Living and Dying Well with Frailty Collaborative | Learning Session 2

Start of day

On 27 February 2020 we were joined by Away Team members from the 22 teams taking part in the Living and Dying Well with Frailty Collaborative. Teams travelled from across Scotland to come together for the second learning session where they learnt about the theory of complexity and the recently published Framework for Community Health and Social Care Integrated Services and considered how this impacts on their work. Teams also spent time sharing and learning from each other’s progress and experiences of implementing their ideas since the first learning session. They then had time as a team to discuss what they had learnt and develop their plans for the next action period.

We had a great turn out on the day and mixture of representatives from the Away Teams:

Attendees LS2 infographic

Setting the scene

The theme for the day was bridging the gap between practice and strategy. We spent the morning focussing on understanding the system, with the afternoon shifting to what teams are doing within that system.

This was brilliantly introduced with an example from Iain Ramsay, National Professional Lead for Social Services with Healthcare Improvement Scotland, who discussed his experiences of the Virtual Community Ward in Aberdeenshire. Absolutely key to any work like this is the building of relationships. This is at the heart of what we are trying to achieve to improve outcomes for people with frailty through this collaborative approach. Working in a health and social care system is complex and can be perplexing and very challenging. Improving services cannot be done on a one size fits all basis, but there are real advantages to testing and implementing in collaboration with other teams and learning how they have approached and overcome similar challenges.

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“Our Social Work advisor (Iain Ramsay) sets the tone. Success: ”It’s pretty much all about relationships”. How true. Looking forward to building on some today” (tweet from attendee)


Understanding the system

The morning session was packed full of thought provoking information and theory. This included a comprehensive walk through of the newly published Framework for Community Health and Social Care Integrated Services and how this could support the design, development and delivery of services for those who are living with frailty. This was an excellent and engaging presentation littered with real life examples by David Rowland, Professional Adviser at Scottish Government. If you would like to know more about the framework, you can watch a recording of the presentation here.

Following this Ruth Glassborow, Director of Improvement at Healthcare Improvement Scotland, gave an engaging talk on complexity theory and how we may need to use different strategies with different problems. The further ahead we look the harder it is to predict what could happen. One tool that may help you to assess your situation more accurately and respond appropriately is the Cynefin framework. This is a problem-solving tool that helps you put situations into five “domains” defined by cause-and-effect relationships.

“What is my style? How do I interact with those who have a different approach or style? It is really obvious to me that there are PROCESS people and RELATIONSHIPS people. I know very few who have mastered both” (comment from attendee)

The morning was wrapped up by Dr Paul Baughan (National Clinical Lead for Palliative and End of Life Care) and Professor Graham Ellis (National Clinical Lead for Older People and Frailty) who looked at complexity and anticipatory care plans (ACPs). By this point there was definitely a theme emerging about cats!

There is a growing evidence base that ACPs and key information summaries (KIS) lead to positive outcomes, with a recent article in the British Journal of General Practice highlighting that the chances of dying in a community setting were 3.7 times higher with a KIS than without one (Finucane et al, Dec 2019). However, there is huge variation in the percentage of the population across Scotland who have a KIS, and this is partly due to the complexity of the process. Here are just some of the reasons people give for not completing an ACP:


Teams had the opportunity to discuss this issue and think how they can apply this to their work during the next stages of the Living and Dying Well with Frailty Collaborative.

What the teams are doing

We wanted the afternoon to be focused on time for teams to come together and learn from each other’s successes and challenges and get the support they needed to move forwards. The teams were split across four rooms and each took turns to share their experiences with each other using presentations they had prepared in advance, with some time for questions and discussions. There was some great learning between teams on the different approaches being taken, and reassurance that people are facing similar issues and challenges. The networking opportunities offered will allow teams to continue to share their learning with each other over the next stages of the collaborative.

