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Long term Conditions Annual Progress Report | 1

Long Term ConditionsCommon Problems, Shared Solutions

Annual Progress Report


IntroductionThe purpose of this report is to update North and South Lanarkshire Community Health Partnerships, NHS Lanarkshire’s Corporate Management Team, NHS Lanarkshire’s Board and the Long Term Conditions National Team on the activities and progress in relation to Long Term Conditions within NHS Lanarkshire.

In 2005 NHS Lanarkshire set out its strategy to manage the current and future challenges of people living with long term conditions. This strategy is consistent with a whole systems way of working and supports the principles within Delivering for Health (SEHD 2005) and Better Health, Better Care (SGHD 2007).

Over the past year the focus on long term conditions has increased. The formation of NHS Lanarkshire’s Long Term Conditions Action Team has facilitated the implementation of a comprehensive action plan with a number of objectives which cross reference with the national HEAT Targets and NHS Lanarkshire’s corporate objectives. How this programme of work links with the national HEAT targets and corporate objectives can be found in appendix I.

BackgroundThe World Health Organisation (WHO) defines long term conditions as health problems that require ongoing management over a period of years or decades. Long term conditions are not curable and last longer than twelve months (SEHD 2005). Some long term conditions are characterised by acute exacerbations of ill health resulting in repeated admissions to hospital.

Long term conditions include a very wide range of health conditions, ranging from a single condition to multiple and complex conditions which can be physical, mental, behavioural or emotional.

In February 2007 the Scottish Executive issued the Community Health Partnership (CHP) Long Term Conditions Self Assessment toolkit with guidance for completion. Each CHP was expected to complete the toolkit,

score themselves against pre determined organisational standards and develop an action plan to address any shortcomings. NHS Lanarkshire’s submission was a joint endeavour reflecting the ethos of whole systems working. A copy of NHS Lanarkshire’s completed tool kit and action plan can be found as appendix I.

The toolkit underlines the importance attached to the development of a generic approach to the management of long term conditions and provides the opportunity to address lesser common conditions.


ObjectivesIn line with NHS Lanarkshire’s self assessment toolkit, national HEAT Targets and Corporate Objectives, the objectives set by the Long Term Conditions Action Team for 2007 - 2008 were as follows:

1. Introduce Integrated Care Management within the Wishaw General Hospital catchment area and pilot sites to reduce emergency readmissions of the over 65 age group.

2. Implement Keep Well.

3. Develop Telehealth proposal & commence implementation programme.

4. Identify Self management subgroup of LTC action group to undertake mapping of current self - management resources and make recommendations.

Initial emphasis will be on self -management of COPD and Diabetes.

5. Align with and influence the condition specific clinical communities.

6. Develop and Implement Directory of Services.

7. Develop Communication Strategy for LTC Action Group.

8. Develop 3 year implementation plan based on LTC Strategy.

9. Create a training & development plan for LTCs and assign budget.

10. Produce LTC Annual Report.

11. Update LTC Tool kit every 4 months.

1 Integrated Care Management

Integrated Care Management within Lanarkshire focuses on people who have complex or rapidly changing needs by providing the most intensive care in the least intensive setting ensuring access to appropriate services when required.

This project officially commenced in September 2006. Although the processes got underway, patient assessment in relation to Integrated Care Management did not take place until January 2007.

Considering the nature of Integrated Care Management it was necessary to examine outcomes beyond the agreed pilot timescale to establish the longer term impact.

Three localities were selected to host pilots of the Integrated Care Management approach:

Coatbridge - selected due to high levels of deprivation

East Kilbride - selected due to an increasing older

population

Clydesdale - selected due to rural location

A full evaluation has been undertaken and a copy is available on request. Although not statistically significant preliminary data shows that compared with baseline information hospital stays for those admitted and included in Integrated Care Management have reduced slightly.

Anecdotal reports from patients, their families and professionals involved suggest that the quality of care has improved. Full qualitative analysis is included in the final report.


1.1 Roll-out of Integrated Care Management

❖ Roll out of integrated care management to Wishaw General catchment area is on target. Practices that refer patients

into Wishaw General have been notified and suitably experienced District Nurses have agreed to take on the role as

Care Managers.

❖ Negotiations are continuing with South Lanarkshire Council regarding joint care management training however North Lanarkshire Council have given their full support with a training programme being developed specifically to facilitate Integrated Care Management. Other training requirements have been identified and secured with training ongoing over the next few months.

❖ Resource materials and documentation have been developed to support the care managers in their role. These resource materials and the general progress within Lanarkshire has generated a lot of interest from other NHS Boards. NHS Lanarkshire has been and continues to be delighted

to assist other NHS Boards by sharing our experience.

❖ The latest SPARRA data now includes systemwatch data which predicts risk of admission until January 2009. Due to recent issues with data protection the latest version has been encrypted. This has led to a slight delay however once the appropriate software has been activated this data will be issued to all localities to facilitate the Integrated Care Management process. The previous issue of SPARRA data was used successfully to inform Winter Planning strategies in

all localities.

❖ Local interdisciplinary/interagency knowledge sharing groups have

been convened.

2 Keep well

The Deputy Health Minister launched Keep Well (KW) in Lanarkshire on the 24 October 2006. Lanarkshire was the first area in Scotland to commence delivery of Keep Well, with screening starting in Coatbridge on 23 October 2006.

❖ NHS Lanarkshire has 29 practices signed up and delivering KW with a total eligible population of 28 547. The first cohorts of patients were invited to attend by letter.

❖ Coatbridge is predominantly delivering KW in practice premises during “office hours”. Eight practices are delivering KW. Four have used fixed appointment letters and the other four have used open letters. The overall uptake was 33.9%. Figures show the Did Not Attend (DNA) rate to be higher using fixed appointments, however the number of appointments made by patients who received open letters were around 20%.

❖ Airdrie is predominately using community venues and have screened both in “office hours” and out of hours. All patients were sent fixed appointments. North Lanarkshire Council Call Centre (NLCCC) supported the administration of changing appointments in four out of the eight practices. Their uptake using this model was 40.2%.

❖ Wishaw has used a combination of both practice and community venues during “office hours” and patients were invited using a fixed appointment letter. NLCCC was used to change appointments in

four of the thirteen practices. Their uptake was 48.5%

❖ Near patient screening is used to assess the CVD risk if a patient has of 20% or more as per SIGN guideline 97. If in a risk category, they are referred for

further investigations including a full lipid profile.


2.3 Screening Activity up to and including 27 Nov 2007

* Note: The interim evaluation report presents the data based on screening activity up until 17th September 2007.

❖ Total patients screened = 7664

❖ Total referrals to Counterweight = 836

❖ Total referrals to smoking cessation = 349

❖ Total referrals to exercise programme = 448

❖ Total referrals to alcohol team = 13

❖ Total referrals to the department of work and pensions = 21

❖ Total direct referrals to the GP = 92

❖ Total referrals to the P/N/ CDMN = 2982

KW have identified the low level of referrals to alcohol services and are addressing this through education of staff and more robust links with current services.

The evaluation has highlighted that there is an equal balance of male and female patients attending and that without using innovative approaches there is a slight tendency for the more affluent population groups to be over-represented. This tendency is not statistically significant but will continue to be monitored. The next phase of KW will focus on “Reaching the Hard to Reach” using a combination of Community Animators to carry out outreach work, including door knocking and NLCCC to call patients to re-appoint patients and remind patients about their appointment. Using this method will allow us to target our most deprived data zones which should resolve the imbalance of the over- representation of the more affluent population. Early anecdotal evidence has shown the uptake to clinics using the combined approach of phone calls and home visits has increased the attendance at clinics from around 40% to 75%. Because of the early success of this model it will now be implemented in all 3 areas. The model will be evaluated to ensure the intensive “reach strategy” is cost effective (Keep Well Team).

❖ In Coatbridge the Practice Nurse is assessing patients who have a CVD risk of 20% or more. Wishaw and Airdrie have appointed KW Chronic Disease Management Nurses who carry out this role. The differing models of delivery will be evaluated as the pilot progresses.

2.1 Progress to Date

The innovative practice being delivered by the Keep Well pilot sites is influenced and supported by the strategies set out in The Joint Health Improvement Plan, developed between North Lanarkshire Council and NHS Lanarkshire. In order to offer a holistic service, the KW pilot is actively linking patients into mainstream activities, such as education, recreational & leisure and the employability programmes.

2.2 Evaluation

Key to the ongoing development of anticipatory care is the evidence of improved outcomes for patients and the sustainability of the services being implemented. Data is being gathered on the patients seen and the outcomes of their KW screen. An interim evaluation has been produced on the implementation phase of KW.


3 Telehealth/Telecare: Supported Self Care

NHS Lanarkshire Respiratory MCN, in collaboration with the Scottish Centre for Telehealth, proposed to implement an alternative approach to the provision of services to patients with Chronic Obstructive Pulmonary Disease (COPD). A proposal was developed and submitted to the Scottish Government Health Directorates Telecare Department for this service development together with a funding request to support the initial period of programme implementation.

❖ £200,000 was awarded to NHS Lanarkshire to take this forward with the caveat that the development linked with Local Authorities and the project was subject to robust evaluation.

❖ A Project Board has been convened and project manager appointed.

❖ It is anticipated that this project will go live in August 2008.

4 Self Management

Self care is all that people do to maintain their health, prevent illness, seek treatment or support, manage symptoms of illness and side effects of treatment, accomplish recovery and rehabilitation and manage the impact of chronic illness and disability on their lives and independence. Self care is a very broad term for this wide range of activities that includes what is also often called self management (www.ascr.ac.uk/selfcare.htm).

In order to facilitate this process people must be fully engaged in their own health and the public health agenda.

People have a distinct role to play in their own healthcare by undertaking a number of strategies to treat minor illness and injuries, preventing disease and by actively managing long term conditions. The recognition of this is crucial to ensuring patient focused healthcare.

It must be acknowledged that most of healthcare is actually delivered by the patient and their family. There is sufficient evidence to support a range of self management interventions with the concept being threaded throughout the Department of Health’s Health and Social Care long term conditions model.

These interventions include:

❖ Self management education

❖ Self monitoring of condition

❖ Self help/support groups

❖ Having access to personal medical Information

❖ The use of Telehealth

NHS Lanarkshire has for many years worked closely with a number of voluntary agencies to provide the necessary support in order to optimise self management of a number of long term conditions. This can range from local support groups to structured education programmes involving patients and their carers It is our intention to strengthen these partnerships and continue with this example of good practice.

❖ The Long term Conditions Action Team has approved a proposal from the

Diabetes MCN to implement two programmes to support self management: DAFNE (Dose Adjustment for Normal Eating) and X-pert (structured group education for people living with Type 2 diabetes). Both programmes will provide participants

with the opportunity to study the implications of living with their long-term condition and preparing for the associated lifestyle changes. However, by building in links to various activities and programmes in their local communities (related to exercise, food provision, community regeneration etc.) it becomes


much more likely that they will action and sustain the necessary changes. This initiative will reach over 5000 people with diabetes. The evaluation will include comment on the applicability of the findings across other long-term conditions, where possible. This proposal links closely with a similar initiative for COPD self-management.

❖ The COPD programme, supported by literature developed by the British Lung Foundation and Chest Heart and Stroke Scotland, aims to provide the necessary confidence, knowledge and skills to patients with COPD enabling them to manage their disease on a daily basis. The introduction of this programme will facilitate potential benefits both to patients and the service. Evidence obtained from other disease specific self-management programmes identify a range of positive outcomes ranging from improved patient autonomy, increased quality of life, positive behavioural change, reduced/rapid management of exacerbations, better utilisation of healthcare services across primary and secondary care including reductions in hospital admissions and length of stay. As COPD is a progressive disease, which often deteriorates significantly with every exacerbation, it is of vital importance to patients and the healthcare system to promote the better day-to-day management of the condition. It will run in conjunction with a structured programme of pulmonary rehabilitation for patients with moderate or severe categories of disease, delivered in a locality setting by a multi-disciplinary team. A modified programme will also be available to those with mild disease and be delivered by practices in partnership with local authority leisure services.

❖ Although at the very early stages of implementation, the NHS Lanarkshire Telehealth/telecare project will complement the above programme by offering patients and carers an

interactive method of symptom surveillance prompting appropriate action when required by the most appropriate healthcare individual. Full training will be offered to those who take part in this initiative.

❖ Chronic pain self management groups have been provided throughout Lanarkshire for over 10 years by Pain Association Scotland. These groups are professionally led and offer structured training to people to facilitate coping with chronic pain and its impact. Group members are invited to attend the ‘Living with Pain’ programme. This is a fully validated seven week programme (one day per week) based on biopsychosocial principles to maximize the quality of life for both the person with pain and their families. With the redesign of the Chronic Pain Service within NHS Lanarkshire this arrangement will continue as an integral part of the patient pathway.

