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NHS Highland Board 28 March 2017

Item 5.7

STAFF GOVERNANCE COMMITTEE

The Board is asked to:

Note that the Staff Governance Committee met on Tuesday 14 February 2017 with attendance as noted below.

Note the Assurance Report and agreed actions resulting from the review of the specific topics detailed below.

Present:

Alasdair Lawton, Board Non-Executive Director (Chair)Anne Gent, Director of Human ResourcesAdam Palmer, Employee DirectorRobin Creelman, Board Non-Executive Director (Videoconference)

In Attendance:

Gaye Boyd, Deputy Director of Human ResourcesPam Cremin, Head of Workforce Planning, Learning and Development and Staff ExperienceMargaret MacRae, Staffside RepresentativeMelanie Newdick, Board Non-Executive DirectorDavid Park, Director of Operations, IMFOU

Apologies:

Elspeth Caithness, Staffside RepresentativePaul Simmons, Learning and Development Facilitator

AGENDA ITEMS

Statutory and Mandatory Training Knowledge and Skills Framework (including National Developments) Update Staff Experience and iMatter Activity Update NHS Scotland Approach to Leadership Development and Talent Management in

Scotland Values Based Recruitment - Update on Project Scoping NHSH Workforce Development Plan 2016/17 Rolling Action Plan Progress Report National Health and Social Care Workforce Planning: Discussion Document Workforce Report Band 1 Review Update National PIN Policy Update Everyone Matters Implementation Plan 2017-18 Scottish Workforce and Staff Governance Committee – Highlights from SWAG

Committee Meeting held on 18 January 2017

DATE OF NEXT MEETING

The next meeting will be held on Tuesday 16 May 2017 in the Board Room, Assynt House, Inverness at 10.00am.

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STAFF GOVERNANCE COMMITTEE – ASSURANCE REPORTMeeting on Tuesday 14 February 2017

1 TOPIC: Welcome and Declarations of InterestIssues Assurance ActionsDo members have any interest to declare in relation to any Item on the agenda?

No declarations made. Action: None

2 TOPIC: Assurance Report from meeting held on 15th November 2016Issues Assurance ActionsAny issues relating to accuracy of draft Assurance Report?

Need to update Action Plan

No matters raised

Action Plan to continue to be updated – Committee Administrator

3 TOPIC: Matters Arising – Review of Terms of ReferenceIssues Assurance ActionsAny issues relating to the review of Terms of Reference?

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It was further noted that a vacancy for a Non-Executive Director existed.

Action:Terms of Reference to be submitted to Board for approval – Board SecretaryFilling of vacancy to be considered – Board Secretary

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3 TOPIC: Other Matters Arising not on the agendaIssues Assurance ActionsWho has ownership of workforce agenda?

What is the progress on development of educational frameworks for key staff groups?

What is the update on Joy in Work

What is the update on whistle blowing?

AG advised that the human resource team lead on the workforce agenda but that engagement and accountability at operational level through the HHSCC in North Highland and the Argyll and Bute IJB is required.

PC advised that the development of Educational Frameworks are progressing well with a number completed. These Frameworks indicate the knowledge and skills individuals require for their roles. This work is overseen by the Education Governance Sub Group. A target date for completion for all staff groups of end April 2017 was noted though it was recognised that this is a significant piece of work and it is being progressed.

It was noted that work is progressing and consideration is being given for wider roll out to support staff experience continuous improvement.

It was noted that local systems require to be in place once national template is finalised.R Creelman requested information as to whether whistle blowing tends to be an action of last resort and it was noted that this can be the case.It was noted that some work on ‘Voicing Concerns’ had been started with Pat Tyrrell, with guidelines to be shared widely.It was noted that ongoing work was taking place encouraging staff to speak up.

Action:Work in progress - A Gent

ActionProgress report to next meeting – P Cremin

ActionUpdate to future meeting of Committee – P Cremin

ActionDetails of numbers to be submitted to a future meeting – G Boyd

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4.1 TOPIC: Minutes of Meetings of the Highland Partnership Forum on 16th December 2016Issues Assurance ActionsAny Issues arising from the Minutes?

It was noted that, further to a national directive, the policy has been amended with regard to uniform laundering, with only scrub suits and infectious uniforms being laundered by the Laundry from 1 February 2017.

This change had not been communicated to staff as fully as anticipated and some managers and staff had been unaware of the change.

Action: Arrangements to be made to ensure that staff have

an adequate supply of uniforms and are aware of how to launder them.

4.2 TOPIC: Assurance report from Meeting of Health and Safety Committee held on 3rd November, 2016Issues Assurance ActionsAny Issues arising from the draft Minute?

