National health and care standards: consultation analysis

1. Executive Summary

1.1 In 2014, Scottish Ministers committed to review, update and improve the 23 National Care Standards established in 2002. New Standards were needed to reflect changes in policy and practice since 2002.

1.2 Scottish Ministers proposed a new, single set of Standards across health and social care, based on human rights and underpinned by the principles of: dignity and respect; compassion; being included; responsive care and support; and wellbeing. A Development Group, made up of a wide range of stakeholders, drafted the new Standards, in collaboration with other key partners.

1.3 Seven draft Standards were proposed and put out to public consultation on 28 October 2016 with views invited by 22 January 2017. An easy-read version of the consultation was also published. In addition, a series of 19 engagement events was held across Scotland by the Care Inspectorate and Healthcare Improvement Scotland.

1.4 440 responses were received to the full consultation and 59 to the easy-read version, making a total of 499 responses overall. Of these, 50% were organisations responding to the full consultation. Of the individuals who reported to the full consultation, 70% were working or volunteering in health and social care; 25% were service users. A summary of the responses to the both the full and easy-read version of the consultation follows.

Overarching views and themes

1.5 Overall there was substantial cross-sector support for the new Standards:

• 79% of those providing a view to the full consultation strongly agreed or agreed that they will be relevant across all health, care and social work settings.
• 74% of those providing a view to the full consultation strongly agreed or agreed that the Standards reflect the experience of people who receive care and support.
• There was much appreciation of what was perceived to be the thorough and thoughtful development work which has gone into the development of the Standards so far.

1.6 Views provided in response to the consultations (both full and easy read) ranged from a mix of very detailed drafting comments on the text of the Standards and their supporting statements, to broad, cross-cutting comments which emerged repeatedly throughout the consultation responses.

1.7 Overarching, common concerns to emerge were:

• The Standards may not apply to all settings and all circumstances.
• They appear to be aspirational in places, which may have advantages, but also posed the threat of undermining their usefulness and setting providers up for failure.
• The language could be refined in places, with various words and phrases identified as vague and ambiguous.

Views on the relevance of the Standards

1.8 Most respondents considered that the Standards will be relevant and can be applied across all health, care and social work settings. 79% of respondents to the full consultation and all but one of those responding to the easy-read version, shared this view.

1.9 The Standards were welcomed as human-rights focused and outcome-focused. They were viewed as person-centred and easy to read, and likely to promote consistency in quality of provision and expectation.

1.10 Some respondents suggested that the balance of focus of the Standards tipped towards social care contexts over health care environments.

1.11 Key concerns were that the universal approach of the Standards may result in their being too general to be useful; some perceived them to be unduly specific in some places and too general in others; many respondents expressed concern that the generalisable nature of the Standards may present challenges for inspection regimes and benchmarking.

Views on whether the Standards reflect the experience of people who receive care and support

1.12 The prevailing view was that the Standards do reflect the experience of people who receive care and support. 74% of respondents to the full consultation and all but one of those responding to the easy-read version, shared this view.

1.13 Although receiving wide support as reflective of real-life experience, the effectiveness of the Standards was perceived to be dependent on broader contexts such as adequate resourcing, appropriate organisational structures, and well-planned implementation, along with robust inspection and enforcement regimes.

1.14 The Standards were viewed as setting up the context of positive outcomes for service users in terms of being: person-centred; written in the first person; comprehensive; and clear and well-structured. Contrasting views were that the Standards were ambiguous, subjective and repetitive in places, risking different interpretations which could undermine their usefulness.

1.15 Gaps in the Standards or areas which could be given greater attention were identified as the experiences of: people receiving care at home; people with dementia; very young children, children and young people; and people in secure care settings. Some respondents considered that the Standards did not pay enough attention to the use of advocates; safety issues for the service user and service provider; and transitions and interfaces between different care and support contexts.

Views on Standard 1: I experience high quality care and support that is right for me.

1.16 89% of those responding to the full consultation and all of those responding to the easy-read version considered that this Standard described what people should expect to experience from health, care and social work services.

1.17 The Standard was perceived to be thorough, comprehensive and detailed, whilst retaining clarity. The section on wellbeing was identified as particularly welcome, as were the statements for children in their early years.

