Development of IJB Strategic Plan 2025-2030

We will continue to invest in services and activities that focus on prevention and early intervention and that support people to look after their health and wellbeing.    

Delivery priorities

• 2.1 Delivering services that support people to remain active and independent
• 2.2 Ensuring services are easy to access
• 2.3 Responding to the increase in people living with multiple long-term conditions
• 2.4 Developing a multi-disciplinary approach to the management of frailty
• 2.5 Improving health and wellbeing from an early age
• 2.6 Supporting people living with dementia to remain active, socially connected, and supported within their local communities
• 2.7 Supporting carers’ health and wellbeing to enable them to continue in their caring roles

 

Why is this a strategic objective for the IJB?  

Investing in prevention and early intervention reduces the need for health and social care support in the longer term and delivers better outcomes for individuals:

• We know that projected population growth and demographic change will lead to an increase in demand for health and social care services over the lifetime of this Strategic Plan.
• Investing in prevention and early intervention will help to mitigate against some of this increase in demand by improving the overall health and wellbeing of the East Lothian population at all life stages.
• Investment will also help to keep people well for longer; maintaining their independence into older age; and reducing or delaying their need for more intensive, and potentially more expensive care and support.
• There are a wide range of other activities and interventions that focus on early intervention and prevention that are not within the direct remit of the IJB (for example, wider NHS Lothian and Public Health Scotland activities) – however, the importance of involvement in a wider system approach is recognised (see also Strategic Objective 3).  

This objective reflects the Scottish Government strategic direction:

• The Scottish Government Health and Care Renewal Framework includes the strategic priority of shifting the focus from reactive treatment to early intervention and prevention. It also identifies a major area for change as ‘ enhancing services that prevent disease, enable early detection and effectively manage long-term conditions.

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What do we need to prioritise to deliver this strategic objective? 

Focusing on the strategic delivery priorities below will help us to achieve this strategic objective. Further details, including timescales and targets, will be included in Annual Delivery Plans developed for each year of the Strategic Plan. In addition, there are a number of strategies / programmes already in place, or under development, that will provide direction (these are highlighted in bold italics below).

As well as the priorities below, the operational delivery of HSCP services will continue to contribute to achieving this Strategic Objective through existing activities and approaches that focus on prevention, early intervention and self-management.    

 

2.1 Delivering services that support people to remain active and independent.

Services delivered by Allied Health Professionals (AHPs)[1]  are key in supporting people to remain active and independent so they can live independently, in their own home, for as long as possible. In East Lothian, these services are delivered by the East Lothian Rehabilitation Service and include physiotherapy, occupational therapy, falls prevention, telecare, and pain management. 

Alongside directly provided services, ELRS staff have developed a range of self-help guides and interactive online tools providing information and advice. ELRS also provides information and advice specifically on the use of consumer technology (Smart TEC) to support independence and keep people safe, and this is an area or potential development as technology continues to develop and improve.

Third sector and community organisations play a key role in delivering services that support people to be active, engaged and independent and to connect with their local community. As noted above, one of the strengths of the sector is organisations’ ability to innovate and respond flexibility, as well as to work collaboratively with communities to develop services that reflect what people want and need.   

Specific activity required over the lifetime of the Strategic Plan will include:

• Continuing to ensure appropriate levels of investment in ELRS and other HSCP delivered services that support people to remain active and independent.
• Ongoing development of activity to support ‘self-management’ of health issues to enable people to remain active and independent.
• Further development of opportunities for the use of consumer and other technology to support independence and self-management (as part of the delivery of an East Lothian HSCP Digital Innovation Strategy – see priority 1.6 above).
• Commissioning services focused on preventative and early intervention approaches that are outcome / recovery focussed and promote independence, participation and self-management (as laid out in the East Lothian HSCP Commissioning Strategy).
• Continued collaboration with third and community sector partners to develop and deliver activities supporting prevention, early intervention, and self-management, including exploring opportunities for innovation and coproduction with communities.
• Working with Public Health Scotland colleagues and other partners through Community Planning to support their delivery of prevention and early intervention activities (see also Strategic Objective 3).

References:
[1] Allied Health Professionals (AHPs) are a group of clinicians who provide care to people across a range of care pathways and in a variety of settings, including Occupational Therapists and Physiotherapists.

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2.2 Right care, in the right place, at the right time   

Ensuring services are quick and easy to access is key to delivering prevention and early intervention approaches. Accessible services mean people are more likely to engage at an early stage and to continue to access and benefit fully from the care and support available. For the HSCP, this includes continuing to develop services that are as local as possible and that can be accessed directly, and, where appropriate, via alternatives to ‘in-person’ appointments. 

Primary care plays an important role in relation to prevention, early intervention and self-management of conditions, so we need to continue to ensure that people are able to access the primary care services they need as quickly and easily - both services delivered by General Practices and those managed and delivered by the HSCP. [2]

We have already made a number of changes to the primary care services delivered directly by the HSCP to make them quicker and easier to access through the development of new delivery models and pathways. We have also improved information on primary care services (including an online directory), helping to guide people to the service best placed to meet their needs.

We know that more people are reporting issues related to mental health and recognise the importance of interventions that provide support as early as possible to help address these issues and to prevent them from becoming more serious or debilitating. The same is true in relation to services that provide early intervention for people experiencing difficulties related to drug and alcohol use.

