NHS Scotland Chief Executive's Annual Report 2017/18

Chapter 5 - Making Change Happen – Our People

‘It is clear that demand on our NHS is high and will rise in the years ahead. That is why progress is underway to deliver a series of commitments to address these demands.’

Visit www.nhsscotannualreport.scot for the online version of the Annual Report, including peoples’ stories and key facts and figures.

Our workforce is our greatest asset and is key to delivering modern, sustainable health services. NHS Scotland needs to have a committed, supported workforce that has the right skills, flexibility and support. Everyone needs to be valued, treated well and supported to give their best. We know that this improves patient care and overall outcomes for patients. Everyone Matters: 2020 Workforce Vision^[183] remains the key strategic statement of our commitment to our workforce.

Our 2020 Workforce Vision is:

We will respond to the needs of the people we care for, adapt to new, improved ways of working, and work seamlessly with colleagues and partner organisations. We will continue to modernise the way we work and embrace technology. We will do this in a way that lives up to our core values. Together we will create a great place to work and deliver a high-quality healthcare service which is among the best in the world.

Promoting Our Values

The NHS Scotland values are:

• Care and compassion;
• Dignity and respect;
• Openness, honesty and responsibility; and
• Quality and teamwork.

To support the delivery of the 2020 Workforce Vision, our priorities remain:

• Healthy Organisational Culture – creating a healthy organisational culture in which our NHS Scotland values are embedded in everything we do, enabling a healthy, engaged and empowered workforce;
• Sustainable Workforce – ensuring that the right people are available to deliver the right care, in the right place, at the right time;
• Capable Workforce – ensuring that everyone has the skills needed to deliver safe, effective, person-centred care;
• Workforce to deliver integrated services (across health and social care) – developing a workforce across NHS Boards, Local Authorities and third-party providers to deliver integrated services (across health and social care); and
• Effective Leadership and Management – leaders and managers lead by example and empower teams and people to deliver the 2020 Vision.

Everyone Matters: 2020 Workforce Vision was published in 2013. For each year, until and including 2016/17, annual implementation plans were published, setting out priorities and actions for that year. The implementation plan^[184] published in December 2017 covers the period 2018–20 and is intended to enable NHS Boards to focus on consolidation, completion and building on progress made in previous years, as well as setting a small number of new actions. This coincided with an increasing focus during 2017/18 on the period beyond 2020 and what is needed to support both the health and the social care workforce in the future. This involved engaging with partners to consider the development of a workforce vision for both health and social care staff working in integrated settings. This work will continue during 2018/19 and will involve engagement across health and social care.

Valuing All Our Staff

Once for Scotland Workforce Policies

Working in partnership, Trade Unions, NHS Boards and the Scottish Government initiated a project in June 2017 to consider the potential for single ‘Once for Scotland’ Workforce Policies to replace existing local human resources (HR) policies for NHS Scotland staff. The proposal was developed and agreed by the Cabinet Secretary for Health and Sport in July 2018.

The current suite of Partnership Information Network policies, which set the standards for local policies, will be replaced by policies that are developed and implemented on a Once for Scotland basis, with the work anticipated to be completed by the end of 2019. Single policies will ensure, in policy terms, consistent treatment of staff throughout and across NHS Scotland. Policies will be more user-friendly and meaningful, with staff and managers at the centre, and will be presented in a refreshed digital format.

The new process will see policies developed and reviewed more quickly and efficiently through a streamlined and simplified process, with more dynamic interactive engagement and shared accountability, responsibility and leadership to drive the work forward.

Improving Junior Doctor Working Lives

Work has been undertaken in partnership with NHS Employers and the British Medical Association (BMA) Scotland to identify and implement further actions to improve the overall working lives and experiences of junior doctors working in NHS Scotland. Agreement has been reached to implement a minimum rest period following night-shift working. From 7 August 2019, all full-shift junior doctor rotas in Scotland will have to ensure that a minimum rest period of 46 hours is given to each junior doctor following a run of night‑shift working. A preliminary target of 85 per cent compliance with this rule is set for February 2019, and the Scottish Government and Management Steering Group (MSG)^[185] will work closely with NHS Boards to monitor progress towards this target.

