Guest Post from Local Integration Lead, Rene Rigby

Test of Change

We are living and working in an inter-connected environment. The use of email for sending messages, exchanging information and assisting with workflow is common place across the public sector. There are many links between the health and care system, but it’s often difficult for health and care professionals to share information. Access to the right information about patients and users of services at the right time is essential to ensure continuity of care.

When patients are discharged from hospital, care homes are still receiving information about that individual by fax, in person or post. Often, key pieces of information are not received at all. This makes it difficult for care homes to prepare for a new patient’s/resident’s arrival or the return of a resident who has been in hospital. As well as being inefficient and slow, paper-based communication is not a secure delivery method.

Lothian Unscheduled Care Board have agreed to fund costs for a one year test of change –Secure emails access for all care independent care homes (circa 103) in Lothian. Each care home will be provided with up to three accounts for a period of one year. Care homes coming on stream during the next few months have also been included in this test of change.

CEO’s or equivalent of each individual independent care home must sign the Data Sharing Contract, as must the staff identified as secure email recipients. Following on from this each identified recipient must sign a NHS Lothian User ID Request Form

The provision of secure emails to all care homes in Lothian will markedly improve communications between care homes general practice and social work. Specifically, it will enable faster discharge of patients through the electronic communication of patient assessments and subsequent discussions rather than this being by post.

Secure email will transform how healthcare organizations in Lothian share and work collectively to provide coherent joined up services for the people concerned the public. Good timeous information underpins good care and on-going support.

Care homes will benefit greatly from having a consistent electronic transfer of medical discharge summaries (typically sent to a GP within 24 hours). This will enable the care home to fully prepare their service for supporting people discharged from hospital by preparing for the persons needs well in advance of their arrival.

Pre admission assessments will be carried out and shared timeously thus supporting early discharge to the care home and help improve the efficiency of the discharge process generally.

Secure emails offers the potential to share Anticipatory Care Plans from statutory services. E.g Person moving into a care home. Referrals, assessments, multidisciplinary review summaries, flu vaccine consent forms will be immediately accessible to care homes. Opportunities for Tissue Viability, Health Protection, Care Home Liaison, CPN’s and pharmacy specialists instant ability to network and support and safely communicate sensitive information with care home staff.

Other benefits are the ability to send and receive patient/resident information quickly and securely. No confusion from messages taken over the phone or illegible writing on faxes. Improved awareness of care home staff in relation to  information governance rules on handling patient information. Secure paper trail in place for example, time emails were sent, removal of fax machines which are costly and require maintenance. Costs of postage for partnership reduced. Reciprocal communication time by health and social care professionals markedly reduced and this initiative supports positive change in service.

This test of change Secure e-mail access for care homes in Lothian should seek to demonstrate measurable improvement in outcomes either directly to individuals or indirectly through improved service design and delivery. There will be on going monitoring to make sure the project is achieving the desired results and to demonstrate the impact of the project to others; as well as to identify issues or problems as they arise within the project so that actions can be taken to change or redesign the project while it is in progress.


Rene Rigby

Local Integration Lead, Edinburgh City

New animation on the importance of integration.

Sharon Blackburn CBE,  is a long-term partner of Scottish Care in our work. In 2015-16 she was awarded a Florence Nightingale Foundation Leadership Scholarship which was sponsored by Garfield Weston Foundation, and supported by her employer , a sister organisation of Scottish Care, the National Care Forum. As part of the scholarship she completed a project on the subject of integration with the sole aim of contributing to the step change that needs to take place for people using services…that’s you and me…not just ‘them’.

Her work included interviews with key players in Scotland. She has now developed an animation to support staff wherever they work to consider ‘how to be the change they want to see’. The animation has been informed by people who use services; their families and so many people who afforded her time across the devolved administrations in the UK to share that which was good and more often that which needed to change. The animation can be accessed at

Sharon writes:

 “Integration has been a theme; an aspiration that has travelled with me during my career to date. During that time, in England much progress has been made in delivering person centred outcomes for people using services but we are not there yet. This looks and feels so different depending where the person is in the system. The language that is used is also confusing. The words may be the same but different meanings are attributed.

