A Review Of How People Are Involved In Their Care
Better care in my handsA review of how people are involvedin their careMAY 2016
The Care Quality Commission is the independentregulator of health and adult social care in England.Our purposeWe make sure health and social care services provide people with safe,effective, compassionate, high-quality care and we encourage care services toimprove.Our roleWe register care providers.We monitor, inspect and rate services.We take action to protect people who use services.We speak with our independent voice, publishing regional and nationalviews of the major quality issues in health and social care.Our valuesExcellence – being a high-performing organisationCaring – treating everyone with dignity and respectIntegrity – doing the right thingTeamwork – learning from each other to be the best we canbBET TER CARE IN MY HANDS
BETTER CARE IN MY HANDSContentsFOREWORD.2SUMMARY .3INTRODUCTION.51. NATIONAL FINDINGS.11NATIONAL TRENDS. 11FINDINGS BY SECTOR. 12FINDINGS FOR DIFFERENT POPULATION GROUPS. 182. GOOD PRACTICE IN INVOLVING PEOPLE.24CONCLUSIONS AND RECOMMENDATIONS.29NEXT STEPS.32ACKNOWLEDGEMENTS.32REFERENCES .33A REVIEW OF HOW PEOPLE ARE INVOLVED IN THEIR CARE1
FOREWORDForewordEnabling people to be more in control of theirown care leads to better and often more costeffective outcomes. This is particularly true forthose with long-term conditions or people whoneed to use services more intensively.This review into how well people are involved intheir own care offers insight into the progressand the continued challenges in this vital area.It also gives some practical recommendations forproviders, commissioners and system partners toensure improvements are made in future.It also comes at a time when there is anopportunity to make real progress in this area,as health and social care services change theirmodels of care to adapt to the changing needs oftheir populations.The findings from this study can be used byproviders and commissioners of health andsocial care to understand what CQC expects to2BET TER CARE IN MY HANDSsee when we regulate how well services involvepeople, to learn from good practice, and to focuson what ‘enables’ people to be involved acrossthe services they use.Putting people in control of decisions abouttheir care has long been a policy aim. Recentlegislation makes it an imperative for those whocommission and provide services. We encourageproviders of care, bodies that commissionservices and their partners in the community andvoluntary sector to reflect on the inequalities inpeople’s involvement in their care highlightedin this report and to make these policy aims areality for everyone.Paul BateExecutive Director of Strategy and IntelligenceCare Quality Commission
SUMMARYSummaryThis report describes the extent and quality ofpeople’s involvement in their health and socialcare. It is based on newly analysed evidence fromCQC’s national reports and inspection findings,national patient surveys and a literature review. Itidentifies what enables people and their familiesto work in partnership with health and social carestaff and illustrates this with examples of howpeople are involved in their care in services wehave rated outstanding.Being involved in your care is an essentialcharacteristic of person-centred care and criticalto the move to successful integrated health andcare services as set out in the NHS Five YearForward View and the Care Act. It has benefits forindividuals and can lead to savings in services too.People have a right in law to be involved in theircare, as set out in the fundamental standard of‘person-centred care’, a standard below whichcare should never fall. This national standarddescribes the action that care providers musttake to ensure that each person receivesappropriate care and treatment based on anassessment of their needs and preferences.CQC can take enforcement action against careproviders that do not meet the standard.National surveys of patients and people usingservices provide some evidence about theextent to which people feel involved in theircare and in decisions about their support andtreatment. Recent survey findings suggest thatover half those surveyed report feeling definitelyinvolved in decisions about their health care andtreatment, and this includes responses for care inhospitals and in the community. Women who usematernity services are particularly positive abouthow well they are involved in decisions abouttheir care. We have also identified good practiceexamples of people being involved in all aspectsof their care and decisions about their lives in arange of services we have rated outstanding.However, the trends in national surveys of patientsand people using services over the last five to10 years highlight there has been little changein