Doctor and Dentist in Training Lead Employer

In August 2018, a Lead Employer model was implemented for all doctors in training in Scotland. Under the new arrangements, trainees will carry on working as they currently do in individual clinical placements across regions and NHS Scotland, but for administrative purposes, the 22 NHS Board employers have been reduced to four, with trainees benefitting from having one employer for the duration of their training programme. This applies initially to doctors in training, but will later include dentists in training. The new model significantly improves the employment experience for Doctors in Training, negating the need to change employer every time they move to a new clinical placement, which is time-consuming and can cause problems for things like mortgages, tax codes, and access to employee service-based schemes. This new model has been negotiated in partnership with the Scottish Government, the BMA and NHS Scotland employers.

Healthy Organisational Culture

Whistleblowing

Over the past few years, much has been done to develop a culture where staff are encouraged and supported to raise any concerns they may have about patient safety or malpractice. This is reflected in the 2017 Dignity at Work Survey where 65 per cent of staff either ‘strongly agreed’ or ‘agreed’ with the statement ‘I believe it is safe to speak up and challenge the way things are done if I have concerns about quality, negligence or wrongdoing’. This compares to 56 per cent in the 2015 NHS Scotland Staff Survey^[186].

It is vital that staff have the confidence to speak up to ensure an open and transparent reporting culture. Over the last year, the Scottish Government has continued to work closely with the Scottish Public Services Ombudsman (SPSO) and key stakeholders to develop and refine the proposals for the role of the Independent National Whistleblowing Officer (INWO) for NHS Scotland, and this new role will be carried out by the SPSO. Work has included engagement events where, amongst others, whistleblowers had the opportunity to contribute their views on how the INWO role should work in practice. It was clear from this engagement that the scope of the role should also extend to primary care and independent providers who deliver services for NHS Scotland. Staff working in these areas will now also have access to the INWO, providing consistent independent challenge on the handling of whistleblowing cases for those delivering services on behalf of the NHS in Scotland.

Focus is also on continuous improvement and the intention is for the INWO to support and improve the response of the relevant body when handling concerns raised by staff, including a duty to record and report all whistleblowing cases in a standardised way. The new Whistleblowing Procedure, developed by the SPSO for this purpose, will provide a simple, time-bound and streamlined process for resolving whistleblowing concerns early and locally by capable and well-trained staff. Work is also underway in partnership

to create a single standardised whistleblowing policy that is user-friendly and puts staff and managers at the centre. This will result in a consistent approach to handling whistleblowing concerns in NHS Boards. Given the expansion of the scope of the role, it is now anticipated that the INWO will become operational in the autumn of 2019.

The contract for Whistleblowing Alert and Advice Line Services (AALS) has been extended until 31 January 2019. The benefits of this service are recognised, offering staff independent confidential advice from legally-trained advisers should they have any concerns about how or whether to whistleblow. AALS has also developed resources to help staff and managers understand what whistleblowing is and the processes that should be followed, and training packages will be issued to NHS Boards. Going forward, the Scottish Government will continue to evaluate this service alongside the role of the INWO.

Improving Staff Experience

Improved staff experience should, ultimately, benefit patient care. The iMatter Staff Experience continuous improvement model (iMatter) has been developed by NHS Scotland staff and provides a mechanism for measuring Employee Engagement. It has been designed as a continuous improvement model, offering individual teams, direct line managers, directors and NHS Boards the facility to measure, understand and improve staff experience. iMatter has now been fully implemented across NHS Scotland.

In 2017, iMatter was supplemented with a short Dignity at Work Survey enabling staff to express their views on working in health and social care in Scotland. The Health and Social Care Staff Experience Report 2017^[187] was published in March 2018 and brought together the results from iMatter and the Dignity at Work Survey. The Report contains a total of 171,494 views provided across both surveys, 36,728 of which came from staff working within Health and Social Care Partnerships.

The iMatter Employee Engagement Index (EEI) is calculated from the scoring of the iMatter questions and results in scores ranging from 16.67 and 100. The overall EEI of 75 indicates that an increasing number of staff are engaged and empowered in their roles. This included a score of 88 (‘strive and celebrate’) for those respondents who say that they clearly understood their role and responsibilities and a score of 82 (‘strive and celebrate’) for those respondents who reported that they were treated with dignity and respect. A score of 74 (‘strive and celebrate’) was achieved for those who responded that they would recommend their organisation as a good place to work.

The report also contains 23 team stories from health and social care teams which offer practical examples where teams have taken action based on feedback from iMatter. It is intended that this learning can be shared across NHS Scotland.

