Official Report: Minutes of Evidence

The Chairperson (Ms Maeve McLaughlin): I welcome Ms Shirley Rogers, who is the director of health workforce; Professor Ian Finlay, who is a senior medical officer; and Mr Grant Hughes, who is head of workforce planning. We are pleased to have this communication today. I invite you to make an opening presentation, after which we will open it up for members' questions and comments.

Ms Shirley Rogers (Scottish Government): Thank you very much, and thank you for the invitation to speak to the Committee. We are delighted to be able to [Inaudible.]

in the context of the review of workforce planning you are undertaking in Transforming Your Care. You have asked us to give evidence on how we developed Everyone Matters, which is our workforce vision [Inaudible.]

—

The Chairperson (Ms Maeve McLaughlin): Can I stop you while we check our sound levels? It might be our end. Can you go ahead now, and we will check that?

Ms Shirley Rogers: Is that better?

The Chairperson (Ms Maeve McLaughlin): Yes.

Ms Shirley Rogers: Thank you.

We are delighted to share that with you. I was just going to briefly touch on how we formulated the work that we have done and particularly concentrate on some of the sustainability and workforce planning issues, which I think are of particular interest to you.

Our workforce strategy covers NHSScotland, which employs 159,000 folk. It supports a 2020 vision for health and social care in Scotland, which is essentially for everyone to live longer and healthier lives in their own home or in a [Inaudible.]

setting. Underpinning that is a healthcare system that has integrated health and social care and a focus on prevention, anticipation and supported self-management. Within that, [Inaudible.]

a shift in our future direction of travel that is much more about community-delivered services. So, when hospital treatment is required and cannot be provided in a community setting, [Inaudible.]

treatment should be the norm.

Whatever the setting, care will be provided to the highest standards of quality and safety, with the person at the centre of all our decisions. There is a particular focus on ensuring that people get back into their local community environment as soon as possible, with the minimum risk of readmission. So we are looking at those issues very carefully to make sure that people are [Inaudible.]

back home, and we are monitoring the impact on readmission, because clearly it is not anybody's interest to have patients who are sent out of hospital only for them to return in quick order.

Our 2020 workforce vision is about responding to the needs of the people we care for, adapting to new and improved ways of working, working seamlessly with colleagues and partner organisations, continuing to modernise the way we work and embracing technology. There is a huge thrust [Inaudible.]

for technology in Scotland. We have a very concentrated population in our central belt, and areas of Scotland clearly have a huge remote rural aspect. We are not dissimilar to you in that way.

The values that we share across NHSScotland are about care and compassion, dignity, respect and openness; the sorts of things you would expect to see. That vision has been co-produced with our workforce. Everyone Matters had an extensive engagement exercise, with over 10,000 NHS workers in the first year contributing to its creation. That discussion has continued with similar numbers each year. The format for that strategy is that we produce something that we have an annual implementation plan for, and we hold our board to account for that implementation. You may wish to talk to us a little bit about how we do that later on.

There are five key priority areas, including something about culture, sustainability and the capability of our workforce. I have just described significant change, and we are supporting our workforce so that they have the skills and confidence to deal with that. A big piece for us is integration, not just in terms of health and social care but also primary and secondary care. Effective leadership and management make all that come to fruition. We produce an annual plan, and we are just about to produce the first annual plan to demonstrate how this approach is having an impact on our system. Some of that has been quite interesting and quite transformative.

I suspect the bit that is of particular interest to the Committee is in the space around sustainability and how we use workforce planning to do that. We have a sustainability and seven-day services task force with a ministerial direction, which I chair. That is a hugely important area of work that has the potential to make significant improvements in care, because it is about service redesign to create excellence and create services for patients in a manner that is appropriate to our vision whilst ensuring that we are doing so in a manner that is sustainable in terms of our workforce.

We recognise, as anybody would, that the NHS already delivers a range of services across seven days. However, we accepted that we could and should do more to ensure that those services that are developed are readily accessible across the weekends, so that we do not get dips in performance and we do not get the characteristic Monday morning pile-ups of activity because services have not been available over the weekend.

Sustainability, as I said, is written all over it. That is the prize of our workforce strategy. We recognise the particular challenges of sustainability in remote and rural Scotland [Inaudible.]

of activity in that place. We have also been looking fundamentally at the sustainability of rural general hospitals, and there has been some really interesting early success in that area. It is not a quick fix; we know that. It is a complex piece of work, and some of the changes that we will need will take time. We have an interim report from the task force, which went to Parliament earlier this year. The Scottish Parliament has endorsed that, and we have an action plan that we are taking forward in respect of it.

