The Impact of the Scottish Health and Social Care Integration Initiatives

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8th Feb 2020 Health And Social Care Reference this

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“Integrating health and social care services is the best way to tackle growing health inequalities in Scotland.”

Introduction

The aim of this assignment is to critically evaluate the impact of the Scottish health and social care integration initiatives have had in reducing the health inequalities for older adults with complex needs. The Scottish Government’s (2017) Strategy for integration of health and social care required one system where all sectors were expected to deliver effective service that ensured they meet the needs of individuals, their carers and other family members. The providers would be lead by professional and clinical leader that would share responsibility jointly for a flexible and financially sustainable person centred service.

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Legislation for health and social care integration was passed by the Scottish Parliament in 2014, and was put in place by 2016 and established 31 integration authorities responsible for £8.5 billion of public funds. The Act provided the local authorities guidance on conducting the integration by outlining the 12 principles of integration and as outlined by the Audit Commission Scotland (2018) 9 health and wellbeing outcomes (Appendix 1& 2).

Health inequalities are the unjust and unfair differences in people’s place in society that are caused by a range of avoidable factors such as marginalisation, poverty, the lack of education opportunities, and environment factors such as poor housing (McCartney et al 2013).  An example of the effects of these inequalities in Scotland (NHS Health Scotland 2018) is that in the most wealthy areas of Scotland, men have 23.8 more years of good health and women have 22.6 more years compared to those living in the more deprived areas of Scotland. Of those living in the most deprived areas 22% reported having either a cardiovascular condition, diabetes, or a stroke compared 12% in the least deprived areas (Scottish Health Survey, 2018).

Older people are also more likely to experience poor health outcomes, and by 2035 it is forecast that there will be a 31% increase of people aged 60 and over and with an associated rise in complex health and social care needs that according to the RCN (2012) cannot be delivered by one professional group alone. Among the factors behind this increase in the older population is the success of medical technology such as advanced screening (ScotPHO 2015) and diagnoses as well as the emphasis on public health and  the promotion of  health conscious behaviours (Ageing-Better 2015).

Main Body

According to Health Scotland, the best way to reduce inequalities in older people is to target services so throughout theperson’s lifetime and it is considered that this  will be achieved through the integration of health and social care which is aimed at supporting assessed  needs at any point in their care journey (NHS Health Scotland 2018). To achieve this requires  the distinct knowledge and expertise of everyone involved from service users, carers, frontline health care professionals, managers and political leaders. More importantly it is suggested that success is reliant on a respect and team working that promotes the independence of the vulnerable people in society. But as Pearson et al (2018) argue, the evidence suggests that most of the potential for integration  is not being realised. and they claim that the essential systems and cultural changes have not emerged todate but what innovation has developed has been the result of individual innovators. They suggest that there remains a financial and power imbalance focused on health to the detriment of other services despite the rhetoric around partnersip working.  

According to (Scottish Health Survey 2018) only 52% of those aged 75 and over, in Scotland are considered to be in “good” or “very good” health (Appendix 13).  As a result of this, spending on long-term care increases, meaning a larger share of the over-all expenditure will be on the elderly. Of this amount more that a quarter goes towards people in their final year of life. This figure has not change since the 1970s despite improvement in medical technology and change in care giving (WHO 2018). From 2016-17 87% for those aged 85+ spent their last 6 months at home or in the community in Scotland (Official Statistics Publication for Scotland, 2017). Those who died in the most deprived areas died on average aged 72.5, 6.3 years earlier than someone in the least deprived areas (Libby Brooks Scotland correspondent, 2018).

The ageing population has increased as a result of advances in medical diagnoses and practice such as advanced screening (Scotpho 2017) and and the fact that people are generally becoming more health conscious (Ageing-Better 2015). Whilst the majority of older people can live independently with minimum support there is also a corresponding growth in the disadvantaged and fail eldery who require access to multiple health and social care services. It is this increasing group of people that the Scottish Government’s (2016) plan for the delivery of intergrated services expects  to benefit the most in terms of reduced inequalities.  It claim is that community home care and carer support which is based on assessment, treatment and rehabilitation will maintains older peoples independence and can prevent long term hospital or institutional care.  

