Agenda Document Pack - Moray Integration Joint Board - 30/06/2022
Moray Council · 30 June 2022
Back to Moray Integration Joint Board — 30 June 2022 and its agenda
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Moray Integration Joint Board Thursday, 30 June 2022 remote locations via video conference NOTICE IS HEREBY GIVEN that a Meeting of the Moray Integration Joint Board, remote locations via video conference, on Thursday, 30 June 2022 at 10:00 to consider the business noted below. AGENDA 1. Welcome and Apologies 2. Declaration of Member's Interests 3. Minute of Meeting of 26 May 2022 5 - 10 4. Action Log - 26 May 2022 11 - 12 5. Membership of Board and Committees Report 13 - 18 6. Chief Officer Report 19 - 24 7. Revenue Budget Outturn 2021-22 Report 25 - 46 8. Unaudited Annual Accounts 47 - 104 9. Proposed Delegation of Children and Families and Justice Social Work to MIJB 105 - 150 10. Self Directed Support Day Opportunities Test of Change Report 151 - 168 11. Unmet Need in Health and Social Care Moray 169 - 182 Page 1
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MORAY INTEGRATION JOINT BOARD SEDERUNT Councillor Tracy Colyer (Chair) Mr Dennis Robertson (Vice-Chair) Professor Siladitya Bhattacharya (Voting Member) Mr Derick Murray (Voting Member) Mr Sandy Riddell (Voting Member) Councillor John Divers (Voting Member) Councillor Scott Lawrence (Voting Member) Councillor Kathleen Robertson (Voting Member) Professor Caroline Hiscox (Ex-Officio) Mr Roddy Burns (Ex-Officio) Mr Ivan Augustus (Non-Voting Member) Mr Sean Coady (Non-Voting Member) Ms Karen Donaldson (Non-Voting Member) Jane Ewen (Non-Voting Member) Mr Graham Hilditch (Non-Voting Member) Mr Steven Lindsay (Non-Voting Member) Ms Jane Mackie (Non-Voting Member) Dr Paul Southworth (Non-Voting Member) Mrs Val Thatcher (Non-Voting Member) Simon Bokor-Ingram (Non-Voting Member) Mr Neil Strachan (Non-Voting Member) Clerk Name: Tracey Sutherland Clerk Telephone: 07971 879268 Clerk Email: committee.services@moray.gov.uk Page 3
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MINUTE OF MEETING OF THE MORAY INTEGRATION JOINT BOARD Thursday, 26 May 2022 Remote Locations via Video Conference, PRESENT Mr Ivan Augustus, Professor Siladitya Bhattacharya, Simon Bokor-Ingram, Councillor Tracy Colyer, Councillor John Divers, Jane Ewen, Councillor Scott Lawrence, Mr Derick Murray, Mr Sandy Riddell, Mr Dennis Robertson, Councillor Kathleen Robertson, Dr Paul Southworth, Mrs Val Thatcher, Dr Lewis Walker APOLOGIES Mr Roddy Burns, Mr Sean Coady, Ms Karen Donaldson, Professor Caroline Hiscox, Mr Steven Lindsay, Ms Jane Mackie, Mr Neil Strachan IN ATTENDANCE In attendance at the meeting were the Head of Governance, Strategy and Performance, Corporate Manager, Iain MacDonald, Locality Manager, Jamie Fraser, Project Manager, Dawn Duncan, Lead Occupational Therapist, Alison Frankland, Practice Manager, Deb O'Shea, Principal Accountant and Tracey Sutherland, Committee Services Officer. Also in attendance was Maggie Bruce, Audit Scotland and Councillor Shona Morrison. 1. Welcome and Apologies The Vice Chair, Mr Dennis Robertson, welcomed everyone to the meeting and advised that he would be chairing today's meeting as this was Councillor Colyer's first meeting of the Integration Joint Board. Councillor Colyer will chair the meetings going forward until the roles reverse in a few months. Councillors Colyer, Robertson and Lawrence were welcomed to their first meeting following the Local Government election at the beginning of May. Councillor Divers was welcomed back as a returning Councillor. Page 5
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2. Order of Business The Vice Chair sought agreement from the Board to take Item 6, Membership of the Board and Committees report first on the agenda. This was unanimously agreed. 3. Membership of Board and Committees Report A report by the Corporate Manager updated the Moray Integration Joint Board of member resignations, appointments required and progress on the recruitment of a third sector representative. Prior to consideration of the report, Mr Robertson took the time to thank Councillor Shona Morrison for her time on the Board. He further thanked Dr Lewis Walker and Dr Malcolm Metcalfe for their contribution on the Board as both had tendered their resignations. He further welcomed the newly elected Councillors to the Board, namely Councillor Colyer, who will be Chair of the IJB, Councillor Robertson and Councillor Lawrence and welcomed Councillor Divers back following his successful re-election. Following consideration the Board agreed to: i) note the resignations from the Board as set out in 4.1; ii) approve the appointment of Moray Council members to the Board following the Local Government Election on 5 May; iii) approve the appointment of Councillor Tracy Colyer as Chair of the MIJB; iv) approve the appointment of Councillors Lawrence and Divers to the Audit, Performance and Risk Committee; v) approve the increase in members to the Clinical and Care Governance Committee to 2 members from NHS Grampian and 2 members from Moray Council; vi) approve the appointment of Councillors Lawrence and Robertson and Professor Siladitya Bhattacharya to the Clinical and Care Governance Committee; vii) note the timeframe set out in 4.4 for the appointment of a third sector representative; viii) note the progress on appointment of the other member vacancies outlined in the body of the report and identified in Appendix 1; and ix) approve the changes to the Scheme of Administration as shown in Appendix 2. 4. Declaration of Member's Interests The Board noted that there were no declarations of Member's interests. Page 6
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5. Minutes of meeting of 31 March 2022 The minute of the meeting of 31 March 2022 was submitted and approved. 6. Action Log - 31 March 2022 The Action Log of the meeting of 31 March 2022 was discussed and updated accordingly. 7. Chief Officer Report A report by the Chief Officer informed the Board of the Chief Officer activities that support the delivery against the Moray Integration Joint Board's strategic priorities articulated in the Strategic Plan and the delivery against the 9 Health and Wellbeing Outcomes. Following consideration the Board agreed: i) to note the content of the report; and ii) that transforming services to meet the aspirations of the MIJB's Strategic Plan remains a priority, with focus on key objectives as we remobilise from the covid pandemic, along with a look ahead as we continue to develop our strategic planning. The Chief Officer then gave a presentation on the NHS Grampian Plan for the Future. 8. Future Moray Integration Joint Board Meetings A report by the Corporate Manager asked the Board to consider future arrangements for holding meetings of the Moray Integration Joint Board, Audit Performance and Risk Committee and the Clinical and Care Governance Committee going forward now that Covid restrictions have been lifted. Following consideration it is recommended that the Moray Integration Joint Board (MIJB) agreed that future meetings would be held as hybrid meetings. 9. Home First - Dishcharge to Assess and Impact on System Flow Report A report by the Head of Service updated the Board on the impact of the Discharge to Assess (D2A) has made on system flow across the Moray Health and Social Care portfolio. Following consideration the Board agreed to: i) note the performance evaluation of the Discharge to Assess Service with an emphasis on impact across system flow and capacity; and ii) note the actions identified in section 4 and that an update on progress will be submitted to the Board within the next 6 months. Page 7
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10. External Audit Plan Report A report by the Interim Chief Financial Officer informed the Board of the Auditor's Annual Plan for 2021/22. Mr Riddell added that the report should have been presented to the Audit, Performance and Risk Committee (AP&R) first to ensure good governance and highlighted that a similar issue would arise with budget reports on 30 June and 24 November 2022 where the IJB meets before AP&R. In response, the Interim Chief Financial Officer acknowledged that reason the report had been presented to the Board first was a timing issue and it was unfortunate. Following consideration the Board agreed to note the contents of the External Auditor's Annual Plan for 2021/22. Post meeting note: It was agreed that 1 item special meetings of AP&R Committee be scheduled prior to the IJB meetings in June and November to allow consideration of the reports prior to consideration at the IJB. 11. Lossiemouth Locality Community Engagement Report A report by the Locality Manager informed the Board of the outcome of the community engagement activity relating to the development of health and wellbeing services within the Lossiemouth locality with a particular emphasis on the future model of General Medical Services (GMS) provision and associated Moray Coast Medical Practice surgery buildings in Burghead, Hopeman and Lossiemouth. Following consideration the Board agreed to: i) approve the continued closure of the Burghead and Hopeman branch surgery buildings and note the continuation of interim measures to support patients in vulnerable groupings to travel to the Lossiemouth surgery; ii) approve the increase in clinical space within Lossiemouth surgery building through the refurbishment of the area previously referred to as the Laich Dental Suite; iii) note the position statement of Moray Coast Medical Practice on not returning to work in the branch surgeries; iv) note the engagement report and the community views on the continued closure of the branch surgeries; v) note the preferred future model of health and care provision which does not include the retention of branch surgeries; vi) approve a formal consultation with patients of Moray Coast on the future model, including permanent closure of the branch surgeries; vii) the outcome of the consultation being reported to a future meeting of the MIJB; and Page 8
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viii) note the intention for the Lossiemouth Locality Community Engagement Steering Group to continue to meet as the Locality Oversight Group to develop and monitor the HSCM Locality Plan for the Lossiemouth and Moray Coast area. Page 9
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MEETING OF MORAY INTEGRATION JOINT BOARD THURSDAY 26 MAY 2022 ACTION LOG ITEM NO. TITLE OF REPORT ACTION REQUIRED DUE DATE ACTION BY UPDATE FOR 30 JUNE 2022 1. Additional Investment Winter Funding A financial report with regard to the additional funding will be reported either within the usual quarterly financial report or a separate financial report specifically in relation to this fund. A development session be arranged to enable thorough discussion on how to best use the fund. March 2022 Chief Financial Officer Incorporated into Budget Report Presentation was made to development Session 6 June 2022 – further sessions to be scheduled 2. Lossiemouth Locality Community Engagement Final report to be submitted summarising the outcomes of the public consultation and seeking agreement to proceed with recommendations. September 2022 Locality Manager Additional time required due to impact of Omicron wave – to be reported in September 2022 along with final report 3. Civil Contingency (Scotland) Act 2004 Annual report to provide assurance on the reslilience arrangments in place to discharge the duties on the IJB under the 2004 Act November 2022 Chief Officer Scheduled Page 11
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ITEM NO. TITLE OF REPORT ACTION REQUIRED DUE DATE ACTION BY UPDATE FOR 30 JUNE 2022 4. Ministerial Strategic Group Improvement Action Plan Update Report An update from the Chief Financial Officer will be provided in a further twelve months’ time January 2023 Chief Financial Officer Scheduled 5. Reserves Policy Review Next review will be no later than March 2023 March 2023 Chief Financial Officer Scheduled 6. Standards Officer and Depute Appointment Letter to be written to Standards Commission detailing the Standards Officer and Depute Appointments until April 2024 April 2022 Chief Officer Completed 7. Locality Planning First draft of Locality Plans to be presented to the Board September 2022 Head of Service Scheduled 8. Home First – Discharge to Assess Development session to be arranged to look at ensuring the system is realistic and sustainable and resources are flexible to ensure the project can continue to move forward. September 2022 Head of Service An additional development session will be scheduled 9. Home First – Discharge to Assess Update on progress with actions identified in section 4 to be submitted to the Board within 6 months November 2022 Head of Service Scheduled Page 12
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REPORT TO: MORAY INTEGRATION JOINT BOARD ON 30 JUNE 2022 SUBJECT: MEMBERSHIP OF BOARD AND COMMITTEES BY: CORPORATE MANAGER 1. REASON FOR REPORT 1.1. To update the Moray Joint Integration Board (MIJB) of vacancies and member appointments. 2. RECOMMENDATION 2.1. It is recommended that the Moray Integration Joint Board (MIJB): i) notes the resignation from the Board as set out in 4.1; ii) notes the confirmation of appointment of members to the Clinical and Care Governance Committee; iii) notes appointment of the third sector representative and substitute; iv) notes the updated membership of Board and committees attached at APPENDIX 1 3. BACKGROUND 3.1. At the meeting of the Board on 28 January 2021 (para 7 of the minute refers) the board approved the changes to the integration scheme to increase voting membership from 3 to 4 from each of the partner organisations (Moray Council and Grampian Health Board) and instructed the Chief Officer to progress with the consultation and to submit to Scottish Government. 3.2. These actions were taken forward following the consultation process and the request was submitted to Scottish Government on 10 May 2021. 3.3. Further work was requested by the Integration Governance and Support Team which was undertaken and following further consultation the revised request was submitted to Mr Stewart, Minister for Mental Wellbeing and Social Care, who approved and agreed the revised integration scheme for Moray, on 23 March 2022. MIJB was updated of the approval on 31 March 2022. Page 13
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4. KEY MATTERS RELEVANT TO RECOMMENDATION 4.1. As intimated at the previous meeting Dr Lewis Walker resigned from the board with effect from 17 June 2022. Processes are underway to identify alternative nominations for this role. 4.2. Following discussion after the MIJB meeting of 26 May it has been confirmed that Cllr Scott Lawrence will be the member for Clinical and Care Governance committee. 4.3. An advert was placed for applicants to the role of third sector representative which closed on 3 June 2022. The appointment committee met on 16 June and offered the membership to Graham Hilditch and substitute position to Sheila Brumby which they both accepted. The advert also sought applications from those interested in being substitutes for service user and carer members however there were no applications at this time. Efforts to attract substitutes to these roles will continue. 4.4. Members’ induction was held on 22 June 2022 and was recorded so that other new members will be able to receive the same information. 4.5. The list of members for each committee along with current vacancies is attached at APPENDIX 1 to this report. 5. SUMMARY OF IMPLICATIONS (a) Corporate Plan and 10 Year Plan (Local Outcomes Improvement Plan (LOIP)) and Moray Integration Joint Board Strategic Plan “Moray Partners in Care 2019 – 2029” Effective governance arrangements support the development and delivery of priorities and plans. (b) Policy and Legal The Board, through its approved Standing Orders for Meetings, established under the Public Bodies (Joint Working) (Integration Joint Board) (Scotland) Order 2014, ensures that affairs are administered in accordance with the law, probity and proper standards. (c) Financial implications There are no financial implications arising as a direct result of this report. (d) Risk Implications and Mitigation There are no risk implications arising as a direct result of this report. (e) Staffing Implications There are no staffing implications arising as a direct result of this report. (f) Property There are no property implications arising as a direct result of this report. (g) Equalities/Socio Economic Impact An Equalities Impact Assessment is not required as there are no changes to policy or procedures as a result of this report. Page 14
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(h) Climate Change and Biodiversity Impacts None arising directly from this report. (i) Directions There are no directions arising from this report. (j) Consultations Consultation on this report has taken place with the Chief Officer and Tracey Sutherland, Committee Services Officer, Moray Council, who are in agreement with the report where it relates to their area of responsibility. 6. CONCLUSION 6.1. This paper sets out the position in relation to the membership of MIJB. Author of Report: Jeanette Netherwood, Corporate Manager Background Papers: None Ref: Page 15
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APPENDIX 1 Moray Integration Joint Board Vacancies Moray Integration Joint Board 4 Council voting members Tracy Colyer (Chair) John Divers Kathleen Robertson Scott Lawrence 4 NHS Grampian voting members Dennis Robertson Derick Murray Sandy Riddell Prof Siladitya Bhattacharya Third Sector Stakeholder Graham Hilditch NHS Grampian Staff Representative Stakeholder Member Steven Lindsay Carer Stakeholder Ivan Augustus Service User Stakeholder Val Thatcher Moray Council Staff Representative Karen Donaldson Chief Officer Professional Simon Bokor-Ingram Chief Social Work Officer Jane Mackie Lead Nurse Jane Ewen GP Lead VACANCY Non Primary Medical Services Lead VACANCY Additional Member Dr Paul Southworth Audit, Performance and Risk Members (note chair needs to be alternate partnership member to the Chair of MIJB) 2 Council voting members John Divers Scott Lawrence 2 Health Board voting members Sandy Riddell (Chair) Derick Murray Third Sector Stakeholder Graham Hilditch NHS Grampian Staff Representative Stakeholder Member Steven Lindsay Clinical and Care Governance Members 1 Council voting member Scott Lawrence 1 Health Board voting member (Chair) Derick Murray (Chair) Carer Stakeholder Ivan Augustus Service User Stakeholder Val Thatcher Third Sector Stakeholder Graham Hilditch Moray Council Staff Representative Karen Donaldson Chief Officer Professional Simon Bokor-Ingram Chief Social Work Officer Jane Mackie Lead Nurse Jane Ewen GP Lead VACANCY Non Primary Medical Services Lead VACANCY Additional Member Dr Paul Southworth Page 17
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REPORT TO: MORAY INTEGRATION JOINT BOARD ON 30 JUNE 2022 SUBJECT: CHIEF OFFICER REPORT BY: CHIEF OFFICER 1. REASON FOR REPORT 1.1 To inform the Board of the Chief Officer activities that support the delivery against the Moray Integration Joint Board’s (MIJB’s) strategic priorities articulated in the Strategic Plan, and the delivery against the 9 Health and Wellbeing outcomes. Key work for the Partnership includes the implementation of Home First; remobilisation from the covid pandemic; supporting measures for the reduction of local covid transmission; and budget control. We also need to continue taking a longer term strategic view and setting out clear plans that will deliver transformational change so we can best meet the needs of our community. 2. RECOMMENDATION 2.1. It is recommended that the MIJB: i) consider and note the content of the report; and ii) agree that transforming services to meet the aspirations of the MIJB’s Strategic Plan remains a priority, with a focus on key objectives as we remobilise from the covid pandemic, along with a look ahead as we continue to develop our strategic planning. 3. BACKGROUND Home First and Hospital without Walls 3.1 Responding to Covid-19 has brought about rapid change, fast tracking many of the plans that had been under development to meet our aspirations set out in the Strategic Plan for Home First. The Hospitals without Walls model would realise our aspiration to meet need more responsively, and to be more anticipatory in our approach. We have completed the return to Scottish Government on our work programme and costs, along with an estimation of the financial envelope required to extend out the Hospitals without Walls model on a larger scale. Page 19
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Remobilisation 3.2 To date the healthcare system has coped with some significant surges in demand. A pan Grampian approach to manage surge and flow through the system ensures patients/service users receive the care they require. Staff within Moray, across all sectors of health and social care, including independent providers and the third sector, have stepped up to the challenge on a daily basis. There is pressure in some service areas which will require a particular focus to work through the backlog of referrals. 3.3 Whilst we are seeing pressure easing in some areas as staff absence rates decrease, for some services the pressures remain. Demand for unscheduled hospital care has not diminished, and Dr Grays is having to manage a very tight capacity position on a daily basis. Community hospital beds, and intermediate options are being fully utilised, with expedient discharge from Dr Grays as soon as beds are available. 3.4 Waiting times for elective procedures has grown significantly over the last 2 years. The health and care system is supporting Dr Gray’s Hospital to restart elective orthopaedics with an understanding that hospital beds need to be protected for elective procedures, and that unscheduled care has to be managed without impacting on the elective bed capacity. In May we carried out 27 orthopaedic cases, 11 being day cases and 16 being major joint surgery. 3.5 Managers are closely monitoring the system, and although we are experiencing particular bottlenecks in flow through the system, most critical services are being maintained, with residents able to access timely emergency care, either from primary or secondary care. Social care provision continues to be under significant pressure, with delayed discharges remaining at a consistently high level (compared to pre-pandemic) and a level of unmet needs in the community, which means that some people are waiting for care after an assessment, or are waiting for the initial assessment. However we are gradually seeing some slow improvements, underpinned by initiatives including the increasing use of Self Directed Support and the Three Conversation Model. Our care homes have at times been unable to admit to vacant beds because of covid infections among staff and/or clients, and this risks the creation of interrupted flow in the overall system. Work is ongoing to risk assess situations, and where necessary derogations will be considered to ensure that critical service delivery continues, with these derogations reported to the Clinical and Care Governance Committee. The embedding of Self Directed Support standards through day opportunities is the subject of a separate paper on today’s agenda, with the ultimate goal of improving outcomes for individuals. Covid Vaccination Programme 3.6 Uptake rate information is available on the Public Health website at https://www.publichealthscotland.scot/news/2021/february/covid-19-daily- dashboard-now-includes-vaccination-data/ . 3.7 Ukrainian Refugee Scheme It has been almost 4 months since the conflict in Ukraine started and 3 months since the UK Government opened its “Ukraine Sponsorship Scheme”. The solidarity shown in Scotland and from citizens in Moray to support the Ukrainian displaced persons (UDP) has been overwhelming and recognised Page 20
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nationally that Scotland offer a “Warm Scots Welcome” to those displaced by the conflict. 3.8 Through the UK sponsorship scheme, Ukrainians can apply for a three-year visa and if they choose Scotland to live, they must either have a private sponsor or select the Scottish Government as their ‘super sponsor’. Scotland’s ‘super sponsor’ scheme removes the need to seek out private sponsors on social media in advance of being able to obtain a visa and travel. 3.9 Moray has welcomed 43 Ukrainian persons, 26 adults and 17 children, through the private sponsor scheme, although others have arrived through different schemes. The Ukrainian families are supported by hosts families scattered throughout Moray. All host families regardless of the scheme must clear mandatory checks, including Disclosure Scotland and property checks, in order to receive their £350 monthly thank you payment. 3.10 As more Ukrainians seek sanctuary in Scotland, a dedicated refugee and resettlement team has been recruited, including a project officer and 1.5 WTE support staff. Alongside the resettlement team, a multi-agency team has been assembled to support the hosts and arrivals to navigate the benefits, education, health systems to name but a few in order to help integration into Moray. 3.11 While the focus over the past 2 months has rightly been on ensuring arrivals receive the care and support to settle into their new home in Moray, a key priority must now be to support the Scotland Super Sponsor Scheme and continue to match more hosts with Ukrainian arrivals to Moray for as long as they need a temporary home. Portfolio arrangements 3.12 Covid-19 has presented the greatest challenge the health service has faced. As NHS Grampian recovers, remobilises and renews as part of the North East system, there has been reflection on how best to move forward to demonstrate learning and improvement from Covid-19 as an imperative. During the pandemic the effectiveness, efficiencies and better outcomes that can be achieved when we work together as public sector have been demonstrated, with partners and communities rather than as individual entities. To deliver further on this whole system, integrated approach, there is a desire to transition from an organisational leadership and management model to a system leadership and management approach. The portfolio leadership arrangements have now been confirmed as permanent. Further opportunities for the alignment of services around pathways will be led by the Chief Officer. 3.13 The impending retirement of our Chief Social Work Officer in October this year means that we will need to recruit a Head of Service who also meets the requirements to be eligible to be Chief Social Work Officer. The decision on assigning the Chief Social Work Officer role is a function of the Council. A refined job description to incorporate the delegation of Children’s Services has been developed, and the Chief Officer has started the recruitment process with Moray Council HR. The requirements of the post means that this will not be advertised jointly with the NHS. Page 21
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3.14 The Chief Finance Officer post remains vacant, and is being covered on a temporary secondment. The post was advertised for a second time and remains unfilled. The Chief Officer is working with the Council and NHS Finance Leads to look at recruitment options to try and attract a suitable candidate. Budget Control 3.15 Transformational change that meets the test of quality and safety must also be efficient, making the best use of available resources. The Senior Management Team (SMT) for the Portfolio are meeting regularly to review spend and consider investment prior to seeking MIJB approval. There is a continuous need to track progress on transformational redesign to ensure it is meeting the aims of the Strategic Plan. Whilst we have presented a balanced budget for 2022/23 to the MIJB, savings will continue to be required to ensure sustainability in the years beyond. 3.16 Ongoing work will be required, led by the Chief Officer, with the Senior Management Team and wider System Leadership Group, to develop options that will align the budget to available resources for 22/23. Payment Verification 3.17 National Services Scotland (NSS) process the payments and have not been in the position to undertake the payment verification meetings since the start of Covid. Their focus has been to maintain protective payments each month and because these are based on same amounts each month, there are no new claims coming through. The payment verification meetings are now recommencing and will start in ophthalmology during quarter 2, dentistry projected for quarter 3 with medicine to be confirmed. Therefore it will be June 2023 before first audit reports are received and a subsequent update report to the Audit Performance and Risk Committee. 4. KEY MATTERS RELEVANT TO RECOMMENDATION 4.1 The opportunity remains to accelerate work of the MIJB ambitions as set out in the Strategic Plan. Home First is the programme designed to do that, with the opportunities of an expanded portfolio of health and care that also encompasses Dr Gray’s Hospital and Children’s Social Work and Justice Services. 4.2 The challenges of finance persists and there remains the need to address the underlying deficit in core services. Funding partners are unlikely to have the ability to cover overspends going forwards. Winter/covid funding will only cover additional expenditure in the short-term and it is important to understand the emerging landscape. 4.3 Transformational change, or redesign, that provides safe, high quality services, whilst bringing more efficient ways of operating, will be the focus for the senior management team as the route to operating within a finite budget, while meeting the health and care needs of the Moray population. Page 22
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5. SUMMARY OF IMPLICATIONS (a) Corporate Plan and 10 Year Plan (Local Outcomes Improvement Plan (LOIP)) and Moray Integration Joint Board Strategic Plan “Moray Partners in Care 2019 – 2029” Working with our partners to support people so they can cope with, and where possible, overcome the health and wellbeing challenges they may face. Ensuring that the right care is provided at the right place at the right time when people are in need. Ensuring that our systems are as simple and efficient as possible. (b) Policy and Legal The Chief Officer continues to operate within the appropriate level of delegated authority, ensuring that the MIJB is sighted on key issues at the earliest opportunity, and continues to influence and agree the strategic direction. (c) Financial implications There are no financial implications arising directly from this report. The interim Chief Finance Officer continues to report regularly. Scottish Government covid related supplier relief ends in June this year, and we will monitor impacts on our independent suppliers as part of the risk management process. (d) Risk Implications and Mitigation The risk of not redesigning services will mean that Health and Social Care Moray and the Moray Portfolio cannot respond adequately to future demands. (e) Staffing Implications Staff remain the organisation’s greatest asset, and we must continue to engage with all sectors to ensure full involvement, which will create the best solutions to the challenges we face. Our staff are facing continued pressures on a daily basis, and we must continue to put effort into ensuring staff well- being. (f) Property There are no issues arising directly from this report. (g) Equalities/Socio Economic Impact Any proposed permanent change to service delivery will need to be impact assessed to ensure that we are not disadvantaging any section of our community. We will continue to work closely with all our partners to ensure that we contribute to the health and well-being of the community and support the recovery phase of the Covid-19 pandemic. (h) Climate Change and Biodiversity Impacts Care closer to and at home, delivered by teams working on a locality basis, will reduce our reliance on centralised fixed assets and their associated use of utilities. (i) Directions There are no directions arising from this report. Page 23
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(j) Consultations The Moray Portfolio Senior Management Team has been consulted in the drafting of this report. 6. CONCLUSION 6.1 The MIJB are asked to acknowledge the significant efforts of staff, across in-house providers, externally commissioned services, the Independent and Third Sector, who are supporting the response to the Covid-19 pandemic, and the drive to create resilience and sustainability through positive change. Author of Report: Simon Bokor-Ingram, Chief Officer, Moray Portfolio Page 24
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REPORT TO: MORAY INTEGRATION JOINT BOARD ON 30 JUNE 2022 SUBJECT: REVENUE BUDGET OUTTURN FOR 2021/2022 BY: INTERIM CHIEF FINANCIAL OFFICER 1. REASON FOR REPORT 1.1 To inform the Moray Integration Joint Board (MIJB) of the financial outturn for 2021/22 for the core budgets and the impact this outturn will have on the 2022/23 budget. 2. RECOMMENDATIONS 2.1 It is recommended that the MIJB: i) consider and note the unaudited revenue outturn position for the financial year 2021/22; ii) consider and note the impact of the 2021/22 outturn on the 2022/23 revenue budget; and iii) approve for issue, the Directions shown in APPENDIX 4 to NHS Grampian and Moray Council. 3. BACKGROUND 3.1 The overall position for the MIJB is that core services were overspent by £2,512,662 as at 31 March 2022. The MIJB’s unaudited financial position for the financial year ending 31 March 2022 is shown at APPENDIX 1. This is summarised in the table below. Annual Budget £ Actual Expenditure £ Variance to date £ MIJB Core Service 130,314,800 132,827,462 (2,512,662) MIJB Strategic Funds & other resources 27,470,558 7,937,272 19,533,286 Set Aside Budget 13,044,000 13,044,000 0 Total MIJB Expenditure 170,829,358 153,808,734 17,020,624 Page 25
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A list of services that are included in each budget heading are shown in APPENDIX 2 for information. 4. KEY MATTERS/SIGNIFICANT VARIANCES FOR 2021/22 Community Nursing 4.1 The Community Nursing budget is underspent by £557,756 to the year-end. This is due to underspends across the Community Health Visiting service and District Nursing related to Vacancies, unplanned leave, including maternity leave and retirements which have contributed to the current underspend across the service. A Recruitment and Retention Plan is in place, to date a number of posts have been appointed to. Challenges remain on the recruitment and retention of qualified and experienced Health Visitors and School Nurses at a local, regional and national level. 4.2 To help mitigate or minimise risk to service delivery, 1 trainee Health Visitor and 2 School Nurses will qualify in 2022, 2 trainee Health Visitors and 2 School Nurses will qualify in 2023.In addition, through vacancies, 2 Health Visitor Trainees will be recruited to start in September 2022 (qualify in 2024). With a clear and planned increase in the number of qualified, skilled and experienced practitioners, this will alleviate a number of key service pressures, stabilise the workforce, ensure modernisation and sustainability of the service, that it is responsive to local need and risk, and help maintain positive staff health and wellbeing 4.3 The outturn for Community Nursing is underspent by £186,285 more than previously forecast. This was primarily due to additional funding received in Month 12 and reduced expenditure among District nursing and Health Visiting service which has increased the underspend. Learning Disabilities 4.4 The Learning Disability (LD) service is overspent by £1,426,891 at the year- end. This budget has been under pressure for a number of years due to demographic pressures, transitions from Children’s services and people living longer and getting frailer whilst staying at home. 4.5 The overspend is essentially due to the purchase of care for people with complex needs which results in an overspend of £1,466,614, less income received than expected £47,305, client transport £11,317 and other minor overspends totalling £4,212.This is offset by an underspends in clinical Speech and Language services and psychology services of £102,556. 4.6 Adults with learning disabilities are some of the most vulnerable people in our community and need a high level of support to live full and active lives. Overspending in this area is not specific to Moray – local authorities across the country face similar difficulties in funding LD services at the required level. The LD team are aware that without appropriate structure and routine, many of our service users will exhibit challenging behaviours which are costly to manage and are not desirable from the perspective of people’s life experience and human rights. Page 26
