Realistic Medicine and Value Based Health and Care Casebook

Personalised Care and Shared Decision Making

Realistic Medicine empowers people and their families to actively participate in decisions around their plans for treatment and care. It ensures care is personalised to the people we care for and shared decision making between people and professionals. This requires open, meaningful and inclusive conversations including what matters most to people.

The 2018 Citizens’ Jury recommended the development of a programme to inform both the people we care for and professionals about the importance of supporting people to ask questions about their care. It also recommended training for all health and care professionals so that they use shared decision making. We know from Citizens’ Panel 14 that the overwhelming majority of people want to participate in shared decision making. And, importantly, we recognise that shared decision making is embedded in the law of consent with an expectation that people and their families will have the opportunity to discuss the potential benefits and risks of a plan for care and consider relevant alternatives including doing nothing.

Practice and understanding of shared decision making conversations can be supported using education and tools such as the BRAN tool. At a national level, we have developed training and education materials to support health and care workers. These existing modules are updated regularly and we have developed multimedia training across a range of Realistic Medicine approaches. Additionally information for people about how they can become effective partners in their care had been provided. Work also continues with NHS Boards and our delivery partners to promote the use of these resources and embed personalised care and shared decision making in all we do. The core aim is to build a personalised approach to care through collaboration, fostering trust and open dialogue to help individuals make informed decisions based on what matters most to them. Now, more than ever, we need to develop systems, and support health and care professionals, to provide personalised care based on shared decision making.

The following examples highlight approaches to personalised care and the difference shared decision making is making to achieve the outcomes that matter most to people.

Community Appointment Days (CAD): A Collaborative Approach to Personalised Care

Community Appointment Days (CADs) aim to foster a personalised approach to health and care by enabling healthcare providers to understand and prioritise what matters most to the individuals they care for. CADs not only support people in managing their health conditions but also encourage the use of community services, emphasise preventive care, and help reduce waiting lists through an innovative care approach.

This case study combines the experiences of NHS Grampian and NHS Lanarkshire in implementing CADs for Musculoskeletal (MSK) Physiotherapy and Podiatry services. Both initiatives demonstrate how personalised care, collaborative partnerships, and a holistic approach can improve outcomes for people and service efficiency.

NHS Grampian launched its first CAD in Moray in September 2024, inviting 250 patients from the MSK Physiotherapy and Podiatry waiting lists. Before the event, each participant underwent screening to assess the appropriateness of the intervention. On the day of the CAD, 210 attendees engaged with various healthcare and community services. Attendees accessed their Personal Health Passport via QR codes and documented their journey through different care zones, promoting self-management and ownership of their health.

In NHS Lanarkshire, trial CADs were initiated in April and June 2024, followed by a larger event in October 2024. The October CAD invited 555 patients, with 449 attending over 2 days. The sessions began with a “what matters to you” conversation to guide subsequent interactions. Services included physiotherapy and support from third-sector agencies such as smoking cessation, healthy lifestyle programs, and financial advice.

Both CADs exemplified strong partnerships with community organisations. In Moray, Versus Arthritis and Walk Moray. played integral roles, while Lanarkshire collaborated with services like Weigh to Go, Community Link Workers and local health and wellbeing groups.

Feedback from both locations was overwhelmingly positive.

In Moray attendees reported feeling the day had been “enlightening”. People also said that they had benefited from having multiple services participate and this helped them find out about the support available to them in their communities. High-level analysis showed that people particularly valued the time given to them by those that were there to help, being listened to, including what matters to them, having access to a one-stop shop and feeling informed. This really supported more personalised care. Participants shared:

"Participants felt the day had been ‘enlightening’ not only did they feel their MSK was almost cured following the session, but they also felt listened to and was amazed at the speed of their next appointment with the team."

"I had a lightbulb moment today – I’ve been to a podiatrist before but today it was said in a different way, and I understood really what they meant and what I can actually do for myself. That’s because I was more relaxed here."

"Each person listened greatly. Both professionals I met with today made me feel like a person rather than a number – it was a pleasant change."

Both NHS Grampian and NHS Lanarkshire utilised the Collaborate tool in their CAD evaluation. In Moray 78% of people reported that every effort was made to help them understand their health issue, 74% reported that every effort was made to include what mattered to them in choosing what they do next, 79% reported that every effort was made to listen to things that mattered to them most about their health issues.

In NHS Lanarkshire over 80% of participants reported high satisfaction with the information provided, the attentiveness of staff, and the personalised nature of the care received. One participant shared:

In Moray, overall, people rated the CAD experience 4.5 out of 5 and within 6 months of the CAD, 50% of attendees were discharged or moved to a Patient-Initiated Review (PIR) pathway.

NHS Lanarkshire’s October CAD resulted in 50% of patients receiving PIR outcomes, 38% scheduled for follow-up appointments, and 12% discharged.

"I’ve never experienced such a holistic approach before. Every person I spoke with took the time to listen to me and my experiences. I left the session with referrals, advice, and a clear plan to manage my condition."

The events significantly improved productivity compared to standard clinics, with Lanarkshire’s two-day CAD serving over 400 patients, a stark contrast to the fewer than 200 appointments achievable under traditional models. Both events increased community engagement, building wider system partnerships and doing things in a more meaningful way, in partnership with the people cared for. These events promote a more sustainable health and care system, by focusing on achieving the outcomes that matter most to people.

The CADs in both NHS Grampian and NHS Lanarkshire successfully integrated personalised care, community services, and prevention, fully aligned to Realistic Medicine principles. People appreciated the focused time, one-stop-shop services, and the opportunity to discuss their health needs and what matters to them. Positive feedback and high satisfaction scores highlight the benefits of a holistic approach to delivering better outcomes through personalised care.

