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Item 4 is a round table with stakeholders to discuss key themes and issues facing the NHS in Scotland. It is intended to inform the committee’s discussions on its future work programme. I welcome Dr Sue Robertson, who is deputy chair of the British Medical Association’s Scottish council; Donald Morrison, who is a general dental practitioner with the British Dental Association; Ross Barrow, who is vice-convener of the Allied Health Professions Federation Scotland; Graeme Henderson, who is executive director of delivery and strategic development for the Scottish Association for Mental Health; Kate Seymour, who is head of advocacy for MacMillan Cancer Support; and Colin Poolman, who is director of the Royal College of Nursing in Scotland.
With six witnesses, we have a little bit of housekeeping to go through. I have asked committee members to direct their questions to specific individuals. If any of the witnesses wish to come in and add anything, please use the chat function; if you put an R in the chat box, the clerks will relay that back to me. I will try to bring you in as much as possible, rather than have everyone answer the same question—we do not have the time for that, sadly.
First, however, I want to open things up by asking a question of everybody—this will be the one exception to the housekeeping rule that I just set out. What do you want the Scottish Government to prioritise in the health and social care portfolio—not only the portfolio of the Cabinet Secretary for Health and Social Care, but the relevant ministerial portfolios—over the next five years?
Good morning, everybody, and thank you for having us.
What do we do for the next five years? We need to address the vacancy rates in the NHS in Scotland, and the fact that the workforce is exhausted. The vacancy rates are high, and demand has gone through the roof. The public messaging around the Scottish Government’s NHS recovery plan states that we can increase capacity to 110 per cent, but there are no realistic plans to increase the workforce in the short term. We think that that creates a perfect storm.
We want to engage to try to find solutions. I was struck by what Professor Burns said in the previous evidence session: that we can create wellbeing by creating an environment where people feel safe and supported, and that “hopelessness and helplessness” create ill health. There are staff in the NHS in Scotland who feel hopeless and helpless; they are keen to engage, but nobody is engaging with them. There is abundant evidence that workforce stress in healthcare organisations affects the quality of care for patients as well as staff health. Prioritising staff health and wellbeing will allow the NHS to retain the staff that it has and make it a better place in which to work.
I offer my apologies to Dr Vipin Zamvar—I stupidly did not read to the end of my list of witnesses, and I did not include you in that list. I will come to you now for your asks of the Scottish Government in its prioritisation.
10:45
Hello—can you hear me, convener?
Yes, we can hear you perfectly.
Thank you for inviting me to the meeting. I am here as the chair of the British Association of Physicians of Indian Origin. I have seen the five-year recovery plan, and I would like to mention a few things. There are issues that affect black, Asian and minority ethnic doctors in particular, and I am here to raise the issues that affect that group of medical professionals. About a third—
Your picture appears to have frozen, Dr Zamvar.
We hope to come back to Dr Zamvar once his connection is re-established. I will bring in Donald Morrison.
Thank you for letting me speak today. For context, I have been a general dental practitioner—a high-street dentist—for nearly 25 years. I worked in the NHS in England for 10 years, and for the past 14 years, I have worked in Scotland. I currently run and work in a practice in Ayrshire; it is a mixed dental practice, and we are responsible for nearly 6,000 registered NHS patients. Today, I am speaking on behalf of the British Dental Association Scotland. Just for the record, I am feeling really nervous. I have not done much of this before, so I will try not to make a fool of myself.
The main thing that I have to say on behalf of the profession—I suspect that I will sound like a broken record—is that, prior to the pandemic, the Scottish Government acknowledged that the NHS system under which dentists were working was broken, or was not fit for purpose. We were in conversations to try to find a funding model and a sustainable plan to move dentistry forward. That seems to have been dropped completely, and the worst thing is that there has been very little communication—or at least meaningful, timely communication—between the profession and the Scottish Government. We beg the committee to look closely at that over the next five years, so that we can discuss the needs of our patients and the needs of the profession in a way that allows us to move forward and come out of the dark ages of dentistry, which is how it feels just now.
Dentists will often talk about the treadmill, given that we work piecemeal in a fee-per-item system. The situation was bad before the pandemic, and Covid has really shone a light on the issues. The situation feels particularly dark and difficult just now. Obviously, we want the Scottish Government to look at funding and engagement, but, most importantly, we want it to engage meaningfully with the profession and to discuss the issues with us so that we can help to develop an approach that enables us to look after our patients properly.
Thank you for inviting me along today. I am here on behalf of the Allied Health Professions Federation Scotland. We are a multiprofessional grouping of 12 professional bodies that represent allied health professionals across Scotland. For context, AHPs make up the third largest workforce in NHS Scotland, with a head count of 14,000 staff who are employed across a range of settings, including acute care, primary and community care and social care.
It is a critical moment for all the professions that are represented here today. As we look to recover from the pandemic, AHPFS is looking for recognition of the fact that AHPs have a lot to offer in the current agenda by using their unique skills and training to treat people in all the settings that I just outlined. Critically, that includes treating people closer to home in primary and community care, in order to focus on supporting people in their communities and reducing the burden on acute care—which was significant before the pandemic and is even more significant now—and waiting times for surgery. Allied health professionals are able to offer solutions in the community.
If we could ask for only one thing—it has been mentioned before, and it will be no surprise—it would be to address workforce planning, which is a key issue that affects all our professions.
It affects us all in slightly different ways, as we are a multiprofessional grouping, but, whether the issue is that there are not enough posts for AHPs in particular settings or whether it is that there is a high number of vacancies—perhaps we can get a chance to talk about those issues later today—we really need integrated allied health professional workforce planning. That has not been on the agenda, or at least it has not been addressed in the way that we would like it to be. The AHPFS would be delighted to be part of a solution by offering what we can to alleviate some of the workforce challenges across Scotland.
We will look in depth at some of the issues around the workforce and workforce planning. Dr Zamvar is now back with us, so I ask him to finish off what he was saying before he was accidentally thrown out of the meeting.
Hello—can you hear me now, convener?
Yes.
I am sorry—when I lost the connection previously, I kept on talking, so I do not know exactly what I was saying when the connection went down.
You only got about a sentence in, so you can start from the beginning.