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4.7 The outturn for the LD service is overspent by £224,835 more than previously forecast. This is due to a provider not invoicing through the year and therefore spend with this provider was not factored into the forecast. Mental Health 4.8 Mental Health services are overspent by £274,911 at the year end. This overspend is primarily due to consultant psychiatrist vacancies being covered by high cost agency medical locums. There is also less income received than expected. However, some of the overall overspend is being offset by underspends in Psychology and Community Mental Health Nursing due to vacancies. Successful recruitment to the adult consultant psychiatrist vacancy which has been vacant since October 2019 will see locum costs greatly reduced in 2022/23. 4.9 The outturn for Mental Health is overspent by £236,078 less than the previous forecast. This was due in part to the purchase of care, since forecasting is difficult as it relies on meeting clients’ needs and reducing overspend on staffing costs relating to medical pay. Care Services Provided In-House 4.10 This budget is underspent by £976,898 at the end of the year. This relates to underspend in staffing across all the services in this budget totalling £1,110,980 and other minor underspends totalling £12,494, which is being reduced by an overspend of £146,576 in day care services due to transport costs and less income received than expected due to the closure during Covid 19. 4.11 Unfilled vacancies have been the main reason for the underspend throughout the year and the issue of recruitment has been an ongoing problem. 4.12 The outturn for this budget is £64,876 less than previously forecast. This is due to the backdated cost of implementing the living wage. Older People and Physical Sensory Disability (Assessment and Care) 4.13 This budget is overspent by £1,521,854 at the end of the year. This primarily relates to overspends for domiciliary care in the area teams £1,131,084, which includes the Hanover very sheltered housing complexes, permanent care £382,345 due to the increase in the number of clients receiving nursing care rather than residential care and other minor variances of £8,425. The variances within this overall budget heading reflect the shift in the balance of care to enable people to remain in their homes for longer. 4.14 Due to increase in need and complexity – increase in double up care at home packages. Limited resource availability through our internal provider and limited availability with Allied partnership provider means a reliance on external providers to continue to support the demand/need. 4.15 The outturn for this budget is £46,099 more overspent than the previous forecast. The nature of this service makes forecasting hard to predict due to its volatile nature. Page 27
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Intermediate Care and Occupational Therapy (OT) 4.16 This budget is overspent by £304,582 at the end of the year, this predominately relates to OT equipment. Costs have increased on all equipment, due to manufacturing and supply to Moray. There have been more complex equipment requests and spend on Augmentative and Alternative Communication (ACC) equipment for which there is no budget. Increase of labour and material costs have impacting on the minor adaptations. 4.17 The outturn for this budget is £149,962 more than previously forecast, due to a backlog of requests and delay with providers nearer the end of the financial year. Care Services provided by External Contractors 4.18 This budget is underspent by £269,008, this primarily relates to underspends in Learning Disability contracts of £305,332 and other minor underspends totalling £8,439 and this is being reduced by the overspends on blue badge £23,545, Commissioning Team £11,501, Older Peoples contracts £5,487 and Carefirst Team £4,230. 4.19 The outturn for this budget is £123,190 more underspent than previously forecast due to the underspend on the Learning Disability contracts being more than expected. Primary Care Prescribing 4.20 The primary care prescribing budget is reporting an over spend of £894,154 for the twelve months to 31 March 2022. The budget to March includes an uplift of £706,000 (non-recurring) for efficiencies not achieved and £115,000 recurring from within Moray IJB. Medicines management practices continue to be applied on an ongoing basis to mitigate the impact of external factors as far as possible and to improve efficiency of prescribing both from clinical and financial perspectives. 4.21 The outturn is £23,681 better than previously forecast for this budget but this is mainly attributable to the funding allocations made at end of the year. The continuation of effective local medicines management practices has limited the negative impact of external factors on this budget. 5. STRATEGIC FUNDS 5.1 Strategic Funds is additional Scottish Government funding for the MIJB, they include: • Additional funding received from NHS Grampian and Moray Council during the year which may not been fully utilised during 2021/22, some of which may be needed to be funded in future years; and • Provisions for earmarked reserves, identified budget pressures, new burdens and savings that were expected at the start of the year. 5.2 At the end of the financial year there was slippage on Strategic Funds of £19,533,286 which has resulted in an overall underspend of £17,020,624. 5.3 During the 2021/22 financial year, Scottish Government made the full allocation of funding aligned to the Primary Care Improvement Fund, Covid-19 allocation and the additional winter funding, to help support current system Page 28
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pressures. The Scottish Government made a commitment to ensuring full sums would be invested and spent on the priorities identified in support of this. Allocations made during the year, that remain unspent, are considered as earmarked funding and to be used for these specific purposes in future years. This has contributed to the overall increase in MIJB reserves. 5.4 After consideration of funding received, earmarked reserves and application of slippage on Strategic Funds, the MIJB financial position resulted in an underspend of £17,020,624 constituting the MIJB balance to carry forward to 2022/23. The reserves are detailed below in paragraph 9. 6. CHANGES TO STAFFING ARRANGEMENTS 6.1 At the meeting of the Board on 28 March 2019, the Financial Regulations were approved (para 11 of the minute refers). All changes to staffing arrangements with financial implications and effects on establishment are to be advised to the Board. 6.2 The staffing arrangements are noted in APPENDIX 3 as dealt with under delegated powers for the period 1 Jan to 31 March 2022. 7. IMPACT ON 2022/23 BUDGET 7.1 The actual out-turn for the 2021/22 Core Services budget year is an overspend of £2,512,662. Due to the ongoing impact of Covid 19 it is difficult to ascertain with certainty the 2021/22 variances to budget and the likely impact moving in to the next financial year. However, the variances against the budget have been reviewed and classified as one-off or likely to be recurring. Impact in 2022/23 will be monitored continuously and reported regularly to the MIJB. The overall position is summarised below: Area Para Ref Recurring Non-Recurring £ £ OVERSPEND Staff 7.2 (1,440,301) (19,629) Purchasing of Care 7.3 (3,994,620) (5,141) Income 7.4 (619,949) 0 Supplies & Services 7.5 (115,110) (77) Property costs 7.6 (62,885) 0 Client transport 7.7 (11,317) 0 Aids & Adaptations 7.8 (276,250) 0 Other 7.9 (1,032,082) 0 Sub-total (7,592,514) (24,847) UNDERSPEND Staff 7.2 2,492,783 14,020 Purchasing of Care 7.3 904,548 5,616 Income 7.4 444,039 0 Supplies & Services 7.5 197,697 444,871 Property costs 7.6 49,325 48,368 Page 29
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Client transport 7.7 123,514 0 Aids & Adaptations 7.8 0 181,936 Other 7.9 92,033 105,949 Sub-total 4,303,939 800,759 TOTAL (3,288,574) 775,912 Net Underspend (2,512,662) 7.2 Staff turnover can incur both under and overspends. Underspends can be attributed to the process of recruitment, which adds a natural delay, with posts being filled by new staff at lower points on the pay scale and in some circumstances the nature of the positions have been challenging to recruit to. The Council has recognised this turnover and had set as part of the budget process a vacancy factor saving, which has been met for numerous years. Overspends can be due to the use of bank staff/locum to provide required cover for vacancies/sickness and from the historic incremental drift and efficiency targets imposed. 7.3 The purchasing of care overspend relates to the purchase of domiciliary care by the area teams and the underspend relates to the cessation due to closure of services. The demographics show that Moray has an ageing population and the spend on external domiciliary care is increasing in relation to both increasing hours of commissioned care and the number of packages of care. This also reflects the shift in the balance of care to enable people to remain in their own homes for longer and the new models of care being introduced with Hanover. 7.4 The under recovery of income budgets is apparent across a number of service headings. It is very difficult to predict the level of income accurately as client income is subject to the contributions policy which is based on a client’s financial assessment. Income recovery on all care at home services continues to reduce as well as income from permanent care placements from deferred income. The income will continue to reduce due to the legislation in relation to the Carers Act and free personal care for under 65’s as well as the impact of Covid. The Independent Review of Adult Social Care will likely impact in the longer term. 7.5 The Supplies and services overspend includes purchases of medical supplies, medical equipment and maintenance cost of equipment which is expected to be recurring. The non-recurring underspend includes transport costs which have been reduced during the last year due to restrictions on all travel . 7.6 The net small recurring overspend in property costs primarily relates to energy costs and cleaning for services that were in operation throughout the Covid lockdown. The non-recurring underspend is due to lower energy costs incurred this year and with the rising cost of energy bills it is not expected to continue. . 7.7 Client transport costs are underspent in numerous service headings, which are due to the ongoing impact of Covid 19 Page 30
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7.8 Aids and Adaptations overspend relates to Occupational therapy aids, servicing, stair lifts and day care services. Which is being reduced by a non- recurring underspend in the improvement grants, due to Covid. 7.9 Other category relates to minor variances across the services but also includes recurring overspends relating to Drugs, Primary Care Prescribing and Primary Care services which are expected to continue as prescribing costs remain in excess of the budget. 7.10 The financial results for 2021/22 show that underlying financial pressures on both the NHS and Council budgets remain, with the MIJB assuming responsibility for the budgets of the delegated functions and are expected to prioritise services within the budgets directed to it by Moray Council and NHS Grampian. 7.11 Through in-year reporting of the savings plan progress it was evident that the majority were delivering according to plan, and there was only 1 area that was not achieved which related to increased income from charges where Moray Council did not agree the increase in taper relief, making this saving unachievable. Scottish Government additional funding was made available that covered the underachievement of savings totalling £110,000. The MIJB has committed to continue to identify further efficiencies that will be reported throughout the year, recognising the remaining pressure on the budget and the required disinvestment to allow the programmes of transformation to develop. 7.12 Whilst the 2022/23 revenue budget position as reported to the Board on 31 March 2022 (para of the minute refers) presented a balanced budget position, through the use of reserves, and a small savings plan, there is still the recurring overspend to be addressed. The Senior Management Team are actively addressing the situation to implement alternative measures to limit the financial pressure. Updates on the recovery and transformation process and further savings will be provided to the Board for approval during 2022/23 through the financial reporting processes. 8. IMPACT OF COVID – 19 AND ADDITIONAL FUNDING 8.1 To date there has been continued commitment from Scottish Government to provide additional funding to support health and social care as a result of the pandemic. This includes the use of Covid 19 specific reserves to support the remobilisation of services. 8.2 HSCM continue to provide quarterly returns to Scottish Government on the Local Mobilisation Plan (LMP) via NHS Grampian. Reported expenditure at the end of 2021/21 was £5.197 million. The costs are summarised below: Description Spend to 31 March 2022 £000’s Staffing 160 Provider Sustainability Payments 3,176 Remobilisation 1,178 Cleaning, materials & PPE 90 Page 31
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Elgin Community Hub (Oaks) 556 Prescribing 154 Unachievable Savings 110 Other (244) Additional Capacity in Community 17 Total 5,197 8.3 Scottish Government has recognised the ongoing impacts resulting from Covid and the pressures facing the health and social care system heading into the winter period. On the 5th October, measures were outlined by Scottish Government relating to new investment for Scotland of more than £300 Million as a direct response to the intense winter planning and system pressures work that is taking place. These preparations are predicated based on four key principles: • Maximising capacity • Ensuring Staff wellbeing • Ensuring System Flow • Improving Outcomes Subsequently, on the 4th November Scottish Government provided further detail on key components of the additional funding. Specifically, this covered • £40 million for interim care arrangements • £62 million for enhancing care at home capacity • Up to £48 million for social care staff hourly rate of pay increases; and • £20 million for enhancing multi-disciplinary teams This funding is for the remainder of the current financial year with additional commitments of funding still to be confirmed for future years. Details of the proposed investment were reported to the Board on 27 January 2022 (para 15 of the minute refers) and a further update is subject to a separate report on this Boards agenda. 9. UPDATED BUDGET POSITION 9.1 During the financial year, budget adjustments arise relating in the main to the allocation of non-recurring funding that is received via NHS Grampian. In order to establish clarity of these budget allocations a summary reconciliation has been provided below. 9.2 The MIJB, for the 2021/22 has concluded the financial year in an underspend position due to additional funding being made available for Covid related expenditure, unachieved savings and additional investment by the Scottish Government for winter funding. The additional funding is advance payment and has been carried forward mainly in Earmarked reserves, with a small amount in General Fund Reserves. These additional funding contributions are also shown in the table below: Page 32
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£’s Approved Funding 26.3.21 123,425,128 Set Aside funding 26.3.20 12,252,000 Balance of IJB reserves c/fwd to 21/22 4,788,128 Amended directions from NHSG 3.6.21 80,661 Budget Adjustments qtr 1 1,678,730 Budget Adjustments qtr 2 2,780,546 Budget Adjustments qtr 3 2,459,436 Revised Funding to Quarter 3 152,464,629 Budget adjustments M10-M12 Living Wage shortfall 562,000 Mental Health funding 51,000 Adult social care uplift 450,000 Care at home investment 1,137,000 Interim beds 734,000 Living Wage shortfall 67,828 Removal stat mitigation 33,220 Set Aside amendment 424,000 Moray core budget amendment 19,094 Covid 19 Allocation 11,566,362 Primary Care Improvement Fund 1,586,063 Action 15 259,434 Psychological Facility 257,199 Alcohol & Drug Partnership Funding 214,333 Interface Delayed Discharge 205,157 Out Of Hours Winter Fund 201,857 Hosted Recharges 137,903 Immunisation Funding 108,175 PT Tranche 66,390 Dementia PDS 60,013 School Nurses 46,000 Health Support Care Worker 45,176 District Nurses 36,000 Management Pay Award 35,075 Prescribing 27,927 GP Premises 25,720 Mental Health Primary Care 22,251 Dental Priority Groups 15,392 Other (29,840) Revised 2021/22 Financial Year Funding 170,829,358 9.3 In accordance with the updated budget position, revised Directions have been included at APPENDIX 4 for approval by the Board to be issued to NHS Grampian and Moray Council. Page 33
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10. RESERVES 10.1 Members will recall the MIJB Reserves Policy, most recently approved on 27 January 2022 (para 14 of the minute refers). The next review date should be no later than March 2023. The closing financial position on Reserves for 2021/22 is £17,020,624. Of this reserve, £1,257,139 is a usable general reserve and has been utilised in supporting a balanced budget for 2022/23. The remaining £15,763,576 is an earmarked reserve and will be called upon during the year in line with their specific purpose. The earmarked reserves detail is provided in the table below: Reserve Detail Type £’s Action 15 Earmarked 72,101 Primary Care Improvement Plan Earmarked 2,258,771 Covid-19 Earmarked 9,016,054 GP Premises Earmarked 231,780 Moray care home infection control Earmarked 223,163 Community Living Change Fund Earmarked 319,463 National Drugs MAT Earmarked 102,880 National Drugs Mission Moray Earmarked 206,813 OOH Winter Pressure funding Earmarked 201,857 Moray Cervical screening Earmarked 109,794 Moray hospital at home Earmarked 198,533 Moray interface discharge Earmarked 205,157 Moray School nurse Earmarked 46,000 Moray Psychological Earmarked 492,259 MHO Funding Earmarked 51,000 Care at Home Investment funding Earmarked 656,154 Interim Care Funding Earmarked 695,128 Moray Workforce well being Earmarked 53,671 Moray Winter Fund HCSW Earmarked 255,999 Moray Winter Fund MDT Earmarked 367,000 Flexibility & Surplus (utilised for 22/23 budget) General 1,257,139 TOTAL 17,020,716 11. SUMMARY OF IMPLICATIONS (a) Corporate Plan and 10 Year Plan (Local Outcomes Improvement Plan (LOIP)) and Moray Integration Joint Board Strategic Commissioning Plan 2016 – 2019 This report is consistent with the objectives of the Strategic Plan and includes 2021/22 budget information for services included in MIJB in 2021/22. Page 34
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(b) Policy and Legal In accordance with the MIJB Integration Scheme and in the event that the recovery plan is unsuccessful at the year-end, uncommitted reserves held by the MIJB have been used to address the budget overspend. Following the application of remaining uncommitted reserves, the funding partners were asked to meet the remaining over spend proportionately with their share of the baseline payment. (c) Financial implications The unaudited financial outturn for 2021/22 for the MIJB core budgets is £2,512,662 overspend. The financial details are set out in sections 3- 9 of this report and in APPENDIX 1. The estimated recurring overspend of £3,288,574 as detailed in para 7 will impact on the 2022/23 budget. The movements in the 2021/22 budget as detailed in paragraph 8 have been incorporated in the figures reported. (d) Risk Implications and Mitigations The most significant risk arising from this report is the control and management of expenditure to provide the Health and Social Care services required for the Moray Area, within budget. Due to the ongoing impact and recovery from the current pandemic, additional funding has been received and carried forward to help support the additional costs related to it. Considerations are being given to alternative measures that can be established to support the recurring overspends. There is a need for constant scrutiny around this rapidly changing situation and reporting to the Board will inform throughout 2022/23 (e) Staffing Implications There are no direct implications in this report. (f) Property There are no direct implications in this report. (g) Equalities/Socio Economic Impact An Equality Impact Assessment is not required because there are no changes to policy resulting from this report. (h) Climate Change and Biodiversity Impacts There are no direct climate change and biodiversity implications as there has been no change to policy (i) Directions Directions are detailed in para 9 above and in Appendix 4. Page 35
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(j) Consultations The Chief Officer, the Senior Management Team, Service Managers and the Finance Officers from Health and Social Care Moray have been consulted and their comments have been incorporated in this report as appropriate. 12. CONCLUSION 12.1 This report identifies MIJB’s unaudited final out-turn position on the Core Budget of an overspend of £2,512,662 at 31 March 2022 and identifies major areas of variance between budget and actual for 2021/22. 12.2 The impact of the provisional outturn on the 2022/23 budget, of a recurring overspend of £3,288,574 is detailed in paragraph 7. 12.3 NHS Grampian and Moray Council have both carried forward reserves into 2022/23 which total £17,020,624. Author of Report: D O’Shea Principal Accountant (MC) & B Sivewright Finance Manager (NHSG) Background Papers: Papers held by respective Accountancy teams Ref: Page 36
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APPENDIX 1 JOINT FINANCE REPORT APRIL 2021 - March 2022 Para Annual Budget (Net) Actual Ref Net Budget To Date To Date Variance £'s £'s £'s £'s 2021-22 2021-22 2021-22 2021-22 Community Hospitals 5,494,502 5,494,502 5,477,258 17,244 Community Nursing 4.1 5,489,863 5,489,863 4,932,107 557,756 Learning Disabilities 4.4 8,263,552 8,263,552 9,690,443 (1,426,891) Mental Health 4.8 9,267,110 9,267,110 9,542,021 (274,911) Addictions 1,282,392 1,282,392 1,259,342 23,050 Adult Protection & Health Improvement 151,159 151,159 158,635 (7,476) Care Services provided in-house 4.10 17,214,756 17,214,756 16,237,858 976,898 Older People & PSD Services 4.13 19,014,085 19,014,085 20,535,939 (1,521,854) Intermediate Care & OT 4.16 1,523,772 1,523,772 1,828,354 (304,582) Care Services provided by External Contractors 4.18 8,539,985 8,539,985 8,270,977 269,008 Other Community Services 8,576,252 8,576,252 8,459,989 116,263 Admin & Management 2,399,886 2,399,886 2,404,434 (4,548) Primary Care Prescribing 4.20 17,416,092 17,416,092 18,310,245 (894,154) Primary Care Services 18,277,624 18,277,624 18,306,781 (29,157) Hosted Services 4,618,811 4,618,811 4,631,849 (13,038) Out of Area 669,268 669,268 831,758 (162,490) Improvement Grants 939,600 939,600 757,664 181,936 Total Moray IJB Core 130,314,800 130,314,800 132,827,462 (2,512,662) Other non-recurring Strategic Funds in the ledger 2,568,094 2,568,094 2,783,013 (214,919) Other resources not included in ledger under core and strategic: 24,902,464 24,902,464 5,154,259 19,748,205 Total Moray IJB (incl. other strategic funds) and other costs not in ledger 157,785,358 157,785,358 140,764,734 17,020,624 Set Aside Budget 13,044,000 13,044,000 13,044,000 - Overall Total Moray IJB 170,829,358 170,829,358 153,808,734 17,020,624 Funded By: NHS Grampian 120,098,789 Moray Council 50,730,569 IJB FUNDING 170,829,358 Page 37
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APPENDIX 2 Description of MIJB Core Services 1. Community Hospitals includes community hospitals, community administration and community Medical services in Moray. 2. Community Nursing related to Community Nursing services throughout Moray, including District Nurses and Health Visitors. 3. Learning Disabilities budget comprises of:- • Transitions, • Staff – social work and admin infrastructure, • External purchasing of care for residential & nursing care, • External purchasing of care for respite, day care and domiciliary care, • Medical, Nursing, Allied Health Professionals and other staff. 4. Mental Health budget comprises of:- • Staff social work and admin infrastructure, • External purchasing of care for residential & nursing care, • External purchasing of care for respite, day care and domiciliary care, • In patient accommodation in Buckie & Elgin. • Medical, Nursing, Allied Health Professionals and other staff. 5. Addictions budget comprises of:- • Staff – social work and admin infrastructure, • Medical and nursing staff • External purchasing of care for residential & nursing care, • External purchasing of care for respite, day care and domiciliary care, • Moray Alcohol & Drugs Partnership. 6. Adult Protection and Health Improvement 7. Care Services provided in-house Services budget comprises of:- • Employment Support services, • Care at Home service/ re-ablement, • Integrated Day services (including Moray Resource Centre), • Supported Housing/Respite and • Occupational Therapy Equipment Store. 8. Older People & Physical Sensory Disability (PSD) budget comprises of:- • Staff – social work infrastructure (including access team and area teams), • External purchasing of care for residential & nursing care, • External purchasing of care for respite, day care and domiciliary care and • Residential & Nursing Care home (permanent care), 9. Intermediate Care & Occupational Therapy budget includes:- • Staff – OT infrastructure • Occupational therapy equipment • Telecare/ Community Alarm equipment, • Blue Badge scheme Page 39
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APPENDIX 2 10. The Care Services provided by External Contractors Services budget includes:- • Commissioning and Performance team, • Carefirst team, • Social Work contracts (for all services) • Older People development, • Community Care finance, • Self Directed support. 11. Other Community Services budget comprises of:- • Community services for each locality (Allied Health Professionals (AHP’s), Dental services, Public Health, Pharmacy and other specialist nursing roles). 12. Admin & Management budget comprises of :- • Admin & Management staff infrastructure • Target for staffing efficiencies from vacancies 13. Other Operational Services - range of operational services including – • Community Response • Team • Child Protection • Winter Pressures • Clinical Governance • International Normalised Ratio (INR) blood clotting test Training • Moray Alcohol and Drug Partnership (ADP) 14. Primary Care Prescribing includes cost of drugs prescribed in Moray. 15. Primary Care Services relate to General Practitioner GP services in Moray. 16. Hosted Services, comprises of a range of Grampian wide services. These services are hosted and managed by a specific IJB on a Grampian wide basis and costs are re-allocated to IJB budgets. These services include:- Moray IJB Hosted & Managed services: • GMED out of Hours service. • Primary Care Contracts Team Aberdeen City/Aberdeenshire IJB Hosted & Managed services: • Intermediate care of elderly & rehab. • Marie Curie Nursing Service – out of hours nursing service for end of life patients • Continence Service – provides advice on continence issues and runs continence clinics • Sexual Health service • Diabetes Development Funding – overseen by the diabetes Network. Also covers the retinal screening service • Chronic Oedema Service – provides specialist support to oedema patients • Heart Failure Service – provided specialist nursing support to patients suffering from heart failure. • Police Forensic Examiner Service Page 40
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APPENDIX 2 • HMP Grampian – provision of healthcare to HMP Grampian. 17. Out of Area Placements for a range of needs and conditions in accommodation out with Grampian. These are managed centrally within NHS Grampian and charged to IJB’s. 18. Improvement Grants manged by Council Housing Service, budget comprises of:- • Disabled adaptations • Private Sector Improvement grants • Grass cutting scheme Other definitions: Tier 1- Help to help you (information and advice), universal services to the whole community and an emphasis on prevention. Tier 2- Help when you need it (immediate help in a crisis, re-ablement) and regaining independence. Tier 3- Ongoing support for those in need through the delivery of 1 or more self- directed support options. Page 41
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APPENDIX 3 HEALTH & SOCIAL CARE MORAY DELEGATED AUTHORITY REPORTS - PERIOD January 2022 to March 2022 Title of DAR Summary of Proposal Post(s) Permanent/ Temporary Duration (if Temporary) Effective Dates Funding Community Infant Feeding Co-ordinator 11 month fixed term Band 7 22.5 hrs Temporary 11 months Jan 2022 Scottish Government MIN Funding Physiotherapy First Contact Physiotherapist Band 7 75 hrs Permanent N/A Jan 2022 PCIF OT Highly Specialist Occupational Therapist - ED Band 7 37.5 hrs Permanent N/A Jan 2022 Winter Money - MDT Pharmacy Moray Practice Pharmacy Technician Band 5 75 hrs Temporary 24 months Jan 2022 PCIF Slippage Pharmacy Moray Pharmacotherapy Administrator Band 4 18.75 hrs Permanent N/A Jan 2022 Redesign - Reduction of band 8b 0.20wte Volunteer Development Volunteer Coordinator Band 5 37 hrs Permanent N/A Mar 2022 Winter Money - MDT CTAC Cervical Cytology Nurse Band 5 56.25 hrs Permanent N/A Mar 2022 CTAC CTAC Spirometry Healthcare Support Worker Band 3 56.25 hrs Permanent N/A Mar 2022 CTAC Page 43
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APPENDIX 3 Title of DAR Summary of Proposal Post(s) Permanent/ Temporary Duration (if Temporary) Effective Dates Funding Elgin Community Surgery DN Community Treatment and Care Nurse Coordinator Band 6 37.5 hrs Band 3 37.5 hrs Band 5 37.5 hrs Temporary 24 months Mar 2022 PCIF Slippage Hospital at Home Nurse Practitioner Band 6 60 hrs Temporary 12 months Mar 2022 Hospital at Home Pharmacy Moray Primary Care Pharmacy Technician Band 5 56.25 hrs Permanent N/A Mar 2022 PCIF Temp Advanced Practitioner Access Team Temporary grade 10 for 12 months Grade 10 36.25 hours Temporary 12 months Mar 2022 Vacancy target Page 44
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APPENDIX 4 MORAY INTEGRATION JOINT BOARD DIRECTION Issued under Sections 26-28 of the Public Bodies (Joint Working) (Scotland) Act 2014 1. Title of Direction and Reference Number 2022/01 Core Functions 2. Date Direction issued by the Moray Integration Joint Board 30.06.2022 3. Effective date of the Direction 31.3.2022 4. Direction to: NHS Grampian and Moray Council 5. Does the Direction supersede/update a previous Direction? If yes, include the reference number(s) of previous Direction Yes last budget monitoring report to MIJB on 30.03.2022 6. Functions covered by Direction All functions listed in Annex 1, Part 1 of the Moray Health and Social Care Integration Scheme and all functions listed in Annex 2, Part 1 of the Moray Health and Social Care Integration Scheme. 7. Direction Narrative Directed to deliver for the Board, the services noted below in pursuance of the functions noted below and within the associated budget noted below 8. Budget Allocation by MIJB to deliver on the Direction Moray Council associated budget - £63.4 million, of which £0.5 million is ring fenced for Housing Revenue Account aids and adaptations. NHS Grampian associated budget - £86.9 million, of which £4.6 million relates to Moray’s share for services to be hosted and £18.3 million relates to primary care prescribing. Page 45
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An additional £13 million is set aside for large hospital services. All details contained in APPENDIX 1 to the report 9. Desired Outcomes The direction is intended to update and reflect the budget position for 2021/22 10. Performance monitoring arrangements and review Directions will be reviewed by the Audit Performance & Risk Committee on a six monthly basis for assurance. Any concerns should be escalated at the first available opportunity to the MIJB. An annual report of all current Directions will be presented to the MIJB Page 46
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REPORT TO: MORAY INTEGRATION JOINT BOARD ON 30 JUNE 2022 SUBJECT: UNAUDITED ANNUAL ACCOUNTS BY: CHIEF FINANCIAL OFFICER 1. REASON FOR REPORT 1.1. To inform the Board of the Unaudited Annual Accounts of the Moray Integration Joint Board (MIJB) for the year ended 31 March 2022. 2. RECOMMENDATION 2.1. It is recommended that the Moray Integration Joint Board: i) consider and note the unaudited Annual Accounts prior to their submission to the external auditor, noting that all figures remain subject to audit; ii) note the Annual Governance Statement contained within the unaudited Annual Accounts; and iii) note the accounting policies applied in the production of the unaudited Annual Accounts, pages 41 to 42 of the accounts. 3. BACKGROUND 3.1 The Public Bodies (Joint Working) (Integration Joint Boards) (Scotland) Order 2014 requires that an integration joint board is subject to the audit and accounts regulations and legislation of a body under Section 106 of the Local Government (Scotland) Act 1973. 3.2 The Local Authority Accounts (Scotland) Regulations 2014 (2014 Regulations), places a statutory obligation on the MIJB to submit draft Annual Accounts for the year ended 31 March 2022 to its external auditors by 30 June 2022 and the audited annual accounts are required to be approved by the MIJB and published by the 30 September each year. Regulation 5 of the Local Authority (Capital Finance and Accounting) (Scotland) (Coronavirus) Amendment Regulations 2021 extended the dates, and these have been extended again for 2021/22 by further amendment regulations. This timescale and relates mainly to the timing of the audit. Audited accounts, under the Act are required to be published by 15 December 2022. Page 47
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3.3 In accordance with the governance process the Unaudited Annual Accounts were presented to the Audit, Performance and Risk Committee earlier today for discussion. 3.4 A copy of the unaudited accounts is attached at APPENDIX 1 4. KEY MATTERS RELEVANT TO RECOMMENDATION 4.1 In relation Regulation 5 of the Local Authority (Capital Finance and Accounting) (Scotland) (Coronavirus) Amendment Regulations 2021, Scottish Government has advised that the Act has been extended again for 2021/22. Subsequently, this allows for the ability to delay the publication of Annual Accounts until December 2022. Audit Scotland have assessed the resources they have available to conduct the audit and have made a decision to exercise the powers to extend the timescales as set out in the legislation. The Chief Financial Officer has had regular contact with the external auditor to ensure reporting and inspections periods are appropriate and have adapted timelines accordingly, whilst ensuring the accounts preparation is completed in a timely manner. 4.2 The Annual Accounts have been prepared in accordance with the Code of Practice on Local Authority Accounting in the United Kingdom 2021/22 (the Code) which is underpinned by the International Financial Reporting Standards (IFRS). 4.3 Audit Scotland, under Regulation 5 of the Local Authority (Capital Finance and Accounting) (Scotland) (Coronavirus) Amendment Regulations 2021 is required to complete their audit by 30 November 2022. The audited accounts and the External Auditor’s report will be submitted to the MIJB at its meeting of 26 November 2022 prior to publication. 4.4 The Comprehensive Income and Expenditure Statement shows a surplus of £10.679m on the provision of services for the year. As at 31 March 2021, the Balance Sheet showed total Reserves of £6.155m. This increase is primarily due to late allocation from the Scottish Government as advance payment to support the continued remobilisation of services in relation to Covid-19 and additional winter funding investments. Note 7 within the unaudited accounts breaks down the General Fund Reserve between what is General Reserve and available for utilisation and supporting the budget and what is earmarked for specific purposes. 4.5 The unaudited accounts are given at Appendix 1 and consist of the following: Management Commentary – provides the context through narrative that supports the financial statements. It describes the strategic intent of the MIJB, together with its performance through the year, highlighting areas of risk. It also provides some forward thinking on the forthcoming year and planned developments. Remuneration Report – details the pay and pension benefits accrued by the MIJB senior officers during 2021/22. Annual Governance Statement – is a means of reporting publicly on the MIJB’s governance arrangements, and seeks to provide assurance that its Page 48
