Reflecting on our palliative care work: thoughts from Sandra Campbell


Sandra presenting
Sandra presenting at our recent learning event on identification.

Our Nursing National Clinical Lead for Palliative and End of Life Care, Sandra Campbell, reflects on a year of supporting the Living Well in Communities palliative care work.

What a year! I have loved every minute! Unfortunately the secondment is only one day a week, but fortunately I am able to be flexible with time. I am certainly very grateful to my line manager in my substantive post as Nurse Consultant for Cancer and Palliative Care in NHS Forth Valley for that.

The main purpose of the clinical lead role is to support the Living Well in Communities Team within the ihub at Healthcare Improvement Scotland to deliver on Commitment 1 of the Strategic Framework for Action on Palliative and End of Life Care 2016-2021:

  • Identification of need
  • Coordination of care

The programme has six test sites across Scotland: Dundee, Glasgow City, Perth and Kinross, East Ayrshire, Fife, Western Isles, and Renfrewshire.

Reflecting back to April 2017, it was hard to imagine how these individual projects would evolve, but it has been amazing to see them unfold due to excellent local leadership within each of the Health and Social Care Partnerships, the guidance and support of assistance improvement advisors in each area and the support of the Living Well in Communities team.

Dr Paul Baughan and I, as clinical leads, have supported from a clinical advisory aspect. A Palliative Care Identification Tools Comparator resource has been developed and is available to support teams in understanding the various tools that can support the identification of palliative care. Paul has supported two webex education sessions, and I will be delivering a webex on the key principles in Caring for People in the Last Days of Life and how this relates to coordination of care.

The test sites will test some of these tools, which will inform wider learning across Scotland. This work will be developed further to inform a resource for care staff in care homes on how and when to use particular tools at different trigger points. Three events will share this learning: the first of which took place on the 31st May (and really saw the Strategic Framework for Action for Palliative and End of Life Care come to life) and a further two are planned for October 2018 and March 2019.

All of the work fits perfectly with the agenda in Realising Realistic Medicine, supporting anticipatory care planning that ultimately enables the right thing to be done at the right time, by the right person, to the right quality standard, with the right outcome.

What is needed is:

  • Good assessment and care planning
  • Good decision making
  • Good care
  • Good quality of life until death
  • Good death
  • Good bereavement

The opportunity for the test sites on the project is to try out different ways of working to improve care and make best use of resources available. Enhancing the generalist support is vital if we are to ensure as many people as possible can remain in their own homes as long as possible.

Other developments

New guidance to support Confirmation (previously verification) of Death will be available shortly from the Scottish Government.

Macmillan has supported projects within the test sites with funding of £120,000.

Macmillan and the Scottish Ambulance Service are in early conversations about developing a national project to improve end of life care and prevent inappropriate admission to hospital and reduce inappropriate CPR.

A key aspect of the clinical lead role is to engage with other stakeholders and we do this on an ongoing basis. People and organisations we have engaged with include:

I have also set up a nurse leads group – now reporting to the Scottish Government, SEND and SPPC. We have a practical work plan that includes bereavement. This group is about sharing best practice across all areas. Standardising care at end of life is helpful to teams and welcomed in the absence of a framework such as the Liverpool Care Pathway.

In caring for the dying patients and those close to them, it is important that staff provide care in accordance with the key principles, which I discussed in an earlier blog post.

You can follow Sandra on Twitter and contact her at


Can you make a difference to people’s lives?

Thomas Monaghan, Portfolio Lead for Living Well in Communities

15 June 2015. That’s the day I became part of Healthcare Improvement Scotland.

What attracted me to work in Healthcare Improvement Scotland? I wanted to help people have better lives. People like my late sister, who due to her long list of mental and physical conditions spent the last few years of her life ping-ponging between hospital and home. She could barely live her life because the services that supported her, my family and I were so busy trying to keep her safe that we effectively stopped her from living. I don’t want anyone else to experience that. I want everyone, no matter their background, to have the same opportunity to have a better life. And that’s why I’m part of Healthcare Improvement Scotland, because I’m helping people have a better life.

