Item 7 - Progress Report
North Lanarkshire Council · 19 April 2023
Back to IJB Performance, Finance and Audit Committee — 19 April 2023 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: 7 1. PURPOSE OF REPORT 1.1 This paper is coming to the Performance, Finance and Audit (PFA) Committee: For approval For endorsement For noting 1.2 This report provides an outline of the actions agreed with the External Auditor, Internal Audit, and the Senior Management Team to further develop the IJB governance framework. 2. ROUTE TO THE PERFORMANCE, FINANCE AND AUDIT COMMITTEE 2.1 This paper has been: Prepared By; Chief Financial Officer Reviewed By; Chief Officer 3. RECOMMENDATIONS 3.1 The PFA Committee is asked to agree the following recommendations: (1) That the content of the report is noted; and (2) That further progress reports will be presented to future meetings of the PFA Committee in respect of any ongoing actions. 4. VARIATIONS TO DIRECTIONS 5. BACKGROUND/SUMMARY OF KEY ISSUES 5.1 Recommendations to further strengthen the IJB governance framework were made by both External and Internal Audit. The Senior Management Team (SMT) have also identified improvement opportunities which will further contribute to the IJB’s annual assessment of their governance arrangements. 5.2 The original reports from External and Internal Audit and the SMT were previously reported in full to the IJB and PFA Committee as appropriate. This report summarises the agreed recommendations and provides an update on the progress made to date against each action. Further details are attached at appendices 1 to 3. 5.3 Any actions which are reported as complete will be removed from the next progress report to the PFA Committee. SUBJECT: Progress Report on Agreed Actions TO: Performance, Finance and Audit Committee Lead Officer for Report: Ross McGuffie, Chief Officer NHSCP Author(s) of Report Amanda Kilburn, Chief Financial Officer DATE: 19th April 2023 Yes No N/A
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2 6. CONCLUSIONS 6.1 An update on the progress made to date was reported to the PFA Committee on 16 November 2022. A summary of the current position statement is shown in the table below: Source Total Actions Completed Actions Ongoing Actions External Audit 5 4 1 Internal Audit 5 4 1 Senior Management 6 5 1 Total 16 13 3 81% 19% 6.1 The ongoing actions are measured against the revised timeline set out at appendices 1 to 3. 7. PROGRESS ON NORTH LANARKSHIRE IJB SELF-EVALUATION 7.1 The results of the self-evaluation exercise were presented to the PFA Committee on 31 August 2022 with the main improvement actions being identified as follows: Evidence how Health and Social Care spending contributes to prevention and early intervention; Embed learning and new ways of working in the IJB from the response to the pandemic to ensure plans and governance are fit for purpose; and Review how performance information is used by the IJB to ensure it is timely, relevant and provides a good measure of progress towards agreed outcomes. 7.2 Continuous self-evaluation and embedded learning will become the essence of ensuring the main improvement actions identified above become part of normal business. To date the progress and work undertaken have included the following: In March 2023 the Medium-Term Financial Plan 2023-2026, the Reserves Strategy 2022-2023 and the Strategic Commissioning Plan 2023-2026 will be presented to the IJB for approval. These three strands of work align to strengthen the IJB’s outcomes against available resources by embedding good practise and lessons learned and by ensuring future funding and reserves link to outcomes around prevention and early intervention. During 2022, discussions at staff roadshows considered and reviewed the areas of work which were effective during the pandemic and those which presented more of a challenge. These discussions were informed by key inputs from members of the Strategic Leadership Team. Lessons learned have been shared with a wider audience as part of engagement events and have been further expanded and built upon during discussions with stakeholders across our communities and localities. These insights are reflected in the new Strategic Commissioning Plan 2023-2026 and its associated Programme of Work.
