Priority 1: Prevention and early intervention

Investing in prevention and early intervention services is a key part of our strategy. By identifying those people most at risk of poor outcomes and providing effective early support we can prevent problems occurring or minimise the impact on the individual’s health and wellbeing.

The Edinburgh Wellbeing Pact is framed around the principles of mutuality and reciprocity, and these remain central to all the enactment activities which have been initiated to date. As part of our Community Mobilisation project, we are developing new ways to engage and fund the third sector, with emphasis on community collaboration and assets.

The Edinburgh Pact and community mobilisation work undertaken in the last year has demonstrated how complex the structures and processes are in our commissioning space. The creation of the More Good Days Strategic Public Social Partnership (PSP) will provide a better way of moving forwards with our shared narrative and allow incremental changes and developments to be made. Work with colleagues from procurement, commissioning and Health Improvement Scotland has helped to shape the proposal, and the PSP will enable us to be responsive and flexible to unallocated funding, as well as additional or new allocations received. Our ability to be agile in our responses to an ever-changing context is resulting in a more dynamic and fluid plan. This is helping to build an increasing, citywide social movement with a shared narrative of achieving more good days for everyone.

There are also a number of collaborations continuing to develop thanks to the extension of the current Health Inequalities Grant Programme to 31 March 2025 and the introduction of our innovative Capacity to Collaborate programme. Twenty-two awards ranging from £2,075 to £24,075 were supported during 2022/23 through the Capacity to Collaborate Awards.

We also worked with our City of Edinburgh colleagues on their Warm and Welcoming Spaces initiative, producing the ‘The nights are fair drawin’ in’ booklet with helpful information and sources of help, which was distributed to libraries, community centres and arts venues across the city.

Initiatives supported by community mobilisation Benefits
Edinburgh Community Resilience Programme with Cyrenians and Queen Margaret University The programme helps increase community resilience to support the health and wellbeing of Edinburgh’s older people. The programme builds on previous expertise and research which considers community navigation, social prescribing approaches and the Making it Clear resilience framework.
Op Ready with Edinburgh Leisure The project focuses on those whose current health status is affecting their receiving knee or hip surgical procedures.
Community Taskforce Volunteer Programme The programme received recurring funding to enable the trained task force of over 400 people to continue to help Edinburgh residents with practical tasks such as dog walking, shopping collection and support after a hospital discharge.
Fit and Active programme for People with Learning Disabilities with Edinburgh Leisure The programme has created opportunities for people with learning disabilities to be physically active and socially connected.
Learning by Doing Community Commissioning process This approach has been used for the second year of allocation of the Scottish Government’s Mental Health and Wellbeing fund.

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.

We continue to promote Anticipatory Care Planning (ACP), which helps people living with long term conditions make informed choices about how and where they want to be treated and supported in future. This year we launched ACP pages on the NHS Lothian website, providing guidance and resources for citizens and practitioners. In addition, the 7 steps to ACP for care homes  is now available on the national Homecare Decisions website and app, providing care home staff with guidance and best practice information. Training and improvement support for care home staff across Lothian will be provided through the Lothian Care Academy. The Edinburgh ACP Stakeholder Group continues to share best practice and support for health and social care teams and voluntary sector partners.

In response to identified need, the Edinburgh Self-Management Practitioner Network produced a Self-Management Practitioner Toolkit, providing guidance, tools, and practical tips to improve practice. Facilitated sessions are provided to teams, giving an opportunity to come together to focus on enabling people to be better informed, prepared, and supported in ways that are right for them.

In December 2022 we were appointed as a GIRFE Pathfinder. GIRFE is a Scottish Government initiative that sets out to advance a multi-agency approach of support and services from young adulthood to end of life care. GIRFE will place the person at the centre of decisions that affect them to achieve the best outcomes. The initial focus will be to improve coordinated care and support for people living with frailty and people who frequently attend the Emergency Department (ED) who are also registered at a Deep End GP practice.

In terms of digital support, the LTC team is supporting the implementation of remote blood pressure monitoring for use in GP surgeries across Lothian. The National Blood Pressure Service is being rolled out under a national agreement endorsed by the Scottish Government, supported by National Services Scotland, Technology Enabled Care (NSS TEC).

The LTC Falls co-ordinators are actively engaging with the new Lothian-wide Prevention and Management of Falls Strategic Group, which has been set up to improve collaboration and consistency of falls prevention work through the availability of education and training, Lothian-wide data collection and development of a Lothian-wide Falls strategy for all health and social care staff. Care home falls prevention and management procedures and tools are being updated to facilitate improved practice, data gathering and training. Plans are being developed to meet falls related aspects of My Health, My Care, My Home.

We have a responsibility for adult protection and our Chief Officer sits on the multi-agency Chief Officers Group for Public Protection that is responsible for all areas of public protection across Edinburgh. This group is supported by the Adult Protection Committee.

Between April 2022 and March 2023, there were 2,350 adult protection contacts across the city. This is a 24% increase from the 1,901 contacts in 2021/22, which has put considerable pressure on our social work resources and impacted on our ability to respond to assessments for social care, as adult support and protection cases are prioritised. Of the 2,350 referrals received during the year, further action was taken in almost all cases (97.4%). Roughly half of them required social work involvement other than Adult Protection.

Almost a third of referrals (29.9%, 702) progressed to investigation in the period. Infirmity due to old age was the most common client group for those whose case was being investigated (27.4%), followed by mental health (23.2%). The cases that resulted in an investigation were principally due to neglect (26.6%) and physical harm (25.2%). Of the 702 investigations, almost three quarters (72.9%) resulted in further action. There were also 1,111 adult protection case conferences in the year, of which a third (32.9%) were initial case conferences.

Case Study 1: Health All Round – Ecotherapy

Pete is a man in his late thirties who initially presented with suicidal thoughts and anxiety. Pete was very keen to explore a closer relationship with nature as well as opening up his social circle, and so he was offered a place on the ecotherapy programme. During the first four sessions, Pete was very quiet and seemed to be on the periphery of the group. Although the group made him feel welcome, he was visibly shy and clearly uncomfortable within a group atmosphere. He did, however, continue to come along to the weekly group which occurs in various outdoor locations.

After several months of attending the group, one day Pete was visibly excited and became very chatty during the group check-in. He said that the ecotherapy group had inspired him to drive to the Borders and climb a hill. Whilst he was up there, he had a moment ‘where I felt just amazing…my anxiety didn’t matter, my thoughts didn’t matter. There were little birds and squirrels all around me and the views were amazing. I felt like I was a part of something big and beautiful.’ Since then, there has been a clear change for the better with Pete.

Pete still comes to the weekly ecotherapy group and rarely misses a session. He is now one of the more active group members and he has become popular. He regularly updates us about a friendship that he has developed with a wild fox and he reports on how connecting with nature has been life-changing for him, reporting less anxiety and fewer suicidal thoughts. Pete has also started socialising with some group members outside of the ecotherapy group.

Personal Outcomes:
·       Pete has spent more time in the natural world

·       Pete has become part of a group

·       Pete found that this strategy helped to alleviate his problems with low mood, anxiety and suicidal thoughts.

Wider Impacts:
Building stronger, more resilient communities – Pete’s enthusiasm for nature now inspires new group members and he has helped one or two new people to feel welcome in the group. He has gone from being a quiet presence who didn’t seem to be enjoying himself to someone who helps other group members to connect with nature and is an asset to the group.