Consultation on proposed safe staffing laws for nursing and midwifery: independent analysis of responses

Executive Summary

This summary presents an overview of the independent analysis of responses to a Scottish Government consultation on safe and effective staffing in health and social care. The consultation paper invited views on proposals to introduce legislation that would require organisations providing health and social care to apply nationally agreed, evidence-based workload and workforce planning methodologies and tools; ensure that key principles - notably consideration of professional judgement, local context and quality measures - underpin workload and workforce planning and inform staffing decisions; and monitor and report on how they have done this and provide assurance regarding safe and effective staffing.

The consultation was published on 11 April and closed on 5 July 2017. A series of consultation events were also held across Scotland. A total of 111 responses were received via the Scottish Government's Citizen Space consultation hub. Of these, 35 were submitted by organisations and 76 by individuals. The types of organisations responding were: Health & Social Care Partnerships (five respondents); Independent sector health or social care organisations (two respondents); NHS based professional groups or committees (five respondents); NHS Bodies or Boards (six respondents); Others (three respondents); Other public bodies (two respondents); and Professional colleges, bodies, groups or unions (12 respondents).

A total of 177 people attended the consultation events, with 25 discussion groups held.

Proposed purpose and scope

A majority of Citizen Space respondents answering the question, 90%, agreed that the requirement should apply to organisations providing health and social care services. The majority of both individual and organisational respondents agreed (70 out of 74 respondents and 22 out of 28 respondents respectively). Health and Social Care Partnerships and Other public bodies were the only respondent types in which the majority of those answering the question did not agree. At the consultation events, 21 of the discussion groups agreed, one disagreed, one held a mixed view and two did not answer the question.

The three most frequently-raised themes were:

• Any future development requires to be cognisant of the health and social care integration agenda.
• The specific context and requirements of social care need to be understood.
• The focus should be firmly placed on achieving better patient outcomes.

A clear majority of Citizen Space respondents answering the question, 88%, agreed that that the requirements should be applicable in settings, and for staff groups, where a nationally agreed framework, methodology and tools exist. The majority of both individual and organisational respondents agreed (69 out of 76 respondents and 21 out of 26 respondents respectively). All of the Independent sector health or social care organisations, NHS based professional group or committees, NHS Bodies or Boards, Other and Other public body respondents who answered the question agreed . Health and Social Care Partnerships were the only respondent type in which the majority did not agree. At the consultation events, 17 of the discussion groups agreed, five disagreed, one held a mixed view and two did not answer the question.

The three most frequently-raised themes were:

• The need to ensure any approach is effective, robust and evidence based.
• That relevance and applicability are considered in relation to the social care sector.
• That future proposals should be cross-referenced with other existing developments in relation to workforce planning within the health and social are fields.

In terms of how the proposed requirements should apply or operate within the context of the integration of health and social care, the three most frequently-raised issues were:

• The majority of current tools do not take into account multi-disciplinary or multi-agency working.
• The need for a whole-systems approach to workforce planning capturing the collective contribution of partners.
• That consideration is needed regarding the role, responsibilities and functions of the Integrated Joint Boards ( IJBs).

A majority of Citizen Space respondents answering the question, 82%, agreed that introducing a statutory requirement to apply evidence based workload and workforce planning methodology and tools across Scotland will help support consistent application. The majority of both individual and organisational respondents agreed (65 out of 76 respondents and 19 out of 27 respondents respectively). Health and Social Care Partnerships were the only respondent group in which the majority of those answering the question did not agree. At the consultation events, 20 of the discussion groups agreed, two disagreed, two had mixed views and one did not answer the question.

The three most frequently-identified issues were that:

• The application of a workload and workforce planning tool would support consistent and equitable practice.
• This should extend beyond nursing and midwifery to the wider multi-agency team.
• The relationship with the health and social care integration agenda and the role of IJBs requires consideration.

In terms of other ways in which consistent and appropriate application could be strengthened, the three most frequently-raised themes were the need to:

• Fully understand the challenges experienced with the current tools.
• Work closely and consult with staff.
• Ensure sufficient governance and scrutiny of the workforce planning process.

Approach to workforce planning

The consultation paper moved on to ask a number of questions about the approach to workforce planning. A substantial majority of Citizen Space respondents answering the question, 92%, agreed with the proposal to use a triangulated approach. The majority of both individual and organisational respondents agreed (67 out of 74 respondents and 21 out of 22 respondents respectively). There was only one organisational respondent, from the Professional college, body, group or union group, who disagreed. At the consultation events, 24 of the 25 discussion groups agreed and one discussion group did not answer the question.

The three most frequently-raised themes were:

• It will be important to value professional judgement.
• Developing a 'one size fits all' approach is unlikely to be successful.
• Sufficient consideration needs to be given to the local context in which the tools would be applied.

A majority of Citizen Space respondents answering the question, 71%, thought there are other measures to be considered as part of the triangulation approach to workload and workforce planning. The majority of both individual and organisational respondents agreed (43 out of 69 respondents and 24 out of 25 respondents respectively). There was only one organisational respondent, a Health and Social Care Partnership, who disagreed. At the consultation events, 21 of the 25 discussion groups agreed and four did not answer the question.

The three most frequently-raised themes were:

• That staffing cannot be considered in isolation from other factors ensuring good quality care
• Education, recruitment and retention, and other work supply issues, need to be examined.
• Any approach should be deliverable and supported by sufficient training.

Staff governance

Views were mixed as to whether, given existing staff governance requirements and standards, there are sufficient processes and systems in place to allow concerns regarding safe and effective staffing to be raised. A small majority of Citizen Space respondents who answered the question, 52%, agreed. However, a majority of individual respondents and Professional college, body, group or union respondents disagreed (41 out of 73 respondents and six out of seven respectively). In contrast, all of the other organisational respondents who answered the question were in agreement.

