5. Anticipatory Care and Long Term Conditions
| What this will mean for you |
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- An increased focus on anticipatory care for people of all ages, including greater availability of screening services and health checks
- Individual care plans if you have a long term physical or mental health condition, with better support and information to help you and your carer to better manage your condition
- A focus on supporting the needs of families and carers of people with disabilities and long term illnesses
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Our Approach
We recognise that the challenge of shifting from a reactive system of healthcare to one which seeks to anticipate and prevent health problems before they develop, requires a significant cultural change within NHSScotland and its partners. We need to identify where it is most useful to anticipate problems and where we can offer effective preventive measures and work with partners to provide personalised solutions which are not limited artificially by organisational boundaries. This approach is supported and reinforced by changes that are being made within social care, as part of Changing Lives: Report of the 21st Century Social Work Review, and requires a commitment to working with the voluntary sector to better reflect and respond to individual needs.
Framework for Discussion
This discussion will help us identify new opportunities to enhance anticipatory care and influence the way in which we:
- Provide intensive case management based on individualised care plans which coordinate the services provided by whichever individuals or organisations are most appropriate for the patient's needs
- Further develop the Scottish Patients At Risk of Readmission and Admission ( SPARRA) tool in order to help Community Health Partnerships to identify and support our most vulnerable patients
- Work with the Long Term Conditions Alliance Scotland, to develop and introduce a self care strategy which will improve the quality and accessibility of information available to patients, signpost appropriate education and support and utilise new technology to enhance home based care
- Ensure that Carer Information Strategies in every area help carers to access the information and support they need in their caring role
- Ensure that ideas and initiatives from the voluntary sector are mainstreamed effectively where they are valued by patients and have demonstrated their effectiveness and sustainability
- Work with local government and the voluntary sector to personalise community care services and deliver them increasingly at home or in homely settings
- Abolish prescription charges
- Make the Gold Standards Framework the norm for people nearing the end of their life
- Develop greater capacity for cognitive therapies and other psychological therapies
- Incorporate the treatment of dementia within a set of national clinical priorities that allow us to bring particular focus to a small number of critical healthcare challenges
- Implement the commitment to reduce anti-depressant prescribing by 10%
- Extend screening programmes and health checks, including the development of the "life begins" programme
- Secure the full engagement of the Public Health community in decisions on where best to invest NHSScotland's resources to improve health and prevent disease
- Introduce individual health plans for school pupils and increase the capacity of school nursing across Scotland
- Introduce a vaccination programme to protect against the Human Papilloma Virus ( HPV), subject to the recommendations of the UK expert group on vaccination, to help prevent up to 70% of cervical cancers in Scotland
- Implement Delivering Care, Enabling Health, to support nursing, midwifery and allied health professionals to become enablers and supporters of self care and self management abilities
| Issues to consider |
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- How could the approach described above be developed further to help anticipate healthcare problems and improve the management of long term conditions?
- Which aspects of the suggested approach would you prioritise and which particular conditions do you think should be regarded as national clinical priorities?
- What specific actions should NHSScotland take at national, regional or local level in order to advance this agenda?
- What further opportunities do you see for improving our approach to long term conditions through cooperation and collaboration between NHSScotland and its partners?
- Have you had any recent personal experiences that might help us shape and inform future actions across Scotland?
- Which key performance targets would best focus NHSScotland on anticipating health problems and improving the care we offer to people with long term conditions?
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