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

Chapter 2 - Proposed purpose and scope

The consultation paper set out the proposal that an organisation providing health and social care services would be required to: apply nationally agreed, evidence-based workload and workforce planning framework, 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.

Question 1 - Do you agree that introducing a statutory requirement to apply evidence based workload and workforce planning methodology and tools across Scotland will help support consistent application?

Table 3: Question 1 – Responses by type of respondent.

Type of respondent	Yes	No	Not answered	Total
Individuals	65	11		76
Organisations:
Health & Social Care Partnership	2	3		5
Independent sector health or social care organisation	2			2
NHS based professional group or committee	3	2		5
NHS Body or Board	4	1	1	6
Other			3	3
Other public body	2			2
Professional college, body, group or union	6	2	4	12
Total organisations	19	8	8	35
All respondents	84	19	8	111
% of all respondents	76%	17%	7%	100%
% of those answering the question	82%	18%		100%

A majority of those 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.

Table 4: Question 1 – Discussion Groups

Yes	No	Mixed Views	Not answered	Total
20	2	2	1	25

At the consultation events, 20 of the discussion groups agreed, two disagreed, two had mixed views and one did not answer the question.

There were 71 further comments made through Citizen Space and all of the discussion groups made a comment.

The three most frequently-identified issues in relation to Question 1 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 their further comments, some respondents identified specific advantages to introducing a statutory requirement, including that it should help embed the approach at an organisational level. A robust legislative framework for safe and effective staffing was seen to support the very best practice and drive improvement where needed by using high quality, validated tools that could support equitable practice across services. Those in agreement felt that legislation would provide a means of quality assurance against poor standards or organisational cultures and that the public's right to safe, quality care and appropriate staffing for all those using services would be supported. The most frequently-identified advantage raised by both individuals and organisational respondents was that agreed staffing levels based on patient need and skill mix, would ensure agile teams responsive to changing needs and in turn prepare the workforce to move towards integrated practice.

The legislation was felt to mitigate some of the risks of increasing pressure on the nursing and midwifery workforce through recruitment issues, an increasing ageing population and changing models of care. Staff would therefore feel supported and less likely to experience burn out or stress.

However, there was also a question as to how precisely the 'additional lever of legislation' would increase the current leverage and effective usage of the mandated nursing and midwifery workforce and workload planning tools. This issue was raised at the discussion groups and by individual and organisational respondents. It was suggested that the workforce planning tools are only one of the components required to achieve high quality care and improved outcomes and that setting out further guiding principles on safe and effective staffing in primary legislation would be welcome.

Although in agreement with the principle of introducing a legislative requirement, there were concerns about this requirement extending only to certain staff groups or organisation settings; this was most likely to be raised by Professional College, Body, Group or Union respondents. Their main concern was that if statutory regulation applies to nursing and midwifery services in isolation, and not to multi-disciplinary or multi-agency teams, workforce deployment will be flawed, and this could result in less safe and effective practice. An approach which focused on the nursing and midwifery profession alone was also seen as at odds with how health and social care services are currently delivered.

A number of the respondents who disagreed with the introduction of a statutory requirement raised very similar concerns. The most frequently-raised concern tended to be highlighted by the Health and Social Care Partnerships or NHS Body or Board respondents and was that the proposals were at odds with the integration of health and social care agenda and the delivery of localised health and social care services. Further comments included that the Integrated Joint Boards ( IJBs) should have the flexibility to make workforce planning decisions based on strategic need and should not be restricted or directed by statute. There was equally a common view from the social care sector that despite using the term 'health and social care' throughout, the consultation focuses on the implications for the health sector and NHS Scotland. It was felt that to genuinely consider a health and social care approach the size and diversity of the social care workforce needs to be understood. It was also suggested that there has to be an acknowledgement that the social care sector has existing statutory requirements around both workload and workforce and that there is no demonstrable evidence that the current tools utilised within the NHS are applicable, usable or beneficial to the social care sector.

A small number of respondents, chiefly NHS bodies or Boards and Other public bodies, felt that the introduction of legislation could potentially restrict employers in the delivery of innovative and responsive person-centred services. They raised concerns that the focus of the consultation was on outputs and not on the achievement of improved outcomes for individuals.

