IJB Annual Performance Report 2024-2025
Perth and Kinross Council · 29 October 2025
Back to Perth and Kinross Council — 29 October 2025 and its agenda
Text extracted from the council's PDF. Layout and reading order may differ from the original.
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Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 Ambition Compassion Integrity
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2 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 Contents Preface.................................................................................................................... 4 Introduction ............................................................................................................ 5 Our Vision ........................................................................................................... 5 Our Ambitions ..................................................................................................... 5 Our Strategic Priorities ........................................................................................ 5 Strategic Plan .......................................................................................................... 6 Looking Forward .................................................................................................. 7 Performance ............................................................................................................ 7 Demographics ...................................................................................................... 7 Performance Framework ....................................................................................... 9 Planning ........................................................................................................... 9 Doing ............................................................................................................... 9 Checking .......................................................................................................... 9 Acting ............................................................................................................. 10 Latest Performance ............................................................................................ 10 Feedback from people that use services .............................................................. 13 Health and Care Experience............................................................................. 13 Care Opinion .................................................................................................. 13 Care Group Activities and Achievements ................................................................. 15 Community Mental Health and Wellbeing ............................................................ 15 Access ........................................................................................................... 15 Prevention ...................................................................................................... 15 Person-Centred Care ....................................................................................... 16 Workforce ....................................................................................................... 18 Engagement ................................................................................................... 18 Primary Care ...................................................................................................... 20 Outcomes for People ....................................................................................... 20 Outcomes for Workforce ................................................................................. 21 Outcomes for the System ................................................................................ 21 Learning Disability and Autism ............................................................................ 25 Older People’s Services ...................................................................................... 31 Early intervention ............................................................................................ 31
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3 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 Shifting the balance of care .............................................................................. 34 Optimising Capacity and Flow .......................................................................... 34 Carers ............................................................................................................... 37 Substance Use ................................................................................................... 43 Adult Support and Protection .............................................................................. 45 Lead Partner Services ............................................................................................. 46 Public Dental ..................................................................................................... 46 Podiatry ............................................................................................................. 49 Prison Healthcare ............................................................................................... 52 Workforce ............................................................................................................. 54 Progress Across the Five Pillars ............................................................................ 55 Learning and Development ................................................................................. 55 Progress against the Strategic Plan ...................................................................... 56 Independent Inspection ......................................................................................... 58 Mental Welfare Commission for Scotland ............................................................ 59 Care Inspectorate Inspections ............................................................................. 60 Arrangements for Clinical and Care Governance ................................................... 61 Finance ................................................................................................................. 61 Financial Resources Available to the IJB 2024-2025 .............................................. 61 Financial Performance ........................................................................................ 62 Financial Plan ..................................................................................................... 63 Best Value .......................................................................................................... 63 Governance and Accountability ........................................................................... 64 Use of Resources ............................................................................................... 64 Key Contact ........................................................................................................... 64 Appendix ............................................................................................................... 65 Appendix 1.1: Perth and Kinross HSCP Service Breakdown .................................... 65 Appendix 2.1: National Core Suite Indicator 1 to 9, 5 year comparison .................... 66 Appendix 3.1: Strategic Priorities Mapped to National Indicators and the National Health and Wellbeing Outcomes ......................................................................... 68 To give us feedback ................................................................................................ 69
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4 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 Preface Jacquie Pepper, Chief Officer (Health and Social Care) Welcome to this year’s Annual Performance Report. In it you will read about our performance, including ways in which we have continued to develop and integrate health and social care services in Perth and Kinross during 2024-25. The achievements described have been made possible by the hard work and commitment of our staff who have adapted, innovated, and responded to the numerous and varied challenges that have come their way. You will also see examples of how we have worked with third and independent sector colleagues and local community groups to support the health and wellbeing of Perth and Kinross residents, developing new and innovative ways of responding to individual needs. We continue to focus on developing services based on what is important to, and needed by individuals, reflecting their goals and priorities, and supporting them to be as active and independent as possible. We have included a number of case studies that help to illustrate how our services meet people’s very specific needs and wishes. This report covers a year in which the Integration Joint Board (IJB) was presented with a very challenging financial context reflected by IJBs across the country. Against this backdrop our performance and delivery of positive outcomes for our residents have improved overall. IJB members worked with HSCP Officers to develop a financial recovery plan from September 2024. This was successful, along with a series of savings proposals agreed in March 2024, in reducing projected overspends. Our data shows that our population continues to increase alongside growing levels of need and complexity and this is set to continue as our population ages at a rate higher than Scotland and most of our comparators. The IJB faces ongoing financial uncertainty and is committed to early and ongoing financial planning to ensure that budget decisions are well informed and support the most effective and efficient use of resources. Engagement with individuals, communities, staff, partner organisations, and other stakeholders has underpinned much of our activity during 2024-2025, and positively, both NHS Tayside and Perth and Kinross Council have increased the level of funding to the IJB in 2025-2026.
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5 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 Introduction Perth and Kinross Health and Social Care Partnership (HSCP) provides and commissions local health and social care services to meet the needs of the Perth and Kinross population, and to deliver the strategic objectives of the Integration Joint Board (IJB). Our aim is to improve health and wellbeing outcomes, by providing the right care and support in the right way and at the right time for the population through services delegated by NHS Tayside and Perth and Kinross Council. The IJB Strategic Plan 2024- 2027 sets out a shared vision, ambition and strategic priorities. Perth and Kinross is divided into three localities, North Perthshire, South Perthshire and Perth City, each with distinct population needs and service delivery models. Services are delivered through integrated, multi-disciplinary teams embedded in each locality, enabling rapid, person-centred support. This locality approach ensures services are responsive to local demographics, geography, and health and social care needs. Our Vision For every person in Perth and Kinross to live in the place they call home with the people and things they love, in good health and with the care and support they need, in communities that look out for one another, doing the things that matter most to them. Our Ambitions • For people to stay as well as possible for as long as possible. • For people to live as independently as possible for as long and as safely as possible. • For people to be able to thrive and feel valued members of the community. Our Strategic Priorities 1. Target resources to where people and communities need help most. 2. Make it easier for people to understand where and how to access services. 3. Provide health and social care supports close to home. 4. Work with communities to design the health and social care supports they need. 5. Improve integrated working. 6. Promote self-management and living well. 7. Value our workforce, support them to keep well, learn and develop. We use the National Framework for Community and Social Care Integrated Services to inform the development of local change and transformation plans, drawing on what is known to work in other areas. Priorities are progressed through the implementation of
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6 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 wider strategies and delivery plans with a broad range of outcomes sought via specific care groups as follows: • Mental Health and Wellbeing • Primary Care • Learning Disabilities and Autism • Older People’s Services • Carers • Substance Use These plans provide more detail on how we deliver our services and they are underpinned by outcomes focused performance management frameworks which are strongly linked to the 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 reasonably 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 their 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 provide unpaid care are supported to look after their own health and wellbeing, including to reduce any negative impact of their caring role on their own health and wellbeing. 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. Strategic Plan Each Integration Authority must produce a strategic plan over the medium term, using the integrated budgets under their control. Stakeholders must be fully engaged in the preparation and review of the plan. This ensures a meaningful co-productive approach is taken to deliver the national outcomes for health and wellbeing and achieve the core aims of integration: • To improve the quality and consistency of services for patients, carers, service users and their families. • To provide seamless, integrated, quality health and social care services in
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7 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 order to care for people in their homes, or a homely setting, where it is safe to do so. • To ensure resources are used effectively and efficiently to deliver services that meet the needs of the increasing number of people with long term conditions and often complex needs, many of whom are older. An Integration Authority is required to review its strategic plan at least every three years and may carry out additional reviews. In carrying out a review, Integration Authorities must consider: • The national health and wellbeing outcomes. • The indicators associated with the national outcomes. • The integration delivery principles. • The views of the Strategic Planning Group. Looking Forward To continue the implementation of the strategic plan, new delivery plans for Older Peoples’ Services, Adult Services, and Primary Care are being developed. These will replace the existing care group strategic delivery plans which come to an end within the financial year 2025-2026. The structure of how these plans come together is set out within the IJB Performance Framework. Performance Demographics Perth and Kinross is a geographically large Local Authority area with a total population of circa 152,560 (National Records of Scotland) split evenly across the three HSCP (Health and Social Care Partnership) localities North Perthshire, South Perthshire, and Perth City. Chart 1
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8 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 The population of Perth and Kinross is older compared to the overall population of Scotland. The number of people aged 85 and over is projected to increase substantially, which will significantly increase the demand for health and social care services. Chart 2 illustrates how the age profile of the population is expected to change between 2018 to 2028, with a large increase in the older population, without a similar increase in the working age population. At the year end of 2024-2025, Perth and Kinross was seven years into this population shift and the associated increase in need and demand is driving higher costs and budget pressures. Chart 2 Source: National Records of Scotland -Perth and Kinross Council our Profile This changing population profile combined with rurality, presents substantial challenges in the delivery of services at the scale required to meet the needs of the community. The Scottish Index of Multiple Deprivation indicates that 23.2% of our population live in the least deprived quintile and 6% in the most deprived. Perth and Kinross is classified as “Mainly Rural” (Scottish Government - Rural and Environmental Science and Analytical Services) and is the eighth most rural Local Authority area in Scotland. This means that service accessibility is a significant contributor to inequalities and reduces the potential for economies of scale. Life expectancy is above the Scottish average, 78.8 years for males and 82.6 years for females compared to 76.8 years and 80.8 years respectively. The number of people supported in the treatment of Long-Term Conditions (LTCs) provides some additional context on the health of our population and the consequential need for Health and Social Care support. It is estimated (based on people who have contact with NHS services) that 21.6% of the population have at least one LTC. These include cardiovascular, neurodegenerative and respiratory conditions, as well as other organ conditions namely liver disease and renal failure, arthritis, cancer, diabetes and epilepsy. Chart 3 shows how the population is affected by LTCs overall and with the prevalence of LTCs increasing with age, this demonstrates how the impact of the population shift results in significant additional demand across Health and Social Care services.
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9 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 Chart 3 Performance Framework The Performance Framework (approved June 2025) outlines a structured, cyclical approach to planning, delivering, monitoring, and improving health and social care services. It is built around the Plan-Do-Check-Act (PDCA) model and aims to ensure alignment between strategic goals and operational delivery, with a strong emphasis on continuous improvement and accountability. Planning - Conducted at three levels - Strategic, Delivery, and Operational. Each level aligns with the IJB Strategic Plan (2024–2027),which sets seven key priorities: 1. Target resources to where they are needed most. 2. Improve access and understanding of services. 3. Deliver care close to home. 4. Co-design services with communities. 5. Enhance integrated working. 6. Promote self-management and wellbeing. 7. Value and support the workforce. Doing - Implementation of services based on operational plans that detail required resources, delivery methods, and performance metrics. This phase emphasizes quality improvement and responsiveness to local needs. Checking - Performance is monitored using a layered approach: • Strategic Level: Annual and quarterly reports using national and local indicators. • Delivery Level: Outcome-focused frameworks for care groups. • Operational Level: Real-time metrics on demand, capacity, and service quality. SMART objectives and both qualitative and quantitative data are used to ensure relevance and impact.
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10 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 Acting - Informed decision-making based on performance data leads to service redesign, investment/disinvestment, and transformation. Emphasis is placed on data quality, governance and clear accountability at all levels. Governance and Reporting - Performance data is reviewed by multiple internal and external bodies, including the IJB, NHS Tayside, Perth and Kinross Council, and various management teams. Reporting is tiered to match the strategic, delivery, and operational levels, ensuring appropriate oversight and action. Technology and Tools - It is planned that the framework will leverage tools like Microsoft Power BI and the PK Performs system to integrate data across services, enabling a whole-system view and enhancing decision-making capabilities. Benchmarking and Improvement - Benchmarking against peer groups and national standards supports learning and improvement. Targets are set across short, medium, and long-term horizons, considering resource availability, demand and risk. Latest Performance Strategic performance is measured against the Core Suite of Integration Indicators (National Indicators) combined with those of Ministerial Steering Group (MSG). The table below summarises performance against these indicators, with comparisons to last year and to Scotland overall.
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11 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 Table 1 Ref Indicator Description Perth and Kinross 2023- 2024 Perth and Kinross 2024- 2025 How we compare to last year Scotland 2024- 2025 How we compare to Scotland NI 12 Emergency admissions rate for adults (18+) (per 100,000 population) 14,049 14,394 2.5% 11,559 24.5% NI 13 Emergency bed day rate for adults (18+) (per 100,000 population) 119,654 110,545 -7.6% 113,627 -2.7% NI 14 Emergency readmissions to hospital within 28 days of discharge (rate per 1,000 discharges 18+) 153 153 0.0% n/a n/a NI 15 Proportion of last 6 months of life spent at home or in a community setting 89% 90% 0.8% 89% -0.6% NI 16 Falls rate per 1000 population aged 65+ (falls which result in a hospital admission) 26 25 -1.6% 23 12.4% NI 17 Proportion of care services graded "good" or better in Care Inspectorate inspections 71% 71% 0.4% 82% -10.7% NI 18 Percentage of adults with intensive care needs receiving care at home 64% 64% 0.2% 65% 0.8% NI 19 Number of days people aged 75+ spend in hospital when they are ready to be discharged per 1,000 population 645 654 1.4% 952 -31.3% MSG1a Emergency admissions per 100,000 population (all ages in acute hospital) 12,630 12,725 0.8% 10,822 17.6% MSG2a Number of unscheduled hospital bed days; acute specialties per 100,000 population 77,178 71,254 -7.7% 75,138 -5.2% MSG3a Accident and Emergency attendances 18+ per 100,000 population 18,615 19,629 5.4% 26,028 -24.6% MSG4 Delayed discharge bed days 18+ per 100,000 population 13,982 13,338 -4.6% 15,969 -16.5% Notes: 1. Data for NIs is published via Public Health Scotland. 2. NIs 1 to 9 are reportable every two years only. Please see Appendix 2 for the latest data. 3. NIs 17 and 19 data covers 2024-2025, all others are for calendar year 2024 due to incomplete data for January to March 2025. 4. NI 14 - It is not possible to accurately compare performance to elsewhere due to differences in data recording practices. 5. MSG data is provided for management information only, is unpublished and is subject to change. Exceeding our comparator or within 3% Between 3% and 6% from comparator More than 6% from comparator
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12 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 The rate of emergency admissions (NI 12) has increased by a small amount (performance has declined by 2.5% for the 18+ population and 0.8% when considering all ages (MSG1a)). Performance remains within the current target range which is good when considering the older and more frail population of Perth and Kinross and the related impact on the need for emergency care. When people have been admitted to hospital in an emergency their stay is likely to be shorter compared to 2023-2024 as the rate of emergency bed days (NI 13) has reduced (improved) by 7.6% (for 18+ population and 7.7% for all ages (MSG2a)) which demonstrates the commitment made to discharge people as early as it is safe to do so when their care can be continued in their home or homely setting. The risk of falls increases with age and given the growing older population in Perth and Kinross, higher admission rates due to falls (NI 16) are to be expected. This is reflected in the rate of 25 admissions per 1,000 people aged 65 and over in Perth and Kinross, compared to 23 per 1,000 for Scotland. Despite this, performance against this indicator remains good, with a marginal improvement of 1.6% compared to last year. The number of readmissions within 28 days of discharge per 1,000 discharges (NI 14) has remained stable at 153, which has paused a previous upward trend against this measure. In the last six months of life (NI 15) people in Perth and Kinross spend 90% of their time at home (rather than within inpatient settings). This is similar to the 89% achieved last year and is good evidence of people being supported to remain at home in accordance with their wishes. Supporting people to remain at home as they age or as their care needs increase can be increasingly challenging. However, with 64% of people with intensive care needs receiving ‘care at home’ (NI 18), performance remains positive, consistent with last year and on a par with Scotland. The rate of Accident and Emergency attendances (MSG 3a) has risen by 5.4% compared to last year, indicating a decline in performance. However, it remains 25% better than Scotland overall. The underlying causes of this increase are complex and not yet fully understood. Ongoing efforts to further integrate health and social care services in communities are redesigning how people access services, particularly through the introduction of a Single Point of Contact. As this work progresses, attendance rates will be closely monitored. Performance in managing delayed discharges remains good. For individuals aged 75 and over, Perth and Kinross performs 31% better than Scotland overall (NI 19). Additionally, there has been a 4.6% improvement in delayed discharge performance for the 18+ population compared to last year (MSG 4). To provide additional context, 97% of patients in Perth and Kinross are discharged from hospital without delay (94% for those aged 75+).
