National Care Standards Review: Consultation Analysis

1 Executive Summary

1.1 National Care Standards were established in 2002 to help people to understand what to expect from care standards and services to understand the standards they should deliver. The Scottish Government wishes the standards to be updated and improved to meet current expectations and models of service.

1.2 Scoping work with a range of stakeholders informed the development of a consultation paper, published by the Scottish Government on 25 June 2014 in a variety of formats including easy-read, large print and on-line. 475 responses to the consultation were received, from a wide range of stakeholders, organisations that represent the views of people who use services, providers of services, and professional bodies.

1.3 A summary of views contained in the consultation responses follows.

Foundations of the new National Care Standards

1.4 92% of those who addressed the issue agreed with the Scottish Government's proposal that the new standards should take a human rights-based approach in which people using services are at the centre of how they are planned and delivered. Many felt that human rights are relevant to all and the proposal would ensure people are placed at the heart of services, and treated equally.

1.5 Key advantages to grounding the new standards in human rights were identified as the alignment of this approach with modern UK approaches and European Union legislation; clarification for service providers and users alike of what can be expected in terms of service; and empowering users to be more fully involved in decisions affecting them.

1.6 The main concern expressed was that service providers may not be able to meet service users' raised expectations of service, due to constraints beyond their control, such as limited budgets.

1.7 Other concerns included doubt over the degree to which achieving a human rights-based approach would be measurable; concerns that the human rights framework may be too inflexible to accommodate the broad range of care and health services; that it may result in overly bureaucratic and zealous emphasis out of proportion to the size and nature of the organisation; and the need to balance the human rights of users, providers and carers.

1.8 A common view was that in order to ensure the success of the proposed human rights-based approach, there would need to be clarity on precisely what this means within the context of the new standards, including examples of how human rights would be manifested.

New structure for the National Care Standards

Development of overarching quality standards

1.9 It is proposed that under the new structure for National Care Standards, overarching quality standards should be developed, based on human rights law and standards. These would describe the elements of a quality care experience rather than the requirements that are specific to a particular service type.

1.10 89% of those who addressed the issue expressed support for developing the overarching quality standards. This proposal was viewed as promoting greater consistency between agencies in the way services are delivered; being helpful in that people could expect the same level of care no matter who they are; and beneficial in promoting greater integration of care across health and social care services. The most commonly raised concern was that it may be challenging to produce overarching, relevant standards across both areas of service without the medical model dominating.

1.11 Many respondents called for the overarching standards to dovetail with those to which professionals already work, including those associated with Getting It Right For Every Child (GIRFEC), the Healthcare Quality Strategy, National Health and Wellbeing outcomes and Standards of Care for Dementia.

1.12 92% of those who commented agreed that overarching quality standards should set out essential requirements based on human rights. A common theme was that service providers should have training to help them to understand how human rights-based quality standards should manifest in their daily working practices. Another prevailing theme was that achievement of the overarching standards should be readily measurable, with regulators requiring guidance on how to assess this in their inspection regime.

Streamlining the National Care Standards and developing general standards

1.13 82% of those who addressed the issue agreed with the Scottish Government proposal that the current National Care Standards should be streamlined and a set of general standards developed that would sit below the overarching standards and apply to all services. The prevailing view was that streamlining the standards would help to create a simplified structure of standards, which will be easier for service user and service deliverer to understand and access.

1.14 The joined-up potential of the proposal was viewed as particularly beneficial in circumstances such as: users transferring from one service to another; first-time users unfamiliar with the system; a person using more than one type of service or a person delivering care across more than one type of service.

1.15 A common concern was that streamlining may result in standards that are so vague and general as to be meaningless and unaccountable.

Setting out essential requirements and aspirational elements of the National Care Standards

1.16 It was proposed that the National Care Standards should set out both essential requirements and aspriational elements. 75% of respondents who commented on this agreed with the proposal. The most common view in support of the proposal was that it would help to drive improvement and increase overall quality of care.

1.17 A common concern was that introducing both essential and aspirational elements to this tier of standards could be overly complex and may detract from the key message and expectation that general standards should reflect high quality in themselves. Another prevailing concern was that designating aspects of service "aspirational" may give out the message that these are optional extras, which may result in providers de-prioritising them.

Proposal to develop a suite of specific standards for aspects of care, circumstances or need

1.18 Of the respondents who addressed this proposal 79% were in agreement. In particular, respondents welcomed the tailoring of standards to particular circumstances, which they felt would be meaningful and helpful to user and provider alike. Some felt that specific standards would be more measurable than general standards. Another benefit identified was that basing these around aspects of care, circumstance or need would encourage cross-cutting support and liaison between providers and help to minimise gaps in provision.

1.19 A common concern, however, was that this approach could result in a myriad of standards to cover the diverse range of care, circumstances and need existing, thereby negating the overall aim of streamlining the current standards. It was also considered by many that such specific standards may not align with a human rights-based approach in which the focus is on the whole person and their overall needs.

Views on how the National Care Standards should be written

1.20 There was general agreement that the National Care Standards should be written in a manner which strikes a balance between the need to use language that is simple and easy to understand, whilst also requiring to express standards in a way that makes it clear when a service provider has breached a standard.

1.21 A common view was that the standards should be written in unambiguous, lay terminology, in plain English and avoiding jargon. Easy-read and large print versions were also called for along with production in a range of other accessible formats such as Braille, audio and different languages.

1.22 Repeated calls were made for the standards to be developed in conjunction with service users, carers and providers in order to increase their accessibility.