I will tell you what we would like to see in the next five years, if that is what the Scottish Government is planning for. I represent the British Association of Physicians of Indian Origin. We would like race equality and race relations to move up the agenda for the NHS in Scotland. About one third of the medical workforce in Scotland are either international medical graduates or doctors from a black, Asian and minority ethnic background. A significant portion of that major part of the workforce feels that they do not have a level playing field in terms of career progression in the NHS. Differential attainment starts early, during examinations in medical colleges and postgraduate examinations, and it carries on throughout their careers as doctors and consultants in the NHS.
There is a lot of data about that issue from England, but published data from the Scottish Government is missing, or is at least very limited. The recent “Medical Workforce Race Equality Standard” report, which was published in England, looks at the different issues affecting the differential attainment of doctors in the NHS in general and in the academic part of portions of the NHS. I suggest to the Scottish Government that there should be a similar report in Scotland, because such reports bring out the great disadvantage that black and minority ethnic doctors face. That disadvantage not only relates to their employment; it also involves their regulator, the General Medical Council. BAME doctors are referred to the GMC by NHS employers at twice the rate of their white counterparts. Further, the GMC processes and outcomes are, or appear to be, harsher for BME doctors. There are many anecdotes relating to that, including some from Scottish hospitals, but this is not the time or place to mention them.
In the next five years, as we come out of the pandemic and press the reset button, race equality should move up the agenda. In addition, as we catch up with the Covid backlogs, a lot of extra work will need to be done. We would like the staff grade and associate specialist doctors, not just the consultants, to play an important role in that.
Good morning, everyone. I have been trying to unmute myself—I forgot that you guys are in control of that.
I will address three points that were in the SAMH manifesto on “Standing Up for Scotland’s Mental Health”, which we shared with most members of the committee ahead of the elections, and then I will deal with a fourth issue, around social care reform.
The first thing that we call for is for children to get help when they ask for it. We still have upwards of 7,000 young people being rejected from child and adolescent mental health services referrals. I know that the Government does not like the term “rejected referrals”, but we will continue to use it until there is a change in the system that prevents people from missing out on services.
We would also like an increase in psychological wellbeing support, such as talking therapies. There are still people waiting for months when they have been referred for psychological support. We want a more accessible service so that people do not have to go on waiting lists. We would also like more community support to prevent suicide. We have been supportive of the Government’s approach in its document “Suicide prevention action plan: every life matters”, and of the work of the national suicide prevention leadership group, which we will continue to support and work with.
With regard to social care reform, Derek Feeley made many recommendations in his “Independent Review of Adult Social Care in Scotland” report, which we very much support. Dr Robertson and Mr Barrow each made a point about the workforce. The social care workforce is under great strain; we have a high vacancy level, high turnover and high levels of burnout. We have people who are off sick long term with long Covid. We are really struggling to help our colleagues in the NHS and local authorities to move people out of hospital. As an example, just the other week we spoke to Glasgow City Council about delayed discharge in relation to 34 people in in-patient psychiatric beds; there is no social care for them to enable them to leave hospital. That situation has a knock-on effect through the whole system. We would like social care reform to involve actual reform, not just tinkering around the edges.
Good morning and thank you for the invitation. From a cancer perspective, we have the immediate challenge, which has been caused by the pandemic, of the disruption to diagnosis and some treatment. There is a backlog that needs to be cleared as urgently as possible. Thousands fewer people have come into the system than we would have expected. When more of them come through, they will have more complex needs and, sadly, they are likely to be diagnosed later. That is a huge challenge.
Looking to the next five years, we would like to see effective delivery of personalised care. That involves looking at the full needs of the individual, including their emotional, psychological, financial and practical needs. If we do that well, it will have a very positive impact, not just on the individual but in reducing pressures on the system. It will also help to reduce health inequalities, which are a big issue for us in Scotland. We are very proud of the transforming cancer care programme that we have with the Scottish Government, which is looking to do that in a different way by working with local authorities and the NHS.
We need a radical approach to looking at the workforce. We recently published a report called “Cancer nursing on the line: why we need urgent investment across the UK”, which looks at the challenges for specialist cancer nursing. We also need to look at the workforce in relation to a whole-skills mix and at the opportunities that the integration of health and social care in our system gives us. We need to make sure that all the different aspects of the workforce that other witnesses have talked about work together and are really integrated when it comes to planning and delivery.
Good morning and thank you for the opportunity to come before the committee. Our members are telling us that never in their careers have they experienced greater pressure than they have experienced during Covid. We know that it has highlighted long-standing problems in health and social care, including with workforce planning, which has not been up to what we require it to be. We have not been able to guarantee safe staffing levels. Pay and reward are also important, as is the support that we need to continue to put in place for our staff.
11:00We believe that workforce pressures are key to what you require to look at over the next five years, and that covers a huge number of aspects. If we do not have the correct workforce in the correct place, we cannot deliver what is required for the needs of the population. In the past, workforce planning has been financially driven, but it must be driven by the needs of the population instead. As colleagues have pointed out, we are at a critical point, but we can look back and learn from the past and not make some of the assumptions that we previously made, which have landed us where we are.
Recruitment and retention get mentioned in the same breath, but they must be split up. We need a recruitment strategy that covers us in the medium to long term, as well as a retention strategy that is sustainable enough to allow us to get through what we are going through just now and to move on from Covid. When we talk about recovery, we have to have much more detailed plans and considerations.
I was struck by the previous witnesses’ comments about the importance of listening to the clinicians on the front line. You will not surprised to hear that, as someone who is speaking on behalf of the RCN, I absolutely support that. If we do not engage with our clinicians and ask them to come forward with solutions, we will not get to where we need to be.
Thank you. It has been really helpful to hear from all of you on the general priorities. My colleague Paul O’Kane will direct his first question to a particular witness, but anyone else who wants to comment should put the letter R in the chat function.
I thank the panel for their helpful introductory remarks, which touched on a number of key themes including in particular the pressures that are being experienced in our NHS, the pressure on staff and the staffing challenges that we face.
I am keen to get a sense of what you think about the Government’s recovery plan. There have been a variety of responses to its publication. For example, Dr Lewis Morrison of the BMA has said that it is at best “only a start”, and I have heard the RCN highlight the point that has just been made about the pressure on staff and whether the plan does enough to address staff burn-out and stress. Dr Robertson, will you tell us what confidence you have that the recovery plan will deliver the required transformation?
