Orkney Health and Care
Working together to make a real difference
28 March 2014
Judy Sinclair, Lead Nurse
Lynda Bradford, Service Manager,
Health and Community Care
Aims of Workshop:
Explore how RGSW may support service
improvement within the context and
challenges of integrated care delivery in
Orkney
Using the NES Skills Maximisation Toolkit:
1. Clarifying the patient journey
2. Capturing uniqueness
3. Creating improvement
1. Clarifying the patient journey- what’s
happening now?
 Steps and activities involved when service
user beginning the journey
 How do service users and carers/ families
access the service
2. Capturing uniqueness-what’s the best
contribution?
 Who currently undertakes the various tasks and
activities
 What tasks need the skills only a registered
practitioner can provide
 What could be done by the RGSW
 Identify any other issues
3. Creating improvement- making it happen
• Focus on what the RGSW could do
• Suggest changes to positively impact on patient
journey
• Suggest positive changes for the team and team
working
• Improving the service by using the RGSW
• Contribute to the way forward
20 Participants from a range of
backgrounds:
◦ Service managers, community nurses,
physiotherapists, occupational therapists,
intermediate care team nurses and rehabilitation
support workers, social workers, home care,
practice education for nursing and allied health
professions and Orkney College Lecturer.



An interactive workshop
Background information had been sent in
advance for consideration of a patient journey
Ways of working were agreed by the group:
◦
◦
◦
◦
◦
Focus on the RGSW role
Give up some existing beliefs
Think differently and out with comfort zone
Implications of not changing
The Car Park

Commonalities across teams and geographical
areas
i.e lack of services in isles, identifying need but can’t meet
them, remoteness, expectations of clients, families and
communities, multi assessments

Differences across teams and geographical areas
i.e service capabilities and capacities, inconsistencies in
health and social care roles, differing professional
cultures, communication – with who, by who

Gaps in service provision:
i.e. Continuity of some AHP programmes, respite care,
limited 3rd sector in some areas, different crisis response,
different overnight provision, facilities and equipment
Who currently carries out which
activities and why?
 Could any of these activities be carried
out by a RGSW?
 What other tasks/activities could be
carried out by the RGSW?
 What could be carried out by RGSW:

Pre-discharge
 Referral and outcome
focussed assessment
 Home preparation
 Working with OT,
physio and nursing
staff
 Preparation of
furniture/bed
Discharge
 Support getting home
– travel can be
difficult/air/sea
 Continuation of
programmes of care
 OT and personal care
links
 Accessing equipment
 Agreeing outcomes
with client/family
At Home
 A range of activities in conjunction with OT,
Physio, Home care and nursing such as:
Personal care, meal prep, exercises, nutritional
needs, support with medication, continence
assessments, use of telecare, telehealth etc



Rehabilitation in the home environment
Facilitate social engagement
Liaison with multi-disciplinary team
Groups were asked to consider the potential
RGSW role in Orkney:

What are the opportunities and benefits?

What are the challenges of introducing the
role

How would you overcome these challenges?

What knowledge/skills will be required to
deliver the desired service/outcome for
clients









Island sustainability
Ability to be person centred
Earlier discharge with attendant benefits
Reduced hospital admission
Safer discharge and reduced readmission
Service users able to stay on island
Career development/ improvement for
registered staff
Continuity of care
Delivery of service user vision









Cultural shift required
Boundaries of role and knowing limitations
Existing terms and conditions of employees
Potential lack of confidence by professionals,
clients and public
Potential for duplication
Supervision and mentorship
Developing and maintaining clinical currency and
governance
Funding
Expectations of professionals, clients and public







Magic wand!
Clear criteria - clarity about what is ‘Needs’
and what is ‘Wants’
Minimum training and standards - Education
programme that is available, reasonable,
local, using a blended approach
Flexibility in system of workers
Harnessing IT solutions
Integrated and shared clinical communication
Regular supervision and support










Contract issues
Isles network of care – VC network and
connectivity issues
Isles differences
Gender issues
Capacity
Transport – ferry/air
Risk management
24/7 cover
Organisation of workload
Who owns it – health or social care?








Continuity of care, enabling people to be at
home
Better outcomes for clients and their families
Improved patient centeredness for complex
LTC conditions
Based on the island and flexible
Improved, earlier discharge and rehab at home
Skills and knowledge for rural and island areas
Maintain island life, create opportunities
Better linkages with other services
Something I’ve learned from today;
 All parties on board – the tide has turned, it
can be done
 Other services’ challenges
 Gaps in service
 Professional roles and responsibilities
 Value of education – essential starting point
 How inflexible some professionals are
 The importance of multi disciplinary discussion
 Clarification of the RGSW role
What did you enjoy most about the day?
 Meeting other folk and getting the bigger
picture
 Networking
 Person centred approach
 Well structured programme and ideal group
sizes
 Exchanging and challenging ideas with
others
 Good discussion about the RGSW role
What could have been better?




A service user point of view (5)
Couldn’t have been better
More folk from the isles (2)
Could have discussed the intermediate care
team more to discuss existing roles and
comparisons
Orkney Health and Care
Working together to make a real
difference
Questions?