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13 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 Feedback from people that use services Health and Care Experience The Health and Care Experience survey covers National Indicators 1 to 9 and is published every two years (last publication was in 2024). Respondents for the survey are selected at random from GP practice lists with survey questions covering a broad range of topics including their experience of health and social care services. Please see 2023-2024 Annual Performance Report where more detail is provided on these indicators combined with data gathered through local service user surveys which show high levels of satisfaction. In support of the new strategic plan, and the performance framework, new approaches to gathering service user feedback are now being developed and will be used for future performance reporting. Care Opinion To broaden understanding of people’s experience, Care Opinion gathers real stories of the experiences and outcomes of using our services. All HSCP teams are using Care Opinion and in 2024-2025, 375 stories were shared, building on the 315 stories from the previous year. Some of these stories are provided within this annual performance report and all of these stories can be read on the Care Opinion website. As a result of feedback, improvements are being taken forward which will: • Improve access to nail surgery, • Fill appointment cancellations at short notice, and • Use technology better to improve continuity of care. As people provide feedback, they often mention how they felt about their experience and this word cloud gives a summary of the descriptive words used. People mentioned that they were ‘thankful’ in 12.5% of stories, ‘grateful’ in 12.3%, ‘supported’ in 11.2%, ‘put at ease’ in 9.3% and ‘happy’ in 8.5%. When considering what 100% of stories responded to with a mean response time of 68 hours. 97% of responses were rated as helpful.
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14 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 was good, ‘staff’ were mentioned 37.1% of the time, ‘professional’ was mentioned 26.1% of the time and ‘friendly’ 17.6%. Care Opinion helps staff and managers reflect on what they can do to make all aspects of care and treatment better. For what could be improved, there is a broad range of things, with two or three comments for each, which individuals mentioned that could have improved their experience, ranging from car parking to joined up care to waiting lists. Due to the breadth of comments, it is not possible to draw meaningful themed conclusions. However, 100% of stories are reviewed by staff and where possible, staff make the improvements people mention and these are taken forward on an individual basis. The chart below shows the overall rating for a variety of measures about people’s experiences which, when aggregated, achieved at least 4.73 out of 5 over the year. All the measures showed an improvement from last year. The majority of stories (89%) were submitted via the website, 5% via leaflet and 6% by phone and they have been viewed over 28,900 times (as at 17 April 2025). 43% of people identified themselves as the patient, 36% as a service user and 10% as a relative.
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15 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 Care Group Activities and Achievements Community Mental Health and Wellbeing The Community Mental Health and Wellbeing Strategy has progressed five strategic themes, access, prevention, person-centred care, workforce and engagement. Access Mental health services are currently supporting around 5,000 individuals, with efforts focused on reducing wait times and improving access to care. The Primary Care Mental Health Transformation Programme, launched in March 2024, enhances early intervention through dedicated nursing support via General Practices, offering up to 240 appointments weekly. As well as providing early support and self-management the service enables referral into third sector services which can help to address the wider issues people encounter, not all of which will be mental health related. The inaugural Mental Health and Wellbeing Conference attracted over 230 attendees, fostering collaboration and shared learning. Clinical advancements include the continued excellence in Electroconvulsive Therapy (ECT) delivery, and the establishment of a Mental Health Clinical Care Governance Forum to strengthen oversight and accountability for HSCP provided services. Operational improvements include a dramatic reduction in Occupational Therapy wait times and the appointment of a Neurodevelopmental Disorder Nurse Co-ordinator to address rising ADHD referrals. The new Mental Health Clinical Pharmacy model supports medication management and pathway modernisation. Prevention The Suicide Prevention Strategy Group has worked closely with all sectors to prioritise prevention and early intervention of mental ill-health and suicide. Close working with Andy’s Man Club and Man Talk provides a targeted Men’s Suicide Prevention campaign. Support for adults and young people on suicide is provided through Suicide Awareness and Prevention Co-ordinators, and training is being developed to support
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16 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 families bereaved through suicide. Community-based initiatives like MoveAhead continue to grow, providing inclusive support through group and individual interventions, while the Health Hub at Murray Royal Hospital offers physical health advice and signposting, staffed by volunteers with lived experience. PKAVS delivers mental health and wellbeing support to the local community, from the grounds of The Walled Garden, Perth and Wisecraft in Blairgowrie. Through the facilitation of meaningful and therapeutic activities (creative arts, woodwork, horticulture, hospitality/catering and physical, nutritional and resilience focused activity) they aim for people to have better physical, emotional and mental wellbeing. Person-Centred Care People are supported to have the knowledge and confidence to take control and make decisions about their lives. Roles and services that act as community connectors, such as Social Prescribers and Community Engagement Teams, are fully embedded in communities and services. Specialist services work closely with community services and the third sector to support people to achieve personal outcomes through low level, early interventions. Some clinical interventions are offered successfully through online support and telephone triage. Community Teams and Hospital Teams liaise to ensure the needs of people are being met, and help to facilitate discharge from hospital safely, as early as is possible. There has been a reduction in people experiencing delay in their discharge for adult general psychiatric inpatient services down to zero in most weeks. Partnership working with the third and independent sector is key to delivering against population demands. For example, people with mental health presentations are supported to access the most appropriate service for their needs, depending on the severity of their condition. The Neuk Crisis Centre delivers support to people in crisis in Perth and Kinross, and the MoveAhead service continues to deliver early intervention and community-based services within areas of Perth with higher levels of health inequalities, e.g. Letham. 83 new referrals Jan to Dec 2024 “I have developed my communication skills.” “I have grown in confidence.” “I am happy I have the opportunity to try new things.” “I have developed my gardening skills and learnt how to manage my stress.” “I have built positive friendships in my creative sessions and developed relationships with staff.” “Staff have been very flexible meaning I have been able to attend both The Walled Garden and College.”
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17 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 Digital mental health and wellbeing supports continue with investment in the ‘Brain in Hand’ app. As people engage with services, Silver Cloud (previously known as Beating the Blues) is promoted as a way for them to support their own mental health independently. 862 people have used Silver Cloud in the last 12 months and online CBT (cognitive behavioural therapy) is also provided by psychological services. Perth and Kinross is participating in a pilot with Health Improvement Scotland to assess the feasibility of national Adult Mental Health Core Standards. Staff are also actively engaged in the Pan-Tayside Mental Health and Learning Disability Whole System Change Programme and engaged in co-producing a new model of care for adult mental health at all levels. Third sector partnerships remain vital, with continued investment through the Community Mental Health and Wellbeing Fund and Perth and Kinross Council Budget Motion allocations. Distress Brief Interventions, now delivered by The Neuk, are increasing, with 250 referrals last year. Mindspace delivered 974 counselling sessions, and the Recovery College delivered 266 sessions and 63 courses. A participant on Creativity for Wellbeing said: We have a multi-professional approach to caring and supporting adults with multiple and complex needs and those at risk of harm. All staff are trained in ASP (Adult Support and Protection) legislation and the obligations to ensure faster identification, targeted, and well-co-ordinated responses. Perth Six Circle help disadvantaged adults improve social connections. Activities include weekly social activity clubs, interactive workshops including IT connections, formal or external social interaction opportunities, visits to places of interest, buddy support, joint events for local organisations and attendance at national events. 862 people used Silver Cloud in the last 12 months. “It helped me relax and be more me. It is wonderful to be able to express yourself through art.” “I feel part of a family. It gives me a purpose to get out of bed and engage with others and see places I’ve never been before, seen loads of Scotland I would never see so I feel really better connected to the community. I would not do things on my own. Perth Six Circle has helped me through this last year, particularly with the loss of both parents.”
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18 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 Workforce Workforce developments show progress in nursing recruitment, though challenges persist in securing medical and allied health professionals. Work is progressing to integrate our specialist services like the Integrated Drug and Alcohol Recovery Team (iDART), multi-professional Learning Disabilities Team (SCOPE) and Primary Care Mental Health. This is part of a progression towards wider integration of services across the HSCP, with options around co-location explored. All HSCP mental health teams use Care Opinion to gather feedback and learn from what is working for people and what is not. Currently uptake is low, and the following is some of the work that is ongoing to address this. Depending on patient need, Care Opinion leaflets are provided which can be used to provide written feedback and then posted free of charge. This is a good option for some people as they can struggle to offer feedback via technology. The team also hosts Alzheimer Scotland PDS Link Workers and they collate feedback using the Single Quality Question, managed by Alzheimer Scotland. Another team provides a feedback box in their waiting area and a simple form asking three questions - Who are you open to, what are we doing well and what can we improve? - staff print the feedback in themes and display it in the waiting area to let the client group know that the feedback is used and valued. This has also improved staff morale and the culture around feedback. The feedback box has been massively successful and has provided some really rich and mostly positive feedback and has hopefully empowered people to feel involved in how we plan our service. We encourage development of staff through support, supervision and training and development opportunities to generate real improvement. Staff are supported to understand the importance of the communities we service by continuing to develop integrated working and locality-based services. Engagement Consultation and engagement is underway in relation to the development of the ‘Model of Care’ approach for mental health services. This programme is benefiting from the inclusion of people with lived experience in a co-production approach. A revised strategy for 2025 is in development, with a focus on integration, quality improvement, and whole system working. This strategy aligns with the Tayside-wide Mental Health and Learning Disability Whole System Change Programme and will ensure health “I feel less isolated, it gets me out of the house, and I enjoy the company of other service users. PSC have helped me to do different activities that I would not have done on my own. I’ve joined weekly aquarobics class with another service user. I look forward to attending the Six Circle and really enjoy myself.” For each month of 2024- 2025, over 94% of staff ‘LearnPro’ training complete.
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19 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 inequalities continue to be prioritised along with comprehensive equality, human rights and a person-centred approach. Care Opinion Story - I met with [staff] from Move Ahead during my rehabilitation of an injury that had left me immobilised and isolated for several months. I had lost confidence in being out and in busy environments and was also anxious about the rehabilitation as it had gone through several setbacks. [Staff] was easy to talk to. She had a great knowledge of different groups that are taking place around Perth and also took into account that I wouldn't be able to walk very far to get to them. It was such a was a relief to feel heard and supported in this way after all those months. [Staff] helped me to connect with a group and to create a staged strategy for increasing my exposure to busy environments while also thinking about the ongoing physical rehabilitation. I'm really grateful that this service is available. If there is anything that could have been better - it would be that the impact of anxiety and depression on recovery could have been made more clear in the first place and the referral could have been made sooner. This experience has taught me a lot about the danger of separating physical and mental health from each other. Case Study – The client made a self-referral to MoveAhead following a conversation with the Primary care mental health and wellbeing nurse. The client is a double amputee, she had been coping well until recently when she realised that this was her “life now” and she took a dip in her mental health, feeling depressed, not going out, and only speaking with her husband and two dogs. And the occasional telephone communications with family. She made a self-referral to MoveAhead having moved to Perth from Kinross, due to requiring a house that had the adaptations for her requirements. Initially she felt that she was lacking motivation and looking for building structure and routine to her day. Following our discussions about different support that was available, the client made a self-referral to Mindspace counselling service and has recently started with this finding it beneficial. She identified that she would like to attend a craft group to help build social connections and reduce isolation. She has been attending the CATH connect, “knit and natter” group on Wednesdays and “on the mend” group on Fridays, which she enjoys and has made friendships. She has built a good relationship with the staff at CATH, often helping at events, has been supported into volunteering opportunities, and has now started as a “Purple Lady” in her volunteer role at Tay Ward. She recently got the opportunity to start using her “legal head again” for letting her house. It was a pleasure working with her and watching her grow in confidence and be able to use her personal experience to help others.
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20 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 Primary Care Through the Primary Care Strategic Delivery Plan (update report) strong progress is being made against the delivery of outcomes for ‘people’, ‘workforce’, and ‘the system’. Key successes include the full embedding of First Contact Physiotherapy (FCP) into core services, the expansion of access to Primary Care Mental Health and Wellbeing Nursing, now accessible to all 23 practices, and the continued development of Community Treatment and Care Services (CTAC). These services are now integral to the delivery of modern, community-based care. Outcomes for People The FCP service is available across Perth and Kinross and has delivered 12,398 appointments for people in 2024. This is a utilisation rate of over 90% with DNA rate (patient Did Not Attend) of 7.1%. The chart below shows the spread of utilisation across Perth and Kinross. A high percentage of people (almost 70%) are discharged after their initial appointment demonstrating the value of the service to people and ‘the system’ overall. The Community Treatment and Care (CTAC) service workforce are trained in public protection and work in partnership with GP practices and wider multi-disciplinary teams to safeguard those at risk and to assist with more co-ordinated responses to safeguarding concerns. Advanced Nurse Practitioners focus on urgent care home visiting with a focus on older people, some of whom have the most complex needs. They work within a multi- disciplinary team to ensure people are seen by the right professional for their condition, for example; a Podiatrist, an Occupational Therapist or Physiotherapist. People experiencing a mental health crisis often reach out to their GP. Working in partnership with The Neuk crisis centre, GPs are able to refer people who can benefit from non-stigmatising and holistic support. An example of using technology to support people with their conditions are ‘Near Me’ which provides appointments remotely via video link, reducing the need for travel for physical face to face appointments. ‘Medlink’ is another example. This system is used by 70% of GP practices to help people manage their chronic health conditions. A Digital Development Group has been established to continue the implementation of these and other technologies.