Noted that Health & Safety Committee take responsibility for the staff governance standards in providing a safe and improved working environment. Any issues from Staff Governance Committee about that part of staff governance standard can be remitted back to Health & Safety Committee.

Action: None

4.3 TOPIC: Abridged Minutes of Meetings of Remuneration Sub Committee held on 4th July and 22nd November 2016Issues Assurance ActionsAny Issues arising from the draft Minute?

No matters raised. Action: None

5.1 TOPIC: Statutory and Mandatory Training

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Issues Assurance ActionsWhat is the current position in relation to the provision and recording of Statutory and Mandatory training within NHSH and the actions taken to date?

PC advised that progress is being made on an RPIW into Statutory and Mandatory training. PC advised that although band 5 and band 2 nurse recruitment in Raigmore was in scope for the RPIW, it had highlighted ongoing issues around booking of statutory and mandatory training, staff being released as part of induction; and some managers being unaware of what specific training staff required.

AG reported that a high level value stream had been developed which identified the key challenges with Statutory and Mandatory Training. These included identification of training need, booking, access to Learn Pro and Face to Face training, recording of attendance, compliance and reporting.

PC advised that recruitment letters are currently being refined as part of the RPIW work to better identify training previously received and qualifications already held by new starts.

PC reported that data analysis had been undertaken which identifies staff group status in terms of the 6 Statutory and Mandatory Training that all staff should undertake from induction and during employment: Information Governance Safe Moving and Handling Preventing Violence and Aggression Fire Safety Equality and Human Rights Infection Control.These reports have now been shared with the operational units and discussions are underway with training providers to agree targets and trajectory

Action:Continue to progress all workstreams to improve compliance with Statutory and Mandatory Training – P Cremin

Action:Extraction of reports on current compliance on the 6 key areas of training from LearnPro together with a trajectory to be submitted to May meeting of the Committee – P Cremin

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parameters for future monitoring and reporting.

AG commented that efforts are being made to simplify a complex procedure. She identified objectives as; Being clear what training new starts and staff

already in post require. Being clear of planning of capacity in relation to

demand Being clear how to organise schedules of training

for staff and how to book people onto training Ensuring staff are released to attend face to face

training events Improving recording of training undertaken and

qualifications achieved Improving compliance reporting

PC advised that Paul Maber and Paul Simmons in the L&D Team have developed a tool to support managers to identify what Statutory and Mandatory training their staff have completed in Learnpro. This is currently being piloted by Public Health.

PC also reported that e-Health had achieved 100% compliance with Information Governance Learn Pro training through targeted effort.

The L&D team and recruitment team are considering a role that will support staff and managers with statutory and mandatory training compliance by following up new starts in induction and assisting with information about training requirements and linking these to PDP&R.

An audit of statutory and mandatory training is currently being scoped.

Identify with managers and staff what training is required

Possibility of the identification of a coordinator role to be considered – Action – P Cremin

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There was general discussion around various ideas to encourage training, with issues in accessing PCs and staff not being released for training highlighted. Protected time for statutory and mandatory training is allocated for all new staff and is built into ward establishments. MN advised that there had been discussions around a more risk based approach to training being taken, to enable prioritisation.

The meeting agreed that training compliance is a cultural issue throughout the organisation, with some areas achieving higher compliance rates and recording due to differing priorities and levels of understanding, about what is required within disciplines. It was recognised that commitment from both staff and management was needed to implement change, in taking responsibility to ensure training is delivered appropriately, and that the whole organisation needed to be working together on these issues.

A Palmer advised that a significant amount of time was being incorporated into training in South and Mid Care at Home service.MN advised that at the Health & Safety Committee meeting it had been agreed to take a more risk based approach to training. Moving and Handling, fire safety and preventing violence and aggression for front line staff were noted as the most important from a risk perspective.

It was stressed that it is essential for both the individual and the manager to make a commitment to training and that individuals were required to take responsibility for their own training. It was stressed that this was an issue not just for learning and

Agree parameters for risk based approach – P Cremin

Identify where we need to focus more effort and resource – Action – P Cremin

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development but for the whole organisation.

5.2 TOPIC: Knowledge and Skills Framework Update (including National Developments)Issues Assurance ActionsWhat is the current position in relation to KSF?

What factors have impacted on this figure?

What are the possible ways in which the situation can be improved?

What are the alternative systems?

PC spoke to the circulated report submitted by Paul Simmons highlighting that the percentage figure for reviews completed and signed off within the 2016-17 reporting period for non-bank staff was 15.78%, a drop from 18.95% for the comparative period in 2015-16

PC identified a number of factors had been confirmed by managers which had impacted upon the PDP&R process in the operational units, including service re-design and advised that once concluded, PDP’s for staff could be completed.

