STRATEGIC MIDLOTHIAN HEALTH AND SOCIAL CARE PLAN JOINT INTEGRATION BOARD 2016 - 19

Working Together to Improve the Health and Wellbeing of the People of Midlothian Midlothian Joint Integrated Board –Strategic Plan 2016/19 Page 1

Throughout the document there are links to related national and local strategies. By pressing control and click on the link you can access these documents directly.

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3.10 FUEL POVERTY ...... 26 Contents 3.11 EMPLOYMENT ...... 26 (Ctrl + Click to go to page) 3.12 HEALTH AND WELLBEING ...... 27 Contents (Ctrl + Click to go to page) ...... 3 4. RESHAPING PRIMARY CARE ...... 27

Appendices Link: ...... 4 4.1 POLICY ...... 27

1. IMPROVING HEALTH AND WELLBEING ...... 5 4.2 NEEDS ASSESSMENT ...... 28

WHY HAVE WE WRITTEN THIS PLAN? ...... 5 4.3 DELIVERY OF PRIMARY CARE ...... 30

1.2 REFORMING HEALTH AND CARE IN 4.4 SKILL MIX ...... 31 MIDLOTHIAN ...... 8 4.5 HEALTH AND WELLBEING ...... 32 1.3 THE MAIN CHALLENGES ...... 10 4.6 PRESCRIBING ...... 32 1.4 WORKING IN PARTNERSHIP - KEY TO SUCCESS ...... 11 4.7 DENTISTRY...... 33

1.5 OUR KEY PRIORITIES FOR CHANGE ..... 13 4.8 OPHTHALMOLOGY ...... 33

1.6 HOW WILL WE PROVIDE SERVICES 4.9 CONTINENCE SERVICE ...... 33 DIFFERENTLY ...... 16 4.10 OUT OF HOURS ...... 34 2. WORKING IN LOCALITIES ...... 19 4.11 SEXUAL HEALTH and BLOOD BORNE 3. ADDRESSING HEALTH INEQUALITIES ...... 21 VIRUSES (BBVs) ...... 34

3.1 WHAT ARE “HEALTH INEQUALITIES”? . 21 4.12 HEALTH VISITORS AND SCHOOL NURSES ...... 34 3.2 NEEDS ASSESSMENT ...... 22 5. MAKING BETTER USE OF OUR HOSPITALS 36 3.3 HEALTH AND DEPRIVATION ...... 22 5.1 NEEDS ASSESSMENT ...... 36 3.4 HEALTH, HOUSING AND HOMELESSNESS ...... 23 5.2 ACUTE HOSPITALS ...... 37

3.5 HEALTH INEQUALITIES AND DISABILITY 5.3. MIDLOTHIAN COMMUNITY HOSPITAL ...... 24 (MCH) ...... 39

3.6 VETERANS...... 24 6. SUPPORTING PEOPLE WITH LONG-TERM HEALTH CONDITIONS ...... 40 3.7 LGBT (Lesbian, Gay, Bisexual, and Transgender) ...... 24 6.1 NEEDS ASSESSMENT ...... 40

3.8 TARGETTED PARTNERSHIP WORKING IN 6.2 LIVING WITH A LONG-TERM CONDITION AREAS OF DEPRIVATION ...... 25 ...... 41

3.9 INCOME MAXIMISATION ...... 25

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6.3. SUPPORTING PEOPLE WITH 10.3 SUPPORT PLANNING ...... 70 PARTICULAR CONDITIONS ...... 42 10.4 GOOD HEALTH ...... 71 6.4 PALLIATIVE CARE ...... 45 10.5 BREAKS FROM CARING ...... 71 7. ADDRESSING THE NEEDS OF PEOPLE WITH 10.6 ADVICE AND SUPPORTED SELF- DISABILITIES ...... 47 MANAGEMENT ...... 71 7.1 PHYSICAL DISABILITIES ...... 47 11. MAKING BEST USE OF OUR RESOURCES . 72 7.2 SENSORY IMPAIRMENT ...... 49 11.1 HOUSING ...... 72 7. 3.LEARNING DISABILITIES ...... 51 See Housing Contribution Statement 8. PROMOTING MENTAL WELLBEING ...... 53 (appendix 6) ...... 72

8.1 PREVENTING MENTAL HEALTH 11.2WORKFORCE ...... 75 PROBLEMS AND PROMOTING WELLBEING 11.3 FINANCES ...... 77 ...... 53

8.2. ENCOURAGING AND SUPPORTING 11.4 WORKING WITH THE THIRD SECTOR 80 RECOVERY FROM ALCOHOL OR DRUG 11.5 TECHNOLOGY ENABLED CARE ...... 80 MISUSE ...... 56 Appendices Link: ...... 82 8.3 SUPPORTING PEOPLE WITH AUTISM .. 59

8.4 MEETING THE HEALTH AND CARE

NEEDS OF OFFENDERS ...... 60 Appendices Link: Appendix 1 Joint Needs Assessment 9. OUR AGEING POPULATION: THE CHALLENGES (Scott) ...... 62 Appendix 2 Summary of Feedback from Community Groups and Individuals 9.1 NEEDS ASSESSMENT AND NATIONAL Appendix 3 Strategic Planning Group POLICY ...... 62 Membership 9.2 COMMUNITY SERVICES ...... 63 Appendix 4 Localities and Map of Area

9.3 INTENSIVE SUPPORT INCLUDING Appendix 5 Related Strategies RESPONSES TO CRISIS ...... 63 Appendix 6 Housing Contribution Statement 9.4 ADDRESSING ISOLATION ...... 65 Appendix 7 Performance- Measuring the 9.5 CARE HOMES ...... 66 Impact of the Plan (to follow)

9.6 DEMENTIA ...... 67

10. UNPAID CARERS - OUR KEY PARTNER ..... 69 summarised version of this plan

10.1 NEEDS ASSESSMENT ...... 69

10.2 EARLY IDENTIFICATION ...... 70

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1.1.2 Understanding the Needs of 1. IMPROVING HEALTH People in Midlothian AND WELLBEING Midlothian is a small Local Authority, the second smallest in mainland Scotland in 1.1.1 A New Approach to the population terms. As a result of a major Delivery of Health and Social Care house building programme, the population is likely to rise from 81,156 to Scottish Government passed legislation in approximately 95,490 in 2020, continuing 2014 requiring health and social care to grow up to 2024 to a predicted level of services to become integrated. This is 99,136. Some estimates suggest even regarded as the biggest change in the higher growth with approximately 12,000 organisation of the National Health new houses projected to be built. Service since its creation in 1948. There are significant differences between A new Health and Social Care Partnership, communities within Midlothian in terms the Integration Joint Board (IJB), is now of their histories, resources and needs. responsible for planning health and care Our largest towns are in the region of services for the Midlothian population. 20,000 while there is a large, rural area to WHY HAVE WE WRITTEN THIS the south of the county. PLAN? Primary Care Services are based in local This Plan sets out how the Partnership will communities, however, other health and provide services over the next three years. care services are provided across It will be updated each year to take Midlothian and, in relation to some health account of changing needs and to take services, across Lothian. advantage of new opportunities to This plan takes an overview of Midlothian redesign services as they arise. and has been developed through: We need to strike the right balance  learning about the needs of people in between long-term planning of services Midlothian - these are described in the and responding to new challenges. We Joint Needs Assessment (appendix 1) must make sure we are ready to maximise breakthroughs in medical science and take  understanding the views of users and full advantage of new technology, whilst carers on our current services – see also responding to changes in the delivery appendix 2 “Summary of Feedback and funding of public services. For from Community Groups and example at the time of finalising this plan Individuals” the Government announced an additional £250m per year to address pressures in  drawing on the issues raised by the social care in Scotland along with new public through the 16 Midlothian short term funding in both Primary Care Neighbourhood Planning Groups and Mental Health.

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 having conversations with staff in policies and strategies such as Reshaping health and social work and with Care for Older People, Caring Together voluntary and independent and the Road to Recovery (see appendix 5 organisations to understand their -relevant national and local strategies). views on how services could become Midlothian Council has elected to include more effective services for offenders in the scope of the We have also considered issues and IJB. This will strengthen the local approach planned service developments in our two to addressing their health and care needs localities, East and West Midlothian (see which are often the root causes of Section 2 and appendix 4), with a offending behaviour. Developing ways of particular focus on those communities reducing offending remains the remit of with high levels of deprivation. the Safer Communities Board.

The Plan has been prepared by the While some children’s services such as Midlothian Strategic Planning Group health visiting and school nursing will fall (appendix 3), which includes User and under the governance of the Partnership, Carer representation. The Group will we will ensure that the planning of these continue to develop the plan and oversee services is firmly aligned with the broader its delivery. The Group will also seek to be strategic planning process for children’s inclusive of the many organisations and services through the Community Planning groups that have an interest in health and Group Getting it Right for Every social care including the Hot Topics (Midlothian) Child (GIRFEC). Forum and the Community Care Close working between children’s services Collaborative, both established to and adult services will remain vital to provide continuing feedback from User ensure effective working with the whole and Carer Groups across Midlothian. family. Additionally, supporting children Specific actions and investments are with special needs as they move into contained in plans compiled by local Joint adulthood is a particularly important Planning Groups (see appendix 5) challenge and we need to ensure their although a number of these are currently transition is as smooth as possible. in the process of being updated. The new Integration Joint Board (IJB) will 1.1.3 Content of the Plan not be directly responsible for overseeing The scope of the Midlothian Partnership is arrangements that protect people at risk outlined in the Integration Scheme. This of harm. This will remain the responsibility covers the full range of community health of the East and Midlothian Public and care services for adults whilst also Protection Committee (EMPPC) the key including some acute hospital-based strategic group dealing with public services. The plan has been developed protection matters across East and taking cognisance of the many national Midlothian, which includes

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representatives from Social Work, Police more connected to and working with local Scotland, NHS Lothian, Education, Housing communities. The relatively small size of and the Third Sector. Midlothian communities provides a real opportunity to engage with local people. The services commissioned by the IJB do however have a crucial role in both Planning services across health and care is safeguarding people from harm in the first a complex exercise and will require all place and in taking decisive steps to four Lothian Integration Joint Boards to ensure that any individuals or groups work together. Whilst significant changes considered at risk of harm are identified, to the design of these services will be supported and protected. critical to achieving the long-term aims of the integration legislation, it is important It is important that, when planning that any such changes are managed in a changes to services, the IJB takes great way that ensures stability and continuity vigilance to ensure that the risk of harm is of service delivery for users and carers. not likely to be increased as a result; indeed service changes should always Developing detailed plans for seek to strengthen arrangements for future years will be ensuring sufficient checks are in place to undertaken during 2016/17. help people to stay safe whilst enabling them to have a greater choice as to how This will include working they live their lives. closely with Acute Hospitals and NHS Lothian Services to The Plan outlines the key areas of service redesign that will take place over the next ensure that pan-Lothian three years. It provides detailed services are more responsive information on the changes initiated to the needs of Midlothian during 2015/16 using new funding people and, wherever available to the Partnership. The use of possible, provided locally. these resources will be particularly influential in reshaping local services 1.1.4 Knowing What Difference during the lifetime of the Plan. the Plan is Making Importantly, the Plan outlines how By redesigning our services, we will be services will be delivered differently. better placed to deliver the key national Changing health and care services for the outcomes. These will include measures, better requires that we improve the which indicate whether: quality as well as the type and volume of  people are being supported to service provided. It is not just what is remain at home for longer provided but how services are delivered.  people are only going to hospital A key change to service delivery will when necessary centre upon service providers becoming

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 people are enabled to return home important that we grasp this opportunity from hospital as soon as they are fit to transform service delivery and achieve to do so the Partnership’s vision of:

 people are able to manage their “People in Midlothian will lead health conditions longer and healthier lives by  there is a real reduction in health getting the right advice, care, and inequalities support, in the right place, at the right time.”  carers are able to continue coping with their caring role We will aim to achieve this ambitious vision by: The Partnership will publish an annual performance report on the impact that  placing greater emphasis on health and social care integration has had supporting people to recover and on the health and wellbeing of the return home Midlothian population. It will include:  working with the whole person  reporting on measures that indicate (Section 1.2.2) whether outcomes for users and  improving patient pathways carers have improved  exploring ways of using new  feedback from users and carers about technologies (Section 11.5) their experience of the quality of health and social care services  working together with carers and local communities The report will enable people to be informed about how the Partnership has  developing stronger partnerships with used its resources and how it has a range of public, private and responded to the needs of localities voluntary agencies (Section 1.4) within Midlothian. The information we will use to measure outcomes and quality Underlying this vision and the key is detailed in the Midlothian IJB objectives of the plan, there is a firm Performance Framework (appendix 7). commitment to the principles of reducing inequalities, promoting opportunities and 1.2 REFORMING HEALTH AND eliminating discrimination in line with the CARE IN MIDLOTHIAN Equality Act and with Human Rights legislation.

1.2.1 Our Vision The creation of a new Health and Care Partnership provides an opportunity for the most significant change in decades to how health and care is delivered. It is

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1.2.2 Work with the Whole Person There is a growing view that people with a We need to think differently about range of health and care needs should be: “health”. We must:  more involved in decision-making  focus on the whole person not only  more in control of their own care the disease  more confident about managing the  recognise the importance of symptoms of their illness physical, mental and social wellbeing to the quality of life of The proposed model for delivering disabled people and those living person-centred, integrated care is the with long-term conditions “House of Care”.

 think differently about disability embracing the principles of independent living

 recognise the role that families, carers, communities and the environment play in supporting people to stay well, recover from ill- health and manage independently

This approach will demand more seamless services - the delivery of care, which is This concept is based upon creating space truly joined up and person-centred. for people to have “a good conversation” The establishment of a single health and about what is important to them and social care budget, including a significant delivering a plan that will help people with proportion of acute hospital resources, such health conditions to live well. The provides the opportunity to create more approach provides a common framework integrated care between hospital, primary for delivering person-centred care care services and social care services. building on the strengths of individuals and communities. The NHS Lothian 10 year Plan seeks to design services around individuals In early 2016 a number of projects were illustrating the complexity of people’s established adopting this approach lives through some fictional patients: including the Wellbeing Team (Section 4.5), TCAT (Cancer Section 6.3.2),  Hannah, a middle-aged person with a Gateways to Recovery (Mental Health long-term condition Section 8.1.4), Lifestyle Management (Section.6.2.2) and the Communities  Scott, a frail older person Health Inequalities Service (see  Callum who has mental health needs Section.3.12).

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1.3 THE MAIN CHALLENGES Older people are more susceptible to developing long-term conditions; most 1.3.1 More people who are frail or people over 65 years have two or more have dementia are living for longer conditions and most over 75s have three or more conditions. at home The health of the population is improving, People living in areas of multiple people are living longer and, as a result, deprivation are at particular risk with, for there are growing numbers of older example, a much greater likelihood of people. early death from heart failure. They are also likely to develop two or more By 2035, the proportion of people in conditions 10-15 years earlier than people Midlothian over the age of 65 years will living in affluent areas (see Section 6). have grown to a quarter of the total population. 1.3.3 There has been little While many older people enjoy good progress in reducing Health health there will inevitably be increased Inequalities pressure on health and care services and Another reason for the move to on unpaid carers. Integration is the need to radically strengthen how we reduce the health With increasing age comes the likelihood inequalities in our Midlothian of living with long-term conditions and communities. People living in particular requiring more frequent support from communities are more likely to be in health services and social care services. poorer health and to die younger with We must support older people to stay in higher rates of cancer, stroke, diabetes good health and recover as fully as and heart disease. possible following ill-health (see Section 9). People with disabilities are also more likely to have lower educational 1.3.2 People are living longer with achievements, higher rates of poverty and multiple Long-term Conditions poorer health outcomes. Managing long-term conditions is one of While ethnic minority groups are small in the biggest challenges facing health care Midlothian - 4% of the population - we services worldwide. must ensure our services are equally People with long-term conditions account accessible and responsive to their for 80% of all GP visits and 60% of all differing cultural needs. We will require hospital admissions. Midlothian has a more comprehensive information about higher occurrence than nationally of such uptake of services by BME groups and conditions as cancer, diabetes, take proactive measures to provide depression, hypertension and asthma. services to refugees resettled here.

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We must also recognise the impact of design services which are sustainable. This caring responsibilities on family members will include emphasising prevention, who themselves are likely to experience providing care closer to home, more poorer health (see Section 3). empowered self-care, more appropriate use of pharmaceuticals and better use of 1.3.4 Our Services are under other health and care resources including pressure the application of new technology.

People place a high value on being able to 1.4 WORKING IN PARTNERSHIP access effective health services when required. They expect to receive high - KEY TO SUCCESS quality care services, when they need 1.4.1 Promoting Health and them whether as a result of age, disability or long-term health conditions. Wellbeing Scottish Government has described the However the financial pressures on public principal outcome of Integration as: services are severe. The difficulties facing health services are often featured in the “People are able to look after their media and are anticipated to become own health and wellbeing and live more challenging in the coming years. in good health for longer”.

We must Use our Services Wisely Being encouraged to live active, healthy Locally the Council continues to face lives depends upon a wide range of major cuts in its overall budget although it services such as the provision of walkways has sought to protect social care budgets. and cycle-paths, and access to affordable There are risks in working under such fruit and vegetables. financial constraints. A failure to invest in During 2016/17, we will review our overall prevention will lead to more pressure on approach to prevention to ensure that the core services in the long-term. current services are effective. We will do In the short term, when the capacity of this by working closely with local networks services is stretched there is the risk of such as the Food Alliance; Council Services using more expensive (and less such as Leisure and Recreation; and the appropriate) alternatives. Local services Voluntary Sector generally. under pressure include Community 1.4.2 Addressing Health Hospital inpatient beds, the Hospital at Home Team, and the Reablement Service. Inequalities A recent national report by Audit Scotland In order to meet the needs of the present concluded that reducing health without compromising the ability to inequalities remains very challenging and address the future challenges we must

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requires effective partnership working opportunities, and we must work with across organisations. Community Planning Partners to address some of these root causes of poor mental In Midlothian, a range of partnership and physical ill health. These issues are groups work together under the umbrella considered in Section 3 on Health of Community Planning to reduce Inequalities. inequalities including the Joint Health Inequalities Partnership (JHIP), the Inclusion also depends upon affordable Midlothian Employment Action Network transport and we must work closely with (MEAN) and Midlothian Financial Inclusion private, public and third sector transport Network (MFIN). agencies to improve access.

