Official Report: Minutes of Evidence

The Chairperson (Mr McGuigan): We are joined by Phil Rodgers, director of workforce policy in the Department of Health; Professor Maria McIlgorm, Chief Nursing Officer; Aine Morrison, Chief Social Work Officer; and Rodney Redmond, the Department's head of workforce strategy. You are all very welcome, and I thank you for coming.

We received some documentation from you in advance of the meeting. I will hand over to you for some brief opening remarks, and then we will take questions from members.

Mr Phil Rodgers (Department of Health): Thank you very much, Chair and Committee members, for the invitation. We are here to talk a little bit about our proposals around safe and effective staffing legislation. This is the first opportunity that we have had to brief you specifically on the proposed legislation. It has probably come up in different sessions as an issue, but this is the first time that we have had the opportunity to brief you in particular on the proposed legislation.

By way of background, members will be aware that the legislation stems from a commitment that was made in 2020 as part of the framework agreement, which, at that time, brought industrial action to a close, that we would consider safe staffing legislation for nursing. Through early engagement on that commitment and that work with stakeholders across Health and Social Care (HSC), it became clear that we needed to think about expanding that. The then Minister Swann took the decision that safe and effective staffing legislation should focus on nursing and reflect the wider HSC workforce. That has evolved into a whole-system approach, which is aimed at supporting workforce planning and the delivery of safe, high-quality care across all the professions in our public health system.

The development of policy has been informed by a substantial programme of engagement and evidence gathering. That has included the consideration of approaches that have been adopted in other countries. Our colleagues in Scotland and Wales have already introduced legislation in that space. There has been engagement with internal and external stakeholders, including chief professional officers and our trusts. There was also significant input from our trade union colleagues; the Royal College of Nursing (RCN), UNISON and NIPSA have been particularly engaged with us in helping to shape the proposals and plans. In addition, we have been reviewing our existing workforce planning practices and our current staffing methodologies.

We put out a public consultation in 2024 and sought views on the key themes to be included in the legislation. I think that it is fair to say that the responses that we received at that time demonstrated significant support for what we were proposing. I think that stakeholders have recognised the importance of having a statutory framework that provides assurance around staffing and workforce planning, while acknowledging the realities of delivering care in a complex and often unpredictable environment.

As I said, the proposals that we put out for consultation have broadly been supported. Trade unions played an important role throughout the policy development process and have been actively involved at all stages. We have taken a co-design approach to developing the legislation. There are differing views on specific aspects, so support for them might vary, but I think that there is broad support for the overall direction of travel and the introduction of the legislative framework that we are proposing.

One of the most significant conclusions from the evidence and the stakeholder engagement was that the legislation should not be based on fixed staffing ratios. Ratios can provide a simple benchmark, but they can lack flexibility, about which stakeholders expressed concerns, so we have not proposed to put fixed staffing ratios in the legislation, although they will be used. Aine and Maria might talk a little bit about some of the work that they have been doing in that respect. The process centred on creating a legislative framework that supports safe and effective staffing and workforce planning. The approach seeks to balance accountability and assurance with the flexibility needed to deliver services safely and effectively.

Our aim is to introduce the Bill to the Assembly following the summer recess. Obviously, it will then be over to you for the scrutiny stage to commence, hopefully in September or October 2026. Again, as the legislation develops, we hope that there will be continued engagement with stakeholders in order to continue to ensure effective implementation and operational readiness across the system.

The legislation is fundamentally about improving outcomes for patients, service users and staff. It seeks to provide a consistent statutory framework that supports safe and effective staffing decisions across HSC. Ultimately, the objective is to ensure that the right people with the right skills and training are in the right place at the right time to deliver safe, high-quality care, which is consistent with our broader workforce strategy objectives. We welcome the Committee's views and look forward to discussing the proposals further. We thought that it might be useful for Maria and Aine to talk a little bit about some of the practical work that they have been doing in nursing and social work to prepare for the introduction of the legislation.

The Chairperson (Mr McGuigan): Apologies, Andrea. I did not have you on my list. We also have with us Andrea Owens, who is the policy lead in the Department on the issue. You are all very welcome.

Thank you very much for that. Even in the past two weeks, I have met representatives of nurses, psychiatrists, doctors and midwives. In the context of those engagements, all of them talked about severe workforce pressures and issues due to short staffing. In real terms, how will the safe staffing Bill improve the levels of staffing not just in those spheres but right across our health and social care sector? How will you get to a safe staffing level when it comes to recruitment and retention, given all the issues that we are currently exposed to?

Mr Rodgers: The legislation will put a duty or requirement on trusts, as the delivery bodies, and other arm's-length bodies to safely and effectively plan their staffing. The legislation — this is the best way in which to think about it — will require them to work out how many people they should have in a particular setting, tell us how many people they have, and tell us what actions they are taking to address that. At an operational level, the safe and effective staffing legislation will require trusts to plan effectively by working out how many people they need using tools or whatever mechanisms are best placed for that particular setting. It will be done by setting.

The Chairperson (Mr McGuigan): Sorry, I will keep interrupting as things come into my head. Apologies for that in advance.

Mr Rodgers: That is OK.

The Chairperson (Mr McGuigan): There will not be figures in the legislation stating, "You need this number".

Mr Rodgers: Practice changes; what is required in a particular situation might change over time as services evolve and practice evolves. To put figures in the legislation would almost bind us at an early stage by saying, "You must have x number of people in the service", when, in fact, that service might change. In 10 years' time, you might not need as many people, or you might need more people.

The Chairperson (Mr McGuigan): The legislation will be produced. Will figures go into the guidance?

Mr Rodgers: The legislation will require trusts to plan effectively and report to the Department how many people they have across different settings, how many they should have and what they are doing to address the gap.

The Chairperson (Mr McGuigan): We had a meeting, a couple of hours ago, with consultant doctors. In the course of that meeting, we were told that there is a 75% vacancy rate for psychiatrists in the Western Health and Social Care Trust. That figure shocked me. Under the legislation, the Western Trust will say, "This is the level". How will it recruit? Given the current conflicts within almost every level with regard to pay, workforce and people leaving, where will we get the staff?