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21 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 We work with communities to develop bespoke care and support, such as the Primary Care Team using a voluntary blood bank service in rural areas, enabling an increase in phlebotomy appointments. Outcomes for Workforce Workforce recruitment, particularly in pharmacy, continues to be a national issue, exacerbated by a mismatch between demand and the levels of people training to become the future workforce. Alterations to how the CTAC service is managed have been successful with Staff Side colleagues applauding the inclusive approach that was taken to support staff. The new arrangements will allow a greater level of consistency of delivery and better utilisation of appointments across the three localities. General Practice ‘Learning Time’ is now embedded in annual plans (training afternoons for all general practice staff), iMatter surveys are completed annually and staff health, safety and wellbeing is a standing item on the Primary Care governance group. Primary Care staff complete annual personal development plans and access TURAS to ensure core training needs are met, and access LearnPro for additional learning. The Primary Care Team achieved the Health and Safety Silver Accreditation Award. Outcomes for the System All 23 GP practices participated in recent prescribing efficiency initiatives, which saw patient’s medication switched to less expensive alternatives. These efforts demonstrate a commitment to cost-effective prescribing and system-wide sustainability. Accommodation constraints are limiting the expansion of multi-disciplinary teams and the services that can be delivered, however, the Premises Group and Sustainability Group are actively addressing these issues, including progressing the Primary Care Premises Strategy 2023–2028. The Primary Care Team undertook public engagement in Bridge of Earn to inform a needs assessment in June 2023, with a report published in 2024. The collaborative Medlink used in 70% of practices Primary Care Team achieved Health and Safety Silver Accreditation Award in November 2024.
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22 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 engagement method was commended for its co-ordinated approach and for strengthening relationships with the local Community Council. A public premises survey was done in September/October 2023 with the report published in August 2024. Drop-in sessions led by third sector colleagues at PKAVS have opened up access to Primary Care services for people seeking asylum. This work will continue throughout 2025-2026 with the Primary Care Conference in September 2025 bringing together Churches Action for The Homeless (CATH), PKAVS, Mindspace and more. Further community connections are now in place through the Letham Hub as a key stakeholder supporting the HSCP commitment around early intervention, prevention. Primary care managed services were developed to support GP Practices, aiming to reduce workload for GPs and improve sustainability. A Primary Care ‘Primary Connections’ event is now scheduled for September 2025 which will bring general practice and HSCP managed services together to network, build stronger relationships and consider improvement ideas for the future. When GP practices close, it impacts substantially on the people that use the service. To mitigate this as much as possible, Equality and Fairness Impact Assessments (EFIAs) are completed whenever a practice signals their intention to close. An example of the mitigation offered was the commissioning of Perth Access Cars to facilitate support to local residents needing transport to see their GP, following the closure of a branch surgery. In conclusion, significant progress has been made with a clear focus on improving access, supporting integrated care, and addressing health inequalities. While financial, premises and workforce pressures remain, the strategic direction and collaborative efforts across Perth and Kinross provide a strong foundation for continued transformation in primary care.
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23 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 Finding my voice: A journey from silence to safety (Care Opinion Story) It was February 2025 when I first visited my GP practice in Perth. I had just spent nearly four months recovering from lower back surgery and was struggling badly with anxiety and insomnia. I believed I just needed a repeat prescription to get through the sleepless nights and the mental fog. But that appointment turned out to be the first step toward uncovering something much deeper - and darker - that I hadn’t fully acknowledged: I was experiencing domestic abuse. My GP referred me to MindSpace, a local mental health support service in Perth. That’s where I met [name], the counsellor who changed everything. She conducted my initial assessment and, despite there being a 3 to 4 month waiting list, kindly took me in right away. Her compassion and understanding were immediate. She helped me recognise that the abuse I was enduring wasn’t just in my head - it was real, and it wasn’t limited to just physical violence. Until then, I had thought domestic abuse only meant bruises and scars. She helped me see the emotional manipulation, coercive control, sexual and digital abuse for what they truly were. She didn’t just stop at helping me understand - she empowered me. She gave me direct helplines, support contacts, and the encouragement to seek help. That’s how I came across several organisations that became lifelines: Abused Men in Scotland, MoveAhead, The Neuk (a mental health and suicide prevention centre), and the Perth and Kinross Access Team for Adult Social Care. Through the Access Team, I was connected to [name], a social worker who didn’t just listen - she gave me hope. She immediately sprang into action, reaching out to her colleagues to start preparing for a safe house placement. She was proactive, reassuring, and determined to help me find safety. That’s when I was referred to MoveAhead, a community mental health and wellbeing service. There, I met [name], a gem of a person who works for the NHS. He was one of the few people who didn’t just understand my situation - he believed me. He made me feel seen and safe in a world where male victims of domestic abuse are often dismissed or overlooked. He literally walked from one building at Perth Royal Infirmary to the bus station just to pick me up for our first appointment. That gesture, small as it may seem, meant everything - it told me I wasn’t alone anymore. He went above and beyond his role. He treated me like a younger brother during a time when I felt utterly alone and broken. He listened without judgment, reassured me when I was full of doubt, and most importantly, he made me believe that men can be victims too. He regularly took me out on walks or to church, helping me open up in safe and calm environments. He even gave me his work number in case I needed him urgently and was always connected over email.
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24 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 Continued - When I had to make a last-minute change to the escape plan, he didn’t hesitate. He adapted immediately, rearranging everything to accommodate the new day, ensuring my safety came first. He also accompanied me to the council, helped me submit a homeless application, and even booked an appointment with my GP on my behalf to make sure my prescriptions were in order. These weren’t just professional duties - they were acts of kindness, humanity, and solidarity that I’ll never forget. During the process, I was also supported by [name] from the Ethnic Minorities Law Centre. He patiently helped with all the paperwork related to the Migrant Victims of Domestic Abuse Concession, using his legal expertise and calm presence to make a very chaotic time feel manageable. Thanks to all these incredible people, I’m writing this from the safety of my council-provided accommodation. My mental health score is getting significantly better, and I can finally breathe like a human being again. I'm no longer living under the shadow of constant surveillance and psychological torment. No more being questioned about where I’m going or who I’m meeting. No more being forced to share passwords, hide my belongings, or live on eggshells fearing the next outburst. No more being told which job I can or cannot take. No more emotional blackmail, threats, or being forced into intimacy. No more replying to constant check-ins or feeling guilty for seeing friends or using social media. I can finally remove the privacy screen protector from my phone, speak freely to my family, and not whisper in the garden to have a private conversation. The coercive control, emotional abuse, sexual intimidation, and digital surveillance had pushed me into hypertension, anxiety, depression, insomnia, and suicidal thoughts. I was alive, but I didn’t feel human. But now - I do. I feel safe. I feel hopeful. And I feel grateful. Every single person I encountered along the way - [names] and the incredible teams behind the organisations that stood by me - helped rebuild the broken pieces of my life. They enrolled me into workshops and seminars to help me rebuild confidence and rediscover purpose. When everyone else in the world made me feel like I had to constantly defend or explain myself, these people just welcomed me with kindness. They treated me like a human being - something I had almost forgotten how to feel. Thank you, from the bottom of my heart, to everyone who walked with me on this journey. And especially - thank you, [names]. I owe you both more than words can ever express.
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25 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 Learning Disability and Autism The implementation of the Learning Disability and Autism Strategy 2022-2025 has made significant progress in delivering person-centred support for people with autism and/or a learning disability. The SCOPE Team is multi-disciplinary and provides specialist support for people with autism and/or a learning disability who have complex needs. Care Opinion Story - I was under unbearable stress at work, was not sleeping, anxious and depressed. I live alone and felt I had no one to openly talk to. I felt like I was trapped, my problems and stresses building up with no release and I have to be honest and say that I did think about ending my life. I decided to go off sick from work and made an urgent appointment with the GP. This was the best thing I could have done as I was able to be open and was given the time to explain how I felt. I was signed off work and this helped remove the guilt I was feeling about taking time off and, most importantly, helped me to focus on my own wellbeing and deal with my problems. I was given an antidepressant and also made an appointment to see the wellbeing nurse. About a couple of weeks passed before I saw the nurse. In that time, I had been taking my meds and trying to eat well, stay active and talk to my family. I was starting to get anxious about going back to work and seeing [staff] helped to reassure me that I still needed some time to get better and went over where I could get support and also, importantly, helped me to plan how to tackle re-engaging with work. I still have some time before my sick line runs out and I will see the GP before that, so, will be able to make a decision about whether I feel ready or not at that time. In the meantime, I will continue to try and look after myself and follow the plan I made with [staff]. Care Opinion Story - I was referred to the mental health team by my GP after I reached out and needed help. I was given an initial appointment very quickly and re-directed to the most appropriate support within a week. I completed a 5-week stress management course which was delivered 1:1 by [staff] at [my GP] Surgery. I found the course extremely useful. [Staff] was very supportive and explained everything I was feeling and experiencing in a clear and understanding way. I was able to unpick so much of the anxiety and find ways to manage my stress and anxiety better. I feel I now have tools to help me in times of crisis, and it’s encouraged me to keep working on coping strategies myself. I’d like to pass on my thanks to [staff] and the mental health team for all of their support - they really helped me when I needed it.
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26 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 The integrated approach of the SCOPE Team helps service users to live as independently as possible in their own communities and, as the team’s reach has developed since it was establishment in May 2022, it has been possible to support more and more people with their needs. The team now supports 367 people which is an 8% increase since March 2024 and has successfully prevented hospital admissions and assisted people to return from long-stay hospital care to their community, in line with the ‘Coming Home’ ambitions. The SCOPE Team also directly supports carers of people with complex needs for example through the establishment of a new carer peer support group with 15 people showing an interest in sessions. Through development of the SCOPE team as part of the Complex Care Transformation Programme, the role of Family Group Decision Making (FGDM) Co-ordinator was developed. This role was seen as essential to ensuring that people and their families/carers had the opportunity and space to have their views heard and be actively involved in the development of their support. The role was initially funded temporarily through the Coming Home Community Change Fund for three years but has now been made permanent. Feedback questionnaires have shown an approval rating of 4.7 out of 5 (25 responses in 2024-2025) for the service, and the comments received have been extremely encouraging and demonstrated the positive impact the service has provided. To support further integration the role of Integrated Team Manager was created to manage SCOPE’s multi-disciplinary Health and Social Care professions (Learning Disability Health Services, Learning Disabilities Nursing, Physiotherapy and Occupational Therapy). Work has commenced to integrate the service further moving away from aligned services to integrated services, including co-location. SCOPE outreach workers have supported 31 service users over the past 12 months, an increase of six from the previous year. They have supported people transitioning to day opportunities, college and in some instances to new accommodation. The team have also supported independent travel, training, accessing community resources and commencing volunteering opportunities. The Learning Disability Day Support Collaborative initiative, "Joining Together for a Good Life," aims to improve day services for people with autism and/or learning disabilities in Scotland. Perth and Kinross is one of four regions collaborating with Health Improvement Scotland on this project. Sixty service users and/or their carers are participating. 4.7 out of 5 approval rating for Family Group Decision Making. increase in people supported by outreach workers. 24%
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27 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 In recent years we have successfully developed “Core and Cluster” supported accommodation for people with learning disabilities and autism so they can remain within their own community. This is now being expanded to the Crieff area and potentially to areas of highland Perthshire. This is a joint project with the community, the HSCP and housing colleagues to explore opportunities to meet service demands and deliver on strategic priorities of supporting people close to home, and to work with communities to design the services they need. The Independent Living Panel (ILP) and SCOPE Team support the local implementation of the Coming Home Report by enabling people with autism and/or a learning disability in a long stay hospital and/or placed outside the area to return to a community setting in Perth and Kinross. The ILP identifies supported accommodation for people with additional needs including those with a learning disability and/or autism. Over the past 2½ years, the ILP has supported 60 people into their own tenancies, including those into Core and Cluster projects. This model of delivering supported accommodation has increased the number of people supported in the community, from 332 in 2018-2019, to 413, an increase of 24%. The average cost of a package has reduced by £4.5k per annum (for people under 65) which is evidence of the cost effectiveness of the new model. Supporting people to access and remain in employment is a priority, and consultations with those with lived experience identifies key support themes and has highlighted barriers people experience in their education and employment. Currently the Employment Support Team assists 83 people with complex needs to overcome barriers and to be included in employment. Check In Giraffe provides valuable work experience and training to those facing barriers to mainstream work opportunities. 60 service users/carers take part in Joining Together for a Good Life. increase in people supported to live more independently. 8% 60 people with supported accommodation needs supported to live independently in the past 2½ years. increase in people supported in the community since 2018 to 2019. 24% Cost of care reduced by £4.5k on average. 67 different activities in the programme.
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28 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 To improve recruitment and retention of people who are neurodivergent, and to become a more inclusive employer, we held learning sessions for 82 managers and staff across Perth and Kinross Council services, which raised awareness and understanding of how to support neurodiverse colleagues. These sessions identified existing supportive resources and areas for enhancing recruitment practices. A Health and Wellbeing Passport was created to help employees share information that impacts their working life with their manager, for example that they have a medical condition affecting their mental or physical health, or that they are a carer for a family member. A staff group for neurodiverse employees was also formed and integrated with the existing Staff Disability Network. This partnership project led to sharing experiences at a Holyrood Insights Conference. To support physical health, Learning Disabilities Service has collaborated with GPs to provide 138 ‘annual health checks’ for people with a learning disability, in the 12 months to February 2025. These are aimed at reducing the impact that having a learning disability can have on people’s physical health. The Learning Disability Intensive Support Service (LDISS) also conducted 74 physical health checks and provided various clinics, including antipsychotic, ADHD monitoring, epilepsy, Clozapine, Down Syndrome screening, and lithium therapy. The Learning Disability Occupational Therapy and Physiotherapy Teams are developing Postural Care Services and have commenced assessments of people’s needs. A transition process between paediatric and adult physiotherapy teams has also been established to ensure a seamless transition for young people and their families. The “Hear Our Roar” involvement network launched successfully in June 2024 with the Centre for Inclusive Living, and will provide a valuable network for people with a learning disability to take part in civic life and for their views to be heard. In February, the group elected leaders from their membership, who will be guided by the Charter of 6,000 work experience hours delivered by Check in Giraffe. 301 sessions and more than 3,500 additional support hours. “I have always felt included and valued at Giraffe. People play different roles in the organisation, but there is no hierarchy of importance. No one person is more important than another.” 82 staff trained in neurodiversity support for colleagues. 138 health checks completed in 12 months. LDISS conducted 74 physical health checks.