1.4.3 Promoting Social Inclusion Transport is a long-standing concern in There is clear evidence of the positive Midlothian with problems such as impact on people’s health when they feel travelling to health appointments and involved in their local community. accessing suitable transport to attend community groups and services. Transport It is difficult to quantify the extent of the is often raised as an issue when people problem of loneliness and social isolation are asked about their experiences, as it is such a subjective experience. regardless of the topic of the consultation However, the Midlothian 2012 Citizens’ or the group of people involved. Panel survey found that, when asked how “connected” and “how much did they A local Transport Working Group was set participate in their local community”, 48% up in 2014 involving representatives of said “very little” and 13% said “not at all”. SEStran (South East Scotland Transport partnership) and the Community While isolation amongst older people (see Transport Association. This Group is Section 9.4) is receiving increased looking at options to address the lack of attention, we know social contact is also affordable, accessible community important and yet can be challenging for transport for people living in Midlothian. people with mental health difficulties, One option being considered is to make addiction, sensory impairment, long-term greater use of Midlothian Council health conditions and disabilities. Transport Division and NHS pool cars. This With a growing proportion of the could involve making use of existing population living alone-(currently 28% in vehicles at ‘down times’ working in Midlothian and expected to rise to 33% partnership with British Red Cross over the next twenty years)-there is a risk volunteer drivers. that this problem will increase.

Inclusion depends on income and employment or volunteering

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1.4.4 Integration of Health and 1.5 OUR KEY PRIORITIES FOR Social Care CHANGE The creation of the local Health and Care Partnership builds on a long history of 1.5.1 Staying Healthy and joint working in areas such as mental Preventing Injury, Illness and health. However, we have a long way go Disability to fully integrate our services; over the Wellbeing: Supporting people to stay coming year we will work with staff and healthy is not a new idea. For example, voluntary organisations to examine how Health Promotion, MELDAP (Midlothian to improve partnership working. This will and East Lothian Drug and Alcohol initially focus on learning disability Partnership ), and the local Licensing services; substance misuse services; Board are all participating in campaign occupational therapy services; and links programmes such as “anti-smoking” and between primary care and social care “drink sensibly”, which have met with services. varying degrees of success. While the emphasis has been on the These campaigns continue to be a priority integration of health and social work, given the strong link to ill-health: for there is no doubt that we need to example the smoking cessation service continue to strengthen links with a wide aims to reduce smoking by 2.5% every range of services. The benefits of doing so two years. have been clear in recent times, working together with, for example, libraries and A growing concern in recent years has leisure centres. been the increase in obesity, which now accounts for 80% of people who develop The relationship between health, social ‘type 2’ diabetes and with it, the long- care and people who use services will be term risk of a range of health problems. central to the successful redesign of health and care as is illustrated by the There are many good examples of the House of Care model (see Section 1.2). promotion of healthy life-styles - for example physical activities such as Integration is intended to ensure we work walking, tai chi, dancing and attendance at better together. This is highly dependent Council leisure centres (which offer upon our capacity to share information reduced charges). This work is co- quickly and effectively and we must ordinated by the Physical Activity and harness new technology to help achieve Health Alliance and delivered through this. programmes such as Ageing Well, which has over 600 older people participating regularly.

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We must continue to develop ways of During 2016/17, we will take steps to encouraging healthy eating which is co- strengthen the local campaign to increase ordinated by the Food and Health the take up of the influenza immunisation Alliance, and to strengthen our capacity to programme, with a particular emphasis on reduce social isolation (see Section 9.4). targeting care staff, unpaid carers and We must pay particular attention to care home residents. supporting the many thousands of unpaid carers in Midlothian to stay in good Screening and Early Diagnosis: There is health, despite the pressures they potential to complement the national experience in their role and the adverse screening programmes for particular impact this can have on their health. illnesses. One local example is screening for COPD (chronic obstructive pulmonary Only by reducing avoidable health diseases) in the area covered by and social care problems can we Newbattle GP Practice, targeted at solve the problem of high and smokers between ages of 55 and 75 years. increasing demand and squeezed Consideration is also being given to resources targeting smokers on the diabetes register particularly in areas of deprivation. This Accidents: The Community Safety could be rolled out and extended to other Partnership takes a lead in developing illnesses/conditions e.g. people who are measures to reduce accidental injuries obese and at risk of diabetes. The and deaths. One of the main issues to be Diabetes – Keep Well Team is piloting the addressed by health and social care use of a prevention programme for people services is reducing injury arising from at high risk of developing diabetes. older people falling and this is considered in some detail in Section 9.3. There may also be potential for our local rapid response service - MERRIT - to We must also work closely with key follow up discharges for people with a agencies such as the Fire and Rescue recent diagnosis of COPD. Service in reducing accidents at home, identifying and referring people who are Access to the right services will be more particularly vulnerable to house fires; for effective if people with specific health example in 2013-14, 10% of house fires in problems have their condition diagnosed Midlothian occurred where the victim was earlier and this Plan includes steps to under the influence of alcohol. achieving this for people with conditions such as dementia, sensory impairment Infectious Disease: The success of and autistic spectrum disorder. immunisation programmes to prevent infectious disease is an issue which we will Fuel Poverty: A third of people (31%) in review during the lifetime of this Plan. Midlothian live in fuel poverty. There is strong evidence that living in fuel poverty

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exacerbates health risks. An older recovery in many areas as diverse as person’s blood pressure rises when substance misuse, pain management, exposed to low temperatures, increasing eating disorders and amputees. their risk of heart attack and strokes. In recent years our ambitions for recovery Getting support to be affordably warm at have increased greatly. This is now the home can have a significant impact on main goal in working with people who people’s health and wellbeing. Facts show experience mental ill-health difficulties or that addressing fuel poverty can reduce: the consequences of substance misuse.

 excess winter deaths; injury and falls; Recovery is not just about how health and and help improve mental health social care services are delivered; it is about helping people to regain a normal  respiratory illness and circulatory life by making it easier to gain disease -the most common health employment, get about, have an problems experienced by people living adequate income, maintain social in cold homes contacts and being able to cope with the The local Warm & Well project, which challenges they face (see Section 6). specifically targets households with health Locally, we have already invested heavily issues, has seen people’s situations in services such as intermediate care beds transformed: nearly 70% of clients said and ‘reablement’ – a care at home service they felt happy about their health and designed to enable people to regain their wellbeing after such support compared skills and independence as far as possible with just 17% before. We need to increase following injury or illness. awareness and develop stronger working relations with Changeworks and other We need now to develop the “House of third sector partners. Care” approach, shifting the emphasis to people managing their own long-term 1.5.2 Enabling People to Recover or health conditions and being able to enjoy Live Well with their Long-term a reasonable quality of life. We recognise Health Condition that people, including carers, will need We must increase the emphasis we place effective support to make this shift (see on helping people to recover their Section 1.2). independence and lead a normal life. Professions such as physiotherapy, 1.5.3 Keeping People Safe from occupational therapy and speech and Risk of Harm language therapy are dedicated to the While being able to live independently for provision of rehabilitation from illnesses longer and in the privacy of one’s own such as stroke or from injuries such as hip home is a central theme of this plan, we fractures. The Psychology Service support must also make sure people are safe from abuse. Midlothian Joint Integrated Board –Strategic Plan 2016/19 Page 15

This requires a very strong approach to As explained in Section 1.2, NHS Lothian’s combating abuse of any type, both at 10 year plan - Our Health, Our Care, Our home and within care homes. The Future - places strong emphasis on creation of the Public Protection Unit treating the whole person whilst involving health, social care and police Midlothian social care services have been staff, all working together with the wider increasingly focused upon meeting the community, will strengthen our efforts to desired outcomes for each individual. address concerns about physical, sexual, We need to continue to strengthen this psychological and financial abuse. It will approach to the provision of services do so in a way that works across the clearly recognising the uniqueness of each whole life-span. individual and their carer(s). This approach also strengthens our capacity to respond to the impact of 1.6.2 Technology Enabled Care traumatic events on the lives of many (TEC) victims of abuse and their increased It is widely recognised that the traditional vulnerability to risk of harm as a service model for health and social care is consequence. untenable going forward. The pressures from the ageing population and the legacy INVESTMENT IN PUBLIC PROTECTION of the financial crisis require that INCLUDES transformation is wrought throughout our services. This will be supported by Support for the delivery of a domestic technology enabled care which is abuse service £20,000 ICF intended to enhance and/or make the 1.6 HOW WILL WE PROVIDE quality of care more efficient through the application of technology. SERVICES DIFFERENTLY TEC should take a whole systems 1.6.1 Treat People as Individuals approach determining the points at which The principle of ‘personalisation’ has been the use of appropriate technology will add a key driver for health and care services in value and enhance the service user’s recent years. This is reflected in the move experience. A strategy is being developed towards a greater focus on improving to take forward this complex and outcomes for individuals rather than on important agenda. providing services or treating particular 1.6.3 Information and health conditions. Communication “What matters to you?” A common theme throughout our rather than programme of consultation with the public was the need for accessible “What is the matter with you?”

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information about where to find help and of available health service advice and how advice. this can be accessed.

While there are comprehensive websites 1.6.5 Planning Ahead and directories available, users, carers and Many people develop and live with long- our staff do not always know where to term conditions such as cancer, heart look for information when faced with a disease or dementia. change in life circumstances. We must find better ways of supporting Alongside improving accessibility to them and their carers by providing clear information, there is a need to provide and concise information and developing more capacity to support people individual anticipatory care plans (ACPs) - effectively, building on the approach planning for the future to help people adopted by Local Area Co-ordination manage as their condition changes. This services. This involves not just giving requires a shift in emphasis by health and people information but supporting them care staff to support people to be more to access the services relevant to them. “in charge” of their own health.

We will invest in communication to help There is a generally held view that it build on the many established local would be helpful to roll out more approaches, including Midlothian comprehensive and holistic ACPs, an Voluntary Action’s website, libraries and approach already used effectively for the national website ALISS (A local people living in care homes and for information system for Scotland). Palliative Care patients.

1.6.4 Access to Services and We will aim to extend this approach, Treatment looking first at patients with complex The need to improve access to health health care needs and those recently advice in the community has been a discharged from hospital – (see work of strong message from the public. the PACT team Section 3.3). Some investment will be needed to enable an Alongside quicker and more direct access, accelerated approach to such there is a desire for more health services, development. including outpatient clinics, day-treatment and rehabilitation, to be provided locally, We must ensure that Accident and whether in Midlothian Community Emergency Staff and the Ambulance Hospital, (see Section 5), Health Centres, Service are able to access ACPs to enable public facilities such as libraries or at them to make the most appropriate home. decisions for each patient.

There is also a need to provide Unpaid carers have raised their concerns information, in a better way, on the range that crises would be managed much more

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effectively if there was a more methodical which can give people more confidence to and widespread approach to planning for manage their own condition(s). emergencies. This will be addressed by the Carers Strategy Group. 1.6.7 Self-Directed Support Another new key dimension to people Planning for the long-term future is exercising more control over their lives is particularly important for families caring Self-Directed Support. for a relative with learning disabilities. This legislation enables people, including The benefits of ensuring families have the carers, to be directly in control of their legal power to act on behalf of their own care arrangements, providing more relatives when they are not capable of flexibility about the type and timing of making their own decisions-for instance as care for the service user and their family. a result of dementia-will be promoted through a campaign to increase the use of This will have a significant impact on the Power of Attorney and when appropriate, way in which services are delivered Welfare or Financial Guardianship through reflecting the general shift away from the Adults with Incapacity legislation. traditional service provision to alternative and more creative ways for individuals to The new Social Care monies announced receive support. A small project team by Scot Govt. will allow investment in the including Users and Carers will continue to expansion of Anticipatory Care Planning co-ordinate the implementation of Self- Directed Support in both directly provided 1.6.6 Self-Management and commissioned services. Supporting people to manage their own health conditions reduces the demands on INVESTMENT IN SELF-DIRECTED SUPPORT health services and social care, whilst INCLUDES Scottish Government funding giving them greater confidence and a (£40k per year for three years) for advice sense of control. and information services in Midlothian Self-management also encourages and provided by LCiL (Lothian Centre for supports people to make adjustments in Inclusive Living) and VOCAL, and building areas of their lives such as employment, capacity among providers. financial matters, leisure and more 1.6.8 Peer Support broadly, addressing the emotional impact There is growing evidence that peer of having long-term conditions. support is highly valued by people who Self-management will only be are unpaid carers or who are coping with strengthened if we invest in providing a particular health condition(s) such as support and education. A number of mental health, physical disability or long- developments are described in this plan term illness. We have some powerful local such as the application of telehealthcare, examples of groups of people supporting

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one another such as the Recovery Café for The Dementia Team is developing a new recovering drug users in Dalkeith. way of working called Dementia Practice Coordination to ensure care of people Peer support is a very effective way of with dementia is effectively co-ordinated. providing self-help, useful information and credible encouragement. It depends The new Social Care monies announced on support from organisations such as by Scot Govt. may allow investment to Midlothian Voluntary Action, those strengthen care planning and in involved in the provision of Local Area particular our capacity to regularly review Coordination (Enable, Red Cross and the needs and care arrangements for Volunteer Midlothian) or on particularly service users active individuals taking the initiative and encouraging such developments.

We need to develop a more consistent 1.6.10 Working together with Users approach that enables people in all and Carers communities to access this form of There has been a growing shift to working support. The first task is to compile a in partnership with users and carers of comprehensive picture of peer support health and social care services. This is now groups in Midlothian. referred to as co-production involving a process of continuing dialogue between INVESTMENT IN PEER SUPPORT INCLUDES people who provide and people who use an allocation of £20,000 to enable services, developing new solutions and Midlothian Voluntary Action to develop supporting people to self-manage. more peer support. One local example of this approach has 1.6.9 Co-ordinated Care been the use of “Family Group More people have a range of complex Conferencing” for those affected by health conditions as a result of living dementia whereby extended families have longer. People who are over 75years are been more directly involved and in control likely to have three or more long- term of care arrangements for their relative. conditions and may require on-going health and care support services. 2. WORKING IN LOCALITIES We must ensure that staff work together There is an increasing recognition that to provide seamless services and co- active, supportive communities are ordinated care arrangements for people fundamental to a good quality of life for with complex health conditions. A new people vulnerable through age, illness or framework, The House of Care (see disability. Inclusive communities can be Section 1. 2), is being introduced to help the key to addressing the harmful effects guide the design of services to achieve a of social isolation, which can lead to more joined-up approach. Midlothian Joint Integrated Board –Strategic Plan 2016/19 Page 19

poorer physical and mental ill health and Partnership Forum (The Hot Topics an increased risk of hospital or care home Group) now addressing social care issues admission. as well as health matters, and with groups who have a specific area of interest e.g. We have strong local communities in Learning Disability, rather than a Midlothian and we must do more to geographical focus - known as harness the strengths they can bring to . improving health and wellbeing. We know communities of interest that key to this includes establishing more There is much work to do to understand effective communication channels and better the needs and current use of demonstrating stronger commitment to resources in our communities. In many working with voluntary organisations regards our approach, until now, has been functioning in those localities. to plan services on a Midlothian wide There are also related challenges for our basis. Our priority over 2016/17 will be to local health and care services in finding develop a much more detailed ways of working more closely with understanding of the varying needs and volunteers (see Section 11.4) and unpaid assets of each community. carers (see Section 10), and recognising As our East/West localities are newly that they rather than formal public defined geographical entities, not services, are critical to the health and previously considered by key data wellbeing of the Midlothian population. providers, this creates challenges for us. Midlothian is small, both geographically Previously the Joint Strategic Needs and in population terms. Due to the Assessment used routinely available data practicalities and implications of planning sources to identify key health issues and commissioning on a small scale, it has affecting the Midlothian population. been agreed to operate on an East/West Many national data sources are currently approach through the establishment of unable to provide information at locality two localities. level, limiting our ability to tailor Whilst our formal approach to locality commissioning of services for the two planning will be on an East/West basis our Midlothian locality areas. intention is to develop better We do know that the key distinguishing connectedness to the natural feature of East Midlothian compared to communities of Midlothian through West Midlothian is the presence of three creating stronger relationships with areas of multiple deprivation (parts of Community Councils and Neighbourhood Gorebridge, Mayfield and Woodburn Planning Groups. [Dalkeith & District]).

Alongside this, we will continue to work In these areas, the life expectancy can be with the newly reformed Public significantly (up to 12 years) less than for Midlothian Joint Integrated Board –Strategic Plan 2016/19 Page 20

people residing in more affluent areas of struggling with poverty and low income Midlothian. Although ‘All Cause Mortality have poorer mental health and wellbeing Rates’ for the population of Midlothian as than those with higher incomes and a whole demonstrates a consistent positive life chances. Scientific evidence downward trend, this hides variation in helps explain how deprivation and other disease specific mortality in East and West forms of chronic stress lead to poor localities. health.

As is described in Section 3 we will seek to Addressing health inequalities is a develop more effective approaches to complex challenge and requires actions to addressing Health Inequalities wherever be taken by many different agencies people live. However our key focus in East working closely with communities. We Midlothian will be to work alongside need to make sure that people vulnerable Community Planning Partners in targeting to or experiencing inequalities have good the three areas of multiple deprivation. access to all public services.

Details of specific plans for East and West By working closely with other agencies we Midlothian are outlined in appendix 4. need to reduce social inequality through addressing poverty, promoting employment opportunities, providing 3. ADDRESSING HEALTH suitable housing etc. This will mean INEQUALITIES increasing resources to those in greatest need -and this may mean some public 3.1 WHAT ARE “HEALTH debate about which services we stop providing- however difficult this will be. INEQUALITIES”? Addressing Health Inequalities is a major The term ‘health inequalities’ describes challenge and one towards which the new the poorer health experienced by some of Health and Social Care Partnerships are our population in comparison with their expected to make a significant neighbours. contribution. Those who experience social disadvantage As policies and programmes are because of low income, social position, developed as part of the strategic gender, ethnic origin, age or disability are planning process, they will be expected to likely to have poorer physical and mental actively consider any potential impact on health than the rest of the population. By health inequalities and report on steps far the most common reason for people that will be taken to reduce these. to experience health inequalities is low income. It is only through concerted efforts across all parts of our services that we will The poorest in our society die earlier and address this issue. have higher rates of disease. People Midlothian Joint Integrated Board –Strategic Plan 2016/19 Page 21

3.2 NEEDS ASSESSMENT homeless population compared to the general population. In Midlothian there are significant inequalities in health between people There are 8 data zones in Midlothian who are socially and economically well in the most deprived 20% areas in off, and those who are socially and Scotland. economically disadvantaged. For example a man living in Dalkeith is likely to live 12 These data zones are concentrated in years less than a man living in Newbattle Dalkeith / Woodburn, Gorebridge and and Dalhousie. Mayfield / Easthouses. Data zones in the most deprived 20-30% are spread more People living in the most deprived widely in Midlothian including parts of communities are more likely to have Loanhead, Penicuik and Rosewell. poorer physical and mental health throughout their lives. An additional challenge is ensuring that we identify people affected by deprivation Health inequalities do not just affect the who are living outside these areas. Some most deprived communities and estimates suggest that around half of individuals. For almost every health people experiencing deprivation live indicator there is a clear link between outside geographical areas that are readily poor health and decreasing affluence identified as experiencing deprivation. while people disadvantaged by race, disability or gender also have poorer Our services need to work consistently to health (see Joint Needs Assessment identify those who are facing appendix 1). disadvantage so that people can access the support they need. There are strong links between health inequality and mental health; for example 3.3 HEALTH AND DEPRIVATION deprivation is a known risk factor for poor The Joint Needs Assessment (appendix 1) mental health. The need to take action to clearly shows that people living in areas of reduce health inequalities is a key multiple deprivation are at particular risk message of the forthcoming Scottish of developing Long-term Health Government Report: Good Mental Health Conditions with, for example, a much for All. greater likelihood of early death from There is also a very strong connection heart failure. between health inequalities and They are also likely to develop 2 or more homelessness. A 2014 review of the conditions 10-15 years earlier than people health of over 2500 homeless people in living in affluent areas. England found a much higher prevalence of physical and mental health problems Deprivation is also strongly linked to the and substance misuse issues in the risk of an emergency hospital admission.