We will have a piece of legislation. How much does the Department envisage that it will cost to go from where we are now to having safe levels of staffing across every aspect of our health service? Has the Department budgeted for that? If you take that 75% vacancy level and multiply it across other services, you will see that it is a lot of vacancies.

Mr Rodgers: Yes.

The Chairperson (Mr McGuigan): The figure of 6,000 has just popped into my head as the number of staff required across healthcare.

Mr Rodgers: I will say a couple of things in response to that. When we look at our macro figures, we see growth across the HSC workforce. We see more doctors, more nurses and more social workers. That pattern is consistent, and it has been growing — year on year — for a number of years. We recognise that there are specific examples, which might be by location or by speciality — in the case that you have cited of psychiatry in the Western Trust, it is location and speciality — where there are challenges in recruitment or perhaps retention. With the new legislation, the trusts would tell us how many people they should have in a service, how many they do have and what actions they are taking at an operational level to address the gap. Some of that might be around recruitment; some might be around retention; and some might be around doing things differently and maybe reconfiguring services so that the trust can deliver the same service but in a different way.

The Chairperson (Mr McGuigan): I will use that example again. Once the legislation is passed, the Western Trust will come to you and say, "Here's what we believe is a safe staffing level for psychiatry in our trust". If it is 10, off the top of my head, but the trust only has five and, six months later, still only has five, what happens to that service if its level has been deemed to be unsafe?

Mr Rodgers: Maria might come in on that. In the case that you have described, the vacancies that they are articulating are probably being filled by locum staff. That is usually what happens at the minute. However, the legislation will require the trusts to come up with an action plan that says, "This is what we are doing to address the gaps".

The Chairperson (Mr McGuigan): This is the last question from me. We are almost mirroring, or using, Scotland's example. Do any positive or negative learnings from there stand out?

Mr Rodgers: Scotland went first on safe and effective staffing legislation, and then Wales moved. We looked at what they were doing in their legislation. In some ways, ours goes a little bit beyond that. I will bring in Andrea to say a little bit about what we are doing or proposing to do if the legislation progresses and what colleagues in Scotland do.

Ms Andrea Owens (Department of Health): Scotland's legislation was introduced before the pandemic; its systems have changed a lot since then. In the first instance, the reports that are coming through are finding that they were not ready. There has been a lot of criticism of the fact that the systems and the learning were not in place. Hopefully, we are learning from that and will have things in place before implementation. We are working with colleagues at all levels to get ready. We are into the second batch of Scottish reporting, so we are starting to see the improvements there. It is definitely about readiness. The Scottish legislation also specifies the common staffing methods, but they are mainly for nursing. We are allowing that to progress by making it a professional judgement and allowing professional leads to determine what is best for them rather than saying, "This is what you should do".

The Chairperson (Mr McGuigan): Is there a danger that the method that we are proposing will allow a professional judgement to lower a figure on the basis of reality rather than specification?

Ms Owens: There is that danger, but any decisions that go outside the evidence have to be justified, whether that be in a report to the strategic oversight board or by exception. As we have said, once a year, we report an exception, if something goes beyond what the legislation states. There has to be a reason for that, and evidence has to be provided as to why the judgement went one way when the facts and figures told us to go another way. We are leaving it a bit more flexible for those who are clinically prepared to make such decisions.

Mr Rodgers: Maria and Aine may want to speak to that question.

The Chairperson (Mr McGuigan): Before you come in, Aine, we have done the Committee Stage of the Adult Protection Bill, and we have a big concern that we will introduce legislation that we may not have the social workers to implement. It is useful that you are here: maybe you can talk to that too.

Ms Aine Morrison (Department of Health): We have had an extensive programme of workforce reform for three or four years. Our workforce position is still vulnerable, but we have made significant strides. We need to keep on that trajectory to continue to improve, but we have plans in place.

There is new legislation that will place demands on the social work workforce, and those will require funding for staff and training places for people coming through. In some ways, 'Safer and Effective Staffing in Social Work' is very much linked to a number of our workforce reform projects, such as our training places. Things such as the Adult Protection Bill are calculated into our judgement of how many training places we need.

We have produced guidance in 'Safer and Effective Staffing in Social Work'. We have been working on it for a number of years. We started with academic input from Queen's and Ulster University (UU) to look at the evidence base for safer staffing, to see what other models were out there and to put together a metric or tool that would work for social work and the particular circumstances in which social workers operate. At the social work level, as Phil said, we have engaged widely with trusts, the Northern Ireland Social Care Council (NISCC), the British Association of Social Workers (BASW) and NIPSA to discuss and understand social work caseloads and workloads. The guidance makes recommendations on workforce planning, caseloads and workloads for the social work workforce. A lot of it is applicable to any field social work model, meaning people working in a team who have a caseload. We have made caseload range recommendations; we have gone for a range to allow for complexity in individual cases. To date, we have calculated recommended caseload ranges for older people's mental health and children's services. This year, we are starting work on other programmes of care. We hope to complete safer staffing guidance for children's homes in the next couple of months. We are also working on workload recommendations for team leaders.

The guidance was issued to trusts in March 2026. It was issued in full recognition of the fact that full implementation is not possible at present, although many things in it can be implemented without funding. They are about professional practice. We have placed the emphasis on collaborative working in and around allocation, grounding decisions about caseload and workload very much in professional social work supervision. The model recognises that a lot of that needs to happen between a team leader or senior social worker and their team. Initial feedback is that we are close to the recommended ranges in some teams, albeit a proportion of that has probably been achieved by having waiting lists. In other teams, there is a lot more work to do.

