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

Chapter 3 - Requirements

The consultation paper moved on ask a number of questions about the approach to workforce planning.

Question 5 - A triangulated approach to workload and workforce planning is proposed that requires:

• Consistent and systematic application of nationally agreed professional judgement methodology and review of tools to all areas where current and future workload and workforce tools are available.
• Consistent and systematic consideration of local context.
• Consistent and systematic review of quality measures provided by a nationally agreed quality framework which is publicly available as part of a triangulated approach to safe and effective staffing.

Do you agree with the proposal to use a triangulated approach?

Table 9: Question 5 – Responses by type of respondent.

Type of respondent	Yes	No	Not answered	Total
Individuals	67	7	2	76
Organisations:
Health & Social Care Partnership	3		2	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			2	2
Professional college, body, group or union	6	1	5	12
Total organisations	21	1	13	35
All respondents	88	8	15	111
% of all respondents	79%	7%	14%	100%
% of those answering the question	92%	8%		100%

A substantial majority of those 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.

Table 10: Question 5 – Discussion Groups

Yes	No	Mixed Views	Not answered	Total
24			1	25

At the consultation events, 24 of the 25 discussion groups agreed and one discussion group did not answer the question.

There were 56 further comments made through Citizen Space and 22 of the discussion groups made a comment.

The three most frequently-raised themes in relation to Question 5 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 will be applied.

In their further comments, many organisational and individual respondents, along with a small number of the discussion groups, noted their support for the principle of using a triangulated approach. However, there was a suggestion that what triangulation means within the context of legislation needs to clearer, along with whether it is focused on workforce planning or on day-to-day operational delivery of safe services. Other comments noted aspects of the approach which were particularly welcomed or seen as a particular strength. For example, a Professional college, body, group or union respondent suggested that triangulation should support real time workforce decisions to be made more responsively.

Robust and consistent application

Other comments welcomed the focus on robust and consistent application and recognition of the complexity of the local context. Individual respondents and discussions groups were particularly likely to highlight these issues.

Examples given, in this case by a small number of Professional college, body, group or union respondents, included:

• That an appropriate level and mix of staffing will vary according to factors such as the local configuration of services, the case mix, geographical and environmental factors, demographic factors and the skill mix of the workforce.
• That taking a 'one-size-fits-all' approach is unlikely to work for all areas of Scotland (as represented by Health and Social Care Partnerships).
• That the professional judgement and quality elements also need to take account of local content.

While a small number of primarily organisational respondents felt that the tools do take account of the local context, a small number of others disagreed. Specific concerns included that they do not take account of local infrastructure issues, such as site location or challenges associated with having staff with the right skills available in the right locations, particularly in rural and island settings. However, a small number of individual respondents had a concern that consideration of local context should not be used as a 'get out clause' and an excuse for ongoing, sub-optimal staffing levels because of, for example, of financial or recruitment pressures. A question was asked about who will judge whether the consideration of the local context has been robust and how they will make this judgement. Finally, a discussion group sought clarification as to what is meant by 'local', including in the context of nursing and midwifery services planning at locality, Health and Social Care Partnership, NHS Board, regional and national levels.

Professional judgment

A frequently-raised issue, particularly by individual respondents and discussion groups, was the value and importance of including professional judgement, although a small number of respondents highlighted that this element inevitably introduces a degree of subjectivity into the process and for some this had the potential to be a concern. With regard to the exercising of professional judgment and the triangulation approach more generally, consistency of application tended to be seen as key to the successful use of the tools. Further comments on the professional judgement element most frequently came from a small number of Professional college, body, group or union respondents and included:

• The professional judgment element is likely to interact with the requirements in the Code for nurses and midwives. The Scottish Government was encouraged to consider how these two requirements could be aligned.
• It should be informed by the most up-to-date evidence available. This should include the use of real time data, for example on acuity, dependency, caseload, available staffing numbers and skill mix.
• Specific guidance and/or training will be required. A specific suggestion was that those using the tools should have access to professional guidance from bodies such as the Royal College of Nursing.
• Further development of professional judgement quality measures would be helpful.
• Some element of scrutiny must be put in place.
• There should be a specific requirement to include local staff and trade unions in setting assumptions and making decisions. A specific comment was that ward managers' views must be taken into account.

