ANNEX C: ADDITIONAL WRITTEN EVIDENCE

SUBMISSION BY ACADEMY OF ROYAL COLLEGES AND FACULTIES IN SCOTLAND

Health Committee Calls for Written Evidence for Inquiry into Workforce Planning in Scotland’s National Health Service

Thank you for extending the deadline for calls for written evidence for the inquiry into workforce planning in Scotland’s NHS. We would however make the general observation regarding the process in that the Academy and many of its constituent colleges have only recently and indirectly received information regarding this request. This is regrettable as we recognise the importance of this inquiry and think that we have a significant contribution to make in the area of medical workforce planning.

Given the short time scale to reply we are only able to outline some of the issues we would wish to raise but are happy to provide more detailed figures and comments at a later date.

Cover the roles and responsibilities of workforce planners

To paraphrase the Royal College of Pathologists report this is to:

(ii) Evaluate accurately the current workforce

(iii) Estimate projected issues through retirement and job changes

(iv) Consider changes in practice that will influence future work force needs

(v) Consult groups who are aware of the work force situation

The majority of our constituent colleges gather annual workforce data for Scotland and have carried out recruitment and retention surveys of their members. This information is freely available. The Academy, SJCC and other professional groups have repeatedly offered this information to the central workforce planning group but have failed to engage the group in discussions in utilising the information. Throughout the planning process there appears to have been little consultation with professional bodies.

We feel it is essential that workforce planners have access to accurate information. Whilst we welcome the Scottish Health Workforce Plan 2004 Baseline because of the format in which this information is organised, we have no way of verifying the numbers against our own census figures produced by the colleges in medical staffing. The Royal Colleges and deaneries produce considerable information pertaining to consultant numbers, norms, doctors in training, retirement statistics which provide an overall picture of medical staffing that could be helpful in feeding into a workforce strategy and implementation recovery plan. At present we have concerns that the Scottish Health workforce plan 2004 in its current format will provide timorous solutions to a rapidly worsening problem of workforce shortages. We would suggest that the key focus of central workforce planning should now be on working in partnership with relevant clinical bodies to implement solutions rather than further descriptions of the problems.

The Academy supports the key recommendations of the Temple Report and was disappointed by the delay in both its publication and in the response to the report by the Scottish Executive.

We think it is important to involve clinicians by specialty rather than leaving workforce planning to a generic model delivered through Human Resource Departments within hospitals and boards. Clinicians have a valuable contribution to make regarding issues particular to their own specialty and the issues around recruitment and retention often vary in different specialties. The model of partnership working between Human Resources departments and clinician is at present absent from current workforce planning. We note for example that for specialties working primarily in community services rather than acute hospitals (e.g. primary care and psychiatry) workforce planning for the NHS cannot take place in isolation from other statutory organisations.

Identify Barriers to Training and Education

A number of recent key policy initiatives have had a significant impact on training and education.

Modernising Medical Careers policy represents a huge challenge to the service both in terms of the pace of change it will entail and the worrying uncertainties over: the processes involved to attain full competency , timescales for achieving competencies in more technical specialties, the lack of primary care experience in the foundation years and the effect on consultant workload due to reduced junior service commitments and increased demand for consultants time for training (additional 50%). The lack of additional Senior House Officer posts and specific initiatives such as the English SHO Schools may increase the figure of 70% of Scotland’s graduates practicing outside Scotland.

The effect of the new Consultant Contract which reduces clinical activities will have a direct affect on teaching and training. Many NHS consultants who previously under their honorary teaching contracts provided considerable input into undergraduate and postgraduate education are finding this cannot be accommodated in their new contract. Similarly the considerable problems of attracting doctors into academic medicine (where the primary drivers arethe research assessment exercises rather than teaching and clinical work) have been well documented.

The ever expanding central change agenda with increasing demands by the Scottish Executive to participate in a wider range of service and policy initiatives continues to remove clinical staff from direct clinical care, teaching and training.

It is essential that protected time is provided for senior doctors to provide education and training to their junior colleagues.

The continuing reduction of budgets for postgraduate deaneries, the lack of appropriate training facilities in many hospitals and community settings and increasing problems in doctors being released from service commitments to provide training appears to be in direct contrast to the Scottish Executive's aspirations for a skilled “fit-for-purpose” workforce.

Identify areas with difficulties in recruitment & retention, as well as best practice.

As indicated previously most colleges collect extensive data in these areas. We are puzzled that this rich source of information has not been utilised by workforce planners in Scotland and it is unclear how this work can be fed into the overall workforce planning process. As a result there may be duplication of effort.

Our data provides information on which specialties in medicine are unattractive to medical graduates, why this is and what may help in alleviating specific shortages. Each college has detailed suggestions for improving recruitment and retention in their own specialty based on surveys and data collected in these areas.

Recruitment Specialties need to appear attractive and identify key issues affecting recruitment in their area. The problem of recruitment is further compounded by the lack of expansion of SHO numbers despite competition for places. This will continue to have a negative effect as unsuccessful candidates will go elsewhere particularly to areas of expansion outside Scotland.

Retention – At present there is a perception that Scottish jobs are unattractive for a variety of reasons including remuneration and poor facilities. We are also concerned to hear that Article 11 and 14 registration may be postponed as this may result in further migration of non consultant career grade doctors elsewhere.

Best practice – Providing best practice in the rapidly changing world of modern medicine is challenging but achievable. Meeting patient expectations, often a term used interchangeably with the concept of best practice, has however stretched the workforce beyond its limits. Concepts of need, demand and core NHS business have to be clearly defined and prioritised to fit with the capacity of the workforce to deliver.

Identify pressures affecting the workforce and how they impact on service delivery e.g. Specialisation of staff skills, European Working Time Directive

The European working time directive coupled with the increasing workloads has had and will continue to have a significant impact on service delivery and workforce planning. The need to remain compliant with the directive has not only redirected the resources from laboratory specialties to acute clinical specialties but has led to fragmentation of traditional supportive working practices in acute hospitals (e.g. disintegration of medical forums) and unsatisfactory fragmentation of care. This has resulted in a poor teaching experiencing for junior doctors in their early years of training.

Subspecialisation has provided greater and more focused expertise to patients, but specialist teams because they are smaller are more vulnerable to staff shortages and less able to be supported by cross cover arrangements.

The significant gender and working practice shift with family friendly policies and increased demands for flexible working have brought additional pressures to bear on the system. Whilst welcome this has to be accommodated within future plans.

Examine what the Executive is doing to address those pressures identified

The Scottish Executive workforce planning group have put forward proposals on skill mix and service redesign as the primary model by which to resolve workforce difficulties. We have concerns as to the extent by which pursuing this single model will improve matters. Whilst we support the principle we question the pace of enactment, the process being used to deliver the redesign, and the overall size of the impact it will have on workforce difficulties.

Examine what the Executive is doing to develop the workforce in areas identified as experiencing recruitment and retention difficulties

At present we think that there has been little progress on medical recruitment and retention. We support the analysis of the issues in the Temple Report but would like to see an operational plan to deliver improvements in these areas.

Workforce planning in Scotland appears to be occurring in isolation from colleges, NHS Education for Scotland, UK wide training bodies (PMETB), deaneries and clinicians. We also recommend that workforce planning in Scotland continues to retain a UK perspective otherwise Scotland will undoubtedly be the loser with a hemorrhaging of doctors to other parts of the UK.

Examine what is being done to identify longer term influences on health service provision and demand, and how this relates to workforce development.

A wide range of influences may affect longer term workforce planning. These will include: patient demography, aging and falling population, a review of skill specific tasks and a redesign of medical careers that may change significantly for the individual between the early years in a consultant post to retirement.

Recommendations

The Academy would wish to work in partnership with the executive to look at issues pertaining to:

1. Modernising Medical Careers

Strategies to make Scotland more attractive to the graduates from Medical School particularly in relation to the foundation programme in Modernising Medical Careers.

Increasing SHO Posts particularly to reintroduce experience in primary care into the foundation programme similar to England. At present that experience cannot be provided in Scotland.

Allocating and funding training time in the consultant contract.

2. Medical Workforce planning of a UK wide and national basis

Planning in smaller units is wasteful of resource and will not allow an overall perspective of the problem. Whilst Health Board and Regional planning linked to developing a team model of service delivery has meant the current urgency to provide medical cover across the country cannot, we feel, be met through this route at least in the next few years. We question how much transfer of work and reconfiguration of skill mix will actually impact on the system overall and whilst we do not reject this work going on in tandem we see an urgent priority to tackle the serious medical workforce shortage through a different strategy based centrally within the Executive.

3. Training Doctors from overseas

All of the Colleges within the Scottish Academy have active training and education links and many overseas members. We would wish to build further on these contacts and facilitate training placements in the UK to provide cross fertilisation of ideas and skills.

We hope you will find this information useful and look forward to further developments on this issue.

Yours sincerely
Andrew A Calder
Chairman

SUBMISSION BY ARGYLL AND CLYDE LOCAL HEATH COUNCIL

Enquiry into the Recruitment, Training and Retention of NHS Staff

At the most recent meeting of Argyll and Clyde Health Council members welcomed the decision of the Health Committee to hold an enquiry into the recruitment, training and retention of doctors and nurses as reported in the Greenock Telegraph of 21st November 2003.

It is apparent to the Health Council that there is a pressing need for decisions made about local health services to be taken in an environment of openness, transparency and full information. Even Health Council members, as informed members of the public, have often felt excluded and confused about the real reasons behind centralisation decisions and the extent to which the professional opinions of the Royal Colleges may be challenged.

This understanding deficit was most evident in relation to the recent decisions around maternity services in which external drivers, such as the professional guidelines on the number of births required per annum to sustain a consultant led unit, overrode the wishes of the local population to retain consultant led services in Inverclyde and the Vale of Leven. This has left these communities feeling disenchanted with the public involvement process. Members also feel that there has been a lack of information in the public domain around how decisions are taken about the number of students admitted to medical, dental and nursing schools.

It was agreed that as interested members of the public we would welcome the opportunity to be involved in the enquiry referred to in the Greenock Telegraph and believe that it will be helpful in furthering a shared understanding of the challenges currently facing the NHS in Scotland.

Yours sincerely
Bob Hall
Chairman

SUBMISSION BY GERALDINE BUTCHER - AYRSHIRE CENTRAL HOSPITAL

I have one main comment in respect to this consultation:

A realistic appraisal should be made in relation to continuous professional development.particularly the need to be able to release staff for mandatory training

At present staffing levels make this problematic and non achievable. this list of such training is also added to on an almost daily basis and we need to think on near future needs as well as what we need now.

Geraldine Butcher
Clinical Development Manager
Ayrshire Central Hospital

SUBMISSION BY BASICS SCOTLAND

BASICS Scotland held its annual clinical meeting in Perth two weeks ago and became the forum for a significant group of health care professionals seriously concerned at the increased risk for their patients with the changes in out of hours (OOH) provision. This diverse group covered a large spectrum of professionals including doctors, district and practice nurses, a nurse practitioner, paramedics, midwives and a hospital manager.

It was the unanimous agreement of this group that whilst the proposed OOH provision would probably manage the routine OOH contacts (minor illnesses) adequately, it would be less able to offer a comprehensive and safe option for life threatening emergencies. As such the proposed OOH cover would represent a reduction in the service available to patients, particularly in isolated, rural and island communities, to a level that has to be considered unsafe. Further, the additional demands that the new system will place on the ambulance service would make it even more difficult for the service to cover these life threatening emergencies in these areas, where cover on the ground is limited.

There may be a means of improving this situation. Scotland -and in particular rural Scotland -is now covered by a large number of professionals who have attended Immediate Care training courses, run by BASICS Scotland and funded through RARARI -over 1,200 course places have been provided in the last three years. Almost 500 of these immediate care providers have been equipped with the Sandpiper Bag since 2001 donated by the Sandpiper Trust which is a Scottish Charity whose aim is to reduce morbidity and mortality in rural Scotland by equipping trained providers. The actual problem is one of communication between these immediate care providers and Ambulance Control. We need some sort of radio or electronic device that would allow the Scottish Ambulance Service to be aware that. these suitably trained and equipped providers were available without the need to telephone several numbers before finding such a practitioner. The latter approach is unsatisfactory for both sides, and the reason that co "operation and involvement of providers has declined over the last two or three years. This is not a criticism of ambulance control which when local knew every thing there was to know locally, but now national lack this local knowledge..

Such technology would have to be user friendly to both sides and easily managed. The vehicle locating system (VLS) installed in modem Scottish Ambulance Service accident and emergency vehicles is a possible solution. Once installed in a vehicle the only effort required is for the provider to switch the device on and the information, with name and mobile number of the provider will appear on the ambulance service control centre's screens.. When the provider chooses to become unavailable simply switching the device off will remove them from the control centre's screen. Thus providers will be available as and when they wish, ambulance service control officers will know that all providers on the screen are available. In fact the vehicle locating system could be considered "simply perfect"

There are several advantages:

• Patients, appropriately triaged, will be attended by suitably trained and equipped practitioners more quickly, thus reducing mortality and morbidity both on the roads and with medical emergencies viz heart attacks and thrombolysis
• many rural practitioners travel around Scotland, and would be available on our major roads and may be the nearest provider to an incident
• many rural doctors are trained in the management of major incidents (MIMMS trained by BASICS Scotland) and were these doctors to be separately identified, then a major incident attendance may be shortened by hours, especially a coach or train crash in an isolated area.
• Clinical governance issues as well as the need to be aware of all aspects relative to emergency care outside the clinical training will also be addressed as the VLS system would only be made available to suitably trained and equipped providers. BASICS Scotland could be the. vehicle to maintain standards, facilitate consumables and continue refresher training.
• The National Enhanced Standards could also be easily defined as the VLS will only be available to specific providers.

The population in the rural areas of Scotland already feels under threat and disadvantaged by the changes that have occurred over the last few years; schools, police, ministers, roads, transport, postal services, post offices and now the loss of previously enjoyed OOH medical cover which is seen as another "nail in the coffin" of rural life. We have dedicated, willing and highly trained immediate care providers available to assist in 'plugging the gap' that these imminent changes will cause. The financial support required to facilitate this proposal is modest, the benefits to the communities will be great, while the practitioners themselves can be available as they wish, knowing that they will only be called by the ambulance service in a genuine emergency.

We urge responsible managers, providers, the First Minister of the Scottish Parliament, The Minister at The Department of Health, Scotland's Chief Medical Officer and The Chief Executive of The Scottish Ambulance Service to consider this suggestion as a solution to an imminent problem, from a group of seriously worried immediate care providers.

Yours sincerely,

Dr Peter A Joiner FIMC RCS (Ed)
Immediate Past Chairman

SUBMISSION BY BRITISH DENTAL ASSOCIATION

The British Dental Association (BDA) represents, supports and advises dentists working in all branches of dentistry and throughout their career, from university through to retirement. In this capacity, it welcomes the opportunity to comment on the Scottish Parliament Health Committee Call for Evidence.

Recently the BDA responded to the Scottish Executive Health Department’s (SEHD) consultation Modernising NHS Dental Services in Scotland. In this response we highlighted areas which are covered by the remit of the current Inquiry and the BDA would like to highlight once again the following points.

1. There has not been a UK wide review of the dental workforce since 1987. Whilst in Scotland there has been some workforce planning undertaken by the SEHD since 1999 there is still a shortage of trained dentists, as well as dental nurses, dental hygienists, dental therapists and dental technicians to meet the oral health needs of the population of Scotland.

2. With regard to the number of dentists in training, the BDA has for some time been calling for a 25 per cent increase in the number of undergraduate dental places in the United Kingdom, with those places being properly supported by adequate funding. This would go some way to help address the workforce shortage in the long term. However, more needs to be done to encourage those who have already qualified to practice in Scotland. From figures presented to the Scottish Dental Vocational Training Committee (SDVTC)1, it appears that almost half the dentists who finished their vocational training in 2003 did not apply to join an NHS dental list in Scotland. According to recent figures from SDVTC 26% of graduates from the two dental schools in 2004 are not applying to do Vocational Training in Scotland. This is before they have even joined the NHSiS workforce. Research is required to find out why practising in Scotland is not an attractive option for these dentists so that incentives can be put in place to address the workforce shortage.

3. Dental services should be developed along with medical services in a properly integrated way, with referral protocols and commissioning taking account of local circumstances. There needs to be a substantial increase in the number of specialists, both hospital- or practice-based, in all the dental specialties in order to improve equity of access and support those practising in primary care in relatively remote and rural areas.

4. There is a need to develop access to high quality consultant led secondary care and/or specialist services in all parts of Scotland. Currently there is inadequate provision and distribution of specialist and consultant services in the dental specialties.

5. Oral healthcare inequalities are increasing in Scotland. Scotland needs a properly resourced, integrated primary and secondary oral healthcare system able to respond to the needs of those it seeks to serve. Such a healthcare system will be better equipped to deal with the oral health inequalities which place some communities in Scotland amongst those with the worst oral health in the UK.

6. The Consumers’ Association in Scotland reports2,3 that patients are finding it increasingly difficult to access NHS dental care and dentists are as frustrated as patients are with this situation. Evidence suggests that Scotland’s oral health is suffering as a result of these access issues. Dentists recognise this and want to help turn the tide, but the current lack of funding and investment makes this difficult, putting them under increasing pressure to continue to provide high quality care for their patients within the NHS.

7. On 5 February 2003, in response to a question by Shona Robison, MSP (SNP)4, the then Deputy Minister for Health and Community Care, Mary Mulligan, stated that 62 dental practices ceased to provide NHS dental services between 1999 and 2002.

8. At the heart of the difficulties faced by NHS dentistry in Scotland are:

• a funding system that doesn’t provide patients with prevention-based, holistic care within the General Dental Services

• a shortage of trained dental professionals, which includes not only dentists but also dental nurses, dental hygienists, dental therapists and dental technicians

• inadequate support for education and training for all members of the dental team

• inadequate provision and distribution of specialist and consultant services in the dental specialties, as demonstrated by NHS waiting times

• increased difficulties including administrative and managerial demands associated with owning a dental practice

• the increasing requirements of professional, employment, decontamination and environmental regulation and legislation and their spiralling costs

9. General dental practices operate as small businesses. The cost of running the practices, including overheads such as buying the practice itself, the purchase and maintenance of equipment and staff remuneration - and all the financial risks are borne entirely by the practice-owning dentists. As a result, many dentists opt to move to an environment where high quality prevention based care can be more easily provided. This is usually into the private sector where they can spend more time motivating and educating their patients and escape the treadmill and piece-work of the NHS, improving the quality of life for both themselves and their dental team.

10. Stress is one of the factors cited by dentists when leaving the NHS workforce, along with emigration and early retirement. The NHS’ own evidence, according to the results of a survey commissioned by the Scottish Committee for Postgraduate Medical and Dental Education5 (now known as NHS Education for Scotland) in 2000, revealed that two-thirds of general dental practitioners planned to retire early, with stress identified by a third of general dental practitioners (GDPs) as a reason for early retirement. There was much useful information published in this report which has largely been ignored since its publication. More must be done to encourage older dentists to be retained within the NHSiS workforce.

11. Evidence obtained by the BDA in Scotland indicates that increasing numbers of recently qualified dentists from the two Scottish University Dental Schools are choosing to spend time in practice in Australia where they perceive an improved lifestyle and a more satisfying working environment.

12. In addition to improvements in the overall environment in which primary and secondary care dentists operate which the BDA hopes will result from the SEHD consultation Modernising NHS Dental Services in Scotland there is a need to take a close look at means of retaining dentists currently in the workforce. The loss of dentists through ill-health and early retirement resulting from the stresses of the current system must be reversed.

13. Dentists are reluctant to commit financially to the infrastructure of NHS dental practice. The financial risks are increasing and there is greater uncertainty and concern about the service jeopardising their investment. Our evidence shows that many have seen no return on their capital, as they are unable to sell their practices as a going concern when they move or retire. This results in the practice closing. More and more young dentists are unwilling to burden themselves with this risk. Unless the situation is addressed there can be no medium to long-term future for the viability of practice ownership.

14. Whilst there are few dentists in Scotland working purely in the independent sector, more and more dentists in primary care are providing some care on a private basis for the reasons given in the preceding paragraphs. With the increasing proportion of women in the workforce and the changes in dentists overall career aspirations there is an urgent need to assess the number of whole time equivalents in the NHSiS workforce in dentistry so that important informed decisions about workforce and service planning can be taken. Even without this important data the latest figures from ISD show a drop in the total numbers of Scottish General Dental Practitioners from 1891 in 2003 to 1884 in 2004.

15. The total spend on adult item of service in the General Dental Services in Scotland has dropped from £128m in 2003 to £125m in 2004.