Respecting Patient Wishes: Home-Based End-of-Life Care for Acute Heart Attack

The Hospital at Home (H@H) service is vital to delivering care outside the traditional hospital setting. Underscoring the importance of respecting what matters to the people we care for (their biology and biography and their autonomy) ensures that we provide personalised care, as well as effective coordination between emergency and community health and care services.

Scottish Ambulance Service (SAS) has developed national guidance for clinicians using Hospital at Home (H@H), based on the Healthcare Improvement Scotland Guiding Principles. This guidance facilitates the rapid establishment of local pathways, providing clear advice on when to consider the service and the available local support for people.

Since January 2024, NHS Borders has had a protocol in place to allow SAS to refer directly to H@H, provided all criteria are met. Referrals require review by a doctor or Advanced Nurse Practitioner (ANP), with exclusion criteria over time-critical conditions such as heart attacks, strokes, and surgical or trauma cases. If someone meets this criterion and doesn’t want to go to the hospital, they are happy to discuss their options — as long as everyone understands the risks of staying at home.

An example is 94-year-old Susan (not her real name), who was referred to the H@H service via SAS following a 999 call due to sudden onset chest pain. The clinical presentation strongly suggested ischemic pain, with the electrocardiogram (ECG) confirming a heart attack. Despite the urgency and severity of the condition, Susan made it clear that she did not want to be admitted to hospital, fully understanding the potential consequences of her decision. Her primary priority was effective pain relief, and her family was present to support her choices.

The H@H team arrived within an hour of referral. By the time they arrived, Susan had received aspirin, glyceryl trinitrate, and morphine from the ambulance crew, which had alleviated her pain.

The team had open, compassionate discussions with Susan and her family, practising Shared Decision Making to explore all available options while prioritising what mattered to Susan. With full mental capacity, Susan reaffirmed her decision to stay at home.

Understanding Susan’s wishes, the team provided personalised care at home, including oral medications to manage pain and symptoms effectively. Together, Susan, her family and her care team discussed and agreed a future care plan, including a ReSPECT form and DNACPR orders. Anticipatory care medications were prescribed to ensure effective management of Susan’s symptoms as her condition evolved.

The community healthcare team was informed to provide additional support when needed. Over the course of five days, the H@H team provided dedicated care, addressing Susan’s medical and emotional needs as her condition progressed.

Five days after the H@H team initiated care, Susan developed symptoms of heart failure. Fulfilling her wishes, Susan was palliated and passed away peacefully at home, surrounded by her family. Her wishes were fully respected throughout the process, and the H@H team ensured that Susan’s final days were as comfortable as possible. While the final outcome was undoubtedly sad, Susan’s experience was made better through the following approaches:

The Power of Patient Autonomy and Shared Decision Making. Respecting Susan’s values and priorities allowed the team to deliver personalised and meaningful care. By ensuring her wishes guided every step of the process, the team provided care that was not only clinically appropriate but also emotionally and ethically aligned with what mattered most to Susan and her family.

Timely, Compassionate Communication. Early and open discussions about prognosis and care options were crucial in helping Susan and her family make informed decisions. Honest, empathetic conversations fostered trust and ensured that her care remained aligned with her preferences and expectations. By proactively addressing concerns, the care team minimised uncertainty and helped Susan and her loved ones navigate the emotional and medical complexities of her condition with greater understanding, confidence and peace of mind.

Coordinated Multidisciplinary Efforts. Excellent collaboration between the H@H team, ambulance crew, and community services played a vital role in delivering comprehensive, high-value, personalised care. Clear and timely communication between these teams ensured they understood both Susan’s biology and biography, ensuring continuity of care. This helped avoid unnecessary hospital admissions, and upheld Susan’s desire to remain at home. This case underscores the importance of shared decision making and well-coordinated multidisciplinary efforts in providing careful and kind home-based care.

By prioritising what mattered most to Susan, the H@H team exemplified a compassionate and dignified approach to home-based end-of-life care. Over the last year the H@H service has accepted 41% of the referrals made to the service via SAS. This has meant that those people have received care based on what matter to them, supporting them to remain at home and ensure they receive the right care in the right place.

Partnering with Pharmacists to Improving Migraine Management

The Partnering with Pharmacists to Improve Migraine Management initiative by NHS Grampian exemplifies Realistic Medicine in action. Migraines affect 1 in 7 people in the UK, yet many cases are poorly recognised or misdiagnosed, leading to inadequate or inappropriate treatment.

This initiative empowers pharmacists with enhanced skills, improves access to timely care, and raises public awareness. Leveraging the Pharmacy First program, it provides a more accessible point of care while aligning with the National Headache Pathway.

Phase 2 builds on these successes, expanding the approach to six additional NHS Scotland health boards. By reducing variation, harm, and waste, the project promotes personalised care and shared decision making, reflecting the core principles of Realistic Medicine.

Key Actions

Focus groups with people living with migraine and pharmacy staff identified a significant need for improved migraine knowledge, which was further confirmed by a wider survey. In response, a TURAS eLearning module and live training sessions led by headache specialists were developed to enhance professional education. Additionally, following feedback from staff, a separate eLearning resource was created in collaboration with NES for nonclinical pharmacy staff.

Public engagement efforts were aimed to increase awareness and accessibility of migraine-related information. Awareness materials were distributed to pharmacies and GP practices across Grampian. To further support patients, NHS Grampian launched a “What is Migraine?” webpage, providing easily accessible and reliable information about the condition. In January 2024, the first Manage Your Migraine webinar successfully raised awareness and offered support to those affected, with a second session held in January 2025.

Beyond education and awareness, the project fostered community engagement through art and creative writing sessions for individuals living with migraine in Grampian. These sessions provided a space for people to connect, share their experiences, and express how the condition affects their lives.

