Care services - planning with people: guidance

Part 3 – Supporting Information

There is a growing body of expertise in community engagement developing within Scotland's public organisations. Sharing learning and best practice across the care sector is an objective of integration, and forums are being developed to support ongoing practice improvement.

This section develops key points outlined in the preceding guidance. Further detail can be accessed via the attached links and tools.

Defining community engagement

The principles that inform this guidance promote a change of focus from a culture of 'telling' to one of really listening when it comes to community engagement. Consistent, relevant, open communication between all parties is vital, and there is an expectation for organisations to do more.

• Community refers to a group of people who share a common place, a common interest, or a common identity. There are also individuals and groups with common needs. It is important to recognise that communities are diverse and that people can belong to several at one time.
• Engagement covers a range of activities that encourage and enable people to be involved in decisions that affect them. This can range from encouraging communities to share their views on how their needs are best met and influence how services should be delivered, to giving communities the power to inform decisions and even provide services.

Co-production is key to successful community engagement. It has been described as the process of active dialogue and engagement between people who use services, and those who provide them.

The case for community engagement

Effective and ongoing engagement brings many benefits:

• Organisations hear new ideas and understand all the issues for communities, creating opportunities to identify sustainable solutions to service challenges
• Communities, especially vulnerable and seldom-reached groups, are connected and engaged with services, improving access to care services and health outcomes
• Community ownership of decisions and 'direction of travel'
• Reduced public resistance to change due to better awareness and understanding of the reasons for change
• Improved public confidence and less protest
• Reduced risk of legal challenge resulting from concern about the process of engagement
• Change that can be implemented and services that meet the needs of communities

Clarity of purpose

It is important, from the outset, to be very clear about the reason for engagement. The issue under consideration may be better suited to formal consultation, or another approach to gathering community views.

Consultation has a defined beginning, middle and end: it might be part of an ongoing period of engagement, but it is a process in its own right. Its remit should be finite and the scope for stakeholder input should be clear. There is a specific requirement for NHS Boards to formally consult on issues which are considered major service change – the process for that has not changed.

Engagement is a broader term, encompassing a range of activities. It is an approach that encourages productive relationships between communities and public bodies.

Organisational self-evaluation

It is important to understand how well your organisation is currently engaging. That can be done systematically, efficiently and quickly using a range of methods. You might want to know:

• What role do communities have in your organisational structures? How do people respond when you communicate with them? Are levels of public satisfaction and trust high or low?
• How does your organisation view engagement? Is it regarded as important and is there a shared view of what it means? Has there been a culture of tokenism?
• Has engagement influenced decisions?

Assessing the views of all stakeholders is essential. This can be done via surveys and interviews, or data reviews and reference to good practice. Following the self-evaluation process will help to identify good practice and show where improvement is required.

The Quality Framework supports self-evaluation in three areas:

• Ongoing engagement and service user involvement
• Involvement of people in service planning and design
• Governance/Organisational Culture and Leadership

The framework will be a guide for improving the quality of engagement. It will help NHS Boards, Local Authorities and Integration Joint Boards to understand what good engagement involves and how it can be evaluated and demonstrated.

Planning engagement

Clear goals set at the start of engagement planning shape the process and indicate the best methods to use to reach the right people and communities of interest. 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 it is important that they have ways in which they can be easily heard.

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.

Questions to 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?

If there are areas that the engaging organisation believes cannot be influenced, for instance safety, working practices 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.

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

Who to involve

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.

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.

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?

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.

NHS Health Scotland Stakeholder Mapping Template

VOiCE Tool a planning and recording software that assists individuals, organisations and partnerships to design and deliver effective community engagement

The Engagement Matrix guidance for improving engagement between health boards and the third sector

The National Involvement Network

Impact assessment

Impact assessment examines how policy or service design proposals may affect different communities taking into consideration equality, human rights, sustainability and the environment. It must be started well before any engagement activity begins, and be updated throughout.

The Equality and Human Rights Commission guidance to help public authorities in Scotland meet their public equality duties.

Scottish Government guidance on the Fairer Scotland duty.

Methods of engagement

Choosing a method, or combination of methods, for engaging is a critical step in the planning process. There are many models to choose from, and the best ones to select will depend on the issues being discussed and the communities involved.

Consider:

• The scope, context and improvement sought
• Who you seek to engage, and the local context
• Budget, timeline and resources allocated
• 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.

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?