We have gone out to trusts. In April and May, we held 20 safer staffing familiarisation events — five in each trust. Those have been well received and well attended by senior managers, team leaders and senior social workers. We are calling the exercise that we are engaged in at the moment an "assess the gap". Surveys have gone out to all teams that employ social workers asking for information about team structure and composition, current caseloads and any waiting lists or unallocated cases. We hope to be in a position to analyse the results of that over the summer. Then we will move on to an implementation plan, which is about saying, "OK, here's the gap: what is it that we need to do?". As I said, I anticipate that there will be demand for increased social work, but I do not believe that all the demands fall into that space. It could be about the skills mix or practice within a team, and quite a lot of it is about professional practice. I hope that we will move very quickly to the things that trusts can implement at this stage and that we will then work out a plan, which will eventually need to be costed, in respect of any of the gaps where more social work resource is required.

That was an update on where we are currently and the progress that we are making.

The Chairperson (Mr McGuigan): Thank you.

Professor Maria McIlgorm (Department of Health): I will give you an update on nursing and midwifery, nursing being the biggest workforce in Health and Social Care.

You will be aware that, in March 2026, the Minister launched the refreshed Delivering Care policy for workforce planning in nursing and midwifery. There had previously been a framework for nursing and midwifery: the Delivering Care policy from 2014. Several workforce reviews were done across different services, and there was investment in increasing the workforce at that time. There have been changes since then, such as population growth and different demands from the population, and there is also the need to ensure that we have safe and effective staffing and that the right skills are in the right place. When I came into post, I therefore asked for a review of the framework. That review was led by one of the executive nurse directors in the trusts with one of my officials. Phil was involved in that work as well. There was wide engagement with staff on the front line: service managers, people who provide service and the Royal College of Nursing.

The refreshed framework is designed to be flexible and responsive to population health need. That links with what was said: as our population changes, our workforce needs to change in order to respond to those needs. The refreshed framework strengthens guidance for trusts and commissioners on workforce and workload planning across nursing and midwifery settings. It supports a culture of safety, improves staff well-being and promotes a more evidence-based approach to determining staffing levels.

Overall, the refreshed framework aims to support high-quality care across hospital and community settings by strengthening consistent and system-wide approaches to nursing and midwifery workforce and workload planning. It also sets out a clear accountability structure from ward to board in workforce planning and its associated roles and responsibilities. That is different from the previous process but very much aligned to the preparations for safe staffing legislation in Scotland.

The other aspect that we have included in the refreshed Delivering Care framework that has been mentioned is the common staffing method. The development and implementation of the common staffing method includes the use of appropriate evidence-based workforce planning tools where they are available. Such tools are not always available; where they are not available, professional judgement and local context need to be considered. The tools can be used to assist the assessment of the nursing and midwifery workforce as part of a triangulated approach to support the delivery of safe and effective care. By "triangulated approach", I mean that we look not only at the workforce numbers but at quality of care, demand for services and complexity; all of that is taken into consideration in determining staffing levels.

When we look at our use of agency staff across the system at this time, we see that it is particularly important that we do that very effectively to deliver safe care. I am aware of the challenges that nurses and midwives face day-to-day with corridor care and high demand. Those are not quick to resolve, but having good, effective processes for workforce and workload planning for nursing and midwifery is essential. We are taking a "Once for Northern Ireland" approach to deciding on the most effective and appropriate workforce tools for nursing and midwifery, and the RCN and Royal College of Midwives (RCM) are fully engaged with us in that process. It will allow benchmarking and reduce unwarranted variation, supporting the utilisation of workforce to ensure that we have the right staff with the right skills in the right place at the right time.

The refreshed framework will strengthen guidance to our provider organisations and commissioners in order to ensure that effective workforce and workload planning for nursing and midwifery is embedded in practice, promoting a safety culture and upholding the well-being of the population. It also supports and is needed for transformation. That we need to transform our services is set out in the reset plan and fully embedded in Delivering Care.

The common staffing method provides a consistent approach to aid clinical leaders to understand and evidence the staffing requirements of their healthcare setting. It provides a clear framework that can be used by everybody. Getting the same approach from everybody every time reduces variation and makes for effective workforce and workload planning. As I said, the method involves a triangulated approach, looking at safety and quality outcomes, professional judgement, the utilisation of evidence-based workforce tools that, where available, are appropriate to the area and an understanding of funded staffing versus actual staff in post. It is critical to ask what the relationship is of funded staffing to bed complement, whether there is a consistent approach to that across Northern Ireland and how we measure and capture it in real time. The method also involves consideration of the local context, demand, complexity, capacity and working environment and ownership by the teams that deliver the care and provide the service.

As part of common staffing method implementation, there will be a programme of webinars that will start shortly for all nurses and midwives from band 7 upwards, which is team leader level. That has been provided by colleagues in Scotland who are familiar with the method. We are developing an animation so that all staff can engage with the process and become familiar with the common staffing method.

A population health approach relies on data-driven decision-making founded on robust integrated data that encompasses workforce demographics, cost implications and patient care activities.

Applying a triangulated approach supports the delivery of safe and effective care by ensuring that staffing levels are responsive to patient demand and acuity. That is really important, and it includes the skill mix in the system.

Across the region, all trusts now have the same e-rostering system. We have started an e-rostering group, which, again, is a "Once for Northern Ireland" approach, so that we reduce variation across the different trust areas and have a more consistent approach. Establishing consistent data definitions, standardising reporting and having an integrated rostering practice will ensure that there is good, effective rostering, because that is key if we are to reduce reliance on agency staff etc. That will be implemented fully, and there will be a "Once for Northern Ireland" approach by the end of March next year. That work is progressing.

Finally, this year, we have purchased the licence for five safer nursing care tools. Those have been procured for 24 months and will be rolled out across Northern Ireland in all the trust areas. The workforce assessments using the evidence-based tools will run twice a year, and that will give us real-time data. We will also be able to get real-time data on our workforce, including the utilisation of agency data from the e-roster system, which will eventually need to link in with A-EQUIP. All band 7 staff and workforce leads in nursing and midwifery will be trained in those tools. That work has already started. Those staff will also be trained in the six-step methodology for assessing staffing levels so that there is a consistent approach.

