ITEM 9 IJB Finance and Performance Audit 2024
North Lanarkshire Council · 25 September 2024
Back to Health and Social Care Integration Joint Board — 25 September 2024 and its agenda
Text extracted from the council's PDF. Layout and reading order may differ from the original.
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1 REPORT Item No: 9 SUBJECT: Integration Joint Boards Finance and Performance Report 2024 TO: Integration Joint Board Committee Lead Officer for Report: Ross McGuffie, Chief Officer NL HSCP Author(s) of Report Stacey Anderson, Service Support Project Manager NL HSCP DATE: 25th September 2024 1. PURPOSE OF REPORT This paper is coming to the IJB for: For approval ☐ For endorsement ☐ To note ☒ 2. ROUTE TO THE BOARD This paper has been: Prepared By: ☐ Reviewed By: SLT and shared at the IJB Liason Session on 11/09/2024 ☒ Endorsed By: ☐
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2 3. RECOMMENDATIONS 3.1 It is recommended that the IJB note the contents of the report. 3.2 Follow the recommendations set out within the report including; • Ensure that their Medium-Term Financial Plans are up to date and reflect all current known and foreseeable costs to reflect short and longer-term financial sustainability challenges. • Ensure that the annual budgets and proposed savings are achievable and sustainable. The budget process should involve collaboration and clear conversations with IJB partners, workforce, people who use services and other stakeholders around the difficult choices required to achieve financial sustainability. • Work collaboratively with other IJBs and partners to systematically share learning to identify and develop: -Service redesign focused on early intervention and prevention. -Approaches focused on improving the recruitment and retention of the workforce. • Work collaboratively with other IJBs and partners to understand what data is available and how it can be developed and used to fully understand and improve outcomes for those using IJB commissioned services. This should include a consideration of gaps in data. It should also include consideration of measures to understand the impact of preventative approaches. • Evaluate whether the local commissioning of care and support services, and the contracting of these services, adheres to the ethical commissioning and procurement principles, improving outcomes for people. 4. VARIATIONS TO DIRECTIONS? 5. BACKGROUND/SUMMARY OF KEY ISSUES 5.1 Background 5.1.1 This report builds on previous audits and shows that Integration Joint Boards - IJBs - are managing in a complex landscape of unprecedented pressures, Yes ☐ No ☒ N/A ☐
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3 challenges and uncertainties. In particular, the demand for services continues to increase. 5.1.2 IJBs are supporting an aging population, with many people having multiple and more complex medical conditions. 5.1.3 Health inequalities are widening, with the focus on crisis medical treatment and care, rather than measures that support people maintain good health and wellbeing. 5.1.4 It is reported that funding has decreased by 9% in real terms in 22-23 and financial sustainability risks have been identified by auditors in the vast majority of IJBs. 5.1.5 These are not easy issues to resolve, despite a driven and committed workforce. 5.1.6 IJBs alone cannot address these challenges across the sector. Whole system collaborative working is needed as part of a clear national strategy that takes account of the wider needs of our communities. 5.2 Finance Overview 5.2.1 The financial health of IJBs continues to weaken and there are indications of more challenging times ahead. 5.2.2 IJB funding has decreased in real terms compared to 2021/22, with non- recurring savings, arising from unfilled vacancies, led to the majority of IJBs reporting a surplus on the cost of providing services. 5.2.3 The majority of the total planned savings were achieved, but over a third were only achieved on a one-off basis. 5.2.4 Total reserves held by IJBs have almost halved in 2022/23 largely due to the use or return of Covid-19 related reserves. 5.2.5 The projected financial position is set to worsen, with increasing reliance on non-recurring sources of income not being sustainable. 5.2.6 Financial sustainability risk has been identified by auditors in the vast majority of IJBs and Medium- Term financial plans need to be updated to reflect all cost pressures currently known. 5.3 Data Overview 5.3.1 Data quality is insufficient to fully assess the performance of IJBs but national indicators show a general decline in performance and outcomes. 5.3.2 Data quality is insufficient to fully assess the performance of IJBs and inform improvement of outcomes for service users with a lack of joined-up data across the system. 5.3.3 Available national indicators show a general decline in performance and outcomes for people using social care and community health services.
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4 5.4 Shifting the Balance of Care 5.4.1 The percentage of expenditure on institutional and community-based Adult Social Care services has largely remained static with a small increase in the proportion spent on accommodation-based services. 5.4.2 Increase in the number of individuals receiving care at home or in the community. However, these changes are marginal when viewed over the time since the inception of health and social care integration in 2015. 5.4.3 Lack of social care capacity remains an obstacle to improving patient flow and reducing the number of delayed discharges. 5.5. Commissioning and Procurement Overview 5.5.1 Commissioning and procurement practices for social care services continues to be largely driven by budgets, competition, and cost rather than outcomes for people. Improvements to commissioning and procurement arrangements have been slow to progress but are developing. 5.5.2 Improvements to commissioning and procurement arrangements have been slow, with cost rather than outcomes driving decision-making. 5.5.3 Current commissioning and procurement practices are a risk for the sustainability of service providers and the workforce and are not always delivering improved outcomes for people. National approaches to improve commissioning have been slow to progress but are developing. 5.5.4 There is an increasing desire to move towards more ethical and collaborative commissioning models but it has not yet been universally adopted. 6. CONCLUSIONS 6.1 In order to support the IJBs in addressing the challenges outlined within the report, it is recommended within the report that Integration Joint Boards should: • Ensure that their Medium-Term Financial Plans are up to date and reflect all current known and foreseeable costs to reflect short and longer-term financial sustainability challenges • Ensure that the annual budgets and proposed savings are achievable and sustainable. The budget process should involve collaboration and clear conversations with IJB partners, workforce, people who use services and other stakeholders around the difficult choices required to achieve financial sustainability • Work collaboratively with other IJBs and partners to systematically share learning to identify and develop: -Service redesign focused on early intervention and prevention
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5 -Approaches focused on improving the recruitment and retention of the workforce • Work collaboratively with other IJBs and partners to understand what data is available and how it can be developed and used to fully understand and improve outcomes for those using IJB commissioned services. This should include a consideration of gaps in data. It should also include consideration of measures to understand the impact of preventative approaches • Evaluate whether the local commissioning of care and support services, and the contracting of these services, adheres to the ethical commissioning and procurement principles, improving outcomes for people. 7. IMPLICATIONS 7.1 NATIONAL OUTCOMES Link(s) to National Health and Wellbeing Outcomes People are able to look after and improve their own health and wellbeing and live in good health for longer ☐ People, including those with disabilities or long-term conditions, or who are frail, are able to live, as far as reasonable practicable, independently and at home or in a homely setting in their community ☐ People who use Health and Social Care Services have positive experiences of those services, and have dignity respected ☐ Health and Social Care Services are centred on helping to maintain or improve the quality of life of people who use those services ☐ Health and Social Care Services contribute to reducing health inequalities ☐ People who use Health and Social Care Services are safe from harm ☐ People who work in Health and Social Care Services feel engaged with the work they do and are supported to continuously improve the information, support, care and treatment they provide ☐ Resources are used effectively and efficiently in the provision of Health and Social Care Services ☒ 7.2 ASSOCIATED MEASURE(S) 7.3 FINANCIAL This paper has been reviewed by Finance: Yes ☒ No ☐ N/A ☐
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6 7.4 RISK ASSESSMENT/RISK MANAGEMENT Relevant Risk Register Details Current Risk Level Risk Owner Financial Challenges Very High AK Notional Set – Aside Budget High RMcG Service Sustainability High RMcG 7.5 ENGAGEMENT & PARTICPATION Please tick the engagement and participation objectives that link(s) with this piece of work and provide further details regarding the engagement and participation that was undertaken. Objectives Further Details ☒ Involve stakeholders in the development work aimed at achieving the national outcomes Engagement and Participation elements of this report were carried out by Audit Scotland. ☐ Provide stakeholders with information on how to get involved ☐ Ensure a diverse range of engagement and participation and opportunities are in place to suit different needs ☐ Measure how well we involve community stakeholders in the planning, design and delivery of our services ☐ Provide regular feedback on how stakeholder engagement and participation is shaping and influencing service development and delivery ☐ Provide support to enable stakeholder representatives to participate meaningfully and confidently at meetings ☒ Develop participation guidelines to ensure a common understanding and set of expectations for both stakeholders and partnership staff ☐ Support engagement planning and participation in localities, taking account of other engagement activity and local plans across the Community Planning Partnership
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7 7.6 INEQUALITIES & FAIRER SCOTLAND DUTY EQIA Completed & Fairer Scotland Impact Assessment Form Completed and attached to report: EQIA added to website: 8. BACKGROUND PAPERS • Integration Joint Boards' Finance and performance 2024 (audit.scot) • Integration Joint Boards' Finance and performance 2024 | Audit Scotland 9. APPENDICES Appendix 1- Integration Joint Boards Finance and Performance 2024 Report. CHIEF ACCOUNTABLE OFFICER (or Depute) Members seeking further information about any aspect of this report, please contact the following; Ross McGuffie Ross.McGuffie@lanarkshire.scot.nhs.uk Yes ☐ No ☐ N/A ☒ Yes / Date added ☐ No ☐ N/A ☒
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8 Direction from North Lanarkshire Integration Joint Board (IJB) 1 Reference Number 2 Report Title 3 Date direction issued by IJB 4 Date from which direction takes effect 5 Direction to: 6 Does this direction supersede, revise or revoke a previous direction – if yes, include reference number(s) 7 Functions covered by direction 8 Full text of direction 9 Budget allocated by Integration Joint Board to carry out direction 10 Performance Management / Governance arrangements 11 Date direction will be reviewed
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9 Appendix 1 Integration Joint Boards Finance and performance 2024 July 2024
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2 Contents 2 Key messages 3 Recommendations 6 1. Introduction 7 2. The context 11 3. Financial performance 15 4. Performance 26 5. Commissioning and procurement 42 Endnotes 48 Appendix 1 50 Appendix 2 58 Audit team The core audit team
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3 Contents 3 consisted of: Kathrine Sibbald, Zoe McGuire, Chris Lewis, Chris Dorrian and Philip Keane, under the direction of Carol Calder.
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Key messages 3 3 Key messages 1 Integration Joint Boards (IJBs) face a complex landscape of unprecedented pressures, challenges and uncertainties. These are not easy to resolve and are worsening, despite a driven and committed workforce. The health inequality gap is widening, there is an increased demand for services and a growing level of unmet and more complex needs. There is also variability in how much choice and control people who use services feel they have, deepening challenges in sustaining the workforce, alongside increasing funding pressures. 2 We have not seen significant evidence of the shift in the balance of care from hospitals to the community intended by the creation of IJBs. They operate within complex governance systems that can make planning and decision making difficult. They cannot address the issues across the sector alone. Whole- system collaborative working is needed as part of a clear national strategy for health and social care that will promote improved outcomes across Scotland but reflects the need to respond to local priorities. 3 The workforce is under immense pressure reflecting the wider pressures in the health and social care system. Across the community health and social care sector there are difficulties in recruiting and retaining a skilled workforce. The Covid- Key messages
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Key messages 4 4 19 pandemic, the cost-of-living crisis and the impact of the withdrawal from the European Union have deepened existing pressures. Unpaid carers are increasingly relied on as part of the system but are also disproportionately affected by the increased cost-of-living. Without significant changes in how services are
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Key messages 5 5 provided and organised, these issues will get worse as demand continues to increase and the workforce pool continues to contract. 4 Uncertainty around the direction of the plans for a National Care Service and continued instability of leadership in IJBs have also contributed to the difficult context for planning and delivering effective services. We are seeing examples of IJBs trying to work in new and different ways, but there is a lack of collaboration and systematic shared learning on improvement activities. 5 The financial outlook for IJBs continues to weaken with indications of more challenging times ahead. • In common with other public sector bodies, financial pressures arising from rising inflation, pay uplifts and Covid- 19 legacy costs are making it difficult to sustain services at their current level and, collaborative, preventative and person-centred working is shrinking at a time when it is most needed. • The financial outlook makes it more important than ever that the budget process involves clear and open conversations with IJB partners, workforce, people who use services and other stakeholders around the difficult choices required to achieve financial sustainability. • Overall funding to IJBs in 2022/23 decreased by nine per cent in real terms or by one per cent in real terms once Covid-19 funding is excluded. The total reserves held by IJBs almost halved in 2022/23, largely due to the use and return of Covid-related reserves. The majority of IJBs reported notable savings, but these were largely arising on a non-recurring basis from unfilled vacancies.
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Key messages 6 6 • IJBs have had to achieve savings as part of their partner funding allocations for several years. The projected funding gap for 2023/24 has almost tripled, in comparison to the previous year, with over a third anticipated to be bridged by non-recurring savings, with a quarter of the gap bridged using reserves. This is not a sustainable approach to balancing budgets. 6 Data quality and availability is insufficient to fully assess the performance of IJBs and inform how to improve outcomes for people who use services with a lack also of joined up data sharing. However, available national indicators show a general decline in performance and outcomes. 7 Current commissioning and procurement practices are driven largely by budgets, competition, and cost rather than outcomes for people. They are not always delivering improved outcomes and are a risk for the sustainability of services. Improvement to commissioning and procurement arrangements has been slow to progress but is developing. There are some positive examples of where more ethical and collaborative commissioning models are being adopted.
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Recommendations 6 6 Recommendations This report and the recommendations focus on IJBs, however to respond to the significant and complex challenges in primary and community health and social care all the bodies involved need to work collaboratively on addressing the issues – IJBs alone cannot address the crisis in the sector. The next iteration of this annual report will be produced jointly with the Auditor General for Scotland and will take a whole system approach and will make recommendations to the Scottish Government, councils, NHS boards as well as IJBs, as appropriate. Integration Joint Boards should: • ensure that their Medium-Term Financial Plans are up to date and reflect all current known and foreseeable costs to reflect short and longer-term financial sustainability challenges • ensure that the annual budgets and proposed savings are achievable and sustainable. The budget process should involve collaboration and clear conversations with IJB partners, workforce, people who use services and other stakeholders around the difficult choices required to achieve financial sustainability • work collaboratively with other IJBs and partners to systematically share learning to identify and develop: – service redesign focused on early intervention and prevention – approaches focused on improving the recruitment and retention of the workforce • work collaboratively with other IJBs and partners to understand what data is available and how it can be developed and used to fully understand and improve
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Recommendations 7 7 outcomes for those using IJB commissioned services. This should include a consideration of gaps in data. It should also include consideration of measures to understand the impact of preventative approaches • evaluate whether the local commissioning of care and support services, and the contracting of these services, adheres to the ethical commissioning and procurement principles, improving outcomes for people.
