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Exclusive: Scottish CNO reflects on legacy and challenges

The outgoing chief nursing officer (CNO) for Scotland has spoken to Nursing Times about his proudest moments as CNO, the legacy that has been left for his successor and the challenges that lie ahead for nursing in the country.

Professor Alex McMahon will retire next month, having served in the national CNO post since October 2021, first on an interim basis before being appointed substantively.

“It really is a privilege to be the professional leader of your profession in your country”

Alex McMahon

Prior to this, he was executive director of nursing, midwifery and allied health professionals for NHS Lothian.

Professor McMahon’s career has spanned 40 years, working in both adult and mental health nursing and across the NHS, private sector and trade unions.

On holding the CNO post, he said: “It really is a privilege to be the professional leader of your profession in your country.”

Under Professor McMahon’s leadership, Scotland became the only country in the UK to settle the recent nurse pay dispute without strike action.

“There was a point where, certainly, nurses in Scotland were prepared to strike, and we avoided that through the negotiations that we had,” Professor McMahon noted.

Unions called off planned strikes after the Scottish Government – for which Professor McMahon works – handed band 5 nurses a 14% pay rise across 2022-23 and 2023-24.

Professor McMahon noted that this pay award “was the biggest in the UK”, making nurses in Scotland the best paid compared with their colleagues in England, Wales and Northern Ireland.

The Scottish Government also promised a package of reforms for many health service staff, including modernising the Agenda for Change contract, reviewing band 5 job profiles and reducing the working week.

Professor McMahon confirmed that work on these commitments was already under way, but that more would need to be done “this year and next year as well”.

Non-pay measures that aim to improve the working lives of nurses were “equally as important” as good pay, because they would incentivise nurses to trainin and then stay in Scotland, explained Professor McMahon.

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He said there remained “a global market of nursing shortages” and that countries within the UK were “competing with each other”.

The Nursing and Midwifery Taskforce, launched in February 2023, is a group that has been tasked with tackling the current staffing crisis in Scotland. Chaired by Scotland’s health secretary, the group is exploring ways to improve nursing recruitment and retention other than those already happening through the recent pay deals.

Professor McMahon praised the “really important” work that had been undertaken so far through the taskforce, as well as the collaboration between members.

He said: “I would struggle to say that there’s been anything we’ve had disagreement on – we’ve all identified things that we think are really important.”

One key focus area of the taskforce is around expanding routes into nursing, explained Professor McMahon.

It follows work already undertaken in Scotland to support career progression and development of the healthcare support worker workforce.

He said: “We’ve now got many more band 4s than we’ve ever had in Scotland and many of those, I hope, will come into registered nursing positions in the future.”

Going forward, the taskforce is considering whether Scotland should introduce the band 4 regulated nursing associate role.

England was the first UK country to introduce the role in 2019 and Wales announced earlier this year that it intended to now follow suit.

Professor McMahon said: “There’s a policy position on that that we need to move on because, like everything in life, I don’t think we can be complacent any longer about the one way that we recruit into nursing.”

He said that university-based nursing programmes alone may not be “the sustainable answer for the future”, as the country was still experiencing high levels of student attrition.

As such, the Scottish Government has also considered expanding other routes into nursing, including earn-as-you-learn models like apprenticeships.

Professor McMahon said to expect “clear recommendations to ministers in the next few months” following these discussions.

“The really important principle for the person coming in is don’t squander that opportunity – make the most of it”

Alex McMahon

He added: “All of those things have to be options that we have to fully exploit, because we cannot just depend on one single intake of student nurses. That isn’t the answer [and] it wouldn’t give us the workforce we need.”

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Meanwhile, the Nursing and Midwifery Taskforce has also been thinking about how to better promote a career in nursing to the next generation.

It comes as Scotland saw an 8% decline in the number of applications to nursing courses in the country last month.

Following the Covid-19 pandemic and recent industrial disputes, Professor McMahon said the profession “needed a bit of marketing”.

He argued that a career in nursing should not be “sugarcoated” but instead there should be emphasis on the “enormous” opportunities that are available.

The taskforce has also considered whether current nursing courses are working as efficiently as they can, which includes discussions around the number of practice placement hours, the role that simulation can play in nurse education, whether there is enough financial support available to students and what preceptorship opportunities are available.

It comes as a recent Nursing Times survey found that just 45% of nurses in Scotland said preceptorship was on offer in their workplace.

Responding to this figure, Professor McMahon said: “We have to support students and then newly qualified registrants as well, and that really is a challenge in areas.

“I’ve had this conversation with many nurses: you can’t choose to be a preceptor or not, it’s something we all have to give back. It’s about looking after our newly qualifieds in order that we nurture them and make them a much more confident practitioner.”

Outside of the taskforce, the CNO has been progressing work on safe staffing legislation.

Next month, Scotland’s long-awaited Health and Care (Staffing) (Scotland) Act 2019 will come into force – the roll-out of which has faced delays due to the Covid-19 pandemic.

This legislation will make organisations legally bound to ensuring appropriate staffing levels across all health and social care settings.

“That’s a massive milestone for us in Scotland, because it covers all disciplines in all care settings,” said Professor McMahon.

Other areas of focus for Professor McMahon have been improving the support available for nurses who are retired and want to return, as well as plans to try to reduce supplementary staffing and agency spend in NHS Scotland.

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Looking forward to the priorities for the incoming CNO, Professor McMahon said there was always “more to do” in the nursing and midwifery space.

“I think the foundations from the work of the taskforce will provide the incoming CNO [with] a good platform to work with, alongside the pay and non-pay bits as well,” he said.

But he added: “The really important point is there’s a chief nursing officer who will be able to influence the direction of our services.”

One area that needed attention was social care, noted Professor McMahon. It comes as Scotland awaits proposals for a National Care Service, something which was put on hold for three years to allow the Scottish Government to work with councils on the idea.

The service would allow Scottish ministers to transfer social care responsibility from local authorities to a new National Care Service.

Nursing staff currently working for the NHS would still be employed by the NHS but could be required to deliver services for which the National Care Service was responsible.

Professor McMahon explained that, in the long term, Scotland needed health and social care to be “working in a synchronised way”.

He said: “Now the cogs are a little bit misaligned. We are not necessarily working in the same direction, going at the same time or going at the same pace. That is causing us to have a system where we’ve got too many people in hospital who don’t need to be there, and that’s frustrating for many people.”

Reflecting on everything that had led him to fulfilling his dream of becoming Scotland’s CNO, Professor McMahon said that he felt “very lucky” and that being in the role was “such a privilege”.

He added: “The opportunities the role will give you to influence so much at a Scotland, UK and international level are really important.

“So, the really important principle for the person coming in is don’t squander that opportunity – make the most of it. Make the most of it for those people who we’re here to serve, and that’s patients and people who use our system, and staff who we need to bring in and retain.”

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