A subgroup of LTC Action team will be convened to consider the National Strategy for Self Management and how this can be applied to NHS Lanarkshire. Draft Terms of Reference have been prepared for approval.

5 Clinical Groupings

Whole systems clinical models provide the whole spectrum of care for patients with specific types of disease and are underpinned by disease specific pathways/algorithms and evidence-based practice to improve clinical outcomes. A clinical model defines the overall approach to prevention, assessment, diagnosis, treatment, rehabilitation, and management of long-term conditions through to palliative care. It is based on need/demand and provides optimised clinical outcomes for patients regardless of where the service is provided. It describes what should happen, which is the essential step prior to description of ‘Service Provision’


❖ The Long Term Conditions Action Team is working with the clinical communities and Managed Clinical Networks (MCNs) to ensure LTC’s are integral to the emerging clinical models and that the models specifically address issues in the LTC Strategy. This is linked to the Boards ‘A Picture of Health’ and through this process all specialties and disease specific groups are currently under review.

6 Directory of Services

❖ There was a recognised need and subsequent request from a number of areas to develop a Directory of Services (DoS) concept for NHSL. This would be available via the web initially for GPs and relevant community staff and would roll out to Secondary care once there had been a “proof of concept” and good roadtesting in primary care.

❖ The DoS would need to be maintained in a robust fashion and this would require the creation of a dedicated resource (at a level yet to be determined) that would sit in primary care to begin with. This resource and function would migrate towards the Emergency Response Centre in due course.

❖ There is a clear desire to ensure that the DoS is resilient and meet the needs of a range of services with NHS Lanarkshire.

❖ It was agreed that there would be a need to commence gathering the DoS information to populate the Directory. Dr Vijay Sonthalia has developed a template for this and will continue to

work with Information Services to develop the project plan

❖ Consideration will be given to provide a specific level of access for patients, carers and members of the public.

7 Communication Strategy

❖ The Long Conditions Action Team acknowledge the range and sheer volume of people and organisations involved in the long communications arena. Every effort has been made to ensure the most effective routes of communication. Work

in progress.

8 3 year implementation plan

❖ The Board has already committed to £3M investment in community nursing over the next few years which is anticipated will go a considerable way to addressing the LTC agenda. The 3 year implementation plan is currently being considered with development of the plan commencing shortly. Work in Progress.

9 Training & Development plan

❖ Whilst acknowledging the various levels of existing knowledge and specialist practice it is evident that practitioners within the generalist arena require access to information on numerous clinical conditions generated from the latest research evidence in order to maintain best practice and support the shift in focus of care to within the community.

❖ To support this transition and in an attempt to address some of the more immediate requests for training, a series of clinical knowledge update sessions is currently being offered to practitioners utilising all available resources. In the first instance this programme is being offered to Nurses and AHPs within Primary and Secondary care.

❖ Linking with the Practice Development Centre, a project board has been convened and includes all relevant stakeholders to oversee the development, implementation and evaluation of the Clinical Knowledge Update Programme.


❖ Based on current intelligence, the outcome of a focus group, clinical activities and developments within NHS Lanarkshire

the following clinical conditions have been proposed for inclusion within the

planned programme:

• Asthma

• COPD

• Heart Failure

• Dementia

• Neurological Conditions

❖ The principles of the proactive management of long term conditions are inherent in each session.

❖ The overall aim of the clinical knowledge programme is to enable health professionals with previous clinical experience to maintain up to date evidence based practice and

• to provide practitioners an opportunity to access the latest clinical research evidence within specified conditions,

• to improve and update knowledge to meet the requirements of the knowledge and skills framework,

• to share and enhance best practice,

• to increase awareness of the contribution made by

multidisciplinary team members,

• to increase awareness of the contribution made by patients and their carers in the management of their own condition.

❖ The LTC Action Team has set up a subgroup to consider the overall training and development requirements in relation to long term conditions and links to workforce /workload planning to ensure a competent, capable and confident workforce.

9.1 Aims and Objectives of Sub Group

The LTC Learning and Development group will act as a sub group of the LTC Action Team and carry out the following functions:

❖ Map out current learning and development activity in relation to LTCs.

❖ Identify current gaps in learning and development activity for LTCs.

❖ Scope out and prioritise future learning and development needs.

❖ Provide a structure within which new learning and development initiatives can be considered and delivery coordinated.

❖ Prepare learning and development plan in line with long term conditions strategy and self assessment toolkit.

❖ Identify specific budget to support learning and development plan.

❖ Provide the LTC Action Team an overview of learning and development activity.

❖ Provide the LTC Action Team linkage to learning and development initiatives.

❖ Advise the LTC Action Team on local and national developments or issues.

10 Annual Report

In line with the commitment made within the Long Term Conditions Self Assessment toolkit this document will be submitted as evidence of the progress made within NHS Lanarkshire.

11 Update tool kit

It was acknowledged that the SGHD self assessment toolkit was and continues to be a working document subject to version control. The most up to date version has been reissued on a quarterly basis indicating progress. This allowed progress to be identified and the outcome score recalculated.


12 Miscellaneous

The Long Term Conditions Action Team has responded to a number of enquiries from other sources.

❖ Following a number of enquiries to NHS lanarkshire regarding nursing support for people with Neurological conditions, a brief overview was requested.

❖ The overall aim of this piece of work was to establish the current level of specialist nursing support for people with Neurological conditions within the Primary Care Division of NHS Lanarkshire.

❖ The approach taken was to establish the number of nurses, their area of specialty, services and support offered, highlight examples of best practice and highlight any particular challenges/barriers to providing best practice. The following conditions were been included within this report although it must be acknowledged that this does not address the full list of conditions included under the specialty

of neurology:

• Multiple Sclerosis

• Epilepsy

• Parkinson’s Disease

• Motor Neurone Disease

• Huntington’s Disease

❖ This piece of work has influenced the more general review of Neurology

Services currently underway which included an event to explore and map

the patient’s journey through current services. A larger stakeholder event is planned for later this year.

❖ A copy of the Neurological Nursing services report is available on request.

Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME) ❖ With the recent publication of the Health

Technology Assessment on the treatment and management of Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME) and subsequent NICE clinical guideline number 53, Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (or encephalopathy): diagnosis and management of CFS/ME in adults and children in August, an opportunity existed to consider how this evidence could be applied within NHS Lanarkshire to aid diagnosis and management.

❖ Considering current thinking and emphasis on the management of long term conditions and the diverse range of symptoms associated with this condition an opportunity exists to add to the evidence base for the management of this condition whilst improving quality of life.

❖ Therefore while the review of NHS Lanarkshire’s Neurological Service continues and the debate into the cause and treatment of CFS/ME is ongoing, the CMT were asked to consider the evidence and the following:

• To support and fund a number of Master Classes aimed at GPs and Primary Care staff to increase awareness and knowledge of this condition to assist diagnosis and management, with the ultimate view

of adopting a diagnostic protocol.

• To support and fund a time limited research project to identify the structure and content of a specialised self management programme for people with CFS/ME involving Lanarkshire residents and members of related voluntary organisations in the development and research process.


• A specialised programme could include areas such as the management of fatigue, managing activity and periods of rest, sleep patterns, diet, etc, based on individual needs. This could be enhanced with the use of a CFS/ME personal symptom management plan.

• A draft version of the tender document has been issued to a small group for comment with the overall project on target.

Chronic Pain Management Recently, NHS Quality Improvement Scotland published “Getting to GRIPS with Chronic Pain in Scotland” (NHS QIS 2007). This report has been described as the most comprehensive stocktake of chronic pain services ever produced and highlights many deficiencies.

The Cabinet Secretary for Health and Wellbeing announced recently that she wants chronic pain to be recognised as a long term condition and expects NHS Boards to implement the recommendations made within the report.

For the past year NHS Lanarkshire has been developing and taking forward plans to completely redesign chronic pain services. The new service which was launched on 1st May 2008 involves a two phased approach incorporating the principles of whole systems working.

Phase one addresses the supporting infrastructure within secondary care services. A new Lead Consultant, Dr Sabu James, has been appointed as has a Chronic Pain Support Nurse. Clinical sessions are also being provided by the Nurse Consultant for Long Term Conditions. Job descriptions for a specialist chronic pain physiotherapist and clinical psychologist are currently with agenda for change for approval.

To complement this service and support phase two implementation, the shift to Primary Care, funding for a chronic pain training programme was secured with the programme now underway. Six GPs and a number of Practice and Community Nurses have enrolled in this year long programme aimed at improving knowledge, practice and services for people with chronic pain in Lanarkshire.

Long Term Conditions Collaborative ProgrammeIn April this year the National Long Term Conditions Collaborative was launched. The overall aim of the Long Term Conditions Collaborative Programme is to improve the quality and range of care and experience for patients in particular allowing patients to manage their conditions more effectively. The resulting goal is to improve health outcomes for these patients, reduce their requirements to use secondary care services and as a by product reduce unnecessary demands on acute services so optimising the use of resources. Reflecting upon what has already been achieved within NHS Lanarkshire over the past year it is clear that opportunity for direct synergy exists within this initiative.

Programme Objectives

❖ Improve the management of care in

the community

❖ Shift the balance of care where appropriate from hospital to community led service

❖ Optimise quality of life for patients, carers and families

❖ Reduce preventable hospital admissions and length of stay

❖ Increase concordance of medicine regimes


❖ Increase the involvement and influence of patients in the decision

making process

❖ Generate empowerment and ownership of their condition

❖ Develop informed and supported unpaid carers

❖ Ensure efficient and effective delivery of care

❖ Improve communication and seamless care

❖ Improved local access to quality services

NHS Lanarkshire’s Long Term Conditions Collaborative Programme (LTCCP) will support the delivery of Better Health, Better Care and delivery of HEAT targets, and will be part of the strategy for development of continuous quality improvement across NHSScotland. It will also support a smooth transition from the action plan generated from the self assessment tool kit to more tangible person-centred outcomes.

The LTCCP is an essential component of the national strategy to ensure an integrated approach to the delivery of service improvement programmes that also includes 18 Weeks Referral to Treatment Time (RTT) and Mental Health Collaborative Programme. In addition, it links with the Scottish Patient Safety Programme, the Patient Experience Programme (Better Together), Rehabilitation Framework, Audit Scotland Report LTC (2007), and the emerging Performance Support Programme for Efficiency and Productivity.

NHS Lanarkshire has developed an infrastructure that supports a whole system approach to modernisation and continuous service improvement. A Modernisation Board is supported by Service Improvement Boards (SIB) as outlined:

❖ Health Improvement SIB

❖ Primary, Community and Acute SIB

❖ Maternity and Children Services SIB

❖ Learning Disability SIB

❖ Mental Health SIB

❖ Older People SIB

❖ Regional Planning SIB

The Long Term Conditions Collaborative Programme and 18 Week RTT Programme link directly to the Primary, Community and Acute Service Improvement Board (PCASIB). NHS Lanarkshire will establish an Emergency Access Programme Board that will ensure an integrated approach to the emergency element of the Long Term Conditions Collaborative, 18 Weeks RTT, and the transition of the Unscheduled Care Collaborative Programme. The Executive Sponsor, Alan Lawrie, Director of South Lanarkshire CHP, will also chair the Emergency Access Programme Board.


ConclusionReflecting upon activity described within this update it is clear that the Long Term Conditions Action Team are progressing and supporting implementation of NHS Lanarkshire’s Long Term Conditions Strategy.

The activity within NHS Lanarkshire has generated a lot of interest from other NHS Boards and other organisations. An abstract of activity was submitted to the European Nurse Researchers Committee. As a result of this submission NHS Lanarkshire has been invited to hold a dedicated symposium at the 13th European Nurse Researchers Conference in Vienna later this year.

To deliver the commitment made to the Long Term Conditions Reference Group the LTC Action team will hold a seminar to showcase achievements and progress made within the Long Term Conditions Strategy. This event will take place in the early autumn.

Over the coming years NHS Lanarkshire will continue its commitment to the Long Term Conditions agenda, the Long Term Conditions Collaborative and associated workstreams.

ReferencesBetter Health, Better Care (2007)Scottish Government Health DirectorateEdinburgh

Bagnall AM., Hempel S., Chambers D., Orton V., Forbes C (2007)The treatment and management of chronic fatigue syndrome (CFS)/Myalgic encephalomyelitis(ME) in adults and children.Centre for Reviews and DisseminationUniversity of York

Delivering for Health (2005)Scottish Executive Health DepartmentEdinburgh

Getting to GRIPS with Chronic Pain in Scotland (2007)NHS Quality Improvement ScotlandEdinburgh

National Institute for Clinical Evidence (2007)Chronic Fatigue syndrome/Myalgic Encephalomyelitis (or encephalopathy):Diagnosis and Management of CFS/ME in Children and AdultsNICELondon

AcknowledgementsThe Long Term Conditions Action Team would like to thank all those individuals and organisations involved for all their hard work over the past year and their continuing support. We look forward to making even more progress over this year.


