There’s No Place Like Home: Living Well in Communities at the NHSScotland Event

The Living Well in Communities team held two workshops at the NHSScotland Event, which took place at the SECC on 14th-15th June 2016. These sessions explored initiatives from Health and Social Care Partnerships across Scotland that are helping people to spend more time at home or a homely setting that would otherwise have been spent in hospital.

We’ve put together a Storify of the tweets from the sessions.

The sessions were chaired by Susanne Miller, Chief Officer for Strategy, Planning and Commissioning and Chief Social Work Officer for Glasgow City Health and Social Care Partnership. June Wylie, Head of Implementation and Improvement at Healthcare Improvement Scotland, introduced the Living Well in Communities portfolio and frontline speakers from across the different Living Well workstreams and related areas of work:

  • High Resource Individuals – Anne Palmer, Programme Manager, Connected Care, NHS Borders
  • Frailty and Falls – Rebekah Wilson, Ayrshire and Arran Falls Lead and Falls Community Connector.
  • Anticipatory Care Planning – Janette Barrie, Nationa Clinical Lead (Nursing) Anticipatory Care Planning, Healthcare Improvement Scotland
  • Housing – Maureen Cameron, Manager, Lochaber Care & Repair
  • Intermediate Care and Reablement – Lorna Dunipace (Day 1), Interim Head of Transformational Change (Older People), and Christine Ashcroft (Day 2), Service Manager, Glasgow City Health and Social Care Partnership
  • Palliative Care – Caroline Sime, Research Fellow University of the West of Scotland and Ardgowan Hospice

Here are some of the themes from the workshops:

Managing risk

There was discussion about how we could better manage risk for older people. Susanne Miller stressed that in attempting to mitigate all risks we run the risk of infantilising older people.


Collaboration was a clear theme from the initiatives which were discussed, including innovative partnerships with the third sector such as Connected Care’s work with the Red Cross. Rebekah Wilson discussed work with other sectors such as the Scottish Ambulance service and the Fire Service to identify people at risk of falls in the community. She highlighted a case in which the ambulance crew who attended to older gentleman who had fallen at home were able to help him to avoid hospital admission.

Multi-agency and multi-disciplinary teams have been improving intermediate care in Glasgow, and culture change and joint working have played an important part in reducing delayed discharge. Delegates observed that we need to shift away from working in silos.

Delayed discharge

Many local initiatives are tackling delayed discharge. Connected Care in NHS Borders aims to eliminate delays in care interventions and delayed discharge. They have been improving decision making in multi-disciplinary teams in older adult ward, and the introduction of the Red Cross in supporting discharge has been a great success. Glasgow City Health and Social Care Partnership has achieved substantial reductions in delayed discharge through the provision of intermediate care beds. Lochaber Care & Repair is also working to reduce delayed discharge, and provides repairs and adaptations, and community aids and equipment. It is launching Be@Home, a one-stop-shop that brings together all the services that people need to live at home independently.


Technology was a hot topic, both in terms of sharing information across services, and telecare and other forms of support which can help people to maintain their independence. Lochaber Care & Repair is aiming to increase use of telecare. Janette Barrie commented on the need to extend access to the Key Information Summary to social care, and discussed the anticipatory care planning app which is currently in development to help people to share information about their wishes (see the Storify from our recent anticipatory care planning event).

Person-centred care

There was a clear emphasis on providing care in a way which better meets people’s needs. Caroline Sime has been working with Ardgowan Hospice to improve the waiting times from referral to services starting, improve patient experiences and introduce the use of patient-reported outcome measures in a variety of hospice services. The anticipatory care planning video Alice’s Story prompted delegates to consider how care could be improved for Alice.

Sharing learning

Sharing good practice was a key concern for delegates. June Wylie emphasised the importance of sharing information to improve services. There was a general consensus that many NHS boards are involved in similar initiatives, and that it is essential to share learning on what works. There were also concerns that a lot of initiatives are not written up or evaluated, so that lessons from tests of change are disseminated more widely.

The Living Well in Communities team is working to capture and share the learning from our work, both between test sites and across all health and social care partnerships. We’re aiming to share knowledge in a variety of formats which are appropriate for different stakeholder groups, from infographics and videos to leaflets and reports.

The Living Well in Communities team also had two posters at the event on our anticipatory care planning work, and the deep dives which we’ve been delivering with Health and Social Care Partnerships and Information Services Division. The deep dive poster was shortlisted in the Infrastructure category in the poster competition.

The NHSScotland Event page on our community site has our presentation and other materials from the event.

You can keep up to date with the latest developments through Twitter and our blog, and you can also access our resources on our community site.


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