We have just introduced the nursing and midwifery band 7 toolkit, which helps ward managers, team leaders and teams to understand more clearly their roles and responsibilities. It focuses on personal leadership, team leadership, quality and safety, and effective management of resources.

That is where we are with nursing and midwifery. In midwifery, we use Birthrate Plus. That was last done in 2022. That tool is being reviewed across the UK, so we are waiting for the outcome of that before we redo it in Northern Ireland. That will be part of the implementation of the Renfrew work. I am happy to take any questions.

The Chairperson (Mr McGuigan): Thank you very much, both of you. That was a lot.

Mr Rodgers: To summarise all that quickly, what we have learned from Scotland is this: be prepared for implementation. Aine and Maria outlined the work on the preparations that we are undertaking in their respective professions.

The Chairperson (Mr McGuigan): Thank you.

Mrs Dodds: I note that you said — this is in your briefing paper — that you met a number of the trade unions and that they had played an important role in formulating the legislation. When the representatives from the Royal College of Emergency Medicine (RCEM) were here, I asked them whether they had taken part in any discussion with you, and they said no. Yesterday, we all received a letter from the BMA. I will quote directly from that:

and it indicated that this evidence session will be a "useful update". From what people are telling us, it seems that there is clearly a gap. The BMA is also saying that, while it is supportive of the Bill — the intention of the Bill is right — it has:

Do you want to comment on that?

Mr Rodgers: As I said in my opening remarks, we put the policy proposals out for public consultation, so everybody will have had the opportunity to engage. We had very good engagement across royal colleges. It is unfortunate that the Royal College of Emergency Medicine did not get that opportunity or were not able to respond, and, similarly, the BMA. We are open to talking to all the trade unions about the Bill and how it might progress. I am encouraged by the fact that the BMA has said that it supports the direction of travel. We share its concerns about the timescales for progress, and we are trying to get the Bill through before the end of the mandate. We hope to have it with you as early as we can in September so that you can go through the processes that you need to go through. We are hopeful that, by working together, we will be able to progress the Bill. I think that the Committee and, certainly, the Department are willing to speak to the BMA in order to understand any concerns that it has and to see whether they can be addressed.

Mrs Dodds: I do not want to labour the point, Phil, but I raised it because each Committee member received the same email from the BMA. It talked about how there had been "little meaningful engagement". Safe staffing is a huge and important issue, and on the day that we have consultant doctors on strike, it is incumbent on us to engage with people and ascertain their views on such an important issue. I do not want to go further with that, but it is a huge issue.

Mr Rodgers: As I said, we did a public consultation, which was issued to the BMA, but it did not respond.

Ms Owens: Sorry; the BMA responded to the consultation, but it did not respond to a request for a meeting to ascertain its opinion on the consultation prior to the commencement of the consultation.

Mrs Dodds: Rather than prolong this, my advice, for what it is worth, is to talk to the BMA. I will leave it there, because that is important.

The Chair asked whether there will be any figures in the Bill. Will it be almost like a framework Bill with very little information and with everything to be done by regulation? We are not overly keen on leaving everything up in the air, particularly on such an important issue.

Mr Rodgers: The straightforward answer is yes: this is a framework Bill.

Mrs Dodds: Yes.

Mr Rodgers: It sets a framework within which — .

Mrs Dodds: The Bill, as you have proposed it, will be a series of frameworks that will not be detailed. How will you work out the detail?

Mr Rodgers: As Aine and Maria outlined, the detail will be worked out in the guidance that will be produced to support the Bill when it is enacted. There will be requirements in the Bill. As I said at the outset, we will require the trusts to report staff numbers, the number of staff they should have and what is being done to address any gaps. Requirements will be placed on the commissioners at a regional level to use that information to come up with proposals and plans at that level to support us. We in the Department will work on the strategic high-level planning that looks ahead and uses all the information that we are getting in order to determine what that means for use when commissioning places or whatever. I often talk about how the Bill will put a legislative framework around either what we already do or what we should be doing better, which is workforce planning. It is about workforce planning and knowing the number of people that we have in the different settings and the number of people that we should have.

Mrs Dodds: With the greatest respect, we on the Health Committee have been talking about workforce planning since I came back to the Assembly. I mean that with the greatest respect. A framework Bill that does not give much detail means that it will be years before any of it is implemented. I know that there is probably not enough time for anything more than that. That will be disappointing for those people who are eagerly looking for guidance on safe staffing. I have nurses calling my office to say, "I had a certain number of staff on last night. I work on a ward full of patients with very complex needs, so, while I had the required number of staff, I did not have the required expertise".

That is what safe staffing is about, and we need to understand that.

Professor McIlgorm: The work that is being done through Delivering Care and all the work on e-rostering, the combined staffing method, training staff and the production of an annual report has not been done in this way before. The standards and work come from the framework that was set out in Scotland. The framework will provide the legislation on that, but good guidance needs to come from that that sets it all out. We have done it for nursing and midwifery through Delivering Care, but the legislation goes wider than just nursing and midwifery, so that guidance will need to include the other professional groups, as happens in Scotland.

Mrs Dodds: You just picked up on an issue that I was going to talk about: midwifery. Very little of the Renfrew report has been enacted. It talks about a service that is under stress. Daisy Hill is not in my constituency, but I live in a part of the constituency where my constituents regularly use Daisy Hill. Last weekend, in an emergency, its obs and gynae department had to close and everybody was shuffled down the road to Craigavon. I am told that that was because one doctor, who is a junior doctor, was not available to work. The service is threadbare if that is the situation and that is who we are relying on. Am I correct about that?

Professor McIlgorm: I am not over the detail of the Daisy Hill episode this weekend, but, where rota sustainability is concerned, , I know that that can happen. The safe thing to do is to redirect the intake for that period, but I know, from having a maternity services background, that through the maternity programme board the whole sustainability of the workforce in our maternity services will need to be looked at fully.