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3 In August 2022, the PFA Committee endorsed the development of a revised whole system performance framework for the partnership. The Strategic Commissioning Plan 2023-2026 has endorsed this framework by focussing on the participation and engagement of key partners and drawing together and building upon the richness of their contributions. A whole system working group has been established to support the performance framework allowing committee members to exercise effective oversight, scrutiny, and challenge. 7.3 The self-evaluation exercise has recognised the extent to which the assessment team considered the current arrangements for the North Lanarkshire IJB to be effective and has identified how well the Board is meeting its intended outcomes. To ensure continuous improvement will be ongoing, the next steps include: To continue to update and refresh the Medium-Term Financial Plan, the Reserves Strategy, and the Strategic Commissioning Plan to reflect the changing financial environment and outcomes and priorities of the Board; Ongoing monitoring of progress by the IJB in terms of delivery of the actions in the Improvement Plan and realisation of the intended outcomes set out therein; Consideration of the need for a further follow up self-evaluation exercise (where appropriate within the context of developments around the future of the National Care Service for Scotland) to provide ongoing assurance on the extent to which the IJB is meeting its statutory best values duty; and Preparing for future Best Value audits led by Audit Scotland following confirmation that the audits of IJBs will recommence in 2023/24. 8. IMPLICATIONS 8.1 NATIONAL OUTCOMES This report relates to all national outcomes as effective governance arrangements will ensure the IJB can fulfil its statutory duties. Good governance enables the IJB to pursue its vision effectively as well as underpinning that vision with mechanisms for control and management of risk. 8.2 ASSOCIATED MEASURE(S) The implementation of agreed actions will contribute to the ongoing development of the internal control framework and will also inform the Annual Governance Statement for 2022/2023. 8.3 FINANCIAL This paper has been reviewed by Finance: Yes No N/A 8.4 RISK ASSESSMENT/RISK MANAGEMENT When reviewing the current position and achievable timescales, the risks associated with this have been considered. 8.5 PEOPLE None 8.6 INEQUALITIES & FAIRER SCOTLAND DUTY
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4 Equality and Diversity Impact Assessment Completed & Fairer Scotland Impact Assessment Form Completed: Yes No N/A 8.7 CARBON MANAGEMENT IMPLICATIONS Yes No N/A 9. BACKGROUND PAPERS None. 10. APPENDICES External Audit Actions Appendix 1 Internal Audit Actions Appendix 2 Senior Management Actions Appendix 3 ........................................... Chief Finance Officer Members seeking further information about any aspect of this report, please contact Amanda Kilburn on telephone number 07816 126362.
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5 Update on External Audit Actions Appendix 1 Ref Finding Recommendation Management Response Current Position 1 Accounts inspection advert The notice of inspection should state the objection end date and the advert should be posted on the IJB website in addition to the North Lanarkshire Council website. Original The IJB should ensure it has procedures in place to ensure the accounts inspection advert is published in line with criteria set out in the Local Authority Accounts (Scotland) Regulations 2014. Agreed The IJB will ensure future adverts are posted on the IJB website in addition to the North Lanarkshire Council website. IJB Chief Financial Officer Original Timeline: June 2023 2 2022/23 Reserves Strategy There are significant reserves held at 31 March 2022. A reserves strategy for 2022/23 which sets out how and when monies will be spent, has not yet been developed. Original The IJB should develop a reserves strategy for 2022/23 which sets out how and when monies will be spent. The IJB 2022/23 Reserves Strategy will be presented to the PFA Committee on 16th November and to the IJB on 30th November 2022. The reserves strategy will continue to be updated in line with the new Strategic Commissioning Plan 2023- 2026 and the new Medium Term Financial Plan 2023-2026. IJB Chief Financial Officer Original Timeline: November 2022 COMPLETE – 2022/23 Reserves Strategy was approved at the IJB on 22 March 2023. 3 Review of Financial Regulations The financial regulations were approved on 8 March 2016. They require to be updated to reflect the budget disaggregation of Children, Families and Justice Services and to also note the arrangements for the management of financial resources for hosted services. Original The financial regulations should be reviewed to ensure they remain up- to-date and fit for purpose. Agreed The services currently delegated by each partner to the IJB will be specified in the IJB Financial Regulations. The principal method of accounting for Hosted Services will also be included. IJB Chief Financial Officer Original Timeline: 31 March 2023 COMPLETE – Revised regulations went to PF&A Committee on 15 Feb 2023. b/f 4 Website Refresh Recommendation It should be clear who has ownership of the IJB website and responsibility for maintaining it. The website should be refreshed to reflect the IJB’s current operating model. Ongoing HSCP working group is currently completing the development of the website. IJB Chief Officer Revised Timeline: 31 March 2023 Complete – Website launched end of February 2023 with paper celebrating the launch endorsed by the IJB Committee on 22 March 2023.
