Improving Health, Wellbeing and Independence

The aim of Angus HSCP’s Strategic Commissioning Plan is to progress approaches that support individuals to live longer and healthier lives. Much of this work is delivered by Locality Improvement Groups.

North East Locality Improvement Group Update

The North East Locality Improvement Plan was published in January 2020 which identifies the improvements that have been identified by the locality to enhance health and wellbeing outcomes in the locality. Importantly, much of the plan is based on what people who live in the North East Locality and those currently involved in delivering health and social care in the area have said about how things could be better and what would make a difference.

Throughout 2019/20 members of the NE Locality Improvement Group (NE LIG) have worked closely with partners in the statutory and third sectors to promote health and wellbeing. For example, on 2nd/3rd November 2019 members attended the Health fair In Brechin High school. The community was treated to a market place in the school Atrium called ‘Balanced life’ and stalls included art and craft activities, hair, beauty and massage tasters, a photobooth and numerous other interactive opportunities.

Throughout January and February 2020 successful participatory budgeting events ‘Choice for Angus – your voice – your future’ were held in Montrose and Brechin. Members of the NE LIG were vital members of the steering group who planned, delivered and evaluated the sessions that ensured a number of projects focused on health and wellbeing received funding.

In 2019/20:

  • Montrose Public Participant Group (MPPG) held six successful drop-in sessions to assist patients of the Links Medical Centre access the new on-line prescription and appointments service. They also held two successful coffee and chat mornings at the Health Centre in order to promote the work of the MPPG.
  • Montrose Community Trust (MCT) were awarded funding from the NE LIG to initiate Men’s Health Checks in Montrose Football Club with the aim to ‘tackle’ men’s apparent lack of awareness about health issues, and also their reluctance to visit their GP. The pilot initiative started in October 2019 and included measurements of blood pressure (BP), height, weight and body mass index, all undertaken by a Keep Well nurse. The initial six month pilot proved to be very successful with all men presenting with a higher than healthy BP. Individuals were given advice and some were advised to visit their GP. MCT are exploring with Keep Well, about making the project, and facility, a permanent fixture, possibility as a ‘satellite centre’ for Keep Well’ as there seems to be a need/demand for this service, particularly amongst the client group targeted.
  • Funding was provided to deliver a combination of employability, literacy and basic IT provision to adults in Brechin for a six month pilot in Brechin Library. Feedback from the learners illustrate that their health and wellbeing has improved which has had a positive impact on their mental health.
  • In October 2019 the Edzell Participatory Budgeting (PB) initiative evaluation concluded that the initiative had been very successful and met its objectives.
  • Following a successful fund-raising initiative, staff at Dorward House took delivery of a trishaw, named of Daisy Bell, on May 2019. Residents can be taken out for trips around Montrose by volunteer pilots. Feedback from residents, families, staff and the local community, has been very positive.
  • Montrose tennis Club have provided indoor tennis sessions to The Adam Centre in Montrose. In March 2020 the Centre was approached by the Judy Murray Partnership to find out about the work and to build on this as part of a national initiative.
  • People attending the Dalhousie Day Care Centre in Brechin have been encouraged to improve their independence when taking off/on coats when arriving/leaving. They now use a spacious cloakroom with new pegs have been made by Brechin Men’s Shed and new seating was provided.
North West Locality Improvement Group Update

Good progress has been made in the North West locality over the past year with a number of projects and improvements progressed to enhance health and wellbeing outcomes.

Test of change funding from the North West Locality enabled Angus Creative Minds to open on 18th October 2019 providing access to creativity for anyone who may experience health or social barriers to taking part in creative activities. Driven by people from Angus with lived experience of mental and physical ill health, Angus Creative Minds reduces isolation, promotes integration and tackles inequalities in the community by providing opportunities for anyone – regardless of ability, age or gender – to take part and benefit from creative expression.

