Health and social care - Planning with People: community engagement and participation guidance

Part 4 – How to use Planning with People

NHS Boards, Integration Joint Boards and Local Authorities should engage with the people and communities they serve following the principles set out in the National Standards for Community Engagement.

The National Standards for Community Engagement are a set of clear principles that describe the main elements of effective community engagement. The standards are not designed to replace existing community engagement or participation frameworks. They are intended to act as a benchmark for best practice and are helpful for organisations across public, third and private sectors to reference during community engagement and user involvement.

The engagement cycle illustrated below is underpinned by principles of the National Standards for Community Engagement, and should be followed in order to demonstrate good practice. Each stage is important and should be applied proportionately to the scale of the activity and level of change proposed.

Engagement Cycle

• Identify the issue
• Identify stakeholders
• Plan engagement
• Engage people potentially affected
• Evaluation
• Feedback and decision making

Identify the issue

Agree a clear purpose to identify engagement objectives, anticipate outcomes, and to help determine the scope of the engagement. There should be clarity and a shared understanding of the objectives at the outset to help shape the process and identify the best methods to reach people and communities. Project goals may evolve as engagement progresses, but they are necessary to keep the process focused.

Identify stakeholders who may be affected by the issue

Stakeholder mapping is important to identify all groups and individuals within the community who may be affected, or who might have an interest in the proposal. Existing networks can help to identify potentially affected people, including those who do not find it easy to share their views. Recruiting representatives of communities to the engagement planning team at the earliest possible stage will help to inform the process and ensure an effective approach.

Plan engagement

Identifying the best approaches to reach the people whose views need to be shared is vital. All steps in the cycle, including an early EQIA, as well as an evaluation of the project’s development so far, should be considered to ensure an inclusive approach from the outset. By involving community representatives, providing any support they may require, will help to encourage the flow of ideas and suggestions, resulting in better engagement and robust and sustainable outcomes.

Engage those potentially affected

Every effort should be made to engage with the right people throughout planning, development and options appraisal of potential options or models. There are many different engagement methods and no one method will suit all engagement purposes. A range of methods should be considered at the planning stage. This ensures that all views are heard and considered.

Evaluation

It is important to carry out evaluation throughout the engagement process to ensure that outcomes set at the beginning, are being met. On-going evaluation also demonstrates that people are being listened to by adapting the approach where appropriate. Evaluation can also identify areas for improvement and will help you understand what works and what doesn't. All information gathered from the engagement process should be captured and evaluated to support future learning.

Feedback and decision making

It is important to keep participants informed about a project’s development throughout the engagement cycle and to encourage on-going feedback. This helps to improve project and programme management by supporting two-way communication, as well as continuous review and reflection. It also helps to monitor progress towards the goals outlined at the planning stage and improves accountability by fully reporting what is being done and what is being achieved.

Throughout the engagement process, decisions will need to be made and community representatives must be involved so that robust, evidence-based and person-centred outcomes are achieved. When engagement activity reaches conclusion, it is the responsibility of NHS Boards, Integration Joint Boards and Local Authorities that must approve or reject recommendations. The quality of the engagement process should be taken into account by decision makers.

4.1 Identify the issue

The objective of all care service change should be to achieve an improvement in the quality, safety and sustainability of person-centred services.

Agreeing a clear purpose to identify engagement objectives, anticipate outcomes and determine the scope of the engagement, must be the first step of engagement planning. Project goals may evolve as engagement progresses, but they are necessary to keep the process focused.

Sometimes the purpose of engagement is clear, as it is the result of an identified issue. In other cases, communities will raise issues that matter to them and they must be heard. Regardless, the remit of the engaging organisation should be finite and the scope for stakeholder input and influence should be clearly stated. It is important to explain clearly the process of engagement, including how and when decisions will be made, to allow people^[9] to understand how their involvement will be taken into account.

Organisations should consider using current / recent data to help provide clarity, e.g. use existing feedback to gather together and review patients’, service users’ and carers’ experiences and expectations and take this into account in informing service review.

It is important to involve community representatives in engagement planning from the outset. As part of the planning team, they can help to inform the design of an inclusive process.

Consider:

• What are the challenges you want engagement to address?
• What would you like engagement to achieve?
• What level of engagement is considered proportionate?
• Who will be making final decisions?