People who use services do not understand the differences and nuances until it personally impacts upon them or their loved ones. They expect people to share relevant and pertinent information about them; they do not expect each professional to carry out duplicate assessments.

All  staff working across health; social care and housing systems need to work together to achieve the best outcomes for people, irrespective of the constraints that can sometimes conspire to work against what they would like to achieve, such as existing policy; cultures of organisations; legislation…the list could go on.

Achieving it will depend on each person in the various systems playing their part. It will require a shift in how nurses; care and all staff across Health; Care and Housing Systems think and behave, this means you and me!.

Ask yourself “do you know what you don’t know…what will you do to rectify this”…”how can you and will you be the change you wish to see?””

Care Home Week 18: Change & Adaptation Blog from Margaret McKeith

If you could change one thing what would it be?

How often have you been asked that? Probably as often as “If you won the lottery, what would you do?” or “If you had three wishes, what would they be?”

Even I, the eternal optimist, have realised that a lottery win is very unlikely and that the chances of a genie springing out of a magic lantern is zilch.

Resigning myself to these two facts, what I can do is acknowledge my ability to create change and hope that I use this ability to both my advantage and to the advantage of others.

Whether they have an impact on only me or on others, whether they are significant and transformational, whether they are so slight they are barely noticeable, whether they are made on impulse or the result of long and careful planning, whether they are the result of situations out with my control, each and every one will make a difference of varying degree. My hope is that whatever change I make, the consequences will be positive.

If I was given three wishes, perhaps always making a positive difference to others would be one of them.

I am in no way unique, each and every one of us has the ability to change and adapt and to make “that difference”.  

Those of us who have been involved in health and social care for some time (longer than I am prepared to admit!) are used to change. No matter what role we play, we are continually changing and adapting to the environment we work in and to those around us.

This week we are celebrating care homes and the people who live and work in them. On being asked to write a blog on “change and adaptation” I thought about these people and considered what to focus on. I could have written about changes in technology and equipment, changes in registration requirements, changes in dependency levels, changes in expectations, changes in legislation and employment law and so on, but I haven’t.

 Although these all undoubtedly necessitate adaptation and change, I want to take the opportunity to acknowledge the “change” moving to live in a care home has on a person and their families and on the skills and dedication of the care home staff involved in supporting them through that process. Having the ability to support a family well during this time of transition is absolutely crucial. Providing this support requires a chameleon like ability to change and adapt as well all know that no two people or their circumstances are alike.

Some family members may have an enormous feeling of guilt and think they have let their loved one down while others view their loved one going into a care home and an exciting and positive new adventure. Sadly, in my experience, the former is more likely.

Negative media coverage, often biased and ill-informed, do not help. Though incidents of poor care in unsatisfactory surroundings do exist they are fortunately very much in the minority. Sadly good news and celebrating good care does not always sell newspapers, so is not always what springs to the publics minds when they hear the words “care home”.

The dedication of those working in care homes must be highlighted. Their commitment to making changes which result in a positive outcomes of those they support, their ability to continually adapt their approach and use different skills to best meet the individual needs of those in their care, their ability to adapt and respond appropriately to highly sensitive and often emotionally charged situations, their quest to gain further knowledge and expertise and their relentless drive to make a positive difference must be acknowledged must be and celebrated.

If the words “care home” immediately conjured up the public’s visions of happy, stimulated, active, valued, involved older people living in bright, stimulating, safe environments then the prospect of a loved one going into care would be much less daunting.

I mentioned earlier us all having the ability to make change. One I, and my colleagues in the Partners for Integration and Improvement team within Scottish Care, can make and strive to make is to change the impressions the public has of our sector. By highlighting and sharing good practice and by supporting innovation, we hope we are making a difference. We feel we owe that to our colleagues working on the front line.