Ideally, engagement is personal and relational and should be ongoing. Sometimes, however, it may be appropriate to seek independent external support. 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 methods chosen should be continually reviewed throughout the engagement activity and changed or adapted based on community feedback.

Healthcare Improvement Scotland – Community Engagement Participation Toolkit

The Place Standard 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.

There are specific considerations for consultations:

• No final decision must have been reached
• The information provided must relate to the consultation and must be available, accessible, and easy to interpret to enable consultees to provide an informed response
• There must be sufficient opportunity for consultees to participate
• Decision-makers must be able to provide evidence that they took consultation responses into account

Right First Time: A practical guide for public authorities in Scotland to decision-making and the law

Options appraisal

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

Options Appraisal Guidance

Timeframes and budgets

The length of time it will take to engage the community, and the budget that will require, 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. Consideration must also be given to any legislative requirements and timeframes which may apply.

The higher the level of impact and more stakeholders there are, the more time and resources will need to be allocated to community engagement.

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.

When considering budget and resource allocation, the types of engagement tool chosen will be a significant factor. Each tool requires different levels of practitioner skill, time and budget.

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.

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 may require training in order to ensure effective delivery.
• 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.

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

Accessible information

Everyone needs access to accurate information in order to engage effectively. Transparency is essential to generate trust, and to promote equity all information should be made available in a variety of formats and languages. 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 a variety of formats – online, on paper or by another means – on request.

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.

Communication and feedback

Providing regular updates and feedback to participants in the engagement process should happen regularly and be planned into engagement activity. All information should be co-produced, presented clearly, and made widely available.

The Scottish Co-production Network describes co-production using a variety of sources.

Privacy and confidentiality must always be observed. Reporting and feedback must be anonymised unless there is the written consent of each individual to publish or release their personal information.

Patient and Service User Feedback

Producing a report of findings

Scottish Co-Production Network: What is Co-production?

Evaluation

All information gathered from the engagement process should be captured. That can be done by:

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

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 monitor progress and act on lessons that emerge during the process.

Consider:

• Are we meeting our objectives?
• Are we reaching all the people we need to reach?
• Are we developing our knowledge of communities and gathering useful data?

Undertaking evaluation helps to improve your organisation's community engagement processes, and supports learning.

Evaluation Toolkit

VOiCE Tool a planning and recording software that assists individuals, organisations and partnerships to design and deliver effective community engagement.

Governance and decision-making

While different organisations may have evolved with different ways of working, and may have different statutory functions to fulfil, the Community Empowerment (Scotland) Act 2015 requires equal duties when it comes to participation.

NHS Boards: major service change

- Identifying major service change

Healthcare Improvement Scotland - Community Engagement provides guidance to help identify potentially major service changes. There is a range of factors that NHS Boards will consider to be important drivers for change, including workforce issues and clinical standards. However the guidance concentrates on key issues that are relevant for identifying when a proposed service change might be classed as major. These include:

• The impact on patients and carers
• Changes to the accessibility of services
• Emergency and unscheduled care
• Public or political concern
• Changes to how services are delivered
• Financial implications
• Consequences for other services.

NHS Boards can designate proposals as major change themselves, as informed by the Healthcare Improvement Scotland - Community Engagement guidance, and then follow the process detailed below.

While Healthcare Improvement Scotland - Community Engagement can offer a view on the designation of specific proposals, if a final decision is required as to whether proposals should be considered major, this should be sought from the Scottish Government.

- Major service change process

Proposals for major service change in the NHS must be subject to at least three months of public consultation and, ultimately, Ministerial approval.

Where a proposed service change will have a major impact, Healthcare Improvement Scotland - Community Engagement is required to quality assure the process. It can advise on the nature and extent of the process considered appropriate in similar cases.

For any service changes considered to be major, NHS Boards should not move to the consultation stage until they have confirmation from Healthcare Improvement Scotland – Community Engagement that their engagement up to that point has been in accordance with this guidance.

Following the public consultation, a full meeting of the NHS Board will then consider the proposals and make a decision. A range of information, including responses to the consultation and a report from Healthcare Improvement Scotland – Community Engagement, will help to inform the Board's decision.

Healthcare Improvement Scotland - Community Engagement does not comment on clinical or financial issues or the effectiveness of an organisation's engagement with its own staff. It will, however, look to the organisation to provide evidence that the views of potentially affected people and communities have been sought, listened to and acted on, and treated with the same priority (unless in exceptional circumstances) as clinical standards and financial performance.