16. Overall NHS dental services in Scotland would appear to be in decline.

17. There is inadequate support for education and training for members of the dental team. Sufficient funding for the initial education and training and continuing professional development of all members of the dental team must be identified and provided. There should be an increase in the number of undergraduate dental places with those places being properly supported by adequate funding. Vocational Training is an important factor in ensuring and maintaining quality in the delivery of oral health care and should continue to be strongly supported. The extension of the Vocational Training system to other members of the dental team could be considered.

18. There needs to be much better communication between the relevant bodies responsible for education and training of members of the dental team, such as Health Boards, the Scottish Executive Health Department, the Scottish Executive Education Department, the Universities, the Scottish Higher Education Funding Council and NHS Education Scotland.

19. The BDA recognises that there are difficulties in recruiting dentists to operate in rural and remote areas of the country. Incentives like those listed below would encourage dentists to operate in these areas. However, incentives should also be provided to those who are already providing NHS services to encourage them to continue to do so.

• More promotion of rural practice as part of the undergraduate curriculum.

• Purpose-built, fit-for-purpose dental premises

• Purpose-built premises, employing salaried practitioners with no productivity targets, who are offered transport, accommodation/family care

• Improved terms and conditions

• Increased use of IT to link up with consultants and specialists for consultations for patients with more complex dental needs to enhance the secondary care support for the primary care service

• Recognise the need for increased time and finances to attend training/educational courses

• Provision of cover for holiday periods and out-of-hours service

20. The SEHD have already introduced a number of incentives to encourage dentists to work in the remote and rural areas of Scotland. The impact of these initiatives is unclear. In addition to a review of these initiatives it is important that the needs of those existing practitioners are more fully understood.

SUMMARY

• Too few dentists and support staff are being trained in Scotland.

• The current funding mechanisms for NHS general dental services are becoming I ncreasingly inadequate and unattractive.

• NHSiS is loosing dentists to the private sector and to other countries.

• Increasing numbers of dentists are seeking to retire early.

BIBLIOGRAPHY

1. Figures from official annual report on Vocational Training numbers issued, presented to NHS Education for Scotland’s Scottish Dental Vocational Training Committee at a meeting on 28 January 2004.

2. Consumers’ Association Health Briefing March 2003

3. Consumers’ Association Health Briefing November 2003

4. Parliamentary Question S1W-33454

5. A Scottish Survey of General and Community Dental Practitioners 2000 – The Toothousand Project

SUBMISSION BY BUTE KIDNEY PATIENTS SUPPORT GROUP

Health Committee Public Consultation: Workforce Planning in Scotland's NHS

Following the meeting held in Greenock on 25th May, I should like to make further comment on the provision of renal dialysis facilities. I attended the meeting with my husband who was then travelling three days a week to the Royal Infirmary, Glasgow, for treatment, although he normally dialyses at home.

Hospital dialysis was necessary as a result of a problem with his fistula and the reason for going to the Royal Infirmary was that there was no free slot at either Inverclyde Royal, Greenock or Stobhill Hospital where he attends as an out-patient, an indication of the current lack of capacity.

He is usually quite well on home dialysis but the need to travel, leaving home after am has left him very tired. I make this point because the difference in the health of one person caused by a change in the method of delivery of his treatment, highlights the problems faced by people who have to travel every week.

Our Group has been making representations to NHS Argyll& Clyde over the last two years to locate a small satellite dialysis unit at the Victoria Hospital, Rothesay. One of the reasons given for not making this provision, was the shortage of renal nurses and the 2nd Report by the Cross Party Group on Kidney Disease has cited this as a serious problem.

An employee of the renal service has given me two possible reasons why the service cannot retain renal nurses. One is that they are constantly stressed working in overcrowded units and the other is that some staff see themselves as simply machine operators and leave to do what they consider to be 'proper nursing'.

It seems to me that sitting small units in smaller hospitals would have several benefits viz. it would relieve the pressure on larger units; it would save patients having to , travel for hours to get their treatment; and staff would not require to be full time on renal work but could do general nursing as well. I understand that some of the staff at the Victoria Hospital in Rothesay are prepared to train in renal work and, if this was replicated in other small hospitals, it would help to ease recruitment problems, as well as widening the experience of these nurses.

I am not under the illusion that providing such small dialysis units would be entirely straightforward, but I think that any problems should not be insurmountable and that the benefits, certainly in patient welfare, would outweigh any disadvantages.

At the moment, NHS Argyll& Clyde is doing what it has to do in providing treatment to save lives. However, the method of delivery of that treatment is making the quality of those lives sometimes barely worth living.

Also, the current policy of withdrawing consultant-led services to central locations increases the need for more local provision. The extent to which provision can be expanded in one hospital is necessarily constrained by the size of the site.

I have just waded through the public consultation paper for The Clinical Strategy for NHS Argyll& Clyde for the next fifteen years and found only one reference to renal dialysis. This was for an unspecified increase in provision at Inverclyde Royal Hospital. Despite constant reference throughout this document to the need to provide more services on a local basis, this proposal will do nothing for the people who are already having to travel for treatment. I hope this submission, while pointing out the problems of dialysis patients on Bute, will also indicate one way in which the problem may be eased.

Yours faithfully
Ann Polea
Secretary

SUBMISSION BY EMPLOYMENT RESEARCH INSTITUTE NAPIER UNIVERSITY

Work-life Balance and Careers in NHS Nursing and Midwifery

Work-life balance policies and practices are promoted by government, unions and employers as an important tool in the drive to recruit and retain skilled employees. Research from the Employment Research Institute, Napier University examined the challenges of implementing this agenda in the context of NHS nursing and midwifery. The main findings were:

• In common with other employment sectors, awareness and take up of organisational and statutory-based family leave was low. There were pressures not to use paid leave policies and many felt guilty about taking time off work.

• The length of shifts, the number of shifts worked consecutively, rotation between nights and days and short notice of shifts had serious implications for employees’ work-life balance and potentially their health.

• The most desired flexible working practice was greater control over shifts. A business case for broadening access to working time autonomy and best practice examples of how this could be achieved were identified.

• The majority of nurses and midwives in the study worked longer than their contracted hours and approximately 13% worked over 48 hours per week. Few were fully compensated for this additional commitment. Three broad causes of long working hours were identified: high workloads; tensions between managerial and clinical roles; and a culture of expectation to work extra hours.

• The high workload, stress and the increasing administrative content of senior nursing roles meant only 10% of nurses and midwives in the study said that, eventually, they would like to their line manager’s job. This presents significant problems for the future operation of NHS hospitals where nurses and midwives provide much of the day-to-day and strategic management.

• There were indications of increasing (but not universal) opportunities to combine part-time work with career progression. Men and women were equally represented at all grade. However, the fact that men rarely worked part-time meant that they progressed more quickly to G grade, Charge Nurse, level.

• Satisfaction with working hours and feeling valued by the organisation were positively associated with intentions to

Introduction

Work-life balance has gained increasing prominence in recent years. Concerns about the effects of long working hours, stress, the feminisation and aging of the workforce and high employment rates have increased the pressure on employers to provide working conditions to attract and retain skilled staff.

This pressure is acutely felt by the NHS which has a significant and well-publicised shortage of nurses and midwives, its largest workforce. As an overwhelmingly female-dominated workforce in a society where care responsibilities and domestic labour remains divided along gendered lines, the demand for leave and flexible working is extremely high. To compound this challenge, the nature of nursing and midwifery work (a resource-constrained, 24/7, front-line service employing staff with specialist skills) presents significant barriers to implementing work-life policies.

The research examined the work-life balance agenda for qualified nurses and midwives employed by a large acute NHS Trust (now a “Division”). There was a widespread understanding and acceptance of its role as a recruitment and retention tool and some best practice was found but overall, the approach to implementation was ad hoc and narrowly focussed.

Time off work

Employees’ main source of information on leave policies was their line manager but managers (G grade and above) had received training and rarely consulted the formal policy documents. Awareness and use of organisational and legal rights to leave for family reasons was, unsurprisingly, low.

In implementing carers leave (paid time off at short notice for a dependant), some managers operated an individualised approach which they believed helped foster a positive working relationship and increased employee commitment. For most, there was a lengthy, multi-level decision-making process operating under the strict supervision of a senior line manager.

Pressures on resources meant some senior line managers imposed a restrictive interpretation of formal policy to limit access to paid leave.

I had to take annual leave to pick a sick child up from school because I knew he was unwell … so that’s considered “knowing in advance”, it’s not an emergency. (G grade nurse)

Allowances were not made in staff budgets for this type of leave resulting in considerable impact on the wards. For this reason, many nurses and midwives felt guilty about using policies like carers leave.

I see that in this unit staff could find it difficult to ask for carers leave because of the staffing problems. Staffing is so very thin, even if you are off sick you feel guilty… (F grade nurse)

Despite these difficulties, 73% thought their boss was sympathetic about personal matters and good practice was found in using flexible working to help employees cope with ongoing domestic problems.

Number of Working hours

Average worked in the average week (n = 1033)

39% felt that, overall, they were not compensated for this overtime, an approximate value of £776,000 per annum for the sample. This figure assumes that everyone took all the time of in lieu they were entitled to but evidence from the interviews suggests that many did not because of workload pressures or an expectation not to.

Taking overtime, contracted hours and other additional paid shifts (e.g. agency), an estimated 13% of respondents worked over the limits of the working time directive (48 hours per week) compared to a UK average of 11% (5% for women). Staff at all grades commented that an expectation to work longer than contracted hours was part of NHS culture.

All staff nurses stay on after hours and do extra duties they’re not paid for to cover staff shortages – this has been going on for the twenty five years I have been a nurse. The NHS wouldn’t survive if we didn’t do it. (E grade nurse)

Nursing and midwifery managers, who worked the longest hours of all, reported high workloads, poor time management at the organisational level and difficulties in finding a balance between their expanding clinical and managerial roles. Participants raised concerns about the effects of their working hours on their life, their family and their health.

In recent times I’ve felt like I’ve had no life, been totally exhausted. When you try to switch off from work you feel like you are compromising your profession and you can’t switch off from your family… a ward manager’s job is too much for anyone, even without children – life’s too short. (G grade nurse)

The nurse quoted above has since left the service to work for a private agency and filling her post may not be easy. Only 10% said that eventually they wanted to do their line managers job. There were perceived to be few rewards, monetary or otherwise, for the increased stress, hours and responsibility and reduced clinical contact that progression often entailed. This presents significant problems for the future operation of NHS hospitals where nurses and midwives provide much of the day-to-day and strategic management.

Shift Work

For those working in frontline, 24/7 services, 12½ hour shifts were the norm (11½ hours plus one hour unpaid rest break). While popular because of increased rest days, those with care responsibilities (especially school-age children) were significantly more likely to think the long shifts had made balancing work and family life more difficult. Some areas were more flexible than others in responding to the childcare or fatigue problems experienced by their staff working long shifts.

The research also found that there were no minimum standards in relation to the ‘quick rotation’ between spells of day and night shifts or the number of shifts worked consecutively. Many staff prefer to compress their hours by working consecutive shifts but previous research suggests that this may lead to dangerous levels of accumulated sleep debt.

Almost half of the nurses and midwives in the study were satisfied with their working hours and this group were more likely to see a long term career future in the NHS. For the other half, the most popular change they would make would be to have greater control of their working hours. The organisation had responded to this demand, in the main, by granting requests from parents. While the challenges faced by parents should not be underestimated, this narrowly focussed response was perceived by some to have a negative impact on other staff. However, the research suggests that it was those without care responsibilities who were most at risk of leaving indicating a business case for taking a more strategic, inclusive approach to work-life balance as a retention tool.

Careers and Work-life Balance

Staff development is central to the new pay and reward system Agenda for Change. All NHS staff will have the right to clear and consistent development objectives and be supported to achieve them. Some barriers to fulfilling this pledge were identified. 65% of respondents thought their line manager was supportive of their career development and just over half had taken study leave in the last year. However, budget constraints meant access to paid leave and course fees was variable. Many praised the support they had received:

I would like to highlight the support I am receiving while doing my MSc both in terms of paid leave and personal support. (F grade nurse)

For those who did their professional development in non-work time, the impact on work-life balance was significant:

There are several nurses in my area who are studying for degrees in our days off and don’t get any help with study leave. When you are working full-time and running a home it is very difficult to have quality time for your family and yourself. (E grade nurse)

There were indications of increasing (but not universal) opportunities to combine part-time work with career progression. 21% of full-timers compared to 16% of part-timers worked in senior grades (G and above), a considerably smaller gap than in previous studies. There were also some positive findings on gender equality. Other studies have noted that male nurses tend to over-represented in the higher grades. In this organisation, men and women were equally represented through the clinical grades. Men tended to reach more quickly to G grades because they rarely work part-time, which tended to slow progression.

Policy Implications

Like most employers, the Division’s work-life balance performance was mixed but there was a strong appreciation of the role of work-life policies in attracting and retaining staff. What is needed perhaps, however, is a move away from the current reactive, ad hoc approach. In developing new formal policies and setting up a working group to tackle the issues raised by the research, a significant step towards this has already been taken by the organisation. For these efforts to be effective however, employee welfare and work-life balance needs to occupy a more central position in workload and workforce planning at the national level.

About the Research

The research comprised 1084 questionnaires and 64 in-depth interviews with qualified nursing and midwifery staff employed by Lothian University Hospitals Division. The project was part-funded by the Scottish ESF Objective 3 programme and conducted in partnership with Lothian Health Board and RCN Scotland.

SUBMISSION BY FUTURESKILLS SCOTLAND – PART OF SCOTTISH ENTERPRISE AND HIGHLANDS & ISLANDS ENTERPRISE

Introduction

• 1. Futureskills Scotland welcomes the opportunity to submit evidence to the Committee.

• 2. Futureskills Scotland is part of Scottish Enterprise (SE) and Highlands & Islands Enterprise (HIE). Its role is to:
• analyse the labour market to inform policy and decision making;
• make information about the labour market more accessible; and
• work with Careers Scotland to provide information for use by it and its clients.

• 3. Futureskills Scotland has no specialist knowledge of the health sector. This submission draws on work that it has undertaken, including:
• a survey of workplaces, which provides evidence about recruitment, retention and training. This has enabled production of the health sector labour market profile which is attached as Appendix 1. It places evidence about the health sector labour market in the context of the rest of the economy; and
• an analysis of the Labour Force Survey (LFS), which provides further evidence about retention and training.

• 4. In addition, details are provided of:
• pay in the health sector and the rest of the economy; and
• the age distribution of employees in the health sector and the rest of the economy.

• 5. Drawing on this evidence, the submission presents information about aspects of the health sector labour market and compares it with the rest of the economy, as well as addressing two of the topics that are the focus of the Inquiry:
• identification of areas with difficulties in recruitment and retention; and
• identification of barriers to training and education in the sector.

• 6. Futureskills Scotland, working with the Scottish Further Education Funding Council, has recently completed interviews with 7,500 workplaces, 250 in the health sector. The results will be available in November and can be supplied to the Committee on request.

Background to the health sector labour market

• 7. There were 203,000 health sector employees in Scotland in 2002. It accounted for 8.9% of employees in Scotland compared with 6.6% of employees in England and Wales.

• 8. Between 1998 and 2002, the number of health sector employees increased by more than 21,000 (12%). Over that period, the number of employees in other industries rose by 5.4%. Thus, the health sector has recently grown in absolute terms and as a proportion of all employees.

• 9. Other important characteristics of the health sector labour market are that it has:
• a very significantly higher proportion of its labour force who are in professional and related roles: almost two-thirds as compared with one-fifth in the rest of the economy;
• a very high proportion of women employees: around 80% (50%); and
• a very high proportion of part-time jobs: 50% (30%).

Recruitment and retention

Recruitment

• 10. In mid-2002, Futureskills Scotland interviewed 8,500 workplaces, 190 of them in the health sector. Employers provided information about current vacancies and about whether any vacancies were hard-to-fill. The results are summarised in Table 1 and are adjusted to be representative of all workplaces, not only those which were interviewed.

• 11. The data show that:
• the vacancy rate in the health sector was lower than in the rest of the economy;
• the hard-to-fill vacancy rate was around half of that in the rest of the economy;
• the skill shortage rate was significantly lower in the health sector than in the rest of the economy; and
• health sector workplaces were half as likely as others to report skill shortage vacancies.

• 12. The recruitment rate in the health sector was 13%. In the rest of the economy it was 22%. Thus, markedly less recruitment was undertaken in the health sector, despite its expansion, than in other sectors.

• 13. To the extent the health sector faces recruitment difficulties, those problems are, on average, not as substantial as in the rest of the economy. This may suggest that as compared with other sectors, health sector employers are more effective at recruiting.

Retention

• 14. In the year to mid-2002, labour turnover in the health sector was 12%, while in the rest of the economy it was 21%.

• 15. As a proportion of employees 12 months earlier, the leaver rate in the health sector was 11% in the health sector and 20% in the rest of the economy.
• 16. Another perspective on retention is the length of time which employees have been with their current employer. Results for the UK from the LFS are summarised in Table 2.

• 17. Compared with the rest of the economy:
• health sector employees have on average been in their jobs for longer;
• a higher proportion of health sector employees has been with their current employer for more than two years or more than ten years; and
• a lower proportion of health sector employees has been with their current employer for less than one year.

• 18. Thus, the evidence of both surveys is that health sector in general retains a higher proportion of employees than other sectors.

Training in the health sector

• 19. The LFS asks people if they had received job-related training the preceding four weeks and the preceding 13 weeks. The Employers Skill Survey in 2002 asked employers if they had funded or arranged off-the-job training for their employees in the last 12 months.

• 20. Health sector employees are more likely than those in other sectors to receive job-related training, according to both sources as summarised in Table 3.

• 21. Data from the LFS show that for every two employees in the rest of the economy who receive training, three health sector employees are trained. The Employers Skill Survey shows a modestly higher proportion of employees in health than in other sectors having received off-the-job training.

Other relevant information

Wages

• 22. A leading determinant of recruitment and retention rates is pay. In Great Britain, between 2000 and 2003 average hourly earnings for full-time employees increased by 14.5%. In the health sector, the rise was 16.4%. The faster rate of growth of health sector wages may have contributed to the lower rates of hard-to-fill vacancies and labour turnover.

• 23. While comparisons are difficult to make, and in spite of the above average rise in earnings in recent years across the sector as a whole, the evidence about the competitiveness of pay in the health sector is mixed. In general:
• rates of pay for medical professionals and associate professionals are either higher than or close to the average for people in similar occupational groups;
• earnings of professionals in health grew significantly faster than average earnings as a whole and the average earnings of all professionals between 2000 and 2003. The rapid growth in health sector professionals’ earnings was the main cause of the above average rate of growth in health sector earnings;
• earnings of associate professionals in the health sector grew faster than for associate professionals across the economy. However, with the exception of medical radiographers, earnings of health sector associate professionals increased more slowly than average earnings. For example, nurses earnings increased by 9.6%, compared with the average increase across the economy of 14.5%;
• rates of pay for secretarial, personal service and elementary jobs are close to or below the average for people in similar occupational groups;
• earnings growth among secretarial, personal service and elementary occupations was generally slightly slower than across the economy as a whole.

• 24. Details of earnings and changes in earnings are summarised in Appendix 2.

Age distribution of employees

• 25. The average age of employees in the health sector in Scotland is approximately 41 years compared with 39 years in the rest of the economy. The median ages are 42 years and 39 years, respectively. Thus, the health sector workforce is ‘older’ than the workforce as a whole.

• 26. The main source of this difference is the very low proportion of young employees in the health sector. Across the economy, 15% of employees are aged 16-24. In health the figure is 7%, reflecting the fact that there are certain health sector jobs that young workers are prohibited from doing or which require extended periods of education and training. These factors mean that even ‘young’ new entrants in the health sector are towards the upper end of the 16-24 age group. (Details are provided in Table 4.)

• 27. Focusing on the people aged 25 years and above, the health sector has slightly lower proportions of employees aged 25-34 and 50-64 and a higher proportion aged 35-49.

Futureskills Scotland

August 2004

The profile can also be downloaded at: http://www.futureskillsscotland.org.uk/uploadedreports/0712pp_FSS_HEALTH_SECTOR_2003.pdf

For the purpose of calculating the number of employees, the definition of the health sector is ‘human health activities’, Section 85.1 of the Standard Industrial Classification 1992, which comprises: Hospital activities; Medical practice activities; Dental practice activities; Other human health activities.

Appendix 1 - Health Sector Scottish Sector Profile

http://www.futureskillsscotland.org.uk/uploadedreports/0712pp_FSS_HEALTH_SECTOR_2003.pdf

SUBMISSION BY NHS GREATER GLASGOW NHS BOARD

Introduction

This submission from NHS Greater Glasgow focuses on three particular areas:

our plans to reorganise the traditional arrangements for the recruitment, retention and development of non-professionally qualified employees – “Care Careers”

our initiative to ensure closer working with the higher and further education sector to improve the quality and quantity of education in healthcare – the “Strategic Alliance”

our concerns regarding arrangements for Criminal Disclosure.

