Edinburgh Health and Social Care Partnership Long Term Conditions Programme

Edinburgh Health and Social Care Partnership’s (EHSCP) Long Term Conditions Programme provides support to locality teams to improve care for people living with long-term health conditions and those who are at risk of falls. The Long Term Conditions programme supports practitioners to deliver improvement interventions in three key delivery areas:

  • Prevention and early intervention
  • Anticipation
  • Supported self management

Within each delivery area there are key quality improvement workstreams. Quality improvement projects and tests of change form the basis of delivery for these workstreams. The Long Term Conditions programme works in partnership with the third sector, managed clinical networks, emergency services and unscheduled care services to deliver improvements across the wider delivery areas.

Testing improvements to Anticipatory Care Planning

The Long Term Conditions Programme recognises the value in supporting people to improve clinical and personal outcomes by planning ahead for their health and care. The programme’s Anticipatory Care Planning (ACP) team provides dedicated project and improvement support to test improvements to ACP for people living with long term conditions in Edinburgh.

In 2016 the ACP team began working in partnership with care homes and GP practices with the shared aim of supporting residents to think ahead about what matters to them, ensuring they have greater choice and control over their care and treatment should their condition deteriorate. Over the past three years ACP learning and improvements have been shared and tested with 30 care homes and their aligned GP practices. The ACP team is working with locality teams within EHSCP and partners across Edinburgh’s community to spread ACP learning and test improvements with services supporting people living at home with long term conditions.