4.2 Identify stakeholders

‘Stakeholder mapping’ or identifying the people who have an interest in, or who are potentially affected by the design /re-design of a service, is an essential part of effective communication and engagement. Stakeholders can be internal, such as members of your organisation’s staff (e.g., hospital managers and clinicians) or external, such as patients, carers, the general public, third sector and community groups.

Existing networks can help to identify potentially affected people, including those who do not find it easy to share their views. Support for stakeholder mapping may come from community groups, localities, third sector organisations or Community Councils. Identifying and building relationship with key individuals, who can act as links for information-sharing makes a huge difference.

Consideration should be given to carrying out an initial EQIA to ensure an inclusive approach at this early stage in the engagement process. This is the right time to ensure the right people are involved.

Equality Impact Assessment (EQIA) – in brief

Not everyone will identify themselves as ‘stakeholders’, so organisations need to ensure they have fully considered everyone who may have an interest in a particular matter. Wider impact assessment, including Equality Impact Assessments, are discussed in section 4.4, however, organisations should consider carrying out an EQIA at this stage to ensure that all potential stakeholders have been identified.

Individuals, groups and communities that may have an interest or be affected by the proposed changes should include:

• Patients and people who may be directly affected by change, including family members and carers
• Groups or organisations who support people who may be affected
• Health and social care staff who deliver services being considered for change
• Managers of services being considered for change
• Members of the local community who may not be affected directly but have an interest in potential changes, including the media
• Elective representatives and government officials

It is good practice to involve people in this exercise, including members of the public, to ensure the list is inclusive and considers everyone who may have an interest.

Not all stakeholders will want to be engaged in the same way, so it is important to identify their needs to determine what engagement activities might be required, and at which stage of the project.

Healthcare Improvement Scotland – Community Engagement has developed a range of supporting tools to support the process  HIS-CE: Stakeholder Identification.

Consider:

• Who is directly impacted by this work?
• Who is indirectly impacted?
• Whose engagement is essential?
• What are the key issues or areas of interest?
• What is the level of public interest?
• Who are the key contacts?

Don’t forget to evaluate – it is important to evaluate continuously, not just at the end of the engagement process. Evaluation should be prioritised and factored into the initial plan for engagement and implemented throughout.

Once stakeholder analysis is complete, it may be necessary to revisit the original objectives of the engagement and review any negotiable and non-negotiable goals.

In time, effective engagement should become routine, with fewer decisions being challenged and referred for review, which can carry significant costs.

Trusted and open dialogue achieves:

• Clear communication and information sharing to achieve mutual understanding of challenges
• Agreement about what is out of scope - the more non-negotiable elements there are, the less likely members of the community will want to participate
• Realistic expectations and reduced risk of conflict or disappointment

4.3 Plan engagement

People and communities who may be affected by a proposed service development or change should be involved at the earliest opportunity and throughout the development of the engagement plan. It is vital that the best approaches for engaging with individuals and groups are identified. This will help to ensure that views are shared, and ideas encouraged. This will result in better engagement and robust and sustainable outcomes.

Timeframes and budgets

The length of time it will take to engage the community, and the budget required, is dependent on a range of factors, including the level of impact, level of public participation required, and the community engagement tools and techniques chosen for each stakeholder group. The higher the level of impact and more stakeholders there are, the more time and resources will need to be allocated to community engagement. Existing stakeholder feedback should be taken into account when developing the materials for engagement.

Consideration must also be given to any legislative requirements and timeframes which may apply. Timeframes must take into account key events such as school holidays, public holidays or religious festivals. These should be avoided to maximise people’s ability to participate.

Resourcing engagement

To engage effectively, organisations must be committed to supporting and improving the participation of people. That means dedicating resources to engagement activity, which may include:

• Engagement and inclusion champions – senior staff to promote and support meaningful engagement and inclusion. Executives and Board non-executives need to understand why engagement is essential and must ensure that engagement is undertaken effectively. Organisational barriers that could hinder or impact negatively on engagement, should be identified and addressed by effective leadership.
• Engagement and inclusion leads – members of staff who know how to help individual services to reach communities and access any support that may be required.
• Skilled staff – the right number of skilled staff ensure that engagement activity is conducted in depth, monitored and evaluated. Training may be required.
• Dedicated budget – there are costs associated with community engagement, depending on the scale. Realistic budgets have to be agreed.
• Sufficient time – effective engagement cannot be rushed. Adequate time is required to reach affected community members, and flexible and innovative approaches may be required.
• Collaboration – organisations should embrace partnership working to help promote efficiency and effectiveness of engagement.