Use and review of measures

In terms of the reviewing of quality measures and the nationally agreed framework, a series of questions was asked, particularly through the discussion groups. These included:

• What will the thresholds and judgements associated with the quality measures look like? It was suggested that they need further refinement.
• How often will the quality measures be reviewed and by whom? What system or approach to review will be used?
• Should there be different care quality indicators by speciality and/or for different parts of the country?

Other more general comments or suggestions often came from the discussion groups or Health and Social Care Partnership or NHS based professional group or committee respondents. In each case they were raised by one or a small number of respondents or discussion groups and they included:

• Which, if any, element of the triangulated approach will be the primary measure?
• The approach must have the principle of quality and links to positive patient outcomes at its heart.
• It would be helpful to clarify how the approach relates to EiC.
• Further evidence would be useful on the triangulated approach working in practice, including a better understanding of the feedback from those in the service who are currently using the tools and the actions taken as a result of using the tools.
• It will be important for the principle of triangulation to apply equally to real time service, service planning and student commissioning decisions.
• The primary legislation should not name specific tools and methodologies. This sort of detail should be included in secondary legislation or statutory guidance.
• There will be a resource-intensive but unfunded package of work required including awareness raising, collation and analysis of data, report writing and action planning.
• There is no national reporting template and such a template would ensure data is collated and considered systematically.
• National support for staff training in using the tools was being planned in 2014 but has yet to be delivered. Training on the correct use of the tools would be required.

Multi-agency or non- NHS contexts

Other comments focused on how the approach would translate into a multi-agency context or would work outwith NHS settings. Comments included:

• How the approach would work within a non- NHS setting, and particularly within care home settings, needs to be explore. This was highlighted by an independent sector health or social care organisation and was also covered at one of the discussion groups. It was noted that the development of a staffing tool is under way and it was suggested that this work needs to be linked into the workload and planning tools presently used in the NHS. One of the discussion groups suggested that some larger private companies may already be using an approach/tools developed to meet legislative requirements in England but that smaller companies may find this agenda challenging.
• The approach needs to work for multi-disciplinary teams and the types of community-based, integrated workforces of which nursing and midwifery will be a part if the shift in the balance of care is really to be made. This was raised by a Health and Social Care Partnership respondent.
• It is important to ensure that this approach is person-led and is able to assess and understand the needs of people and ensure the right staff are available to meet their needs in a way that works for them. This was raised by a Public body respondent.

Current tools

A small number of primarily organisational respondents, including a Health and Social Care Partnership and a small number of NHS based professional groups or committees, raised issues about the current tools themselves. These included that it is difficult to see how they could be applied to multi-disciplinary, multi-agency patient care. It was also noted that the tools have not been reviewed since 2014; those highlighting this issue felt that a review is now required and that the tools need to be updated to reflect current practice and be more user-friendly. One suggestion was that health care professionals with an understanding of the Scottish health care system should be involved in any further development work required.

In terms of factors which any tools should take into account, but which were not seen as featuring in current versions, the following were cited:

• Staff skill mix. A potential unintended consequence of increased use of unregistered nursing staff in order to 'make up the numbers' was highlighted.
• Levels of use of bank or agency staff.
• Shift patterns and rostering practice.
• Levels of patient dependency and the complexity of the care load.
• The potential need for short term adjustments to staffing compliments to meet a particular set of circumstances (for example a patient requiring 1:1 supervision).
• The amount of clinical time required to ensure staff maintain their statutory and mandatory training requirements.

One of the discussion groups suggested that the current tools do not give consideration to winter planning.