I mentioned the public messaging around the recovery plan. The Scottish Government has told the public that we can increase capacity to 110 per cent, but as far as we can see, the plan contains nothing realistic that will deliver that or increase the workforce in the short term. New treatment centres have been talked about, but they need new staff. We cannot just move the deck chairs by taking staff from one place and putting them in another, because that will leave no staff at the first place. We just do not have enough medical and nursing staff, AHPs or social care staff. If that is not addressed in the short to medium term, we will not be able to deliver what we are trying to deliver now, never mind increase capacity.
The public messaging makes it harder to be a front-line member of staff. Even before the pandemic, a dignity at work survey that was carried out showed that a third of doctors were suffering emotional and verbal abuse from members of the public. That comes from the public not being told what is really happening and what they can really expect from the service. The people in the service are all working at and possibly past their maximum capacity, and they are tired and exhausted. They feel that they have little control over their work environment, and often the culture that they work in is not ideal, either.
I suggest that committee members consider reading the GMC publication from November 2019 “Caring for doctors, Caring for patients: How to transform UK healthcare environments to support doctors and medical students to care for patients”. We could include healthcare and social care staff in that, too, but of course the GMC concerns itself with doctors. If you read the eight key recommendations, you will see that they are based on the three themes of autonomy and control, belonging, and competence—or ABC. That means people having a voice, having work conditions that are appropriate for them, being able to work in a team and having a culture that allows them to feel that their voices are valued. It also means people being able to manage their workload; being allowed to learn, train and develop; being allowed to be part of the solutions; and working as a team to do that. However, none of that can be done if there are not enough staff on the ground.
The plan talks about recruiting people from overseas. That is a longer-term measure. The most important thing that we can do now is to retain the valuable staff that we have and give them places and a system that are better to work in. We will then recruit easily. If we retain our present short-term and medium-term staff, we will be able to deliver the service that we have now. I am not sure that we can deliver any more than we are doing at present, and that needs to be addressed. However, if we retain our short-term and medium-term staff, recruitment will be much easier because the NHS will be a better place to work. That debate goes all the way back to the Sturrock report in 2019, which examined workplace culture.
We need proper workforce planning. There is still a lack of clarity about the plans for GP recruitment. We were told that there would be 800 more GPs by 2027, but we have no clarity on how that is to be achieved. We still do not know what the plan is. If we do not know that, I am not sure that anybody will, but I would love to know if somebody else at the meeting is aware.
We need more than soundbites; we need action. We need to consider the culture, retain the workforce that we have and involve it in finding solutions.
That is key. Retention has been identified across the board as being important, and successfully encouraging people to stay in the professions is about culture. Does the Royal College of Nursing want to add anything, particularly on the comments about burn-out in the nursing profession? [Interruption.]
We will just wait for broadcasting to unmute Colin Poolman.
Speaking only to oneself is never good.
Dr Robertson is absolutely right. We really need to look at what we need to do to retain staff. We need to allow staff time to rest and recuperate. They have been through a horrendous time and they were already working in a pressured service. That might seem basic, but we need to get back to basics for the staff. We need to think about safe staffing levels and simple things such as ensuring that people have rest breaks and work their contracted hours. We also need to think about offering them a good work-life balance, as well as the support systems that we need to put in place. We are improving the support systems—I have to acknowledge that—but we need to do more.
It comes back to having a sustainable retention plan. We talk about recruitment and retention in one breath and pass over it, but they are two completely different things. We need to think specifically about how we keep people in the workforce. The nursing workforce has nearly 5,000 vacancies at the moment. That is huge. How do we retain in the service the people who might be considering flexible retirement? We need to look at that.
I come from a professional organisation—a trade union—and you will not be surprised to hear that I believe that pay is a major element that we need to consider. Pay for all healthcare workers has not kept up with inflation over the past 10 years. We need to look at that.
I agree with Dr Robertson that we need to work at making the NHS and social care in Scotland places that people want not only to come and work in, but to stay in.
I have been in social care for just over 30 years. I am a registered nurse—I came from the NHS. When I joined social care at SAMH, we had parity of conditions with the NHS or local authorities and our salaries were all tied, typically, to the local authority bandings. Over the past 30 years, that has been eroded. Competition has been allowed to run like wildfire through the social care sector, and we are now mostly paying people on the Scottish living wage. We cannot compete, and we often lose people who go into social work, back into education or into nursing. We have very few nurses working at SAMH. We have about 600 staff. When I joined, we had many nurses and they were on equal pay with their NHS colleagues.
We are not in it for the money, but if our salary conditions are eroded over time, it becomes difficult for people to feel valued as equal partners when they are doing the same work. It is important that individuals in the social care world are given equal value to that of their colleagues. Sue Robertson and Ross Barrow have made points about how we are all in it together and we are all interdependent. We have to work together, and the point about valuing the social care workforce is a really important one.
I agree with what other panellists have said about the recovery plan. Of course we need a mobilisation recovery plan—no one would deny that. However, there is an element—sadly—of putting the cart before the horse. What we actually need is a workforce plan, which is what everyone has commented on.
The challenge around the recovery plan concerns the mismatch between patient expectations and the reality of what is happening on the ground. I hope that you do not mind if I run through some examples of that. I am sure that you are familiar with these points, but I want to highlight them. There are people who have gone without treatment during the pandemic because their needs have not been classified as high risk. There are people who have developed complications during the pandemic as a result of shielding, for example, or of being unable to get out and about. There are people who are experiencing long Covid and are suffering due to the challenges of that.
A mobilisation recovery plan is great, but there must be a workforce plan at the heart of it, not only for AHPs but for all the professions and services that are represented round the table. It must identify where we can get the right people at the right place and at the right time to tackle each of the three challenges that I have just mentioned. I reiterate that a mobilisation recovery plan is great, but it needs to be fully integrated with an understanding of where the workforce pressures and needs are. From an AHPFS perspective, that is where we would like to start.
We have heard from Sue Robertson—and indeed from the whole panel—about the difficulties that we have with staffing. Adding race inequality on top of that makes life for BAME staff even worse. What can we do to improve race equality in our NHS?