The 2017 report did, however, show that the response rate to the Dignity at Work Survey remained low at 36 per cent and similar to previous national staff surveys. This suggests that staff are not engaging with this approach and that a better way to engage with staff on these issues needs to be found. In contrast, the iMatter results have been very positive and this has become the most engaging and inclusive staff experience measurement ever run across NHS Scotland, with 108,230 respondents from 22 NHS Boards and 23 Health and Social Care Partnerships and a response rate of 63 per cent.

The Scottish Government has commissioned an external evaluation of the approach to measuring staff experience, including iMatter and the Dignity at Work Survey. This commenced in the autumn of 2018 with the expectation that the final report will be available in June 2019. This exercise will engage staff, their representatives and other key stakeholders to consider how iMatter and the Dignity at Work Survey mechanisms inform actions to enable NHS Boards to implement the Staff Governance Standard. This will provide a platform to continuously reflect on and improve the approach.

NHS Scotland Global Citizenship Programme

For many years, staff from across NHS Scotland have made a significant personal and professional contribution to global health work in developing countries. This valuable work not only helps to reduce common challenges such as disease epidemics, but also provides mutual learning opportunities for NHS staff and NHS Scotland, thereby benefitting people in Scotland.

To increase NHS Scotland’s global health contribution, we launched the NHS Scotland Global Citizenship Programme^[188] in June 2016. The Programme supports the Scottish Government’s International Development Strategy, in particular the commitment to support the strengthening of capacity in the area of health by making it easier for all NHS staff to participate in global citizenship, both in Scotland and abroad. The approach adopted builds on best practice, including the work that NHS Borders has developed over the last 20 years with their twinning arrangement with St Francis Hospital, Zambia.

Traditionally, global citizenship has been considered through the lens of overseas placements. However, staff from across the NHS contribute in multiple and innovative ways, including: mentoring healthcare staff from low- and middle-income countries who come and work in NHS Scotland in order to observe or develop new skills and learning; providing remote support, including virtual learning, networks, coaching and mentoring using a wide range of technology; and fundraising to support local initiatives and health-partnership work and through the everyday choices they make in the products they buy.

There is clear evidence that involvement in global health benefits the Scottish population through a reinvigorated, self-sufficient, innovative and productive workforce. As this unique NHS Scotland approach to Global Citizenship develops, it will be important to understand more about the impact this valuable work has on NHS staff and to maximise the opportunities to realise the benefits for staff, the healthcare system and ultimately patients in Scotland.

Building a Sustainable Workforce

NHS Scotland staffing numbers continued to rise, with the June 2018 figures showing 139,095.2 whole-time equivalent (wte). While there has been six consecutive years of annual growth, the rate of growth has slowed from 1.6 per cent as at March 2013 to 0.1 per cent as at June 2018. The workforce is also ageing, with 21.5 per cent of staff over 55 years of age, and with a median age of 46^[189].

It is clear that demand on our NHS is high and will rise in the years ahead. That is why progress is underway to deliver a series of commitments to address these demands, including:

• 800 more GPs (headcount);
• 50 additional medical undergraduates;
• 100 more medical undergraduate places by 2021 (15 to Scottish Graduate Entry Medicine Programme or ScotGEM);
• 500 additional health visitors;
• Training 500 additional Advanced Nurse Practitioners (ANPs) by 2021;
• 2,600 extra nursing and midwifery training places over this Parliament;
• Increased General Practitioner Specialist Training (GPST) posts from 300 to 400 per year; and
• An additional £3 million to increase the number of radiology trainees in Scotland by at least 50 over next five years.

National Health and Social Care Workforce Plan

The National Health and Social Care Workforce Plan was published in three parts between June 2017 and May 2018^[190]. The plan includes a number of recommendations that, when delivered, will bring about improvements in workforce planning across NHS Scotland, primary care and social care, covering four main themes: guidance, redesign, data and intelligence, and recruitment, training and education. The National Workforce Planning Group and sub-groups of key stakeholders have been established to oversee and take forward the recommendations.

In part 3 of the Workforce Plan, the Scottish Government committed to working alongside partners, including the Royal College of Nursing, to understand the requirements and investment necessary to grow the District Nursing workforce. This work will be presented to the Cabinet Secretary for Health and Sport by the end of October 2018.

The first integrated National Health and Social Care Workforce Plan will be published by the end of 2018, to provide levers and a framework of support at national level for regional and local workforce planners, ultimately supporting the integration of health and social care services in Scotland.