A small number of other comments focused on the potential the tools offer, particularly in relation to gathering information to inform and drive best practice and improved service delivery. Points raised included:

• Making decisions on safe staffing levels based on the use of the tools would be difficult to justify given the range and complexity of the factors to be taken into account.
• The tools reflect a period in time and do not present a comprehensive picture of service provision. Any suggestion that they offer the potential to deliver a national performance 'dashboard' should therefore be viewed with caution.
• The use of the tools could make available a range of reports on issues which impact of the quality of care delivery, such as ward skill mix and reasons for use of supplementary.

Finally, a small number of primarily individual respondents (essentially those who had answered No at Question 5 and then went on to make a further comment), raised concerns including that:

• The approach as described is neither measurable nor tangible.
• If the approach aims to remove variance, but then factors in professional judgment and contextual and local issues, national comparison may not be possible, and the level of effort required may therefore not be justified.
• Unless all professional groups can be included, conclusions for workforce and workload planning will be adopted based on results from an unrepresentative workforce and this would negate any benefit from a triangulated approach.
• It is not possible to make the types of generalised judgments that would appear to be a part of the approach. For example, the requirements of a mental health unit would be very different to those of an elective surgery unit.

Question 6 - Are there other measures to be considered as part of the triangulation approach to workload and workforce planning? If yes, what measures?

Table 11: Question 6 – Responses by type of respondent.

Type of respondent	Yes	No	Not answered	Total
Individuals	43	26	7	76
Organisations:
Health & Social Care Partnership	3	1	1	5
Independent sector health or social care organisation	2			2
NHS based professional group or committee	5			5
NHS Body or Board	6			6
Other			3	3
Other public body	1		1	2
Professional college, body, group or union	7		5	12
Total organisations	24	1	10	35
All respondents	67	27	17	111
% of all respondents	60%	24%	15%	100%
% of those answering the question	71%	29%		100%

A majority of those 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.

Table 12: Question 6 – Discussion Groups

Yes	No	Mixed Views	Not answered	Total
21			4	25

At the consultation events, 21 of the 25 discussion groups agreed and four did not answer the question.

There were 73 further comments made through Citizen Space and all of the discussion groups made a comment (albeit in both cases some were only to refer back to their comments at the previous question). A very broad range of comments or suggestions was made and although some were more frequently-raised, most points were made by only one or a small number of respondents or discussion groups.

Nevertheless, the three most frequently-raised themes in relation to Question 6 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.

A small number of organisational respondents from across the range of respondent types made overarching comments, including that:

• Conflating workload and workforce planning is unhelpful.
• Staffing levels cannot be addressed in isolation from other factors that contribute to ensuring that safe, effective, patient-centred care is delivered.
• Workforce planning tools often do not fit with, or reflect, the service delivery realities of very small services in remote and rural areas.
• The potential for unintended consequences should be considered. Specifically, there was a suggestion that workload management or increased staffing in one area could lead to reductions in service or the skills mix in other areas or groups.
• Consideration should be given to whether workload can be shared across professions or is profession specific. This approach was suggested as incorporating all aspects of the triangulated approach while also making the link with outcomes.
• There is a danger that any inflexible legislation could become outdated as care delivery models change, and new evidence bases develop.

Whole-system issues

Moving on to other measures, some of those suggested also focused on whole-system issues that could impact on workforce planning. They were raised by a small number of discussion groups, organisational and individual respondents and included:

• Sustainability and attractiveness of health and social care career paths.
• Workforce supply issues, including: the possible impact of Brexit; succession planning and the demographics of the current workforce; and student numbers for nursing and midwifery and social care roles.

Other suggested measures were also systemic, potentially at both national or local level although respondents tended not to specify. Again, these issues were raised by small numbers of respondents from across the respondent types and also by a small number of discussion groups. They included:

• Integration of services and the needs of integrated management structures in particular.
• Multi-disciplinary working practices and impact.
• Productive working practices.
• Funding levels and affordability, including for both health and social care services. This was the most frequently-suggested measure and was raised primarily by discussion groups and organisational respondents.
• Available social care provision.
• Autonomy and accountability of Local Authorities, Health Boards and IJBs.
• Consideration of future plans, developments and changing circumstances likely to impact on patient/service user numbers or their needs. Local factors in particular.