From personal experiences in practice it was clear that the lack of effective communication between health care professionals and social workers had a major impact on joint working  resulting in delayed discharges. While on placement (Apendix 14.) I looked after a man that had Exacerbation of his Chronic Obstructive Pulmonary Disease (COPD) who lived in unsanitary conditions in a deprived area of Scotland. When the patient was ready for discharge, he was unable to go home for a futher r 2 weeks because  the social workers could not finalise arrangements..

A review of the literature conducted by Payne et al (2002)  on the communication between health and social care concluded that, problems were caused because both the health and social workers are under pressure and focusing on different goals and neither of which was a wear of each others. Of the 375 potential relevant studies retrived only 53 of these were actually used within the study, this was done by systematic sampling, creating a criteria. (Newell, Burnard ,Dawson Books, 2013). This is appropriate due to the specific aim of the study. The Trustworthiness of the study was reassured due to  a Wide range of databases used to gather litature with a mix of Peer, non peer reviewed and policy sources. Credibility seem slightly biest due to only  4 of the 53 papers were written by social workers and the mejority health care professioanals.16 of the papers from patietns ecpirencing the brakedown in communication. Qualitive Results were clearly catergorised using a table and quanative findings discussed.Thet study also dicussed the strengths or limitations of theinvest agation. Though this study was conducted in 2002, it is still very relevant to personal experienced in practice 16-year post report (Aveyard, Sharp, Woolliams, VLeBooks, 2015). 

Another example of where integration could improve inequalities occurred while  on placement with the borders District nurses  (Appendix 15). The  elderly Patient living in a deprived area was admitted to hospital after being diagnosed with breast cancer for mastectomy. Despite the community nurses support and advised on the best way to keep the wound from infection as well as how to take the antibiotics. The wound got infected and the patient required readmission to hospital. This was potentially a result of the unsanitary living conditions, drug and alcohol misuse, smoking and the fact she was taking her antibiotics incorrectly or forgetting to take them at all.

53%,Over half of all death caused by cancers in the uk are in people aged 75 and over and 15% of all cancers are caused by smoking, a preventable cause (Cancer reseach, 2018).

When I asked the district nurse was unaware of any social work contribution to the patients care and no advice was given to the patient regarding help with her alcohol, drug misuse and smoking, such as community . According to (NICE Clinical Guideline, 2007) for drug misuse prevention: targeted intervention, there are many ways of intervention depending on the situation. Its important to make it clear to the patient the effect of the misuse can have on their health and offering support and advice on ways to stop such as offering “community based detoxification programmes” and other social care services. There are specific Social workers that specialise in drug and alcohol misuse as well as finances, that can provide help from support groups to applications on patients phones (The City of Edinburgh Council, 2018). Although the support is available, Local authorities can not impose their help on people that are not willing to be helped unless they are deemed an Adult with incapacity (Scottish Drugs Forum,2007), nor can health care professionals refer patients without consent due to data protection (British Parliament, 1998).

Even though integration seems to be the best way to reduce inequalities (NHS Health Scotland, 2018), The National Audit Office (2017) has stated that the progress of the integration of health and social care has so far, been less successful than planned and has not delivered patient centred care as first envisioned.  For example proposed target to decrease admissions to Accident and Emergency by 106,000 was set in 2015-16. Since 2014-15 there has been an increased of 87,000 admissions. Barriers to integration have been identified to be, financial, workforce challenges and reluctances of information sharing between organisations, restricting

the progress (NAO, 2017). More concerning is the gap between policy and

commitment of staff as highlighted by (Munoz, 2013) at the  University of the Highlands and Islands who found some positive outcomes direived from the co-produced health and social services in remote and rural community members. The professionals working in the rural setting would prefer for there not to be integration due to the strain and frustration of working along side other agencies and health boards that have slightly different models, vision and language used when caring for patients.

Conclusion

Scotland’s populations health is improving rapidly but not fast enough for the deprived areas of society. Resulting in health inequalities to continue to be a massive part of society (Scottish Government, 2008). In principle the integration of health and social care is a sound concept but it is a quality and quantity format that requires more clarification and action plans to make it effective in practice and it hasn’t been proven that is the most effective way to tackle inequalities in Scotland yet. It has also been made clear by the (Health and social care integration – National Audit Office, 2017) there is not the evidence to show that integration of health social care can deliver their commitment to have fully integrated services by 2020. Thoughout reserch its clear that bring attention to the goal that both health and social workers have and the establish common goals and over all improving communication is essential when closing the gap between health and social care staff. (Payne et al, 2002).  