A letter in Alasdair Lawton’s name had been sent to operational units in November 2016 to encourage engagement and participation with KSF.

Opportunities for Improvement – work had taken place to rationalise KSF outlines to make it PDP&R process easier and less resource intensive for staff. The possibility of allowing staff to ‘complete on paper’ without submitting evidence and have this signed off during routine 1:1 meetings were also being considered. The aim was to simplify the KSF process.

Oracle Performance Management System (OPM) was due to replace eKSF on 31 March 2018, but will now not be ready for this deadline. It is being tested nationally and PC advised that a tool called Turas,

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which is already being used by junior doctors and dentists, is also being considered.

DP advised that he did not consider that eKSF was as burdensome as anticipated and but he welcomed the proposals outlines that would simplify the process.

It was noted that there was a national project board looking at KSF/Turas which was attended by Paul Maber and Alasdair Lawton expressed an interest in attending.

R Creelman stressed the importance of spreading the KSF work throughout the year and he questioned whether managers valued the process enough. There had been feedback some staff do feel valued by the process.PC advised that some work was taking place with another NHS Board, testing out agreed work around simplifying the PDP&R process.

AP concluded that a decision needed to be made at a national level as to whether the current system was beneficial, or whether an alternative should be considered.

Staff engagement was highlighted as a necessity for any system to succeed, and for there to be realistic outcomes and expectations.AG stressed that face to face conversations regarding individuals performance and training needs was critical and fundamental to good staff management. It was noted that eKSF had in some areas become disconnected from this requirement. She suggested alternative methods of recording and training to obtain more productive results. AG stated that in view of the

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national context around eKSF, NHS Highland should continue to pursue the programme but make some improvements.

DP suggested that clarity of outcome was needed, and that the current system should be maintained with a view to a realistic level of progression.

It was suggested that small tests of change could be applied in areas, and these could be assessed and, if successful, applied in other areas.

AG supported different ways of thinking and approaching these issues and it was stressed that operational managers were required to take more ownership of the situation. In addition it was noted that as part of the weekly wall walk managers were sighted on KSF performance with a view to focussing them on action that requires to be addressed.

ACTION: It was agreed to develop a plan to demonstrate progress and to bring this back to the next meeting. – P Cremin

6.1 TOPIC: Staff Experience and iMatter Activity UpdateIssues Assurance ActionsWhat is the current position in relation to iMatter implementation with NHS Highland?

PC spoke to the circulated report advising the meeting that progress has been going well during this implementation phase.

Referring to the Cohort Status report, PC gave an update to the Committee advising that the current Board response rate as of 14 February was 66%.PC outlined plans to merge cohorts 1 & 2 and to move the Executive team and HR into cohort 3,

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corporate services, Raigmore becoming a single separate cohort.

PC and DP had discussed action plans in detail, and it was noted that DP was keen that the leadership team complete their iMatter action plans and share these with their teams demonstrating visible leadership.

PC confirmed that Adult Social Care staff had been engaged in i-Matter in North & West and South & Mid with Argyll & Bute IJB having also agreed to be included in iMatter questionnaire.

PC advised that information is updated weekly for the accountability wall and the data was used to focus the operational unit directors to work with their teams in terms of iMatter process.

AP expressed some disappointment at the South & Mid response rate and PC highlighted the opportunity of the anniversary cycle to try to achieve better success next time. Cognisance also had to be taken of the team sizes, as smaller teams with fewer responses would not generate a team report. It was noted that DP is keen to lead this in Raigmore, with Gill McVicar championing iMatter in the N&W.

A&B was noted to have continuous improvements as the cycle progresses.

With regard to Highlands national position, PC indicated that the Scottish Government has asked NHS Highland to be used as an exemplar for some of the work around iMatter, cohorts, daily management, Joy in Work and how these approaches underpinned

AG suggested looking at ways to promote staff engagement on a regular basis rather than once or

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How is the Highland Quality Approach being progressed?

continuous quality improvement in service delivery and staff experience. There has been success with the links with quality improvement and engaging staff through RPIWs and that the Board had participated in the IHI Joy in Work prototyping.

It was further noted that the Highland Quality Approach Award was still being awarded on a monthly basis and that this was now being awarded explicitly in the categories of People, Quality and Care Board Objectives.

twice per year

6.2 TOPIC: NHS Scotland approach to Leadership development and Talent Management in ScotlandIssues Assurance ActionsHow is national work on leadership and talent management in Scotland progressing?