As my third work anniversary approached I started reflecting about the roles I’ve had in the past, from teaching undergraduates during my biomedical studies to service improvement in a large social housing and care group. And I realised that working in Healthcare Improvement Scotland combines the best parts of all my previous roles. I have the methods and thought-provoking challenges of scientific research. The buzz from helping people put new skills into practice. And the heart-felt satisfaction of helping people have better lives. And that’s with the pleasure of working with like-minded people.

My work

I started out at Healthcare Improvement Scotland as an Improvement Advisor. With the help and support of the team at Healthcare Improvement Scotland I developed my own skills and knowledge, growing my experience and confidence to enable me to develop with the organisation to become the team lead of Living Well in Communities. The team delivers a wide range of improvement programmes that work with health and social care organisations to help people have a better life at home, wherever that’s their family home or a care home.

There are many aspects to having a better life. One of them is avoiding time in hospital. Hospitals are great places to be when you need them, but many people have a similar experience to my late sister and have episodes where their lives are put on hold as they ping-pong in and out of hospital. But it’s not inevitable.

Helping people to live well in their community

The Living Well in Communities team have been working with services in over 20 health and social care partnerships (HSCPs) to find ways to improve support for people in the key population groups below to help them live well at home for longer.

We have been doing this by:

  • testing ways to identify people in these groups before a crisis occurs leading to repeat hospital admissions,
  • developing tools and approaches to help practitioners have a conversation with people at risk of crisis about what they want for their future, and
  • implementing preventative models of care to support people live well in their community for longer.


Scaling up change across Scotland

Much of our early testing work, particularly around frailty, is now complete and we are about to offer all HSCPs support to change their local systems to help people to live well in their communities for longer. We have already started working with the ten HSCPs in the north of Scotland and we will soon be able to support the HSCPs in the east of Scotland.

To further enhance our work, we are seeking to appoint a new Improvement Advisor to join our dynamic and driven team of liked-minded individuals to offer support to the HSCPs in the west of Scotland.

Could that be you?

Join us and help change lives

You would be joining a great team with a mix of people from various sectors. Some of the team have traditional health backgrounds, but others have joined us from local authorities, the Mental Welfare Commission, third sector providers and even a national sports association. I value that diversity and we’d like to continue to invite applications from a wide range of backgrounds.

There are some essentials for joining the team. You need practical improvement skills that you have used to help professionals change the way they work by using structured methods to systematically drive improvement. Methods such as the IHI Model for Improvement, system thinking methods such as Lean, experience based co-design or even RADAR from the EFQM Excellence Model. Data skills are also incredibly useful, not just traditional quantitative data for run charts, but also using qualitative data to drive improvement.

Key to the success of this role is the ability to establish and maintain good relationships. You will need to form and manage excellent working relationships with the Health and Social Care services you serve throughout the west of Scotland. You will also need to work closely with the rest of the Living Well in Communities team, especially the National Clinical Leads, National Professional Leads and national partners who bring substantial health and social care subject matter expertise to our work.

As you will be leading regional improvement support, it is important that you have some practical experience managing large projects or programmes. Our regional work is more responsive to local needs than traditional national programmes, which means you need to be comfortable managing programmes that will change with local needs and often start with a lot of ambiguity.

And finally, what we need is a passionate leader. Someone who truly cares about helping people have better lives and can use that passion to inspire others to change. We need someone who can persuade others to break old habits and try something different. We need someone who is self-aware and is driven to continuously develop their own skills, experience and behaviours as they strive to improve the support they provide to HSCPs.

If you have these skills, the energy and drive to be part of the Living Well in Communities team, then we would love to hear from you.

Apply now at our website. If you’d like have an informal chat to a current Improvement Advisor about their experience in the role, then please email Nathan at You can also find more information about us on our website and on our blog.

If you join the team we’ll put your skills to good use to work with health and social care services to shape the care experience of tens of thousands of people. That won’t reverse my late sister’s experience, but it will help thousands of others to have better lives.

The community-based interventions that can make a difference for people with frailty

Cover image

We have recently published a resource that summarises the evidence for different community-based frailty interventions. This blog post gives an overview of the document and its features.

Why focus on frailty?

A person with frailty can experience serious adverse consequences following even a relatively minor illness. Its impact can be very significant in terms of consequent disability or admission to a nursing home.

If frailty is identified at an early stage and individuals are targeted with evidence-based interventions that can manage frailty, or reverse it, this can improve people’s quality of life and wellbeing. This reduces the likelihood that they will need to access unplanned services due to a crisis, which, in turn, reduces the use of expensive, unscheduled care.

