Long term conditions framework: consultation analysis

17. Question 15

Is there anything currently working well within your community to prevent or slow progression of long term conditions?

The vast majority (79%) of respondents answered Question 15. This section provides an overview of:

• the views of respondents who identified examples of things that worked well within their community to prevent or slow progression of long term conditions
• the views of respondents who said they could not think of anything that currently worked well within their community to prevent or slow progression of long term conditions

Examples of things that worked well within communities to prevent or slow progression of long term conditions

The vast majority of respondents highlighted several aspects which they considered to work well within their community to prevent or slow progression of long term conditions. The main themes that emerged from these responses were:

• theme 1: prevention and early intervention
• theme 2: community based support
• theme 3: integrated and coordinated care

Theme 1: Prevention and early intervention approaches

Many individual and organisation respondents said that approaches aimed at prevention and early intervention currently worked well within their community. They often noted such approaches and support ensured a focus on stopping problems before they started and supported early detection of issues that enabled early intervention to halt or slow progression of long term conditions.

Points raised under theme 1 can be grouped as follows:

• lifestyle and behavioural change programmes – some respondents, particularly service providers, highlighted interventions aimed at encouraging physical activity, health eating and nutrition, falls prevention and physiotherapy. These programmes were considered effective as they: reduced risk factors associated with long term conditions; encouraged and promoted healthy lifestyle; reduced demand and pressure on primary care services; and could be more cost-effective if intervention happens early. These respondents highlighted the important role of a wide range of service providers in signposting and referring people to lifestyle and behavioural change activities and programmes
• supported self-management – some respondents identified the importance of educational support and information, personalised action plans, self-management plans, coaching, digital resources, group sessions, drop-in sessions, the provision of practical tools, self-monitoring equipment and structured self-monitoring plans, and regular check-ins. Self-referrals were highlighted as important mechanisms to access care and support in a timely manner and to support early detection
• public health campaigns – some respondents said it was vital that people with long term conditions (or at risk of developing long term conditions) were provided with clear, accessible information to support and empower them to make informed decisions about their care, lifestyle choices and behaviours. Public health campaigns (including those supported by legislation) mentioned as good examples were smoking cessation and ultra processed food
• detection, screening and regular reviews – a small number of respondents highlighted examples such as national eye screening programmes for optometry, physiotherapy, cardiovascular health, diabetes. A key example noted was the Psychology Adding Value Epilepsy Screening (PAVES) programme which is targeted at children and young people with epilepsy who experience mental health issues providing mental health screening and, if required, access to a tailored early intervention pathway. Respondents also referred to the important role of community pharmacies in terms of their accessibility in local communities and skilled and experienced staff
• evidence-based prescribing of clinically proven drugs or treatments – a small number of respondents identified pharmacological interventions and innovations with proven efficacy as important preventative measures. Examples included: SGLT2 inhibitors which are primarily used to treat diabetes, heart failure and chronic kidney disease; and the growing use of weight loss medication from both private and public health providers to slow or prevent many long term conditions by maintaining healthy weight to increase mobility

Respondent quotes to illustrate points raised are provided below.

“The CHS Self-management Skills programme has been hugely beneficial to my daughter, she thoroughly enjoys her time at the group, and it has increased her confidence. It's usually quite difficult to get her to take part in activities especially with new people. It is especially hard to get her out the house on time. However, with SMS she is up and ready to leave early and never wants to miss a session.” RCPCH Scotland and Children's Health Scotland

“The option to re-refer back into services has been helpful and avoids waits for GP referral back into specialist services. Re-referral means that symptoms can be treated promptly and often stops progression to more severe or limiting symptoms.” The Innovative Healthcare Delivery Programme (IHDP) Patient and lived experience reference group

Theme 2: Community based support

Many individual and organisation respondents highlighted the valuable role of third sector organisations and community based support as examples of good practice within their community to prevent or slow progression of long term conditions. Points raised under theme 2 have been grouped as follows:

• accessibility of community based support
• social aspect of community based support

Accessibility of community based support

Some respondents emphasised the importance of the accessibility of local community hubs, day centres, leisure centres and libraries and how they could be used to deliver information sessions, drop-in support and advice, lifestyle and health improvement programmes and signposting for people with long term conditions. Such facilities were close to home and familiar.