Additional support

Depending on the capacity within organisations and the scale of the engagement activity, it may be appropriate to procure the services of specialist providers to deliver some services.

Consideration must be given to whether this a ‘quick fix’ option, potentially less effective than using existing methods and working with people who are known to the community. Alternatively, independence of the organisation can be an advantage if there is community mistrust.

Any independent or external contractors will be expected to follow this guidance and to adhere to its principles.

There is no handy formula to work out what an engagement project might cost. Each element has to be assessed separately to project an accurate budget.

4.4 Impact assessment

The Scottish Government: Health and Social Care Standards set out what we should expect when using health, social care or social work services in Scotland. They seek to provide better outcomes for everyone; to ensure that individuals are treated with respect and dignity, and that the basic human rights we are all entitled to are upheld.

Impact assessment examines how policy or service design proposals may affect different communities taking into consideration equality, human rights, sustainability and environment. Impact assessment should inform and be an integral part of engagement plans, which should also make it clear which assessments have been identified and how engagement will inform these.

Healthcare Improvement Scotland – Community Engagement has developed a range of supporting information to help guide organisations through this important key step on the engagement journey, HIS-CE: Integrating Service Change and Impact Assessment

Equality Impact Assessment (EQIA)

Nobody should be treated unfairly because of their age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex, sexual orientation or any other status. These are known as ‘protected characteristics’.

The Equality Act 2010 and Human Rights Act 1998 should be considered as early as possible to help identify people and groups who should be involved, as well as highlight any potential barriers or imbalance of power that may need to be considered.

Undertaking an Equality Impact Assessment (EQIA) can help to identify potential disadvantages and offer an opportunity to take appropriate actions to remove or minimise any adverse impact. People who face the biggest barriers to realising their rights should be prioritised when it comes to taking action.

Fairer Scotland Duty

The Fairer Scotland Duty (The Duty) came into force in April 2018. The Duty seeks to tackle socio-economic disadvantage and reduce the inequalities that are associated with being disadvantaged. It places a legal responsibility on named public bodies in Scotland to actively consider how they can reduce inequalities of outcome caused by socio-economic disadvantage, when making strategic decisions. The Fairer Scotland Duty guidance for public bodies should be consulted for advice on undertaking assessment – Scottish Government: Fairer Scotland Duty: guidance for public bodies

Island Communities Impact Assessment

An Island Communities Impact Assessment (ICIA) should also be considered were relevant, to ensure improved outcomes for island communities. This is particularly relevant when planning regional or national services. The Island Communities Impact Assessment guidance should be consulted for advice before undertaking assessment – Scottish Government: Island Communities Impact Assessment guidance (and tools)

4.5 Engage people potentially affected

Choosing a method, or combination of methods, for engaging both digitally and/or in person, is a critical step in the planning process.

Organisations have adapted their approaches to engagement and are using digital technology, including social media, more than ever before. Although digital technologies will not meet everyone's needs, a growing number of people find digital engagement easier.

However, organisations should consider the appropriateness of a ‘digital-first, not digital only’ approach to engagement. The methods and medium used should take into consideration the needs of the people you are trying to reach and the topic of engagement. While the use of online engagement has increased, it should not replace all face-to-face approaches. There will continue to be a role for traditional engagement, as this type of activity allows for deliberative engagement and building trust over the long term.

Healthcare Improvement Scotland-Community Engagement has completed an HIS-CE Equality Impact Assessment of a digital-first approach to community engagement which will be of value in planning and designing such activity.

Healthcare Improvement Scotland – Community Engagement has produced Engaging Differently for digital engagement during the pandemic. HIS-CE Engaging Differently

Healthcare Improvement Scotland – Community Engagement has also developed the HIS-CE Participation Toolkit to support organisations to select the most appropriate methods of engagement.

‘Our Place’ has developed the Place Standard assessment tool. It is useful in helping generate the discussions required to understand the assets of a place and ensuring the experiences of people living in a particular place are captured, valued and integrated into the heart of decision-making processes.

Options appraisal

Organisations need to consider a wide range of options to decide what care services to provide for their communities / local populations, and how to best deliver them. Local people should be involved in developing options that are robust, evidence-based and person-centred.

Engagement plans should consider how and when an options appraisal will be used, what will happen with the outcome, and how engagement will influence the selection of options that will then be consulted on.

There may be occasions where the number of practical options is limited, for example, by requirements to comply with national policy or legislation. Where this is the case, the option development process should still be used to involve potentially affected people and communities, and to seek to achieve a consensus around the limited number of practical options.