The community-based interventions that can make a difference

The literature on frailty is vast. For the purposes of our resource we focused on interventions in frailty that are community-based, focused on the prevention of harms or poor outcomes, and supported by relatively high-level evidence. The Evidence and Evaluation for Improvement Team carried out literature searches and produced evidence summaries for the following topics:

  • Exercise interventions and physical activity
  • Polypharmacy review
  • Immunisation
  • Primary care interventions
  • Community geriatric services
  • Lifestyle factors: physical activity diet, obesity, smoking alcohol and their relation to frailty
  • Nutritional interventions for the prevention and treatment of frailty
  • Hospital at home: admission prevention and early discharge
  • Reablement (including rehabilitation)
  • Bed-based intermediate care
  • Anticipatory care planning

Making the evidence accessible

We then created visual abstracts for each topic, which allow readers to compare the different interventions at a glance, and provide a route into the more detailed evidence summaries and further reading. The visual abstracts include information on the potential benefits of each intervention, evidence quality, costs, and frailty level:

Reablement visual abstract
Reablement visual abstract
Reablement summary
Reablement evidence summary


We hope that this document will help Health and Social Care Partnerships to compare different interventions for frailty and the evidence behind them, and to consider which interventions could make a difference for people with frailty in their local areas.

You can access the report, Living Well in Communities with Frailty: evidence for what works by clicking on the document image below:

Cover image

What is it like being an Improvement Advisor?

ND_bwNathan Devereux shares his experience of being an Improvement Advisor in Living Well in Communities team.

Being an Improvement Advisor is an incredibly diverse role which constantly keeps me on my toes! I spend most of my time working with people to bring their ideas and creativity out so that everyone can work towards improving what they do.

Day-to-day that means supporting people to:

  • understand their challenges and opportunities, by using their experience, data and evidence,
  • generate ideas for doing things differently by facilitating workshops with teams, having one-to-one conversations, and, connecting teams from different parts of Scotland, and
  • evaluate how those changes are tested and what the impacts are for people who require care and support.

As an Improvement Advisor I spend a lot of my time working with people to help improve what they do, whether that’s with service managers, frontline staff, or strategic leaders in health and social care partnerships. The time I spend can be looking how to improve identification of people with frailty, or sharing the learning from our programme nationally. So it’s important that you enjoy working with people, as the technical aspects of improvement can only result in positive change when used to help people change and improve what they do.

One of the biggest challenges, but also the most interesting part of the role of being an Improvement Advisor is the diversity and scope of the work. My job is to meet the needs of the organisations I work with and help them to improve. This broad focus can be overwhelming so you need to be able to use a combination of quality improvement and project management skills to understand the situation from the point of view of those you support and then plan and deliver a programme that will focus on achieving outcomes you and your partners want to deliver.

This is also why it’s really important to have a generic set of improvement skills, because the topic or area is determined by the priorities of the organisations I work with. For example, I can go from working with a health and social care partnership to improve how people with palliative care needs are identified and cared for, to advising organisations how to evaluate their intermediate care services.

I don’t think there is a standard route to becoming an Improvement Advisor. The broad set of skills needed means that you can transfer from so many backgrounds and professions.

I started my career working with political groups in a local authority in England before deciding to travel and work abroad, including teaching English in Korea. After relocating to Scotland I then joined Healthcare Improvement Scotland to undertake a number of project roles.

While working on a number of projects related to the assurance and improvement of care, I became increasingly interested in quality improvement itself. I therefore decided to complete online courses and took the opportunity to shadow colleagues who provide improvement advice directly to teams who deliver care and support. I wanted to test my new-found learning, so I used the improvement methods to improve my project work and also got involved in internal improvement projects. These experiences showed me that improvement was something I wanted to pursue, and that I had the generic skills that could be developed to work in improvement. After a little while I eventually secured a place on a formal quality improvement training programme and shortly after secured a post as an Associate Improvement Advisor.