Long Term ConditionsAction Plan

CHP’s: Lanarkshire

Executive Lead: Alan Lawrie

Lead Clinician: Anne Armstrong

Manager: Alan Lawrie

Date Completed: 23rd July 2007

Version 5.0: Last updated 31st March 2008


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nsur

e LT

C’s

are

inte

gral

to

the

emer

ging

clin

ical

mod

els

and

they

LT

C 1

.6

C

om

mun

ity

sp

ecifi

cally

add

ress

issu

es in

the

LTC

Str

ateg

y. T

his

is li

nked

to

the

LT

C 3

.5

g

roup

s co

nti

nue

Bo

ards

‘A P

ictu

re o

f H

ealt

h’ a

nd t

hrou

gh t

his

pro

cess

all

spec

ialti

es

to d

evel

op

th

e

and

dise

ase

spec

ific

grou

ps

are

curr

ently

und

er r

evie

w

clin

ical

mo

del

s

w

ith

th

e fi

rst

b

atch

of

mo

del

s

curr

entl

y b

ein

g

revi

ewed

by

the

LT

C A

ctio

n T

eam

6.

Dev

elop

and

Imp

lem

ent

serv

ices

dire

ctor

y LT

C 1

.6

VJ S

onth

alia

A

ugus

t 07

M

arch

08

On

go

ing

LTC

2.1

&

LTC

2.4

A

Hen

dry

LTC

2.7

7.

Dev

elop

Com

mun

icat

ion

Stra

tegy

for

LTC

Act

ion

Gro

up

LTC

1.5

J B

arrie

A

ugus

t 07

O

ctob

er 0

7 O

ng

oin

g

LT

C 2

.1

&

LT

C 2

.2

Cal

vin

Brow

n

LT

C 2

.3

LT

C 2

.5

LT

C 6

.10

8.

Dev

elop

3 y

ear

imp

lem

enta

tion

pla

n ba

sed

on L

TC s

trat

egy.

LTC

Act

ion

Team

Ju

ne 0

7 Se

pte

mbe

r 07

O

ng

oin

g

The

Boar

d ha

s al

read

y co

mm

itted

to

£3M

inve

stm

ent

in c

omm

unity

nurs

ing

over

the

nex

t fe

w y

ears

whi

ch is

ant

icip

ated

will

go

a

co

nsid

erab

le w

ay t

o ad

dres

sing

the

LTC

age

nda


O

bje

ctiv

e H

EAT

Targ

ets/

R

esp

on

sib

le

Init

iate

d

Co

mp

lete

by

Stat

us

LT

C S

tan

dar

d

9.

Cre

ate

a tr

aini

ng &

dev

elop

men

t p

lan

for

LTC

s an

d as

sign

bud

get

LTC

4.1

M

Cer

inus

Ju

ne 0

7 D

ecem

ber

07

The

firs

t

Spec

ific

task

s:

LTC

4.2

mee

tin

g o

f th

e

•

Set

up

LTC

tra

inin

g &

dev

elop

men

t su

bgro

up

LTC

4.3

Lear

nin

g a

nd

• L

ink

with

Pra

ctic

e D

evel

opm

ent

boar

d LT

C 4

.4

D

evel

op

men

t

•

Lin

k w

ith W

orkf

orce

/wor

kloa

d p

lann

ing

take

pla

ce o

n

5th

May

08

10.

Prod

uce

LTC

ann

ual r

epor

t us

ing

self

asse

ssm

ent

tool

kit

LTC

6.7

A

Arm

stro

ng

Ap

ril 0

7 A

pril

08

Pub

licat

ion

cos

ts

LT

C 6

.8

Fi

rst

dra

ft

LT

C 6

.10

su

bm

itte

d

11.

Revi

ew, r

efine

and

up

date

act

ions

in s

elf a

sses

smen

t to

ol k

it to

ens

ure

LTC

Act

ion

Team

A

ugus

t 07

O

ctob

er 0

7 Se

lf a

sses

smen

t

clar

ity a

nd c

omp

rehe

nsiv

e co

ver

of a

ll el

emen

ts.

too

lkit

up

dat

ed

on

a q

uart

erly

b

asis


Stan

dar

d 1

- O

rgan

isat

ion

of

Lon

g t

erm

Co

nd

itio

ns

Man

agem

ent

O

bje

ctiv

e Ev

iden

ce

Cur

ren

t

Act

ion

R

esp

on

sib

le

Tim

esca

le

Val

ue

Pe

rso

n/L

ead

1.1

The

Com

mun

ity H

ealth

Pa

rtne

rshi

p h

as a

des

igna

ted

clin

ical

lead

for

long

ter

m

cond

ition

s m

anag

emen

t.

The

long

ter

m c

ondi

tions

cl

inic

al le

ad is

a m

embe

r of

th

e C

HP

com

mitt

ee o

r cl

inic

al e

xecu

tive.

The

clin

ical

lead

has

sen

ior

man

ager

ial s

upp

ort

and

the

CH

P ha

s a

mul

tidis

cip

linar

y Lo

ng T

erm

Con

ditio

ns A

ctio

n Te

am t

o op

erat

iona

lise

agre

ed a

ctio

ns.

The

CH

P, t

hrou

gh t

he L

ong

Term

Con

ditio

ns A

ctio

n Te

am, e

ngag

es w

ith t

he lo

cal

Man

aged

Clin

ical

/Car

e N

etw

orks

whi

ch r

elat

e to

a

spec

ific

long

ter

m c

ondi

tion.

Ann

e A

rmst

rong

Nur

se D

irect

or

Com

mun

ity &

Prim

ary

Car

e ha

s a

lead

re

spon

sibi

lity

and

is s

upp

orte

d by

a N

urse

C

onsu

ltant

Lon

g Te

rm C

ondi

tions

/GP

Lead

for

Long

Ter

m C

ondi

tions

.

The

Nur

se D

irect

or C

omm

unity

&

Prim

ary

Car

e is

a m

embe

r of

the

CH

P C

omm

ittee

and

the

Join

t C

HP

Stra

tegi

c Im

ple

men

tatio

n G

roup

.

Long

Ter

m C

ondi

tions

Act

ion

Team

form

s p

art

of t

he P

rimar

y C

are

Mod

erni

satio

n Pr

ogra

mm

e Bo

ard

deliv

erab

les.

Wor

king

G

roup

s ha

ve b

een

esta

blis

hed

to p

ilot

spec

ific

elem

ents

of t

he s

trat

egy

such

as

Car

e M

anag

emen

t, K

eep

wel

l, w

ith s

ub

grou

ps

for

Sup

por

ted

self

care

, edu

catio

n &

tra

inin

g to

follo

w.

The

MC

N m

anag

ers/

clin

ical

lead

s w

ill

be k

ey m

embe

rs o

f the

Lon

g Te

rm

Con

ditio

ns A

ctio

n Te

am.

1.2

1.3

1.4

3 3 3 3

No

furt

her

actio

n re

qui

red

No

furt

her

actio

n re

qui

red

Long

Ter

m C

ondi

tion

Act

ion

Team

to

rep

ort

into

the

Pr

imar

y C

are

Mod

erni

satio

n Pr

ogra

mm

e Bo

ard.

Thi

s w

ill

req

uire

the

est

ablis

hmen

t of

a

dedi

cate

d LT

C P

rogr

amm

e M

anag

emen

t re

sour

ces.

The

Man

aged

Clin

ical

N

etw

orks

will

feed

dis

ease

sp

ecifi

c ac

tion

pla

ns in

to

LTC

Act

ion

team

. The

LTC

A

ctio

n te

am t

o ex

plo

re h

ow

serv

ices

will

be

prio

ritis

ed

and

deliv

ered

and

con

side

r p

roce

sses

for

the

LTC

’s w

here

M

CN

’s d

o no

t ex

ist

- i.e

. Rh

eum

atoi

d A

rthr

itis.

Ala

n La

wrie

Ala

n La

wrie

Ala

n La

wrie

Ann

e A

rmst

rong

Ach

ieve

d

Ach

ieve

d

Ach

ieve

d

Ach

ieve

d -

how

ever

p

rogr

ess

cont

inue

s

Appendix I


O

bje

ctiv

e Ev

iden

ce

Cur

ren

t

Act

ion

R

esp

on

sib

le

Tim

esca

le

Val

ue

Pe

rso

n/L

ead

1.6

3

The

CH

P’s,

thr

ough

the

Lo

ng T

erm

Con

ditio

ns

Act

ion

Team

, has

cle

ar li

nks

with

old

er p

eop

le’s

and

in

tegr

ated

chi

ldre

n’s

serv

ices

.

The

CH

P ha

s sh

ared

ob

ject

ives

for

long

ter

m

cond

ition

s w

ith a

cute

ho

spita

ls t

o de

liver

a r

ange

of

inte

grat

ed s

ervi

ces

whi

ch

shift

the

bal

ance

of c

are

to

com

mun

ity s

ettin

gs.

The

CH

P en

gage

s w

ith

com

mun

ity p

lann

ing

par

tner

s an

d w

ith p

atie

nt

rep

rese

ntat

ives

, vol

unta

ry

sect

or, c

arer

s or

gani

satio

ns

and

rep

rese

ntat

ives

of

cultu

ral a

nd r

elig

ious

or

gani

satio

ns in

pla

nnin

g an

d de

velo

pin

g se

rvic

es fo

r lo

ng t

erm

con

ditio

ns.

This

is a

chie

ved

thro

ugh

the

mod

erni

satio

n st

ruct

ure,

whi

ch in

clud

es

cros

s m

embe

rshi

p o

f the

Prim

ary

Car

e M

oder

nisa

tion

Prog

ram

me

Boar

d an

d th

e O

lder

Peo

ple

s Pr

ogra

mm

e Bo

ard.

Fur

ther

w

ork

is r

equi

red

in r

elat

ion

to in

tegr

ated

ch

ildre

n’s

serv

ices

.

A r

ange

of c

linic

al c

omm

uniti

es is

bei

ng

esta

blis

hed

to e

nsur

e a

who

le s

yste

m

app

roac

h to

clin

ical

and

ser

vice

mod

els.

Th

roug

h th

e LT

C a

nd P

rimar

y C

are

Stra

tegy

and

cur

rent

ly t

hrou

gh t

he

Uns

ched

uled

Car

e.

Org

anis

atio

nally

we

are

com

mitt

ed t

o as

sess

ing

serv

ice/

stra

tegy

dev

elop

men

t th

roug

h th

e Eq

ualit

y D

iver

sity

Imp

act

Ass

essm

ent

pro

cess

. Pa

rtne

rshi

p

com

mitm

ent

exis

ts w

ith o

ngoi

ng

enga

gem

ent

at a

loca

lity

leve

l thr

ough

the

H

ealth

& C

are

Part

ners

hip

s, Jo

int

Futu

re,

and

Publ

ic P

artn

ersh

ip F

orum

s in

bot

h C

HP’

s.

Nor

th L

anar

kshi

re C

arer

s to

geth

er

has

rep

rese

ntat

ives

on

the

Hea

lth &

C

are

Part

ners

hip

s an

d th

e fo

ur N

orth

La

nark

shire

Par

tner

ship

Boa

rds,

Nor

th

Lana

rksh

ire P

ublic

Par

tner

ship

foru

m

Refe

renc

e gr

oup

.

1.7

3

1.5

3En

sure

com

mun

icat

ion

is c

ross

cut

ting

and

links

ar

e m

ade

betw

een

LTC

/O

lder

Peo

ple

/Chi

ldre

n’s

serv

ices

and

men

tal h

ealth

an

d Le

arni

ng D

isab

ility

p

rogr

amm

es.

Agr

ee t

he o

bjec

tives

and

set

p

riorit

ies

and

timef

ram

es v

ia

the

Long

Ter

m C

ondi

tions

A

ctio

n Te

am g

aini

ng

endo

rsem

ent

via

the

Prim

ary

Car

e M

oder

nisa

tion

Prog

ram

me

Boar

d.

Firs

tly a

udit

wha

t w

e cu

rren

tly d

o an

d p

rovi

de

evid

ence

on

stat

us o

f p

rogr

ess

for

this

wor

k.

Con

tinue

with

and

furt

her

deve

lop

cur

rent

ap

pro

ach

at a

ll le

vels

. Foc

us w

ork

on

‘Har

d to

Rea

ch’ g

roup

s an

d co

mm

uniti

es.