If there are areas that the engaging organisation believes cannot be influenced, for instance safety, working practices, national policy decisions or budgetary restraints, they must be clearly explained. Any such limitations should be evidenced, and organisations receptive to challenge over scope. It is important to be ready to revisit assumptions or decisions following discussions with the community, or the emergence of new evidence.

Healthcare Improvement Scotland – Community Engagement (HIS-CE) has produced an Options Appraisal guide HIS-CE Options Appraisal Guide

By this stage, you should have considered:

1. The scope, context and improvement sought

2. Identified the people and communities potentially affected.

3. Budget, timeline and resources required

4. Skills of team and their availability to lead events at times and in locations to maximise attendance

People’s needs will vary. Involving community representatives in the planning process will make it easier to choose appropriate engagement methods.

Also consider:

• Given the timeframe, budget and resources which engagement technique(s) might work best?
• What are the strengths and weaknesses of these?
• Will the people to be engaged feel comfortable with this approach?
• Will it reach the target group?
• Will it help to achieve the stated improvements sought?
• Is the information provided balanced, written in plain language and easy to understand.
• Does it require to be translated into other languages?
• Are updates and feedback provided regularly and made widely available?
• Is all the information co-produced?
• Do people have the information and support they need to effectively participate in the process.
• Local people have been involved in developing and considering a wide range of options to identify sustainable solutions; heard new ideas and understood all the issues.

Everyone needs access to accurate information in order to engage effectively. It should be co-produced, presented clearly, and made widely available. If there are reasons why information cannot be shared (for instance it would allow identification), that must be clearly explained.

For some people, the headline facts are sufficient, while others prefer to analyse raw data. So, it is important to present background information in different languages and formats – online, on paper or by another means – on request.

4.6 Evaluation

It is important that engagement activity is continually assessed and that evaluation arrangements are part of the initial plan for engagement. The key to successful evaluation is to evaluate progress and act on lessons that emerge during the process.

Evaluating an engagement process will help you to consider if it has met the outcomes set out at the beginning of the project, and the difference that engaging with communities has made. It demonstrates that you are listening to people and flexible in your approach to engagement. Evaluation can also identify areas for improvement and will help you understand what works and what doesn't. All information gathered from the engagement process should be captured. That can be done by:

• Surveys
• Reports
• Themes
• Audio and/or video recordings
• Graphics

Consider:

• Did we meet our objectives?
• Did we reach all the people we needed to reach?
• Did we develop our knowledge of communities and gather useful data?

Undertaking evaluation helps to improve your organisation’s community engagement processes, and supports learning for future projects.

Healthcare Improvement Scotland – Community Engagement has developed an HIS-CE Evaluation guide and toolkit for health and social care practitioners. A partner to the HIS-CE Participation Toolkit, the evaluation guide is a stand-alone support for assessing the way in which engagement has been undertaken (process) and the results of that activity (outcomes). It does not set out to be a definitive guide to evaluation, but aims to provide resources, references and tools to help you to develop your own approach to evaluation.

Any methods chosen should be continually reviewed throughout the engagement activity and changed or adapted based on community feedback.

4.7 Feedback and decision-making

It is important to keep participants up to date and informed about the engagement process as it develops.

Throughout the engagement cycle, decisions will need to be made and community representatives must be involved, so that robust, evidence-based, and person-centred outcomes are achieved. When engagement activity reaches conclusion, it is the responsibility of NHS Boards, Integration Joint Boards and Local Authorities to approve or reject recommendations. The feedback received and the quality of the engagement process will be taken into account.

When decisions are reached, speedy information sharing should be provided as a priority explaining the impact of community engagement on the outcome.

It is important to welcome critical challenges and respond to them by demonstrating a willingness to answer questions openly and to consider adapting plans according to emerging evidence.

Organisations must explain clearly the rationale for decision making and the impact this has had on the outcome. Transparency is essential to generate trust.

The feedback stage is of vital importance in maintaining public confidence and trust in the integrity of the involvement process. Stakeholders who take part in a consultation must be given feedback to:

• inform them of the outcome of the consultation process and the final agreed development or change.
• provide a full and open explanation of how views were taken into account in arriving at the final decision.
• provide reasons for not accepting any widely expressed views.

Privacy and confidentiality must always be observed. Reporting and feedback must be anonymised unless consent has been given by individuals to publish or release their personal information.