Delivering a Sustainable Medical Workforce

The National Health and Social Care Workforce Plan commits to creating additional undergraduate medical places. The medical schools were asked to put forward proposals for new courses with a focus on General Practice. The three successful bids are:

• Thirty additional undergraduate medical places will be created at the University of Aberdeen; all students will undertake an enhanced GP programme, with a set minimum of teaching time and an additional range of GP options;
• Thirty additional undergraduate medical places will be created at the University of Glasgow; all students will gain enhanced exposure to primary care and students can opt for intensive experience of primary care in deprived and rural settings on the new Community Orientated Medical Experience Track (COMET); and
• Twenty-five additional undergraduate medical places will be created at the University of Edinburgh; this innovative course will allow experienced healthcare professionals to enter medicine and combine part-time study with their existing job, with large parts of the course delivered online – it is designed to target high-calibre candidates who are more likely to be retained in NHS Scotland.

Sixty of the additional places will begin in 2019/20, and 25 places will begin in 2020/21. With the additional 15 SCOTGEM places, this is a total of 100 additional undergraduate places.

In addition to these places, several innovative initiatives have been introduced.

The pre-medical entry programme commenced in autumn 2017 at Glasgow and Aberdeen Universities. The Scottish Government is funding 40 places for pupils from less-affluent areas to better prepare them to undertake undergraduate medical education by providing students with the experience and qualifications needed to meet the entry-level requirements.

Meeting Recruitment Challenges

The Scottish Government continues to directly support NHS Boards in their efforts to recruit staff to meet their service provision responsibilities. In early 2018, nine NHS Boards across Scotland came together to undertake an international recruitment campaign for consultant-grade radiologists. A number of NHS Boards have since made offers of appointment to candidates, though the campaign highlighted a number of the supply challenges presented by recruiting to highly specialist roles in areas of acute staffing need. Evaluation of the campaign has demonstrated that there is potential to undertake further co-ordinated international recruitment activity, which will allow NHS Boards to benefit directly from economies of scale by recruiting collectively, whilst also improving recognition of the NHS Scotland brand in healthcare markets across the globe. As announced by the Cabinet Secretary for Health and Sport in June 2018, work is now underway to scope further international recruitment activity, which will launch before the end of the financial year.

In addition to efforts to expand international recruitment, the Scottish Government has already announced investment of £4 million in marketing campaigns across primary care, nursing and midwifery and the social care workforce over the next three years. This activity will look to recruit existing qualified staff, alongside individuals into specialist medical training and pre-registration nursing. This significant investment demonstrates the continuing commitment to be responsive where there is evidence of shortages across services, whilst also looking to promote service sustainability into the future.

Developing a Capable Workforce

Expanding Youth Employment Opportunities

During 2017/18, NHS Boards and the Scottish Government have worked in partnership with the Prince’s Trust to deliver a number of pilot Get into Healthcare^[191] employability programmes. These are designed to expand access to entry-level posts across the service. The programme has been developed to allow young people from a variety of backgrounds to move into various roles in nursing and midwifery, administration, facilities and estates, and support services – providing six weeks of intensive work experience, supported by classroom learning and workplace mentoring. Pilots were run in four NHS Board areas in 2017/18, delivered to approximately 100 trainees in total, with a number of success stories^[192].

Emerging evidence from the pilots has indicated that the majority of participants successfully secure permanent employment with NHS Scotland thereafter, with many transitioning directly onto a Modern Apprenticeship pathway. The pilot programmes have highlighted the potential of Get into Healthcare to help meet the ambition of increasing the proportion of the workforce aged 16–24, while at the same time increasing the number of employees undertaking a Foundation of Modern Apprenticeship. Going forward, we will look both to consolidate and expand our partnership with the Prince’s Trust.

Medical Revalidation and Appraisal

Medical Revalidation was introduced as a legal requirement in the UK in 2012 to ensure doctors maintain their skills and remain fit to practise medicine in the UK. The first five-year cycle of medical revalidation ended in 2017/18. It is founded on robust annual appraisals, and discussion must take account of a range of information, including feedback from colleagues and patients.

Since the introduction of Medical Revalidation, an annual report has been published in Scotland by Healthcare Improvement Scotland. The report demonstrates that Scotland has successfully embedded a robust process whereby annual appraisal rates have risen from a starting point of 80 per cent in 2012 to 94 per cent in 2016/17^[193]. The 2017/18 report will be published in autumn 2018, which will represent the conclusion of the first five-year roll-out process to ensure all doctors are subject to regular appraisals that will inform the General Medical Council’s (GMC’s) decision whether to renew their licence to practise in the UK. The Scottish Government will continue to work with key stakeholders to review areas of possible improvement in order to sustain this excellent progress into the next five-year cycle.