1.2. In May 2004, the Scottish Executive Health Department published a report entitled: “Scottish Health Workforce Plan – 2004 Baseline” in which it states that NHS Boards are expected to:

“Produce integrated NHS Board workforce development plans in March each year with key stakeholders in local authorities, education providers and others”.

This submission indicates key aspects of our work to meet this requirement.

2. Background

2.1. Like other NHS Boards, the workforce in NHS Greater Glasgow is working through a series of significant changes:

the new consultant and GMS contracts

the implementation of the European Working Time Directive

Scottish Executive targets e.g. on access to an appropriate health professional

new grading, pay and development arrangements under Agenda For Change.

In service terms, NHS Greater Glasgow is planning a significant reshaping of acute hospital care over the next decade.

In addition to a project to redesign the clinical workforce in acute care, we have been developing workforce plans for our primary care, mental health, learning disabilities and children’s services – in the case of the last two, working jointly with Glasgow City Council. We are also preparing workforce plans for nursing, midwifery and health visiting and for all our allied health professions.

We have developed the model shown below to provide a structure for this work.

Our picture of the future workforce (over the next five years) is based on both the workforce implications of service changes and on an analysis of the current workforce and workforce dynamics. The future workforce is defined both qualitatively and quantitatively for each of the likely, reasonable best case and reasonable worst-case scenarios. From these scenarios, a series of challenges are set out under the headings of recruitment, retention and development. Actions are developed to meet these challenges and are brought together in an action plan with arrangements for implementation and monitoring.

3.Future Care Workers

3.1 Workforce planning activity for several staff groups within NHS Greater Glasgow is beginning to highlight a number of common themes. The most obvious is the demandfor more work to be done by professionally qualified staff over the next five years to meet the effects of expansion of services; the impact of the Working Time Directive; 48 hour access to a healthcare professional; and a move from five to six or seven day working. We know that, with the possible exception of nursing and midwifery, the education sector is not going to produce enough additional professionally qualified recruits to meet this demand over the next five years.

As well as improving the recruitment and retention of professionally qualified staff, we need to provide more care workers to support professionally qualified staff. This will allow professionally qualified staff to concentrate on work requiring their professional qualification and post-qualification experience.

Some of the present and additional care workers will be trained to take on bigger jobs; some will be further trained to provide a higher level of support; and some will be encouraged to progress towards acquiring a professional qualification.

NHS Greater Glasgow is, therefore, faced with having to recruit an increasing number of care workers at a time when the labour market in Glasgow is shrinking. We, therefore, have to make working with NHS Greater Glasgow more attractive - particularly to those who would prefer a career to an entry-level job. We also have to widen the labour market - tapping into areas where we do not normally recruit.

In short we need to be better at recruiting, retaining and developing our staff, at all levels within the organisation. In 2003 we launched our Care Careers initiative. It has three elements:

the development of career pathways

the development of a care worker foundation training programme

more structured pre-employment training.

These are described in more detail below.

3.2 Career Pathway

This element of the Care Careers initiative envisages bringing together existing training and development activities within NHS Greater Glasgow; making arrangements to ensure equity of provision; and branding and marketing these activities so as to facilitate not only development of the workforce but also to recruit and retain.

3.3 Care Worker Foundation Training Programme

Current practice is that when a line manager has a vacancy for an unqualified employee, the vacancy is referred to JobcentrePlus and/or advertised internally. Applications are sought; short-listing takes place; interviews are scheduled and take place; references are obtained; disclosure of any criminal record obtained where appropriate; occupational health clearance obtained; and any period of notice is worked. After taking up post, the new recruit has to be released for induction training including fire safety and lifting and handling training. This can take many weeks.

The concept of a Care Worker Foundation Training Programme would radically alter this lengthy process. Recruitment would be to the programme and disclosure would be obtained prior to commencement. The “trainees” would be employees from day one. They would receive induction and associated training and would progressively spend a greater proportion of their time in work placements and, through time, these would become longer and their service contribution would increase. At some stage, participants would opt for clinical or non-clinical care work.

When a vacancy arose, the line manager would contact the programme coordinator and could arrange to interview a few of the programme participants (including, perhaps, someone who has had a work placement in the department) as soon as the following day. Because they are already employees, the person chosen could start work in the department immediately – even before the resigning employee has left. On filling a vacancy (as a nursing assistant, porter, clerical officer, etc.) the person would then be paid the rate for the job. If there were not a suitable participant, the line manager would proceed to recruit in the traditional manner.

3.4. Pre-Employment Training

Known as “WHIGG” (Working for Health in Greater Glasgow), the pre-employment training programme aims to widen the labour market; improve the diversity of the workforce; and improve the health of new recruits. Participants are nominated by organisations offering one to one support to those who have barriers to employment (e.g. lone parents) to attend a six-week training programme. Participants remain on benefits / allowances during this training.

Those who successfully complete the pre-employment training programme are guaranteed an interview for an appropriate job in NHS Greater Glasgow. In future, they will be guaranteed a place on the Care Worker Foundation Training Programme.

3.5. We believe that this approach will enable us to more effectively workforce plan for the less qualified part of our workforce

4. Strategic Alliance with Higher and Further Education

In June 2004, we formally established a Strategic Alliance between NHS Greater Glasgow and the four Universities and ten Colleges within the local higher and further education sector.

The alliance now creates a strategic partnership between NHS Greater Glasgow and the local higher and further education sector with the fundamental aim of supporting the workforce development needs of the NHS in the future. By developing joint goals for education and training provision this will help secure the health provision needs of the local population over the next decade.

The overarching role of this Alliance is to work together, in partnership, to enhance the workforce capability and capacity for the future of the NHS across Greater Glasgow and beyond.

The Alliance, at top level, is about ensuring that workforce development is recognised as a key priority.

5. Disclosure of Criminal Disclosure

A particular issue we raised with you related to the disclosure of criminal records. All potential employees are required to disclose any criminal record. In order to work in some areas – e.g. with contact with children – “enhanced” disclosure is required. The former can take up to nine weeks to obtain and the latter can take longer.

Our managers frequently find that, having made a job offer pending criminal disclosure, the recipient of the job offer has obtained another job over the intervening weeks.

Criminal disclosure is employer specific i.e. disclosure obtained by one employer may not be passed on to another employer even if the old and new employers are both NHS Boards. This will become more of a problem as joint working with local authorities increases. In relation to “Care Careers”, this delay mitigates against seamless transfer from pre-employment training and work. This may be a more minor issue which the Committee may want to consider as part of its deliberation.

6. Conclusion

We are very conscious in NHS Greater Glasgow of the significance of effective workforce planning and in addition to our own activity, are active participants in the workforce planning activity with neighbouring NHS Boards in regional workforce planning.

We would be happy to provide the Committee with further information if required.

SUBMISSION BY THE GUILD OF HEALTHCARE PHARMACISTS

The Guild of Healthcare Pharmacists is the representative body of the majority of pharmacists working in secondary care, as well as for many pharmacists employed in Primary Care settings by Health Boards in Scotland.

Pharmacists and other pharmacy staff are a relatively small group compared with other staff groupings within the NHS. However, the role is sufficiently different from many other professions to warrant a Chief Pharmaceutical Officer and several staff within the Health Department. Until last year, there has also been a separate Whitley Council for pharmacists for the purposes of negotiating pay and conditions for pharmacists.

Pharmacy has had significant problems for a number of years in both recruiting pharmacists into the managed service and in retaining them within it. Pharmacy has quite a different profile than most health service professions. The majority of pharmacists work in community pharmacy practice and are contracted to the NHS rather than employed by it. Community pharmacy offers higher remuneration and benefits packages and this dissuades many from making a career in hospital practice. Therefore the biggest workforce competitor for the managed sector is the community sector.

This difficulty has been recognised within the forthcoming pay modernisation package, Agenda for Change, where pharmacists are one of the groups listed as requiring a Recruitment and retention Premium.

There have been at least two attempts to create a workforce plan for pharmacy in the past 10 years. A review was carried out by Dr. Gordon Jefferson in the early-mid 1990s and a report produced, but never published.

In March 1999, a Pharmacy Workforce Planning Conference held in Dunblane brought together the stakeholders to discuss the situation. To our knowledge, nothing was ever published from that meeting either.

"The Right Medicine, A Strategy for Pharmaceutical Care in Scotland" lists several tasks with workforce planning implications.

• SEHD will commission a review of the education needs of pharmacists in NHSScotland, including the role of professional doctorates. In addition, they work with the Profession, the Schools of Pharmacy and the new Special Health Board for NHS Education to encourage shared learning at both undergraduate and postgraduate levels. (May 2005)

• The SEHD will work with the Royal Pharmaceutical Society of Great Britain (RPSGB) and the Department of Health to support the early implementation of a compulsory obligation for pharmacists to undertake and document their CPD as a requirement for their registration to practice. (December 2005)

• The SEHD will work with the Profession, the Schools of Pharmacy and Colleges of Further Education to ensure that there are sufficient registered pharmacists and qualified pharmacy technicians for the needs of the NHSScotland. This will include reviewing the skill mix requirements in hospital and community pharmacy and examining how to fully utilise the skills of pharmacy technicians, dispensers and assistants. (December 2005)

• SEHD will work with NHSScotland and the Profession to explore standards of workload. (December 2004)

The Human Resources section of SEHD has to deal with huge numbers of staff and cannot deal with small groups completely separately for functions such as workforce planning and training.

Therefore, in England, pharmacists have been officially included within the healthcare scientists grouping for workforce planning and training by the Department of Health. In Scotland, pharmacists are specifically excluded from the equivalent body, the Scottish Forum for Healthcare Science. The reason for this is that in Scotland it is considered that workforce planning for pharmacy should encompass pharmacy as a whole, not just the managed service. As stated previously, most pharmacists work in community pharmacy practice and a much smaller proportion in the managed service. In this respect, pharmacy most closely resembles the medical profession and therefore the contention is that for workforce planning, pharmacy should be considered with the medical profession.

The greater integration of community pharmacy into the health agenda in Scotland makes things more complicated than in England. There are difficulties in engaging the private sector in workforce planning as much of the information will be commercially sensitive and this may hinder the transfer of information.

The position of GHP has been that, as a small profession, and to ensure access to funding and provide the basics of a structured strategy, pharmacy may need to be considered along with another, larger, group when developing a workforce planning strategy. This should overcome the risk that, as a small group, pharmacy is forgotten or neglected. It may be that elements of the infrastructure of other groups can be used to achieve success.

Considerable work has been done on ensuring that the KSF can be applied to pharmacy, but it is not certain it will be ready in time. Funding for continuing professional development (CPD) is necessary to support the "skills escalator" and this is unlikely to be forthcoming without a K & S framework in place for pharmacy. This will mean continuation of variable standards of training and CPD for pharmacy staff and thus varying standards of patient care. The Scottish Executive agenda is clearly to promote consistent levels of safe professional practice.

With no proper career pathway or means of retaining staff, by offering them easier career progression, recruitment difficulties are likely to be exacerbated at a time when the NHS is facing serious shortages of pharmacy staff.

Other pressures include the Working Time Directive, which has serious implications for pharmacy residency services being operated in some hospitals.

The reduction in junior doctors hours has resulted in pharmacy taking on some of their duties to aid compliance with the requirements. This has been made possible by reviewing skill mix and delegating some pharmacist duties to appropriately trained and qualified technicians.

There are challenges with the changing demographics of the pharmacy profession. According to the “Pharmacist Work Patterns 2003” research1, the majority (52.2%) of the profession are female. However, over 60% of the entrants to the Pharmaceutical Register in 2003 were female and it is envisaged that most will take career breaks before retiring. The majority of pharmacists leaving the profession are males over the retirement age and females under 39. 32.5% of the workforce work part time and this proportion is increasing. Finally, despite an increase in numbers on the Register, there has been a slight fall in the proportion actively employed in a pharmacy related occupation.

The number of university places for pharmacy undergraduates is decided by the universities and is not directly influenced or controlled by the Health Department or the needs of the service. In addition, universities tend to prefer overseas students due to the greater income they provide in tuition fees. Most of these students then return home to practice and so are not available for recruitment to the NHS.

One other barrier to increasing the number of pharmacists available is the capacity to train pre-registration graduates. Although more pharmacy graduates are coming through the universities, the ability of the managed service to provide the capacity to offer the training required for their pre-registration year is limited. The managed service in England is currently at capacity whilst Scotland, if not at capacity already, is very close to it.

The overall result of this is that the managed service is unlikely to be able to achieve the aspirations and intentions contained within "The Right Medicine" unless some serious workforce planning is carried out and implemented.

Our response may be made freely available.

Colin Rodden

Guild of Healthcare Pharmacists

SUBMISSION BY: HEALTH ECONOMICS RESEARCH UNIT, UNIVERSITY OF ABERDEEN

The Health Economics Research Unit (HERU) is supported by funding from the Chief Scientist Office of the Scottish Executive, the University of Aberdeen and through grants for specific research projects which are commissioned by a variety of public and private organisations. The Unit currently employs 24 full-time researchers and has a budget of nearly £1.2 million.

The research of the Unit is focused within four programmes of work; these are Economic Evaluation, the Evaluation of Health Improvement, the Valuation and Implementation Programme and Behaviour, Performance and Organisation of Care (BPOC) programme. It is the research undertaken in this last programme, which is of greatest relevance to the committee and is reported below. In particular that research has looked at:

Areas with difficulties in recruitment and retention:

Pressures affecting the workforce and how they impact on service delivery;

HERU has also been involved with workforce planners at a number of levels in order to identify and implement new methods for forecasting the future balance of supply and demand.

The research in BPOC is undertaken for a wide variety of clients and where these are outwith Scotland they enable a broader perspective to inform the Scottish policy research agenda. This submission draws upon two pieces of work that have recently been completed by members of the programme and identifies research that is proposed.

The first a report, titled ‘Labour Markets and NHS Scotland’, to the Scottish Integrated Workforce Planning Group via the Central Research Unit of the Scottish Executive completed in 2001 identified the main labour market patterns and trends for medical and nursing staff employed by NHS Scotland during the nineteen nineties. The main data used was provided by ISD, and was supplemented by data from the Quarterly Labour Force Survey and New Earnings Survey Panel Dataset. Detailed analysis of the labour market for each of these two staff groups was undertaken (Download from: http://www.abdn.ac.uk/heru/bpocpublications.hti#reports/).

NHS Scotland recruited in a market that saw substantial change during the 1990s. During this period unemployment fell, activity rates rose and competition for workers intensified. The labour market for women was particularly buoyant, both labour supply and employment rose sharply.

The composition of the NHS Scotland workforce changed during the 1990s. There were fewer nurses but more doctors and Allied Health Professionals (AHPs). Among hospital doctors a greater proportion were consultants and among nurses a slightly higher proportion were qualified. The hospital workforce thus became more highly qualified during the decade, so that by 2000 hospital services were delivered by a more highly qualified, and increasingly consultant-led, workforce.

NHS Scotland employed more managers and fewer ancillary staff in 2000 than in 1990. Many of the tasks previously performed by ancillaries had been contracted out during the 1990s. More managers and administrators monitored performance and managed the delivery of health services. The balance of care had also changed slightly. By 2000 more care was delivered, and a larger proportion of nurses were employed, in the community.

There was evidence that NHS Scotland remained competitive in the labour markets for some of its core skills during the 1990s. Vacancy rates for doctors and nurses fell at a time when vacancy rates elsewhere were rising. For nurses there was also evidence that the number joining NHS Scotland from other employers exceeded the number who left. One explanation for the attractiveness of nursing in Scotland may be that some aspects of the pay and conditions package had improved in relative terms over this period. National pay rates may be part of the explanation for they are more attractive in relatively low cost areas such as most of Scotland.

There was evidence that Scottish medical schools were net exporters, they trained more doctors than found employment in Scotland. Yet among hospital doctors there was evidence that an increasing proportion of vacancies were filled by doctors who qualified overseas. This suggested that NHS Scotland competed less effectively in the domestic market for doctors than it did in some overseas markets. The relative attractiveness of NHS Scotland employment for both doctors and nurses was identified as a critical area for further research.

The competitiveness of NHS Scotland is also revealed by turnover rates. Turnover among NHS staff differed between doctors and nurses. It was highest among junior doctors in training who gain experience through a variety of posts elsewhere in the UK. Turnover among nurses in Scotland also fell sharply over the period. The fall in turnover at a time when the labour market in Scotland was characterised by substantial competition for workers, was again evidence of NHS Scotland’s competitiveness.

The lead times for training nurses are shorter than those for doctors but the labour market for women was particularly competitive by the end of the 1990s. Unemployment among nurses in Scotland was very low, at less than 1 per cent, in 2000. In 2000 90 per cent of those people of working age with nursing qualifications were active in the workforce. One opportunity to increase nurse numbers in the short run was suggested to be to seek to attract back into nursing some of those qualified nurses working in other jobs.

In 2000 almost 89,000 people of working age living in Scotland held a nursing qualification. Many of these, around 49,000, were working in NHS Scotland; 41,500 as qualified nurses, and 7,500 in other jobs. A further 15,000 were working in non-nursing jobs which did not appear to require caring skills or nurse training. If more nurses are required this group could be targeted and attracted back into NHS Scotland work. Shift working is a prominent feature of the jobs of nurses. In this respect the jobs available in NHS Scotland may be less flexible than those available elsewhere. On the other hand the availability within NHS Scotland of high quality part-time jobs may be one way to enhance recruitment and retention. Research into the role of relative wages and the attractiveness of NHS jobs relative to other occupations is required to identify the prospects for attracting qualified nurses back into NHS Scotland.

There was evidence of a substantial change in the gender composition of the medical workforce. Many more women became hospital doctors and GPs; these were all previously predominantly male occupations. Among nurses on the other hand there was a small rise in the proportion of male nurses. The rise in the share of women hospital doctors and GPs might have been expected to result in a demand for more ‘flexible’ working and part-time jobs. However only in General Practice had this been realised with an increase in part-time working. Part-time working among women hospital doctors fell for most of the 1990s.

Demand for medical school places in Scotland remained buoyant. By 2001 women accounted for almost 60 per cent of acceptances and over half of all graduates. Scottish medical schools appeared to be net exporters of medical graduates. It was therefore surprising to find that the proportion of hospital doctors who qualified overseas and who were working in NHS Scotland rose from 12 per cent in 1990 to 17 per cent in 2000.

There were substantial differences in the medical workforce mix between Health Boards. GPs comprised a large share of the hospital workforce in most rural Health Boards; around 40 per cent in the three Island Health Boards. The GP workforce is aging more quickly than the hospital doctor workforce. This suggests that any increases in retirements amongst GPs would influence both the hospital and GP workforce in the three Island and some rural Health Boards. Understanding the reasons for the differences in skill mix, and the cost and nature of provision in Health Boards is an important area for further research.

The age of the NHS workforce is a subject of much comment. Among qualified nurses almost 20 per cent will become eligible to retire in the 10 years to 2010. This is not particularly high moreover many nurses choose to work beyond the eligible retirement age. Among hospital doctors, 10 per cent will become eligible to retire in the 10 years to 2010. The figure for GPs is 14 per cent.

A second study titled ‘The Impact of Local Labour Market Factors on the Organisation and Delivery of Health Services’, commissioned by the NHS Service Delivery and Organisation (SDO) R&D Programme, in England and was completed in October 2003. This was a scoping study designed to document our current understanding of the competitiveness of the NHS within local labour markets. In particular, it sought to document the way in which NHS organisations respond to labour market conditions, to document best practice in other sectors, and to document the impact on service delivery and organisation. Gaps in current knowledge were then used to map a research agenda.

Interviews were conducted in 10 sites across the UK, selected on the basis of their different experiences of recruitment and retention problems and geographical diversity. This included interviews with two Workforce Development Confederations, six NHS Trusts in England, and one NHS Trust in both Wales and Scotland.

Three areas of the literature were also reviewed. The first was the general economics literature comparing the competitiveness of the public and private sectors. The second was the literature on the competitiveness of the NHS both between different parts of the NHS and with other sectors. The third area of literature examined the experiences of the non-NHS and private sectors.

The analysis of the interviews and the literature was based on four criteria that were used to select studies and to place the interview data and literature into themes. These were: NHS competitiveness; local flexibility; responses to local labour market conditions, and; the impact on service delivery and organisation.

A framework for understanding the link between local labour markets and service delivery was also proposed. This included the local market as a source of supply of labour for the NHS; the influence of the local labour market on the pay and conditions of staff as a way to recruit and retain staff, including those working in national labour markets (i.e. doctors), and; the influence of the local labour market on the pattern of demand for health services and therefore for different types of skills.