Workforce planning has been a key focus in our work on sustainability. Essentially, we are trying to put some science and some really robust data into what had previously been the art of workforce planning. We are working with a range of stakeholders to improve on the established models and processes. We are keen to identify workforce risks earlier and make sure that, instead of those risks coming to us as a surprise, we have done sufficient analysis to be able to adjust our pipeline to give us a ready supply. We have worked very closely with HR directors and medical directors in boards to put this in place, and we have established a community of our workforce planners across boards, which government leads, to make sure that all the boards are supporting government action and vice versa in respect of it.

There has been a lot of work around developing better intelligence. We now have medical specialty profiles for every one of our acute hospital-based specialties, and we are just starting to do the same in respect of our GP workforce so that we have got all of the supply chain that we need to make that happen. It is not restricted to medicine: we are doing similar work in respect of nursing and the allied health professions (AHP) workforce. We have a significant amount of work underpinning that in terms of nurse workload profiling, so we know the numbers of nurses we need in particular specialties in particular wards at a particular time.

Some of the stuff that we have been using to yield that information includes medical training establishments; pre-emptive, targeted and strategic approaches to management of rota gaps and service pressures; working much more intelligently around recruitment processes in our hard-to-fill posts; taking forward the transition to the shape of training, which you will be aware of, and I am sure that other people have spoken to you about the Greenaway review; and making sure that we have appropriate information to be able to feed into other processes, such as [Inaudible.]

in terms of shortages, gaps and so on. As I said, we have got all of our hospital specialties profiled. When I say "profiled", I am talking about the consultant workforce that we already have and the [Inaudible.]

trainees and medical students who are in the pipeline coming forward. We have focused a lot on some of the key acute specialties, including emergency medicine, anaesthesia, intensive care, clinical oncology, psychiatry, radiology and that kind of stuff. We have also developed profiles for newer specialties such as intensive care medicine, joint infection training and so on. As I mentioned, the focus for 2015 is on the GP medical workforce.

We believe that sustainability will be delivered through different service models and through our ability to craft a workforce that is genuinely multiskilled and multidisciplinary as appropriate, not just in terms of health but in terms of our local authority colleagues and others working in the voluntary and independent sector.

If I may, I will stop there. I can go back through all of the five priorities of Everyone Matters if that is helpful, but I think that your Committee is concentrating particularly on workforce planning. If that is helpful to you, that is great, and we are very happy to take whatever questions you might have.

The Chairperson (Ms Maeve McLaughlin): Thank you, Shirley, for that. Apologies; we probably missed a bit at the start because the sound was not great. The sound has improved in the last while, but be mindful of all of us here speaking clearly into the mic. Apologies, Shirley, if we ask you a question that you have already dealt with. Please bear with us.

I am particularly interested in the planning guidance for workforce planning. You talk about workforce planning being a statutory requirement that was established in 2005. Can you maybe give us more detail around that in relation to who monitors its compliance with the law?

Ms Shirley Rogers: I will give you the general parameters of that and then invite Grant to put some of the flesh around that. Our relationship with our 22 boards is very close. We have a requirement on boards to produce something called a local delivery plan (LDP). They do that annually, and that is, essentially, their contract with Government. When we receive that LDP, that gives us an opportunity to talk to them about budgets and all of that kind of stuff. We have an annual accountability process with those boards, and that accountability review is generally chaired by a Minister. Sometimes not, if it is a small board with not that many issues, but almost all of those accountability reviews are ministerial reviews. In the course of that LDP process, which includes workforce planning, we will go through with the board all of the issues of concern that they may have, development plans and, essentially, their plan for ensuring the sustainability and the delivery of that service.

The guidance that underpins that is produced in something that we call chief exec letters (CEL), which are essentially the instruction from our director general, who is also the chief executive of the NHS in Scotland. He issues those letters, which cover how we expect boards to do that. We will go back to them if we believe that the plans that have been produced are not sufficiently robust or not sufficiently detailed for us to be able to make an assessment. We sign that off as part of their contractual arrangements — contract is too strong — with the Scottish Government. Grant, do you want to talk through the specifics of the statutory bit?

Mr Grant Hughes (Scottish Government): Yes. Thanks, Shirley. Hello there. I am the head of workforce planning. I am responsible for ensuring that the boards adhere to the guidance that we put out. You have a copy of the most recent of that guidance. That is in what is known as CEL 32 (2011). Regarding the practice around that, it is mandatory that boards have to provide us with workforce plans. That has been mandatory for around 10 years now. Quite a lot of background is given in that chief executive's letter and the guidance that accompanies it, and I will focus in one or two things that might help members to understand where we sit on those areas.

We play a monitoring role within the Scottish Government in terms of our requirements on boards to provide workforce plans, and also three-year projections. Part of that is around the local service planning process, which they are required to fulfil by the Scottish Government. As Shirley mentioned, the implementation framework for Everyone Matters, which is the overriding policy strand that we deal with, is also something by which we hold boards to account.