The

use

of r

ole

desc

riptio

ns w

ill e

nsur

e ex

plic

it re

spon

sibi

litie

s

Ann

e A

rmst

rong

Step

hen

Kerr

Ach

ieve

d

May

200

7

TBC


O

bje

ctiv

e Ev

iden

ce

Cur

ren

t

Act

ion

R

esp

on

sib

le

Tim

esca

le

Val

ue

Pe

rso

n/L

ead

1.8

1Th

e C

HP

max

imis

es t

he

effe

ctiv

e us

e of

pre

mis

es

whi

ch a

re fi

t fo

r p

urp

ose

in

the

deliv

ery

of lo

ng t

erm

co

nditi

ons

man

agem

ent,

e

g th

roug

h co

-loca

tion,

di

sabi

lity

acce

ss.

Whe

re o

pp

ortu

nitie

s cu

rren

tly e

xist

to

co-lo

cate

and

inte

grat

ed w

e p

rovi

de e

.g.

cons

ulta

nt o

utre

ach

clin

ics,

phy

siot

hera

py

serv

ices

and

co-

loca

tion

with

Inte

grat

ed

Day

Car

e Se

rvic

es.

As

clin

ical

mod

els

are

deve

lop

ed in

all

clin

ical

dev

elop

men

t gr

oup

s th

e se

rvic

e m

odel

ling

will

be

imp

lem

ente

d. A

ll of

the

ca

pita

l dev

elop

men

t p

rogr

amm

es h

ave

the

faci

litie

s in

corp

orat

ed t

o fa

cilit

ate

mor

e in

tegr

ated

wor

king

, out

reac

h m

odel

s of

car

e an

d m

ulti-

disc

iplin

ary

app

roac

h to

the

del

iver

y of

car

e. W

ork

has

com

men

ced

in d

evel

opin

g th

e se

rvic

e m

odel

s fo

r th

e p

lann

ed c

apita

l de

velo

pm

ents

.

Imp

lem

ent

the

orga

nisa

tions

lo

ng t

erm

con

ditio

ns

stra

tegy

ens

urin

g th

at

all f

utur

e p

rem

ises

are

de

velo

ped

to

mee

t re

qui

rem

ents

.

This

has

bee

n fa

ctor

ed

into

the

des

ign

of b

oth

of

the

build

ing

and

of t

he

serv

ice

mod

ellin

g w

ith m

ore

inte

grat

ion,

mor

e w

hole

sy

stem

s w

orki

ng w

hich

will

be

driv

en t

hrou

gh s

ome

on t

he e

xist

ing

grou

ps

ie

Clin

ical

Ser

vice

Gro

ups

and

Prog

ram

me

Boar

ds.

A p

roce

ss w

ill s

et o

ut fo

r m

atch

ing

up o

pp

ortu

nitie

s to

mee

t St

rate

gic

Obj

ectiv

es o

f ser

vice

s cl

oser

to

hom

e w

ith t

he

imp

lem

enta

tion

of t

he L

TC

Stra

tegy

. Thi

s w

ill in

clud

e a

clea

r un

ders

tand

ing

of h

ow

com

mun

ity p

rem

ises

will

id

entif

y ac

tual

hea

droo

m fo

r de

velo

pm

ents

tha

t sh

ift t

he

bala

nce

of c

are,

incl

udin

g th

e ne

ed fo

r fa

cilit

ies

that

ar

e fit

for

pur

pos

e of

mul

ti di

scip

linar

y w

orki

ng.

Cur

rent

ly o

n ho

ld

Robe

rt P

eat

Prop

erty

Ser

vice

s/C

apita

l Pla

nnin

g

Robe

rt P

eat

Ong

oing

Stan

dar

d 1

: Cur

ren

t V

alue

s su

b t

ota

l: 22


Stan

dar

d 2

- P

atie

nt

info

rmat

ion

an

d S

upp

ort

ed S

elf

Car

e

O

bje

ctiv

e Ev

iden

ce

Cur

ren

t

Act

ion

R

esp

on

sib

le

Tim

esca

le

Val

ue

Pe

rso

n

2.1

2A

n id

entifi

ed m

embe

r of

the

C

HP

long

ter

m c

ondi

tions

ac

tion

team

is r

esp

onsi

ble

for

upda

ting

and

dist

ribut

ing

info

rmat

ion

reso

urce

s of

hig

h st

anda

rd a

nd e

vide

nce-

base

d ab

out

long

ter

m c

ondi

tions

, ad

ding

loca

l inf

orm

atio

n as

ne

cess

ary,

whi

ch is

eas

ily

acce

ssib

le t

o al

l.

The

CH

P fo

llow

s th

e C

arer

In

form

atio

n St

rate

gy w

hich

ha

s be

en d

evel

oped

by

the

Boar

d an

d its

par

tner

ag

enci

es.

The

MC

N H

ealth

Imp

rove

men

t gr

oup

co

ncen

trat

es o

n th

is a

rea

of w

ork.

N

HSL

als

o ha

ve a

Pat

ient

Info

rmat

ion

wor

ker

conc

entr

atin

g on

pos

t di

scha

rge

info

rmat

ion.

Thi

s is

not

co-

ordi

nate

d ac

ross

the

who

le s

yste

m.

The

Car

er In

form

atio

n St

rate

gy h

as b

een

com

ple

ted

and

has

been

ap

pro

ved

by t

he

NH

S Bo

ard

Mar

ch 2

007.

A fi

ve p

erso

n ca

rer

sup

por

t te

am w

as r

ecom

men

ded

and

app

rove

d.

Revi

ew a

nd r

evis

e cu

rren

t ar

eas

of r

esp

onsi

bilit

y en

surin

g a

who

le s

yste

ms

app

roac

h is

util

ised

thr

ough

th

e en

tiret

y of

the

pat

ient

’s

jour

ney.

Esta

blis

h an

Inte

grat

ed a

nd

mul

ti fo

rmat

ted

dire

ctor

y of

se

rvic

es.

Und

erta

ke s

take

hold

er

even

t, a

gree

defi

nitio

n of

re

qui

rem

ents

, und

erta

ke

scop

ing

exer

cise

to

info

rm

deve

lop

men

t of

the

dire

ctor

y.

Link

LTC

act

ion

team

m

embe

rshi

p t

o im

ple

men

tatio

n of

the

st

rate

gy

32.

2

Ann

e A

rmst

rong

Ann

e A

rmst

rong

/Bo

b Sh

orte

r

Aug

ust

2007

Ap

ril 2

007


O

bje

ctiv

e Ev

iden

ce

Cur

ren

t

Act

ion

R

esp

on

sib

le

Tim

esca

le

Val

ue

Pe

rso

n

2.3

2Th

e sp

ecifi

c in

form

atio

n ne

eds

of p

eop

le w

ith

visu

al a

nd c

omm

unic

atio

n im

pai

rmen

ts a

nd fr

om

min

ority

eth

nic

grou

ps

are

addr

esse

d.

This

is c

urre

ntly

ach

ieve

d th

roug

h th

e tr

ansl

atio

n se

rvic

es w

ith in

form

atio

n av

aila

ble

in a

ran

ge o

f for

mat

s an

d la

ngua

ges

on r

eque

st.

- A

cces

sibi

lity

addr

esse

d in

Writ

ten

Patie

nt/c

arer

Info

rmat

ion

pol

icy

- C

ore

gene

ric In

form

atio

n al

read

y tr

ansl

ated

/ av

aila

ble

in a

ltern

ativ

e fo

rmat

s (A

cute

Div

isio

n) -

oth

er

info

rmat

ion

can

be t

rans

late

d/re

- fo

rmat

ted

on r

eque

st-

Inf

orm

atio

n ca

n be

sou

rced

up

on

req

uest

via

var

ious

net

wor

ks -

i.e

PIF.

Li

mite

d In

form

atio

n al

so a

vaila

ble

for

peo

ple

with

lear

ning

dis

abili

ties

The

spec

ific

need

s of

peo

ple

with

vis

ual

and

com

mun

icat

ion

imp

airm

ents

is

curr

ently

bei

ng a

chie

ved

thro

ugh

the

alre

ady

esta

blis

hed

Tran

slat

ion

Serv

ices

.•

Cor

e se

rvic

e in

form

atio

n an

d H

AI

info

rmat

ion

is c

urre

ntly

ava

ilabl

e in

al

tern

ativ

e fo

rmat

s/ot

her

lang

uage

s•

Oth

er in

form

atio

n ca

n be

tra

nsla

ted/

refo

rmat

ted

upon

req

uest

• In

form

atio

n in

alte

rnat

ive

form

ats

/oth

er la

ngua

ges

can

be s

ourc

ed

thro

ugh

the

Patie

nt In

form

atio

n M

anag

er

LTC

Act

ion

team

to

link

with

St

akeh

olde

r En

gage

men

t p

roce

ss

Shon

a W

elto

n/A

rlene

Cam

pbe

llO

ngoi

ng


O

bje

ctiv

e Ev

iden

ce

Cur

ren

t

Act

ion

R

esp

on

sib

le

Tim

esca

le

Val

ue

Pe

rso

n

2.3

cont

• D

isab

ility

Eng

agem

ent

Gro

up -

C

omm

unic

atio

ns S

ub G

roup

(C

haire

d by

the

Pat

ient

Info

rmat

ion

Man

ager

) es

tabl

ishe

d Fe

brua

ry 2

008

to e

xplo

re

and

addr

ess

the

com

mun

icat

ion

req

uire

men

ts o

f peo

ple

with

add

ition

al

com

mun

icat

ion

need

s.

• A

ctio

n fo

cuss

ed w

orkp

lan

incl

udes

-

•

Dev

elop

men

t of

an

acce

ssib

ility

gu

ide

for

staf

f (fo

rms

part

of t

he

NH

SL C

usto

mer

Car

e St

anda

rds)

• H

int’s

and

Tip

’s g

uide

for

staf

f •

Dev

elop

men

t of

a F

irstp

ort

site

w

hich

will

bec

ome

esse

ntia

lly

a to

olki

t fo

r st

aff e

ngag

ing

with

peo

ple

with

diff

eren

t co

mm

unic

atio

n su

pp

ort

need

s•

Dat

abas

e of

info

rmat

ion

for

peo

ple

w

ith a

lear

ning

dis

abili

ty a

nd t

heir

fam

ily/c

arer

s•

Staf

f aw

aren

ess

and

trai

ning

.

• N

HSL

Cus

tom

er C

are

Stan

dard

s (F

inal

Dra

ft)

whi

ch in

clud

es g

uida

nce

on a

ll

as

pec

ts o

f out

goin

g co

rres

pon

denc

e

- W

ritte

n in

form

atio

n &

pos

ters

-

E-m

ail c

orre

spon

denc

e

- B

riefin

gs/

bulle

tins

• W

eb b

ased

info

rmat

ion


O

bje

ctiv

e Ev

iden

ce

Cur

ren

t

Act

ion

R

esp

on

sib

le

Tim

esca

le

Val

ue

Pe

rso

n

2.4

2Fe

w e

xist

ing

advo

cacy

ser

vice

s fo

r LT

C’s

al

thou

gh t

his

occu

rs t

hrou

gh t

he E

nabl

e gr

oup

in t

he N

orth

and

the

Adv

ocac

y p

roje

ct in

Sou

th fo

r LD

and

Old

er P

eop

le

Age

Con

cern

.

Patie

nts

unde

r th

e ca

re o

f com

mun

ity

nurs

es/A

HP’

s w

ill h

ave

indi

vidu

al c

are

pla

ns a

nd c

arer

s m

ay b

e in

volv

ed in

de

velo

pin

g th

ese.

C

PA, M

.H.C

&T

Act

200

3.

Som

e di

seas

e sp

ecifi

c ex

amp

les

exis

t fo

r D

iabe

tes

and

Stro

ke. P

atie

nts

unde

r ca

re

& t

reat

men

t or

ders

.

The

CH

P ha

s lin

ks w

ith t

he

inde

pen

dent

loca

l adv

ocac

y se

rvic

es e

stab

lishe

d by

the

Bo

ard

and

par

tner

age

ncie

s fo

r p

atie

nts

and

care

rs, a

nd

info

rms

pat

ient

s an

d ca

rers

ab

out

advo

cacy

sup

por

t,

incl

udin

g is

sues

ass

ocia

ted

with

inca

pac

ity.

Mul

ti-di

scip

linar

y te

ams

invo

lve

peo

ple

and

the

ir ca

rers

in d

evel

opin

g in

divi

dual

car

e p

lans

.

Patie

nt-h

eld

care

pla

ns

are

used

and

incl

ude

indi

vidu

alis

ed s

elf

man

agem

ent

tool

s.

Link

into

the

Lan

arks

hire

A

dvoc

acy

Foru

m w

ith a

vie

w

to u

nder

taki

ng a

n as

sess

men

t of

thi

s ar

ea a

nd t

o sc

ope

advo

cacy

ser

vice

s to

iden

tify

gap

s in

ser

vice

prio

ritie

s an

d au

dit

of e

ffect

ives

.