Mrs Dodds: As a last question — sorry, I feel as though I have been negative. I am not negative about the purpose and intention of the Bill at all, but I am tired, as are a lot of people, of hearing of not only good intentions but a lot of detail and processes that go on and on forever.

We have now had the Adult Protection Bill. I am happy to legislate in that way; I have done a considerable amount of work on understanding the Bill, as has the Committee, and on trying to improve it. However, we have been told that, while we are going to legislate in that way, we can only partially implement it, as and when. What would a safe staffing Bill's position be on both finance and people?

Mr Rodgers: Do you mean on having the finance in place?

Mrs Dodds: We have been told, for example, that we cannot implement all of the Adult Protection Bill and that we can implement only bits of it as and when we can. When we look at the Mental Capacity Act (Northern Ireland) 2016, we see that only one part of it, which is the part pertaining to the deprivation of liberty, has been enacted, but the part that advocates for patients has not. How realistic is it that we will have a safe staffing Bill that has both the finance and the people to support safe staffing?

Mr Rodgers: We have been working closely with colleagues to try to prepare for implementation. Investment will be needed in trusts at operational level to undertake the appropriate levels of workforce planning that we have talked about, as well as the reporting. Similarly, that will be the case at a regional level and probably in the Department. We do not know what that investment is yet; It will become clearer as we work through the legislation. The ambition is that we will have that investment in place, if the Bill progresses into an Act, for the beginning of the implementation phase.

The Chairperson (Mr McGuigan): Normally, at the start of our scrutiny of a Bill, we get an explanatory and financial memorandum (EFM). Are you telling us that we will not get that at the Bill's initial stage?

Mr Rodgers: No. We will provide whatever is normal.

Mrs Dodds: Will that be a best guess? What will it be?

Mr Rodgers: Anything at this stage will always be an estimate, but it will be a robust estimate of the likely cost impact. As I said, there will be a need for investment in the people who will undertake the work.

Ms Morrison: There will be work at a professional level on our next stages. That will be very much about assessing the gap and looking at an implementation plan, which we will absolutely have to cost.

To go back to an earlier point, we have looked at complexity in the guidance. We have divided cases into complex, moderate and minor, and we are trying to allow for a fairly balanced caseload within that. As a result of our ongoing recent staffing difficulties, we have, perhaps, had teams of staff that solely comprise band 5 assessed-year-in-employment social workers. Clearly, that is not where we want to be. We are trying to address that as well.

One of the other bits of work that accompanies this is team composition. I said that this work is one part of a wider package of workforce measures. We have work ongoing that asks, "What should a team in gateway child protection look like? How many senior practitioners and assessed-year-in-employment social workers should it have?". We have also made recommendations, particularly for those people who are early in their career and who are in either their assessed year in employment or the one to two years after that, on moderating the caseload in a way that recognises their stage of career and their skills and experience at that point. All that is included.

Mr Rodgers: Rodney may want to come in here.

Mr Rodney Redmond (Department of Health): I will come in on a few of those points. The Bill will place workforce planning on a statutory footing. We have three elements of workforce planning. There is the operational workforce planning, which is the day-to-day planning on the ground, carried out by the health and social care trusts and organisations. What we see as the middle layer is the regional oversight of the operational workforce planning by our commissioning organisations. Above that, we have our strategic workforce planning, which is a five to 10-year view of the number of staff that we need to train and what our future talent pipeline is.

That organisational workforce planning is being undertaken, but there is not necessarily any consistency across trusts or across the region. The Bill will mandate driving that consistency so that there will be a consistent approach to operational workforce planning across all specialties and services. That will tell us the number of staff that we need, and that will be driven by the work that Aine and Maria just discussed. That will give us a better, more robust and consistent estimate of that and of the number of staff that we have. That will then drive into the regional view of our situation with supply versus demand and how we make the most effective use of our staff across the HSC.

You are absolutely right to say that we have been talking about workforce planning for a long time. Hopefully, the Bill will drive those improvements in robustness and consistency, which are necessary to feed all elements of workforce planning. We will then be able to identify the areas that are of particular stress across the region. We will be able to look at ways in which we can utilise our staff more effectively. Do we need to have specific initiatives for recruitment, retention and so forth? All that is underpinned and supported by the workforce strategy that we are undertaking. For example, we are in the throes of developing a retention framework for our employers. We are engaging with staff, and just this week we have had thousands of responses telling us the factors that would make staff want to remain in or leave the HSC. All that will help us to address the gaps that you talked about. It is about putting that requirement on a statutory footing across the piece so that all organisations can be workforce planning consistently. That is one of the main tenets that will drive the information and intelligence that will help us to plan services in a more effective way.

Mrs Dodds: That means that, hopefully, it will be more than a high-level set of instructions to trusts, telling them to do what they should already be doing.

Mr Redmond: Yes.

Mrs Dodds: I will stop there, Chair.

Mr Redmond: The requirement will be for workforce plans to be produced. That will give us a regionally consistent view from which we can then assess the number of staff that we have, the number that we need and how we go about bridging those gaps.

The Chairperson (Mr McGuigan): I am conscious that we might be getting into the detail of the legislation.

Mr Rodgers: Yes, and you have not seen the legislation yet. Neither have we.

Mrs Dillon: You will be glad to know that I am not going to ask anybody to get into the detail of the legislation, but I look forward to seeing that detail. As Diane just said, you would like to think that the trusts are already doing that work, but there is also a piece of work to do on how well the trusts, the Department and the strategic planning and performance group (SPPG) work together. Nobody could do that in isolation. If it is a case of asking the trusts what they are doing, what they need and how they are going to get it without our helping them, that will not work. I hope that that will all be fleshed out in the Bill. If it is not, we will have problems.