We should talk about it and acknowledge that there is a problem, or at least a perception of a problem. That would be the first step. I do not know how many of you have seen the “Medical Workforce Race Equality Standard” report, which was produced by NHS England just last month. There is a race equality report for all NHS staff, but the MWRES report focuses on the medical workforce and it has brought out the stark inequalities that BAME doctors face. As a first step, we should do something similar in Scotland. That would mean that we at least knew what the problem was so that we could start to address it.
My second suggestion is that we look at why NHS employers refer BAME doctors to the GMC more often and whether anything can be done to solve the problem at trust level rather than it having to go to the regulator—the GMC. Those suggestions would help to address the problem.
11:15
We will move on to discuss Covid-19 and the backlogs, on which Emma Harper will lead.
Over the past few weeks since the recovery plan was published, we have heard that there will be a need to address backlogs in the diagnosis of cancer—including breast and bowel cancer diagnostic processes and cervical smear tests—ophthalmic surgery and cataract treatments and hip and knee replacements. How will we address that demand? During the pandemic, elective work basically stopped. Even now, the intensive care units are filled with Covid patients rather than, for example, elective bowel surgery patients. Where do you think that the backlog of surgery requirements and diagnostic testing needs to be tackled?
Who would you like to answer that first?
Dr Sue Robertson.
It is a massive problem. We were under great strain before the pandemic. We have changed the way that we do everything, at least temporarily, and some of those changes will remain. The backlog of people who are waiting for elective surgery is huge. For example, last week I was told that, in my region, it will probably be about 70 weeks before somebody who clinically needs a hip replacement, because they are being woken up by pain every night and are on the maximum dose of painkillers, will get one. That is a long, long time. That will increase the morbidity that they will suffer as a result of taking painkillers and their lack of mobility. During that 70 weeks, they will probably feel quite hopeless. They will probably have to go on more and more painkillers, which may have adverse effects on their health. They will get less and less active, which will impact adversely on their health. It will mean that they may well go rolling down the hill of health before they get their hip replacement, and they will then have to climb that hill again.
It is a massive problem, but we do not have the facility or the staff to meet that demand. We only have the staff to do what we were doing anyway, and everybody was working to the maximum. We must retain staff and increase staff numbers. I am talking about not only doctors but all of us who deal with patients who are in the position of waiting for what we call elective surgery, but which they probably feel is urgent surgery, because they are in pain. Without bringing in extra staff and stopping existing staff feeling as though they need to retire because they cannot do their job any longer, as it is having adverse effects on their health and their family, we will not be able to deliver the increased capacity that we need.
Therefore, it is not simply a case of building treatment centres and doing all the elective surgery there. As I said, it is a very complex and difficult problem. If we are to address the backlog, we might have to stop doing some of the things that we do at the moment. That will require a societal discussion and honesty—there needs to be honest public messaging about what we can do, not what we might wish to do, and what we can deliver over the next five years.
Being honest with the public is key. That will allow the public to be part of the debate, but it will also protect front-line healthcare staff, who are often abused by members of the public because they do not understand why we are not doing what they feel we should be doing. We are all working to our maximum.
I will build on what Sue Robertson has said. There are pressures on all parts of the system. If someone has had their cancer diagnosed late because of the pandemic, it is likely that they will have had their diagnosis through attending an accident and emergency department, so there are increased pressures on the emergency part of the system. Those people’s needs are more complex, so they might need more input from AHPs or from people in other professions. There will also be impacts on palliative and end-of-life care, because more people will be diagnosed at a later stage. We have to think about the issue from a whole-system perspective, because there will be pressures everywhere. There is a need for additional resource everywhere in order to make the system work well.
I go back to the importance of integrated thinking and workforce planning, so that we reduce pressures when we can and ensure that people’s needs are dealt with by the most appropriate part of the health and social care system. That is a huge challenge. The most obvious example is when we talk about bed blocking. We have to be better at such planning if we are even to begin to address the resource challenges that we face.
I am probably repeating what has been said, but one of the most important things for us to highlight, as health professionals, is that oral cancer is one of the cancers that is picked up asymptomatically. It is picked up through regular screening. Scotland has one of the highest oral cancer rates in Europe. The treatment of the cancer in its early stages is relatively simple, but the sequelae of it are horrible disfigurement and quite drastic and difficult surgery. The imbalance between the two is a major reason for screening patients and seeing them regularly, which we cannot physically do just now.
People from a deprived community are twice as likely to die from oral cancer in Scotland, so the inequalities gap will grow larger and larger. We are only at the tip of the iceberg; in the next 18 to 24 months, the problem will come home to roost. I am very concerned that we are not even feeding people into the system yet because of how screening works and because we do not get to see them.
To clarify, do you pick up signs of oral cancer during check-ups and more routine dental work? Is that how you spot it early?
Not only is that how we spot it early, but people do not feel it when we find it. Often, someone presents with something and says, “This is a bit sore. I’ve noticed it. Can you do something about it?” The dentist looks in the mouth as a routine and sees a lesion. They ask the patient how long they have had that for, and the patient says, “I haven’t even felt it. I didn’t even know it was there.” The dentist then says that they will look at it in a couple of weeks. If the issue is unresolved, it is put in the system, oral surgeons see it and a biopsy is done. The cancer is found, scanned and removed in the space of six to eight weeks.
If the cancer is left untreated, the patient does not always feel very uncomfortable, but, by the time that it has spread, a radical neck dissection and major chemo are needed and the patient will be deformed by the surgery. All those things go into treating someone with hidden neck cancer. Through the screening process and seeing patients every six months, we can detect the cancer and treat it very early. Now, every time that a dentist has a patient in front of them, for whatever reason, they do the screening and try to keep that going. However, 4 million attendances were lost last year through Covid. We lost so much but, yes, oral cancer can generally be detected just through looking in the mouth.
I will come back to Emma Harper in a moment but, first, I will pick up on something that Dr Robertson said around what patients can expect. It is a difficult line to tread because, on the one hand, during lockdown periods, people who really should have engaged with their health professionals did not do so, because they were worried about adding to the stress, but we are all seeing in our inboxes that the public might now be expecting more than the services can give. How do we strike that balance and manage patient expectation?
I think that we have to have honest conversations with the public. At the moment, we are almost in a place where the people who shout loudest get what they want.