people’s perceptions of how well they areinvolved in their health or social care, despite thenational drive for person-centred care. In addition,a significant minority of people have consistentlyreported only feeling involved in their care tosome extent or not at all over this period.Importantly we have found that people withlong-term health and care needs are leastlikely to report feeling involved in their careand in making choices about their daily life.New analysis of national patient survey datahighlights that adults and young people withlong-term physical and mental health conditions,people with a learning disability and people over75 years all report feeling less involved in theircare than other groups. Further evidence fromour analysis of CQC’s own thematic and nationalreviews from the last five years highlights poorpractice in this area for these same groups ofpeople, particularly as they move betweenservices.A REVIEW OF HOW PEOPLE ARE INVOLVED IN THEIR CARE3
SUMMARYWe have also reported a lack of progress overthe last six years in involving people in their carewhen they are detained under the Mental HealthAct. Poor involvement in care is the biggest issuewe found in monitoring the use of the MentalHealth Act in 2014/15. Our monitoring drawson evidence from people using services and theirfamilies and advocates, staff, and patient records.zzThis report identifies common problems inhealth and social care services, which can createa ‘vicious circle’ of poor involvement and whichbecome more significant when people needto use different services or use them for longperiods of time. These include:zz failing to regularly assess and monitorpeople’s capacity to make decisions abouttheir care and provide advocacy supportzz limited understanding, recording andmonitoring of people’s wishes and preferenceszz inadequate family and carer involvementzz insufficient information and explanation ofcare and support options.We encourage commissioners to ensure newmodels of care are developed taking accountof the enablers to good involvement describedin this report. In particular that there is acoordinated approach to the development of:zz accessible information about health and careoptions and treatment or support for peopleand their families/carerszz flexible advocacy provision as people usedifferent serviceszz community and peer support for people tomanage their care through programmes withvoluntary sector partners.Given the policy commitments, nationalstandards and movement towards new models ofintegrated care, there is now an opportunity tomake sure people’s involvement in their own carebecomes embedded in practice – for everyone. Toencourage this, our report also presents evidencefrom services rated outstanding following aCQC inspection since April 2015. These includeexamples of the good characteristics of involvingpeople in their care, identified from a range ofoutstanding individual service providers.Our evidence also repeatedly points to a set of‘enablers’ that service providers, commissionersand partners across the local health and caresystem can put in place to create an ‘involving’culture for people using services.We encourage service providers to focus theirefforts on the following enablers that evidencesuggests support people to be effectivelyinvolved in their care:zz personalised care plans – written withpeople, for people, and with their wishes andpreferences clearly identified and monitored4BET TER CARE IN MY HANDSzzthe sustained and supported involvement offamilies and carers in the care of their lovedonesthe coordination of people’s involvement intheir care as they move between services – forexample, through the use of health and carepassports and the provision of community andpeer support programmes.The development of new models of careprovides an opportunity to strengthen people’sinvolvement in more person-centred care.CQC will use the findings from this report tostrengthen our regulation and reporting ofpeople’s involvement in their care in specificservices. We will explore options to strengthennational survey questions in this area. We willalso consider developing a framework to assesspeople’s involvement in care as they movebetween services and use this in our futurethematic reviews and assessments of qualityof care for pathways or populations. This willprovide more evidence of good practice toencourage providers to improve.We will work with NHS England, NHSImprovement, Healthwatch England, NationalVoices and the Social Care Institute forExcellence to encourage the use of an integratedframework for people’s involvement in care. Thiscould support providers and commissioners toboth meet their duties to involve people, andsupport the enhanced role of the voluntary andcommunity sector as a partner in new models ofcare.