The North West locality has also seen a Mental Health and Wellbeing peer worker in place in every practice in the North West locality this year to work alongside primary care in supporting mental health and wellbeing. A Mental Health nurse has also been located in Academy Medical Centre to achieve early access to treatment and quicker support. Voluntary Action Angus have placed a worker in Academy Medical Centre as a social prescriber to take referrals where the benefit of non-medical support and intervention was identified.

A test of change of the ‘Advanced Risk Modelling for Early Detection’ (ARMED) project has been progressed with identified key workers in Forfar. This was developed in partnership with Edinburgh Napier University and involves a wrist tracker linked to mobile phone software with notifications going to a health professional, carer, relative or the patient themselves to promote self-management of health and wellbeing.

The North West locality funded the Strathmore Rugby Club in Forfar to undertake a test of change to achieve their aim of increasing public participation in sport in the North West Locality through rugby union and rugby league; by promoting health, wellbeing and community inclusion and providing opportunities for anyone – regardless of ability, age or gender – to take part and benefit from rugby. This included Walking Rugby, Autism Friendly Rugby and Unified Rugby. This has really made a difference to people’s lives as illustrated in the quote below –

“These sessions are an absolute lifeline for us, getting my son out and socialising with other kids like himself opens his world up in ways I couldn’t do myself. He gets to experience something I’m not sure he’d manage under normal circumstances plus he sees he is not the only child to get over excited/ stimulated etc and can see that he has a place in the world around him rather than feeling closed off as so many do. Getting involved in sports is brilliant for kids but can be incredibly difficult for those with additional needs as there are so few places willing to put real effort in, you guys have done a fabulous job I cannot thank you enough for what you provide.” (parent of child participating in autism friendly rugby).

Improving dementia diagnosis in primary care for non-complex cases was another test of change supported by the North West locality which has further developed the integration of primary and secondary care, reduced the need for referrals to secondary care with a positive impact on waiting times within Psychiatry of Old Age allowing a more timeously response to urgent referrals and more complex cases.

A test of change to implement mobile data enabled technology to support Occupational therapists in a community role was also undertaken. This is now being tested more widely across other services.

This is just a sample of the work undertaken in the North West locality this year. More projects and achievements can be viewed in the North West Locality Improvement Plan.

South East Locality Improvement Group Update

South East Angus includes some of the 20% most deprived areas in Scotland. The Arbroath Healthy Living Project was originally launched as a test of change, in recognition of the need to do more to support health and wellbeing and build capacity in the Arbroath community. It has continued to evolve and brings a range of health and community partners together with local people, to design and deliver health projects that meet local needs. The project started with a pop-up community café in Strathairlie and community-based activities such as exercise groups, healthy eating classes, welfare rights sessions, mental health support sessions and family learning activities. It also led to the development of the “Oot N Aboot” group focusing on outdoor learning activities. A further pop-up café at the Learning Tree in Arbroath has been supported by the project as well as a Community Café in partnership with Dundee & Angus College.

Another local test of change in the South East Locality is an Anticipatory Care Planning project. It’s about supporting people to think ahead, understand their health and make more informed decisions about their future care. It gives people and their carers more control over their health and care and can especially benefit people with chronic health problems or long-term conditions. We recruited a temporary Project Nurse to promote advance care planning for care home residents in the South East locality. She has worked closely with local care homes, to support and empower their staff to complete advance care plans with residents.

The South East Locality Improvement Plan 2019-22 identifies the group’s current priorities which are to address the needs of local people who are income-deprived in retirement; to improve access to information; to increase physical activity levels and improve mental wellbeing in the locality; to improve health and wellbeing for unpaid carers; and to address the high local prevalence of type 2 diabetes.

South West Locality Improvement Group Update

The South West Locality Improvement Group (LIG) have supported a range of improvements over the past year.

