National health and wellbeing outcomes framework

4. Overview

The national health and wellbeing outcomes apply across all integrated health and social care services, ensuring that Health Boards, Local Authorities and Integration Authorities are clear about their shared priorities by bringing together responsibility and accountability for their delivery. The national health and wellbeing outcomes also provide for the mechanism by which the Scottish Ministers will bring together the performance management mechanisms for health and social care.

The national health and wellbeing outcomes provide a strategic framework for the planning and delivery of health and social care services. This suite of outcomes, together, focus on improving the experiences and quality of services for people using those services, carers and their families. These outcomes focus on improving how services are provided, as well as, the difference that integrated health and social care services should make, for individuals.

Each Integration Authority will be required to publish an annual performance report^[4] which will set out how the national health and wellbeing outcomes are being improved. This will include reports on a core suite of indicators and measures, identified by the integration authority in line with guidance from the Scottish Government, and contextualising data to provide a broader picture and a rationale of local performance.

Mrs Taylor's Story

Mrs Taylor is a retired maths teacher. She lives with her husband in a small village, where she has always been an active member of her community.

She has lived with diabetes since she was born and has always managed it very well. A few years after she retired she began to experience some confusion and struggled with her memory. She visited her GP who referred her to a memory clinic where she was diagnosed with dementia.

A specialist Dementia Nurse spent time with her after the diagnosis. She listened to them and together they talked through what was important in her life, how the condition might affect her and what support could be put in place to work alongside her own strengths and networks.

Mrs and Mr Taylor received a great deal of support from a specialist third sector organisation that the nurse put them in touch with. This included help to learn about self-management and a chance to join a peer support group in a nearby town, providing new friendships and invaluable mutual support.

'The Taylors visited their GP who listened to the daily challenges that they were facing. The GP was concerned that Mrs Taylor was no longer safe at home and that they were both becoming isolated and experiencing symptoms of depression and anxiety due to their personal circumstances.'

After a few years, Mrs Taylor's dementia progressed to a stage where she was finding daily activities increasingly difficult and feared she might have to move into a nursing home.

Her husband began providing more support and worried about her health including her diabetes, which she was now less able to manage. Getting out and about, including to the peer support group, wasn't possible as Mrs Taylor could no longer use public transport.

Their local GP, a Dementia Specialist Nurse and an Occupational Therapist worked together with the Taylors to agree the support that would enable them to stay well and independent at home. Their GP also arranged for a Diabetes Specialist Nurse to help Mr Taylor to learn how to support Mrs Taylor. Their daughter also called a helpline run by a third sector organisation and was able to get details of a local carer's centre who offered support to her father.

Mrs and Mr Taylor and their family feel that the quick, joined-up response of their health and social care team, along with support from their community, enabled them to continue living life the way they wanted to. Without this support, they believe they would have had a lot more trips to hospital as a result of Mrs Taylor's conditions.