To ensure a lasting impact, the project collaborated with NHS Education for Scotland, Community Pharmacy Scotland, and Higher Education Institutes. These partnerships support the long-term sustainability of the initiative, ensuring that migraine education and awareness continue to grow across healthcare and community settings.

Impact

To date, over 350 people have engaged with the eLearning module, and 226 have attended workshops. This project has significantly enhanced the skills and confidence of pharmacy teams, with feedback highlighting its “massive impact on practice” and “this knowledge and confidence has directly transferred to providing better patient care”.

"I consider many more patients that present with headache with the possibility that it may be migraine. In one instance I had a patient who thought they were suffering recurrent sinus infections causing headache but on further questioning and discussion I found they were also exhibiting classic migraine
aura symptoms."

Quote from a Community Pharmacist

"Understanding better the role migraine has on mental health has been invaluable to me and my patients."

Quote from a Nurse

The January 2024 public webinar had over 900 sign-ups, 463 attendees, and as of February 2025 has 1,493 views of its recording. The January 2025 public webinar had 358 sign-ups, 150 attendees, and as of February 2025 has 313 views of its recording. Evaluation of the surveys completed during and after the webinars found that 93% of attendees felt their understanding of migraine improved, and 76% reported reduced concerns. Additionally, 91% expressed willingness to discuss migraine with pharmacists post-webinar, up from 53% before.

The focus on patient education and self-management empowered individuals to take an active role in the management of their condition. People reported better migraine management, with reduced frequency and severity of attacks. The project’s success in Grampian led to its expansion to six additional Health Boards in Scotland, ensuring broader access to improved migraine management in line with the National Headache Pathway.

"I would like to say that what I have discovered because of this project has been absolutely life changing. I cannot iterate enough how taking simple (and cheap) aspirin has cleared my headaches."

Quote from the public survey

"During the webinar, I discovered various treatments and strategies to better manage my symptoms. This has made a significant difference for me, and I’m experiencing fewer migraines now that I’m applying what I learned having identified my triggers."

Quote from a webinar attendee

In early 2024 all Health Boards were invited to apply to participate in the upcoming year. Year 2 proceeded with six other boards – NHS Highland, NHS Lanarkshire, NHS Lothian, NHS Orkney, NHS Shetland, and NHS Tayside. Phase 2 builds on these successes, expanding the approach to six additional NHS Scotland health boards. By reducing variation, harm, and waste, the project promotes personalised care and shared decision making, reflecting the core principles of Realistic Medicine.

These partnerships have facilitated significant engagement and education in migraine management. A total of 310 individuals attended live training workshops, with 567 engagements in eLearning modules. Post-workshop feedback showed a 73.5% increase in clinicians’ understanding of migraine management, a 71% increase in confidence assessing migraine presentations, and a 56.5% increase in confidence supplying medication. Public engagement was strong, with 613 people attending live webinars and 1,747 YouTube views of the recorded session.

By aligning with Realistic Medicine, this initiative promotes personalised care, shared decision making, and better self-management, leading to improved outcomes for people with migraine across Scotland.

Supporting Shared Decision Making - It’s OK to Ask – and BRAN

Shared decision making should not be seen as a “nice to do”. It sits at the heart of delivering personalised care, and is enshrined in law, as Michael Stewart, Director of the Central Legal Office in Scotland explains here.

We know that a personalised approach to care and shared decision making support people to make better choices about their health and care based on what matters to them and helps us to achieve the outcomes that matter to them.

Citizens’ Panel 14 revealed that 97% of people support getting involved in shared decision making with their healthcare professionals and 93% agree people should be encouraged to ask the BRAN questions to help them choose the treatment and care that is right for them. The BRAN questions are now in widespread use across Scotland. Here we share just one example of how BRAN was implemented in the State Hospital, and reveal how NHS 24 have supported shared decision making through the It’s OK to Ask campaign.

It’s OK to Ask – NHS 24

In response to the 2019 Our Voice Citizens’ Jury on shared decision making, NHS 24 developed, delivered, and evaluated a national, accessible, and effective awareness campaign to educate, encourage and empower people to ask questions when speaking with their health and care professionals. We conducted extensive user research with health and care professionals and citizens to develop effective campaign messaging. To reach a broad audience we created a range of resources designed for multichannel use across various health and care settings.

We created posters and displayed them in over 1,200 community pharmacy windows. The campaign was delivered in three phases including a digital presence on the NHS Inform website accompanied by social media activity and radio presence across eleven radio stations for two weeks. Roadside six-sheet posters were deployed near GP surgeries/hospitals e.g. bus shelters, Pharmacy Screens, Pharmacy Bags, and local/national press.

We shared the digital toolkit with local health boards and printed/distributed campaign information leaflets for them to use.

The ‘It’s OK to Ask’ campaign significantly increased public awareness. The NHS Inform website recorded 11,000 page views and 555 leaflet downloads. The radio campaign reached approximately 1.75 million people across Scotland. Social media efforts generated over six million impressions, engaging 2.2 million users, particularly among older adults. Press coverage extended to 1.1 million readers, while roadside posters garnered over 20 million views. Pharmacy screens, displaying the campaign messages, were viewed an estimated 182,000 times.

A survey revealed that 83% of respondents found the ‘It’s OK to Ask’campaign useful, with many indicating a greater willingness to ask questions during healthcare appointments. By empowering patients to seek clarity and participate actively in their care, the initiative reinforced the principles of Realistic Medicine and encouraged more meaningful health and care conversations.

BRAN questions at the State Hospital

The State Hospital is one of four high secure hospitals in the UK. It is a national service for Scotland and Northern Ireland and one part of the pathway of care that should be available for those with secure care needs. The principal aim is to rehabilitate people, ensuring safe transfer to appropriate lower levels of security.

Due to the clinical and legal context of the State Hospital, many of the people cared for may lack the confidence or capacity to ask questions about their care. Others may feel disengaged from their treatment or be unable or unwilling to interact with health and care professionals. Given these challenges, it is essential to adopt approaches that support informed discussions and ensure people understand their treatment and care options.