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Reducing health inequalities is a matter of Similarly Social Landlords (Housing social justice but it is also in the interests Associations) have an overall objective to of the health care system to reduce provide high quality housing whether preventable ill health. through new build or by upgrading properties through improvements to We will look to support people to develop insulation, heating, double glazing confidence in self-management, coping etcetera. Alongside this, they provide with their long-term conditions and housing support services such as money leading a healthy lifestyle (see Sections advice, income maximisation and advice 4.5 & 6.2 outlining plans to provide health on adaptations. and wellbeing support). Good information is also crucial to enabling people to live There is also a strong connection between well (see Section 1.6.2). homelessness and health inequalities. It was described in the recent Scottish Public We have begun working with the PACT Health Network report as a ‘late marker’ Team (Patient Experience and of severe and complex disadvantage, Anticipatory Care Plan Team) in the Royal which can be identified over the life- Infirmary. This provides a targeted service course of individuals. for people whose illnesses and life circumstances bring them into regular Unfortunately, homeless people contact with the hospital. The first action experience much higher levels of physical will be to develop stronger links and ill-health, mental ill-health, alcohol abuse effective information sharing between the and illicit drug use than the rest of the PACT Service and local GP Practices. population and dual diagnosis is frequent.

3.4 HEALTH, HOUSING AND Injuries through assaults are also a threat to the physical and psychological health of HOMELESSNESS homeless people. Evidence suggests that living in poor housing can lead to an increased risk of Health problems develop at a much cardiovascular and respiratory disease as younger age and the average age of well as to anxiety and depression. death for a homeless person is 47yrs, compared to 77yrs in the general Dampness, mould, and structural defects population. that increase the risk of an accident also present hazards to health. The provision of a new facility for people who are homeless in Penicuik during The Council has, over a number of years, 2015/16 will create an opportunity to invested significantly in new build provide focused support to residents programmes and extensive upgrading of regarding their health and wellbeing. This existing properties. could include advice and information on dentistry, mental health, smoking and Midlothian Joint Integrated Board –Strategic Plan 2016/19 Page 23

healthy eating as well as income and Locally we are fortunate to have a employment advice. dedicated support service based in Dalkeith - Lothian Veterans Service. This We will develop a co-ordinated approach service provides advice on health, to providing such support linking to the housing, employment and comradeship. House of Care work (see Section 6.2). We must develop closer links with this More generally there is considerable service and more generally ensure that scope to be more proactive in addressing veterans are signposted and provided the health care needs of people who are with appropriate support. homeless and we will work with the Homelessness Service and the Health and 3.7 LGBT (Lesbian, Gay, Wellbeing Team to refresh concrete plans to achieve this. Bisexual, and Transgender) The national report on health inequalities, 3.5 HEALTH INEQUALITIES AND Equally Well (2008) reported that lesbian/gay/bisexual and transgender DISABILITY people experience lower self-esteem and Health inequality is not only associated higher rates of mental health problems, with particular geographical areas; there which have an impact on health is a strong link to long-term disabilities. behaviours, including higher reported People with learning disability are at rates of smoking, alcohol and drug use. particular risk being four times more likely While there is no local data available, to die from a treatable illness. national estimates suggest between 5 - Measures have been taken to address 8% of the population are LGBT. these inequalities and are summarised in It is important to ensure that services are the Learning Disability Section (7.3). We readily accessible for people within this need to develop a similar, proactive significant portion of the population. For approach with people with physical instance it is estimated that older LGBT disabilities. people are 5 times less likely to access services than older people in general. 3.6 VETERANS Veterans of the armed forces and their Awareness raising and staff training families can face many challenges upon programmes will be designed to help leaving the services. These can include address the needs of people who are mental health issues, ill-health and LGBT. disability affecting their quality of life and opportunities to find employment.

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3.8 TARGETTED PARTNERSHIP national average. Poorer health is consistently associated with poverty. WORKING IN AREAS OF DEPRIVATION The economic downturn had a particularly adverse effect on areas with high levels of The Community Planning Partnership has deprivation including parts of Gorebridge, given a strong commitment to working Woodburn and Dalkeith. together to address inequalities in the three areas of multiple deprivation and is Welfare Reform has been a major source seeking to attract funding, including of concern and hardship to many people through the European Union, to support in Midlothian and the Council and its such work. partners have sought to mitigate the worst effects through a range of proactive This project will seek to improve measures: outcomes for residents of these areas by engaging local public services and the  The Midlothian Area Resource local community to investigate the causes Coordination for Hardship (MARCH) of poorer outcomes and develop actions project supports people whose health to reduce these gaps. and wellbeing may be affected by low income The Health and Care Partnership will play  The Citizens Advice Bureaux (CAB) an active part in this work and if the EU operates an advice surgery in project bid is successful there will be a Newbyres Health Centres and also dedicated Health Promotion Specialist targets people with mental health working as part of the core team. problems in the Orchard Centre, the Royal Edinburgh Hospital and Alongside this, NHS Lothian has Midlothian Community Hospital commissioned Midlothian Voluntary Action to support community work in  CAB provides a dedicated service for Mayfield and Easthouses. unpaid carers (see Section 9)

 The Council and local Social Landlords INVESTMENT IN AREA TARGETING WORK provide welfare benefits advice and INCLUDES INCLUDES a Community Empowerment money advice Development Worker £30,000 (NHS Lothian) and, if successful, EU funding for  There is a dedicated Macmillan a dedicated Health Promotion Specialist. income maximisation service for people with cancer (see Section 6)

3.9 INCOME MAXIMISATION  The Money Matters Toolkit is now While employment rates are above the being used by some frontline health Scottish average, 12.5% of the Midlothian and social care staff to check hardship population have a lower income than the issues and provide direct referral to local services. We need to extend this

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approach given the impact which 3.11 EMPLOYMENT poverty has on people’s physical and mental wellbeing ( Low Commission Employment is a key factor in wellbeing, Report 2015) both in helping reduce poverty and as a result of the psychological benefits of  A new service - VOCAL Advocacy being in work – a sense of worth, social Service - is being established to support carers and the people they contact etc. support, with face to face assessments for Personal Midlothian Employment Area Network Independence Payments and seeks to improve opportunities for Employment Support Allowance education, employment and training for people in Midlothian. Support to find INVESTMENT IN INCOME MAXIMISATION employment is provided by the Council’s WORK INCLUDES CAB Service for Unpaid Midlothian Training Services and by Carers £12,500 (Carers Information specialist voluntary organisations. Strategy) and Macmillan Income Maximisation post £35,000 (Macmillan) Funding through social work has been provided to support this work in areas 3.10 FUEL POVERTY such as mental health, substance misuse Those most vulnerable to fuel poverty and and learning disability. Alongside this, NHS cold homes include the elderly, disabled Lothian Working Health Services provides people and people with existing physical advice for people who do not have access and mental ill health. to occupational health in their workplace and are struggling at work because of These groups are often living on fixed their health. incomes and so cannot cope with fuel price rises. Evidence shows that: Support and advice for people with long- term health conditions or enduring  they spend longer in their homes and mental health needs is available through require longer periods of heating specialist Occupational Therapists.

 their temperature control is weaker We will review the scope for strengthening these types of services for  they are more likely to have existing other vulnerable groups such as unpaid medical conditions, and live in the carers and people with physical least energy efficient properties disabilities. Front-line support staff have frequent The Council (3351) and NHS Lothian (526) contact with vulnerable people and are are the major employers in Midlothian well placed to target support that and should lead by example providing promotes warmer and healthier homes, good employment and supporting the and prevention of worsening health employability of others. conditions.

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3.12 HEALTH AND WELLBEING covered by the Newbattle GP Practice (Mayfield and surrounding area), and a Health and wellbeing can encompass a similar project is planned in West broad range of developments, involving Midlothian, to develop peer support, many partners, which interlink with the provide lifestyle advice and promote overarching ambition to reduce health people’s capacity for self-management. inequalities A number of developments, supported by the Health Promotion INVESTMENTS IN WELLBEING INCLUDE: Service, set out to address health inequalities in a range of areas such as  Health and Wellbeing Practitioners sexual health, substance use, alcohol, (House of Care) £40,000 Integrated tobacco, mental health and wellbeing, Care Fund ICF workplace health, ‘Ageing Well’, ‘Money  Specialist Occupational Therapists Matters’ and community empowerment. £70,000 ICF In addition partnership groups such as Health Promoting Hospitals and the Food  Dietetics Weight Management and Health Alliance have a key role to play £25,000 ICF progress this agenda  Public Health Practitioner £45,000 ICF The Keep Well programme was based in  Two part-time Nurses from the two General Practices and sought to Communities Inequalities Team support people to change their behaviours and improve their health outcomes. This programme supplied a 4. RESHAPING PRIMARY wealth of learning on working with people and providing them with support to make CARE positive lifestyle choices, including health behaviour change and access to a range of 4.1 POLICY services. The national 2020 Vision for Scotland’s We are now working with the new Health Service is clear about the need to Communities Health Inequalities Team to strengthen the role of primary care to reach out to people with long-term keep people healthy in the community for conditions and health inequalities to as long as possible. better manage their own health in line Primary Care is also considered critical to with the House of Care model (see tackling health inequalities and to Section 1.2). addressing the challenges facing unscheduled care in hospitals. In recognition of the high incidence of Long-term Conditions in areas of The NHS Lothian 10 year strategy Our deprivation, a pilot project is underway Health, Our Care, Our Future, highlights led by the Thistle Foundation, in the area Midlothian Joint Integrated Board –Strategic Plan 2016/19 Page 27

the vital role that Primary Care will play. We need to find ways of ensuring that the While much of the planning and service best use of GPs’ limited time is being redesign will, in time, be managed at a made and that our health services are local level through the IJB, there are a being used wisely. This includes reducing range of issues which are currently being missed appointments, more self-help managed on a Lothian wide basis. through easier access to information, promoting the use of recovery networks The key long-term priority of the NHS and by encouraging people to seek the Lothian Primary Care Forward Group is advice of other primary care the development of a new model of care professionals. to support the frail elderly (see Section 9). Alongside this we need to develop 4.2 NEEDS ASSESSMENT alternatives including more direct access to social care services and more joint 4.2.1 GPs working between primary care and social The demand for GP appointments is high work services including the option of and it is estimated that about 0.5 million integrated teams. appointments are offered each year in Midlothian. GPs are seeing approximately We will continually review with each of 10% of the Practice population every the local GP Practices what support and week. alternative ways of working would help reduce pressure on GPs. This will include: With recruitment difficulties and additional demands to support the frail  considering the potential to increase elderly at home, in care homes and in- the role of nurses and pharmacists patient continuing care and step up/down  reviewing the medical and nursing facilities, in addition to supporting their services provided to care home core practice population needs, the residents pressures on GPs are increasing.  evaluating the impact of new The number of GPs working in Midlothian measures introduced to support GPs has increased slightly between 2008/9 and 2012/13. However, working practices GPs provide services through a contract are changing, with increasing numbers of between GPs and NHS Scotland. This younger GPs choosing to work less than contract is due to be renewed in 2017 and full-time hours. we will participate in Lothian-wide discussions about how this will be As a result, some Practices have struggled managed. to meet the standard of offering telephone advice or an appointment 4.2.2 Nursing within 48 hours and this has been the Community nursing services provide care subject of concerns raised by the public. for people who are housebound, or who, Midlothian Joint Integrated Board –Strategic Plan 2016/19 Page 28

for health reasons, are unable to access This has resulted in an increasing their GP surgery. Services are available workload for community nursing teams locally between the hours of 8am and and as a consequence, we are reviewing midnight, and, outwith these hours our district nursing services. This will through NHS24. ensure we work in the most efficient way to meet growing demand and that we can The services aim to support patients to continue to provide person-centred care manage their conditions as independently of the highest standard. as possible, and where appropriate to avoid hospital admission. The role of Recent information indicates an overall community nursing staff is vital to enable 1.5% increase in the community nursing patients to manage their health conditions workforce in the past 3 years, mainly without necessarily requiring the achieved through a changing skill mix of attention of their GP. the district nursing workforce. Further investment will be required if we are to Steps are being taken to increase further meet the growing needs of the increased the skills of community nurses, including frail elderly population and complexity of the training and appointment of Advanced caring for people with long-term Nurse Practitioners who will be able to conditions in the community. provide nursing care, which, in the past, has only been available in a hospital We are developing staff to ensure they setting. Investment in a Hospital at have the skills required to provide a Home Service as part of the Midlothian quality service to the local community. Enhanced Rapid Response and This is being done taking into account the Intervention Team (MERRIT) is allowing national and NHS Lothian reviews of patients to receive this advanced care District Nursing. New roles are being within their own home. created such as the Care Home Nurse Advisor, to ensure the quality of nursing There is a shift from hospital care to care care within our care homes is also of a at home, with services now being high standard. provided that were previously only available in a hospital setting. In addition An added concern in Midlothian is that we are facilitating earlier discharge to the service is dependent upon an ageing reduce hospital length of stay. workforce and plans are being drawn up to ensure the service is sustainable in the In line with the Lothian Palliative Care longer term. As part of our broader Strategy we are increasingly managing workforce planning strategy (see Section people receiving palliative care, up to and 11) we will review the future needs of the including end of life care, within their own service in conjunction with NHS Lothian. home or care home (see Section 6.4).

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4.2.3 Allied Health Professionals Lothian in relation to Penicuik, Danderhall (AHPs) and Newbattle. The role and scope of allied health The direction of travel in Midlothian, professionals (physiotherapists, supported by General Practice, has been occupational therapists, speech and to extend existing capacity to manage language therapists and dieticians) to increased demand rather than introduce a support GPs within Primary Care is in the new Practice to the area. However this early stages of being developed in position will remain under continual Midlothian. review with the Midlothian population set The aim is to offer more responsive and to grow significantly over the next 10 accessible services that contribute to years alongside the added pressure diagnosis, support and alternatives to brought about by the continuing trend of treatment that will support self treating more people at home rather than management and preventative, health- in hospital. promoting treatment. 4.3 DELIVERY OF PRIMARY 4.2.4 Primary Care Premises CARE There are 12 GP Practices in Midlothian operating from 10 premises. A number of 4.3.1 Better use of the wider these premises are good quality and Primary Care Team modern, the latest being the new Dalkeith Local opticians provide open access to Health Centre. expert care for eye problems.

A number of GP practices in Midlothian District nurses and practice nurses are have, or are likely, to outgrow the skilled practitioners who can diagnose and capacity of their premises and plans are treat many conditions without the need being developed to address the main for a GP's advice. pressure points. For muscular and skeletal conditions As part of the move to strengthen and physiotherapy services can be accessed expand Health Centre facilities in directly by patients via the MATS Loanhead and Gorebridge, consideration (Muscular-Skeletal Advice and Triage is also being given as to how to design Service) advice line, which is open every improved arrangements for access to afternoon. appropriate care. Dentists provide expert oral care advice, Further developments to support and NHS and private podiatrists provide a improvements and capacity will be range of treatments for lower limb brought forward for consideration by NHS problems.

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There is considerable potential to Other types of testing could be provided maximise the resource of Community but resources would need to be Pharmacists in line with the national transferred from hospital settings. There strategy: Prescription for Excellence. This are, for example, plans to restart includes addressing minor illnesses, ambulatory blood pressure monitoring, smoking cessation and pharmacy initially in West Midlothian via the provision of a chronic medication service Penicuik GP Practice. for those with long-term conditions. There Similarly, more minor injuries could be is also work underway for pharmacists to dealt with in the community through a undertake additional training which, when unit and/or nurse-led clinics rather than in put into practice, will help relieve pressure hospital if GPs and Community Nurses on GPs. were better resourced. There is considerable scope to do more in We will consider a satellite nurse ensuring the public are better informed practitioner from Accident & Emergency and have clearer pathways about when to at the Royal Infirmary being based in go to a member of the wider primary care Midlothian Community Hospital and team. This will include improving the whether it would be viable to establish a provision of information through local and local minor injuries unit. national websites. 4.4 SKILL MIX 4.3.2 Improved Access There are a range of options to be Advanced Nurse Practitioners explored to improve patients’ access to (ANPs) health services. There is considerable scope for Local GP Practices have been testing strengthening Health Centres and telephone triage as way of speeding up Specialist Teams such as MERRIT by access to health advice. Triage can take recruiting ANPs. This would have the the form of a GP, nurse or receptionist additional benefit of supporting a helping to guide patients to the most reduction in GP workload. appropriate resource. Whilst the direction, implementation and It is increasingly possible to undertake management of this approach needs to be various investigations in health centres undertaken at a local level, there is rather than in hospital; in Midlothian support for this being progressed initially coagucheck – a ' near patient' blood test on a Lothian-wide basis. - is provided by GPs and is considerably Health Centre-based Pharmacists more convenient for patients to use than Pharmacists employed directly by NHS the system currently used elsewhere in Lothian and directed by the Prescribing Lothian.