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1. Introduction 7 7 1. In 2022 and 2023 the Accounts Commission published a bulletin setting out the financial position of the 30 Scottish IJBs. This year’s report expands on this and provides a high-level independent analysis of IJBs, commenting on: • the financial performance of IJBs in 2022/23 and the financial outlook for IJBs in 2023/24 and beyond • performance against national health and wellbeing outcomes and targets alongside other publicly available performance information • a ‘spotlight’ focus on commissioning and procurement of social care. 2. This report focuses solely on IJBs. While it comments on how they interact and perform within the wider system, the work does not comment on the work of councils, NHS boards or the Scottish Government or make recommendations to these bodies. In future reports we will expand the scope to include these public bodies. This will allow us to consider community health and social care as a whole system and look at how different parts work together when planning and delivering services. 3. Supporting this report we have also published: • a supplement collating the performance information considered in the report • a checklist of questions, based on the issues raised in this report, for IJB board members to consider • a summary of the discussion at a stakeholders’ roundtable session we hosted in February 2024 that has helped inform this report. 1. Introduction About this report
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1. Introduction 8 8 What is an IJB? 4. An IJB is responsible for the governance, planning and resourcing of social care, primary and community healthcare and unscheduled hospital care for adults in its area. 5. The Public Bodies (Joint Working) (Scotland) Act 2014 (the Act) requires the 32 Scottish councils and 14 territorial NHS boards to work together in partnerships to integrate how social care and community healthcare services are provided. IJBs were created as part of the Act as separate legal bodies. Exhibit 1 (page 9) sets out how these IJBs operate. 6. There are 31 partnerships across Scotland. Stirling and Clackmannanshire councils have formed a single partnership with NHS Forth Valley. The majority of NHS boards have a partnership with more than one IJB and five IJBs cover the same geographical area as their health boards. 7. Highland follows a different arrangement, a Lead Agency model.1 This Accounts Commission report focuses on the work of the IJBs and does not comment on the performance of the Highland Health and Social Care Partnership as its scrutiny sits with the Auditor General for Scotland rather than the Accounts Commission. 8. The aim of integration is to ensure that people receive the care they need at the right time and in the right setting, with a focus on community-based, preventative care; improving the outcomes for patients, people who use services, carers and their families. The services are provided by a mixture of public, private and third sector providers dependent on who is most suitable to deliver those services. 9. The Act sets out which services are required to be delegated by councils and NHS boards to the IJBs as a minimum. This includes social care and primary and community healthcare. Services within this scope include for example, services for adults with physical disabilities, mental health services, drug and alcohol services and unscheduled health care. Some IJBs have also integrated other services. For example, 11 IJBs also have strategic responsibility for children’s social care services and 16 IJBs have strategic responsibility for criminal justice social work.
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1. Introduction 9 9 Service delivery • IJB directs the NHS board and council to deliver services • The extent of the IJB’s operational responsibility for delivering services is defined by the level of detail included in its directions to each partner. The more detailed its directions, the more it will monitor operational delivery. NHS board and council Level of operational responsibility Accountable to: the electorate Accountable to: Scottish ministers and the Scottish Parliament, and ultimately the electorate IJB • Responsible for planning health and care services • Has full power to decide how to use resources and deliver delegated services to improve quality and people’s outcomes Council • Delegates specific services to the IJB • Provides money and resources NHS board • • Delegates specific services to the IJB Provides money and resources Jointly accountable to: council and NHS board through its voting membership and reporting to the public Exhibit 1. How IJBs work NHS board and council accountable to IJB for the delivery of services as directed
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1. Introduction 10 10 IJB Source: What is integration? A short guide to the integration of health and social care services in Scotland, April 2018, Audit Scotland IJB accountable for overseeing the delivery of services
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1. Introduction 11 11 10. Audit Scotland has published reports and is currently undertaking work, on behalf of the Accounts Commission and the Auditor General for Scotland, on some of these service areas. • Adult mental health Report published 13 September 2023. • Children and young people who need additional support for learning Blog published 17 May 2022. • Drug and alcohol services: An update Report published 8 March 2022 and Drug and alcohol services – audit scope Ongoing work to be published Autumn 2024. • Social care briefing Report published 27 January 2022. • General Medical Services contract progress Audit scope report to be published spring 2025.
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2. The context 11 11 11. Social care and primary and community healthcare services in Scotland currently face complex and unprecedented pressures and challenges. These challenges are not easily resolved and are worsening. There is an increased demand for services, deepening challenges in sustaining the workforce, alongside increasing financial pressures. These longstanding challenges have been exacerbated by the cost-of-living crisis, increasing cost of provision of services and a changing policy landscape. The Covid-19 pandemic has also had a lasting impact on this sector, given the impact on health and social care staff and the need to continue to protect vulnerable people. 12. The Independent Review of Adult Social Care2 (Feeley Review) (published in February 2021), and the scrutiny of the National Care Service (Scotland) Bill has stimulated a lot of public debate and consideration of the need for change in the sector. But, to date there has been limited change for people experiencing or working in social care. It is important to emphasise that this is not a reflection on individuals working in the sector. Our experience, through this work, is that those involved, at all levels, are driven and passionate about improving the lives of people who need support. 13. IJBs cannot address the issues across the sector alone, whole- system collaborative working is needed as part of a clear national strategy. In the Auditor General for Scotland’s NHS in Scotland 2023 report, he stated that ‘there are a range of strategies, plans and policies in place for the future delivery of healthcare, but no overall vision. To shift from recovery to reform, the Scottish Government needs to lead on the development of a clear national strategy for health and social care. It should include investment in preventative measures and put patients at the centre of future services’. IJBs are facing significant financial sustainability challenges and cost pressures are only increasing 2. The context IJBs face a complex landscape of considerable challenges and uncertainties
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2. The context 12 12 14. In common with other public sector bodies, financial pressures arising from rising inflation, pay uplifts, the cost-of-living crisis and Covid-19 legacy costs are making it difficult to sustain services at their current level. IJBs are also experiencing an increase in prescribing costs. IJBs have had to achieve savings as part of their partner funding allocations for several years and achieving these savings, while maintaining service levels, has become increasingly difficult. IJBs are now having to consider more significant options as statutory duties have to be prioritised. This
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2. The context 13 13 includes ending funding for some care and support services, to ensure financial sustainability in the medium to long term. The demand and need for services continue to increase and become more complex 15. Demographic changes and the increasing complexity of care needed are driving an increase in the demand for services. For example, an estimated one in 25 people of all ages in Scotland received social care support and services at some point during 2022/23. It is estimated that 76 per cent of these people are aged 65 and over, and 63 per cent are aged 75 and over.3 An estimated 20 per cent of Scotland’s population is aged over 65. In many rural and island areas this population group is even higher, for example 27 per cent of the population in Argyll and Bute and the Western Isles are over 65.4 16. The proportion of the population over the age of 65 is projected to grow by nearly a third by mid-2045. Since currently around three-quarters of people receiving social care support are aged 65 or over, this means that there will likely be a substantial rise in the number of people requiring social care support. It is likely this pattern reflects the challenges across most other services commissioned by IJBs. A recent study found that 93 per cent of people aged over 65 who received social care had two or more medical conditions simultaneously.5 People over 75 are around twice as likely to require outpatient or inpatient care compared to those aged in their mid-20s.6 The workforce is under immense pressure 17. Across the primary and community health and social care sector there are difficulties in recruiting and retaining a skilled workforce. Without significant changes in how services are provided and organised, this issue will get worse as demand continues to increase and the workforce pool continues to contract. The number of people aged 25-44 is predicted to fall from 1.4 million to 1.3 million by 2045. Meanwhile the number of people aged over 75 will rise from 469,000 in 2021 to 774,000 in 2045.7 18. We have previously highlighted how the effects of the pandemic worsened existing pressures on the social care workforce causing experienced staff to leave their posts. Our ongoing monitoring and discussions with stakeholders show that these issues remain and the cost-of-living crisis and the ongoing impact of withdrawal from the European Union have added to the pressures. 19. The staff vacancy rates across social care and support services in Scotland is high. At 31 December 2022, 49 per cent of services
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2. The context 14 14 reported vacancies; 63 per cent of these services with vacancies reported problems filling them. The percentage of care services reporting vacancies had been consistent over time up to and including 2020, before a large increase of 11 percentage points reported in 2021.8
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2. The context 15 15 20. Almost 90 per cent of social care providers stated recruitment and retention was problematic for them in a survey carried out by Scottish Care.9 This survey also found that a quarter of staff leave an organisation within the first three months of joining. Providers find they are competing for staff: • across other public, independent and third sector providers with differences in pay and terms and conditions • with the hospitality and retail sectors, who pay more for less demanding roles • with the health sector with an increasing disparity between health sector and social care sector wages – the current pay gap is 19 per cent between adult social care workers and NHS entry level pay. The cost-of-living crisis is affecting the demand for services as well as the ability to provide them 21. The increased costs of living have exacerbated the workforce challenges as the low wages are making it a less favourable career choice. This is particularly an issue for those providing care at home services who are experiencing an increase in petrol costs and are not always reimbursed in a timely manner, or, in some cases, at all for all their journeys. 22. Unpaid carers are also disproportionately affected by the increased cost-of-living crisis. People in the most deprived areas are more likely to provide 50 or more hours of unpaid care a week compared to people living in the least deprived areas.10 23. The cost of provision of services has also increased. Homecare costs per hour have increased by 19 per cent between 2016/17 and 2022/23. Residential care costs per week (for those aged 65 and over) have increased by 23 per cent between 2016/17 and 2022/23. There are also significant cost differences between urban and rural areas.11 24. In particular, for smaller, independent and third sector service providers, increased costs are causing problems for the sustainability of services. For example, in residential care homes, an increase in fuel costs to heat and provide power for residents has made their financial viability increasingly challenging. IJBs operate within complex governance systems that can make planning and decision making difficult 25. We previously reported in our Health and social care integration: update of progress report, that the current model of governance is An unpaid carer is anyone who cares for someone who is ill, disabled, older, has mental health concerns or is experiencing addiction and is not paid by a company or council to do this. Primarily, this is a family member or friend.
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2. The context 16 16 complicated, with decisions made at IJB, council and health board level. We found that cultural differences between partner organisations are a barrier to achieving collaborative working and achieving key priorities. These challenges have not been resolved.
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2. The context 17 17 Instability of leadership continues to be a challenge for IJBs 26. A notable turnover of senior leadership positions since the start of health and social care integration continues to be a concern. Half of all IJBs experienced turnover in either their chief officer and/or chief finance officer posts in the last two years. Across 2021/22 and 2022/23, seven Chief Officers, 11 Chief Financial Officers, one IJB chair and one chief social work officer changed. Instability in leadership teams has the potential to disrupt strategic planning at a time when difficult and significant decisions need to be made. It can affect the culture of an organisation at a time when the workforce is under pressure. Plans for a National Care Service have brought uncertainty for IJBs 27. In June 2022, the Scottish Government introduced the National Care Service (Scotland) Bill to Scottish Parliament. The Bill was intended to ensure: • consistent delivery of high-quality social care support to every single person who needs it across Scotland, including better support for unpaid carers • that care workers are respected and valued. 28. The main elements of the Bill were the proposed creation of a National Care Service, including a national board, making Scottish Ministers accountable for social work and social care support. The original Bill also set out to transfer social care and social work council functions, staff and assets to Scottish Ministers or local care boards. This put in question the role and responsibility of IJBs and caused uncertainty for IJBs on the timescales for implementing the proposed National Care Service and what form it would likely take. This has complicated IJBs ability to undertake medium- and long-term financial planning. 29. After some delays, Stage 1 of the Bill was passed in March 2024. Amendments planned for the NCS Bill now mean IJBs will be reformed rather than replaced by 2029/30. IJBs should therefore ensure they have effective medium- and longer-term planning in place and continue to drive improvements in how they commission and deliver services.
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3. Financial performance 15 15 IJB funding has decreased in real terms compared to 2021/22 30. IJBs receive their funding as annually agreed contributions from their council and NHS board partners. Funding is largely received to cover in-year expenditure on providing services but can also be received for specific services and national initiatives to be funded in future years. 31. Funding to IJBs in 2022/23 decreased by £1.1 billion (nine per cent) in real terms to £11.0 billion; a £342 million decrease in cash terms Exhibit 2. IJBs received £1.0 billion of additional funding in 2021/22 to support their response to the Covid-19 pandemic. Excluding the 2021/22 Covid-19 related funding, this shows an underlying decrease of £68 million in real terms, representing a 1.0 per cent decrease. £553m £1,024m 3. Financial performance The financial health of IJBs continues to weaken and there are indications of more challenging times ahead Exhibit 2. Real terms movement in IJB funding £10,987m £11,025m £10,957m
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3. Financial performance 16 16 2020/21 2021/22 2022/23 Partner funding (real terms) Covid-19 funding (real terms) Source: IJB audited annual accounts 2020/21, 2021/22 and 2022/23 and ONS deflators
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3. Financial performance 17 17 Non-recurring savings, largely arising from unfilled vacancies, led to the majority of IJBs reporting a surplus on the cost of providing services 32. Nineteen IJBs reported a surplus on the cost of providing services, but these underspends were driven largely by vacancies and staff turnover (Exhibit 3, page 17). Three IJBs reported a break-even position and the remaining eight IJBs recorded an overspend of two per cent, or under, of their net cost of services. The three IJBs reporting a break-even position did so after receiving additional funding allocations from their partner bodies. The net underspend position on the costs of providing services across IJBs was £110 million. 33. The IJBs ability to meet the rising demand for their services and maintain service quality, is weakened by unfilled vacancies. The IJBs reporting a surplus would be unlikely to do so if the workforce was at full capacity. The majority of the total planned savings were achieved, but over a third were achieved only on a one-off basis 34. IJBs achieved 84 per cent of their £77 million planned savings target in 2022/23. Over a third of this was achieved on a non-recurring basis. This means that these savings will be carried forward to be found again in future years. Identifying and achieving savings every year on a recurring basis, and moving away from relying on one-off savings, is essential for IJBs to maintain financial sustainability. Total reserves held by IJBs have almost halved in 2022/23 due largely to the use or return of Covid-19 related reserves 35. By the end of 2022/23, all IJBs reported a reduction in their total level of reserves, decreasing by £560 million to £702 million, a 44 per cent reduction. 36. The decrease in the overall reserves balance was largely the result of a reduction in the reserves of funding that the Scottish Government specifically provided for the response to the Covid-19 pandemic. The Covid-19 related reserves decreased by 97 per cent, from £502 million to £14 million. Auditors confirmed that over two-thirds (£333 million) of the Covid-19 reserve reduction was a result of unused balances being
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3. Financial performance 18 18 returned to the Scottish Government.
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3. Financial performance 19 19 Eilean Siar South Ayrshire North Lanarkshire Angus Moray Argyll & Bute East Ayrshire Dundee East Dunbartonshire South Lanarkshire Perth & Kinross Falkirk Inverclyde Fife North Ayrshire Renfrewshire Clackmannanshire & Stirling East Renfrewshire East Lothian Edinburgh Dumfries & Galloway Orkney West Dunbartonshire Glasgow West Lothian Midlothian Aberdeen Exhibit 3. Operational surplus as a proportion of net cost of service
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3. Financial performance 20 20 Scottish Borders Aberdeenshire Shetland -3 -2 -1 0 1 2 3 4 5 6 7 Percentage Source: IJB audited annual accounts 2022/23
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3. Financial performance 21 21 37. The exceptional impact of Covid-19 reserve movements can obscure underlying reserve movements. When Covid-19 reserve movements are excluded, the total value of reserves was reduced by 10 per cent (£72 million) from £760 million to £687 million. 38. IJBs hold reserves for a variety of reasons, including reserves held to address specific local or national policy initiatives or to mitigate the financial impact of unforeseen circumstances. The reserves held by IJBs consisted largely of four main areas (Exhibit 4, page 19), as follows: • Earmarked reserves of £426 million (£426 million in 2021/22) held by individual IJBs for a range of local planned purposes, such as reserves for multidisciplinary teams, interim care beds, as well as more generic reserves associated with winter planning and local reserves to support newer innovative practices that contribute towards strategic change. • Ring-fenced reserves of £79 million (£185 million in 2021/22) provided to support Scottish Government national policy objectives. Examples include the Primary Care Improvement Fund, Mental Health Recovery and Renewal, Mental Health Action 15, Community Living Change Fund and Alcohol and Drug Partnership funding. • Contingency reserves of £183 million (£148 million in 2021/22) that have not been earmarked for a specific purpose. IJBs have more flexibility on the use of this type of reserves which are often used to mitigate the financial impact of unforeseen circumstances. • Covid-19 related reserves of £14 million (£502 million in 2021/22), representing all unspent funding received to support the impact of the pandemic on IJB services.