This was followed by more in depth discussions on topics that the attendees self-selected via unconferencing. We wanted to put improvement into action and practice what we preach, so ran a test of change to ask attendees to submit the topics they wanted to discuss in more detail into This produced a word cloud from which key themes could be identified and attendees could choose which of these topics to join a conversation on. An example of a word cloud generated on the day can be seen below, and key information from the topics discussed in each room can be found here.

wordcloud LS2

We wish we had more time on the day to devote to sharing of learning and discussions, but hope the mixture of theory and discussion was valuable to all who came and will help inform the next steps of the teams.

Teams were then given time to work together to plan the next steps for their team to undertake during the second action period.

If you are undertaking similar improvement work you may find the below resources helpful:

What next?

During the second action period Away Teams will share their learning with the Home Teams and work together to collect and submit data and progress reports. They will be supported by the national team at Healthcare Improvement Scotland and encouraged to continue to share their learning with each other.

For more information about the collaborative please visit

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“Finally home after a brilliant day at LWiC Frailty Collaborative. A day spent learning, networking and planning for the future. Amazing what you can achieve when you work collaboratively across all sectors of care.” (tweet from attendee)

Covid-19 update – 16th March 2020

Since the learning session we have seen a rapid escalation of the Covid-19 outbreak across Scotland. Healthcare Improvement Scotland has taken the decision to place all national improvement support on hold until later in the year. We have made this decision for two reasons:

  1. We do not want to place any additional pressure on services at a time when they are heavily involved in preparing for and responding to COVID-19.
  2. We will be temporarily refocusing our improvement resource to support work aligned with COVID-19 resilience.

This means that Learning Session 3 on Thursday 4th June is now cancelled. If you have any questions please do not hesitate to contact the Living Well in Communities on:

Please be aware that this is a rapidly changing situation. Please check our website for more information. You can also find more information on Covid-19 at NHS Inform.



The Living and Dying Well with Frailty Collaborative and COVID-19

Image credit: NIAID / CC BY-SA

by Dr Paul Baughan. GP, Dollar Health Centre. National Clinical Lead for Palliative Care with Living Well in Communities, Healthcare Improvement Scotland

Healthcare Improvement Scotland is temporarily refocusing improvement resource to support work aligned with COVID-19 resilience. The primary care team in the ihub and LWiC have been working together to pull together some resources to help respond to increased service demand. The topics will include developing Hospital at Home services, using NHS Near Me, and proactive Anticipatory Care Planning. More information will be available soon.

People living with frailty are among the most vulnerable to severe illness and death from the COVID-19 infection, and so the activities which teams have undertaken to identify this group, and then to develop anticipatory care plans will likely prove to be extremely helpful.

Some practices may be able to use the information within their frailty registers in a proactive way to target support for people with frailty.  The practice that I work in is planning the following activities:

  • Contacting people with severe frailty by phone to check that they understand what they need to do to minimise their risk of infection, and know how and where to seek advice if they have symptoms. We have produced a template for proactive COVID-19 – frailty work.
  • Asking people with severe frailty if they are happy to have a Key Information Summary (KIS), explaining that this will allow NHS24 to be aware of their medical conditions should they need to phone for help or advice.
  • Checking that any next of kin and power of attorney information is up to date on the KIS.
  • Adding a note on the KIS that this person has been identified through the electronic frailty index (eFI) as living with frailty.

Whilst the above activities fall short of a comprehensive ‘anticipatory care plan’, they will prove to be helpful should someone with frailty require to call NHS 24, or need help from a provider of unscheduled care.

These phone calls could be undertaken by several different members of the primary care team, and could even be undertaken by a well staff member with access to an NHS laptop who is self-isolating at home.

Please do not hesitate to contact a member of the team on if you have any questions about the frailty collaborative in the context of COVID-19.

Meet Paulo Nunes de Moura!

Paulo pictureHere’s a short introduction from Paulo Nunes de Moura, who has recently joined the Living Well in Communities team.