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6 Update on External Audit Actions (Cont.) Appendix 1 (Cont.) Ref Finding Recommendation Management Response Current Position b/f 7 Medium to long term financial plan Recommendation The IJB’s medium to long term financial plan should be reviewed due to the impact of Covid-19 and EU withdrawal. Ongoing The new Medium Term Financial Plan 2023-2026 reflects the impact of recovering from Covid-19 and other challenging factors facing the IJB. It has been condensed to a three-year plan due to the pending formation of the National Care Service (NCS) and the continuing uncertainty around future funding. The MTFP will align to the Strategic Commissioning Plan 2023-2026 and the current IJB Reserves Strategy. IJB Chief Financial Officer Revised Timeline: 31 March 2023 COMPLETE – Medium Term Financial Plan 2023 – 2026 was approved at the IJB on 22 March 2023.
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7 Update on Internal Audit Actions Appendix 2 Ref Risk Management Maturity Audit Report Adequate Assurance (Audit Ref: NL04/18) Recommendations / Management Response Current Position 1 The PFA Committee does not receive an annual assurance report on risk management and there are no defined KPIs or performance measures for risk management. There is a risk that the PFA Committee may not be able to conclude on the overall adequacy and effectiveness of Risk Management arrangements. (Priority: Amber) Agreed An appropriate methodology for assessing the adequacy and effectiveness of risk management arrangements will be developed. This will include suitable KPIs and performance measures. Performance Manager Original Timeline: March 2020 Revised Timeline: March 2022 Revised Timeline: March 2023 Complete As previously advised, the annual review of the current suite of indicators and targets has been completed. An appropriate methodology for assessing the adequacy and effectiveness of risk management arrangements will be developed. This will include consideration of suitable key performance indicators and performance measures as part of the current review of the HSCP’s performance framework. Annual performance report submitted to the PFA Committee on 14 Feb 23 along with a performance update report which included key performance indicators and measures. 2 Improvements are needed to the way in which performance information is reported to better enable Committee members to exercise effective oversight, scrutiny, and challenge. It is considered there is scope for significant improvement in what and how this information is presented. There is a risk that the IJB may not provide adequate performance information to key stakeholders to enable them to make informed decisions and recommend remedial actions to address concerns arising. The IJB Performance, Finance and Audit Committee may not therefore be in a position to fulfil its remit which includes the requirement to ‘Review quarterly performance and recommend remedial action to address concerns’ and to ‘Ensure effective arrangements are in place to register all performance and operational risks’. (Priority: Amber) Agreed Management will undertake a formal review of the current arrangements for monitoring and reporting performance to reflect on whether reports are fit for purpose and contain relevant, comprehensive information useful to stakeholders. This could include comparison with other IJB published reports. Particular consideration should be given to the following areas: an overview of all indicators on the performance scorecard including a mechanism to provide an update on indicators previously reported but now considered satisfactory; proposed actions with timescales, progress with these and how effective they are; greater use of benchmarking with other IJBs and trend information; and incorporating reporting by locality. Performance Manager Original Timeline: January 2020 Revised Timeline: March 2022 Revised timeline: March 2023 Complete As previously advised, the annual review of the current suite of indicators and targets has been completed. In August 2022, the IJB’s Performance, Audit and Finance Committee endorsed the development of a revised whole system performance framework for the partnership. The current engagement and participation activity taking place in relation to the development of the new Strategic Commissioning Plan will draw together and build upon the richness of contribution across key partners. A whole system working group will be established to support the performance framework for the emerging Strategic Commissioning Plan. The richness of information that will comprise whole system performance reports will allow Committee members to exercise effective oversight, scrutiny, and challenge. As per update given above, the new Strategic Commissioning Plan 2023-2026 was approved at the IJB on 22 March 2023. Annual performance report submitted to the PFA Committee on 14 Feb 23 along with a performance update report which included key performance indicators and measures.