To r

ecog

nise

car

ers

as

‘par

tner

s in

car

e’ a

nd

cont

inuo

usly

imp

rove

p

ract

ice

and

docu

men

tatio

n,

and

incl

ude

in t

rain

ing

need

s an

alys

es fo

r LT

C’s

to

be

unde

rtak

en b

y LT

C A

ctio

n te

am.

Revi

ew c

urre

nt p

ract

ice

with

a v

iew

to

deve

lop

ing

a co

nsis

tent

evi

denc

e ba

sed

app

roac

h fo

r th

e or

gani

satio

n an

d de

velo

p a

n im

ple

men

tatio

n p

lan

linke

d to

the

org

anis

atio

ns e

Hea

lth

stra

tegy

.

22.

5

22.

6

Step

hen

Kerr

Jane

tte

Barr

ie

E H

ealth

Clin

ical

D

eliv

ery

Gro

up

Oct

200

7

Ong

oing

2009


O

bje

ctiv

e Ev

iden

ce

Cur

ren

t

Act

ion

R

esp

on

sib

le

Tim

esca

le

Val

ue

Pe

rso

n

2.7

2 12.

8

Ther

e ar

e p

eer

sup

por

t gr

oup

s fo

r p

eop

le w

ith lo

ng

term

con

ditio

ns a

nd t

heir

care

rs.

The

cap

acity

of s

ervi

ces

to

pro

vide

pat

ient

info

rmat

ion

and

sup

por

t se

lf ca

re is

en

hanc

ed t

o m

eet

the

need

s of

peo

ple

from

the

mos

t de

priv

ed c

omm

uniti

es.

Inde

pen

dent

pee

r su

pp

ort

grou

ps

exis

t w

ith t

he M

CN

’s, t

he v

olun

tary

sec

tor

e.g.

BLF

, Bre

athe

Easy

, Dia

bete

s U

K, P

ain

Ass

ocia

tion

Scot

land

, Art

hriti

s C

are,

La

nark

shire

Lin

ks, C

umbe

rnau

ld A

ctio

n fo

r C

are

of t

he E

lder

ly. C

arer

sup

por

t vi

a Pr

ince

ss R

oyal

tru

st fo

r C

arer

s, C

arer

’s

netw

ork

Sout

h an

d C

arer

s To

geth

er

Nor

th.

Keep

wel

l pilo

ts h

ave

a re

ach

stra

tegy

w

hich

look

s at

how

info

rmat

ion

and

sup

por

t ca

n be

del

iver

ed t

o th

ose

hard

to

reac

h gr

oup

s in

the

mos

t de

priv

ed a

reas

. Th

is w

ill in

form

goo

d p

ract

ice

acro

ss t

he

rest

of L

anar

kshi

re. S

ervi

ce c

apac

ity in

C

omm

unity

Nur

sing

is a

lloca

ted

in t

erm

s of

nee

d. M

ore

wor

k is

pla

nned

to

sup

por

t se

lf ca

re.

Wor

k w

ith t

he C

arer

s or

gani

satio

ns is

on

goin

g -

com

mun

ity o

utre

ach

Key

Wor

kers

, coo

rdin

ator

s in

the

Acu

te

sett

ing

etc

Com

mun

ity p

roje

cts

- i.e

Wel

l Man

/he

alth

bus

als

o p

rom

ote

a nu

mbe

r of

sel

f m

anag

emen

t st

rate

gies

. See

ap

pen

dix

III

Intr

oduc

tion

of C

arer

s su

pp

ort

team

will

id

entif

y C

arer

s, t

heir

indi

vidu

al n

eeds

an

d en

sure

con

tinui

ty a

nd c

onsi

sten

cy o

f in

form

atio

n.

Add

ed t

o 2.

4 w

ork

the

LTC

A

ctio

n te

am w

ill id

entif

y cu

rren

t re

sour

ces

to s

upp

ort

pee

r gr

oup

s to

est

ablis

h ge

neric

sup

por

t gr

oup

s.

NH

SL w

ill e

xplo

re t

he a

ctio

n to

est

ablis

h a

mul

ti ag

ency

, m

ixed

sta

keho

lder

gro

up

to u

nder

take

a r

evie

w o

f cu

rren

t p

ract

ice

and

serv

ices

.

Revi

ew c

urre

nt a

pp

roac

h,

unde

rtak

e an

acc

essi

bilit

y re

view

and

sto

ckta

ke t

o de

velo

p a

str

ateg

ic a

pp

roac

h fo

r im

ple

men

tatio

n ac

ross

or

gani

satio

ns.

This

will

incl

ude

par

ticul

ar

focu

s on

the

rol

e of

vol

unta

ry

orga

nisa

tions

with

reg

ard

to

outr

each

with

in r

emot

e an

d ru

ral a

reas

, min

ority

gro

ups

and

hard

to

reac

h gr

oup

s,

educ

atio

n an

d de

velo

pm

ent

as w

ell a

s in

form

atio

n ad

vice

an

d su

pp

ort.

Mak

e lin

ks t

o th

e de

velo

pin

g co

nnec

tions

p

roje

ct (

Big

Lott

ery

bid)

and

co

-ord

inat

e w

ith t

he P

ublic

H

ealth

Pra

ctiti

oner

s an

d M

CN

act

iviti

es.

Stan

dar

d 2

: Cur

ren

t V

alue

s su

b t

ota

l: 15

Step

hen

Kerr

Shon

a W

elto

n/

Arle

ne C

amp

bell

Oct

ober

200

7

Mar

ch 2

008


Stan

dar

d 3

- S

ervi

ce D

esig

n a

nd

Mul

ti-d

isci

plin

ary/

mul

ti-a

gen

cy w

ork

ing

O

bje

ctiv

e Ev

iden

ce

Cur

ren

t

Act

ion

R

esp

on

sib

le

Tim

esca

le

Val

ue

Pe

rso

n

3.1

2O

per

atio

nal p

olic

ies

clar

ify t

he r

oles

of h

ealth

p

rofe

ssio

nals

, unp

aid

care

rs,

loca

l aut

horit

y se

rvic

es,

volu

ntar

y se

ctor

, vol

unte

ers

and

inde

pen

dent

con

trac

tors

in

long

ter

m c

ondi

tions

m

anag

emen

t, b

ut a

re

flexi

ble

enou

gh t

o fa

cilit

ate

new

way

s of

wor

king

, with

in

regu

lato

ry fr

amew

orks

.

Join

t ca

re p

lans

refl

ect

optim

um o

utco

mes

for

indi

vidu

als

and

thei

r ca

rers

.

The

CH

P ha

s a

rang

e of

se

rvic

es in

clud

e; p

reve

ntio

n,

diag

nosi

s an

d tr

eatm

ent,

re

habi

litat

ion

and

pal

liativ

e ca

re w

hich

are

des

igne

d to

del

iver

car

e m

ore

qui

ckly

clo

ser

to h

ome

by

mul

tidis

cip

linar

y sp

ecia

lists

w

orki

ng in

com

mun

ity

sett

ings

.

All

of t

hese

are

con

side

red

as fu

ll p

artn

ers

in c

are;

how

ever

the

abi

lity

of s

ervi

ce

user

s an

d ca

rers

to

cont

ribut

e is

ver

y m

uch

dep

ende

nt o

n th

eir

abili

ties

and

the

clie

nts’

nee

ds.

The

eval

uatio

n of

the

Car

e M

anag

emen

t p

ilots

will

pro

vide

val

uabl

e le

arni

ng in

thi

s re

gard

and

will

info

rm fu

ture

pra

ctic

e in

La

nark

shire

.

Ther

e ar

e is

olat

ed e

xam

ple

s of

Join

t C

are

Plan

s e.

g. O

utre

ach

Dem

entia

se

rvic

e; C

HIP

S p

roje

ct in

Car

luke

, C

are

Man

agem

ent

pilo

t, b

ut m

ore

deve

lop

men

t is

req

uire

d in

thi

s ar

ea.

Eval

uatio

n of

Sin

gle

Shar

ed A

sses

smen

t bo

th in

ter

ms

of q

ualit

y an

d sh

arin

g of

da

ta is

pla

nned

.

Thes

e se

rvic

es a

re u

nder

dev

elop

men

t,

how

ever

the

y w

ould

all

bene

fit fr

om a

m

ore

cons

iste

nt, c

oord

inat

ed a

pp

roac

h in

clud

ing

the

deve

lop

men

t of

mor

e co

mm

unity

bas

ed r

ehab

ilita

tion.

Som

e of

th

is w

ill b

e ad

dres

sed

thro

ugh

rede

sign

p

roje

cts

i.e. G

old

Stan

dard

Pal

liativ

e C

are

80%

sig

n up

and

SW

ITC

H fo

r O

ccup

atio

nal T

hera

py

serv

ices

.

Dev

elop

fram

ewor

ks,

pol

icie

s an

d cl

ear

spec

ific

role

des

crip

tions

to

ensu

re

seam

less

car

e su

ch a

s k

eep

w

ell a

nd i

nteg

rate

d ca

re

man

agem

ent.

Revi

ew c

urre

nt g

ood

pra

ctic

e; d

evel

op a

co

nsis

tent

ap

pro

ach

for

imp

lem

enta

tions

acr

oss

Lana

rksh

ire e

nsur

ing

staf

f ar

e su

pp

orte

d to

ach

ieve

th

is. S

cop

e ou

t re

sour

ce

req

uire

men

ts t

o ac

hiev

e th

is.

The

mod

el o

f car

e w

ill b

e fu

rthe

r de

velo

ped

thr

ough

a

who

le s

yste

ms

app

roac

h w

hich

will

invo

lve

the

clin

ical

co

mm

unity

to

esta

blis

h th

e cl

inic

al a

nd s

ervi

ce m

odel

for

Lana

rksh

ire.

23.

2

Jane

tte

Barr

ie

Jane

tte

Barr

ie &

Hel

en E

dmon

d

LTC

Act

ion

Team

Com

men

ce

2007

Com

men

ce

Sep

t 07

Com

men

ce

Ap

ril 2

007

23.

3


O

bje

ctiv

e Ev

iden

ce

Cur

ren

t

Act

ion

R

esp

on

sib

le

Tim

esca

le

Val

ue

Pe

rso

n

3.4

3 23.

5

23.

6

Long

ter

m c

ondi

tions

m

anag

emen

t is

sup

por

ted

by in

ter-

agen

cy p

roto

cols

for

man

agem

ent,

e.g

. ref

erra

ls.

Con

ditio

n-sp

ecifi

c p

athw

ays

sign

pos

t p

atie

nts

and

pro

fess

iona

ls t

o th

e ap

pro

pria

te in

terv

entio

n/

clin

icia

n.

The

CH

P de

liver

s ca

se/c

are

man

agem

ent

pro

gram

mes

, ba

sed

on t

he r

isk

stra

tifica

tion

tool

, whi

ch

targ

et p

eop

le w

ith t

he m

ost

com

ple

x ne

eds.

The

CH

P p

rovi

des

an in

ter-

agen

cy m

odel

of c

are

to

sup

por

t th

e sp

ecia

list

heal

th

need

s of

peo

ple

in c

are

hom

es/s

helte

red

hous

ing.

This

is b

eing

dev

elop

ed a

s p

art

of t

he

Car

e M

anag

emen

t Pi

lots

e.g

“Pr

oact

ive

Inte

grat

ed C

are

Man

agem

ent

in

Lana

rksh

ire”.

Thi

s w

ill in

form

futu

re

pra

ctic

e in

thi

s ar

ea.

Thro

ugh

MC

Ns,

CH

D P

ost

MI t

he S

trok

e M

CN

, Dia

bete

s p

athw

ays

and

clin

ical

m

odel

, Car

e M

anag

emen

t an

d Ke

ep

Wel

l thi

s is

bei

ng m

et b

ut is

not

yet

fully

de

velo

ped

.

Pilo

t un

derw

ay in

3 L

ocal

ities

. Will

un

dert

ake

6 m

onth

rev

iew

by

31st

Mar

ch

2007

. Rol

l-out

of c

are

man

agem

ent

unde

rway

.

Liai

son

nurs

ing

pos

ts c

urre

ntly

exi

st

how

ever

the

se a

re n

ot in

tegr

ated

at

pre

sent

. Fa

lls t

eam

s, R

apid

Res

pon

se a

nd

Com

mun

ity N

urse

inte

rfac

e gr

oup

. Lia

ison

C

PN in

eac

h D

GH

.

Inte

rage

ncy

pro

toco

ls w

ill

be fu

rthe

r de

velo

ped

and

re

fined

and

will

be

dire

cted

by

the

Lon

g Te

rm C

ondi

tions

A

ctio

n Te

am i.

e. C

hron

ic

Med

icat

ion

Serv

ices

via

the

ne

w P

harm

acy

cont

ract

.