The small empirical literature on the competitiveness of the public and private sectors revealed substantial differentials in pay between sectors, such that the public sector underpays in the low amenity and high cost areas, such as London and the South East, and overpays in the high amenity and low cost areas such as the Cornwall. The data for Scotland is not yet available to allow a sufficiently detailed analysis of the different labour markets within which NHS Scotland operates.

Though there were, surprisingly, few studies of local pay flexibility in the private sector a recent review of a number of the largest private sector organisations with a UK wide workforce showed that though they too used national rates of pay, they employed a wider variety of different systems to geographically differentiate pay than does the NHS. National bargaining in the private sector has declined steeply in the last 20 years and a more decentralised approach to pay setting has been adopted.

The literature review revealed wide ranging empirical evidence from the NHS. Forty four studies were included that addressed the criteria. There was some evidence on the relative attractiveness of jobs, but few of the studies explicitly compared across jobs with different employers. Little evidence existed on the role of local flexibility. There were a number of studies reporting details of NHS organisations’ responses to shortages that listed a wide variety of local policies and interventions. However, there were no systematic and rigorous evaluations of such interventions. There appeared to be no studies that rigorously evaluated the impact on service delivery and organisation.

The interviews suggested that the nature and characteristics of the local labour market (e.g. ethnic composition, socio-economic status and geography) were crucial in shaping Trusts’ responses to shortages and in turn their competitiveness but Trusts had often not been able to develop policies to respond appropriately to these external factors.

NHS Trusts seemed more likely to compete with each other rather than with other sectors, and Workforce Develolment Confederations in England could play a role in reducing the negative effects of this. Relative pay was mentioned most frequently as a critical determinant of the attractiveness of NHS nursing jobs, though this was largely in the context of nursing agencies. The role of other non-pay factors in attracting and retaining staff appeared to be very important but from the literature this was less clear. Trusts also competed on the basis of their reputation, particularly for medical staff, where this was related to teaching status and the advantages that status afforded, and to new capital developments.

Some Trusts had used local flexibility in setting pay and conditions, but many seemed reluctant to use these avenues although an understanding of the reasons for this did not emerge from either the interviews or literature review. Trusts responded to shortages by participating in national initiatives, such as international recruitment, although a few had also developed their own initiatives including training and job enhancement.

A number of trusts reported that labour shortages affected the quantity and quality of health care. This included cancelled operations, longer waiting times because of shortages of staff in diagnostic areas, dissatisfaction and low morale, and a high rate of sickness absence. The speed of service development was also compromised. Trusts mentioned the necessity to share services and work in partnership with other trusts.

The study concluded that overall there was an absence of high quality empirical evidence and a marked lack of primary data collection. There have been no rigorous evaluations of the costs and benefits of the myriad of policy interventions that exist to address recruitment and retention. Those studies that exist have been small and the results are not generalisable. Human Resources Directors in the NHS seem to have little data or rigorous evidence on which to base their decisions.

The scoping study recommended that research should focus on specific staff groups within the NHS: medical and nursing staff are a priority because of their centrality to service delivery but allied health professionals, radiology and diagnostic services, pathology, and anaesthesia require analysis for they are fundamental to the speed of throughput.

The Unit intends to undertake further research into three major areas of concern to the committee. This is based on collaboration with ISD and the Analytical Service Unit of the Health Department. The first is into the pressures on recruitment to consultant grade that might result from the changed pay relativities between consultants and junior hospital doctors as a result of the Junior Hospital Doctors agreement and the European Working Time Directive. The relationship between labour markets and NHS performance is also a key area of future work. Further research is required into the changed incentives, including incentives for working in rural areas, that might result from the new GPs’ and the new consultants’ contract. Research is also proposed into the impact of non-pay factors in the recruitment and retention of nurses in Scotland.

Report compiled by Professor Bob Elliott (Director of the Health Economics Research Unit) and Dr Anthony Scott (Director of the Behaviour Performance and Organisation of Care research programme in HERU)

SUBMISSION BY HEALTH SERVICE FORUM SOUTH EAST

We understand that the Health Committee has just started an inquiry ‘To review workforce planning for all professions within the NHSiS and how this is being developed to meet the needs and demands of patients.’

The Forum believes that the DoH document entitled Keeping the NHS Local - A new direction to follow is very relevant to the health of the Scottish people and therefore can contribute to your current inquiry.

Would it be possible to take into consideration the ideas which the DoH are implementing in England and Wales ?

Margaret Hinds
Chair
Health Service Forum S.E.

SUBMISSION BY HUMAN RESOURCE FORUM AND SCOTTISH PARTNERSHIP FORUM

Thank you for your letter of 26 July inviting comments from both the Human Resources Forum (HRF) and Scottish Partnership Forum (SPF) on the above. Apologies for the delay in responding. The response below has been discussed and agreed in partnership.

Introduction

Members welcome both the invitation to comment on and the decision by the Health Committee to hold an inquiry into workforce planning. Members also acknowledge the efforts being made to improve the extent of workforce planning in NHSScotland and the increased focus on long term and integrated planning including with local authorities. Special mention should be made of the Workload and Workforce report prepared by the Facing the Future Group which is a start in identifying relations between the quality of workforce and clinical outcomes for patients. However, it is now critical that the resource implications of the report are met.

Workforce Planning

It is the opinion of members that more needs to be done to ensure that NHSScotland retains the staff that it has invested time and money into training. Graduates, for example, should be encouraged to to stay in Scotland upon completion of their training together with better training, better access to facilities such as IT and career development for those already in post thus ensuring continuous ongoing development. The whole issue of retention needs to be addressed as more and more staff are being tempted away from working within NHSScotland to seek more favourable employment in England and even overseas in countries such as America and Canada. Iniatives such as the European Working Time Directive (EWTD) will have a major impact on the number of hours that a junior doctor can work, which will inevitably result in gaps in service which will need to be addressed. The new GP contract will address some of the workload pressures facing many GPs but it will not happen overnight.

Short-term solutions such as flexible working and the GP retainer scheme will provide a degree of stability to the workforce but not in the longer term. The introduction of the new Consultant Contract will improve morale among existing consultants and which in turn will have a positive knock on effect on recruitment.

If numbers are to be increased in areas such as nursing, then the profession and service must be made to look more attractive. The NHS is competing with other more attractive and better paid careers in all sectors and equitable packages must be offered in order to entice and boost recruitment in all areas.

Conclusion

Members recognise and are aware that each area of care is facing its own specific difficulties whilst dealing with the added pressure of changes to medical training and the introduction of EC Regulations. However, it is also vital that we identify, not only the immediate pressures, but future pressures and demands to ensure that the growing workforce is developed to meet those demands.

Yours faithfully
Trevor Jones
Chief Executive NHSScotland
Co-Chair SPF

James Kennedy
Director RCN Scotland
Co-Chair SPF

Mark Butler
Director of Human Resources
Co-Chair HRF

BillyParker
Regional Officer, AMICUS
Co-Chair HRF

SUBMISSION BY NHS ARGYLL AND CLYDE

Other initiatives that have been implemented which have focussed specifically on recruitment i and retention are:

• Rewriting and issuing of all job descriptions creating openness, honesty and complete transparency in the area of career progression and level of expectation.
• Fostering partnerships with Strathclyde University, including the shared employment of a Clinical Tutor that has provided increased opportunity for undergraduate i placements and training. This allows us to target and attract high calibre, new I graduates to our service.
• Having a framework of objectives for newly qualified staff, which marries into a Mentoring programme, which is also available for returnees to the profession. .
• Opportunities for flexible working patterns including term time working, part time and job share, annualised hours, varied start/finish times and the development of evening clinics, (subject to patient demand).
• The creation of rotational/shared posts which gives increased opportunity of experience and learning.

As outlined above we have made great gains over the past few months, however there are still issues that affect recruitment and retention to our service. Some of these are:

• Lack of parity of grading across different health boards -competing market forces.
• Agenda for Change
• Increased challenges due to ever-increasing referral rates and waiting times but resources haven't increased accordingly resulting in low staff morale in some areas.
• Financial constraints due to Argyll and Clyde funding deficits which demand efficiency savings which could have supported day to day pressures and further developments and redesign."
• Lack of adequate training budgets.

Wendy Blyth Toner
Clinical Lead Speech and Language Therapist
(Adult Acquired Disorders and Medicine for The Elderly) May 2004

HEALTH COMMITTEE INQUIRY INTO WORKFORCE PLANNING:

SPEECH AND LANGUAGE THERAPY ( INVERCLYDE ROYAL HOSPITAL)

Over the past eighteen months the Speech and Language Therapy department of Inverclyde and Renfrewshire (the former RENVERTrust), has undergone a process of service redesign.

Many positive benefits have been gained by this, one of which has been a very positive effect on recruitment and retention.

It is acknowledged that there is a national shortfall of Speech and Language Therapists. Despite this our service has risen from having a vacancy factor around 20% in 2002 to around 2 % in 2004.

To help with the inquiry, it is anticipated that the following notes may be of benefit by outlining some of the key components of our model of practice, which in turn has helped to deal with historical difficulties with staff recruitment and retention.

The focus of our redesign has been Clinical Leadership, which is driven by delivering effective and efficient patient care, locally and is based entirely on a clinical governance framework. This has resulted in the creation of teams of staff, grouped by clinical speciality and expertise and who are managed by Lead Clinicians who are recognized leaders in their field. Our teams are also co-terminus with local authorities permitting easier discussion with colleagues in primary care and of the agreeing of contracts with our partners in education. Some of the many benefits of this model of devolved, clinical management are:

• Budgetary responsibility and thus clinical autonomy, leading to clear development of patient pathways and locally delivered services.
• Clear outline of personal and thus team strengths which can then inform training requirements and issues of personal development, which feed into a team, department and ultimately an organizational development plan.
• Building of specialist skills to meet local need whilst having an overview area wide and we can therefore provide specialist area wide services.
• A move to a more consultative model of practice (where appropriate), as opposed to a more traditional impairment based approach, has empowered and enabled staff to be more effective and is based entirely on evidence based practice.
• Taking our service 'out to the patients' rather that:) expecting them to come to us.
• Standardising procedures in clinics resulting in a sharp decrease in 'fail to attends'.
• Implementation of TOREX department wide, which is a computerised data collection service allowing a complete overview of all activity.
• Regular peer review, team meetings, clinical networks and organized area wide study days throughout Argyll and Clyde.
• The imminent introduction of Care Aims, which is a model of service delivery, which is entirely patient, focussed and provides clear outcomes from our interventions.

Leadership from all staff within our department is positively encouraged and one of the many benefits that this has produced is a strong team ethos and a feeling of ownership and enabling. This and the factors outlined above we firmly believe has contributed to staff retention. In fact, evidence from within our profession maintains that Leadership is crucial to retention.

Report to Health Committee -June 2004

Background

The Parliamentary Health Committee visit to Inverclyde on 26th May 2004 asked that a summary of good practice be submitted.

The "new way of working" outlined to the Committee at the meeting was the

deployment of a Physiotherapy Extended Scope Practitioner in Orthopaedic Out- Patient Clinics.

This project began as a 6-month pilot in 2003. A Consultant Orthopaedic surgeon agreed to work with an experienced superintendent grade Physiotherapist to develop extended skills and work toward independent assessment of new Orthopaedic patients, previously screened only by medical staff. Integral to this project was audit activity to demonstrate compliance with all legal requirements, agreed training and development of protocols plus service information for GPs and patients.

Outcome

By the end of the pilot, clear service benefits and further development potential became apparent and it was proposed that the initiative be expanded to other clinics. A vacancy within the Physiotherapy service presented the opportunity for staff reconfiguration. This secured the extended scope practitioner as permanent staff establishment.

Currently Back and Knee conditions are assessed at outpatient clinics, with the Extended Scope Practitioner working independently but in close proximity to Consultant Orthopaedic surgeons. This ensures that more complex patients can be discussed and that there is ongoing provision for further role development and sharing of knowledge among clinical staff from a variety of professional backgrounds.

Turnover

The workload of the extended scope practitioner is currently up to 6 patients per session (depending on the condition). This provides an additional 270 new patient slots per year, allowing for annual leave and public holidays, based on a one session per week basis. Current utilisation is 3 sessions per week with expansion. planned via Centre for Innovation & Change funding. The 3 sessions at present will manage 810 Orthopaedic patients over the next year. Experience and role consolidation will probably result in an even greater caseload per session over the next 2 years.

Future Development

There is potential for this type of service redesign to be equally effective in other specialisms and work is currently being conducted to evaluate the impact of introducing extended scope working in Women's Health and Rheumatology. This will involve scrutiny of practice and service benefit in other parts of the UK.

It is hoped that GPs in primary care will also develop "Associate Specialist" skills and work with Extended Scope Practitioners in Primary Care settings to vet/triage referrals to Secondary Care Consultant lists.

Other areas of Physiotherapy Good Practice (in partnership)

Development of Primary Care Continence Service (PMS funded)

Introduction of "Falls Management Programmes" across Inverclyde

(Community Safety Partnership funded)

Specialist Paediatric Physiotherapy support to rural areas (Skylark Centre)

Implementation of SCI Outpatient e-booking system (Records, IT and

Referrals Advisor)

Staff Mentoring system to facilitate Personal Development Planning (Staff &

Professional Body)

Development of Video-Based Cardiac Rehabilitation (Lottery Funded)

Development of Home-Based Pulmonary Rehabilitation Programmes (with

Respiratory Nurses and Medical staff)

NHS Argyll& Clyde NHS

Department of Podiatry -Inverclyde & Renfrewshire Divisions

Examples of Good Practice

The Department of Podiatry within NHS Argyll & Clyde -Renfrewshire & Inverclyde Divisions, manages services to all primary care and community locations, in addition to both Acute Hospitals south of the river, the Cowal peninsula and the Island of Bute. The Podiatry service is fully comprehensive and integrated, delivering an essential healthcare service. Any investment in recent years has necessarily been achieved by taking a lateral approach to changes in service delivery with a view to extending our scope of practice towards Podiatric Consultancy posts.

Listed below are some examples of innovation and good practice.

• Introduction of a Diabetes Drop-in Clinic (Acute & Community) -working in collaboration with GP; Specialist Nurse; Diabetes and Vascular Consultant.
• Vascular Assessment Clinic -Primary care based service linking with Vascular Consultant
• Diabetes Managed Clinical Network -podiatry leads on multidisciplinary footcare group.
• PMS (Personal Medical Services) Diabetes Clinic -One Stop -GP; Specialist Nurse; Dietician; Pharmacist.
• Orthopaedic Redesign -Podiatry is part of board wide multidisciplinary redesign team.
• Emergency Clinics -specific podiatric concerns.
• Wound Care -seamless collaborative working with acute and community teams.
• Larva Therapy -joint working with district nursing & specialist nursing, an alternative treatment to otherwise unresponsive ulceration.
• Involvement of carers in basic foot care (social/hygiene care) -nursing/residential homes and domiciliary.
• Staff teams -specific initiatives; diabetes; audit group; clinical governance.
• Self-help footcare programme -enabling patients to undertake appropriate self-care.
• Homeopathy & Acupuncture Clinics.
• Decontamination Group -multidisciplinary working with the Scottish Centre for Infection and Environmental Health.
• Collaboration with Universities, including students clinical experience placement and recruitment symposia
• QIS Allied Health Professionals Clinical Effectiveness Project -Regional Podiatry Rep (Argyll & Clyde).
• AHP Forum -podiatrist is chair; interdisciplinary networking.
• Liaison with social work and/or local authority exploring the possibility of collaborative working. )- Interdisciplinary referral- AHP's.
• Better Neighbourhood Services -podiatry health screening in social inclusion priority areas. Negotiated with Inverclyde LHCC from social inclusion monies.
• Celebrating good practice nationally and locally -facilitating AHP's information seminars.
• Surgical specialism -e.g. surgical nail avulsion which is cost effective; frees up theatre and specialist surgical time; quality of outcome; no negative impact on acute.
• Team Working:- Learning Disability; Adult Physically Disabled; Frail Elderly; Multi-disciplinary teams.
• Partnership Forum -management and staff side representation.
• Health & Safety -embracing requirements under Health & Safety legislation & contributing to shaping the future.
• Screening upper primary school children for developmental anomalies; podiatric management of special needs children; general foot health education within schools -joint working with Education staff, School nursing, Community Medical Officers and Paediatricians.
• Public Involvement including Health Promotion events.
• Podiatry Assistant Clinics -using skill mix to maximise service delivery.
• Practice Development Podiatrist -recently developed post from identified existing resources.
• Digital Imaging and Diabetes/Wound Assessment Database -integrated wound care and diabetes management with the ability to chart patient progress.
• Warwick Certificate in Diabetes Care (recognised benchmark) -training for specialist clinicians
• Scottish Vocational Qualification Award -Management training.
• Homelessness -out reach multi-disciplinary working to offer alternative treatment venue to traditional NHS locations.
• Scottish Healthcare Supplies -position on national panel which advises on best value procurement of specialist equipment.

SUBMISSION BY COUNCILLOR ISOBEL STRONG – ISLE OF BUTE COUNCIL

As a councillor from the Isle of Bute and unable to attend either the Glasgow or Greenock meeting because of prior commitments I would like to make the following points:-

1) Provision of renal dialysis. At present patients have to travel 3 times a week to mainland hospitals spending a very long day with a long return journey by road & ferry. With an already ageing population this problem can only increase. I feel that local provision should be made on a part time basis but the NHS are unwilling to invest in the training of staff or equipment.

2) Maternity Services. On Bute we have a maternity unit staffed by midwives and when complications occur mothers are treated at Paisley since The Rankin Maternity Unit at Inverclyde closed. Expectant mothers are supposed to make their own way to Paisley and once they have delivered could be discharged after 12 hours without an ambulance being available as of right.

3) maternity cont. At present we have 24 hour cover with midwives providing nursing cover in the Victoria Hospital. There are consultations ongoing which propose only an on-call service at night which is frightening in an island situation. This situation will not help staff retention and recruitment

4) Transfer of patients from Inverclyde etc. When patients have had surgery etc. they could be transferred back to the Victoria hospital but the beds have been cut back so much that they often have to remain in a mainland hospital with the implications for recovery and difficulties and expense for relatives visiting.

These are the main concerns which people have reported to me and I would be grateful if they could be passed on to the Health Committee

Regards
Cllr. Isobel Strong

SUBMISSION BY LOTHIAN HEALTH COUNCIL

Improving Care, Investing in Change – Plans for Health Services in NHS Lothian

The Health Council was interested to receive a copy of the letter sent to you by senior clinicians working in NHS Lothian.

We note that the letter states on page 2 that “this is not a crude effort to ‘centralise’ services”, and this the Health Council welcomes.

However, by stating in the next paragraph that the planned changes will mean the majority of elective surgery in Lothian will take place in St John’s Hospital, this would appear to be centralisation, which will mainly effect people from East Lothian, Midlothian and Edinburgh. In addition it could be that prior to admission patients may be required to travel to St John’s for pre-admission tests and then outpatient appointments following surgery, thereby resulting in considerable additional travel.

We wonder how this enables more people to have “inpatient treatment nearer where they live” (page 1). It is such assurances, which when examined more closely, appear inconsistent with the facts.

The letter also proposes the development of Community Treatment Centres (CTC) to provide a range of locally based centres and this is welcomed.

However, we note CTCs were originally proposed in North East Edinburgh, Sighthill/Wester Hailes, Edinburgh City Centre (Lauriston Building), Haddington and the Midlothian Community Hospital in November 1996 as part of the Health Board’s Integration Healthcare Plan 1996-2003. Although the Leith CTC planned to open in 1998, it only opened earlier this year. The Health Council is concerned that decisions made by Lothian Health Board in November 1996 regarding the development of locally based services through CTCs have not yet come into fruition apart from the one in Leith.

After 8 years it appears very similar developments are again being proposed, we can therefore understand why the population of Lothian is sceptical about the Board’s proposals as outlined in the current consultation document Improving Services, Investing in Change.

Yours sincerely
Merlyn Branston
Chief Officer

SUBMISSION BY LOTHIAN NHS BOARD

IMPROVING CARE, INVESTING IN CHANGE – PLANS FOR HEALTH SERVICES IN NHS LOTHIAN

As senior doctors from NHS Lothian, we have been following the Committee’s deliberations as part of your workforce planning enquiry, and the key issues and debates that this has stimulated across Scotland.

We think this debate is crucial to the future of health services in Scotland.

Here in NHS Lothian, as with many other health systems across Scotland and indeed the UK, we are facing challenges in how we best deliver our health services. In NHS Lothian, underpinning our proposals is the drive to make sure patients get the best care we can provide, that we guarantee safe, standards of care for all with equity of access to specialist services, and to implement the challenges of the European Work Directive.

Like every organisation, NHS Lothian has to ensure that skilled staff are deployed to deliver safe, high quality services. What we do know is that, with the new limits on all medical staff, it is not whether we change, but how.