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8 Update on Internal Audit Actions (Cont.) Appendix 2 (Cont.) Ref Risk Management Maturity Audit Report Adequate Assurance (Audit Ref: 0600/2019/004) Recommendations / Management Response Current Position 3 There is no formal record of the setting and approval of targets and trajectories for indicators on the performance scorecard. Internal Audit noted that targets and trajectories for underlying performance measures are discussed and agreed at the Chief Executives’ Performance Review meetings but no formal record of this is retained. There is therefore no formal documented record or clear rationale for the targets and trajectories set. (Priority: Amber) Agreed Management should ensure that a formal record is retained detailing the rationale for and approval of the targets and trajectories set for the indicators on the performance scorecard and this information should be shared with the Performance, Finance and Audit Committee. Performance Manager Original Timeline: October 2019 Revised Timeline: March 2022 Revised Timeline: December 2022 Complete The annual review of the current reporting arrangements was rescheduled as a result of the Covid-19 pandemic. This work however is now being progressed in line with the revised timeline. The annual review of the current reporting arrangements will be reported to the IJB in December 2022 and will set out the agreement for future years. From 23/24 onwards, this will be presented to the board each year in line with quarter one performance cycle. Annual performance report submitted to the PFA Committee on 14 Feb 23 along with a performance update report which included key performance indicators and measures.
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9 Update on Internal Audit Actions (Cont.) Appendix 2 (Cont.) Ref Financial Due Diligence Audit Report Adequate Assurance (Audit Ref: 0700/2020/003 Recommendations / Management Response Current Position 4 Management needs to formalise and agree the proposed arrangements for those services with a ‘cross cutting function’, to be hosted by either Health and Social Care or Education and Families, and following the approval of the IJB and NLC, to finalise and process the agreed transfer of the remaining cost centres, in relation to the disaggregation of Children, Families and Justice Social Work Services, and their resultant budget. (Priority: Amber) Agreed. IJB management will: (1) liaise with relevant Council officers to ensure that the transfer of the remaining cost centres, and the resultant resources transferred, are agreed/completed as a matter of urgency; (2) in conjunction with Education and Families, determine, agree, and fully document the proposed arrangements for those functions to be ‘hosted’ by Education and Families and accessed by Adult Health and Social Work Services and vice versa, including giving consideration as to whether there should be a recharge system; (3) in conjunction with relevant Council officers, ensure that both the IJB and NLC approve the proposed ‘hosting’ arrangements for the budgets in respect of the cross-cutting services; and (4) liaise with the Council to resolve any other outstanding issues with regards to the disaggregation of Children, Families and Justice Services’ budgets and the treatment thereof. Internal Audit Comment Management should ensure that: (1) the hosting arrangements for the budgets in respect of cross-cutting services are finalised; (2) the hosting arrangements and detail of the disaggregated budgets which have been agreed are submitted to the IJB and to the relevant Council committees (Adult Health and Social Care and Education and Families). Original Responsible Officer: Chief Officer Original Timeline: October 2020 Revised Responsible Officer: Chief Financial Officer Revised Timeline: September 2021 Revised Responsible Officer: Head of Adult Social Work and Head of Planning, Performance and Quality Assurance Revised Timeline: TBC Complete The budget disaggregation exercise has been concluded. The revised IJB direction to NLC issued on 23 March 2021 excludes the total budget transfer in respect of Children, Families and Justice Services. Within the Financial Monitoring Report to the IJB on 9 December 2020, the IJB approved the revised direction to North Lanarkshire Council to reflect the conclusion of the budget disaggregation exercise in line with the Revised Integration Scheme – Transfer of Functions. This included the budget transfer of ‘direct’ Children, Families and Justice budgets and the transferring of budgets for the cross-cutting and support services. Ongoing The finalisation of the Service Level Agreement is overdue as per the original timeline of March 2021 which was initially revised to September 2021 but has been extended again to June 2022. Once finalised, the Service Level Agreement will be presented to a future meeting of the NLC Adult Health and Social Care Committee, the NLC Education and Families Committee and the IJB for approval. The Service Level Agreement between Children, Families and Justice Services will be revisited once further clarity has been obtained around what services will be part of the new National Care Service. 5 There is a need for a more formal record of the methodology adopted for disaggregation/the resultant figures/cost centres being transferred from Health and Social Care to Education and Families and the associated risks as a result of changes to the Integration Scheme to be formally reported to key stakeholders (i.e. the IJB and relevant Council Committee). (Priority: Amber) Agreed IJB management should, in conjunction with relevant Council officers, ensure that a report is submitted to the IJB setting out the methodology for the disaggregation of cost centres and budgets associated with Children, Families and Justice Social Work Services, detailing the implications of the full disaggregation. Internal Audit Comment Management should ensure that: (1) the hosting arrangements for the budgets in respect of cross-cutting services are finalised. (2) the hosting arrangements and detail of the disaggregated budgets which have been agreed are submitted to the IJB and to the relevant Council committees (Adult Health and Social Care and Education and Families). Original Responsible Officer: Chief Officer Original Timeline: October 2020 Revised Responsible Officer: Chief Financial Officer Revised Timeline: September 2021 Revised Timeline: June 2022 Revised Responsible Officer: Head of Adult Social Work and Head of Planning, Performance and Quality Assurance Complete The budget disaggregation exercise has been concluded. The revised IJB direction to NLC issued on 23 March 2021 excludes the total budget transfer in respect of Children, Families and Justice Services. Within the Financial Monitoring Report to the IJB on 9 December 2020, the IJB approved the revised direction to North Lanarkshire Council to reflect the conclusion of the budget disaggregation exercise in line with the Revised Integration Scheme – Transfer of Functions. This included the budget transfer of ‘direct’ Children, Families and Justice budgets and the transferring of budgets for the cross-cutting and support services.