This

ap

pro

ach

will

be

deve

lop

ed fo

r al

l con

ditio

ns

and

will

be

sup

por

ted

by

the

Man

aged

Clin

ical

/Car

e N

etw

ork

Base

d on

eva

luat

ion

roll

out

acro

ss L

anar

kshi

re.

Eval

uate

& r

oll o

ut s

ucce

ssfu

l el

emen

ts s

uch

as t

he

imp

lem

enta

tion

pla

n fo

r th

e W

inte

r p

lann

ing.

Med

ical

Ser

vice

to

Car

e H

omes

bei

ng e

stab

lishe

d an

d p

ilote

d in

EK.

A R

evie

w o

f Ear

ly s

upp

orte

d di

scha

rge

and

rap

id r

esp

onse

te

ams

is u

nder

way

by

Mr

Roy

Gar

scad

den.

23.

7

Ann

e A

rmst

rong

MC

N’s

& C

athy

Dun

n

Ann

e A

rmst

rong

Dr

Shio

na M

acki

e

Com

ple

ted

by

Dec

200

7

Ong

oing

Dec

embe

r 20

07

May

200

7


O

bje

ctiv

e Ev

iden

ce

Cur

ren

t

Act

ion

R

esp

on

sib

le

Tim

esca

le

Val

ue

Pe

rso

n

3.8

3C

linic

ians

use

com

mon

fu

nctio

nal o

utco

me

mea

sure

s

AH

P’s

use

a va

riety

of o

utco

me

mea

sure

s e.

g. E

lder

ly m

obili

ty s

core

, fun

ctio

nal

reac

h, m

odifi

ed r

iver

mea

d.

The

Reha

bilit

atio

n Fr

amew

ork

grou

p

is n

ow u

nder

way

Cha

ired

by P

eter

M

cCro

ssan

and

has

as

a su

b gr

oup

C

haire

d by

Jim

Wrig

ht a

nd S

enga

Cre

e de

velo

pin

g a

Falls

and

Bon

e H

ealth

St

rate

gy fo

r co

nsid

erat

ion

at N

HSL

. Thi

s w

ill d

etai

l the

pat

hway

of c

are

for

falls

an

d bo

ne h

ealth

and

brin

g a

cons

iste

nt,

high

qua

lity

and

evid

ence

bas

ed s

ervi

ce

acro

ss L

anar

kshi

re.

The

Inte

rmed

iate

Car

e C

apab

ility

fr

amew

ork

is c

urre

ntly

out

for

natio

nal

cons

ulta

tion.

Thi

s w

ill g

uide

dev

elop

men

t of

inte

rmed

iate

car

e se

rvic

es a

nd

asso

ciat

ed m

ulti-

agen

cy t

eam

s

Con

sist

ency

dev

elop

ed

thro

ugh

cond

ition

sp

ecifi

c M

CN

s an

d cl

inic

al

com

mun

ities

. Wor

k is

un

derw

ay t

o re

view

and

re

desi

gn t

he In

term

edia

te

Car

e te

ams

and

pos

t ac

ute

reha

bilit

atio

n se

rvic

es

to h

arm

onis

e p

roto

cols

, fu

nctio

nal a

sses

smen

ts a

nd

outc

ome

mea

sure

s.

Pete

r M

cCro

ssan

/A

nne

Hen

dry

Mar

ch 2

008

Stan

dar

d 3

: Cur

ren

t V

alue

s su

b t

ota

l: 17


Stan

dar

d 4

- In

terd

isci

plin

ary

Educ

atio

n a

nd

Tra

inin

g

O

bje

ctiv

e Ev

iden

ce

Cur

ren

t

Act

ion

R

esp

on

sib

le

Tim

esca

le

Val

ue

Pe

rso

n

4.1

3G

ener

ic a

pp

roac

hes

to

man

agem

ent

of lo

ng t

erm

co

nditi

ons

are

incl

uded

in

con

ditio

n sp

ecifi

c C

PD

pro

gram

mes

.

Prac

titio

ners

and

m

anag

ers

from

par

tner

ag

enci

es p

artic

ipat

e in

In

terd

isci

plin

ary

CPD

and

sh

are

lear

ning

and

ski

lls.

Trai

ning

and

dev

elop

men

t p

rogr

amm

es

have

bee

n de

velo

ped

on

a w

ide

rang

e of

issu

es s

uch

as C

are

Man

agem

ent

and

clin

ical

inte

rven

tions

. Str

ong

links

to

the

NES

re

inte

rmed

iate

tre

atm

ent

pro

ject

.

A P

rimar

y C

are

Prac

tice

Dev

elop

men

t Pr

actit

ione

r an

d a

Nur

se C

onsu

ltant

fo

r Lo

ng T

erm

Con

ditio

ns h

ave

been

ap

poi

nted

. Ea

ch o

f the

ir ro

les

enco

mp

asse

s p

ract

ice

deve

lop

men

t in

lo

ng t

erm

con

ditio

ns e

nsur

ing

that

all

trai

ning

and

dev

elop

men

t p

rogr

amm

es

that

are

dev

elop

ed a

nd d

eliv

ered

focu

s ap

pro

pria

tely

on

long

ter

m c

ondi

tions

. In

ad

ditio

n th

e N

ES p

roje

ct o

n in

term

edia

te

care

men

tione

d ab

ove

has

been

in

corp

orat

ed w

ithin

the

um

brel

la o

f p

ract

ice

deve

lop

men

t.

Exam

ple

s of

par

tner

age

ncie

s in

clud

e Si

ngle

Sha

red

Ass

essm

ent,

Add

ictio

n se

rvic

es a

nd M

anag

ed C

are/

Clin

ical

N

etw

orks

for

Stro

ke, D

iabe

tes,

PVD

, Re

spira

tory

and

Cor

onar

y H

eart

Dis

ease

, th

e D

istr

ict

Nur

se/H

omec

are

staf

f in

terf

ace.

Revi

ew c

urre

nt a

pp

roac

h an

d de

velo

p a

CPD

str

ateg

y to

con

tinuo

usly

imp

rove

the

m

anag

emen

t of

Lon

g Te

rm

Con

ditio

ns.

In d

evel

opin

g a

CPD

str

ateg

y th

is w

ill e

nsur

e a

who

le

syst

ems

app

roac

h is

util

ised

in

clud

ing

inte

rage

ncy

and

inte

rdis

cip

linar

y C

PD

req

uire

men

ts.

34.

2

LTC

Act

ion

Team

, Pr

actic

e D

evel

opm

ent

Cen

tre/

NH

SL

Org

anis

atio

nal

Dev

elop

men

t Te

am

As

abov

e

Ong

oing

Ong

oing


O

bje

ctiv

e Ev

iden

ce

Cur

ren

t

Act

ion

R

esp

on

sib

le

Tim

esca

le

Val

ue

Pe

rso

n

4.2

cont

Ther

e is

affi

liatio

n w

ith

lear

ning

net

wor

ks t

o su

pp

ort

best

pra

ctic

e, w

hich

incl

udes

N

HS

Hea

lth S

cotla

nd, N

HS

Educ

atio

n fo

r Sc

otla

nd a

nd

acad

emic

cen

tres

.

Whi

le t

he p

ract

ice

Dev

elop

men

t C

entr

e fo

cuse

s its

edu

catio

n an

d tr

aini

ng

pro

visi

on o

n m

eetin

g th

e ne

eds

of

AH

Ps, M

idw

ives

and

Nur

ses

(and

the

ir su

ppor

t w

orke

rs)

thes

e ar

e us

ually

on

a m

ultid

isci

plin

ary

basi

s w

ith u

ni-

disc

iplin

ary

app

roac

hes

take

n w

hen

abso

lute

ly n

eces

sary

. Th

e Pr

actic

e D

evel

opm

ent

Cen

tre

has

rece

ntly

co

llate

d a

retu

rn t

o N

ES o

n in

tera

genc

y tr

aini

ng w

hich

indi

cate

d a

wid

e ra

nge

of

inte

rdis

cip

linar

y le

arni

ng o

ccur

s ac

ross

lo

ng t

erm

con

ditio

ns.

The

Prac

tice

Dev

elop

men

t C

entr

e co

ntin

ues

to li

nk w

ith t

he S

cott

ish

Exec

utiv

e, N

ES, N

HS

QIS

and

NH

S H

ealth

Sco

tland

in n

atio

nal e

duca

tion

pro

ject

s su

ch a

s th

e re

view

of t

he

role

of t

he C

harg

e N

urse

and

sup

por

t w

orke

r re

gula

tion

all o

f whi

ch h

ave

imp

licat

ions

for

imp

rovi

ng s

ervi

ces

to

pat

ient

s in

clud

ing

thos

e w

ith lo

ng t

erm

co

nditi

ons.

In a

dditi

on li

nks

are

mad

e as

re

qui

red

with

Fur

ther

and

Hig

her,

and

othe

r ed

ucat

ion

pro

vide

rs t

o m

aint

ain

or

esta

blis

h le

arni

ng p

rogr

amm

es p

ertin

ent

to l

ong

term

con

ditio

ns (

for

exam

ple

supp

ort

wor

ker

deve

lopm

ent,

CPD

mod

ules

in

pai

n m

anag

emen

t, a

dvan

ced

phys

ical

as

sess

men

t, c

are

man

agem

ent)

Furt

her

deve

lop

the

ne

twor

k w

ithin

a lo

ng t

erm

s co

nditi

ons

cont

ext.

34.

3A

s ab

ove

Ong

oing


O

bje

ctiv

e Ev

iden

ce

Cur

ren

t

Act

ion

R

esp

on

sib

le

Tim

esca

le

Val

ue

Pe

rso

n

4.4

2Th

e Lo

ng T

erm

Con

ditio

ns

Act

ion

Team

is r

esp

onsi

ble

for

acce

ss t

o ed

ucat

ion

and

trai

ning

abo

ut lo

ng t

erm

co

nditi

ons.

It d

evel

ops

a tr

aini

ng p

lan

for

long

ter

m

cond

ition

s th

at in

clud

es

imp

rove

men

ts in

acc

ess

to

educ

atio

n an

d tr

aini

ng.

Patie

nts

and

care

rs

par

ticip

ate

in t

he

deve

lop

men

t of

edu

catio

nal

mat

eria

l and

in t

he p

lann

ing

and

deliv

ery

of t

rain

ing.

A t

rain

ing

and

deve

lop

men

t p

lan

exis

ts

for

the

care

man

agem

ent

and

Keep

Wel

l el

emen

ts o

f the

LTC

Str

ateg

y. In

add

ition

a

Trai

ning

pla

n ha

s be

en d

evel

oped

for

Dis

tric

t N

ursi

ng.

The

Prac

tice

Dev

elop

men

t C

entr

e co

ntin

ues

to s

upp

ort

actio

ns id

entifi

ed

with

in lo

ng t

erm

con

ditio

ns le

arni

ng

pla

ns.

This

may

be

thro

ugh

advi

ce

and

guid

ance

on

natu

re a

nd d

esig

n of

p

rogr

amm

es (

eg c

are

man

agem

ent)

, di

rect

del

iver

y (e

g cl

inic

al s

kills

), o

r co

mm

issi

onin

g (e

g ad

vanc

ed p

hysi

cal

asse

ssm

ent)

. In

addi

tion

the

Prac

tice

deve

lop

men

t ce

ntre

pro

cure

d a

maj

or

inve

stm

ent

from

NES

in r

esp

ect

of a

p

ract

ice

deve

lop

men

t st

rate

gy fo

r p

rimar

y ca

re t

hat

incl

uded

long

ter

m c

ondi

tions

(t

o su

ppor

t eg

, min

imal

inte

rven

tion

trai

ning

, sui

cide

pre

vent

ion

trai

ning

, and

nu

rse

pres

crib

ing)

Thro

ugh

the

MC

N p

atie

nt g

roup

s w

ork

has

com

men

ced

to r

evie

w a

nd a

udit

patie

nt

info

rmat

ion

and

educ

atio

n m

ater

ials

.A

pp

endi

x III

The

Prac

tice

Dev

elop

men

t C

entr

e ac

tions

do

not

dra

w d

irect

ly u

pon

pat

ient

and

p

ublic

feed

back

but

are

bas

ed o

n in

dire

ct

feed

back

gai

ned

from

oth

er fo

ra, s

urve

ys,

com

pla

ints

and

inci

dent

rep

ortin

g to

en

sure

res

pon

sive

ness

to

pat

ient

and

ca

rer

need

at

all t

imes

.Va

lues

bas

ed t

rain

ing

is b

eing

pla

nned

for

Men

tal H

ealth

Nur

sing

.

24.