As I said in the chat, I work in an admissions unit, where we see patients who have not wanted to bother anyone because they know that we are really busy. However, as a result, we see them further down the line of their illness trajectory, so they need more powerful drugs or more major surgery than they might have done otherwise. Therefore, it is about having that conversation with the public about what we can deliver and the fact that the people who shout loudest are not necessarily the ones that get the care, because the care has to be delivered on clinical priorities, not on who complains loudest. If we are to be the caring, equitable society that we want to be, we have to have that societal conversation.
If it is not done carefully, it could exacerbate the problems, so what are your thoughts on the role that politicians and, by extension, the media—because that is where a lot of the messaging lies—need to play in that honest conversation?
At the moment, it is almost as though we are working against the politicians and the media. It feels like we are trying to deliver the best care that we can but then we see that, for example, the big headline for the NHS recovery plan is that we will increase service to 110 per cent. We ask politicians to engage with us and the other organisations that are represented in this evidence session, so that we can work out how best to message the public. We need to take the approach away from vote-winning or vote-losing decisions and towards what is best for our society and the individuals within it. It has to be a long-term, societal conversation about where there is a match between what can be delivered and what people are demanding, where there is a mismatch, and how we address that, perhaps in other ways.
Thank you, that is very helpful. Before we move on to talk about staffing more generally, Emma Harper has a quick supplementary question.
I will try and be quick. In the last session of Parliament, we did a report on social prescribing. We can keep people out of hospital in the first place by engaging them in practices that support health, wellbeing and physical activity, thereby preventing complications of type 2 diabetes, because 10 per cent of the NHS budget is spent on mitigating those complications. I am interested in what the witnesses think and I suppose that the convener can choose someone to answer the question.
It would be good if you could choose the person to answer the question, Emma.
What value do we need to place on social prescribing, in order to stop folk people getting poor health in the first place, as well as support work such as pulmonary rehab and mitigation of type 2 diabetes complications? That question goes to Dr Robertson again.
11:30
We probably need to step back even further. I listened to the first panel, in which Sir Harry Burns talked about poverty and health, helplessness and hopelessness. We need to consider the health of the population and try to improve it in any way that we can through giving people opportunity and support, and making them feel like valued members of society.
We also need to increase the possibilities and the encouragement for people to be more active and live healthier lives—Emma Harper knows that I would say that, because I am a big physical activity person. However, people need to have the opportunity to do so, so we need to consider how every policy impacts on health, as Sir Michael Marmot said. For example, we need to consider the built environment and build schools in places that children can walk and cycle to, so that walking and cycling becomes the norm. When children walk and cycle, then the parents walk and cycle and become healthier, reduce their risk of type 2 diabetes and other diseases, and improve their lung health and general health.
We need to consider health in all our policies. Only by doing so can we shift around the big oil tanker that is our unhealthy population to make it more resilient and healthier the next time something like Covid comes around, so that people are less likely to become ill or to die of some other illness that will attack the least healthy in our society.
A number of years ago, the Government funded the Health and Social Care Alliance Scotland and SAMH to test out link workers in primary care services in Glasgow. Those link workers are social prescribers, who link people to things that are happening in their communities. Many of those activities are physical, but people can partake in many other activities that would benefit their health.
The pilot, which described the training and the approach, and the lessons that were learned, was written up and then went out to local authorities. I asked Public Health Scotland for information on the matter, as I am aware that we have a variety of different approaches to link working, because of tendering processes: some local authorities have band 7 nurses who carry a case load; others have Scottish living wage third sector workers, who do not carry a case load.
There is a lack of consistency across Scotland in our approach to link working, which is confusing for patients and workers. We have missed an opportunity to learn and implement the lessons from the pilot. I do not argue against local democracy, but perhaps the Government could have been a bit more robust in its guidance to local authorities about link working, based on that pilot study from some time ago.
I totally agree with the point that Graeme has made, which is why MacMillan Cancer Support set up a transforming cancer care partnership with the Government, in which link workers in local authorities support people with all their needs around cancer. Obviously, those services are just for cancer patients, but that is what that model attempts to do.
I completely agree with Sue Robertson on the need to improve the general health of our population. Equally, however, it is not too late to act once someone is in the system and has ill health. Once a person has had a cancer diagnosis, we do a lot of work around prehabilitation. We also consider all areas of support in relation to their physical activity and financial needs, and also their emotional and psychological wellbeing. If we can give people that support through their cancer journey, it becomes less likely that they will come back into the system through an emergency admission or just because their health has deteriorated due to their cancer treatment.
Although getting in earlier is key, it is never too late. However, when someone receives a major diagnosis such as one of cancer, that is often a good point to look at interventions such as social prescribing and other supports, in order to improve people’s health through that and lessen the likelihood of them needing more support later.
A number of members want to dig deeper into the staffing issues that all the witnesses have raised. I go first to David Torrance.
The panel members have talked about recruitment vacancies in the NHS. I think that Dr Robertson mentioned that it can take years to recruit from abroad, and Brexit has not helped with that. How do we make the NHS attractive for people to retrain for, and how do we encourage school leavers to consider working in the NHS as a career path?
Is that directed to Dr Robertson?
Yes—sorry.
As I said, retaining the workforce is the first thing. If you can provide a place of work that makes people feel valued, supported and included, you will retain the workforce. It is about workforce culture and workload. The GMC paper that I referred to sets out how to improve the work environment for doctors and gives an ABC of their needs. The A involves giving people autonomy and control so that they have some sort of influence on what happens around them and how their service is delivered. The B is that they need a feeling of belonging, which requires improved teamworking, culture and leadership. The C is competence, which means that we need to provide an environment that allows doctors to manage their workload appropriately and that gives them appropriate supervision and the ability to learn, train and develop.
On top of that, you have to pay people well enough for the job that they do. That goes not just for doctors, but for everyone. Many of us have had our wages go down in real terms over the past 10 years. We want the brightest and the best in the NHS and in social care. We want people who really want to be there and who will give a piece of their life force to each patient to help them get better. However, you need to give those people a place to work that does not impact badly on their health and leave them—as evidence has suggested the current situation does—feeling that they have no energy left for their families and loved ones, because they are so burned out from working in the environment that we work in at the moment.
If people want to stay in their job because they want to work in that workplace, they will immediately tell school leavers that it is a great place to work. They will say, “Come and work here. You will feel valued. You will able to innovate and develop, and be part of improving service and developing things as they go forward. You will be financially valued and personally valued.”
