National Care Standards Review: Consultation Analysis - Research Findings

National Care Standards Review: Consultation Analysis

National Care Standards were established in 2002 to help people to understand what to expect from care services and to help services understand the standards they should deliver. There are currently 23 sets of standards which cover a wide range of care services from childminders and nurseries to care homes and independent hospitals. The Scottish Government wishes the 2002 National Care Standards to be updated and improved to meet current expectations and models of service. Central to its proposals are that people working in health and care services should have a common understanding of what quality means and they should work to common core values, through the introduction of quality standards for health and care services.

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.

Main Findings

• 92% of those who addressed the issue agreed with the proposal that the new standards should take a human rights-based approach in which people using the services are at the centre of how services are planned and delivered.
• 89% of those who provided a view supported the development of overarching quality standards, based on human rights law and standards, which describe the elements of a quality care experience rather than the requirements that are specific to a particular service type.
• 82% of those who addressed the topic agreed with the 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 which would apply to all services.
• 75% of those who commented agreed that the National Care Standards should set out both essential requirements and aspirational elements. 79% of those providing a view agreed with the proposal to develop a suite of specific standards for aspects of care, circumstances or need.
• 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 to make it clear when they have been breached by a service provider.
• 88% of those who provided a view agreed that the Care Inspectorate and Healthcare Improvement Scotland should hold services they regulate to account for meeting the proposed overarching standards, the general standards and the suite of specific standards.
• 85% of those who commented agreed that the Care Inspectorate and Healthcare Improvement Scotland should develop the suite of specific standards in consultation with others, these bodies being considered as well placed to lead on the development of these standards.

Background

National Care Standards were established in 2002 to help people to understand what to expect from care services and to help services understand the standards they should deliver. There are currently 23 sets of standards which cover a wide range of care services from childminders and nurseries to care homes and independent hospitals.

Significant changes have occurred since 2002 in terms of demographics (for example, an ageing population); greater focus on community and home settings for care rather than previous institutional models of care provision; integration of health and social care; greater emphasis on user-empowerment and choice of care (e.g. through self-directed support); and priority afforded to human rights-based approaches to planning services and delivering care.

The Scottish Government wishes the 2002 National Care Standards to be updated and improved to meet current expectations and models of service. Central to its proposals are that people working in health and care services should have a common understanding of what quality means and they should work to common core values, through the introduction of quality standards for health and care services.

Scoping work with a range of stakeholders informed the development of a consultation paper which the Scottish Government published on 25 June 2014 in a variety of formats including easy-read, large print and on-line. Views were invited by 17 September on proposals to update the care standards. The views expressed in responses will inform further discussions with stakeholders and the introduction of new standards in April 2015.

Overview of respondents

The Scottish Government received 475 responses to the consultation, Just over half (52%) of all respondents were individuals, including members of the public, service users, and those with experience of working in the care services profession. The largest organisation sector to respond was voluntary organisations and groups which accounted for just under one-quarter (22%) of all respondents. In addition, Scottish Independent Advocacy Alliance, Age Scotland and Social Care Alliance Scotland hosted 10 events in partnership with the Scottish Government to capture the views of people who use services.

The foundations of new National Care Standards

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.

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.

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.

Other concerns included doubt over the degree to which achieving a human rights-based approach would be measurable. Whilst some respondents perceived the approach to be measurable, concrete and able to be enforced and inspected, others viewed it as intangible, more of a reference point and a philosophy. Further key concerns were that the human rights framework may be too inflexible to accommodate the broad range of care and health services; and that it may result in overly bureaucratic and zealous emphasis out of proportion to the size and nature of the organisation.

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: overarching quality standards

Development of overarching quality standards

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.

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.

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 care wellbeing outcomes and Standards of Care for Dementia.

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

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 users and service deliverers to understand and access.

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.

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

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.

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 present the message that these are optional extras, which could result in de-prioritisation by providers.

Proposal to develop a suite of specific standards

Of the respondents who addressed this proposal 79% were in agreement that specific standards for aspects of care, circumstances or need should be developed. 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.

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, 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

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.

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.

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

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.

Accountability and enforcement

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

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.

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.

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.

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.

Assessing impact

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 for those with "protected characteristics".

The aspect of the proposals most frequently identified as positive 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.

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.

Implementation costs of the proposals were envisaged but some respondents predicted savings would result over the longer term, largely from streamlined standards reducing bureaucracy.