Planning and delivering integrated health and social care: guidance

Guidance on the planning and delivery principles which describe how integrated care should be planned and delivered and how the principles will work in tandem with the National Health and Wellbeing Outcomes.

This document is part of a collection

12. Make the best use of available facilities, people and other resources

People should have access to the right support and services, at the right time and in the right place. For some people this may mean a reduction in the number of individuals involved in their care and support, or accessing a range of services in a co-ordinated or co-located environment. It should also mean people not being admitted to hospital when this may not be the best option for them, or having underlying issues addressed so that higher levels of support are not needed.

People can often benefit from services that share facilities. This makes access easier as well as saving money that can be spent on other support and services.

People in local areas will need to work together to make sure they know about all the resources that are available to them, including the assets that individuals and communities themselves contribute. This will help enable good planning that makes best use of all the resources that can support health and wellbeing and avoids gaps or overlaps in provision.

This principle underpins better outcomes for individuals and communities, as well as, best value for public money.Challenge questions and resources

This section is intended to provide a series of questions for partnerships and health and social care providers to challenge their own effectiveness in integrating the planning and delivery principles into their work. These questions have been developed by partners, including scrutiny organisations, with the aim of providing a direct link to external integrated scrutiny and improvement activity. We have included links to just a few resources that may help you as you develop and assess your work. This is not a comprehensive list. Though these resources are grouped under the most relevant section, many of these resources support the implementation of most, if not all, of the principles together.

Principle(s) What do we want to know? (challenge questions) Useful resources
1: Is integrated from the point of view of service- users
  • How have you reduced complexity for people who use support and services so that they share their stories once?
  • How have you ensured this information is shared effectively and appropriately between those who need to use it?
  • How well can you evidence a seamless access to care and support regardless of point of entry?
  • How can you evidence increased choice and control for people in managing their health and wellbeing?
  • How have you changed your practices to evidence that peoples’ views are listened to and they are supported in making decisions?
Scottish Government: The 2020 Vision

The Social Care (Self-directed Support) (Scotland) Act 2013

Self Directed Support Values and Principles Statement Resources for Caldicott Guardians (including the revised principles 2013)
2: Takes account of the particular needs of different service users

4:Takes account of the particular characteristics and circumstances of different service users

10: Is planned and led locally in a way which is engaged with the community (including in particular service users, those who look after service users and those who are involved in the provision of health or social care)
  • How can you demonstrate that you are applying this principle to all groups, particularly those at greater risk of experiencing poorer health and wellbeing (for example, older people, people with poor mental health, disabled people)?
  • What supports do people already have?
  • How can you evidence you have reduced barriers?
  • How have you allocated time to enable all staff to work together with people who use support and services to achieve their outcomes?
  • How are practitioners building on supports that are already in place with families and carers?
  • Have you taken into account the different assets, needs and circumstances of people who use support and services to achieve the best possible outcomes?
  • In what ways are staff working effectively and sensitively with people with diverse characteristics, from a diverse range of backgrounds and circumstances?
  • How can you demonstrate that you are using a range of tools and approaches that meet the diverse needs of people using services and maximise their participation?
  • How do you ensure that support and services are effective in helping to improve people’s lives and the outcomes that matter to them?
  • How are you supporting frontline staff to free up time and develop skills to engage meaningfully in the planning and delivery of integrated care?
Joint Improvement Team: Talking Points Personal Outcomes Approach: Practical Guide

NHS Health Scotland: Health Inequalities Impact Assessment - An approach to fair and effective policy making: Guidance, tools and templates

Equality and Human Rights Commission

Scottish Health Council: Our Voice

Five Good Communication Standards

The Scottish Health Council has local offices across Scotland which are able to provide advice and support on participation approaches. It has also produced a Participation Toolkit which can be accessed at The Alliance People Powered Health and Wellbeing

Scottish Government, Principles of Inclusive Communication

IRISS, Coalition of Carers in Scotland and Scottish Government: Equal and expert: 3 best practice standards for carer engagement:

MECOPP: On the Margins - An audit tool for Minority Ethnic Carers

NHSScotland, Staff Governance Standard

Inclusion Scotland
3:Takes account of the particular needs of service users in different part of the area in which the service is being provided

7:Takes account of the participation by service-users in the community in which service users live
  • How have different locality and community needs been identified and how have these differed in practice?
  • How are you supporting community development activity in your area to enable local people to engage meaningfully in the planning and delivery of integrated care?
  • How have local people and community leaders been involved in shaping future care provision?
  • How are existing community assets factored in to local decision making?
  • How do support and services help enable people to participate and exercise their full citizenship rights as members of their community?
Joseph Rowntree Foundation: Involving Older People: more power to their elbow

Community Development/Alliance Scotland: Principles of Community Development Practice

