Transferable lessons from the care of older adults in rural Scotland

Samantha Horwill
May 7, 2021

Dr Martin Wilson is a Care of the Elderly consultant working in Inverness. In a recent webinar hosted by Yma, Martin discussed his experience of finding solutions to care for the growing elderly population in Highland. This provided the opportunity to discuss the challenges facing primary care in rural and remote parts of Wales, and whether lessons learned in rural Scotland could be applied.  

Martin began by discussing the difficulties in delivering care to older adults in rural areas like Highland. Highland is sparsely populated with a decreasing population of working adults compared to retired adults. This produces specific challenges particularly around choosing how best to use the limited number of working age adults available in any area.

In 2012 Highland adopted a Lead Agency Model which involved the integration of health and social care. NHS Highland was established as the lead agency with all social work staff moving to NHS contracts. Integrating these services reduced overlap and allowed the NHS to interact directly with private providers such as care homes. This improved working relationships and allowed services to be delivered more efficiently. A question was raised about whether there was any resistance in the workforce to the process of integration. Martin explained that the benefits of the NHS employment terms and conditions helped to smooth this change for people working in the services. It was highlighted that the differences in the health and social care financial models in Scotland and Wales could limit the application of this model in Wales.

The integration allowed all areas to have a dedicated single point of contact for professionals and patients which improved the patient triage and allowed more initial assessments to be completed. Home care provision was zoned, and home carers were provided with paid travel which released time and allowed them to travel further to provide care. In response to a question about the process of integrating digital health and digital care, Martin discussed how the ‘SciScore’ platform has been key to this. The platform was originally used as a repository for results and is now used for all clinical notes including those from community groups, improving access to information. A portal called ‘Care First’ also allowed hospital managers and senior nurses to access all social work information out of hours. A discussion followed on data collection and the difficulties in producing comparable data over such a large and geographically variable area. Martin explained that data is collected but because areas in Highland are so distinct, the data is more valuable for identifying areas requiring more resources, rather than for comparative studies.

Martin went on to discuss upstream and downstream interventions and their effect on emergency hospital admissions. Upstream interventions include pre-emptive reviews of high-risk adults, early AHP intervention and housing adaptions, in contrast to downstream interventions such as hospital at home, expedited discharge, and rapid access clinics. Downstream interventions are important in large areas and produce ‘exciting’ stories but require large numbers of staff for long hours which is not an option in Highland largely due to there being insufficient population density to support the number of staff required. Upstream interventions are ‘less exciting’ but are planned activities, allowing more time for decision making and for keeping patients involved. Upstream interventions also allow more patients to be cared for within a given time in comparison to downstream interventions and are essential in reducing the peak of hospital admissions.

The value of proactive work was acknowledged by the group, but a concern was raised around how to move towards proactive work without taking time and resources away from the teams currently working with patients in crisis. In Highland, Martin explained that this was done by securing funding for practices so that they could expand their resources to carry out anticipatory care which is now embedded within the practices’ contracts. A discussion followed on the use of clinical tools in proactively identify high-risk patients. Martin reflected that in smaller practices, local knowledge had been more useful for identifying patients, while tools were more effective in larger practices.

The full video of the presentation and discussion is available below:

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