References

  • Audit Scotland. (2018) What is integration?. edinubrugh Retrieved from http://www.audit-scotland.gov.uk/uploads/docs/report/2018/briefing_180412_integration.pdf
  • Aveyard, H., Sharp, P., Woolliams, M., & VLeBooks. (2015). A beginner’s guide to critical thinking and writing in health and social care (Second ed.). Maidenhead: Open University Press.
  • British Parliament, (1998). Data protection act of 1998.
  • Bryan, K. (2010). Policies for reducing delayed discharge from hospital. British Medical Bulletin95(1), 33-46.
  • Bratanova, Loughnan, Klein, Claassen, & Wood. (2016). Poverty, inequality, and increased consumption of high calorie food: Experimental evidence for a causal link. Appetite, 100(C), 162-171.
  •  
  • Beeston, C., McCartney, G., & Ford, J.  (2014) Health Inequalities Policy Review for the Scottish Ministerial Task Force on Health Inequalities. Edinburgh: NHS Health Scotland.; 2014.

         Cancer reseach (2018). Cancer mortality statistics. Retrived from:https://www.cancerresearchuk.org/health-professional/cancer-statistics/mortality#heading-Two

         The City of Edinburgh Council, 2018. Recovery from alcohol and drug problems. Edinburgh. Retrieved from: http://www.edinburgh.gov.uk/info/20081/health_and_well_being/241/recovery_from_alcohol_and_drug_problems

  • Delayed Discharge. (2017). Gov.scot. Retrieved from http://www.gov.scot/Topics/Health/Quality-Improvement-Performance/NHS-Performance-Targets/Delayed-Discharge
  • Hojjat, T., & Hojjat, Rata. (2017). The economics of obesity : Poverty, income inequality and health (SpringerBriefs in public health). Singapore: Springer.
  • Libby Brooks Scotland correspondent. (2018). Scotland’s most deprived ‘more likely to die alone at home’; Study shows impact of health inequalities on end-of-life care across areas of country. The Guardian (London, England), p. The Guardian (London, England), Sept 13, 2018.
  • McCartney, G., Collins, C., & Mackenzie, M. (2013). What (or who) causes health inequalities: theories, evidence and implications?. Health Policy113(3), 221-227.
  • Munoz, S. (2013). Co-producing care services in rural areas. Journal of Integrated Care, 21(5), 276-287. doi:http://dx.doi.org.ezproxy.napier.ac.uk/10.1108/JICA-05-2013-0014
  • NHS Health  health Scotland (2018) Older people Retrieved from http://www.healthscotland.scot/population-groups/older-people [Accessed 20th October 2018]
  • The National Audit Office. (2017) –Health and social care integration. London. Retrieved from https://www.nao.org.uk/wp-content/uploads/2017/02/Health-and-social-care-integration.pdf
  • National Institute for Health and Clinical Excellence. (2007). Drug Misuse: Psychosocial Interventions. NICE Clinical Guideline 51.
  • Newell, R., Burnard, P., & Dawson Books. (2013). Research for evidence-based practice in healthcare (Second ed., Vital notes). United Kingdom: Dawson Books.
  • O’Brien, M., & Jack, B. (2010). Barriers to dying at home: The impact of poor co‐ordination of community service provision for patients with cancer. Health & Social Care in the Community, 18(4), 337-345.
  •  
  • Payne, S., Kerr, C., Hawker, S., Hardey, M., & Powell, J. (2002). The communication of information about older people between health and social care practitioners. Age and ageing31(2), 107-117.
  •  
  •  
  • Scotpho. (2017). Screening. GlasagowGlasgow: Retrieved from:  http://www.scotpho.org.uk/health-wellbeing-and-disease/screening/key-points/ [Accessed 20th October 2018]
  • Scotpho (2018). Health inequalities. Glasagow: Retrieved from:  http://www.scotpho.org.uk/comparative-health/health-inequalities/introduction/
  • Scottish government (2018) The Scottish Health Survey. Edinburgh. Retrieved from: https://www.gov.scot/Resource/0054/00540654.pdf
  • Scotland. Taskforce on Health Inequalities. (2008). Equally well: report of the ministerial task force on health inequalities. Scottish Government.
  • Shaw, A., Egan, J., & Gillespie, M. (2007). Drugs and poverty: A literature review. In Glasgow: Scottish Drugs Forum.
  • World Health Organization. (2008). Closing the gap in a generation. Geneva: WHO.
  • World Health Organization(WHO) (2018). The economics of healthy and active ageing series. Denmark
         An Official Statistics Publication for Scotland (2017). The Scottish Index of Multiple Deprivation. Edinburgh. Retrived from:
  •  
  • https://www2.gov.scot/Topics/Statistics/SIMD?utm_source=website&utm_medium=navigation&utm_campaign=statistics-evaluation-tools