Widening Participation in Nursing and Midwifery Education and Careers

The CNO Commission on Widening Participation in Nursing and Midwifery Education and Careers^[194] was published in December 2017. The aim was to maximise opportunities for participation in nursing and midwifery education and careers, including creating and extending new routes into nursing for healthcare support workers.

One of the initiatives was the introduction of a pilot in NHS Grampian to enable healthcare support workers to undertake numeracy and literacy access courses, thereby helping them to apply for a pre-registration nursing degree. In October 2017, with support funding of £27,000 from the Scottish Government, the first cohort of 24 healthcare support workers in NHS Grampian began their access courses. While the pilot is ongoing, a number of healthcare support workers have already successfully gained places on pre-registration nursing with the Open University or are progressing into further studies. This initiative is being extended across other areas in Scotland.

Following the recommendations arising from the CNO Commission on Widening Participation in Nursing and Midwifery Education and Training, a nursing and midwifery recruitment campaign is being developed. The campaign is being designed around the needs of different audiences, such as young people, mature students, men, people from disadvantaged communities and those with disabilities and from ethnic minorities. The campaign is due to be launched over the coming months, with the opportunity for some targeted campaign work aimed at younger people in the lead up to this.

Expansion of the Transforming Roles Programme

The Transforming Roles programme aims to provide strategic oversight, direction and governance to develop and transform nursing, midwifery and health professions (NMaHP) roles to meet the current and future needs of Scotland’s health and social care system to ensure nationally-consistent, sustainable and progressive roles, education and career pathways.

Five papers were published to update stakeholders on the professions’ contribution to the wider transformational change agenda in health and social care in Scotland. The series began with an introductory paper, followed by papers on Advanced Nursing Practice, District Nursing Roles, School Nursing Roles and Education and Career Development. The Programme was also expanded to include midwives and to develop effective governance for other healthcare roles not statutorily regulated but employed in small numbers within NHS Scotland, such as Physician Associates and Physician Associates in Anaesthesia.

The Chief Nursing Officer commissioned NHS Education for Scotland (NES) in 2017 to provide additional Advanced Nurse Practitioner (ANP) education to enable the training of an additional 500 ANPs by 2021 to equip nurses across Scotland to maximise their leading role in the integrated healthcare of the future and achieve our 2030 Nursing Vision. NHS Boards completed a service needs analysis to identify their respective areas to be prioritised for funding.

Workload Planning for Safe and Effective Care

Preparatory work was undertaken in 2017/18 for the Health and Care (Staffing) (Scotland) Bill^[195]. The Bill was subsequently introduced to the Scottish Parliament on 23 May 2018. The Bill provides a statutory basis for the provision of appropriate staffing in health and social care service settings and will build on the profession-led development of evidence-based approaches to workload planning that have been successful for nursing and midwifery, supporting the development of this approach across health and social care. The innovative approach taken by the nursing and midwifery workload and workforce planning tools and methodology have, when applied properly, enabled the delivery of safe, high-quality care and improved outcomes for service users by ensuring the right numbers of nurses and midwives with the right skills are in the right place at the right time. Placing this approach on a statutory footing is an important step and will enable this to be achieved irrespective of health or social care setting.

The staffing tools and methodologies developed in this way will support local decision-making, flexibility, transparency in staffing decisions and enable the ability to redesign and innovate across multi-disciplinary settings. The Bill will make clear the role of professional judgement in ensuring appropriate staffing and will be triangulated with an agreed set of outcome measures. It will support NHS Boards to strengthen their approach to staffing decisions and provide more‑robust information to inform the projection of staff requirements and workforce planning. The Bill is part of a package of measures to support and sustain the health and care workforce.

Effective Leadership and Management

Project Lift

In order to deliver the best outcomes for patients and ensure the development of person-centred, safe and effective care in our communities, our leaders have to be able to operate in a complex landscape, taking a collective approach to leadership along with the many stakeholders they must work with. During the course of 2017/18, a new approach to leadership and talent management in NHS Scotland has been designed and developed, and implementation is under way.

This new approach, Project Lift^[196], will help identify and develop future leaders at all levels in NHS Scotland. It places as much emphasis on an individual’s values as it does on their skills and experience. Project Lift is not a traditional, linear approach to development but seeks to support and develop each participant in a manner that best suits them. Since June 2018, this values-based approach is being used for the recruitment and selection of those at the highest level in NHS Scotland.