Tip Top Toes

The LIG provided Tip Top Toes with start up funding. Tip Top Toes offers an alternative, affordable basic foot care option to those who cannot manage their foot care in the Carnoustie and Monifieth area. This service is run by volunteers and helps to support adults to manage their foot care and encourages social interaction. Tip top toes average about 18 clients each session and feedback is collated to identify improvements.

Practice-based pain management service

A small budget from the LIG enabled a collaborative working relationship to develop to enhance the existing practice-based pain management service within Carnoustie Medical Centre. This project combined the practice pharmacist led review of medication with specialist social work motivational assessment, awareness-raising and support for patients in the management of dependence and potential dependence on prescribed drugs. This project has been paused due to COVID-19 but the 5 month clinic provided significant learning which can be taken forward.

Quality Improvement Award

The South West GP cluster won the RCGP Scotland/Scottish Government Cluster Local Quality Improvement Project Award in 2019. The award recognised the development of innovative support in the practice such as Penumbra and Parent to Parent, which are two previous South West LIG innovations. The successfully funded Penumbra mental health and wellbeing peer worker pilot project is currently being expanded to deliver mental health and wellbeing support in all GP Practice in Angus.

Mental Health and Wellbeing

The LIG in collaboration with Angus Mental Health and Wellbeing Network, developed a range of posters which have been distributed to promote self help and prevention, and signpost adults towards strategies which support positive mental health and wellbeing and highlight a range of easily accessible supports online and in the local community.

Accessible Care and Treatment

Several new initiatives promote increased accessibility to care and treatment, and stronger links and relationships with patients to assist in treating and monitoring health conditions. The LIG has funded a small, efficient and easy to use mobile piece of equipment to help screen and diagnose a range of cardiac problems. This will be used for patients who cannot attend the surgery, especially housebound patients, and will enable patients to be identified and potentially treated and medicated earlier. Additional technology has been funded to enable patients to safely administer medication. This technology will improve the experience for patients, and reduce staff time spent supporting routine tasks and enable more time to be spent supporting people with complex needs.

Voluntary Action Angus have provided the Monifieth Medical Practice with an electric car to transport patients to and from appointments, where no other transport means are available, or where the patient is housebound. The LIG have funded an electric charging point to enable this car to be charged quickly and easily. This will have a positive effect on care inequalities in the locality and improve health outcomes through timely access to care, will reduce the number of GP house visits and enable GPs to offer more appointments in the Practice.

Our current priorities are improving health, wellbeing and independence, supporting care needs at home, developing integrated and enhanced primary care and community responses, and improving Integrated care pathways for priorities in care.

Our Measures




More Detail can be found here.

This priority is also concerned with our work with the Third Sector and with Carers.

Our Practice


There is an increasing number of the Angus population who are aged over 75. The level of frailty appears to be increasing. The rate of admissions to hospital following a fall has been increasing. The use of personal are services has been increasing suggesting that there is a need to focus on supporting people to independence through enablement.

Action taken by Angus HSCP

Funding from the Technology Enabled Care (TEC) fund enabled the introduction of ADL Smartcare in Angus – renamed Independent Living Angus (ILA) for local use. This system is recommended as part of the Scottish Governments National Allied Health Professional Plan; Active and Independent Living Programme.

Locally the system has been designed with input from occupational therapists who are responsible for the clinical content including the hints and tips that are provided and the decision making protocols. ILA aims to reduce demand on occupational therapy services for advice on minor equipment. Orders can be placed directly with the equipment store for certain pieces of equipment that continue to be provided free of charge. This includes self-referral for community alarm, including some peripherals.

People who are having difficulty with everyday activities will likely benefit the most from the using ILA. There are a wide range of solutions available to help people including bathing, showering and toileting equipment, bed and chair raisers, grab rails, banister rails as well as community alarm, smoke alarms and falls detectors. There are also solutions for people who have hearing and/or visual loss.”