Appendix

Integration planning and delivery principles The integration planning and delivery principles are—

 (a) that the main purpose of services which are provided in pursuance of integration functions is to improve the wellbeing of service-users,

(b) that, in so far as consistent with the main purpose, those services should be provided in a way which, so far as possible—

(i) is integrated from the point of view of service-users,

(ii) takes account of the particular needs of different service-users,

(iii) takes account of the particular needs of service-users in different parts of the area in which the service is being provided,

(iv) takes account of the particular characteristics and circumstances of different service-users,

(v) respects the rights of service-users,

(vi) takes account of the dignity of service-users,

(vii) takes account of the participation by service-users in the community in which service-users live,

(viii) protects and improves the safety of service-users,

(ix) improves the quality of the service,

(x) is planned and led locally in a way which is engaged with the community (including in particular service-users, those who look after service-users and those who are involved in the provision of health or social care),

(xi) best anticipates needs and prevents them arising, and

(xii) makes the best use of the available facilities, people and other resources. The Scottish government. (2014). 

13. Self-assessed general health among adults in 2017

, by age and sex

14. While on a 6 week  placement in a busy respetory ward  looking after a wide range of people from all different backgronds, with many different respatory conditions.

15. 8 week Community placement  during the summer making visits to many different patients with different help needs from very depreived and affluent areas. Looking after a elderly lady post surgery. On her discharge home, district nurses helped with dressing changes daily and administer of Delteparin.

“Integrating health and social care services is the best way to tackle growing health inequalities in Scotland.”

Introduction

The aim of this assignment is to critically evaluate the impact of the Scottish health and social care integration initiatives have had in reducing the health inequalities for older adults with complex needs. The Scottish Government’s (2017) Strategy for integration of health and social care required one system where all sectors were expected to deliver effective service that ensured they meet the needs of individuals, their carers and other family members. The providers would be lead by professional and clinical leader that would share responsibility jointly for a flexible and financially sustainable person centred service.

Legislation for health and social care integration was passed by the Scottish Parliament in 2014, and was put in place by 2016 and established 31 integration authorities responsible for £8.5 billion of public funds. The Act provided the local authorities guidance on conducting the integration by outlining the 12 principles of integration and as outlined by the Audit Commission Scotland (2018) 9 health and wellbeing outcomes (Appendix 1& 2).

Health inequalities are the unjust and unfair differences in people’s place in society that are caused by a range of avoidable factors such as marginalisation, poverty, the lack of education opportunities, and environment factors such as poor housing (McCartney et al 2013).  An example of the effects of these inequalities in Scotland (NHS Health Scotland 2018) is that in the most wealthy areas of Scotland, men have 23.8 more years of good health and women have 22.6 more years compared to those living in the more deprived areas of Scotland. Of those living in the most deprived areas 22% reported having either a cardiovascular condition, diabetes, or a stroke compared 12% in the least deprived areas (Scottish Health Survey, 2018).

Older people are also more likely to experience poor health outcomes, and by 2035 it is forecast that there will be a 31% increase of people aged 60 and over and with an associated rise in complex health and social care needs that according to the RCN (2012) cannot be delivered by one professional group alone. Among the factors behind this increase in the older population is the success of medical technology such as advanced screening (ScotPHO 2015) and diagnoses as well as the emphasis on public health and  the promotion of  health conscious behaviours (Ageing-Better 2015).