Other of the suggested measures also related very clearly to the local context and tended to be raised by individual respondents or at the discussion groups. They included:

• The geography of the area and how this impacts on staff travel time. How the range of new and emerging technologies will then impact on staff travel time.
• Ward layout and use of single rooms.
• Use of mixed speciality wards.

System management and review

Other suggested measures related to system management and review. Again, these issues were raised by small numbers of respondents from across the respondent types and also by a small number of discussion groups. They included service user and patient experience feedback. This was the most frequently-raised of these issues and was highlighted by discussion groups, individual and organisational respondents. Other less frequently-raised issues were:

• Standards implementation.
• Benchmarking.
• Practice observation.
• Service evaluation and re-design. Specifically, supported staff engagement in service improvement/re-design.
• Significant adverse events and complaints.
• Consideration of future plans, developments and changing circumstances likely to impact on patient or service user numbers or needs. This would include local factors.

Staff skills and wellbeing

A set of suggested measures related to staff skills, development and management. They included workforce capability, skills and experience mix and specifically, the ratio of newly qualified to experienced staff. This was the most frequently-raised of these measures and was particularly likely to have been highlighted by discussion groups and individual respondents.

Other less frequently-raised points were:

• Learning and development opportunities.
• Clinical leadership and peer review.
• Time dedicated to staff supervision.
• Protected teaching, education and professional development time, including for those taking mentoring, link nurse or Training the Trainer roles.
• Professional Development Planning reviews and exit interviews.

Others focused specifically on staff-related planning and wellbeing measures. The most frequently-raised was staff sickness rates. This was highlighted by discussion groups, organisational respondents and an individual respondent. Other less frequently-raised points were:

• Funded establishment to in-post staffing level.
• Staff recruitment and retention, including staff turnover. Some of the existing challenges around recruiting and retaining staff in rural and remote areas were again highlighted.
• Supplementary staffing levels and the use of agencies/agency staff.
• Psychological safety.
• Planned leave or absences (such as maternity leave).
• Rates of aggression towards staff.
• Staff satisfaction levels.
• Day-to-day workload.
• Unpaid overtime or missed breaks.

Patient and service user population

Other suggestions focused on the profile of those using services, their needs or on measures of system capacity. The most frequently-suggested measure, including by organisational and individual respondents and at the discussion groups, was patient acuity and caseload management. It was sometimes suggested that this should be linked specifically to the patient population at the time of the report. It was also noted that some services are subject to peaks and troughs in demand throughout the year, with maternity series cited as an example. Other less frequently-raised suggestions were:

• Escalation procedures. This was about ensuring that services are able to respond promptly to sudden fluctuations in activity, or changes in staffing levels.
• Number of hospital beds. It was suggested that hospitals must balance the provision of staffed beds against anticipated demand.
• Bed occupancy.
• Some way of measuring any care deficit (in terms of what cannot be done today).

Other systems to be considered

A small number of comments referenced other guidelines, reporting systems or processes which should be considered. These included:

• The new National Health and Care Standards ^[2] .
• Nursing and Midwifery Council and National Institute for Health and Care Excellence ( NICE) guidelines.
• The proposed EiC or Quality Dashboard measures.
• NHS e- KSF (Knowledge and Skills Framework).
• IMATTER ^[3] .
• Datix ^[4] .

Use of the tools

Other of the further comments made more general points about the use of the tools rather than proposing specific measures. They tended to be made by individual respondents and included:

• The approach must be easy to use in real time.
• Adequate training must be provided.
• Providing expert support around data analysis would be helpful.
• Results should be published and easily accessible.

Question 7 - Given existing staff governance requirements and standards are there sufficient processes and systems in place to allow concerns regarding safe and effective staffing to be raised?