As noted above, concerns were raised about areas of potential overlap or duplication in terms of workforce development and planning, particularly in relation to integrated and/or social services. Suggestions as to other responsibilities or developments which respondents felt needed to be taken into account included:

• The existing statutory requirement to ensure appropriate workload and workforce planning, as set out in The Social Care and Social Work Improvement Scotland (Requirement for Care Services) Regulations 2011. This statutory requirement informs the scrutiny activity of the Care Inspectorate during initial registration and during subsequent inspection.
• The new Health and Social Care Standards, which will be implemented in April 2018, will apply to the NHS as well as services registered with the Care Inspectorate and will set out the standards people should expect when using health or social care services.
• COSLA is currently co-producing, with the Scottish Government, a National Workforce Plan ( NWP) on Health and Social Care. The NWP is intended to lead the social care sector's approach to workload and workforce planning methodologies and tools. Part two of the NWP will consider ways to address the challenges facing the social care workforce as a result of health and social care integration. It will be published in Autumn 2017.

Although the majority supported the introduction of a statutory requirement, they frequently made their support conditional on certain issues being addressed if the proposed legislation is taken forward. Discussions groups and organisational respondents were particularly likely to have made comments along these lines. A number of their concerns were about the existing workforce and workload planning tools. They included that:

• The tools do not necessarily work across the range of differing care environments, and this can undermine consistent application. Respondents sometimes noted that it will be challenging to apply any 'rigid formulae' to potentially complex, integrated services. In particular, it was highlighted that the approach will need to take account of employment, commissioning and resourcing practices.
• They may not be sufficiently responsive to new developments and innovation.
• They do not address adequately the impact of using bank, agency or non-nursing and midwifery staff.

Finally, resources were seen to be essential to the implementation of any new requirement, with some respondents commenting that the constitution of the workforce can be driven by financial imperatives rather than just clinical need.

Question 2 - Are there other ways in which consistent and appropriate application could be strengthened?

There were 92 further comments made through Citizen Space and 24 of the discussion groups made a comment.

The three most frequently-raised themes in relation to Question 2 were the need to:

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

A wide range of views were offered on how consistent and appropriate application could be achieved, including that it is essential that patients and their relatives are assured that their care will be of consistently good quality. Getting staffing right was seen as key to providing this assurance. Otherwise, comments tended to address one of four main themes: National Standards; external scrutiny; organisational governance and workforce management tools. The last of these -workforce management tools - was the most frequently-raised.

Workforce Management Tools

Although the benefits of using workforce planning tools were recognised, it was seen as important to spend time understanding the challenges organisations face in using the existing tools. Discussion groups and individual respondents were particularly likely to make this suggestion. Other suggestions about issues to be addressed, or how any future approach should be framed, included that workforce planning should be applied across all multi-disciplinary teams but also consider opportunities for integrated working to improve client outcomes; this could include the sharing of good workforce planning practices across partnerships and beyond nursing and midwifery. It was also noted that better quality working environments aid in the recruitment and retention of staff and that health and social care career paths could be considered.

Individual respondents were particularly likely to have highlighted the issue that there should be closer working between local staff to increase confidence and support better and consistent application. It was also suggested that clinical and managerial staff competence and confidence in using the frameworks could be enhanced through the use of a clear workforce framework, including agreed timelines and processes for tool completion, analysis and triangulation and acting on any recommendations.

It was also suggested that the application and consistency of workforce management tools would be strengthened by clarifying their role in service planning and that, where a gap between current and safe and effective staffing levels is identified, organisations should be required to develop, publish and implement suitable risk management plans.

In terms of the tools themselves, respondents suggested that any approach should be based on nationally agreed staffing numbers in relation to patients and should consider individual care environments. It was also suggested that it is unlikely that a single tool will be sufficient, and a suite of tools may be required to take account of the many and varied contexts in which they will be used. For example, tools might be developed for hospital and community settings and for individual ward, theatre or community teams. Other comments included that the tools should:

• Allow for flexibility as staff and services respond to change and redesign.
• Consider projected demand, population levels and vulnerability and not be based on historically negotiated staffing provisions.

