Read Standard 6: service user and patient involvement

Clinical Governance Standards
National

Standard statement

People and communities are meaningfully engaged in the design, delivery and governance of clinical services, in line with statutory duties and national guidance. 

Rationale

Effective clinical governance requires routine engagement with people and communities in shaping the services that affect, or may potentially affect, them. Meaningful engagement with people and communities supports quality, promotes equity and helps public sector bodies, including the NHS, meet their legal obligations in line with legislation and national guidance.51, 57-60 Independent providers can benefit from adopting similar collaborative approaches to improve the quality, relevance and accessibility of their services.  

Embedding public engagement within governance and quality systems ensures that services are informed by lived experience, inclusive of diverse voices and responsive to changing population needs.4, 61. Services should engage proactively, transparently and accountably, using quality assured approaches that demonstrate a clear link between feedback and service improvement. 

The Scottish Approach to Change supports services to combine service design, engagement and quality improvement methodologies so that they can fully and meaningfully engage with communities and service users to understand how to improve or design services.  

Healthcare Improvement Scotland has a statutory responsibility to support, ensure and monitor the quality of public involvement across health services. NHS boards and Health and Social Care Partnerships should ensure that community engagement is embedded within planning, reporting and governance processes.  

Public involvement and engagement activities should be proportionate to the organisation's role, function, size, scope and model of delivery of clinical services.  

References

Criteria

6.1

Organisations demonstrate compliance with relevant national guidance and statutory duties on public involvement and engagement.  

6.2

Organisations clinical governance structures should have oversight and assurance of community engagement and include clear lines of accountability, reporting and assurance. 

6.3

Organisations use validated engagement approaches and frameworks to ensure engagement is: 

  • appropriate to the local population  
  • inclusive 
  • meaningful. 
6.4

Organisations use evidence-based user design approaches to engage people and communities in clinical services in: 

  • planning 
  • codesign 
  • delivery 
  • monitoring and evaluation 
  • service change and service development. 
6.5

Organisations undertake equality and other impact assessments of clinical services to understand and address: 

  • barriers in accessing healthcare and services 
  • the needs of any underserved communities or locations 
  • the prevalence and impact of health inequalities and intersectionality in their local population. 
6.6

Organisations routinely collect and respond to data on deprivation, rurality, sex, gender, age, disability, race and ethnicity to understand and reduce inequalities in engagement and service improvement. 

6.7

Organisations provide accessible, inclusive and timely information about services, engagement opportunities and how to participate in decisions that affect clinical care. 

6.8

Organisations routinely gather and respond to feedback and publish how this has informed decisions and improvements. Feedback should be actively sought from:  

  • people who use clinical services and, where appropriate, their care partners 
  • volunteers 
  • local communities. 
6.9

Organisations review data from complaints and feedback and publish reports that: 

  • are easily accessible 
  • include improvement action plans 
  • demonstrate where learning has led to improvements in clinical services. 
6.10

Organisations ensure that involvement of people with lived experience is effectively governed, including appropriate mechanisms to protect confidentiality. 

6.11

Organisations ensure staff: 

  • are supported to understand their responsibilities in engaging people and communities 
  • have access to training and tools to support high-quality involvement. 

What does this standard mean for....

What does the standard mean for people?

  • You can be involved in the design and delivery of clinical services in your area in a way that works for you. 
  • Information on services will be provided in a way that is easy to understand.  
  • You will be able to give feedback on your experience of services. 
  • You will hear how your feedback has been considered and what has changed as a result.  
  • Services will be inclusive and accessible, having been codesigned with people and communities. 

What does the standard mean for staff?

Staff, in line with roles, responsibilities and workplace setting: 

  • are supported to take part in communication, engagement or participation programmes 
  • understand the populations they work with 
  • understand their role in involving people and communities in the design and delivery of services 
  • understand and apply national guidance on involving people and communities 
  • use inclusive and evidence-based methods to involve people in service design and improvement 
  • work collaboratively with engagement specialists and communities to improve quality and safety. 

What does the standard mean for the organisation?

Organisations, in line with their respective governance and delivery structures: 

  • listen and respond to feedback from people and communities about the services they provide 
  • have processes in place to facilitate codesign when planning and redesigning services 
  • demonstrate compliance with accessibility requirements and standards 
  • embed service user and community involvement within their governance, quality and planning systems 
  • provide assurance that engagement activity is compliant with statutory duties and best practice 
  • use data, evidence and feedback to identify inequalities and act on these  
  • work with Healthcare Improvement Scotland and local partners to continuously improve the quality of engagement practice 
  • evaluate involvement activities and capture learning to inform future projects. 

Benchmarking and measuring performance: Examples of what meeting this standard might look like [linked criteria]

Examples may vary according to the size and scale of the service, NHS board, organisation. 

  • Review of communications against accessibility requirements. For example, ensuring websites meet accessibility guidance. [6.1, 6.3, 6.7] 
  • Use of participation, engagement and public involvement approaches and tools. [6.3, 6.7] 
  • Evidence of active engagement with the local population when setting up, changing and delivering services. [6.3, 6.4, 6.7, 6.8] 
  • Establishment of patient or public participation groups or forums. [6.4, 6.8] 
  • Evidence of adherence to Planning with People and use of the Quality Framework for Community Engagement and Participation. [6.1-6.5, 6.7-6.11] 
  • Governance papers and minutes demonstrating discussion and scrutiny of engagement activity at board level or equivalent. [6.2] 
  • Equality and other impact assessments and community profiling data used to inform planning and service design and improvement. For example, islands impact assessments or child wellbeing and rights impact assessments. [6.5, 6.6]
  • ‘You said, we did’ reports and case studies published on public platforms. [6.8, 6.9] 
  • Training records for staff involved in engagement on service planning and improvement. [6.3] 
  • Active collaboration with Healthcare Improvement Scotland in the design and assurance of engagement approaches. [6.1, 6.3, 6.4, 6.7]