The briefing refers to workforce planning taking account of "local contexts". It will not come as any surprise to you, given that I am a representative from Mid Ulster, to hear that my particular concern about the local context is the rural element. Obviously, you have a greater challenge with recruiting and retaining staff in rural areas. I want to make sure that there are things in the Bill that will support those areas. I am very lucky, because one part of my constituency is very close to a number of hospitals, particularly Craigavon Area Hospital, but some areas, such as those that are covered by the Northern Health and Social Care Trust and those that are in the middle, such as Pomeroy, Kildress and Rock, are very far away from any service. I want to make sure that the Bill has protections for rural communities. If you could give me some reassurance about that, I would really appreciate it.

Mr Rodgers: I certainly expect the planning tools and the tools that Maria and Aine described to recognise local circumstances, whether they be rurality, distance or whatever.

Professor McIlgorm: As part of the workforce planning process, you factor in things such as rurality, travel distance and the potential use of technology, as opposed to bringing people to places. There are lots of different things that you factor in for context, and that would need to be very clearly set out in the guidance.

Mrs Dillon: The other questions that I had have been covered. I will just add to what Diane said: bring them with you. This is something that the royal colleges want. They are keen to be part of it. If they are not responsive but you can show that you have done everything that you can to engage them, that is different, but you have to do more than just say, "The consultation went out". They are not like the rest of the public when it comes to a consultation on something such as this; they need to be part of it and fully engaged. That is just a comment; you do not need to respond.

Mr Donnelly: Thanks very much for coming today, and thanks for your presentation. The Bill is long awaited, so I absolutely welcome it. Lots of staff are very keen to see it. I declare an interest: I come from a nursing background, having worked as a nurse in the health service.

I read recently that, as of 31 March, there were 1,875 nursing vacancies across Northern Ireland spread across our hospital wards. That is felt. A lot of staff feel overworked, overstretched and overburdened. That stress and strain has a physical and mental impact on them. We talked about retention. How will the Bill improve the stress and strain that our staff are feeling because of the burden that is being put on them?

Professor McIlgorm: From my perspective, it is very hard to have visibility on a day-to-day basis of the workforce data that you are talking about, Danny. By developing the e-roster system, real-time data will be produced that will feed into workforce plans not just annually but regularly.

That will then be seen as part of the safety culture in the trusts. That visibility is really important for health staff so that they realise that they are being listened to and that people understand the pressures that they are working under.

The other aspect is to make sure that we have identified the right establishments for each of the areas that we are working in. It is very hard to differentiate that at the moment. When I look at the utilisation of an agency, I am not currently able to say what it is being used for. Is it being used for additional beds in the ward or corridor beds or because we have not factored in the predicted absence allowance when people have been doing their roster duty. There are many unknown factors at the moment, so it feels very overwhelming. Staff and team leaders having that knowledge will be really powerful because it will allow them to actually articulate the pressures that they feel rather than just sounding as though they are under pressure. It will give them really hard evidence of what is happening. They will also be able to demonstrate acuity and complexity in the wards, and it will allow us to benchmark across Northern Ireland, which is really important. It will allow us to see whether a 30-bed respiratory ward in the Western Trust is staffed in a similar way to a 30-bed respiratory ward in the Belfast Health and Social Care Trust. There should not be much variation there. That system will give us much better information for staff to work with and will put the power back in their hands when it comes to not only escalating concerns but doing so with data. That cannot be argued with. That is a good place for staff to be in.

Mr Donnelly: Absolutely. That sounds as though it will be a powerful change. I certainly hope that it will be.

Professor McIlgorm: In Delivering Care, the accountability framework goes from the ward to the board. That is very clearly part of the new quality and safety measures. If your workforce is challenged, inevitably, the safety of your care can also be challenged, so it is really important that we get that right.

Mr Donnelly: Nursing is a safety-critical profession. If we do not have enough nurses, patient safety could be compromised.

Professor McIlgorm: Absolutely.

Mr Donnelly: Although there will not be hard figures in the legislation, I am glad that you mentioned the use of tools for measuring. Standardised evidence-based tools are very important. I know that tools are used regularly, such as the baseline emergency staffing tool (BEST), which is used in A&E, and the safer nursing care tool (SNCT), which is used in acute wards. Are those the tools that you are talking about? If so, will they be mentioned in the legislation, and will the need for them be mentioned in the legislation?

Professor McIlgorm: Yes. If there is an evidence-based workforce tool for an area, it will be mentioned in the legislation. However, that should not be specific, because those tools will change over time and others will emerge. We have been having conversations with colleagues in Scotland, and they have agreed that we can utilise their tools if necessary. Northern Ireland is probably too small to develop its own evidence-based tools, but there are tools that we can utilise. We have gone with the imperial tools for the moment. We have funded their use for two years, and that will be implemented. The training is ongoing and will run twice a year. At the end of this year, we will have had the first run of that. I expect to have the trend for that over time by the following year, then a decision will be made about whether those are the right tools for Northern Ireland. The RCN is very supportive of that work, but it is a test, because there are lots of different tools. However, those are the ones that we know have been evidenced-based.

Mr Donnelly: Phil, in your opening remarks, you mentioned the fact that this has been co-designed with the trade unions. Diane mentioned the fact that neither the Royal College of Emergency Medicine nor the BMA have been involved. Linda, I think, picked up on that as well. Those are key stakeholders, so I am quite surprised to hear that they have not been involved or engaged with. If we were to ask the trade unions about co-design, would they tell us that they feel that the process has been co-designed?

Mr Rodgers: If you spoke to Rita Devlin, I think — I hope — that she would say that it has been.

Professor McIlgorm: I think that she would say that.

Mr Rodgers: I think that she would.

Mr Donnelly: We will be asking her. [Laughter.]

Professor McIlgorm: She works very closely with us.

Mr Rodgers: If you think back to the start of this evidence session, you will find that I said that the Bill started as a piece of legislation for the nursing profession. Rita and the RCN have been very much involved from the beginning.

Mr Donnelly: You are quite confident about that, but I agree with those who asked you to engage with all the stakeholders, because their input will be invaluable to the legislation.

Mr Rodgers: We are happy to do that. As Andrea outlined, the BMA responded to the consultation but did not respond to an invitation to talk about it. We will follow up on that.