Table 13: Question 7 – Responses by type of respondent.

Type of respondent	Yes	No	Not answered	Total
Individuals	32	41	3	76
Organisations:
Health & Social Care Partnership	5			5
Independent sector health or social care organisation	1		1	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	1	6	5	12
Total organisations	18	6	11	35
All respondents	50	47	14	111
% of all respondents	45%	42%	13%	100%
% of those answering the question	52%	48%		100%

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 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.

Table 14: Question 7 – Discussion Groups

Yes	No	Mixed Views	Not answered	Total
13	7	2	3	25

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.

There were 77 further comments made through Citizen Space and all of the discussion groups made a comment.

The three most frequently-raised themes in relation to Question 7 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.

Existing systems

While some did raise concerns, others highlighted the range of processes, systems and responsibilities which are already in place. Health and Social Care Partnerships, NHS based professional groups or committees and NHS bodies or Boards were most likely to have raised these issues. They included that the IJBs are required to have in place robust clinical and care governance processes, with clear professional leadership to support operational teams. It was also suggested that there are a range of routes through which staff can raise a concern, including the National Confidential Alert Line, through Whistleblowing Champions and through Confidential Contacts at NHS Board level. Other less frequently-made comments were:

• The Care Inspectorate is statutorily empowered to provide a comprehensive scrutiny framework which looks at the quality of provision across social care and social work. It has a particular interest in facilitating concerns, complaints and whistleblowing activities in social care and social work services, which would include any concerns regarding safe and effective staffing.
• Governance structures within organisations will also be relevant, for example having Employee Directors or Clinical Directors on Boards.
• In independent hospitals, concerns are escalated via clinical leaders to senior nursing management under Scottish Independent Hospitals Association members' clinical governance structures.
• There are already processes in place for safe and effective rostering policies which help ensure the right staff are in the right place at the right time. This includes risk assessment and monitoring and escalation guidance.
• Existing arrangements in place under the Public Interest Disclosure Act, and developing work in support of the duty of candour, will all support the raising of concerns about safe and effective staffing.
• Performance reports provide a mechanism for NHS Boards and Assurance Committees to triangulate service delivery and performance with other quality and efficiency metrics. As at the previous question, reference was made to Datix and unsafe staffing levels reports.

Impact of current approaches and working culture

However, the most frequently-made comment (primarily but not exclusively by those who did not think the current systems are sufficient), was that while the systems may be in place to allow to staff to raise concerns, this does not necessarily translate into staff feeling listened to or any action being possible and/or taken. These issues were raised primarily by discussion groups and individual respondents. A number of individual respondents referred to concerns around staffing levels not resulting in additional staff being agreed or, even if agreed, being available.

A concern was that the operational culture may mean that processes are seen as little more than a 'tick box' requirement and it was suggested that no amount of systems and processes will control for a poor organisational culture. It was suggested that staff being listened to and responded to appropriately is key to safe and effective staffing. There were also a small number of discussion group or individual respondents who reported that, within their own organisations, an element of anxiety or fear means that staff do not feel able to raise any concerns they may have.

Small numbers of primarily individual respondents highlighted a range of other issues or concerns about how the current approach works. These included that:

• Current leadership models, particularly within IJBs, mean that Allied Health Professions ( AHPs) may not be present at most senior levels of management or in a position to influence policy or legislative development. Consequently, some staff may have concerns that their perspectives will not be heard.
• The current criteria to monitor standards of healthcare in prisons are not ideal.
• If the workload planning tools do not adequately reflect service demands, any workload-related complaints will be measured against unrealistic caseload sizes. The individual practitioner then has to prove their concerns, potentially including proving they are not inefficient or lacking in clinical skills.
• There can be significant delays in dealing with concerns raised. In particular, the timeframes from referral to investigation are too long.
• Datix does not always get completed when services are short staffed.