BRAN questions were introduced to wards to provide a structured framework for engagement with people cared for in the hospital, alongside ongoing efforts to enhance physical healthcare, as a framework for discussions around physical health care planning. Nursing staff incorporated BRAN into care planning conversations, enabling people to fully consider the potential benefits and risks of treatment, explore alternative options and understand the consequences of choosing no intervention. The BRAN questions were incorporated into care and review processes such that patient documentation reflected clear evidence of understanding, awareness of treatment options and, where appropriate, autonomy in decision making. For example, nursing staff used the BRAN framework to guide discussions with a person who was experiencing severe side effects from medication.

By systematically addressing the benefits of continuing treatment, the risks of side effects, potential alternative medications or therapies, and the option of doing nothing, staff were able to support the person in making an informed decision about their care. This shared decision making not only improved their engagement but also strengthened trust and communication between the person and the health and care team.

Using the BRAN questions has had impact beyond immediate decision making. People have been empowered by fostering autonomy in their decision making. And by clarifying treatment expectations, BRAN helped reduce anxiety and uncertainty among the people cared for in the hospital. This approach also strengthened trust and collaboration between people and our team, ensuring that care planning decisions were well informed and documented. Lastly, the team found the BRAN model beneficial, leading to its broader adoption across wider aspects of health and care planning and delivery.

Care Opinion - The Public as Partners in Change

Over the past decade, the Scottish Government, through the independent platform Care Opinion, has provided people and those closest to them with a way to share their feedback about the health and care services across Scotland. This approach aligns with the principles of Realistic Medicine by empowering people to share their experiences, and ensuring care is tailored to what matters most to people.

In that time, more than 50,000 people have shared their experiences – highlighting what worked well in their care and what could be improved. This valuable feedback has given health and care services the opportunity to learn, adapt, and grow, reinforcing the principles of Value Based Health and Care by ensuring resources are directed toward interventions that improve outcomes and experiences.

In 2024 alone, 11,098 members of the public shared their stories about hundreds of health and care services across Scotland. Of these, 77% were entirely positive, making services feel proud of the care they had provided. They also recognise and reinforce good practice. The remaining 23% were critical of the care they had received, allowing services the opportunity to reflect, learn, and improve.

All Care Opinion feedback is publicly available. Services can respond openly, demonstrating their commitment to transparency and continuous improvement. In 2024, health and care staff responded to stories 13,763 times, engaging directly with the public. This willingness to listen and engage with the people they care for translates directly into improvement action.

Care Opinion provides rich insight into the values and behaviours that shape good health and care experiences. However, it is in how services respond that these values are truly put into practice. Staff and teams openly share what they have learned, the changes they have made, and the practices they have reinforced – creating a culture where learning is visible, and the public feels heard and valued.

Capturing both positive and negative experiences doesn’t just enhance services – it can help health and care staff connect with the core purpose and impact of their work, building relationships that strengthen workplace culture, boost morale, and motivate teams by celebrating success and driving meaningful change. You can find a recent example of how Care Opinion has been used to improve the health and care service here.

Listening to people and acting on their feedback is essential to deliver better value care, where professionals work with people to achieve the outcomes that matter to them.

One Care Opinion author, Anne, shared why feedback is so important to health and care services:

By embracing the principles of Realistic Medicine and Value Based Health and Care, the health and care system can continue to ensure that people’s voices shape the future of care delivery in a meaningful and impactful way.

You can find out more here: Annual Review of stories told about NHS Scotland services in 2023-2024.

"I would encourage everybody, whether they have a positive
or a negative experience, to share their story. Please share positive feedback because it really boosts morale. And please share when it’s negative—because a lot of us patients think, ‘What’s the point? Nothing will change.’ But it’s only through the volume and frequency of feedback that staff and managers can build a case for making real change in the NHS."

Care-Experienced Health Checks

People with experiences of care have often faced disadvantage in childhood and, as a consequence, have poorer outcomes as a group at a population level. Research tends to view this through a lens of clinical disorder however Corporate Parents can and must advocate for our children’s right to health. Poor health and health inequalities are not inevitable for care-experienced infants, children, young people or adults.

With the right support, care-experienced children and young people can attain excellent health that continues throughout their lives. The Health Safety Check is a practical example of a “cog” in the wider care system which could contribute to positive health outcomes and uphold rights for infants, children and young people (ICYP) when they need support most.

This case study outlines the process for conducting health assessments and safety checks for children and young people who become care-experienced in NHS Ayrshire and Arran. Care experienced children are subject to health assessments at various stages of their care journey to ensure their physical, emotional, and developmental health needs are met.

Upon entering care, children must receive a comprehensive health assessment within four weeks, following Scottish Government guidelines. For children under 5 years old, assessments are recommended every six months, while those over 5 years of age should be assessed annually. Additionally, health assessments are required within six months of adoption or permanency planning panels.

When a child moves home in an emergency, for example from their family home to foster parents or between foster parents, there has been no reliable mechanism to inform emergency carers of the ICYP health needs. This has in the past resulted in the ICYP not receiving medication or not attending appointments. This is especially pertinent to relatively common but potentially life threatening, if untreated, conditions such as diabetes, severe allergies and asthma.

A pathway has been created for when an ICYP moves home in an emergency. This is called the Health Safety Check (HSC). Through collaboration with social work, acute paediatrics and the Corporate Parenting Programme board the HSC form has been developed.

Social work has a designated telephone line that connects directly to the Paediatrics Assessment Unit. This triggers the completion of the HSC by the assessment unit, which is then emailed to the relevant professional within four hours.