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business is conducted in accordance with law, regulations and proper practices and that public money is safeguarded and properly accounted for. Financial Statements – provides detail of the main financial transactions through the Comprehensive Income & Expenditure Statement, Movement in Reserves Statement, and Balance Sheet. Notes to the Accounts – explains the use of accounting policies and provides supporting information to the main financial statements. 4.6 As at 31 March 2022 there were significant variances between budget and actual on several services. These are evident in the Comprehensive Income and Expenditure Statement and are detailed in a separate report being presented to this Board entitled ‘Revenue Budget Outturn for 2021/22’. A summary on the major variances is included within the Management Commentary as part of the Unaudited Annual Accounts. 5. SUMMARY OF IMPLICATIONS (a) Corporate Plan and 10 Year Plan (Local Outcomes Improvement Plan (LOIP)) and Moray Integration Joint Board Strategic Commissioning Plan 2019 – 2029 ‘Partners in Care’ The unaudited Annual Accounts have been completed and are available for audit inspection within the specified timescale. (b) Policy and Legal The Public Bodies (Joint Working) (Scotland) Act 2014 requires that the MIJB is subject to the audit and accounts provisions of a body under Section 106 of the Local Government (Scotland) Act 1973. The MIJB’s accounts are prepared in accordance with the Code of Practice on Local Authority Accounting in the United Kingdom 2021/22 which is underpinned by IFRS. (c) Financial implications The unaudited Annual Accounts provide all required information about the MIJB in relation to its financial position at 31 March 2022. The overriding principle in relation to annual accounts preparation is to provide a true and fair view. (d) Risk Implications and Mitigation There are no risk issues arising directly from this report. The unaudited Annual Accounts will be subjected to audit by external auditors, Audit Scotland, which will provide assurance that the Accounts for 2021/22 give a true and fair view of the financial position and expenditure and income of the MIJB for the year ended 31 March 2022. (e) Staffing Implications None arising directly from this report. (f) Property None arising directly from this report. (g) Equalities/Socio Economic Impact Page 49
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None arising directly from this report as there has been no change to policy as a result of this report. (h) Climate Change and Biodiversity Impacts There are no direct climate change and biodiversity implications as there has been no change to policy. (i) Directions None arising directly from this report. (j) Consultations In preparation of the unaudited Annual Accounts, consultations have taken place between finance staff of both Moray Council and NHS Grampian. The Chief Officer and other key senior officers have been consulted for comment where appropriate 6. CONCLUSION 6.1 The Annual Accounts, subject to audit, show an underspend on the provision of services of £10.679m for MIJB for the year ending 31 March 2022. At the beginning of the year the MIJB, held in its reserves £6.155m. The closing balance on the general fund reserve as at 31 March 2022 is £17.021m, consisting of £1.257m in a general reserve and £15.764m that has been earmarked for specific purposes as detailed in the unaudited annual accounts 2021/22. Author of Report: Deborah O’Shea, Interim Chief Financial Officer Background Papers: with author Ref: Page 50
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Moray Integration Joint Board Annual Accounts 2021/22 Appendix 1 UNAUDITED ANNUAL ACCOUNTS FOR THE YEAR ENDED 31 MARCH 2022 MORAY INTEGRATION JOINT BOARD Page 51
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Moray Integration Joint Board Annual Accounts 2021/22 If you need information from the Moray Council in a different language or format, such as Braille, audio tape or large print, please contact: ياروم سلجم لبق نم تامولعم لىإ ةجاح ي ف متنك اذإ نوكتو ةغلب وأ ويدوأ ةناوطسأ ،يا ربلا لثم فلتخم لكش لىعوأ ةفلتخم نوكت نأ مطب لاصّتلإا ءاجّرلاف ةظيلغ فورح لامعتساب ةعوب Jei pageidaujate tarnybos Moray tarybos teikiamą informaciją gauti kitokiu formatu, pvz., Brailio raštu, garso įrašu ar stambiu šriftu, kreipkitės: Jeśli potrzebują Państwo informacji od Rady Okręgu Moray w innym formacie, takim jak alfabet Braille'a, kasety audio lub druk dużą czcionką, prosimy o kontakt: Se necessitar de receber informações por parte do Concelho de Moray num formato diferente, como Braille, cassete áudio ou letras grandes, contacte: Ja Jums vajadzīga informācija no Marejas domes (Moray Council) citā valodā vai formātā, piemēram, Braila rakstā, audio lentā vai lielā drukā, sazinieties ar: ای نابز رگید یسک ےس لسنوک ےروم وک پآرگاتروص راکرد تامولعم ںیم لاثم ںوہ˝ ،فورح ےڑب ای پیٹ ویڈآ ،ےلیربںیئامرف ہطبار رک امرف ینابرہم وت: Chief Financial Officer to the Moray Integration Joint Board, High Street, Elgin, IV30 1BX 01343 563125 accountancy.support@moray.gov.uk Page 52
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Moray Integration Joint Board Annual Accounts 2021/22 Table of Contents MORAY INTEGRATION JOINT BOARD MEMBERS ............................................................ 1 MANAGEMENT COMMENTARY .......................................................................................... 1 STATEMENT OF RESPONSIBILITIES ............................................................................... 23 REMUNERATION REPORT ............................................................................................... 25 ANNUAL GOVERNANCE STATEMENT ............................................................................. 29 COMPREHENSIVE INCOME AND EXPENDITURE STATEMENT ..................................... 39 MOVEMENT IN RESERVES STATEMENT ........................................................................ 40 BALANCE SHEET .............................................................................................................. 41 NOTES TO THE FINANCIAL STATEMENTS ..................................................................... 42 Note 1 Significant Accounting Policies ............................................................................. 42 Note 2 Critical Judgements and Estimation Uncertainty .................................................. 43 Note 3 Events after the Reporting Period ........................................................................ 44 Note 4 Expenditure and Income Analysis by Nature ........................................................ 44 Note 5 Taxation and Non-Specific Grant Income ............................................................. 45 Note 6 Debtors ................................................................................................................ 45 Note 7 Usable Reserve: General Fund ............................................................................ 46 Note 8 Agency Income and Expenditure .......................................................................... 47 Note 9 Related Party Transactions .................................................................................. 48 Note 10 VAT .................................................................................................................... 50 Note 11 Accounting Standards That Have Been Issued but Have Yet To Be Adopted .... 50 Page 53
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Moray Integration Joint Board Annual Accounts 2021/22 1 MORAY INTEGRATION JOINT BOARD MEMBERS Voting Members Cllr. Shona Morrison (Chair) Moray Council Dennis Robertson (Vice-Chair) The Grampian Health Board Sandy Riddell The Grampian Health Board Derick Murray The Grampian Health Board Professor Siladitya Bhattacharya The Grampian Health Board Cllr. Theresa Coull Moray Council Cllr. Frank Brown Moray Council Cllr. John Divers Moray Council Non-Voting Members Simon Bokor-Ingram Interim Chief Officer Tracey Abdy Chief Financial Officer Jane Mackie Chief Social Work Officer Jane Ewen Lead Nurse Dr Malcolm Metcalfe Deputy Medical Director Dr Lewis Walker Registered Medical Practitioner Heidi Tweedie tsiMoray Val Thatcher Public Partnership Forum Representative Ivan Augustus Carer Representative Steven Lindsay Grampian Health Board Staff Partnership Karen Donaldson UNISON, Moray Council Co-opted Members Sean Coady Head of Service and IJB Hosted Services Dr Paul Southworth Consultant in Public Health Professor Caroline Hiscox The Grampian Health Board Roddy Burns Moray Council Page 54
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Moray Integration Joint Board Annual Accounts 2021/22 2 MANAGEMENT COMMENTARY The Role and Remit of the Moray Integration Joint Board The Public Bodies (Joint Working) (Scotland) Act 2014 required that Moray Council and the Grampian Health Board prepared an Integration Scheme for the area of the local authority detailing the governance arrangements for the integration of health and social care services. This legislation resulted in the establishment of the Moray Integration Joint Board (MIJB) that became operational from 1 April 2016. Moray Council and Grampian Health Board, as the parties to the Integration Scheme, each nominate voting members to the MIJB. Currently, three elected members from Moray Council and three Grampian Health Board members (one executive and two non-executives). Under the Public Bodies (Joint Working) (Scotland) Act 2014, a range of health and social care functions have been delegated from Moray Council and Grampian Health Board to the MIJB who has assumed responsibility for the planning and operational oversight of delivery of integrated services. MIJB also has a role to play in the strategic planning of unscheduled acute hospital based services provided by Grampian Health Board as part of the ‘set aside’ arrangements. Hosted services also form part of the MIJB budget. There are a number of services which are hosted by one of the 3 IJB’s within the Grampian Health Board area on behalf of all the IJBs. Responsibilities include the planning and operational oversight of delivery of services managed by one IJB on a day to day basis. MIJB has responsibility for hosting services relating to Primary Care Contracts and the Grampian Medical Emergency Department (GMED) Out of Hours service. Key Purpose and Strategy Following review and consultation, our second Strategic Planning (2019-29) – Partners in Care was launched in December 2019. The current plan emphasises the strength of integration and in addition to our two main Partners – Moray Council and the Grampian Health Board, the MIJB recognises the importance of the Third and Independent Sectors in facilitating the successful operation of the partnership of Health & Social Care Moray. As with all health and social care systems Moray is facing increasing demand for services at the same time as resources – both funding and workforce availability are under pressure. These challenges will intensify in the coming years as our population ages and more people with increasing complex needs require support to meet their health and care needs. The MIJB sets the direction and strategic intent through the development and implementation of the Strategic Plan and seeks assurance on the management and delivery of services through Board level performance reporting which ensures an appropriate level of scrutiny and challenge. The Strategic Plan identifies priority areas to support strategic direction and vision. Page 55
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Moray Integration Joint Board Annual Accounts 2021/22 3 MANAGEMENT COMMENTARY (continued) STRATEGIC PLAN KEY THEMES The Plan purposefully places an emphasis on prevention activities and seeks to prioritise these activities as a long term goal, actively pursuing good health and wellbeing for the population, this will mean increased investment in this area of work. It highlights the HOMEFIRST approach and the rationale for this is to assist people in understanding that “hospital is not always the best place for people”, a statement frequently used and in particular if you are frail and elderly can be counter intuitive to a successful recovery. The response to Covid-19 has escalated elements of the HOMEFIRST approach. Through 21/22 the pandemic has driven a level of transformational change. This pace will need to continue in the next year and beyond as we face significant levels of demand. Our Strategic Plan will be refreshed in 22/23 and will be accompanied by a delivery plan to reflect the recovery phase that will be needed to deal with day to day demand and a backlog that has accumulated. BUILDING RESILIENCE – Taking greater responsibility for our health and wellbeing HOME FIRST – Being supported at home or in a homely setting as far as possible PARTNERS IN CARE – Making choices and taking control over decisions WE ARE PARTNERS IN CARE OUR VISION: “We come together as equal and valued partners in care to achieve the best health and wellbeing possible for everyone in Moray throughout their lives.” OUR VALUES: Dignity and respect; person-centred; care and compassion; safe, effective and responsive OUTCOMES: Lives are healthier – People live more independently – Experiences of services are positive – Quality of life is improved – Health inequalities are reduced – Carers are supported – People are safe – The workforce continually improves – Resources are used effectively and efficiently Page 56
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Moray Integration Joint Board Annual Accounts 2021/22 4 MANAGEMENT COMMENTARY (continued) Population Moray is a largely rural area covering a land mass of 2,238 sq. km. It has a long coastline on the Moray Firth with harbours, fishing villages and world-class beaches. The area’s projected population for 2022 is 95,780. The main centre of population is Elgin, which is home to more than one quarter of the people living in Moray. Other towns of population between 5,000 and 10,000 are Forres, Buckie, Lossiemouth and Keith. Moray’s population has grown significantly in recent years from 87,160 in 1997. The population growth in Moray is slowing and it is projected that against the 2018 baseline1 Moray will be one of the 14 councils in Scotland who will have had a population decline by 2030. This trend is forecast to continue. The table below sets out projected population growth based on the 2018 baseline. Across Scotland there is a projected reduction in children, limited change in the working age population, but significant growth in adults of pensionable age. By comparison it is projected that Moray will have a greater decrease in children, a marked decrease in those of a working age, but a significantly higher change in those of a pensionable age. 1 https://www.nrscotland.gov.uk/files//statistics/nrs-visual/sub-nat-pop-proj-18/pop-proj-principal-2018- infographic.pdf Page 57
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Moray Integration Joint Board Annual Accounts 2021/22 5 MANAGEMENT COMMENTARY (continued) Performance Reporting Performance is reported quarterly to the Audit, Performance and Risk Committee of the MIJB. In addition to the quarterly reporting, there is a requirement under the Public Sector (Joint Working) (Scotland) Act 2014 for the MIJB to produce and publish an Annual Performance Report setting out an assessment of performance in planning and carrying out the delegated functions for which they are responsible. The Annual Performance Report is due to be published by 30 November this year and will be published on the Health & Social Care Moray website. The Coronavirus Act (Scotland) has made provision to delay the publication of this document as prior to Covid it was published by 31 July. One of the major aims of integration and a key measurable target for MIJB is to reduce the number of Moray residents that are ready to be sent home from hospital but have been delayed in this process. This is referred to as a ‘delayed discharge’. Delayed discharge can occur due to several reasons but quite often involves the onward provision of social care which can be complex in nature. The table below notes performance over a four year period showing the number of delayed discharge bed days occupied varying significantly and with minimal seasonal pattern up to March 2022. There was a significant reduction in delayed discharges in April to June 2020 onwards as the focus of the COVID-19 response in Moray was assessing and finding suitable support for those in hospital (specifically those ready for discharge) to allow for the anticipated influx of COVID-19 patients. After a sharp increase in quarter 2 of 2020-21 an immense amount of work was undertaken across the Moray system to improve the position, however the challenges in identifying capacity in the community to provide care for those who need it has proved extremely challenging. The impact of covid on existing staffing levels combined with the increasing needs identified in the community and the increase in elderly and frail people attending hospital and then requiring some form of assistance has resulted in increased delayed discharges and increased unmet need in the community. Despite these efforts the number per 1000 population of bed days occupied by Delayed Discharges was at its highest level for five years in March 2022. Improvements throughout the year include twice weekly (moving to daily when required) operational meetings to scrutinise the Delayed Discharge workflow, looking specifically at issues and implementing solutions. A new contract commenced in November 2021 for Care at Home service provision. A new model has been established where there is a primary provider who will work in close partnership with HSCM provider services. It is intended that this will increase stability in the market for care at home, enhance partnership working and facilitate our continued development of the outcome approach to commissioning. Page 58
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Moray Integration Joint Board Annual Accounts 2021/22 6 MANAGEMENT COMMENTARY (continued) Th The Number of Bed Days Occupied by Delayed Discharges 18+ per 1,000 population Jun 21 Sept 21 Dec 21 Mar 22 592 784 1,142 1,294 Jun 20 Sept 20 Dec 20 Mar 21 242 803 672 496 Jun 19 Sept 19 Dec 19 Mar 20 768 751 971 1,208 Jun 18 Sept 18 Dec 18 Mar 19 1,008 1,276 1,070 926 Jun 17 Sept 17 Dec 17 Mar 18 1,161 749 823 1,089 e Nu of Bed Days Occupied by Delayed Discharges (inc code 9) 18+ per 1,000 po In relation to Emergency occupied bed days, there continues to be a focus on ensuring people are getting home quickly and can maintain their independence. This had resulted in a long- term downward trend in the rate of emergency occupied bed days for over 65’s per 1,000 population from June 2017 to March 2021. However, the reduction of 18% in this rate from Mar 20 to Mar 21 was not maintained and levels are back up to that of March 2021. Rate of Emergency Occupied Bed Days for over 65’s per 1000 Population Jun 21 Sept 21 Dec 21 Mar 22 1,859 1,934 2,045 2,140 Jun 20 Sept 20 Dec 20 Mar 21 2,087 2,040 1,840 1,780 Jun 19 Sept 19 Dec 19 Mar 20 2,117 2,097 2,112 2,173 Jun 18 Sept 18 Dec 18 Mar 19 2,380 2,375 2,344 2,274 Jun 17 Sept 17 Dec 17 Mar 18 2,558 2,531 2,495 2,444 Covid 19 challenges and successes Throughout 2021/22, the IJB continued to deliver services in line with the Integration Scheme and Strategic Plan, however the planning and delivery of services remained impacted by the COVID pandemic. Some services remained temporarily paused whilst others rapidly adapted their delivery method and the majority of the non-frontline workforce continued to work from home. Page 59
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Moray Integration Joint Board Annual Accounts 2021/22 7 MANAGEMENT COMMENTARY (continued) For much of the year Moray remained in a pandemic response phase, flexing and stepping up quickly to respond to spikes in COVID infection rates. It was clear it would not be possible in all cases to restore services to pre-pandemic levels as long as enhanced public health measures remained in place. It was further evident that what could be delivered from within existing resources (workforce, infrastructure, and finance) was diminished. Even at this level, the requirement to operate core services alongside the additional measures in place to support the pandemic response meant there was an immediate and ongoing resource impact The health and social care system was challenged by some significant periods of demand. A pan-Grampian approach was taken in how surge and flow through the system was managed to ensure people in the community and in hospital received the care they required. Those working in health and social care in Moray across all sectors, including independent providers and the third sector stepped up to the challenge on a daily basis but have felt the negative effects of the pandemic on our communities more keenly than others. They have continued to respond with compassion, empathy and dedication in protecting and promoting people’s opportunities to have the best possible lives. By November, Grampian had experienced three waves of raised levels of COVID-19 infection and was currently in a fourth cycle of elevated disease which left the entire health and care system struggling to meet the normal level of performance despite the incredible efforts of a reduced and exhausted workforce. The social care sector in Moray faced continued periods of extreme pressure that had an impact on the wider community and the effectiveness and efficiency of health services. Service managers implemented business continuity arrangements to ensure available staff resources were focussed on maintaining business critical functions, particularly in care at home, to try to ensure that all essential care was covered. Page 60
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Moray Integration Joint Board Annual Accounts 2021/22 8 MANAGEMENT COMMENTARY (continued) One of our key challenges was effective communication and engagement with all of our stakeholders (public, staff and partner organisations). Weekly updates were produced and widely circulated. The reach of our social media platforms has expanded and the website continued to be utilised to promote information about the work of the IJB. Much of the focus of the last 12 months has been to consolidate learning and positive developments arising out of the pandemic. This included collaboration across the sector to mitigate negative impacts on the lives of individuals, families, communities and colleagues who worked tirelessly to support people, their unpaid carers and each other. Vaccination Programme Take-up of the COVID-19 vaccine was high among all cohorts in Moray. In April 2021, Phase 2 of the COVID- 19 vaccination programme for the over 18s progressed. The offer of vaccinations progressed by age, starting with those aged 40-49. In August, 16 and 17 year olds were invited to come forward for vaccination and in September the offer was extended to children and young people aged 12- 15. In February 2022 it was confirmed children aged five to 11 would be offered a COVID vaccine on the recommendation of the Joint Committee on Vaccination and Immunisation (JCVI). Thanks to the efforts of vaccinators and frontline staff, the Scottish Government met its target of offering every eligible adult over 18 an appointment by 30 December. Nearly 77% of eligible adults in Scotland had received a booster or third dose by that date. The Covid vaccination programme was primarily delivered at the Fiona Alcock Vaccination Centre in Elgin through appointments and walk-in opportunities, with pop-up outreach clinics held in workplaces and community venues as well as the Mobile Information Bus, to increase vaccine uptake among the vaccine hesitant in all cohorts Page 61
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Moray Integration Joint Board Annual Accounts 2021/22 9 MANAGEMENT COMMENTARY (continued) Longer Term Impact of Covid-19 and Wellbeing There was real concern that after such a sustained period of intense physically and emotionally draining work, staff’s own resilience had been badly hit, with the recognition that they would need support and opportunities to decompress, reflect and recharge in order to find the reserves required to continue to respond to ongoing and future challenges. The We Care staff health and wellbeing programme was established to deliver, co-ordinate and enhance staff wellbeing across NHS Grampian and the Health and Social Care Partnerships. The website acted as a hub where people could access information, help and advice related to their own and or their team’s physical and mental wellbeing. Recovery and Re-mobilisation Resource was directed into supporting people to look after themselves by encouraging good infection control, testing and vaccination, and to protecting the most vulnerable, including vulnerable care home residents. Waiting times for care and support grew longer due to sustained service pressures. Additional work was directed towards increasing capacity and planning ahead for winter. Operation Iris was enacted at a Grampian wide level for an initial six month period to manage the health and care system through winter, with the NHS continuing to operate on an emergency footing. The interdependencies between services formed part of the assessment on how we remobilised, as no part of the system operates in isolation. While demand on the health and care system continued to be immense, we remained focused on planning for the longer term to ensure that services remained responsive to the community. Work on developing some areas of strategic and locality planning slowed as operational issues continued to be prioritised, but we also saw the acceleration of transformational redesign around the Home First programme alongside the opportunities presented by an expanded portfolio of health and care that now encompasses Dr Gray’s Hospital. Changes to Business as Usual Activities/ Transformation Care home and care at home assurance groups continued to meet to provide oversight and support to internal and external social care providers within the context of Covid in Moray. The group monitored information with an overview of cases staffing, safety, PPE, testing and any other pertinent issues. This is a multi-agency group that has supported and guided care homes and care at home in a positive way through the ongoing challenges Page 62
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Moray Integration Joint Board Annual Accounts 2021/22 10 MANAGEMENT COMMENTARY (continued) Care home and care at home assurance groups continued to meet to provide oversight and support to internal and external social care providers within the context of Covid in Moray. The group monitored information with an overview of cases staffing, safety, PPE, testing and any other pertinent issues. This is a multi-agency group that has supported and guided care homes and care at home in a positive way through the ongoing challenges. A new model of care at home has been implemented since October 2021. Health & Social Care Moray commissioned a single care at home external partner to jointly deliver an outcome based care at home service across Moray. Since its establishment, Health & Social Care Moray has liaised and worked closely with both NHS Grampian and Moray Council, along with other resilience partners, to ensure that the duties of Category 1 responders are adhered to. Following an amendment to legislation, IJBs are now included within the within the Civil Contingencies Act 2004 as Category 1 responders Longer Term Changes to Strategies and Plans Strategic planning has been delayed due to operation matters in response to the pandemic taking priority. The Strategic Planning and Commissioning Group (SPCG) was re- established in September 2021 and began to oversee the development of key programmes of work across the interfaces between primary, secondary and social care, developing the locality planning approach and coordination of the many enabling elements upon which planning and delivery of services is reliant. Locality planning resumed with intelligence gathering to inform locality profiles. Locality managers agreed terms of reference for the locality steering groups which will involve stakeholders developing approaches to community engagement to identify local health and wellbeing priorities for improvement. Locality engagement work commenced in the Lossiemouth area to consider future health and wellbeing provision and the impact on patients of the continued closure of the GP branch surgery buildings in Hopeman and Burghead Page 63
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Moray Integration Joint Board Annual Accounts 2021/22 11 MANAGEMENT COMMENTARY (continued) The strategic plan Moray Partners in Care was published in 2019 and it is recognised that the health and social care landscape has changed considerably since then. A refresh of the plan is essential to set the approach for the next 10 years. The revised plan – to be published in 2022 - will set out clearly our aims and objectives to the public and our workforce, building on what has already been achieved Other Impacts on services In November 2021, Moray was hit by Storm Arwen at one of the coldest periods of the year. All partners deployed an emergency response to power outages, road closures, water supply issues and the risk of flooding. Health & Social Care Moray and the local authority took action to ensure vulnerable residents were safe in their homes and access to hot food or had alternative accommodation. Throughout the stormy weather and despite access issues, staff worked diligently to ensure critical services were maintained. The Future Moray continued to progress the Home First approach to supporting people to avoid unnecessary hospital admission and to return home, wherever possible, without delay. This work has developed into Hospital without Walls, an ambitious model involving all aspects of Home First alongside unscheduled care, primary/secondary care and acute services. Hospital without Walls will offer hospital-level care to patients who are acutely unwell in their own home. It will establish a suite of responsive, co-ordinated, multi-disciplinary care supporting older people with frailty and multi-morbidity. Initial effort has been concentrated on developing a Home First Frailty Team who will be primarily focused at the ‘front door’ of Dr Gray’s Hospital but will also offer support within the community. The multi-disciplinary team will provide rapid geriatric assessments and allow a quick turnaround of those presenting at the front door. This will combine elements of the Discharge to Assess service which is now embedded into the system and provides an intermediate support approach for hospital in-patients who are medically stable and do not require acute hospital care but may still require rehabilitation. They are discharged home with short-term support to be fully assessed for longer-term needs in their own home. The IJB responded to the Scottish Government’s consultation on a National Care Service for Scotland following the recommendation of the Independent Review of adult social care. The National Care Service would operate as a new body to oversee social care, similar to how the National Health Service oversees health, enabling social care to have a more equal footing with health care. Page 64
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Moray Integration Joint Board Annual Accounts 2021/22 12 MANAGEMENT COMMENTARY (continued) It proposes that Local Integration Authorities would have more powers and would be directly funded by national government, rather than receiving their funding from local authorities and Health Boards as they do at the moment. Officers continued to work on developing the business case for the delegation of Moray Children’s Social Work and Criminal Justice to the IJB. Moray Council and NHS Grampian have now agreed the delegation, the next step to update the Integration Scheme and get approval from the Scottish Government. Financial Review and Performance Financial performance forms part of the regular reporting cycle to the MIJB. Throughout the year the Board, through the reports it receives is asked to consider the financial position at a given point and any management action deemed as necessary to ensure delivery of services within the designated financial framework. From the mid-point in the financial year, the Board was presented with financial information that included a forecast position to the end of the year. In November 2021 the Board received a financial report which forecast an expected overspend to the end of the financial year of £2.3m. This forecast reduced throughout the remainder of the year and in December 2021, MIJB were forecasting a small underspend to the end of the year of £0.2m. In March 2021, the MIJB agreed a savings plan of £0.407m. At the end of the financial year, only £0.11m had not been achieved. Scottish Government additional funding was made available that covered the underachievement on the savings target and £0.11m was received as part of Covid funding. Given the uncertainties associated with Covid-19, it was necessary to update the Board regularly on the emerging financial position. This was done formally through MIJB meetings and informally through development sessions. To support the response to Covid-19, the Scottish Government developed a process to assess the impact of Covid on Integration Authorities’ budgets. They did this through the development of local mobilisation plans for each health board area, which in turn captured each Integration Authority. The objective was to demonstrate the impact on IJB budgets and provide appropriate financial support. The local mobilisation plans were updated regularly throughout the year and funding allocations were made by the Scottish Government on the basis of these updates. At the end of the financial year, the cost of the mobilisation plan for Moray was £5.197m, this included £0.110m for the underachievement of the approved savings plan. The largest element of spend was £3.176m which was used to support sustainability payments to external providers of care. Any unspent funds are held in an earmarked reserve and drawn down as appropriate for the continued support to the pandemic response and recovery. Additional detail on the areas of spend supported through Covid-19 funding is highlighted in the table below: Page 65
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Moray Integration Joint Board Annual Accounts 2021/22 13 MANAGEMENT COMMENTARY (continued) Description Spend to 31 March 2022 £000’s Additional Staffing Costs 160 Provider Sustainability Payments 3,176 Remobilisation 1,178 Cleaning, materials & PPE 90 Elgin Community Hub 556 Prescribing 154 Other (244) Additional Capacity in Community 17 Underachievement of Savings 110 Total 5,197 Service Area Budget £000’s Actual £000’s Variance (Over)/ under spend Note Community Hospitals 5,494 5,477 17 Community Health104,360 5,490 4,932 558 4 Learning Disabilities 8,264 9,691 (1,427) 2 Mental Health 9,267 9,542 (275) Addictions 1,282 1,259 23 Adult Protection & Health Improvement 151 158 (7) Care Services Provided In-House 17,215 16,238 977 3 Older People Services & Physical & Sensory Disability 19,014 20,536 (1,522) 1 Intermediate Care & OT 1,524 1,828 (304) 5 Care Services Provided by External Contractors 8,540 8,271 269 Other Community Services 8,576 8,460 116 Administration & Management 2,400 2,404 (4) Other Operational Services 1,176 1,192 (16) Primary Care Prescribing 17,416 18,310 (894) Primary Care Services 18,278 18,307 (29) Hosted Services 4,619 4,632 (13) Out of Area Placements 669 832 (163) Improvement Grants 940 758 182 Total Core Services 130,315 132,827 (2,512) Strategic Funds & Other Resources 27,470 7,937 19,533 TOTALS (before set aside) 157,785 140,764 17,021 Page 66
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Moray Integration Joint Board Annual Accounts 2021/22 14 MANAGEMENT COMMENTARY (continued) The table above summarises the financial performance of the MIJB by comparing budget against actual performance for the year. MIJB’s financial performance is presented in the comprehensive income and expenditure statement (CIES), which can be seen on page 39. At 31 March 2022 there were usable reserves of £17.021m available to the MIJB, compared to £6.342m at 31 March 2021. These remaining reserves of £17.021m are for various purposes as described below: Earmarked Reserves Amount £000’s Action 15 72 Primary Care Improvement Plan 2,259 Covid-19 9,016 GP Premises 232 Moray care home infection control 223 Community Living Change Fund 319 National Drugs MAT 103 National Drugs Mission Moray 207 OOH Winter Pressure funding 202 Moray Cervical screening 110 Moray hospital at home 199 Moray interface discharge 205 Moray School nurse 46 Moray Psychological 492 MHO Funding 51 Care at Home Investment funding 656 Interim Care Funding 695 Moray Workforce well being 54 Moray Winter Fund HCSW 256 Moray Winter Fund MDT 367 Total Earmarked 15,764 General Reserves 1,257 TOTAL Earmarked & General 17,021 Page 67
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Moray Integration Joint Board Annual Accounts 2021/22 15 Action 15 – as part of the Mental Health Strategy 2017-2027, Scottish Government Ministers made a commitment to provide funding to support employment of 800 additional mental health workers to improve access. Primary Care Improvement Plan – Scottish Government investment to support the GP contract that was agreed in 2018. Covers 6 priority areas identified by Government. Covid 19 - additional funding provided by Scottish Government to address the impacts of the pandemic. GP Premises – balance of funding for improvement grants including the making of premises improvement grants to GP contractors. The continued digitalisation of paper GP records. Modifications for the purposes of improving ventilation and increase to the space available in NHS owned or leased premises for primary care multi-disciplinary teams. Community Living Change Fund – funding to be used over a three year period (2021-2024) to support reducing delayed discharge of those with complex needs, repatriate people inappropriately placed outside Scotland and to redesign the way service are provided for people with complex needs. Care Home Infection Control – to support Care Homes through the pandemic. National Drugs Medication Assisted Treatment (MAT) for embedding and implementation of the standards will he be overseen by the MAT implementation support team (MIST). National Drugs Mission Moray – balance of funding for range of activities including: drug deaths, taskforce funding, priorities of national mission, residential rehabilitation, whole family approach, outreach, bear fatal overdose pathways and lived and living experience. Out of Hours Winter Pressure funding – balance of funding to sustain GO out of hours and to support resilience to explore operational solutions. Moray Cervical Screening – balance of funding for smear test catch up campaign. Moray Hospital at home – development of Hospital at Home provides Acute hospital level care delivered by healthcare professionals, in a home context for a condition that would otherwise require acute hospital inpatient care. Moray Interface Care & Discharge without Delay (DWD)- interface care programme is part of the urgent and unschedules care programme. DWD programme is to prevent delay and reduce length of stay. Moray School Nurse – balance of school nursing programme for additional school nurses. Moray Psychological – funding streams for mental health, psychological wellbeing, facilities, post diagnostic support and psychological therapies. Mental Health Officer (MHO) funding – funding to support additional mental health officer capacity. Care at Home investment funding – balance of funding to build capacity in care at home community based services. Interim Care funding – balance of non-recurring funding basis to enable patients currently in hospital to move into care homes and other community settings. Page 68