I’m delighted to have joined the LWiC team as a project officer, and I’m focusing on the Living and Dying Well with Frailty Collaborative. I’m enjoying learning the work, and feel that I also have a lot to contribute because of my previous work experience, both paid and voluntary.

Previously, I worked as an events coordinator, being the lead organiser of the 8th European Alcohol Policy Conference, which took place at the Royal College of Physicians of Edinburgh. Other positions include working as a policy officer at the European Alcohol Policy Alliance, and in administrative posts at the University of Edinburgh.

I enjoy learning, and over the recent years I did complete Open University programmes for French and Spanish, completed a part-time master’s degree in Social Justice at Queen Margaret University, and graduated with a Bachelor of Laws from Robert Gordon University.

I also volunteered until recently at the Castlemilk Law Centre, where I completed detailed benefit application forms for clients living with complex physical and / or mental health conditions. This gave me an invaluable insight into the health issues that people face, as well as an appreciation for NHS online resources. I explored these with clients to identify information on conditions, as varied as schizophrenia, osteoarthritis and chronic obstructive pulmonary disease (COPD), with a view to gathering evidence to meet the necessary legal tests to access benefits.

Going off-topic a bit, another memorable experience from volunteering was meeting Queen Silvia of Sweden at a charity event in London, with whom I spoke briefly in Portuguese, as we are both Brazilian!

I’ve been enjoying working with many talented colleagues, who are very generous in sharing their great knowledge and enthusiasm about the fantastic work being done here. I’m also excited about having been given the opportunity to work with different professionals from organisations across Scotland. We are all focusing on improving people’s lives.

If you have any questions, then please do get in touch.

Getting ready for change

Michelle Church updated 2019

by Michelle Church, Improvement Advisor

‘Change matters. It forces us to act.’ – Will Storr

I started out writing this blog post like a report, out of habit. I want to develop a new writing style that is more appropriate for blogging, and it’s proving harder than I thought. This got me thinking, ‘Why is changing so challenging?’


A bit about habit…

I recently learnt that around half our waking day is habitual (see this study by Neal et al, which looks at experience-sampling diary studies), and that all of us have neurological loops that drive our behaviour. In Charles Duhigg’s, The Power of Habit, he explains that researchers at MIT discovered a simple neurological loop: cue, routine and reward.

They discovered that when designing new routines it is essential to identify the trigger for the action, otherwise old behaviours will continue. Also it turns out we don’t need to change the cue and reward for the change to stick. In fact, their research concluded not to: change only the routine. For new habits to form, we need to keep the same cue and reward.

Modes of thought

I have learned about how our brains are wired to be energy efficient. Daniel Kahneman, winner of the 2002 Nobel Memorial Prize in Economics, argues that we have two modes of thought: fast and slow.

The first mode of thought is fast. This is our natural state – automatic, intuitive, effortless. In this mode we create habits (patterns such as our route to work) to make living efficient. In the work environment these habits become the routines and processes that drive nearly every aspect of our working lives.

The second mode of thought is slow. It is deliberate, reflective and analytical. We go into this mode when planning a trip overseas, or learning something new.

When we experience change, when we learn or change a routine, we think more slowly and it takes effort. This may seem obvious, but it has transformed my ability to support improvement work. I have a greater understanding that the resistance to change is because we don’t like disrupting our habits – it goes against our energy-saving neuro-programming and reward structures.

There’s some good news, though, as it seems that we are also neuro-programmed for change. In The Science of Storytelling, Will Storr observes that we are alerted to things that might threaten our sense of control, becoming curious to discover the whole story and regain a sense of control. Our ability to be curious is a great starting point for improvement. Despite the effort required, most of us love to explore and learn.

Stepping outside of your comfort zone

If I’m honest, I normally want to explore a good castle or hillside and quickly return to my creature comforts. My experience of change that involves deep learning or changing my habits, where I am not sure what the change will involve and it seems beyond my control… well, it can often feel like the pits. James Nottingham sums it up well in his visual journey of the learning challenge. He uses the image of a pit to illustrate the obstacles that people encounter in learning something new, and how it takes them out of their comfort zone.