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10 Revised Timeline: TBC Update on Senior Management Actions Appendix 3 Ref Annual Governance Statement Continuous Improvement Actions Current Position 1 Further consideration of the Ministerial Strategic Group (MSG) proposals. Original Responsible Officer: Chief Officer Original Timeline: March 2021 Revised Responsible Officer: Chief Officer Revised Timeline: March 2022 Complete A range of actions were agreed across the partnership to take forward the MSG proposals. These actions were included as part of the overall North Lanarkshire Integration Review and Self-Assessment. An update report on the total of 38 actions was presented to the IJB PFA Committee on 24 August 2021. 35 actions have been completed and 3 actions remain outstanding. Complete Two of the outstanding actions relate to the finance workstream. This includes a review of the support arrangements for the Chief Financial Officer and the link between strategic and operational finance. On 8 December 2021, the North Lanarkshire IJB agreed to create a full-time Chief Financial Officer for each IJB. On 25 January 2022, the South Lanarkshire IJB also agreed to this approach. This option is now being progressed. Complete The third outstanding action relates to the development of systems to support integrated IT arrangements. The Lanarkshire Data Sharing Partnership Board was reviewed, and new structures have been agreed. The role out of Microsoft 365 across all partners is the current priority. Complete The MSG had previously indicated that a second self-evaluation will be undertaken in 12 months to assess progress. The follow up was rescheduled due to the Covid-19 pandemic. The second self-evaluation is currently being progressed in February 2022. Work is also progressing nationally in respect of the development of the National Care Service. Complete The Improvement Service is carrying out a self-evaluation of the function of the IJB as part of a national best value audit. Effective from February 2022, a review of current participation and engagement structures is also being progressed. Complete 2 Review the IJB governance arrangements This will include the review of the following: IJB joint internal audit arrangements IJB Code of Corporate Governance Complete The outcome of the overall North Lanarkshire Integration Review and Self-Assessment was reported to the IJB PFA Committee on 24 August 2021. The review of the North Lanarkshire Integration Scheme included consideration of governance arrangements. The governance structure moving forward proposed key interfaces around clinical and care governance.
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11 IJB emergency response arrangements and the further development of the IJB website. Original Responsible Officer: Chief Financial Officer Original Timeline: March 2021 Revised Responsible Officer: Chief Financial Officer Revised Timeline: March 2022 Revised Timeline: March 2023 The understanding of the governance requirements underpinning health and social care integration continues to develop and includes an increased awareness of decision-making responsibilities. The further development of collaborative leadership and building relationships with key stakeholders continue to be key improvement actions. The outcome of the National Care Service Consultation will also influence future governance arrangements for the IJB and both partners. The External Audit of the North Lanarkshire IJB Annual Accounts 2020/2021 has now been completed. The External Auditor has concluded that the financial statements of the North Lanarkshire IJB for 2020/2021 give a true and fair view of the state of affairs and of its net expenditure for the year and have therefore issued an unqualified independent auditor’s report. The findings of the audit process have also been reported to the IJB and an action plan approved as set out in the External Auditor’s Annual Audit Report. Current process will remain however further work may be required due to the introduction of the National Care Service. Complete The working group continue to develop the IJB website which will be complete by March 2023. Website launched end of February 2023 with paper celebrating the launch endorsed by the IJB Committee on 22 March 2023.