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Moray Integration Joint Board Annual Accounts 2021/22 16 MANAGEMENT COMMENTARY (continued) Moray Workforce Wellbeing – funding to the health and wellbeing of those working in health and social care. Moray Winter Fund Health Care Social Workers (HCSW) – additional funding for further HCSW in both the IJB and Emergency department. Moray Winter fund Multi Disciplinary Team – additional funding for service pressures includes Discharge to Assess, Home First Frailty team and volunteer development. All reserves are expected to be utilised for their intended purpose during 2022/23. Significant variances against the budget were notably: Note 1 Older People Services and Physical & Sensory Disability - This budget was overspent by £1.5m at the end of the year. The final position includes an overspend for domiciliary care in the area teams, which incorporates the Hanover complexes for very sheltered housing in Forres and Elgin and for permanent care due to more clients receiving nursing care than residential care. The ageing population requiring more complex care and local demographics also contributes to this overspend. Note 2 Learning Disabilities – The Learning Disability (LD) service was overspent by £1.4m at the end of 2021-22. This consists of a £1.5m overspend, primarily relating to day services and the purchase of care for people with complex needs. Adults with learning disabilities are some of the most vulnerable people in our community and need a high level of support to live full and active lives. The overspend was offset in part by an underspend of £0.1m, relating primarily to staffing in speech and language and psychology services. The transformational change programme in learning disabilities helps to ensure that every opportunity for progressing people’s potential for independence is taken, and every support plan involves intense scrutiny which in turn ensures expenditure is appropriate to meeting individual outcomes. Note 3 Care Services Provided In-House – This budget was underspent by £1.0M at the end of the year. The most significant variances relate to the Care at Home services for all client groups and the Supported Living services which are underspent predominantly due to vacancies and issues with recruitment and retention. Overspends in internal day services £0.1m mainly due to transport costs and less income received than expected. Note 4 Community Health – This budget was underspent overall by £0.6m at the end of 2021-22 and is primarily due to vacancies, unplanned leave and retirements. Recruitment and retention is an issue, which is not just apparent in Moray and a plan is currently in place to deal with this going forward. Note 5 Intermediate Care & Occupational Therapy (OT) – This budget was overspent by £0.3m. This relates primarily to OT equipment where costs have increased due to manufacturing and supply to Moray and more complex equipment requests . Page 69
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Moray Integration Joint Board Annual Accounts 2021/22 17 MANAGEMENT COMMENTARY (continued) Set Aside – Excluded from the financial performance table above on page 14 but included within the Comprehensive Income & Expenditure Account is £13.04m for Set Aside services. Set Aside is an amount representing resource consumption for large hospital services that are managed on a day to day basis by the NHS Grampian. MIJB has a responsibility for the strategic planning of these services in partnership with the Acute Sector. Set Aside services include: Accident and emergency services at Aberdeen Royal Infirmary and Dr Gray’s inpatient and outpatient departments; Inpatient hospital services relating to general medicine, geriatric medicine, rehabilitation medicine, respiratory medicine, learning disabilities, old age psychiatry and general psychiatry; and Palliative care services provided at Roxburgh House Aberdeen and The Oaks Elgin. The budget allocated to Moray is designed to represent the consumption of these services by the Moray population. As a result of prioritising resources to support the Covid pandemic Public Health Scotland have not produced activity data for Set Aside services for the 2019/20 or 2020/21 financial years. The figures for 2021/22 have been derived by uplifting 2019/20 figures by baseline funding uplift in 2020/21 (3.00%) and 2021/22 (3.36%): 2021/22 2020/21 2019/20 2018/19 Budget 13.04m 12.62m 12.252m 11.765m Number of Bed Days and A&E Attendances -------- ------- ------- 47,047 Page 70
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Moray Integration Joint Board Annual Accounts 2021/22 18 MANAGEMENT COMMENTARY (continued) Risks, Uncertainties and Future Developments The MIJB Chief Officer has a responsibility to maintain a risk strategy and risk reporting framework. Risks inherent within the MIJB are monitored, managed and reported at each meeting of the Audit, Performance and Risk Committee. In addition, a risk action log is monitored and managed by the Senior Management Team. The key strategic risks of the MIJB classed as ‘High’ and ‘Very High’ are presented below: VERY HIGH Risk 2 - There is a risk of MIJB financial failure in that the demand for services outstrips available financial resources. Financial pressures being experienced both by the funding Partners and Community Planning Partners will directly impact on decision making and prioritisation of MIJB. Mitigating Actions - Risk remains of the challenge that the MIJB can deliver transformation and efficiencies at the pace required. Financial information is reported regularly to both the MIJB, Senior Management Team and System Leadership Group. The Chief Officer and Chief Financial Officer (CFO) continue to engage in finance discussions with key personnel of both NHS Grampian and Moray Council. These conversations have continued throughout the Covid-19 pandemic. The Chief Officer and CFO will continue to engage with the partner organisations in respect of the financial position throughout the year. Cross partnership performance meetings are in place with partner CEOs, Finance Directors and the Chair/Vice Chair of the MIJB. The CFO and Senior Management Team have worked together to address further savings which will be presented to the Board for approval as part of the budget setting procedures for 2022/23. This should be a focus of continuous review to ensure any investment is made taking cognisance of existing budget pressures. Page 71
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Moray Integration Joint Board Annual Accounts 2021/22 19 MANAGEMENT COMMENTARY (continued) HIGH Risk 1 - The Integration Joint Board (IJB) does not function as set out within the Integration Scheme, Strategic Plan and Scheme of Administration and fails to deliver its objectives or expected outcomes. Inability to recruit and retain qualified and experience staff to provide and maintain sustainable, safe care. Mitigating Actions - Induction sessions are held for new IJB members and IJB members briefings are held regularly. Conduct and Standards training was held for IJB members in December 2020 with update provided by Legal Services as appropriate. Senior Management Team (SMT) regular meetings and directing managers and teams to focus on priorities. Regular development sessions are held with IJB and System Leadership Group (SLG) Strategic Plan and locality management structure is in place The work that has been progressed through the Covid19 response has escalated developments in some areas as a matter of priority. This has been achieved through collaborative working with partner organisations and the third sector Risk 3 - Inability to recruit and retain qualified and experience staff to provide and maintain sustainable, safe care. Mitigating Actions - System re-design and transformation. Organisational Development Plan and Workforce plan were updated and approved by MIJB in November 2019 and they are being progressed by the Workforce Forum. Workforce planning has recommenced alongside plans for NShG and Moray Council and an initial draft will be submitted to Senior Management Team 8 June 2022. Staff Wellbeing is a key focus and there are many initiatives being made available to all staff including training, support, information and access to activities. Locality Managers are developing the Multi-disciplinary teams in their areas and some project officer support has been provided to develop the locality planning model across Moray. Lead Managers are involved in regional and national initiatives to ensure all learning is adopted to improve this position. They are also linked to University Planning for intakes and programmes for future workforce development Page 72
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Moray Integration Joint Board Annual Accounts 2021/22 20 MANAGEMENT COMMENTARY (continued) HIGH (continued) Risk 5 - Inability to cope with unforeseen external emergencies or incidents as a result of inadequate emergency and resilience planning. Mitigating Actions – Information from the updated Business Impact Assessments /Business Continuity Plans has informed elements of the Winter Preparedness Plan (Surge plan). A Friday huddle is in place which gathers the status of services across the whole system to provide information and contact details to the Senior Manager on Call (SMOC) over the weekend. NHS Grampian have introduced system wide daily huddles to manage the flow and allocation of resources which require attendance from Dr Grays and HSCM. NHS Grampian have amended their approach to Pandemic preparation so HSCM Pandemic plan requires redrafting and testing. Practitioner group established for Moray with representation from HSCM, Dr Grays, Moray Council and NHS Grampian to discuss matters arising from the Local Resilience Forum and within our respective organisations. In addition it will provide a forum for discussion of the linkages between organisational response plans to ensure there are no gaps or over reliance on particular local resources. HSCM represented at Grampian Local Resilience Partnership meetings and working groups and at NHSG Civil Contingencies group to ensure that plans are aligned and networks are established and maintained for use to support a response. Risk 7 - Inability to achieve progress in relation to national Health and Wellbeing Outcomes. Performance of services falls below acceptable level. Mitigating Actions – Service managers monitor performance regularly within their teams and escalate any issues to the System Leadership Group (SLG) for further discussion to provide wider support, developing shared ownership and a greater understanding across the whole system. Key operational performance data is being circulated daily to all managers in the Daily dashboard to ensure any potential issues are identified quickly so action can be taken. This dashboard is being reviewed and will be further developed with the intention of further dashboards to provide a whole system overview. This has been discussed at SLG and agreed. Performance information is presented to the Performance sub group of Practice Governance Group to inform Social Care managers of the trends in service demands so that resources can be allocated appropriately. Page 73
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Moray Integration Joint Board Annual Accounts 2021/22 21 MANAGEMENT COMMENTARY (continued) HIGH (continued) Risk 8 - Inability to progress with delivery of Strategic Objectives and Transformation projects. Mitigating Actions - Integrated Infrastructure Group previously established, with ICT representation from NHS Grampian and Moray Council, to consider and provide solutions to data sharing issues and ICT infrastructure matters. Linkages to Infrastructure Board and information sharing groups had been established albeit these meetings are not taking place regularly at the moment. Data sharing groups for Grampian and Health and Social Care Moray were established and meetings were held regularly but have not taken place regularly during Covid. These meetings have oversight of any issues arising from Data protection and GDPR matters from either Council or NHS systems. During covid the issues have been dealt with as they arose Risk 9 - Requirements for support services are not prioritised by NHS Grampian and Moray Council. Mitigating Actions – Membership of the Board was reviewed and revised to ensure representation of all existing infrastructure processes and funding opportunities. Process for ensuring infrastructure change/investment requests developed. Infrastructure Manager in post and linking into other Infrastructure groups within NHS Grampian and Moray Council to ensure level of ‘gatekeeping’. Dr Gray’s site development plan is being produced collaboratively with input from NHS Grampian and HSCM management. Work is progressing on identification of needs for some services with regard to accommodation which will be communicated with partners to find the most effective solution Development Aims for 2022/23 HOME FIRST The planning and delivery to meet the threat of Covid-19 has led to some rapid change and has created a new starting point. Home First continues to be the key strategic theme/over- arching project to embed change going forwards, to ensure that in a new environment we can continue to meet health and care needs safely, and can react to further waves of Covid-19; winter pressures; and future unknown events. Developing from last year’s Operation Home First, Moray has continued to mature it’s Home First work streams whilst also ensuring they are targeted and coordinated. In an effort to explore the entire patient pathway Hospital without Walls was devised. This programme will ensure there is a suite of responsive, seamless, coordinated, multi-disciplinary care supporting older people with frailty and multi-morbidity. Hospital without Walls pulls together the individual work streams under Home First whilst also considering unscheduled care, primary and secondary care services. Page 74
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Moray Integration Joint Board Annual Accounts 2021/22 22 MANAGEMENT COMMENTARY (continued) As a result of the Covid 19 activity and diversion, the Strategic Plan 2019-29, the Medium Term Financial Strategy and other supporting plans are due to revisited in 22/23. As the organisation continues to remobilise following the impacts of response, new, transformational ways of working are being adopted and are informing our approach to delivery of the strategic objectives outlined in the plan. In addition we will seek to: Continue to develop systems leadership with a Portfolio approach; Further embed Home First and develop Hospital without walls; Ensure successful embedding of Discharge to Assess and how it interfaces with other services in support of reducing Delayed Discharges; Continually develop by progressing the MIJB Improvement Action Plan measured against the Ministerial Strategic Objectives; Ensure compliance with the Governance Framework as approved by the MIJB in January 2021; Progress the Primary Care Improvement Plan; and Embed recommendations from the Independent Review of Adult Social Care, and continue to embed Self Directed Support into mainstream activities. Progress Housing development for people with a Learning Disabilities ………………………… ……………………… ……………………… Cllr. Tracy Colyer Simon Bokor-Ingram Deborah O’Shea Chair of Moray IJB Chief Officer Interim Chief Financial Officer 30 June 2022 Page 75
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Moray Integration Joint Board Annual Accounts 2021/22 23 STATEMENT OF RESPONSIBILITIES Responsibilities of the MIJB To make arrangements for the proper administration of its financial affairs and to secure that it has an officer responsible for the administration of those affairs. In Moray Integration Joint Board, that officer is the Chief Financial Officer; To manage its affairs to achieve best value in the use of its resources and safeguard its assets; Ensure the Annual Accounts are prepared in accordance with legislation (The Local Authority Accounts (Scotland) Regulations 2014) and the Local Authority (Capital Financing and Accounting) (Scotland) (Coronavirus) Amendment Regulations 2021, and so far as is compatible with that legislation, in accordance with proper accounting practices (section 12 of the Local Government in Scotland Act 2003); and To approve the Annual Accounts. Cllr. Tracy Colyer Chair of Moray IJB 30 June 2022 Page 76
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Moray Integration Joint Board Annual Accounts 2021/22 24 STATEMENT OF RESPONSIBILITIES (continued) Responsibilities of the Chief Financial Officer The Chief Financial Officer is responsible for the preparation of the Moray Integration Joint Board’s Annual Accounts in accordance with proper practices as required by legislation and as set out in the CIPFA/LASAAC Code of Practice on Local Authority Accounting in the United Kingdom (the Code). In preparing the Annual Accounts the Chief Financial Officer has: Selected suitable accounting policies and applied them consistently; Made judgements and estimates that were reasonable and prudent; Complied with legislation; and Complied with the local authority code (in so far as it is compatible with legislation). The Chief Financial Officer has also: Kept proper accounting records which were up to date; and Taken reasonable steps for the prevention and detection of fraud and other irregularities. I certify that the financial statements give a true and fair view of the financial position of the Moray Integration Joint Board as at 31 March 2022 and the transactions for the year then ended Deborah O’Shea FCCA Interim Chief Financial Officer 30 June 2022 Page 77
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Moray Integration Joint Board Annual Accounts 2021/22 25 REMUNERATION REPORT Introduction This Remuneration Report is provided in accordance with the Local Authority Accounts (Scotland) Regulations 2014 (SSI2014/200) as part of the MIJB annual accounts. This report discloses information relating to the remuneration and pension benefits of specified MIJB members. All information disclosed in the tables is subject to external audit. Other sections within the Remuneration Report will be reviewed for consistency with the financial statements. Moray Integration Joint Board The voting members of MIJB are appointed through nomination by Moray Council and the Grampian Health Board. There is provision within the Order to identify a suitably experienced proxy or deputy member for both the voting and non-voting membership to ensure that business is not disrupted by lack of attendance by any individual. MIJB Chair and Vice-Chair Nomination of the MIJB Chair and Vice-Chair post holders alternates every 18 months between a Councillor and a Health Board non-executive member. The MIJB does not provide any additional remuneration to the Chair, Vice-Chair or any other board members relating to their role on the MIJB. The MIJB does not reimburse the relevant partner organisations for any voting member costs borne by the partner. The MIJB does not have responsibilities in either the current or in future years for funding any pension entitlements of voting MIJB members. Therefore no pension rights disclosures are provided for the Chair or Vice-Chair. Taxable Expenses 2020/21 Name Position Held Nomination By Taxable Expenses 2021/22 £ £ Nil Dennis Robertson Vice-Chair 29/04/21 to date Chair 24/09/20 to 29/04/21 Grampian Health Board Nil Nil Cllr Shona Morrison Chair 29/04/21 to date Vice-Chair 01/10/19 to 29/04/2021 Moray Council Nil Page 78
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Moray Integration Joint Board Annual Accounts 2021/22 26 REMUNERATION REPORT (continued) Officers of the MIJB The MIJB does not directly employ any staff in its own right; however specific post-holding officers are non-voting members of the Board. Chief Officer Under section 10 of the Public Bodies (Joint Working) (Scotland) Act 2014 a Chief Officer for the integration joint board has to be appointed and the employing partner has to formally second the officer to the Board. The employment contract for the Chief Officer will adhere to the legislative and regulatory framework of the employing partner organisation. The remuneration terms of the Chief Officer‘s employment are approved by the Board. Other Officers No other staff are appointed by the MIJB under a similar legal regime. Other non-voting board members who meet the criteria for disclosure are included in the disclosures below. Total 2020/21 Senior Employees Salary, Fees & Allowances Total 2021/22 £ £ £ 96,115 Simon Bokor-Ingram Chief Officer 109,826 109,826 87,271 Tracey Abdy Chief Financial Officer 93,904 93,904 In respect of officers’ pension benefits, the statutory liability for any future contributions to be made rests with the relevant employing partner organisation. On this basis there is no pensions liability reflected on the MIJB balance sheet for the Chief Officer or any other officers. The MIJB however has a responsibility for funding the employer contributions for the current year in respect of the officer time spent on fulfilling the responsibilities of their role on the MIJB. The following table shows the MIJB’s funding during the year to support the officers’ pension benefits. The table also shows the total value of accrued pension benefits which may include benefits earned in other employment positions and from each officer’s own contributions. NOTE: no bonuses, expenses allowances, compensation for loss of office or any taxable benefits were made in 2021/22 Page 79
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Moray Integration Joint Board Annual Accounts 2021/22 27 REMUNERATION REPORT (continued) In Year Pension Contributions Accrued Pension Benefits Year to 31/03/21 Year to 31/03/22 As at 31/03/2022 Difference from 31/03/2021 £ £ £ 000’s £ 000’s Simon Bokor- Ingram, Chief Officer 13,142 (from 20/4/20) 12,954 Pension 43 5 Lump Sum 87 7 Tracey Abdy Chief Financial Officer 18,075 18,561 Pension 20 2 Lump Sum 18 - Disclosure by Pay bands As required by the regulations, the following table shows the number of persons whose remuneration for the year was £50,000 or above, in bands of £5,000. Number of Employees in Band 2020/21 Remuneration Band Number of Employees in Band 2021/22 1 £85,000 - £89,999 0 0 £90,000 - £94,999 1 1 £95,000 - £99,999 0 0 £105,000 - £109,999 1 Page 80
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Moray Integration Joint Board Annual Accounts 2021/22 28 REMUNERATION REPORT (continued) Exit Packages There were no exit packages agreed by the MIJB during 2021/22 financial year, or in the preceding year. ……………………….. ……………………… Cllr. Tracy Colyer Simon Bokor-Ingram Chair of Moray IJB Chief Officer 30 June 2022 Page 81
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Moray Integration Joint Board Annual Accounts 2021/22 29 ANNUAL GOVERNANCE STATEMENT The Annual Governance Statement describes the Moray Integration Joint Board’s (MIJB) governance arrangements and reports on the effectiveness of the MIJB’s system of internal control. Scope of Responsibility The MIJB is responsible for ensuring that its business is conducted in accordance with the law and appropriate standards, and that public money is safeguarded and used efficiently and effectively in pursuit of best value. In discharging its responsibilities, the MIJB has established arrangements for its governance which includes the system of internal control. This system is intended to manage risk and support the achievement of the MIJB’s policies, aims and objectives. The system provides reasonable but not absolute assurance of effectiveness. The MIJB places reliance of the systems of internal control of NHS Grampian systems and Moray Council, which supports organisational compliance of policies and procedures in addition to those of the MIJB. Assurances are required on the effectiveness of the governance arrangements of all three organisations, meaning a significant failure in one of the three Partners may require to be disclosed in the annual accounts of all three Partners. The Governance Framework The CIPFA/SOLACE framework for ‘Delivering Good Governance in Local Government’ last updated in 2016 remains current and provides a structured approach in defining seven principles that underpin effective governance arrangements. Whilst the framework is written specifically for Local Government, the principles apply equally to integration authorities, and while the MIJB continues to evolve as an entity in its own right. It continues to draw on the governance assurances of NHS Grampian and Moray Council as its principal funding partners. Given the scope of responsibility within the MIJB and the complexities surrounding the assurance arrangements, a Local Code of Corporate Governance was developed and the MIJB assesses the effectiveness of its governance arrangements against the principles set out in the document. The Code outlines the seven governance principles from the CIPFA/SOLACE guidance (as referenced below) and provides the sources of assurance for assessing compliance relative to the MIJB, Moray Council and NHS Grampian. These assurances include referencing the governance arrangements of NHS Grampian and Moray Council which are summarised annually and published in their respective Annual Governance Statements which form part of the annual accounts of each organisation. The respective governance statements can be found on the individual organisations websites: Moray Council: Annual Accounts - Moray Council and NHS Grampian: https://www.nhsgrampian.org/about- us/annual-accounts/ Key Governance Arrangements Covid-19 has had a significant impact on the MIJB and its approach to dealing with the pandemic has involved the use of amended governance arrangements granted under delegated powers. Page 82
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Moray Integration Joint Board Annual Accounts 2021/22 30 ANNUAL GOVERNANCE STATEMENT (continued) All of the scheduled Audit Performance and Risk Committee meetings were held as timetabled during 2021/22. An interim arrangement was agreed for the operation of the Clinical and Care Governance Committee whereby the Chair of the Committee received monthly updates on the key issues arising during the pandemic response. This related principally to the provision of care, care home oversight and child and adult protection matters. In addition the Chief Officer committed to providing weekly updates on the emerging situation to IJB Members, elected Members and staff. Health and Social Care Moray (HSCM) established an emergency response group that has been operational since the end of March 2020, with the frequency of meetings being adapted throughout the year dependent on the stage of response. Representation on the emergency response groups of the Partner organisations is provided by HSCM staff, ensuring the necessary links and flow of information to ensure a co-ordinated response on a pan Grampian basis and locally within Moray. The collaborative working across the whole system increased with the Omicron wave of Covid as the impact on staffing levels and demand for services put extreme pressure on all aspects of service delivery. Up to three times daily meetings were held 7 days a week to ensure a co- ordinated response. In addition a Grampian Operation Performance Escalation System (GOPES) was established to enable senior leaders to have oversight of where pressures were located in the system and to direct responses accordingly. This development has also strengthened the identification of key metric thresholds to inform the levels for escalation Evaluation of the Effectiveness of Governance Governance Principle 1 – Behaving with integrity, demonstrating strong commitment to ethical values and respecting the rule of law Assessment of Effectiveness The activities of the MIJB are directed by a Board comprising voting and non-voting members. The Board meets every two months and draws its membership from a broad range of sources. Formal Board meetings are augmented by regular development sessions that focus in detail on specific areas. The Board is also supported by an Audit, Performance and Risk Committee, and a Clinical and Care Governance Committee, each with a specific remit to support effective governance arrangements. The Scheme of Integration was reviewed during 2021 to increase by one voting member from each partner organisation to facilitate increased membership at the Committees The MIJB operates in line with Standing Orders that govern proceedings of the Board and its Committees, and which incorporates the Board’s Scheme of Administration that deals with the Board’s committee structure and working groups. The MIJB has appointed a Standards Officer to support compliance with an ethical standards framework in line with the Ethical Standards in Public Life etc. (Scotland) Act 2000 whereby members of devolved public bodies such as the MIJB are required to comply with Codes of Conduct, approved by Scottish Ministers, together with guidance issued by the Standards Commission. . Page 83
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Moray Integration Joint Board Annual Accounts 2021/22 31 ANNUAL GOVERNANCE STATEMENT (continued) Governance Principle 2 – Ensuring openness and comprehensive stakeholder engagement Assessment of Effectiveness Provision is made within MIJB’s Standing Orders for public and press access to meetings and reports. During the 2021/22 year there was a continued need to broadcast live Board meetings with attendance being virtual for all. A specific web- site has been developed for Health and Social Care Moray and is continuously monitored for improvement. Agendas, reports and minutes for all committees can be accessed via the website in addition to all the linked strategies of the MIJB. Both the voting and non-voting membership arrangements of the MIJB are in line with the Public Bodies (Joint Working) (Integration Joint Boards) (Scotland) Order 2014. The non-voting membership comprises six professional members and five stakeholder members representing: staff, third sector bodies carrying out activities in relation to health and social care, service users and unpaid carers, and four additional non-voting members which include the Chief Executives of Moray Council and NHS Grampian in an Ex-officio capacity. The broad membership of the MIJB ensures valued input and engagement from a wide range of stakeholders. The Community Empowerment (Scotland) Act 2015 places a statutory duty on MIJB and its Community Planning Partners to engage with communities on the planning and delivery of services and securing local outcomes. The MIJB has an approved Communications and Engagement Strategy which recognises and promotes the active and meaningful engagement with all stakeholders. Governance Principle 3 – Defining outcomes in terms of sustainable economic, social and environmental benefits Assessment of Effectiveness The MIJB has in place a Strategic Plan 2019-29 which is supported by various documents including a medium term financial framework. Following the impact of the pandemic a review is planned for both documents. The plan is underpinned by a performance framework, workforce plan, organisational development strategy, and a communications, engagement and participation plan. Initial work has commenced for an updated workforce plan due for completion by July 2022 The suite of documents are designed to identify outcomes and forward-thinking on direction over the medium term. Outcomes are closely linked to the delivery of health and social care and the planned improvements for the population of Moray. A climate change duties report is collated and submitted annually on behalf of the MIJB. Page 84
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Moray Integration Joint Board Annual Accounts 2021/22 32 ANNUAL GOVERNANCE STATEMENT (continued) Governance Principle 4 – Determining the interventions necessary to optimise the achievement of intended outcomes Assessment of Effectiveness The MIJB’s decision making process ensures that the members of the Board receive objective and robust analysis of a variety of options indicating how the intended outcomes will be achieved, providing information on the associated risks and opportunities. Board papers reflect the broad range of matters under consideration including regular update reports by the Chief Officer on topical matters and agenda items covering opportunities and challenges arising from reconfiguration of services. The Financial Management Code promoted by CIPFA is recognised as a means of assisting in ensuring good financial administration. A medium term financial strategy was approved by the MIJB in March 2022 and will be reviewed in the new financial year, once the strategic plan has been reviewed. Governance Principle 5 – Developing the entity’s capacity, including the capability of its leadership and the individuals within it Assessment of Effectiveness The Senior and Operational Management teams were due to continue to take part in a Systems Leadership Programme led by The Kings Fund to support the leadership teams however this has been further paused for the Covid 19 response. During the Covid 19 response there has been increased opportunity to work collaboratively across organisations through use of new technology. The MIJB has met with Officers regularly for development sessions to increase the opportunity for shared learning and constructive challenge. Page 85
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Moray Integration Joint Board Annual Accounts 2021/22 33 ANNUAL GOVERNANCE STATEMENT (continued) Governance Principle 6 – Managing risk and performance through robust internal control and strong public financial management Assessment of Effectiveness As part of a robust risk monitoring framework, the Strategic Risk Register is reviewed and updated regularly and presented to every Audit, Performance and Risk Committee. A related action log was created for monitoring purposes and is owned and monitored by the Senior Management Team. A Performance Management Framework has been developed. Performance reporting falls within the scope of the Audit, Performance and Risk Committee and reporting is quarterly. The internal control system links closely with those of the Partners, given their operational remit for delivery of services under direction of the MIJB. The Audit, Performance and Risk committee through its consideration of reports monitors the effectiveness of internal control procedures. The MIJB Chief Internal Auditor undertakes an annual review of the adequacy of internal controls and the opinion is included within this statement. The MIJB has an independent S95 Officer who is a member of the MIJB, providing advice on all financial matters and ensure timely production and reporting of budget estimates, budget monitoring reports and annual accounts. Governance arrangements have been developed and maintained to comply with the core functions of various good framework guidelines including Code of Practice on Managing the Risk of Fraud and Corruption, Public Sector Internal Audit Standards (incorporating the principles of the Role of the Head of Internal Audit), Audit Committees: Practical Guidance for Local Authorities and Police, etc. Governance Principle 7 – Implementing good practices in transparency, reporting and audit to deliver effective accountability Assessment of Effectiveness MIJB business is conducted through an approved cycle of Board meetings. During the year, recordings of Board meetings were made available to the public. Agendas, reports and minutes are available for the public to inspect. There is a standard reporting format in place to ensure consistency of approach and consideration by Members to provide transparency in decision making. The MIJB publishes both Annual Accounts and an Annual Performance Report following Board approval. The Chief Internal Auditor reports directly to the Audit, Performance and Risk committee with the right of access to the Chief Officer, Chief Financial Officer and Chair of the Audit, Performance and Risk committee on any matter. The Chief Internal Auditor has continued to report to Committee during 2021/22. Page 86