INTRODUCTIONIntroductionAbout this reportMethodsThis report describes the extent and quality ofpeople’s involvement in their own care across allcare sectors, drawing on new analysis of nationalsurveys of patients and people using services,CQC’s national and thematic reviews and aliterature review.We have analysed evidence from a range ofsources for this report. The following methodswere used to generate the evidence:zz a literature review (2010 to present of policyand research into people’s involvement inhealth and social care)zz a review of patient survey data from sevennational patient surveys from 2005 to 2016(where possible), the Personal Social ServicesAdult Social Care Survey 2010-15 and CQC’spre-inspection survey of people using adultsocial care services (April 2015-March 2016)zz further statistical analysis of six nationalpatient surveys to compare responses ofdifferent groups of people (see separateanalysis appendix on our website)zz a review of the findings of CQC thematicreview reports published since 2012zz a review of other CQC national reportsproduced for Parliament since 2009 about thestate of care in England,1 the Mental HealthAct2 and Deprivation of Liberty Safeguards3zz a review of all registered providers ratedas outstanding between April 2015 andAugust 2015 (a total of 96 inspection reportsincluding four NHS trusts, 60 GP practices,and 32 adult social care services that includedhospices, care homes and nursing homes).It describes the fundamental standards ofpeople’s involvement in their care that applyacross all the sectors we regulate, and the keylines of enquiry our inspectors follow wheninspecting how well people are involved intheir care.We highlight how people can be involved as‘partners’ in their care, using examples from CQCnational reviews of the last five years, and fromproviders of outstanding services, as rated by ournew comprehensive inspections in the last year.The report concludes with our recommendationsas to how service commissioners, providers andthe voluntary sector can do the same.This study forms part of a wider programmeof CQC work to strengthen our regulation ofintegrated services, and of people’s care acrossan area and along different care pathways. Thisin turn will help encourage improvement in thequality of joined-up person-centred care.A REVIEW OF HOW PEOPLE ARE INVOLVED IN THEIR CARE5
INTRODUCTIONDefinition of involving people intheir careFor the purpose of this review, we have takenas our starting point the definition of people’sinvolvement in their care in the fundamentalstandard of ‘person-centred care’ and thecommitments in the Five Year Forward View forthe NHS on people’s involvement in their care.In 2013, together with 12 other national partnersand the Department of Health, CQC made acommitment to encouraging better integratedcare. The resulting person-centred care narrativehighlights what this means from the perspectiveof a person using care services:“I can plan my care with people who worktogether to understand me and my carer(s),allowing me control, and bringing togetherservices to achieve the outcomes important tome.”4A series of ‘I statements’ to reflect goodcoordinated care from a person-centredperspective were used as the basis of this sharedcommitment (FIGURE 1). They were developedby user-led organisations in partnership withpeople who use services.5 We have based ourdefinition of people being involved in their careon these statements.FIGURE 1: BEING INVOLVED IN YOUR CAREI am offered theopportunity tobecome moreeducated abouthow to managemy symptomsMy wishes andpreferences arerespected,recorded andtaken intoaccountI am as involvedin discussionsabout my care,treatment anddaily life as Iwant to beMy capacity to beinvolved is takeninto account –wherever I receivecareI am involved indaily life choicesin care settings6BET TER CARE IN MY HANDSMy family andloved ones helpme plan my careand support asmuch as I wantthem toStaff in differentservices workwith me to adaptmy plans as myneeds changeI am offeredappropriateinformation,support andadvocacy about keydecisions for mycare andtreatment
INTRODUCTIONWe recognise that many people do not need touse multiple health and social care services orneed long-term care. Someone who uses servicesoccasionally may wish to be involved in theircare in different ways, or to a different extent,to someone with a long-term condition or whoneeds long-term care. However, the I statementsreflect the key aspects of ‘being involved’, andprovide the starting point for conversationsbetween anyone using health or care servicesand staff providing care.The benefits of involving peoplein their careA growing body of literature shows that peoplebenefit from being involved in making decisionsabout their care and in how that care is deliveredto meet their needs and wishes.6-10 The impactsinclude:zz improved knowledge of their condition andtreatment optionszz increased confidence to self-manage aspectsof their own carezz increasing the likelihood of keeping to achosen course of treatment and participatingin monitoring and prevention programmeszz improved satisfaction with their care andchosen treatmentzz more accurate risk perceptionszz reduced length of hospital stay andreadmission rates.Those in receipt of personal budgets reportpositive outcomes for feeling independent,in control and positive about their health andwellbeing. Carers also report improved quality oflife. The