Independent Living in Scotland: Co-production Toolkit
5: Respects the rights of service users
  • In what ways have you demonstrated that you are applying PANEL principles across design commissioning and delivery of services?
  • In what ways do you promote and support awareness of peoples’ understanding of their rights?
  • What training and support have staff had in ensuring a consistent approach to rights based practice?
  • In what ways have you used impact assessments to promote people’s rights and address health inequalities?
The Scottish Human Rights Commission: Care About Rights (including the PANEL and FAIR approaches)

Scottish National Action Plan for Human Rights

Alliance Scotland: Being Human: A Human Rights Based Approach to Health and Social Care in Scotland

Scottish Government: The Charter of Patients Rights and Responsibilities

Information on rights / duties in relation to social care

Charter of Rights for People with Dementia and their Carers in Scotland

Inclusion Scotland: Human Rights Toolkit

The Human Rights Act 1998

The United Nations Convention on the Rights of Disabled People ratified by the UK in 2009

WHO, UNHCHR: The right to health

The Equality Act 2010

Equality and Human Rights Commission

Health Rights Information Scotland

British Institute for Human Rights
6: Takes account of the dignity of service users
  • What practice guidelines are already in place to ensure people are treated with dignity and respect?
  • How are these guidelines monitored and reviewed?
  • What improvements have there been to services to ensure dignity and rights are respected?
RCN: Dignity Resources
8:Protects and improves the safety and well-being of service users
  • Are there clear guidelines and education programmes in place for staff to ensure a consistent approach to safety and risk that also allow for local professional judgement?
  • How is this monitored, discussed and continually improved to achieve the best possible outcomes?
  • How are people who use support and services supported to make the right choices for them in relation to health and well-being?
  • How can staff, people who use support and services and carers easily raise concerns about the safety of services in your area so immediate action can be taken?
  • Do actions taken to address safety concerns raised in your area demonstrate a prompt and appropriate response each and every time?
The Nursing and Midwifery Council: The Code: Standards of conduct, performance and ethics for nurses and midwives

Health and Care Professions Council: Standards of Conduct, Performance and Ethics

Scottish Social Services Council: Codes of Practice for Scottish Social Service Workers and Employers

General Medical Council: Good Medical Practice

Scotland’s National Care Standards

Scottish Intercollegiate Guidelines Network

National Institute for Health and Care Excellence

Scottish Patient Safety Programme

Patient Opinion Scotland
9: Improves the quality of the service
  • Is your current quality improvement strategy leading to genuine improvements for people who use support and services?
  • How do you involve people who use support and services and families/carers in assessing and improving quality?
  • How do you ensure that the services you commission and/or deliver are providing appropriate education, training and supervision to staff to improve care quality?
  • Are you assured that staff in your area are clear about lines of professional accountability for care, whichever sector they work in?
  • How are you assured that the services you commission and /or deliver have appropriate numbers of staff and skill mix to provide quality care?
  • How does your approach to joint delivery of health and social care improve outcomes and add greater value for people who use support and services?
  • How do you ensure that the nature of high quality care in your service area is easily understood by staff, people who use support and services and their families/carers?
  • How do you currently measure the quality of this care to maximise its effectiveness?
  • How do you ensure you have access to all available, relevant intelligence and use this to inform decisions and planning?
  • Can you demonstrate that feedback and complaints are being used actively to make improvements to the quality of care?
  • Do you support staff to make improvements to the care they provide by always giving feedback on the outcome of feedback, complaints, scrutiny activity and other performance assessments?
  • How does your commissioning and procurement practice support all providers to deliver Best Value?
Improvement support is available from a number of different sources:

Joint Improvement Team
Improvement Service
Care Inspectorate
Healthcare Improvement Scotland
Quality Improvement Hub
Institute for Healthcare Improvement
Scottish Government: The Healthcare
Quality Strategy for NHSScotland
Nursing and Midwifery Workforce and Workload Planning
Leading Better Care
11:Best anticipate needs and prevents them arising

12: Make the best use of available facilities, people and other resources
  • What community supports are available to enable active and independent living?
  • How does your service proactively inform anticipatory care planning?
  • How are you involved in, and how can you evidence, reducing health inequalities?
  • How do you ensure the earliest possible intervention?
  • How have you ensured that people in local areas know about the resources and assets available to them?
  • How can you evidence the positive benefits of shared resources within developments in your service or local area?
  • What processes do you have in place to help identify unmet need in your area?
Scottish Government: Our shared vision for independent living in Scotland

Information Services Division data support for integration authorities

NHS Health Scotland: Health Inequalities Impact Assessments FAQs

Guidance: For Public Benefit: Engaging With Scotland’s Enterprising Third Sector A Guide for Public Sector Service Managers, Commissioners, and Procurement Professionals

Scottish Government: Scottish Public Finance Manual (Best Value)

Scottish Government resources on public sector procurement


Email: Frances Conlan

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