For over 18 months, we have worked with over 1,000 patients, public and staff in developing the three options for acute hospital services which are currently out for consultation.

The Board’s preferred option, (option 2) which we all support in principle involves service redesign where all 3 of Lothian’s acute hospitals will continue to play key roles. We believe this is a realistic and pragmatic way of addressing the current pressures for change.

This option has our support because it ensures that more people will have inpatient treatment nearer where they live. The Western General and St. John’s Hospital will remain as acute hospitals, internationally known for excellence in their fields, and will provide excellent opportunities to train health professionals such as nurses and allied health professionals for extended roles. But importantly, this option also makes the best use of the current high quality facilities within Lothian. No acute hospital will close under these proposals but changes in they way services are delivered will have positive advantages for all patients.

Some service redesign has already taken place in parallel with the consultation – this is the redesign of Trauma Orthopaedics, and later this month redesign of life-threatening, abdominal emergency surgery. These changes are due to problems with training at St Johns that had been under discussion for some considerable time, and the limits imposed by the new consultant contract; we cannot provide sufficient numbers of doctors in training or consultants to sustain the current emergency service. The problem St Johns faced was nothing to do with the excellent services the hospital already provides. In fact it faces the same problems as many other district general hospitals right across Scotland in its inability to appoint full-time permanent consultants to posts to provide adequate and sustainable training for junior hospital doctors. This was neither a fault of the then Trust, nor the Board, who have worked tirelessly to recruit locums from as far a field as Australia and South Africa to fill these posts.

In order to maintain all the other important specialist services such as Accident & Emergency, ITU, Cardiology – which will all remain in their original locations – consultants across Lothian have come together as an NHS Lothian specialist surgical team to provide the full range of services in all three of the acute hospitals.

We do not believe that this is a crude effort to ‘centalise’ services but rather the implementation of realistic plans for a network of surgery services across the three hospital sites in Lothian. St. Johns will treat more patients than before, West Lothian residents will now have equal access to specialist surgical care which they did not have before, and the services within St Johns will be sustainable in the future for everyone in Lothian. The important point is that this is not about meeting the needs of doctors. Rather it is crucial that the services for patients are safe and sustainable. Trauma orthopaedics and emergency general surgery at St Johns could not be sustained in the face of these changes. With all of the doctors in Lothian now working together in a single surgical service it means that the vast majority of patients will continue to be treated at St Johns with around only 8 – 10 patients per day transferring to Edinburgh for specialist care.

These planned changes will mean the majority of elective surgery in Lothian will take place in St Johns. By concentrating elective surgery in one site, there will be fewer cancellations because of emergency admissions and we know that this will reduce the waiting list – there is strong evidence from other parts of the UK that this is the case. We also know that the time that patients have to wait for treatment is a key issue for them. These plans will prevent the random collapse of services because of inability to secure staff. Adequate resources are needed also to pump prime planned change.

Prior to this re-design, West Lothian residents had a 1:5 chance of seeing a specialist, a doctor who had specialised in their particular area. They will now have equal access to the wide range of specialist services that NHS Lothian provides. That doesn’t mean, however, that they will all have to travel a central place to see these specialists. The consultants across Lothian will all be working on at least 2 hospital sites and the services at St Johns will be provided by rotation of specialists, who have in the past worked only in the Royal Infirmary of Edinburgh or the Western General Hospital. In fact, some people have already moved – Professor James Garden, Regius Professor of Surgery now has a regular session in St Johns hospital. Many others of his colleagues will follow. These proposals are not about patients moving round the system, but the consultants moving to improve local access.

We know that 90% of care is already delivered in a Primary or Community setting. Our proposals build on that and plan to extend more services out to local communities. The Leith Community Treatment Centre opened earlier this year and provides a wide range of outpatient and day services for adults and children including x-rays, community dental services and maternity services. This new, ultra-modern centre will allow local patients to be treated within their own community rather than having to travel to hospitals and clinics in the City and beyond. This centre is a flagship for the type of treatments we want to offer right across Lothian. Consultants from the Royal Hospital for Sick Children, the Royal Infirmary of Edinburgh and the Western General Hospital will all hold clinics at the Community treatment centres. This is the first of the treatment centres we have plans to develop in East Lothian and Mid Lothian.

The driver for all of this is increased local access for patients. NHS Lothian plans that the new Community Health Partnerships will the key organisations for continuing to de-centralise health care and integrate more services back into the community. The British Association of Day Surgeons have already suggested that within the next 10 years over 90% of surgery could be carried out in a day surgery basis. These CHPs and the new community treatment centres will be important to support even more de-centralisation services to improve local access.

None of the signatories to this letter support a “centralised” NHS. But it is crucial that we have sustainable, safe services for all of the patients and that we increase local access for all our communities. As some of the many clinicians that have been involved in inputting and shaping these proposals, we reassure the Committee that clinicians within Lothian have no intention of centralising services in Edinburgh. We want to see good quality training for junior doctors who will provide our services well into the future. We also recognise that everyone should have equal access to specialised services. We see our plans as a network of services with the demanding, risky emergency elements of some specialised services being concentrated appropriately, so they are sustainable for all of the population we serve, balanced by increased local access to lower risk, planned services.

Yours sincerely,
Dr Charles Swainson
Medical Director, NHS Lothian
Dr Brian Montgomery
Medical Director, West Lothian Division, NHS Lothian
Dr Mike Winter
Medical Director, Primary and Community Division, NHS Lothian
Dr Ian MacKay
General Practitioner and Clinical Director North-East Edinburgh LHCC
Professor James Garden
Regius Professor of Surgery and honorary Consultant Surgeon
Dr Simon Paterson Brown
Clinical Director for Surgical Services, NHS Lothian
Professor Stuart Macpherson
Postgraduate Dean, NHS Education Scotland
Dr Patricia Jackson
Chair, Area Medical Committee, NHS Lothian
Professor John Savill
Professor of Medicine and honorary Consultant Physician
Head, College of Medicine and Vetinary Medicine, University of Edinburgh

SUBMISSION BY MRS ANN MACQUEEN

Out of Hours Service by local G.P.

Starting in October of this year, we on the island of Luing can no longer expect emergency medical cover by our local Doctor, after six o'clock in the evening. Because of financial constraints the local practice of Dr. George Hannah and Dr. Fiona Graham will no longer respond to calls for medical assistance from 6pm to 8am on any day and will be unavailable on Bank holidays as well. This is a drastic reduction in the service that we are used to in this area.

We have, for many years, been fortunate in having doctors in attendance, who are fully aware of the difficulties of serving a rural and island community, and yet are able and willing to fulfil that duty.

As an alternative to this service we are being offered a call-centre diagnosis from NHS24. If this unknown person thinks fit, a call will be made to the only doctor on duty, 16 miles away in Oban. He could easily be on calI somewhere else, and would likely send an ambulance. While that is infinitely better than nothing: it is a dilution of the service we have at present, and as there are a limited number of ambulances available in Oban, even that cannot be guaranteed.

As we live on an island we have the added problem of the Ferry. At the moment the attending doctor informs the Ferry of the need for a boat out of hours. In the proposed situation we may find ourselves in,. it is unlikely that the on-call doctor would be fully aware of the local problems, and would also likely be unwilling to cross the ferry on a wild night. If the family of the patient deemed hospitalisation was necessary would they be able to callout the ferry themselves?

I feel no consideration has been given to the technicalities involved in providing Luing with the medical out of hour's service that we expect, and that NHS Argyll & Clyde, have difficulty in appreciating the constraints of living on an island.

Moira Newiss, NHS Argyll & Clyde, replied to my letter and stated that the decision to provide an out of hour's service is that of the local GPs, but when insufficient finds are available for its continuation, I feel that the decision is taken away from them.

I would be obliged if you would voice my concerns to the appropriate bodies, and look forward to your reply.

Yours sincerely,
Mrs. Ann MacQueen

SUBMISSION BY LUING COMMUNITY COUNCIL

Inquiry into Workforce Planning.

Living on the island of Luing and within the Easdale Practice catchment area, we have been exceedingly lucky, to date, with our Out of Hours (OOH) service. Our GP can at best be in attendance on Luing within about 20 minutes. Attention from an ambulance crew is, at best, 30-40 minutes. Both of these require a working protocol to call out the ferry to get vehicles on and off the island.

In the winter the vehicle ferry goes to its mooring at 1830 and back on duty at 0730 Monday to Saturday. A small open boat passenger ferry is quickly available at other times but would be totally unsuitable for an ill person to travel in. It takes at least 20 minutes for the vehicle ferry to be back at the slipway, once the ferrymen have been notified. The crossing takes 5 minutes and the journey time to the extremities of the Luing community is a further 15 minutes. All the timings indicated above make no allowance for problems, failure in communication, farm stock on the roads etc. Furthermore, individuals cannot call out the vehicle ferry for emergencies. At present, the doctor and ambulance control have been the only ones allowed to do so.

Our medical practice has now opted out of providing an OOH service and we will have to rely on the service being provided by the Lorn & Islands Hospital from the end of this month. Dr George Hannah, our GP, believes that the service could be workable, provided all the protocols are set up correctly. If not, then he is concerned that his patients will not receive the attention he would wish them to receive. He will be shadowing the new system for the first six months in his own time which is an indication of his concern.

Residents of Luing think the system is likely to fail with all the communication networks that have to work without a hitch. There is the additional concern of how to get to and from Oban hospital out of hours, if a visit to the duty GP is required, even if the patient has access to a vehicle and driver. As of 3rd September, there had been no contact between the NHS and Argyll & Bute Council concerning ferry call-outs. We have been informed that a local taxi service will be contracted to provide transport for those without their own, but the fact that the advertisement inviting tenders has only appeared two weeks before the new system is due to go live does not engender confidence in the planning. Nor can we understand why NHS24 is being introduced at the same time as the OOHs scheme, without any preliminary trials in this area.

For elderly or chronically ill people who may not require emergency attention and who might be very distressed at the thought of having to travel to Oban, any medical input could be well in excess of an hour and could be exceedingly upsetting to both the patient and anyone providing assistance. In this case residents on Luing, and probably Dr Hannah would deem the system to have failed.

The published standards for OOH’s cover is not specific as to recommended times to access the service. With the NHS24 interface and lack of local knowledge, the best access time to receiving medical attention would be in excess of 40 minutes for emergencies and much longer for none emergencies. These times can scarcely be classified as ‘accessible’.

As the proposed system stands, we have no choice but to give it a try. We are assured that any failure to provide an adequate OOHs service will be looked at and remedial action taken. We only hope that the first failure does not result in a death. The OOH’s standards put the obligation on the NHS and the Scottish Executive to provide the resources to provide an accessible service to everyone. This could mean an Emergency Nurse Practitioner or an ambulance and paramedic based on the island is the only safe solution.

There are other islands and remote mainland areas where the problems are similar to ours, so there might well be additional workforce requirements necessary to fill these shortfalls.

Could you please ensure that these points are passed to the Committee for the Inquiry on Workforce Planning, for their consideration.

Lasta King, Joe Hughes & Morag Watson

On behalf of the Luing Community Council

SUBMISSION BY NHS AYRSHIRE AND ARRAN

Thank you for the opportunity to inform Committee of the difficulties that workforce planners face within Ayrshire and Arran with regard to staff recruitment, retention and training.

The patient-centred approach to care encourages and empowers health care teams to redesign services to provide improved care. Accordingly, workforce planning and service planning must be approached in a co-ordinated framework and delegated widely.

The model to be adopted by Ayrshire and Arran will include:-

The Ayrshire and Arran Workforce Development Steering Group which will involve a broad multi-disciplinary membership, with operational, discipline specific, working groups led by a “champion” who will link with service managers and Directors and will be supported by HR/OD.

HR/OD facilitates the process by providing factual analysis of the current workforce and factors affecting performance (sickness absence, turnover etc.) Support is also provided in the form of OD professionals encouraging appropriate behaviours and facilitation of workshops and meetings, plus the provision of advice on job design and support to service re-design. The annual Workforce Plan will result from this process and will be an integral part of the Local Health Plan.

A number of barriers to efficient and effective Workforce Planning have been identified within Ayrshire and Arran.

1. The operational context of the NHS means that patient services must come first. As a consequence training and development provisions may be disrupted by operational necessities, at the 11th hour, preventing full utilisation of the resources provided.

2. Workforce planning in the context of independent contractors is particularly challenging, for example, commercial considerations feature in the decision of say dentists and pharmacists on where to locate.

3. A future concern is the impact of “Modernising Medical Careers” has resulted in particular activities being passed to other staff groups and reduced training opportunities available to junior doctors.

4. Recruitment problems are being experienced in relation to the following disciplines:

Physiotherapy

Some of the Workforce planning issues in Physiotherapy stem from a national shortage but often the posts which are hard to fill are the higher grade posts. Consequently, as there then may be a higher number of students or individuals in a junior position, they cannot effectively act up as they require the supervision provided by the seniors. In addition, as this is a female dominated profession, career breaks and flexibility are required which unfortunately can be extremely difficult to accommodate, in an already short staffed profession. Issues around training numbers from educational institutions and succession planning need to be addressed.

Dentistry

The closure of the dental school in Edinburgh has had an impact on the number of young dentists in Scotland. Either the reinstatement of the dental school or an increase in the number of undergraduates in the remaining two dental schools in Scottish Universities would help in this matter. It is however, acknowledged from the Baseline report 2004, plans to establish a Dental Training Centre in Aberdeen. There is believed to be a significant loss from Scotland of trained dentists once they become qualified.

Another area of concern relates to the number of senior Dentists who find themselves unable to retire and sell their practice as a going concern. An idea proposed at a recent ADPC meeting was for Health Boards to purchase the goodwill and the premises (if DDA compliant) and staff them with Salaried Dentists. Many of the younger Dentists would prefer to be salaried rather than Associates or Principles so this may be more attractive for them to remain and practice their profession in Scotland as opposed to crossing the border. If we consider graduates financial position in relation to student loans, and entrance to the property market, they are unlikely to be able to buy into practice.

Nursing and Midwifery and Allied Health professions

There are many activities and tasks that have migrated from medical staff to Nursing, Midwifery and AHPs. Encouragement should be given to carefully scoping such proposals before implementation to ensure the impact on the other professions can be established and planned for.

General Comments

There are also serious issues around the impact of the introduction and implementation of Employee Friendly policies with no additional funding for back-fill. Early evidence would suggest that the hoped for reduction in absence and special leave that policies like parental leave should produce, have not yet been realised. There is also concern that those staff who do not benefit from these policies are now raising issues of equity.

It is contended that to assist the overall recruitment and retention issues, staff should receive time to be appropriately trained to deliver high quality services in addition to the provision of protected time being consistently applied for the Continuous Professional Development for all staff.

Yours sincerely

K M S Croan

DIRECTOR OF HUMAN RESOURCES

SUBMISSION BY HAZEL MCWHINNIE, AREA HEAD ORTHOPTIST, NHS AYRSHIRE & ARRAN

I am most grateful for the opportunity to respond to your call for views on the above and for your extended period of consultation.

It is stated that specifically the inquiry will:

“Identify barriers to training and education” :

Due to the closure of the only Scottish school of orthoptics, which was based within Glasgow Caledonian University, training and education of orthoptists is now only possible at two universities in England. Unfortunately these universities are not managing to attract Scottish students to their courses, therefore in the very near future there will be no qualified orthoptists to recruit to Scottish NHS posts.

“Identify areas with difficulties in recruitment and retention…” :

Orthoptists who trained in Scotland in the past and moved south of the border to work initially, have been filling vacant posts back in Scotland for the past few years. This source is ‘drying up’ and those orthoptists, currently being trained in England, are in the position that, as there is an overall shortage of orthoptists nationally, they are not forced to seek employment or desiring to seek employment in Scotland. Therefore the future recruitment and retention of qualified orthoptists in Scotland’s NHS is going to be a huge problem.

“Examine what the Executive is doing to address those pressures identified and to develop the workforce in areas identified as experiencing recruitment and retention difficulties” :

The Executive have been ‘bombarded’ with pleas from The British Orthoptic Society, The Royal College of Ophthalmologists and orthoptists, ophthalmologists and health professionals, to address this issue before it becomes a crisis. However as yet the Executive has failed to recognise the scale of the potential problem. As far as I’m aware, the Executive will only be interested when services are at crisis point. I fear this point is fast approaching and therefore we cannot and must not delay in establishing a Scottish School of Orthoptics and safe guard the eye care and health of Scotland’s children and adults.

I trust these comments will be taken into consideration when reviewing the Workforce planning for NHS Scotland.

Hazel McWhinnie

Area Head Orthoptist

NHS Ayrshire & Arran

The Ayr Hospital

SUBMISSION BY NHS FORTH VALLEY

INQUIRY INTO WORKFORCE PLANNING IN SCOTLAND’S NHS

I refer to correspondence that was circulated to NHS organisations by the Scottish Parliament seeking evidence to the Health Committee relating to its enquiry into Workforce Planning within Scotland’s NHS.

I enclose for your information comments on behalf of NHS Forth Valley. NHS Forth Valley has a very focussed vision around its Healthcare Strategy and in planning its future until at least 2009. We have taken cognisance of the fact that in order to meet our future long term strategy we will need to have a workforce that is fit for purpose and is in the right place at the right time.

We welcome the Health Committee’s enquiry into Workforce Planning in Scotland as it is such a fundamental driver to ensuring that we find solutions to specific problems relating to recruitment, retention, education, training and developing new ways of working to improve patient services.

NHS Scotland and the National Workforce Unit report Scottish Health Workforce Plan assists the NHS system to focus not only on the Workforce Strategy, which is continually being developed by the HR unit, but also will allow us to develop practical steps in creating national baseline date and local baseline workforce information.

• Cover the roles and responsibilities of workforce planners

The inquiry are currently looking at roles and responsibilities for workforce planners, this is welcomed. It is recognised that as we address this agenda there is a skills gap identified of key HR and Finance individuals who have a dedicated skill set around Workforce Planning. There will be a need to identify through succession planning individuals who may slot into these roles, but also that within the NHS we need to provide supported education and training to ensure that workforce planning is sustainable in the future.

• Identify barriers to training and education

Again this is welcomed by NHS Forth Valley. We already have in place successful programmes like Return to Learn which then feed into SVQ programmes to try and generate more interest in the nursing professions amongst female returnees and other areas where it is difficult to recruit. It is, however, recognised that there needs to be in the UK more flexibility around education programmes linking to professional qualifications in order that the workforce that we need now does not necessarily have to go through very detailed educational programmes and that more of the education and training is focussed on the job.

It is also key that we work at a national and local level with the education establishment ensuring that programmes that we need can be influenced by us to ensure that they do meet our future employment/skills needs and not just our current needs. Work in progress around modernising medical careers is exciting and we look forward to delivering outcomes around this.

• Identify areas with difficulties in recruitment and retention, as well as best practice

NHS Forth Valley is currently in a position that we are positively recruiting medical staff. We believe that this is mainly due to a positive Healthcare Strategy and that medical staff see NHS Forth Valley as a real opportunity for future career development recognising that this will lead to improved patient care. Like other areas, however, we also have challenges around our nurse workforce and it is clear that taking account of nursing establishment requirements, that there is an ever competing market across Scotland and other parts of the UK, to recruit the best person.

• Identify pressures affecting the workforce and how they impact on service delivery e.g. Specialisation of staff skills and European Working Time Directive

Within NHS Forth Valley it is recognised that we have a high percentage of specialist nurses, however the areas in which we have created specialist nurses are such that they benefit and support the clinical model and team structure that we have within our Acute setting. We are also further expanding on Managed Clinical Networks and identifying not only patient pathways but the staff pathway to ensure the most appropriate individual with the most appropriate skills set deals with patients through their journey.

The European Working Time Directive is a challenge for most organisations as the health environment is very much a 24/7 culture which does not necessarily fit with the framework of the European Working Time Directive. The basic principles of the Working Time Directive have been applied in that through best practice we ensure that none of our employees are in a position of working on average more than 48 hours per week. There are, however new challenges arising for August 2004 for our junior doctors which is in ensuring that there is appropriate rest periods. This is obviously welcomed from a staff governance perspective but will have challenges within organisations in how junior doctors will fit with other teams and colleagues.

• Examine what the Executive is doing to address those pressures identified

The Scottish Health Workforce Plan is a welcomed document which clearly identifies the National Workforce Strategy and for this purpose the specific section related to supply and demand which will pick up Workforce Modelling Planning, alliances with education, recruitment, education, alliances with local authorities voluntary sector and other organisations, information systems, performance and the new workforce observatory. The Scottish Health Workforce Plan is welcomed with the introduction of the National Workforce Committee to oversee and support NHS Scotland and also the Workforce Numbers Group which should assist with forecasting and planning.

