If integration is the biggest change in health and social care for decades, it is going to take time to embed.
For integration to be transformational and improve the experiences of people, then organisations and systems will have to learn to work together in different ways. Across Scotland, that is happening in different ways at a local and national level.
The new health and social care standards (this link will take you away from our website), commencing in April 2018, are one of the early pieces of national policy to respond directly to the new integration arrangements. They set out what people should experience from care and support, regardless of setting or profession.
They are radically different to anything that has gone before and are designed to focus quality on the personal experience of care, firmly based on human rights and wellbeing. This world-leading approach is attracting wide and global interest in what is happening in Scotland, because of what the standards looks like and how they were developed.
The first national care standards in Scotland were introduced almost seventeen years ago – but only focused on registered care and independent health services. They were largely designed to set minimum expectations for providers and tied closely to the regulatory and inspection approaches of the time. The new standards quite literally turn this on their head, in three main ways.
First, the outcomes are decoupled from settings. Instead of separate standards for care homes, hospitals, children’s services, there is a common set of outcomes across all care. The standards are relevant for planning, commissioning, assessment and care delivery. This is to allow coherence and improvement activity at every level and is important as services are increasingly planned in an integrated way. The standards are relevant across health and social care – services that are integrated, services that are not, early learning and childcare, children’s services, social work, the National Health Service, and community justice. The extensive public involvement of people in developing the standards shows that people want a consistently high quality service regardless of setting. They want to be treated with dignity and respect. They want to experience compassion and kindness from those supporting them. They generally want to be involved in leading their own care and want that care to be responsive to their rights, needs and choices.
Second, the standards are person-led, deliberately pushing the boundary of person-centeredness towards something even more empowering. Virtually all the statements start with “I experience…” or “I am…”. They locate quality firmly through the lens of the person experiencing care. This is empowering for people who may be in unfamiliar or distressing environments and is designed to ensure care professionals reflect on their practice from the perspective of the person.
Third, they are outcome-focused, describing what the consequence of good care should be, not how it should be delivered. Detailed and technical inputs about staff ratios and nutritional intake are replaced by outcome indicators, reflecting that people’s needs, wants and choices are not always the same. For example, a previous descriptor about the minimum square footage of a care home room is replaced by a new descriptor which states “I have enough physical space to meet my needs and wishes”.
Of course, it is very easy to plan and measure to a minimum square footage of a room; it is harder to plan care in a way which is tailored to people’s individual needs. But the new standards are not designed for the convenience of inspectors or professionals. Instead of telling care and support providers what to do, they describe what people should experience as a result of that care and support.
Inputs characteristic of high-quality care will continue to be described in guidance, practice notes and peer-reviewed research. That is how we create a learning and improving system. The assessment of quality, however, becomes whether the experience and outcomes for people are positive. This radical approach means inspectors cannot rely on lists of policies and inputs to check, and practitioners cannot assume their inspections will be positive just by following processes. Practitioners are released to creatively solve problems and innovate to improve. The new standards are designed so practitioners can plan, do, study, act. Inspectors no longer see whether something is done ‘correctly’, but instead ask ‘how successful is this change in improving experiences and outcomes for people?’
This change of thinking is part of a broad shift towards measuring the success of public services by reference to outcomes; that is, the impact they are having of people, rather than the way they are designed and delivered. In health and social care, this releases professionals from having to “do what the regulator says”, and instead fosters innovation. To ensure that people experience the high quality envisaged by the standards, care staff will need to work closely together and with people experiencing care to plan, innovate, change and improve.
The new standards were published in 2017 and are implemented from April 2018. Scrutiny bodies have structured programmes in place to incorporate the standards into inspection and improvement activity from 2018 onwards. Over time, a common set of standards across care will allow people to understand what they should experience, and practitioners to devise innovative and high-quality ways of ensuring they do.
We should not fall into the trap of thinking that because standards have been published, they will immediately become a lived reality for every citizen. If everyone experienced care that was already consistent with the standards, there would be no need for them. Standards which are focused on outcomes are about improvement, not compliance. Their applicability across such a wide range of sectors is an important part of the integration of health and social care.
Rami can be found on Twitter at @RamiOkasha (this link will take you away from our website).
Rami’s Opinion is part of the ALLIANCE’s ‘We Need To Talk About Integration’ anthology which is available at the link below.