Healthcare Improvement Scotland – Community Engagement will set out its views in its report as to whether the relevant NHS Board has appropriately involved local patients, carers and communities in line with this guidance.

Following the Board decision, the major service change proposal must be submitted to Scottish Ministers for final approval. Ministers will take all the available information and representations into account, including the report of Healthcare Improvement Scotland – Community Engagement.

The proposals may ultimately be approved or rejected by Scottish Ministers. Where appropriate, they may also instruct the relevant NHS Board to carry out further engagement activity.

Integration Joint Board decision-making

Specific requirements (known as Planning Principles) are laid out for involvement and participation of a range of stakeholders. Integration Joint Boards are required to have as members a carer representative, a person using social care services, a patient using health care services and third sector representatives.

Each Integration Joint Board should have its own strategy for community engagement and participation, which should be taking place on a regular and routine basis and not just at time of change. Strategies must take this guidance into account.

- Strategic Commissioning Planning

Decision-making by Integration Joint Boards takes place within the context of strategic commissioning, and so it is important that community engagement is part of this process.

Strategic commissioning is the term used for all activities involved in assessing and forecasting needs, linking investment to agreed outcomes, considering options, planning the nature, range and quality of future services, and working in partnership to put these in place.

There is a duty on Integration Joint Boards to create strategic commissioning plans for the functions and budgets they control, which must be reviewed every three years. This requires close working with professionals and local communities to deliver sustainable new models of care and support that are focused on improving outcomes for people.

A key principle of the commissioning process is that it should be equitable and transparent. Therefore it must be open to influence from all stakeholders, including the community, via ongoing dialogue with people who use services, their carers and service providers.

During the development of their strategic plan, each Integration Joint Board is required to run consultations on various drafts of the document.

The role and minimum composition of a Strategic Planning Group can be found in Strategic Commissioning Plans: Guidance.

It is important that Integration Joint Boards develop agreed communication and engagement plans at an early stage to suit the needs and makeup of their community. Boards should use this guidance to help develop their approach to engagement.

- Localities

Another important route for community engagement is through locality arrangements. Each Integration Joint Board divides its geographical area into at least two localities, and the views of people who live there must be taken into account as part of the strategic commissioning process to inform strategic thinking.

Many Integration Joint Boards have well established locality planning forums that bring together professionals and local community representatives involved in strategic commissioning planning.

Further information can be found in Health and social care integration - localities: guidance.

- Significant decisions outwith the Strategic Commissioning Plan

Sometimes, an Integration Joint Board must make a decision that would have a significant effect on the provision of an integrated service, outwith the context of the strategic planning cycle. It must then involve and consult its Strategic Planning Group, along with users (or potential users) of the service.

- Decisions for specific services and functions

While the Strategic Commissioning Plan provides the direction of travel and ambition for the Integration Joint Board, decisions about service change, service redesign, and investment and disinvestment may be made at regular meetings. These are open to members of the public who may attend but not participate, with papers and minutes available online.

Alongside this, Integration Joint Boards are required to undertake ongoing engagement and feedback with the local community, so that the views of service users, their carers and service providers are taken into account in this continuous process of decision-making. The form of this engagement will vary between Boards and should reflect the makeup of the local community.

Local Authority decision-making

A full council meeting is the key governing body of a Local Authority, where councillors debate and take key decisions. The Local Government (Scotland) Act 1973 allows Local Authorities to devolve most decision-making to committees, sub-committees or council officers. Individual councils set out their arrangements for delegation to committees in their internal governance documents.

Legislation has been introduced to give communities a stronger say in how public services are planned and provided and to allow communities to have a greater say in local decisions and in scrutinising local services.

The Local Government (Scotland) Act 2003 gave a statutory basis to partnership working between all agencies responsible for delivering public services in an area, including Health Boards. This act established the role of councils in facilitating the community planning process, at the heart of which is 'making sure people and communities are genuinely engaged in decisions made on public services which will affect them'.

The duty to involve people in the design and delivery of services has increased since the publication of the Christie Report in 2011 and subsequently the enactment of the Community Empowerment (Scotland) Act 2015.

- Community Planning Partnerships

There are 32 Community Planning Partnerships across Scotland, one for each council area, which represent all the services that come together to take part in community planning. Each focuses on where partners' collective efforts and resources can add the most value to their local communities, with particular emphasis on reducing inequality.