Futures plans

Going forward, a Professional college, body, group or union respondent suggested that, whilst the Staff Governance Standard already applies to the NHS, there is resistance to any assumption that it will apply to other sectors. On a similar note, another Professional college, body, group or union respondent and an Other public body respondent suggested that any approach needs to work for all staff, including AHPs and those working in social services and that clarity with regard to the role of IJBs and Health and Social Care Partnerships would be welcome. It was also suggested that far greater emphasis must be placed on the role of care and clinical governance structures within the legislation to provide appropriate and equal oversight from staff and clinical governance perspectives.

Other suggestions, in each case made by only one or a small number of individual or organisational respondents, included:

• Organisational accountability needs to be built into the system. It may be that the focus of any further work on the nursing and midwifery workforce should be on supporting the development of open and transparent cultures and improvements around using the existing tools.
• Additional advice, support and education would be helpful in ensuring informed decisions and appropriate escalation during implementation and embedding of any new requirement. In particular, senior nurses and team leaders need clarity around escalation processes.
• Datix should be strengthened to ensure that concerns and responses are properly recorded and analysed.

Question 8 - If not, what additional mechanisms would be required?

There were 64 further comments through Citizen Space and 12 discussions groups made a further comment (over and above those made at Question 7).

The three most frequently-raised themes in relation to Question 8 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.

Although a range of suggestions were made, most comments were made by only one or a small number of respondents. Suggestions for change or future action included that there should be clear lines of management accountability for all staffing groups. It was also suggested that that leadership for AHP groups should be at the same senior level as for other health care groups, such as nursing. Another suggestion was that overall governance should sit within the Clinical Governance Committee and the Health and Safety Committee in the workplace or that there should be reporting to Staff Governance and Partnership Fora on incidents where staffing falls below agreed safe levels.

Reporting systems or tools

In terms of reporting systems or tools, the most frequently-made suggestion was that there should be clear pathways for escalation to appropriate decision makers. This point was most likely to be raised at the discussion groups. Other less frequently-made comments were:

• Existing mechanisms should be linked up to ensure that one does not have an unintended impact upon another. The example given was that the introduction of legislation could mitigate against work to develop open and transparent cultures.
• There should be an accessible, national reporting system. There should be a contact point outwith local teams which staff can go to.
• There should be a procedure within NHS primary and acute settings that ensures concerns about safe staffing levels, raised by family members, are recorded. It should set out what then happens to this information.
• Nursing and Midwifery Workload and Workforce Planning tools should be updated regularly to ensure that changes in service delivery, the impact of other evidence-based care, and /or national drivers are incorporated.
• Additional measures, such as those contained in the NICE safe staffing guideline for midwives working in maternity settings, should be adopted. In particular, the guideline recommends the use of 'midwifery red flags' to act as warning signs that delays in treatment or other serious incidents may have been triggered by staffing problems.
• There should be real-time analysis, for example using SafeCare.

Staff involvement

Other suggestions focused on how staff should be involved in the process. These issues were most likely to be raised at the discussion groups or by individual respondents, with the most frequently-raised being that there should be staff awareness raising and training on how to report concerns. Other less frequently-made suggestions were:

• There should be some form of independent staff forum at which concerns can be raised.
• There should be regular surveys of staff. Also, exit interviews might shed more light on why some staff feel that their career in the health and social care service has been unsustainable and what might have been improved. Listening to these messages could help improve staff retention.
• Measures should be taken to ensure Datix is always completed.
• There should be paper incident forms.

Scrutiny and review

Finally, there were a small number of suggestions around scrutiny and review. The most frequently-made was that there should be an element of independent review and external scrutiny and accountability. This was most likely to be raised by individual respondents. A specific suggestion was that there should be surveillance by a national body that has the power to take action if standards are not being adhered to. Other less frequently-made suggestions were:

• There should be full clinical governance reviews, including service and case note audits.
• Mechanisms relating to service measurement and evaluation, such as outcome measures and audits which evaluate service provision and inform safe and effective staffing across and within organisations, should be utilised.
• Performance against recommended staffing levels should be published.