Mr Donnelly: You mentioned reports. What reporting mechanisms will exist if organisations fail to meet the requirements? What will be the enforcement? What teeth will the Bill have?

Mr Rodgers: Do you want to take that one, Andrea?

Ms Owens: It is all about accountability and transparency. We are not talking about extreme circumstances, such as those that led to the decision to close the ward in Daisy Hill. We do not want that. We are setting the tools to improve the service. We recommend a full report and interim reporting so that there is accountability. There has to be transparency. If things are going wrong, that information will be out there for everyone to see. As mentioned, we will then need the action plans for all the levels so that we can see where the system has fallen down and where it can be improved. There will be a constant cycle of improvement, and we will always be improving. Once we reach a steady state, we will not say, "That's us"; we will have to keep improving to make sure that we stay ahead of things, if we can.

Given that the legislation is dealing with public health, we cannot mention any of the standard punishments, if you like, such as financial penalties or closure, because that will be of no use to anybody. This process will not fix every problem, and we are aware of that. Whenever humans are involved, there will always be some kind of risk, but it is about saying who is accountable for the risk and what they are doing to address it. That information will be transparent and out there for everybody to see.

Mr Donnelly: Where is the accountability, and what will happen if the issues are not addressed and places are running while being short-staffed?

Ms Owens: The accountability will go right up. It will not be based just at trust level; the reports will go through the chain of reporting. The reports will go to the trust, the SPPG, the Public Health Agency (PHA), the Department and even higher if necessary. They can go right up. When we get to punishment level, we do not want to close hospitals, but, again, it is about being accountable for where we have gone wrong and trying to make that right or better and to stop it happening again.

Mr Donnelly: It should all be based on patient outcomes. We hope that outcomes for patients will improve; that is the point of doing this. How will the Department measure the impact of the legislation on patient outcomes?

Professor McIlgorm: If you go back to the common staffing method, which uses a triangulation approach, you will find that we look not just at the workforce numbers but at workforce numbers, quality of care, complaints and safety indicators. All that data is then triangulated. For example, if I were running with a low workforce and the number of complaints and incidents were going up and the quality was changing, that would be seen in the round rather than each area being treated as separate aspects of our service delivery.

The process for a statutory framework for safe staffing gives very clear evidence of and transparency in what is happening. That needs to be supported by good data across the common staffing method. That does not mean that you can get nurses or midwives immediately; there is training, a supply line and a turnover rate to consider. You know that you can have high sickness levels or maternity leave at any time, but, through those trends, the process will allow clearer and better sight of how supplementary staff, such as bank or agency staff, are used. That will give you better and much more detailed information that we do not have in Northern Ireland at this time.

Mr Donnelly: I have heard from staff that they are being pushed towards bank shifts. As you know, when you do a bank shift, you are paid your basic rate. If those who have worked their full complement of hours, which is 37·5 hours, are asked to do extra shifts and are pushed to do them on a bank as opposed to through overtime, is that fair on them? Are you aware of that happening?

Professor McIlgorm: Yes, I am aware of it. There is a variation. Some staff will have worked full-time hours. As you know, we have a big percentage of staff who do not work full time, so those additional hours will be paid at their grade as though they were working full-time hours. Doing that on the bank is the right thing to do. We are accountable to the public for how we utilise our funds across the service. Overtime arrangements are an area of negotiation.

Mr Rodgers: Yes, that is part of the —.

Mr Donnelly: It would be more attractive to those staff if they were paid on an overtime rate when they did overtime rather than being pushed directly towards —.

Professor McIlgorm: That needs to be negotiated, but I hear what you say.

Mr Rodgers: I suspect that, if you are hearing that, you will be aware of the ongoing work on agency reduction. We are trying to push people from agency to bank. That would help. If a shift is unfilled because of sickness or for whatever reason and needs to be filled but not by a substantive member of staff, the options are overtime, bank and agency, which should be the last resort. The trust and the ward managers will make the decisions on what people should do.

Mr Donnelly: If people are doing more than their 37·5 hours, that should certainly be reflected as overtime.

Mr Rodgers: Any hours above their full-time hours that they do should certainly be paid at overtime rates.

Professor McIlgorm: That needs to be looked at on the basis of asking why people are using the supplementary staffing, Danny, but also on the basis of, for example, whether somebody is full time or part time and whether they want to do the additional hours but within their 40 hours. It is hard to have it completely set. There needs to be a range in that that people can use. However, we need to move away from agency utilisation in Northern Ireland. We have had huge expenditure on that, which is why this is really important for understanding what we use agency for.

Mr Donnelly: When you have higher rates at agency and lower rates at bank, it encourages people to go to the agency — of course it does.

Professor McIlgorm: Yes.

Mr Donnelly: I really look forward to seeing the legislation. I share the concern that we will not have a lot of time to scrutinise it. If we get it in September, that will give us six months, effectively, and there will be gaps in it at a time when we will be looking at other legislation. It will be intense, but I very much look forward to it. Thank you.

Mr Rodgers: I appreciate that. We have met Keith and his colleagues to see how we can better work together when the legislation is with you and you are going through Committee Stage. We will try to work as best we can with the Clerk and the Committee to progress it.

Mr Chambers: I have a couple of questions. I will ask them all at once, and the panel can reply to them all at once, if that suits.

I appreciate that there is a regional overview of all this and that frameworks and benchmarking will be deployed across the various settings, but there will always be an individual setting that does not fit into a pigeonhole. In such a case, where the trust has to decide what a safe staffing level is, is there a danger that that judgement could be clouded by budgetary concerns or a lack of budget? If staff in any setting have concerns that safe levels may have been cut a little too fine, is there a mechanism in the Bill whereby staff can ask the Department to arbitrate or look at the level that the trust has set? The Chair talked about shortfalls, such as a psychiatric ward in the Western Trust needing 10 nurses but having only five. He asked what would happen, and you said that you would encourage them to recruit and blah, blah, blah. Danny just asked these questions: how long will that go on, and what will be the enforcement at the end of all that? If I heard you right, you said that you are reluctant to go down that road and that you will escalate it up various levels. However, if something goes horrendously wrong while you are elevating it, looking at it and encouraging, where does the buck stop?