Going back to my three wishes, if I was granted these, one would be that the myths that Karen Hedge (National Director, Scottish Care) discussed in her blog earlier in the week, would be completely and utterly busted.

Let’s make that change.

Margaret McKeith

National Lead, Partners for Integration



Care Home Week 18: Being Human

Marnie MacDonald from Scottish Care, Aberdeen City presented at the Being Human Conference hosted by C-Change Scotland, which focused on Human Rights and Self Directed Support. Scottish Care was part a range of influential speakers on the subject as well as stories from individuals whose lives have been transformed for the better. Scottish Care covered the topic of Enabling Human Rights.

During 2013-2016 Scottish Care was involved in a major piece of work, prior to the current engagement project, on Enablement.

The Enablement Project focused on personalised planning and working with teams to create enabling support plans. Enabling support plans are holistic assessments of the service user and their abilities, with the focus being on a whole person approach and optimising of abilities.

An enabling support plan captures all necessary needs and information about an individual:

  • Physical
  • Sensory
  • Cognitive
  • Spiritual
  • Environmental

With recording the necessary information and providing it to all staff, this ensures a consistent form of support and allows changes to be monitored and addressed, whether positive or negative, effectively.


Guest post by Local Integration Lead, Glenda Hanna: What Matters to you?

I started work as Local Integration Lead for South Ayrshire Health & Social Care Partnership last June and on reflection, almost one year on, “it is the best job ever!”.

No two days are the same; even in the course of one day I have the privilege of sitting in strategic planning level meetings getting my head around ‘the big picture’ and then later on, meeting with the unsung heroes delivering the real quality care – person to person, day by day and one conversation at a time, in our local community and often in very challenging circumstances. A recent example of how the various aspects of my job come together is the Community Led Support initiative.

The South Ayrshire Partnership is one of three in Scotland who are working with National Development Team for Inclusion (NDTi) to innovate the delivery of services using the Community Led Support (CLS) approach. CLS is “designed and driven by practitioners along with local partners and members of the community they are serving…it builds on what is already working, joining up good practice and strengthening common sense, empowerment and trust”.

So as part of this, last Tuesday I participated in ‘Effective Conversations’ Training, which focuses on having a good conversation with people who may need help and support by posing the question “What matters to you?”. Through listening carefully to the response first, we can then identify how the most effective help and support might be delivered.

It was an opportunity to have time to think about what is an effective conversation, and if we were to have one, how might that redefine the care and support which we then deliver.

But the best part for me was the informal discussion and the individual conversations I had, giving me a better understanding & appreciation of each person’s job roles – they represented all sectors of the Partnership, and I reflected afterwards that while we each have a distinct role, it will ultimately be our ability to converse effectively, build relationship and work together in real partnership which will define good quality care that works for the people of South Ayrshire.

Then yesterday, in the discussion at the Partnership’s CLS Steering Group, one of the Community Engagement Officers reported how two Home Care Services staff had come back after a subsequent EC training session requesting further details on “Train the Trainer” opportunities. My heart soared – the Carers who work in our sector respond spontaneously to opportunities to engage in Partnership working and I strongly suspect they are already having ‘effective conversations’ that could transform how we deliver care, and they are waiting for the rest of us to catch up.

Glenda Hanna

Local Integration Lead

South Ayrshire

Job: Development Officer – Partners for Integration and Improvement (2 posts)

DEVELOPMENT OFFICERS PARTNERS FOR INTEGRATION AND IMPROVEMENT, Health and Social Care Integration – Independent Sector Initiative.

12 months contract initially
£30,000 per annum pro rata – full and part time posts available

Integration of Health and Social Care is the Scottish Government’s ambitious programme of reform to improve services for people who use health and social care services.

Scottish Care is a membership organisation representing the largest group of independent health and social care providers across Scotland.

The Independent Care sector is a key player in health and social care integration agenda and we are seeking to engage Development Officers support this programme. Hosted by Scottish Care and working closely with Independent sector Regional Lead, providers and partners, the post involves ensuring sector involvement in the delivery of the agreed outcomes for integration.