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3. Financial performance 22 22 Source: IJB audited annual accounts 2022/23 39. Reserves ring-fenced to support Scottish Government national policy objectives saw a 57 per cent reduction of £106 million to £79 million. These national initiatives include programmes for primary care improvement and mental health programmes. 40. These reserve balances largely represent non-recurring amounts 2% Covid-19 reserves 61% Earmarked reserves 11% Ringfenced reserves 26% Contingency reserves Exhibit 4. 2022/23 Reserves
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3. Financial performance 23 23 of money that can only be used for specific and defined national policy priorities. As these non-recurring reserves are utilised, funding will need to be identified to fund any continuing associated initiatives on a sustainable basis. 41. The reduction in reserves was slightly offset by increases in the contingency reserves and other locally earmarked reserves. Contingency reserves have continued to increase, largely as a result of unplanned vacancy savings, and now represent a quarter of the total year end reserves balance.
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3. Financial performance 20 20 Eilean Siar North Lanarkshire Inverclyde West Dunbartonshire Angus Falkirk Renfrewshire East Dunbartonshire Clackmannanshire & Stirling Dundee South Ayrshire Midlothian East Ayrshire Aberdeen Perth & Kinross South Lanarkshire North Ayrshire Fife Glasgow Argyll & Bute East Lothian Aberdeenshire Orkney Scottish Borders West Lothian East Renfrewshire Dumfries & Galloway Moray Edinburgh Shetland Exhibit 5. Year end IJB reserves as a proportion of net cost of services
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3. Financial performance 21 21 Contingency as a proportion of net cost of service Ringfenced/ earmarked reserves as a proportion of net costs of services 0 2 4 6 8 10 12 14 16 Percentage Source: IJB audited annual accounts 2022/23
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3. Financial performance 22 22 42. Contingency reserves are uncommitted funds held by IJBs to mitigate the financial impact of unforeseen circumstances and the amount held will vary depending on individual IJB reserve policies. A review of a sample of ten IJB reserve policies showed that the majority (eight) had a contingency reserve target of two per cent of annually budgeted expenditure. There is no statutory maximum or minimum level of contingency reserves. 43. Seventeen IJBs reported an increase in their contingency reserves leading to a net increase of 24 per cent (£35 million) to £183 million between 2021/22 and 2022/23. Across the IJBs, contingency reserves, as a proportion of the net cost of services, ranged from zero per cent to four per cent (Exhibit 5, page 20). Two thirds of IJBs had contingency reserve levels of over two per cent of the net cost of services. Five IJBs had no contingency reserves. The projected financial position is set to worsen 44. Twenty five IJBs agreed their 2023/24 budget before the start of the financial year. Delays in the agreement of savings plans and uncertainty around NHS partner funding were the most common reasons for IJBs not agreeing a balanced budgets before the start of the financial year. 45. IJBs do not always receive notification of funding allocations from NHS boards before the start of the financial year. This adversely affects the IJBs’ ability to plan expenditure, can cause delays to decision-making and lead to vacancies being held unfilled due to uncertainty over funding. 46. The projected funding gap for 2023/24 has almost tripled in comparison to the previous year. All IJBs reported an increase in their projected funding gap with the exception of Orkney IJB. The 2023/24 projected funding gap was £357 million representing a 187 per cent increase from the 2022/23 projected funding gap (£124 million). Funding gaps, as a proportion of the 2022/23 net cost of services, ranged from one to ten per cent (Exhibit 6, page 22).
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3. Financial performance 23 23 Dumfries & Galloway Eilean Siar Scottish Borders Edinburgh Falkirk Perth and Kinross Orkney Midlothian Moray Argyll & Bute South Lanarkshire Fife East Lothian West Dunbartonshire Renfrewshire Glasgow Clackmannanshire & Stirling West Lothian Aberdeen Shetland East Ayrshire North Lanarkshire Angus Aberdeenshire North Ayrshire Exhibit 6. Funding gap as a proportion of net cost of service
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3. Financial performance 24 24 Orkney East Dunbartonshire Dundee South Ayrshire Inverclyde 0 2 4 6 8 10 Percentage Source: Auditor data return
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3. Financial performance 25 25 47. Of the total funding gap, 53 per cent (57 per cent in 2021/22) is anticipated to be met by identified savings, 24 per cent from the use of reserves, with actions yet to be identified to bridge the remaining gap Exhibit 7. Source: Auditor data return 6% Other 43% Agreed savings - recurring 11% Agreed savings - non- recurring 16% Unidentified savings (includes savings for which no detailed or agreed plans are in place) 24% Use of reserves Exhibit 7. 2023/24 IJB funding gap planned action
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3. Financial performance 26 26 The increasing reliance on non-recurring sources of income is not sustainable 48. At the time of the 2023/24 budget setting, over a third of the projected funding gap was anticipated to be bridged by one-off sources of funding, ie on a non-recurring basis. A quarter of the projected funding gap was planned to be bridged by the use of non-recurring reserves and a further fifth of the identified savings were anticipated to be non- recurring. 49. In addition, a significant proportion of the funding gap did not have planned savings action agreed against it at the time of budget setting. These unidentified savings made up 16 per cent of the total projected funding gap and were the result of eight IJBs not starting the 2023/24 financial year with a balanced budget. 50. The increased reliance on non-recurring sources of income to fund recurring budget pressures is unsustainable in the medium to long term. The identification and delivery of recurring savings and a reduced reliance on drawing from reserves to fund revenue expenditure will be key to ensuring long-term financial sustainability. Financial sustainability risks have been identified by auditors in the vast majority of IJBs 51. Auditors identified financial sustainability risks for 80 per cent of IJBs as part of their 2022/23 audits. Findings suggested that there was a reliance on non-recurring savings and sources of income to achieve financial balance. 52. As recurring savings get more difficult to identify and achieve, the need for a more significant transformation of services, in order to achieve financial sustainability, becomes more important. 53. IJBs are currently facing a range of significant and growing challenges and uncertainties impacting financial sustainability and service provision, including: • uncertainty around the level and terms of future funding settlements and funding allocations for specific initiatives • significant recruitment and retention challenges, both with the IJB and partner bodies and with external providers in the sector • rising demand and increasing complexity of care arising from the
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3. Financial performance 27 27 demographic challenges of an ageing population • cost-of-living crisis and inflationary cost pressures, including prescribing costs, making it more expensive to maintain the same level of services
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3. Financial performance 28 28 • ongoing legacy cost impacts of Covid-19, including vaccination programmes, testing and Personal Protective Equipment costs. 54. An initial analysis of 2024/25 budget setting reveals that the projected funding gap for IJBs has increased again to £456 million. This increase underlines the importance of IJB board members having clear and frank conversations not only at the board level, but with partners, providers and the wider public, about the decisions that will be required to achieve future savings and the likely implication these decisions will have on the services individuals currently receive. Medium-Term Financial Plans need to be updated to reflect all cost pressures currently known 55. The majority of IJBs have an up to date Medium-Term Financial Plan in place, but auditors found a third needed to update their plan. It is essential that IJBs ensure Medium-Term Financial Plans are updated, reflecting all known and foreseeable costs, to allow informed decision- making on the delivery of sustainable service provision and reform in the future.
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4. Performance 26 26 Data quality and availability is insufficient to fully assess the performance of IJBs and inform actions to improve outcomes for service users with a lack of joint data across the system 56. The Public Bodies (Joint Working) (Scotland) Act 2014 sets out nine National Health and Wellbeing Outcomes. These seek to measure the impact that integration is having on people’s lives. These national outcomes are underpinned by 23 associated national indicators, although four indicators have not been finalised for reporting. These national indicators have been developed from national data sources to provide consistency in measurement. IJBs are also encouraged to devise their own performance indicators for their area. Each IJB produces an annual performance report which sets out publicly its performance against key performance indicators. 57. Our review of IJB annual performance reports for 2022/23 shows the majority report against the key national performance indicators. All set out performance against their own identified strategic priorities. Some IJBs have developed their own indicators, as suggested in the Act, to help demonstrate how they are working towards their strategic outcomes. This allows for flexibility in reporting on local performance but means that describing a comprehensive national picture of performance is not possible. 58. Published performance information is not always clearly linked to the National Health and Wellbeing Outcomes with some gaps in the completeness of national performance information. Nine of the national integration performance indicators are based on the biennial 4. Performance Data quality and availability is insufficient to fully assess the performance of IJBs, but national indicators show a general decline in performance and outcomes The IJB Performance Supplement to this report sets out the performance of each IJB against the 19 national indicators available under the National Health and Wellbeing Outcomes.
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4. Performance 27 27 Health and Care Experience Survey (HACE). Response rates for the HACE are generally quite low, with more deprived areas experiencing the lowest response rates. This increases the risk that there may be underrepresentation of the experience of certain groups of people and areas.
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4. Performance 28 28 59. In our engagement with stakeholders, we heard a consistent message that data is key to a whole system approach and performance management needs to be redefined to reflect this. They indicated a range of challenges around data that is currently collected: • The current data does not provide good evidence on how the performance of one part of the system impacts on either other parts of the social care system or the system as a whole. This means the current performance data is of limited use in helping to inform system changes which might improve performance and deliver better long-term outcomes. • There is too much emphasis on data that is used by individual organisations for their governance and operational purposes rather than the collective partnership focus on its priorities. Current arrangements do not reflect a ‘whole-systems’ approach to performance management and reporting. • A lack of good data on primary care as it is voluntary for GP’s to report. • Data is more routinely collected and published on health services than social care services. Work to improve the data sets is at an early stage but is progressing 60. Work is being carried out by the Scottish Government and Public Health Scotland to improve data and allow the comparison of performance including the development of the Care & Wellbeing dashboard. This was launched in November 2023 and is populated with management information and updated on a weekly basis. IJB chairs and chief officers have access to the system to monitor significant shifts in performance and anomalies in the data. The system is still in its early stages of development and use. 61. There are other resources that can be utilised to assist in the analysis of data. In our Health and social care integration: update of progress 2018 report we set out the existence of Local Intelligence Support Team (LIST) analysts. Using a LIST analyst to tailor and interpret local data helps IJBs to better understand local need and demand and to plan and target services. 62. There are also examples of individual IJBs starting to manage their data in more innovative ways, for example at Midlothian IJB. (Case study 1, page 28)
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4. Performance 29 29 Midlothian IJB coordinates health and social care support to nearly 97,000 people. To better understand how the IJB contributes to personal outcomes for people, it asked all Midlothian HSCP services to track their contribution to improving outcomes using an outcome mapping approach by January 2024. Outcome mapping is a way to understand how services contribute to people achieving the outcomes that matter to them and can help services make more targeted, locally informed decisions about how to design, deliver or commission services. This approach allows them to describe what they do, who with, what people learn and gain as a result, how this makes them feel and the difference this makes in their lives. The outcome mapping approach was developed by ‘a Scottish software and consultancy company in partnership with the Midlothian HSCP Planning and Performance team. Each ‘stepping-stone’ of the outcome map framework includes a set of success criteria aligned to the Care Inspectorate joint inspection framework. The outcome map is colour-coded to show an evaluation of the extent to which the service is making progress towards personal outcomes and confidence in how strong the evidence is to support that progress rating. This results in a two-factor rating system for each ‘stepping-stone’ in the outcome map. The IJB also uses outcome mapping and has developed a Strategic Commissioning Map that provides a real-time picture of the whole system progress towards their strategic aims and the nine National Health and Wellbeing Outcomes by linking to service outcome maps. Outcome mapping is now central to performance measurement in the planning and performance teams. It is part of the triangulation of three types of data: service activity, population experience, and personal outcomes. The information collected from each of these three areas together provides objective, whole system evidence that supports services to develop meaningful action plans for change. Currently 60 per cent of service areas are using the framework. Some services are using this system to articulate, record, examine, and evaluate service provision and actively using this tool to support service redesign. Resourcing pressures continue to present challenges for some areas to find the time and space to complete a first map and a programme of targeted support is in place to help those areas with the most significant delivery pressures. The partnership has shared this work with Healthcare Improvement Case study 1. Midlothian IJB outcome mapping
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4. Performance 30 30 Scotland (HIS), the Scottish Government team developing the National Improvement Framework for Adult Social Care and Community Health and most recently the team developing a new improvement framework for health that will support person centred care. Source: Midlothian HSCP
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4. Performance 31 31 Available national indicators show a general decline in performance and outcomes for people using social care and primary and community healthcare services 63. As set out in the thematic sections below (and in the performance information supplement) there is a general decline in performance against the national indicators. 64. The following sections draw out performance findings against key themes set out in the bullet points below. Alongside nationally available data, for each theme we also describe the context and challenges. Some case studies of examples are also set out in Appendix 1 (page 50). These illustrate examples of where IJBs are using or developing different working practice to improve performance and outcomes. • Theme 1 – Prevention and early intervention • Theme 2 – Shifting the balance of care • Theme 3 – Person-centred care/choice and control • Theme 4 – Reducing inequalities • Theme 5 – Unpaid carers/community resilience. Theme 1 Indicators – Prevention and early intervention Collaborative, preventative and person-centred working is shrinking at a time when it is most needed. Instead of a focus on care at the right place at the right time, there is a shift to reactive services with little capacity to invest in early intervention and prevention. 65. Addressing individuals’ health and social care needs at an earlier stage through prevention and early intervention promotes better outcomes for individuals, improving their quality of life and independence, and reduces the need for costly support and care later on. The 2021 Independent Review of Adult Social Care in Scotland (Feeley Review) set out the need for an increased focus on preventative, early intervention and anticipatory forms of support and a shift away from a crisis intervention. However, this is difficult to progress when the pressures on services are so acute. 66. As financial pressures have increased, eligibility criteria for individuals accessing social care services have tightened. With this, opportunities to undertake prevention and early intervention focused services have
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4. Performance 32 32 decreased. IJBs and their partner bodies have instead signposted less formalised support in the community, often provided by third and voluntary sector organisations. However, we have found that the financial challenges are leading IJBs and other funding bodies such as NHS boards and councils to reduce grant funding to these service providers reducing the capacity to meet and address these lower level, often more preventative focused needs.