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Adviser could undertake medicine avoid admission. SAS are also prepared to reconciliation and other prescribing work proactively in areas such as projects. This includes repeat anticipatory care planning and provision prescriptions which constitute a high of minor safety adaptations. proportion of the total prescribing budget of £14.4m per annum. 4.5 HEALTH AND WELLBEING People who have long-term conditions This would reduce GP workload, improve account for 80% of GP appointments. It is patient safety and assist practices which vital that we develop other ways of drive cost savings. supporting people to manage their own Work is underway on a pan-Lothian basis conditions more effectively through the to review funding for polypharmacy appointment of staff who can spend more reviews with GPs. time with patients and signpost them to relevant support and specialist advice. Health Care Assistants An expansion of this workforce could The House of Care approach will be support GP and District Nurse workloads. piloted in a number of health centres There is also scope to develop a more focusing upon people with long-term integrated approach whereby HCAs health conditions (Section 6.3.). undertake a case management role in In relation to people with cancer, relation to the provision of social care Midlothian is participating in the national packages. ‘Transforming Care after Treatment’ Training is available through a variety of programme (Section 6.3). sources and modern apprenticeships may Providing quick access to Psychological provide a source of funding. Ensuring Therapies remains challenging in appropriate clinical governance will be Midlothian (see Section 8.2). However, vital. there are opportunities to improve access Scottish Ambulance Service (SAS) to community based services for people The service is committed to becoming with “common” mental health problems more directly involved with local services who do not require psychiatric support. A and utilising the skills of paramedics when new approach is being developed to they have down time. Joint work is provide a single point of contact in health already in place in relation to falls and centres or other suitable venues, to responding to call outs for patients with signpost people to relevant services. dementia. 4.6 PRESCRIBING There is the potential for the service to Medication is vital in helping people provide more direct treatment rather than recover and keeping people well. transport patients to hospital and thereby However the costs are high; almost £15m Midlothian Joint Integrated Board –Strategic Plan 2016/19 Page 32

of the total £45m budget for NHS Services The objective is to increase the in Midlothian is spent on prescribing. registration rates for older people and for Considerable effort is being made to people who are housebound or living in a reduce these costs safely whilst care home. developing alternatives. These include exercise referral schemes and “a healthy 4.8 OPHTHALMOLOGY reading” scheme which is now very well A Lothian Eye Health Network is being used in Midlothian with people using established in 2015/16. books and DVD material to help them cope better with their condition(s) This network is a system of collaboration including through group discussion- A between GPs and optometrists to have Braw Blether. patients with eye problems assessed in the community and when necessary, to Within Midlothian, there are 20 utilise the new optometry referral community pharmacies located in the pathways to allow effective triage by areas of greater population density. The ophthalmology services. new community pharmacy contract aims This collaborative network will hopefully to use the skills and knowledge of encourage individuals with eye problems pharmacists better. This will ensure for to approach optometrists as a first point instance that all patients have access to of contact rather than GPs. support in the management of their medicines as well as providing a minor 4.9 CONTINENCE SERVICE ailment service for advice on such The main objectives of the report, conditions as hay fever, athlete’s foot and cold sores. Promoting Continence in Lothian, are being implemented in Midlothian through 4.7 DENTISTRY a local coordinating group. There is good access to an NHS dentist for These include the Continence Promotion people living in Midlothian with 84% of Pathway and the Adult Urinary adults registered with a dentist (87% in Continence Protocol that are intended to Scotland, March 2015). improve support to people in their own homes and to care home residents. There is a dental strategy for Lothian but it is out of date and a new one is being The option of providing a continence clinic developed during 2015. in Midlothian will be assessed.

Older people (and children under 3years) The Continence Service will be launching a are less likely to see a dentist in “Urinary Catheter Patient Passport” which Midlothian compared with other areas in allows patients and/or carers to be more Scotland.

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informed and able to manage their increasing access to early abortion catheter. services.

4.10 OUT OF HOURS There is also a commitment to: The role of Lothian Unscheduled Care  reducing infection and transmission of Service (LUCS) is to provide urgent sexually transmitted infection and primary medical care services across BBVs (HIV and Hepatitis B and C) Lothian in the evenings and weekends as  improving gender reassignment well as on Public Holidays. services

All requests for healthcare from members  improving sexual health and of the public come to LUCS hub via NHS relationship education in schools and 24, which handles external calls. Following community settings triage, they then pass to LUCS those calls assessed as needing the advice of a This will involve work with: Doctor, a home visit or to be seen at a  men who have sex with men Primary Care Emergency Centre (PCEC). Stronger links are being established  women and men involved in the sex between the Out of Hours Service, industry MERRIT and the District Nursing Service  people who use drugs (DN). The DN Service is available in the evenings and at weekends.  people with a diagnosis of HIV and Hepatitis C The service was the subject of a review during 2014 but in light of public Work will continue to improve access comments and an impending national to services, in both primary care and review, no major changes were made. We specialist services. However there will will consider the outcome of the national also be an increased focus on self review before determining the best way management. Specialist sexual health forward in collaboration with the other and BBV services are delivered by staff Lothian IJBs. from Chalmers Clinic and clinics in Midlothian. 4.11 SEXUAL HEALTH and 4.12 HEALTH VISITORS AND BLOOD BORNE VIRUSES (BBVs) SCHOOL NURSES There is an increased focus on reducing teenage pregnancy as well as unintended Whilst the strategic planning responsibility pregnancies for those over 20 years of for health visiting and school nurses is a age; increasing uptake of LARC (long- delegated function of the Integrated Joint acting reversible contraception); and Board, we recognise the established

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strong partnership working within  Provision of Health and Wellbeing Children’s Services across Midlothian and advice in Health Centres £50,000 ICF the existing alignment to the Integrated plus NHSL and Thistle investment Children’s Services Plan, which reports  Appointment of Pharmacist to support through the GIRFEMC (Getting it Right for GPs £50,000 ICF Every Midlothian Child) Board.  Medication Management - Home Care It is proposed that this arrangement will £5,000 ICF continue and the IJB will support and endorse the Integrated Children’s Services  Medication Management Advice to Plan when it is refreshed in 2016. This will MERRIT & Intermediate Care Services ensure that Health Visiting and School £19,000 (ICF) Nursing are firmly embedded within the strategic planning processes within  GPs home based blood pressure Midlothian, whilst also providing monitoring - £10,000 (ICF) assurance in terms of governance and  Extended COPD Screening in Primary accountability. The current Integrated Care £15,000 ICF Children’s Services Plan can be accessed here. The new Social Care monies announced by Scot Govt. will allow further There are significant challenges currently investment in the Health and Wellbeing facing Health Visiting in Midlothian in Services. In addition in February 2016 relation to recruitment and retention of Scottish Govt invited Health Boards in staff and to the introduction of the collaboration with IJBs, to submit bids for Named Person and other aspects of the Primary Care Transformation Funding. If new Children & Young People’s Act. Midlothian is successful this will enable Whilst these are being managed some additional investment to be made. operationally, both within Midlothian and across NHS Lothian, these pressures will potentially impact on service ability to deliver against strategic outcomes.

SERVICE REDESIGN AND INVESTMENTS IN PRIMARY CARE INCLUDE:

 Capital Investment by NHS Lothian of between £40,000 and £100,000 to upgrade local Health Centre provision and in 2017-18, and in the region of £3.5m for new Health Centre facilities in Loanhead

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5. MAKING BETTER USE OF  Facilitating Early Discharge OUR HOSPITALS  Intermediate Care We recognise that there is no ‘silver 5.1 NEEDS ASSESSMENT bullet’ to solving the challenge of reducing The capacity of acute hospitals to deliver unscheduled care but rather a range of high quality, targeted and timely services evidence-based interventions that have a depends upon community services being cumulative effect of ensuring people can able to prevent inappropriate or avoidable be cared for in their own home or admissions and ensure the fastest community setting. possible discharge. In seeking to change the model and Likewise the effectiveness of community balance of care, we must develop a more services depends upon good quality and sophisticated understanding of how the timely information from hospital staff. Midlothian population is using acute hospitals. This will help determine what Any impediment to smooth working of the services to put in place to provide safe hospital has a direct impact on people and effective alternatives. from Midlothian who require acute hospital care. We welcome the planned introduction of the 72 hours target for delayed discharge Midlothian Partnership has a shared from 2018. We recognise that we must interest with the acute sector in review all the approaches and processes maximising the efficiency of the hospital associated with our relevant community systems. In particular, we recognise that based services. In particular we must delayed discharge, even for a day, is in no- strengthen our capacity to provide one’s interests and that while Midlothian community based services out of hours has consistently met national discharge and at weekends. target in recent years, we should be working towards the complete elimination We are being supported by Scottish of delays in hospital. Government, which has initiated a national programme of work to reduce Furthermore we are also keen to ensure reliance on hospital beds. there are a range of interventions which avoid unplanned admissions and A&E Our performance in relation to repeat attendances. emergency admissions, whilst improving, remains relatively poor. We are taking THERE ARE THREE MAIN STRANDS TO THE further action to reduce unnecessary WORK BEING DELIVERED WITHIN admissions including more intermediate MIDLOTHIAN: care beds. We will carefully review investments made in recent years through  Admission Prevention Midlothian Joint Integrated Board –Strategic Plan 2016/19 Page 36

Unscheduled Care monies and the used successfully in other parts of the Integrated Care Fund. country such as the Western Isles.

The local rapid response service – In-Reach MERRIT - now incorporates a Hospital at The In-Reach Service has been very Home Service, which in 2015 responded successful in enabling Midlothian to to 264 referrals, 77% of which were for consistently meet delayed discharge people over 75 years. targets. With the move towards avoiding delays beyond 72 hours this service will The service has recently extended its be further strengthened including the hours to evenings and weekends and we possible move to a weekend service. will assess the need for an overnight social care service. There are plans to support the hospital In- Reach team through an additional 5.2 ACUTE HOSPITALS community care assistant to ensure more timely discharge from hospital. Given the Discharge Hub high proportion of bed days lost as a The development of the Discharge Hub result of “Health” related delays, we will within the acute services has created an pilot the presence of a District Nurse in opportunity to establish a single point of the In Reach Team to help ‘pull out’ contact between the Hub and Midlothian patients for whom there is judged to be social care services. sufficient health practitioner capacity in the community to enable safe, early All discharge-related enquiries from the discharge. Hub for Midlothian residents will be channelled through a single number and Finally the involvement of unpaid carers in triaged to the relevant local service. This discharge arrangements is critical. The will ensure appropriate referrals and full Carers In-Reach Worker service, piloted in knowledge of support services available recent years, will be continued and we will locally, as well as making it easier for the work with hospital staff to overcome Hub to arrange discharges of patients confidentiality issues to ensure carers are from acute settings. able to support their relative effectively upon discharge. If hospital discharge is To support improved discharge well-planned and the right services put in arrangements there is an undertaking to place then there is a much greater explore methods of improving liaison likelihood of the cared-for person between hospital consultants and GPs. remaining at home with carer support. This will include work shadowing, attendance by consultants at local Discharge to Assess Model Professional Forums and an evaluation of Midlothian Partnership has committed to the potential benefits of teleconferencing, explore the impact on both the hospital

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system, and on the wellbeing of patients delays in hospital for people living with and their carers, of adopting an approach dementia. through which people’s needs are We will also promote a campaign to assessed following discharge rather than encourage more people to arrange Power undertake this process in an acute of Attorney at an earlier stage - an hospital setting. approach that has met with success in Initially the project focused on other parts of the country. unscheduled orthopaedic admissions particularly amongst the frail elderly Liberton Hospital population and supporting the discharge Liberton currently provides approximately of patients with COPD (chronic obstructive 33 post-acute beds primarily for Older pulmonary disease) from Liberton People from Midlothian. Hospital. This service will transfer to the local It has now been extended to include all Community Hospital and to enhanced unscheduled acute admissions to RIE and community based rehabilitation services. Liberton Hospital including general The timing of this depends upon East medicine, medicine of the elderly and Lothian hospital bed capacity increasing, stroke. enabling East Lothian patients to move from Midlothian Community Hospital. Current capacity is limited to weekdays and is dependent on available packages of Reablement care. If, however, this approach proves Discharge to community settings is successful then therapies such as dependent on the capacity of the occupational therapy, physiotherapy and Reablement Service to respond very speech and language therapy will need to quickly to referrals. To ensure we can be enhanced. meet the two week target and work towards the new 72 hour for delayed Discharge arrangements for discharge, we will increase the capacity of Patients with Complex Needs this service. We will also seek to better There is a particular concern that patients understand the impact of reablement with complex needs, particularly those through the application of the IoRN with dementia, are vulnerable to longer (Indicator of Relative Need). This tool is a length of stays in hospital. questionnaire to measure a person’s functional independence. This sometimes arises as a result of legal proceedings being taken by families to obtain Guardianship.

A review of the legal position is being pursued to reduce potentially unhelpful

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5.3. MIDLOTHIAN seeking wherever possible to enable people to die at home if that is their wish. COMMUNITY HOSPITAL (MCH) We have seen the length of stay in our Out-patient clinics wards reduce in recent months as patients There is physical space to hold outpatient are admitted nearer the end of their life. clinics in MCH rather than people undertaking journeys to one of the Our wards continue to have a reputation Edinburgh hospitals. for excellent palliative and end of life care provision. Through training and education For some conditions this will not be of our staff we will continue to make possible because of the need for specialist admission a positive experience and treat professionals or equipment. our patients with dignity and respect.

Work is underway with the NHS Lothian Rehabilitation Out-Patient Board to determine which Additional capacity will be available in services could be provided in this way MCH when developments in East Lothian without incurring significant additional allow in the region of 24 patients to return costs. This may include investigating the to their home area. use of video-conferencing for clinics. There may be a need to strengthen This provides an opportunity to establish transport systems within Midlothian to post-acute rehabilitation services for older ensure good access to MCH. people in MCH rather than in Liberton Hospital, which will improve links with We have seen the benefit of extending local health and care services and support provision of X-Rays in MCH and there have a successful return home. been active discussions about the feasibility of providing local audiology Day Hospital Services clinics given the difficulties associated A review of this service has been with attending the clinic in the centre of undertaken and to ensure high quality, Edinburgh. (Clinics in Midlothian) safe services, the numbers of people attending each day will be reduced. Continuing Care Over the past 10-15 years there has been This will be managed in conjunction with a move away from providing long-term the Day Services Review to ensure that care in hospital settings. People who need people whose primary needs are social long-term 24 hour care should have this rather than medical, are able to access provided in a homely setting. appropriate services.

We will continue to try to reduce the length of time people spend in hospital including those with terminal illness,

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INVESTMENTS TO REDUCE PRESSURES ON 6. SUPPORTING PEOPLE THE HOSPITAL SYSTEM INCLUDE: WITH LONG-TERM HEALTH  Extension of Hospital In-Reach, CONDITIONS Increased Intermediate Care Beds, Assisted Discharge and Single Point of Many conditions, One Life: Living Well Contact Total £432,000 Delayed with Multiple Conditions. Discharge Monies 6.1 NEEDS ASSESSMENT  Transfer of Inpatient Services (20 beds) Managing long-term conditions is one of from Liberton Hospital to Community the biggest challenges facing health care Hospital services worldwide, with 60% of all deaths  Transfer of resources from Liberton attributable to them. Hospital to support 15 patients at home Long-term conditions are illnesses which require ongoing medical care, limit what a  Further expansion of Reablement person can do for a year or more and have Service £164,000 Delayed Discharge a clear diagnosis. Better treatment and Fund earlier diagnosis mean that people are living longer with long-term conditions.  Hospital to Home Reablement service Midlothian has a higher occurrence than ICF £164,000 national averages of cancer, diabetes,  Discharge to Assess Model £41,000 depression, hypertension and asthma. Delayed Discharge Fund Older people are more susceptible to  Overnight Care – Subject to option developing long-term conditions; most appraisal £46,000 Delayed Discharge over 65s have two or more conditions and Fund most over 75s have three or more  Volunteer Service –support following conditions. (This is referred to as ‘multiple discharge £60,000 ICF morbidity’)

The new Social Care monies announced It is estimated that people with long-term by Scot Govt. will allow further conditions are twice as likely to be investment in Reablement; the In-Reach admitted to hospital, have a longer length Team; and Hospital to Home Team of stay and account for 80% of all GP visits and for 60% of hospital admissions.

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6.2 LIVING WITH A LONG-  activities such as employment, leisure and social contacts TERM CONDITION  being able to adjust to the emotional 6.2.1 Work with whole person impact - being told you have a (Hannah) and House of Care condition for which there may be no There is a growing view that people living cure can be devastating both for the with long-term conditions should be person and their families supported to be more involved in Building on previous work undertaken on decision-making, more in control of their the stroke pathway, we will seek to own care and more confident about develop support through specialist managing the impact of their conditions Occupational Therapists, other Allied on their lives. Health Professionals and the Third Sector. There is also increasing recognition of the The importance of maintaining a healthy greater vulnerability to mental health lifestyle is particularly important and problems for those living with long-term services such as Midlothian Active health conditions. Choices will be extended to support The House of Care (Section 1.2.2) is a people to eat well, stay active and take way of describing what is needed to suitable exercise encourage the development of this approach. Using the image of a house 6.2.3 Rehabilitation- Under 65s helps us to appreciate how all the parts Early access to rehabilitation is vital for need to be in place and joined up for this conditions such as stroke, as is on-going approach to be successful. support to maximise the potential for recovery. 6.2.2 Self Management and We need to ensure that intensive Quality of Life rehabilitation is available to people under Increased priority has been given to the age of 65 years. The option of supporting and enabling people to providing this service in Highbank care manage their own conditions such as facility will be considered during 2015-16. Multiple Sclerosis, Parkinson’s disease and COPD - diseases of the lung - which are Sustaining and enhancing current service particularly common as a result provision delivered by the Midlothian Midlothian’s history of mining. Community Physical Rehabilitation Team (MCPRT) will also be important. Self-management is not just about managing the condition itself but also how 6.2.4 Multi-morbidity it influences the person’s lifestyle. As people age they are more likely to have a long-term condition- people over 75 This includes:

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years are likely to have three or more In part, the higher numbers of people with conditions- while people living in areas of diabetes is due to better survival; it is also deprivation will be at risk of developing because diabetes is more common with long-term conditions at a much earlier age and our population is living longer. age. We may also be detecting diabetes earlier It is therefore important that services than in the past. It is estimated that 3533 learn to support the person and their people live with the condition in carer(s) rather than just treating the Midlothian; the majority are over 60 years condition and doing this poses a particular and there is a higher rate in areas of challenge to hospital staff to ensure co- multiple deprivation. Diabetes is a ordinated treatment and support. particularly prevalent condition experienced by people with learning A range of developments are planned disabilities. through the Integrated Care Fund (Midlothian’s allocation: £1.44m) which, There are two broad types of diabetes, although not specific to people with long- ‘type 1’ affects people at a younger term conditions, will enhance local service age and they are treated with insulin responses. These include rehabilitation, injections to control their symptoms. in-reach, intermediate care and services Type 2 affects slightly older people and designed to prevent isolation. is often, although not always, SPECIFIC INVESTMENTS INCLUDE: associated with being overweight.