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29 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 Involvement and improve the lives of people with additional support needs by increasing their ability to shape the decisions that affect their lives. A Neurodevelopmental Co-ordinator has improved access to attention deficit hyperactivity disorder (ADHD) and autism assessment. Based on feedback from people with autism and ADHD, and from their families and carers, we have implemented a new approach within Community Mental Health services which is furthered aimed at improving waiting times. This is at an early stage and over the coming year further feedback and the lived experience of those that need support will be gathered and used to shape future delivery. The Overnight Responder service (delivered by the Community Alarm service) uses technology in the form of Komp which allows people to communicate through a video call type function which is simple to use. Dedicated staff can provide a physical response if needed but often communication via a visual call is all that is needed. A trial of the technology in January 2024 with five people was such a success that it has been possible to reduce the reliance on ‘waking night’ support, improving efficiency. The technology has since been rolled out to further people expanding the trial. This has concentrated on Perth City with opportunities to expand the technology’s use in other areas, being explored. The Brain in Hand App (further information on this is in the Community Mental Health and Wellbeing Section) supports people with learning disabilities and autism to self- manage their mental wellbeing. The testimonial below reflects the positive experience of people using the application. Collaborative workshops and the “Collab” group have shaped improvements in autism and mental health services. There is a strong commitment to inclusion, independence, and co-production evident throughout HSCP services. We are enhancing our links with TAACT (Tayside Adult Autism Consultancy Team), to improve clarity of how to access services for people with autism. 67 people with lived experience attended ‘Collab’ workshops to drive change and improvement. The Collab gained funding to support the development of a training resource using storytelling. Technology Enabled Care trials reduced overnight staffing needs. “I can now travel on buses on my own, and more often than not when I do feel panicky, I know I can and do open my app for reminder of my tools to help keep mind occupied and not over thinking about my surroundings.” “Brain in hand helps remind me of appointments and keep track of my varied mental health on a daily basis. Problems and solutions help with anxiety as I don't have to think about solving my problem which only makes me more anxious.”
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30 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 PAMIS - 46 families in Perth and Kinross are registered with PAMIS, but the organisation reaches many more through open, inclusive community events. In 2024, two digital passports were supported and developed. We regularly connect with people who access our services to hear about their experiences and explore what matters most to them. The poster was created by a person supported by the care provider Ark at a Continuous Conversation event at Rannoch Road. The poem was composed by a member of staff after conversations with people in Core and Cluster accommodation and the testimonial reflects the positive impact on someone of being able to live independently. Lived experience shapes services, 67 people attended ‘Collab’ workshops. 219 enquiries and 100 online meetings. 50 face to face meetings and events. ”PAMIS staff consistently go above and beyond to support our family.” “PAMIS are always such a great support to me.” “Knowing that there is a family support service available in my area gives me great reassurance.”
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31 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 Older People’s Services As the Older People’s Strategic Delivery Plan (2022–2025) concludes, significant progress has been made in transforming services for older adults, despite ongoing demographic, financial, and workforce challenges. The key themes for this transformation are early intervention, shifting the balance of care, and optimising capacity and flow, each of which has seen tangible progress. Early intervention Early intervention efforts have expanded significantly. Programmes such as CAPA (Care About Physical Activity), dementia-friendly walking routes, and the Go for Gold initiative in care homes have promoted physical wellbeing and social engagement. Our Age Friendly work continues to develop, with a range of projects/groups being developed seeking to identify the challenges faced by older residents, and collaboratively develop practical solutions. We also celebrated International Day of Older People (1 October) with an event in the Civic Hall with several community groups What My Home Means to Me – A poem reflecting conversations with some people in Core and Cluster accommodation In my own house, my name on the door, A place of pride, I cherish and adore. Walls painted in colours I chose with care, A garden where I breathe the fresh air. Quiet surrounds me, peace I find, No more noise, just a tranquil mind. Visitors come, family and friends, no staff needed, we feel safe. I live my best life, with space to roam, Shows and discos, I call it home. Holidays planned, adventures await, From Poland to Wales, memories create. In the countryside, I feel alive, Walks and bus rides, I thrive. Football banter at the local pub, Outreach Garden, a social hub. More space now, no single room, Intercom buzzes, no need to assume. Support planned, week by week, Staff who listen, changes we seek. From homeless unit to a flat so grand, Quiet and spacious, a life well planned. Fitness shared, tips and tricks, Cats to care for, my heart they fix. Plans in place, two weeks ahead, Time alone, no longer a dread. Finances managed, cooking too, Dreams of learning, a car brand new. My home is more than walls and floors, A place to grow, to laugh, to be. This is what my home means to me.
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32 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 coming together, which highlighted the range of options and activities available to older people in their communities. 1 October at Civic Hall event to commemorate International Older People’s Day. Over the 2024 Olympic period, 20 care homes and three day centres took part in the annual Go4Gold challenge. Residents and service users take part in physical and wellbeing challenges in their own setting. This themed event was jointly facilitated by the HSCP and Scottish Care. Watch the full awards ceremony, Go4Gold 2024 (18.39 minutes) – with additional footage from parties at care homes to celebrate. We have supported the upskilling of staff from Live Active Leisure to enable them to deliver evidence-based falls prevention classes. These classes are based on later life training, postural stability instructor training, and have been shown to be highly effective in reducing falls among community dwelling older adults. Wellbeing Community Classes bridge the gap for older people between their home and Live Active facilities. They give the opportunity for people to be active in their community, closer to home. Over 2,000 Wellbeing Community Classes have been delivered supporting over 20,000 individual attendances with some people attending multiple classes. Examples of the types of activities undertaken include chair based social classes; social circuits; aqua circuits/aerobics; chair-based yoga.
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33 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 Volunteer engagement has also grown, with 110 active volunteers supporting care homes, inpatient settings, community services, clinics for vaccination and hearing aids and inpatient areas. Stanley Development Trust supports people to lead independent, healthy and active lives through activities and by creating a safe and sustainable place for further generations, by encouraging all members of the community to engage. Weekly soup and sandwich clubs attract older people who may not otherwise leave their homes. Stanley Development Trust have become members of Age Scotland, giving access to training and resources specifically for older people. 20,000 attendances at over 2,000 wellbeing classes. 110 Volunteers supporting people and services “I enjoy working side by side with others, making sure patients don't feel alone or simply just putting a smile on their face. I feel privileged to be one of those who are able to sit and talk to people, who may not have anyone else to talk to.” “Volunteering is about purpose, responsibility, and friendship. After being away from work for a while, volunteering has allowed me to work towards a needed service under a supportive team. It has given me the chance to be responsible without too much pressure and to grow those responsibilities as I recover. Lastly, it has given me new friends and acquaintances which make the volunteering enjoyable and make me feel a part of something bigger.” “The volunteers we have here at MoveAhead are an integral part of the team when it comes to the facilitation of the many groups that we have running at present. All of our volunteers go above and beyond what is expected of them in the respective roles. The service that the volunteers provide ensures that the groups can continue to run and also allows the MoveAhead staff to carry out their work supporting people in their local communities. I would like to take this opportunity to thank them for their continued support and service.” 496 attendances at the Lunch Club in 2024. 7% 280 attendances at the Soup Club in 2024. “Soup and lunch clubs are great value for money and a good social occasion for older people.”
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34 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 Shifting the balance of care In shifting the balance of care, 113 people were supported by local integrated care services to remain at home and avoid crisis placements or hospital admissions service (between April 2024 and February 2025), and urgent care Advanced Nurse Practitioners are working with locality teams to develop integrated hubs across Perth and Kinross. In Perth City the integrated hub is fully established enabling rapid, multi- disciplinary responses to people when their health deteriorates. Dementia support has expanded through Alzheimer Scotland’s Brain Health Centre and dementia cafés, with 275 Post Diagnostic Support (PDS) referrals made to Alzheimer Scotland and 279 people receiving PDS (Post Diagnostic Support). Alzheimer Scotland – The number of people receiving post diagnostic support rose from 258 in January 2024 to 289 in December 2024. Technology-enabled care has also advanced. The Community Alarm service handled 260,911 calls, with 99.26% answered within 60 seconds, up from 98.83% the previous year. This service now supports over 3,900 clients and 12,000 devices, ensuring timely responses and enhancing safety at home. Within the stroke unit at Perth Royal Infirmary a more person-centred approach has been developed. People who have suffered a stroke are now assisted to identify individual rehabilitation goals that are achievable and meaningful for them. Uptake and maintenance of person-centred goal planning is monitored regularly and has become a routine part of service delivery. Optimising Capacity and Flow Progress in delivering the DWD programme was presented to the IJB in March 2025. This programme takes a whole system view of the discharge process and is 113 people supported to remain at home. “Our Link Worker was extremely kind, sensitive and professional with our family and particularly Mum. Very practical guidance, readily available and flexible. I found her support to be invaluable in the early stages of Mum’s diagnosis, when I was struggling to access support via Social Work. My only criticism of the service is that it ends too soon, because I suspect things are just going to get more challenging. However, I massively appreciate the support we have had and the Link Worker was wonderful.” Over 99% of Community Alarms answered within 60 secs.
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35 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 transforming the flow of people through inpatient services and back to their home as early as safely possible. The national target for delayed discharges is set at fewer than 34.6 per 100,000 adults which has been consistently met in Perth and Kinross. This translates to 97.6% of adults being discharged without any delay. Key to this progress has been the redesign of Care at Home services. A new alliance- based contract introduced in September 2024, brought 15 providers into a collaborative model, improving flexibility and responsiveness, and this has helped increase hours of delivery from 6,302 to 8,073. This model of delivery is helped by the introduction of technology where providers access a mapping tool (PinPoint) which identifies where people need support with a new or altered package of care. Internally, HART and HART+ (Home Assessment and Reablement Teams) were restructured to support a Discharge to Assess model, enabling more personalised and timely discharges. Internally, teams delivering care at home have supported 256 people (an increase from 230) and increased hours of delivery from 1,450 to 1,847. These changes, alongside innovations such as the use of mapping tools, have helped reduce unmet care needs by approximately 800 hours since August 2024. As part of Older People’s transformation, we have developed individual communication and engagement plans as part of our process and we work closely with the engagement team to deliver this. Care Opinion is in place for all Older People’s teams, and the feedback is used to enhance and redesign services where needed. These achievements lay the foundation for future transformation. A ten-year Ageing Well Strategy is in development, aiming to address the complex needs of our ageing population, with the focus remaining on delivering high-quality, person-centred care, which enables older people to live well, independently, and with dignity in their communities. 97.6% of adults DWD. Unmet need reduced by 800 hours increase in internal care at home hours provided. 27% increase in external care at home hours provided. 28%
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36 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 Case Study - In January 2024. Rannoch Community Trust and Dunkeld, Birnam and District Community Development Trust collaborated to co-produce a community led approach to provide social care services for their communities. There have been a number of social work and social care representatives who are involved in project discussions. Consultation was undertaken with people who reside in Kinloch Rannoch in March 2025, this community asset project continues to develop and a service level agreement has been established to which formalises the nature of the service delivered. Testimonial - My Mum, who was 94 at the time, had a fall in her kitchen in mid-January and fractured her pelvis. She spent four weeks in Ninewells Hospital, Dundee and on her return home to Auchterarder she received care from the HART team. From the outset, the team was very professional; understanding of my Mum and her needs and exceedingly patient. I was concerned that she would have difficulty accepting care from male staff, but this was never the case. The aim of the carers was to always let her do as much as she could herself, make her own decisions about how she would like to do things and to do those things at her own pace - nothing has ever been rushed. Her short-term memory was badly affected when she came out of hospital, and this has led to a lot of confusion and lack of confidence for my Mum. This has remained a problem but with the ongoing patience and care from the team, her confidence has improved, and she can now manage her medication, which is sent in a weekly tray from the pharmacy. She also manages to get most of her meals by herself although she likes to have reassurance from her carer that she is doing things correctly. The family was involved in her care plan, and she was given a key worker who was extremely knowledgeable and informative about what the carers hoped to achieve. It was decided that one carer in the morning, teatime and nighttime would best serve her needs, and this has worked very well. My Mum now tends to doze quite a lot during the day, and the morning carer can assist with getting her lunch ready, if necessary. Help was also provided with bin collection. We were not aware that such a thing as "assisted bin lifts" existed and this has now been organised and makes everything much easier.
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37 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 Carers Delivery of the Joint Carers’ Strategy 2023–2026 is designed to have a positive impact on carers through a co-production approach, ensuring carers are valued, recognised, supported and empowered. An Equalities Impact Assessment was completed prior to the approval of the Carers’ Strategy to ensure no negative impacts of the actions in the strategy for people with protected characteristics. Continued - A carer is present when my Mum has a shower, although she likes to wash herself, and this gives both the family and Mum great peace of mind as she can be quite unsteady on her feet. My Mum's preferences are always asked for, and permission given, before anything is done - the very definition of Person-Centred Care. The carers are all very good at keeping in contact with myself and they are willing to have a chat and let me know how Mum is doing or if there is anything I need to know. I have had regular updates from her key worker, both by email and phone calls, and as I live in Devon this has been of great comfort, knowing that she is in very capable hands and her needs are being looked after. I cannot say enough good things about the HART team. Their excellent training and abilities shine through. I used to get myself very concerned about Mum being alone at home after my Dad died in 2014. She values her independence greatly and wants nothing more than to remain in her own home. After meeting the HART team, seeing their commitment to my Mum and seeing the improvement in her confidence over the past weeks, we now know that she can remain in her own home, with carers, at least for the foreseeable future. My brother, myself, my Mum and the entire family are eternally grateful to HART; many thanks to you all for your kindness, commitment and care. Testimonial - I was referred for a consultation to Occupational Therapy to help me to manage worsening arthritis in my hands. My Occupational Therapist was very friendly and approachable; she listened well and was very knowledgeable about how to treat my condition. She gave me a number of aids to use if and when I need them and advised me how to keep my hands as protected and healthy as possible. I saw her again two weeks later and she then gave me exercises to do and explained them fully. I then saw her six weeks after that and was able to see the benefit of doing the exercises and a marked improvement in my grip strength. I found the sessions very useful, and I see how important protecting my hands through strengthening exercises and extra care is for the future.