Main Body

According to Health Scotland, the best way to reduce inequalities in older people is to target services so throughout theperson’s lifetime and it is considered that this  will be achieved through the integration of health and social care which is aimed at supporting assessed  needs at any point in their care journey (NHS Health Scotland 2018). To achieve this requires  the distinct knowledge and expertise of everyone involved from service users, carers, frontline health care professionals, managers and political leaders. More importantly it is suggested that success is reliant on a respect and team working that promotes the independence of the vulnerable people in society. But as Pearson et al (2018) argue, the evidence suggests that most of the potential for integration  is not being realised. and they claim that the essential systems and cultural changes have not emerged todate but what innovation has developed has been the result of individual innovators. They suggest that there remains a financial and power imbalance focused on health to the detriment of other services despite the rhetoric around partnersip working.  

According to (Scottish Health Survey 2018) only 52% of those aged 75 and over, in Scotland are considered to be in “good” or “very good” health (Appendix 13).  As a result of this, spending on long-term care increases, meaning a larger share of the over-all expenditure will be on the elderly. Of this amount more that a quarter goes towards people in their final year of life. This figure has not change since the 1970s despite improvement in medical technology and change in care giving (WHO 2018). From 2016-17 87% for those aged 85+ spent their last 6 months at home or in the community in Scotland (Official Statistics Publication for Scotland, 2017). Those who died in the most deprived areas died on average aged 72.5, 6.3 years earlier than someone in the least deprived areas (Libby Brooks Scotland correspondent, 2018).

The ageing population has increased as a result of advances in medical diagnoses and practice such as advanced screening (Scotpho 2017) and and the fact that people are generally becoming more health conscious (Ageing-Better 2015). Whilst the majority of older people can live independently with minimum support there is also a corresponding growth in the disadvantaged and fail eldery who require access to multiple health and social care services. It is this increasing group of people that the Scottish Government’s (2016) plan for the delivery of intergrated services expects  to benefit the most in terms of reduced inequalities.  It claim is that community home care and carer support which is based on assessment, treatment and rehabilitation will maintains older peoples independence and can prevent long term hospital or institutional care.  

From personal experiences in practice it was clear that the lack of effective communication between health care professionals and social workers had a major impact on joint working  resulting in delayed discharges. While on placement (Apendix 14.) I looked after a man that had Exacerbation of his Chronic Obstructive Pulmonary Disease (COPD) who lived in unsanitary conditions in a deprived area of Scotland. When the patient was ready for discharge, he was unable to go home for a futher r 2 weeks because  the social workers could not finalise arrangements..

A review of the literature conducted by Payne et al (2002)  on the communication between health and social care concluded that, problems were caused because both the health and social workers are under pressure and focusing on different goals and neither of which was a wear of each others. Of the 375 potential relevant studies retrived only 53 of these were actually used within the study, this was done by systematic sampling, creating a criteria. (Newell, Burnard ,Dawson Books, 2013). This is appropriate due to the specific aim of the study. The Trustworthiness of the study was reassured due to  a Wide range of databases used to gather litature with a mix of Peer, non peer reviewed and policy sources. Credibility seem slightly biest due to only  4 of the 53 papers were written by social workers and the mejority health care professioanals.16 of the papers from patietns ecpirencing the brakedown in communication. Qualitive Results were clearly catergorised using a table and quanative findings discussed.Thet study also dicussed the strengths or limitations of theinvest agation. Though this study was conducted in 2002, it is still very relevant to personal experienced in practice 16-year post report (Aveyard, Sharp, Woolliams, VLeBooks, 2015). 

Another example of where integration could improve inequalities occurred while  on placement with the borders District nurses  (Appendix 15). The  elderly Patient living in a deprived area was admitted to hospital after being diagnosed with breast cancer for mastectomy. Despite the community nurses support and advised on the best way to keep the wound from infection as well as how to take the antibiotics. The wound got infected and the patient required readmission to hospital. This was potentially a result of the unsanitary living conditions, drug and alcohol misuse, smoking and the fact she was taking her antibiotics incorrectly or forgetting to take them at all.

53%,Over half of all death caused by cancers in the uk are in people aged 75 and over and 15% of all cancers are caused by smoking, a preventable cause (Cancer reseach, 2018).