National standards and requirements

Developing nationally agreed workforce standards and performance targets was seen as positive and was particularly favoured by NHS body or Board and NHS based professional group or committee respondents. This included because patients and their relatives could be assured that their care would be consistently of good quality. It was suggested that a focus on quality care and improved outcomes should be at the heart of the safe and effective staffing agenda, rather than the emphasis being on the tools or processes to be used. Other comments included:

• Those using services have increasingly complex needs that will be best met by considering all the services and professions that have a contribution to make towards meeting those needs.
• There should be detailed guidance setting out the responsibilities for organisations to not only ensure enough staff are employed but that staffing levels are regularly monitored and adjusted according to local need. Provisions could then be made to develop and implement nationally agreed reporting mechanisms to support benchmarking, improvement and national scrutiny of safe and effective staffing.
• The Scottish Government should themselves use robust and evidence-based methodologies to develop a better understanding of the national need for nursing and midwifery staff, in terms of both numbers and skills.
• Based on that understanding, the Scottish Government should commission pre-registration places, as well as post-registration education and training.

External scrutiny

A number of respondents, including two out of five Health and Social Care Partnership respondents and three out of five NHS based professional group or committee respondents, favoured independent and external inspection, including through existing routes, as a means of quality assuring workload and workforce management and decisions. Specific suggestions included that:

• The approach could be based on national standards and agreed quality indicators.
• Organisations should have a clear duty to make available all workforce information to support this process, as well as to provide sufficient education and necessary support.

The existing scrutiny role of the Care Inspectorate, which can set conditions about staffing prior to service operation and examine the quality of staff at annual inspections, was highlighted. Health Improvement Scotland ( HIS) was considered to have a key role in the provision of this type of scrutiny within the NHS and it was suggested that an annual national overview of safe and effective staffing within healthcare should be published, with improvement support also provided where necessary.

It was noted that HIS is in the process of developing a Quality of Care approach and is supporting the development of the Excellence in Care ( EiC) nursing assurance framework ^[1] . Particular points made about this work included:

• The inclusion of workforce and leadership elements as an indicator of overall quality will, it is believed, increase the focus on both assurance and improvement which can drive a sustainable change.
• It is expected that this in turn will support NHS Boards, IJBs and localities to tailor improvement efforts targeting key areas such as skill mix, rostering, sickness absence, staff training, communication, teamwork and cultural barriers to safety.

In terms of routes through which organisations could report on safe staffing, the following were suggested:

• Via more sophisticated reporting through the EiC nursing assurance framework.
• Through the Local Delivery Planning Process.
• Via the NHS Boards' Annual report to the Scottish Government.

Organisational governance

With regard to the governance arrangements which would underpin the safe and effective staffing approach, comments included that it is essential that any duties in the Bill are placed on organisations and not individuals. Other elements which respondents felt should form part of the governance arrangements included:

• Directors of Nursing should have a key role in providing advice and assurance on safe nursing and midwifery staff levels, including in relation to any measures not being consistently or effectively applied.
• Internal audit processes will have a role to play.
• The role of the Nurse Member within an IJB was also noted as key, particularly in the context of multi-agency, integrated services.
• It was suggested that the statutory role of the Chief Social Work Officer within Scotland could serve as an example of good practice. The role's responsibilities in terms of effective discharge of duty and quality assurance were highlighted.

Finally, the importance of any Bill being sensitive to the different spheres of responsibility within professional structures was highlighted. In particular, it was suggested that it will be important to ensure that any legislation supports professional leaders to assist organisations to discharge their duties appropriately.

Question 3 - Our proposal is that requirements should apply to organisations providing health and social care services, and be applicable only in settings and for staff groups where a nationally agreed framework, methodology and tools exist.

3a - Do you agree that the requirement should apply to organisations providing health and social care services?

3b - Do you agree that the requirements should be applicable in settings and for staff groups where a nationally agreed framework, methodology and tools exist?

Table 5: Question 3a – Responses by type of respondent.

Do you agree that the requirement should apply to organisations providing health and social care services?

Type of respondent	Yes	No	Not answered	Total
Individuals	70	4	2	76
Organisations:
Health & Social Care Partnership	2	3		5
Independent sector health or social care organisation	2			2
NHS based professional group or committee	5			5
NHS Body or Board	4	1	1	6
Other			3	3
Other public body		2		2
Professional college, body, group or union	9		3	12
Total organisations	22	6	7	35
All respondents	92	10	9	111
% of all respondents	83%	9%	8%	100%
% of those answering the question	90%	10%		100%

A majority of those 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.