The HSC has been designed to mitigate risks associated with emergency placements, where children might move without essential health information or medications. This check ensures critical health data is available to social workers and caregivers, allowing for safe placement and continuity of care, particularly in urgent situations.

An example of the Impact of the Health Safety Check

A Health Safety Check was requested for a young person moving from home to a residential children’s house. Upon checking, the young person had a diagnosis of diabetes and also ADHD. They had various medications prescribed. These were unknown to the social care team. The young person did not know themselves the types of medication they were on and due to difficulties and complexity within their home life, this information could not have been gathered from their family.

The HSC facilitated nursing teams, social care and the young person’s GP to work together to ensure that both medicines were obtained via an additional prescription form. As a result the diabetic team involved in the young person’s care, the residential care staff and the young person were aware of the requirements to keep the young person healthy and well.

Training needs within the children’s residential house were explored and training was put in place in partnership with the appropriate community nurse. Sharps bins were provided to ensure appropriate disposal of sharps and appropriate training around this was made available to the residential care staff who would be looking after the young person. Contacts for the diabetic team and out of hours information was made available. The responsible school nurse was made aware of the situation and reached out to offer support for further awareness sessions for the carers.

The Health Safety Check emphasises the need for collaboration between health and care professionals, social workers, and carers to safeguard children’s health. It also addresses equality and diversity, ensuring that communication is tailored to the needs of care-experienced children and young people and their carers.

This service has generated great interest across Scotland from corporate parenting partners. This process is designed to reduce the risk of missed health information and improve overall health outcomes for care-experienced children, who are often more vulnerable to health inequalities.

It reduces variation in practice and allows for early conversations about a child’s health and the opportunities for shared decision making when a child is moving homes in an emergency. It starts early conversations about tailoring health and care to children and young people who may have previously missed healthcare encounters and has provided an efficient pathway for social work and health teams to collaborate in emergency situations.

"I am a Clinical Team Leader for school nurses with a specific remit for the School-Aged Children and Care Experienced Children and Young People in South Ayrshire. I have been part of the team who carry out health safety checks at the request of social work colleagues. Myself and the teams I manage have interrogated health systems and shared relevant, necessary and proportionate information with social care colleagues, to uphold the rights of the children we look after, to good health."

Clinical Team Leader, Children’s Health,
South Ayrshire Health and Social Care Partnership

Study phase results demonstrate that the Health Safety Check has directly enhanced safety and continuity of care for children in emergency placements. From March 2021 – February 2025, 70 ICYP across Ayrshire had a HSC completed and had vital health information transferred to their new carers as a result.

• 46% (32) were on at least one medication.
• 21% (15) had at least one medical condition.
• 24% (17) had outstanding appointments.
• 59% (41) were known to other professionals (e.g. CAMHS/ Diabetic Teams etc.).
• 10% (7) of the ICYP who had an HSC completed required their new staff/carers to undergo further training to meet their health needs.

Insights from children and young people, and the experiences of our corporate family across Ayrshire and Arran highlight the importance of robust information sharing and collaborative partnership working across health and social care. Strengthening these connections enables corporate parents to identify and address key health priorities for ICYP earlier.

The Health Safety Check service was developed, tested, implemented, and rolled out to enhance early identification and support for the health needs of ICYP. By practising Realistic Medicine, a personalised approach to care is being delivered, ensuring the young people cared for are involved in shared decision making, with a focus on what matters most to the children and young people.

Promoting Prevention & Self-Management: The Ageing Well Tool

NHS Grampian has developed the Ageing Well tool to support healthy ageing by:

• promoting prevention and self-management.
• supporting people to assess their health and wellbeing.
• identifying areas for change and access relevant support services.

Developed using Making Every Opportunity Count (MeOC) resources, the tool can be used both as a conversation starter, where professionals can support completion, or by individuals, to reflect on their own health and wellbeing, and can be used in a variety of settings. Questions use non-clinical language not relying on specific health literacy. They prompt consideration of health and wellbeing needs and an accompanying service list offers signposting to appropriate services in local communities. The tool also features a version of the Rockwood scale for frailty self-perception which is also used in primary and secondary care settings, supporting a uniformed approach across the healthcare system.

The tool was initially tested with over 200 people at vaccination centres. The majority of participants found the tool easy to read and understand with 80% indicating that they were more aware of services than before. The tool facilitated meaningful conversations with older people about their health and wellbeing and participants felt grateful to have the opportunity to express what matters most to them. In addition, the service list was considered a useful resource for reliable information and advice. The tool is now in use across Moray in primary, acute, social care and community settings and is currently being trialled in three GP practices.

The tool prompts people to consider key aspects of their health, such as social engagement and physical activity, and links them to appropriate services. When Martha self-identified a need for improved opportunities to socialise, the tool provided prompts to contact the Moray Community Wellbeing Development Team who offer a programme of activities for residents who are over 60, at locations across Moray.

When Mohammed expressed a desire for more opportunities to socialise and stay active, a local coordinator supported him with a self-check showing him the contact details for “Walk Moray”, a local project offering free health walks across Moray every week, and the “Community Wellbeing Development Team”, which provides a wide program of activities for residents over 60 at various locations. Mohammed was “grateful” to have the service list to take home and “will definitely contact the services.” Another user said about the tool: “really good, provides useful information about services. When you go to GP you don’t get his information.”

As an older person, Grace was supported to complete the self-check when discussing options for toenail cutting services, and signposted to the “Moray Handyperson Service”, which has volunteers who cut toenails for those who can’t cut their own. Grace was also interested in the handyperson service to help with home maintenance tasks, including help to change a lightbulb. The discussion and signposting tool allowed the individual to be aware of a source of preventative footcare and to help a friend keep their home safe.

Health and care professionals said:

"…very useful for the random questions patients often ask as it covers so many bases."

"Ageing Well Tool gives people a resource to consider their health in their own time, as people can be overwhelmed during a consultation."