5

Onc

e es

tabl

ishe

d th

e Lo

ng

Term

Con

ditio

ns A

ctio

n Te

am w

ill d

o a

Trai

ning

N

eeds

Ana

lysi

s an

d fu

rthe

r de

velo

p t

he t

rain

ing

pla

ns

in p

artn

ersh

ip w

ith k

ey

stak

ehol

ders

and

the

Pra

ctic

e D

evel

opm

ent

Cen

tre.

Exte

nd c

urre

nt a

pp

roac

h to

in

clud

e th

e p

lann

ing

and

deliv

ery

of t

rain

ing.

LTC

Act

ion

Team

MC

Ns

Prac

tice

Dev

elop

men

t C

entr

e

Ong

oing

Ong

oing


O

bje

ctiv

e Ev

iden

ce

Cur

ren

t

Act

ion

R

esp

on

sib

le

Tim

esca

le

Val

ue

Pe

rso

n

4.6

1 14.

7

The

pla

n in

clud

es t

rain

ing

whi

ch e

qui

ps

staf

f to

emp

ower

pat

ient

s an

d ca

rers

in

sel

f man

agem

ent.

Trai

ning

cov

ers

issu

es o

f di

vers

ity a

nd c

apac

ity,

and

the

pro

mot

ion

of

psy

chol

ogic

al, m

enta

l and

em

otio

nal w

ellb

eing

.

The

CH

P p

artic

ipat

es in

loca

l an

d co

llabo

rativ

e re

sear

ch

to e

valu

ate

mod

els

of c

are

for

man

agin

g lo

ng t

erm

co

nditi

ons.

Valu

es b

ased

tra

inin

g is

bei

ng p

rogr

esse

d na

tiona

lly a

nd w

e w

ill w

ork

with

in t

hat

deve

lop

men

t en

surin

g al

l tar

gets

are

met

.

The

Prac

tice

Dev

elop

men

t ce

ntre

doe

s no

t of

fer

spec

ific

trai

ning

in t

hese

are

as

but

all a

re u

nder

pin

ning

prin

cip

les

of

all p

ract

ice

deve

lop

men

t in

terv

entio

ns,

witn

esse

d th

roug

h th

e re

cogn

ition

of

the

need

to

addr

ess

imp

rove

men

t in

th

erap

eutic

rel

atio

nshi

ps

with

pat

ient

s,

incl

udin

g th

ose

with

long

ter

m

cond

ition

s.

Link

s ha

ve b

een

mai

ntai

ned

with

the

Re

sear

ch C

onso

rtia

and

prio

ritie

s fo

r re

sear

ch e

stab

lishe

d th

roug

h N

MA

HP

R &

D

gro

up w

hich

incl

uded

ref

eren

ce t

o lo

ng

term

con

ditio

ns.

Wor

k is

als

o un

derw

ay t

o ev

alua

te C

are

Man

agem

ent,

CO

P Te

am a

nd K

eep

Wel

l p

ilots

.

Imp

lem

ent

valu

es b

ased

tr

aini

ng fo

r ke

y st

aff t

o su

pp

ort

pat

ient

and

car

er

emp

ower

men

t. D

evel

op

and

imp

lem

ent

a ca

rers

ed

ucat

ion

pro

gram

me

to

sup

por

t se

lf m

anag

emen

t.

Con

tinue

to

imp

lem

ent

valu

es b

ased

tra

inin

g m

entio

ned

abov

e, f

or k

ey

staf

f to

sup

por

t p

atie

nt a

nd

care

r em

pow

erm

ent.

Link

out

com

es o

f the

re

sear

ch g

ener

ated

by

the

Con

sort

ia in

to t

he

imp

lem

enta

tion

of t

he L

ong

Term

Con

ditio

ns s

trat

egy.

24.

8

MC

Ns

MC

Ns

Prac

tice

Dev

elop

men

t C

entr

e

As

abov

e

Stan

dar

d 4

: Cur

ren

t V

alue

s su

b t

ota

l: 17

Ong

oing

Ong

oing

Ong

oing


Stan

dar

d 5

- In

form

atio

n a

nd

Inte

llig

ence

O

bje

ctiv

e Ev

iden

ce

Cur

ren

t

Act

ion

R

esp

on

sib

le

Tim

esca

le

Val

ue

Pe

rso

n

5.1

2A

ll he

alth

car

e re

cord

s us

e C

HI a

s th

e un

ique

pat

ient

id

entifi

er.

a) I

nfor

mat

ion

syst

ems

iden

tify

peo

ple

with

sp

ecifi

c di

seas

es b)

and

with

mul

tiple

long

te

rm c

ondi

tions

.

Sing

le s

hare

d as

sess

men

t p

olic

ies,

incl

udin

g ca

rers

’ as

sess

men

t, a

re im

ple

men

ted

and

the

aggr

egat

ed d

ata,

w

hich

sho

uld

be g

athe

red

elec

tron

ical

ly w

here

p

ossi

ble,

use

d to

info

rm jo

int

pla

nnin

g.

Prot

ocol

s fo

r do

cum

enta

tion

and

exch

ange

of i

nfor

mat

ion

are

used

and

the

re is

sha

red

reco

rdin

g of

goa

ls, w

ith d

ata

reco

rded

onc

e be

ing

used

fo

r m

ultip

le p

urp

oses

.

The

orga

nisa

tion

is w

orki

ng t

owar

ds fu

ll im

ple

men

tatio

n of

CH

I. A

udits

are

bei

ng

unde

rtak

en t

o su

pp

ort

com

plia

nce.

a) S

PARR

A d

ata

is c

urre

ntly

bei

ng u

tilis

ed

to t

arge

t th

ose

mos

t in

nee

d of

C

are

Man

agem

ent.

GP

info

rmat

ion

tech

nolo

gy s

yste

ms

such

as

GPA

SS

curr

ently

rec

ordi

ng d

isea

se r

egis

ters

as

per

the

GM

S co

ntra

ct.

b) N

o G

P IT

sys

tem

is c

apab

le o

f id

entif

ying

Co-

mor

bidi

ty.

Sing

le s

hare

d A

sses

smen

t an

d C

arer

s A

sses

smen

t ar

e im

ple

men

ted.

SSA

Adu

lt gr

oup

, dat

a be

ing

agre

ed fo

r ca

rers

.

Join

t do

cum

enta

tion

and

pro

toco

ls e

xist

fo

r Si

ngle

Sha

red

Ass

essm

ent,

Inte

grat

ed

Day

Car

e C

entr

e, a

cces

sing

ser

vice

s su

ch

as H

ome

Car

e an

d th

e Jo

int

Equi

pm

ent

Stor

e.

Mon

itor

pro

gres

s to

war

ds

univ

ersa

l use

of C

HI a

nd

cont

inue

to

sup

por

t de

velo

pm

ent.

Con

tinue

to

wor

k cl

osel

y w

ith

the

Del

iver

ing

For

Hea

lth

Info

rmat

ion

Prog

ram

me

to

esta

blis

h lo

cal m

echa

nism

s w

ithin

GP

IT s

yste

ms

to u

nder

ta

ke t

his

task

.

Imp

lem

ent

new

sys

tem

s as

th

ey a

re c

omp

lete

d th

roug

h th

e w

ork

of t

he d

ata

shar

ing

pro

cess

. In

line

with

thi

s de

velo

p s

yste

ms

to s

upp

ort

data

agg

rega

tion

to in

form

jo

int

pla

nnin

g.

Furt

her

deve

lop

a p

an

Lana

rksh

ire a

pp

roac

h ba

sed

on e

xam

ple

s of

cur

rent

goo

d p

ract

ice.

Con

tinue

as

outli

ned

25.

2

Robi

n W

right

a) A

nne

Arm

stro

ng

b) E

hea

lth c

linic

al

deliv

ery

grou

p

Ala

n La

wrie

Dat

a Pa

rtne

rshi

p B

oard

HEA

T Ta

rget

97

% c

over

Dec

20

06

a) A

chie

ved

b) 2

009/

10

Dat

es v

ary

for

each

set

of

pol

icie

s -

04/0

7 to

Com

ple

tion

of G

ettin

g it

right

for

ever

y ch

ild 0

3/09

Mar

ch 0

8

25.

3

25.

4


O

bje

ctiv

e Ev

iden

ce

Cur

ren

t

Act

ion

R

esp

on

sib

le

Tim

esca

le

Val

ue

Pe

rso

n

5.5

3 25.

6

05.

7

35.

8

Unp

aid

care

rs a

nd t

heir

carin

g ro

le a

re s

yste

mat

ical

ly

iden

tified

and

rec

orde

d, w

ith

cons

ent,

and

link

ed t

o th

e p

atie

nt r

ecor

d.

Leve

ls o

f pop

ulat

ion

risk

deriv

ed fr

om t

he C

HP

pop

ulat

ion

are

used

in t

he

orga

nisa

tion

of lo

cal s

ervi

ces

for

long

ter

m c

ondi

tions

.

The

IM &

T s

yste

m is

st

ruct

ured

to

sup

por

t on

goin

g ca

re /

cas

e m

anag

emen

t fo

r in

divi

dual

s w

ith lo

ng t

erm

con

ditio

ns.

The

CH

P ha

s p

erfo

rman

ce

arra

ngem

ents

whi

ch a

re

clea

r an

d th

roug

h w

hich

th

ey c

an d

emon

stra

te

outc

omes

tha

t de

liver

co

ntin

uous

imp

rove

men

t.

This

is r

ecor

ded

on a

n in

divi

dual

bas

es

in G

P C

arer

s re

gist

ers

and

case

rec

ords

an

d ca

re p

lans

if d

iscl

osed

by

the

pat

ient

an

d or

car

er. C

onse

nt fo

rm s

igne

d by

ca

rers

. NLC

T -

wor

k is

cur

rent

ly b

eing

un

dert

aken

thr

ough

the

wor

k w

ith t

he

DES

crit

eria

. Se

e A

pp

endi

x III

Dem

ogra

phi

c p

rofil

ing

of lo

calit

ies

has

resu

lted

in C

omm

unity

Nur

sing

sta

ff be

ing

refo

cuse

d an

d al

igne

d in

to a

reas

of

grea

test

nee

d. In

add

ition

the

pro

file

was

ut

ilise

d to

det

erm

ine

the

loca

tion

of t

he

Keep

Wel

l and

Car

e M

anag

emen

t p

ilots

.

Proc

ess

com

men

ced

to p

ut in

pla

ce

pro

ject

str

uctu

re t

o de

velo

p s

yste

ms

and

best

link

ages

acr

oss

the

who

le s

yste

m

The

CH

Ps h

ave

esta

blis

hed

Man

agem

ent

Stru

ctur

es, O

per

atin

g M

anag

emen

t C

omm

ittee

s to

rev

iew

per

form

ance

ag

ains

t ke

y de

liver

able

s. A

lso

6 m

onth

ly

mee

tings

rev

iew

loca

l per

form

ance

. A

sys

tem

of o

bjec

tive

sett

ing

and

per

form

ance

man

agem

ent

exis

ts.

Thro

ugh

Car

ers

orga

nisa

tions

ra

ise

awar

enes

s of

thi

s p

roce

ss w

ithin

the

C

omm

unity

.

Con

tinue

to

incl

ude

in S

ingl

e Sh

ared

Ass

essm

ent

pro

cess

.

Req

uest

info

rmat

ion

be

audi

ted

at lo

calit

y le

vel a

nd

rep

orte

d in

to t

he L

TC A

ctio

n te

am t

o di

scus

s im

pro

ved

man

agem

ent

pro

cess

es if

re

qui

red.

Wor

k w

ith t

he E

Hea

lth

Clin

ical

del

iver

y gr

oup

, D

eliv

erin

g Fo

r H

ealth

In

form

atio

n Pr

ogra

mm

e to

est

ablis

h Pr

imar

y C

are

and

CH

P ris

k st

ratifi

catio

n m

echa

nism

s.

The

LTC

Sel

f ass

essm

ent

fram

ewor

k w

ill b

e ut

ilise

d w

ithin

the

se s

truc

ture

s to

fu

rthe

r m

anag

e p

erfo

rman

ce

in r

elat

ion

to L

ong

Term

C

ondi

tions

man

agem

ent.

Bob

Shor

ter

Loca

lity

Gen

eral

M

anag

ers

EHea

lth C

linic

al

Del

iver

y G

roup

Ann

e A

rmst

rong

2008

Dec

200

8

2009

/10

As

req

uire

d

Stan

dar

d 5

: Cur

ren

t V

alue

s su

b t

ota

l: 16


Stan

dar

d 6

- Q

ualit

y an

d D

eliv

ery

O

bje

ctiv

e Ev

iden

ce

Cur

ren

t

Act

ion

R

esp

on

sib

le

Tim

esca

le

Val

ue

Pe

rso

n

6.1

3Th

e C

HP

has

a de

liver

y p

lan

for

long

ter

m c

ondi

tions

w

hich

sp

ecifi

es o

utco

mes

, m

ilest

ones

, and

mea

sure

s to

dem

onst

rate

con

tinuo

us

imp

rove

men

t in

ser

vice

s.

