Supporting people to lead independent, healthy and active lives

Ambition

People in Perth and Kinross lead independent, healthy and active lives, with choice and control over the decisions they make about their health, care and support.

The Challenges

Our key challenges in delivering our improvements include:

  • Perth and Kinross has an ageing population, particularly in rural areas, so we need local services and support to be designed around specific communities’ needs.
  • Recruitment and retention of health staff and social care staff remains a challenge, reflecting the national picture.
  • Shifting the balance of care and spend to support people at home and focus intervening early to enable people to remain at home, supported by innovative local options and support.
  • Reducing unplanned admissions to hospital and managing those delayed when ready for discharge.
  • Addressing health inequalities, including access and use of services, reducing isolation and loneliness
  • Improving support for carers, including access flexible respite.
  • Working with local people and the 3 rd Sector to encourage and empower them to run initiatives for and by themselves.
  •  Ensuring a supply of affordable mainstream and supported housing and tackling homelessness.

What we are doing

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The Health and Social Care Partnership, established in 2016, includes NHS Tayside and Perth and Kinross Council with representatives and close working with housing, the 3rd and independent sectors. The Partnership is overseen by the Integrated Joint Board (IJB) , responsible for delivering integrated health and social care.

The Partnership’s Strategic Commissioning Plan outlines their priorities for 2016-2019, including the need for services and support to intervene early to prevent later, longer term issues arising, enabling people to manage their own care and support by taking control and being empowered to manage their situation.

Self- Directed Support (SDS) continues to expand and enable people to choose the way their care and support are provided, promoting choice and control.

Technology Enabled Care (TEC) is also expanding, supporting people with their health and social care needs (telecare, telehealth and telemedicine) helping them remain at home for longer.

Reducing social isolation and loneliness is a priority as it affects people of all ages. Having contact with others is important and participating in activities improves people’s physical and mental wellbeing. Working alongside local communities we have developed a range of projects to reduce isolation and will continue to build on this.

Many people who suffer from poor mental health, obesity and long term disease also experience poverty and social disadvantage, so our Perth and Kinross Health Inequality Strategy has a number of key priorities to address and reduce these.

Mental health and wellbeing continues to be a priority and we have some excellent examples of initiatives which promote mental health recovery, working alongside people to support their recovery.

The introduction of Universal Credit, which replaces six means-tested benefits and tax credits, in April 2018, presents a significant challenge. The Partnership is committed to working jointly to make sure vulnerable people are supported.

We know many people who provide an unpaid caring role, may be unaware of the support they could receive, so we want to radically improve support for carers, particularly access to flexible respite.

Drugs and Alcohol support in Perth and Kinross are currently being redesigned as part of the implementation of a Recovery Oriented System of Care (ROSC) which is a Scottish Government initiative. This is to join up services and make them easily accessible.

We will continue to work with housing partners to make sure there’s a good supply of affordable mainstream and supported housing, with services attached to support people to live as independently as possible. We are planning future housing for people with particular needs, including people with learning disabilities, physical disabilities and older people, developing new build and supported accommodation over the next 5 years.

Regular physical activity provides general health benefits across a range of diseases and across all ages. There is strong evidence that the greatest health benefits happen when the least active people become moderately active. We will continue to work with partners on wellbeing programmes based in communities across Perth and Kinross and support older adults and people with or at risk of longterm conditions to live actively and improve their physical and mental wellbeing.

We will develop programmes such as “Woods for Wellbeing” to promote improved health and wellbeing, capitalising on Perth and Kinross’ natural beauty and the benefits associated with nature, outdoor informal exercise and social interaction.

What next and what difference will it make?

We will work together on the following priorities to support people to lead independent, healthy and active lives:

1. Work with our communities to deliver person-centred healthcare and support

Current

    We want to build on the skills, knowledge, experience and resources that already exist within local communities, involving people in developing person-centred healthcare and support so they can receive the care and support that they need in the way that they want.