AG spoke to the circulated report on the new approach to leadership, development and talent management in NHS Scotland and advised on the progress with this workstream, noting its discussion at a national level.

AG advised that as of 2018 the ambition was that people who had come through the talent management and succession planning process would be ready to compete for executive positions.

5 key pieces of work had been identified as being: review of performance management arrangements; leadership development; talent management and succession planning; performance management and appraisal; values based recruitment; and governance/ oversight/direction.

AG reflected how new executive leadership systems would operate, and discussed implementation at a local level. She advised that local work had taken

Action : Noted

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place around talent development and succession planning within NHS Highland following previous discussions with the Virginia Mason institute. It was noted that this linked into KSF. AG highlighted the summary of the document which indicated an emerging leadership and management framework, detailing the layers of management together with the interface between local and national levels. Some leadership capabilities and qualities and behaviours were also being developed such as self leadership, creativity and innovation, collaborating and influencing, vision, motivating and inspiring and empowering.

MD advised that she was about to start the mentorship programme for future leads.

7.1 TOPIC: Values based Recruitment – Update on Project Scoping.Issues Assurance ActionsWhat is the progress on Values Based Recruitment?

GB spoke to the previously circulated report emphasizing that although this is being explored locally, it also required marrying up with national initiatives.She advised that Values Based Recruitment (VBR) is an approach to help attract individuals whose personal values and behaviours align with the NHS values with benefits to be gained including improving staff morale, creating a more positive work environment, reducing sickness absence, increasing job satisfaction, positively impacting on staff turnover and ensuring that patients receive the best care possible.

ActionVBR processes and techniques to be implemented as soon as possible - G Boyd

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It was noted that a group has been formed with a view to taking VBR forward, with its initial meeting taking place on 17 January 2017. Links had been made with other workstreams including values based recruitment, embedding values in NHS Highland, medical staffing RPIW actions and recruitment pack, employee induction, and national VBR work (the Golden Jubilee Hospital).

The position of this group was queried, and GB confirmed that anything emerging from the new group was to be routed through the HPF and the Staff Governance Committee for validation.

With regard to next steps, GB advised that sample questions for VBR interviews would be drafted, there would be link in with managers leading on the workstreams identified as having potential overlap to ensure a collaborative approach, there would be link in with Golden Jubilee for updates on the national initiative, a review of existing paperwork would take place with values being more readily promoted on recruitment documentation, a possible pilot of using VBR questions at interviews would also be considered.

8.1 TOPIC: NHS Highland Workforce Plan 2016/17 Rolling Action Plan Progress ReportIssues Assurance ActionsWhat progress has been made in implementing the Workforce Plan?

PC updated the Committee on the NHSH Workforce Plan for 2016/17 and the accompanying, ongoing and iterative Rolling Action Plan up to 31 December 2016. It was noted that that were 2 workforce risks on the NHS Highland risk register. PC advised that in

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association with Gaye Boyd and Bob Summers, she had been reviewing the risks on the NHS Highland agenda. A number of workforce plans were in development such as Badenoch and Strathspey redesign, small specialties, with emphasis on succession planning. An RPIW had been undertaken to improve the medical recruitment process. An increased spend in supplementary staffing was being investigated and monitored. In addition the spend on recruitment of locums had been reduced when likened to a comparable period last year.As regards staff in post - these are showing an increase in staff.There was discussion and clarification around the report referring to number staff in posts or funded posts. It was confirmed that the report reflected staff funded posts in the financial ledger.

It was noted that more work was needed around the employment of modern apprentices with a national group being convened regarding apprentice roles. PC will feed back to the Board in due course.

The meeting discussed the remainder of the report in more general terms, including work which the UHI are undertaking around Care Academies, the ageing workforce, and the supplementary staffing figures which showed a tendency to dip around month 9.

ActionFurther report workforce risks to be submitted to the May meeting of Committee – P Cremin

Further clarification of these figures and terminology around staff in posts to be provided to next meeting of the Committee- P Cremin/A Gent

Further detail to be provided on employment of modern apprentices – P Cremin

8.2 TOPIC: National Health and Social Care Workforce Planning: Discussion DocumentIssues Assurance ActionsAny issues arising from the report content?

PC reminded members that the circulated draft discussion document had been amended following the suggestions made at the last meeting of the

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Committee

It was noted that Scottish Government intended to publish a work plan in 2017 reflecting the integration of health and social care and overall ageing workforce. It was noted that all boards are duplicating their workforce planning effort and reporting on their individual health board need whereas an overall NHS Scotland Workforce Plan was required to take account of workforce risks, affordability and succession planning. Engagement would also be delivered though collaboration at regional level.