The system also operates LifeCurve ( an ADL Smartcare trademark) which is a simple system offering advice for enablement and improving independence. The LifeCurve questionnaire is repeatable and can provide information on change in an individual’s abilities over time. The system can be further developed to offer other forms of self-management support such a money advice, physiotherapy triage, long term conditions information. The development potential as a self-serve solution to reduce assessment demand in a number of areas is significant. Ultimately the system can deliver referrals for supports and services where eligibility criteria are met e.g. where the level of need is substantial or critical.


2,183 people accessed ILA. 44% of users are finding help through the self-assessment and LifeCurve section and people are also using the equipment catalogue and the local information section, finding help from local services and organisations embedded within the site. This may be the only help that someone needed and may be enough to prevent a call to First Contact. Using LifeCurve is already helping staff work through enablement approaches with people.

The work continues and we expect to grow ILA.


A 72 year old lady was referred to the Angus Falls service following attendance by the Scottish Ambulance Service overnight following 2x falls. Community Alarm had attended and had got the lady sitting up in a chair before the ambulance crew arrived. There was no medical reason for her to be conveyed to the ED at Ninewells hospital and so the crew followed the SAS-Falls service pathway and telephoned with the required details. This was picked up in the morning by the falls assessor.

The falls assessor carried out a phone call triage that morning, consisting of a multifactorial falls assessment, and it emerged that this lady had had 4x falls in the last two weeks and had only called community alarm and SAS for the last one.


  • Urgent referral to physiotherapy for balance and mobility assessment indicating the likely need for a walking aid.
  • OT referral to community rehab team for bathing assessment as was now scared to use the shower due to loss of confidence following the fall, and also to provide a commode for overnight in the bedroom.
  • Letter to GP to highlight recent falls and requesting review of continence as urgency overnight to toilet (falls happening overnight)
  • Falls prevention literature sent out to the lady.
  • Community Alarm service contacted as pendant band had broken so reluctant to wear.

A follow up evaluation call was carried out 2 months post triage. The lady had then been referred on for specialist assessment at the MFE clinic. She felt her confidence had been affected by the fall but that the measures above put in place had helped to increase her confidence and as a result, had had no further falls at this point.

Social Prescribing in GP Practice

An elderly couple were referred to the service for support at home. Identified needs were high risk of phone scamming, social isolation and financial concerns. The service facilitated installation of a call blocker to reduce risk of phone scams. An assessment of the heating system was undertaken as the couple were struggling with upkeep and cost. This was having a negative impact on the couple’s health, both physically and mentally. They described a real worry and concern over how they “would manage another winter” if nothing changed. This was affecting all aspects of their life and they described putting this worry above all else. Works were organised for the home, and a benefits check identified all appropriate benefits were not in place, resulting in a financial increase to the household. The couple also received information on local, appropriate social groups and clubs which they were excited to join. They described the support they received from all services as extremely helpful and “marvellous”. Since then, they have used the Citizen’s Advice Bureau and the social prescribing service to access other support and now feel they know who to ask when unsure where to go for help.

Good Practice

The First Contact Physiotherapy (FCP) service aims to deliver efficient, high quality management of musculo-skeletal (MSK) patients evidenced through achievement of clinical outcomes and feedback from patients and clinicians. Angus FCP Service started initially in Brechin Health Centre and then via the new GP contract, our first FCP hub began in South Angus in June 2019. Recently we have increased capacity within the service with existing MSK staff who have provided additional sessions to support the delivery of the service. We now have established hubs in each of the Angus localities covering all 16 GP practices and deliver 36 sessions per week. The service is now delivered over various platforms including both telephone consultations and video consultations via Near Me, and in person when required. Funding has been secured for 6.0wte B7 Physiotherapy staff and we have just recently been able to recruit to all posts with the aim of all staff in place by the end of October. At this point we will be aiming to deliver 48 sessions of FCP per week across Angus. In the 12 months leading up to June 2020, the FCP service has assessed 5908 patients, discharging 57% from the first appointment.

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