(Source: Information Services Division Integrated Resource Framework. Data from 2012/13)

Representatives from the Scottish Government, National Services Scotland, Health Boards, Care Inspectorate, Healthcare Improvement Scotland and Health Scotland got together on 11th May to discuss the work taking place around High Resource Individuals (HRIs) across the country.

Background

In Scotland, a small number of people use a high percentage of hospital and community prescribing resources and inpatient bed days. By focussing on people with a high level of need there is potential to better understand and align the resources used, manage service capacity and demand, and ultimately improve care pathways for those that require the most support.

2020 Vision

Starting with the principles of the Scottish Governments 2020 Vision – that everyone is able to live longer healthier lives at home, or in a homely setting – the group aimed to set out clear objectives and actions for these HRI projects, such as:

• supporting practical, independent living
• ensuring care is person-centred
• fostering a culture of improvement
• effective and efficient use of resources

Presentations & Workshop

A number of short presentations highlighted some of the work currently taking place, sparking discussion on potential values and challenges so far.

Paul Leak, from the Scottish Government Directorate for Health and Social Care Integration, spoke on the work commissioned for Information Services Division developing the SOURCE database to record High Resource data.

Thomas Monaghan from Healthcare Improvement Scotland introduced the HRI work within Living Well in Communities, who aim to help people spend less time in hospital and more at home or in a homely setting.

Calum Macdonald from NHS National Services Scotland gave an overview of the Local Intelligence Support Team (LIST), who provide data analysis support for Health and Social Care Partnerships (HSCPs). LIST are working with the Living Well in Communities team on deep dives to help partnerships gain a clearer understanding of high needs in their area.

Other projects covered included:

• The Lothian Patient experience and Anticipatory Care Team Lothian PACT team (Scottish Patients at Risk of Readmission and Admission (SPARRA) and frequent A&E attendees)
• The Nairn model for focussing Anticipatory Care Planning
• Pathway analysis of HRIs
• NHS Fife linking health and housing data (HL1)

 The future of HRI work and how to progress it

The group reflected on what the next steps might be. Knowledge sharing, learning from good practice and understanding the value of data were considered crucial.

The aim of this data collection and analysis is to help HSCPs explore:

• how they deliver services
• who they deliver services to
• how to meet the needs of those requiring more care
• how to better target those who use the services most

Living Well in Communities are developing a methodology to use the HRI data for improvement. By sharing this methodology more partnerships can use their High Resource data to target improvement work.

Engagement with other organisations that could benefit from the HRI data should be encouraged, and intelligence from areas linked in, such as:

• deprivation
• housing and homelessness
• the prison service
• public health
• the care inspectorate

New arrangements for Primary Care will result in GP clusters. Healthcare Improvement Scotland is looking at ways to better connect them and support developing more patient specific data.

In closing, the group stressed the importance of showing what difference the HRI work has made to individuals lives. Putting people’s stories to the data will add meaning to the work and help engage with a broader audience.