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Moray Integration Joint Board Annual Accounts 2021/22 34 ANNUAL GOVERNANCE STATEMENT (continued) Review of Adequacy and Effectiveness The MIJB has a responsibility for conducting, at least annually, a review of the effectiveness of the governance arrangements, including the system of internal control. The review is informed by the work of the Senior Management Team (which has responsibility for the development and maintenance of the internal control framework environment); the work of the Internal Auditors and the Chief Internal Auditor’s annual report and the reports from the External Auditor and other review agencies and inspectorates. Internal Audit Opinion The Internal Audit Service for the MIJB is delivered by Moray Council’s Internal Audit Section, and the Council’s Audit and Risk Manager holds the Chief Internal Auditor appointment to the MIJB until the 31st of March 2024. The Council’s Internal Audit Section has adopted the Public Sector Internal Audit Standards (PSIAS) that requires the Chief Internal Auditor to deliver an annual internal audit opinion and report, which has also been used to inform this governance statement. The Chief Internal Auditor’s evaluation of the adequacy and effectiveness of the MIJB framework of governance, risk management and internal control includes consideration of the findings from the audit work undertaken by the Chief Internal Auditor in his role as the Audit and Risk Manager for the Moray Council. Assurance is also sought from the Internal Audit Service Provider for NHS Grampian of the governance processes adopted by that organisation. In addition, reports issued by other external review agencies are considered in the opinion provided by the Chief Internal Auditor. In accordance with PSIAS, the Chief Internal Auditor prepares a risk based Audit Plan for the MIJB, which has regard to the internal audit arrangements of both the Moray Council and NHS Grampian functions. The impact of the pandemic continued to affect the Internal Audit Section in that officers have been working from home with a need to change established working practices and make greater use of audio, video, and screen sharing software applications. In addition, the Section has also had several staff vacancies during the year. Despite these constraints, the Audit Plan for 2021/22 was completed. The audits reported to the MIJB Audit, Performance and Risk Committee included a review of the financial monitoring arrangements within the Self Directed Support Team for direct payments made to service users. The audit found several areas where improvements were required to current operating systems and procedures, including a need to review all the care packages of the service user to recover any excess funds. An audit report was also received into the management arrangements of income held for individuals under Corporate Appointeeship Arrangements. The review found that the service was administered well, but findings were noted, including a need to review cash handling procedures and further management overview of the corporate bank account reconciliation process. Page 87
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Moray Integration Joint Board Annual Accounts 2021/22 35 ANNUAL GOVERNANCE STATEMENT (continued) However, the Chief Internal Auditor has raised concerns regarding a report to the Audit, Performance and Risk Committee on the 31st of March that detailed the outcome of a review of the Health and Social Care Moray Commissioning Service into how social care contracts are currently being managed. This was a “peer” review led by the Strategic Procurement Manager (Social Care) of Aberdeen City and Aberdeenshire Councils. The report has highlighted a number of significant concerns about how social care contracts are managed. The Audit, Performance and Risk Committee have agreed for an external organisation to undertake a review of the Commissioning Service. The Chief Internal Auditor, after consideration to the results of the work carried out by Internal Audit, taken together with other sources of assurance, with specific reference to the peer review into how the Commissioning Service manages social care contracts; only limited assurance can be provided that the Moray Integration Joint Board has adequate systems of governance and internal control, for the year ended 31 March 2022. Page 88
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Moray Integration Joint Board Annual Accounts 2021/22 36 ANNUAL GOVERNANCE STATEMENT (continued) Prior Year Governance Issues The Annual Governance Statement for 2020/21 highlighted a number of areas for development in looking to secure continuous improvement. An assessment of progress is provided below: Area for Improvement Identified in 2020/21 Action Undertaken / Progress Made in 2021/22 It is recognised that the impact the pandemic has had on services drives the need to review the Strategic Plan 2019-29 during 2021/22. The review will require engagement of key stakeholders and MIJB approval following the governance framework. The Medium Term Financial Framework will be reviewed to reflect the emerging and anticipated financial challenge arising from Covid 19 and Scottish Government policy changes Focus will be placed on the Governance Framework approved by the Board in January 2021 to ensure this key document is embedded into operational and strategic delivery As part of the financial challenge it is necessary to ensure continuous dialogue and identification of further savings opportunities. This was a commitment made as part of the revenue budget setting for 2021/22, recognising current and future impact and the drive for transformation through Home First. Increase focus on the development of commissioning capabilities to deliver best value with a tender exercise for outcome based care at home services. The Strategic plan is being refreshed and will be presented to the IJB in November 2022. The Moray Portfolio is also working with NHS Grampian on their plan for the future, and will be undertaking a joint planning process in 2022 to define the future for Dr Grays Hospital. The Medium Term Financial Framework 22/23 to 26/27 was presented to the IJB in March 2022. It will be reviewed once the Strategic plan has been refreshed. The Governance Framework continues to be embedded. Portfolio arrangements will mean a refresh is required. Transformational redesign has continued at pace. Levels of demand, including backlogs post Covid, has resulted in it being more challenging to identify cash savings. Outcome based commissioning model in place, with evaluation in 2022/23. Further development of Self Directed Support and progressive changes to practice using the Three Conversation Model Page 89
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Moray Integration Joint Board Annual Accounts 2021/22 37 ANNUAL GOVERNANCE STATEMENT (continued) Further Developments Following consideration of the review of adequacy and effectiveness, the following action plan has been established to ensure continual improvement of the MIJB’s governance arrangements and progress against the implementation of these issues will be assessed as part of the next annual review. Areas of focus for 2022/23 1. Extending the Hospital Without Walls model to move care closer to home, with a shift to earlier intervention that reduces the demands on acute hospital care. 2. Developing the Portfolio approach for the Moray Portfolio, and the interlink with the other Portfolios in Grampian, along with developing the governance framework for this whole system approach 3. Refresh the Strategic Plan during 2022, building on the learning of the last 2 years of the pandemic, and the transformational change that has begun 4. Using the 22/23 to 26/27 Medium Term Financial Framework to match the ambitions of the Strategic Plan so that services are sustainable 5. Work with the Digital Health and Care Innovation Centre as part of the Moray Growth Deal to test new ways of working that benefit the Moray population and bring improvements to the delivery of health and social care 6. Continue to extend the reach of Self Directed Support with an ambition for Moray to be an exemplar in this arena of supporting our residents in innovative ways that promote independence and choice 7. With the potential delegation of Children’s Social Work and Criminal Justice to the Moray IJB, better align service delivery in the Portfolio to the benefit of our residents, where care is seamless and access is clear Key Governance challenges going forward will involve: Providing capacity to meet statutory obligations whilst managing expectation and rising demand for services, with a backlog of demand from the pandemic, and wider societal economic challenges which will also drive demand; As a Board, difficult decisions will require to be made in ensuring we operate within available funding whilst meeting the needs of our residents; Continue to address our work force challenges in respect of recruitment and retention; Page 90
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Moray Integration Joint Board Annual Accounts 2021/22 38 ANNUAL GOVERNANCE STATEMENT (continued) Continuing to work closely with NHS Grampian and Moray Council to build on existing relationships and establishing collaborative leadership, and to maximise the opportunities from an expanded health and social care remit with the Portfolio approach, including Dr Grays hospital, and the potential delegation to the IJB of Children’s Social Work and Criminal Justice Services; The challenges being faced from the pandemic are expected to be a continued focus for additional scrutiny for an extended period of time, and how well we manage the recovery of service delivery. Statement In our respective roles as Chair and Chief Officer of the MIJB, we are committed to ensuring good governance and recognise the contribution it makes to securing delivery of service outcomes in an effective and efficient manner. This annual governance statement summarises the MIJB’s current governance arrangements, and affirms our commitment to ensuring they are regularly reviewed, developed and fit for purpose. Whilst recognising that improvements are required, as detailed earlier in the statement, it is our opinion that a reasonable level of assurance can be placed upon the adequacy and effectiveness of the MIJB’s governance arrangements. The immediate challenge will be to continue to meet all operational demands as we continue to recover from the Covid-19 Pandemic and through re-mobilisation whilst not compromising the safety of employees and people that use our services; beyond that, pressure on financial settlements is set to continue during the incoming period, and we will continue to engage with our Partners and the wider community to agree plans and outcome targets that are both sustainable and achievable. Taking those forward will be challenging as we aim to fulfil the nine Health and Wellbeing national outcomes and the strategic priorities identified and detailed in our Strategic Plan. Good governance remains an essential focus in delivering services in a way that both meets the needs of communities and discharges statutory best value responsibilities. ………………………… ……………………… Cllr. Tracy Colyer Simon Bokor-Ingram Chair of Moray IJB Chief Officer 30 June 2022 Page 91
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Moray Integration Joint Board Annual Accounts 2021/22 39 COMPREHENSIVE INCOME AND EXPENDITURE STATEMENT This statement shows the cost of providing services for the year ended 31 March 2022 according to generally accepted accounting practices. 2020/21 2021/22 Net Expenditure Net Expenditure Restated £ 000 £ 000 5,587 Community Hospitals 5,477 4,853 Community Nursing 4,932 8,546 Learning Disabilities 9,691 8,649 Mental Health 9,542 1,143 Addictions 1,259 152 Adult Protection & Health Improvement 158 15,183 Care Services Provided In-House 16,238 19,835 Older People & Physical & Sensory Disability Services 20,536 1,497 Intermediate Care and Occupational Therapy 1,828 8,067 Care Services Provided by External Providers 8,271 7,725 Other Community Services 8,460 3,033 Administration & Management 2,404 871 Other Operational services 1,192 17,451 Primary Care Prescribing 18,310 17,541 Primary Care Services 18,307 4,526 Hosted Services 4,632 808 Out of Area Placements 832 613 Improvement Grants 758 6,702 Strategic Funds & Other Resources 7,937 12,620 Set Aside 13,044 145,402 Cost of Services 153,808 151,557 Taxation and Non-Specific Grant Income (note 5) 164,487 (6,155) (Surplus) or Deficit on provision of Services (10,679) (6,155) Total Comprehensive Income and Expenditure (10,679) The 2020/21 figures have been restated to take into account the administration and Management area being split into administration and management and other operational services. There are no statutory or presentational adjustments which reflect the MIJB’s application of the funding received from partners. The movement in the General Fund balance is therefore solely due to the transactions shown in the Comprehensive Income and Expenditure Statement. Consequently, an Expenditure and Funding Analysis is not provided in these annual accounts. Page 92
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Moray Integration Joint Board Annual Accounts 2021/22 40 MOVEMENT IN RESERVES STATEMENT This statement shows the movement in the year on the Moray Integration Joint Boards (MIJB) reserves. The movements which arise due to statutory adjustments which affect the General Fund balance are separately identified from the movements due to accounting practices. Additional detail included within note 7 on page 46. Movement of Reserves During 2021/22 General Fund Balance £000 Opening Balance at 1 April 2021 (6,342) Total Comprehensive Income and Expenditure (10,679) (Increase) or Decrease in 2021/22 (10,679) Closing Balance at 31 March 2022 (17,021) Movement of Reserves During 2020/21 General Fund Balance £000 Opening Balance at 1 April 2020 (187) Total Comprehensive Income and Expenditure (6,155) (Increase) or Decrease in 2020/21 (6,155) Closing Balance at 31 March 2021 (6,342) Page 93
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Moray Integration Joint Board Annual Accounts 2021/22 41 BALANCE SHEET The Balance Sheet shows the value of the Moray Integration Joint Board’s (MIJB) assets and liabilities as at the balance sheet date. The net assets of the MIJB (assets less liabilities) are matched by the reserves held by the MIJB. 31 March 2021 £000 Notes 31 March 2022 £000 6,342 Short Term Debtors 6 17,021 Current Assets 0 Short Term Creditors 0 Current Liabilities 0 Provisions 0 Long Term Liabilities 6,342 Net Assets 17,021 6,342 Usable Reserve General Fund 7 17,021 6,342 Total Reserves 17,021 The unaudited annual accounts were issued on 30 June 2022. . Deborah O’Shea FCCA Interim Chief Financial Officer 30 June 2022 Page 94
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Moray Integration Joint Board Annual Accounts 2021/22 42 NOTES TO THE FINANCIAL STATEMENTS Note 1 Significant Accounting Policies General Principles The Financial Statements summarise the Moray Integration Joint Board’s (MIJB) transactions for the 2021/22 financial year and its position at the year-end of 31 March 2022. The MIJB was established under the requirements of the Public Bodies (Joint Working) (Integration Joint Boards) (Scotland) Act 2014 and is a Section 106 body as defined in the Local Government (Scotland) Act 1973. The Financial Statements are therefore prepared in compliance with the Code of Practice on Local Authority Accounting in the United Kingdom 2021/22, supported by International Financial Reporting Standards (IFRS), unless legislation or statutory guidance requires different treatment. The accounts are prepared on a going concern basis, which assumes that the MIJB will continue in operational existence for the foreseeable future. The historical cost convention has been adopted. Accruals of Income and Expenditure Activity is accounted for in the year that it takes place, not simply when settlement in cash occurs. In particular: Expenditure is recognised when goods or services are received and their benefits are used by the MIJB. Income is recognised when the MIJB has a right to the income, for instance by meeting any terms and conditions required to earn the income, and receipt of the income is probable. Where income and expenditure have been recognised but settlement in cash has not taken place, a debtor or creditor is recorded in the Balance Sheet. Where debts may not be received, the balance of debtors is written down. Funding The MIJB is primarily funded through funding contributions from the statutory funding partners, Moray Council and the Grampian Health Board. Expenditure is incurred as the MIJB commissions’ specified health and social care services from the funding partners for the benefit of service recipients in Moray area. Cash and Cash Equivalents The MIJB does not operate a bank account or hold cash. Transactions are settled on behalf of the MIJB by the funding partners. Consequently the MIJB does not present a ‘Cash and Cash Equivalent’ figure on the balance sheet. The funding balance due to or from each funding partner as at 31 March is represented as a debtor or creditor on the MIJB’s Balance Sheet. Page 95
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Moray Integration Joint Board Annual Accounts 2021/22 43 NOTES TO THE FINANCIAL STATEMENTS (continued) Note 1 Significant Accounting Policies (continued) Employee Benefits The MIJB does not directly employ staff. Staff are formally employed by the funding partners who retain the liability for pension benefits payable in the future. The MIJB therefore does not present a Pensions Liability on its Balance Sheet. The MIJB has a legal responsibility to appoint a Chief Officer. More details on the arrangements are provided in the Remuneration Report. The charges from the employing partner are treated as employee costs. Where material the Chief Officer’s absence entitlement as at 31 March is accrued, for example in relation to annual leave earned but not yet taken. Charges from funding partners for other staff are treated as administration costs. Reserves The MIJB’s reserves are classified as either Usable or Unusable Reserves. The MIJB’s only Usable Reserve is the General Fund. The balance of the General Fund as at 31 March shows the extent of resources which the MIJB can use in later years to support service provision. Indemnity Insurance The MIJB has indemnity insurance for costs relating primarily to potential claim liabilities regarding Board members. The Grampian Health Board and Moray Council have responsibility for claims in respect of the services that they are statutorily responsible for and that they provide. Unlike NHS Boards, the MIJB does not have any ‘shared risk’ exposure from participation in the Clinical Negligence and Other Risks Indemnity Scheme (CNORIS). The MIJB participation in the CNORIS scheme is therefore analogous to normal insurance arrangements. Note 2 Critical Judgements and Estimation Uncertainty In applying the accounting policies, the MIJB has had to make certain judgements about complex transactions or those involving uncertainty about future events. There are no material critical judgements. During the overall Covid-19 response, a number of additional costs have been incurred beyond business as usual. The MIJB has followed national guidance regarding these and a range of additional costs are included in the MIJB’s accounts reflecting the MIJB acting as principal in the transactions including:- social care sustainability costs; all increase direct care Covid-19 costs; Page 96
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Moray Integration Joint Board Annual Accounts 2021/22 44 NOTES TO THE FINANCIAL STATEMENTS (continued) Note 2 Critical Judgements and Estimation Uncertainty (continued) A further range of Covid-19 related costs and associated funding have not been recognised in the MIJB’s accounts in accordance with national accounting guidance. In these cases Moray Council is acting as principal and MIJB as the agent. This includes:- £0.527m related to PPE and testing kits provided by NHS National Services Scotland to Moray for social care services. Note 3 Events after the Reporting Period The unaudited accounts were issued by Deborah O’Shea, Interim Chief Financial Officer on 30 June 2022. Events taking place after this date are not reflected in the financial statements or notes. Where events taking place before this date provided information about conditions existing at 31 March 2022, the figures in the financial statements and notes have been adjusted in all material respects to reflect the impact of this information. Note 4 Expenditure and Income Analysis by Nature 2020/21 2020/21 £000 £000 60,984 Services commissioned from Moray Council 65,020 84,391 Services commissioned from The Grampian Health Board 88,760 27 Auditor Fee: External Audit Work 28 145,402 Total Expenditure 153,808 (151,557) Partners Funding Contributions and Non- Specific Grant Income (164,487) (6,155) (Surplus) or Deficit on the Provision of Services (10,679) Page 97
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Moray Integration Joint Board Annual Accounts 2021/22 45 NOTES TO THE FINANCIAL STATEMENTS (continued) Note 5 Taxation and Non-Specific Grant Income 2020/21 2020/21 £000 £000 45,060 Funding Contribution from Moray Council 50,549 106,497 Funding Contribution from The Grampian Health Board 113,938 151,557 Taxation and Non-specific Grant Income 164,487 The funding contribution from The Grampian Health Board shown above includes £13.044m in respect of ‘set aside’ resources relating to acute hospital and other resources. These are provided by The Grampian Health Board who retains responsibility for managing the costs of providing the services. The MIJB however has responsibility for the consumption of, and level of demand placed on, these resources. Note 6 Debtors 31 March 2021 31 March 2022 £000 £000 6,160 The Grampian Health Board 15,739 182 Moray Council 1,282 6,342 Debtors 17,021 Amounts owed by the funding partners are stated on a net basis. Creditor balances relating to expenditure obligations incurred by the funding partners but not yet settled in cash terms are offset against the funds they are holding on behalf of the MIJB. Page 98
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Moray Integration Joint Board Annual Accounts 2021/22 46 NOTES TO THE FINANCIAL STATEMENTS (continued) Note 7 Usable Reserve: General Fund The MIJB holds a balance on the General Fund for two main purposes: To earmark, or build up, funds which are to be used for specific purposes in the future, such as known or predicted future expenditure needs. This supports strategic financial management. To provide a contingency fund to cushion the impact of unexpected events or emergencies. This is regarded as a key part of the MIJB’s risk management framework. The table below shows the movements on the General Fund balance: Earmarked Reserves General Reserves PCIP & Action 15 Covid-19 Other Earmarked Total £000 £000 £000 £000 £000 Balance at 1 April 2020 0 187 0 0 187 Transfers (out)/in 2020/21 1,598 1,480 2,725 352 6,155 Balance at 31 March 2021 1,598 1,667 2,725 352 6,342 Transfer out 2020/21 (360) 0 0 0 (360) Transfers in 2020/21 0 664 6,291 4,065 11,020 Balance at 31 March 2021 1,257 2,331 9,016 4,417 17,021 Primary Care Improvement Fund (PCIP) - The purpose of this fund is to ring fence funding received from the Scottish Government as part of its Primary Care Transformation Plan, this includes Action 15 funding as part of this plan. Covid – 19 – are funds received by Scottish Government during 2021/22 being held in an earmarked reserve to support the MIJB through the pandemic and remobilisation. Page 99
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Moray Integration Joint Board Annual Accounts 2021/22 47 NOTES TO THE FINANCIAL STATEMENTS (continued) Note 8 Agency Income and Expenditure On behalf of all IJB’s within The Grampian Health Board, the MIJB acts as the lead manager for Grampian Medical Emergency Department (GMED) and Primary Care Contracts. It commissions services on behalf of the other IJBs and reclaims the costs involved. The payments that are made on behalf of the other IJBs, and the consequential reimbursement, are not included in the Comprehensive Income and Expenditure Statement (CIES) since the MIJB is not acting as principal in these transactions. The amount of expenditure and income relating to the agency arrangement is shown below: 2020/21 2021/22 £000 £000 10,032 Expenditure on Agency Services 9,136 (10,032) Reimbursement for Agency Services (9,136) 0 Net Agency Expenditure excluded from the CIES 0 Page 100
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Moray Integration Joint Board Annual Accounts 2021/22 48 NOTES TO THE FINANCIAL STATEMENTS (continued) Note 9 Related Party Transactions The MIJB has related party relationships with The Grampian Health Board and Moray Council. In particular the nature of the partnership means that the MIJB may influence, and be influenced by, its partners. The following transactions and balances included in the MIJB’s accounts are presented to provide additional information on the relationships. Transactions with the Grampian Health Board 2020/21 2021/22 £000 £000 (106,497) Funding Contributions received from the NHS Board (113,938) 84,208 Expenditure on Services Provided by the NHS Board 88,558 183 Key Management Personnel: Non-Voting Board Members 202 (22,106) Net Transactions with The Grampian Health Board (25,178) Key Management Personnel: The Chief Officer and Chief Financial Officer, are non-voting Board members and are both employed by The Grampian Health Board and recharged to the MIJB. Details of the remuneration of both officers are provided in the Remuneration Report. The Chief Officer is a joint appointment made by Moray Council and The Grampian Health Board and is jointly accountable to the Chief Executives of both organisations, as such this post is jointly funded. The Chief Financial Officer, whilst a Board appointment, does not share this arrangement of funding. Balances with the Grampian Health Board 31 March 2021 31 March 2021 £000 £000 6,160 Debtor balances: Amounts due from The Grampian Health Board 15,739 6,160 Net Balance due from The Grampian Health Board 15,739 Page 101
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Moray Integration Joint Board Annual Accounts 2021/22 49 NOTES TO THE FINANCIAL STATEMENTS (continued) Note 9 Related Party Transactions (continued) Transactions with Moray Council 2020/21 2020/21 £000 £000 (45,060) Funding Contributions received from the Council (50,731) 60,945 Expenditure on Services Provided by the Council 64,971 66 Key Management Personnel: Non-Voting Board Members 78 15,951 Net Transactions with Moray Council 14,318 Balances with Moray Council 31 March 2021 31 March 2022 £000 £000 182 Debtor balances: Amounts due from Moray Council 1,282 0 Creditor balances: Amounts due to Moray Council 0 182 Net Balance due from Moray Council 1,282 Page 102
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Moray Integration Joint Board Annual Accounts 2021/22 50 NOTES TO THE FINANCIAL STATEMENTS (continued) Note 10 VAT The MIJB is not registered for VAT and as such the VAT is settled or recovered by the partners. The VAT treatment of expenditure in the MIJB accounts depends on which of the partners is providing the services as each of these partners are treated differently for VAT purposes. VAT payable is included as an expense only to the extent that it is not recoverable from Her Majesty’s Revenue and Customs. VAT receivable is excluded from income. Note 11 Accounting Standards That Have Been Issued but Have Yet To Be Adopted The Code requires the MIJB to identify any accounting standards that have been issued but have yet to be adopted and could have material impact on the accounts. There are no accounting standards issued but not yet adopted that impact on the 2021/22 financial statements. Page 103
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Moray Integration Joint Board Annual Accounts 2021/22 51 Page 104
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REPORT TO: MORAY INTEGRATION JOINT BOARD ON 30 JUNE 2022 SUBJECT: PROPOSED DELEGATION OF CHILDREN AND FAMILIES AND JUSTICE SOCIAL WORK SERVICES TO MORAY INTEGRATION JOINT BOARD BY: CHIEF OFFICER, MORAY INEGRATION JOINT BOARD 1. REASON FOR REPORT 1.1 To ask the Board to consider the outcomes of the business case on the proposed delegation of Children and Families and Justice Social Work to the Moray Integration Joint Board. 2. RECOMMENDATION 2.1. It is recommended that the Moray Integration Joint Board (MIJB): i) consider and approve the Business Case for delegation of Children’s and Families and Justice Social Work Services to MIJB attached as Appendix 1 ii) note that the Business Case has been submitted to Moray Council and NHS Grampian Board for their respective approvals. iii) agree that financial accountability for the service remains with the Council for a period of 18 months up to 21 March 2024. iv) agree that Officers enter into dialogue with the Scottish Government (as the statutory approval body) over the formal amendments required to the Integration Scheme to enable the delegation; and v) note the final version of the Scheme will come back to the MIJB on 29 September 2022 for approval. 3. BACKGROUND 3.1. In Moray there was recognition of a need for improvement and transformational change within Children’s Social Work. The Care Inspection in 2016 pointed towards a need for radical improvement. National Benchmarking Data showed Moray did not compare well with comparator local authorities and an agreement Page 105
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was made for the reinvestment of savings to achieve sustained and robust change and improvement, which is underway 3.2. Proprietary work to delegate Children and Families and Justice Social Work Services has been ongoing since late 2019 with progress updates to NHS Grampian board on 5 December 2019 and 11 November 2020 whilst governed by a Programme Board with representation from all 3 bodies (NHS Grampian, Moray Council and MIJB) 3.3. When approvals from all three bodies (NHS Grampian, Moray Council and MIJB) are gained, a further report will be presented with the amendments to the Scheme of Integration for final approval. 4. KEY MATTERS RELEVANT TO RECOMMENDATION 4.1. On 6 April 2022 Moray Council agreed to progress with the delegation of Children and Families and Justice Social Work Services (para 12 of the minute refers). The members were presented with the Business Case which supports the decision of the Programme Board to recommend the delegation of Children and Families and Justice Services to MIJB. There is a clear understanding of the services which are lawful to delegate whilst recognising further work is required for final financial due diligence and to support the development and implementation of a change management plan. 4.2. The report presented to Moray Council can be found in Appendix 3, with reference to the Business Case in Appendix 1 and Proposed Timeline for delegation in Appendix 2. 4.3. For consistency of approach, the Moray Council report (Appendix 3) was presented to the NHS Grampian Board on 2 June 2022 with agreement to proceed to delegate Children and Families and Justice Social Work Services. 4.4. When approvals from all three bodies (NHS Grampian, Moray Council and MIJB) are gained, a further report will be presented with the amendments to the Scheme of Integration for final approval on 29 September. 5. SUMMARY OF IMPLICATIONS (a) Corporate Plan and 10 Year Plan (Local Outcomes Improvement Plan (LOIP)) and Moray Integration Joint Board Strategic Plan “Moray Partners in Care 2019 – 2029” Moray Council Corporate Plan 2020-23 outlines its ambitions to support children and families and communities (b) Policy and Legal Legal resource is required to undertake any due diligence for amending the Integration Scheme, and that process is ongoing. This will be assisted by Brodies Solicitors and the indicative timescale is accepted with the caveat that the Scottish Ministers lead time to sign off the amended Scheme of Integrate may vary according to their priorities. The Children and Young People (Scotland) Act 2014 (Part 3) sets out a legal framework for children’s services planning, including its scope and aims Page 106
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(c) Financial implications In preparation for the delegation of additional functions to the MIJB it will be necessary for the MIJB to obtain assurance that financial resources are adequate to allow it to carry out the functions delegated and to assess the risks associated with this. The MIJB Chief Finance Officer will work with both the Council Section 95 Officer and the Health Board Director of Finance in establishing the required assurance. (d) Risk Implications and Mitigation To continue at pace, the scale of this work should not be underestimated. Financial due diligence and workforce engagement is essential to a successful transition. There is a high risk if we are unable to gain agreement from all 3 bodies to delegate. Through the business case it has been recognised that children and families and justice services has a good fit best for with adult services. If delegation does not proceed this will have implications for the escalation of the costs of services, not only for opportunities for efficiencies and professional development across the social work workforce, but more importantly the lost opportunity for an improved workforce alignment which will offer better outcomes for our most vulnerable children and families. (e) Staffing Implications Once a formal decision has been made any proposals for change to team structures and lines of responsibility will be documented through a change management plan including consultation with relevant parties, including our staff and unions. (f) Property No property issues identified at this point. (g) Equalities/Socio Economic Impact Not required at this point. (h) Climate Change and Biodiversity Impacts None arising from this report (i) Directions None arising directly from this report. (j) Consultations Chief Executive Moray Council, Chief Finance Officer NHS Grampian, Interim Chief Financial Officer MIJB, Chief Executive NHS Grampian, Chief Social Work Officer; Head of Governance, Strategy and Performance, Tracey Sutherland, Committee Services Officer; Head of Financial Services, Head of Children’s and Families and Justice Social Work all Moray Council have been consulted. 6. CONCLUSION 6.1. The Business case supports the decision of the Programme Board to recommend the delegation of Children and Families Social Work and Criminal Justice Services to MIJB. There is a clear understanding of the Page 107
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services which are lawful to delegate whilst recognising further work is required for final financial due diligence and to support the development and implementation of a change management plan. 6.2. Approvals have been gained from Moray Council and NHS Grampian to formally delegate children and families and justice social work services. When approvals from all three bodies are gained, a further report will be presented with the amendments to the Scheme of Integration for final approval Author of Report: Simon Bokor-Ingram, Chief Officer MIJB Background Papers: With Author Ref: Page 108
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APPENDIX 1 Children and Families Social Work and Criminal Justice The business case for delegating social work services into Moray Integration Joint Board Health & Social Care Moray Page 109
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2 Table of Contents 1. Version History...................................................................................................... 2 2. Executive Summary .............................................................................................. 2 2.1 Delegation of Children and Families Social Work and Criminal Justice to Moray Integration Joint Board (MIJB). .............................................................................. 3 3. The Strategic Case ................................................................................................ 7 3.1 The Strategic Context .............................................................................................. 7 3.2 Aim and Benefits of Social Work Delegation ..................................................... 13 3.3 Business Needs – Current Needs, Risk and Issues .......................................... 17 3.4 Main Risks .............................................................................................................. 19 3.5 Dependencies ......................................................................................................... 20 4. The Recommendation ........................................................................................ 20 5.0 APPENDICIES .................................................................................................. 23 Appendix 1- Option Appraisal .................................................................................... 23 Appendix 2 High Level Risk and Issue to Potential Delegation............................ 28 Annex 3. Integrated Joint Board Integrated Functions ......................................... 30 1. Version History Version Date Details 0.1 30/06/21 Initial draft created by Carmen Gillies 0.2 08/07/21 Amendment by SBI 0.3 07/03/22 CG added Appendix 3. IJB Integrated Functions + National Care Service information 2. Executive Summary Page 110