Table 6: Question 3a – Discussion Groups

Yes	No	Mixed Views	Not answered	Total
21	1	1	2	25

At the consultation events, 21 of the discussion groups agreed, one disagreed, one had a mixed view and two did not answer the question.

There were 40 further comments made through Citizen Space and 21 of the discussion groups made a comment across Questions 3a and b. For the purposes of the analysis presented below, their comments have been considered under the most appropriate sub-question.

The three most frequently-raised themes in relation to Question 3a 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.

Very much reflecting the level of agreement at the yes/no question, many of the further comments noted respondents' support for the requirements applying to organisations providing health and social care services. There was particular reference to this approach being in line with the developing health and social care integration agenda and there were concerns that, if all services and professional disciplines were not taken into account, any conclusions drawn from workforce planning would be skewed. The requirement to align with the developing integration agenda was most likely to have been raised at the discussion groups or by individual respondents. It was also noted that the NHS and their partners are under growing pressure due to an increasing ageing population with complex needs; in this context, the need to work together around recruitment, retention, learning and integrating services was seen as paramount.

Respondents who agreed with the proposal gave a range of reasons why the requirements should apply to organisations providing health and social care services. Those most frequently-raised were that all health and social care services should be included for reasons of patient safety and that the public would expect the same assurance regarding staff, skill and safety in all settings. There was a clear view that consistency is required, not least with the developing of the National Health and Social Care Standards. If interdisciplinary and interagency working are not considered, it was felt that decisions by a single discipline could negatively impact on others and inadvertently restrict service delivery or development.

Although most respondents agreed with the proposals, some issues to be addressed were highlighted, particularly by Professional college, body, group or union respondents. The nursing and midwifery professions were reported as having been through a long process to develop and apply national tools and frameworks for their workforce. It was suggested that this process is yet to be concluded and should not be disrupted. In particular, it was felt that the potential impact of the Bill for nursing and midwifery should not be weakened by diluting its content in an attempt to avoid any need for future revision.

It was noted that any legislation should be written in such a way to permit extension to other settings but that one sector's norm will not necessarily apply to another. It was suggested that the Scottish Government may need to engage and collaborate to build collective support for the development of new tools applicable to other sectors and professions.

Other of the comments addressed which disciplines or types of service within health and social care should be covered. Points made included:

• All health care providers, sectors and areas of care should be covered. This was particularly likely to have been raised by the discussion groups or by individual respondents.
• All NHS clinical staff should be included. There was a concern that some staff who are not subject to nationally agreed frameworks could be excluded and that this would create a resource imbalance.
• The independent sector for patients who choose to self-pay or use private medical insurance is a key NHS partner, providing additional capacity at times of pressure. Safe staffing is an equally important aspect of independent healthcare quality standards and these services should be covered by the Bill.
• With the shifting of the balance of care, the third sector is playing an increasingly important role and one which warrants them being covered by the Bill.
• Services commissioned by either the NHS or local authorities should be covered.
• Nursing homes and other facilities for older people should be included.

Those who disagreed with the proposal frequently felt that that further consideration needs to be given to the role and requirements of the social care sector before any changes are made. In particular, it was suggested that the case for including social care services, and the benefit such an approach would bring, is yet to be made. It was also suggested that sectors should be determining their own needs rather than having requirements placed upon them.

A final observation was in relation to who would be included within the definition of 'health and social care'. It was suggested that if some providers became subject to a legislative requirement then others, such as teachers or child minders, might need to be considered by default.

Table 7: Question 3b – Responses by type of respondent.

Do you agree that the requirement should be applicable in settings and for staff groups where a nationally agreed framework, methodology and tools exist?

Type of respondent	Yes	No	Not answered	Total
Individuals	69	7		76
Organisations:
Health & Social Care Partnership	1	3	1	5
Independent sector health or social care organisation	2			2
NHS based professional group or committee	5			5
NHS Body or Board	5		1	6
Other			3	3
Other public body	1		1	2
Professional college, body, group or union	7	2	3	12
Total organisations	21	5	9	35
All respondents	90	12	9	111
% of all respondents	81%	11%	8%	100%
% of those answering the question	88%	12%		100%

A majority of those 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, Others 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.

