;
• taking account of the views of staff and service users;
• ensuring the wellbeing of staff;
• being open with staff and service users about decisions on staffing;
• allocating staff efficiently and effectively; and
• promoting multi-disciplinary services as appropriate.

All of these principles need to be read in the context of achieving the overarching outcome of safe and high-quality services and the best health care outcomes for service users. The focus of the guiding principles should always be to look at how these impact on patients and service users. No one factor is more important than another and they should all be considered together when determining staffing.

The guiding principles closely follow the principles set out in section 4 of the Public Bodies (Joint Working) (Scotland) Act 2014 and therefore the Statutory guidance accompanying the 2014 Act is relevant.

3.9 Improving standards and outcomes for service users

Established standards such as the Health and Social Care Standards, and suitable outcome measures of the quality of services being provided, should be considered; identifying trends, and exploring whether staffing has had an impact. The emphasis should be on identifying how standards and outcomes for service users could be improved.

3.10 Taking account of the particular needs, abilities, characteristics and circumstances of different service users

No two service users are the same and the outcomes that matter to a particular person will vary. Relevant organisations need to ensure a holistic person-centred approach which involves service users and / or their representatives (such as those with a Power of Attorney) in decision making about meeting their individual needs. This could include the range of support the service user has, or does not have, through family, friends and the wider community and would be relevant, for example, in ensuring carer involvement in the discharge of cared-for persons from hospital under the Carers (Scotland) Act 2016. Staffing decisions also need to reflect the ability of service users, for example the extent to which they can participate in their own health or care needs

This is in line with the Health and Social Care Standards, examples of which include:

• 2.9 I receive and understand information and advice in a format or language that is right for me; and
• 2.11 My views will always be sought and my choices respected, including when I have reduced capacity to fully make my own decisions.

The principles of Getting it right for every child (GIRFEC) would also be applicable here.

3.11 Respecting the dignity and rights of service users

Service users can expect to experience health care services which are underpinned by a Human Rights and Children’s Rights based approach. This means service users’ rights are respected, protected and fulfilled; they are involved in decisions that affect them; informed of their rights and entitlements; and provided with a form of redress if they believe their rights are being denied. Service users should be treated with dignity and, as far as possible, be in control and able to express themselves about their requirements. This would include involvement of their representatives as appropriate.

For example, the Health and Social Care Standards, state in paragraph 4.1 ‘My human rights are central to the organisations that support and care for me’. Other publications relevant to an individual could include Adults with Incapacity (Scotland) Act 2000 and the Children and Young People (Scotland) Act 2014.

3.12 Taking account of the views of staff and service users

The views of staff and service users are crucial to ensuring service users’ dignity and rights are respected and standards and outcomes are improved. Organisations should be able to demonstrate how the views of service users and staff have been gathered and how they have informed decision-making.

3.13 Ensuring the wellbeing of staff

There is a link between the safety of service users and the wellbeing of staff delivering the service. Increased staff wellbeing can reduce sickness absence, burnout and work-related stress, meaning that staff are available to care for service users. Healthy, engaged and well supported staff are also more able to provide safe and high-quality services. In some situations, staff will be working in challenging environments or as lone workers, which can increase risks to their wellbeing. In order to provide safe and high-quality services, appropriate measures and checks need to be in place to maintain staff wellbeing.

An environment where staff feel able to raise issues with patient safety, mistakes or areas of concern is vital to their wellbeing. This involves creating a culture of transparency, continuous improvement and open communication and an environment where it is clear to staff that the relevant organisation(s) have a culture of system improvement rather than blaming individuals. Staff need to feel safe to raise concerns at all times regarding any risks resulting from staffing.

3.14 Being open with staff and service users about decisions on staffing

As well as taking into account the views of staff and service users, organisations must be open with staff and service users about decisions on staffing. Organisations should foster the development of an open culture which allows and encourages staff to raise issues and be supported in finding new ways to overcome risks without fear of adverse consequences.

3.15 Allocating staff efficiently and effectively

Staffing arrangements should allocate staff so they have the greatest impact on providing safe and high-quality services that result in the best outcomes for patients and service users. This could include effective rostering and / or use of real-time staffing resources which ensure staff with the right knowledge and skills are in the right place at the right time to meet the needs of service users.

3.16 Promoting multi-disciplinary services as appropriate

Staffing arrangements should promote a multi-disciplinary approach where this is appropriate to meet the needs of patients or service users. The definition of “multi-disciplinary services” provided in this section of the Act makes it clear that this refers to either a health care, care service or integrated service delivered by individuals from different professional disciplines. This may, or may not, be in close proximity, but always in collaboration.