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38 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 The number of carers continues to grow, as reported in the most recent National Carers’ Census (21% increase from 2023-2024). Support to carers is provided by dedicated Carer Support Workers based in integrated locality teams. There are a further six funded Carer Support Workers, supporting carer needs in SCOPE and iDART teams, Day Services, Hospital-based and Palliative Carer Support. This promotes early identification of carers across the spectrum of needs and enables quick and effective support. Adult unpaid carers have a right to an Adult Carer Support Plan which identifies carers’ personalised outcomes and applies self-directed support options by dedicated carer support workers and wider assessing teams (Access Team). Any needs which meet the eligibility criteria, and cannot be met through universal or commissioned services, are supported internally. In 2024-2025, 692 unpaid carers were supported by statutory services. This includes the application of self-directed support, for example providing replacement care through day centres, the sitting service and residential respite. Replacement care allows carers to get a vital break from their caring role. Breaks enable carers the time for social, recreational, emotional or therapeutic activities, and supports improved life balance. The provision of personalised support strives to reduce any negative impact of caring, and to enable carers to continue to provide care. During the lifetime of this strategy there has been a significant reduction of funded permanent placements due to carers not feeling able to continue their caring role, reducing a further 10.5% this year alone, from 17.5% to 7% (April to December 2024). Not only does this suggest carers feel more able, but importantly, it also allows the cared for person to remain in their own home and community. 166 adult unpaid carers received Respitality Breaks. 252 adult unpaid carers were referred to Live Active. 472 carers received grants under the Time to Live Scheme.
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39 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 PKAVS Carers’ Centre - One of the standout achievements for the Carers’ Centre in 2024 was being awarded the Carers’ Trust for Carers’ Quality Award, a recognition of commitment to outstanding service delivery. PKAVS had 1,622 Adult Carers registered to their service this year, increasing 15% from June 2024. The Carers’ Centre has delivered the following supports to carers in 2024-2025. Carers are at increased risk of inequalities, including financial exclusion. Work with the Carers’ Centre, along with internal assessments, identifies carers experiencing financial difficulties. This work enables carers to be signposted to the Citizens’ Advice Bureau for financial advice. Citizens’ Advice Bureau have supported 847 unpaid carers, mainly with debt and energy advice. This is an increase of 40% from last year. 3,810 day centre spaces provided for cared-for individuals, offering carers valuable respite. 359 short breaks awards distributed through various funding streams. 672 packs of complementary therapy vouchers issued. Telephone Support: 7,026 outgoing calls made. Information and Advice: 27,540 requests handled. 168 adult carer support plans/self-assessments and 53 Young Carers’ Service delivered. 3,296 personal outcomes supporting 1,066 carers actioned. 179 counselling sessions provided for adult and young carers. 847 private tuition sessions delivered to 78 young carers approaching exams. 127 adult unpaid carers signposted to Citizens’ Advice and Welfare Rights by PKAVS. Citizens’ Advice supported 847 unpaid carers, mainly with debt and energy advice. “My husband has been attending the Day Centre every Wednesday for nearly a year. When I pick him up, he is always cheerful. I know he has enjoyed himself, even if he cannot always recall the details. This helps me relax during the precious hours I have to myself.”
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40 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 Carers have improved access to clear, accessible information, including refreshed online content, multilingual resources, and animated videos on Looking After Someone, Carers’ Rights, Emergency Planning for Carers, and Financial Support for Carers. Training opportunities are provided for unpaid carers to enable them to feel confident in their caring role. Additionally, we have targeted areas we know carers are likely to attend. We have worked with the GP Communication Group to improve identification of unpaid carers in GP practices, deploying information across 28 sites including GP surgeries and vaccine centres. Information resources are provided and promoted across community groups on potential support options for carers. Improvement work for the Carers’ Centres online resources is underway, and improvements have been achieved relating to information on the support carers can access at different transitional points in their caring role. Perth and Kinross Healthcare Improvement Scotland Frailty project strives to provide carers with useful information about the cared for person’s needs. This safeguards the person who is cared for, reducing the risk of readmission, and promotes the safety of the carer in their caring role. Training opportunities are provided for unpaid carers to enable them to feel confident in their caring role. In 2024-2025, the Carers’ Centre ran 61 training courses with 291 attendances. Multi-disciplinary team meetings and assessments ensure key information about individuals is shared appropriately. The Emergency Planning document for Carers has been revised so that the information recorded is complete for care and treatment planning, and translations are available in four languages, and in easy read. “The opportunity to attend trips and meet others in a similar position restores a sense of normality when things seem tough.” “Young Adult Carer events always have a positive atmosphere and act as an escapism from any anxiety and stress. Thank you to all involved. We had a marvellous afternoon, met new friends, and have a better idea of what is going on with support for carers. Food was amazing and the company fantastic. It has been great getting away from my mundane daily tasks. Thank you again for a wonderful day.” 61 PKAVS training courses with 291 attendances.
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41 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 Change Mental Health provide support to unpaid carers looking after someone with mental health needs and the Carers’ Centre signposts to relevant agencies. Carers’ assessments provide information around what carers need and information sharing protocols with other agencies have been developed so people do not have to share information multiple times. This is something people find frustrating and can be a barrier to access. The Hospital Discharge Team are supported by a Hospital Link Worker which has improved information sharing and supported discharges better, by ensuring carers have the information they need to continue in their caring role. Peer support groups, including cafés and a Carers’ Choir, have grown, and 360 grants were awarded to enable carers to take breaks. Carer Support Workers are embedded across services, and training has been enhanced for both staff and carers. The Training Programme for The Carers’ (Scotland) Act equips the health and social care workforce with the relevant knowledge to assess carers, and to enable effective supports to meet their individual outcomes. 117 Health and Social care professionals have undertaken this training over 21 sessions. Carers who are in employment can face additional barriers and challenges. Ongoing work to increase the number of Carer Positive employers aims to encourage supportive and inclusive workplaces for carers. This work has included our attendance at a local Careers Fair, employers’ fora, and using our presence as a commissioner to promote this vital initiative to help unpaid carers remain in employment. Perth and Kinross Council, NHS Tayside, our local Carers’ Centre, and Change Mental Health are all Carer positive employers, supporting the health and wellbeing of our employees who are also unpaid carers. The National Census and the Carers’ Census are used to gather feedback and evaluation to understand the impact of inequalities on unpaid carers including financial exclusion. Our work with PKAVS Carers’ Centre and signposting to Welfare Rights and Citizens’ Advice is intrinsic to the assessment of the financial impact of a caring role when undertaking an Adult Carers’ Assessment. Carers are actively involved in service planning through Carers’ Voice and through other strategic groups embracing the principles of Equal, Valued and Expert. Independent Advocacy is commissioned from Independent Advocacy Perth and Kinross (IAPK), which received 1,607 new referrals in 2024, and a total of 2,205 people were supported. 29.8% of referrals were for people who had previous IAPK support. Independent advocacy is offered to all service users including those whose liberty is restricted, for example, 116 referrals were for people in prison, and 59 referrals for inpatients of Rohallion forensic services. 25 referrals were for people supported by drug and alcohol services. IAPK supported eight Large Scale Investigations and 15 referrals 360 grants enabled carers to take breaks.
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42 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 were for unpaid carers. The New Scots Project was started in 2024 to support those living in Perth seeking asylum to navigate barriers and opportunities. Crossroads held their annual coffee morning with approximately 175 people attending, including care staff, board members, office staff and service users and carers. This is a very popular event, allowing staff to meet people they speak to on the phone and it lets the volunteer board members meet staff and services users. The Supporting Unpaid Carers’ Booklet was revised and promoted across community settings for Carers’ Week 2024. Promotion within communities at various times and venues throughout the year is highlighted on the Staying Connected map. Carers’ Week 2024 – Putting Carers on the Map Total Community Engagement – events happening within communities 45 Community Support – unpaid carers groups. 21 Information Drops – public access points. 105 Information Mail Drop – GP surgeries 28 “No one understands me, thank you for taking the time to listen and understand.” “You've been a huge support to myself.” “Your professionalism, passion, enthusiasm and caring nature should be bottled and given to everyone.” “They felt safe to express their views to you.” “Thank you for being there.” “I don’t think I'd have had the same response if I had done this on my own.”
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43 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 Substance Use In 2024-2025, the Perth and Kinross Alcohol and Drug Partnership (ADP annual update report) made substantial progress in delivering its Strategic Delivery Plan, focusing on prevention, harm reduction, recovery, and family support which was person-centred and trauma-informed. Testimonial from Carer supported by North Locality Team - Thanks again you wonderful woman, have made me feel like there’s hope again. Testimonial from Carer Supported by South Locality Team - Thank you for all you’ve done. We have a new carer, who I think will be really good. She’s very nice and first day is this Saturday so I can visit my sisters. I’m very excited. Testimonial from a Carer supported by Scope Team - My family moved to Perth and Kinross three years ago and within weeks I had a meeting discussing my role and needs, something that had never happened before! As a result, I was granted four hours weekly respite which I use on Friday mornings. This gives my son a busy time and allows me time to relax before the weekend. I have also used funds for an overnight away leaving the Personal Assistant in charge. My Carer Support Worker has encouraged me to consider doing this on a more regular basis and has said that she will fully support me in applying for funding. I also regularly receive information on meetings and events that are relevant to my situation. With the help of my support worker, I was recently awarded funds from Time to Live to attend a Linocut two-day workshop which I thoroughly enjoyed. I know that I can contact my Carer Support Worker at any time to discuss my needs and that she has a good knowledge of my situation. Testimonial from Carers’ Centre - I'll never forget the support I have received from PKAVS and The Carers’ Trust. I've met with such kindness and care from all of you, during such a heart-breaking time, at the loss of my son. Another part of journey. The £400 received in my bank on 23 December 2024 came at such a time for me to be able to catch my breath and time to refresh. I came into the centre because I knew I needed to do something. I took to the lady I spoke to straight away; she was so kind. She must have thought I was crazy, but it was so easy to open up to her. Even today speaking to you, I normally need to see someone’s face to get to trust them, but I can hear in your voice that you really care and that I can trust you. Thank you for calling and for listening.
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44 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 There was a significant expansion in youth and community engagement, with 25 people completing the Professional Development Award in Youth Work, and 14 more are scheduled for training. The Drug Ambassador Project was successfully integrated into the Mental Health Ambassador Programme, now active in all high schools, promoting early intervention and reducing stigma. More Alcohol Brief Interventions (ABIs) were delivered than had been achieved previously, with 158 delivered in the final quarter alone, which is the most delivered in any quarter in recent years. There has been a reduction in drug-related deaths over 2024-2025, and community-based recovery has been strengthened through peer-led initiatives, lived experience networks, and wider Naloxone distribution, with a 37% increase from quarters three to four. There has been an increase in the number of reported Nitazene detections, which are a new group of potent synthetic opioids, posing a substantial risk of overdose, drug- related hospitalisation and drug-related death. In response, the ADP commissioned Turning Point Scotland (TPS) to undertake a local drug testing project. The three-month study saw staff from the TPS Perth and Kinross Floating Housing Support Service offering Nitazene testing strip kits to people known to be using street drugs and offering harm reduction advice, and ensuring people have naloxone and know how to use it. This project is being evaluated and, if successful, the ADP will work with other partners to widen the roll-out of drug testing strips. The ADP also strengthened its Recovery-Oriented System of Care (ROSC), ensuring more integrated and person-centred support to provide the right support, at the right time for individuals, families and communities impacted and harmed by alcohol and drugs. This will be further supported in 2025 as the ADP has partnered with SRC (Scottish Recovery Consortium), a national organisation which supports, represents and connects recovery across Scotland. Progress in introducing MAT (Medication Assisted Treatment) Standards has already seen improvements to the services that people receive. This is evidenced by more people starting treatment and shorter waiting times for treatment to commence. The ADP has also expanded access to treatment, with 80% of those referred offered appointments within three weeks. For Opioid Substitution Therapy (OST), although the caseload declined slightly from 471 to 446 over the year, people who accessed treatment have had the benefit of three options for their OST, and 75% of people offered the treatment receive a prescription within one day of engaging with the service. Community engagement flourished with the launch of a new ADP website, the expansion of recovery cafés in Perth City, Pitlochry and Aberfeldy, and the second annual RecoverMay celebration, which included events like art exhibitions, recovery coaching graduations and outdoor activities like the Ben Vrackie Walk. Recognising the impact of substance use on families, the ADP funded several initiatives, including Hillcrest Futures, Tayside Council on Alcohol’s Birch Project, and Barnardo’s Hopscotch. These services provided trauma-informed, whole-family support, addressing both prevention and recovery.
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45 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 Tayside Council on Alcohol (TCA) - Through the delivery of counselling and creative therapies, the TCA supports individuals experiencing difficulties, or with concerns around alcohol, gambling, cannabis, cocaine and other non-opioid recreational substance use. TCA also provides support to significant others who are affected by these issues within their family or wider social network. From January to December 2024, there were 224 new referrals and a wait time of three months. All clients had a first contact appointment within three weeks of referral, and these had an engagement level of 72%. For assessment and one to one counselling appointments the engagement level was 71%. iDART (Integrated Drug and Alcohol Team) moved to significantly improved premises, valuing people who use services and providing support in a quality, trauma-informed environment. During 2024-2025, the team developed a multi-agency consultation hub for people with co-occurring mental health and substance use issues who require additional support or specialist care and treatment. Coupled with the continued development of a local mental health and substance use protocol, this will ensure that people will benefit from a whole system, person-centred and evidence-based care plan throughout their recovery journey. This will build on the improvements already evidenced following the implementation of MAT Standard 9. Overall, the ADP’s work in 2024-2025 reflects a comprehensive, collaborative approach to reducing harm and supporting recovery across Perth and Kinross. Collaborative working with third-sector partners, Police Scotland, and NHS Tayside has underpinned progress, ensuring services are responsive, inclusive, and aligned with the national mission to reduce drug harm and save lives. Skinnergate supported 99 people over the year. It is now a pet friendly temporary accommodation service which improves the emotional wellbeing of residents. Five dogs were accommodated with their owners over the year. The first "Sober Event" was held in Perth and included music, comedy and food. A Recovery Café was started, and it provides a safe, supported environment. Trauma informed spaces were introduced within the unit for staff and clients. Adult Support and Protection A multi-agency approach to safeguarding people is taken in complex cases of adult protection concerns. The Adult Protection Committee (APC) programme of self- evaluation and audit work shows that where complexity exists, we use the Adult Support and Protection Act to deliver a multi-agency approach to safeguarding. “Skinnergate saved my life.” “The staff go above and beyond.” “Love the new residents’ lounges.” “Great place to be.”
