Health and social care: safe and effective staffing consultation

1. Introduction

1.1 A range of statutory duties and mechanisms are already in place to ensure and assure provision of high quality care, effective workforce planning and staff governance. However, the proposals set out in this consultation would take a further step to ensure - and assure - safe and effective staffing.

1.2 This consultation paper invites views on proposals to introduce legislation that will require organisations providing health and social care 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.
• Monitor and report on how they have done this and provide assurance regarding safe and effective staffing.

1.3 Proposals are intended to:

• Strengthen and enhance arrangements already in place to support continuous improvements and transparency in workforce planning and employment practice across Scotland.
• Enable consideration of service delivery models and service redesign to ensure Scotland's health and social care services meet the needs of the people they serve.
• Provide assurance - including for patients and staff - that safe and effective staffing is in place to enable the provision of high quality care.
• Actively foster an open and honest culture where all staff feel safe to raise concerns regarding safe and effective staffing.

1.4 The proposals focus intentionally on the application of evidence based approaches to nursing and midwifery workload and workforce planning as there is already a validated framework, methodology and suite of planning tools that are mandated for use in NHSScotland as part of Local Delivery Planning and which cover 98% of nursing and midwifery care settings. However, the consultation proposes that this approach could be extended to other settings and staff groups when methodologies are developed.

Background

1.5 The Healthcare Quality Strategy for NHSScotland ^[1] published in May 2010 developed three Quality Ambitions:

• Safe - There will be no avoidable injury or harm to people from healthcare, and an appropriate, clean and safe environment will be provided for the delivery of healthcare services at all time.
• Person-centred - Mutually beneficial partnerships between patients, their families and those delivering healthcare services which respect individual needs and values and which demonstrates compassion, continuity, clear communication and shared decision-making.
• Effective - The most appropriate treatments, interventions, support and services will be provided at the right time to everyone who will benefit, and wasteful or harmful variation will be eradicated.

1.6 The Healthcare Quality Strategy is the approach and shared focus for all work to realise the 2020 Vision ^[2] .

1.7 The priorities for action identified in the Everyone Matters 2020 Workforce Vision ^[3] are:

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

1.8 The Health and Social Care Delivery Plan, published in December 2016 (available at http://www.gov.scot/Publications/2016/12/4275) sets out our programme to enhance health and social care services. The Health and Social Care Delivery Plan recognises that actions which have greatest impact on delivery must be prioritised. It focuses on three areas often referred to as the Triple Aim: better care; better health; better value. The Delivery Plan states that "we need services that have the capacity, focus and workforce to continue to address the increasing pressures of a changing society. Our approach to primary and community care on the one hand, and acute and hospital services on the other, should support the critical health challenges our society faces, not least with respect to an ageing population". A National Health and Social Care Workforce Plan is planned for publication in Spring 2017. The Plan will present an opportunity to refresh guidance for the production of NHS workforce plans; and introduce workforce planning which provides an overall picture for health and social care staff.

1.9 Local authorities and other social care service employers operate various approaches to workforce planning for their workforce. This was recognised in a 2016 research project supported by the Social Work Service Strategic Forum.

Ensuring a sustainable nursing and midwifery workforce

1.10 There is growing research evidence showing the link between nursing and midwifery staffing and patient outcomes (including mortality rates, patient safety, patient experience and other quality of care measures); staff experience and morale; and the efficiency of care delivery ^{[4] [5] [6] [7]} . It is vital to have right number and mix of staff in place, with the right skills to enable the provision of high quality care.

1.11 This relationship was reinforced in the Vale of Leven Hospital Inquiry Report (2014) ^[8] , which made specific recommendations regarding nurse staffing and skill-mix. The Francis Report (2013) on care quality at Mid Staffordshire NHS Foundation Trust ^[9] also made a broad range of recommendations covering local and national NHS management, governance, quality assurance and staffing. A common theme from these reports is the importance of organisations taking a systematic and responsive approach to determining staffing levels to ensure high quality care.

1.12 Scotland's nursing and midwifery workforce plays a critical role in delivering high quality care across the health and social care landscape. Nurses and midwives comprise the largest part of the NHSScotland workforce, with 59,709.1 WTE staff in post at 31 December 2016 (of these, 43,820.9 WTE are registered staff). There are a significant number of registered nurses working in various settings other than the NHS, including over 2,000 registered nurses working in primary care in 2015 who are employed by Scottish General Practices. There were also approximately 7,000 registered nurses working in other social services in 2014 based on data from the Scottish Social Services Council. They are providing care across a diverse range of hospital and community settings and are practicing in a rapidly evolving and dynamic service.