The post holder will have a key role in supporting Health and Social Care Integration in Aberdeen City. They will develop close working relationships with Scottish Care’s Aberdeen City team (Regional Integration Manager and Reablement Trainers) as well as key stakeholders from Aberdeen City Health and Social Care Partnership, Third and Independent sectors, NHS Grampian and people who use services and their carers and family members. The overall aim of this role is “to inform, engage with and support care providers from the Independent Sector so that we can fulfil our obligations and be an equal partner in Health and Social Care Integration”.

The post holder will require to be highly motivated and be able to use initiative, possess excellent communication and networking skills, demonstrate success and experience working with providers, regulators, people supported by services and carers. Qualifications and experience at a management level in health or social care would be an advantage as would knowledge of relevant policy, practice and the needs and aspirations of the Independent sector.

The post will be based in Aberdeen and hosted through Scottish Care. Consultancy, employment, secondment and job share opportunities considered. Employment is the default position.

For further information please contact Julia White, Regional Lead, Aberdeen City at [email protected]. Application forms are available through Scottish Care [email protected]

Closing date 4pm on Friday 26th May 2017 Interviews will be held in Aberdeen on Tuesday 6th June 2017

New overnight care at home service in Inverness

The following news item appeared in The Press and Journal on 20th April 2017 and highlights the success of a pilot undertaken by Scottish Care Local Integration Leads in Inverness.

A new overnight care-at-home service is to be trialled in Inverness to ease pressure on hospital beds.

NHS Highland announced yesterday that it was launching the year-long pilot project in partnership with care provider group Scottish Care.

It will involve staff at three independent providers – Gateway, Castle Care and Eildon – helping support patients in the Highland capital in their homes at night.

The initiative, which is expected to be rolled out across the region in the future, aims to reduce the length of hospital stays in the region and enable patients to receive more care at home.

Announcing the pilot, NHS Highland’s special projects lead Jean-Pierre Sieczkarek said: “The overnight service is a response to the need for support during the night to allow safe discharge from hospital where required, to respond to social care interventions such as falls and help calls and support people to be safely supported in their own home.

“We are hopeful that this type of intervention will take pressure off our hospitals by reducing the number of admissions and speeding up discharge for patients.

“We are confident that this initiative can prevent people from being placed in residential care, when support overnight could allow them the choice of returning home.”

Rhoda Grant, Highlands and Islands Labour MSP, said: “It’s a good initiative. Anything that keeps people at home, or allows them to get home more quickly, is to be welcomed.

“I often speak to GPs who say they have no alternative but to send vulnerable people to hospital because there is no alternative at night when they should not be left alone either due to illness or a fall.”

Innovative care at home

Older people have benefited from a pilot project which saw Glasgow Caledonian University (GCU) physiotherapy students provide care at home.

The project was delivered in partnership with Carers Direct, NHS Highland, NES, Scottish Care, and the Care Inspectorate.

Fourth year physiotherapy students undertook placements with two providers, Carers Direct, a care at home service, in Argyll and Bute, and an NHS reablement physiotherapy service. The placement combined time spent in a physiotherapy practice and care delivered in the home.

The Care Inspectorate praised the work of the students and tutors.

Karen Reid, Chief Executive of the Care Inspectorate said:

“For people who receive care at home, it can sometimes be difficult to get out and about to access services like physiotherapy.

“We were delighted to be involved in this project and it demonstrated that by rethinking the way care is provided, we can better meet people’s needs and provide the care which matters to them, in a setting which suits them.

“We know that as more people are living longer, healthier lives, rethinking the way services are provided will become more important.”


GCU Senior Physiotherapy Lecturer Douglas Lauchlan said:

“The integration of health and social care and reablement of clients at home and in community settings is a strategic drive of Scottish Government. It is important that physiotherapy students, many of whom are graduating, work alongside acute NHS services and independent providers of care within the home.