 Health and Wellbeing Practitioners- We need to work harder to help people £80,000 ICF and Scottish Govt funding with diabetes stay healthy and reduce the number of people with ‘type 1’ whose  Specialist Occupational Therapists diabetes is poorly controlled. £75,000 ICF We will continue with work to implement  Public Health Practitioner £45,000 ICF the national Diabetes Action Plan including supporting self-management.  Midlothian Active Choices £40,000 ICF We will support the work of the Managed 6.3. SUPPORTING PEOPLE Clinical Network in strengthening links between acute, primary care and WITH PARTICULAR community services. Locally we will also CONDITIONS invest in the provision of more weight management courses through our 6.3.1 Diabetes Dietetics Service. An increasing concern for local health services is the rising number of people living with diabetes.

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INVESTMENTS INCLUDE a specific project in the community and by staff in the to address Weight Management £25,000 Western General Hospital. ICF. We will also increase access to physical 6.3.2 Cancer exercise, healthy eating advice and social People are increasingly surviving for activity, as well as supporting people to longer following treatment for cancer. manage their lives more effectively through lifestyle management courses, At this present time there are in the employment and benefits advice. region of 2140 people in Midlothian who have had cancer. INVESTMENTS IN THIS AREA INCLUDE £50,000 per annum 2015/17 to develop Services have focused upon treatment, local services Transforming Care after mainly at the Western General, with Treatment and continued funding for the active follow up and support through Macmillan Income Maximisation Officer Primary Care, Marie Curie staff and the post. local Community Nursing Service which provides care and support for people who 6.3.3 Stroke are terminally ill. The numbers of stroke patients discharged to their own homes in The Partnership has been successful in its Midlothian (i.e. not into care homes) is application to participate in the Macmillan around 90 per annum. Cancer Support TCAT programme (Transforming Care after Treatment’) to There are established pathways and test a new and transformative approach collaborative services available to support to service delivery. early discharge and community rehabilitation. This programme aims to ensure people who are diagnosed with cancer are Work is on-going to ensure adequate prepared for and supported to live with intensity of rehabilitation for stroke the consequences of the diagnosis and survivors in the Midlothian community treatment. and services are constantly evolving to meet the needs of this population. The primary aim is to enable people to access services through effective The on-going collaboration of the signposting and good information. This rehabilitation (MCPRT) and rapid response will be achieved by a process called a services (MERRIT) working with third “holistic needs assessment”, designed to sector partner organisations is providing identify which aspects of life people need this local rehabilitation pathway. assistance with following their treatment. These assessments will be conducted both Stroke-trained exercise professionals currently provide a pathway into exercise

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after stroke in Midlothian, delivered in a The Plan identifies six priority areas for number of Leisure Centres. improvement including prevention, rehabilitation and addressing the mental While vocational rehabilitation and self health needs of people affected by heart management can be delivered locally disease. specialist services required by some people living with stroke in Midlothian are The Heart Disease Strategy Programme accessed in the City of Edinburgh. These Board in NHS Lothian is leading on the include psychology, specialist outpatient implementation of this plan and we will rehabilitation for younger stroke patients, work with this Board to strengthen our postural management, orthotics and approach to heart disease locally. driving assessment. 6.3.5 Chronic Obstructive It is important that patients have access to Pulmonary Disease stroke specialists at an appropriate The Pulmonary Rehabilitation (PR) intensity and duration based on the needs Programme is a Lothian wide of the individual in hospital. However physiotherapy-led service. It is available there is scope to move people sooner for anyone with chronic lung disease and from acute hospital settings and provide provides an exercise-based programme rehabilitation nearer home. We will with a large educational and self examine the potential for doing so both in management component within the Midlothian Community Hospital and community. Highbank Care Facility as well as promoting a “discharge to assess” model This expanding service has built on (see Section 5.2). success within Midlothian and has recently been streamlined and The creation of the new 44 bedded strengthened with additional staffing, and Integrated Stroke Unit at Royal Infirmary a corresponding reduction in waiting is based on the assumption that the times. It is also looking to increase the length of stay there will be 12/14 days so number of venues across Midlothian to the development of stronger community increase availability. based services will be vital. The original service, set up across East and 6.3.4 Heart Disease Midlothian, led on remote telehealthcare The Scottish Government and National provision to offer increased access, Advisory Committee Heart Disease availability and uptake especially for those (NACHD) published a Heart Disease in rural and remote areas. This service has Improvement Plan in 2014 setting out the been expanded and now provides nationally agreed priorities to improve additional occupational therapy, Heart Disease Services for health and nutritional screening and first line social care. nutritional support.

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Acute and crises support in the migraine and on strengthening self community continues to be strengthened management approaches. by Rapid Response and the developing A specialist rehabilitation services for Hospital at Home team (MERRIT). people with Myalgic Encephalomyelitis 6.3.6 Neurological Conditions and Chronic Fatigue Syndrome has been (including Epilepsy, Parkinson’s piloted and implications for future service Disease and Multiple Sclerosis) delivery in Midlothian will be considered. The Neurological Care Improvement Plan As well as the Lothian wide services that 2014-17 was recently published to are based at WGH, RIE (Integrated Stroke improve care and outcomes for people Services) and rehabilitation at Astley with a neurological condition, described Ainslie Hospital, the local MERRIT service as: will respond to urgent / acute aspects of assessment and intensive rehabilitation in ‘The missing millions experiencing the community for people with a disadvantages of complex disability neurological condition. at a young age with fragmented For those individuals requiring longer and inconsistent service provision term community rehabilitation (and across the public sector as a whole possibly supported self management) and within health and social care there is provision by Midlothian systems’. Community Physical Rehab Team (MCPRT), consisting of occupational For example 1 in 97 people are affected therapy, physiotherapy and speech and by epilepsy. Having a neurological language therapy input. condition is the most likely reason for experiencing complex and physical Locally, work is currently being disability for people aged less than 65 undertaken to build on the progress made years. In the region of 20 people living on the Early Supported Discharge locally have Huntington’s disease, an pathway. This was for people following a inherited condition which causes brain stroke within Midlothian and for those damage. The Scottish Huntington’s with other neurological conditions, for Association provides specialist advice and example multiple sclerosis, Parkinson’s support. disease, epilepsy and motor neurone disease. A newly formed Lothian Neurological Leadership Group is focusing on improving 6.4 PALLIATIVE CARE neurological care and outcomes from High quality palliative care is central to all acute to rehabilitation and longer term our services and we strive to achieve a management. Initial work will focus on the pathway for people with headache /

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person-centred approach to care, up to Social care staff have an important role to and including care at the end of life. play. Increased attention is required to ensure that they receive appropriate Primary Care services focus on early training from health staff and specialist identification of the need for palliative services. This has been a particular care, which will ensure that people priority for care homes in Midlothian, receive a gradual, holistic, anticipatory which are considered to be providing high approach to their care needs. quality palliative care. Our Care Home This is particularly important for the Nurse Advisor is supporting this and increasing population who also live with further development of a nurse led dementia, which can make diagnosis more approach is being explored. challenging. We are working to ensure One of the key measures of success is the early identification of patients whose proportion of people who are supported health is deteriorating. to die at home or in a care home rather We are encouraging early conversations than in a hospital setting. In Midlothian to establish people’s wishes and choices in this figure is calculated to be 92.6% which relation to care at the end of their life, shows a small increase since 2008 and is including place of death. Services are above the national average. In real terms changing to ensure care is given according this does represent progress, as the to need and not diagnosis. numbers of people surviving for longer with conditions such as cancer increase. It With many more people living with is important to recognise that for some multiple long-term conditions, often non- people, a transfer to hospice or hospital cancer related, it is important our staff for end of life care may be appropriate. recognise the course of dying and can respond appropriately. This makes it difficult to quantify the scope for further progress and also For the more complex cases, support is highlights the importance of measuring available from specialist palliative care place of care in addition to place of death. services provided by Marie Curie. There is a concern amongst practitioners New guidelines and standards are being that it is important to mirror the very high developed both locally and nationally, quality standards provided for people with including the Palliative and End of Life cancer, with those for people who have Care Strategy Specialist services are being non-cancer conditions. We are working to redesigned and, recognising the changing develop a more balanced approach as we needs of our care home population, there move forward. is a focus on support to care homes to improve standards. When the opportunity arises we will look to invest in nursing and social care

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capacity to increase our ability to support We must also seek to strengthen the people to die at home. provision of bereavement services recognising the impact of loss on families Where hospital care is required and friends. Midlothian Community Hospital has had an increasingly important role to play in providing a high quality local service, 7. ADDRESSING THE NEEDS enabling families and friends to maintain regular contact. Our wards and staff OF PEOPLE WITH already have a reputation for providing DISABILITIES high standards of care, particularly for Closely linked to long-term conditions is those nearing the end of their life. We will the prevalence of disability. continue to ensure our staff, and the facility they work in, provide the highest People who have developed particular standards of care to our population. conditions such as stroke may be disabled as a result. People with learning The strengthening of the Rapid Response disabilities are more likely to have other Service and the establishment of the conditions such as diabetes or epilepsy. ‘Hospital at Home’ service (MERRIT) has increased our capacity to avoid hospital The common theme in this Section is a admissions for people receiving palliative consideration of how the Partnership can care at home as they work closely with take steps to deliver services that GPs and community nursing staff. promote Independent Living as a basic human right reflecting the principles A particular concern is reviewing how we outlined in the UN Convention of Rights of respond to the needs of younger people People with Disabilities. with life limiting conditions. We will establish a local palliative care steering 7.1 PHYSICAL DISABILITIES group to oversee the quality of service delivery, provision of training and 7.1.1 Needs assessment and monitoring of outcomes for users and national policy families. The Equality Act (2010) defines disability We will also work with the local as a physical or mental impairment that population to facilitate a change in has a ‘substantial and long-term adverse attitudes to death and dying and, through effect on people’s ability to carry out day this, ensure that there are conversations to day activities’. In Midlothian we will when appropriate and any health adopt a social model of disability aimed inequalities relating to end of life care are at removing barriers inhibiting everyday addressed. This will include ensuring life. effective links with those who can provide spiritual support. Midlothian Joint Integrated Board –Strategic Plan 2016/19 Page 47

The most recent estimates suggest there 7.1.3 Inclusion are approximately 4,800 people between The primary concern of local people with the ages of 16-64 in Midlothian who have disabilities has been the need for a significant physical impairment. This improvements in access to mainstream includes those born with impairment, services including suitable housing, those who have been disabled through transport, employment and physical injury and those whose disability has access to buildings. developed as a result of an illness. Ensuring housing is suitable, including Prevalence studies indicate that 1200 of through adaptations and providing these will be wheelchair users in equipment to support independent living, Midlothian. can make a huge difference to people’s ability to manage independently. Leisure Unlike other areas of health and social activity and social contact are also very care there is no national policy driving important. improvements for service users. Instead in Midlothian the drive has come from local Local Area Coordination services provided disabled people working co-productively by Enable, Volunteer Midlothian and the with public services. Red Cross, support people to access and develop such opportunities. 7.1.2 Health Inequalities There is national evidence that people Welfare Reform has been a major worry with disabilities are more likely to for people with disabilities and both the experience health inequalities because Voluntary Sector and Midlothian Council they are more likely to live in poverty and have sought to provide support and because disabled people experience advice to mitigate the impact of these discrimination in accessing and securing reforms on local people. health services. Access remains a problem in relation to It is also the case that people experiencing transport (Section 1.4.3), public buildings social deprivation are more likely to and the built environment. Midlothian become disabled for example through Access Panel has a key role to play in accidents, intentional injury and coronary improving physical accessibility and there vascular disease. is a need to develop more comprehensive information about accessibility. We need A proactive approach to addressing health to continue to find ways of improving inequalities is needed, building on the access to buildings and services including successful work undertaken locally in the seeking to strengthen the role and field of learning disability. This will be influence of the Access Panel. considered through the Joint Physical Disability Planning Group. Employment has been an area in which very limited progress has been made. Midlothian Joint Integrated Board –Strategic Plan 2016/19 Page 48

There is now a commitment to key We are at an early stage of this new way agencies coming together to develop an of working and there will be a continued improvement plan and this will hopefully programme of work to ensure that Self- include, amongst others, Job Centre Plus, Directed Support is easily accessed and Business Gateways, the Council and FE managed for those who wish to take more Colleges .(see Section 3.11) control over their care arrangements.

7.1.4 Information and Support IMPROVEMENTS TO SERVICES INCLUDE The local User Group, Forward Mid, has INVESTMENTS AND SERVICE REDESIGN: been proactive in compiling a service directory, newsletters and its own website  The work planned in relation to people to provide information on useful services with Long-term Conditions through the and accessibility. House of Care pilots in Primary Care will be of direct benefit to some Work has also been taken forward people with disabilities through Council libraries to disseminate information to people with disabilities. £40,000 Integrated Care Fund and £40,000 NHS Lothian for the House of Progress has also been made in promoting Care pilot. peer support as an effective way of sharing information as well as providing  With integration there is an credible psychological support. opportunity to streamline access to Occupational Therapy in all areas and 7.1.5 Self-Directed Support this work is underway to reduce Promoting independent living involves duplication especially at transition supporting disabled people to have the points on an individual’s journey same freedom, choice, dignity and control Highbank Care Home is increasingly as other citizens in all aspects of life. providing short-term care for assessment Increasing opportunities for people to be and rehabilitation purposes (see Section in control of their lives has been 9.3.3). Whilst this is primarily for older strengthened through the implementation people, work will be undertaken to scope of new legislation. out the need to adapt the facility to meet the needs of younger people with People with disabilities have traditionally disabilities or complex health needs. been the main users of Direct Payments and are actively involved in the 7.2 SENSORY IMPAIRMENT implementation of Self-Directed Support (see Section 1.6.5). For some people SDS 7.2.1 Needs Assessment and provides a very important means of National Policy maintaining control over their day-to-day See Hear, the national strategy, lives. developed to address sight and hearing Midlothian Joint Integrated Board –Strategic Plan 2016/19 Page 49

impairment, was published in 2014. This considered as part of the review of the requires all Partnerships to produce and Community Hospital. implement a local action plan. 7.2.3 Early Diagnosis Nationally it is estimated that 1 in 6 of the There is a need to improve diagnosis; for population have a hearing loss; in instance it is estimated that 50% of sight Midlothian the 2011 census revealed that loss is preventable or treatable - eye tests 5656 were aware of experiencing some are free and readily accessible. hearing impairment. Deteriorating sight can result in an Significant sight loss is estimated to affect increased risk of falling and sustaining 1 in 30 of the population; in Midlothian, associated injuries. through the Census, 1913 reported having such impairment. Deteriorating hearing can make social interaction more difficult and increase 7.2.2 Communication support isolation and yet people delay addressing The ability to communicate effectively is a the problem for many years. major factor in people being able to live We need to increase awareness amongst independently and feel included. all staff in health and care to be alert to New legislation is being drafted to possible sight or hearing loss and where increase access to British Sign Language appropriate undertake sensory checks for services. Technology offers new people most at risk. opportunities to access support with Older people are most vulnerable and videoconferencing now being made sensory impairment can remain hidden available to enable people access to sign for people who have had a stroke, live language support; the Council has recently with dementia or have learning made this available in their main disabilities, all of whom are more likely to buildings. have some degree of sight or hearing loss. Improving access to communication We must raise awareness of the benefits supports will require work across all of referral to specialist agencies and, in agencies, public and private, in the case of sight loss, of registration. Midlothian. This will include working with In addition, early diagnosis can help NHS Lothian Audiology to provide more contribute towards prevention of falls and services locally where possible; an injury. Sensory Impairment Champions example during 2014 was the provision of have been trained to support local staff replacement hearing aid batteries through training and improve awareness within local libraries rather than people having to their service area. travel into Edinburgh. The possibility of providing services such as testing or hearing aid repairs services will be

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INVESTMENTS TO ADDRESS SENSORY learning disability of 3.2%, there is a need IMPAIRMENT INCLUDE A £15,000 See for change driven by a combination of constrained resources, increasing demand Hear monies for the development and and changing expectations. implementation of a local improvement plan. The growth in the number of people with a Learning Disability known to Midlothian 7. 3.LEARNING DISABILITIES Council from 2012 to 2013 alone was 565 to 596 or 5.5%. 7.3.1 Needs Assessment and National Policy 7.3.2 Health Inequality The development of services has been Reducing the stark health inequalities driven by the national strategy ‘The Same faced by people with a learning disability as You?’ and its focus on ensuring is a key priority. services are as inclusive and community- Initiatives have included better ways of based as possible. combating hate crime and helping people The new national strategy 2013 Keys to to safely manage social media and the use Life, places an emphasis on human rights, of the internet. Work has been tackling health inequality, and living an successfully undertaken in areas such as ordinary life with individualised local sexual health, supporting people to solutions for people. maintain a healthy weight and accessing dentistry. It is estimated that there are 1695 People with a Learning Disability in Midlothian, Focused attention is now being given to 596 of who received a service from hidden sight and hearing impairment. Midlothian Council Health and Social Care Three trained sensory impairment over the past three years. Of these 40 to champions are based in local learning 50 people have very Complex Care Needs. disability services.

The occurrence rate using the latter figure 7.3.3 Accommodation and Support is 8.7 per 1000, compared to the Scottish Many people, who previously would have average is 5.9. One of the contributing lived in hospital or residential care, now factors to the higher figure in Midlothian live successfully in supported is likely to have been the presence of a accommodation on their own or in small large learning disability hospital, St groups. However, for a few people this Joseph’s, which closed in the late 1990s model of care has proven very expensive. when residents moved to houses located For example it is estimated that the across the county. current cost of care for 37 named individuals is in the region of £5 million In addition to an expected average annual per year. A small number of high growth in numbers of people with a

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packages of care cost in the region of 7.3.4 Older People £300k per year. There is significant growth in the number of older people with a Learning Disability Approximately 40 people in Midlothian as better health care has helped increase have particularly complex needs and life expectancy. building has started on a 12 person unit in Penicuik. This will provide local facilities Very recently, funding has been obtained and will enable people to retain their to encourage older people with a learning family links whilst reducing the cost of disability to be more physically active. specialist provision from elsewhere in the country. People with learning disabilities have an increased risk of developing dementia as This service will also develop local they age and generally develop dementia expertise and best practice in supporting at a younger age. people with complex needs using approaches such as Positive Behavioural 7.3.5 Transition to Adulthood Support. More generally, people who More young people with complex needs require specialist health care services are surviving into adulthood. We need to arising from their learning disability will be continue to strengthen the transition to able to access these services in the adult services. community as the model of treatment is The increased emphasis over the past two shifting away further from hospital based years on people using local facilities with care. The new Social Care monies support from the Community Access announced by Scot Govt. may allow the Team rather than going to day centres has development of community based been very successful. This is despite services to support people with supported employment opportunities challenging behaviour. continuing to be very limited given the Alongside this there is a need to provide general economic climate. more suitable accommodation for those More recently steps have been taken to with lower levels of need. Proposals are provide more local day activity facilities being developed in collaboration with for young people rather than them having housing providers. to travel to Edinburgh. INVESTMENT IS PLANNED AS FOLLOWS: : We will examine whether the creation of a  Build programme for the new 12 lifelong disability service would result in person complex care unit £3million more effective transition arrangements (capital) for children and young people with complex needs.