PC highlighted the series of consultation questions starting on page 104 of the document and requested feedback from the Committee for her to collate on behalf of NHSH by the end of March 2017.

PC also commented that if a change of care model is to be considered, that this would need to be developed and articulated in order that workforce plans could be aligned accordingly to ensure future service sustainability.

Action: Feedback to be submitted by the end of March- All

9.1 TOPIC: Workforce ReportIssues Assurance ActionsWhat are the key issues highlighted in the Workforce Report?

GB introduced the circulated narrative and workforce report as at end November 2016 and highlighted matters relating to establishment monitoring where it was noted that the full time equivalent for funded posts remained static at approximately 8,600. It was further noted that the number of vacancies processed has decreased over the last 3 months, and is down on the comparable period last year. A small number of posts was waiting progression since

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the RPIW in recruitment. As regards supplementary staff – there has been an increase in spend in the last 3 months, largely related to bank and agency staff, reflecting the increase in agency hours. As regards consultant locums, potential savings could be made following an RPIW on locum recruitment processes, with the possibility of a bank being established. The number of fixed term contracts continues to be a concern with all existing fixed term contracts having been reviewed and no further fixed term contract vacancy papers to be accepted without clear justification of fixed term use. It was noted that when the data is cleansed there may be a decrease in this figure. No changes were noted in job families and age profiles. Work was being undertaken on equality & diversity which is underreported – work is being undertaken currently. GB advised an intention to improve upon section 2, and highlighted unexplained fluctuations in section 3. As regards sickness – it was noted that all Operational Units had sickness levels in excess of 4% national target. She advised that there is an RPIW scheduled for June based around promoting attendance focussing on Adult Social Care staff in the North. In the short term, there will be monthly reports made to the Operating Units. As regards employee relations it was noted that the majority of cases related to capability. Bullying and harassment cases remained low. As regards the redeployment figures it was noted that the data for this is incomplete and will be amended for the next meeting.During discussion, AP noted the reason for A&B redeployment figures rising in October had been down to reporting issues. MM commented that it is not necessarily easy to redeploy staff within the 12

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week timescale prescribed. GB cited other factors affecting the timescales as rural locations, and issues around redeploying these staff.AG stated that there are still issues regarding accuracy and dates; GB stressed that there is an awareness of where potential inaccuracies are.

Action:GB to continue to refine the Workforce Report

9.2 TOPIC: Band 1 Review UpdateIssues Assurance ActionsWhat is the position in relation to the Review of Band 1 posts in NHSH?

GB spoke to the circulated review paper by Kevin Colclough advising that of the 920 band 1 employees in Highland, over 600 had been offered band 2 grading.

Of the remaining 320 posts, 170 were currently progressing currently through the agenda for change process. It was hoped that a March 2017 completion date could be achieved.

AP highlighted that staff are being supported and encouraged to accept the move to band 2.

Action:Further update on the Band 1 Review to the next Committee Meeting. – G Boyd

10. National PIN Policy UpdateIssues Assurance ActionsWhat is the current position at National level with the Review of PIN Policies?

Concerns were noted regarding the further delay to receiving the ‘Additional Employment’, ‘Managing Health at Work’ and ‘Promoting Attendance’ policies which have been outstanding since 2012.

None

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10.2 Everyone matters Implementation Plan 2017 – 18Issues Assurance ActionsAre there any comments on the document?

PC advised that the Everyone Matters Action plan was being updated and the local delivery plan guidance require us to report on the Everyone Matters actions across the 5 priority areas as part of the normal workforce annex. The action plan and narrative would be drafted and considered at the Highland Partnership Forum and subsequently at a future meeting of the Staff Governance Committee.

MM requested that more information be provided on support available to support the health, well being and resilience of the workforce to ensure all staff are able to play an active role throughout their careers and are aware of the help available to them within NHSH.

AG advised Cathy Steer would be updating at the next meeting on staff health and wellbeing.

Action:Staff health and well being framework being updated with a view to being presented to the May Committee meeting - Cathy Steer

Staff Health and Well being report to next meeting – AG/CS

10.3 TOPIC: Scottish workforce and Staff Governance Committee (SWAG) – Highlights from SWAG Committee meeting held on 18 January 2017.

Issues Assurance ActionsAre there any comments on the document?

None Noted

12.1 TOPIC: AOCBIssues Assurance ActionsNone

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Meeting closed 12:25

14 DATE OF NEXT MEETING

The next meeting of the Committee will take place on Tuesday, 16 May in the Board Room, Assynt House, Inverness at 10.00am.

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