Learning pit

Source: Challenging Learning

Combining John Fisher’s Personal Transition Curve with this image of the learning journey can help us to understand how individuals might respond to change, and consider what might move people into acceptance and take up new behaviours.

In addition to understanding the challenges associated with learning something new, it is also important to consider what motivates people. Daniel Pink (author of Drive, which explores human motivation) argues that intrinsic reward, doing something because we find it gratifying, is as just as important as biological and extrinsic rewards.

Discovering the personal and relational, intrinsic and extrinsic motivations is essential to understand the reward we all need.

Breaking habits

Change is challenging, as habit is such a dominant force in our lives. However, understanding the reasons why we find it difficult to change, tapping into people’s curiosity and desire to learn, and understanding their motivations can help us to break away from old habits, and create new ones.


Sharing knowledge through podcasts

Paul and Calvin

by Laura Dobie, Knowledge and Information Skills Specialist

Dr Calvin Lightbody is a consultant in Emergency Medicine at NHS Lanarkshire, and he also produces the Talking Mortality podcast. He recently recorded an episode with our clinical lead for palliative and end of life care, Dr Paul Baughan, on supporting people with frailty in the community.

Everybody’s talking about podcasts…

Podcasts are becoming increasingly popular, and are available on a variety of platforms, which makes them very easy to access. They cover a wealth of subjects, and the format lends itself equally to presenting bite-sized chunks of information, to more in-depth exploration of a topic.

There is a podcast for everyone, whatever their interests or time commitment. This growing appetite for audio is also reflected in audiobook sales, which are growing as sales of print books are falling.

Getting into it

Calvin has 20 years of healthcare experience, and has recently been working to improve the care that hospital patients receive towards the end of life. He decided to give podcasting a try after putting a lot of time and effort into preparing and promoting a presentation at an event, which was not as well-attended as he had hoped. This prompted him to consider how he could reach more people, and he thought that podcasts could be the ideal medium.

Why podcasts?

Podcasts have numerous benefits. You can listen to them anywhere, at any time. They have multitasking potential: people can listen to them while doing other things, allowing them to take in information on their commute, while hanging up the washing, or cooking. They also cater to expectations for on-demand content: Calvin observed that people do not tend to watch live TV as much as they used to, and are increasingly shifting to streaming services to watch what they want, when they want.

Podcasts provide people with information and entertainment, in a format that fits around their busy lives. They also have considerable potential for learning and development: Calvin listens to a lot of medical podcasts that contribute to his CPD.

The Talking Mortality podcast

Talking Mortality explores the difficulties and challenges of human mortality. Individuals, society in general and health and care professionals all struggle with this issue. The podcast aims to start conversations on this topic. Previous episodes have covered areas such as dementia, palliative care, anticipatory care planning, and the death taboo.

DollarCalvin’s recording studio for the day was Dollar Health Centre, where Paul works as a GP. His set up is fairly minimal: a USB microphone plugged into laptop to record the audio, and headphones to check the sound. The podcast format is an intro from Calvin, an interview with his guest speaker, and a recap of key learning from the podcast at the end. This really reinforces potential of the podcast for sharing knowledge and getting it into practice.

The recording with Paul is seamless. Calvin records a brief intro to check the sound, then they go straight into a conversation, which is recorded in one take. Half an hour flies by, taking in the importance of identifying people with frailty, what GP practices can do to support people with frailty, and anticipatory care planning, amongst other topics.

After editing, Calvin adds the podcast to Buzzsprout, a podcast hosting site. You can listen to Paul’s episode now, and access all the earlier episodes.

Want to continue listening?