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INVESTMENT IS PLANNED AS FOLLOWS people’s needs. The savings target is approximately £500,000 per annum.  Additional funding to address care needs of identified youngsters leaving school (In 2015/16 £400k)) 8. PROMOTING MENTAL 7.3.6 Respite and Short Breaks WELLBEING Short Breaks provide a chance for family carers to have a break from caring and 8.1 PREVENTING MENTAL provides an opportunity for them to meet HEALTH PROBLEMS AND new people and do new things. Currently PROMOTING WELLBEING Short Breaks for people with a Learning Disability could be in a respite unit or 8.1.1 Needs Assessment involve going to stay at another person’s Mental Health problems are very house. common. One in four of us will experience From April 2016 we plan to offer a wider difficulties sometime in our lives. It is very range of services with less reliance on important that we promote positive traditional buildings based respite and mental wellbeing whilst continuing to more opportunity for flexible breaks. This challenge stigma and discrimination for is in keeping with the move towards Self- those living with a mental illness. Directed Support. Poor mental health is not distributed Service Redesign evenly across the population and there is evidence of mental health inequalities We will work with the Lothian Learning across Scotland. Health inequalities (see Disability Collaborative and look to Section 3.1) are unfair differences in the redesign and integrate community health health of the population that occur across and social work staff. social classes or between population The Council’s contribution to the delivery groups. These are largely determined by of services for people with learning social and economic factors and the way disability is in excess of £11 million per that resources of income, power and annum. wealth are distributed. Recent reviews have shown that the distribution of these In view of the overall reduction in the resources has a significant impact on both Council’s budget, service redesign physical and mental health. proposals are being drawn up for the delivery of supported accommodation, Nationally it is estimated that mental respite care, community based day health issues account for 45% of all illness. services and care packages to find more This was reinforced locally by a snapshot efficient ways of continuing to meet survey undertaken by a local GP who found that for one third of his patients,

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mental health was the main presenting health problems. The possibility of co- issue and for another third, mental health location of these services will be explored. issues were a significant factor. The in-patient facilities in the Royal In Midlothian 4.2% of the population Edinburgh Hospital are being redesigned. reported themselves as having a long- We will ensure that the needs of term mental health condition. Midlothian’s patients continue to be fully met in the new facilities due to open in Developing new approaches to 2016. Alongside this we will seek to prevention, treatment and recovery have strengthen local rehabilitation services been outlined in national and Lothian provided in Park Cottage. wide strategies (Sense of Belonging) and these have helped shape our approach in For older people with mental health Midlothian. problems, Midlothian Community Hospital provides 24 inpatient assessment beds 8.1.2 Psychiatric Support and 24 continuing care beds. These beds Midlothian has seen very significant have been under pressure for some time changes in the approach to treating and and we will consider how best to build supporting people with acute mental greater capacity, if possible through health problems. community based provision. There is also an on-going concern that older people Provision for acute inpatient services for with mental health needs do not always adults was transferred from Rosslynlee receive equal access to mental health Hospital to the Royal Edinburgh in 2007. services. We need to better understand Health, social work and voluntary services this concern and put in place measures in the community were also strengthened. which address any such inequity. As a result, fewer people are admitted to 8.1.3 Support in a Crisis hospital (seventh lowest rate in Scotland) The changes referred to in paragraph and spend less time there when admission 8.1.2 included the establishment of the is necessary. There has however been Joint Mental Health Team made up of the growing concern about the impact of new Intensive Home Treatment Team (IHTT), psychoactive substances (also known as the Continued Recovery Team (CRT) and Legal Highs) leading to serious mental the Psychological Therapies Service (PTS). health problems and self-harm. It is a multi-disciplinary team employed by More generally there is a need to NHS Lothian and Midlothian Council, and strengthen joint working between mental works closely with voluntary organisations health and substance misuse services, to support people at home rather than in given the numbers of people who abuse a hospital setting. substances and are experiencing mental

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The local Suicide Prevention Strategy aims groups, physical exercise programmes or to reduce the incidence of suicide through healthy reading (there is a specialist a range of approaches. These include Bibilotherapist based with the Midlothian raising staff awareness and ensuring that library service). people who are in distress know how to Through some limited new Scottish access support. Government funding there will be the We need to do more to follow up on potential to develop quicker and more people who self-harm, many of whom will direct access to services. Direct access to attend A&E Departments (in 2008/09, a services has been a common theme in the snap shot survey found there were 169 feedback received from the public. We patients from Midlothian discharged will look to invest in psychological following injury through self-harm). Work support services and roll out the is underway to offer local support more “Gateways to Treatment” approach. quickly. We must also work with the The impact of welfare reform on local Police to improve triage arrangements people with mental health difficulties has when they are called to respond. been significant. For many, being able to 8.1.4 Promoting Recovery find employment and have a decent We need to reduce those factors that income will have a particularly important contribute to poor mental health (risk role in enabling them to recover. Support factors) and promote factors that enhance is available through Midlothian Training good mental health (protective factors). Services and through a “Want to Work” programme supported by the Mental In Midlothian, 16% of all patients are Health Team. A review of employment receiving medications for anxiety, support is underway to consider whether depression or psychosis. While such the current arrangements can be medication is often very effective, many strengthened further. people would prefer to have access to alternative forms of support. For others the opportunity to take on a volunteering role can be helpful to Historically, Midlothian has not performed recovery and Volunteer Midlothian has a well in providing quick access to vital role to play in supporting people to psychological therapies - a national HEAT access such opportunities, although care target. must be taken not to jeopardise A review is underway to speed up access entitlement to benefits and a subsequent and identify alternative forms of support drop in income. (This can feel like a ‘catch for people who do require this form of 22’ for people trying to recover and regain intervention. This includes providing independence) direct access to staff who can guide People with long-term health conditions people to alternatives such as support are vulnerable to also experiencing poor Midlothian Joint Integrated Board –Strategic Plan 2016/19 Page 55

mental health. The work planned under substance misuse is a common issue the House of Care model (Section 1.2.2) affecting people who come into contact will help develop responses that take with the Criminal Justice System. account of people’s emotional Substance misuse: vulnerability when having to cope with long-term health conditions.  affects the quality of life and, eventually, the physical wellbeing of It is also the case that people with mental the individual health problems often have poor physical health and we must take steps to ensure  results in family breakdown they have equality of access to the appropriate health care they require.  affects the sense of community and public safety INVESTMENTS IN MENTAL HEALTH WILL  can lead to crime INCLUDE £30,000 through the Mental Health Innovation Fund to develop  causes significant demands on the Gateways for mental health and wellbeing health system through accidents or issues in Primary Care settings long-term acquired brain injury

The application of Primary Care Funding There are approximately 570 regular drug for Mental Health Services may allow users in Midlothian with, on average, 7.5 further development of these type of drugs-related deaths per year. services. Midlothian residents accounted for 1233 8.2. ENCOURAGING AND discharges from hospital in 2012 following the abuse of alcohol. SUPPORTING RECOVERY FROM ALCOHOL OR DRUG MISUSE 1500 children are estimated to live in households in Midlothian where one or 8.2.1 Needs Assessment and both parents have some level of National Policy problematic alcohol abuse. The issue of substance misuse is an An emerging issue of major concern, emotive one - there is a need to ensure locally and nationally, is that of “New that services recognise the complex Psychoactive Substances”, which are causes and the very significant effect on difficult to control, have serious health individuals and their families. consequences and have led to a particular demand on mental health services. There is a strong link between substance misuse and inequalities; some people who 8.2.2 Prevention misuse drugs and/or alcohol can also The Midlothian and East Lothian Drug and experience mental health problems; and Alcohol Partnership (MELDAP) include the

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two Councils, NHS Lothian, Police Scotland being in work increases the likelihood of a and the Voluntary Sector. full recovery.

The Partnership works to raise awareness 8.2.4 Access to Treatment of the work to reduce the harm caused to Accessing treatment quickly is vital. Good individuals, families and communities by progress has been made over the past 18 the misuse of alcohol and drugs. months with 95% of people seeking assistance being seen within the target One of its key objectives is to shift the use time of three weeks. This has been made of resources from specialist treatment and possible by moving towards a self-referral pay more attention to prevention and system: . early intervention. Gateways to Recovery

Counselling, education, enhancement of We must build on this and ensure that employability skills, paid or voluntary people also obtain quick access to support employment and access to sport and for any co-existing mental health issues. leisure can support people at risk of 8.2.5 Support developing serious alcohol or drug abuse. Peer support has proved particularly 8.2.3 Focus on Recovery effective in supporting recovery with a Road to Recovery flourishing ‘Horizons Cafe’ well established in Dalkeith. Research tells us that people often make a full recovery. It may take some people MELDAP has also expanded a pilot Peer years but “recovery is the norm” (Scottish Support Worker role within Midlothian. Government 2010). Yet this is not always This role is proving successful in assisting reflected in the way in which we provide people to access and sustain contact with services. We need to adopt a more services that assist in the development of positive and optimistic approach when their recovery from substance misuse. working with people who have substance During 2015-16 a successful pilot peer misuse problems. support project was developed in Dalhousie Medical Practice with clear MELDAP have established a pilot benefits in terms of reduced prescriptions ‘Recovery College’ in Midlothian providing and life changes. We will consider the adult education opportunities for people possible expansion of the peer support to manage their own recovery. services provided through CLEAR (Community Lived Experience for Alcohol We must also invest more in supporting & Drugs Recovery). people to return to employment, building on the success of LEAP (Lothian and A more neglected area is that of unpaid Edinburgh Abstinence Programme); as carers, which includes young carers with people with mental health needs, (children of parents with substance misuse problems) and kinship carers, Midlothian Joint Integrated Board –Strategic Plan 2016/19 Page 57

grandparents who may be supporting Recovery Cafe and specialist services their offspring and their grandchildren as described below which we must ensure a result of the parents’ alcohol or drug are accessed by people in Midlothian: misuse. MELDAP has recently agreed to fund more dedicated support for carers.  LEAP: is a treatment and rehabilitation programme for those 8.2.6 Partnership Working dependent on alcohol and drugs. It is Addressing substance misuse involves the suitable for those who want to achieve cooperation of a wide range of public and a substance-free recovery. MELDAP third sector agencies. purchases 10 places at LEAP for people in Midlothian. Between 70% and 80% Steps have been taken to ensure closer of people successfully complete the working with other bodies such as the programme and continue to use Police through the creation of a Public aftercare support. MELDAP will Protection Office, which recognises the investigate the need and options for close links between domestic abuse, increased investment in this offending and substance misuse. successful service. Operationally we are now establishing  RITSON CLINIC: The Ritson Clinic is a closer links between mental health, Lothian wide residential stabilisation, substance misuse and offender services. reduction and detox unit for people During 2015/16 we will work towards the with drug and alcohol misuse issues. creation of more integrated health and Clinic staff will engage more closely care services in substance misuse; with people and services in Midlothian currently NHS Lothian services are to ensure a smooth transition in and provided on a Lothian wide basis and out of the clinic. there is common agreement that a more localised approach will be beneficial.  HARM REDUCTION TEAM: Harm Reduction services in Midlothian are The Substance Misuse Service is a provided by staff from the NEON multidisciplinary treatment team which is service (based in the Harm Reduction well integrated working in partnership Team). These include Needle Exchange with the voluntary sector agency- MELD and Blood Borne Virus services. (Mid and East Lothian Drugs), social work Discussions are planned regarding the and other agencies. The service offers a future development of service delivery range of interventions including to Midlothian. assessment, motivational interviewing, recovery support planning, SMART Recovery Groups and pharmacological interventions. The service maintains strong links with GPs, the Horizons Midlothian Joint Integrated Board –Strategic Plan 2016/19 Page 58

8.3 SUPPORTING PEOPLE WITH support, but have a higher likelihood of remaining unemployed, and of mental AUTISM health issues.

8.3.1 Needs Assessment and 8.3.2 Diagnosis National Policy Timely diagnosis, accompanied by clear The Scottish Strategy for Autism was information and early support and published in 2011. Its first indicator of intervention, has emerged as the key good practice was the establishment of issue locally. local Autism Strategies, which have been developed in co-operation with people The strategy focuses on the importance of across the autism spectrum, carers, and early diagnosis and personalised support professionals. for people right across the spectrum, and their families, setting out a clear pathway Midlothian published its Autism Spectrum for them. Disorder Strategy in draft form in March 2014. The subsequent writing of the full 8.3.3 Transition from School strategy is being facilitated by a local arts The Autism Strategy presents an organisation in partnership with a creative opportunity to address the needs of writer with family experience of autism. people with autism throughout the whole of their lives. This includes: The idea is to bring together a collective authorship that harnesses the experience  during those early years when parents and knowledge of people who are close to need help and support to understand autism as part of their everyday life. autism and to begin to prepare their child for a life of inclusion rather than This will be complete by autumn 2015 and segregation will detail how we plan to improve things for people with autism, making sure that  after they finish education, when the right people and the right services are entry into adult life and developing there to support them at the points in independence may be challenging as a their lives when they most need it. consequence of losing the structure that schools provide to parents and We estimate that there are 748 people in young people with autism Midlothian with some form of autism. Midlothian Community Care Services Young people with autism should know about 62 people with autism and experience a personalised and carefully Midlothian Children’s Services know of planned transition from school and 226 young people. children’s services.

Many adults with Asperger’s syndrome do not seek social care or health service

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8.3.4 Opportunities for People Psychology Services in schools, with Autism Spectrum Disorder Regeneration and Community Planning, The local strategy details the development and partners from NHS Lothian. Its of a range of personalised services to objective is to further develop and support adults with autism to live implement the strategy for Midlothian independently, with a particular focus on and to oversee the action plan. supporting participation in meaningful More detailed planning of services for activities including employment. adults with autism in addition to learning disability is covered in Section 7.3. 8.3.5 The Built Environment A built environment is a key determinant INVESTMENTS IN THIS AREA INCLUDE of successful outcomes for some people £35,000 to develop and implement the with autism spectrum disorder. local action plan We are well advanced in our plans to develop and build Council tenancies 8.4 MEETING THE HEALTH AND specifically designed for people with CARE NEEDS OF OFFENDERS Autism and Complex Care needs. 8.4.1 Needs Assessment and 8.3.6 The Regional Autism Service National Policy The Lothian Autism Action Group is A report published in England in 2012 responsible for developing a matched care (Balancing Act) highlighted the health model (ensuring people access the level of inequalities experienced by people in care appropriate to their needs) for contact with the criminal justice system as people with autism who do not have a being well above the national average. In Learning Disability, and taking forward a addition to those in a custodial setting, plan of action to ensure that resources this includes offenders serving community and services are available across Lothian sentences and those in contact with the to provide care, treatment and support. criminal justice system on suspicion of The group provides second opinion committing a criminal offence. assessments, works with colleagues in People who have offended, or are at risk Midlothian to support individuals and of doing so, are much more likely to takes referrals for complex cases. experience multiple and complex health 8.3.7 Implementation of Local issues. These include including mental and physical health problems and substance Action Plan misuse. The Midlothian Autism Spectrum Disorder Strategy Group is a core group that They are three times more likely to die includes representatives from Children’s prematurely and ten times more likely and Adult Services, Resource Managers, to commit suicide.

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Some people who offend have learning population in Scotland has doubled in the disabilities and may need access to past 10 years. It highlights that many support services such as the Appropriate women in the criminal justice system are Adult Scheme. More focussed work is frequent re-offenders with complex needs needed to seek to prevent people with that relate to their social circumstances, a learning disabilities from offending. history of abuse, mental health and addiction problems. 8.4.2 Mental Health and Substance Misuse The local Spring service has been The high incidence of mental health developed on a multi-agency approach problems and substance misuse with based on the Willow Model and is people who offend is well recognised. delivered by local authority, health and voluntary sector staff. In Midlothian between 2009 and 2012 there were on average 1770 people The service is aimed at women with convicted of offences each year, of which multiple and complex needs who have 71 were for drugs related offences and been involved in, or who are at risk of, 384 for alcohol related offences. offending. The project provides cognitive behavioural therapy, support with social The continuing challenge is how to ensure skills and advice on substance misuse, that support to address underlying sexual health and lifestyle. problems is available at an early stage. 8.4.4 High Risk Offenders Of particular concern is how to provide There are multi agency public protection psychological services to people who have arrangements (MAPPA) in place for a history of being abused and other assessing and managing the risks posed by traumatic life experiences, which leads to all sexual offenders. In 2016 MAPPA will various forms of self-harm including self- be extended to those violent offenders medicating with drugs and alcohol. assessed as posing a serious risk of harm.

We will work with the Community Justice We will continue to explore how to Service to improve access to such services strengthen non-statutory services with a particular emphasis on continuity including housing, employment, of care from prison. We will also seek to psychological therapies and third sector strengthen the availability of peer support services all of which can help reduce risk. such as that provided by CLEAR and Pink Ladies. INVESTMENTS TO HELP ADDRESS THE HEALTH AND CARE NEEDS OF OFFENDERS 8.4.3 Women Offenders INCLUDE £15,000 through the Integrated The national report published in 2012 INCLUDE Commission on Women Offenders Care Fund to support the Spring Service for Women at Risk of Offending reported that the female prison

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9. OUR AGEING significantly greater risk of living with dementia. POPULATION: THE Older people are also at risk of frailty, CHALLENGES (Scott) which is a distinctive health state related to the ageing process. It results in 9.1 NEEDS ASSESSMENT AND multiple body systems gradually losing NATIONAL POLICY their inbuilt reserves.

Approximately 14,700 people are over the Living with frailty typically means a person age of 65 years in Midlothian-one sixth of is at a higher risk of sudden deterioration the population. By 2035, this proportion in their physical and mental health. will have grown to one quarter of the population. It is estimated that 10% of people over 65 years have frailty and this rises to The number of people over 75 years is between a quarter and a half of those expected to double over this 20 year aged over 85 years. This would suggest period, and the number of people over there are between 2,700 and 4,200 90 years is expected to treble. people living with frailty in Midlothian.