By 2018/19 there will be:

  • Enhanced community support and support for carers to enable people to remain in their own homes for longer, avoiding unnecessary admissions and longer stays in hospital.
  • Recognition of the role of unpaid carers and flexible support to help them cope with the challenges they may face.
  • An increase in the number of people who use Self-Directed Support, to commission and control their own care.
  • More support to local communities to build on their skills, knowledge and experience, fostering self-reliance and resilience and more access to Participatory Budgeting where local people choose how resources are spent.
  • Pathways and support for transition in relation to Autism and Additional Support Needs.

By 2020/2021 there will be:-

  • Wider community based support to maintain people in their homes, avoiding unnecessary hospital admission and reducing the need for permanent care home.
  • Enhanced community support to support people from hospital back home, when they are fit.
  • Preventative support for carers, enabling them to continue their caring role.

By 2027/2028 there will be:-

  • Recognition and acceptance that people will receive all but the most complex care in their own homes and they will be using technology enabled care as a key part of their support.
  • People will be living longer and have good health longer because of innovative and early support in their local community.
  • A significant reduction in health and social inequalities.

2. Design our services around prevention and early intervention.

Current

Services will be designed with our local communities who are well suited to enable early, preventive support, encouraging people to live independent and active lives.

By 2018/19 there will be:

  • Locally-based integrated, multi-agency teams including GPs, pharmacies and the 3 rd Sector to facilitate opportunities for more personalised, joined up care and support for people.
  • Continued delivery of outreach activities to promote health and wellbeing.

By 2020/2021 there will be:-

  • A reduction in crisis support as a result of enhanced earlier community support. GPs, social work, health, the 3rd and independent sectors, as well as service users and carers, will work together to redesign services.
  • Improved signposting and increased referrals to local activities and wellbeing programmes.

By 2027/2028 there will be:-

  • Services accessed through self-service, avoiding bureaucracy and giving people more control in accessing the care and support they need.
  • More volunteers, the 3 rd sector activities and initiatives developed by local communities.

3. Reduce inequalities and unequal health and social outcomes.

Current

Tackling health inequalities is challenging because it involves access to education, employment opportunities, suitable housing which is warm, safe and affordable, equitable access to healthcare, and individual circumstances and behaviour. Reducing health inequalities will increase life expectancy, increase health and wellbeing of individuals, and reduce the personal, social and economic cost of reacting to the impact of poverty and inequality.

By 2018/19 there will be:

  • Further engagement across communities and 3rd sector with people not normally reached by mainstream health services
  • People supported and prepared for Universal Credit, with local outreach services available for support.
  • A review of the use of hospital-based services for older people with mental health needs and people with learning disabilities.
  • Healthcare needs assessment undertaken across the prison establishments and review and redesigned prisoner healthcare

By 2020/2021 there will be:-

  • A single point of contact that supports access to health and care services and staff working in localities with communities to support those most in need

By 2027/2028 there will be:

  • More integrated services delivered in people’s homes and from locality hubs, with greater citizen participation in the design and delivery of care and support.

4. Provide opportunities and support people to live active and independent lives.

Current

Promoting sports and active recreation and mentally stimulating activities helps people have a healthier lifestyle and mental wellbeing. It reduces social isolation and increases general wellbeing. Leading an active and independent life, that is relevant to an individual’s circumstances, increases resilience when faced with periods of poor health.

By 2018/19 there will be:

  • Health interventions and physical activity for people who are at the highest risk of ill health to prevent illness including smoking, alcohol and drug use, oral health, sexual health and undernutrition.
  • Varied local initiatives to encourage physical activity and social interaction.
  • An increase in the use of Technology Enabled Care to compliment support for carers and to reduce the need for care at home where this is appropriate.
  • Initiatives to reduce the number of people who are overweight or obese, targeting resources at those most at risk.

By 2020/2021 there will be:-

  • Technology Enabled Care (TEC) fully embedded in the assessment and referral process with sophisticated monitoring in home and out and about to enable safe independent living. This will also support social connection and digital inclusion.

By 2027/2028 there will be:

  • Fully digital TEC solutions in the home as standard, able to adapt to changing needs combining monitoring of health, care and overcoming isolation.