Workforce planning is integral to all of that. That is what the CEL 32 guidance covers. We give boards guidance on a methodology of how to workforce plan. We give boards tools to enable them to match their service requirements with the right workforce. For example, on the nursing and midwifery workforce, we currently have some groundbreaking tools that are helping boards to determine what their future nursing workforce needs are. What boards provide to us is evidence about what they are doing and how that links to service planning.

I will stop there for the moment, because I am conscious that I could probably go on for quite a long time here. I do not know if members have particular areas that they want to highlight.

The Chairperson (Ms Maeve McLaughlin): Thanks for that. Has the fact that workforce planning is statutory raised the profile of workforce planning within Government?

Ms Shirley Rogers: Absolutely. We publish national workforce statistics on a quarterly basis in February, May, September and December. We use that to ensure that the boards are absolutely cognisant of our direction of travel. There are certain things that we are starting to be able to look at — for example, spend in the primary care world. If our objective, as I said at the outset, is to have more services provided on a community and primary care basis, it follows that we should be spending more in that area, so we look at how we are allocating resources from the centre. We have comprehensive plans around doctors, nurses, midwives and AHPs. We subject those to quite considerable levels of scrutiny, both as entities in themselves and to see whether or not there are sufficient numbers of each of those groups to be able to provide multidisciplinary teams.

The profile is extremely high. It is demonstrating Government's commitment to sustainable health services, so it comes in for a great deal of public scrutiny, media scrutiny and so on, as well. It runs alongside certain other of our commitments about supporting our workforce in an appropriate way to adapt to change and making sure that they are invested in in the appropriate ways through training. Workforce planning is as high profile as it gets. As the director for workforce, which is everything from how many people we allow into med school in the first place to paying for pensions and everything else, including uniforms and standards of conduct, I would certainly put workforce planning at the top of my job description in terms of the things that we absolutely have to get right.

The Chairperson (Ms Maeve McLaughlin): Thank you; that is very clear. What we are struggling with is that we have a policy direction of shift left but are only now, some three-plus years into that policy direction, looking at the area of workforce planning. I am very interested in your clarity around workforce planning as a statutory requirement and how that is assisted in terms of the profile, monitoring and priority that it is given.

One of the issues that are very apparent — it was also apparent when our Committee visited the Scottish Health Committee recently — is the area of partnership and cooperation. I notice that your workforce vision states that it was informed by 10,000 people, including NHS staff, trade unions and professional organisations. I am very interested in that model. The question for me is this: who was the lead in charge of that overall vision and strategy?

Ms Shirley Rogers: I will give the easy answer to that bit first. The lead responsible for the formulation of the workforce vision is me. It was me at the outset and it continues to be me and my team. On those other two issues, fundamentally, whatever you want to do with health and the delivery of health is dependent upon — I am going to say something blindingly obvious, so forgive me if it sounds blindingly obvious — having a workforce to be able to do it with. The first objective of the vision of workforce planning was to make sure that the people of Scotland were going to have a sustainable health service because we had enough people to be able to deliver it. More importantly, perhaps, given that a lot of this agenda is about changing the workforce and not just about adding to it, we had to have a workforce that was flexible enough and could be planned enough to be able to deliver sustainable solutions. Our approach has been that workforce planning is a bedrock thing from which you can vision, as opposed to a second-order thing that you come to when you get to it, because you cannot do without it.

The partnership approach is deeply embedded in the way that NHSScotland does its business. I am a workforce director within the Scottish Government, but I have previously worked in a board, and our relationships with the boards are very strong and our partnership model is very strong. It is not fluffy. It is not that we engage with people because we want them to feel that we are engaging with them. It is about saying, "We co-produce with you because you have responsibilities in this space as well as we do." We take it for granted that we will engage with our workforce and listen to the issues that it has, but we will also seek responsibility from it in terms of the implementation.

I will give an illustration that is not solely in this space. We have a no-compulsory-redundancy policy in the NHS in Scotland. The price of that is that we expect people to be flexible in order to allow us to manage service change. That works for us. We are strongly in the space of co-production and spend a lot of time working with our trade unions to do that, but part of the benefit of that, apart from the fact that they are on the front line and know some of the stuff that is going on, is that we expect them, when they are co-signatories to something, to also be part of the implementation of that. That expectation is very high.

Ms McCorley: Thanks very much for the presentation. Can I ask you about the shift left, if that is what actually happened in Scotland and that is how you would describe it? Here, we have a policy known as Transforming Your Care, which is an overarching road map for change in the provision of health and social care services, and its aim is to provide more care at home or in the community and to reduce the amount of care required in hospitals. Was there a similar attempt in Scotland to shift left?