“In addition to the students’ learning, all partners involved in the project gained an insight into a fast-developing area of care where collaborative working is key to its success.”


Student Lindsey Justine Chisholm, from the School of Health and Life Sciences, delivered care to patients before returning to Canada to work in physiotherapy and kinesiology.

She said:

“Delivering care in the home offers the patient greater choice. Seeing patients in their own environments allowed me to tailor and understand the challenges many of them experience on a daily basis. Working as part of a team, we were able to learn from patients, our colleagues and carers and provide the care needed to patients. ”

Vacancy: East Liaison Officer for the Independent Sector, Dumfries and Galloway

Scottish Care (Dumfries and Galloway) is recruiting a new team member to work with the new Regional Integration Manager for the Independent Sector. The new post is

  • An East Liaison Officer supporting independent sector providers in the Localities of Annandale & Eskdale and Nithsdale. This is a part time post – 2.5 days per week.

The post is hosted by Scottish Care, a membership organisation representing the largest group of independent health and social care providers across Scotland.

Part time East Liaison Officer (£29,311 pro rata, initially fixed term contract to end of March 2018 )

The post holder will support independent care providers in their Locality areas and will have a key role in supporting Health and Social Care Integration in Dumfries and Galloway. The successful candidate will develop close working relationships with Scottish Care Dumfries & Galloway’s team (especially the Regional Integration Manager, Locality Representatives and the Independent Sector Support Officer) as well as key Locality stakeholders (including the Locality Manager, local partner colleagues from NHS Dumfries and Galloway, Dumfries and Galloway Council and Third Sector Dumfries and Galloway and those in receipt of services).

The post holder will be highly motivated and be able to use initiative, possess excellent communication and networking skills, demonstrate success and experience working in partnership with policy makers, providers, regulators, people supported by services and carers. Qualifications and experience at a management level in a current health or social care provider organisation operating in Dumfries & Galloway is an advantage as well as knowledge of relevant policy, practice and the needs and aspirations of the Independent sector.

The post holder will attend Scottish Care D&G Team Meetings on a monthly basis. They will liaise with local providers and contribute to Locality Meetings with Locality Representatives. They will have an active role in supporting Health and Social Care Integration and delivering the business plan for the team in D&G. They will also contribute to ongoing Research and Development activities to support independent providers in the region. They will be supported by the Independent Sector Support Officer and report to the Regional Integration Manager for the Independent Sector in D&G.

The post is 18.75 hours per week (2.5 days per week) and will be paid at £29,311 pro rata. Travel expenses will be paid at 45p per mile.

The post will be primarily home-based and hosted through Scottish Care. Consultancy, employment, secondment and job share opportunities considered. Hot desk facilities are available to support your work with partners in each Locality and you will be expected to spend at least some of your time in each Locality each week.

For further information:

To express an interest and request a job description please contact [email protected] or telephone Dawn on 08456 434 022 for further information.

If you are interested in the role you will be asked to submit a tailored CV showing how your knowledge, skills and experience are relevant for the post and a Personal Profile (a template will be provided).

The closing date is 5pm Friday 27th January 2017.

Shortlisting will take place 30th January 2017 and interviews will take place 1st & 2nd February 2017.

Opportunity to participate in Tests of Change for Technology Enabled Care

Building on the work of the Technology Enabled Care (TEC) programme, funding of up to £15,000 is being offered for around 6 technology enabled care Tests of Change.  This offer is open to any NHS Board, Integration Authority, Housing, Independent or Third Sector organisation and is intended, primarily, as a support to inform local or organisational planning and commissioning activity.

The aim of any application must align with the overarching TEC programme aim which is to support more citizens to make greater use of technology to manage their own health and wellbeing at home and in the community.  A test of change should seek to demonstrate measurable improvement in outcomes either directly to individuals or indirectly through improved service delivery processes.

For more information, please read the letter of invitation.

To apply, you must complete a Test of Change Planning template and table (contained in the above letter of invitation).

These must be submitted to NSS.TEC by the 11th November 2016