This role enabled me to work directly with health and social care partnerships, using my expertise to improve service provision. I really focused on developing my quality improvement, project management, communication, and, crucially, leadership skills, so that I could become a more effective leader of change. A key part of that development was taking responsibility for national programmes, such as work that looked at how to plan services to meet the needs of a population group. After a couple years working as an Associate Improvement Advisor I then progressed to the Improvement Advisor role, and I have really enjoyed leading programmes, developing others in improvement, and experiencing even more subject matter areas.

Hopefully that gives you an idea of what it’s like to be an Improvement Advisor. It’s such a diverse role, so beyond skills and experience it’s really important that you have the right attitude for the role. The key things for me are that you are adaptable and genuinely open about your strengths and weaknesses. I’m always developing and think that will continue as I aim to improve how I meet the needs of the organisations I work with.

If this sounds like something you would enjoy then I’d recommend you submit an application, or get in touch to discuss more about the role! My email address is

For more information about the role or to apply please visit the Healthcare Improvement Scotland’s website.

Palliative and End of Life Care: Focus on Identification

Michelle Church, Improvement Advisor, reflects on our recent learning event, which explored ways of identifying people who could benefit from a palliative approach to their care.

On 31st May 2018, test site participants from six health and social care partnerships (HSCPs) and key delivery partners across Scotland joined the Living Well in Communities team to learn and share knowledge about tools that can support identification of people who could benefit from a palliative approach to their care.

Making the case for early identification

Kirsty Boyd, consultant and lecturer in Palliative Medicine, talked about the many benefits of earlier identification:

  • Helps people say what matters to them.
  • Increases the opportunity for people to participate in decision-making.
  • Reduces the risk of later regrets and poor outcomes.
  • Gives people time for planning ahead, resulting in fewer crises.
  • Reduces unplanned admissions of low benefit.
  • Encourages medication review and treatment planning.
  • Improves continuity and coordination of care by sharing information.

 How can we do earlier identification?

Our national clinical leads, Dr Paul Baughan and Sandra Campbell, gave an overview of the visual resource the LWiC team have developed to help compare different identification tools that are currently used in Scotland. Sandra did a before and after survey of how aware and confident participants were about the variety of tools.

How did we mobilise knowledge?

Experts from across the UK shared their tools, knowledge and experience of doing identification. People got the chance to participate in interactive workshops looking at the tools that a number of palliative care test sites. Some insights from the sessions are included below:

Anticipal and eFI electronic tools

FAST and PPP tools

PPS and SPAR Tools

SPICT4ALL and carers identification

What did people think of the event?

People felt that they had learnt about why, when and how to use different tools to support identification and inform practice. People really liked that they had the chance to network with experts and colleagues.

Overwhelmingly, the take home message was that earlier identification and communication is key to supporting those who would benefit from a palliative approach to their care.

What did you likeTake home message

What next?

HSCP palliative care test sites are now using the comparator to consider what tools will benefit local people and services and how people identified can be supported. This work will contribute to the vision that by 2021 everyone who could benefit from palliative care will have access to it and will support the Realistic Medicine ambition of shared decision-making and a personalised approach to care.

Reflecting on our palliative care work: thoughts from Paul Baughan

Paul Baughan 2Dr Paul Baughan, our palliative care GP clinical lead, discusses the benefits of early palliative care, highlights a resource that we’ve developed to compare different palliative care identification tools, and looks ahead to future work on care planning and care coordination.

Having worked within General Practice for over 20 years, I have seen the transition from hospital-based care to community care for a wide variety of clinical conditions and diseases. We look after many more people who are living with complex medical diagnoses well into their 80s, 90s and beyond. It can be difficult to identify when a palliative approach to care should be considered, and as a result we sometimes find ourselves on the back-foot, reacting to events and changes in clinical condition. Often, with the benefit of hindsight, it might have been possible to anticipate and plan for these episodes before they happen.

This is one of the reasons that I have enjoyed the opportunity to work with Healthcare Improvement Scotland and five test sites across Scotland (Dundee, East Ayrshire, Fife, Glasgow, and Perth and Kinross) to explore how we might identify people who could benefit from a palliative approach to their care at a much earlier stage.

Although a variety of different electronic and paper ‘tools’ have been developed by academics to help identify those who might benefit from a palliative approach to their care, it can be confusing to know which tool to use, and in which situation. Some are electronic, some are designed for particular diseases such as cancer or dementia, or for particular settings such as care homes.  Some tools are intended for health professionals and some for the general population. I have therefore enjoyed working with the team in Healthcare Improvement Scotland to design a resource which will help health and social care professionals become more familiar with the different identification tools, and most importantly, decide which one suits them best. Our five test sites have chosen different identification tools to use within their local Health and Social Care Partnerships.