Specific activity required over the lifetime of the Strategic Plan will include:

• Delivery of priorities within the Primary Care Strategy that focus on further improving the accessibility of primary care services. 
• Ongoing development of the Mental Health Single Point of Access model to improve access to mental health services ‘at the front door’.
• Continued investment in Mental Health services providing early intervention – including the CWIC Mental Health and Distress Brief Intervention services. 
• Continuing to develop and deliver substance use services that provide quick and easy access to information, advice, and support - including access to treatment where appropriate[3]. 

References

[2] HSCP managed primary care services include CWIC, CTAC, Vaccinations, and Pharmacotherapy teams. 
[3] Including through ongoing delivery of the national Medication Assisted Treatment (MAT) Standards.

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2.3 Responding to the increase in people living with multiple long-term conditions

The number of the people in East Lothian living with one or more long-term condition[4] continues to increase. National figures and projections on the proportion of the population living with multiple long-term conditions (MLTCs), also known as multi-morbidity, is of particular concern and is considered to be one of the most significant challenges facing health and social care services now and in the future. In general, the prevalence of MLTCs increases as people get older, but also tends to increase with higher levels of deprivation.

Planning and delivery of healthcare services that meet the needs of people with long-term conditions, including support with self-management, needs to be a key delivery priority for the IJB.

Specific activity required over the lifetime of the Strategic Plan will include:

• The identification and delivery of priorities related to the management of long-term conditions (as part of the development of the East Lothian Primary Care Strategy).
• These priorities should include multi-disciplinary approaches; early intervention to prevent or slow down the progression of conditions; and activity to support self-management. 

References:

[4] ‘Long term conditions’ are defined as those that persist over an extended period and may require lifelong management – for example, diabetes, arthritis, heart disease, and respiratory conditions such as COPD.

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2.4 Developing a multi-disciplinary approach to the management of frailty

The growth in the older population will be of particular significance as this demographic group has the highest use of health and social care services. As the older population increases, so will number of people living with one or more long term health condition and / or with challenges related to ageing, including frailty. 

Falls continue to be the most common cause of emergency hospital admission for adults in Scotland. Falls put pressure on hospital beds and often lead to people requiring new or additional social care and rehabilitation services. Falls can result in reduced confidence and increased frailty for older people, significantly reducing their health, wellbeing, and independence.

Specific activity required over the lifetime of the Strategic Plan will include:

• Development and delivery of East Lothian Frailty Programme to implement a multi-disciplinary approach to the management of frailty across primary and community care services in line with Health Improvement Scotland (HIS) Frailty Standards.
• Linking in with other Lothian IJBs and NHS Lothian as part of pan Lothian work on frailty.  
• Further development of the local approach to the prevention and management of falls in East Lothian and working as part of the pan Lothian multidisciplinary group to deliver the Lothian Falls Framework.

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2.5 Improving health and wellbeing from an early age   

Prevention and early intervention from pregnancy, through to early years, and on into childhood and adolescence is important in terms of improving overall population health, leading to better health outcomes throughout adulthood and reducing the need for health and social care support.

Although children’s social work services are not delegated to the IJB in East Lothian, there are a number of HSCP healthcare services provided to children and families (including, for example, primary care services; health visiting; and school nursing). HSCP services also work with parents and other adults within families, so are part of the multi-disciplinary approach to supporting the whole family. 

Specific activity required over the lifetime of the Strategic Plan will include:

• Continuing to strengthen partnership working through active involvement in the East Lothian Children’s Strategic Partnership to deliver the priorities identified in the Children’s Services Plan.
• Ongoing development of HSCP teams involvement in multi-disciplinary working across services and organisations to identify and respond to needs within families.
• Involvement the development of ‘whole family support services’ to provide families with effective, early help.   

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2.6 Supporting people living with dementia to remain active, socially connected, and supported in their local communities.

Rates of dementia are expected to increase significantly over the next 25 years. The impact of a dementia diagnosis is wide ranging, not only for the person with dementia, but also for families and carers. The East Lothian Dementia Strategy outlines the IJB’s commitment to ensuring that people living with dementia remain active, socially connected, and supported within their local communities.

Specific activity required over the lifetime of the Strategic Plan will include:

• Delivery of related priorities within the East Lothian Dementia Strategy - including expansion of Post Diagnostic Support (PDS), as well as broader services across the entire dementia care pathway. 
• (Note - the IJB has an existing commitment to the delivery of these and other priorities within the East Lothian Dementia Strategy – the Strategy can be viewed in full here.)

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2.7 Supporting carers’ health and wellbeing to enable them to continue in their caring roles

The number of people providing unpaid care will continue to grow as the population ages and the percentage of people living with a limiting health condition or disability increases. Unpaid carers play a crucial role, supporting people to live at home and often avoiding or reducing their need for support from formal social care services.

Providing support to carers is important in terms of promoting their health and wellbeing and enabling them to continue to in their caring role.

Specific activity required over the lifetime of the Strategic Plan will include:

• Delivery of priorities within the East Lothian Carers Strategy related to supporting carers’ health and wellbeing to enable them to continue in their caring roles.
• (Note - the IJB has an existing commitment to the delivery of these and other priorities within the East Lothian Carers Strategy – the Strategy can be viewed in full here.) 

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