You need to provide workplaces that have facilities for decent rests in breaks. You need to look after people when they are tired and give them a place to lie down so that they do not have to drive home after a night shift when they are too tired, thereby preventing them from having a crash on the way home. We need workplaces that leave people feeling that they still have compassion left for their families, their loved ones and themselves. If you can provide workplaces like that, school leavers will want to work there. Society will say, “This is a great place to work. You should want to come here.” People in the job will not be saying, “I can’t do this any longer. I’m not at retirement age, but I need to find a way to get out of it and do something else.”
The whole thing stands and falls on value. If people feel valued and supported, they will feel well. Harry Burns said that we can create wellbeing by creating an environment where people feel safe and supported—I would add that they need to feel valued. If you can do that with the NHS and social care, you will have no problems with staffing levels. If you can be realistic with the public about what they can expect of the people who are trying their best at the moment, and if you can talk about being gentle to those people, you will make it a better place to be. That will mean that people will stay, they will develop the service, they will make it better and we will be in a better place in Scotland.
Other members wish to ask questions. I remind all panellists that, if you have anything to contribute on the issues that come up, please just put an R in the chat box. I will get notice of it and I will come to you.
Following on from Dr Robertson’s contributions, I am particularly interested in staff morale and wellbeing. Are clinical and other staff getting enough support? What can be done in the immediate short term to prevent a crisis of morale? What could be done in the long term to improve overall recruitment and retention in each of the groups that you represent?
If we can create a workplace just like the one that Sue Robertson described in answering the previous question, that would go miles towards improving staff morale. Better financial rewards do not provide the whole answer; there is a resource crunch, too. It is about making people feel valued and being realistic, at least, with all the staff about what they can expect from the workplace.
To echo Sue Robertson’s point about value, it is not just about financial value; it is about status as a worker and as a sector that is valued by the public and politicians.
For example, in the past 18 months, we have brought in an additional two days of annual leave, which are called wellbeing days. They are specifically addressed to wellbeing, because we value people’s wellbeing and we want people to take time for their wellbeing, not just for their holidays. We have also given every individual staff member a £100 wellbeing budget for them to use for whatever they want.
Obviously, that costs money. SAMH has the capacity to do it, but a lot of our third sector colleagues do not. There is the money to pay people, but we also need money in the system to give organisations capacity to do things such as what I have just suggested.
On the question about improving morale, allied health professionals, like all health and social care professionals, care passionately about the work that they do and about using their skills to provide the best care. One way that we can improve morale is by ensuring that we have the right healthcare professionals in the right place at the right time.
We talked about backlogs. Allied health professionals all have the ability to asses, diagnose and treat, and to work as first-point-of-contact practitioners within primary and community care. If they are put in the right places because there is enough workforce to support that overall package across the system, instead of a patient being on a waiting list for 12 to 18 months, they will be seen immediately by an allied health professional or someone else in primary or community care, and they can get immediate access to treatment. It will be such a bonus and will give a morale lift if people can do what they came into the profession to do.
On staffing, Mr Torrance asked about how we raise awareness of the professions in schools. There is a lot of work to be done by all the stakeholders to raise awareness of allied health professions and the range of things that people can do in their careers as an allied health professional.
There are a couple of things that we could do from a policy perspective to improve the different routes into training. The introduction of degree apprenticeships for allied health professionals is very important. We do not currently have that in Scotland, although it is available in other parts of the UK. We should also consider bursaries to incentivise people to come into particular professions that are struggling to recruit over a longer-term basis.
Finally, return to practice is an important part of the jigsaw. It is about how we incentivise people who might not currently be working in health and care but who have really good skills and could come back into the system, and how we can support people with good-quality continuous professional development and training so that they can really make the most of that and can contribute.
11:45
Paul O’Kane has a question. I am aware that other witnesses want to come in. I am bringing in members to put some other things into the mix, and then the witnesses can pick up on any of the issues that have been raised.
I would not disagree with much of what has been said about the real pressure on staff.
I am interested in our immediate crises, and particularly in the onset of winter and winter pressures across the piece. Obviously, there is long-term workforce planning, but there is clearly an immediate need, particularly in acute settings, when it comes to how we physically keep the show on the road. We are seeing a lot of pressures at the moment, and we are not even at peak winter yet when it comes to admissions and use of service.
I am therefore keen to understand what is needed and what can be done to increase resources and staffing right now, and what would make most difference. I appreciate that that is not easy to answer, but I am keen to get a sense of that, possibly again from Dr Sue Robertson or the RCN, although I can ask everyone, I suppose.
I will come to Colin Poolman first and then to Dr Robertson.
Thank you—I have been keen to come in.
I agree with most of what has been said in relation to everything that we need to do on environment, culture and support for staff. Morale is clearly under huge pressure at the moment. Mr Torrance asked what we need to do. We need to work through what is an incredibly difficult time. Nobody has all the answers.
It comes back to the issue of the conversation that we have to have with the public. We have the unintended consequences of longer waits and people wishing to be treated, but we also have the pressures of the system. We get that every day, and we see it in the media. It is about allowing our health and social care employers to work with their staff and to be honest about what we can provide. We need to work that through in sustainable planning and, when we cannot do something, we need to be very clear about why we cannot do it.
It comes back to the pressure on staff, who read in the papers that we have to do X and Y, when they know what the reality is. We need to come back to that reality and say what we can provide now and why we have those pressures. At times, that will mean that we need to reel back what we can do, because we need to use the resource that we have, as well as looking in the short term at every possible avenue for bringing back into the service the people who wish to be there. That will include providing free training and support, and looking at other ways of staffing so that we are not just putting increased pressures on the existing workforce.
The more that we ask the existing workforce to do extra shifts to cover, for example, for a big increase in sickness, the more pressure and absence there will be. That will add more problems, especially as we go into winter. Our members are telling us that it feels like winter right now, in the middle of summer.
We need to do all those things, but it comes back to the really hard public message from the NHS and from social care—and from the media and politicians—about what, honestly, we can provide currently, and saying that we are doing everything that we can to move forward in the future. It is going to be a difficult road.
I absolutely agree with everything that Colin Poolman just said. Public messaging is absolutely key. That is the bit that we are not in control of—we are not in control of what the public are told; all we can do is try to deliver the best service that we are capable of delivering. The messaging needs to be done centrally, it needs to be done honestly and it needs to engage the public.