1.13 The Scottish Government, in partnership with key stakeholders including employers, partnership organisations and Higher Education Institutions, is already doing a great deal to ensure a sustainable and capable nursing and midwifery workforce, and promote and assure high quality care. Key building blocks are already in place, including evidence based workload and workforce planning tools; higher numbers of staff; strengthened student intake planning; a clear strategy for nursing and midwifery education; and work to transform nursing roles to meet the current and future needs of Scotland's health and social care system. Work is in train to develop and roll-out Excellence in Care, Scotland's national approach to assuring nursing and midwifery care, which will include an agreed set of quality measures and indicators. Work is also ongoing to develop a refreshed vision for nursing in Scotland, which will support and sustain nurses' contribution to improving health and delivering care towards 2030 and beyond.

Scotland's Nursing and Midwifery Workload and Workforce Planning Programme

1.14 In its 2002 report "Planning Ward Nursing Legacy or Design" ^[10] Audit Scotland identified that little was known about how NHS systems plan nursing and midwifery workforce or how staffing levels were set at ward level. The report identified that improvements were required and recommended a consistent approach to workforce planning, which included consideration of quality measures.

1.15 As a result, the Scottish Executive Nurse Directors group ( SEND) commissioned the Nursing and Midwifery Workload and Workforce Planning Programme ( NMWWPP) in 2004. Its aims were to develop a nationally validated, fit for purpose approach to measuring nursing and midwifery workload and providing information on staffing establishments required for that workload. The subsequent report ^[11] made 20 recommendations which included a requirement for:

• A national standardised approach to nursing and midwifery workforce planning.
• Development of workforce tools which take account of patient acuity, professional judgement and include nationally agreed predictable absence allowance and leadership time to support setting of nurse/midwife staffing establishments.
• Development of indicators that allow accurate national comparisons of workload and workforce planning data.
• Inclusion of flexible working arrangements.
• Planning reduction in nurse agency spend.
• Education and training in workforce planning for senior charge nurses and professional leaders.

1.16 Research has shown that while workforce and workload measurement tools offer useful assistance in planning nursing and midwifery workforce requirements, there is no perfect tool which can provide definitive staff requirements on its own, (Arthur and James 1994 Carr-Hill and Jenkins-Clarke 1995, Hughes 1999) ^{[12] [13]} . However, evidence suggests that application of validated workforce tools with the addition of a consistent professional judgement approach improved sensitivity of outcome. ^[14]

1.17 Following review of the evidence, the NMWWPP concluded that in order to establish nurse/midwifery staffing requirements:

• Specific workforce/workload tools which take account of specialty and patient dependency should be applied.
• A nationally agreed professional judgement approach should be applied, as a minimum.
• Quality measures should be considered, recommending that as patient dependency measures offered a means of recording changing patient acuity and associated workload, this type of methodology should be used.
• Current funded establishment and local context should be considered.

1.18 The report went on to state that a combination of tools should be used, with all services using a nationally agreed professional judgement approach as a minimum.

1.19 Since 2004, Scotland has led the rest of the UK in developing a series of ground-breaking nursing and midwifery workload and workforce planning tools. The NMWWPP has made significant progress and we now have a validated framework, methodology and suite of 12 workload measurement and workforce planning tools that cover 98% of nursing and midwifery service areas. Further details of the approach are set out in the next section. The work of the NMWWPP has been overseen by a steering group which has wide stakeholder engagement and representation including Executive Nurse Directors and professional leaders and partnership bodies.

1.20 The approach and suite of tools are endorsed by Scottish Nurse Directors and professional bodies, mandated for use in NHSScotland as part of Local Delivery Planning and are widely used. Although significant progress has been made, the proposals within this consultation will ensure more consistent application and broader use within and across NHS Board areas and ensure that approaches are further embedded at an organisational level.

Staff governance

1.21 NHSScotland recognises that effective Staff Governance is an investment in patient care. Staff who feel engaged, involved and valued provide for a strong workforce which is essential to achieve continuous improvement in delivering healthcare services. NHSScotland's commitment to Staff Governance was reinforced by the legislative underpinning within the NHS Reform (Scotland) Act 2004. This legislation aims to improve how NHSScotland's diverse workforce is treated at work. The NHSScotland Staff Governance Standard ^[15] and framework has also been developed to support staff on this basis and is therefore the key policy document to support this legislation.

1.22 The Freedom to Speak Up Review, chaired by Sir Robert Francis QC, highlighted the importance of encouraging staff to speak freely about any concerns, and the important contribution this makes to patient safety. Although it relates entirely to NHS England, its report, published in 2015 ^[16] , provided independent advice and recommendations aimed at creating an open and honest reporting culture. Many of the recommended actions outlined in the Report from the Freedom to Speak Up Review are already in place or being developed in NHSScotland.