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4. Performance 30 30 67. Leaving lower-level health and social care needs unaddressed until they become more significant tends to lead to increased complexity of need, the requirement for a more resource intensive intervention and less positive outcomes for individuals in the longer term. It is essential that IJBs and their partner bodies find ways to protect and increase the health and social care interventions at an earlier stage. This will be key to addressing future demand pressures arising from demographic shifts to an older population in a more financially sustainable manner. 68. How well individuals consider themselves able to look after their health is indicative of the IJBs’ and partner bodies’ effectiveness in addressing and supporting individual needs to sustain healthy lives in the community. Since 2013/14, there has been a deterioration by four percentage points of adults who are able to look after their health either ‘very well’ or ‘quite well’ Exhibit 8. All the IJBs recorded a reduction in this measure over the period 2013/14 to 2022/23. Fourteen IJBs saw a reduction greater than average over this period, with three IJBs recording a reduction greater than five percentage points. Percentage of adults able to look after their health very well or quite well 95% 91% -4% 2015/16 2017/18 2019/20 2021/22 2023/24 Exhibit 8. Theme 1 indicators
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4. Performance 31 31 Source: Core Suite of Integration Indicators, Public Health Scotland
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4. Performance 32 32 Source: Core Suite of Integration Indicators, Public Health Scotland 69. Emergency admissions rate and the emergency bed day rate are often used as indicators of how well IJBs are reducing unnecessary hospital stays and situations where individuals remain in hospital while they are deemed to be fit enough to return to a more community-based setting. 70. Positively, there has been an eight per cent reduction in the emergency admissions rate as well as a five per cent reduction in the emergency bed day rate since 2016/17. Compared to 2020/21 there is an 16 per cent increase in the emergency bed day rate, however this reflects the impact of the Covid-19 pandemic Exhibit 9. 71. Eighteen IJBs recorded a reduction in emergency bed day rate over the period 2016/17 to 2022/23 Exhibit 9. Of the twelve that recorded an 12,229 11,276 Emergency admission rate (per 100,000 population) 2016/17 2018/19 2020/21 2022/23 -8% 2017/18 2019/20 2021/22 125,979 119,806 Emergency bed day rate (per 100,000 population) -5% 2016/17 2018/19 2020/21 2022/23 2017/18 2019/20 2021/22 Exhibit 9. Theme 1 indicators
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4. Performance 33 33 increase, two IJBs record an increase of over 10 per cent. 72. Some IJBs have put in place schemes and plans and maintain early intervention and prevention services. For example, Aberdeen City have set up a listening service to offer first-level support for people with low- level mental health challenges, addressing issues such as bereavement, redundancy, and life changes that can impact overall wellbeing. In Fife, a text chat service was launched in November 2022 enabling young people aged 12 to 19 to have direct, confidential access to the school nursing service. Further examples are set out in Appendix 1 (page 50).
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4. Performance 34 34 Theme 2 Indicators – Shifting the balance of care There is a recognition by the Scottish Government, councils and NHS boards that the balance of care needs to shift out of hospital to the community. Although this was the intention of the creation of IJBs, we have not seen significant evidence of this happening. 73. Part of the aims of the integration of health and social care was to help shift resources away from the institutional settings, such as hospitals and residential care institutions, and into more community- based services. The rationale for this is that, alongside it often being a more cost-effective way of providing services, it also helps promote greater independence and improved outcomes for the individual. 74. There has been an increase in the provision of services in the community, with an increase in the percentage of adults with intensive care needs receiving care at home and in the proportion of end-of-life care provided at home or in a community setting. At the same time, the percentage of expenditure on institutional and community-based Adult Social Care services has largely remained static with a small increase in the proportion spent on accommodation-based services. 75. Indicators tracking the balance of care and provision of services in the community have largely shown an increase in the number of individuals receiving care at home or in the community. However, these changes are marginal when viewed over the period since the inception of health and social care integration in 2015. There are also indications of pressures impacting the access to community-based services and the capacity of community services (Exhibit 10, page 33).
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4. Performance 35 35 Percentage of adults with intensive care needs receiving care at home 62% 65% +3% 2016 2017 2018 2019 2020 2021 2022 2023 Proportion of last 6 months of life spent at home or in a community setting 87% 89% 2016/17 2018/19 2020/21 2022/23 +2% 2017/18 2019/20 2021/22 Percentage of patients provided with advanced booking to GP practice (3 or more working days in advance) 77% 50% -27% 2013/14 2015/16 2017/18 2019/20 2020/21 2022/23 841 902 Number of days people aged 75+ spend in hospital when they are ready to be discharged (per 1,000 population) +7% 2016/17 2018/19 2020/21 2022/23 2017/18 2019/20 2021/22 2023/24 Exhibit 10. Theme 2 indicators
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4. Performance 36 36 Source: Core Suite of Integration Indicators, Public Health Scotland
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4. Performance 37 37 76. At the same time there has been a deterioration in the experience of those receiving those services in the community nationally Exhibit 11. Source: Core Suite of Integration Indicators, Public Health Scotland 77. The Auditor General for Scotland NHS in Scotland 2023 report states that ‘lack of social care capacity remains an obstacle to improving patient flow and reducing the number of delayed discharges from hospital. This is supported by data showing that many patients whose discharge is delayed are awaiting the completion of care arrangements to allow them to live in their own home (awaiting social care support), waiting for a place in a nursing home, or awaiting the completion of a post-hospital social care assessment’. Percentage of adults supported at home who agree that they are supported to live as independently as possible 81% 79% -2% 2019/20 2021/22 Percentage of adults supported at home who agree that their services and support had an impact in improving or maintaining their quality of life 80% 78% -2% 2019/20 2021/22 Exhibit 11. Theme 2 indicators
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4. Performance 38 38 78. Examples of approaches to shift the balance of care from the hospital to community settings are set out in Appendix 1 (page 50).
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4. Performance 39 39 Theme 3 Indicators – Person-centred care: choice and control The amount of choice and control service users feel they have is variable across the country 79. In 2010, the Scottish Government and COSLA set out a ten-year self-directed support (SDS) strategy with the aim of supporting people’s right to direct their own social care support. The Social Care (Self-directed Support) (Scotland) Act 2013 was part of the SDS strategy and set out how councils should offer people options for how their social care is managed.12 80. The Scottish Government, IJBs, councils, providers and service users and their carers recognise the gap between what the SDS legislation is designed to do and what is happening for people trying to access services in parts of Scotland. While there are examples of people being supported in effective ways through SDS, not everyone is getting the choice and control envisaged through the strategy. Some people who use services feel they have a lack of choice and need to accept what is offered with the type of care they receive being driven by the service provider. This is most recently evidenced in the Scottish Parliament’s Health, Social Care and Sport Committee post-legislative scrutiny of the Self-directed Support (Scotland) Act 2013 phase 1 report.13 Examples of increased flexibility, choice and control were given for both individuals and unpaid carers but the Committee also reflected that many areas of improvement are required. For example, a need to improve the consistency of implementation between councils and improve clarity and knowledge around SDS by providing more support and guidance to navigate the process. 81. People who use services and their carers highlight issues accessing services. Either the times at which services are available is unsuitable or the process required to access them is overly complicated. Service users also highlighted a lack of coordination and communication between services, often having to repeat their symptoms or issues multiple times as they move from service to service. Poor data sharing was highlighted as a contributing factor. 82. People who use services described being put to bed at 2pm or left in bed for hours at a time during the day. This was largely attributed to care services being under-resourced and care workers having to schedule their day to fit in additional people. 83. Research14 has found that while those who received SDS generally had positive experiences and found it beneficial, more than one-quarter of people who use SDS had their option chosen by someone else.
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4. Performance 40 40 84. The percentage of people who are receiving social care support through SDS is increasing, estimated at 88.5 per cent in 2021/22, up from 77.1 per cent in 2017/18.
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4. Performance 41 41 2019/20 2021/22 Agreed Disagreed Source: Core Suite of Integration Indicators, Public Health Scotland 85. In general, there has been a deterioration in the proportion of adults who felt that they had a say in how their care is provided Exhibit 12. The latest year of data (for 2023/24) shows that 60 per cent of adults supported at home who disagreed that they had a say in how their help, care or support was provided. Due to how the data is collected this data is not comparable to previous years. 86. The Care Inspectorate amended their approach to inspections of care services in response to the Covid-19 pandemic. Inspection activity was shifted to focus on services where there were concerns or intelligence suggesting that they are a higher risk. The overall trend since 2020/21 has seen a reduction in the number of care services graded as either ‘good’ or better Exhibit 13. 29% 71% 25% 75% Exhibit 13. Proportion of care services graded ‘good’ (4) or better in Care Inspectorate inspections
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4. Performance 42 42 83% 76% 75% 77% 2020/21 2021/22 2022/23 2023/24 Source: Core Suite of Integration Indicators, Public Health Scotland Exhibit 12. Percentage of adults supported at home who agree that they had a say in how their help, care or support was provided
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4. Performance 43 43 87. There is limited national data on access to GPs. (The Auditor General for Scotland’s upcoming report on the General Medical Services contract will look further at the availability and quality of data.) However, the percentage of people reporting a positive experience of care at their GP practice between 2015/16 and 2023/24 has declined by 17 points Exhibit 14. There has been a decline across all IJBs and the gap between the best and worst performing areas has widened. 88. Some examples of IJBs working with partners to intervene to give people more choice and control and feedback on the services they receive are set out in Appendix 1 (page 50). Percentage 100 90 80 70 60 50 40 30 20 10 0 2015/16 2017/18 2019/20 2021/22 2023/24 Exhibit 14. Percentage of people with positive experience of care at their GP practice
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4. Performance 44 44 Min Scottish average Max Source: Core Suite of Integration Indicators, Public Health Scotland
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4. Performance 45 45 Theme 4 Indicators – Reducing inequalities The Covid-19 pandemic has exacerbated existing inequalities 89. A recent review15 of health inequalities found that the health of people living in Scotland’s most deprived areas is not keeping up with the rest of society. The health inequality gap is widening, evident through increased drug deaths, infant mortality and a fall in life expectancy in more deprived areas. People living in deprived areas have a significantly lower healthy life expectancy, 26 years less for males and 25 for females in the most deprived decile compared to the least deprived decile. This gap has been widening over the past decade.16 90. Research has found people who access social care, unpaid carers and those who work in the social care sector have been disproportionately impacted (both directly and indirectly) by the Covid- 19 pandemic and mitigation measures.17 The review also highlights that some groups could experience multiple and compounding inequalities. There is a risk that equality groups and people most at risk of having their human rights breached are set back by changes to and reductions in service provision, particularly as finances become tighter. 91. Respondents to a survey about their experiences of social care18 who did not receive support but felt they needed it, were proportionally more likely to be non-white, disabled, living in deprived areas, LGBO (lesbian, gay, bisexual, other) and unpaid carers. The premature mortality rate is increasing with rates higher in more urban and more deprived areas 92. The premature mortality rate is increasing across Scotland Exhibit 15 with a one per cent increase between 2016 and 2022. Exhibit 15. Theme 4 indicator
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4. Performance 46 46 Source: Core Suite of Integration Indicators, Public Health Scotland Premature mortality rate per 100,000 population 440 442 +1% 2016 2017 2018 2019 2020 2021 2022
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4. Performance 47 47 93. IJBs were found to have consistently lower rates of premature mortality in areas that were more rural and/or relatively more affluent. Five IJBs, all from more urban and less affluent areas (Dundee, Glasgow City, Inverclyde, North Lanarkshire, West Dunbartonshire), have consistently had relatively high premature mortality rates. Emergency bed day rates are greater in areas with higher levels of deprivation 94. There is a clear relationship between the emergency bed day rate and the deprivation and affluence of an area. Using the Improvement Service’s family groupings of IJB areas, shows that areas with higher levels of deprivation have higher levels of emergency day bed rates than areas that are more affluent Exhibit 16. 30000 20000 10000 0 -10000 -20000 -30000 -40000 2016/17 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 Family groups are groupings of IJBs that are similar in the type of population they serve (deprivation and affluence levels) as well as the type of area they serve (rural, semi-rural and urban). Exhibit 16. Emergency bed day rate (per 100,000 population): Difference to Scottish rate
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4. Performance 48 48 Note: Grouping 1 represents the least deprived/affluent IJB areas and grouping 4 represents the most deprived/affluent Source: Core Suite of Integration Indicators, Public Health Scotland, Improvement Service (deprivation and affluence grouping)
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4. Performance 40 40 95. Example case studies in Appendix 1 (page 50) set out some programmes IJBs have in place to tackle inequalities in their communities and improve outcomes for all. Theme 5 Indicators – Unpaid carers The reliance on unpaid carers is increasing as the social care workforce is under added pressure 96. There is an enormous reliance on unpaid carers to support the social care system. These carers provide support to friends or family who need it. Carers can claim an allowance of £81.90 a week if they care for someone at least 35 hours a week. An additional carer support payment of £288.60 twice a year is also available to some carers. Although the exact number of unpaid carers is not known, as many carers don’t identify themselves as such, there are an estimated 800,000 unpaid carers in Scotland; this includes 30,000 young carers under the age of 18.19 The social care system relies on the contribution of the community and unpaid carers with the value of unpaid care estimated at £36 billion a year in Scotland.20 The Feeley Review stated that ‘The role communities play in supporting adults to remain active in their community simply cannot be overstated.’21 97. This reliance on unpaid carers is increasing as the social care paid workforce is under increased pressure. This is unsustainable. 98. Carers are feeling the mental, physical and financial pressure of a system under strain. Carers Scotland’s latest State of Caring survey22 found that over half (54 per cent) of carers said that their physical health had suffered because of their caring role, with one in five (20 per cent) suffering a physical injury from caring. Forty-four per cent of those on Carers Allowance are cutting back on food and heating. Research23 carried out by the Carers Trust on the experience of older carers found: • 80 per cent said their physical health had been affected by their caring role • 87 per cent said their mental health and wellbeing had been affected by their caring role • 82 per cent felt as though their caring role has financially affected them; 37 per cent have used less gas and electricity in their homes as a way to save money, and 19 per cent have skipped meals in the past 12 months • 46 per cent of carers had missed some form of health appointment due to their caring role. This will have knock effects for the efficiency of the health service.
