Our long-term conditions programme provides support to health and social care teams to improve care for people living with long-term health conditions and those who are at risk of falls. There is a Long-Term Conditions Section on our website with information for people living with long term conditions, their families and carers.

Supporting people at risk of falls

During the pandemic, many people became less active, leading to an increased risk of falls. Preventative input is of particular importance as reports highlight the significant increase in falls risk due to this reduced activity and associated deconditioning (Public Health England Report 2021).

We have improved and clarified ways people can:

• access urgent assistance following a fall if uninjured but unable to get up
• participate in an assessment to help identify their risk factors of falling
• access rehabilitation to help maintain or regain their confidence and physical ability following a fall

Many referral routes are now via centralised contact centres which, with the additional increase in the use of technology, have improved efficiency.

We have ensured that consistent information is available across various mediums for ​the public and health and social care staff to access, including a tool with rapidly available links to assessments, cross-sector referral options and signposting. Care home falls prevention and management documents and guides are being updated to facilitate improved practice, data gathering and training. Training for health and social care practitioners and third sector organisations on falls and available resources has been developed and provided as required.

In partnership with the Red Cross, the Staying Active project is now under way in Leith, aiming to better understand how we identify risks of falls and frailty early, and to offer optimal support with a view to keeping people active and changing future outcomes.

These improvements have enabled more people to access and receive the support they require to manage an acute fall, and to reduce their risk of future falls by addressing preventable risk factors and promoting improvements in physical function and strength.

Anticipatory Care Planning

A high-quality Anticipatory Care Plan (ACP) shared on a Key Information Summary (KIS) is the most effective way of making sure that the voices of individuals are heard when decisions are being made about their care and treatment. We have taken innovative approaches to ensure everyone involved in a person’s care can have a role in discussing future care and treatment preferences and contribute to creating a shared plan. The ACP community bundle and the 7 steps to ACP for care homes are recognised best-practice models, developed by Edinburgh practitioners to deliver an integrated approach to improving outcomes through ACP.  We have provided ACP training and improvement support to a range of health and social care teams, and continue to see an upwards trend in the number of ACP-KISs for citizens in Edinburgh, with a 23% increase during 2021/22. During 2021/22, 58,751 ACP-KISs were created and in March 2022 a total of 279,177 active ACP-KISs were shared across the integrated system.

Supporting Self-Management: ‘I don’t live with my condition, it lives with me.’

Supporting Self-Management describes the ways in which we aim to support, empower and enable people living with long term conditions to manage their health and wellbeing and live well.  The Self-Management Support Worker Service, hosted with Lothian Centre for Inclusive Living ​(LCiL), has adapted to the challenges of COVID-19 by re-designing the referral and service pathway to increase access for people in most need of support.

Responding to ‘what matters to you’ conversations with people and their families, the Self-Management Service designed and facilitated two Self-Management workshops. The first, ‘Easing Out of Lockdown’, helped people develop their own resilience and coping mechanisms to live their lives as fully as possible during the pandemic. The second, ‘Understanding Pain & Managing Symptoms’, helped participants develop a greater understanding of their pain, how it impacts them and what they might be able to do themselves to help manage their pain.

The Self-Management section of our website includes a new page hosting the Connect Here community resources, which provides information and contact details for over 1,400 services, groups and activities to help people find the support that is right for them, connecting with their community and improving their health and wellbeing.