Question 9 - Do you agree 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?

Table 15: Question 9 – Responses by type of respondent.

Type of respondent	Yes	No	Not answered	Total
Individuals	72	4		76
Organisations:
Health & Social Care Partnership	4		1	5
Independent sector health or social care organisation	2			2
NHS based professional group or committee	5			5
NHS Body or Board	6			6
Other			3	3
Other public body	1		1	2
Professional college, body, group or union	8		4	12
Total organisations	26		9	35
All respondents	98	4	9	111
% of all respondents	88%	4%	8%	100%
% of those answering the question	96%	4%		100%

A substantial majority of those 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.

Table 16: Question 9 – Discussion Groups

Yes	No	Mixed Views	Not answered	Total
25				25

All of the discussion groups also agreed.

There were 51 further comments made through Citizen Space and 22 of the discussion groups made a comment.

The three most frequently-raised themes in relation to Question 9 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 number of the further comments suggested that having an agreed national approach will be key and that appropriate training would be essential. Discussion groups or individual respondents were most likely to make these points. Reasons given for the importance of training included that it would help ensure consistent and transparent practice. It was also suggested that it will support proactive rather than reactive practice, confidence in decision-making, and could help foster a more positive attitude towards the completion of workload planning tools.

A small number of respondents, including individual and organisational respondents and discussion groups, commented on the focus and coverage of the training, including that:

• Training requirements will vary according to staff role.
• There should be an emphasis on shared ownership, responsibility, application and interpretation of tools and best practice in relation to triangulation.
• Cross sector training could be considered.
• It should include guidance on why a safe and sustainable workforce is necessary and how to plan for future demographic change.
• Operational managers and leaders should learn about the issues of retention of staff and how to make careers more attractive and sustainable in their areas.
• It will be important to recognise that 'health' tools will not always fit a social care or integrated service. The Care Inspectorate and the Scottish Social Services Council could work together to ensure that refreshed guidance and training are available in the social care sector.

With regard to who should receive the training, the following points were made, primarily by a small number of NHS based professional groups or committees and NHS bodies or Boards respondents:

• The training would need to extend to all staff but to varying degrees. learnPro ^[5] could support such an approach.
• The training could be included within pre-registration nursing training or as part of induction processes. There could then be annual updates to include changes to methods, tools, mandate and legislation.
• There should be particular support to middle managers and finance managers to understand implications of decision-making and the impact on outcomes for people, their families and carers as well as all staff.
• NHS band 7 staff do the majority of rotas and staffing plans on a daily basis and are often the ones held to account. Their training needs should be paramount.
• Training must extend to Trade Unions.
• There was also a question as to whether Board members should receive training?

There were also a small number of comments, primarily from organisational respondents, about the resources implications. They included that the resource implications could be considerable, including because nursing staff are taken away from clinical duties. It was suggested that there could also be major challenges in non- NHS settings, that there should be a national view of equitable access to resources, and that implementation of a full education and training programme should be included in the financial memorandum to the Bill.

Other points made about training included that, as it stands, the wording of the Bill is not sufficient to ensure that organisations can provide evidence of the competence of those given responsibility for workforce and workload planning, including their professional judgement. It was suggested that this should be reflected in the draft Bill. Other comments included:

• Training to support workforce planning in line with the Revised Workforce Planning Guidance ( CEL32, 2011) ^[6] is still valid. However, there may be some lack of understanding when it comes to application of these tools, especially when working in multi-disciplinary teams.
• Leaders of multi-disciplinary teams should be required to consult with equally experienced and senior professional leaders from each of the disciplines they manage.

Question 10 - Do you agree with the proposal to require organisations to ensure effective, transparent monitoring and reporting arrangements are in place to provide information on how requirements have been met and to provide organisational assurance that safe and effective staffing is in place, including provision of information for staff, patients and the public?

Table 17: Question 10 – Responses by type of respondent.