In it

s de

velo

pm

ent

of s

ervi

ces,

the

CH

P in

corp

orat

es e

vide

nce

from

sou

rces

suc

h as

p

ilots

, dem

onst

ratio

n p

roje

cts,

goo

d p

ract

ice,

re

sear

ch, g

uide

lines

and

O

mbu

dsm

an’s

rep

orts

.

The

CH

P ad

opts

a s

yste

mat

ic

app

roac

h to

mon

itorin

g de

liver

y of

Hea

lth

Imp

rove

men

t ta

rget

s.

All

agen

cies

invo

lved

in

pro

vidi

ng s

ervi

ces

for

peo

ple

w

ith lo

ng t

erm

con

ditio

ns

par

ticip

ate

in a

udit

of t

he

man

agem

ent

of lo

ng t

erm

co

nditi

ons.

NH

SL h

as a

Lon

g Te

rm C

ondi

tions

St

rate

gy t

hat

is c

urre

ntly

bei

ng li

nked

to

the

Prim

ary

Car

e St

rate

gy, w

hich

w

ill h

ave

spec

ific

outc

ome

mea

sure

s to

de

mon

stra

te c

ontin

uous

imp

rove

men

t lin

ked

to t

imes

cale

s fo

r de

liver

y.

The

curr

ent

app

roac

h is

to

mod

el c

urre

nt

pra

ctic

e on

loca

l pilo

t w

ork,

inco

rpor

atin

g em

ergi

ng b

est

pra

ctic

e /

evid

ence

i.e.

C

are

Man

agem

ent

pilo

ts w

ill b

e ro

lled

out,

Kee

p w

ell.

Pra

ctic

e w

ill b

e gu

ided

by

SIG

N g

uide

lines

, NH

S Q

IS, b

est

pra

ctic

e st

atem

ents

, Pee

r re

view

ed r

esea

rch,

and

p

atie

nt o

pin

ion

and

exp

erie

nce.

Loca

l Del

iver

y Pl

an p

roce

ss t

hat

deve

lop

s,

deliv

ers

and

acco

unts

for

Hea

lth

Imp

rove

men

t (H

EAT)

tar

gets

ann

ually

.Q

uart

erly

mon

itorin

g of

HEA

T ta

rget

s by

Pe

rfor

man

ce M

anag

emen

t C

omm

ittee

an

d D

fH.

Loca

lity

Plan

ning

Gro

ups,

No

curr

ent

syst

em e

xist

s

The

resu

ltant

act

ion

pla

n fr

om t

he p

lann

ing

even

t in

M

arch

200

7 w

ill a

ct a

s th

e fo

unda

tion

for

this

wor

k.

The

LTC

act

ion

team

w

ill w

ork

on a

CH

P ac

tion

& d

eliv

ery

pla

n to

in

corp

orat

e al

l asp

ects

of

LTC

Man

agem

ent

and

ensu

re t

his

is p

erfo

rman

ce

man

aged

thr

ough

the

agr

eed

stru

ctur

es.

Mak

e th

e ne

cess

ary

links

; fo

rm t

he L

ong

Term

C

ondi

tion

Act

ion

Team

into

re

por

ting

mec

hani

sms.

The

LTC

Act

ion

will

in

corp

orat

e th

is a

s a

key

prio

rity

to e

nsur

e jo

ined

up

p

lann

ing

and

deliv

ery.

36.

2

Ann

e A

rmst

rong

Ann

e A

rmst

rong

Roy

Wat

ts/S

tep

hen

Kerr

w

ith li

nks

to

LTC

Act

ion

Team

Ann

e A

rmst

rong

May

200

7

June

200

7

Ong

oing

Dec

200

8

36.

3

06.

4


O

bje

ctiv

e Ev

iden

ce

Cur

ren

t

Act

ion

R

esp

on

sib

le

Tim

esca

le

Val

ue

Pe

rso

n

6.5

3 26.

6

36.

7

06.

8

The

CH

P m

onito

rs lo

ng t

erm

co

nditi

on o

utco

mes

, as

par

t of

ove

rall

CH

P ob

ject

ives

an

d JP

IAF

outc

omes

.

Syst

emat

ic p

rovi

sion

is

in p

lace

for

feed

back

fr

om p

atie

nts

and

care

rs

rega

rdin

g in

form

atio

n on

the

con

ditio

n an

d ac

cess

to

qua

lity

of c

are

pro

vide

d lo

cally

.

The

CH

P lo

ng t

erm

co

nditi

ons

actio

n te

am

pre

par

es a

n an

nual

rep

ort,

us

ing

the

self-

asse

ssm

ent

tool

kit,

aga

inst

the

ir p

lan.

Th

e an

nual

rep

ort

is

subm

itted

to

the

CH

P C

omm

ittee

, the

NH

S Bo

ard

Clin

ical

Gov

erna

nce

and

Rede

sign

Com

mitt

ees,

to

the

Boar

d as

par

t of

the

an

nual

rev

iew

pro

cess

and

to

rel

evan

t lo

cal a

utho

rity

com

mitt

ees.

All

asp

ects

of s

ervi

ce d

eliv

ery,

des

ign

and

heal

th im

pro

vem

ent

that

imp

inge

on

long

ter

m c

ondi

tions

are

an

inte

gral

par

t of

Cor

por

ate

Obj

ectiv

es a

nd t

heir

revi

ew.

JPIA

F p

roce

sses

and

out

put

s ar

e p

roxi

es

for

outc

ome

and

are

subj

ect

to a

n an

nual

p

rogr

amm

e of

rep

ortin

g, e

valu

atio

n an

d ta

rget

set

ting.

Car

e M

anag

emen

t p

ilots

hav

e p

atie

nt

satis

fact

ion

built

into

face

to

face

pra

ctic

e an

d ev

alua

tion

docu

men

tatio

n. S

yste

ms

exis

t to

rec

ord

and

resp

ond

to c

omp

lain

ts

with

cle

ar li

nkag

es t

o p

roce

sses

aro

und

PFPI

. Car

er-P

atie

nt s

atis

fact

ion

audi

ts.

Rep

ortin

g in

to t

he M

oder

nisa

tion

Boar

d an

d th

e C

MT

thro

ugh

the

Prim

ary

and

Com

mun

ity C

are

Mod

erni

satio

n p

roce

ss

and

the

stra

tegi

c re

desi

gn p

roje

ct o

n Lo

ng T

erm

Con

ditio

ns.

This

will

feat

ure

thro

ugh

Mod

erni

satio

n,

CH

P M

anag

emen

t C

omm

ittee

s an

d N

HS

Boar

d Le

vel.

Con

tinue

to

utili

se c

urre

nt

syst

em/m

echa

nism

of

rep

ortin

g to

CH

P M

anag

emen

t an

d O

per

atin

g C

omm

ittee

s.

Aud

it th

is t

hrou

gh t

he L

TC

Act

ion

Team

and

agr

ee a

se

t of

sta

ndar

d sy

stem

s an

d m

etho

ds fo

r ca

ptu

ring

this

in

form

atio

n. E

nsur

e th

is

is r

eflec

ted

in t

he s

ervi

ce

pro

visi

on lo

cally

pos

t im

ple

men

tatio

n.

Prod

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Appendix II

Terms of Reference:

NHS Lanarkshire Long Term Conditions Action Team

Aim

To systematically and consistently implement NHS Lanarkshire’s Long Term Conditions Strategy to meet the needs of the people of Lanarkshire.

Objectives

1. Raise awareness of NHS Lanarkshire’s Long Term Conditions Strategy across the Organisation and partner agencies.

2. Scope out the current position ensuring evidence based practice is identified and replicated where appropriate.

3. Develop a comprehensive action plan to support the implementation of the strategy utilising a risk management approach to prioritise action where appropriate ensuring key targets such as HEAT targets are achieved.

4. Monitor implementation and report on progress to Programme Board 2, (Community and Primary Care Strategy).

5. Evaluate the impact of implementing key aspects of the long terms conditions strategy.

Strategic Documents

In meeting the above objectives the following documents must be considered:

❖ Delivering For Health

❖ Lanarkshire Long Term Conditions Strategy

❖ The National Service Framework For Long Term Conditions,

❖ Caring For Scotland

❖ New Pharmacy Contract

❖ NHS Lanarkshire Community Nursing Review: Future Vision

❖ Delivering Care Enabling Health

❖ Visible, Accessible And Integrated Care

❖ GMS Contract

❖ NHS Lanarkshire Carer Information Strategy

Chairperson

Anne Armstrong: Nurse Director Community & Primary Care


Membership

❖ CHP Lead GP - Long Term Conditions

❖ Change and Innovation Manager - Long Term Conditions

❖ Head Of Planning - North or South CHP

❖ Nurse Consultant - Long Term Conditions

❖ Carer Representative

❖ Patient Representative

❖ Patient Services Manager

❖ SDM Long Term Conditions & Lead For Supported Self Care

❖ General Manager

❖ Trade Union Representative

❖ Chief Pharmacist

❖ Lead Clinician MCN

❖ Project Lead - Care Management

❖ Project Lead - Intermediate Care

❖ Project Lead - Anticipatory Care

❖ Clinical Effectiveness Representative

❖ Local Authority Representative - North

❖ Local Authority representative - South

❖ Associate Director - AHPs

❖ Children’s Services Representative

❖ NHS Lanarkshire acute Division Representative

The Group has the ability to co-opt members on an ad hoc basis as required.

Links with Key Groups

❖ Managed Clinical /Care Networks

❖ Older Peoples Programme Board

❖ Children’s Services Programme Board

❖ Community Nursing Implementation Group

❖ Care Management Steering Group

❖ Keep Well Project Board

Communication

The Sub Group is responsible for ensuring that front line staff are involved in their work and are able to influence the shape of the future service within the realms of strategic guidance. Regular updates will be provided via the PULSE.

Reporting Mechanism

The Action Team will report through the chair to the Primary Care Strategy Programme Board, (Programme Board 2) providing regular progress reports as required. This will include endorsement and review of the Groups work programme. Sub Groups established to progress work streams will provide a regular report outlining progress at each of the Action Teams meetings. This will include exception reporting outlining activity to ensure timeous implementation of the strategy.

MCNs will provide the Long Term Conditions Action team with one page updates on work progress on a regular basis.


Update on NHS Lanarkshire Long Term Conditions Action Plan

The following comments are an update on the Long Term Conditions Action Plan with a focus on the meaningful involvement of North Lanarkshire Carers Together.

Appendix III

Objective 1.7

NLCT has representatives on the Health & Care Partnership and the four North Lanarkshire Partnership Boards. We are also represented on the North Lanarkshire Public Partnership Forum Reference Group and our Development Manager is currently planning Health Issues in the Community Training with this group to ensure involvement is focussed on a community development approach.

Objective 2.2

As part of the Carer Information Strategy a five person Carer Support Team was recommended. The post within South Lanarkshire Carers Network was filled in January 2008. The part time seconded post with our organisation has been advertised on NHS Lanarkshire intranet and the three part time Carers Coordinator posts are currently being advertised. These posts are now for four days per week.

Due to the delay in implementing this initiative “once off slippage money” became available and North Lanarkshire Carers Together has been successful in accessing funding for a Carer Coordinator/Trainer to identify, train and support carers to become actively involved in this joint work with NHS Lanarkshire and North Lanarkshire Council and to train “Expert Carers” to take this work forward when this funding ends.

Objective 2.5

NLCT is truly focussed in ensuring that carers are recognised as “key partners in care” and welcome any initiative that encourage and support this practice.

Objective 2.7

NLCT and our colleagues in South Lanarkshire Carers Network ensure that any information relevant to carers is disseminated throughout the relevant authority therefore it is important that both organisations are kept up-to-date on developments and new initiatives.

Objective 2.8

Ensure that, while undertaking a review of outreach services, there is a link with NLCT as we have input in various rural areas of North Lanarkshire.


Objectives 4.5 & 5.3

NLCT has current input to Single Shared Assessment and Carer Awareness training as well as GP Clinical Fora. We are also involved in social work student induction training and have “signed up” to take student placements for four days within our organisation thus ensuring staff are aware of the key role of carers and the benefits of including them at all levels of the planning, consultation and assessment process.

Objective 5.5

It is planned that the seconded worker with NLCT will develop good links with the person in each GP surgery responsible for the Carers Register and link with the Carers Coordinators within each of the Acute Hospitals to provide a seamless approach to the identification of carers and the provision of good quality and up-to-date information.

Since the initiation of the Scottish Enhanced Service, and carers being one of the three priorities in this initiative, this will further enhance and support the initial work undertaken by our organisation as a result of the Direct Enhance Service.

Update on NHS Lanarkshire Long Term Conditions Action Plan cont’