1.18 Broad concerns were raised that the Standard was more aspirational than achievable; the Standard was overly long and repetitive; some of the statements were too prescriptive; and some of the language was too subjective.

Views on Standard 2: I am at the heart of decisions about my care and support

1.19 87% of those responding to the full consultation and all but two of those responding to the easy-read version considered that this Standard described what people should expect to experience from health, care and social work services.

1.20 The Standard was viewed as being comprehensive, written clearly, and aligned with broader policy context such as self-directed support and outcome-focused models of commissioned care and support. Aspects of the Standard which were particularly welcomed included: the focus on positive risk-taking; focus on communication; significance given to the service user having choice and control; and the implied emphasis on empowerment.

1.21 A repeated view across different sectors was that contextual factors such as resources, physical structures of care settings, and staffing ratios, will impact on the degree to which this Standard can be implemented and achieved.

1.22 Some respondents considered that not all of the statements will apply in all settings, with prison and acute health care settings mentioned in this regard.

Views on Standard 3: I am confident in the people who support and care for me

1.23 90% of those responding to the full consultation and all but two of those responding to the easy-read version considered that this Standard described what people should expect to experience from health, care and social work services.

1.24 There were many supportive comments about Standard 3 as a whole, and key elements within. What was perceived as a person-centred approach was welcomed; the emphasis on communication and relationships was valued; and links with a wider context of guidance and legislation were identified. The layout of the section was viewed as helpful to providers; the Standard was seen as providing reassurance to those most vulnerable, both in its title and also under sections such as "Compassion".

1.25 A minority view was that some of the language of this Standard was vague, and whilst its aims appeared laudable, they required adequate funding and could be challenging to ensure and enforce.

1.26 A key emerging theme was that this Standard required robust underpinning with a framework of training for paid and unpaid workers. Some queried how it would be measured and assessed, with examples requested.

Views on Standard 4: I am confident in the organisation providing my care and support

1.27 87% of those responding to the full consultation and all but one of those responding to the easy-read version considered that this Standard described what people should expect to experience from health, care and social work services.

1.28 This Standard was perceived to be well written, comprehensive, aligned with patient-centred care, and focused on human rights and participation.

1.29 A number of broad concerns were raised. Respondents queried how achievement of the Standard would be measured, evidenced and enforced. Some questioned whether service users, particularly children, would know if this Standard was being met. A repeated view was that people may not know if their human rights are being respected if they are not educated on what these are.

Views on Standard 5: And if the organisation also provides the premises I use.

1.30 81% of those responding to the full consultation and all but one of those responding to the easy-read version considered that this Standard described what people should expect to experience from health, care and social work services.

1.31 The Standard was perceived to be thorough and comprehensive, whilst retaining clarity. The section on compassion was particularly welcome as was the statement on access to the internet.

1.32 Key concerns were that: the Standard appears more aspirational than practical; the heading appears to be unfinished; "premises" needs further explanation; some words and phrases appear to be woolly and not easily measurable.

Views on Standard 6: And where my liberty is restricted by law.

1.33 77% of those responding to the full consultation and all but one of those responding to the easy-read version considered that this Standard described what people should expect to experience from health, care and social work services.

1.34 The Standard was welcomed as focusing strongly on human rights, and establishing a helpful basis for assisting in balancing issues of risks, whilst ensuring individual rights are respected. Some considered that the Standard captured well the role which restrictions play in ensuring security and wellbeing of the individual, underpinned by compassion, dignity and respect.

1.35 The most common concern regarding Standard 6 was over the word "by law" in the heading. A recurring view was that the Standard should apply also to settings where liberty is restricted due to other factors, such as safety and security of the individual.

1.36 There were mixed views on whether this Standard should be stand-alone or whether it should be mainstreamed across the other Standards. A key argument in favour of mainstreaming was that human rights should underpin all care provision rather than be associated only with settings where liberty is restricted by law. A contrasting view was that human rights merits prominence in a dedicated Standard.

Views on Standard 7: And if I am a child or young person needing social work care and support.