There is a wealth of health and social care podcasts within easy reach of your headphones. Here are a few to get you started:

  • MDTea podcast – A series of podcasts aimed at healthcare professionals working with older adults.
  • Nice Talks – Individual stories behind NICE’s work to improve care through evidence-based guidelines.
  • Iriss fm – Research, projects and events on topics related to social work and social care.
  • GEMCAST – A geriatric emergency medicine podcast aimed at clinicians, nurses, or paramedics who take care of older adults, particularly in the Emergency Department.

Do you listen to podcasts? What are your favourite podcasts that cover health and social care?

Meet Sarah O’Shaughnessy!

Sarah O'Shaughnessy

Sarah O’Shaughnessy, one of the project officers in our team, talks about her role and what she enjoys about the job. It’s all about the people!

I started working with the Living Well in Communities (LWiC) team at the end of July, having been project officer with the Mental Health Improvement Team in the six months before that. I have been working at Healthcare Improvement Scotland (HIS) for two and a half years.

The thing that I really enjoy about my job is working with people. Some of my favourite experiences since starting with the LWiC Team five months ago have been engaging with stakeholders. This might be in person or over the phone, discussing how they can put their skills together and achieve the goal of improving the lives of people in Scotland.

At the moment one of my main pieces of work if the Living and Dying Well with Frailty Collaborative. I am responsible for supporting my colleagues and the teams in the west. I am gradually getting to know the teams and really enjoy the opportunities I get to speak with team members more. From my point of view, the better I know the teams, the better I can support them. What I like to know is how people like to be communicated with? Do they prefer a phone call or an email, do they like reminders, do they use Twitter, how do they find using the Knowledge Hub? If you are one of the people in these teams, please feel free to get in touch and let me know how I can communicate with you more effectively!

I have recently started working with some of my colleagues on our anticipatory care planning (ACP) documentation. This has been quite a steep learning curve for me, but it has been fascinating. I am particularly enjoying seeing how ACP can be used to support work across Health and Social Care Partnerships, and we have had some invaluable feedback on how it is currently being used and how it could be used better in future.

While I am finding both projects interesting, the thing that I am really enjoying is the people. The passion and the knowledge of the people I work with, both within and outside of HIS, never ceases to amaze me. In the last few months I have learned so much because of people around me and the opportunities that I have been given.

My hope is that my learning will continue and that people will continue to let me engage with them. I would love to hear back from people about what interests them about the work they do, if you are someone I engage with, let me know how I can do this better too! If you are on Twitter my handle is @SarahOShaughne3 Feel free to follow me, especially if you like the occasional update on the Glasgow Warriors!

Mr Lucas’ Story

Dr Paul Baughan, our National Clinical Lead for Palliative and End of Life Care and GP in Dollar, tells us about Mr Lucas who appears in our new video below.

My first contact with Mr Lucas was sadly not a pleasant one.  It was Christmas Eve 2014 and he had travelled from Birmingham to spend time with his family. I was called when he suddenly took unwell, and I sent him to hospital for treatment of an evolving stroke.  Mr Lucas spent that Christmas in hospital.

Stroke disease is one of many conditions which contribute to ‘frailty’. People living with frailty have reduced resilience to illnesses such as infections, to injuries following falls, or to emotional stress such as following a loss or bereavement. This makes people living with frailty particularly vulnerable and at risk of unplanned admission to hospital.

However by identifying people living with frailty at an earlier stage through tools such as the eFI (electronic frailty index), it is possible to provide evidence-based interventions and support which can help them live independently at home. At the moment 21 teams across Scotland are taking part in the Living and Dying Well with Frailty Collaborative to improve the care provided to people with frailty. These teams are looking at how health and social care can work more closely together to support people as they become more frail.

By identifying people early, before a crisis, and putting in the right services and support, it is possible to help those with frailty to live a fulfilling life in their own homes.

Mr Lucas moved to live in Clackmannanshire following his stroke so that he could be closer to his family.  In this video Mr Lucas gives a clear account of how he is supported to enjoy the things that are important to him – his books and good music.  He describes how aids and equipment around his house have helped him, and the huge impact that professional carers make to his day to day life.  I first met Mr Lucas in difficult circumstances.  It was a delight to interview him for this video and to see how his life has changed and been enhanced through this vital support.