Table 8: Question 3b – Discussion Groups

Yes	No	Mixed Views	Not answered	Total
17	5	1	2	25

At the consultation events, 17 of the discussion groups agreed, five disagreed, one had a mixed view and two did not answer the question.

There were 46 further comments made through Citizen Space and 21 of the discussion groups made a comment across Questions 3a and b. A number of the further comments simply referred back to those made at Question 3a.

The three most frequently-raised themes in Question 3b 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 care fields.

Some respondents noted that their support was conditional on the approach being effective and robust. Others noted the value of having a consistent approach and a degree of commonality in the governance arrangements across health and social care. As at previous questions, some respondents also commented on possible issues arising from not applying the approach across the whole care system. In essence, the concern was that staff groups or settings that are not included may be disadvantaged.

Those who agreed nevertheless raised a number of issues they felt should be considered if the proposals progress. These included that, in practice, Health and Social Work are still separate employers and there was a concern that it is difficult to see how the approach will work whilst this remains the case. Similarly, it was suggested that it will be important to consider the principles underpinning multi-disciplinary working when developing any tools and that to fail to do so could lead to skewing of staffing or resources and could affect the equity of care. It was also suggested that it needs to be clear how the tools will consider tasks that can be undertaken by more than one profession or in the context of multi-agency care.

A frequently cited view was that any approach needs to be evidence based, effective, robust and approved by both workforce planning professionals and the professional specialists representing any specific setting. Individual respondents were particularly likely to highlight this need and to go on to suggest that any agreed framework needs to offer some consistency whilst also allowing for diversity and variation. This issue was raised at discussion groups and by individual and organisational respondents. The need to take account of varied geographies and the challenges associated with delivering services in rural and island settings were cited as examples. Actual time spent travelling was given as a specific example of the type of issue to be considered if the approach is to be robust in a range of settings.

It was considered important to expedite tool development and validation in different settings. It was suggested that an agreed framework, methodology and timeframes for implementation should be established. However, it was also suggested that the application of any framework must still allow for local autonomy to make decisions about the services and resources that they provide.

A number of specific considerations were noted in relation to the arrangements extending to the care home sector. For example, it was suggested that the National Care Home Contract would need to be aligned with the methodology proposed and that, if covering the independent health care sector, the provision of legal standards and clear guidance to both regulator and providers would be beneficial.

Respondents made a number of points about the existing tools, including that they draw on different evidence bases. Examples given include the Community Nursing Service tool focusing on activity and the Health Visitors tool being based on Scottish Index of Multiple Deprivation data. It was suggested that many of the tools are currently designed for uni-disciplinary groups of staff and would benefit from a review to ensure they are compatible with an integrated care approach. It was also noted that there are no tools for mental health, learning disability or for addictions community nursing staff for example.

Other comments focused on the specifics of extending any approach to the social care sector. They included that:

• In social services, statutory provision is expressed in outcome-focused terms and care providers are free to select the tool that best suits their needs. Requiring social care services to apply the evidence-based workload and workforce planning methodology currently used in NHS Scotland is neither helpful or necessary given current practices.
• The Care Inspectorate, in collaboration with COSLA, Scottish Care, The Coalition of Care and Support Providers, Scotland Excel and NHS National Services Scotland, is actively exploring the development of a shared dependency tool specifically for care homes and which could be used to calculate staffing.

Respondents who did not agree with the proposal overall sometimes raised similar issues to those who had agreed. Specific points made included:

• There should not be a presumption that a national formula can be applied in singular, uniform ways to specific services and settings.
• It is important to avoid a narrow focus on 'frontline' staffing needs at the expense of the capacity required to support continuous quality improvement through clinical leadership, continuous professional development or service evaluation.
• A prescriptive approach runs the risk of partnerships focussing on process, rather than aiming for an ambitious vision for their future workforce.

There were reservations about whether a legislative requirement to use the tools is necessary, especially when tools such as the Critical Care Guidelines are already in place. It was suggested that aligning overall principles across sectors could be a more achievable and sufficient option.

Finally, there were a range of concerns about the current workforce planning tools, including that current limitations would not be resolved simply by making their use a statutory requirement. Other concerns included that the tools apply to a limited number of professional groups, are limited to certain settings, are focused primarily on staffing ratios, and are time consuming for already stretched clinical staff to use.