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4. Performance 41 41 Source: Core Suite of Integration Indicators, Public Health Scotland 99. Caring responsibilities fall disproportionately on women, people living in rural areas and people living in deprived areas. National indicators also illustrate the declining sense of wellbeing for unpaid carers and those needing care Exhibit 17. There are provisions in the NCS Bill to improve support to unpaid carers but this has been subject to ongoing delays. 100. Some IJBs have set up interventions to support unpaid carers such as Falkirk and Clackmannanshire Carers Centre who provide information and signposting to those who are assessed as low or moderate on the unpaid carers eligibility for support. 40% Percentage of carers who feel supported to continue in their caring role 31% -9% 2015/16 2017/18 2019/20 2021/22 2023/24 Exhibit 17. Theme 5 indicator
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5. Commissioning and procurement 42 42 5. Commissioning and procurement Commissioning and procurement practices for social care services continue to be largely driven by budgets, competition, and cost rather than outcomes for people. Improvements to commissioning and procurement arrangements have been slow to progress but are developing 101. Our 2022 Social Care briefing highlighted commissioning arrangements as a key issue stating: ‘Commissioning tends to focus on cost rather than quality or outcomes. Current commissioning and procurement procedures have led to competition at the expense of collaboration and quality.’ In this section of this report, we focus on this issue and consider what progress is being made. What are commissioning and procurement? 102. Commissioning identifies what is to be provided. It is the process each IJB uses to set out to its partner councils and NHS boards, what it requires them to provide to meet its strategic plan for social care and primary and community health services, based on population needs and available budgets. Procurement establishes how and who will provide the services. It is the process of contracting or purchasing specific services to meet those requirements. The IJBs do not procure the services. This is done by the relevant councils or the NHS and can be from the public, private and third sector. Scotland Excel assists some councils in procuring services and has developed national adult social care frameworks. Currently, the private sector provide 54 per cent of social care services, 24 per cent by councils, 21 per cent by the third sector and the remaining element (one per cent) by health boards.24 103. All IJBs have integration strategic commissioning plans. The 2014 Act sets out requirements for the plans that are also supported by Scottish Government guidance issued in 2015.25 The plans are required to: • be reviewed at least every three years
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5. Commissioning and procurement 43 43 • set out what the arrangements are to carry out the tasks of the IJB over the three years
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5. Commissioning and procurement 44 44 • divide the area geographically into at least two localities for setting out these arrangements with each locality done separately • include how the arrangements are intended to contribute to achieving the national health and wellbeing outcomes. 104. The commissioning of social care and primary and community health services is a cyclical process carried out by a Strategic Planning Group for each IJB. This group must consider the outcomes for people and how the needs and availability of services change. Healthcare Improvement Scotland and the Care Inspectorate have produced a quality framework26 to evaluate the effectiveness of strategic planning. 105. The Independent Review of Adult Social Care in Scotland, considered in detail the arrangements for commissioning and procuring social care services in Scotland. The review identified ten changes needed in commissioning and procurement practices. Improvements to commissioning and procurement arrangements have been slow, with cost rather than outcomes driving decision-making 106. Commissioning and procurement decisions are currently driven largely by achieving the range and volume of services required at the lowest cost. This is understandable given the financial pressures and increased demand faced by IJBs, but the pressure on the service providers to remain competitive can reinforce a focus on driving down prices. This can be at the cost of promoting service quality, equality, innovation and collaboration with others, to improve people’s outcomes. 107. Tenders for support packages for people are often constructed around time and task of the service, rather than the outcomes. This lack of flexibility in the system means that NHS and council resources can get tied up in providing services that aren’t effective in improving outcomes. More flexibility is needed across the system. 108. The cyclical nature of the commissioning and procurement, mean that time and resource are focused on contracts renewal processes instead of a more strategic long-term approach. 109. As set out at paragraph 25, the current model of governance is complicated. This can cause difficulties when trying to commission services in a collaborative way. All stakeholders, including providers and users need to be part the strategic commissioning process in order to reflect what people need and want. This current approach also does not
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5. Commissioning and procurement 45 45 fully allow for innovation of the sector in finding solutions. 110. The current commissioning and procurement system lacks a process of accountability when people do not receive the services they need. People have described the process of accessing social care as
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5. Commissioning and procurement 46 46 ‘notoriously difficult’ and ‘over-complicated’ and needing to ‘fight for’ and ‘justify’ their support where they had a negative experience.27 Current commissioning and procurement practices are a risk for the sustainability of service providers and the workforce 111. Current arrangements are heavily reliant on a stable provider market and workforce but there are exacerbating financial and workforce issues facing providers, risking the viability of some. 112. A consequence of the current cyclical commissioning and procurement arrangements is that many risks around the effective delivery of service are largely put onto the providers. For example, where the cost of energy makes a service more expensive to deliver than the contract provides for, the provider is still required to provide the service, bearing the loss. 113. There is uncertainty for all providers, particularly in the third sector around future funding and their role in service provision. Providers are also experiencing challenges with providing services and fulfilling contracts largely due to difficulties with workforce recruitment and retention: • Private and third sector providers find that council commissioning rates are not enough to deliver social care and support and residential, personal and nursing care, and pay expenses such as staff, training and overheads. These providers say they cannot compete with councils where pay and terms and conditions are better than they can provide due to the flat cash settlement local government receives from the Scottish Government. • Non-committal framework agreements leading to zero hours or short hour contracts for staff. • Contracts that do not cover travel costs, especially challenging in rural Scotland which were particularly badly affected by fuel price rises. • Growth in split shifts and reduction in paid sleepovers for staff. • Although there has been an uplift in adult social care workers’ wages, this has not been universally applied for all social care workers as some roles have been out of scope for the intended policy outcome. This has focused on uprating pay for those on the lowest incomes. There is no equivalent uplift for those with supervisor or manager roles making these positions less desirable.
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5. Commissioning and procurement 47 47 • High levels of overtime and agency costs. • High and ongoing recruitment costs, particularly in more rural areas.
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5. Commissioning and procurement 48 48 114. Local government have been calling for multi-year funding settlements from the Scottish Government to support providers with medium- to long-term planning. This is currently being discussed through the Verity House Agreement and the fiscal framework discussions. 115. As set out in the context section, the workforce feel undervalued in the system and there are unprecedented numbers of vacancies (paragraph 19). The Fair Work Convention Report28 set out that ‘Despite some good practice and efforts by individual employers, the wider funding and commissioning system makes it almost impossible for providers to offer fair work.’ Without urgent progress on the fair working agenda nationally it is likely that the risks to the sustainability of the sector will deepen. Current commissioning and procurement practices are not always delivering improved outcomes for people 116. People who use services are often not involved in commissioning and procurement processes and therefore services are not necessarily reflective of what people need and want. The Independent Review of Adult Social Care in Scotland29 reported that commissioning using generic frameworks based on an hourly rate does not work well for people who have fluctuating needs for support, particularly support for mental health. 117. The Self-directed Support (Scotland) Act 2013 was designed to ensure people had choice and control in how their social care support is provided. As highlighted at paragraph 80, there is a recognised implementation gap in this policy. The Scottish Parliament’s Health, Social Care and Sport Committee post-legislative scrutiny of the Act has highlighted concerns around commissioning in relation to SDS including: • the importance of facilitating collaborative commissioning conversations • a need to develop a marketplace of providers • a need to end competitive tendering and restrictive procurement processes • the disparity in the relative available funding under different SDS options. Fair work is work that offers all individuals an effective voice, opportunity, security, fulfilment and respect. It balances the rights and responsibilities of employers and workers.
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5. Commissioning and procurement 49 49 There is an increasing desire to move towards more ethical and collaborative commissioning models but it has not yet been universally adopted 118. There are examples of IJBs attempting to adopt collaborative and ethical commissioning processes in their strategies but these appear to be at an early stage. Almost a third of IJBs have adopted the Unison Ethical Charter for Social Care Commissioning30 which is based on ethical commissioning principles. 119. IJBs are reaching out for support from IRISS (Institute for Research and Innovation in Social Services) in collaborative commissioning, for example work to improve outcomes-based commissioning with East Dunbartonshire, East Ayrshire and Orkney IJBs with Healthcare Improvement Scotland. IRISS has also been supporting West Dunbartonshire and North Ayrshire IJBs to change commissioning to a more collaborative approach. Both projects are at an early stage but they have highlighted that the relationship between stakeholders are a key aspect of addressing commissioning arrangements. Significant time and resource capacity is needed to work out these relationship issues. 120. There are some strong examples of how IJBs are working to commission in a more collaborative and flexible way including Aberdeen IJB and Fife IJB. Two examples are set out in Appendix 1 (page 50). National approaches to improve commissioning have been slow to progress but are developing 121. Across stakeholders we have engaged with, there is a recognition that commissioning needs to improve. The Feeley Report recommended that the Scottish Government and COSLA develop and agree ethical commissioning principles and core requirements. This is happening through the development of the NCS Bill, an Adult Social Care Ethical Commissioning Working Group was set up (also including the Institute for Research and Innovation in Social Services (IRISS), Social Work Scotland (SWS) and the Coalition of Care and Support Providers in Scotland (CCPS)). This group is developing a framework for ethical commissioning and has identified nine ethical commissioning principles: • Person-led care and support • Outcomes-focused practices • Human rights approach • Full involvement of people with lived experience Ethical commissioning aims to embed ethical standards into the commissioning and procurement process to ensure the process is around equity and quality for people, not just around efficiency and cost.
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5. Commissioning and procurement 50 50 • Fair working practices • High-quality care and support • Climate and circular economy
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5. Commissioning and procurement 51 51 • Financial transparency, sustainable pricing and commercial viability • Shared accountability. 122. Current Scottish Government plans are that the NCS Bill will include a clear and comprehensive definition of ethical commissioning, with a National Care Service Board31 providing national oversight, guidance and practical support.32
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Endnotes 48 48 1 Lead Agency model - In Highland the NHS Board and council have adopted a different model for integration, a lead agency model. NHS Highland leads on adult services and Highland Council leads on children’s services. Therefore, there is no Integrated Joint Board but an Integration Joint Monitoring Committee to monitor the planning and delivery of services. Revisions to the National Care Service Bill currently being developed, propose that Highland adopt a reformed IJB model as these are implemented. 2 Independent Review of Adult Social Care in Scotland, Derek Feeley, February 2021 3 People supported through Social Care Services: Support provided or funded by health and social care partnerships in Scotland 2022/23, Public Health Scotland, March 2024. 4 Mid-2022 Population Estimates, Scotland, National Records of Scotland, March 2024. 5 Scotland’s Health and Demographic profile, Social Research, Scottish Government, June 2022. 6 Scotland’s Unsustainable Health Service Modelling NHS demand to 2040, Our Scottish Future Health Commission, December 2023. 7 Population projections of Scotland - National Records of Scotland January 2023. 8 Staff vacancies in care services 2022, Care Inspectorate and Scottish Social Services Council, September 2023. 9 Workforce Recruitment and Retention Survey Findings, Scottish Care, September 2021 10 People who access social care and unpaid carers in Scotland, Scottish Government, June 2022 11 Local Government Benchmarking Framework, Improvement Service, February 2024 12 Self-directed support (SDS) aims to improve the lives of people with social care needs by empowering them to be equal partners in decisions about their care and support. Four fundamental principles of SDS are built into legislation – participation and dignity, involvement, informed choice and collaboration. The Social Care (Self-directed Support) (Scotland) Act 2013 gave councils responsibility, from April 2014 onwards, for offering people four options for how their social care is managed: – Option 1: The individual or carer chooses and arranges the support and manages the budget as a direct payment. – Option 2: The individual chooses the support and the authority or other organisation arranges the chosen support and manages the budget. Endnotes
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Endnotes 49 49 – Option 3: The authority chooses and arranges the support. – Option 4: A mixture of options 1, 2 and 3. 13 Post-legislative scrutiny of the Social Care (Self-directed Support) (Scotland) Act 2013: Phase 1: SP Paper 577, Health, Social Care and Sport Committee, May 2024.
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Endnotes 50 50 14 My Support My Choice: People’s Experiences of Self-directed Support and Social Care in Scotland National Report, ALLIANCE and Self Directed Support Scotland, October 2020. 15 Leave No-one Behind The state of health and health inequalities in Scotland, The Health Foundation, An Independent Review, David Finch, Heather Wilson, Jo Bibby, January 2023. 16 Health Life Expectancy in Scotland 2019-2021, National Records of Scotland, December 2022. 17 Adult Social Care in Scotland – Equality Evidence Review, Scottish Government, June 2022. 18 Health and Care Experience Survey, Scottish Government, May 2022. 19 Scotland’s Carers Update Release, Scottish Government, December 2022. 20 Independent Review of Adult Social Care in Scotland, Derek Feeley, February 2021. 21 Independent Review of Adult Social Care in Scotland, Derek Feeley, February 2021. 22 State of Caring Survey 2023, Carers Scotland, November 2023. 23 Experiences of Older Adult Unpaid Carers in Scotland, Carers Trust Scotland, March 2023. 24 Summary of No. of registered care services at 31 March 2024, Care Inspectorate. 25 Strategic commissioning plans: guidance, Scottish Government, December 2015. 26 Evaluating the Effectiveness of Strategic Planning: Quality Framework, Care Inspectorate and Healthcare Improvement Scotland. 27 Independent Review of Adult Social Care in Scotland, Derek Feeley, February 2021. 28 Fair Work in Scotland’s Social Care Sector 2019, Fair Work Convention, February 2021. 29 Independent Review of Adult Social Care in Scotland, Derek Feeley, February 2021. 30 UNISON’s ethical care charter, UNISON. 31 The remit and membership of a National Care Service Board will be determined by at Stage 2 of the National Care Service Bill. The overarching purpose of the Board ‘will be to ensure consistent, fair, human rights-based social care support and community health services, underpinned by effective complaints mechanisms and enhanced advocacy services’. 32 National Care Service (NCS) (Scotland) Bill: Scottish Government Response to Stage 1 report, Letter from Minister for Social Care, Mental Wellbeing and Sport to Health, Social Care and Sport Committee, March 2024.
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Appendix 1 50 50 These case studies set out some examples of where integrated joint boards are using or developing different working practice to improve performance and outcomes. Preventing Frailty by Improving Nutrition (Shetland) People providing care and support have an important role in recognising risk and preventing malnutrition. A project in the summer of 2022 led by the dietetics department in collaboration with Shetland residential teams including social care workers, seniors, care home cooks and care at home staff in the community. The project included reviewing dietetic patients care, menu and mealtime observations and advice, training needs analysis and delivery of MUST (Malnutrition Universal Screening Tool) training. The IJB reported that confidence in ability to screen for malnutrition, provide nutrition advice and care, and actioning nutritional care plans was considerably increased following training, which was provided to more than 100 staff across Shetland. Whole Family Wellbeing Funding programme (national scheme) The Whole Family Wellbeing Funding (WFWF) is a £500 million Scottish Government investment in preventative whole family support measures. Appendix 1 Case studies Case study 2. Early intervention and prevention services
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Appendix 1 51 51 The aims of the fund are to support the change that is necessary for reducing the need for crisis interventions in families, and to move investment towards early intervention and prevention. The scheme is funded nationally from 2022 to 2026 with any new systems or services funded locally after that period.
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Appendix 1 52 52 The programme is split into three parts: • to provide direct support to Children’s Services Planning Partnerships (CSPPs) to help expand and deliver whole family support services as well as support transformational change • to support local transformation through National Support for Local Delivery • support projects that take a cross Scottish Government approach to system change which progress the aims of WFWF. An evaluation report of year one funding of the first two parts reports that substantial progress has been made so far across most CSPPs. However, they have found it difficult to achieve the pace of progress envisaged by the Scottish Government in year one of the funding. In South Lanarkshire, the funding has enabled the recruitment of peer support workers with lived experience who are able to reduce the stigma of needing support. The funding also enabled the creation of a team of early years staff, based in NHS Lanarkshire, that will give support to families that have children under the age of five. In addition, the funding enabled the expansion of Pathfinders, a school-based family project that aims to reduce the need for later intervention. The funding has supported North Ayrshire to add two further locations to their Family Centred Wellbeing Service. The fund has also seen the expansion of North Ayrshire’s Health Visiting Team, which aims to support early intervention and prevention for children by working with the whole family. Source: Scottish Government and Shetland Health and Social Care Partnership
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Appendix 1 53 53 Home First Response Service (Glasgow) Glasgow’s Home First Response Service has the aim of ensuring frail people spend less time in hospital. The service is community led and made of multi-disciplinary frailty teams. Each team is led by advanced frailty practitioners based in hospitals with 26 now in post following a successful pilot of the service. One in three people identified during the pilot were discharged the same day with a care plan having been put in place. To enable fast access to the community services needed to move frail people out of hospitals and back home, the service uses a hub and spoke service model with each of the six Health Partnerships in Glasgow having their own frailty teams. The teams liaise with other healthcare colleagues in the community including advanced nurse practitioners, pharmacists and allied health practitioners. This ensures that people receive the same level of care that they would in a hospital setting. The Home First Response Service has been achieving, on average, a 50 per cent early turnaround rate per month. Integrated Discharge Hub (West Lothian) The West Lothian Integrated Discharge Hub (IDH) was set up in 2018 at St John’s Hospital to improve delayed discharges and reduce the time it was taking make arrangements for people requiring care and support in the community following discharge from hospital. To plan the safe and timely discharge of patients, an inter-agency team consisting of discharge coordinators, hospital social workers, Carers of West Lothian as well as inhouse care team staff work with patients and their families to plan their discharge and how their ongoing requirements will be met in the community. Since the implementation of the discharge hub the IJB reports that improvements have been seen, with reduced lengths of stay, reduced occupied acute bed days, improved performance for days lost to delays in discharge and improved processes for interim placements when a patient is waiting for care home placement. Between December 2022 and April 2023, the average number of days between a person being admitted to St John’s Hospital and being identified as needing the support of the discharge hub has been reduced by 52 per cent. The length of stay for patients getting help from the Case study 3. IJBs shifting the balance of care
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Appendix 1 54 54 discharge hub has also been reduced by 28 per cent during the same period. The success of the discharge hub has drawn interest from other IJBs across Scotland.