"It’s about allowing that time and opportunity to know what’s out there."

The tool has proven to be a valuable resource in supporting older individuals to take proactive steps toward better health, applying the principles of Realistic Medicine to support prevention and self-management. Connecting people to relevant help within the community, the Ageing Well tool helps to empower individuals to become more involved in their care. The tool enables collection of locality data enabling comparison of health outcomes across communities within Moray. As such, it has potential to both improve awareness of and tackle unwarranted variation. Pilot work revealed that people residing in the most rural communities were not seeking opportunities to keep active, compared to those living in population centres. This information can be used to focus our approach for these communities.

Self-Management, Shared Decision Making and Motivational Interviewing in Podiatry Care

Self-management puts people living with long-term conditions in ‘the driving seat’ of their care. It supports and encourages them to access information and to develop skills that will enable them to live their lives well, on their own terms, with whatever health conditions they have. A pilot project in Renfrewshire integrated Motivational Interviewing (MI) into podiatry care to enhance engagement with the people cared for, promote self-care, and reduce unnecessary return visits.

MI is a personalised counselling approach which helps people explore and strengthen their own motivation for change. It emphasises collaboration, evocation, and compassion using open-ended questions and techniques like reflective listening and affirmations to empower individuals in making positive health changes. MI uses a four quadrant approach: Engaging, to build a relationship; Focusing, to identify a specific agenda or direction for change; Evoking, to uncover the patient’s own motivations for change; Planning, to agree the plan for action.

A 12-week pilot focused on people with recurrent foot ulcerations, supporting them to better manage their own care. The pilot was based in Renfrewshire community clinics, with two clinicians dedicating one day per week to the MI-based model of care. MI techniques were integrated into podiatry practices to enhance engagement, shared decision making, and collaboration. Appointment times were extended from 40 to 50 minutes to enable the MI approach.

To support this approach, Renfrewshire Foot Protection Team staff attended one-day MI training, followed by weekly meetings for peer support over 12 weeks, to discuss the practical application of these techniques. MI was embedded into routine appointments to support shared decision making. People were enabled to take an active role, including self-administering dressings, to support increased independence. The project tracked outcomes through surveys, caseload metrics, and patient/staff feedback.

Pilot Outcomes

Self Care: prior to the pilot, it was not known how many people were carrying out direct self-care, however, at the start of the project, no patients were managing their own dressings. Following the 12-week pilot, 46% of people had adopted directed self-care practices, including dressings which was a significant increase from baseline.

Reduced Return Visits: there was a significant reduction in return visits for people with ulcerations, indicating that an MI-based approach effectively supported people to manage their care more independently. In the Rclinic, on average, there were three return appointments per person in the 12 weeks prior to the pilot compared to 1.5 return appointments per person during the project.

Fewer return appointments mean more clinic time for others. This improves efficiency and allows the clinic team to focus on providing higher value care to people who need our help the most.

Improved Patient Experience: people felt more in control of their health.

"I’m happy doing it myself. You can’t keep it clean waiting for the next appointment, so I change it myself after a few days."

The post-pilot survey results highlighted significant improvements in people’s experience and engagement:

• 75% of participants reported learning something new about wound care.
• 100% felt more confident in the care they received and agreed that their thoughts and opinions mattered.
• Additionally, those who said they had been able to make an informed choice about their care increased from 67% pre-project to 84% post-project, demonstrating the positive impact of the initiative on empowerment and shared decision making.

Enhanced Staff Engagement: initially, staff were concerned about longer appointment times, but they later saw the benefits.

"People took more ownership of their treatment and gained confidence in self care."

"I was able to offer directed self care today, which eases the burden on the family bringing the person into the clinic. The family are very pleased."

Personalised care and shared decision making led to better engagement and increased self-management in our service. MI supports self-management and shared decision making and improved clinic efficiency by reducing unnecessary visits while empowering people. Providing ongoing training and reflection helped clinicians effectively integrate MI into their practice. Facilitated peer support sessions provide a forum for staff to discuss challenges and share successes.

Shared Decision Making with Orkney’s Young People: It’s OK to Ask

A key focus for NHS Orkney in delivery Value Based Health and Care, has been promoting shared decision making among young people, empowering them to take an active role in their health and care choices as they transition to independent appointments. This initiative aligns with the United Nations Convention on the Rights of the Child (UNCRC).

The “It’s OK to Ask” campaign encourages young people to consider the Benefits, Risks, Alternatives, and potential consequences of doing Nothing (BRAN) when making health and care decisions.

To ensure the campaign was relevant and impactful, education staff, school nurses and Public Health Managers were consulted. The topic aligned well with the Health and Wellbeing Curriculum for Excellence and the Meta Skills approach developed by Skills Development Scotland.

Our Realistic Medicine Clinical Lead engaged with secondary school guidance teams, the Developing the Young Workforce Team, and two Orkney Members of the Scottish Youth Parliament. School nurses were involved to ensure long-term sustainability by embedding the campaign within their health sessions. Additionally, information was shared with relevant health services to help prepare them for questions from young people.

This culminated in a keynote presentation at a S5-S6 Health and Wellbeing Event, which aimed to support students during exam time. The presentation used Mentimeter to facilitate engagement and feedback, introduced the “It’s OK to Ask” campaign, BRAN questions, and suggested phrases to empower young people in health and care conversations.

A second school, located on a remote island, also participated in the project. With only a GP and nurse available locally, most health and care services are accessed on the Orkney Mainland. The junior high school (S1-S4) students engaged with the same Mentimeter presentation, providing valuable data on their confidence in asking health-related questions.

Early feedback has been encouraging with the first session having 350 attendees. Out of 54 students who accessed the Mentimeter link, 48 had never heard of “It’s OK to Ask”. After the session, 24 students agreed they were more likely to ask questions when making health and care decisions.