Ms Shirley Rogers: Yes. We do not use that expression. I know what you mean by that. I think that the commonality of it is quite tight, though. Our premise is health care for an aging population. To ensure that that aging population is able to age as healthily as possible, we believe that it is best delivered in community settings or at home. As a result of that, we are in the process of shifting some of our resource to be able to do that. It is also a feature of how we are designing specialist services, because we recognise that Scotland cannot have all those high-intensity specialties in every town, particularly in rural Scotland. Our commitment to our population is that for heart/lung surgery, you will go the Golden Jubilee National Hospital in the west of Scotland, because, frankly, a population of five or six million people would not sustain a heart/lung centre in every town in Scotland. The price of that is that you will have enhanced community-led and other services in the place where you live. It is about having high-end specialties where we need them.

The quid pro quo for the public is that, for the things that you do not need high-level intensive acute therapy, we will make sure you have sustainable local services.

Ms McCorley: OK. I was going to ask you whether service delivery models were required and had been developed, but clearly they had. Were service delivery models in place before you started to look at the workforce and the workforce strategy?

Ms Shirley Rogers: Some were; others were not. Parts of the system flexed because they needed to do so because of the nature of its sustainability. There was some creative thinking at a local level. Some of that required policy thought. I mentioned in the presentation that we looked at the sustainability of our district general hospitals. That required us to help local systems by producing models that look at their workforce.

Another illustration might be helpful. We were struggling to get hospital specialists who wanted to go into district general hospitals, and when we spoke to them, they said that they wanted to be in a rural setting but were anxious about losing some of their educational and other links as a result of being in rural locations as opposed to big centres of excellence. We were able to work with them to develop a model of mentoring and educational links, and fellowship links in some instances, allowing them to adopt rural practice and get all the benefits of that, while not feeling that they had abandoned all their links to the great centres of excellence in the centre belt. So, some things happened locally, and some things we developed and shared with the boards to help them steer a different route than they might take to a sustainable workforce.

Ms McCorley: Did the workforce strategy necessitate training or retraining in new skills, and, if so, who took the lead in implementing that?

Ms Shirley Rogers: I think that a version of our workforce strategy was sent to you. In it, one of the five priorities was capability, which addresses exactly the points you have made. Capability was about making sure that people had educational support where necessary to allow them to make the necessary changes. Some of that was driven by me and my team, and Ian Finlay might want to say something about it in a second. Some was driven by NHS Education for Scotland. We have a special health board that delivers education solutions, sponsored by my directorate. It works with the deans, the medical schools, the nursing colleges, the nursing universities, and AHP development across the piece to make sure that people have good skills.

We have also done quite a lot of work in leadership and management development, because we wanted managers to lead the NHS in Scotland who were looking for creative solutions and were happy working in an integrated space. There is an awful lot of activity that takes place in the boards too. We have a network of organisational development and education leads in the boards. Some people from the Scottish Government and my team helped support them by sharing the vision and helping them to craft a syllabus that would deliver educational excellence. Ian, would you like to add something?

Professor Ian Finlay (Scottish Government): Thank you. I am Ian Finlay. I am medical adviser to NHS Workforce for the Scottish Government. The only thing I would add is that this is a dynamic process. Our anticipation is that we will need to find a different kind of doctor now and going forward to meet the differing needs of patients. In that respect, we are quite interested in some aspects of the Greenaway review, which talks about a more general doctor providing a wider range of care in the community. We are actively exploring whether the time is right to look at new training programmes that will help us blur the interface between the community and the acute hospital sector. We are considering pilots of that type even as we speak.

Ms McCorley: I have one final question. What do you feel is the importance of self-referral physiotherapy and suchlike in transforming the delivery of healthcare in Scotland?

Ms Shirley Rogers: If the question is targeted at the workforce as regards self-referral to occupational health services (OHS) and physiotherapy, then it is a lot. We have done a lot around the working longer agenda. If the question is about patient care, then I do not know whether you heard me at the beginning talking about our triple ambition, which is safe, effective and person-centred. We are working as hard as we can to support the population of Scotland to be healthy. Like you, we have been very thoughtful and proactive in anti-smoking, minimum pricing for alcohol, obesity, and exercise and its contribution to physical and mental health well-being. We encourage patients and their carers, as best we can, to access services that are appropriate to them. We have had quite an interesting debate about the extent to which access has to be through the gateway of a GP. We have a model emerging that is GP-led but not necessarily GP-delivered. There is something there about how people access. We have a number of walk-in facilities and minor injuries units that allow people to access services in that way. We have also spent a lot of time looking at extended nurse practice. We are working with AHPs around extended practice.

Mr McCarthy: Thank you very much. Good afternoon, Shirley, Ian and Grant. I detect that the answer to my question was probably given to our Chair earlier. It seems from your workforce vision implementation framework and plan for 2014-15 that your NHS boards and the Scottish Government have the majority of the roles and responsibilities. What is the relationship between those two bodies when it comes to workforce strategy?

Ms Shirley Rogers: The policy for workforce strategy sits with the Scottish Government. We developed that strategy with the boards. We have also been a bit more direct in some of this. As you would expect, boards have a very strong strategic role, but they are also in the everyday and work in very close time frames sometimes. If we look at medical education, in particular, then I struggle to think of anything in public-planning terms, other than big capital builds, that takes longer than it does to get somebody from medical school through to a certificate of completion of training (CCT) and a consultant's licence.