When I asked the district nurse was unaware of any social work contribution to the patients care and no advice was given to the patient regarding help with her alcohol, drug misuse and smoking, such as community . According to (NICE Clinical Guideline, 2007) for drug misuse prevention: targeted intervention, there are many ways of intervention depending on the situation. Its important to make it clear to the patient the effect of the misuse can have on their health and offering support and advice on ways to stop such as offering “community based detoxification programmes” and other social care services. There are specific Social workers that specialise in drug and alcohol misuse as well as finances, that can provide help from support groups to applications on patients phones (The City of Edinburgh Council, 2018). Although the support is available, Local authorities can not impose their help on people that are not willing to be helped unless they are deemed an Adult with incapacity (Scottish Drugs Forum,2007), nor can health care professionals refer patients without consent due to data protection (British Parliament, 1998).

Even though integration seems to be the best way to reduce inequalities (NHS Health Scotland, 2018), The National Audit Office (2017) has stated that the progress of the integration of health and social care has so far, been less successful than planned and has not delivered patient centred care as first envisioned.  For example proposed target to decrease admissions to Accident and Emergency by 106,000 was set in 2015-16. Since 2014-15 there has been an increased of 87,000 admissions. Barriers to integration have been identified to be, financial, workforce challenges and reluctances of information sharing between organisations, restricting

the progress (NAO, 2017). More concerning is the gap between policy and

commitment of staff as highlighted by (Munoz, 2013) at the  University of the Highlands and Islands who found some positive outcomes direived from the co-produced health and social services in remote and rural community members. The professionals working in the rural setting would prefer for there not to be integration due to the strain and frustration of working along side other agencies and health boards that have slightly different models, vision and language used when caring for patients.

Conclusion

Scotland’s populations health is improving rapidly but not fast enough for the deprived areas of society. Resulting in health inequalities to continue to be a massive part of society (Scottish Government, 2008). In principle the integration of health and social care is a sound concept but it is a quality and quantity format that requires more clarification and action plans to make it effective in practice and it hasn’t been proven that is the most effective way to tackle inequalities in Scotland yet. It has also been made clear by the (Health and social care integration – National Audit Office, 2017) there is not the evidence to show that integration of health social care can deliver their commitment to have fully integrated services by 2020. Thoughout reserch its clear that bring attention to the goal that both health and social workers have and the establish common goals and over all improving communication is essential when closing the gap between health and social care staff. (Payne et al, 2002).  

References

  • Audit Scotland. (2018) What is integration?. edinubrugh Retrieved from http://www.audit-scotland.gov.uk/uploads/docs/report/2018/briefing_180412_integration.pdf
  • Aveyard, H., Sharp, P., Woolliams, M., & VLeBooks. (2015). A beginner’s guide to critical thinking and writing in health and social care (Second ed.). Maidenhead: Open University Press.
  • British Parliament, (1998). Data protection act of 1998.
  • Bryan, K. (2010). Policies for reducing delayed discharge from hospital. British Medical Bulletin95(1), 33-46.
  • Bratanova, Loughnan, Klein, Claassen, & Wood. (2016). Poverty, inequality, and increased consumption of high calorie food: Experimental evidence for a causal link. Appetite, 100(C), 162-171.
  •  
  • Beeston, C., McCartney, G., & Ford, J.  (2014) Health Inequalities Policy Review for the Scottish Ministerial Task Force on Health Inequalities. Edinburgh: NHS Health Scotland.; 2014.

         Cancer reseach (2018). Cancer mortality statistics. Retrived from:https://www.cancerresearchuk.org/health-professional/cancer-statistics/mortality#heading-Two

         The City of Edinburgh Council, 2018. Recovery from alcohol and drug problems. Edinburgh. Retrieved from: http://www.edinburgh.gov.uk/info/20081/health_and_well_being/241/recovery_from_alcohol_and_drug_problems