Respondents identified targeted outreach delivered through community based support as a key strength. For example, Community Appointment Days, where a range of allied health professionals provided triage and connected people to relevant services, were considered highly effective and valued by people with long term conditions and health professionals alike.

Similarly, responses noted the creation of Health Defence Hubs in areas of high deprivation allowed interventions to be tailored to the needs of local communities. They added that this approach helped remove barriers to accessing care and support services. Another example of good practice in the third sector included volunteer-led community transport, befriending and buddying schemes – respondents said these helped to remove barriers to accessing healthcare appointments as well as social activities – and were important lifelines for people with long term conditions.

Social aspect of community based support

Some respondents mentioned the social value and benefit of community based support. They said that support networks and peer groups were crucial for providing a shared sense of community for people with long term conditions which could often be isolating. Key people identified in responses included Community Link Workers and similar roles that helped build relationships and connect people with the right local support provided by the third sector and community organisations. They identified the important role of social prescribing approaches (for example, physical activity, social or hobby groups) to help people access non-medical interventions that could help prevent or slow progression of long term conditions and reduce pressure and demand on primary care.

Respondents stated that community based support also increased the visibility of long term conditions and the services available – it helped to widen access and ensure more people received timely support.

Responses noted this support could help address issues such as mobility, isolation and wellbeing by linking people to support networks (for example, social prescribing of Men’s Sheds) – and could help to improve quality of life.

Another social benefit identified was that access to community based support increased the confidence of people with long term conditions, and could encourage them to access other support, and stay engaged with their own care – all of which contributed to better management of long term conditions.

Respondent quotes to illustrate theme 2 are provided below.

“Our hubs take a Community Development approach to design services, making sure they service the needs of the community and build trust. For example, our Dundee Health Defence Hub team has worked with the local Gypsy Traveller community to build trust and help them access services.” Chest Heart and Stroke Scotland

“Community Link Workers are a success story locally and support people in the community to live their lives to the fullest and reduce demand on primary care and other health and social care services.” Clackmannanshire and Stirling Health and Social Care Partnership

Theme 3: Integrated and coordinated care

Some respondents, mostly representative organisations/groups for health and social care staff, highlighted examples where multidisciplinary teams provided integrated and coordinated care and support to people with long term conditions and said this worked well in practice. These respondents said the prevention and slowing of long term conditions was best supported when care was integrated and coordinated across different parts of the healthcare system. They added that this was often enabled and facilitated (and accelerated) by clear referral pathways, joined-up service delivery, and the co-location of different services.

Key strengths of this approach were considered to include: timely access to care and support; holistic and person-centred support; and strong relationships and communication between people and service providers (consistency and continuity of care). Organisations (mostly service providers) noted that integrated rather than fragmented care helped to raise awareness and understanding of long term conditions (and how individual conditions may progress) amongst healthcare professionals.

While integrated and coordinated care was highlighted as an example of good practice, a small number of respondents highlighted that the level and efficiency of collaboration and joint working varied across Scotland. They stated more could be done to ensure a more integrated and coordinated approach to care and support regardless of where a person lived, and that such an approach would require to be supported by workforce education, development and training.

Respondents who could not identify any examples of what is working well within their community

Some respondents (mainly individuals) stated they could not identify anything that worked well within their community to prevent or slow progression of long term conditions. The main points that emerged from these responses were:

• a lack of available care and support for certain long term conditions – for example, long COVID was mentioned in responses
• that a continuing pressure on budgets has reduced funding and resources for activities that prevent or slow the progression of long term conditions