Amongst this number there will be many This very significant change in population older people who are also undertaking a might suggest we need to plan for major caring role, supporting their partner with investments in services such as day care frailty and long-term health conditions. and care home provision. However, over the previous 8 years, we have seen the The fact that we are living longer is a impact of the transformation of local cause for celebration. Increasing numbers services with investments in home care, of older people should not be considered rehabilitation and local area coordination a problem for society. and a significant drop in care home and The majority of older people live long stay inpatient provision. independently without any formal support The challenge is to continue to develop and many make a very significant this approach, promoting good health, contribution as volunteers, helping run enabling recovery, and meeting people’s local organisations, participating in local needs in more inclusive ways. government, providing unpaid carer or being supportive grandparents. In this regard, Midlothian is receiving national support to develop further our Nevertheless old age does not come approach to frailty. This will include alone. There is a greater likelihood of working with primary care teams to developing long-term health conditions develop tools such as the eFrailty Index and those over 85 years are at for earlier identification of people who are

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frail A key area of focus for this package of care of 10 hours per week. All improvement work will be determining referrals will be responded to within one whether the approaches currently in place working day and package of care will start are having the right impact and outcomes within two working days of receipt of for people living with frailty (and their referral. family and carers). We will also review the possible need for This will also identify what further work is overnight care at home services to required, where the gaps are and, ensure people can remain at home rather crucially, will ensure there is the range of than move into hospital or a care home. service responses are working effectively Alongside this we must continue to together a patients journey in the health support older people to stay healthy by: and social care system.  remaining physically active The work will draw upon the patient pathways developed by NHS Lothian,  having strong social networks which emphasise the need to see people within the context of their whole lives and  avoiding smoking and excessive to understand what is important to them. alcohol  staying warm and safe in winter 9.2 COMMUNITY SERVICES Care at Home services were the subject of Ageing Well programmes, Day Services a major re-tendering exercise and the new provided through the Voluntary Sector providers took over service delivery from and Local Area Coordination services will April 2015. continue to be funded by the Partnership, and where possible, strengthened. The tender requirements sought to help address recruitment and retention issues 9.3 INTENSIVE SUPPORT but there remain significant challenges in INCLUDING RESPONSES TO developing a sustainable social care workforce (see Section 11.2). CRISIS

The new Social Care monies announced 9.3.1 MERRIT (Midlothian by Scot Govt. in late 2015 will allow Enhanced Rapid Response further investment in the reablement Intervention Team) service particularly in supporting earlier As described in Section 5, it is vital that we hospital discharge but also in seeking to provide services that help avoid reduce demand for on-going home care. unnecessary hospital admissions and The planned extension to the service will support people to be discharged as allow for an average of 15 hospital quickly as they are fit to do so. referrals per week and an average

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The enhanced rapid response service In Midlothian we need to do more to (MERRIT) is now fully operational and it is prevent falls through risk assessments by about to be extended to evenings and all multidisciplinary teams, physiotherapy, weekends. exercise programmes and the use of telehealthcare technology. This will support a further reduction in unplanned admissions. The significant Screening people who have fallen can help expansion of the service has led to the reduce the likelihood of a reoccurrence; establishment of a Hospital at Home diet changes and drug treatments for model to avoid unplanned admissions to osteoporosis can reduce the likelihood of acute hospital. a fracture from falling.

This new development now provides a The Falls Coordinator provides falls real alternative to hospital admission, education, information and advice and dealing with an average of 15 new assessment for complex residents of care referrals a month for a wide range of homes. medical conditions. The new Social Care The Midlothian falls service for uninjured monies announced by Scot Govt. will fallers responds to approximately 90 calls allow further investment in the MERRIT a month. The overwhelming majority of Service. falls responses are to those aged 75years AN INVESTMENT OF £77,750 will be made and over. to enhance the operating hours (NHS Falls Pathways have been established with Lothian –Uncommitted Frailty Budget). NHS 24, Scottish Ambulance Service, Fire 9.3.2 Falls and Rescue Service (Bariatric/Fallen Uninjured Person) and Police Scotland. Older people are at particular risk of The Pathways are providing appropriate falling; 30% of the 65+ population and referrals to the Falls Service and ensure 50% of those over 80 years fall each year. that emergency service resources are Falling is the most common reason for appropriately triaged. The service offers older people being admitted to hospital. follow-up support and assessment of a range of risk factors to reduce the Approximately 50% of older people who likelihood of further incidents of falling. fracture their hip are never functional walkers again and 20% will die within six Despite the considerable activity of the months. Falls Response Service, the rate of admissions to hospital as a result of a fall The costs associated with treatment and has risen significantly in Midlothian in longer term care are considerable and has 2012/13, higher than elsewhere in Lothian become a growing focus of attention. and in Scotland as a whole.

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Further analysis is needed to establish occupational therapy input to help whether this is as a result of a few improved rehabilitation. individuals falling frequently or whether a This will enable the ‘Discharge to Assess’ larger number of individuals are affected. model to be piloted in Midlothian. This Stronger partnership working with will be achieved by creating 7 additional Scottish Ambulance Service and beds in Highbank through the relocation preventative work undertaken in care of the MERRIT team base to Bonnyrigg homes over the past 12 months will Health Centre. hopefully have helped arrest this upward There will be a need to consider the long- trend. term suitability of the accommodation in The Falls Practitioner within the MERRIT Highbank given its age and limitations Team is able to provide a falls follow up to such as the lack of en suite facilities. all residents while work is underway to identify “Falls Champions” within Care INVESTMENTS TO HELP PROVIDE STEP Homes. DOWN FACILITIES INCLUDE:

INVESTMENTS TO HELP ADDRESS THE  Maintain the new Intermediate Care services in Highbank £405,000 ICF ISSUE OF FALLS INCLUDE:  Provide 7 additional beds in Highbank  Telehealthcare & Falls Strategy £79,000 Development Work £30,000 ICF

 Falls Response Service £39,000 ICF 9.4 ADDRESSING ISOLATION

 Falls Co-ordinator £9,000 ICF 9.4.1 Impact of isolation on health Isolation and the importance of 9.3.3 Intermediate Care/ Step- relationships were highlighted by a wide Down Beds range of people during the preparation of The increasing number of beds in this plan. It has a particularly high profile Highbank Care Home enables both early in relation to older people including those discharge and prevention of admission. with dementia. Evidence of the benefits of this approach can be seen through comparisons of Along with bereavement, loss of dependency scores (IoRN) employment and debt, social isolation can make us more vulnerable in terms of our We believe there is considerable mental wellbeing whilst increased potential to further extend assessment mobility of families has weakened the and rehabilitation outwith the acute family care network. hospitals, supported by additional The effects of isolation can include increased blood pressure, abnormal stress Midlothian Joint Integrated Board –Strategic Plan 2016/19 Page 65

response, heart disease and poor sleep, based on strong evidence that and substantially increased chances of Neighbourhood Approaches to Loneliness developing dementia. There is a strong are particularly effective in combating association with depression. loneliness.

The impact of isolation is complex and can We will work with Third Sector providers include an increase in self-destructive to review how to maximise our resources habits (overeating, alcohol consumption, to reach as many people as possible. and smoking and lowered activity levels). In older age social isolation is a significant INVESTMENTS PLANNED TO HELP ADDRESS factor leading to admission to care homes. ISOLATION OF OLDER PEOPLE INCLUDE:

Joseph Rowntree research found that  Continuation of Local Area stronger social relationships lead to a 50% Coordination £154,000 ICF increased likelihood of survival.  Development of Peer Support £20,000 We know medication rates for common ICF mental health problems - depression,  Continued additional funding to Day anxiety etc - are high with 16% of the Services £61,000 ICF Midlothian population on some form of medication. Reducing isolation, whilst not  Part funding of Ageing Well the only solution (medication can be very Programme £11,000 ICF effective for some people), will undoubtedly contribute positively to 9.5 CARE HOMES people’s sense of wellbeing. Although there is a strong emphasis on 9.4.2 Local Area Coordination and enabling people to stay at home or in extra care housing for longer, care homes Third Sector Day Services will continue to play a vital, albeit a The traditional approach of attendance at changing role. day centres works well for some people and there is a strong network of local In Midlothian, at any one time, 400 older voluntary organisations providing such people are supported in a care home. This services. figure represents a drop in recent years mainly because people are being admitted The model of Local Area Coordination, at a later stage with the average length of which has been successfully applied in stay now being just over a year. Learning Disability, has been extended to older people and people with dementia This is when their health condition(s) is alongside similar services such as such that they need to be in a more neighbourhood links. This approach of protected environment with constant care enabling people to become more – particularly those with advanced connected with their own community is Midlothian Joint Integrated Board –Strategic Plan 2016/19 Page 66

dementia and those in the latter stage of INVESTMENTS TO HELP SUPPORT THE their lives. DEVELOPMENT OF CARE HOME SERVICES There have been some concerns about INCLUDE Two Care Home Nurse Advisors the quality of service provided and given £54,000 ICF the increasing vulnerability and complexity of care home residents, we 9.6 DEMENTIA need to be fully confident that they are being well looked after. 9.6.1 Needs Assessment While dementia is a condition that can This requires further investment in staff affect younger people (there are training and some work has been approximately 50 people under 65 years undertaken to make videoconferencing living with dementia in Midlothian), it is facilities available so that staff can access strongly linked with increasing age with an training more easily. estimated 31% of people over the age of 85 years estimated to be affected. One key element of our review of care home provision is a consideration of how The rapidly ageing population will result in to ensure the best possible medical and significantly more people living with nursing arrangements. This is being dementia rising from approximately 1400 considered as part of the broader review to 2800 by 2035. of Primary Care (see Section 4). People with dementia are also very likely We will look to strengthen the to have other long-term conditions contribution of other disciplines such as affecting their health and some will have dieticians, and speech and language undiagnosed sight loss. therapists. The EMPAT (East and Midlothian Psychological Approaches Providing services for people with Team) now provides specialist holistic dementia is resource intensive - estimated support for individuals experiencing stress to account for 24% of the total health and relating to dementia. Occupational care expenditure by the Partnership for Therapists will explore opportunities to people aged over 65 years. enhance the environment in relation to 9.6.2 Early Diagnosis and Post residents with dementia. Diagnostic support Given the increasing emphasis on care at There is a drive to increase the rate of home and the development of extra care diagnosis of dementia. However, that is housing we will redesign the model of only of real value if follow-up support is care in Newbyres, recognising the available. A new role of voluntary sector increased needs of residents in terms of post diagnostic support was introduced in their physical health and those in the 2013, working alongside the specialist advanced stage of dementia. health and social care team. This will

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continue and the capacity of this service day care, local voluntary day centres for will be increased in 2015-16. older people and the Volunteer Midlothian Local Area Coordinator for We will also explore how best to support people with dementia. younger people with dementia, recognising their life circumstances may We will undertake a full review of these be very different; they may for instance services to ensure access to the right type be parents or in employment. of support.

We introduced a new way of working with 9.6.4 Acute Hospital Care families referred to as ‘Family Group There are particular concerns about the Conferencing’. This has been successful in experience of people with dementia empowering family members to support admitted to acute hospitals where they their relatives in a co-ordinated way, and are likely to stay significantly longer than a we are now considering how best to patient of the same age and physical sustain this approach beyond the pilot condition but not living with dementia. phase. The move towards a 72 hour target for 9.6.3 Support in later stages people being discharged once they are Midlothian was one of three pilot sites medically fit to do so will require new selected for the implementation of the ways of working; it will be important that first National Dementia Strategy. people with dementia are given the time necessary to make appropriate discharge This led to new service developments arrangements. such as the establishment of a Single Team (health, social work and voluntary It will place even greater importance on sector). This should help ensure that working in close partnership with unpaid people receive a more co-ordinated carers, ensuring the necessary supports service than in the past. are in place and reducing the likelihood of readmission. Providing carer support and reassurance is possible through telecare such as Supporting people with dementia in acute “wandering” alerts. As described in the hospital requires careful planning; the Technology Section (see Section 11.5), we unfamiliar surroundings and the general hope to extend the use of new technology business of acute hospital settings can for people with dementia. lead to distress and agitation.

Day services and local area coordination Strengthening arrangements for people are crucial in providing activity, with dementia in acute settings is being companionship and respite for carers. enhanced by the work of AHP Dementia There are a range of supports from Day Champions Hospital to Alzheimer Scotland specialist

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The use of anticipatory care plans and an effects, helping to make our communities increased take up of Power of Attorney more “dementia friendly”. (see Section 1.6.5) may help ensure that quick and more appropriate decisions can INVESTMENTS IN SUPPORTING PEOPLE be made both at the point of admission WITH DEMENTIA AND THEIR CARERS and in planning discharge. INCLUDE:

Alongside this we will seek to reduce  Dementia Link Workers (Post unnecessary admissions of people with Diagnostic Support) Two posts £72,000 dementia to acute hospital given the - ICF distress this can cause. This will entail the Single Dementia Team working alongside  8 Pillars Project-Housing Guides, the MERRIT (rapid response service) and Training Programmes etc £50,000 the Scottish Ambulance Service with Dementia 8 Pillars Monies whom a hospital at home referral  Carers Support Worker £15,000 - pathway has been developed. The Carers Information Strategy monies Psychology Approaches Team (EMPAT) works to prevent unnecessary admissions  Local Area Coordination £26,000 - ICF from care homes of people with advanced dementia and early results have been encouraging. 10. UNPAID CARERS - OUR KEY PARTNER 9.6.5 Environment and Dementia Caring Together (National Strategy) Friendly Communities Midlothian has been selected to be a site 10.1 NEEDS ASSESSMENT for Scottish Government’s testing of Relatives, friends and neighbours are Alzheimer Scotland’s 8 Pillars Model of often the main unpaid source of support Community Support. We have a particular without necessarily identifying themselves focus on finding ways to make people’s as “carers”. houses more ‘dementia friendly’. There are approximately 14,000 people in Joint work is underway with Council Midlothian who consider themselves to be Commercial Services to develop more in a caring role with 70% receiving no dementia friendly designed housing and support themselves. to enable housing and maintenance staff to take measures that may support people It is difficult to put a monetary value on with dementia in their own homes. the contribution of families and unpaid carers; whether as grandparents, parents, More generally, as with mental health, spouses, siblings or children we all help there is a need to enable everyone to care for one another. However if we try to better understand dementia and its do so it emphasises how crucial carers Midlothian Joint Integrated Board –Strategic Plan 2016/19 Page 69

are; their contribution in Midlothian is (approximately 4% of the Midlothian estimated to be in the region of £170 carers’ population) and this includes million per year - almost twice as much as having access to interpreting resources the budget for the local health and social and culturally sensitive support. care service. GPs and other members of the primary While much attention is focused on the health care team’s contact with patients negative aspects of caring, it is important has been considered a particularly to also consider the positive aspects so effective way to identify hidden carers. that we understand the range of factors We need to ensure that there is easy that can sustain carers in their role. We access to support, following identification, need interventions to reduce the negative as there is little value in simply placing aspects of caring and to enhance the people on a GP Practice carers’ register. positive aspects. Acute Hospital and social care staff are also well placed to identify hidden carers. While many carers view their role as a personal responsibility and one which Early identification and preventing crises they can manage without formal support, helps to reduce pressure on health and we believe many carers in need of support care services. remain hidden. This includes young carers or carers from minority ethnic 10.3 SUPPORT PLANNING backgrounds. Of particular concern are In Midlothian carer’s assessments are those carers who are providing in excess referred to as “carer’s conversations” of 50 hours care per week. The 2011 reflecting the philosophy of a partnership census identified 2173 such unpaid carers approach. Good progress has been made in Midlothian. through joint working between VOCAL and Council staff in improving the It is worth noting that carers living in more effectiveness and quality of outcome deprived areas are more likely to provide based carers’ assessments. longer hours of care than other carers. Further work will be required to embrace 10.2 EARLY IDENTIFICATION the changes planned through legislation Carers cannot be supported without being to strengthen carers’ rights and support identified. In recent years proactive work provided through the Carers (Scotland) Bill has been undertaken to identify hidden including the move towards providing carers and provide support, particularly in Carer Support Plans replacing local schools. “assessments”.

Local voluntary organisations are exploring how to more effectively reach carers from minority ethnic groups

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10.4 GOOD HEALTH 10.5 BREAKS FROM CARING Poor carer health and wellbeing is A more flexible and individualised concerning for both the carer and the approach to respite care has been cared for person. developed through the establishment of the Wee Breaks service. There is a wealth of evidence that carers may experience ill-health particularly as The continued implementation of the the intensity of care giving increases funding of breaks from caring and the roll Research quoted by Carers Scotland has out of Self-Directed Support will enable found that 8 in 10 carers surveyed in individuals to exercise more direct control Scotland say that looking after a over the type and timing of breaks. relative or friend has had a negative However, as more carers are identified impact on their health, including not and more people with complex needs are getting enough sleep, feeling stressed supported at home it is likely that further and experiencing depression. investment in respite care will be needed.

We must consider what other proactive There are particular issues concerning the steps can be taken to reduce the adverse type and capacity of respite care for health impact of caring in addition to the people with learning disabilities and for following: those with dementia. Options for redesign of these services will be developed.  carers are now entitled to the annual flu immunisation 10.6 ADVICE AND SUPPORTED  emotional support is provided through SELF-MANAGEMENT peer groups and through individual VOCAL has established a new Carers counselling Centre in Dalkeith providing a hub for the  access to breaks from caring (see provision of information, advice and Section 10.5) support.

We will develop a more planned approach Demand for individual support is growing to dealing with emergencies (see Section and as a result more emphasis is being 1.6.5) and consider what scope there may placed on enabling access to peer be to establish some form of health clinic support. for carers. We will also consider the Many services including Crossroads and needs of people whose health may have those voluntary organisations providing been affected by providing lifelong care. day services for older people, have their own dedicated carer support arrangements and these are being

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strengthened in areas such as dementia  Carers Support - Older People and substance misuse. attending Day Services £61,000 (ICF)

Sustaining employment becomes difficult  Carers Support in Primary Care – Pilot as caring responsibilities increase. We Project £35,000 (ICF) must work with employers and encourage them to identify and support carers in 11. MAKING BEST USE OF their workplace. OUR RESOURCES Financial advice has been a particularly significant issue in recent times in 11.1 HOUSING response to the Welfare Reform changes. Specialist provision continues to be See Housing Contribution Statement provided through the Citizens Advice (appendix 6) Bureaux (CAB). 11.1.1 Projecting Future Need Carers Scotland quotes that new research, Suitable housing has long been regarded based on the experiences of carers across as vital in supporting people who are frail, the UK, reveals that almost half of carers or have some form of disability, to live in Scotland are struggling to make ends successfully in the community. meet. Staying at home is a viable option for 41% of carers in Scotland want most of us as we age, depending on our increasing financial support for families home’s location, accessibility, size, energy providing unpaid care to be efficiency and proximity to local Government’s top priority. amenities.