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46 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 Analysis of adult protection referrals has led to the implementation of triage pathways for referrals of those considered at risk of harm who experience addiction and/or mental health concerns. This supports the principles of early intervention and prevention within an HSCP context. The ASP assessment framework was refreshed and updated using the findings from the ASP audit and self-evaluation work. It takes a more qualitative approach and focusses on the impact and the outcomes for the adult and his or her unpaid carer. The APC (Adult Protection Committee), made up of representatives from a wide range of professions including Police Scotland, Social Work and Health, supports a trauma informed approach to safeguarding and, to embed this in all that is done, specific ASP trauma informed e-learning has been developed for staff. The APC sees engaging with adults and their unpaid carers throughout the ASP episode as a key area for improvement. The APC audit following the publication of national Adult Support and Protection guidance in this area supports this. Our Adult Support and Protection workforce is sufficient to ensure that those who live in urban and rural areas are safeguarded under the ASP Act equally. In terms of cross cutting work, the adult and child protection committees are undertaking joint community engagement work with the Letham community to understand what adult and child protection means to them. Lead Partner Services A recent report to the IJB, Lead Partner Services Perth and Kinross, outlines the responsibilities for Perth and Kinross IJB in relation to lead partner services. The Lead Partner Services Update for Angus gives an update on the position of the services for which Angus IJB holds lead partner responsibility. Public Dental Our Public Dental Service (PDS) is delivered Tayside wide, taking forward the following priorities: • Continued provision of dental services and preventive care for core PDS patients across Tayside. (Core PDS patients are those who cannot access care in general dental services). • Maintain current service levels for sedation referral service for children and adults. • Maintain current service levels for paediatric and special care adult referral service. • Maintain current service levels for general anaesthetic (GA) paediatric exodontia. • Improved GA access for special care adults. • Continue rolling programme of dental examinations and comprehensive dental care for Care Home residents. • Respond to patient feedback particularly through Care Opinion as a means of continued service improvement.
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47 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 The service provides care for people in high priority and vulnerable groups that cannot access dental care elsewhere. It provides a referral service for treatment which requires general anaesthetic or sedation, and for patients requiring specialist input. This covers a wide range of dental care for paediatric and adult patient groups. Teaching for undergraduate dental and dental therapy students is provided through the Outreach Teaching Programme, and there is a daily emergency service for unregistered patients. Dental care is provided at fixed clinic locations, in prisons, care homes and hospitals and in domiciliary settings. The service operates a mobile dental van for socially excluded groups and special care patients who cannot leave their care home setting and there is provision for bariatric services and wheelchair access at fixed clinics in Perth, Dundee and Arbroath. Patients can be treated in their wheelchairs. NHS Tayside’s Oral Health Improvement Team continue to deliver the national oral health improvement programmes (Childsmile, Caring for Smiles, Mouth Matters, Smile4Life and Open Wide) with ongoing development to collaborate with wider partners and reach out to support those at greatest risk of poor oral health. Based on clinical evidence, the Childsmile programme is adapting to focus on the aspects which have been demonstrated to be most clinically effective. Over the next two years there will be a change in emphasis to focus on supporting children and families from the most deprived areas and to optimise the supervised toothbrushing programme in nurseries and targeted primary schools, which has been shown to be a hugely successful cost- effective intervention. The PDS delivers the National Dental Inspection Programme (NDIP) every year and assesses the dental health of Primary 1 and Primary 7 children. This data supports access to dental care for vulnerable and high-risk children. The NDIP report published in October 2024 describes the detailed inspection of Primary 1 children during the academic year 2023-2024 when 74% of Primary 1 children were found to have no obvious decay experience, similar to the national figure of 73.2%. These figures had remained relatively stable since the previous detailed inspection of Primary 1 children in 2019-2020 (73.4% in Tayside and 73.5% nationally). No detailed inspection was undertaken from 2021-2022 as a result of disruption during the pandemic. NDIP reports have consistently described a social gradient in oral health, with children from more deprived areas more likely to have experienced dental decay. This is evident in Tayside in both Primary 1 and Primary 7 with children from less deprived areas being more likely to receive a report of ‘no evidence of cavities’. At national level, based on results of detailed inspections it is notable that the 2024 report, for the first time, describes improved oral health only in Primary 1 children from the most deprived areas (SIMD 1 and 2), with a slight worsening in children from less deprived areas. Though clear inequalities in oral health remain evident the gap has reduced slightly. 74% of P1 children have no obvious dental decay.
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48 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 General dental practitioners have been recruited to work sessions in Perth Prison to address waiting lists there. Limited access to adult special care general anaesthetic lists and subsequent long waits are being addressed at Board level. The Public Dental Service continues to face some recruitment challenges and there are still some vacant dental officer positions. Several training level posts were also unfilled this year and this has also had a negative effect on service provision. Demand for dental care is high, and the availability of General Dental Services is limited with only one practice in Perth and Kinross currently accepting new NHS patients (limited postcodes only). Further specialist services, including emergency care is provided for unregistered patients via Dundee Dental Hospital. We have reduced waiting times for paediatric tooth extraction. The median wait in Tayside is now 59 days. 92% waits are under 26 weeks (Scottish figure 65% waits under 26 weeks). The Public Dental Service deliver a highly valued drop-in service for people experiencing homelessness or experiencing addiction through a Mobile Dental Unit which visits locations such as The Steeple in Dundee. The Public Dental Service works with partner organisations such as Parish Nursing to deliver care to this vulnerable group. The value of this service has been recognised through awards including the Tackling Health Inequalities Award at Scotland’s Health Awards 2024, and the bronze award for Social Impact and Global Citizenship at the 2024-2025 NHS Tayside Star Awards. The undergraduate teaching provided through the Outreach programme has delivered consistently high standards of teaching for undergraduate dental and therapy students from the University of Dundee, and University of the Highlands and Islands. The Outreach service allows patients who do not meet the Public Dental Service remit but are suitable for student teaching to receive care under supervision at our centres. The Outreach centres at Broxden Dental Centre Perth, Kings Cross Dundee and Springfield 92% waits under 26 weeks for paediatric tooth extraction.
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49 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 Medical Centre Arbroath were inspected by NHS Education for Scotland this year and all received excellent reports. Podiatry NHS Podiatrists are experts in all aspects of foot and lower limb function and health; relieving pain; maintaining tissue viability; treating wounds; keeping people mobile and active, thereby supporting people to maintain their independence and quality of life. The podiatry service supports the National Preventative and Proactive Care Agenda by identifying and mitigating the impact of future foot health demands and reducing the burden on both primary and secondary care. Demand for the service remains high, driven by an ageing population and a growing number of people presenting with long term conditions leading to complex lower limb problems, resulting in greater dependency on the service. The service has a fluid and constantly evolving clinical caseload of approximately 6,379 people and delivered approximately 46,071 patient contacts in this year. The referral rate remains consistent at an average of 600 per month. Podiatry new patient referrals are prioritised as follows: Testimonial - My Dad developed a gum abscess and subsequently required treatment to resolve this. He was reviewed by a very kind and caring Dentist called [name] who was accompanied by a Nurse called [name]. They were both extremely friendly, supportive and very professional in a time when my Dad was experiencing pain and discomfort. In addition, my Dad was anxious as this was affecting the caring role he provides for my Mum. My parents are elderly and mostly housebound, so the domiciliary care and attention delivered by both was beyond excellent. They provided the relevant dental treatment and reassurance with a calm approach which made the world of difference to my Dad. Our family are extremely grateful to [them] and can’t thank them enough for their support and kindness. Testimonial - I started to get toothache and swelling but being so scared of the dentist I ignored the is for a few days until it got to the point where I had to call. I phoned Broxden and got an emergency appointment with a fifth year dental student. Her and the dental nurse could not have been nicer to me. They were so kind and explained everything, even wiped my tears as I was so scared. The treatment all went so smoothly, and I didn’t feel a thing. 600 people per month are referred to Podiatry resulting in over 46,000 patient contacts.
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50 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 • Urgent - infection/ulceration – appointed within five working days. • Soon – moderate/high risk diabetes foot risk score, severe peripheral arterial disease, nail surgery – appointed within 12 weeks. • Routine – referrals that do not indicate any condition which puts the person at immediate risk but meets the clinical criteria for assessment are placed on a waiting list with a target date of 18 weeks. The service continues to meet the ‘urgent’ and ‘soon’ targets. Improvements have been made over the last year in relation to the routine waits, with 308 people waiting over 18 weeks at the end of April 2024, reducing to 93 at the end of March 2025. Recruitment to podiatry posts continues to be a national issue. In response our service has increased its capacity for student placements and improved the placement programme offered to them. As a result, we have been able to appoint new graduates over the past few years, including four full-time equivalent graduates this year. The service has worked collaboratively with the Scottish Social Services Council (SSSC), and NHS Fife to produce two, foot care resources – Personal Care for Feet and CPR for Feet. These are designed to support staff working in various care sectors to help them maintain and improve their knowledge and skills in footcare. Below is an example of the impact of the learning from these resources: “I've discussed the importance of feet care with a colleague, who again was not aware until discussing how important feet care is in our line of work, and we both never realised how dangerous pressure ulcers can be, never realised people could end up needing amputation through this.” In the previous year, the service introduced Care Opinion to gain feedback on the Podiatry Nail Surgery Service. During this reporting period Care Opinion has been rolled out to include Podiatry Musculoskeletal and Rheumatology Services. Testimonial - My daughter aged 10 had to have a partial toenail removal due to a recurring in growing toenail. The podiatrist and healthcare worker who dealt with my daughter were truly wonderful. They were so good with her as she was really scared, they made a very frightening experience for her as easy as possible. Testimonial - I attended in the morning, the podiatry/rheumatology department at PRI, Perth and wanted to express my thanks for the staff members I met with. Especially the young lady who helped me tremendously. My experience was 100%. Thank you! Testimonial - Excellent service at MSK Podiatry, Ninewells Hospital, Dundee. Was seen by [staff], a very caring and competent professional who listened to me, explained what the problem was and what exercises to do to improve my condition. NHS at its best. Thank you.
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51 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 Patient Initiated Returns (PIR) - Continual increase in demand for podiatry care and the increasing burden of wounds necessitates the transformation of parts of our service to help us tackle the challenges we face and maintain a service fit for future demand. The service sees the introduction of PIR as a positive change. It empowers patients with the knowledge to take control of their own care based on their individual needs at any given time. PIR gives patients control over their follow-up care allowing them to be seen quickly when required, while avoiding the inconvenience of appointments of low clinical value, for example, a patient attending a routine appointment as part of their care plan for us to check or monitor, despite nothing in their foot health having changed since their last visit. For patients this means more flexibility around when they access care. For clinicians, it means fewer appointments of low clinical value freeing up time to support the patients most in need, and decreases cost associated with these routine or Case Study - The introduction of Prescription Only Medicines Supply (POM-S) NHS Tayside Podiatry Service is looking to introduce a First Contact Nail Surgery Service to improve the patient pathway/journey for people with painful nail conditions whilst supporting the antimicrobial agenda. Podiatrists registered with the Health and Care Professions Council who have a POM-S annotation on their registration can lawfully supply and administer certain medications within the course of their professional practice. A recent audit on nail surgery pathways highlighted a variation in practice within Primary Care in the use of antibiotic therapy prior to referral to podiatry for acute nail conditions. It was noted that many patients had received multiple courses of antibiotics before a referral to podiatry was made. This practice does not comply with antimicrobial stewardship guidance and has a detrimental impact on; the patient experience/journey and capacity within General Practice. Continued - The service invokes the use of the podiatry POM-S annotation for podiatrist working within NHS Tayside. To comply with local NHS governance arrangements the service drafted NHS Tayside Podiatry and Prescription Only Medicine (POM-S) Exemptions Guidance. This guidance was required to be presented to both the NHS Tayside Medicines Policy Group and the Antimicrobial Stewardship Group. In addition to support the continued professional education of staff and to maintain safe and effective practice, a POM-S LearnPro has been introduced. The guidance document was supported and approved by both the above groups. The service now has governance in place to support the use of POM-S annotation allowing further improvement as part of a test of change to address above situation.
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52 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 low value follow-ups, thereby supporting the long-term sustainability of the service. It should however be recognised that this model will not be suitable for our entire patient cohort and further governance and guidance around application of PIR is in the process of being developed. Podiatry Led Vascular Assessment Service - Evidence shows that Podiatrists are clinically effective in reducing health and social care cost burdens by improving early diagnosis of peripheral arterial disease (PAD). NHS Tayside Podiatry has commenced a two-year project to support the early identification, diagnosis and management of people with symptoms of PAD; with a view to improve health and reduce the risk of associated heart attacks, strokes and lower limb amputations. It is anticipated that providing vascular trained podiatrists to assess, diagnose and triage people with suspected PAD, will see a reduction in the demand on other primary and secondary care services in relation, not only to the PAD management, but also to wider cardio- vascular health. Evidence shows that maximising on the skills of a community-based vascular podiatrist also has the potential to reduce the future burden on social care services. Prison Healthcare Prison Healthcare provides Primary and some Secondary Health Care Services to the populations of HMP Perth (His Majesty’s Prison), HMP Castle Huntly and the HMP and YOI (Young Offenders Institute) Bella (Dundee). The service operates seven days per week (daytime hours only) and aims to deliver equitable provision of healthcare to that delivered in the community. Out of hours care is provided by NHS Tayside, Out of Hours Service and emergency care is via the Scottish Ambulance Service. HMP Perth has a population of approximately 650 prisoners at any one time with an annual turnover of approximately 3,500, with prisoners primarily being from Tayside and Fife. HMP Castle Huntly is a national progression establishment, offering access to the community through placements and home leave. It is now recognised as a single cell site, with a design capacity of 184, however, an assessed capacity can be increased 220 where necessary. HMP and YOI Bella was initially designed for women from Tayside and Fife, however the unit now provides accommodation for 16 women from the East of Scotland. It provides secure living accommodation through independent housing units, to support people to learn life skills, build independence, self-reliance and resilience, before accessing the community. Prison Healthcare services span a number of specialties; Primary Care - GP and Nurses, Clinical Pharmacy, Pharmacy Technician, Optician, Dentistry, Podiatry, Psychology, Mental Health Team, Substance Use Team, Occupational Therapy, and Physiotherapy, who deliver services such as management, administration and distribution of medication (in possession and supervised medication), sexual health and blood borne virus, enhanced care, first responder services for acutely unwell or injured people. Everyone admitted to HMP Prison is assessed by a nurse on admission and by a doctor within two weeks. Individuals transferred to HMP Castle Huntly or HMP Bella (non-admitting prisons) receive a transfer assessment by a nurse within 72 hours of arrival.