This principle should not be interpreted as requiring relevant organisations to prioritise multi-disciplinary services over and above other services or where this is not deemed appropriate. This principle must be consistent with the main purposes of the guiding principles, namely the provision of safe, high-quality services and to ensure the best health care outcomes for service users. Organisations should consider multi-disciplinary service models as well as uni-professional models in terms of opportunities / benefits when deciding what is suited to the needs of the person receiving care.

Again this aligns with the Health and Social Care Standards, which state in, for example in 1.13 ‘I am assessed by a qualified person, who involves other people and professionals as required’ and 2.26 ‘I know how different organisations can support my health and wellbeing and I am helped to contact them if I wish’.

The unique role of each profession in a multi-disciplinary service should continue to be recognised and promoted within the context of ensuring the highest quality of care is provided to service users. This consideration is central to determining whether or not the involvement of another discipline from the multi-disciplinary team is “appropriate” or not. Where a multi-disciplinary approach is not deemed appropriate, best practice would be to provide clear rational for the decision-making process that led to this decision.

3.17 How are the guiding principles applied in health care (section 2 of the Act)?

Section 12IA of the 1978 Act places a general duty on relevant organisations to ensure appropriate staffing. Section 2 of the Act states that in carrying out this duty, relevant organisations must have regard to the guiding principles for health and care staffing. This means that whenever relevant organisations are putting in place staffing arrangements to comply with the duty to ensure appropriate staffing, they must take into account the guiding principles.

The guiding principles must also be considered when relevant organisations are planning or securing the provision of health care from a third party provider, whether that be under a contract, agreement or other arrangement made under or by virtue of the 1978 Act. Further guidance on this can be found in chapter 4.

The relevant organisation is also expected to provide information to the Scottish Ministers on the steps they have taken to have regard to the guiding principles in meeting the general duty to ensure appropriate staffing and when planning or securing health care services. More details on these requirements can be found in Chapter 12.

3.18 What could a relevant organisation use to evidence compliance?

It would be for the relevant organisation to decide how they could evidence compliance, however examples of evidence that could be used could include:

• Measures against quality standards and safety outcome data, demonstrating improved outcomes or areas requiring further action;
• Details of person-centred approach to care and treatment;
• A range of mechanisms for collecting, reviewing and having regard to staff feedback;
• A range of mechanisms for collecting, reviewing and having regard to service user feedback;
• Mechanisms for assessing and responding to staff wellbeing as it relates to the guiding principles in the Act;
• Demonstrating a culture of transparency and open communication with staff and service users about decisions on staffing;
• Effective procedures for rostering and real-time allocation of staff to respond to risks; and
• Details of how different service models are considered, e.g. uni-professional and multi-disciplinary.

This list is not exhaustive.

3.19 Other relevant guidance and legislation

The Health and Social Care Standards, the principles set out in section 4 of the Public Bodies (Joint Working) (Scotland) Act 2014, and the Healthcare quality strategy for NHS Scotland all continue to apply. The guiding principles sit alongside, and complement, these.

The Scottish Government published the Health and Social Care Standards in June 2017, which set out what the public should expect when using health, social care or social work services in Scotland. The standards seek to provide better outcomes for everyone, to ensure that individuals are treated with respect and dignity, and that the basic human rights we are all entitled to are upheld. The objectives of the standards are to promote improvement, encourage flexibility and enable innovation in how people are cared for and supported. All services and support organisations, whether registered or not, should use the standards as a guideline for how to achieve high quality care. From 1 April 2018, the standards have been taken into account by Healthcare Improvement Scotland, the Care Inspectorate and other scrutiny bodies in relation to inspections and registration of health and care services.

Other guidance can be found at:

Health and Care (Staffing) (Scotland) Act 2019: overview - gov.scot (www.gov.scot)

Healthcare Staffing Programme – Healthcare Improvement Scotland

Health and Care Staffing in Scotland | Turas | Learn (nhs.scot)

Health and Care (Staffing) (Scotland) Act 2019 (cloud.microsoft)

ihub | Healthcare Improvement Scotland - Home

Engaging communities – Healthcare Improvement Scotland

Right decision service (RDS) – Healthcare Improvement Scotland

Home - National Wellbeing Hub

Standards and indicators for care services – Healthcare Improvement Scotland

Decision-making: children and young people's participation - gov.scot

Health and social care - Planning with People: community engagement and participation guidance - gov.scot

Realistic Medicine – Shared decision making, reducing harm, waste and tackling unwarranted variation

Staff Governance Standard — NHS Scotland Staff Governance