At the junior high school, all 19 students participated. Figure 1 illustrates the average responses from the 19 pupils who rated their agreement with various statements on a scale of 1 to 5 (1 = strongly disagree, 5 = strongly agree) at the end of their session. The results indicate an increased awareness of the “It’s OK to Ask” campaign, with an average agreement score of 4.2 out of 5, and 57% of students expressing greater confidence in asking questions about their health decisions.

Figure 1: End-of-session feedback from pupils at the Junior High School

Feedback from stakeholders

Developing the Young Workforce Team: “Young people need to feel listened to and valued. The ‘It’s OK to Ask’ campaign empowers them to seek clarification, take time to think about decisions, and build confidence in healthcare settings. These skills extend beyond healthcare and can positively impact their broader lives.”

Teacher: “It’s crucial to equip young people with the skills and confidence to ask about their treatment. No matter where they go, these skills will help them advocate for themselves and others.”

Student feedback

"BRAN is a useful way to structure my questions."

"I wasn’t aware of this campaign before, but now I feel informed and confident to ask questions."

School nurses will continue embedding “It’s OK to Ask” messages in health sessions for P7-S4 students. The campaign has been shared with children’s health services, including Paediatric Occupational Therapy, Physiotherapy, Speech and Language Therapy, CAMHS, Dental, and General Practice teams. NHS Orkney’s Medical Director has endorsed the initiative, recognising it as a creative and innovative approach to engagement.

When asked about the qualities they seek in a health and care professional, young people identified key traits: kind, helpful, knowledgeable, a good listener, understanding, calm, and approachable. This feedback highlights the importance of personalised care.

Empowering young people to ask questions today will lead to more informed, confident health and care users in the future.

Peri-Operative Care of Older People in Surgery

Shared Decision Making (SDM) is a critical component in delivering truly personalised care, ensuring that people are actively involved in decisions about their treatment. The Peri-Operative Care of Older People in Surgery (POPS) team in NHS Lothian has integrated an enhanced SDM process, specifically tailored for people who are frail and have been referred for elective urological or colorectal surgery. Meaningful discussions are structured around the BRAN questions – considering the Benefits, Risks, Alternatives, and the option of doing Nothing – to support people to make an informed choice about their care options.

For people who are frail, the decision to proceed with surgery is particularly complex, as it requires balancing the potential benefits of intervention with the risks associated with invasive procedures. They often face heightened vulnerability due to multimorbidity and a higher likelihood of post-operative complications. SDM plays a crucial role in helping them and their families navigate this complexity and ensures clinical teams work with them to align treatment choices with the outcomes that matter to people.

By adopting this structured and personalised SDM approach, the POPS team is empowering the people we care for to make informed decisions that optimise both quality of life and long-term outcomes. This not only enhances their care experiences but also contributes to more efficient resource use within the health and care system, reducing unnecessary interventions and prioritising care that aligns with individuals’ preferences.

Between December 2023 and March 2024, people who attended the POPS clinic were invited to participate in a follow-up telephone interview to assess their experiences with the Shared Decision Making process. The interview was structured around the CollaboRATE tool, a validated, three-question survey designed to evaluate SDM from the patient’s perspective.

Of the 29 people (or their proxies) who had consented to participate, 22 (76%) took part in the evaluation. The results were overwhelmingly positive: all participants (100%, n=22) reported that the POPS team had made “a lot” or “every” effort to help them understand their health issues and to actively listen to what mattered most to them. Additionally, 86% (n=19) felt that the team had made “a lot” or “every” effort to incorporate their priorities into the decision making process.

Beyond the quantitative findings, people were also encouraged to share unstructured comments about their experience, which further reinforce the value of the POPS clinic approach:

"The staff were excellent – my husband transformed in front of my eyes; he was so happy with the decision."

"Whatever help I needed I’d get it from POPS, that’s how I felt. POPS is an oasis in the middle of the hospital."

"I don’t normally give full marks for anything, but they were excellent, I really couldn’t fault them.  They made what could have been a very difficult process,
quite acceptable."

This feedback highlights the profound impact of personalised care, demonstrating not only the effectiveness of SDM in clinical decision making but also its ability to improve overall patient and caregiver satisfaction.

The SDM process within the POPS clinic is highly regarded by the people we care for and has demonstrated significant value in both patient outcomes and health and care system efficiency. Between April and July 2023, SDM led to a 30% reduction in the number of people opting for surgery, with 9 out of 30 individuals decided against the procedure after engaging in informed discussions about their options.

More recent data from January to August 2024 further underscores the impact of SDM, revealing that 42 planned procedures did not go ahead as a result of these meaningful shared decision making conversations.

This equates to around £300,000 in costs avoided factoring in staff time, surgical resources, and overhead expenses. By facilitating informed choices, SDM not only enhances individual care and achieved the outcomes that matter most to people, but it also optimises resource allocation, contributing to a more sustainable and personalised health and care system.

SAS - Improving Shared Decision Making – Reducing Refusals

On occasion, people who have contacted 999 decline further care or support. Often these people may have an urgent health care need but this may not be immediately life threatening. The decision not to continue care or support sometimes stems from concern about transport rather than the willingness to engage with a plan for care. However, clinician documentation of a refusal for further care was often based in defensive practice and risk of complaint or litigation as opposed to it being centred around the needs and concerns of individuals.

Following a review of incidents, we identified that a number of people would benefit from a more personalised approach supported by shared decision making. We wanted to encourage and support our clinicians to manage risk differently and better with more of a focus more on what matters to the people we care for.