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3 2.1 Delegation of Children and Families Social Work and Criminal Justice to Moray Integration Joint Board (MIJB). 2.1.1 This business cases provides the opportunity to undertake a comprehensive analysis of the preferred option, to delegate children and families social work and criminal justice to the MIJB. The two viable options include Option 1, to delegate children and families social work and criminal justice to the MIJB or option 2, to reposition children and families social work and criminal justice into the Council structure. An options appraisal is at Appendix 1. Background 2.1.2 The integration of Scottish public services is a policy agenda with deep roots and multiple drivers. Eager to accelerate the rate of cooperation and joint strategic planning the Scottish Government introduced Local Government (Scotland) Act 2003 (establishing community planning partnerships) and in the following year the National Health Service Reform Act (Scotland) mandating Community Health Partnerships. However, these statutory structures did not deliver the central policy objective of “integrated” working, particular in respect of the experiences of service users. 2.1.3 Integration from the perspective of the service users was one of the overarching conclusions of the Christie Commission 2010 to consider the delivery of service in the future, with an orientation decisively towards prevention rather than crisis response. Statutory Requirements 2.1.4 The Public Bodies (Joint Working) (Scotland) Act 2014 (‘the Act’), and its associated regulations, provide the legislative framework within which Scotland’s adult health and social care services are endeavouring to realise the Christie Commission’s vision. In summary, the legislation requires NHS Boards and local authorities to integrate the governance, planning, and resourcing of adult social care services, adult primary care community health services, and some hospital services. The legislation allows NHS boards and local authorities to integrate other areas such as children health and social care services, criminal justice at their discretion. Integrated Authority 2.1.5 Integration Authorities are responsible for planning, designing, and commissioning services in an integrated way from a single budget in order to take a joined-up approach, more easily shifting resources to best meet need. These Integration Authorities are jointly accountable to Scottish Ministers, Local Authorities (Elected members) and NHS Board Chairs for the delivery of nationally agreed outcomes. 2.1.6 Integration Authorities manage almost £9 billion of resources that Health Boards and Local Authorities previously managed separately, and they have the power and authority to drive real change. Page 111
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4 Moray Integrated Joint Board (MIJB) 2.1.7 The first integration scheme for Moray was approved by the Scottish Ministers in 2016 following the establishment of the Morays Integration Joint Board (MIJB) with a legal duty to publish a strategic (commissioning) plan for integrated functions and budgets under their control. MIJB manages £141m (£12.6m set aside)of resources with the delegated authority to manage adult social care services, and latterly manage within the partnership but not delegated the function the of Dr Gray’s hospital (although the set-aside for unscheduled adult care is part of the original delegation to the MIJB). Context 2.1.8 Moray is committed to improving outcomes contained in the Children Service Plan 2020-2023 for children, young people, and families. http://www.yourmoray.org.uk/downloads/file136160.pdf . This 3 year strategy clearly articulates the commitment to working collaboratively with children, families and communities to tackle the 4 priorities: • The wellbeing of children, young people and families is improved • The impact of poverty on children, young people and families is mitigated • Children and young people feel safe and free from harm • The outcomes and life chances of looked after and care experienced children and young people are improved 2.1.9 The Children services inspection in 2016 demonstrated a need for considerable improvements across the partnership. Nevertheless, Moray’s performance for Looked After Children has over recent years been very close to the bottom of the local government benchmarking framework. Social Work Transformation 2.1.10 To address the need for improvement, a transformation business case was approved with the aim to deliver a service that provides the best possible outcomes for the children and families in Moray to meet their full potential and aspirations. To achieve this aspirational aim, Moray must place children and families at the centre of decision making, which is one of the foundations of The Promise (voice) and focus on a strengths-based practice. This will be achieved by focusing on 3 themes for improvement: • Social work practice • Commissioning • Out of area placements 2.1.11 Morays collective commitment to The Promise, following the independent care review and continuing to embed local improvements has acknowledged the need for a responsive and agile workforce particularly recognising the need to support more vulnerable children, young people and families as a priority throughout the pandemic. Page 112
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5 Principal Recommendations 2.1.12 To achieve improvements both effectively and meaningfully, there needs to be a foundation of nurturing and strengthening of the social work workforce which is identified as one of the 3 themes for improvement. 2.1.13 As evidenced in this business case, the workforce is under considerable pressure led by local improvement agendas, driven by national policies such as implementation of the Promise and Self-Directed Support standards as well as operating under the shadow board of the MIJB for over 2 years. 2.1.14 The first critical response to address is the stabilisation of the workforce with regards to identifying where the “best fit” is for children and families and criminal justice social work workforce. Identifying specific beneficial outcomes to human learning systems via a business case is challenging given the subjectivity and complex mix of factors which influence the operations of a human led system. 2.1.15 The proposed delegation initially came from a review undertaken by Mr John W Mundell, OBE as part of the Council’s response in considering the transformation required to be able to deliver its priorities while also significantly reducing budgets and managing the impact of this on services. 2.1.16 One of the proposed organisational structure changes recommended suitable governance arrangements associated with vesting all the Chief Social Work Officer services in the MIJB. In conjunction with the Mundell review, Health and Social Care Moray (HSCM) reviewed and recommended a change to the HSCM workforce structure to be agile and adaptable to accept the future delegation of additional services as required. 2.1.17 By focussing on a stable and strengthen workforce through the proposed delegation of services to the MIJB, improved benefits can be achieved, ultimately reducing need, creating a real opportunity to reduce the level of expenditure and develop a more sustainable financial model for supporting children to remain in Moray. To date financial savings have accrued over £900,000 from the reduction of out of area placements. Outcomes 2.1.18 The delegation of children and families and criminal justice social work will individually and collectively create a flexible, responsive social work service ensuring consistency of outcomes and approaches in SDS practice across Moray, experienced by children and adults and carers, whilst continuing to maintain and support existing partnerships across Education and other external agencies. Delegation will lead to the outcomes below which will create strong and effective social care foundations by strengthening the Page 113
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6 workforce to deliver the step change required to increase capacity across the system, to scale up and spread promising practice much more effectively and be empowered and proud to be part of a capable and successful team. Specific measures will be developed to assess progress against the following outcomes. Outcome for Children and Families: • Moray’s children and families have more choice, control and flexibility of their care through the implementation of national legislation (The Promise, SDS standards) • Morays looked after children remain in Moray where practical • Morays families feel supported, valued and heard • Engagement with children and families to support continuous improvement is regular and welcomed • Preparing for adulthood is embedded across the disciplines to improve outcomes for the young people and their families • Support and understanding of the transition pathway is seamless through joint processes driven by SDS standards and a collective workforce. Outcomes for the Workforce: • Improved sense of belonging and work satisfaction • Staff are empowered and motivated • Workforce is supported to become positive risk enablers • Workers are enabled to exercise professional autonomy in support planning and set personal budgets within agreed delegated parameter • Engagement with children and families to support continuous improvements is regular and welcomed Outcomes for the Business: • Improved performance data through good recording practices clearly capture conversations between people and workers identifying what matters to the person • Commissioning is flexible and personal centred across the system • Robust self-evaluation is systematic, robust and comprehensive • Resilient workforce through shared learnings, training and processes • Economies of scale through shared resources 2.1.19 These outcomes will drive the redesign of the system to address the need to transform the way we plan, commission, and procure social care support. This will develop and build trusted relationships rather than competition and to build partnerships not marketplaces. Literary Review 2.1.20 A comprehensive literature review followed by engagement from IJBs across Scotland was undertaken to identify the benefits and barriers on the potential effects of delegating children and family services, reflecting on the Public Page 114
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7 Services (Joint Working) (Scotland) Act 2014 as a mechanism for real transformational change. 2.1.21 In relation to children, young people, and families, the original literature review explored how changes to adult health and social care services could have implications for four groups: (i) young people transitioning to adult services, (ii) young carers, (iii) care leavers, and (iv) vulnerable children, whose parents are in receipt of adult services, such as mental health support, or drug and alcohol services. The review concluded that, while the integration of adult health and social care in Scotland was likely to impact on these groups of children and young people, there was the potential for that impact to be positive if children and young people’s specific needs were properly considered in local service planning and delivery. 2.1.22 Nearly six years on from the commencement of the Act, Moray has taken the opportunity to reflect on how the needs of Morays children, young people and families can be best served to achieve positive outcomes through the potential delegation of children and families’ services to the MIJB. 3. The Strategic Case 3.1 The Strategic Context Introduction 3.1.1 The care system is enshrined in ground-breaking legislation offering a mechanism to implement real change to those people who need support. It is without a doubt that multiple, regulation-driven integration agendas are now underway such as SDS standards. A coherent, consistent, and evidenced based policy approach underpins them all, but at a practical level re-alignment of planning, resourcing and workforce structures will need to be addressed to bring services closer together to maximise on improving outcomes for children and families. It is the legislation and policies below which aid the benefits of being one workforce through delegation in order to build trust, understand and practice implementation of policies through shared learning, co-location and other formal and informal opportunities to encourage the development of workforce relationships. Legislative Drivers Integration Authority - Public Bodies (Joint Working) (Scotland) Act 2014 3.1.2 To facilitate the process of joint strategic commissioning, the local authority and health board must delegate a range of functions to an ‘Integration Authority’. These Integration Authorities are jointly accountable to Scottish Ministers, local authorities (i.e., elected councillors) and NHS Board Chairs for the delivery of nationally agreed outcomes. To understand the picture of integration across Scotland, Please referent to the table in Appendix 3. 3.1.3 The Integration Scheme is intended to achieve the National Health and Wellbeing Outcomes prescribed by the Scottish Ministers in Regulations Page 115
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8 under section 5(1) of the Public Bodies (Joint Working) (Scotland) Act 2014 namely: 1. People are able to look after and improve their own health and wellbeing and live-in good health for longer. 2. 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. 3. People who use health and social care services have positive experiences of those services, and have their dignity respected. 4. Health and social care services are centred on helping to maintain or improve the quality of life of people who use those services. 5. Health and social care services contribute to reducing health inequalities. 6. 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. 7. People using health and social care services are safe from harm. 8. 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. 9. Resources are used effectively and efficiently in the provision of health and social care services. Self-Directed Support - Social Care (Self-Directed Support) (Scotland) Act 2013 3.1.4 Scotland's approach to social care and support places human rights and independent living at the heart of delivery. The aim of self-directed support is to ensure that care and support is centred around a person's own care and wellbeing outcomes, and that people exercise the level of choice and control they desire over that support 3..15 Major changes required by legislation on Social Care (Self-Directed Support) (Scotland) Act 2013 introduced the new SDS standards to support the for the support personalised outcomes for children, young people and adults experiencing care. The three assumptions involved include: • taking a strengths-based, asset-based approach to assessment support planning and review processes • focusing on community supports • systems and processes being aligned to SDS values and principles 3.1.6 SDS standards have been developed to ensure consistency of outcomes and approaches in SDS practice across Scotland experienced by supported people (children and adults) and carers, building a framework of good practice in assessments for support, support planning and in provision of care and support resources. These standards are instrumental in the transformation of social work practice across both children and adult services, aiding the decision to delegate so one consistent approach can be embedded with uniformity. 3.1.7 Eleven SDS Standards are across children and adults to promote: i. Independent Support and Advocacy - Within every Local Authority/ Health and Social Care Partnership area there are independently funded Page 116
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9 organisations able to provide independent advice, support, information and advocacy for anyone who needs it and in ways which are accessible to everyone ii. Early help and support - Early help and community support offers a universal approach where everyone is welcome to have a good conversation about what matters to them, and to identify solutions to improve their quality of life. This approach can serve as a gateway into more formal assessment and access to services. However, this approach should not be regarded as a replacement for registered statutory services when these are needed. Community solutions do require investment and ongoing commitment and support from national and local government. iii. Strength and asset-based approach - Trust-based relationships and good conversations between workers and people are at the heart of assessment, support planning and review practice and processes, recognising people’s strengths, assets, human rights, community, and funded supports. Personal outcomes are agreed on the basis of what matters to the person iv. Meaningful and measurable recording practices - Recording practice and information systems demonstrate the extent to which practice is carried out in line with the values and principles of Self-directed Support. Records show how the person’s lived experience and preferences have been acknowledged and expressed in their support plan and connect personal outcomes to the subsequent review process. Recording systems are designed such that data can be aggregated and used for continuous improvement, resource planning and commissioning purposes v. Accountability Processes ensure that people’s legal rights are upheld. Human rights underpin practice, policy and processes, and actively provide opportunities for constructive feedback, learning and improvement. vi. Risk enablement - People will be regarded as experts in their own lives and how they wish to meet their own personal outcomes. This needs to be taken into account and a shared responsibility to risk agreed. Self-directed Support is not separate from safeguarding. Self-directed Support is used creatively to enhance people’s and families’ resilience towards preventative, protective and positive outcomes. vii. Flexible and outcome focused commissioning - Social care services and supports are planned, commissioned, and procured in a way that involves people and offers them real choice and flexibility in how they meet their personal outcomes. Provision of services and supports start with the good conversation that has been had with the person, what matters to them and what they need to help them live their best life. viii. Worker autonomy - Workers feel trusted, confident and resilient, and are enabled to be autonomous in exercising their professional judgement, and using their own knowledge, skills and abilities, in partnership with supported people. Workers have the authority to plan support and set personal budgets within agreed delegated parameters Page 117
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10 ix. Transparency - People are helped to understand that Self-directed Support allows for maximal choice and flexibility in using a budget to achieve what matters to the person in the form of agreed personal outcomes. The process leading to decisions about a person’s social care budget and support, and their level of financial contribution, is recorded, shared and explained in ways that make sense to the person. x. Early planning for transitions - Transition planning processes have the person’s wellbeing, aspirations, and personal outcomes at the centre. People are given the time, information and help they need to make choices and have control of their care and support as they move into new phases of their lives. xi. Consistency of practice - To reduce inconsistency of experience across the country, a consistently high-quality approach to practice is required, including assessment, support planning and review; eligibility; charging and contributions; commissioning and procurement, and the process by which budgets are calculated. 3.1.8 Policy Drivers which can bring improvements to the new world of care have the child or adult at the centre of their support, making their own decisions through a workforce culture of trust, care, and respect. Independent Review of Adult Social Care – Feely Report 3.1.9 At the centre of the review was the voices and the stories of many people with lived experiences of social care support, unpaid carers and staff working in the sector. Three fundamental changes must occur to secure better outcomes. These can be summaries as: Shifting the paradigm Adult social care support does not stand alone. It has strong links to social work, children's services and the wider services. But we can do better. There is a gap between how we want things to be and how it is done. The system we have now is not getting the results we want. So we need a new system. We need to start by changing the way some people think about social care support. Good social care is important for everyone in Scotland. It is a good investment in our economy and citizens. Strengthening the foundations – There are many strengths in the Scottish systems of social care support. The need is to build on the foundations of self- directed support, health and social care integration and the Independent Living Fund. The challenge is the implementation. Redesigning the System – A new delivery system through the National care Service to drive national improvements where they are required, to ensure strategic integration, to set national standards, terms, and conditions. The transformation of the way planning, commissioning, and procurement of social care support is accrued. Building trusted relationships rather than competition. Whilst providing a stronger voice of the unpaid carer. The review has not made recommendations about the Social Work workforce in the proposed new arrangements as these will require careful consideration Page 118
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11 alongside the implementation of The Promise and any changes planned for criminal justice. National Care Service The IRASC recommended the establishment of a National care Service, with Scottish Ministers being accountable for the delivery of consistent and high standards in health and social care services. Whilst building on the recommendations of the IRASC to create a social care system which is rights-based, and people powered. Consultation has concluded on the NCS within the first 100 days of Parliament and has set up a social covenant steering group, including people with living, and lived experience of social care. Both pledges have been met. • Children Services There were 521 responses to the question on whatever the NS should include both adults and children social work and social care services. The majority of individual, 75% and 78& of organisations agreed that it should include both adults and children’s services. For those that agreed, commonly cited reasons were: o An alignment with a “cradle to grave” approach o It would help ease the transition between children services and adult services, and create a more joined up approach o Greater standardisation across Scotland. • Criminal Justice Services Nearly two thirds agreed that Justice Social Work should be included within the remit of the NCS. Reasons given included the need to keep all forms of social work together and the fact that offending behaviour is often linked to other care needs. Those who disagreed tended to say that the proposed NCS is too large and centralised and there is a need to reflect local requirements. The main benefit was thought to be “more consistent delivery of justice social work services” At the time of writing this report, a decision has not yet been made on the composition of the NCS. However, to aid decision making, Moray is consistent with the national policy for the direction of travel for future improvements for citizens of Moray through the delegation of children and families and justice service to MIJB. Notwithstanding the improvements this will potentially offer across the health and social care system Independent Review of Children Services – The Promise 3.1.10 The promise is responsible for driving the work of change demanded by the findings of the independent care review. The seven publish reports narrate a vision for Scotland built on 5 foundations to make sure that Scotland’s children grow up “loved, safe and respected”. Voice is central to the foundations of Family, People, Care and Scaffolding I. Children and young people must be listened to and meaningfully involved II. When living with a family is not possible, children must stay with their brothers and sisters Page 119
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12 III. Whenever children are safe in their families and feel loved, they must stay IV. All of the people involved in the care of children must be supported to develop relationships with them, and those children must also be supported to develop relationships with the wider community V. We need an infrastructure and system around all this that’s responsive and accountable The strength of pulling together one social work workforce to deliver a consistent approach from childhood to adulthood will not only aid outcomes for children and young people but also create a consistent system for the unpaid carer Moray Policy Context 3.1.11 Morays Children's Services Plan is connected into the wider planning landscape. Given the requirement to plan for children's services and other related services, children's services planning relates to the duties included in Part 1 (Children's Rights), Part 6 (Early Learning and Childcare) and Part 9 (Corporate Parenting) of the Children and Young People (Scotland) Act 2014, as well as the Public Bodies (Joint Working) (Scotland Act) 2014, Community Empowerment (Scotland) Act 2015, Carers (Scotland) Act 2016 and the Community Learning and Development (Scotland) Regulations 2013. This complex landscape requires the plan to set out a joint visions and partnership approach to improving outcomes for children and young people and families in Moray. The scope of Morays plan includes all children’s services provided locally by the Local Authority, Health Board and other Service Providers which falls into the categories “children’s service” e.g., schools, health visitors, youth group, children and families social work or “related service” e.g. leisure services, drug and alcohol service. This includes services delivered by private or third sector organisations on behalf of, or in partnership with, the local authority, relevant health board or “other service providers” e.g., Police Scotland, Scottish Fire and Rescue Service. It spans the age range of birth to eighteen years old and extends to age twenty-five for young people in the care system. Spanning both adults and services belonging on the young Page 120
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13 persons criteria aid the decision to create a delegated workforce operating under one reporting structure. 3.1.12 The Moray Local Outcome Improvement Plan (LOIP) reflects the above principles of building a better future for our young people, with the ambition that Moray is a place where all children and young people thrive, have a voice and are able to reach their full potential. The Moray Council Corporate Plan (2019-2024) prioritises supporting people to be the best they can be, with a strong and sustained focus on those individuals and groups in society who experience the most disadvantage and discrimination. 3.1.13 The Council Improvement and Modernisation Programme provides a number of design principles to guide service transformation and the two recently added principles are highlighted below as particularly relevant to the project: • Targeting early intervention and prevention; • Developing the skills, knowledge, and capacity of the workforce to deliver better 3.1.14 Morays Health and Social Care Strategic Plan – Partners in Care reflects the national drivers by focusing on the 3 Strategic Outcomes: • BUILDING RESILIENCE - Taking greater responsibility for our health and wellbeing • HOMEFIRST - Being supported at home or in a homely setting as far as possible. • PARTNERS IN CARE - Making choices and taking control over decisions 3.2 Aim and Benefits of Social Work Delegation 3.2.1 The strategic aim for children and families is to deliver a service that provides the best possible outcomes for children and families to achieve their full potential and meet their aspirations. To contribute to the success of the aim, it is recognised that the “best fit” for the service should be included within functions to be delegated to the Integration Joint Board. 3.2.2 The separate business case for social work transformation focuses on the three main themes to achieve the strategic aim. In summary, these include improving social work practice, commissioning, and reducing out of area placements. This will introduce whole systems change which is aligned with the changes in adult services. For further details refer to the transformation of children services business case. Benefits - Aligned with Adult Services 3.2.3 In 2017 the direct link between local health and social care integration arrangements and the strengths of local services for children and young people cannot be definitively established from the self-evaluations and inspection framework. The time frame was still too early to establish a confirmed trend. However, the strength, effectiveness, and maturity of strategic leadership and partnership working have tangible positive impacts on outcomes for children and young people. Where strong leadership exists, Page 121
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14 the inspection partners are beginning to see how the benefits of integration can be maximised. 3.2.4 Recent consultation with IJBs who have their services delegated have responded with the following benefits: • Improved Health and Social Care Outcomes for Children: Looked after children have high levels of health and social care needs, linked to their background of neglect and maltreatment. Through supporting the direct needs of the parents/carers improved outcomes can be directed achieved by the children. • Creating better outcomes for Families: Where there is a vulnerable child these is often a vulnerable adult - Supporting the family as a whole entity creates better outcomes and less dependency on services. • Greater Control of the Budget: Children and family’s budget was nearly always overspent. Integration can create a collective budget and track spend easier, whilst creating new opportunities. • Building Workforce Capacity: Streamline and development of workforce capacity and capability by creating the skills to deliver agreeable outcomes across the system. For example, train SW to be multiskilled across all SW disciplines. • Strengthening Workforce Relationships: Through creating stronger relationships Social Work and Health can build capacity through supporting each other’s needs for example Health Visitor can offer a brief intervention, making every opportunity count. • Professional Identity and Sense of Belonging: All SW together is a “no brainer”. Professionals (SW) are able to support each other and focus on early prevention and intervention creating efficiencies cross the system. Moreover, clients are experiencing a positive value transfer by accessing services/support without having to go through a different pathways or departments. • Enhanced Professional Leadership and Development: By creating CPD and training for all, equity is given to allow those who want to progress the opportunity to try. This can offer new energy and capacity increases with willingness and a view to advance. • Stronger Working Relationships with Public Protection Committee: By reporting to IJB and Council, relationships are stronger and can support faster outcomes and speedier involvement • Support the Direction of Travel for the National Care Service: Data from the NCS consultation showed three quarters of individuals agreed with the delegation of children’s and two thirds agreed to criminal justice services. Benefits identified mirrored those identified as to why Moray wishes to delegated services to MIJB. This endorses Morays approach to delegate locally as this support the national thoughts. Benefits Identified for Moray Page 122
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15 3.2.5 Through engagement with partners, benefits to Moray through delegation have been identified as: • Whole systems approach: is relevant to considering the family as a system. As integration should be person centred, this allows for a shared vision and shared practice to be achieved between professionals across children and adults’ services. • Transitions: Close attention has to be paid to the transition points both between service areas (e.g., from health to social care) and between child and adult service. Transitions planning and work around the family rather than families being passed from service to service, using a consistent model will add value to the system and improve outcomes for the supported person and family. • Supporting young people who are leaving care and meeting our corporate parenting responsibilities in ensuring young people have a foot up and smooth transitions into adulthood, getting what they need when they need it. • Better alignment with adult services means that children living in chronic neglect, substance misuse or households where mental health prevents children reaching their potential can be minimised and children’s rights can be upheld. • Shared models of working with families, e.g. three conversation model and SDS standard approach created a consistent and equitable share of resources and services, which are underpinned by human rights. • Changing the model of conversation with children and families “Three conversation model” allows social workers to stick with families for as long as they need us. Through adopting a model as a whole system, this will offer consistency across the workforce and support to those who are in crisis. • Shared commissioning to support SDS options and joint creation of a market facilitation strategy. • Social workers will have a sense of belonging and able to share best practice with colleagues whilst supporting each other though change management. • Increase in morale to be part of the social work family. • Lifetime support for people living with a disability. • Locality models to support communities can be aligned and reducing duplication of effort. • Transformational journey through process of change together with adult services to implement the independent care review of adults and The Promise can be achieved as a partnership. Both independent care reviews and the SDS standards are all supportive and mirror each other, creating ease and drive to implement change in a uniformed manner. • Creating better outcomes for children through supporting the vulnerable adult through closer working relationships and information sharing. Interagency collaboration becomes part of day-to-day practice. Many vulnerable adults require support due to the effects from substance and Page 123
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16 alcohol use. Supporting the family to reduce a child’s exposure to Adverse Childhood Experience and build family resilience will create a positive impact for the children and young people within the family unit. In turn potentially reducing the need for long-term services from children and young people, through adulthood. • Strategic decision making can enhance the long-term resilience of the partnership particularly in the changing landscape due to the independent reviews offering an improved world. • Joint strategic planning based on the long-term vision and a deep understanding of the MIJB core proposition for children and families and adults generate more value to reputation and most importantly better outcomes for our children and adults in Moray. • Building capacity into the social work system in Moray through joint training, initiatives, and shared learnings, in turn improving performance. • Enhanced risk management – collective responsibility with a proactive approach to the long-term strategic vision. • Active and regular re-evaluation of resource allocation across the system, based on sound assessments of risk and statutory responsibilities. Creates more value in the system. • Increased service user/ public confidence in the partnership through a collective vision and leadership. • Scottish Government SDS transformation funds along with Carers funds can create more value and better return on investment by building on the existing scaffolding across all ages in a unified approach. • Belonging is empowering, which is key to creating a flexible workforce ready to collaborate, innovate, mentor and support each other. 3.2.6 For integration to be effective in its aim of improving the availability and quality of services, the Social Work Scotland 2018 review suggests that: • Government and local partners must keep the focus of integration squarely on improving the lives of service users and the wider community; enabling service users to shape changes, to be part of the process, sharing their insight and expertise. Cost savings should be a welcome by-product, not the central purpose. • Government and local partners should bring together leadership teams who can address, simultaneously, the technical and adaptive challenges associated with major change processes (addressing specific, boundary issues (such as contract terms and conditions) at the same time as on- going issues, like staff morale, change fatigue, etc. • Policy and leaders must build trust and understanding between different professional groups and organisations, through shared learning, co- location, and other formal and informal opportunities that encourage the development of relationships. • Data sets that give insight into people’s outcomes, not just service inputs and outputs, must continue to be developed. Page 124