However, identifying those who might benefit from a palliative approach to their care is just the first step.  It is the conversations that follow, between the health and social care professionals and the person, that are important. And then of course the care planning that results from these discussions. This is our next area of focus at Healthcare Improvement Scotland. We are now working with our test sites to explore how best to plan, coordinate and deliver care to those who are living with a progressive life-limiting condition.

This is an exciting phase of our work, as each test site is considering innovative and practical ways to provide this care within existing resources, and across health and social care. We will have the opportunity to share some of the learning from across Scotland in the Autumn, with the full outcomes from our test site projects available in 2019.

Back at my own general practice, my colleagues and I will continue to see an increase in the number of people with complex progressive life-limiting conditions in the years ahead. Therefore, the outcomes from the five test sites will be very relevant to the work that we do on a daily basis. We know that a proactive, multi-professional, care planning approach is required, and eagerly await advice from the test sites regarding how best to achieve this.

Highlights from the Neighbourhood Care Learning Network Event


On 11 May 2018 we held our latest neighbourhood care learning network event at the Care Inspectorate Offices in Hamilton. The session was well -attended by representatives from the neighbourhood care test sites, national organisations and third sector organisations. The purpose of this meeting was to discuss neighbourhood care and regulation, with a focus on questions raised by the test sites before the meeting. We also took the opportunity to discuss measurement ideas and learn what plans were already in place for local evaluation.

Sharing learning from the test sites

After introductions, staff from each test site provided an update on the neighbourhood care work in their area. There has been a lot of activity across the test sites with positives discussed on this way of working, offers of support and an eagerness from sites to arrange visits to learn from one another. Common challenges faced by the sites include those around culture and shifting perceptions, but the passion for the concept and success stories continue to drive this work forwards and motivate the teams.

Care Inspectorate – from enforcers to enablers

Catherine Agnew from the Care Inspectorate gave an informative presentation about the role of the Care Inspectorate in supporting services as enablers of innovation, rather than the traditional perception of enforcing regulation. There is acknowledgement that services for the public are evolving with the integration of health and social care. In support of this, the Care Inspectorate have developed regulatory sandboxes, where normal regulatory requirements are waived to support innovation which has the potential for public benefit.

Attendees discussed the new health and social care standards in Scotland and were pleased to note that the principles of the Buurtzorg model mirror these standards (Dignity and respect; Compassion; Be included; Responsive care and support; Wellbeing).


We facilitated a group discussion on evaluation and undertook an exercise to look at measures, how important these are and how easy they are to use. Representatives from the test sites rated examples and entered them into a prioritisation tool, which could help the teams to look at work priorities and measurements in their areas. They highlighted difficulties with measuring face-to-face contact time, although this is an important measure to show effectiveness of this model and the test site representatives acknowledged that this is a measure that is important to care givers: ‘more time with the person needing care’.

They are aware that while test sites will have different measures and there will be local variation, there is a need to have some standardisation for comparisons. Evaluation should be meaningful in a local context for individuals, their carers and staff. However, an element of evaluation will be required for national interest to look at areas such as cost saving, avoiding hospital admissions and reducing length of stays, etc.

Prioritisation matrix

The King’s Fund has recently published a paper on transformational change in health and care in response to the growing pressures and demands on the health and care system. The paper highlights four case studies that have been recognised as successful transformation initiatives, led by staff that directly provide care and service users. One of these successful initiatives is the Buurtzorg Nederland model.

Next steps

The test site representatives agreed to try a new approach to the learning network, with an option to move to the IHI model of a breakthrough series collaborative alongside action learning sets facilitated by the Scottish Social Services Council in the future. Once logistics have been further discussed, options will be presented to the group to take forward. Members of the group were happy to share their plans for evaluation with the Living Well in Communities (LWiC) team and there are steps to visit each site. Further information will be available soon.

Meet Rob Corrigan!

Rob square b&w

I have never been one for blogging or being photographed, I never enjoy being centre of attention for that matter! However in the interest of challenging myself and trying to improve, I fancy having a go at it, particularly given the excellent blog debut my colleague and fellow project officer Gemma Stewart recently produced.