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Appendix 1 55 55 The Joint Dementia Initiative (Falkirk) The Joint Dementia Initiative (JDI) is a registered service in the Falkirk Health and Social Care Partnership. It has two main services: a one-to- one support service, which provides care and support at the user’s own home, and a Home from Home service, which provides support to users in a group setting. The JDI service aims to help people with dementia to continue to live the life they want to live by continuing to live at home in their own communities for as long as possible. This is delivered through meaningful engagement with service users, families, and key stakeholders from across Falkirk HSCP following a person-centred approach to the care provided. A review of the JDI was carried out in April 2021 that included arranging engagement events with service users, their families, carers, staff, and stakeholders. The aim was to improve outcomes for families and carers and identify specific areas of concern and gaps in service delivery. Identified as an important issue at the engagement events, the partnership looked at the flexibility of the service and dementia being a 24/7 illness. The partnership is working to provide evening and weekend support for families and carers, due to start in August 2024. These improvements would allow the partnership to achieve outcomes from their strategic plan. A current project is being carried out to change Adult Placement Carers in the Home from Home service from self-employed to employees of the partnership. This change aims to improve recruitment and retention rates for the service. The JDI has been successful in achieving funding from multiple funds including the Dementia Innovation Fund and the Carers Challenge Fund. This has allowed the Initiative to renovate their community space as well as create two part time support worker posts to help provide evening and weekend support to service users Source: NHS Greater Glasgow and Clyde, West Lothian Health and Social Care Partnership, and Falkirk Health and Social Care Partnership
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Appendix 1 56 56 Community Brokerage Network (North and South Ayrshire) The Community Brokerage Network is well established in the Ayrshires and provide brokers, who offer free independent information about self-directed support to people and their carers at any stage in their social care journey, whether they are entitled to a formal social care assessment or not. They have successfully connected people with services that have helped them achieve their personal outcomes in a way that works for them. A Brokerage Framework for Scotland has recently been produced by Self-directed Support Scotland and its partners to help encourage the use of this model further across Scotland. Care Opinion (Falkirk) Care Opinion is an online integrated platform where people can safely share their experience of any health service or Care Inspectorate- registered providers of adult social care services. Care Opinion has national scale and visibility and has worked with all Scottish health boards as well as ten HSCPs. Over 29,000 stories have been shared about health and social care services in Scotland on the Care Opinion platform. Care Opinion enables Falkirk HSCP and the commissioned providers to use online feedback as one method of learning from lived experience. The aim is to drive forward quality service improvements, build a reputation for openness, to potentially avoid formal complaints, and develop a culture of transparency across the Partnership. Source: Self Directed Support Scotland, Falkirk Health and Social Care Partnership Case study 4. Choice and control
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Appendix 1 55 Case study 5. Work to reduce inequalities 55 Welfare Advice & Health Partnerships (WAHPs) programme (Glasgow) Scottish Government funding is enabling 84 GP Practices across the most deprived parts of Glasgow to host a dedicated welfare and health adviser one day per week. According to the Partnership this has had a positive impact on patient health, poverty and health inequalities, while also freeing up staff time for clinical care. In the last year, there have been 3,997 referrals made by WAHP practice staff across Glasgow, achieving a reported £3.3 million in financial gains and £1.1 million in debt managed for people. eFRAILTY Power BI dashboard (West Lothian) The eFRAILTY Power BI Dashboard was created with the aim to provide a snapshot of the make-up of frailty within the West Lothian population with the goal of identifying people who could benefit from help, improving the health inequality gap. The dashboard also has the aim of mapping frailty data by GP postcode to enable the targeting of resources. The data in the dashboard uses the Rockwood clinical frailty score from patient and carer self-assessment forms. These forms are collected at vaccination centres each year during the patient’s annual flu jab. The frailty data is collected by the vaccination nurses and then entered into GP systems before being extracted and used to populate the eFRAILTY dashboard. The dashboard is still in the scoping and data-gathering phase, however the Partnership is looking at options for how to put the data to use. An example given by the Partnership for the use of the data was to refer patients graded as having mild frailty to their Xcite Exercise referral scheme. Source: Glasgow City Health and Social Care Partnership, Scottish Government, and West Lothian Health and Social Care Partnership
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Appendix 1 56 56 Established in October 2020, Granite Care Consortium (GCC) is composed of a mix of ten independent and third sector care providers delivering over 12,000 hours of care a week to more than 1,200 people. GCC was set up with the aim of creating market stability, improving outcomes for service users and building a consistent trained and skilled workforce. Competitive methods of commissioning and procurement were identified as presenting a risk of providers reducing their services or exiting the market completely. Providers also often work in silos with little input or communication from other services. Aberdeen City Health and Social Care Partnership (ACHSCP), commissioned GCC to take a collaborative approach, with a focus on the outcomes for the individual. This saw GCC move away from a ’time and task’ model towards one built around the service user. The collaboration between providers allows different types of support to be added to a care plan without the need for time consuming reassessments. For example, someone receiving mental health support who then required personal care could have this added to their care plan in a matter of hours. Collaboration has also enabled greater data sharing and visibility. GCC use data at a local level as well as city wide to inform decision-making. A recent test of change has seen the introducing of hotspots allowing GCC to focus on where demand for care is greatest. Funding is provided in monthly blocks by ACHSCP which allows GCC to flex individual care and support packages without the need for social worker authorisation. This speeds up the process, improving outcomes for individuals. The number of days those aged 75+ in Aberdeen City are waiting to be discharged from hospital (per 1,000 population) stands at 112 as of November 2023. This is down from 579 in 2019/20. GCC faces the same workforce challenges as the wider sector but is using its outcomes focussed model as a positive tool to aid recruitment and retention. Learning and development is also a large part of the workforce strategy with GCC working in partnership with Robert Gordon University to develop new ways of delivering training. I have felt partnership working between ACHSCP and GCC has been stronger than my previous experience before GCC – Social Worker Building trust, both from ACHSCP and the ten partnering service providers, was crucial in delivering this model. Challenging traditional ways of working and thinking was acknowledged by GCC as difficult Case study 6. Granite Care Consortium
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Appendix 1 57 57 but it reports that there is now genuine trust between all parties and the culture of collaboration is now embedded within the consortium.
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Appendix 1 58 58 The Scottish Parliament Health, Social Care and Sport Committee have identified this work as a good model to provide the basis to develop best practice in ethical commissioning. Source: LGBF Indicators, GCC Annual Report 2020-21 Established in 2021 the Care at Home Collaborative was a Collaborative of 16 Independent Care at Home Providers who delivered over 90 per cent of externally commissioned care at home services in the Fife IJB area. The Collaborative in June 2024 are now made up of 41 care at home Providers including Fife Council. The split between service delivery is approximately 30 per cent Council and 70 per cent Collaborative. The aim of the collaborative is to involve all member organisations in active engagement and participation as well as to share best practice and lessons learned. The collaborative also aims to benefit from the economy of scale of working together, for example securing funding to maintain a higher weekend pay rate has helped the retention of staff. One of the members of the collaborative, Cera Care, commented: ‘Since joining the Collaborative we have seen a dramatic improvement in the services we deliver as a whole in Fife. It has given us the opportunity to communicate with Scottish Care, Fife Council and External Providers together to input ideas and suggestions across to help each other and the people we care for.’ The collaborative makes use of a GPS tool called ‘Pin-Point’ which is a live dashboard of services used to manage commissioning. The IJB is able to manage capacity across the whole system by using monitoring and escalation systems that are connected to the collaborative. A recent self-evaluation saw that previous recruitment and retention issues encountered by providers have been continuously improving and attributable to the success of the Collaborative. Case study 7. Fife Care Collaborative
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Appendix 1 59 59 Source: Fife Health and Social Care Partnership
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Appendix 2 58 58 Previous work In 2022 and in 2023, the Accounts Commission published bulletins setting out the financial performance of IJBs. Together with the Auditor General for Scotland and Audit Scotland, we have reported more widely on the progress of health and social care integration and social care in Scotland. This includes reports in 2015 and 2018 setting out improvements needed by integration authorities. Our work in 2014 and 2017 set out the progress of the self-directed support legislation implementation and found while implementation was happening successfully in some areas, not everyone was getting the choice and control in their social care support envisaged in the legislation. In January 2022, a joint Social Care briefing set out the significant ongoing challenges impacting the delivery of social care services. We aim to answer the following audit questions in this report: • How well are IJBs responding to contextual challenges and improving their performance and the outcomes for people? • How financially sustainable are IJBs and how are they responding to the financial challenges they face? • How are IJBs using commissioning and procurement to improve performance and deliver improved outcomes in the lives of people who use social care services? Our findings are based upon: • the 2022/23 audited accounts and annual audit reports of IJBs and supplementary returns provided by appointed auditors • the 2022/23 annual performance reports and Chief Social Work Officer reports of IJBs • national data sets including core integration indicators and the Local Government Benchmarking Framework (LGBF) Appendix 2 Methodology
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Appendix 2 59 59 • a review national reports and guidance • a review of relevant published research • interviews with key stakeholders including IJB chief officers and chief finance officers. In February 2024, we hosted a roundtable discussion bringing together key stakeholders to consider the critical issues for IJBs and in particular
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Appendix 2 60 60 the provision of social care. The discussion covered immediate challenges as upcoming issues in the medium and long term. The discussion helped to inform this report and also identify future work for the Accounts Commission. The additional output sets out a summary of discussion. Advisory Group To support our work, an Advisory Panel was established to provide challenge and insight at key stages of the audit process. Members sat in an advisory capacity only and the content and conclusions of this report are the sole responsibility of Audit Scotland. Members of the group included representatives from Health and Social Care Scotland, COSLA, Care Inspectorate, The ALLIANCE, Coalition of Care and Support Providers Scotland, Scottish Care and SPICe. We would like to thank them for their support.
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61 Integration Joint Boards Finance and performance 2024
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62 Audit Scotland, 4th Floor, 102 West Port, Edinburgh EH3 9DN Phone: 0131 625 1500 Email: info@audit.scot www.audit.scot ISBN 978 1 915839 44 2
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63 1. The Public Bodies (Joint Working) (Scotland) Act 2014 created a legislative requirement for IJBs to report on their performance against a suite of care integration indicators. 2. Around half of the indicators are based on information coming out of the biennial Health and Care Experience Survey and the remaining indicators are largely based on health, community and death information and are available on an annual basis. 3. Public Health Scotland collect and report on this information annually. Background Information on the core integration indicators, including caveats and detailed source information, can be found here. 4. Below, we set out the trend in the available data and an indication of the movement since the indicator was last reported on. Note: Where there is an asterix * the data for 2023/24 is not comparable to previous years due to changes in survey question wording. Where the data is not directly comparable in the trend data a dotted line depicts the change. Supplement 1. Prepared by Audit Scotland | July 2024 Core suite of integration indicators IJB Finance and performance 2024 National trend information
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64 National Indicator 1. Percentage of adults able to look after their health very well or quite well Yearly trend data for all IJBs across Scotland Latest year change (percentage points) 94.5 92.9 92.9 90.9 90.7 -0.2 2015/16 2023/24 2. Percentage of adults supported at home who agree that they are supported to live as independently as possible 80.8 78.8 72.4 *Data not comparable 2019/20 2023/24 Cont.
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Supplement 1. Core suite of integration indicators 2 2 National Indicator 3. Percentage of adults supported at home who agree that they had a say in how their help, care or support was provided 4. Percentage of adults supported at home who agree that their health and social care services seemed to be well coordinated 5. Percentage of adults receiving any care or support who rate it as excellent or good 6. Percentage of people with positive experience of Yearly trend data for all IJBs across Scotland 75.4 70.6 2019/20 73.5 66.4 2019/20 80.2 75.3 2019/20 85.3 82.7 78.7 Latest year change (percentage points) 59.6 *Data not comparable 2023/24 61.4 *Data not comparable 2023/24 70.0 *Data not comparable 2023/24 care at their GP practice 7. Percentage of adults supported at home who 2015/16 80.0 78.1 66.5 68.5 2023/24 2.0 agree that their services and support had an impact in improving or maintaining their quality of life 8. Percentage of carers who 2019/20 69.8 *Data not comparable 2023/24 feel supported to continue in their caring role 40.0 36.6 34.3 29.7 31.2 1.5 9. Percentage of adults supported at home who agree they felt safe 11. Premature mortality rate
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Supplement 1. Core suite of integration indicators 3 3 2015/16 82.8 79.7 2019/20 2023/24 72.7 *Da t a n o t c o m p a r a b l e 2023/24 457 466 per 100,000 persons 440 2016 42 5 432 426 442 2022 -5.1 Cont.
