National Care Standards Review: Consultation Analysis

7 Assessing Impact

7.1 The consultation sought views on potential impacts of the proposals, particularly with reference to the "protected" characteristics of age; disability; gender reassignment; pregnancy and maternity; race; religion and belief; sex and sexual orientation. Views provided will inform a full Equality Impact Assessment and help in considerations of whether any further work is required in this area. Views were also sought on potential costs or savings that may occur as a result of the proposals.

General comments on impacts

7.2 Many respondents simply provided general support for the proposals, indicating that they expected there to be positive impacts for protected characteristic groups (although it was noted that the online response form did not list the protected characteristic groups and this could account for the lack of specific reference to them in most responses). A few respondents stated that it is too early to say, and they would put off judgement until the final standards had been confirmed and implemented.

7.3 It was generally agreed that there may be short-term challenges for providers and users as they become acquainted with the standards, and providers make any required adjustments to their current operations and reporting systems. Over the long term, however, most respondents viewed the proposals as having positive impacts.

7.4 Two respondents (Oth, Ind) recommended robust monitoring systems to be in place in order to identify experiences and outcomes arising from the proposals. One (Ind) called for case reviews and formal complaints to be monitored as indicators of service delivery standards.

7.5 Various respondents advocated Equalities Impact Assessments and/or Health Inequality Impact Assessments as part of the identification of impact. One respondent remarked:

"Equalities legislation is in place to ensure certain characteristics are protected. However, looking at this in the context of inequalities and involving people in decision-making, the most deprived and disadvantaged in society may or may not be included within protective legislation or protected groupings. We would therefore recommend that equalities assessments be extended to include health inequalities impact assessments as a systematic way to consider how a policy or plan may affect people differently" (Voluntary Health Scotland).

Views on positive impacts

7.6 The aspect of the proposals most frequently identified as positive for those with protected characteristics, and for other service users, was the grounding of the new standards in human rights. Respondents from a wide range of sectors viewed the human rights-based approach as contributing to placing the individual user at the centre of the service provision, having control over their care and being listened to. This approach was seen as promoting equality of access to and provision of care. Typical comments included:

"A human rights-based approach will have positive impact on all groups - if the standards clearly indicate they are linked to rights people have in law in all aspects of their lives - not just in relation to support services. The Human Rights based approach may raise general awareness - a good thing!" (Scottish Disability Equality Forum).

"We believe that the standards provide an opportunity to put the individual service user at the heart of their care provision and the PANEL approach will recognise that not everyone with a common diagnosis has the same care needs and encourage a person centred approach to care" (Mental Welfare Commission for Scotland).

7.7 Another benefit of the proposals identified by respondents from a range of sectors, was that they would result in higher standards of care, with users more likely to be protected from harm and services tailored more to their individual needs.

7.8 Other potentially positive impacts were each raised by only a few respondents:

• The standards will be more easily understood with people more aware of them. For example:
  "It seems that generally, the care standards are being changed to make them easier to read, whether you are looking for a care provider or a care provider yourself. This should have a positive impact on anyone looking for information about what they should expect from a care provider, especially for those that felt confused by the current system with its many different versions of the standards and so much duplication of information" (Assistance in Care Services).
• They will promote a consistency in approach by service providers.
• They will help people to live independently in the community.
• Stigma will be reduced by everyone being treated the same.

7.9 A few respondents identified positive impacts for service providers, including the reduction in bureaucracy as the system becomes more streamlined, the sharing of good practice between organisations, and generally, more respectful services for staff, management and users.

7.10 Some respondents qualified their support by stating that positive impacts will emerge only:

• If people with protected characteristics are involved in the development of the standards.
• If service provider staff have training to help them implement and deliver the standards.
• If the standards are well publicised, accessible and presented in a constructive manner.
• If the standards are written clearly and in formats for all communication needs.

Views on negative impacts

7.11 The most prominent concern was that service users with cognitive impairment, dementia, learning disabilities and/or those with communication challenges may find the changes to the standards confusing. Some respondents considered that even those without these difficulties may perceive the multi-layered standards to be complex and vague. Many respondents emphasised the need for the standards to be produced in range of formats including easy-read and using different media to suit a wide range of communication needs.

7.12 A few respondents remarked that due to difficulties with understanding the new standards, more use may need to be made of advocacy and interpreting services, which would need to be resourced.

7.13 Another key concern amongst many respondents was that the streamlining and rationalisation of standards could lead to some people, particularly those with protected characteristics, falling between different categories of service. Hard-to-reach groups were identified specifically in this respect, along with those moving between children's and adults' services.

7.14 Other potential negative impacts of the proposals were each identified by only a few respondents:

• The promotion of self-directed support could result in a two-tier quality of service, one regulated, the other not.
• Service user expectations may be raised too high by words such as "rights".
• The human rights-based approach may lead to carers feeling left out with their rights of lesser importance than the rights of those they care for.