Our direction has been quite strong. Essentially, we are planting the seeds for the whole of Scotland to harvest. We have not necessarily relied on boards anticipating some of these things. Government has a legitimate place in the 15-year or 20-year planning time frames for that workforce. It is probably a place that only government can have.

We work very closely with the universities. We have the Scottish Board for Academic Medicine, which is, essentially, a board created from the five medical and two dental schools in Scotland. I meet it on an annual basis to discuss how many people from Scotland we are going to allow into the medical schools and how that is going to operate. We are represented there.

On occasions, we have looked at the information we are getting from our profiling and have said that the boards are not looking far enough ahead. For example, we have seen a significant expansion in consultancy in emergency medicine in Scotland. We have been able to do that because, essentially, we took a view a few years ago that we were going to need more consultants in emergency medicine. So, it is not a strategy that is done to the boards. We work very closely with them and try, as best we can, to have something that suits everybody's needs in the short-, medium- and long-term.

In strategic terms, it is probably driven more by us in government than it is by the boards. Of course, board management is only one group of people who make healthcare strategy come alive. We need the cooperation of our medical schools and colleges of nursing. We need a whole raft of different organisations. We worked very closely with colleagues in education and worked very strongly to reduce inequalities in Scotland; so we are looking at things like the postcodes from which we draw our medical students, and we are working with education colleagues to see if there is more we can do to target them. I guess the point I am making is that there are some things that government can do much more easily than boards can. There is also a coherence from government that can knit together what the varying positions of 22 boards might be and can project a bit further to think about what we might need to do in strategic terms. That is what we try to do.

Mr McCarthy: Thank you very much. It sounds like it is very important, indeed vital, that all organisations work closely together to get to the end result that you want. I will take this opportunity to wish you all the best and thank you very much for enlightening us this afternoon. Thank you very much.

Mrs Cameron: Good afternoon. Thank you very much for your time today.

Ms Shirley Rogers: It is a pleasure.

Mrs Cameron: The Committee has received evidence from a number of professional bodies. One of the major issues here is recruitment and retention of healthcare staff, particularly doctors and nurses. Is that the case in Scotland? If so, how are you addressing those issues? For example, are you using any incentives or penalties to keep qualified staff in your jurisdiction?

Ms Shirley Rogers: Recruitment and retention are issues for us in certain key specialties and in certain locations. The practices that make up for those recruitment and retention issues are multiple. Some are about work/life balance choices. We operate a significant number of our services on an on-call basis, and earlier we touched on some of the rural issues which make that the case. We have the same kind of challenges that some of our UK brethren suffer from in relation to the general dearth of certain specialties. We are being very proactive there, and some of it comes about because of the intelligent data we now have from planning.

I will share with you that we now know, precisely, the destinations of the kids from Scotland who go to medical schools: we know how many we retain in Scotland, how many have an aspiration to work on a full-time basis, and whether any of them wish to work on a part-time basis. That has allowed us to adjust the ratios of numbers that we train to fill those key specialties. For example, for certain key specialties such as anaesthetics, paediatrics, and so on, we now train on a 1·6:1 ratio. That is really to make sure that we have a sufficient supply at the end of it.

Currently, we do not incentivise our medical workforce with bonuses for joining, or anything like that. We have a bonding scheme for our dental students, which we use to good effect, and we now have a sufficient supply of dentists. We are thoughtful about that as we know that other parts of the UK are thinking in that area, and we have not yet reached a position on it.

We do not operate any kind of disincentive to leave. We work on the principle that we are trying to create a working environment in Scotland that is good enough so that people will want to participate in it; and in the vast majority of cases, that is the case. We are thoughtful about how we support people; so, for example, we have a GP returners scheme for people who left general practice a little while ago and are seeking to come back. We have several initiatives about returners into the workforce that encourage people to be able to do that.

We are as creative as we are can be in talking to people about the career choices they want to make and in sending a very strong message that the NHS in Scotland values its people and wants them to continue to work with us. That has generated significant payback for us; there are a lot of people who appreciate the fact that they are appreciated. We are not perfect by any means and there are challenges around sustainability, particularly in remote and rural areas.

Our spread of hospitals is quite significant. We have 29 A&E receiving units across Scotland. Some rotas for units in rural Scotland are quite small, so a gap on a rota can be quite significant. The rota in the Southern General Hospital in Glasgow has hundreds of people on it, but some smaller hospitals in rural Scotland have rotas with half a dozen people on them. Gaps in those rotas can have a significant impact. A member of my team here works very closely with the boards to look at how rotas can be designed to be most attractive and how we can support junior doctors through those rotas. We have been very creative in saying that our expectations of junior doctors are that we no longer have seven night shifts in a row in Scotland. We are just about to be able to say something similar about our day shifts. Our message is that the workforce in Scotland is valued and that, as a result of that, we want them to stay.