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53 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 Successes over the past year: • Routine GP waiting times are now three weeks. • Routine Mental Health Nurse Waiting Times are now four to six weeks. • Mental Health Team Delivery of Safety and Stabilisation and Anxiety Management Groups. • Introduction of computer based psychological intervention for those with mild to moderate mental health conditions. • Focused MDT medicines management service improvements for safer prescribing. • Successfully recruited a full-time physiotherapist to deliver services across all three establishments, including a pain management group. • Pain Association Scotland delivered pain management sessions in HMP Castle Huntly and HMP Bella. • Introduction of diabetes and asthma long term condition clinics. • Move to Advanced Nurse Practitioner and Specialist Pharmacist run clinics to review all transfers into HMP Castle Huntly, freeing up GP time. Our challenges over the past year have been the administration of medicines to approximately 250 patients each morning and 150 each evening. There is no substantive GP workforce, we have nursing and pharmacy vacancies and a growing demand for Psychology and Physiotherapy Services. From 1 March 2024 to 28 February 2025, the service received 397 complaints. Stage 1 complaints accounted for 55% (n=217) and stage 2 complaints were 180. 12% of complaints were fully upheld, 61% were not upheld and 23% were partially upheld. The top three complaint themes were medication related (40%), disagreement with treatment/care plan (37%) and waiting times (17%). The service is progressing work with the ‘What Matters to You’ team to implement the, What Matters to You principles, and a culture of kindness, jointly with the Scottish Prison Service, exploring ‘What Matters to You’ with patients across the three prison establishments. Joint Trauma Informed Leadership Training with the Scottish Prison Service at HMP Castle Huntly, with the vision of expanding and including HMP Perth, to support working towards trauma informed prisons is being progressed, and we are expanding the workforce, introducing new roles for Advanced Nurse Practitioners across both Primary Care and Substance Misuse, Clinical Educator and Senior Pharmacy Technician. We are strengthening nurse leadership at HMP Castle Huntly and HMP and YOI Bella. We are promoting staff wellbeing and embedding SAFECARE to meet the requirements of the Healthcare Staffing Act. We are also strengthening care and professional governance and recommencing service user forums to aid service improvements. We
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54 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 are raising the profile of prison healthcare and are continuing to work with the National Prison Healthcare Network. Hillcrest Futures has employed a peer worker based within HMP Perth Prison who provides activities to deliver harm reduction and peer led recovery. This is delivered in partnership with the Scottish Prison Service. Type of Group Number of Groups Total Attendees SMART Recovery 49 483 Relapse Prevention/Mindfulness 40 312 Recovery Café 64 501 Recovery Discussion/Book Group 43 289 Recovery Coaching 39 302 Art Group 48 293 Yoga 38 478 TOTAL 321 2,658 Prison One to One Total Number of People Harm Reduction 66 Mental Health/Wellbeing 42 Advice and Information 72 Recovery Support 81 Family Interventions 40 TOTAL 301 Workforce Perth and Kinross is dedicated to creating a learning culture that respects, equips, and supports our workforce. Through collaborative efforts, creative approaches, and a commitment to continuous improvement, we strive to make a tangible impact on our workforce and the communities we serve. Our learning and development initiatives from April 2024 to March 2025 reflect our values of integrity, compassion, and ambition, driving us towards a sustainable and inclusive future. The HSCP developed and implemented a comprehensive 3-Year Workforce Plan (2022–2025), structured around the Five Pillars of Workforce: Plan, Attract, Train, Employ and Nurture. This strategic framework aims to ensure a sustainable, skilled, and responsive workforce capable of meeting current and future demands. Governance and Structure - A Workforce Programme Board has been established and is supported by four subgroups for Education and Development, Safer Staffing, Testimonial: The Recovery Hub has been brilliant, I have learned so much, and I will not be using drugs again. It’s hard sometimes when you are on your on in your cell, but I am determined to stay clean as drugs have really messed up my life. Testimonial: I can’t believe that you can do all the things in the Recovery Hub when you are in Prison. I never thought I would do yoga, but it has been really good, and I also use the breathing techniques then I am feeling stressed, I can’t recommend the Hub enough.
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55 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 Recruitment/Retention and Attraction, and Staff Health and Wellbeing. A Workforce Planning Programme Manager was appointed in 2024 to drive delivery across services. Legislative Compliance - The Health and Care (Staffing) (Scotland) Act 2019 mandates annual use of staffing level tools and the Common Staffing Methodology. A pan-Tayside schedule and local training supports compliance. Workforce Planning and Integration - Locality Integrated Teams enhance multi- disciplinary collaboration and reduce duplication. The Six Steps Workforce Planning Methodology is used to ensure consistency and responsiveness, and this is being rolled out across each locality. Progress Across the Five Pillars Plan - Systems for real-time staffing data, risk escalation, and workforce analytics are being developed and a pan-Tayside data group has supported evidence-based planning. Attract - Recruitment campaigns, youth engagement, and international recruitment (for example, six staff from the Philippines) are progressing. The pilot participation in the Newly Qualified Social Worker Supported Year Framework has doubled. Train - Expansion of foundation, modern, and graduate apprenticeships. Development of Band 4 Assistant Practitioners and Advanced Nurse Practitioners (ANPs) to address skill gaps. Succession planning workshops and competency frameworks are being implemented. Employ - New employment models and career pathways have been explored and E- rostering and SafeCare systems have been rolled out to support safe staffing. Nurture - Initiatives like “What Matters to You” and Leading Excellence in Care promote staff wellbeing and engagement. Annual appraisals, clinical supervision, and restorative practices are emphasised. Social care and nursing vacancies have decreased acceptably. Unmet Care at Home hours reduced from 1,500 to 1,000 per week. Persistent challenges remain in recruitment, especially in Occupational Therapy and AHP roles. Significant strides have been made in workforce development, integration, and retention. Continued focus on the Five Pillars and collaborative governance is essential to meet strategic goals and ensure high-quality care delivery across Perth and Kinross. Learning and Development We are committed to our ambition of being a learning organisation and this underpins the approach to workforce development, recognising that individuals bring unique skills, qualities, and attributes. Guided by the values of integrity and compassion, the aim is to create the conditions where both the workforce and communities can learn, grow, and flourish. A diverse range of learning opportunities is offered to our workforce which are aligned to statutory requirements and developmental needs, supporting personal, professional, team, and partnership growth.
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56 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 Listening to the workforce and our communities is central to shaping learning experiences. Insights from both data and lived experience inform the co-design of inclusive, innovative learning that respects individual learning styles and equips people to collaborate and deliver care with empathy and confidence. Ongoing engagement has helped identify learning needs and shape targeted development opportunities. These include accredited qualifications, personal and team development, peer learning forums, and improvement and innovation sessions. The learning culture aims to build knowledge and skills while unlocking the potential within individuals to deliver personalised, compassionate support. Strategic learning and development plans are informed by workforce feedback, service provider input, and local and national priorities. The current ‘Learning and Development Plan on a Page’ includes areas such as Practice Learning, the Newly Qualified Social Worker Supported Year, SVQs, Trauma-Informed Practice, general development, Living Well care, and Manual Handling. These plans support continuous professional development, compliance with legislation, and alignment with national policy. Sustained financial investment reflects the recognition that learning is central to workforce wellbeing, productivity, recruitment, retention, and service performance. Despite financial pressures, efforts continue to secure additional funding to sustain and enhance learning opportunities. Learning events, workshops, and development days have been positively received, with feedback highlighting their practical relevance and impact on service delivery. The Learning and Development team works collaboratively across the Council, Health and Social Care Partnership, NHS Tayside, multi-agency partners, and the public to maximise capacity and impact. A skill-mix approach supports co-ordination and delivery, even amid staffing changes. Progress against the Strategic Plan We continue to work in partnership with employers across statutory, third and independent sectors to attract and retain the best candidates for vacant roles. To create a culture of continuous improvement and development, a ‘grow our own’ approach, we continue to develop career pathways and succession planning mechanisms. We continue to engage with local Higher Education institutions, Practice Professional Development, NHS Education for Scotland and the Scottish Social Services Council. This is to ensure our staff are well informed and that we have a comprehensive local, regional and national approach to training at all levels. Our ‘What matters to you’ approach to staff engagement supports us to listen to service user and staff concerns and provide them with support and mitigate issues which might adversely impact work experiences and retention at an early stage. We promote a culture of continuous learning and development in terms of personal skills development and new ways of working. We are undertaking preparatory work for the introduction of real-time staffing data collection, improved risk escalation processes and improved risk mitigation across the
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57 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 partnership and key stakeholder organisations. This is to provide staff with a continually improving and safe working environment, promoting the health and wellbeing of staff. To ensure we treat staff fairly and consistently with dignity and respect in an environment where diversity is valued, we have designed mechanisms to address cultural barriers and prevent discrimination toward ethnic minority workers. These mechanisms are equally accessible for all groups, irrespective of sex, disability or any other protected characteristic. Leaders are expected to address organisational cultures and develop a culture where concerns can be raised freely and there is confidence that appropriate action will follow. Leaders should model the behaviours they expect of others and make diversity and inclusion a priority. To ensure that our area is an attractive and forward-thinking place to work, we promote and develop new roles, such as Advanced Practice roles and those for Band 4 Healthcare Support Workers. We continue to work with key stakeholders to engage with young people in schools and youth groups as an Employer of Choice, and we explore the potential of international recruitment programmes. We are developing current and future leaders by supporting the implementation of Excellence in Care, and Leading Excellence in Care frameworks across the Partnership. We are reviewing and developing measures to support the retention of experienced staff in our services and continuing to work in partnership with employers across statutory, third and independent sectors to attract and retain the best candidates for vacant roles. We value the role of each profession, community and organisation we work with, and to understand what each partner brings, we review recruitment and retention pathways and continue to explore and develop new models of employment into health and social care roles. We work with partners and key stakeholders to increase the number of sustainable employment programmes we participate in, including foundation, modern and graduate apprenticeships, ‘Earn as you learn’ and the Princes Trust. We continue to work in partnership with employers across statutory, third and independent sectors to attract and retain the best candidates for vacant roles, aligning all partners to locality integrated structures. We are further developing relationships with NHS and third sector partners to allow more people to be signposted to community services, by promoting a culture of continuous learning and development in terms of personal skills development and new ways of working. We have begun the process of reviewing our statutory responsibilities in collaboration with our partners in both General Practice and the third sector, with the aim of providing an integrated, whole system service. This will provide an opportunity to explore alternative roles and ways of working; these will support mutual development and creativity across the service, and create opportunities to recruit, retain and develop our workforce within the framework of an integrated care model. Our work to ensure all partners understand what is available within our localities continues by developing and implementing systems and processes to gather and report on workforce data and do preparatory work for the introduction of real-time staffing data
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58 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 collection, improved risk escalation processes and risk mitigation in the Partnership and key stakeholder organisations. Our career development and succession planning processes reflect our commitment to the provision of integrated health and social care services including for our specialist services. We review skillsets, roles and remits in the framework of ‘right staff, right skills, right place, right time’. Independent Inspection During the period April 2024 to March 2025, the inspection report regarding the inspection of HMP Bella in March 2024 was published. There were also visits by the Mental Welfare Commission to our three inpatient psychiatry of old age, mental health wards at Murray Royal Hospital. The Care Inspectorate has also carried out a programme of risk based inspections to commissioned Care Homes and Care at Home services. HM Inspectorate of Prisons for Scotland inspected HMP Bella in March 2024. The Bella Centre became operational in 2022 and houses low supervision women and young people. Located in the Hilltown area of Dundee, the centre's accommodation consists of three ‘shared houses' with capacity for 16 individuals. Women are supported to live independently in accommodation based on a ‘shared house’ principle to develop a range of independent living skills, which are reflective of real life. The overall rating for Health and Wellbeing with the establishment was Satisfactory. There were eleven examples of good practice highlighted and four recommendations for improvement. The good practice highlighted was: 1. Occupational therapy familiarisation visits were arranged for patients to support the transfer to Bella and ensure a smooth transition for patients. 2. Accessible information was provided to patients on arrival to Bella, including a healthcare information booklet. 3. Bella benefits from the input of the occupational therapy service that provided a wide range of therapeutic supports for patients. 4. Naloxone kits and training were available to patients including access to a service that delivers naloxone kits to the patient’s home address in preparation for home leave and liberation. 5. Processes were in place to obtain feedback from patients to help inform service improvements. 6. Routine appointments and dental treatments would be offered to all people at Bella.
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59 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 7. People who had dental treatments in progress on liberation would have their details passed to their local public or community dental services to ensure their treatment could continue. 8. The pharmacy technicians were aware of who to contact when the pharmacist was absent. 9. A process was in place to review a person’s medicine Kardex’s before they were transferred to Bella. This allowed medicines to be reconciled, the Kardex to be rewritten and ensured a supply of medication was available when the person arrived at the Bella. 10. A proactive approach to in-possession medication at the Bella was described. This meant that most medications including Schedule 3 or 4 controlled drugs were in-possession. This approach encourages people to manage their own medication in preparation for liberation. 11. A risk-based approach based on the vulnerability of the person was taken to guide the frequency of dispensing of the month’s supply of medication for those patients being liberated or going on home leave. The recommendations were in relation to: 1. NHS Tayside/HSCP should ensure that complaint forms are readily available to ensure all patients can provide feedback, raise concerns and make a complaint. 2. NHS Tayside/HSCP should ensure referral forms are available in picture format and in the most common languages spoken at Bella. 3. NHS Tayside/HSCP should ensure that self-referral forms are made available for all patients to access. 4. NHS Tayside/HSCP should ensure that checks on emergency equipment are carried out and consistently recorded to ensure that all equipment is within date and ready for use. The Prison Healthcare service has an improvement plan in place to progress the recommendations identified, and all recommendations are either complete or progressing to completion. Mental Welfare Commission for Scotland Visit to Leven Ward at Murray Royal Hospital, May 2024 Leven is a 14-bedded, mixed-sex, functional admission ward for older adults, typically over the age of 65. On the day of the visit, there were 14 people on the ward and no vacant beds. The commission made three recommendations as a result of the visit: 1. Managers should ensure that individuals and/or relatives are involved in developing care plans where possible. Their participation should be documented
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60 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 in care records, and they should be offered a copy of care plans. If individuals choose not to or cannot be involved, this should be recorded. 2. Managers should ensure that where a welfare proxy is in place for an individual, and they have powers to decide about the individual’s treatment, the proxy should be consulted and consent sought. A section 47 certificate should record this consultation. 3. Managers should ensure the ‘NHS Tayside locked door in mental health settings’ protocol is explained to individuals who are admitted informally to the ward and that they are also informed of the procedure for accessing and leaving the ward when the door is locked. These discussions should be recorded in the care records. Visit to Garry and Tummel Wards at Murray Royal Hospital, July 2024 Garry and Tummel Wards are both 12-bedded, mixed-sex wards that provide assessment and treatment for older adults with dementia, based in Murray Royal Hospital. The commission made two recommendations as a result of the visit: 1. Managers should ensure nursing staff document clinical descriptions of an individual’s presentation in care records. 2. Managers for Tummel Ward should ensure the activities offered are documented in the individual’s case notes and whether they chose to participate or not. Care Inspectorate Inspections During the period 1 April 2024 to 31 March 2025, there were a total of 60 inspections; 23 to Care Homes, 25 to Supported Accommodation and 12 to Care at Home Services. This compares to 39 total inspections held during the 2023-2024 year. The graph shows the results of the Inspections and the overall grades. 0% 20% 40% 60% 80% 100% How well do we support peoples wellbeing How good is your leadership How good is your staff team How good is your setting How good is care and support planned 1 - Unsatisfactory 2 - Weak 3 - Adequate 4 - Good 5 - Very Good 6 - Excellent
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61 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 There were no unsatisfactory ratings given during the year, and eight weak ratings given. This compares to no unsatisfactory ratings and one weak rating given during the 2023-2024 year. The findings are considered by the Care Home Oversight Group and inform ongoing support and improvement activity. Arrangements for Clinical and Care Governance Assurance and Reporting The HSCP Care and Professional Governance Forum (CPGF) has responsibility for ensuring appropriate scrutiny, assurance and advice within the HSCP, and during 2024- 2025 was co-chaired by Perth and Kinross Council’s Chief Social Work Officer and HSCP Clinical Director. The CPGF receives assurance reporting from all localities and services within the partnership, and all have provided an annual report providing details and assurances regarding the provision of safe, effective and person-centred services, and any ongoing improvement. Each locality has in place a Clinical, Care and Professional Governance Group, all of which are now firmly established. These groups have representation across both Health and Social Care, and provide an opportunity for a focus on improvement, shared learning as well as ensuring effective clinical and care governance processes across the locality. Finance Financial Resources Available to the IJB 2024-2025 The IJB is responsible for the planning and oversight of a broad range of health and adult social care services for the people of Perth and Kinross. These services are provided by Perth and Kinross Council and NHS Tayside via Perth and Kinross Health and Social Care Partnership. This is funded through budgets delegated from Perth and Kinross Council and NHS Tayside. The resources available to the IJB in 2024-2025, totalled £316.290m. The following charts provide a breakdown of where these resources came from, and how it was allocated. Included within the Resources Available to the IJB is ‘Large Hospital Services’ (Set Aside) totalling £28.180m. This resource is in respect of those functions carried out within a large hospital setting and operationally managed by NHS Tayside but for which planning is the responsibility of the IJB.