5. Reducing social isolation.

Current

Social isolation is an issue for people of all ages, but more common in older people who live in rural and remote areas. Intergenerational activities help share skills and knowledge within communities, and reduces loneliness. We will focus on improving connections between individuals, communities and organisations

By 2018/19 there will be:

  • Expanded intergenerational work, building on projects between nurseries and schools and older people.
  • A range of physical activity opportunities across targeted localities to promote social interaction and improve the wellbeing of those experiencing social isolation, with an increase in the number of unique users engaged in targeted health improvement programmes

By 2020/2021 there will be:-

  • Further development of socially inclusive, inter-generational and cultural initiatives across the area to reduce the social isolation.

By 2027/2028 there will be:

  • Increased and varied initiatives run for and by communities themselves.
  • More support for the 3 rd sector to empower communities, such as Befriending and Your Community PKC.
  • Supporting initiatives such as Care Co-operative Highland Perthshire to share skills and knowledge and increase the resilience of individuals and communities

6. Housing

Current

    We will continue to work with social housing colleagues, organisations and the private sector to manage and improve housing stock and achieve our ambition to increase affordable homes and meet the housing needs of people in Perth and Kinross.

By 2018/19 there will be:

  • An increased number of affordable houses.
  • More energy efficiency homes within private and social housing through a range of improvements and initiatives.

By 2020/2021 there will be:-

  • A continued increase in affordable accommodation in urban and rural areas.
  • Ongoing work with private landlords to provide enhanced housing options, bringing empty homes into use and improving the quality of privately rented accommodation

By 2027/2028 there will be:

  • A balanced housing market where the supply of affordable housing meets demand, levels of homelessness are minimal and the quality of homes and their environment are of a high standard

 

Delivery Group

The Health and Social Care Partnership is responsible for planning and delivering health and social care services in Perth and Kinross.

Third Sector Forum

The Health and Social Care Forum is made up of representatives of charity and voluntary organisations which deliver health and social care services in Perth and Kinross.

Strategies 

The Strategic Commissioning Plan 2016-19 was approved by the Integrated Joint Board. The integration of adult health and social care is part of the Scottish Government’s programme of reform of public services designed to improve the outcomes for people and the communities in which they live.

The Perth and Kinross Health Inequality Strategy sets out the ambition to reduce health inequalities in Perth and Kinross.

Carers’ Strategies: In the last three years there has been a marked cultural change in the way in which carers are recognised, both nationally and locally. It is more readily accepted that carers have rights. In particular, carers have a right to be considered as equal partners in the provision of care, and who also have a specific right to a personal quality of life which will enable them to be included in society.

Perth and Kinross Alcohol and Drug Partnership (ADP) Strategy 2015-20  ADP is a strategic organisation committed to working together for the benefit of local people.

Performance and Data

The Scottish Public Health Observatory (ScotPHO) collaboration is led by Information Services Division (ISD) Scotland and NHS Health Scotland, and includes the Glasgow Centre for Population Health, National Records of Scotland and Health Protection Scotland.

The Scottish Health Survey (SHeS) provides a detailed picture of the health of the Scottish population in private households and is designed to make a major contribution to the monitoring of health in Scotland.

Useful links 

Active Perth and Kinross 2016-2021 outlines Perth and Kinross Council’s strategic priorities for sport.

Integrated Joint Board Agendas and Minutes 

Guide to Health and Social Care Integration: Integration means delivering Social Care in a better way in the future. Over the coming years, GPs, hospitals, health workers, social care staff and others will increasingly work side-by-side to share information and take a much more co-ordinated approach to the way social care services are delivered.

Health and Social Care Partnership Facebook Page

Mental Health and Wellbeing gives information in relation to Mental Health and Wellbeing.

Adult Support and Protection Perth & Kinross Council work with the NHS, Police, private and voluntary sector, to ensure adults at risk in Perth and Kinross are protected from harm.

NHS Tayside Public Health: Page to find out more on public health in Tayside including their Annual Report which explore health inequality and prevention issues in Tayside.

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