trials of this scheme have also shown amore cost-effective use of treatment – peoplechoosing less costly treatments.10-12There is also growing evidence that greaterparticipation in decision-making for those withlong-term conditions and for those with higherlevels of physical and mental health needsprovides cost savings. In a recent study, thecharity Nesta concluded that involving patients,their families and communities more directlyin the management of long-term conditionsreduces admissions to hospital care, which couldlead to savings of at least 4.4 billion a year inEngland.18In mental health, there is increasingly evidencethat those who feel less in control report lowerself-esteem and poorer quality of life, whereasresearch into shared decision-making aroundmanaging medicines has the potential to improveautonomy, choice and health outcomes.11,19,20Other research has found that the greatestbenefits from involvement in individual mentalhealth care and treatment are when people agreewith the purpose of their care and treatment,have some choice about it and some degree ofcontrol over it.21Why involving people mattersWithin NHS care there is a long history ofpolicies and initiatives to increase patient rightsto choose services, support people to take morecontrol over their own health and to support therights of patients (Box A). These have combinedwith a growing movement from people who useservices demanding a more open and more equalsystem of decision-making.8Shared decision-making, a process whichrecognises the expertise that clinicians andpatients bring and treats them as equallyimportant, may also lead to people choosing lessinterventional and less costly treatment, and thatinvolvement in care may lead to reduced hospitaladmission rates.13-17A REVIEW OF HOW PEOPLE ARE INVOLVED IN THEIR CARE7
INTRODUCTIONBOX A: INVOLVING PEOPLE IN THEIRCARE – POLICY COMMITMENTS“You have the right to be involved in planningand making decisions about your health andcare with your care provider or providers,including your end of life care, and to begiven information and support to enable youto do this.”NHS Constitution22“We will make good on the NHS’longstanding promise to give patients choiceover where and how they receive care. Onlyhalf of patients say they were offered achoice of hospitals for their care, and onlyhalf of patients say they are as involvedas they wish to be in decisions about theircare and treatment. We will also introduceintegrated personal commissioning (IPC), anew voluntary approach to blending healthand social care funding for individuals withcomplex needs.”Five Year Forward View 23“Local authorities must have regard to theimportance of the individual participatingas fully as possible in decisions relating totheir care and support, and being providedwith the information and support necessaryto enable the individual to participate. Inpreparing a care and support plan, theymust involve the person, their carers andany person the adult asks the authority toinvolve.”Care Act 201424In recent years this emphasis has increased, forexample through a drive for personalised careplans, commissioning models that focus on theneeds of individuals, and extensive triallingof personal health budgets. Major reports,such as the Francis Inquiry into the failures atMid Staffordshire NHS Foundation Trust, haveidentified people’s involvement in decisions,and those of their family and carers as key toensuring safe and effective care.258BET TER CARE IN MY HANDSFor the first time, local commissioners of carehave been given specific duties to promote theinvolvement of patients and their carers andrepresentatives in decisions that relate to careand treatment. The 2012 Health and SocialCare Act (amending the National Service Act of2006) specifically separates the duty to involvesomeone as an individual in their care from dutiesto inform or consult patients and the public onchanges to services or in planning services.24,26The NHS Five Year Forward View reflects thecommitments to a new relationship betweenthe NHS, patients and communities and toincrease the direct control patients have overthe care that is provided to them. The launchof the vanguard sites for the new care modelsprogramme, and the integrated personalcommissioning sites in 2015, were heralded as asystems-wide approach to increasing the powerthat people who use services have over theirhealth and social care.27Mental health policy has also placed a strongemphasis on a greater partnership betweenpeople using services and staff. The recentlypublished Five Year Forward View for MentalHealth makes a series of recommendations aboutimproving people’s ability to manage their ownconditions and creating greater partnershipbetween people and services in supporting this.19There has been a comparable move within adultsocial care towards greater personal control overresources through direct payments schemes,and a joint ownership of care planning. The CareAct 2014 sets out a range of duties for localauthorities to ensure that people’s wishes andpreferences are taken into account and that theyare better supported to choose their care andhow to live their lives.24Standards for involving people intheir careAll health and social care services that CQCregulates are expected to meet the fundamentalstandards of care introduced in April 2015,based on government regulations. These set thestandards below which care should never fall.