Proposal for an overall statement of standards

1.23 The main consultation document proposed a clear overall statement of standards which includes both appropriately worded explanations of the rights of people using the services and the responsibilities of service providers to deliver high quality care. There was much support for the proposal with this perceived to be a clear and user-friendly way of presenting rights and responsibilities for both users and providers of services. The visual appearance of the proposal, which included two columns side-by-side written from the perspectives of the service user and service provider respectively, was singled out for praise by a few respondents who considered this created the impression of partnership working. A few others, however, perceived this as potentially combative in appearance.

1.24 A minority of respondents criticised the text used in the proposal, deeming this to be vague, jargonistic and overly complex.

1.25 Calls were made for the proposal to be supplemented with specific examples and case studies, perhaps in an additional third column. Others requested the addition of links to related policy documents and standards.

Accountability and enforcement

Inspection of regulated services

1.26 88% of those who addressed the issue agreed that the Care Inspectorate (CI) and Healthcare Improvement Scotland (HIS) should hold services they regulate to account for meeting the proposed overarching standards, the general standards and the suite of specific standards.

1.27 It was commonly felt that without this arrangement the standards would be rendered ineffective, with patchy take up. The proposal was viewed as contributing to a transparent and independent scrutiny process which would promote consistent standards of care.

1.28 A dominant theme was that incorporating these standards within these regulatory regimes will help to make expectations of service provision clear for both service providers and users. Calls were made for greater consistency in approaches to inspection and clarity on the criteria against which providers will be held to account.

1.29 Many respondents emphasised that the new scrutiny processes should operate within an overarching supportive framework in which services are helped to work towards the standards, whether by additional funding, staff training or advice. Some called for the involvement of service users, carers and staff in the scrutiny process, to enhance its value.

1.30 Concerns were raised that the proposal could lead to confusion and duplication with inspections of all three sets of standards imposed over and above existing regulatory regimes and inspections. Some cautioned that the inspection regime should avoid being relegated to a paper-based tick-box exercise.

Inspection of non-regulated services

1.31 A recurring comment was that the implementation of self-directed support made it much more likely that non-regulated services may be procured by users, thus increasing the current challenge around ensuring compliance with standards.

1.32 A common view amongst individual respondents was that all providers of health and social care services should be required to become regulated. Others, however, acknowledged that the potential disproportionate cost and bureaucracy this may incur for some small providers and recommended compromises, such as voluntary registration with quality schemes which could be publicised and assessed by service users.

1.33 Another commonly held view was that the inspectorate bodies should have their remits extended to encompass monitoring of compliance amongst non-regulated service providers, even if this is done on an "informal" basis. Others recommended that commissioners of services such as local health and social care partnerships be responsible for monitoring adherence to standards amongst the services they procure, with compliance specified in the service contracts.

1.34 A prevailing theme was that awareness-raising of the standards amongst service providers and service users could go some way to ensuring shared, high expectations of service provision with failure to achieve these more readily identified by all. Calls were made for discreet complaints procedures in which users and whistle-blowers can air their grievances in confidence.

Views on the proposal that the CI and HIS develop the suite of specific standards in consultation with others

1.35 Amongst those who addressed this issue 85% agreed with it. These inspectorates were considered to be well placed to lead the development of the specific standards, being in the position to engage with stakeholders and using their experience and expertise.

1.36 It was felt that standards developed in this way would have credibility, be meaningful, realistic and achievable and cover all of the relevant aspects of care.

1.37 Many respondents advocated a co-productive process with collaborators working alongside each other, engaging specialists where necessary, in order to develop the standards.

1.38 A minority of respondents expressed concern, however, over scrutiny bodies being involved in developing the standards which they will subsequently be scrutinising, suggesting that this proposal lacked independence and rigour.

Assessing impact

1.39 Views were sought on potential impacts of the proposals, particularly with reference to the "protected" characteristics. It was generally agreed that there may be short-term challenges as providers and users become acquainted with the standards and make necessary adjustments to procedures, but over the longer term, most respondents viewed the proposals as having positive impacts.

1.40 The aspect of the proposals most frequently identified as positive for those with protected characteristics was the grounding of the new standards in human rights. This was seen as ensuring the individual user is at the centre of service provision, having control over their care and being listened to. Another benefit identified by many was that those with protected characteristics would receive higher standards of care, with users more likely to be protected from harm and services tailored more to their individual needs.

1.41 The most prominent concern was that service users with cognitive impairment and/or communication challenges, may find the changes to the standards confusing. Some respondents expressed concern that people with complex needs may fall between the different categories of service provision.

1.42 Implementation costs of the proposals were envisaged, largely connected with training of staff, public and provider awareness-raising, and re-working regulatory and guidance materials. Some envisaged the inspectorates having to expand to accommodate broader responsibilities, particularly if required to inspect non-regulated services.

1.43 Some respondents predicted savings would result largely from streamlined standards reducing bureaucracy and a reduction in the need for staff training over time, as procedures simplify. A recurring view was that higher standards of preventative work would lead to a reduction in remedial action required in the longer term.

Additional comments

1.44 Many respondents made additional comments over and above those documented in response to the specific questions raised in the consultation.

1.45 There was much support for the proposal for further consultation on the new standards before they are finalised. However, many respondents emphasised that this should be inclusive, in order to get views from a wide variety of perspectives.

1.46 A recurring view was that the new standards would require to be widely publicised using a variety of media. Some felt that proposed implementation date of April 2015 was ambitious.

1.47 Other significant additional comments related largely to: implementing the standards in phased approach; welcoming the outcome-focus of the standards as making them more meaningful; suggesting the word "care" is removed from their title; urging greater acknowledgement of the influence of resourcing in achieving the standards; and establishing clear timings for reviewing the standards.