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12 Update on Senior Management Actions (Cont.) Appendix 3 (Cont.) Ref Annual Governance Statement Continuous Improvement Actions Current Position 3 Finalise the budget transfer from the IJB to NLC, in line with the revised Integration Scheme This will include the following: the conclusion of the budget disaggregation exercise for the transfer of the remaining cost centres and their resultant budgets the finalisation of the Service Level Agreement including the arrangements for those services with a ‘cross cutting function’ the issue of a revised direction to reflect the 2020/2021 financial allocations Original Responsible Officer: Chief Officer Original Timeline: September 2020 Revised Responsible Officer: Chief Financial Officer Revised Timeline: September 2021 Revised Responsible Officer: Head of Adult Social Work and Head of Planning, Performance and Quality Assurance Revised Timeline: TBC Internal Audit Comment Management should ensure that: (1) the hosting arrangements for the budgets in respect of cross-cutting services are finalised; (2) the hosting arrangements and detail of the disaggregated budgets which have been agreed are submitted to the IJB and to the relevant Council committees (Adult Health and Social Care and Education and Families). Complete The budget disaggregation exercise has been concluded. The revised IJB direction to NLC issued on 23 March 2021 excludes the total budget transfer in respect of Children, Families and Justice Services. Within the Financial Monitoring Report to the IJB on 9 December 2020, the IJB approved the revised direction to North Lanarkshire Council to reflect the conclusion of the budget disaggregation exercise in line with the Revised Integration Scheme – Transfer of Functions. This included the budget transfer of ‘direct’ Children, Families and Justice budgets and the transferring of budgets for the cross-cutting and support services. Update Once finalised, the Service Level Agreement will be presented to a future meeting of the NLC Adult Health and Social Care Committee, the NLC Education and Families Committee and the IJB for approval. The Service Level Agreement between Children, Families and Justice Services will be revisited once further clarity has been obtained around what services will be part of the new National Care Service. The outstanding Service Level Agreement will be incorporated into the same outstanding action highlighted by Internal Audit under ‘Financial Due Diligence Audit Report’ 0700/2020/003 action note 4 above. 4 National Care Service To develop a sound understanding of the impact for the NLHSCP of the outputs of the National Care Service legislation. Ongoing Due to the uncertainty and lack of detail currently available, this will be revisited once further clarity has been obtained. 5 Category 1 Responder Review the IJB’s progress in becoming a Category 1 Responder as set out within the Civil Contingencies Act. In conjunction with the Local Resilience Partnership undertake a self- assessment review against the seven duties, reporting progress to the West of Scotland Regional Resilience Partnership. Original Responsible Officer: Chief Officer Original Timeline: March 2023 Complete IJB Category 1 Responders in Civil Contingencies Act 2004 was presented to the IJB on 22 March 2023.
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13 Update on Senior Management Actions (Cont.) Appendix 3 (Cont.) Ref Self-Evaluation of the North Lanarkshire Health and Social Care Integration Joint Board (IJB) Current Position 6 Evidence how Health and Social Care spending contributes to prevention and early intervention This will include the following: review of the Strategic Commissioning Plan to strengthen outcome 5 around inequalities review of opportunities against resources include a question in all board papers regarding how it impacts upon prevention and early intervention undertake a review of good practice from across Scotland ring-fence funding for prevention and early intervention as part of the Reserves Strategy engage with Academia to establish how we measure success evidence how existing work links to prevention and early intervention and how this aligns to outcomes Original Responsible Officer: Head of Planning, Performance and Quality Assurance and Chief Finance Officer Original Timeline: February 2023 Complete Both the Strategic Commissioning Plan 2023-2026 and Medium-Term Financial Plan 2023-2026 are currently underway and will align to strengthen outcomes against resources. By ensuring good practise and lessons learned, both plans will review future funding and reserves to link with outcomes around prevention and early intervention. Medium Term Financial Plan 2023 – 2026 was approved at the IJB on 22 March 2023. Strategic Commissioning Plan 2023-2026 was approved at the IJB on 22 March 2023. IJB Reserves Strategy 2022-2023 was approved at the IJB on 22 March 2023.