Mr Rodgers: OK. There were a few questions there. The first one is probably for difficult settings. It is about using professional judgement. I will invite Maria or Aine to say something about that.

Professor McIlgorm: Usually, for difficult settings or if there is not an evidenced-based tool that could be applied to that staffing level, it is about professional judgement based on the number of beds, the staffing or the complexity of the patients. If the situation is in a community setting, there is a similar approach. In the community setting, it may be that you have a certain number of caseloads or there are a certain number of nurses for a population group; it may be 1:10,000, which, I think, it is for some areas. You apply that methodology to that. There has to be a level of local context that takes that into account, and that is built into the process through the common staffing method as well. That is a process that people can work through, but it is a consistent process that will now be applied to every area every time in Northern Ireland, which is the right thing to do. There will be variation initially until people become more familiar with the utilisation of that process. There needs to be training on it, which we are starting, but that will take a while to roll out. You want everybody who is doing anything to do with workforce planning to be trained in that process, because it requires a level of skill and knowledge. That is really important.

Mr Chambers: If a member of staff — you would maybe call them a "whistle-blower" at some point — feels that the level of staffing is not sufficient and is causing a risk to patients, is there a mechanism to deal with that, and who would arbitrate on that?

Ms Owens: We propose that there be visible risk-escalation processes in the legislation. When we talk about risk escalation, we are not talking about it at a high level; we are talking about it at every level. That should be transparent, and everybody should know, "If this is wrong at my level, I go here. If that doesn't happen, I go here". That way, if the escalation is not being followed through those transparent processes, constituents could go to you and say, "This isn't being processed or followed". It is in the legislation that there should be risk-escalation processes.

Mr Chambers: If a whistle-blower goes to somebody and that goes to another level and another level, is there a danger that it can get lost and people would be discouraged from whistle-blowing because they feel, "What is the point? This is not getting acted on"? They do not see what is going on behind the scenes.

Professor McIlgorm: In the Scottish legislation, one of the key things about escalation is that documents are recorded so that there is an evidence-based trail of escalations. That is important, and there are systems that we can utilise to do that across the trusts. The other point about escalations is that sometimes a staff member might think, "This feels very busy to me", but a more experienced person might say, "Actually, that is not unsafe, because there is not much complexity" or, "You have a fair complement of staff". There has to be a bit of that in the process. Charge nurses are skilled at that, and they do it every day. However, it is also about the demand for those services, whether we are seeing an increase in demand for services and how we respond to that. The big thing about escalations is that they should be documented, captured and monitored and be part of the workforce plan. Your annual workforce plan details the number of escalations that you have had in a year, as well as everything else, so that is a really important part that needs to be built into any guidance for the process.

Mr Chambers: The big question for me is this: if something were to go wrong during that vacuum when you are trying to work staffing numbers up and get them to sufficient levels, where would the buck stop?

Professor McIlgorm: Accountability for day-to-day operational matters needs to be at board level. Escalation from the board would be to the SPPG — the commissioners — and then into the Department.

Ms Morrison: I will come in on some of that. You talked about a concern that safer staffing might be decided on the basis of budgetary implications. I hope that we would avoid that, given that we have recommended caseload ranges. Although professional judgement may be exercised within those, a standard is set. This is the first time that we have had standards set for social work, so it is a significant move. The profession welcomes there being a standard to work to that gives us guidance. We have built into the guidance escalation and the importance of contingency planning — we talked about that — when a team does not have the required staff. We hear a lot of discussion about what happens when a staff member is feeling under particular pressure or there are known vacancies in the system. Again, we rely heavily on the professional supervision process to allow staff to air such concerns, and that very much forms part of our recommendations on what needs to be discussed about caseload and workload.

Mr Chambers: Thank you.

Mr Robinson: Phil, just help dispel the concern about this that is in my train of thought. I listened to you intently. You said that locums are brought in to cover. I presume that, in the legislation, there is a heavy onus on the trusts: is that correct?

Mr Rodgers: Requirements in the legislation will set out the things that the trusts, the commissioners and the Department are expected to do.

Mr Robinson: The trusts are already expected to deliver millions upon millions in savings. This is where my mind took me when you talked about locum cover: ultimately, will the endgame and outcome of this — I hope that I am on the wrong track here — be that, in order to fix the issue, more money will be spent on bringing in locums, when, according to the figures that we were given, half a billion pounds has already been spent on locums in the past three years?

Mr Rodgers: Our expectation is that the outcome will be that we will employ not locums but substantive staff.

Mr Robinson: Substantive staff.

Mr Rodgers: You identify the number of people whom you need in a particular service. You then identify the number of people whom you have in that service. The requirement will be to detail the actions that you are taking to address the gap. We would expect that, in most cases, the actions will be to increase the number of substantive staff who are delivering the service.

Professor McIlgorm: It needs to be focused on population health need. It comes back to the Chair's conversation with Phil about psychiatrists. I am not a psychiatrist, so I will not comment for them, but, if our population health needs are changing in that more people require geriatric psychiatry services, for example, that may be the workforce that we need. However, it is also about asking how psychologists and members of the wider healthcare team, such as occupational therapists and nurses, can contribute to that. How can you redesign your services so that you do not just ask for the same workforce as you have always had and that may have been suitable 20 years ago for services that could be delivered differently today? That is part of the effective workforce planning that we need to do so that we can respond to and ensure the sustainability of services whilst maintaining good outcomes for people.

Ms Morrison: We also hope that having safer staffing guidance and standards in place would eventually lead to staff feeling more supported and stable in what they do and that that would reduce sick leave and pressure, which in turn would reduce the need for any form of temporary staffing.

Mr Robinson: OK. We look forward to September.

The Chairperson (Mr McGuigan): Thank you very much. Do not be delaying in September. [Laughter.]