Living Well in the North

The ihub is working with 10 HSCPs across the north of Scotland to improve community- based care and support for people with frailty. This work will take the ihub’s testing of the electronic Frailty Index (eFI) and community-based interventions from a handful of test GP practices to implementation in over 200 practices covering a population of 1.3 million people.

The ihub’s Living Well in the North programme started in early 2018 in response to a request by the Chief Officers of the 10 HSCPs. It aims to improve the early identification of people with frailty and to improve their access to appropriate levels of care and support. This helps them to live well in their community for longer and avoid unplanned time in hospital.

The ihub is working with NHS National Services Scotland (NSS) to use the learning from early testing of the eFI to build the infrastructure required for all GP practices to be able to use the eFI through the Scottish Primary Care Information Resource (SPIRE). While this is being built the ihub has been supporting local clinical and social care engagement to ensure buy in across the area and to help the HSCPs design their community frailty interventions.

Local leads from the 10 HSCPs specified that their community frailty interventions needed to be evidence based. The ihub responded by creating the Living Well in Communities with Frailty evidence summary. This is being used by HSCPs to inform the design of local community frailty interventions and to build business cases for linking improved identification of people with frailty to care models that can support them to live well in their community.

The ihub has also responded to requests from HSCPs, such as Shetland, for support to map their local health and social care system to identify existing services that could support people with frailty. This involved using an integrated system mapping method developed by the ihub in 2016.

A virtual space for local sites and the ihub to share experience, resources and learning has been created. The online platform is provided by the Improvement Service and is accessible to both local authority and NHS staff.

Another key aspect of knowledge exchange is the programme’s reporting structure. In response to local areas’ requests to keep the reporting burden to a minimum, the main reporting mechanism is a monthly call between the local lead and the ihub Improvement Advisor. This reduces the burden on local sites to write additional reports and allows two-way dialogue for knowledge exchange and a rapid response to issues and challenges.

Plans to evaluate the impact that the work has on people with frailty, staff that support people with frailty, and the wider health and social care system are in development.

This has involved support from the ihub’s Evidence and Evaluation Improvement Team and the University of Edinburgh.

The lead Chief Officer, Adam Coldwells from Aberdeenshire HSCP said, “The collaborative work will allow us to do something at scale across the north of Scotland that will impact on our whole system and the wider population.”