1.37 80% of those responding to the full consultation and all but one of those responding to the easy-read version considered that this Standard described what people should expect to experience from health, care and social work services.

1.38 The Standard was seen to be appropriate, comprehensive, yet proportionate. It was perceived to fit with wider, relevant guidance, and used positive language which reflected high expectations.

1.39 Again respondents questioned whether this Standard merited being stand-alone. A recurring view was that several of the statements were not specific to children and young people, and were equally applicable across all ages and demographics.

1.40 Several respondents perceived this Standard to duplicate elements of previous Standards; some considered the terminology to be subjective in parts.

Views on whether the Standards will help support improvement in care services

1.41 75% of those responding to the full consultation considered that the Standards will help to support improvement in care services, as did all but three of those responding to the easy-read version.

1.42 The three most common reasons given as to why the Standards will support improvement were: they are easy to understand, user-friendly and accessible; they provide a common understanding and framework which ensures shared expectations and which will promote consistency of provision; and the rights-based approach will help providers and service users to understand what is required.

1.42 A common view was that the effectiveness of the Standards could be enhanced by the provision of practice-based guidance to support providers in implementing the Standards in their setting. Another recurring suggestion was for the development of a clear inspection framework.

1.43 Although supporting the Standards, some respondents considered that they may be too broad and risked service providers and service users interpreting them differently, which could detract from their effectiveness.

1.44 Another commonly mentioned concern was that applying all aspects of the Standards to all settings will be challenging. What was perceived to be the aspirational nature of elements of the Standards was viewed as potentially undermining, whilst raising expectations which may not be fulfilled.

1.45 Some respondents considered that the Standards were too vague to be measurable or enforceable; some criticised what they saw as the "one size fits all" approach; others considered the scope for different interpretation of the Standards was too great; and a few respondents emphasised the need for a review framework for feedback on, and revision of, the Standards.

1.46 Many respondents suggested that to be successful, the Standards required to be adequately resourced; effectively launched and implemented; and robustly inspected and enforced. Training opportunities for the workforce were highlighted as important; as was awareness-raising amongst service users and workforce alike.

Views on anything else to be included in the Standards

1.47 A wide variety of suggestions was made for additional content. The four most frequent suggestions were: feedback/complaints/appeal mechanisms; end of life care including anticipatory care plans and advanced statements; management of transitions; and right to advocacy/recognition of representatives, both formal and informal.

Views on anything else to be aware of in the implementation of the Standards

1.48 The most frequently emerging view was that the current inspection regimes will need to be updated to reflect the new Standards, with these communicated widely in time for implementation.

1.49 Another common view was that the Standards will need to be made widely available and accessible, and in a variety of formats, to meet the needs of those with communication difficulties.

Views on what the new Standards should be called

1.50 Of the five options provided in the consultation, the option receiving most support amongst respondents to the full consultation was, "National Health and Social Care Standards". Amongst respondents to the easy-read version, the option with the most support was, "National Care and Support Standards".

1.51 Many other suggestions for names were proposed, with key themes emerging: "Scotland" or "Scottish" to be in the title; the person-centred approach to be reflected, perhaps using the terms "People's Standards…" or "My Standards…" or "People first Standards"; include a strapline then a title, such as "Raising Expectations, Raising Standards" followed by "National Care Standards" or similar.

Any other comments or suggestions

1.52 There was much appreciation of what was perceived to be the thorough and thoughtful development work which has gone into the development of the Standards so far. The Standards were viewed as a potential tool for partnership working, underpinned by a shared understanding between partners of expectations of provision.

1.53 Some respondents considered that the Standards required further editing to make them shorter and more streamlined. Others suggested that links between broader, related frameworks and regulatory regimes should be made more explicit.

1.54 Whilst some respondents welcomed the universal approach of the Standards, others viewed this as too broad-brush, and masking the complexities of health and social care provision.

1.55 A common view was that whilst the Standards are generally applicable, they will need to be implemented in a meaningful and systematic way to ensure effectiveness. Respondents recommended thorough preparation before the launch of the new Standards. This was envisaged as including sufficient lead-in time to allow for structured implementation, including revised inspection regimes, awareness-raising and educating.