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Supplement 1. Core suite of integration indicators 4 4 National Indicator 12. Emergency admission rate (per 100,000 population) Yearly trend data for all IJBs across Scotland 12,229 11,942 12,284 12,529 10,964 11,643 11,276 Latest year change (percentage points) -3.2 13. Emergency bed day rate (per 100,000 population) 2016/17 2016/17 125,979 121,174 2022/23 2022/23 119,806 14. Emergency readmissions to hospital 124,118 20210166/1/717 119,75 3 102,875 120 115,308 20220222/2/323 3.9 within 28 days of discharge (rate per 1,000 discharges) 101 20210166/1/717 103 103 105 107 102 20220222/2/323 -4.3 15. Proportion of last 6 months of life spent at home or in a community setting 87.4 20210166/1/717 88.0 88.0 88.2 90.2 89.7 88.9 20220222/2/323 -0.8 16. Falls rate per 1,000 population aged 65+ 21. 4 20210166/1/717 22.2 22. 5 22.8
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Supplement 1. Core suite of integration indicators 5 5 21.7 22.6 2 2 . 6 0 2 0 2 2 0 2 2 2 / 2 / 3 2 3 17. Proportion of care services graded ‘good’ (4) or better in Care Inspectorate inspections 82.5 2020/21 75.8 75.2 77.0 2023/24 1.8 18. Percentage of adults with intensive care needs receiving care at home 61.6 2016 19. Number of days 61.1 62.1 63.0 63.0 64.5 64.6 919 64.8 2023 0.2 people aged 75+ spend in hospital when they are ready to be discharged 84 1 762 79 3 77 4 484 748 90 2 -1.9 (per 1,000 population) 20201166/17/17 20220323//224 4
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Supplement 1. Core suite of integration indicators 6 6 1. Percentage of adults able to look after their health very well or quite well IJB 2023/24 Scotland average 90.7 Trend from previous year Compared to Scottish average Aberdeen City 90.4 Down Below Aberdeenshire 93.4 Down Above Angus 91.1 Down Above Argyll and Bute 92.4 Up Above Clackmannanshire and Stirling 90.8 Down Above Dumfries and Galloway 91.2 Down Above Dundee City 88.3 Down Below East Ayrshire 89.1 Down Below East Dunbartonshire 93.8 Up Above East Lothian 92.0 Down Above East Renfrewshire 92.7 Up Above Edinburgh 91.9 Up Above Falkirk 91.0 Up Above Fife 91.4 Up Above Glasgow City 87.6 Down Below Inverclyde 88.9 Down Below Midlothian 92.5 Up Above Moray 92.2 Down Above North Ayrshire 89.1 Up Below North Lanarkshire 87.4 Down Below Orkney Islands 93.7 Up Above Perth and Kinross 93.9 Up Above Renfrewshire 88.7 Down Below Scottish Borders 93.5 Up Above Shetland Islands 94.6 Up Above South Ayrshire 91.9 Up Above Individual current IJB performance, change since previous year reported and comparison to Scottish average in current year
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Supplement 1. Core suite of integration indicators 7 7 South Lanarkshire 89.4 Down Below West Dunbartonshire 88.4 Down Below West Lothian 89.5 Down Below Western Isles 91.7 Down Above
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Supplement 1. Core suite of integration indicators 8 8 2. Percentage of adults supported at home who agree that they are supported to live as independently as possible IJB 2023/24 Scotland average 72.4 Compared to Scottish average Aberdeen City 76.8 Above Aberdeenshire 78.4 Above Angus 74.1 Above Argyll and Bute 79.4 Above Clackmannanshire and Stirling 67.2 Below Dumfries and Galloway 73.0 Above Dundee City 77.1 Above East Ayrshire 81.2 Above East Dunbartonshire 79.8 Above East Lothian 74.7 Above East Renfrewshire 80.4 Above Edinburgh 75.2 Above Falkirk 67.6 Below Fife 70.0 Below Glasgow City 72.3 Below Inverclyde 75.9 Above Midlothian 76.5 Above Moray 71.9 Below North Ayrshire 67.5 Below North Lanarkshire 67.7 Below Orkney Islands 77.7 Above Perth and Kinross 73.9 Above Renfrewshire 65.5 Below Scottish Borders 77.4 Above Shetland Islands 95.4 Above South Ayrshire 70.5 Below South Lanarkshire 67.2 Below West Dunbartonshire 62.7 Below West Lothian 69.7 Below Western Isles 78.9 Above Note: results for indicators 2, 3, 4, 5, 7 and 9 for 2023/24 are not comparable to previous years
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Supplement 1. Core suite of integration indicators 9 9 due to changes in survey wording.
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Supplement 1. Core suite of integration indicators 10 10 3. Percentage of adults supported at home who agree that they had a say in how their help, care or support was provided IJB 2023/24 Scotland average 59.6 Compared to Scottish average Aberdeen City 56.5 Below Aberdeenshire 66.2 Above Angus 62.4 Above Argyll and Bute 56.9 Below Clackmannanshire and Stirling 57.9 Below Dumfries and Galloway 60.3 Above Dundee City 65.1 Above East Ayrshire 69.5 Above East Dunbartonshire 67.7 Above East Lothian 63.9 Above East Renfrewshire 75.0 Above Edinburgh 57.2 Below Falkirk 59.7 Above Fife 51.0 Below Glasgow City 61.5 Above Inverclyde 67.8 Above Midlothian 61.9 Above Moray 59.5 Below North Ayrshire 50.6 Below North Lanarkshire 57.1 Below Orkney Islands 68.1 Above Perth and Kinross 67.9 Above Renfrewshire 54.3 Below Scottish Borders 63.4 Above Shetland Islands 66.5 Above South Ayrshire 59.5 Below South Lanarkshire 55.4 Below West Dunbartonshire 59.1 Below West Lothian 53.5 Below Western Isles 69.0 Above Note: results for indicators 2, 3, 4, 5, 7 and 9 for 2023/24 are not comparable to previous years
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Supplement 1. Core suite of integration indicators 11 11 due to changes in survey wording.
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Supplement 1. Core suite of integration indicators 12 12 4. Percentage of adults supported at home who agree that their health and social care services seemed to be well coordinated IJB 2023/24 Scotland average 61.4 Compared to Scottish average Aberdeen City 63.1 Above Aberdeenshire 69.8 Above Angus 55.6 Below Argyll and Bute 66.2 Above Clackmannanshire and Stirling 56.0 Below Dumfries and Galloway 61.3 Below Dundee City 63.9 Above East Ayrshire 70.4 Above East Dunbartonshire 66.4 Above East Lothian 67.1 Above East Renfrewshire 63.6 Above Edinburgh 63.1 Above Falkirk 53.9 Below Fife 53.0 Below Glasgow City 65.2 Above Inverclyde 68.7 Above Midlothian 74.4 Above Moray 65.7 Above North Ayrshire 55.5 Below North Lanarkshire 56.0 Below Orkney Islands 68.2 Above Perth and Kinross 57.3 Below Renfrewshire 55.3 Below Scottish Borders 62.1 Above Shetland Islands 72.8 Above South Ayrshire 62.8 Above South Lanarkshire 58.2 Below West Dunbartonshire 54.3 Below West Lothian 58.2 Below Western Isles 63.2 Above Note: results for indicators 2, 3, 4, 5, 7 and 9 for 2023/24 are not comparable to previous years
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Supplement 1. Core suite of integration indicators 13 13 due to changes in survey wording.
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Supplement 1. Core suite of integration indicators 14 14 5. Percentage of adults receiving any care or support who rate it as excellent or good IJB 2023/24 Scotland average 70.0 Compared to Scottish average Aberdeen City 74.9 Above Aberdeenshire 70.0 Equal Angus 65.2 Below Argyll and Bute 76.8 Above Clackmannanshire and Stirling 64.8 Below Dumfries and Galloway 68.8 Below Dundee City 68.0 Below East Ayrshire 78.6 Above East Dunbartonshire 77.7 Above East Lothian 76.3 Above East Renfrewshire 74.0 Above Edinburgh 74.1 Above Falkirk 73.1 Above Fife 63.0 Below Glasgow City 71.2 Above Inverclyde 70.7 Above Midlothian 65.6 Below Moray 68.7 Below North Ayrshire 68.4 Below North Lanarkshire 65.8 Below Orkney Islands 82.5 Above Perth and Kinross 70.1 Above Renfrewshire 66.1 Below Scottish Borders 72.6 Above Shetland Islands 88.2 Above South Ayrshire 75.4 Above South Lanarkshire 66.7 Below West Dunbartonshire 66.9 Below West Lothian 62.1 Below Western Isles 76.1 Above Note: results for indicators 2, 3, 4, 5, 7 and 9 for 2023/24 are not comparable to previous years
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Supplement 1. Core suite of integration indicators 15 15 due to changes in survey wording.
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Supplement 1. Core suite of integration indicators 16 16 6. Percentage of people with positive experience of care at their GP practice IJB 2023/24 Scotland average 68.5 Trend from previous year Compared to Scottish average Aberdeen City 60.2 Down Below Aberdeenshire 62.3 Up Below Angus 62.1 Down Below Argyll and Bute 83.9 Up Above Clackmannanshire and Stirling 72.3 Up Above Dumfries and Galloway 77.0 Up Above Dundee City 71.2 Up Above East Ayrshire 55.7 Down Below East Dunbartonshire 69.4 Up Above East Lothian 71.1 Up Above East Renfrewshire 74.9 Up Above Edinburgh 75.1 Up Above Falkirk 69.4 Up Above Fife 65.1 Up Below Glasgow City 73.7 Up Above Inverclyde 65.0 Up Below Midlothian 67.9 Up Below Moray 68.6 Up Above North Ayrshire 60.0 Down Below North Lanarkshire 52.8 Up Below Orkney Islands 90.1 Up Above Perth and Kinross 75.7 Up Above Renfrewshire 63.3 Down Below Scottish Borders 73.7 Up Above Shetland Islands 87.4 Up Above South Ayrshire 78.0 Up Above South Lanarkshire 56.5 Up Below West Dunbartonshire 63.8 Down Below West Lothian 65.7 Up Below Western Isles 85.5 Up Above
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Supplement 1. Core suite of integration indicators 17 17 7. Percentage of adults supported at home who agree that their services and support had an impact in improving or maintaining their quality of life Compared to IJB 2023/24 Scotland average 69.8 Scottish average Aberdeen City 74.4 Above Aberdeenshire 73.6 Above Angus 70.1 Above Argyll and Bute 75.0 Above Clackmannanshire and Stirling 66.1 Below Dumfries and Galloway 69.1 Below Dundee City 71.3 Above East Ayrshire 74.0 Above East Dunbartonshire 69.8 Equal East Lothian 76.1 Above East Renfrewshire 89.6 Above Edinburgh 72.0 Above Falkirk 61.4 Below Fife 67.0 Below Glasgow City 69.7 Below Inverclyde 73.6 Above Midlothian 76.0 Above Moray 69.3 Below North Ayrshire 67.6 Below North Lanarkshire 67.7 Below Orkney Islands 79.6 Above Perth and Kinross 75.8 Above Renfrewshire 64.2 Below Scottish Borders 76.2 Above Shetland Islands 70.7 Above South Ayrshire 67.4 Below South Lanarkshire 63.3 Below West Dunbartonshire 64.0 Below West Lothian 64.9 Below Western Isles 67.0 Below Note: results for indicators 2, 3, 4, 5, 7 and 9 for 2023/24 are not comparable to previous years
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Supplement 1. Core suite of integration indicators 18 18 due to changes in survey wording.
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Supplement 1. Core suite of integration indicators 19 19 8. Percentage of carers who feel supported to continue in their caring role IJB 2023/24 Scotland average 31.2 Trend from previous year Compared to Scottish average Aberdeen City 37.1 Up Above Aberdeenshire 29.7 Down Below Angus 33.7 Up Above Argyll and Bute 37.6 Down Above Clackmannanshire and Stirling 32.8 Up Above Dumfries and Galloway 28.8 Down Below Dundee City 34.3 Up Above East Ayrshire 36.0 Up Above East Dunbartonshire 25.8 Down Below East Lothian 35.8 Up Above East Renfrewshire 28.4 Up Below Edinburgh 31.3 Up Above Falkirk 30.7 Up Below Fife 30.3 Up Below Glasgow City 34.5 Up Above Inverclyde 31.9 Up Above Midlothian 34.6 Up Above Moray 28.2 Down Below North Ayrshire 31.6 Up Above North Lanarkshire 28.5 Up Below Orkney Islands 34.0 Down Above Perth and Kinross 31.9 Down Above Renfrewshire 28.5 Up Below Scottish Borders 28.0 Down Below Shetland Islands 46.3 Up Above South Ayrshire 30.0 Down Below South Lanarkshire 28.1 Down Below West Dunbartonshire 26.7 Down Below West Lothian 25.8 Up Below Western Isles 32.6 Down Above
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Supplement 1. Core suite of integration indicators 20 20 9. Percentage of adults supported at home who agree they felt safe IJB 2023/24 Scotland average 72.7 Compared to Scottish average Aberdeen City 72.4 Below Aberdeenshire 79.3 Above Angus 63.7 Below Argyll and Bute 72.6 Below Clackmannanshire and Stirling 66.8 Below Dumfries and Galloway 76.3 Above Dundee City 76.5 Above East Ayrshire 75.8 Above East Dunbartonshire 84.6 Above East Lothian 79.6 Above East Renfrewshire 79.5 Above Edinburgh 78.6 Above Falkirk 69.5 Below Fife 69.1 Below Glasgow City 72.6 Below Inverclyde 72.7 Equal Midlothian 79.9 Above Moray 70.0 Below North Ayrshire 67.5 Below North Lanarkshire 68.4 Below Orkney Islands 84.1 Above Perth and Kinross 76.8 Above Renfrewshire 66.9 Below Scottish Borders 71.9 Below Shetland Islands 87.5 Above South Ayrshire 73.6 Above South Lanarkshire 66.2 Below West Dunbartonshire 66.7 Below West Lothian 67.6 Below Western Isles 75.8 Above Note: results for indicators 2, 3, 4, 5, 7 and 9 for 2023/24 are not comparable to previous years
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Supplement 1. Core suite of integration indicators 21 21 due to changes in survey wording.