As to what else can be done right now, we need better pay in social care so that people take those jobs and stay in them, instead of taking a job as a carer and then finding that they could earn twice as much stacking the shelves in Aldi. We need to value social care for what it is, which is the bedrock of all this. If we get social care right, we can be a national health service that delivers what is needed. People can stay at home if they want to, with appropriate care, or they can access appropriate care facilities if they need them. If we get all that right, we will take a massive amount of pressure off the NHS, and people will be happier. People do not want to be in acute hospital unless they absolutely need to be. That is another key message.
The need for better information technology is a huge issue. It is a constant bugbear for all of us that the IT that supports our work is glitchy and not as good as it could be. We have lots of young people working in the service who have lots of really useful suggestions about how we could improve our IT to make it easier and quicker to do our jobs. It is about asking people who are doing the job how we could support them and what we could put in place for them to do their job better.
We also need to increase the number of nursing staff, AHP staff and other members of staff around us to do jobs that we do not absolutely have to do, so that we can do the things that only we can do. For example, having a dietician in my team allows me to refer to them to ask about nutritional requirements for a patient to keep them well while they are in hospital with an acute illness, so that they will be well when they go home, instead of having slipped a little bit down that hill.
In relation to physiotherapy, pharmacy and all the other parts of our healthcare team, we need the ability to work as a team and the connectivity to work together with primary and secondary care. All those things could be addressed now.
The culture within organisations is another issue. In that regard, I signpost the committee to NHS Dumfries and Galloway. We are part of the prosocial health project, which aims to improve teamworking, personal wellbeing and culture in our organisation. It was set up by our psychologists, but I am part of that group. People from operational development, learning, psychology, medicine—me—and our spiritual lead are all working together to help teams to improve the culture where they work and consider and improve the way that they work as teams.
Lots of work can be done. However, people need to be given the time to do it. It is almost a spend-to-save situation—if you give people time now, it will absolutely save time in the future.
I will go to Donald Morrison and then to questions from members. I ask members to direct their questions to the individual from whom they want an answer, because we are rapidly running out of time, as I knew we would.
I will try to be brief.
On recruitment into the NHS in dentistry, one of the big problems in relation to the hit of Covid is that it affected extremely heavily the university intake and the qualifying dentists coming through. In essence, we lost a cohort—or they were sent back to do another year of study.
In addition, in Dumfries and Galloway—which Sue Robertson mentioned—more than 40 per cent of dentists are from outside the UK, so I do not know how Brexit will affect us. Although we have not seen a drop-off of registrants, the general feeling from practitioners is that anybody of retirement age will try to retire soon. We do not seem to have an immediate influx of dentists from outside the UK, and we have a backlog of training.
The dentists who are coming into the profession are in a position in which there is not really any funding in the classic sense. High-street dentists are not salaried. We have talked about various issues today, and, of course, patients are the priority, but it is important to point out that 95 per cent of dentists do a mix of NHS and private dentistry, and the set-up is geared against them working for the NHS. The funding for them to continue to work has been reduced by 15 per cent, although there is also reduced activity.
However, the process that they have to put in place means that it takes four or five times longer to do each unit of work—such as giving someone a filling—but they get the same money. That puts such stress on the workforce that they do not want to work in the NHS, and means that it might not be financially viable for them to do so. The luxury that a dentist has to spend a lot of time looking after their patients and seeing as many as possible is lost when they have to make a business that continues to be viable.
Sometimes, dentists can feel like they are in a Cinderella service, because they run small and medium-sized businesses as an annexe of the NHS. We work hard for our patients and want to do all that we can for them but, ultimately, the perfect storm of there not being enough sustainable future funding and there not being a model that we can all work with and understand will mean that we will lose dentists in the NHS hand over fist.
I invite Sue Webber to ask a question. I remind you, Sue, that it would be good if you could say to whom your question is directed.
Earlier, we heard that all policy should be focused on healthcare, and we have heard from members of the panel that workforce planning should come before a remobilisation plan. We have also heard about the diverse careers that are available to people in health and social care—including dentistry; I will not ignore that one.
My question is for Sue Robertson, given that we have a short timeframe. Is the cap on Scottish young people getting into medical schools and universities in Scotland negatively affecting long-term recruitment and our ability to create a sustainable workforce plan?
The question requires something a little more complex than a yes or no answer, I am afraid.
There is no doubt that we have very many able school pupils who would make good doctors and who want to do medicine. However, we must also have the ability to train them. Without the workforce to train those young, developing doctors, there are issues around removing the cap. We know that school pupils from Scotland are more likely to work in Scotland in the longer term, so that is a tick, because we want more school pupils in Scotland to do medicine and stay with us. At the moment, if we increase the number of medical students in total, there is a significant risk that there would be not enough doctors to train them and help them to develop.
One of the main things that we need to consider is the number of doctors who go elsewhere after the first two years of their practice. Research suggests that around 40 per cent of young doctors go elsewhere in the world after doing their foundation years in Scotland. Scottish medical training is high quality and is respected around the world. That is a good thing, but if we lose half our young doctors to other countries because, having had experience of the healthcare structure that we work in, they decide that they do not like the culture and the way in which doctors are treated, or they do not feel that their opinions are valued, we will face the same problem. If they are to stay, we need there to be a workplace that they want to work in.
I absolutely want more young people in Scotland to be able to do medicine, but only if there are enough doctors to be able to train them appropriately while also providing the healthcare that we need to provide. Further, I want there to be a workplace that those young doctors would want to stay in.
12:00I applaud the Scottish graduate entry medicine courses, which are increasing the number of young doctors born in Scotland who want to work in general practice or psychiatry—areas in which we definitely need more doctors. I support increasing the diversity of people who become doctors and looking at how we pick people for medical school and at how to increase the availability of medical school places for people who have perhaps not had the best opportunities in life in school and so might not have quite as good a CV as someone who has had the best opportunities. We want more young people to do medicine, but we want them to be able to do medicine while looking at working as doctors in NHS Scotland and seeing that as an attractive career, rather than training in Scotland and leaving because they see how burned out their senior colleagues are when they experience time on the wards or in general practice.