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62 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 Financial Performance The Financial Plan, approved by the IJB in March 2024, projected a break-even position across Health and Social Care after the application of general reserves. The IJB’s financial performance compared to the Financial Plan for 2024-2025 is summarised in the table below. Finance updates have been presented to the IJB throughout 2024-2025, reporting on the projected in year position. The main movements from plan relate to an increased provision of Care at Home and Care Home placements, driven by demographic growth and rising care needs, resulting in higher costs. The Care at Home Transformation Programme reduced unmet need and delayed discharges but also added financial pressure. Continued reliance on supplementary staffing in community hospitals and inpatient wards, due to sickness absence and patient acuity, further contributed to the overspend. 2024-2025 Financial Plan Position Over/(Under) £m 2024-2025 Year-End Out-Turn Over/(Under) £m Movement from Plan Over/(Under) £m Health 1.042 3.585 2.543 Social Care 2.086 5.493 3.407 Financial Recovery Actions - (1.305) (1.305) Sub-Total 3.128 7.773 4.645 PKIJB Approved Earmarked Reserves (1.684) (1.684) - PKIJB General Reserve (1.444) (4.485) (3.041) Total - 1.604 1.604 Contribution to Inpatient Mental Health Overspend - 1.325 1.325 Total - 2.929 2.929
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63 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 Within Adult Services, higher than planned expenditure reflected increasing volume and greater complexity of needs throughout the year. Prescribing volumes increased above anticipated levels, leading to an overspend. While local savings initiatives progressed well, limited delivery on national initiatives added pressure. Drug costs and prescribing remain a source of pressure, with measures to address the position included within the 2025-2026 budget. Earmarked reserves have also been used to provide additional capacity and support service resilience. Budget has not been delegated to the Perth and Kinross IJB for Inpatient Mental Health in 2024-2025. However, given the IJB have strategic planning responsibility for the services, there is a requirement to show a delegated budget and spend position within the annual accounts. On 19 March 2025, the IJB authorised the Chief Finance Officer and the Chief Officer to finalise an agreement on contributions towards the 2024-2025 Inpatient Mental Health Service overspend. A total of £1.325m in relation to Inpatient Mental Health has been reflected within the 2024-2025 position. Financial Plan In March 2025, the IJB approved a budget for 2025-2026 and provisional budgets for 2026-2027 and 2027-2028. Increased funding from both Perth and Kinross Council and NHS Tayside, combined with an ambitious savings plan, allowed for the approval of a balanced budget for 2025-2026. The budget is based on several assumptions including projected levels of need, costs, transformation, pay and funding availability. It also builds on previous efforts to enhance efficiency and make best use of resources. The provisional budgets for 2026-2027 and 2027-2028, developed using the same assumptions, identified a considerable funding gap. This shortfall is a result of increasing pressures across all care groups including drug costs and prescribing. To achieve financial sustainability in future years, the IJB will need to consider additional funding solutions and identify opportunities to reduce overall expenditure, while acknowledging the challenge of doing so with minimal detrimental impact on the strategic plan and to the population’s health and care needs. Addressing these pressures will require further funding, strengthened collaborative working, strategic planning, robust financial management, a reserves policy and effective workforce planning. Best Value Best Value is about creating an effective organisational context from which public bodies can deliver key outcomes. The following building blocks ensure we are organised to deliver good outcomes, by ensuring delivery in a manner which is: economic, efficient, sustainable, and supportive of continuous improvement. Best Value Self-Assessment Update - Following the Best Value self-assessment completed in 2024, an improvement plan was developed to address the 11 criteria identified for action. This plan was monitored and reported to the Audit and Performance Committee throughout the 2024-2025 financial year. The full and final
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64 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 action plan was presented to the Audit and Performance Committee in June 2025, confirming that all 11 actions have now been completed. This marks the successful conclusion of the improvement process and demonstrates the IJB’s continued commitment to good governance, effective resource management, and continuous improvement across all seven Best Value themes. To maintain this momentum, an annual rotational self-assessment programme will be introduced, focusing on one Best Value theme each year. This will support Perth and Kinross IJB in ensuring that good governance and effective management of resources remain in place to deliver the best possible outcomes for the people of Perth and Kinross. Governance and Accountability The IJB undertakes an annual review of its governance arrangements and is able to demonstrate structures, policies and leadership behaviours which demonstrate good standards of governance and accountability. No significant decisions have been made outside of the scope of the strategic plan in the reporting year. Use of Resources The IJB is supported by a robust Financial Planning process which forms the basis for budget agreement each year with NHS Tayside and Perth and Kinross Council. Performance against the Financial Plan is reported to the IJB on a regular basis during the year. Finance update reports have been presented to the IJB throughout 2024- 2025, reporting on the projected financial position. The IJB’s three-year financial planning process is directly linked to the development of strategic plans, ensuring resources are continuously prioritised to best meet the needs to the people of Perth and Kinross. Key Contact For further information on any area of this report please contact: Chris Jolly, Service Manager (Business Planning and Performance), or Claire McCarthy, Team Leader (Performance Management and Reporting) at tay.pkijbbusinesssupport@nhs.scot.
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65 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 Appendix Appendix 1.1: Perth and Kinross HSCP Service Breakdown
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66 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 Appendix 2.1: National Core Suite Indicator 1 to 9, 5 year comparison Ref Indicator 2019- 2020 2021- 2022 2023-2024 Latest data NI 1 Percentage of adults able to look after their health very well or quite well 94% 94% 94% NI 2 Percentage of adults supported at home who agree that they are supported to live as independently as possible 82% 80% 74% NI 3 Percentage of adults supported at home who agree that they had a say in how their help, care or support was provided 77% 74% 68% NI 4 Percentage of adults supported at home who agree that their health and social care services seemed to be well co-ordinated 73% 65% 57% NI 5 Percentage of adults receiving any care or support who rate it as excellent or good 83% 79% 70% NI 6 Percentage of people with positive experience of care at their GP practice 86% 74% 76% NI 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 80% 76% 76% NI 8 Percentage of carers who feel supported to continue in their caring role 37% 33% 32% NI 9 Percentage of adults supported at home who agree they felt safe 84% 79% 77% Notes 1. Data comes from the national Health and Care Experience Survey which is undertaken two yearly.
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67 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 Appendix 2.1: (cont’d) National Core Suite Indicator 11 to 19, 5 year comparison Ref Indicator 2019- 2020 2020- 2021 2021- 2022 2022- 2023 2023- 2024 2024- 2025 NI 11 Premature Mortality rate per 100,000 persons (calendar year) 333 366 358.4 382.1 344 n/a NI 12 Emergency admissions rate for adults (18+) (per 100,000 population) 11,486 10,582 11,318 12,779 14,049 14,394 NI 13 Emergency bed day rate for adults (18+) (per 100,000 population) 109,715 94,638 112,891 126,480 119,654 110,545 NI 14 Emergency readmissions to hospital within 28 days of discharge (rate per 1,000 discharges 18+) 116 141 129 137 153 153 NI 15 Proportion of last 6 months of life spent at home or in a community setting 90% 90% 91% 89% 89% 90% NI 16 Falls rate per 1000 population aged 65+ (falls which result in a hospital admission) 22 24 23 28 26 25 NI 17 Proportion of care services graded "good" or better in Care Inspectorate inspections 86% 89% 77% 73% 71% 71% NI 18 Percentage of adults with intensive care needs receiving care at home 59% 60% 55% 67% 64% 64% NI 19 Number of days people aged 75+ spend in hospital when they are ready to be discharged per 1,000 population 502 197 594 912 645 654 Notes 1. Data for NIs is published via Public Health Scotland. 2. NI 11 - no data published for 2024-2025. 3. NIs 17 and 19 data covers 2024-2025, all others are for calendar year 2024 due to incomplete data for January to March 2025.
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68 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 Appendix 3.1: Strategic Priorities Mapped to National Indicators and the National Health and Wellbeing Outcomes Strategic Priority National Health and Wellbeing Outcomes Core Suite of Integration Indicators Relevant Plans, Projects and Strategies Target resources to where people and communities need help most. NHWO 4 NHWO 5 NHWO 6 NI 7, NI 8, NI 11, NI 12, NI 13, NI 16, NI 17, NI 19, NI 20 Older People Delivery Plan, Carers Strategy, TEC Strategy, Primary Care Strategy. Draft Physical Disability and Sensory Impairment Strategy, Community Mental Health and Wellbeing Strategy 2022-2025, Learning Disability and Autism Delivery Plan, Suicide Prevention Plan, ADP Delivery Plan. Make it easier for people to understand where and how to access services. NHWO 1 NHWO 3 NHWO 4 NHWO 6 NI 1, NI 3, NI 4, NI 5, NI 6, NI 7, NI 8, NI 11, NI 12, NI 13, NI 14, NI 15, NI 16, NI 17, NI 19, NI 20 Draft Physical Disability and Sensory Impairment Strategy, Community Mental Health and Wellbeing Strategy 2022-2025, Learning Disability and Autism Delivery Plan, Older People Delivery Plan and Carers Strategy. Provide health and social care supports close to home. NHWO 2 NHWO 3 NHWO 4 NHWO 5 NHWO 6 NHWO 9 NI 2, NI 3, NI 4, NI 5, NI 6, NI 7, NI 8, NI 11, NI 12, NI 13, NI 14, NI 15, NI 16, NI 17, NI 18, NI 19, NI 20 Community Mental Health and Wellbeing Strategy 2022-2025, Learning Disability and Autism Delivery Plan, Older People Delivery Plan and Carers Strategy. Work with communities to design the health and social care supports they need. NHWO 1 NHWO 2 NHWO 3 NHWO 4 NHWO 6 NHWO 7 NHWO 9 NI 1, NI 2, NI 3, NI 4, NI 5, NI 6, NI 7, NI 8, NI 9, NI 11, NI 12, NI 13, NI 14, NI 15, NI 16, NI 17, NI 18, NI 19, NI 20 Older People Delivery Plan, Carers Strategy, Primary Care Strategy, Community Mental Health and Wellbeing Strategy 2022-2025, TEC Action Plan, Community Action Plans. Improved integrated working. NHWO 2 NHWO 3 NHWO 4 NHWO 6 NHWO 9 NI 2, NI 3, NI 4, NI 5, NI 6, NI 7, NI 8, NI 12, NI 13, NI 14, NI 15, NI 16, NI 17, NI 18, NI 19, NI 20 Older People Delivery Plan, Carers Strategy, TEC Strategy, Primary Care Strategy, NHST Integrated Clinical Strategy, Community Action Plans, Community Mental Health and Wellbeing Strategy 2022-2025, Learning Disability and Autism Delivery Plan.
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69 Perth and Kinross Integration Joint Board Annual Performance Report 2024-2025 Strategic Priority National Health and Wellbeing Outcomes Core Suite of Integration Indicators Relevant Plans, Projects and Strategies Promote self- management and living well. NHWO 1 NHWO 2 NHWO 4 NHWO 6 NHWO 7 NI 1, NI 2, NI 3, NI 7, NI 8, NI 9, NI 11, NI 12, NI 13, NI 14, NI 15, NI 16, NI 17, NI 18, NI 19, NI 20 Older People Delivery Plan, Carers Strategy, TEC Strategy, Primary Care Strategy, Community Action Plans, Community Mental Health and Wellbeing Strategy 2022-2025, Learning Disability and Autism Delivery Plan. Value our workforce, support them to keep well, learn and develop. NHWO 3 NHWO 4 NHWO 8 NHWO 9 NI 3, NI 4, NI 5, NI 6, NI 7, NI 10, NI 12, NI 13, NI 14, NI 15, NI 16, NI 17, NI 19, NI 20 Workforce Plan 2023-2026, Celebrating People Document. To give us feedback If you, a family member or someone you care for has recently used one of our health and social care services, and would like to share your experience, please use the QR code or visit Perth and Kinross Health and Social Care Partnership | Care Opinion. https://www.careopinion.org.uk/services/s37000023 How We Use Your Personal Information The information provided by you will be used by Perth and Kinross Council and NHS Tayside to improve services. The information will not be disclosed to third parties except as described below. The Council or NHS Tayside may check information provided by you, or information about you provided by a third party, with other information held by us. We may also get information from certain third parties or share your information with them in order to verify its accuracy, prevent or detect crime, protect public funds or where required by law. For further information, please see www.pkc.gov.uk/dataprotection, email DataProtection@pkc.gov.uk or telephone 01738 477933. If you or someone you know would like a copy of this document in another language or format, (on occasion, only a summary of the document will be provided in translation), this can be arranged by contacting the Customer Service Centre on 01738 475000. You can also send us a text message on 07824 498145. All Council Services can offer a telephone translation facility. BSL users can contact us via Contact Scotland BSL, the online British Sign Language video relay interpreting service. Find out more on the Contact Scotland BSL website https://contactscotland-bsl.org/.