You will have heard evidence — I hear it too — of individual instances where we have issues and need to address them. I am not saying that we do not have recruitment and retention issues, because we do, but we are working very hard and creatively in that space. That is why we started the Everyone Matters vision with some values. In my experience, people want to work in the health service, and when we reinforce those messages we have found that it has generally had a very positive effect.

Mrs Cameron: Thank you very much.

The Chairperson (Ms Maeve McLaughlin): Were the Scottish Government able to influence GP contracts?

Ms Shirley Rogers: The Scottish Government have a slightly different position on GP contracts, in that they were negotiated with a view that there would be a two-year window to allow us to look at and review service redesign. My colleagues in primary care work very closely with the GPs and I am just in the foothills of starting to think about what a GP contract in Scotland might look like. However, it will reflect the changed service delivery model that we have just been discussing.

The Chairperson (Ms Maeve McLaughlin): Thank you for clarifying that.

Ms Shirley Rogers: May I just make an observation? There is an interesting point there about the tactics of how this has worked. In all the service redesign work we have done, we have been very up front with all our staff side partners that service redesign will drive the terms and conditions rather than the other way round. We will design the service model that is appropriate for the needs of the people of Scotland and then we will talk about the pounds, shillings and pence attached to that, rather than having a more negotiated terms and conditions package which, in the early 2000s, left us with service issues to address.

The Chairperson (Ms Maeve McLaughlin): I understand that. I ask about this because one of the issues has been about recruitment, training and retention. Every time the issue of retention is raised, we are informed that we cannot negotiate and that GP contracts are set. I am talking about retention in terms of GPs being trained and then, in terms of their contractual commitment, delivering the service in the North. I am interested in the approach you have taken on that because this is an issue for us.

Ms Shirley Rogers: We looked at the quality framework used for GP contracts quite carefully, and we looked to see what it was that we wanted to buy. We have tried to get ourselves into a position where we are having some very positive early discussions about how a GP contract needs to reflect the reality of how GP services are delivered in Scotland.

That is not the same as the way that they are delivered in Westminster, Kensington or wherever. We have to have a contract that reflects the nature of the practice here.

While we are on the subject of GPs, we are also very thoughtful about some of the messages that we are getting from young GPs who were talking to us about their desire for a different kind of contract. Coming back into the vocabulary in Scotland is a much more positive discussion about the potential around the salaried GPs, for example.

Mrs Dobson: Good afternoon. Thank you for your briefing. It is always interesting to hear of experiences in other regions. We can learn so much from that, and we should do it more often. The majority of the health and social care workforce in Northern Ireland is made of up women: is that the case in Scotland?

Ms Shirley Rogers: Yes. I think that the feminisation of the workforce in health and in our medical communities is evident, and that is also the case in our nursing communities and among our care providers; yes, absolutely. There are variations in that. Ambulance Service provision is still largely male, for example, but a number of other specialities are now more than 50% female.

Mrs Dobson: I noticed earlier that you talked about a workforce that is flexible enough to deliver that vision. With that in mind, whilst developing your workforce strategy, did you have to take into account the number of women and, for example, maternity leave and part-time working patterns?

Ms Shirley Rogers: Yes, absolutely. I made reference earlier to the ratios that we are currently supporting through training, and those ratios are largely predicated on the fact that women make different choices and that we have extended training programmes; for example, there are extended time frames for the delivery of those training programmes, because people take maternity leave and come back on a part-time basis. Indeed, as we have an aging population, people have caring responsibilities for their parents as well as for their children increasingly, and obviously that is not just restricted to women. Yes, there is flexibility and an approach that says that we should come at an issue with a view to finding a flexible solution. We have a high degree of part-time working, a high degree of school contract hours and term-time working and a raft of provisions that allow for as much flexibility as we can give. We have to be thoughtful of that through the rotas, because we want to do that as an employer, and, at the same time, we know that we need to be able to deliver a 24/7 service to patients. We work very hard to craft rotas that allow for that flexibility and maintain appropriate levels of staffing at all times.

Mrs Dobson: It was good to hear you speak about work/life balance issues earlier and how important that was in Scotland. That takes me on to my next point, which is the provision or desirability of seven-day working. One of the terms of reference for this review is to examine the extent to which work planning is taking account of seven-day working. Is that an issue for Scotland, and, if so, how long has it been addressed?

