1. From Gaun Yersel
to Older and Better
Anne Hendry
National Clinical Lead for Quality
JIT Associate

2. 7 steps for changing the world
• A compelling vision
• A story
• Actions / Stepping stones
• Securing the improvement
• Engaging the workforce
• Making the change work locally (everywhere)
• Resilience, authorisation and a guiding coalition

3. Cocreating our Vision
Throughout Scotland, people with long term conditions
and those who support them, feel valued, confident
and enjoy full and positive lives

4. Culture of Quality and Ambition
Collaboration, capacity & capability

5. 7 High Impact High Level Outcome Statements
Changes Bundles of Improvement Actions
Self Management
Partnership We empower people living with long term conditions, their carers and
the voluntary sector to be full partners in planning, improving quality
and enhancing the experience of care.
Mutuality We support people with long term conditions and their unpaid carers to
be involved in person-centred care planning.
Self Management We commission self management support for people with long term
conditions and their carers and provide relevant, accessible information
Workforce We train staff to have the right knowledge, skills and approach to long
Development term conditions care.
Integrated Care We provide better, local and faster access to healthcare, social care and
housing services for long term conditions
We strengthen the contribution of Managed Clinical/Care Networks
Quality Improvement
(MCNs) in improving support for people with long term conditions
We have information systems that support registration, recall and review
Clinical Information Systems of people with multiple conditions, and support data sharing across all
partners.

6. Implementation & Improvement Support
• LTC Programme Board – governance and key
strategic partners eg NES; LTCAS; NHS 24
• Delivery group – Operational exec and clinical
leaders witrh a focus on performance
• LTC Collaborative - local programme teams with a
focus on improvement
• Engagement – LTC are everyone’s business

7. Improvement Activists
• Visible leaders across professions
• Influential at all levels and across system
• Leverage in professional structures
• Influence on corporate focus
• Influential in workforce planning
• Lead roles in practice development
• Users and carers

8. 2 Million Lives : people not patients
Digital Story Library

9. Top Tips and Practical Guidance

10. Spread and Adoption
Buddying, Networking and Practice Exchange

11. Food for Thought ……. Using Local Improvement Data
Extended
Sutor Ward Invergordon Community
Team Meetings
60.0
+
Spot Purchase
50.0 Home Care
40.0
30.0
20.0
10.0
0.0
Aug-06 Feb-07 Aug-07 Feb-08 Aug-08 Feb-09 Aug-09 Feb-10 Aug-10 Feb-11
LOS Discharges

12. Driving National Performance
Bed Days per 100,000 population for T6 Long Term Conditions
Monthly Trend
Scotland 12 month moving Average Scotland 12 month moving Average Scotland Monthly T6 Bed Days
Scotland Trajectory Target Scotland Trajectory Target Linear (Scotland Trajectory Target)
1,000
900 LTCC launch High Impact
800 Changes and support
Monthly Bed Days per 100K pop
700
600
500
400
300
200
100
0
A 6
A 7
A 8
A 9
A 0
O 6
F 6
7
O 7
F 7
8
O 8
F 8
F 9
9
O 9
0
O 0
F 0
1
Ju 6
D 6
Ju 7
D 7
Ju 8
D 8
Ju 9
D 9
Ju 0
D 0
-0
-0
-0
-0
-0
-0
-0
-0
-1
-1
-0
0
-0
0
-0
0
-0
0
-1
1
-0
-0
-0
-1
-1
-0
-0
-0
-0
-1
n-
n-
n-
n-
n-
ec
ec
ec
ec
ec
ug
ug
ug
ug
ug
ct
ct
ct
ct
ct
pr
pr
pr
pr
pr
eb
eb
eb
eb
eb
A
A
A
A
A
M onth of Discharge
15% reduction in bed day rate

13. The Next Challenge
Reshaping Care

14. Reshaping Care for Older People
‘Older people in Scotland are valued
as an asset, their voices are
heard, and older people are supported
to enjoy full and positive lives in their
own home or in a homely setting.’

15. Implementation & Improvement
• Shared Vision – An Older and Better Scotland
• 3 workstreams – co-production and community capacity
building; housing and care settings; care pathways
• Change Fund as catalyst to lever change in spend
• Local Change Plans agreed by NHS, council, third sector
and independent sector partners and agreed Joint
Commissioning plans by 2012 / 13
• Improvement network and support from JIT
• Core set of measures of success

16. Reshaping Care Pathway

17. Integrated Community Team

18. 75+ emergency bed days
NHS Lothian
Area Rates of All Emergency Admission Bed Days Scotland Rates of All Emergency Admission Bed Days
Area Trajectory Target Scotland Trajectory Target
Area Trajectory Baseline / Milestone Scotland Trajectory Baseline / Milestone
Area Linear Trajectory Scotland Linear Trajectory
Management information only. Not for onward distribution.
Annual Bed Days per 1,000 Population
6500
6000
5500
5000
4500
4000
3500
3000
9 9 9 9 9 0 0 0 0 0 0 1 1 1 1 1 1 2 2
r-0 ay-0 ul-0 ep-0 ov-0 an-1 ar-1 ay-1 ul-1 ep-1 ov-1 an-1 ar-1 ay-1 ul-1 ep-1 ov-1 an-1 ar-1
Ma M J S N J M M J S N J M M J S N J M

19. Expected trend in emergency bed use (65+)
at 2006/07 rates ( P Knight)
occupied beds patients aged 65+
9000
Expected at
8500 2006 / 07 rates
Demand
Management
8000 ~ 500 beds
7500
Actual bed
use
7000
6500
6000
/01
/02
/03
/04
/05
/06
/07
/08
/09
/10 Year to 30
00
01
02
03
04
05
06
07
08
09
Sept 10
20
20
20
20
20
20
20
20
20
20
(prov)
year