Living and Dying Well with Frailty Collaborative – Learning Session One

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On 19 September 2019, 21 teams  taking part in the Living and Dying Well with Frailty Collaborative came together for the first learning session where they learned how to test their ideas using a range of improvement methods, and how to measure their activities and the impact they make. They also heard from each other about the frailty work being undertaken in the various Health and Social Care Partnerships and GP practices, and had time as a team to look at their project charter and develop their plans for their next test of change during the learning session action period.

Living with Frailty

People are at the heart of what we do, so we started the day by hearing from those living with frailty. We heard about the experience of Mr Lucas, who featured in our video. He spoke about how the support that he receives from services and family helps him to live independently with frailty. Mr Lucas is one of Dr Paul Baughan’s patients, the Living Well in Communities (LWiC) National Clinical Lead for Palliative and End of Life Care and GP at Dollar Health Centre.


twitter-logo (2)“I hope I’m as able as Mr Lucas when I have moderate frailty. I love how it was the carers, reading and music that helped him live well with frailty.”


We also had Hugh Donaghy join us for the day. Mr Donaghy is a carer for his mother and spoke to Professor Graham Ellis, the LWiC National Clinical Lead for Older People and Frailty, about his experience of providing care to someone living with frailty. Hugh discussed how technology is helping him to support his mother in her home, the blurred line between being a carer and a relative, and the challenges of hospital stays: each time his mother comes out of hospital, her frailty increases.


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“Carer experience of mum with long term conditions going in to hospital ‘each time she comes home she’s that bit frailer’ – how can we build resilience when someone comes back home?”


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I want to be involved in the Frailty Collaborative because…

Alec Murray, Associate Improvement Advisor, led a short ice breaker with the teams using Slido to ask the teams how they felt about being involved in the collaborative, creating the word cloud below…

LS1 Word Cloud

It was great to see people and care at the centre.

Throughout the day there were a number of questions asked on Slido. We didn’t have the opportunity to respond to all of these on the day, so we’ve pulled together our answers in this form: Slido Questions and Answers

Learning about Improvement

The teams then had the opportunity to learn about Quality Improvement Methods and Measurement for Improvement, led by the Living Well in Communities Improvement Advisors and Associate Improvement Advisors (Nathan Devereux, Scott Purdie, Dianne Foster, Tom McCarthy and Michelle Church).

Quality Improvement Methods

When we designed this session we wanted to explore with the teams a range of Quality Improvement concepts and tools. We held an introductory WebEx where we polled the teams to find out how much knowledge and experience everyone had in using QI tools. The teams told us that there was a real mix of skills and experiences in the room, and the results indicated that we should spend a little bit more time on the change package. Therefore the session was designed to give everyone a flavour of some of the approaches that might help teams in the action period.

At the end of the session, the teams were asked for their lightbulb moments:

“Build on existing practice and evidence with data”


“Small steps to improvement are better than a leap of faith”


“Even failed attempts are learning and a critical part of improvement”


“Don’t reinvent the wheel – SHARE”


“In order to spread change, you need to explain to others why it’s important, how it works and have a narrative”


Measurement for Improvement

As this was the first session we aimed to get everyone on the same level, so that teams were prepared for the first action period. We covered some of the practical elements of measurement for this collaborative, including the data collection method.

The collaborative is focused on three core measures, which represent an increase in involving people in conversations about their needs and care, and also a shift to more planned activity.

In the session we introduced the measurement plan tool designed to help teams collect this data and also provided time for teams to consider what their measurement priorities are, including local priorities and measures which take account of interventions (such as polypharmacy).

It was great to discuss measurement of the collaborative at the first learning session and particularly to hear the views of teams about how best to approach what can be one of the trickiest parts of improvement – measuring whether you make a difference.

