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Demonstrating Impact Aberdeenshire CHP & Council. Linda Reid Project Manager (Integration H&C). Joint Performance Framework. OPSOG had an Action Plan and monitoring process prior to Change Plan Modified for Change Plan Now has JCS Action Plan and JPF Template updated for each meeting

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Demonstrating Impact Aberdeenshire CHP & Council

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Demonstrating impact aberdeenshire chp council

Demonstrating ImpactAberdeenshire CHP & Council

Linda Reid

Project Manager (Integration H&C)

Joint performance framework

Joint Performance Framework

  • OPSOG had an Action Plan and monitoring process prior to Change Plan

  • Modified for Change Plan

  • Now has JCS Action Plan and JPF

  • Template updated for each meeting

  • Not all measures recorded with same frequency, tends to be delay in reporting



  • Measures mostly still outputs eg bed days, care home places, telecare but target driven

  • Outcomes personal improving some challenge to get strategic

  • Softer data updates from all work streams reviewed in sub groups or OPSOG

  • Funding can be granted, removed, increased, extended on data presented

At a glance score card

At a Glance Score Card

  • For last 2 years

  • Issued monthly

  • 25 measures for CHP

    Includes data relating to

  • Heat targets

  • Bed Days

  • Delayed Discharges

Prevention signposting

Prevention: Signposting

  • The service has used the Warwick-Edinburgh mental wellbeing scale (WEMWBS) to gauge the ultimate effect of its interventions on those who use its services and some startling results have emerged.

  • Service users reported improved mental wellbeing with significant drops in GP visits and use and/or strength of prescription drugs.

  • This shows the project supports the achievement of personal outcomes for people as reported by those people and also system/service outcomes, that is changes in the pattern of individuals use of other services.



  • Anticipatory Care Planning 10.3% reduction in EBDs for practices using ACPs compared to 2.5% reduction for other practices. Equals 33 less beds £3.12m. Now in Scottish GP Contract

  • Point of Care Testing 4 months in 3 centres 51 patients screened, prevented admission or transfer in 41. If 7 centres working well could prevent at least 300 admissions or transfers.



  • Using BNP avoid 300 referrals for echocardiography, and D-dimer halves number of patients referred to outpatient DVT services.

  • Heart Failure Nurses

    69 hours of nurse time per week

    Prevented 62 admissions

    236 primary care contacts avoided



  • MD REACH team established 3 models

  • Data evidencing reduced or stabilised amount of care at end of work

  • For some work achieved care previously rejected leading to repeat crises/admissions

  • RGU commissioned to evaluate fully to inform roll out

Improving long term care

Improving Long Term Care

  • Training in Dementia Care across sectors

  • Note numbers trained

  • Care Inspectorate Grades rising

  • Soft data

    Staff increased job satisfaction & understanding

    Better standards of dementia care

    Use of medication for behaviour modification is closely scrutinised and it appears to have reduced.

Sheltered and extra care housing

Sheltered and Extra Care Housing

  • Thorough work to measure dependency and service models with costs

  • Extensive consultation

  • New models introduced in VSH &SH

  • Decision to convert SH complexes to VSH to offer increased choice in each locality

  • Evidence VSH takes most to end of life

  • Significantly shifts balance of care

Joint equipment store

Joint Equipment Store

  • JES developed based on analysis of stores, delivery times, cleansing and ordering across Council area and Health

  • Immediate increase in efficiency and effectiveness

  • Stats re workload & DD evidence to Change Fund for increase in staff.

  • Council & Health staff will shortly order off Health Code to save duplication.

Future work

Future Work

  • Examination of requirement for Care Home Beds based on current projections

  • Plan to share with Planners and Providers

  • Challenge Commissioning Quality versus Choice Guidance

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