I have been part of the Living Well in Communities (LWiC) team for over a year now. My current role is to provide project support to the palliative and end of life care workstream, which aims to support health and social care partnerships across Scotland to test improvements in the identification of people who could benefit from a palliative approach to their care, and care coordination.

I find this a hugely interesting and engaging workstream to work on. It’s an emotive subject, which is really helping me challenge and think through my ideas and perception of what palliative care is, and can be. To date my biggest learning point has been around the necessity of good conversations. Whether that is with a professional or a loved one.

Like Gemma I have a varied background, having studied social science at an undergraduate level, then criminology and criminal justice at a master’s level. My studies led me to a role in the third sector with Victim Support Scotland, in which I was part of the day-to-day running of the Edinburgh service. I then took up a role with Healthcare Improvement Scotland, working for a number of teams, including networks and knowledge exchange, and my current role with LWiC.

The LWiC team are a hard-working bunch, with a real commitment to providing a high quality of work that supports people to live at home or in a homely setting. We are always happy to answer any questions about our work – so please do get in touch.


Meet Gemma Stewart!

Gemma Stewart b&wI would like to introduce myself as a new project officer for the Living Well in Communities team.

I will initially be assisting with establishing a programme of work LWiC are undertaking to support the health and social care partnerships in the North of Scotland.

This is an exciting new role for me in an established team, where I know I will be given the opportunity to learn lots and hopefully make a difference at the same time.

I have quite a varied work history, but one I think that has given me good experience and learning which I can bring to this role. I initially trained as a Physiotherapist and worked for a few years in NHS England in both acute and outpatient settings. This has given me a great insight into the challenges services and clinicians face on a day-to-day basis to support patients, their families and carers.

Having taken a break to explore the travel bug, I settled in Scotland where I have held office roles in both the private and third sector. For the last two and a half years I have been working in Healthcare Improvement Scotland’s ihub, initially as an administrative officer and then project officer for the Tailored and Responsive Improvement Support team. Here I have been largely responsible for managing the ihub associates framework agreement, and more recently working on the 90-day innovation cycle to explore quality management systems in health and social care in Scotland. I hope to be able to bring the valuable skills I have developed in these roles to my new position.

In the short time that I have been a member of the LWiC team, I have been struck by the enthusiasm and drive of the whole team, who have a multitude of varied skills and experiences behind them. There is a real passion for the work they undertake and an awareness that although there may be challenges ahead, by working together with our partners and communicating clearly these can be overcome.

I am incredibly excited to be a part of this team and to have the opportunity to make a difference and support people to live well for longer at home or in a homely setting.

If you have any questions please do get in touch.


Comparing tools that can help to identify people who could benefit from a palliative care approach

PC tools comparator cover

We have recently published a resource that compares different tools that could be used to identify people who could benefit from a palliative care approach. This blog post gives an overview of the document and its features.

The benefits of early identification

Early identification of people who could benefit from a palliative approach to their care has many advantages. It can allow people to make informed choices about what medical treatments and care they would like to receive, or not receive, and to prioritise things that are important to them when length of life may be short, or when the presence of irreversible illness has altered life for that person.

Palliative care identification tools

It can be very difficult to recognise when someone is nearing the end of their life due to a chronic, progressive medical condition, frailty or old age. A number of tools are available to help identify individuals who could benefit from a palliative care approach at an earlier stage.

Comparing different tools – at a glance

We have designed a visual resource comprising a table and a decision tree (see below) to make it easier for Health and Social Care Partnerships to compare the key features of different identification tools, and to select the tools that are most appropriate for their contexts.

PC tools table

Palliative care tools decision tree v0.7


This resource is not intended to be a comprehensive literature review, but rather a visual comparison of some of the main identification tools that are currently used in Scotland. There are brief outlines of all of the tools featured in the comparison table and decision tree, together with links to some key research and further information on these tools.

We have focused on tools that were identified in a literature review by Maas et al, and discussions with palliative care clinicians in Scotland. Some have been validated and others have not. We have tried as far as possible to include information on the limitations of different tools.

You can access the palliative care identification tools comparator on the ihub website by clicking on the document image below:


PC tools comparator cover