Ms Shirley Rogers: As I said at the beginning of my presentation, one of the messages that we have worked really hard to get over publicly in the seven-day service debate is that the NHS in Scotland has always delivered a seven-day service. If you have a heart attack on a Saturday, you will get treated; it does not matter that it is not a Friday. We have had a slightly different tone in some of the seven-day services stuff in Scotland than has come from the Department of Health in England stuff. We have tried very much to make clear that we are not talking about a Tesco solution; we are not saying everything every day and every hour of the day. We are not talking about old ladies being taken in for hip replacements at 2.00 am and then being ejected out onto the street. We are talking about things that really make a difference to the quality of care. Some of those have been the ability to have diagnostic tests at the weekend, and we have concentrated hard on that area. There is a whole raft of other wee bits that you will have seen in seven-day services plan.

All that has been mindful that we have a workforce that has a number of aspirations. Some are able to extend their hours and want to do that. Some want to work in different ways, so Agenda for Change has been helpful for the number of people who want to look at extended hours. However, some people simply cannot do that, and we have to be mindful of that because we want to retain the people we have.

When we started the 2020 Vision a few years ago, one point that I needed to make routinely was that a good 90% of the workforce that we were going to have in 2020 we already had. So it was not enough to focus on new folk coming in; we had to produce something that was supportive of the people we already had and that adapted to their changing needs and to the fact that our workforce is ageing and how we support them. Therefore, we have spent a lot of time on education and training and supported occupational health. All those things allow people to feel that they can be fully effective at work and have a life.

Mrs Dobson: It sounds good. Thank you.

Mr G Robinson: Good afternoon, Shirley, Ian and Grant. Does Scotland have recruitment issues in particular areas, such as rural locations? If so, how is that addressed? Are incentives used to recruit staff?

Ms Shirley Rogers: We have recruitment challenges in rural Scotland, particularly in the area of GP recruitment. Ian mentioned the work we are doing to look at the community GP training model to see if there is more that we can do in that space. We have, in common with you in some parts, high use of locums in order to maintain delivery. We are looking hard to see whether or not there is a salaried GP model that might help us.

We are doing a lot educationally to look at how we support GPs. We are also working hard with our medical schools to encourage people to look at general practice in the first instance as a specialty in its own right. I know it sounds a bit perverse to talk about a specialty around general practice, but essentially it is to make sure that general practice is perceived to have the same status and level of credence as everybody else. We have rural fellowships that I might invite Ian Finlay to talk about in more detail. There is a lot of activity in the area of rural recruitment.

We have been active internationally, working with European colleagues through the EURES. We were in Amsterdam a couple of weeks ago, looking at how to recruit from countries of oversupply in Europe. We are committed to ethical recruitment, so we do not go fishing in the ponds of countries where they need their GP workforce as much as we do. We have generated a good deal of interest internationally, not least because most people's second language is English. So we are attracting a good deal of interest from the European Union from general practitioners who may be interested in coming to work in Scotland. We are doing work with NHS Education for Scotland to make sure that we support them with whatever it is that they need to be able to practise to the fullest extent of their licence in Scotland.

Ian, do you want to pick up the rural fellowship thing?

Professor Finlay: Yes, I will talk about rural initiatives in general. About 15% of our population live in remote and rural areas. Shirley said a bit about general practice, but we have developed specific rural fellowships where people have the opportunity to train specifically to provide a wider range of services in rural areas.

One of our key challenges has been the sustainability of our six rural general hospitals. One solution that we recently developed was to network those hospitals with larger urban hospitals for training and the provision of staff. That has proved to be very successful. Finally, we have been looking at multi-skilling in the community hospitals, where our general practitioners have a wider range of skills supported by enhanced-skill non-doctors, enhanced-role nurses and others, in delivering the service from community hospitals. Some of those have now become non- [Inaudible.]

So we have a raft of initiatives to try to support our remote and rural services.

Ms Shirley Rogers: I will give an illustration to try to put a bit of meat on the bone of that. We have a district general hospital in Fort William, in the south of the Highlands. It has had some sustainability issues in terms of recruitment. It had a couple of consultant posts that had been vacant for some time. We worked with NHS Lothian, which is the Edinburgh board and which has our biggest concentration of teaching hospitals, and we asked its consultant population whether, if we expanded its establishment a little bit, we could put those two vacant posts into Edinburgh and develop with them a rota that allowed some of those consultants to go and work in Fort William. I was not terribly optimistic about that, but actually it worked incredibly well. There are a number of people who are very interested in rural practice but do not want to commit to it full time. We went from a situation where they had had a couple of vacancies for 18 months to having seven suitable applicants for those two posts. [Inaudible.]

Mr G Robinson: Do you use any incentives to recruit staff? You may have already answered that question.

The Chairperson (Ms Maeve McLaughlin): Do you want to ask that question again, George? I do not know that they heard it.

Ms Shirley Rogers: We heard the question: do we incentivise them in any way?

Mr G Robinson: That is correct.

Ms Shirley Rogers: We do not give any additional payments in that respect. There is a small payment for those who operate on the island boards, because it reflects the high cost of living and some of that stuff. So there is a remote rural island allowance, but there are no specific financial incentives to encourage people to work in rural practice at the moment.