Learning from Across Scotland

We had 15 teams and national organisation representatives host tables where they presented on what work they have undertaken on frailty in their area. This was ‘world café’ style, where everyone had an opportunity to go to three tables and hear about work in other areas and ask questions.

There were some great discussions, and the feedback we received indicated this was a very popular session. It was beneficial for them to hear about what is happening in other areas and have the chance to discuss challenges faced, as well as successes.

For example, Rebecca McLaren and Eileen Downham from the Angus team presented work on their Enhanced Community Service and community multidisciplinary team (MDT) meetings. The challenge faced in Angus is that a person can be registered to any of eight GP practices because practice boundaries overlap. The group were particularly interested that a medicine for the elderly consultant from hospital attends the community MDT meetings.​ If a consultant can’t attend then an advanced nurse practitioner attends in their place.

North Lanarkshire HSCP has been working with hospital at home and 30 GP practices to test MDTs. They found the challenges were around data and how home visits can be recorded. Also whether it is possible to measure the quality of ACPs, and creating an infrastructure to support people wishing to stay at home.

For a full list of these topics please click here. For more information about anything which was discussed, please get in touch via email – – and we can put you in touch with the relevant team.

Team planning

Teams were then given time to work together on their project charter and action planning for the first action period of the collaborative.

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If you are undertaking similar improvement work you may find the below resources helpful:

National Change Package

Project Charter Template

RACI Action Plan


twitter-logo (2)“Fantastic reasons to be at #LWiCFrailty today. But “a goal without a plan is just a wish” so now time for action! Thanks for a useful day of sharing & learning @LWiC_QI @eFI_Midlothian”


What next?

Away teams will share their learning with the Home Teams and begin their tests of change, or continue with any tests already underway. They will be documenting their progress and recording data over time, with the support of the Improvement Advisors and Associate Improvement Advisors who are area leads for each of the teams.

For more information about the collaborative please visit

For the PowerPoint slides from the day from all sessions, please click here.

Welcoming 21 Teams on our Collaborative

Thomas Monaghan, our Portfolio Lead, announces the successful teams on our Living and Dying Well with Frailty Collaborative

We’ve got the key of the door, never been twenty-one before!

21!  What a magical number.

It was my age when I met my wife.  It’s the name of my favourite Adele album.  It’s the name of my favourite card game.

But 21 has a new meaning for me now as we now have 21 teams that are part of the Living and Dying Well with Frailty Collaborative.

21 teams from 19 Health and Social Care Partnerships (HSCP).

21 teams that include over 70 GP practices, but will grow over the next year to include even more practices.

21 teams from across Scotland working together to improve the outcomes for people with frailty who are living in our communities.

map with space 2HSCPs with teams in the collaborative:

Argyll and Bute
Clackmannanshire and Stirling
Dumfries and Galloway
East Dunbartonshire
East Renfrewshire
Glasgow City
North Ayrshire*
North Lanarkshire
Perth and Kinross*
South Ayrshire
South Lanarkshire
West Dunbartonshire
Western Isles

*indicates when there are two teams from the HSCP.

Living and Dying Well with Frailty Collaborative

Over the next year we will be working with the 21 teams to improve earlier identification, anticipatory care planning and shared decision-making, to ensure that people living with frailty get the support they need, at the right time, at the right place.

We will do this by helping teams to use tools, evidence and quality improvement methods to:

  • find people who are becoming frail before they reach crisis point using the eFrailty Index,
  • have anticipatory care planning conversations with people with frailty to understand their wishes for future care, and
  • work with a range of health, social care, third sector, independent sector and housing providers in local areas to support people with frailty to achieve what they want for their future.

We welcomed the 21 teams to the collaborative in August and our first Learning Session is in September. The Learning Session will be an opportunity for 21 teams to meet each other and share the work they have already done, learn improvement skills and come together as teams to plan their improvement projects.

The 21 teams have outlined excellent and innovative ideas for their local improvement and we can’t wait to work with them as they implement their ideas over the next year.