• Examine what the Executive is doing to develop the workforce in areas identified as experiencing recruitment and retention difficulties

This Scottish Health Workforce Plan sets out a way forward including national, regional and local workforce development plans. There is still a need for a discussion at national level regarding joined up approach to recruitment and retention across Scotland. This in some way is being addressed by the set up of the regional workforce planning groups and there is active involvement with the HR community with special events being held over June and July looking clearly at each area and the specific service challenges around recruitment, retention and other workforce planning issues. It is hoped that this approach will lead to a more dynamic model of finding solutions to some of these challenges.

• Examine what is being done to identify longer term influences on health service provision and demand, and how this relates to workforce development

Within NHS Forth Valley we are supportive of any national initiative which identifies not only medium term planning activities between e.g. now and 2010 but also looks beyond this. To look beyond this we also need to take cognisance of the work that we are undertaking through Community Healthcare Partnerships and with particularly our local authority colleagues and the joint futures agenda.

NHS Forth Valley would welcome any opportunity for the committee to consider not only how health looks at Workforce Planning of its own workforce but also how across the Scottish Executive and other departments, particularly Local Government and how we can work together to identify common challenges and find solutions. The basic example is the challenge local authority colleagues have around home care services and that we equally have individuals who often fit the skills criteria for these roles. There has been some local activity to look at joint ways of working, however it would assist and if in the longer term there was a strategy around workforce planning and modelling which linked up the public sector.

If you require any further details around any of these areas or you wish us to explore any of them in further detail through the committee please do not hesitate to contact me at Forth Valley Acute Operating Division. I have lead HR responsibility for Workforce Development and Planning for NHS Forth Valley.

SUBMISSION BY PROFESSOR GILLIAN NEEDHAM, POSTGRADUATE DEAN, NORTH SCOTLAND REGION

I wish to give a personal perspective based on my background as a radiologist working in NHSiS since 1987, a Postgraduate Dean working with now NHS Education for Scotland (NES) since 1999, Chair of the short life Scottish Integrated Workforce Planning Group and a co-author of Planning Together (SEHD, 2000) and most recently member of the National Workforce Committee. Based in Aberdeen, North Scotland Region, I also currently act as interim Regional Workforce Champion and will not cover issues which Dr Annie Ingram has addressed in her response to the Committee of 31 May 2004, made on behalf of the North of Scotland Regional Workforce Group.

‘Scotland, UK, the world’

There is good evidence that viewed from a national or broader system perspective there are shortages of competent health professions. ‘Little Scotland’ is potentially vulnerable, particularly around staff retention and recruitment. We need to continue the good work around better articulating what constitutes ‘our service’ – now and into the future. The National Service Planning work will hopefully contribute to this, and must work closely with the National Workforce Committee and its sub-groups and with NES and educational providers to ensure the circle of linked work (service planning, workforce planning, educational planning) is unbroken. Break this chain and our ambitions will falter. The system is currently riddled with examples of where this circle has not been followed:

- The consequences to the medical workforce of EWTD implementation could have been predicted, planned, modelled and managed without some quarters now crying ‘crisis’

(Ref: Royal College of Radiologist’s: Annual Report and Accounts 2003-2004. p27-28 Standing Scottish Committee)

The consequences to the other health professions of EWTD and Modernising Medical Careers implementation are only now being tackled in a more co-ordinated way, but even so the professional silo mentality pervades and entrenched educational cultures persist as potential blockers.

The ethics of international (trained and graduate) recruitment is a concern, where NHSiS looks to fill staffing gaps. Whilst we proportionately provide more graduate doctors as a nation than the rest of the UK, we appear to ‘leak’ to the rest of the UK and internationally.

(Ref: Trainee doctors in Scotland – what becomes of them? BMJ Careers (in press): MacEwen, Olson et al)

Better links between health board planning, regional planning and national systems around demand/supply planning of the workforce are needed. Dr Ingram’s paper addresses this, but we need to revisit NHSiS’s values and how we demonstrably value staff, we need to challenge some basic assumptions around our qualities as an employer and learn lessons from other health systems and possibly look further afield to the commercial sector for innovation. I do believe that ‘Team HR’ are on the right track with some of this.

Education – the missing link

NES are rightly recognised as suppliers of health professionals to the NHSiS. Their pivotal position in partnership with HEIs and the service needs attention. In the past they have been victim to criticism from all quarters if the demand/supply balance is wrong. In fact this has often reflected a disconnection between the service and its direction or planning, rather than a lack of education planning. The establishing of a Scottish Workforce Numbers Group, the devolving of aspects of workforce monitoring to regions and the increasing sophistication of the health boards in health intelligence and foresight will undoubtedly assist NES in its best attempts to get it right around workforce supply.

With the support of colleges and other standard setters, NES is ambitious to improve the fit of programme outputs (trained staff) to service need. It is no good having creative innovation at service design level if there is no connection to, or alignment with, the education of the workforce. As it is a truism that the workforce of today is in the main the workforce of tomorrow, up-skilling, re-skilling, back-filling all require consideration and concerted action that isn’t restrained by poor change management capability or entrenched professional perspectives. New ways of equipping the workforce for the future will require new partnerships, open mindedness to new ways of learning and bravery to embrace disruptive innovation.

(Ref: Will disruptive innovations cure healthcare? Harvard Business Review, Sept-Oct 2000 Christensen, Bohmer et al)

The Scottish people

The NHSiS uniquely serves, sources staff, is sustained by and suffers the scrutiny of the Scottish people. First and last, the NHSiS needs to assure them that they strive to delivery of a high quality, safe service.

But we need to nurture them to want to be part of their service, to feel responsible for that service and, as appropriate, to see the NHSiS as a future employer and in the context of a learning organisation. Fulfilling the true potential of NHSiS means supporting its people to fulfil their personal potential.

Professor Gillian Needham

Postgraduate Dean

SUBMISSION FROM DOROTHY GRACE ELDER PETITIONER PE643

I submit as member of the Scottish Parliament¹s cross party group on chronic pain, being ex convener of the Group. This group has attracted Scotland¹s pain specialists, nurses, doctors, physiotherapists and psychologists as well as patient members and MSPs. It is believed that tackling the huge number suffering chronic pain with radical improvements in facilities and workforce training would lead to great benefits for the NHS on workforce planning affecting many areas, from GP practices to hospital work.

The Group is now under the excellent stewardship of Dr. Jean Turner and Mary Scanlon, who should be consulted.

I would point out that this was- and remains- a public-inspired campaign. The public is still waiting for real action, almost four years later, years in which the Parliament gained good publicity for “responding” to public demand, including featuring the pain campaign on the video of ³The first 1,000 days of the Scottish Parliament² as an example of heeding the public.

The campaign attracted 130,000 hits on the Parliament's web site from people in 17 countries. There has been no direct action since, except that the Scottish Executive commissioned a report in 2003 from Professor Jim McEwen on chronic pain services - this report has gone to the Executive and we await its publication, hopefully with urgency. In May 2002, the Parliament¹s Health & Community Care Committee agreed that Scottish chronic pain services were “patchy and inadequate” and formally asked the Executive to create “comprehensive chronic pain services throughout Scotland”. The Executive and the Health Minister have been very sympathetic. We simply await action.

At present however there is even the threat of closure of the in patient service at Glasgow¹s Homeopathic Hospital, which has a pain service.

LOSS OF NURSES THROUGH INJURY AND CHRONIC PAIN.

The nursing profession is still one of the lead job categories which end up suffering chronic pain. Scotland has hundreds of”wasted” nurses, especially through back injuries resulting from lifting and other tasks. Moreover, patients are getting heavier, as increased bed strength in the NHS shows. Adhering to good lifting practice is an obvious requirement - but try telling that to nurses in an understaffed ward, where risks may be taken to put the patient first. See comment below marked *

SUGGESTIONS: REHABILITATION OF INJURED NURSES.

a) The inquiry requires knowing up to date figures on how many nurses leave the profession after work related injuries. b) The inquiry requires knowing the precise circumstances under which nurses were injured during hospital tasks and subsequently left the profession. How much of a role did short staffing play? How much of a role did availability of adequate lifting equipment play? c) The inquiry should ask if Scotland can institute a service specifically for rehabilitating injured nurses to alleviate their suffering and attract them back into the profession. This may require re-organisation of duties to avoid certain tasks, plus part time incentives. Injured nurses feel “written off” by the NHS - their experience and training should still count more than diminished physical abilities. The unions and the Scottish Chronic Pain Network should be consulted by the inquiry.

*(A patient reported to me this month his deep concern for nurses at Inverclyde Hospital where he said that, on one shift, he was in a ward of 20 patients, staffed by only one staff nurse and an auxiliary. This patient, who is physically helpless, told me: ³I was very worried about the staff in case I required lifting or anyone else did. At times when you are in hospital nowadays, you feel real pity for the staff. The pressures on them are far too great ²)

STAFF TRAINING AND CHRONIC PAIN FACILITY SHORTAGES AFFECTING THE NHS WORKFORCE

All health professionals involved directly with any category of patient - GPs, hospital medical and nursing staff, physiotherapists, occupational therapists, psychiatrists and psychologists - should have specific, updated training in dealing with patients suffering from chronic pain, as opposed to short term pain. ( Abertay University has some courses). At present, there is no evidence of uniformity of training, or if everyone receives such training, bearing in mind that many health professionals are likely to encounter more chronic pain sufferers in their careers than other categories of patients.

a) The inquiry should try to pinpoint the inadequacies in present chronic pain training; the time allocated to such training (where it exists) and discover best practice.

THE SIZE OF THE PROBLEM & RELIEVING THE NHS.

Chronic pain, in number of sufferers, amounts to the largest category of sufferers from any condition - estimates are of 500,0000 in the Scottish community and European estimates are one in seven to one in 10. Obviously, the range of suffering is wide, veering from those with constant pain to those with spasmodic bouts - but even the latter is enough to lose someone a job and inhibit their lives. Many self medicate, writing off contact with primary care so obviously not all that 500,000 are in GP waiting rooms.”

However, a sufficient proportion is. Around 70% of “regulars” in some areas are there primarily because of long term pain, one estimate says. Because chronic pain has suffered long term neglect as a subject, figures for GP surgery load are not precise. b) The inquiry should consult the Scottish Chronic Pain Network, health professionals and patients on the Parliament¹s chronic pain cross party

Group, currently led by Mary Scanlon MSP and Dr Jean Turner. If Scotland produced more specific chronic pain clinics, the pressure on GP surgeries would be relieved - the average GP only has time to issue another prescription for pain killers. It is also known that many patients who are long term on pain killers or who go over the prescribed limit return to GP surgeries with secondary problems. If we could alleviate this problem in a more modern way and have consistent facilities throughout Scotland there would be considerable relief to primary care services as well as to the patients who suffer job losses, loss of homes through being reduced in income and even family break ups.

In 2002, SPICE analysed Scottish Health Board returns to a questionnaire SPICE compiled with me The result showed that Scotland has only 48 full time equivalents dealing with chronic pain - an absurdly small number, and largely confined to certain areas. It is already known to the Executive and Parliament that Scotland has whole areas which do not have comprehensive specialist chronic pain services - e.g. Highlands. A 20 year old woman from Nairn informed the Parliament that she had to be sent regularly to a hospice to obtain chronic pain relief, although her condition was not terminal. Her grandfather also wrote in, stressing the emotional effect on this 20 year old of being sent to a hospice, however good the treatment.

It is also accepted that the few existing services - e.g. Dundee Ninewells and the Astley Ainslie hospital in Edinburgh- are over stretched, having to take patients from distant areas because of huge gaps in services. This is post code medicine/treatment on a vast scale, considering the huge numbers of sufferers. People can get proper relief from pain and learn coping mechanisms according to where they live. The SPICE report showed two years ago that only Glasgow¹s health board had improved on chronic pain facilities. However, because of the current threatened closure of the in patient service at the Homeopathic Hospital in Glasgow, who have a pain service, Glasgow¹s improvements stand to be diminished. Scotland cannot afford to lose any pain services. It must be stressed however that specialist pain clinics are not thirled to homeopathic treatment as a whole but use a mixture of means of help tailored to individuals - from drugs to alternative methods.

The returns to SPICE from Health Boards showed that Scottish patients in pain were being sent around Scotland, some even sent to England, for specialist pain management - a totally unacceptable situation considering pain is the problem and suffering increased and/or good treatment at risk of being lessened by such long journeys. It also became clear that Health Boards could tick boxes claiming they had a pain service - but there was tremendous variation in the levels. For example, that service might be staffed only on certain days or half days by a part timer whereas a proper pain service includes pain management techniques and input from not only a pain specialist but physiotherapists and others. The figure of 48 Full Time Equivalents in Scotland is an indicator that a box tick did not show the proper picture. Estimates of loss to the economy through chronic pain range from £6 billion to £12 billion in Britain counting in benefits and the drugs bill. The weight of human misery caused beyond that by pain cannot be calculated but has been shown to lead to suicide. This is a key area where the NHS could relieve its primary care services and also some of its over stretched specialist services - e.g. the patient suffering from pain caused by arthritis has often already been through specialist services for arthritic conditions as well as his or her GP services. The patients accept they will not be ³cured²; their primary concern is relief of their pain and resultant improvement in their lives. Waiting lists for operations might also be relieved - some pain specialists have time and again pointed out that certain patients are better treated by means other than operations and they have had to cope with the aftermath of operations which have failed to relieve pain - 40 operations in the case of one patient example to the Cross Party Chronic Pain Group from a specialist.

Dorothy-Grace Elder.

SUBMISSION BY JAMIE STONE MSP PETITIONER 689

DOWNGRADING OF MATERNITY SERVICES IN THE NORTH

We wish assurance that the report from the Expert Group on Acute Maternity Services will not lead to a decision to downgrade the Caithness General Hospital from a Level IIa, consultant led maternity unit, to a Level Id ,midwife managed community maternity unit, as this would compromise the health of mothers and newborn infants across the North of Scotland.

The petitioners therefore now request that the Scottish Parliament take the necessary steps to maintain the availability of consultant led maternity units for all mothers in all areas of Scotland, and thus avoiding the downgrading of services to midwife managed community a facilities in parts of the Highlands.

Jamie Stone MSP

SUBMISSION BY PROFESSOR F COCKBURN PETITIONER 707

We the undersigned, declare that the pre-consultation and consultation process of NHS Greater Glasgow Board have:

1. failed to document and to take into consideration the expert views of those currently providing integrated services for mothers and children on the Yorkhill site and the views of ourselves, a group of recently retired consultants and University professors who previously helped to develop these services

2. consistently and repeatedly provided misinformation the public and misquoted national Guidance documents including EGAMS and BAPs

3. failed to consider the disastrous consequences of the closure of National Services provided from Yorkhill to perinatal and continuing services throughout Scotland and have failed adequately to reflect the views of perinatal experts from centres in Scotland other than NHS GG Board

4. Shows a serious lack of transparency. Only one of the outside “experts” reports has been made available and that by an individual who did not visit Glasgow and we understand did not have any contact with local clinicians and worked form assumptions which are erroneous and do not reflect the Scottish Practice.

The petitioners therefore request that the Scottish Parliament :-

1. consider a new legal framework for consultation on the configuration of Health Services which includes advice on the proper use of guidelines and an independent process for the selection of expert advice, particularly where the provision of the National Health Service is affectec.

2. create a process for the establishment of integrated Maternal and Child Heath Services for Scotland/.

We, the petitioners have already approached the following organisations/elected representatives for assistance in resolving the issues contained in our petition:-

1. pre consultation Group chaired by Prof Margaret Reid – no evidence from the report or other published information that any attention was paid to our input

2. Professor Sir John Arbuthnott –Reply awaited

3. Pauline MacNeil MSP , Sandra White MSP, Caroline Leckie MSP at various public meetings.

Professor F Cockburn and Professor D G Young

SUBMISSION BY FREDA FERGUSON PETITIONER 718

Inquiry into Workforce Planning in the N H S in Scotland.

As an enrolled nurse for the past 25 years I worked in every department at the Victoria Hospital in Rothesay This included being on call overnight one week in four when I could be called in to the night duty midwife during deliveries in the Maternity Department. Then for reasons of safety this changed and justifiably so.

The midwife on night duty who is also RGN and the hospital cover dealt with the women in labour who presented during the night and when the birth became imminent the on call midwife was telephoned to come to the hospital to assist at the birth. When both midwives were satisfied that all was well the on call midwife went home. Which meant there was always a midwife in the building overnight to monitor the women in labour and also deal with any maternity related issues including breast-feeding and the care of babies up to 10 days old. This meant the on call midwife was out for the shortest possible time as she was only assisting during the delivery.

The experienced night duty RGN/Midwife is part of the sparse night duty team and helps out in crucial situations at Accident and Emergency until the arrival of the duty GP she is also responsible for the acute medical and special care wards so in a sense you are getting two skill experiences for the price of one. So why take the midwives from nights to days and leave the hospital without a dual role midwife on the premises overnight? It is not as if they do not earn their salary

Figures from our local Registrar for the past 10 years show that most babies are born During the night or the early hours of the morning the number of births registered Locally shows that though all the babies were not born in Rothesay a fair number of Women received ante /postnatal care during their pregnancy

The trend is now to encourage more prims (first time mothers) if they are low risk to deliver locally so you can be looking at an increase in the number of births .

Rothesay is a holiday island visiting pregnant women presenting unexpectedly are an "unknown quantity" therefore the person responsible for the maternity has to be a midwife.

I do not consider myself an idiot but some of the situations I was faced with and felt competent enough to deal with during my time spent working in the Maternity Department I hold my hand up I was so glad to leave it to the experts. I cannot for the life of me think why they feel that by giving general trained staff or auxiliaries some training they will be able to substitute until the arrival of a midwife

Most of the midwives in Rotheasy are dual role and have a wealth of experience gained through years of practice and keeping their skills updated their communication skills within the department are first class,

The supervisor of midwives in Rothesay makes sure her staff is given the opportunity to attend ALSO courses. Scanning courses and anything else relevant to midwifery care

At present the Rothesay midwives are working long hours to try and maintain the 24 - hour services, They have been short of midwives during the day due to sickness and maternity leave. According to "The Framework for Action Maternity Services Scotland" page 76 " a locum bank of suitably skilled professionals" was to be set up by Spring 2002 to cover such eventualities. This obviously was not done or is it perhaps they do not want this service to be sustainable?

We are informed regularly "It is difficult to recruit and retain in rural areas I think we should be giving a great deal of consideration to the staff already in post in order to retain them

The direct entry midwives on completion of 3 years training have to be supervised for a further 3 years before working unsupervised. It is suggested to them to go to England for experience and having gained said experience apply for posts in Scotland

Scotland trains the midwives England reaps the benefits. .Would it not be more in keeping employing newly trained midwives supernumery with a mentor so that they can gain their experience locally and maybe this would go someway towards helping with the retention issue?

What really matters is that the midwives delivering maternity services are experienced

Giving birth is not a new concept. The midwives want to provide as high a standard of care as possible for the people in Rothesay. This includes keeping the midwives on night duty.

Yours Sincerely

Freda Ferguson.

SUBMISSION BY THE ROYAL COLLEGE OF RADIOLOGISTS STANDING SCOTTISH COMMITTEE

Workforce management in Clinical Radiology is in crisis with nearly a fifth of advertised consultant posts unfilled. This position has been slowly worsening over the last ten years despite considerable efforts being made to ameliorate the situation.

It is largely due to the imbalance between the numbers of trainees ( specialist registrars) reaching consultant status and the numbers of retrials of established consultants within a speciality which has and is still expanding considerably.

It has resulted in a shortfall of qualified applicants for consultant posts (advertised and fully funded) of 19.3% this year*. This does not include many posts which were previously advertised and had no applicants or the posts which were not advertised because the hospital knew there were no potential applicants or any aspirations of expansion or redesign of services.

• 1. The complexity of radiological investigations has increased considerably over the last few years due to the introduction of ultrasound, computed tomography and magnetic resonance imaging. There has also been a dramatic increase in the involvement of clinical radiologists in interventional, diagnostic and therapeutic procedures, including angioplasty, vascular embolisation and stent procedures, abscess drainage and percutaneous biopsy.

At the same time there is evidence that the workload of traditional clinical radiological examinations has increased steadily over the years.

Since the Royal College of Radiologists published documents on “Workload and Manpower in Clinical Radiology” (1999) and “Workload, Workforce and Equipment in Departments of Clinical Radiology – Scotland” (1999) in which these concerns were raised there has only been a very modest increase in the numbers of specialist registrars being trained. Unfortunately even this has not been maintained this year with one training scheme having insufficient resources to fill all their training positions.

The are large numbers of doctors of sufficient quality applying for Clinical Radiology training posts but the numbers of posts are insufficient to produce the required numbers of future consultants.