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Supplement 1. Core suite of integration indicators 22 22 11. Premature mortality rate per 100,000 persons, by calendar year Trend from Compared to IJB 2022 Scotland average 442 previous year Scottish average Aberdeen City 441 Down Below Aberdeenshire 338 Down Below Angus 390 Down Below Argyll and Bute 398 Up Below Clackmannanshire and Stirling 407 Down Below Dumfries and Galloway 428 Down Below Dundee City 546 Down Above East Ayrshire 515 Down Above East Dunbartonshire 302 Up Below East Lothian 357 Down Below East Renfrewshire 264 Down Below Edinburgh 411 Up Below Falkirk 473 Down Above Fife 431 Down Below Glasgow City 615 Down Above Inverclyde 542 Up Above Midlothian 428 Up Below Moray 330 Down Below North Ayrshire 527 Down Above North Lanarkshire 510 Down Above Orkney Islands 393 Up Below Perth and Kinross 380 Up Below Renfrewshire 463 Down Above Scottish Borders 358 Up Below Shetland Islands 282 Down Below South Ayrshire 422 Down Below South Lanarkshire 459 Down Above West Dunbartonshire 551 Down Above West Lothian 439 Down Below Western Isles 473 Up Above
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Supplement 1. Core suite of integration indicators 23 23 12. Emergency admission rate (per 100,000 population) Trend from Compared to IJB 2022/23 Scotland average 11,276 previous year Scottish average Aberdeen City 9,360 Down Below Aberdeenshire 8,572 Up Below Angus 11,525 Up Above Argyll and Bute 11,968 Down Above Clackmannanshire and Stirling 13,037 Up Above Dumfries and Galloway 12,102 Down Above Dundee City 13,097 Up Above East Ayrshire 13,582 Down Above East Dunbartonshire 11,098 Up Below East Lothian 9,173 Down Below East Renfrewshire 9,216 Down Below Edinburgh 7,340 Down Below Falkirk 14,679 Up Above Fife 12,872 Up Above Glasgow City 11,163 Down Below Inverclyde 12,444 Down Above Midlothian 9,517 Down Below Moray 8,273 Down Below North Ayrshire 13,449 Down Above North Lanarkshire 15,111 Down Above Orkney Islands 9,538 Down Below Perth and Kinross 12,526 Up Above Renfrewshire 10,778 Down Below Scottish Borders 9,840 Down Below Shetland Islands 9,746 Up Below South Ayrshire 14,303 Down Above South Lanarkshire 12,530 Down Above West Dunbartonshire 13,015 Down Above West Lothian 11,153 Down Below Western Isles 14,277 Up Above
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Supplement 1. Core suite of integration indicators 24 24 13. Emergency bed day rate (per 100,000 population) Trend from Compared to IJB 2022/23 Scotland average 119,806 previous year Scottish average Aberdeen City 99,923 Up Below Aberdeenshire 87,853 Up Below Angus 96,778 Up Below Argyll and Bute 118,552 Up Below Clackmannanshire and Stirling 115,181 Up Below Dumfries and Galloway 142,256 Up Above Dundee City 114,287 Up Below East Ayrshire 130,667 Up Above East Dunbartonshire 126,381 Up Above East Lothian 115,986 Down Below East Renfrewshire 108,721 Up Below Edinburgh 98,783 Down Below Falkirk 135,305 Up Above Fife 118,148 Up Below Glasgow City 133,843 Up Above Inverclyde 154,188 Up Above Midlothian 118,079 Up Below Moray 98,741 Up Below North Ayrshire 151,553 Down Above North Lanarkshire 126,261 Up Above Orkney Islands 86,572 Down Below Perth and Kinross 121,394 Up Above Renfrewshire 130,472 Down Above Scottish Borders 131,395 Up Above Shetland Islands 72,909 Up Below South Ayrshire 172,992 Up Above South Lanarkshire 122,237 Up Above West Dunbartonshire 152,062 Up Above West Lothian 95,797 Up Below Western Isles 133,554 Up Above
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Supplement 1. Core suite of integration indicators 25 25 14. Emergency readmissions to hospital within 28 days of discharge (rate per 1,000 discharges) IJB 2022/23 Scotland average 102 Trend from previous year Compared to Scottish average Aberdeen City 119 Down Above Aberdeenshire 92 Down Below Angus 115 Up Above Argyll and Bute 84 Down Below Clackmannanshire and Stirling 126 Down Above Dumfries and Galloway 95 Up Below Dundee City 139 Down Above East Ayrshire 104 Down Above East Dunbartonshire 79 Down Below East Lothian 88 Down Below East Renfrewshire 69 Down Below Edinburgh 92 Down Below Falkirk 141 Down Above Fife 117 Up Above Glasgow City 96 Down Below Inverclyde 76 Down Below Midlothian 96 Down Below Moray 80 Down Below North Ayrshire 100 Down Below North Lanarkshire 117 Up Above Orkney Islands 69 Down Below Perth and Kinross 137 Up Above Renfrewshire 80 Down Below Scottish Borders 121 Up Above Shetland Islands 68 Down Below South Ayrshire 100 Down Below South Lanarkshire 100 Down Below West Dunbartonshire 82 Down Below West Lothian 95 Down Below Western Isles 108 Down Above
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Supplement 1. Core suite of integration indicators 26 26 15. Proportion of last 6 months of life spent at home or in a community setting IJB 2022/23 Scotland average 88.9 Trend from previous year Compared to Scottish average Aberdeen City 90.3 Down Above Aberdeenshire 90.7 Down Above Angus 92.2 Down Above Argyll and Bute 89.6 Down Above Clackmannanshire and Stirling 89.3 Down Above Dumfries and Galloway 88.5 Down Below Dundee City 90.0 Down Above East Ayrshire 88.9 Down Equal East Dunbartonshire 88.1 Down Below East Lothian 88.0 Up Below East Renfrewshire 87.7 Down Below Edinburgh 88.0 Down Below Falkirk 88.1 Down Below Fife 89.8 Down Above Glasgow City 88.0 Down Below Inverclyde 87.8 Down Below Midlothian 87.1 Down Below Moray 90.5 Down Above North Ayrshire 87.9 Down Below North Lanarkshire 89.0 Down Above Orkney Islands 90.9 Down Above Perth and Kinross 88.7 Down Below Renfrewshire 88.8 Up Below Scottish Borders 87.7 Down Below Shetland Islands 93.4 Down Above South Ayrshire 87.6 Down Below South Lanarkshire 88.8 Down Below West Dunbartonshire 87.7 Down Below West Lothian 89.8 Down Above Western Isles 90.1 Down Above
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Supplement 1. Core suite of integration indicators 27 27 16. Falls rate per 1,000 population aged 65+ IJB 2022/23 Scotland average 22.6 Trend from previous year Compared to Scottish average Aberdeen City 20.8 Down Below Aberdeenshire 17.2 Down Below Angus 26.5 Up Above Argyll and Bute 27.6 Down Above Clackmannanshire and Stirling 23.8 Up Above Dumfries and Galloway 20.2 Up Below Dundee City 33.5 Up Above East Ayrshire 18.4 Down Below East Dunbartonshire 22.6 Up Equal East Lothian 21.3 Down Below East Renfrewshire 23.7 Down Above Edinburgh 23.1 Down Above Falkirk 25.3 Up Above Fife 26.8 Down Above Glasgow City 27.3 Down Above Inverclyde 23.7 Up Above Midlothian 20.0 Down Below Moray 17.7 Down Below North Ayrshire 20.4 Up Below North Lanarkshire 20.0 Down Below Orkney Islands 19.9 Up Below Perth and Kinross 27.8 Up Above Renfrewshire 25.1 Up Above Scottish Borders 15.8 Down Below Shetland Islands 24.4 Up Above South Ayrshire 19.4 Down Below South Lanarkshire 22.7 Up Above West Dunbartonshire 23.7 Up Above West Lothian 19.8 Down Below Western Isles 22.8 Down Above
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Supplement 1. Core suite of integration indicators 28 28 17. Proportion of care services graded ‘good’ (4) or better in Care Inspectorate inspections IJB 2023/24 Scotland average 77.0 Trend from previous year Compared to Scottish average Aberdeen City 70.7 Up Below Aberdeenshire 78.5 Up Above Angus 71.3 Up Below Argyll and Bute 77.3 Down Above Clackmannanshire and Stirling 84.6 Up Above Dumfries and Galloway 74.2 Down Below Dundee City 77.5 Up Above East Ayrshire 78.0 Up Above East Dunbartonshire 85.6 Down Above East Lothian 82.5 Up Above East Renfrewshire 89.3 Up Above Edinburgh 83.5 Up Above Falkirk 86.9 Up Above Fife 68.7 Up Below Glasgow City 82.7 Up Above Inverclyde 80.6 Up Above Midlothian 76.4 Up Below Moray 81.1 Up Above North Ayrshire 82.9 Up Above North Lanarkshire 75.8 Down Below Orkney Islands 70.7 Up Below Perth and Kinross 70.8 Down Below Renfrewshire 75.4 Down Below Scottish Borders 70.6 Down Below Shetland Islands 88.9 Up Above South Ayrshire 73.4 Up Below South Lanarkshire 79.9 Up Above West Dunbartonshire 81.4 Down Above West Lothian 85.1 Up Above Western Isles 89.8 Up Above
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Supplement 1. Core suite of integration indicators 29 29 18. Percentage of adults with intensive care needs receiving care at home IJB 2023 Scotland average 64.8 Trend from previous year Compared to Scottish average Aberdeen City 54.6 Equal Below Aberdeenshire 62.9 Down Below Angus 63.1 Up Below Argyll and Bute 68.3 Down Above Clackmannanshire and Stirling 70.4 Up Above Dumfries and Galloway 77.8 Up Above Dundee City 61.8 Up Below East Ayrshire 71.6 Up Above East Dunbartonshire 65.1 Down Above East Lothian 62.0 Up Below East Renfrewshire 64.4 Down Below Edinburgh 68.8 Up Above Falkirk 67.8 Up Above Fife 59.2 Down Below Glasgow City 59.3 Up Below Inverclyde 67.4 Down Above Midlothian 70.3 Up Above Moray 60.6 Down Below North Ayrshire 77.7 Up Above North Lanarkshire 69.9 Down Above Orkney Islands 69.5 Down Above Perth and Kinross 63.8 Down Below Renfrewshire 63.8 Up Below Scottish Borders 59.5 Down Below Shetland Islands 77.7 Down Above South Ayrshire 63.6 Down Below South Lanarkshire 62.9 Down Below West Dunbartonshire 70.2 Down Above West Lothian 63.7 Up Below Western Isles 60.2 Equal Below
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Supplement 1. Core suite of integration indicators 30 30 19. Number of days people aged 75+ spend in hospital when they are ready to be discharged (per 1,000 population) IJB 2023/24 Scotland average 902 Trend from previous year Compared to Scottish average Aberdeen City 220 Down Below Aberdeenshire 667 Up Below Angus 166 Down Below Argyll and Bute 912 Up Above Clackmannanshire and Stirling 814 Up Below Dumfries and Galloway 1,304 Down Above Dundee City 428 Down Below East Ayrshire 700 Up Below East Dunbartonshire 444 Down Below East Lothian 238 Up Below East Renfrewshire 391 Down Below Edinburgh 1,087 Down Above Falkirk 1,283 Down Above Fife 681 Down Below Glasgow City 962 Down Above Inverclyde 554 Up Below Midlothian 639 Down Below Moray 980 Down Above North Ayrshire 1,087 Up Above North Lanarkshire 973 Up Above Orkney Islands 1,002 Up Above Perth and Kinross 664 Down Below Renfrewshire 150 Down Below Scottish Borders 1,605 Up Above Shetland Islands 452 Down Below South Ayrshire 1,943 Down Above South Lanarkshire 1,008 Down Above West Dunbartonshire 1,327 Down Above West Lothian 871 Up Below Western Isles 1,478 Up Above
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31 Supplement 1. Core suite of integration indicators 22
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32 AUDITSCOTLAND Audit Scotland, 4th Floor, 102 West Port, Edinburgh EH3 9DN T: 0131 625 1500 E: info@ audit.scot www.audit.scot
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33 IJB members questions This tool is designed to provide IJB members with examples of questions they may wish to use to consider the IJB’s financial and performance position. The questions relate to points raised in our report Integration Joint Boards: Finance and performance 2024. Please note, this is not an exhaustive list of questions and considerations should be made of your individual IJB’s particular circumstances and level of applicability in relation to the findings. Findings Questions Notes General Supplement 2. Prepared by Audit Scotland | July 2024 Integration Joint Boards Finance and performance 2024 IJB members questions supplement
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34 • IJBs face a complex landscape of considerable challenges and uncertainties. • IJBs are facing significant financial sustainability challenges and cost pressures are only increasing. • The demand and need for services continue to increase and become more complex. • The workforce is under immense pressure. • The cost-of-living crisis is affecting the demand for services as well as the ability to provide them. • Instability of leadership continues to be a challenge for IJBs. • Plans for a National Care Service have brought uncertainty for IJBs. • Do we, the IJB, have a comprehensive understanding of the present and longer-term needs of the population we serve? • Do we have a clear plan on how to address the significant challenges facing community health and social care? • How are we seeking to address recruitment and retention challenges? • Is there sufficient leadership capacity within the IJB to effectively plan service provision and transformation? • Are you clear about what your roles and responsibilities are as an IJB Board member? Cont.
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Supplement 2. Integration Joint Boards Finance and performance 2024 2 2 Findings Questions Notes Finance • The fi ancial health of IJBs continues to weaken and there are indications of more challenging times ahead. • IJB funding has decreased in real terms compared to 2021/22. • Non-recurring savings, arising from unfilled vacancies, led to the majority of IJBs reporting a surplus on the cost of providing services. • The majority of the total planned savings were achieved, but over a third were only achieved on a one-off basis. • Total reserves held by IJBs have almost halved in 2022/23 largely due to the use or return of Covid-19 related reserves. • The projected fi ancial position is set to worsen. • The increasing reliance on non-recurring sources of income is not sustainable. • Financial sustainability risks have been identified by auditors in the vast majority of IJBs. • Medium-term fi ancial plans need to be updated to reflect all costs pressures currently known. • Has the Medium-term financial plan been updated to reflect all costs pressures currently known? • What proportion of the IJB budget is proposed to be funded from non-recurring sources of income? • Are reserve levels in line with the IJBs reserve policy? How long can current levels of use be maintained? • Are the savings targets achievable on a recurring basis? Cont.
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Supplement 2. Integration Joint Boards Finance and performance 2024 3 3 Findings Questions Notes Data • Data quality is insufficient to fully assess the performance of IJBs but national indicators show a general decline in performance and outcomes. • Data quality is insufficient to fully assess the performance of IJBs and inform improvement of outcomes for service users with a lack of joined-up data across the system. • Work to improve the data sets is at an early stage but is progressing. • Available national indicators show a general decline in performance and outcomes for people using social care and community health services. • Is the current available data suffi ient to assess how well the IJB is performing? • How well does performance data support decision making? • What actions are the IJB undertaking to improve data collection, quality and sharing? Prevention and early intervention • Collaborative, preventative and person-centred working is shrinking at a time when it is most needed. Instead of a focus on care at the right place at the right time, there is a shift to reactive services with little capacity to invest in early intervention and prevention. • How are the IJB prioritising and targeting resources on prevention and early intervention? • How are the IJB working with partner bodies to promote and signpost to preventative services? Cont.
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Supplement 2. Integration Joint Boards Finance and performance 2024 4 4 Findings Questions Notes Shifting the balance of care • The percentage of expenditure on institutional and community-based Adult Social Care services has largely remained static with a small increase in the proportion spent on accommodation-based services. • Increase in the number of individuals receiving care at home or in the community. However, these changes are marginal when viewed over the time since the inception of health and social care integration in 2015. • Lack of social care capacity remains an obstacle to improving patient flow and reducing the number of delayed discharges from hospital. • Are the IJB successfully shifting service provision from an institutional setting to a community setting? • How are the IJB increasing the capacity of services provided in the community? Person centred care – choice and control • The amount of choice and control service users feel they have is variable across the country. • How are the IJB ensuring that the views of service users are considered as part of decision-making? How clearly can you see the impact of this? • What actions are the IJB undertaking to increase the choice and control for service users over their support and care? Cont.
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Supplement 2. Integration Joint Boards Finance and performance 2024 5 5 Findings Questions Notes Reducing inequalities • The Covid-19 pandemic has exacerbated existing inequalities. • The premature mortality rate is increasing with rates higher in more urban and more deprived areas. • Emergency bed day rates are greater in areas with higher levels of deprivation. • What steps are the IJB taking to identify and address inequality? • Is consideration of inequalities embedded in IJB decision-making? Unpaid carers • The reliance on unpaid carers is increasing as the social care workforce is under added pressure. • Does the IJB know the number of unpaid carers in their area? • What proportion of these unpaid carers have carer support plans in place? • How is the IJB improving support for unpaid carers? Cont.
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Supplement 2. Integration Joint Boards Finance and performance 2024 6 6 Findings Questions Notes Commissioning and procurement • Commissioning and procurement practices for social care services continues to be largely driven by budgets, competition, and cost rather than outcomes for people. Improvements to commissioning and procurement arrangements have been slow to progress but are developing. • Improvements to commissioning and procurement arrangements have been slow, with cost rather than outcomes driving decision-making. • Current commissioning and procurement practices are a risk for the sustainability of service providers and the workforce. • Current commissioning and procurement practices are not always delivering improved outcomes for people. • There is an increasing desire to move towards more ethical and collaborative commissioning models but it has not yet been universally adopted. • National approaches to improve commissioning have been slow to progress but are developing. • What steps have the IJB made to move towards commissioning in a more collaborative way? • What steps have the IJB taken to move the focus of commissioning to a basis of quality or outcomes rather than on cost?
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Supplement 2. Integration Joint Boards Finance and performance 2024 7 7 Audit Scotland, 4th Floor, 102 West Port, Edinburgh EH3 9DN T: 0131 625 1500 E: info@audit.scot www.audit.scot