Strategic priority one: 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.

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The commitment to create an Edinburgh offer was one of the key elements of our Strategic Plan for 2019-2022. To achieve this, we have been developing the Edinburgh Wellbeing Pact – a reciprocal agreement between the Partnership and everyone who lives and works in Edinburgh, inviting citizens, staff and partners to contribute to realising a shared vision. We are working towards an ambition to create healthy communities, empowered by local services and organisations that support people to prevent crisis and manage their health and personal independence at home.

In 2020-21, we began a dialogue with citizens, staff from EHSCP and partner agencies, communities of interest, community planning partners, and interested stakeholders. Due to restrictions, all engagement activities took place online, including:

  • 12 focus groups with 84 frontline staff and practitioners
  • Public survey through our website with 356 responses
  • 11 Community of Interest groups with 91 participants including black and minority ethnic communities, faith groups, and people with specific health conditions
  • 8 voluntary sector forum meetings with 191 participants
  • 23 in-depth interviews with city leaders from the third sector, public sector, elected members, Board members, academia and private sector
  • 115 images submitted through “Picturing Health”, a project inviting people to take photographs of what health and care meant to them

From all the conversations to date we identified 6 emerging themes: Shared Purpose; Relationships; Community Mobilisation; Agility; Radical Transformation; and Measuring and Evidencing Change. We want to build thriving communities in Edinburgh and embrace the opportunity to create a different type of relationship with residents, communities and organisations across the city.

We are now moving to enactment of the Wellbeing Pact through a 3-year community mobilisation and commissioning plan. The plan, which was approved by the EIJB in April 2021, will see the development of more collaborative, partnership approaches to supporting community sector organisations, including the roll-out of community-based approaches to commissioning to replace traditional grants programmes. To shape what community mobilisation can look like for Edinburgh, we held two collaboration events with a wide range of key stakeholders in January and March 2021, with further events planned in 2021-22.

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. This year we created a new Long Term Conditions Section on our website. As well as information for people living with long term conditions, it includes information for families and carers.

Supporting people living with Chronic Obstructive Pulmonary Disease (COPD)

Edinburgh’s Community Respiratory Hub provides support to people living with Chronic Obstructive Pulmonary Disease (COPD) who are at high risk of hospital admission. During 2020, the Community Respiratory Team assessed 414 people, who were at immediate high risk of hospital admission because of an acute exacerbation of their COPD. Following assessment, the Community Respiratory Team supported 84% of these people to be safely cared for at home, avoiding hospital admission.

In place of our Pulmonary Rehabilitation classes we offered support for those already engaged, or with completed assessments, to use the myCOPD app. The myCOPD app supports people living with COPD to better manage their condition and improve their outcomes. Telephone coaching and group virtual classes were also offered.

Supporting people at risk of falls

By proactively providing support on how people can stay active and steady on their feet, we can either prevent falls happening or improve the way a fall is managed. Working in partnership with the British Red Cross, 250 ‘Staying Active’ packs were distributed via community nurses and physiotherapists to people who were shielding and at risk of falls during the Covid-19 pandemic and 600 Staying Active leaflets were distributed via the City of Edinburgh Council’s shielding phone line.

Anticipatory care planning

Anticipatory care planning (ACP) is a person-centred, proactive, ‘thinking ahead’ approach, with health and care professionals working with individuals, carers and their families to make informed choices about their care and support. Key Information Summaries, which contain anticipatory care planning information such as care preferences taken securely from the GP electronic record, are shared with health professionals if people need urgent care.

During the pandemic, we focussed on supporting practitioners to have care planning conversations and create plans for people living with long term conditions who were most at risk of Covid-19. The number of Key Information Summaries for people living in Edinburgh has increased from 66,966 in March 2020 to 237,372 in March 2021 (254% increase).

To support the creation of Covid-19 relevant ACPs, all care homes for older people and GP practices in Edinburgh were provided with a Covid-19 revised edition of the 7 steps to ACP for care homes. We also continue to work with VOCAL and the Edinburgh Carer Support Team to support carers through care planning conversations.

Self Management

Self management supports people living with long term conditions to be actively involved in their own health and wellbeing as the leading partner in their care. In partnership with Lothian Centre for Inclusive Living, we successfully tested and adopted a new Self Management Support Worker post during the pandemic. This role will help people with long term conditions develop self-management skills and connections with community support.

We also launched the Edinburgh Self Management Network during Self Management week (28th September-2nd October 2020). This online network supports practitioners to share good practice, find out about services, activities and events, and innovate self-management approaches. This network has created a self-management toolkit, including the Edinburgh Connect Here Directory of City Wide Community Resources, which contains over 2,000 community resources to help people live with their long term condition.

Digital support

an icon of a computer mouseWe also accelerated the rollout of the telemonitoring programme to support diagnosis and self-care of hypertension and reduce the requirement for patients to attend health centres to have their blood pressure checked. People using this approach require one less consultation per annum on average, a 25% reduction in face to face contacts with a clinician. This was particularly important for patients who were shielding over the last year, many of whom have cardiovascular disease.

Between April 2020 and March 2021, 1,561 new patients have used the Florence Scale Up Blood Pressure programme in Edinburgh to remotely monitor their blood pressure and adhere to their shared management plan. In total, 4,014 patients in Edinburgh from across 60 GP practices use this programme.

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.

The Adult Protection Committee meets bi-monthly to provide assurance and governance of the quality of Adult Support and Protection in Edinburgh. Its membership is drawn from agencies across the public and voluntary sector involved in Adult Protection. The committee considers routine reports to ensure the policies and processes in place keep adults in Edinburgh safe. It also considers what can be learnt and applied from case reviews.

Between April 2020 and March 2021, there were 1,868 adult protection contacts across the city. 43.5% of these referrals were made by Police Scotland, followed by City of Edinburgh Council (22.5%) and NHS Lothian (7.5%). Of the 1,868 referrals received during the year further action was taken in nine out of ten cases.

Just over a quarter of referrals (505) progressed to investigation in the period. Mental health was the most common client group for those whose case was being investigated, followed by infirmity due to old age. The cases that resulted in an investigation were principally due to physical harm (24.4%) and financial harm (20.2%). Of the 505 investigations, seven out of ten resulted in further action.

There were also 641 adult protection case conferences in the year, of which just under a third were initial case conferences.