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17 Delegated Authorities 3.2.7 There is no consistent approach to the decision to delegate further functions to the integrated authority. Ten local authorities have delegated their children and families social work services with 15 delegating criminal justice. No integrated authority has amended their scheme of delegation post the first iteration except for North Lanarkshire who originally positioned children’s social care services and criminal justice social work into their integrated authority, to later ‘undelegated’ in 2019, bringing it in line with South Lanarkshire. Appendix 3 shows which Local Authorities have delegated their services. Workforce 3.2.8 Children Services is split into number of teams, Criminal Justice, Placement Services, Children and Families review team, existing support, east west teams and self-directed support. Admin support staff are not included as they are all part of the business support team across the former Education and Social Care Directorate. Total budget Children Services £19,858,986 Total Staffing costs £7,604,930 3.3 Business Needs – Current Needs, Risk and Issues 3.3.1 Issues and challenges to be addressed in potential delegation include: Delegation of Functions 3.3.2 To comply with statutory requirements there is an obligation on the NHS Board and Local Authority to consult with prescribed consultees on the content of any revised Integration Scheme in according with the provisions set out in Scottish Statutory instrument 2014 No.283. A period of 4-week consultation is standard prior to seeking final approval from respective parties and final sign off by the Scottish Ministers. 3.3.3 The integration scheme comprises of 4 main sections, and it is proposed that 4 short life working groups containing appropriate officers from the partnership to focus on: • Scope and Governance • Provision of support services, including but not limited to planning, performance, workforce, OD, information sharing and complaints; • Clinical and Care Governance and Risk; and • Finance 3.3.4 Joint working and quality assurance within and across the services will be needed to ensure consistency and compliance around the ethos, culture and practice required to model and evidence positive outcomes for the workforce and supported person in line with the SDS standards and independent care reviews. Page 125
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18 3.3.5 Organisational structure must be designed to deliver the service required and the workforce skilled and equipped to ensure that curricula are progressive and appropriately delivered and the quality of service is assured. Issues - Managing and Responding to Demand 3.3.6 Partnerships are fully aware that current models of care are not sustainable and that new models of care are required to address the pressures of growing demand and limited finances. The prioritisation process must therefore be able to facilitate the local review of existing services and existing resource allocation, bringing decommissioning and commissioning decisions within the same process. This will provide a basis for developing new models of care, redesigning existing services, phasing out services and the redirection of resources to ensure these are better focused on meeting need and improving outcomes. All of which is built on the foundation of legislative change and transformational redesign of the whole system of care. 3.3.7 With redesigning the whole system this will require consideration of flexible and responsive staff structures that can accommodate service and individual needs that changes over time. It also requires an integrated response from all partners, and the adoption of the three-conversation model which will support this transformation redesign of social work services in Moray. Issues - Culture and Workforce 3.3.8 The workforce has continued to operate under the shadow arrangements of the Health and Social Care Partnership for almost 3 years. This current situation is non tenable in the longer term as an interim arrangement, and a decision needs to be made in the very near future as to where the “best fit” is for children and families and criminal justice. Workforce fatigue and motivation has been tested with three interim Heads of Service in 3 years. Workforce succession planning requires attention as recent recruitment of vacant posts proved unsuccessful, almost certainly as they were fixed term posts because of the knock-on effect of the interim arrangements for the Head of Service post. Issues – Loss of Professional Identify 3.3.9 As the social work profession is fragmented across two reporting parties, delegation is designed to strengthen and enhance the professional capabilities of social workers in Moray aligning person centred outcomes, strengthen the foundations of social work practices whilst collectively redesigning the system to complement The Promise and the Independent review of adult social care in Scotland. 3.3.10 Supportive and collective response to funding for innovation spanning across all ages for Self-Directed Support and the implementation of the Carers Act can drive change at pace through a system supported and facilitate by the MIJB. This in turn can support the collective identify of social work and drive Page 126
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19 a uniformed approach to social work practice whilst having the person at the heart of the decision-making process. 3.4 Main Risks 3.4.1 The main challenges and risks associated with the identified issues and the successful delivery of delegation are: Delegation of Functions i. Resources delegated from the partner organisations are insufficient for the IJB to carry out its functions, mitigated by financial strategic planning. ii. Failure to deliver delegation through actions not agreed by all 3 parties to move from a shadow board to delegated authority, mitigated by the development of a Programme Board. iii. Service model of integration does not facilitate continued partnerships working with agencies, organisations and services that are out with the new integrated arrangements, mitigated by structured partnership meetings e.g., GIRFEC Leadership Group. Managing and Responding to Demand i. Lack of resource sharing through funding received to span across children’s and adults’ services can create duplication of funding and efforts. ii. Fragmented transitions. iii. Managing escalation of needs, exacerbated by covid pandemic. iv. Reluctance to support the new model of practice, embedding SDS and 3 conversation model. Culture and Workforce i. Deliver a front facing workforce whilst restructuring. ii. Recruiting skilled staff to vacant positions. iii. Training – to ensure Continuing Professional Development is delivered, and time is allocated to staff iv. Effective consultation with timescales, mitigated by realistic timeframe for delegation. Loss of Professional Identify i. Shadow arrangements give no sense of belonging, mitigated by programme board driving forward a decision ii. Shift in practice requires to use an asset-based approach, mitigated by working as one social work department from shared learnings across adults and children social work iii. Professional identity continues to erode through lack of robust structure Page 127
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20 3.4.2 A risk and issue log can be found at Appendix 2 specifically associated with high level risk as identified through engagement with key stakeholders. 3.5 Dependencies 3.5.1 The success of delegation is dependent on: i. All parties agreeing the direction for delegation ii. All financial due diligence is agreed iii. Integrated work with staff from all partners (Education, Police, Health Third sector to name a few) continue to operate in a partnership approach iv. The creation of a committed, empowered, skilled social work workforce is operating to offer best outcomes for all. v. The embedding and quality assurance of assets-based approach is throughout children and adults social work practice. vi. The management of social work staff being aligned to the ethos and principles and SDS and 3 conversation model is standardised to ensure clarity and consistency. vii. Resilience and commitment to the vision of The Promise aligned with the independent Adults Care review is essential to drive the improvements across children services as well as aligning with the transformation change across the whole of the system. viii. Joint training and CPD is offered to staff to aid succession planning and continuous learning. ix. The embracing of SDS standards including worker autonomy to empower social workers in their roles. 3.5.2 These dependencies will be mitigated through the Programme Board and then thereafter through planning, monitoring, partnership work and the use of relational approaches, consultation and effective communication across partners, teams, communities, and families. 4. The Recommendation 4.1.1. As part of this business case, the driver to make any decisions on delegation must be based on improving and delivering better outcomes for people, including children and their families. Appropriate evidence to support the recommendation to delegate Children and Families Social Work and Criminal Justice to the MIJB as the most robust solution has been driven by the data offered from a literary review, data identifying key legislative drivers for change, recognising outcomes not only for children and families but also for the social work workforce and overarching business benefits. Engagement with IJBs across Scotland and consultation with key partners supported the benefits and risk analysis in order to recommend the proposal of delegation. 4.1.2 Across the 32 Local Authorities, there is not a standardise approach to the delegation of children and families and criminal justice, which creates a conundrum Page 128
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21 as to identifying the right mechanism to guarantee improve outcomes for children and families. Although there was widespread acceptance and positive outcomes from those that chose to delegate, there was a shortage of hard evidence on the direct causal relationships between social work delegated to an IJB. In part because of the infancy of IJBs and the complexity to evidence direct correlation within a human learning system. 4.1.3 In relation to children, young people, and families, the original literature review explored how the development of integrated authorities could have implications for four groups: (i) young people transitioning to adult services, (ii) young carers, (iii) care leavers, and (iv) vulnerable children, whose parents are in receipt of adult services, such as mental health support, or drug and alcohol services. The review concluded that, there was a potential for that impact to be positive if children and young people’s specific needs were properly considered in local service planning and delivery cutting across adult’s services. Where these is a vulnerable child, there is a vulnerable adult. Focusing on the adult will support the improved outcomes of the child through a whole family approach to social work delivery. 4.1.4 The development of SDS standards are the pillars on which social work practice is built. They represent the thread which ties distinct processes together into a broader strategic agenda, by empowering the workforce and communities to use an asset-based approach underpinned by human rights. SDS policy cuts across children and adult services to ensure consistency of outcomes and approaches in practice experienced by supported people (children and adults) and carers, building a framework of good practice in assessments for support, support planning and in provision of care and support resources. These standards are instrumental in the transformation of social work practice across both children and adults’ services, aiding the decision to delegate so one consistent approach can be embedded with uniformity. 4.1.5 Linking the decision to delegate with the business care for improvements in children services is welcomed through creating a coordinated approach to offer local based services that enables young people to remain in Moray combined with working on all young person’s strengths and skills through asset-based plans to ensure when young people reach adulthood, they are able to be as independent as possible and be active members of their communities. This requires integrated working with commissioning, health, education and adult services to create a pathway for transitions which meets the outcomes of the young person and their family. Families and young people receive good support and understanding of the transition pathway due to the strong co-production of plans and mirrored processes across children and adult services, aiding the decision to delegate children services and criminal justice to the IJB. 4.1.6 To date partnership working is considered strong between strategic partners including Education and Health. Respectful relationships and a sense of reciprocity characterised a positive response to the working relationships which already exist. These will not change with the delegation of services. 4.1.7 In conclusion, nearly six years on from the commencement of The Public Bodies (Joint Working) (Scotland) Act 2014, Moray has taken the opportunity to reflect on how the needs of Morays children, young people and families can be best served to achieve positive outcomes. Through the delegation of children and families’ services to the Moray Integrated Joint Board, we have the opportunity to be Page 129
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22 bold and create a system of support where children and families in Moray have the opportunity to flourish. If not now, when? Page 130
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23 5.0 APPENDICIES Appendix 1 Option Appraisal Option 1: To Delegate to MIJB – Preferred Option Description The management of Children and Families and Criminal Justice Social Work is to be managed and delegated to the MIJB with scheme of delegation updated accordingly Pros/Benefits • Whole systems approach: is relevant to considering the family as a system. As integration should be person centred, this allows for a shared vision and shared practice to be achieved between professionals across children and adults’ services. • Transitions: Close attention has to be paid to the transition points both between service areas (e.g., from health to social care) and between child and adult service. Transitions planning and work around the family rather than families being passed from service to service, using a Pod model will add value to the system and improve outcomes for the supported Person and family. • Supporting young people who are leaving care and meeting our corporate parenting responsibilities in ensuring young people have a foot up and smooth transitions into adulthood, getting what they need when they need it • Better alignment with adult services means that children living in chronic neglect, substance misuse or households where mental health prevents children reaching their potential can be minimised and children’s rights can be upheld • Shared models of working with families, eg three conversation model and SDS standard approach created a consistent and equitable share of resources and services • Changing the model of conversation between children and families “The Three conversation model” allows social workers to stick with families for as long as they need us. Through adopting a model as a whole system, this will offer consistency across the workforce and support to those who are in crisis. Page 131
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24 • Shared commissioning to support SDS options and joint creation of Markey facilitation strategy • Social workers will have a sense of belonging and able to share best practice with colleagues whilst supporting each other though change management. • Increase in morale to be part of the social work family. • Lifetime support for people living with a disability • Locality models to support communities can be aligned • Transformational journey through process of change together with adult services to implement the independent care review of adults and The Promise can be achieved as a partnership. The independent care rereviews and the SDS standards are all supportive and mirror each other, creating ease and drive to implement change. • Creating better outcomes for children through supporting the vulnerable adult through closer working relationships and information sharing. Interagency collaboration becomes part of day-to-day practice. Many vulnerable adults require support due to the effects from substance and alcohol use. Supporting the family to reduce a child’s exposure to ACE and build family resilience will create a positive impact for the children and young people within the family unit. In turn potentially reducing the need for long-term services from children and young people. • Strategic decision making can enhance the long-term resilience of the partnership particularly in the changing landscape due to the independent reviews offering an improved world. • Joint strategic planning based on the long-term vision and a deep understanding of the MIJB core proposition for children and families and adults generate more value to reputation and most importantly better outcomes for our children and adults in Moray. • Building capacity into the social work system in Moray through joint training, initiatives and shared learnings, in turn improving performance. Page 132
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25 • Enhanced risk management – collective responsibility with a proactive approach to the long-term strategic vision. • Active and regular re-evaluation of resource allocation across the system, based on sound assessments of risk and statutory responsibilities. Creates more value in the system. • Increased service user/ public confidence in the partnership through a collective vision and leadership. • Scottish Government SDS transformation funds along with Carers funds can create more value and better return on investment by building on the existing scaffolding across all ages in a unified approach. • Belonging is empowering, which is key to creating a flexible workforce ready to collaborate, innovate, mentor and support each other. Cons/Risks • Financial Risk – Resources delegated by partners are insufficient for the IJB to carry out its functions • Failure to staff governance; systems and processes are not sufficiently robust to support effective CPD and supervision to ensure delivery of practice that promotes public protection and meets health & Social Care need. • Service model of integration does not facilitate continued partnerships working with agencies, organisations and services that are out with the new integrated arrangements • Damage to reputation - Failure to meet local and national priorities and indicators for the additional delegated services, or conduct in a manner that brings the Partnership into disrepute • Failure to identify and manage risks arising from shared services, commissioned services, support services • Failure to work to the ethos and principles of SDS and The Promise Page 133
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26 Costs The financial arrangements will be part of the due diligence process for delegation with a permanent head of service for children and families to be considered. Equalities Impact The proposal will impact on children and young people and families both children in need and children in care as they move into adulthood. The focus of the proposal is on improving outcomes for this group of young people Option 2: To Manage Services in Moray Council Structure Description The management of Children and Families and Criminal Justice Social Work is to be managed and restructured into the Moray Council. It is unclear what the future arrangements would look like if this option was to proceed. Pros/Benefits • Easy of working with Education through same reporting structure • Provides a defined identity embedded within the local authority • No change management required to establish additional support functions • No risk to status quo • Staff priorities will remain the same as they have now and no integration planning will take place • Safe and predictable • Easy of communication and sharing data with Council Officers Cons/Risks • No capacity in present structure to ensure robust enough changes to new systems to embed SDS standards, 3 conversation model and The Promise • Added management coordination between children’s and adults to ensure new practices are adopted across the whole system, Page 134
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27 • Is not consistent with other LA who have good Care Inspectorate inspections • No shared commissioning • No seamless system for children transitioning into adulthood • Lack of consistency with different approval systems • Teams will have little influence in designing a whole family approach • Transitions will remain challenging and fragmented under different reporting structure • Pooling of budgets will be challenging • Loss of professional identity by segregation with adult social work • Reduced shared learnings though siloed structures • Little opportunity to develop trusted relationship with adult social workers • Reduced links to shared resources including adults SDS and carers team • Limitations to address workforce capacity Costs Additional funding required to establish a head of service through a restructure plan to reposition services back into the Moray Council portfolio will need to be considered. Equalities Impact The proposal will impact on children and young people and families both children in need and children in care as they move into adulthood. The focus of the proposal is on improving outcomes for this group of young people Page 135
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28 Appendix 2 High Level Risk and Issue to Potential Delegation Risk Register Risk Category Risk Description Likelihood Consequence Score Overall Risk Mitigation 1a Financial Risk Resources delegated from the partner organisations are insufficient for the IJB to carry out its functions 3 3 9 Red Strategic plan supports financial governance 2a Workforce – Failure to manage succession planning/loss of key staff Failure to staff governance; systems and processes are not sufficiently robust to support effective CPD and supervision to ensure delivery of practice that promotes public protection and meets health & Social Care need. 3 3 9 Moderate Work force review strategy and delivery plan and with organisational development strategy and delivery plan to be in place. 2b Workforce – Failure to manage delegation Failure to deliver delegation – Actions are not agreed by all 3 partners to move from a state of uncertainty/transition to a state of final delegation 3 4 12 High Project plan with define dates and actions for accountability and monthly Board meetings with appraisal of risk. All 3 partners will require signoff before formal delegation can proceed. 3a Service Delivery & value for money/Effective Delivery Failure to staff governance; systems and processes are not sufficiently robust to support effective CPD and supervision to ensure delivery of practice that promotes public protection and meets health & Social Care need. 3 3 9 Moderate Public protection systems are in place through Children Support and Protection Committee, Adult Support and Protection Committee, MAPPA. 3b Service Delivery & value for money: Partnership Arrangement Service model of integration does not facilitate continued partnerships working with agencies, organisations and services that are out with the new integrated arrangements 2 3 6 Moderate Strategic and locality planning groups are now in place. LOIP cover interagency working relationships. Page 136
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29 4a Damage to Reputation – National and Local Outcomes Failure to meet local and national priorities and indicators for the additional delegated services, or conduct in a manner that brings the Partnership into disrepute 2 4 8 Moderate Core suite of measurements and indicators to be clearly defined and measured. 4b Damage to Reputation – Integration Process Failure to deliver scheme of delegation to meet requirements of Public Bodies Act and other relevant legislation including Children’s and Families 2 4 8 Moderate Policies and procedures to be updated: training, integration plan to be implemented 5a Failure to identify and Manage risks arising from shared services, commissioned services, support services Commissioning; appropriate and sufficient capacity available across sectors to deliver a range of supports to meet parentship priorities. The IJB required legal assurance from the Council and NHS as to shared use of services/resources 2 4 8 Moderate Commissioning / Procurement/ Contract monitoring arrangements are put in place to manage supply and demand. Page 137
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30 Appendix 3 Integrated Joint Board Integrated Functions Integrated Joint Board Children’s Health Services Children’s Social Care Services Criminal Justice Social Work All Acute Services Argyll and Bute (1) Delegated Delegated Delegated Delegated East Ayrshire, North Ayrshire, South Ayrshire, West Dunbartonshire, East Dunbartonshire, East Renfrewshire, Glasgow City, Inverclyde, Orkney (9) Delegated Delegated Delegated Minimum Services Delegated East Lothian, Shetland, North Lanarkshire, Eilean Sair (3) Delegated Not Delegated Delegated Minimum Services Delegated Dumfries and Galloway (1) Delegated Not Delegated Not Delegated Delegated Fife, Renfrewshire, North Lanarkshire, South Lanarkshire, Midlothian (5) Delegated Not Delegated Not Delegated Minimum Services Delegated Aberdeen City, Aberdeenshire (2). Not Delegated Not Delegated Delegated Minimum Services Delegated Scottish Boarders, Clackmannanshire/Stirling, Falkirk, Moray, Edinburgh, Angus, Dundee City, Perth and Kinross, West Lothian (9) Not Delegated Not Delegated Not Delegated Minimum Services Delegated Highland Health and Social Care Partnership have adopted a lead agency model. This has seen NHS Highland assume responsibility for Adult Health and Social Care Service and Highland Council assume responsibility for Children’s Health and Social Care Services Page 138
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1 Appendix 2 - Timeline Potential Delegation of Children and Families and Criminal Justice Assumptions • Members of the Programme Board have capacity to progress the timeline for delegation with briefing sessions to Boards and Committees pre committee report. • Board and Committees have capacity to discuss this project as an agenda item • Scottish Government budgetary allocations are within the predicted parameters to forecast financial package to delegate. • Finance team have capacity to deliver on financial plan. • Legal team can successfully subcontract with external agent to hit milestone due to limited capacity with internal team. • Schedule of work will continue during 2022 acknowledging the local elections in May which may cause a disruption to the timeline. • Schedule of work will continue during 2022 acknowledging the winter pressures across the Health and Social Care system Page 139
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2 Approval Plan Task Date Subject Matter Dependency Programme Board Meeting 3 Mar / 10 Mar Consultation on Committee paper Approval: Moray Council Full Committee 6 April Committee paper requesting delegation Successful Children Services plan for transformation Approval: NHS Board 2 Jun Board paper requesting delegation Successful board seminar discussions (pre report) in May Approval: IJB 30 Jun Board report with agreements from MC and NHS Approvals from Moray Council and NHS and with success development session on 28 April Approval: NHSG 4 Aug Scheme of Integration approved by NHS Board and MC Board Approvals from all 3 parties to delegate Approval: MC TBC Scheme of Integration approved by NHS Board and MC Board Approvals from all 3 parties to delegate Amendment – Scheme of Integration Jun Revision to scheme of integration by Legal ready for submission to Scottish Government Ministerial Amendments Sent Sep AIM: Delegation Complete Oct + Subject to Ministerial timeline Page 140
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REPORT TO: MORAY COUNCIL ON 6 APRIL 2022 SUBJECT: PROPOSED DELEGATION OF CHILDREN AND FAMILIES AND JUSTICE SOCIAL WORK BY: CHIEF OFFICER, MORAY INEGRATION JOINT BOARD 1. REASON FOR REPORT 1.1 To ask the Council to consider the outcomes of the business case on the proposed delegation of Children and Families and Justice Social Work to the Moray Integrated Joint Board (MIJB). 1.2 This report is submitted to Council in terms of Section II (22) of the Council's Scheme of Administration relating to alterations to the Moray Integrated Joint Board (MIJB) 2. RECOMMENDATION 2.1 It is recommended that The Council: (i) consider and approve the Business Case for delegation of Children’s and Families and Justice Social Work Service to MIJB attached as Appendix 1; (ii) note that the Business case is being submitted to MIJB and Grampian NHS Board for their respective approvals; (iii) agree that financial accountability for the service remains with the Council for a period of 18 months up to 31 March 2024; (iv) agree that Officers enter into dialogue with the Scottish Government (as the statutory approval body) over the formal amendments required to the Integration Scheme to enable the delegation; and (v) note the final version of the Scheme will come to a future meeting of the Council for approval. Page 143
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3. BACKGROUND 3.1 The Scottish Government National Performance Framework sets out the ambitions of the Scottish Government underpinned with the values of treating all people with kindness, dignity, and compassion; with respect for the rule of law; and to act in an open and transparent manner. The national outcome most relevant to Children and Families and Justice Social Work is that people grow up loved, safe and respected so that they realise their full potential. This includes a requirement to understand the lifelong impact of children being placed into care. 3.2 Improving outcomes for our most vulnerable children and families, to meet the ambitions contained in the National Performance Framework, our Moray Children’s Services Plan 2020-23, and the Independent Care Review’s “The Promise”, requires a shift in approach of how we work with families to one which focuses on family strengths and assets, recognising the enduring and lifelong nature of family relationships which need to be nurtured and enhanced. There was a recognised need for improvement and transformation, and this is underway. 3.3 In Moray there was recognition of a need for improvement and transformational change within Children’s Social Work. The Care Inspection in 2016 pointed towards a need for radical improvement. National Benchmarking Data showed Moray did not compare well with comparator local authorities and an agreement was made for the reinvestment of savings to achieve sustained and robust change and improvement, which is underway. Data from the most recent benchmarking 2019-2020* 2019-2020 Moray comparison score out of 32 Local Authorities (1 being the best) Cost of residential care 29/32 Children looked after in kinship and foster care 25/32 Balance of care being weighted towards non-family placements 31/32 Children who have had more than one placement 29/32 * 2020/21 results for children and families are always later than the initial publication as not made public by Scottish Government until May so are added in at a later date so comparisons for 2019/20 are the most current we have until that update in a couple of months. Management Structure 3.4 On 25 September 2019 (para 5 of the minutes refers) the Council approved the revised management structure that would ensure the continuity, stability and availability of strategic leadership and direction to meet the challenges of the future as efficiently and effectively as possible with the flexibility to meet future requirements. The agreed management structure showed Children and Families and Justice Social Work services moving under the direct oversight of the Head of Service and Chief Social Work Officer within the Moray Integration Page 144
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Joint Board (MIJB). The Council restructure saw the deletion of the Head of Service post for Children’s and Families and Justice services; however, this post has remained as an interim position whilst the propriety work for delegation continues, with a recognising that Children and Justice Social Work services require robust and assured leadership. Progress Updates 3.5 Progress updates were presented to Moray Council on 27 November 2019 (para 22 of the minute refers) and NHS Grampian on 5 December 2019 (para 11 of the minute refers) where both parties agreed to proceed to the next steps of assessing the various gateways and milestones of the potential delegation of Children’s Social Work and Criminal Justice to the MIJB. It was anticipated that the work required for the transfer would take between 12-18 months with an initial target date for any delegation of 1 April 2021. 3.6 Progress updates were presented to the MIJB on 28 May 20 (para 12 of the minute refers) and on 1st July 20 (para 8 of the minute refers) Moray Council Emergency Cabinet noted the position statement on Children and Families and Justice Social Work, including an overview of the National Context; the Local Context; The Independent Care Review; the current position in Moray; rationale for transformational change; and delegation of services to Moray Integration Joint Board. The MC Emergency Cabinet agreed to note the working being carried out to make improvements to the service and to continue with the programme which would seek agreement at a future date to delegate services to the MIJB. 3.7 Further updates were presented to the Moray Council on 30 June 21 (para 11 of the minutes refers) noting the work being carried out by the Programme Board which focused on both development of the service and the business case for where the service is best aligned. Programme Board 3.8 The Programme Board was inaugurated on 16 November 2020 with the purpose being to lead and provide strategic direction in relation to the potential delegation and modernisation of Children and Families and Justice Social Work, and potential delegation to the MIJB in line with national policy, legislation, and local requirements. This was noted by Council on 16 December 2020 (para 10 of the minutes refers). 3.9 The delay in establishing the Programme Board was due to the disruption from the Covid-19 pandemic. Lock down began March 2020 with the focus for Local Governments and NHS Boards to deliver essential services and support the delivery of widespread public health measures. As the virus began circulating, vaccination programmes became a priority followed by the third wave fuelled by a new Delta variant in July 2021. Most recently NHS Grampian entered Operation Iris in November 2021 until April 2022 to manage demands placed on the system by Covid-19, This contributed to the loss of momentum and slowed the progression to undertake the necessary due diligence required to progress with delegation of children and families and justice social work. 3.10 The remit of the Programme Board was to provide a joint forum for discussion amongst key partners and stakeholders regarding delegation whilst offering support and scrutiny to aid a decision for all parties to agree on taking forward a proposal around delegation. The ambition of the Programme Board was to aim Page 145