  • Delayed Discharge. (2017). Gov.scot. Retrieved from http://www.gov.scot/Topics/Health/Quality-Improvement-Performance/NHS-Performance-Targets/Delayed-Discharge
  • Hojjat, T., & Hojjat, Rata. (2017). The economics of obesity : Poverty, income inequality and health (SpringerBriefs in public health). Singapore: Springer.
  • Libby Brooks Scotland correspondent. (2018). Scotland’s most deprived ‘more likely to die alone at home’; Study shows impact of health inequalities on end-of-life care across areas of country. The Guardian (London, England), p. The Guardian (London, England), Sept 13, 2018.
  • McCartney, G., Collins, C., & Mackenzie, M. (2013). What (or who) causes health inequalities: theories, evidence and implications?. Health Policy113(3), 221-227.
  • Munoz, S. (2013). Co-producing care services in rural areas. Journal of Integrated Care, 21(5), 276-287. doi:http://dx.doi.org.ezproxy.napier.ac.uk/10.1108/JICA-05-2013-0014
  • NHS Health  health Scotland (2018) Older people Retrieved from http://www.healthscotland.scot/population-groups/older-people [Accessed 20th October 2018]
  • The National Audit Office. (2017) –Health and social care integration. London. Retrieved from https://www.nao.org.uk/wp-content/uploads/2017/02/Health-and-social-care-integration.pdf
  • National Institute for Health and Clinical Excellence. (2007). Drug Misuse: Psychosocial Interventions. NICE Clinical Guideline 51.
  • Newell, R., Burnard, P., & Dawson Books. (2013). Research for evidence-based practice in healthcare (Second ed., Vital notes). United Kingdom: Dawson Books.
  • O’Brien, M., & Jack, B. (2010). Barriers to dying at home: The impact of poor co‐ordination of community service provision for patients with cancer. Health & Social Care in the Community, 18(4), 337-345.
  •  
  • Payne, S., Kerr, C., Hawker, S., Hardey, M., & Powell, J. (2002). The communication of information about older people between health and social care practitioners. Age and ageing31(2), 107-117.
  •  
  •  
  • Scotpho. (2017). Screening. GlasagowGlasgow: Retrieved from:  http://www.scotpho.org.uk/health-wellbeing-and-disease/screening/key-points/ [Accessed 20th October 2018]
  • Scotpho (2018). Health inequalities. Glasagow: Retrieved from:  http://www.scotpho.org.uk/comparative-health/health-inequalities/introduction/
  • Scottish government (2018) The Scottish Health Survey. Edinburgh. Retrieved from: https://www.gov.scot/Resource/0054/00540654.pdf
  • Scotland. Taskforce on Health Inequalities. (2008). Equally well: report of the ministerial task force on health inequalities. Scottish Government.
  • Shaw, A., Egan, J., & Gillespie, M. (2007). Drugs and poverty: A literature review. In Glasgow: Scottish Drugs Forum.
  • World Health Organization. (2008). Closing the gap in a generation. Geneva: WHO.
  • World Health Organization(WHO) (2018). The economics of healthy and active ageing series. Denmark
         An Official Statistics Publication for Scotland (2017). The Scottish Index of Multiple Deprivation. Edinburgh. Retrived from:
  •  
  • https://www2.gov.scot/Topics/Statistics/SIMD?utm_source=website&utm_medium=navigation&utm_campaign=statistics-evaluation-tools

Appendix

Integration planning and delivery principles The integration planning and delivery principles are—

 (a) that the main purpose of services which are provided in pursuance of integration functions is to improve the wellbeing of service-users,

(b) that, in so far as consistent with the main purpose, those services should be provided in a way which, so far as possible—

(i) is integrated from the point of view of service-users,

(ii) takes account of the particular needs of different service-users,

(iii) takes account of the particular needs of service-users in different parts of the area in which the service is being provided,

(iv) takes account of the particular characteristics and circumstances of different service-users,

(v) respects the rights of service-users,

(vi) takes account of the dignity of service-users,

(vii) takes account of the participation by service-users in the community in which service-users live,

(viii) protects and improves the safety of service-users,

(ix) improves the quality of the service,

(x) is planned and led locally in a way which is engaged with the community (including in particular service-users, those who look after service-users and those who are involved in the provision of health or social care),

(xi) best anticipates needs and prevents them arising, and

(xii) makes the best use of the available facilities, people and other resources. The Scottish government. (2014). 

13. Self-assessed general health among adults in 2017

, by age and sex

14. While on a 6 week  placement in a busy respetory ward  looking after a wide range of people from all different backgronds, with many different respatory conditions.

15. 8 week Community placement  during the summer making visits to many different patients with different help needs from very depreived and affluent areas. Looking after a elderly lady post surgery. On her discharge home, district nurses helped with dressing changes daily and administer of Delteparin.

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