Skills Mix has been advocated as a solution to this problem and in 1999 the Royal College of Radiologists published a document suggesting how this could be carried out safely. This has been successfully embraced by most if not all hospitals in Scotland. The workforce crisis we see now is despite the enthusiastic application of Skills Mix and Team working. If this had not been undertaken the system would have collapsed entirely.

Internal and external locums are providing some cover for the vacant posts but depending on five sets of South African locums in different hospitals in Scotland is unacceptable and has detrimental effects on the long term planning, teaching and the viability of hospitals now that Clinical Radiology is such a fundamental link in the patient’s journey through the NHS

A considerable increase in the number of specialist registrars training in Clinical Radiology is required urgently. This will require an increase in training posts or more innovative training schemes.

The increase in posts could be partly accommodated by using more College accredited posts in District General Hospitals such as at Inverness and Paisley which would only require a modest increase in resources.

To remedy the complete shortfall over the few years of a training generation (currently five years) the Colleges “Integrated Training Initiative” could be set up in Scotland (it has already started in England with DoH funding) with Radiology Academies. This scheme could double the output of consultants and could eventually be used as a model for other specialities such as Radiographers, Histopathologists and Bacteriologists.

Most recently a shortage of skilled radiolgraphers is becoming evident. Many hospitals have unfilled posts particularly where experience is required (e.g. running a magnetic resonance unit). This appears to be due to radiogrphers being seconded into management roles or leaving the profession altogether using their radiography degree to acquire jobs with better remuneration and better prospects.

The College census results which have informed the above comments for 2001 to 2004 are presented below. These are robust figures which have been checked with the Clinical Directors and against BMJ advertisements:

*CONSULTANT RADIOLOGIST POSTS IN SCOTLAND

SUBMISSION BY THE ROYAL COLLEGE OF PHYSICIANS OF EDINBURGH

The Royal College of Physicians of Edinburgh is pleased to offer evidence to the Health Committee. Comments are offered for some of the key areas of the inquiry, namely:

1 The roles and responsibilities of workforce planners

Effective workforce planning is critical to the standards of care for patients. Medical vacancies must be filled with appropriately trained and high quality specialists, excessive workload pressures must be eased through service redesign and innovative team working, and training protected to secure the future. It is critical that planners have access to accurate workforce information and medical advice by specialty and that planning is not undertaken in isolation by individual hospitals/Boards.

The College welcomes the report from Professor Sir John Temple (June 2004) and agrees with his main recommendations on robust workforce planning systems in Scotland. However, the College is concerned that this valuable analysis and report has taken some time to be released by the Scottish Executive and arrives after key decisions about UK wide medical training have been taken through the Postgraduate Medical and Education Training Board (PMETB) and the Modernising Medical Careers initiatives. The College strongly supports Professor Temple’s main messages to deliver the highest standards of care for patients by securing a fully trained medical workforce in Scotland. Achieving this in the more remote and rural areas of Scotland will be more challenging, particularly now that the previous focus for development work (RARARI) has been dismantled.

2 Barriers to training and education

a) Modernising Medical Careers

This initiative seeks to change and, in many cases, reduce the training programmes for hospital consultants. The College agrees that a review is timely and welcomes the opportunity to introduce greater flexibility into training, addressing the differential shortages between specialties and creating space for movement between them. This will also support flexible training and permit greater movement between the non-consultant career grade posts and consultant posts, allowing doctors to proceed through training at a different pace.

Although much of what is planned is welcomed, the College is concerned, as are the trainees themselves, about the effects on their training at a time when, in addition to this pressure to reduce the length of training programmes, there is the requirement to reduce their working hours. This will necessitate more education from their consultants who are under pressure to reduce activities not directly related to patient care (see Contract below). Young doctors will not have the same level of clinical experience when they complete their formal training and, until objective tests of competency are established, it will be difficult to assure standards of knowledge and practice.

b) The Effect of the New Contract

The College is working closely with sister Colleges to develop new curricula and improved assessment procedures for all postgraduate training in internal medicine. It is important that Fellows across Scotland are supported to participate in this essential development work with agreed time in their job plans. The Pan Scotland Employers Group reached agreement recently with the Royal Colleges and the BMA over a letter to Trusts clarifying the importance to the NHS of College work. This has been welcomed by the College, and elected officers, educational tutors and examiners will negotiate time away from their Trusts for such duties. It is crucial that the workforce planning teams understand the need to protect medical capacity both for this development work and for the increased training and assessment duties.

c) Training budgets

The College also understands that some Postgraduate Deaneries are facing a reduction in their budgets that may limit their ability to fund tutors and other support for medical trainees. This comes at a time when the pressure on such tutors is increasing with the changes in training programmes and assessment procedures. In addition, trainees require access to ever more sophisticated training courses and facilities to complement the knowledge gained through practical experience. For example, the 3 UK Colleges of Physicians have developed a 2-day course in the care of ill medical patients (IMPACT). A recent survey of Postgraduate Deans confirms that the course curriculum matches training needs and early feedback from the trainees is very positive, adding to their competence and confidence. The main barriers are limited training budgets and an inability to release trainees or trainers from their service commitment.

d) Crisis in Academic Medicine

There is a particular crisis in academic medicine that requires specific attention if the research and educational reputation of Scottish Medical Schools and hospitals is to be maintained. This is attributed in the main to the financial disincentives within such posts and there is a real risk that the new contract will worsen this by rewarding Academics at a lower level for a working week which is at least as long and arduous as that for NHS colleagues. This will have a further and major deleterious effect on recruitment to Academic Medicine.

e) Medical School Applications

The College welcomes initiatives designed to widen access to medicine from all sections of society and participates in various national groups to deliver an improved mix of undergraduate students. However, the recent Calman Report into undergraduate training implies that admissions policies should aim to retain a higher proportion of Scottish students in Scottish medical schools. While we fully agree that applicants from all geographical and social sectors of Scotland should be encouraged to apply to study medicine, entry into medical school should remain competitive, attracting high quality candidates from the UK and, indeed, internationally, to maintain the standards and reputation of Scottish medical education.

3 Identifying areas with difficulty in recruitment and retention

a) Expansion of trainees and recruiting from overseas

The College welcomes the expansion in training numbers and cautions that the placing of these new posts is critical to ensure that their training and educational needs can be delivered to an approved standard. However, the expansion of the Specialist Registrar grade will not bring immediate results and in the meantime, national (UK) recruitment efforts to encourage qualified doctors from overseas to take up vacant consultant posts have had mixed success. There are also ethical concerns about inducing trained doctors and nurses from the developing world to travel to the UK.

b) Article 11 and 14 Registrations

Later this year a large number of registered doctors, trained overseas but working in the UK, will be eligible to have their training and experience assessed under Articles 11 and 14 of the General and Specialist Medical Practice (Education, Training and Qualifications) Order 2003 with a view to joining the Specialist Register. It is important that this is not delayed and that Scottish Boards are prepared for the possible migration of doctors from non-consultant career grade posts in Scotland to consultant vacancies across the UK.

c) College Census Data

The College has participated in a 3-College annual census of physicians for some years and believes this may represent the most detailed information on consultant physician working patterns in the UK and certainly in Scotland. It is a rich source of evidence for workforce planners nationally. There are plans to extend the scope of this census to include non-consultant career grade doctors. Recruitment messages from the 2002 census include:

The reported increase in consultant physicians in Scotland between 2001 and 2002 was 8.8% with similar growth rates in England and Wales. However, this compares poorly with the 30% increase identified as being necessary to deliver targets within the English NHS Plan. In England, Wales and Northern Ireland they can identify that over 30% of vacant posts are left unfilled after advertising, and the recent Temple report indicates a 29% failure to appoint in Scotland.

Average retirement age is between 60 and 61 in the UK with an increase in the number of consultants who propose retiring before they are 65. Flexible retirement initiatives may ease this pressure but the College is unaware of any firm commitment to address this challenge (see demographic changes - below)

Demographic and attitude changes to full time working among young doctors have a major impact on workforce planning. The proportion of female consultant physicians is just over 20% UK-wide although higher among younger consultants and Specialist Registrars. In some medical schools, the proportion of female medical students is now over 70%. In addition, there is the less quoted and somewhat anecdotal challenge for medical staffing of a relatively large number of medical “marriages”. Increasingly these young doctors are seeking part time training and flexible work opportunities.

d) Flexible working

There is some progress in part time training, although funding disincentives remain. However, flexible working for consultants in the internal medicine specialties is much slower to develop. A recent conference, sponsored by the Scottish Executive and run jointly by the 3 Scottish Royal Colleges, NHS Education Scotland and the Centre for Change and Innovation, was successful in drawing attention to the challenges of flexible working. Urgent action is now required if Scotland is to retain young doctors beyond the completion of their training. Key recommendations from this day include:

An action group should be established with representation from the Colleges, the national Workforce Committee HR forum, NHS Education Scotland and the BMA to consider practical ways of addressing the challenges of flexible working for doctors.

The inequitable funding arrangements for less than full-time trainees must be resolved.

Competency-based curricula and assessment must replace fixed time-based training programmes – the Colleges of Physicians have introduced competency-based curricula and are piloting competency-based assessment.

Flexible trainees must be retained within the system by developing part-time consultant opportunities.

Family friendly policies in the NHS should be capable of accommodating the work patterns of doctors.

Job sharing and matching schemes in medicine should be developed in Scotland.

4 Identifying pressures affecting the workforce and how they impact on service delivery

a) Rising Workload

In addition to the demographic problems listed above, workload is rising ahead of the expansion in the consultant workforce and the College accepts that training more doctors cannot be the only solution. As an indicator, the 2002 College census data indicates that average daily emergency admissions in UK increased by 14% between 2001 and 2002.

b) European Working Time Directive (EWTD)

The effects of the EWTD exacerbate the impact of this increasing emergency workload and must be considered in the context of workforce planning. The EWTD will have a significant effect on services delivered by trainee doctors, in terms of shift working and the reduction of hours. This reduction in service capacity will extend to eroding working time for consultants if compensatory rest provisions are implemented fully. The UK government is in discussion with the EU over the interpretation of key aspects of the European Working Time Directive and is optimistic that new rules will ease this pressure. Strategic Health Authorities in England are monitoring the situation closely as they expect many hospitals will struggle to comply by 1st August 2004. The College understands that most hospitals report that their trainee rotas will be compliant, but it is too early to determine the knock-on effect to consultants working hours, their ability to deliver elective work (waiting lists) and the effect on recruitment and retention.

c) Redesign solutions

Skill mix and redesign solutions will moderate these pressures but many have not progressed beyond the early pilot stages and have yet to report. These include the use of senior nursing staff to cover duties undertaken previously by doctors at night. The College welcomes the opportunity to work in multi-disciplinary teams and supports the concept of team working. However, workforce planning systems should not make definitive plans based on expected results until more is known about the impact of new ways of working on all professional groups and on patient care. In addition, there are well-documented shortages in nursing.

d) Acute medicine

Acute medicine is developing as a sub-specialty of general medicine, with consultants assuming lead responsibility for the leadership of acute medical units. However, Scotland cannot support the emergency/acute services without the support of consultants in the various medical specialities. The Physicians’ census indicates that if consultants had to reduce their working hours as a result of the EWTD, this would be at the expense of emergency work, which creates something of a crisis in acute medicine. These problems are exacerbated in the more remote and rural areas of Scotland.

Acute and emergency work involves higher out-of-hours commitment, can be less intrinsically rewarding and demands regular updates outwith a consultant’s own specialty. The College agrees with the recommendation in the first Temple Report in 2002 that all doctors participating in unselected emergency work must be able to update their general medical skills and knowledge. This should become a routine component of discussions at appraisal and be reflected in the provision of appropriate opportunities for Continuing Professional Development. This was discussed at a meeting of this College’s Lay Advisory Committee in June 2004 where it was agreed that patients expect consultant physicians to be trained fully within their own (sub) specialty and have the benefit of updates in general medicine. There is a clear message here for workforce planning in terms of provision of study leave for consultants if the acute and emergency services are to be protected.

5 How the Scottish Executive is responding to pressures

a) Planning framework

The College responded to Scottish Executive proposals for medical workforce planning in March 2002. The College registered concerns then about the lack of clarity in the proposed model, which created national, regional and board level planning in Scotland but with no apparent linkages to UK-wide training bodies including the PMETB. Since then, UK planning has developed at a furious pace with the new Foundation Year Programmes and the proposals for “run through” training. The relationship between the Scottish workforce planning teams and national ( UK) initiatives remains unclear. Professor Temple’s follow-up report identifies the need for robust regional workforce planning mechanisms and a national work programme must be developed and implemented urgently to manage the growth of the medical workforce. The College recommends strongly that workforce planning systems retain a UK perspective.

b) Postgraduate Medical Training and Education Board (PMETB)

PMETB has been established to assume the responsibilities of the Statutory Training Authority and Joint Committee on Postgraduate Training in General Practice, and has a UK remit in terms of national training schemes. However, it has been slow to take decisions and confirm the shape of future training and the College remains concerned that workforce planning may proceed independently of changes to training. It is crucial that Scottish interests are well represented within UK medical planning, lest training and consultant posts in Scotland become less attractive than their English equivalents.

c) Innovation in training and assessment

Simulation technology and web-based education will improve some of the education and assessment pressures and may address the considerable geographical challenges in the more remote and rural areas. Scotland has invested to an extent in developments in this area and the College would encourage the Health Committee to accelerate this effort. The College is in an ideal position to support these developments through our network of interested Fellows and Members.

d) Training Doctors from Overseas

Scotland has enjoyed a worldwide reputation for training doctors from overseas. This has a significant impact on the reputation of Scottish medicine and of Scotland generally within developing and growing economies. Recently this has become ever more difficult to achieve, although there is now agreement with the Scottish Executive to re-launch overseas specialist training in a limited way, using the spare educational capacity within approved training centres. This will not disadvantage UK graduates, but will allow hospitals with excess training capacity to invite high calibre senior trainees from overseas to complete their training. Most of these doctors will return home and this is not intended as an additional recruitment device. The College is developing plans to accredit such specialist training and facilitate the first placements. It is important that this initiative is recognised as a legitimate and integral part of workforce planning.

SUBMISSION BY THE ROYAL COLLEGE OF PSYCHIATRISTS

Health Committee calls for written evidence for enquiry into workforce planning in Scotland’s National Health Service.

The Royal College of Psychiatrists is happy to respond to the request for written evidence into workforce planning. I should point out that this came to us fairly late in the day and indeed after the original deadline of 18th June. I am pleased to note the deadline has been extended to 13th August and now provide our response. The most important preliminary remark we would make is to emphasise that workforce planning cannot take place in isolation and must be carried out with due regard on the impact that it will have on the provision of clinical care for patients. Good workforce planning is essential to the provision of good care and should improve it.

In making our own response we have considered a number of other documents including John Temple’s report released in June 2004, the Modernising Medical Careers initiative and the Initiatives of the Post Graduate Medical and Education Training Board (PMETB). In this regard it is unfortunate that the Temple report was released so long after Modernising Medical Careers and important PMETB decisions. We have also read with interest and welcome the Scottish Health Workforce Plan 2004 baseline but do feel it is a rather general document with not enough specific information about medical specialties to really inform workforce planning with the necessary degree of detail.

Finally, we would point out that we have significant workforce difficulties in psychiatry. For the last decade consultant vacancies in psychiatry has been never less than 8% and sometimes as high as 12% (see below for more details). This particularly affects General Adult Psychiatry and Child & Adolescent Psychiatry and indeed in this latter speciality vacancies have been running as high as 25%. Further, vacancies are not evenly distributed around Scotland but are particularly bad in certain areas of the country. We have a workforce group both within the Scottish Division and a UK wide recruitment and retention group. The Royal College of Psychiatrists regards workforce planning as one of the most significant issues on its current agenda.

ISSUES IMPACTING ON WORKFORCE PLANNING

1. Modernising medical careers

This initiative focusing on training programmes and reducing training time for hospital consultants (as well as lengthening it for General Practitioners) is to be welcomed and the College agrees with much of what is contained therein, particularly its emphasis on increased flexibility, enabling amongst other things, trainees to move between specialties, emphasis on flexible training of trainees and improving access for non-consultant career grades to move to consultant posts with appropriate training. All this is most welcome. There are, however, a number of factors related to reducing the length of training which concern us. It is clear that doctors entering a consultant grade in future will be less experienced. Much work remains to be done in terms of assessing competency to ensure that standards of clinical care remain at the highest level. Further the increased emphasis on teaching and training of junior staff surely will have a huge impact on how consultants spend their time. There will be an increased need for consultants to devote time for teaching and training and this seems to fly in the face of what is happening with the new consultant contract (see below). Further, with less trainee time given over to the provision of direct clinical care, it is obvious that more of this will need to be done by others including consultants (though we acknowledge work done by non-consultant career grades and indeed other clinical staff in this regard).

One way to improve matters in this regard would be to fund additional SHO/Foundation Posts. The ratio of SHO to SpR’s in psychiatry is not high, particularly if one removes GP trainees from the equation.

2. The New Consultant Contract

This clearly emphasises protecting time for consultant’s clinical work and limits time available for teaching and/or training and at a time when the demand for more teaching/training seems likely (see above) presents a real challenge. Workforce planners need to be aware of the tension between consultant medical staff increasingly being involved in the direct provision of clinical services whilst at the same time probably being expected to spend more time teaching and training whilst signed up to a contract which paradoxically may limit this.

3. Academic Medicine

Difficulties in attracting doctors into academic medicine are well recognized and have been highlighted by virtually all the Royal Colleges as well as by others. It is unlikely the new consultant contract will help this. There clearly remain financial disincentives to going into academic medicine.

4. Medical Students

We are aware of data suggesting that many medical students trained in Scotland, leave Scotland to work in England and Wales and there are some concerns that the advent of Foundation Programmes may increase this. Initiatives to encourage medical students to stay in Scotland are to be encouraged.

5. European Working Time Directive (EWTD)

This will have a significant impact on the provision of clinical services and this needs to be taken on board in any workforce planning initiatives. Its’ potential effect on training of junior staff should also be noted. One thing that is becoming apparent is that the kind of rotas being enacted to ensure delivery of the EWTD impact on the kind of contact a junior doctor will have with a consultant. The significance of this should not be under-rated. It is very important for juniors to have individual role models and mentors that they look up to. The Royal College of Psychiatrists’ recent recruitment and retention survey identified this as a crucial factor in recruiting trainees to psychiatry. It is certainly a worry that the EWTD will impact on this by reducing the level of contact between individual consultants and trainees in the clinical workplace.

6. Training Budget

The training budgets of post graduate deans has not increased significantly over the last few years and indeed there are rumours that some Deaneries are facing a reduction in their budgets. The trainees access to some aspects of training is under threat (we can provide evidence for this, if required) and there is ever-increasing pressure to provide training “internally”. This inevitably will have to be largely carried out by consultants further exacerbating the problem above.

7. The New Mental Health Act

Last and by no means least, there has been considerable concern within psychiatry on the impact of the New Mental Health Act. This will probably increase the clinical burden of consultant psychiatrists. The pressure to attend tribunals, which will be mandatory in the new act should not be underestimated. This will not only impact on the current workforce and possibly the delivery of clinical services but there is some evidence from our recruitment and retention survey that it may act as a disincentive to choosing psychiatry as a career.

8. Overseas Fellowship

The Department of Health and RCPsych in England has an Overseas Fellowship Programme from which Scotland has not benefited. This has successfully recruited a number of overseas doctors to consultant posts in England Wales. We believe that consideration should be given to setting up a similar scheme in Scotland.

COLLEGE OF PSYCHIATRISTS RECRUITMENT AND RETENTION AND MANPOWER SURVEY

The Royal College of Psychiatrists has for many years now conducted an annual manpower survey at a UK level. It now plans to do this only every five years, however, the Scottish Division of this college has undertaken to carry out a Scotland wide manpower survey on an annual basis and indeed we do have accurate data for last year. Last year we also carried out a recruitment and retention survey. The big issues around recruitment raised were exposure at undergraduate level and foundation level (and we would wish to see this emphasised in the foundation programmes as appears to be the case), and good exposure to inspirational consultant mentors either at undergraduate level or during the early parts of training (see above). We would further argue that workforce planning places too little attention on retirement. The mean proposed retirement age of respondents to our survey was 58 years and 45% of the current workforce proposed to retire within the next ten years. I am sure you will agree this is important information and we would be happy to provide you with more details of the findings of our recruitment and retention survey. Another thing, which unsurprisingly emerged from the survey, is that working in an under-resourced specialty with a large number of consultant vacancies was indeed itself a factor which encouraged earlier retirement. As a corollary addressing the manpower problems within psychiatry may induce some of the current consultant psychiatrists to work for longer and indeed when asked about this in our survey, many indicated that this would indeed be the case.

Finally, we would note that psychiatry is a specialty which has a high number of female consultants and you will be well aware that the majority of intake into medical schools is now female and the impact on this on workforce planning down the line will surely be huge.