INTRODUCTIONPerson-centred care is one of the fundamentalstandards of care (Regulation 9) and includesthe key elements expected of care providers toinvolve someone in their care and treatment –whatever service they use. This includes workingin partnership with the person, making anyreasonable adjustments and providing supportto help them understand and make informeddecisions about their care and treatment options,including the extent to which they may wish tomanage these options themselves.28In addition CQC asks five key questions aboutthe quality and safety of care: are services safe,effective, caring, responsive and well-led?We follow key lines of enquiry as part of ourassessment, asking whether services involvepeople in their care, particularly in relation towhether services are caring and well-led. We askcommon but tailored questions across all thesectors we regulate. We check:zz whether people who use services and thoseclose to them are involved ‘as partners’ intheir carezz how a service supports people to expresstheir views and be actively involved in makingdecisions about their care, treatment andsupportzz that people receive personalised care plansthat are responsive to their needszz that people’s needs, wishes and choices arerecognised, respected and shared when theymove between services, and their individualpreferences and needs continue to be met.The detailed questions we ask for each servicetype can be found in the links to our providerhandbooks for different services (available on ourwebsite).We also describe what people should expectto see in care services across the health, adultsocial care and primary care sectors in ourcharacteristics of each rating level. Boxes Band C overleaf summarise what we wouldexpect to see when services are outstanding forinvolving people in their care and when they areinadequate.A REVIEW OF HOW PEOPLE ARE INVOLVED IN THEIR CARE9
INTRODUCTIONBOX B: CQC’S CHARACTERISTICS OF OUTSTANDING INVOLVEMENT INCARECQC identifies outstanding involvement of individuals where:zz People are truly respected and valued as individuals and are empowered aspartners in their care.zz There is a strong, visible person-centred culture.zz Relationships between people who use the service, those close to them and staff are strong,caring and supportive.zz Staff and management are fully committed to working in partnership with people and makingthis a reality for each person.zz Staff empower people who use the service to have a voice and to realise their potential.zz People’s individual preferences and needs are always reflected in how care is delivered.zz The service is exceptional at helping people to express their views so they understand thingsfrom their points of view.zz They use creative ways to make sure that people have accessible, tailored and inclusive methodsof communication.BOX C: CQC’S CHARACTERISTICS OF INADEQUATE INVOLVEMENT IN CARECQC identifies inadequate involvement of individuals where:zz People are not involved in their care or treatment.zz People do not know how to seek help or are ignored when they do.zz People do not know or do not understand what is going to happen to them during their care.zz People’s preferences and choices are not heard or acted on.zz The service does not listen to people or understand how to support them to express their views.zz Staff communication with people with complex needs is poor so they are often not understood.Also, staff do not have access to or understand the different methods of communication thatcan be used.10BET TER CARE IN MY HANDS
1 . N AT I O N A L F I N D I N G S1. National findingsNational trendszzOverall, national surveys of patients and peopleusing services across almost all sectors highlightthat, over the last five years, there has beenno substantial change in people’s reportedexperiences of being involved in their care. Forinpatient care, these trends are found over thelast nine years. The one exception is maternitycare, where national surveys demonstrate asustained increase in women reporting greaterinvolvement in their care. Key trends are:zz People’s reported involvement in theirinpatient care has not changed substantiallyover the last nine years, according to newtrend analysis of national inpatient surveydata from 2005 to 2014.29 In 2005, 53% ofpeople reported they definitely felt involvedin decisions about their care and treatment,increasing slightly to 57% in 2014.zz The national inpatient survey shows thatpeople’s involvement in decisions arounddischarge from hospital has not changedover the last five years, with just over half ofsurvey respondents saying they definitely feltinvolved in these decisions.zz Community mental health survey responsesfrom people with a care plan show thatthe number who felt definitely involved indecisions about their care plans was 57% in2014 and 56% in 2015.zzzzPeople using adult social care servicesprovided by local authorities report very littlechange in their feeling of control over theirdaily lives in annual surveys since 2010(30-32% reporting feeling they haveadequate control between 2011 and 2014).We have reported consistent concernsregarding people detained under the MentalHealth Act experiencing poor involvement intheir care over the same period in our MentalHealth Act annual reports 2009 to 2014.2We have reported on people’s experiencesof the Deprivation of Liberty Safeguardsover the last six years (2009 to 2015).3 Thishas also consistently raised concerns aboutthe variation in the use of the Safeguards inhospitals and care homes. These result in poorpractice where people are not being involvedappropriately in decisions about having theirliberty deprived, or having an advocate tosupport best interest decisions being made.A REVIEW OF HOW PEOPLE ARE INVOLVED IN THEIR CARE11