7.15 Negative impacts were also predicted for services with concerns largely focused on possible increased workload related to implementing the proposals. One private organisation cautioned that the proposals may result in focusing on evidencing standards rather than delivering excellent care. Three respondents considered that should the system become too bureaucratic, then some private service providers may be forced to close down. There was also concern that the proposals may require extra resourcing which some organisations would struggle to find in the short term.

General views on potential costs or savings

7.16 The consultation sought views on any potential costs of savings that may occur as a result of the proposals. There was a broad agreement amongst many respondents that costs would increase in the short term, particularly associated with implementing the proposals, but over the longer term there would be savings to be made, or the costs could be neutral. Some felt that it was too early to predict costs or savings, particularly as the standards were still subject to consultation. A few respondents remarked that resource considerations should not be the main focus, and instead, achieving better outcomes should drive the change. One respondent commented:

"Should there be a concern about the cost of regulating good care? I know it costs money to provide good care and to ensure good care standards are being delivered, but in the long run better public knowledge means better care, which means less burden on the health care system. It will take time but there should be a light at the end of the tunnel so to speak" (Ind).

Identification of potential costs

7.17 A recurring view was that costs would be incurred initially associated with implementation of the new standards. 69 respondents from a wide range of sectors referred specifically to potential costs linked with training staff.

7.18 Another cost identified repeatedly (35 mentions, around half from voluntary organisations) was that of promoting the new standards through advertising, marketing, awareness-raising, and production of literature in appropriate formats.

7.19 Initial re-working of regulatory and guidance materials was identified by 12 respondents as potentially increasing costs at the start; and five respondents referred specifically to costs of further consultation and piloting of the new standards.

Costs specific to service providers

7.20 Many respondents identified potential costs to be incurred by service providers as a result of the proposals. Costs were associated with ongoing staff training, adapting internal procedures and monitoring systems, increased evidence-gathering and investment in the human and operational resources needed to meet standards (aspirational standards were referred to particularly here). Some respondents identified particular items of additional expenditure such as BSL interpreters and structural adaptations of premises.

7.21 Several respondents commented that whilst recognising what is required to meet the standards, many service providers may fall short due to lack of funding. One respondent remarked:

"A particular tension may exist between the capacity and resources of a service and the specific standard that a regulatory body may be seeking to impose. It would, therefore, be important to encourage and foster partnership working from the start and where services are failing to meet a particular standard that they are actively supported where appropriate" (NHS Education for Scotland).

7.22 Other potential costs for service providers each identified by only a few respondents were:

• keeping users involved, consulting with them and raising awareness
• new administrative costs for unregulated providers who may be brought within the scope of inspection
• possible increase in the regulation fee
• addressing need which was previously not identified and not met
• longer-term erosion of quality with impacts on remedial action due to the standards being too vague and not relevant.

7.23 Costs specific to regulatorsA minority of respondents identified potential ongoing costs associated with the regulators. 17 respondents referred specifically to the need to expand the inspectorate workforce and ensure it has the expertise to undertake specialist inspection and be more than merely a process and "desk top" review mechanism.

7.24 A few respondents considered that the proposals could incur potential costs for regulators other than the CI and HIS (the Scottish Housing Regulator mentioned in this regard).

7.25 The prospect of the inspection encompassing non-regulated providers was also identified by a few respondents as potentially increasing costs.

7.26 Two voluntary organisations referred to possible increased need for independent advocates with the costs possibly falling to local authorities.

Views on potential savings

7.27 As highlighted above, many respondents commented in broad terms about the potential for longer-terms savings as a result of the proposals. Some were more specific about where they felt that savings could accrue:

• Streamlined standards resulting in less bureaucracy, rationalisation of inspection, information all in one place, shared expectations.
• Simplification of processes resulting in reduced staff training costs and resource materials/paper.
• Opportunities for shared training between agencies and providers.
• Rationalisation of inspection function, combining the work of CI and HIS
• Better standard of preventative work leading to less remedial action required in the longer term;
  "If commissioning is properly held to account as part of the inspection process linked to human rights based standards, then costs may be saved later by ensuring people get the right support, at the right time, in a way that suits them. Too often, people with complex support needs are passed from pillar to post because commissioning agencies (not necessarily commissioners - often finance staff) have tried to cut back on cost at an early stage, leading to disastrous consequences" (Scottish Disability Equality Forum).
  
  "If oral health care requirements were made explicit in the revised standards this would likely help improve the daily preventive oral care practice in care homes, and NOPOHIG feel the potential savings to the health sector could be significant" (National Older People's Oral Health Improvement Group).
• Lower legal costs due to reduced cases of litigation associated with alleged poor practices.
• Boosted staff morale could lead to lower staff turnover and associated costs.

Summary of main findings

• There was general agreement that positive impacts would be evident in the longer-term following a period of short-term challenges in which service providers and users become acquainted with the new standards and make necessary adjustments to procedures.
• Grounding the standards in human rights was viewed as particularly positive for people with protected characteristics, ensuring the individual user remains at the centre of service provision, having control over their care and being listened to.
• There was some concern that service users with cognitive impairment and/or communication challenges, may find the changes to the standards confusing.