ONGOING CONSULTATION AND INVOLVEMENT OF OTHER AGENCIES

Finally, we would emphasise yet again the need for ongoing consultation and involvement of a variety of other agencies with a real interest in workforce planning. These include the Medical Royal Colleges and we ourselves would be more than happy to be involved in this process (and indeed some of us are through the Mental Health Divisions Workforce Planning Group). Other such agencies obviously include PMETB,NES and the BMA. We believe that workforce planning needs to be carried out at a Scottish national level and also may need to be specialty specific particularly with an eye on specialties that appear to have serious difficulties including ourselves, General Practice and Radiology. A UK perspective does, however, need to be retained particularly in view of what we are already aware of the drift of graduates from Scotland to England.

TOM M BROWN

Hon. Secretary

Scottish Division Royal College of Psychiatrists

SUBMISSION BY SCOTTISH PHARMACEUTICAL FEDERATION

Inquiry Into Workforce Planning in Scotland’s National Health Service.

I am writing on behalf of the Scottish Pharmaceutical Federation (SPF) in response to the Health and Community Care Committee’s request for evidence relating to workforce planning in the NHS in Scotland.

The Scottish Pharmaceutical Federation is the trade association which represents the professional and commercial interests of the owners of the vast majority of Scotland's community pharmacies, and is the principal body representing the community pharmacy sector.

We are pleased the H&CCC is seeking to “ …review workforce planning for all professions (our emphasis) within the NHSiS…” with particular reference to the identification of barriers to training and education and examining what is being done to pin point longer term influences on health service provision and demand, and how this relates to workforce development.

The inquiry’s intention maybe to consider all professions but we are not certain if the H&CCC is addressing community pharmacy. This is a time of a great many changes in community pharmacy and we suggest it would be in the interests of the H&CCC to consider this submission against the background of The Right Medicine: A Strategy for Pharmaceutical Care in Scotland, Modernising NHS Community Pharmacy in Scotland (and the associated responses) and the new pharmacy contract expected to be implemented from April 2005.

Any inquiry into workforce planning that does not include community pharmacy will be flawed. We believe this results in part from a lack of clarity over just who are and who are not NHS staff. A more exact definition is required to differentiate between the staff of the wider NHS and its providers of care, and the directly employed staff of the NHS itself. Currently the lack of such a definition blurs the comprehension of all stakeholders, to the detriment of the perceived value of community pharmacists and their employees.

“In order to optimise pharmaceutical care there is a need to review the current infrastructure to ensure that pharmacies and pharmacists have the capacity to deliver new and improved services.” (pp35)

The Right Medicine

For community pharmacy to deliver it is essential workforce planners address the community pharmacy team - including pharmacy support staff. Applying greater clarity when defining NHS staff would, we believe, allow community pharmacists and their staff to access training and development opportunities comparable to other NHS staff. This greater clarity would impact elsewhere.

For example, in terms of recruitment and retention, there is a recognised shortage of pharmacists as well as pharmacy support staff. Community pharmacy support staff roles should be seen as being an NHS career, with investment in profiling the roles of medicines counter assistant, pharmacy assistant and pharmacy technicians as well as pharmacists. The creation of joint vacancies across primary and secondary care may also aid recruitment. The skills escalator could be adapted to community pharmacy so that it would not be unthinkable that a medicines counter assistant could one day become a community pharmacist with the right development opportunities.

From 2005, the Royal Pharmaceutical Society of Great Britain (RPSGB) is introducing minimum competence requirements for all pharmacy/dispensary assistants and will begin to register and regulate pharmacy technicians. These changes are to be welcomed however there are still barriers to training and education within community pharmacy. These include funding, protected learning time for staff in small pharmacies and large numbers of part time staff.

For the longer term, we would like to see the SEHD workforce planning units engage with the pharmacy bodies to identify ways they can be supported. This may be in terms of training needs assessment and access to funding streams.

We draw the Committee’s attention to the working group established by The National Pharmaceutical Forum established to look at the development of pharmacy support staff in line with the principles of The Right Medicine. This working group is expected to report to the Chief Pharmaceutical Officer later in 2004. We recommend this report be included in the Committee’s evidence.

SUBMISSION BY GIANNA HENRY SUPPORTER OF PE718

Although I had my first child in Inverclyde Hospital I required to stay in the Rothesay Victoria for an extended period as my baby had difficulty feeding and suffered problems with his blood sugar. The support of the midwives during this period was invaluable and I eventually managed to breastfeed my son for a considerable period. I don’t consider that the present proposals to change midwives working hours would be conductive to assisting nursing mothers and imagine there would be reduced rates of breastfeeding as a consequence.

My second child was born in Rothesay Victoria and stopped breathing some twelve hours or so after she was born and is only alive today because the midwife was looking after her at the time; if the present proposals were in place at that time no midwife would have been available to let me sleep and my child would probably have died beside me as I slept.

My third child was born very quickly it was as well there was a midwife in hospital when I arrived as my labour had progressed very rapidly and despite being an experienced mother I found the support from the dedicated team once again invaluable. The maternity department on the island may not be the most modern but the present system works well and in fact other maternity unit should aspire to attain such great standards. By changing the present system staff will be demoralised and will not be able to offer the superb advice they presently do and ultimately lives will be put at risk.

Gianna Henry

SUBMISSION BY ANNE LAING SUPPORTER OF PE718

I am writing to you concerning the above Petition re the proposed changes to the Maternity Services on the Island of Bute.

I am a retired midwife who worked for fifteen years in the Victoria Hospital as a dual-role nurse/midwife. I believe that we gave, and the present staff continue to give, a very good service to mothers and babies on Bute. We are now being told that this must change from a 24hour service to a Mon. to Fri. day-time only service. There have been various reasons given for this, but as far as we can ascertain the main reason seems to be that such a system is in place in Mid-Argyll, which the Health Board seem to have decided is their flagship. I can see no way that this system is better for anyone than the system operating at present in Rothesay.

The women here have always known that they can visit or telephone the hospital day or night and a midwife will be there to attend to them. Emergencies, both obstetric and neonatal, can occur at any time, and it is surely less satisfactory to have to wait until someone "on call" is summoned.

As there would be no midwifery cover overnight, post-natal women are to be sent home six/twelve hours after delivery. Many post-natal problems arise after this period and are more likely to be recognized and promptly treated by a midwife on the spot, other than someone visiting at home once or twice a day. Breastfeeding , which is supposed to be being promoted nationally, often takes several days to establish with the third and fourth days being most likely to be difficult If a baby is being fed "on demand" a community midwife cannot guarantee to be there at the right moment, whereas a 24hr cover provides on the spot help. The same applies with post-natal depression, the signs of which can be more easily recognized when a woman is observed round the clock.

I worked for many years as a community midwife and know the benefits of being 'at home', but I have also seen the exhaustion and distress too early discharge can cause, and that was when the women chose that option and did not have it thrust upon them. Was the emphasis in the Framework for Maternity Services not about consultation and choice ?

Some women are just not well enough for first day discharge. We are told that when this occurs the woman can remain in, or be transferred to, Paisley Maternity. This is an island. It is not easy for most partners or other children to travel to , or stay , on the mainland. I understand that accommodation for partners to stay overnight in Paisley is very limited and may not be available at all even when labour is imminent.

Another reason we have been given for the change is the sustainability of the present arrangements. At present we have two nurse/midwives who are not only willing, but prefer to work on night duty. If we are looking to the future when these women will no longer be there no one knows what prospective staff might be available by then. One way of covering this eventuality would be to fund me of the present general nurses to do a midwifery training, rather than the proposed plan to give some of them a limited obstetric training in order that they can cope with emergencies arising before the on-call midwife arrives at the hospital. None of it even makes sense financially. If the present night duty Staff are to be moved to days to be solely midwifes, they will have to be replaced with other trained staff to cover the general wards. Who-ever does this will have to be experienced, for though it is just a cottage hospital any and every type of emergency can occur., and , of course, they will need the above-mentioned obstetric emergency training. Meanwhile, the on-call payments will increase for the midwives and the two ex- night staff will still be employed. At present the Health Board are getting two for the price of one, but seem to prefer to pay double salaries.

Since moving here from the mainland and a large maternity unit, I have always thought that the mothers and babies of Bute had the best of both worlds -a homelike atmosphere, with easy access for relatives and friends, and yet professional care round the clock for as long as they needed it. I would have thought that this was the model everyone should be aiming for, not a reduced service.

I would urge the Health Committee to remember the most important people involved here -the mothers and babies. Why should they have an inferior service to the one in existence, because it is reportedly 'working' elsewhere?

Yours sincerely

Anne M Laing

SUBMISSION BY JEAN N. LYON SUPPORTER OF PE718

Proposed changes to Maternity Services at Victoria Hospital, Rothesay, Isle of Bute.

I am compelled to write to you to express my concerns regarding the proposed changes to the Midwifery services here on Bute.

Thirty years ago having completed my training, RG.N.S.C.M., I returned home to work as a midwife at the cottage hospital. In those days there were just 2 midwives, single duty and on call. As you can imagine we could be on call 24 hours per day for several days or several weeks if the other midwife was on days off, on holiday or off sick.

Then the health authority decided that there should be midwives on night duty and we would all be dual role. Thankfully the extra staff reduced our on call considerably. It also meant that the unit was covered with trained nurses 24 hours a day. This was a great benefit and reassurance to the patients. Therefore I can not understand why the Health Service wish to go back to these working conditions!

In a small hospital such as ours, staff have to deal with a variety of patients with different conditions, surely if funding is not the issue, it would be more economical to have a nurse with 2 certificates able to treat most patients. Than a nurse on night duty who will not be able to deal with any antenatal, intranatal or postnatal patients and their babies.

Why are our services continuing to be cut in the name of progress?

Why if something is working and patients are satisfied with the service, would you want to change it?

Who wants to regress 30 years!

Jean N. Lyon

SUBMISSION BY MRS CAROL MCDERMOTT SUPPORTER OF PE718

I feel that I have to write and let you know of the absolutely brilliant support I had from the Midwives at the Victoria Hospital Rothesay before and after the birth of my son. It is now just over 7 years since Daniel was born but I still remember very clearly the support and advice that the Midwives gave me. Being a first time mum I didn't know what was going to happen and when, it was so reassuring that I could just go up to the Victoria Hospital at anytime and speak to which ever Midwife was on duty.

Two weeks before my due date I was admitted to the Victoria Hospital for bed rest as my blood pressure was going up slightly and I had a bit of swelling. I was very worried about this as I had never spent the night in hospital before and the Midwives were able to explain everything to me 24 hours a day. After

returning from Inverclyde Royal Hospital where I had given birth, both the care of my newborn son and myself was what can only be described as absolutely brilliant!

Daniel suffered badly from Colic and again being a first time mum it was hard to distinguish if it was the colic that was causing him discomfort or something else and in the early hours of the morning it was so reassuring to be able to speak to a midwife who was able to give advice. This actually happened to me a couple of times and without their support it would have been so much harder to deal with.

I hope in the next year or two to have another child and with my previous experiences of the help and support that the Midwives at the Victoria Hospital gave me it would be something to look forward to knowing that I was in safe, capable and very friendly care.

Please please please, do not allow the Health Board to cut Maternity Services at the Victoria Hospital to 8am till 8pm instead of Midwifery care 24hours a day 7 days a week as I certainly found out that I problems can occur anytime and it would be so reassuring to know that there was a midwife at the hospital no matter what hour of the day to give me the advice that I needed.

Yours faithfully

Mrs Carol McDermott

SUBMISSION BY IRMA MCFIE SUPPORTER OF PE718

We keep being told the current maternity service (24 hour midwife present in Victoria Hospital Rothesay is not sustainable. I could quote from numerous pages of ""A Framework for Maternity Services in Scotland"" that would prove they should not/cannot cut the service to 8am-8pm, but then this letter would become too long. As a first time mother (at the age of 35) I was lucky enough to deliver in Rothesay, during the night (not being Airlifted, going to a ""strange"" place and making my own wa9 back home b9 train & ferry a few hours later..) had some problems trying to breastfeed and my son was difficult to settle. Being from Holland originally, I have no family on the island and would not have coped for the first few days/nights without the constant 24 hour excellent support from the Midwifes. Coming to see me a few times a day at home, as proposed in the changes, would not have been enough.

This is only one small example that causes concern RE. ' the proposed changes. What about: * Midwives (if they can recruit them) will be tired being on call after hours (European Working Time Directive), is that safe? * Insufficient postnatal care provision (especially postnatal depression and single parents)

Local figures prove more births happen between 10pm and 9am * If staying in maternity unit is required for certain concerns Paisley is too far (and too costly) for fathers to visit And the list goes on and on. We live on an island and have a brilliant maternity service, why change it? The petition was carried out over 2 weeks and we collected 2000 signatures. Give us 8 weeks and we will collect 8000 signatures, (the entire population) as being AGAINST THE PROPOSED CHANGES!!!!!!!!!

Irma McFie

SUBMISSION BY DONNA YOUNG SUPPORTER OF PE718

I wish to express my thoughts and concerns on changing the present excellent Maternity Service in Rothesay Victoria Hospital, Isle of Bute.

I gave birth to a baby son 10 months ago and cannot express my how well I was treated both ante and post natally. The service they provide was excellent. They made you feel special and well looked after. To take this service away to those mothers needing care after giving birth is criminal whether it be a first time mum, second or third, their care is next to none.

After giving birth I felt unwell for several days and I found it comforting that I had excellent midwives at Rothesay to help me and assist in looking after my new baby boy.

My brief spell at Inverclyde after giving birth I can honestly say was ok, although I did feel that the midwives were too busy to really concentrate on my efforts to breast feed, but I had one to one when I returned back to Rothesay -this is invaluable to any mother wishing to breast feed as the first few days are crucial for both mother and child. To have maternity assistant or to provide training to auxiliary nurses to cover the maternity ward at night is demeaning to those people who have spent years training to be Midwives.

At the beginning of my pregnancy I suffered terrible stomach cramps and only phoned the maternity department at 6am because I knew that there was a midwife on, I would not have done this if I knew that I would have to disturb anyone or that I would be getting a nurse trained to ask the relevant questions. It is reassuring to know that you do have midwife cover for 24hrs and this I don't mean by awaking someone on call at home.

To change the present excellent service here is the beginning of the end for choice for women. You are told that you have a choice but I'm afraid if these changes happen there is no CHOICE what so ever. I personally feel that the Health Board is treating pregnant women as 2nd class citizens and this change could have a devastating affect to the population of the future. The promotion of home births is ridiculous, having spoke to many women, none are in favour, why go back the way.

I hope that our Maternity Unit in Rothesay stays as it is.

Yours Faithfully

C Donna Young

SUBMISSION BY JOYCE M ZAVARONI SUPPORTER OF PE718

I am writing to express my support for Petition 718 ie to maintain 24 hour midwifery cover at the Victoria Hospital, Rothesay.

I am a concerned member of the community, a mother, a grandmother and a retired midwifery sister, having commenced employment as a midwife in the Victoria in 1963. I retired in 2000 when I was the senior midwife and also supervisor of midwives. I am writing, having had many years of experience at clinical level, often working 12-hour shifts (or longer), then being on call at night and having to work in normal shift work only. It was exhausting at times and potentially judgement could be impaired.

When 24 hour cover was introduced, it was much safer. The midwife on duty was fresh and only the second midwife was called in to assist with deliveries. I can think of many situations which could have ended tragically had there not been a midwife on duty and this is so important nowadays when GPs no longer wish to be called out during the night.

I know of several young mothers who have given up breast feeding in the first few days due to lack of support and help from midwives in units which do not have 24 hour cover. These babies are our investment in the future and deserve the best possible start in life.

At the present time all midwives in the Victoria are trained. We have at least 2 general nurses who would like to train as midwives. This would solve the sustainability problem but there seems to be no funding for this. There is talk of giving auxiliary and general nurses extra “support” training but young mothers wish to be cared for by experienced midwives.

We keep hearing the words “Women’s choice” and our young women, without exception, choose, if at all possible, to retain the 24 hour midwifery cover at the Victoria. Not to have this excellent service would be to turn the clock back 40 years. I know; I was there.

Ours is an island community and if midwives have to work extra hours “on call” this can raise immense problems with child care especially if their husbands/partners work off the island. This could lead to recruitment problems. We can also have problems in winter with transfers if the weather is bad and to have a midwife on duty at night is of great benefit.

I do hope you will consider our petition 718 most carefully.

Joyce M Zavaroni

SUBMISSION BY ANN AND EUAN THOMPSON SUPPORTER OF PE718

The maternity services on the Isle of Bute have been well used by me as I was lucky enough to deliver all four of my children in the Victoria Hospital, Rothesay. The first in 1988 and the last in 1994. I think it is only in retrospect and in light of changes and proposals for change over the years and now, that my husband and I appreciate and value so much the expert care and attention we and our babies received. It alarms me and saddens me to hear that not only is there such a rationalisation of maternity and child services, especially in more remote areas, but we are at risk of creating such a weak maternity service when it should be so skilled, professionally reassuring to expectant mums (and dads),safe, confident and constant.

We have been so privileged here in Rothesay with the expert, warm and 24 hour availability of medical and maternity services. I am of the view this is a human right and should be available to everyone without question and developed not constrained. Please take account of the voices of the stakeholders - real people.

Thank you

Ann and Euan Thompson

SUBMISSION BY KIRSTY BROWN SUPPORTER OF PE718

I am writing to you in support of petition number PE718. The midwifery service at the Rothesay Victoria Hospital as it stands is absolutely 1 st class. It is a vital service to our community and if the proposed changes go ahead think it will be a great loss.

The travel transfers where we are due to ambulance shortages is absolutely dreadful. I was previously diagnosed with severe pre-eclampsia in my first pregnancy and was a priority transfer for a consultant led unit. I had to wait for 6 hours beforeI I got transferred from the island. Now if my midwife had been on call surely that would have caused an even bigger delay with maybe more severe consequences. On my return transfer from Paisley Maternity I was taken in a taxi, 3 days after a Caesarean section to Wemyss Bay pier, and then had to walk the length of the pier to the boat, where I had to sit in a public room for the journey. I was then taken to the Rothesay Victoria Hospital by taxi at the Rothesay pier. I also had to purchase my own fare while on the ferry. I was assured by staff in Paisley I would be transferred by ambulance but this was certainly not the case.

During my second pregnancy my blood pressure was raised again on my due date and my midwife decided to sent me to inverclyde Royal Hospital. When she telephoned for an ambulance she as told none were available and she was asked if the patient could make their own way there, however she called in the helimed instead.

I hope you take these points into consideration because it is not as easy living on an island from a medical point of view when you have a large stretch of water to consider.

Kirsty Brown

SUBMISSION BY JIM BEATTIE CONSULTANT PAEDIATRICIAN AND NEPHROLOGIST, RHSC YORKHILL

I appreciate that the deadline for submission of written evidence to the above enquiry has passed but I would appreciate the following comments being taken into account.

I am a consultant paediatrician in RHSC Glasgow and also Workforce Officer for the Royal College of Paediatrics and Child Health in Scotland and have been closely involved in workforce issues for the last 2 -3 years.

I would like to briefly respond to each of the headings that the enquiry will cover:

Roles and Responsibilities for Workforce Planners

The RCPCH welcomes the development of the National Workfoce Unit as well as the appointment of regional Workforce Officers. As clinicians we are very keen to input our thoughts and ideas on the future workforce configuration within our specialty.

Barriers to Training and Education

You are probably aware of the recent publication by Professor Calman on undergraduate medical education in Scotland. There are several recommendations within this document that I personally support e.g. review of school academic qualifications and socio economic background of medical school applicants. In addition I would suggest that in order to improve recruitment to geographically distant parts of Scotland some weighting should be given to applicants from these areas.

Recruitment and retention Difficulties

In addition to the points alluded to above, I would add two further suggestions.

Firstly, a recognition that the future medical workforce will be predominantly female and the need therefore to maximize in all respects, the opportunities for flexible working. Secondly, a real issue for consultants in the final five to ten years of their career is the absence of any "step down" arrangements from out of hours/emergency cover requirement. If this was introduced this would markedly increase the likelihood of individuals at this stage of their career remaining until they reach the official retirement age.

Pressures affecting the workforce and how they impact on service delivery

I am sure you will hear from many sources of the numerous drivers for change, the working time directive being the most obvious. There is a recognition within our specialty that most care will be delivered by trained doctors rather than those in training and we have submitted proposals on that basis to the National Workforce Unit. Critical to these developments is a need for both reconfiguration and redesign of services rather than duplication of existing service configurations. Reconfiguration although perhaps politically unpalatable, needs to happen!

I hope these comments are of value and if you wish me to expand on any of them please do not hesitate to get in touch.

Jim Beattie

Consultant Paediatrician and Nephrologist

RHSC Yorkhill