Amongst the discussion groups, 13 groups agreed, two held a mixed view, and seven disagreed. The remaining three discussion groups did not answer the question.

The three most frequently-raised themes were:

• Systems are in place to support safe practice and raise concerns, but these are not resulting in a change in practice.
• Poor organisational cultures can make staff feel that they are not listened to.
• It would be beneficial to place a greater emphasis on current care and clinical governance structures.

In terms of additional mechanisms required, the three most frequently-raised themes were:

• There need to be clear pathways and processes for escalation of issues.
• Ongoing consultation and discussion with staff regarding their experiences is important.
• There is potential value in independent review or external scrutiny of service standards.

A substantial majority of Citizen Space respondents answering the question, 96%, agreed with the proposal to require organisations to ensure that professional and operational managers and leaders have appropriate training in workforce planning in accordance with current guidance. All organisational respondents who answered the question agreed and only four individual respondents disagreed. All of the discussion groups also agreed.

The three most frequently-raised themes were:

• Training would support consistent and transparent practice and help embed workforce principles.
• The impact of training on clinical duties should be considered.
• There are already tools, with associated training packages, in existence.

A substantial majority of those answering the question, 95%, agreed with the proposal to require organisations to ensure effective, transparent monitoring and reporting arrangements in place. The majority of both individual and organisational respondents agreed (71 out of 73 respondents and 25 out of 28 respondents respectively). Health and Social Care Partnerships, Professional college, body, group or union and individual respondents were the only respondent types in which anyone disagreed. Twenty-two of the discussion groups agreed, one disagreed and two did not answer the question.

The three most frequently-raised themes were:

• Transparency is crucial in terms of both staff and public confidence.
• Any reporting information produced should be both easy to understand and contextualised.
• A number of external scrutiny bodies are in existence that may currently, or could, play a monitoring role.

Future approach and priorities

A majority of Citizen Space respondents answering the question, 86%, agreed with the proposal to consider extending the requirement to apply nursing and midwifery workload and workforce planning approach to other settings and/or staff groups in the future. The majority of both individual and organisational respondents agreed (66 out of 75 respondents and 20 out of 25 respondents respectively). However, a majority of Health and Social Care Partnership respondents disagreed. Twenty-two of the discussion groups agreed, one disagreed and two did not answer the question.

The three most frequently-raised themes were:

• A whole-systems, multi-disciplinary approach is required, rather than having a focus on particular professions or specialties.
• In terms of particular staff groups, all AHPs and medical staff were the most-frequently suggested.
• In terms of the clinical areas or settings respondents felt should be considered, the suggestions were again many and varied but the most frequently-identified was nursing and care homes.

Risks and unintended consequences

A majority of Citizen Space respondents answering the question, 90%, thought there are risks or could be unintended consequences arising as a result of the proposed legislation and the potential requirements to extend the requirement to other settings and/or staff groups in the future. A majority of individual respondents agreed (58 out of 68 respondents), and all organisational respondents who answered the question agreed. Twenty-one of the discussion groups agreed there were risks or could be unintended consequences and four did not answer the question.

The three most frequently-raised risks were:

• Insufficient funding to address additional staffing requirements.
• Difficulties in recruiting and retaining staff.
• Resources being drawn from one service to another if a whole-systems approach is not taken.

In terms of what steps could be taken to deal with these risks, the three most frequently-identified themes were that:

• Ensuring adequate funding is in place for health and social care services will be important.
• Any future workforce planning legislation needs to take into account the integrated practices of the Health and Social Care Partnerships
• Collaboration with educational establishments should be improved.

Monitoring requirements

A majority of Citizen Space respondents, 70% of those who answered the question, agreed with the proposals to use existing performance and monitoring processes to ensure compliance with the legislative duty and associated requirements. The majority of both individual and organisational respondents agreed (47 out of 71 respondents and 19 out of 23 respondents respectively). However, a majority of Health and Social Care Partnership respondents disagreed. Fifteen discussion groups agreed, five disagreed and five did not answer the question.

The three most frequently-identified themes were:

• The implications of legislation on social care and Health and Social Care Partnerships needs to be better understood.
• The role of existing scrutiny bodies, for example the Care Inspectorate, needs to be considered.
• Clear lines of accountability will be required across both professions and organisations.

In terms of what other ways organisations' progress in meeting requirements could be monitored, the three most frequently-identified themes were:

• There are existing scrutiny or governance processes which could be drawn on.
• Staff feedback, including anonymous feedback and any data on staff morale, should be used.
• There would be value in external reporting to a central body or the Scottish Government.

In terms of the consequences if organisations do not comply with requirements, the three most frequently-identified themes were:

• The focus should be on improvement and on being supportive rather than punitive.
• There should be corporate or political liability when improvements are not made.
• Actions must be set within the context of reducing public sector resources.

Equality considerations

The nine protected equality characteristics are age, sex, gender reassignment, sexual orientation, race, religion or belief, pregnancy and maternity, disability, and marriage and civil partnership.

A majority of Citizen Space respondents answering the question, 79%, did not anticipate any of the proposed options outlined in this consultation will have a direct or indirect positive or negative impact on any protected equality characteristics. The majority of individual and organisational respondents (59 out of 70 and 18 out of 28 respectively) did not expect the proposals to impact on any protected equality characteristics. However, the majority of Professional college, body, group or union respondents did expect the proposals to have an impact. Fifteen discussion groups did not anticipate any impact, six did and four did not answer the question.

The three most frequently-identified themes were:

• The potential impact on individuals using services in the event of service closure.
• The disproportionate impact on women because of the number of women working in the care sector.
• The need to engage with affected staff as well as specialist equality advisors.