Mr Easton: Good afternoon and thank you for your presentation. Just to let you know, I have a good Scottish family background.

Ms Shirley Rogers: You ought to be very proud of that.

Mr Easton: The Eastons come from Aberdeen, so there you go. My question is this: given the financial climate, has Scotland any plans for voluntary exit schemes for the healthcare workforce, and, if so, how will you coordinate it with the workforce strategy in planning?

Ms Shirley Rogers: I mentioned earlier that we currently have a no-compulsory-redundancy policy in Scotland. It is our intention to keep that. It has served us well to be able to reassure our workforce that we are not looking to make cuts, and, as a result, I believe that we have reached some flexibilities because people have not been fearful that, if they are flexible, they will lose their job. The NHSScotland pension scheme already allows for voluntary exit when somebody has reached 50 years of age. As everybody has, we have been thoughtful about the impact of the reduction in the pension pot cap. For our highest-paid workforce, it does not take that long to accrue that amount of money in your pension pot. Earlier, I mentioned our workforce planning tools. I do not know whether you heard the bits where I was describing that we now have profiling, which allows us to model. We currently calculate an average age of retirement from the NHS at 61, and that allows us to model for a workforce that works to 65 or, indeed, 55, and we are therefore able to predict where we think we may have bulges or undersupply and, essentially, turn the tap on a bit further upstream to make sure that we have sufficient workforce coming through in that respect. It is not our view that we will be looking to any large-scale voluntary severance package available to the NHS at the moment. Our efforts are much more around encouraging our workforce to stay with us and continue to work with us, healthily and happily, for as long as they can.

The pension scheme that we operate already gives that voluntary severance exit through the pension route from the age of 50. I have not actually seen a massive growth in that in the last wee while. In fact, the contrary has been true. We have found that, actually, the number of people who are now working beyond 65 is growing. When we ask people the reasons for that, they cite some of the economic challenges that family members and others may be facing, so we have not had the huge mass exodus that we might have thought we were going to have with the pension stuff.

The Chairperson (Ms Maeve McLaughlin): Finally, I am just interested, in general, in the reconfiguration of your system, if you like, and your model of delivery for health from the 28 trusts to the 14 boards. I think I am right in saying that. Has that assisted in responding to workforce planning needs and requirements?

Ms Shirley Rogers: Immeasurably.

The Chairperson (Ms Maeve McLaughlin): Sorry, I did not get that.

Ms Shirley Rogers: Absolutely.

The Chairperson (Ms Maeve McLaughlin): That is one of the things that we find in relation to our system here that we are interested in pursuing with you. The shift in Scotland to the cooperative, traditional NHS model seems to be closer to providing a system that can strategically respond.

Ms Shirley Rogers: Yes. If I reflect on what it used to be like when we had primary care trusts and acute trusts, I have no doubt that we spent a bit of time trying to make those two systems talk to each other. In the formation of the 14 territorial boards that we currently operate, those relationships work better, so when we are talking to boards about their ability to workforce plan, I do not have to talk to them about primary care as a separate thing from the acute sector. When we talk about service models, we talk about how we flex the workforce to do that, so we have GPs who work in hospitals sometimes, and we have consultants who go out into primary care parts of the estate. We are delivering services. We have nurses who work across those areas, so we are working across the estate in a much more intelligent way, which means that boundaries that do not need to exist do not. I think that has helped us immeasurably.

It also means, frankly, that we are talking about 14 workforce plans, which is manageable for us, as opposed to 20, 30, 50 or however many, so for us it has become a much more manageable exercise. It is much easier for us to spot risk, so when those workforce plans come in, my team looks at them through all of the lenses, workforce planning being one of them, but they also include pay risks, staff governance risks or whatever it is that we are particularly interested in. They are looked at through every workforce lens. We can do that because there are 14 of them. If there were 50 of them, that would be a hell of a lot harder. It would be much harder to identify issues that we need to be thoughtful about. So, yes, it is immeasurably improved by the reconfiguration into the existing board structure.

The Chairperson (Ms Maeve McLaughlin): OK. Thank you, all three of you, for today. This has been extremely useful and clear for us in going forward. Obviously, we will reflect on the evidence that you have given us today in our inquiry, and we hope that we will be able to come up with some clear recommendations about reform of the delivery of the service around workforce planning. I thank all three of you for taking the time, and we certainly look forward to continuing this cooperation and collaboration.

Ms Shirley Rogers: Thank you for the very great privilege of being able to speak with you this afternoon. It is always great to share information. We do not have all of the answers — in fact, some of the time, we do not have all of the questions — but we are very happy to help in whatever way you think we can, and it is a very great opportunity for us to learn from [Inaudible.]

yourselves. Thank you very much indeed for giving us the privilege of being able to speak with you.

The Chairperson (Ms Maeve McLaughlin): Thank you.