21 really is a magical number and together, we’ll change outcomes for people with frailty.

If you want to know more please visit our Living and Dying Well with Frailty webpages or follow us on Twitter. You can get in touch by emailing us at, calling us on 0131 314 1232 or tweeting us @LWiC_QI.

Frailty, palliative care and me

by Tim Warren, Policy Lead for Palliative and End of Life Care, Scottish Government

Tim's mumMy mum lives eight hours away, within earshot of Glastonbury (if only her hearing was a little better). Her frailty is a pressing reality. All of the issues which press in at work – frail older people, most with a host of health issues, increasingly lacking capacity, exhausted family carers, stretched paid carers, the role of GPs, district nurses; it all feels very personal.

As the policy lead for palliative and end of life care at the Scottish Government, I frequently have to answer questions about what I do. I usually begin with how ignorant I was when I took on this role, when I mistakenly thought palliative care was basically about hospices and cancer. Of course, I now appreciate that the lion’s share of palliative care is about supporting frail older people like my mum.

When does care become palliative?

So, good care, provided to people at any stage of their care pathway, becomes palliative with hindsight when the person dies. Specialist palliative care, provided in any setting is clearly ‘palliative’. From this perspective, good care, provided in care homes, or by informal carers, supported by district nurses and GPs, and encompassing the spiritual, social and psycho-emotional and the physical, is also ‘palliative care’.

The strategic framework for action on palliative and end of life care (SFA) starts with support for identifying people who stand to benefit from a holistic palliative approach, highlights the importance of conversations with those people (and those who care about and for them), and then aims to provide coordinated care across all settings.

So, who might benefit from a palliative approach?

At what point does support for people with long term conditions become early palliative care? I have come to think about this in two ways. Firstly, thanks to Kirsty Boyd, consultant in palliative care at Royal Infirmary of Edinburgh, I possess the mental metaphor of “umbrella conversations” – conversations to be carried on, not just when it’s raining, but when it might rain. Such conversations might be initiated with a question like, “If you were to get more unwell, what would it be important for us to know about”. Not having these sorts of conversations early, and recording them in a sharable way, can rob people of care and dignity at the end of life. And, although the National Digital Service will in due course enable such information sharing, at the moment the only available mechanism for reliable sharing across settings is the Key Information Summary.

Secondly, another way of looking at who might benefit is by employing “20:20 hindsight”, and reviewing the profiles and care pathways of those who have died over the most recent available year. In 2017 almost 58,000 people died. Around 16,000 of those died suddenly. Of the remainder around 20,000 died with dementia. This gives an additional significance to having those conversations early.

Why early conversations matter

As a policy team we get to see the letters people send to ministers about the care their loved ones receive. One haunts me. It recounts the last months of the writer’s father’s life, in which he experienced increasing frailty, repeated hospital admissions and disjointed care (along with some examples of kind, warm and compassionate staff). He underwent several operations, repeated burst stoma-bags, unmanaged pain and broken promises of ‘fast-tracked care’. The family said it had seemed like a dreadful rollercoaster, which could have been prevented had they just had a realistic conversation about his likely trajectory, and what mattered to him.

Although not all care pathways are like those of this man, all of those who died expectedly should have benefited from conversations about what mattered to them. Paul Baughan, a GP and the Healthcare Improvement Scotland clinical lead for palliative care, led the development of a new palliative care Directed Enhanced Service, to provide some financial support for identifying those who may be moving towards death. (We worked together on the diagram below). It aims to increase the proportion of those with a KIS at the end of life, but especially people with frailty, who have more often been overlooked.

Diagram of the Directed Enhanced Service

And it is brilliant to see a focus on ensuring that people in care homes get to benefit from this approach; the work in Edinburgh and Glasgow comes to mind. There is lots still to do, but the support of colleagues in primary care in doing this, and supporting them to do so feels like a key element in making sure that everyone gets the palliative care they need by 2021.