Type of respondent	Yes	No	Not answered	Total
Individuals	71	2	3	76
Organisations:
Health & Social Care Partnership	3	2		5
Independent sector health or social care organisation	2			2
NHS based professional group or committee	5			5
NHS Body or Board	6			6
Other			3	3
Other public body	1		1	2
Professional college, body, group or union	8	1	3	12
Total organisations	25	3	7	35
All respondents	96	5	10	111
% of all respondents	86%	5%	9%	100%
% of those answering the question	95%	5%		100%

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.

Table 18: Question 10 – Discussion Groups

Yes	No	Mixed Views	Not answered	Total
22	1		2	25

Twenty-two of the discussion groups agreed, one disagreed and two did not answer the question.

There were 49 further comments made through Citizen Space and all of the discussion groups made a comment.

The three most frequently-raised themes in relation to Question 10 were:

• Transparency is crucial in terms of both staff and public confidence.
• Any resulting information 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.

As noted above, the most frequently-made point was that transparency will be crucial, including to give staff and the public confidence in the approach. Discussion groups and individual respondents were most likely to make this point. A number of discussion groups also commented that it will be important for public facing information to be easy to understand but also be set very clearly in context. Otherwise, the remaining comments were generally made by one or a small number of respondents only.

It was suggested that a having more complete overview of staffing requirements provides a mechanism to react to issues as they arise and provides another level of assurance. However, it was also suggested that monitoring and reporting in isolation will not necessarily provide full assurance. Echoing some of the issues covered at earlier questions (and at Question 2 in particular), the argument was that it is essential to look at what is happening in response to the use of the workforce planning tools – the 'so what' – and the subsequent impact.

Other comments addressed the focus of the monitoring and reporting elements and again were made by small numbers of respondents or were raised at a small number of the discussion groups. They included that the monitoring framework needs to be considered carefully as numerical information does not provide the whole picture. It was suggested that context will be important and that reports will need narrative as well as numbers. It was also suggested that they should not be overly long or complex. A specific suggestion was that a 'Red, Amber, Green' approach could be used. With regard to the overall reporting arrangements, comments included:

• An organisation's Board should have overall responsibility for meeting any reporting requirements.
• There should be a minimum requirement that a Board reviews its staffing, monitoring and reporting arrangements at least once every six months or more frequently in the event of concerns being raised.
• Reporting at IJB and NHS Board level would support effective scrutiny and assurance.
• Clarity would be needed as to the respective responsibilities of General Practices and Health Boards in the monitoring and reporting arrangements of staffing levels in a practice setting.
• The approach would need to be monitored to prevent any manipulation of figures to achieve financial gain.

A small number of comments related to how staff and managers will use the tools and included that staff and managers will need to be given the necessary time and resources to deliver the requirements. It was also suggested that requirements should be kept to a necessary minimum so as not to become a drain on resources. Other comments included that:

• Consideration should be given to helping leads to understand better their establishments.
• It will be important to take on board any learning from the use of the tools and to consult with staff on the impact of their use. This could include opportunities to share good news stories.
• Any developments in monitoring and reporting should be subject to full consultation with sufficient lead-in time before changes are introduced.

A small number of NHS body or Board and Other public bBody respondents highlighted existing external scrutiny, monitoring and reporting arrangements that are in place and/or could potentially be built on. Examples included:

• The Care Inspectorate expects all care services to be open and transparent in providing information to people experiencing care. With the new National Health and Social Care Standards, there will be a stronger focus on service providers and integration authorities undertaking regular assessment of needs, rights and choices.
• Performance reports to NHS Board Assurance Committees and to the full NHS Board. These will cover workforce metrics (sickness, vacancy rate, age profile, turnover etc).
• Local Delivery Plans are required to respond/refer to Everyone Matters priorities and in going forward could be extended to append a strategic staffing review for the forthcoming year.

However, an NHS body or Board respondent also noted that Boards will have different levels of development and maturity in relation to monitoring performance.