I thank everyone for their contributions today. I want to ask about the role of technology, which I will come at from two angles. I have had conversations in which I was told that not all the NHS vacancies could be filled at the moment and that more things need to be done with fewer people, which is about the rapid adoption of technology to help in that regard. One of the examples that I was given was about radiology, where there is an artificial intelligence diagnosis but the radiologist does the more complex work. That issue is for Dr Zamvar to consider.
The other issue is preventative care, which possibly Ross Barrow could consider, with regard to bed modelling to keep people out of hospital and look after them at home, or to get them out of hospital more quickly when they are in hospital. It is about the use of technology practices that might help colleagues advance their career by taking on more complex roles. The question is how they would do that.
We definitely need better technology. For example, I have lost my wi-fi so many times this morning. Ms Callaghan mentioned AI for looking at radiology scans and so on. A lot of work is happening in that area, with reports coming mainly from US hospitals that are using that technology. It is possible to use it, and we should consider doing so. However, whenever we introduce new technology, it always costs more money. Pilots might show that it saves money, but it will eventually take over and will cost more. However, that should not prevent us considering using the technology, because it saves time in the long run and will save misdiagnosis in some cases as well.
What was the next part of your question?
It was about doing more with fewer people.
We should be open to ideas on that. For example, I am a cardiac surgeon and practitioners in our department are now doing more ward rounds. We also have surgical care practitioners assisting us in operations, which means that we do not need an assistant surgeon to assist us in operations. That has been happening for a number of years, but given the problem of staff shortages this year because of Covid, we should pay more attention to that issue and say what roles staff can undertake to ensure that we have more time to do other things. That is definitely possible in surgery.
I bring in Ross Barrow to comment on Stephanie Callaghan’s second point.
There are a number of issues around that. The first is on how we do more with fewer people, which relates to self-care management and working with patients and service users to ensure that they understand their own healthcare needs and feel that they are an agent for change in that regard. It is about seeing the healthcare professional as an expert guide and allowing the patient or service user to be seen as a partner who is in control of a lot of interventions.
As for technology, which you asked about, there has been talk of an NHS app that people might be able to access on a tablet or their mobile phone. That presents a massive opportunity in a number of ways. For example, a lot of self-care management advice might be, say, exercise videos or guidance on things that people can do when they come out of hospital after elective surgery. People will still need support from healthcare professionals, but a lot of information can be given directly to a person via their mobile phone or tablet. Of course, that will not be the case for everyone, and we have to be careful with regard to that section of the population in Scotland who are digitally excluded. For some people, though, such a move might be a good opportunity.
We are rapidly running out of time, but I want to bring in Evelyn Tweed, who has a specific question for the panel.
We have talked a lot about the health and wellbeing of our healthcare staff and professionals, but what can we do immediately to support them, give them a listening ear and ensure that they know that they are valued? A lot of the things that we have been discussing are quite medium to long term, and I would like to hear what we can do right now.
I guess that a number of witnesses will want to address that as a final question, so could you tell us whom you are directing it to?
Perhaps Dr Robertson could go first.
For starters, we can listen to the people in their teams. Management and senior management can listen to and value the opinions of those who work on the front line and have boots on the ground. That is key. The fact that you are listening to us is excellent, and it makes me feel that our opinion is valued. It is amazing how far that sort of thing goes.
Our psychological services for staff are gradually improving. Access to psychological services at all levels for all staff who are involved in health and social care is absolutely key, too, and a lot has been done during Covid to shift that forward quite considerably.
There are also simple things that can be done such as having a space where patients and their relatives cannot go and where staff can take a proper break. After all, if staff can have that kind of physical and mental break, they feel stronger when they go back to their shift. Other things that could be done include making hot food available at night to those on the night shift when they go on their break or giving them somewhere to lie down and have the 20-minute power nap that we know will improve their decision making, reduce their compassion fatigue and make them a better team player. The provision of rest facilities and psychological support and the valuing of people’s opinions are all things that could be done right now.
I also come back to the issue of public messaging. We need to send out the message that the people on the front line are doing their best. They did not design the service, so they should not be abused by people when the service does not work for them. We also need to support staff who face abuse by taking a zero-tolerance approach to such things in the health service and in social care.
Those things can be done right now to make staff feel supported and safer in their roles at what is a really difficult time. As has been said, we do not need to wait for winter to see how much busier things are; in fact, I do not think that I have felt things to be so overwhelmed in my 35 years as a doctor—that is happening now. We are therefore really worried about winter. A lot of staff will be just on the edge of their ability to cope, and it will not take much to tip us over. If you can put in the kind of support that I have described and say, “We value you enough to give you hot food at night and to give you a rest space where there are no patients or relatives”, it can go a little way to making people feel that they are valued members of a team and, indeed, a big system and that someone has their backs.
Thank you. I am afraid that we have time to hear only from Donald Morrison and Graeme Henderson. If other members of the panel have anything else to say or feel that anything has been missed, they can, of course, email us and let us know.
I do not want to be the one to say this—I like to be as positive as possible—but on the question of what we can do now, I would say that, as far as dentistry is concerned, the issue is more about what should not be done. Going back to the point that Sue Robertson made about increasing capacity to 110 per cent, I simply note that, when the decision was taken to wheel out free dentistry to 18 to 26-year-olds, we found out about it 24 hours beforehand. It is just a simple thing that we want, but the fact is that such things are not being discussed or worked through with the profession, which feels that it is not being communicated with.
We should also not say that this is just business as usual, because it clearly is not. Our members are having to work in what is a very stressful situation while the message to the public is “Get on with it—it’s business as usual.” That is just not the case, and if we could address that one issue, it would be really helpful.
I just wanted to mention the time for you service, which is a three-tier psychological intervention for front-line workers that SAMH developed and set up last year. It is directed mainly but not exclusively at shop workers, drivers and social care workers; actually, it is available to everyone, and just over 400 people have registered for it.
The service, which has been developed in partnership with Glasgow Caledonian University, uses its trainee psychologists to offer psychological interventions. It does not cost a lot of money—about £150,000 a year—and can accommodate up to 4,000 people. I should also say that it uses an online cognitive behavioural therapy-based approach called living life to the full. It is a low-cost, accessible service that has worked really well over the past year.
Thank you very much. I thank everyone on the panel for their time this morning. I am sorry that we do not have more time to hear your views, but what you have told us has been very useful.
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