1 . N AT I O N A L F I N D I N G SCQC’s national thematic reviewsEvidence gathered by CQC in separate nationalthematic reviews between 2009 and 2015 alsohighlights a lack of people’s involvement in theircare for specific groups of people. This includes:zz people over 75zz people with dementiazz young people with complex health needszz people with a learning disabilityzz people detained under the Mental Health Actor experiencing a mental health crisiszz those people subject to Deprivation of LibertySafeguards (see findings by population groupbelow).Findings by sectorOur analysis of people’s responses from nationalpatient surveys, adult social care surveys andCQC’s Mental Health Act monitoring highlightsthat important differences appear to exist aboutpeople’s involvement in their care when we focuson specific sectors or service areas.The evidence below draws on the most recentsurvey data or national reports available. Insome cases, it is not possible to make directcomparisons between some of the data fromdifferent surveys, as the questions people areasked about involvement in their care differ.FIGURE 2: WERE YOU INVOLVED AS MUCH AS YOUWANTED TO BE IN DECISIONS ABOUT YOUR CAREAND TREATMENT? (2014 INPATIENT SURVEY)10%57%34%Yes, definitelyYes, to some extentNoSource: National Inpatient Survey 2014.There are similar levels of responses aroundpeople’s perceptions of their involvement in A&Eservices, being offered a choice of hospital, anddischarge, from hospital.*These findings remain relatively unchanged overthe last 10 years.There is variation in the responses at NHS trustlevel to patient survey questions about people’sinvolvement in their care. This suggests thatsome trusts are better at involving people in theircare than others.Acute carePeople using acute hospital services report mixedexperiences of being involved in decisions abouttheir care.The 2014 inpatient survey found that only justover half of respondents reported they weredefinitely as involved as they wanted to be.12BET TER CARE IN MY HANDS* Responses to the national inpatient survey 2014show 54% of people reported definitely being involved indecisions about discharge from hospital with 30% sayingthey were involved to some extent and 16% not at all.Twenty-seven per cent of people were offered a choiceof hospital for their first hospital appointment when theywere re
regulator of health and adult social care in England. Our purpose We make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve. Our role We register care providers. We monitor, inspect and rate services. We take action to protect people who use services.
1 EOC Review Unit EOC Review Unit Table of Contents LEFT RIGHT Table of Contents 1 REVIEW Intro 2 REVIEW Intro 3 REVIEW Success Starters 4 REVIEW Success Starters 5 REVIEW Success Starters 6 REVIEW Outline 7 REVIEW Outline 8 REVIEW Outline 9 Step 3: Vocab 10 Step 4: Branch Breakdown 11 Step 6 Choice 12 Step 5: Checks and Balances 13 Step 8: Vocab 14 Step 7: Constitution 15
akuntansi musyarakah (sak no 106) Ayat tentang Musyarakah (Q.S. 39; 29) لًََّز ãَ åِاَ óِ îَخظَْ ó Þَْ ë Þٍجُزَِ ß ا äًَّ àَط لًَّجُرَ íَ åَ îظُِ Ûاَش
Collectively make tawbah to Allāh S so that you may acquire falāḥ [of this world and the Hereafter]. (24:31) The one who repents also becomes the beloved of Allāh S, Âَْ Èِﺑاﻮَّﺘﻟاَّﺐُّ ßُِ çﻪَّٰﻠﻟانَّاِ Verily, Allāh S loves those who are most repenting. (2:22
the public–private partnership law review the real estate law review the real estate m&a and private equity review the renewable energy law review the restructuring review the securities litigation review the shareholder rights and activism review the shipping law review the sports law review the tax disputes and litigation review
the product regulation and liability review the shipping law review the acquisition and leveraged finance review the privacy, data protection and cybersecurity law review the public-private partnership law review the transport finance law review the securities litigation review the lending and secured finance review the international trade law .
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P. 26 Community Theatre 200-400 people P. 27 Proscenium Theatre 400-800 people Multi-Purpose P. 28 Fitness Studio Up to 100 people P. 29 Gymnatorium 100-400 people P. 30 School Auditorium 400-800 people Nightlife P. 31 Bar Up to 200 people P. 32 Dance Club 200-400 people P. 33 Live Music Club 400-800 people Other P. 34 Monitor Systems
Keywords: review genres, academic review genres, review article, critical evaluative review, mixed-mode review, bibliographic review 1. Introduction Review genres are normally written texts or part texts that can provide suitable places for expression of personal ideas, attitudes, and evaluations.