Question 4 - How should these proposed requirements apply or operate within the context of integration of health and social care?

There were 83 further comments made through Citizen Space and 22 of the discussion groups made a comment.

The three most-frequently-raised issues in relation to Question 4 were:

• The majority of current tools do not take multi-disciplinary or multi-agency working into account.
• 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 IJBs.

As at earlier questions, some of the further comments reiterated a view that the proposals do not represent the type of whole-system approach that is required. Health and Social Care Partnership respondents were particularly likely to have highlighted this issue. The proposed requirements were not viewed as supporting local flexibility and responsiveness. There was a particular concern that they will impair Health and Social Care Partnerships in developing and implementing new ways of working at a time when they are working with a reducing budget. In essence, some respondents simply felt the proposed requirements should not apply given the integration of health and social care.

Respondents who agreed with the proposed requirements being applied across health and social care sometimes pointed to the extent to which current work practises are influenced by integration. For example, it was suggested that nurses are increasingly working within joint teams. However, it was also noted that there is already a legislative framework for staffing levels in social care services, along with a scrutiny framework to ensure it is being applied effectively. There was a question as to how, if the proposals are taken forward, these two sets of requirements would work together. The discussion groups were particularly likely to highlight the importance of the proposals being aligned to the health and social care integration agenda.

Other comments considered the structural challenges posed by health and social care integration. The role, accountability and functions of IJBs were highlighted, including that IJBs are charged with the development of integrated workforce plans but, with the exception of Highland, do not employ staff. The employer could be: an NHS Board; a Local Authority; a regulated care service commissioned by the IJB; or an independent healthcare service. To was also noted that NHS nurses, for example, will continue to be employed by the NHS and staffing and governance decisions will continue to be the responsibility of the NHS. However, it was suggested that the decisions of the IJBs are already having an effect on the shape of the nursing and midwifery workforce, particularly if services are being reconfigured. It was suggested that the proposed legislation should place equal duties on IJBs and NHS Boards regarding safe and effective staffing, particularly while the governance arrangements and position of the IJBs are evolving.

A number of other integration and multi-agency issues to be taken into consideration were identified, most frequently that the Care Inspectorate and Healthcare Improvement Scotland have an existing responsibility to jointly inspect the strategic commissioning arrangements of IJBs and to provide scrutiny related to staffing.

It was suggested that any workforce planning tools to be used across different sectors will need to capture the 'collective' contribution of the partners. There was an associated suggestion that their use will need to be supported by an agreement across all agencies to use, apply and respond to the outputs of tools. It was also suggested that care must be taken not to 'skew' potential resources towards the nursing and midwifery professions at the expense of other professional groups or sectors. A range of tools were seen as being required, allowing services to choose a tool which is appropriate to their type of service and the context in which they are delivering a service. It was also noted that safe and effective staffing needs to be defined and articulated as the interpretation of 'safe' will be different within the various health and social care contexts.

There was a suggestion that none of the existing nursing or midwifery tools, with the possible exception of the Emergency Medicine Tool, take account of the effect of multi-disciplinary or multi-agency working on staffing requirements. It was suggested that there will be a need to develop and test tools that would support transformational change work in Scotland. Further, it was suggested that any tool or methodology development should be conducted with a full understanding of the integration agenda, before any legislative change is made, and that all professional groups need to be fully involved. In particular, it was suggested that there needs to be high levels of staff engagement. Individual respondents and discussion groups were particularly likely to highlight this need.

Other comments focused on the tools themselves or their application. They included:

• Consistency in application will be important. The approach to be used could be set out within a joint framework agreement. This was a frequently-raised issue, particularly at discussion groups and by individual respondents.
• It will be important to build in flexibility to allow for challenge, innovation and changes to workforce practice based on emerging evidence. Any arrangements should be flexible and subject to review and adjustment.
• Principles, guidance and tools need to clearly inform how staffing levels - and configurations of staffing – will optimise services' clinical and cost-effectiveness, patients' access to care, and patients' experience and outcomes of care.
• It will be important to avoid any additional burden on smaller non-public sector services as this could render them unprofitable and place unmanageable pressure on them.
• In circumstances where there is no specific tool, service commissioners and regulators should reinforce safe staffing levels by way of ratios and minimum care standards. This could be enforced through contract compliance procedures and embedding workforce planning requirements.