Key Actions

• A review was carried out of incidents of care which have been closed and marked as “refused”. Through this, common themes around improving care for this specific group, such as signposting to supported self-care advice or referral to alternative pathways was identified.
• Analysis was conducted of station areas to understand variations in refusal rates and it was noticed that certain parts of the country had higher rates, indicating there was variation in practice. It was not clear this variation could be explained by patient factors and considered this might represent unwarranted variation.
• There was a focus on station-level engagement and staff feedback. Through group and individual feedback, knowledge and awareness of shared decision making were increased, encouraging the use of tools such as BRAN and the DECIDE model to explore options with people, with an emphasis on reaching an agreed plan.
• The use of the SAS Clinical Decision Making Framework was encouraged, featuring “Shared Decision Making on a Page” as an aide-memoire for clinicians to guide consultations. This was complemented by a continued professional development session, delivered both face-to-face and online, to enhance confidence in shared decision making and reframe a refusal as the inability to reach a shared decision rather than people simply not wishing to go to the hospital.

There has been a marked reduction in the number of incidents ending with people refusing care. In January 2022, 17.1% of incidents managed on scene were identified as a “patient refusing”. This has dropped to a low of 12.2% in December 2024.

Following CPD sessions, clinicians have reported increased confidence in applying shared decision making.

"The session was a good review of the benefits of shared decision making and a valuable reminder that the patient’s wishes are important as well as the opinions of other clinicians"

"This session increased my knowledge surrounding shared decision making and has enabled me to confidently include it in my work practice"

Organisational attitudes, knowledge, and skills were addressed to personalise care, support shared decision making, and provide better value care through the application of Realistic Medicine principles. Moving forward we want to move these sessions into a range of e-learning and scenario based CPD sessions, helping clinicians relate the principles of Realistic Medicine into an ambulance setting.

Enhancing Shared Decision Making in Maternity Care

A recurring theme in national reports including Enabling Safe Quality Midwifery Services and Care In Northern Ireland, Ockenden Review and informed decision making is the necessity for clear and balanced communication regarding risk to aid shared decision making. Currently, in NHS Grampian and NHS Orkney, as well as in local higher education institutions, there is no structured opportunity for health and care professionals to regularly observe, critique, or practice these crucial discussions with women and their families.

The aim of this initiative was to create a psychologically safe space where health and care professionals could enhance their knowledge, skills, and confidence in conducting informed decision making conversations. A secondary aim was to foster connections among colleagues from different regions–Orkney, Shetland, and Grampian–by sharing how these conversations may vary depending on geographical and cultural contexts. The ability to conduct sessions collaboratively across Boards has fostered partnerships, created opportunities, and built networks that exceeded initial expectations.

Key Actions

The Shared Decision Making Masterclass Toolkit on TURAS was adapted to develop an interactive, online masterclass focusing on informed decision making conversations. Key actions included:

• Designing a relevant training scenario that would engage participants and providing preparatory information beforehand;
• Conducting a pre-session survey to establish baseline confidence levels regarding shared decision making conversations;
• Delivering the masterclass via Microsoft Teams, inviting participants from NHS Grampian, NHS Orkney, and NHS Shetland;
• Structuring the session to involve participants in analysing the conversation and providing feedback on observed communication techniques;
• Collecting post-session feedback and survey responses to assess the impact of the training and gather suggestions for future scenarios;
• Extending an invitation to attendees to join the faculty for future masterclasses, building a sustainable community of practice; and
• Expanding the initiative by incorporating in-person sessions at the British Intrapartum Care Society (BICS) conference and using feedback from these sessions to refine the training approach.

There has been a total of 7 sessions carried out to date utilising this format with over 230 participants engaging with the simulations. Overall, the feedback has been strongly positive and has strengthened healthcare professionals’ ability to engage effectively, provide accurate information, and supports personalised care, highlighting the value of continued training investment.

The masterclass training programme has demonstrated a significant positive impact, as evidenced by the pre- and post-survey results. Participants reported a notable increase in their confidence when engaging with women, reflecting an improved ability to facilitate meaningful conversations and address concerns effectively. This boost in confidence has translated into more productive interactions, ensuring that women feel heard, respected, and empowered in their healthcare decisions.

Additionally, the training has enhanced participants’ ability to signpost women to relevant and reliable sources of information. This is a crucial development, as access to accurate information supports informed decision making and fosters a sense of autonomy among people. By being better equipped to guide women toward appropriate resources, healthcare professionals can contribute to more positive experiences and outcomes for people.

Another key improvement observed in the post-survey results is the increased confidence in communicating risk. Participants now feel more assured in discussing potential benefits and drawbacks of various healthcare options, allowing them to facilitate balanced and transparent conversations. This skill is essential in guiding women to make informed choices that align with their values and circumstances, reinforcing the principles of Realistic Medicine.

Overall, the program has strengthened healthcare professionals’ ability to engage effectively, provide accurate information, and supports personalised care, highlighting the value of continued training investment.

Participants were asked for their views on the training session:

• 78% (18 respondents) found it “fascinating and completely relevant” to their practice.

They were asked if they would attend a future Simulated Conversation Workshop:

• 74% (17 respondents) said Yes.
• 17% (4 respondents) said Maybe.
• 9% (2 respondents) said No.
• The workshop was well-received, with the majority (78%) finding it highly relevant.
• There is strong interest in future workshops, with three-quarters of attendees (74%) confirming they would attend again.
• A small percentage (9%) were not interested in attending future sessions.

Our approach is now an ongoing program with sessions planned for 2025/26. These training sessions are continually being developed and delivered across NHS Orkney, Shetland, and Grampian. A repository of scenarios is being built, alongside a growing list of faculty members who can facilitate these sessions. These sessions are also being included in the newly graduated midwifery professional development days as an opportunistic way of providing this approach to a cohort of colleagues.

By embedding the principles of Realistic Medicine and Value Based Health and Care, this initiative fosters a more personalised approach to health and care. Enhanced informed decision making not only improves the experience of individuals receiving care but also contributes to better health outcomes, ensuring that care aligns with personal values and needs.