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Living and Dying Well: A national action plan for palliative and end of life care in Scotland




Advanced Care Plans
The aim of advance care planning is to develop better communication and recording of decisions, thereby leading to provision of care based on the needs and preferences of patients and carers.

Better Together
Better Together is NHSScotland's programme to improve patient experience. It will build upon the improvements already happening across our health service by working with patients, carers and staff to further enhance the quality of care.
The programme will support NHSScotland to make year-on-year improvements for patients and the care they experience.

Care Commission
The Care Commission was set up in April 2002 under the Regulation of Care (Scotland) Act 2001 to regulate all adult, child and independent healthcare services in Scotland. The Care Commission ensures that care service providers meet the Scottish Governments National Care Standards and work to improve the quality of care.

Community Health Partnerships ( CHPs)/Community Health and Care Partnerships ( CHCPs)
CHPs/ CHCPs have been established by NHS Boards as key building blocks in the modernisation of the NHS and joint services, with a vital role in partnership, integration and service redesign. They provide an exciting opportunity for partners to work together to improve the lives of the local communities which they serve.
CHPs provide a focus for the integration between primary care and specialist services and with social care and ensure that local population health improvement is placed at the heart of service planning and delivery.

Community Planning Partnerships
Community Planning Partnerships bring together key participants, and so can act as a 'bridge' to link national and local priorities better. This should be a three-way process whereby local Community Planning partnerships can influence national direction, but also can help to co-ordinate the delivery of national priorities in a way that is sensitive to local needs and circumstances. Local or neighbourhood priorities should also be able to influence the priorities at the Community Planning Partnership level.

The eHealth Programme aims to change the way in which information and related technology are used within NHSScotland in order to improve the quality of patient care.

Gold Standards Framework ( GSF)
GSF is a framework of strategies, tasks and enabling tools designed to help primary care teams improve the organisation and quality of care for patients in the last stages of life in the community.

Indicator of Relative Need ( IoRN)
A standardised tool (currently validated only for use with older people) which groups individuals according to their level of relative need, and is applied following a comprehensive Single Shared Assessment.

Liverpool Care Pathway for the Dying Patient ( LCP)
The LCP has been developed to transfer the hospice model of care into other care settings. It is a multiprofessional document which provides an evidence-based framework for end-of-life care. The LCP provides guidance on the different aspects of care required, including comfort measures, anticipatory prescribing of medicines and discontinuation of inappropriate interventions. Additionally, psychological and spiritual care and family support is included.

Long Term Conditions Collaborative
This is a collaborative to support NHSScotland deliver sustainable improvements in patient centred services. The three year national programme will engage all NHS Boards. The focus will be on clinical systems improvement to improve access, reliability, safety and patient experience.

Patient Focus Public Involvement
This is a framework for delivering a culture change in the NHS where patient focus is at the heart of service design and delivery.

Scottish Patients at Risk of Readmission and Admission ( SPARRA)
Scottish Patients at Risk of Readmission and Admission ( SPARRA) is a risk prediction algorithm, developed by the Information Services Division ( ISD) to identify patients aged 65 years and over at greatest risk of emergency inpatient admission and readmission.

Scottish Patient Safety Alliance
The Scottish Patient Safety Alliance has been established to oversee the development of the Scottish Patient Safety Programme. The Scottish Patient Safety Programme aims to steadily improve the safety of hospital care right across the country. This will be achieved using evidence-based tools and techniques to improve the reliability and safety of everyday health care systems and processes.

Shifting the Balance of Care ( SBC)
The aim of SBC is to improve the health of the people of Scotland by reducing inequalities and increasing our emphasis on health improvement preventative medicine, more continuous care and support in the community. SBC describes changes at different levels across health and social care - all of which are intended to bring about improvements in health and better service outcomes, providing care which is quicker, more personal and closer to home.

Single Shared Assessment ( SSA)
The SSA and Carer's Assessment extend the opportunities to involve a range of staff and agencies in assessment, and stresses the principle that the most appropriate professional should be responsible for carrying out the assessment, co-ordinating any other contributions, and identifying the support or resources needed.

Managed Clinical Networks
A Managed Clinical Network is a network of multi-professional, multidisciplinary and cross-boundary staff (including doctors, pharmacists, nurses, health visitors, physiotherapists and occupational therapists) and organisations from primary, secondary and regional health care working together to make sure that high quality clinically effective services are fairly distributed. Involving patients with experience of the particular illness is an important part of MCNs development.

Mental Health Collaborative Programme
The overall aim of the Mental Health Collaborative is to support NHS Boards to make the improvements needed to deliver against key national targets set out by the Scottish Government.

User Defined Service Evaluation Tool ( UDSET)
The User Defined Service Evaluation Toolkit ( UDSET) has been developed to enable health and social care partnerships to improve practice through application of user and carer defined outcomes tools, and to gather information from service users and carers on the outcomes that are important to them and use this information for performance management, planning, commissioning and service improvement.