Health and Social Care

NHS Tayside Breakthrough Series Collaborative

January 21, 2022 by No Comments | Category health & social care, neurological conditions

Our programme is multi-faceted and covers Primary, Community, Social and Secondary care as well as the third sector. Since it was established in April 2021 our ambition has been to create a community focused on the Neurological Care and Support Framework goals and priority commitments. The community will deliver improvements in care as well as providing a support and learning resource for each other.

The work is led by a steering group and there have been two action learning sets to date. The original intention was for a board wide neurology learning community but this has since shifted to smaller scale learning opportunities within departments and their wider teams. Improvement ideas identified at these learning sets will be taken forward by local staff groups developing, planning, implementing and sharing learning, underpinned by improvement measures.

The programme is focussed on five areas:

  • Rehabilitation – develop practitioner led services which include intensive ambulatory care and outpatient / community support services
  • Patient Initiated Reviews (PIR) – building on a model used in NHS Greater Glasgow and Clyde, this is being tested with epilepsy to reduce delays in people accessing specialist review, meaning they don’t have to go back through the GP referral route
  • Electronic Patient Record (EPR) – single patient record across care settings piloting over the next few months in NHS Tayside NHS Fife & NHS Forth Valley
  • Parkinson’s and collaborative working – Joint transition clinics between Neurology and Medicine for the Elderly and closer working between the specialist nurses from both
  • Support for high risk epilepsy patients through better data tracking and patient alerts

One key learning from the programme is not to be overly ambitious and to consider the multi-faceted environment the projects are set in.  Each project has its own challenges, with different care and leadership models and different management structures. When a project such as rehabilitation or collaborative working is cutting across care providers these challenges are multiplied.

Being realistic with what you can achieve in a fixed period is key to keeping your drive and passion alive. Having the time, capacity and commitment from others is the key to success. Here you will need patience. There will be complexities that you never forecast or organisational aspects that you are unaware of.

Sometimes the organisation itself will have areas of interest that are consistent with your programme plans, though shared goals may have differing timeframes.  The positive is the key people you need to influence or partner with will be on board, though the organisation may need more time to prepare, plan and implement the changes you want in your department.

The Electronic Patient Record (EPR) will enable the same information about the patient to be viewed in different settings. Decisions needed to be made about which system to adopt and this consensus building takes time.

With Patient Initiated Review (PIR), we did not have the correct outcome coding in our patient administration system and waited for the software update. We are now early adopters to test services for PIR and about to launch in the next few weeks.

Patience and being realistic cannot be emphasised enough. I know I will not achieve everything I had hoped for. However I have set in motion the laying of foundations that will secure many of the improvements we are seeking to introduce. Key to this is having the right people and stakeholders around the same table. I know when my fixed term post ends, the work that is outstanding will continue.

This project is funded through the Neurological Care and Support – a National Framework for Action. The framework sets out a vision for driving improvement in the care and support for those with neurological conditions in Scotland. A list of projects being funded through the framework can be found on the Scottish Government website.

If you would like further information about the framework, or for details of any of funded projects, please contact

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