INVESTMENTS IN SUPPORTING CARERS National guidance encourages new build WILL INCLUDE housing to incorporate design features that enable people to remain there longer  Carers Support Services £63,000 or to more easily adapt their homes: (Carers Information Strategy) + £7,000 Building for Life . Midlothian Council 11.1.2 Adaptations  Vocal Support Worker service £44,577 Most people wish to stay in their own  Alzheimer’s Scotland Support Worker homes and every year the Council assist £15,947 people to make the necessary adaptations  CAB £12,648 to their property to enable them to do so.

 Hospital In Reach Carer Support Funding for adaptations comes from a Worker £35,000 (ICF) variety of sources and in total, costs in the region of £1.2 million per annum.

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Local analysis indicates that a higher We need to promote the development of proportion of social rented housing extra care housing in the private sector; tenants are older and they may require 63% of people in Midlothian live in the more support to live independently. private sector and half of the tenants in Cowan Court were owner-occupiers, some Consequently the projections are that the of whom would have preferred to retain a number of people requiring adaptations capital asset. to their homes will rise from 247 in 2013/14 to 463 in 2017/18 with significant INVESTMENTS IN DEVELOPING SUITABLE cost implications. HOUSING INCLUDE £48,000 for an Extra Care Housing Officer 11.1.3 Extra Care Housing Midlothian Council continues to build new 11.1.4 Complex Care Housing housing and give some priority to the Midlothian Council is developing 12 new needs of older people, most recently homes specifically to meet the housing through the construction of Cowan Court needs for people with complex learning extra-care housing in Penicuik. We must disabilities enabling them to live in consider the need for similar services for Midlothian in a homely setting. This will people who are not yet frail older people be operational later in 2016-17. but nevertheless are living with complex INVESTMENTS TO DEVELOP COMPLEX or multiple long-term health conditions. I CARE ACCOMMODATION WILL INCLUDE We are working with Housing Associations Capital costs £3m (Council) to redesign some sheltered housing schemes for older people to enable those 11.1.5 Homelessness and Housing with higher levels of need to be Support supported. Overall there are 310 As described in Section 3.4 on Health apartments in 11 schemes that might be Inequalities, homeless people experience considered for potential future adaptation poorer physical and mental health than for extra care service provision. Hawthorn the general population. Gardens (Trust) in Loanhead has already changed its design and model of care to Though most homeless households do not extra care housing. have specific health needs, a significant number have health needs relating to Gore Avenue extra care housing in mental health, alcohol abuse and illicit Gorebridge will be rebuilt with the drug use while dual diagnosis is frequent. opportunity to make more effective use of these houses. We will assess the case for Preventative approaches through housing investing in the establishment of a options resolves housing needs for some dedicated staff team to support tenants but those with more complex needs are of these houses becoming a higher proportion of homelessness applications. Midlothian Joint Integrated Board –Strategic Plan 2016/19 Page 73

There is a need to ensure the right to outcomes by which work on health and housing should be equally available, homelessness can be delivered, with accessible, adaptable and of good quality opportunities for more collaborative to people experiencing homelessness. working between housing and health.

Research conducted into the housing There is also an opportunity through needs of ex-service personnel indicated health and social care integration to that armed forces, and their families, have maximise the connections between specific housing needs that require housing / homelessness and appropriate support. (see Section 3.6) For example, ex- health services. This will ensure those service personnel are more vulnerable to individuals and families affected by homelessness than the population at homelessness are supported by all of the large, and professional pressures can necessary agencies. present problems for finding stable housing for soldiers and their families as 11.1.6 Specialist Housing Needs they may move frequently to new There are 4,664 households on Midlothian postings. Council’s Housing List and 612 of these households require accommodation In addition to homeless households, suited for their medical needs, such as tenants currently resident in affordable requiring ground floor accommodation or housing may also require support in order specialist, extra care housing. to live independently in their existing tenancy, such as being provided with Midlothian Council continues to provide a advice on overcoming addiction, coping small number of wheelchair adapted new with debt and life skills. build housing as part of its Phase 2 housing programme, in addition to Affordable housing providers generally providing specialist housing provision and provide their own support services for extra care housing. their tenants and this could be utilised more in ensuring the health and wellbeing However, specialist housing provision is of tenants. As described in the chapter on more expensive to develop. This hinders health inequalities, fuel poverty (Section development of particular types of 3.9) is a particular concern given its accommodation as grant funding from impact on health and wellbeing. Scottish Government is limited and is not increased to address the additional costs INVESTMENTS TO HELP ADDRESS FUEL of providing specialist accommodation. POVERTY WILL INCLUDE a programme of Midlothian Council operates a shared external wall insulation for harder to treat Gypsy/Traveller Site with East Lothian housing. Council to ensure that these households Health and social care integration can access good facilities, including use of provides a new structure and set of a community room that can be used by a Midlothian Joint Integrated Board –Strategic Plan 2016/19 Page 74

health visitor. Improved provision of along with an affordable charge for labour suitable accommodation is likely to costs. address health inequalities experienced by this group. MONIES WILL NEED TO BE IDENTIFIED to ensure the continuation of the service 11.1.7 Dementia Friendly 8 Pillars during 2016/17 whilst the service expands Work and is able to be self-sustaining. Midlothian is working as a national test During 2015/16 the cost of the site (see Section 9.6) exploring how better Handyperson service was £29,000 plus the housing design can assist people with separately funded cost of adaptation dementia to live more safely at home. This materials, rails etc. includes compiling guidance for designers, builders and property owners in all 11.2WORKFORCE sectors. 11.2.1 Success Depends on Skilled It will also involve providing training and resource material for maintenance staff Staff and Effective Teams and families who may have an interest in The challenges described in this paper can ensuring housing is appropriate for their only be met by a fully equipped and relative at the early stage of dementia. motivated workforce.

Alongside this we must ensure that our The establishment of the Partnership specialist facilities are dementia friendly - should support the development of a a recent example being the provision of culture whereby staff from all sectors new day care facilities provided by work together as part of a whole, joined- Alzheimer Scotland in Bonnyrigg. up system. The move towards more joint services INVESTMENTS TO SUPPORT THE 8 PILLARS requires staff from different organisations WORK WILL INCLUDE Project Management learning to work together and we must £25,000 provide support to ensure these changes 11.1.8 Handyperson Service are successful. On a day-to-day basis people may require 11.2.2 Organisational Development support with small repairs, changing light The increasing emphasis on self- bulbs etc. and over the past two years we management and Self-Directed Support have provided a Handyperson Service will depend upon all staff embracing a through a local social enterprise company. philosophy of working in genuine The intention is to gradually move partnership with service users/patients towards a self-financing model with and carers. service users paying the costs of materials

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We have made good progress in enabling Ensuring all staff have the ability to staff to be more outcome-focused in respond more effectively to the whole providing care packages. person means that we need to continue to strengthen their awareness of the This shift towards a more personalised impact of issues or conditions that are approach is also reflected in the delivery common but not always recognised or of health services. The NHS Lothian 10 acknowledged by service users year strategy lays very strong emphasis on themselves. These include the early stages working with the whole person rather of dementia, hearing and sight loss, the than focusing only on treating the emotional impact of becoming more presenting medical condition. This is likely isolated, over-reliance on alcohol or the to require the development of a different impact of being in a caring role. balance of specialist and generalist skills. There will be a need for staff to have time This personalised approach is to learn about new aspects of their roles. complemented within social services The integration agenda provides an through legislation and accompanying opportunity to explore new approaches to development work to implement Self- learning in order to ensure that staff Directed Support. learning is embedded into their practice – The increased priority given to recovery with effective outcomes for service users. will entail staff developing increased skills Crucially, if we are to address health to work with and help motivate people inequalities, all staff must be alert and act who may not be optimistic about their upon any signs of poverty and do future, given the conditions they are living everything possible to address this critical with such as cancer or challenges they are factor in poor health and wellbeing. We facing such as drug dependence or must build a workforce which depression. understands the causes of inequalities 11.2.3 Learning and Development and has the skills to develop solutions in collaboration with local communities. The growing emphasis on supporting people at home with complex health and 11.2.4 Communication and social care problems will only be Engagement successful if we ensure that staff are able Ensuring that people work effectively to access appropriate training and to together across organisations, particularly ensure that we have the right mix of skills. at a local level, will require creating For example, as we seek to rely less on opportunities for people to establish hospital care we will need to support the positive working relationships with one development of more advanced skills for another and contribute to the community nurses, allied health development of improved services professionals and for care at home staff.

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A series of locality engagement events is more realistic about managing very planned for 2015/16 as is a programme of challenging behaviour in home settings. multidisciplinary professional forums. This We will need to consider all of these will be continued in 2016/17. issues as decisions are taken about the Communication in the form of possibility of localising some of the newsletters, websites and the use of ‘hosted’ services currently managed social media will be put in place as part of across the whole of NHS Lothian. Work is a broader communication strategy. underway to develop a workforce plan (Appendices Link).There will be a focus on across health and social care, including ensuring that communication is accessible the third and independent sector. to staff and citizens who do not use email, This is needed to ensure that we are able websites or social media. to respond to the growing needs of an 11.2.5 Workforce Planning ageing population, the changing model of We must also ensure we have effective care - reducing reliance upon hospitals recruitment and retention policies. In and care homes - and a strong societal areas such as district nursing and home expectation for high quality and safe care we have an ageing staff group, whilst health and social care services. in social care services generally there is a We will work with the Midlothian need to improve our retention of staff as Employment Action Network and high turnover is wasteful of resources and Economic Development to develop a disruptive to service users. This will more strategic approach to health and include marketing Midlothian as a social care workforce issues. During rewarding place to work. 2015/16, Scottish Government funding of Supporting people at home will also £71,500 was applied to the delivery of the require a continued expansion of 24/7 Organisational Development (OD) Plan. staffing; District Nursing Services already It is likely that some additional OD do so; the Intensive Home Treatment capacity will continue to be needed during Team in Mental Health operates until 2016/17 and work will be undertaken to 10pm; while MERRIT has recently moved identify sources of funding. to weekend working.

We also need to strike the right balance 11.3 FINANCES with regard to the skill levels achievable in 11.3.1 Background community care services and recognise when the specialist skills and services The Strategic Plan is dependent upon the financial resources available to the IJB. required, need to be provided in more These resources will be used to action the specialist settings. We may need to be plan. The financial element of the Strategic Plan is laid out in Section 39 of

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the Public Bodies (Joint Working) Act Establishing the core budgets for Adult (2014), which requires the IJB to publish Social Care and Community Health an annual financial statement. Services is relatively straightforward; work continues to ensure that the allocation is 11.3.2 Initial Amount Available to sufficient given the responsibilities that the IJB move to the IJB. This process is referred to This Section lays out an indicative value as “Financial Assurance”. for the proposed IJB’s 2015/16 budget which is derived from the budgets set by Calculating the Midlothian share of NHS Lothian and Midlothian Council made Lothian wide services’, including its share up of four elements. of acute services, is more complicated. Some initial calculations have been made  ADULT SOCIAL CARE: this is the but work will continue during 2015-16 to budget set by Midlothian Council agree a process that best reflects need but which also ensures the continuing  COMMUNITY HEALTH PARTNERSHIP: stability of these services. core services include Community Nursing, Community Allied Health An agreement was reached in principle Professionals, Midlothian Community by NHS Lothian that the NRAC formula Hospital, GMS, GP Prescribing and (based upon population and health Resource Transfer budgets. These are variations) would guide allocations whilst the budgets set for 2015/16 based on recognising there will be anomalies; the NHS Lothian financial plan. some services may require a different process of determining fair allocations.  DELEGATED HOSTED SERVICES: hosted It is vital that an approach is agreed, services are managed on a pan-Lothian which is fair and equitable and does not basis by the CHPs. The shares of these place the IJB at significant financial risk. pan-Lothian budgets are based on a weighted population model and a The initial budget for the IJB is an programme is being developed to indicative outline. However it does enable finalise these following agreement on the Partnership to agree its specific plans a mechanism to share the budgets. for 2016/17, while continuing to develop as the resource allocation to the IJB is  ACUTE SERVICES: delegated to the IJB. more clearly defined and processes for This is not part of the ‘payment’ but is redesigning services provided on a pan- a ‘set aside’ budget held by NHS Lothian basis are determined. Lothian on the IJB’s behalf. The shares across the IJBs have been prepared on Table 1 below lays out the indicative IJB a weighted population basis. budget for 2015/16 although, as mentioned, work on the Health budgets is still being finalised while new monies for Midlothian Joint Integrated Board –Strategic Plan 2016/19 Page 78

Social Care were announced in late 2015. (including capital investments, which have As outlined previously, there are four revenue implications) without discussion main elements to the IJB’s budget. The with the IJB. Wherever possible budgets for 2016-17 and beyond have yet investment should be geared towards to be set by both the Council and NHS strengthening community based services. Lothian while the budget setting model We recognise the challenge this will pose for hosted services and set aside budgets our acute hospitals given the continual is still being developed. high demand made on their service. However, there is no choice about this Table 1 –IJB 15/16 Budget given the need to achieve long-term Health Set Aside £000’s sustainability of the health and care Acute Delegated 17,541 system. The layout of these programmes Integrated Payment is illustrated in the following table:

CHP Core Services 16,629 Programme 2015/16 2016/17 2017/18 2018/19 GMS 12,116 £000’s £000’s £000’s £000’s

Prescribing 14,404 Older 27,815 Resource Transfer 4,727 People Services Hosted 10,349 Learning 13,750 Adult Social Care 36,930 Disabilities

Total 91,632 Physical 3,550 Disabilities Total Resources £112,697 Mental 8,802 Health 11.3.3 Indication of Change Primary 27,486 Reflected within the Strategic Plan Care

The opening allocation of resources will Other 12,278 be analysed by ‘programmes’. Acute Set 17,503 Aside The ambitions and planned changes reflected in the Strategic Plan will then be Children’s 1,513 Services modelled in financial terms. This will illustrate the impact of the plan on those £112,697 programmes. The required shift in the 11.3.4 ‘Directions’ balance of care means that it is essential The Public Bodies (Joint Working) Act that there are no planned investments in describes how the IJB will action its the acute services delegated to the IJB

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Strategic Plan by issuing ‘directions’ to enabling people to cope with and recover both the Council and the Health Board as from social care and health difficulties. appropriate. These ‘directions’ will be The voluntary sector is particularly issued for each function delegated to the effective in nurturing such support IJB and will lay out how much is to be systems and Midlothian Voluntary Action spent in order to deliver that delegated will be allocated additional resources to function per the Strategic Plan. It is ensure more people access such support. important that these directions map 11.4.3 Contribution of Volunteers clearly onto the strategic plan and even if There is a strong tradition in Midlothian of no changes are proposed to the current people giving of their time to support provision of any function delegated, then others. The value of this support is that position will be reflected in the plan estimated to be in the region of £36m per to support the IJB’s ‘Direction’. annum with 37% of the population 11.3.5 Annual Financial Statement reporting that they are involved in The annual financial statement will lay out volunteering in some capacity. the matters as discussed above. When this is set alongside the huge contribution made by unpaid carers, 11.4 WORKING WITH THE (some estimates suggest this may be as THIRD SECTOR much as £170m per annum), then it is clear that sustainable health and care 11.4.1 Role services are completely dependent on a Third Sector organisations play a critical culture of co-production with families and role in the provision of social care services communities. in Midlothian. They are the major provider in delivering services to people with Access to volunteering opportunities can learning disabilities and people with make a valuable contribution to recovery mental health needs. from ill health as well as providing constructive activity and contact for older They are central to helping reduce people who have much to offer. isolation, particularly of older people, in the provision of lunch clubs, day centres 11.5 TECHNOLOGY ENABLED and, more recently, buddy schemes and CARE local area coordination services. 11.5.1 Telecare 11.4.2 Self Help and Peer Support Telecare offers a wide range of devices to As previously referred to, peer support support people live safely in their own has an increasingly important role in homes.

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significant barrier to training in turn As well as a basic service to summon enhancing the care delivered to residents. assistance, used by some 1900 people in New matched Government funding will Midlothian, a range of monitoring devices enable roll out of this facility to all 11 care are used to monitor for example: homes in Midlothian. Video conferencing  when someone with dementia is also being applied to enable deaf people wanders from their home at night to quickly access interpreting assistance.  when someone who is frail has not got 11.5.3 Dementia out of bed in the morning indicating a Midlothian is keen to broaden the possible health problem application of technology to support the  when someone unsteady on their feet delivery of care. An area in Midlothian needs to summon support in walking Community Hospital has been designated The possible use of smart technology to be a ‘dementia digital hub’. The (phones/tablets) to help family members purpose of this development is to share information about the person for encourage conversations to support self- whom they are caring, with one another, management through the use of and as appropriate, with health and care technology. The Hub will offer a resource staff, enabling us to pick up possible where equipment, resources and deterioration at an earlier stage. environmental adaptations can be INVESTMENT of £93,000 in telecare will demonstrated and tried by service users, continue to be made through the carers and staff. The intention is that the Integrated Care Fund Hub will offer support throughout 11.5.2 Video conferencing people’s dementia journey. The important role of care homes in 11.5.4 Frailty Assessment providing high quality care to the local People who are frail account for a population is well recognised by the significant proportion of those admitted Partnership (see Section 9.5). A key aspect to hospital. To shift away from crises care to supporting a sustainable approach to we will explore how best to use high quality care has been to ensure on- technology to help people and their carers going support and training for care home to assess their functioning in daily life. The staff. Care home staff turnover is high and intention of this is that prevention or the ability to release staff for offsite better anticipatory caring may help avoid training has proved consistently limited. crisis admissions. THE NEW MONIES OF £67,500 allocated through the national Creating an on-site hub for staff to engage Technology-Enabled Care Development in weekly tele-education should reduce a Programme will be applied during 2016/17. Midlothian Joint Integrated Board –Strategic Plan 2016/19 Page 81

Appendices Link:

Appendix 1 Joint Needs Assessment

Appendix 2 Summary of Feedback from Community Groups and Individuals

Appendix 3 Strategic Planning Group Membership

Appendix 4 Localities and Map of Area

Appendix 5 Related Strategies

Appendix 6 Housing Contribution Statement

Appendix 7 Performance- Measuring the Impact of the Plan (to follow)

Throughout the document there are links to related documents. By pressing control and click on Appendices Link you can access these documents directly. A summarised version of this plan is also available.

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