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for the Integration Scheme to be laid before Scottish Ministers and approved by 1 April 2022. This would be subject to agreement by Moray Council, NHS Grampian and MIJB. However, this timeline was revised given competing priorities across the whole system. 3.11 The focus of the Programme Board has been to identify and monitor the risks and issues associated with the potential delegation and to identify the key benefits of delegating Children and Families Social Work and Justice Social Work into the MIJB. The Board received a suit of papers including a problem statement, project Initiation document, draft benefits realisation plan and risk register, along with a comprehensive update backed by a data set on the progress the Children and Families and Justice Social Work were achieving. The subsequent development of a business case including options appraisal formed part of the additional works required to aid the recommendation from the Board of the statutory decision makers. Service Finances 3.12 The Children and Families and Justice Social Work service currently has a budget in 2021/22 of £19.5 million with a forecast underspend of £2.0 million. The Service employs 114 FTE staff. 3.13 A reinvestment of savings of £0.8 million was agreed at Educations, Children’s Services and Leisure Committee on 26th January 2022. This enabled significant system change within Children and Family’s Social Work with a number of key areas developed to sustain and develop improvements. When setting the budget for 2022/23, the Council also agreed budget savings of £0.8 million from the Service in 2022/23 and indicative savings of £0.4 million pa from 2023/24 to 2025/26. The agreed base budget for the service in 2022/23 is £18.45 million (including an element part of which will remain with the Council) and this will be increased to cover pay awards and contract uplifts as and when these are agreed. 3.14 Officers have been working on financial due diligence for the proposed delegation in recent months. There are still two areas of the Education budget, totalling £7 million, where the split of funding between the element that would transfer to MIJB and the element that would remain with the Council needs to be finalised. It is anticipated that this work will be completed before final sign off of amended Integration Schemes by the Council and NHS Grampian in July and August. Currently no issues have been identified from the financial due diligence work that would prevent agreement to delegate. 3.15 Given the scale of the transfer, Finance Officers recommend that assuming a delegation date of 1st October 2022 that financial accountability for the service remains with the Council for a period of 18 months up to 31st March 2024. If delegation took place, this would mean that operational responsibility for the service would sit with MIJB but any financial variance against the budget (whether an underspend or overspend) would remain with the Council. This transitional period would allow the service to become embedded within MIJB without MIJB or NHS Grampian being exposed to undue financial risk over the initial period of the transfer. Business Case 3.16 The Business Case for the delegation of Children and Families and Justice Social Work including an option appraisal is attached in Appendix 1 to this Page 146
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report. A draft version of the Business Case was considered by the Programme Board in June 2021 and their feedback has been incorporated. 3.17 The aim of the Business Case was to provide the opportunity to undertake a comprehensive analysis of the preferred option, for the delegation of Children and Families and Justice Social Work to the MIJB. The two viable options included: Option 1, to delegate Children and Families and Justice Social Work to the MIJB alternatively Option 2, to reposition Children and Families social and Justice Social Work into the Council structure. 3.18 The Business Case has been developed with the input from a number of senior colleagues across NHS Grampian, Moray Council and Health and Social Care Moray, as well as other Integrated Authorities who have already delegated Children and Families and Justice Services. It also sets out the complex landscape of joining national and local policy to providing best outcomes for children and families to meet statutory responsibilities within a Moray context. 3.19 The Business Case acknowledges that there is no consistent approach across Scotland regarding which services are delegated but it recognises the National Care Service consultation responses which highlights the benefits to the services sitting within one structure, endorsing the view that the direction of travel in Moray is comparable to the national picture. Children Transformation Plan 3.20 There is a recognition that professional alignment between adult and children social work would improve several key areas, including substance misuse and mental health work, transitions – particularly for children and young people with disabilities, SDS and people with care experience. It would also afford opportunities for efficiencies and allow a more coherent professional development across the social work workforce, with training and development on human rights and the protection of adults and children being a common practice theme across all areas of social work. 3.21 A reinvestment of savings was agreed at Educations, Children’s Services and Leisure Committee on 26th January 2022. This enabled significant system change within Children and Family’s Social Work with a number of key areas developed to sustain and develop improvements, particularly around prevention of care, policy development, child protection and creating a relational practice model. 4. KEY MATTERS RELEVANT TO RECOMMENDATION 4.1 The Programme Board has agreed the Business Case and the rationale to delegate Children and Families and Justice Social Work, which is primarily to improve outcomes for children and families, and also to meet the ambitions contained in the National Performance Framework, Moray Children’s Services plan 2020-23, and the Scottish Independent Care Review – The Promise. The transformation of Children Social Work is underway with evidence of savings and improvement. 4.2 There is a recognition that professional alignment of Social Work Services across the Partnership would improve a number of key areas and allows for an aligned approach to complexities around mental health and parental substance misuse and offending (including domestic violence), transitions, particularly for Page 147
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children and young people with disabilities, Self-Directed Support (SDS) ad to meet statutory responsibilities towards individuals with care experience. It would create efficiencies and synergised professionals’ development across Social Work Services. A commitment for improvement has been made across the Partnership, with a shared model of support in the 3 conversation Model, a relational, asset-based approach. 4.3 The extended timeline to reaching a formal decision was due to competing priorities but recognised the need for satisfactory due diligence to take place so that officers had full confidence in recommending the delegation of services to MIJB. 4.4 The aim is for Moray Council, NHS and MIJB to agree to the delegation services with the intent for the process to be completed by October 2022. A copy of the indicative timescale is attached at Appendix 2. 5. SUMMARY OF IMPLICATIONS (a) Corporate Plan and 10 Year Plan (Local Outcomes Improvement Plan (LOIP)) and Moray Integration Joint Board Strategic Plan “Moray Partners in Care 2019 – 2029” Moray Council Corporate Plan 2020-23 outlines its ambitions to support children and families and communities (b) Policy and Legal Legal resource is required to undertake any due diligence for amending the Integration Scheme, and that process is ongoing. This will be assisted by Brodies Solicitors and the indicative timescale is accepted with the caveat that the Scottish Ministers lead time to sign off the amended Scheme of Integrate may vary according to their priorities. The Children and Young People (Scotland) Act 2014 (Part 3) sets out a legal framework for children’s services planning, including its scope and aims. (c) Financial implications In preparation for the delegation of additional functions to the MIJB it will be necessary for the MIJB to obtain assurance that financial resources are adequate to allow it to carry out the functions delegated and to assess the risks associated with this. The MIJB Chief Finance Officer will work with both the Council Section 95 Officer and the Health Board Director of Finance in establishing the required assurance. (d) Risk Implications and Mitigation To continue at pace, the scale of this work should not be underestimated. Financial due diligence and workforce engagement is essential to a successful transition. There is a high risk if we are unable to gain agreement from all 3 bodies to delegate. Through the business case it has been recognised that children and families and criminal justice services has a good fit best for with adult services. If delegation does not proceed this will have implications for the escalation of the costs of services, not only for opportunities for efficiencies and professional development across the social work workforce, but more importantly the Page 148
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lost opportunity for an improved workforce alignment which will offer better outcomes for our most vulnerable children and families. (e) Staffing Implications Once a formal decision has been made any proposals for change to team structures and lines of responsibility will be documented through a change management plan including consultation with relevant parties, including our staff and unions. (f) Property No property issues identified at this point. (g) Equalities/Socio Economic Impact Not required at this point. (h) Climate Change/Biodiversity Impact None arising from this report (i) Consultations Chief Executive, Chief Finance Officer both NHS Grampian, Chief Financial Officer MIJB, Chief Executive, Chief Social Work Officer;, Head of Governance, Strategy and Performance, Tracey Sutherland, Committee Services Officer; Head of Financial Services, Head of Children’s and Families and Justice Social Work all Moray Council have been consulted. 6. CONCLUSION 6.1. The Business case supports the decision of the Programme Board to recommend the delegation of Children and Families Social Work and Criminal Justice Services to MIJB. There is a clear understanding of the services which are lawful to delegate whilst recognising further work is required for final financial due diligence and to support the development and implementation of a change management plan. 6.2. When approvals from all three bodies (NHS Grampian, Moray Council, MIJB) are gained, a further report will be presented with the amendments to the Scheme of Integration for final approval. Author of Report: Simon Bokor-Ingram, Chief Officer MIJB Background Papers: With Author Ref: Page 149
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REPORT TO: MORAY INTEGRATION JOINT BOARD ON 30 JUNE 2022 SUBJECT: SELF-DIRECTED SUPPORT - DAY OPPORTUNITIES TEST OF CHANGE BY: JANE MACKIE, CHIEF SOCIAL WORK OFFICER 1. REASON FOR REPORT 1.1. To inform the Board as to the progress of the Day Opportunities test of change and to consider the permanency of the Self- Directed Support (SDS) Enablers. 2. RECOMMENDATION 2.1. It is recommended that the Moray Integration Joint Board : i) notes the work undertaken to meet the aims and objectives of the test of change ii) approves the movement of budget from the decommissioned contracts to fund the permanency of the Day Opportunities team and the role of the SDS Enablers 3. BACKGROUND 3.1. The Social Care (Self-Directed Support) (Scotland) Act 2013 was enacted in April 2014 with the Self-Directed Support (SDS) Standards being implemented in March 2021. The focus of both the legislation and the standards is to deliver independent living, enabling people of all ages to have the same freedom, dignity and control as other citizens at home, work and in the community. 3.2. It should be acknowledged that in March 2020, the Westminster and Scottish Governments announced measures to restrict the spread of coronavirus. The impact on society was considerable, but more so for services delivering to children, adults and their families already facing significant challenge. Universal, statutory and third sector services were required to respond almost overnight to continue to meet the needs of families and ensure that children and young people remained safe and well. 3.3. Weekly remobilisation meetings commenced in order review those services which had been paused and to explore the safe parameters in which building based day services could reopen in line with current COVID-19 guidance. Page 151
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Partnerships are fully aware that current models of social care are not sustainable and that new models of social care are required to address the pressures of growing demand and limited finances. The prioritisation process must therefore be able to facilitate the local review of existing services and existing resource allocation, bringing decommissioning and commissioning decisions within the same process. This will provide a basis for developing new models of care, redesigning existing services, phasing out services and the redirection of resources to ensure these are better focused on meeting need and improving outcomes. All of which is built on the foundation of legislative change around the National Care Service and transformational redesign of the whole system of care. This includes a focus on developing and strengthening community connections for day opportunities as an alternative to building based day services, keeping individuals in their own communities, reducing the need to transport individuals around Moray. This will result in more bespoke, efficient and effective supports for individuals and their unpaid carers. Through collaboration with Health Improvement Scotland (HIS) and Social Work Scotland (SWS), we are able to feed into national work being undertaken to support the workforce capacity. 3.4. Redesigning part of the system for Older People will require consideration of flexible and responsive staff structures that can accommodate service and individual needs that changes over time. It also requires an integrated response from all partners, and the redesign of services. Following consideration, an initial test of change has commenced that delivers an alternative model to previous building- based older people day service. This is embedding the strength and asset based approach which is one of the 12 SDS standards. 3.5. Older people’s day service’s in Elgin and Forres were predominantly delivered by Hanover, a commissioned service operating from sheltered housing complexes in Elgin (Chandlers Court) and Forres (Cameron Court), as well as, Abbey Vale in Elgin under a commissioned contract. The day service contract was due to expire in June 2021, with alternative methods of service delivery being agreed as an alternative to recommissioning these services (Appendix 1; SBAR Day Service for Older People in Moray). The cost of these contracts collectively was £306,005.00 per annum (Hanover £305,955.00, Abbey Vale £50,000.00) 4. KEY MATTERS RELEVANT TO RECOMMENDATION 4.1. The demand for social care has increased each year with people living longer, and with longer term conditions and complex needs. There is increased expectation to deliver more personal and flexible support for those eligible for social care support. In order to respond to these challenges Health and Social Care Moray need to transform the services they offer, meaning more collaboration with third sector partners and communities to support individuals in a person centred way. Offers of support should focus on maximising an individual’s potential utilising their own capabilities, their family and community resources and there should be less reliance on formal building based and funded council support (SDS standard 3; Strength Based, Asset Based Approach) Page 152
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4.2. As health and social care shifts to more creative and holistic models of care, there is an increased need for community based supports to enable individuals to remain safely in their own local community. The Day Opportunities test of change commenced February 2022, (See Appendix 2 Proposal Form– Flexible day opportunities) with a multi- disciplinary team developed to explore delivering placed based, flexible support in an outcome focussed way to meet individual outcomes. The aim is to support individuals to connect into their own communities, focussing on personal interests and hobbies, taking a strength base, asset based approach in line with the SDS Standards to make a positive change in people’s lives. 4.3. The Day Opportunities team work alongside the social work teams to take referrals for those individuals who require support, treatment or care to be explored. The aim is to move from Case Management (process driven) to relational based models of delivery by focusing on building good relationships with the people they support, which can be a resource in its own right and more bespoke to that individual. To help and encourage individuals to explore community-based supports that are right for them takes a significant amount of time which the SDS Enablers are there to explore. The Day Opportunities team includes the SDS Enablers, SDS & Carers Officer, Shared Lives, Community Support Services, Internal Building Based Day Service, Community Well-Being Development Officer and a Community Connector. 4.4. Unpaid carers provide a valuable resource both in terms of supporting the individual whilst they are at home and giving reassurance to the person they care for in relation to their agreed activities they have, in order to give planned respite to the unpaid carer. We recognise the importance of ensuring unpaid carers have a break, but also need to ensure the individual receiving the care has support delivered that is meaningful and person centred to them. 4.5. The Day Opportunities team recognise that building based day services are a vital resource to many individuals and due to the increase in the need for support, we need to ensure that this finite resource is accessed by those who require a high level of support where they cannot be supported safely in their community. Since the SDS Enablers commenced the test of change, one significant change is that a total of four individuals have used traditional building based day services from a total of approximately 30 referrals as a result of person centred planning, taking the time to get to know the individuals and exploring activities that are meaningful to them. This is approximately 13% of individuals with whom the SDS Enablers have contact with attend a traditional building based day service, the other 87% are supported to engage in their own local community either independently or with support. 4.6. The Day Opportunities team now has a number of clear examples whereby having good conversations, getting to know the individual and the unpaid carer and what is meaningful to them, can have positive outcomes for both the individual and the unpaid carer. Qualitative Evidence Example 1 4.7. One lady previously attended a building based day service prior to COVID -19 forcing their closure. The SDS Enabler worked with the lady where it was clear Page 153
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that the intended outcomes for the lady being at Day Service were not being met, the days were too long and not meeting her needs. The SDS Enabler introduced her to the local S.E.T (Singing Exercise Tea) group which is a group led by the Community Wellbeing Development Team in collaboration with ’Dance North’ a third sector provided. This community-based group offers chair-based activities whilst building local friendships to reduce social isolation and maintain physical strength and mobility, address the fragility and loneliness of our older population. This lady now attends regularly and is very content with this option which is achieving the intended outcomes. As this is a community group there is no charge to HSCM. An unintended outcome is the collaboration with our Third Sector partners and the ability to explore alternative funding though the Third sector to deliver health and wellbeing activities in a true collaborative approach. The Financial package for the lady who used to attend day services 4 days per week was at a cost of £51.47 per day (£205.88 per week). Through having meaningful conversations with the SDS Enabler, this lady is being supported to meet her outcomes in her community at a 100% financial cost reduction. Theoretically, this would have a saving over £8235 per annum, if the old package was to continue (based on 40weeks of day service/year). Example 2 4.8. A lady was referred to the Day Opportunities team to support her unpaid carer to get a break from his caring role on a weekly basis. It was initially thought that a building based day service would be suitable for this lady as in the coming months she would be moving into long term care. It was thought that supporting this lady to get into a day care environment would support with the transition into long term residential care (SDS standard 10; Early Planning for Transitions). The SDS Enabler visited the individual and her family, and due to the strengths-based conversation by the SDS enabler, it was evident that the lady had a passion for bingo. To support the lady to meet her personal outcomes (to continue to live a normal life) and to engage in her community, a befriender was sourced by the SDS enabler to support the lady to attend the local bingo and to take her for walks in her local village. This lady would have been assessed as requiring two days at a building-based day service at a total cost of approximately £103 but instead is able to access her community, doing meaningful activities and being orientated around her local village for a slight reduction in budget at £96.00. This is before taking into consideration the cost of transport to the day service The benefits to the lady being connected in her local community has had a positive effect on her and also enabled a level of continuity and normality to the life of this lady is creating persona centred outcomes with the hope that the befriender will support the lady for a few weeks once the lady transitional into residential care, supporting the individual further whilst embedding the SDS standards into everyday practice. 4.9. Through the Day Opportunities team attending daily huddles, a greater oversight is obtained as to local community based resources. The development officer within the team focusses on community connections, ascertaining the resources which are already available within the communities and supporting them to become a trusted provider. Where gaps are identified within specific communities, work is undertaken in conjunction with the Community Well Being Development Team to support the creation and establishment of groups/ providers who can meet these outcomes, with Page 154
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collaboration with our Third sector at the heart of any discussion. More recently a Day Opportunities strategic oversight group has been established, which will report directly into the SDS Change Board. This board will then link into the higher strategic aims for Health and Social Care Moray. 4.10. At present the Day Opportunities team have 58 individuals allocated between the two SDS Enablers, with a further 54 waiting to be allocated. A further discussion is to take place at the daily huddles for 13 individuals open to the Learning Disability team. Due to the increasing number of referrals to the team, temporary changes have had to be put in place to manage the demand, this includes where those individuals identified as requiring additional days at day care or shared lives will not be allocated to an SDS Enabler to arrange to visit and have the intended conversations. Instead the team will have oversight of these at the daily huddle. This has already been identified as a risk, with one such example being referred back to the Day Opportunities team as the extra day allocated at day care was not suitable and alternatives needed to be explored. 4.11. To effectively support individuals, the SDS Enablers are working in collaboration with internal day services and shared lives, looking at any waiting lists for these services to ensure that this is the most suitable way for their outcomes to be met. This has resulted in several individuals having good conversations with the SDS Enablers and community resources being used which have been more suitable. Where an individual may be placed on a waiting list for support, the SDS Enablers would look for support to be put in place, including the exploration of technology to support them to wait well. 4.12. Associated benefits include supporting the social care system by looking to create alternative innovative practice which supports longer term sustainability. The SDS Enablers support the social work workforce through removing the case management aspect from them, freeing them up to build positive relationships. This supports the national research recently undertaken by SWS; Setting the Bar: Towards an indicative maximum caseload for Scotland’s public sector social workers. This research highlights the pressures faced by social work and the impact on their caseloads process and paperwork has on their ability to form effective and strong relationships with the people they support. The work of the SDS Enablers would have a positive impact on the social work caseloads in conjunction with the care assessors in place for care at home. 4.13. In order to effectively manage the demands of the SDS Enablers, and to expand the positive outcomes being achieved to other client groups, wider than the primary focus of older people, it is evident that additional SDS Enablers are required. It is proposed that a further three additional SDS Enablers are funded to support the change to this effective model of working across the Social Work teams at an additional cost of £119,403. This has been evidenced through the current caseload allocated to the SDS Enablers and the referrals waiting to be allocated. It is further requested that the two current SDS Enabler posts are made permanent at cost of £79,602 per annum. This fits with the national picture of decommissioning to recommission supports that are bespoke and person centred. A business case has been developed to evidence the requirement for the SDS Enablers and the continuation to explore community assets, engaging with communities to deliver need in order to meet individual Page 155
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outcomes in a person centred way, adhering to the SDS Standards (Business Case attached as Appendix 3). 4.14. The Day Opportunities test of change has been presented at the Strategic Planning and Commissioning Group (SPCG) and SMT where it was positively noted, agreeing that this is the direction we are striving to achieve, and fully support this model going forward. 5. SUMMARY OF IMPLICATIONS (a) Corporate Plan and 10 Year Plan (Local Outcomes Improvement Plan (LOIP)) and Moray Integration Joint Board Strategic Plan “Moray Partners in Care 2019 – 2029” Moray has made a commitment to the development of SDS as a means of promoting independent living and equalities. The independent living and equalities agenda cuts across all areas. In line with the Integration Joint Board strategic plan there is a commitment to respect individual needs and values, demonstrating compassion, continuity, clear communication and shared decision making. The test of change compliments the NHS Grampian Plan for the Future specifically around people; treating citizens as individuals, supporting specific needs and circumstances, and also places; having placed based well-being in partnership with community. Moray has a commitment to support unpaid carers, with the current strategy being developed. The test of change supports emerging key themes to support carers to have a life outside of their caring role, and to support them to have regular breaks. (b) Policy and Legal The Council has a legal duty under the Social Care (Self Directed Support) (Scotland) Act 2013 to promote collaborative working, and ensuring individuals can lead a fulfilling life. The Self Directed Support legislation requires the values and principles which underpin the SDS strategy and legislation to be promoted. The values highlighted are Respect, Fairness, Independence, Freedom and Safety. The underpinning principles are, Collaboration, Dignity, Informed Choice, Innovation, Involvement, Participation, Responsibility and Risk Enablement. (c) Financial implications From the decommissioned services budget, to vire to the SDS budget to enable the two temporary SDS Enablers be made permanent at a cost of £79,602.00, with an additional three SDS Enablers to be recruited at a cost of £119,403.00. This figure is based on the current workload capacity of the SDS Enablers, in comparison to the number of unallocated referrals to the team at present and the additional capacity required to effectively support the Learning Disability team. (d) Risk Implications and Mitigation Without the continued funding available from the ceasing of externally commissioned building based day services, the positive work being Page 156
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undertaken will no longer be able to continue. This will result in the work being passed back to the Social Work teams, where there is already a significant number of social work assessments waiting to take place. The continued work of the SDS Enablers will support with the flow of these assessments, ensuring that positive connection are made in the community for these individuals. In the absence of the SDS Enablers, there is a risk that individuals will return to being slotted into services that are already there at a higher cost to HSCM. (e) Staffing Implication To allow for the test of change to move to become established on a permanent basis there is a need for the 2 SDS Enablers to be appointed on a permanent basis and appoint a further 3. In the absence of these posts, the test of change will cease. (f) Property There are no implications (g) Equalities/Socio Economic Impact No negative impact has been identified. Through the work of the SDS Enablers, there are anticipated positive impact for individuals promoting equality of opportunity for the following groups: age, disability (h) Climate Change and Biodiversity Impacts There are no implications (i) Directions There are no directions arising out of this report. (j) Consultations Consultations have taken place with: Jane Mackie Chief Social Work Officer Deborah O’Shea Chief Finance Officer Sean Coady Head of Service John Campbell Service Manager Carmen Gilles Interim Strategy & Planning Lead Charles McKerron Service Manager, Learning Disability Lisa Brennan HR Advisor Jeanette Netherwood Corporate Manager Don Toonen Equal Opportunities Officer Day Opportunities Strategic Direction Group Strategic Planning & Commissioning Group 6. CONCLUSION 6.1. For the board to have an awareness and understanding of the work undertaken by the Day Opportunities team, in particular the role of the SDS Enablers. Page 157
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6.2. For the Board to agree to the remodelling of day care for older people and to reinvest monies from previously commissioned Older People’s Day Services provided by External Partners into Day Opportunities. Author of Report: Michelle Fleming, SDS & Unpaid Carers Officer Background Papers: Business Case- Day Opportunities SDS Enablers Ref: Page 158
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Appendix 1 Carmen Gillies V1 Day Service for Older People in Moray SITUATION Scots are enjoying longer lives, which often are accompanied by more complex care needs. Demand for social care is growing faster than our traditional services were designed for. Prevention programmes for improving health later in life, particular those with lower health status, will be vital to enabling people live in good health and wellbeing in older age, whilst recognising that good health and wellbeing and the ability to access health services are vitally important to older people. Moray’s Day Services began the journey of remobilisation in August 2020. With guidance from the Scottish Government a Moray framework for remobilisation was agreed in early September. The framework directed, supported, and documented the process required to remobilise safely and fairly for all day service providers and service users across Moray. External commissioned day service for Older People has not remobilised during the pandemic due to the unsuitability of the environment in which the services were being delivered. Furthermore, day service contract for older people is due to expire 12 June 21 which has presented an opportunity to understand intrinsically and intimately the evolving needs of the older people as well as the key priorities for their unpaid carers. Engagement with unpaid carers, creating design groups and listening to Social Workers all contributes to the design and deliver of appropriate services to meet the needs of Morays older people and carers, utilising the full capabilities of internal services, market providers as well as voluntary and community groups. BACKGROUND Day service in Elgin and Forres was predominantly cover by Hanover, a commissioned service operating from sheltered housing complexes in Elgin (Chandlers Court) and Forres (Cameron Court). Likewise, Abbey Vale in Elgin also offer day service provision under a commissioned contract. As the day service contract is due to 12 June 21, Abbey Vale has no aspirations to continue to offer a day service provision. Through the design group alternative provision is under exploration, however there is a need for short term provision to meet the current demand and to offer respite for unpaid carers. CONTRACT INFORMATION AbbeyVale Service Delivery: 2 or 3 clients attending Cost of Contract: £51.47 Per person (not including transport costs) Hanover Service Delivery: Cameron Court Capacity 8 / Chandlers Capacity 12-15 Cost of contract: £51.47 Per person (not including transport costs) Page 159
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Appendix 1 Carmen Gillies V1 Service Capacity Service Level of Physical Need Capacity Free Capacity Operating Days Additional Information DAYCARE Keith Day Service 6 5 days per week LinnBurn Day Service 8 5 days per week MRC High 16 Building designed for high end needs. Equipment available to meet needs. Outreach Temporary option until MRC opens – Carers Stress Staff will need to be retrained into new service for MRC Gurness Circle Low/Medium 2 3 days per week 3 members of staff needed Stevens Hospital Medium/High 4 5 Days per week 3 members of staff needed Alternatives Shared Lives EAST Low/Medium EAST: 21 ½ day sessions ½ days available Mon – Fri Sessions are counted as ½ days. Findochty: 7 Keith: 9 Buckie: 2 Portnockie: 3 Shared Lives WEST Low/Medium WEST:5 ½ day sessions Kinloss: 2 By Elgin: 2 Hopeman: 1 Waiting list for the west of Moray – availability will be used up. Page 160
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Appendix 1 Carmen Gillies V1 NEED A full needs analysis of the individuals can be found in the attached excel spread sheet. Need Elgin Forres Lossie Total Supportive Environment 4 6 3 13 Supportive environment with staff 4 2 6 Community Group inc. Befriending or Shared Lives 5 1 1 7 Support for confidence 2 2 Respite /MRC Complex needs 5 2 7 OPTIONS Model 1 - Flexible Workforce to respond to Cared for and Carers Need Through the development of a flexible and agile workforce, a range of options can be delivered. Option 1 supporting a community-based service in partnership with CWDT, Internal Services and Quarriers. Option 2 continuing to offer outreach service for those who choose this support Option 3 offering an adhoc outreach service to support the Carers needs for RESPITE. Option 1 – Attend a community-based activity with support staff The cared for and carers can engage in community health and wellbeing activities using locality-based community assets for example at the Moray Sports Centre. CWDT will facilitate the delivery of meaningful physical and mental stimulation using their extensive network of micro providers. Trained staff will support the 3 hour session from Internal Services with support from Quarriers to offer carers simultaneous activities if desired by the Carers. Outcomes • Reducing social isolation and increasing confidence for the individuals. • Carers can attend and have respite whilst waiting in the building accessing their own activities (if required supported by Quarriers) to allow for an increase in confidence that their cared for is settled and safe. Venue Community building based setting e.g. Moray Sports Centre Page 161
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Appendix 1 Carmen Gillies V1 Cared For: Access 3-hour session (physical activity plus social interaction – designed by the users) Carers: Can access activity/ gym/ lunch Access exiting community-based provision within the venue e.g. Callum’s Kitchen Lunch can be provided or simple refreshments. Personal choice and control. Capacity and Frequency 16 Participants with 3 members of internal staff 1 session per week for 3 hours. Option 2 – Outreach Clients have the choice of support required by offering outreach. This can also be valuable to offer to the unpaid carers to support their own SDS outcomes for respite. This offers more choice for people. Option 3 – Adhoc Outreach / Respite Similar to above. The needs of the unpaid carer are recognised as their individual needs through their own SDS assessment. Carers can access emergency respite for the anomalies like dentist appointments, hairdressers etc The above options have been discussed with Quarriers who are in support of the choices. RECOMMENDATION Invest and strengthen a multi-disciplinary teams to deliver an enhanced and sustainable workforce to improve older peoples’ outcomes in community settings. This requires a HSCM workforce that is both sufficient to meet demand and flexible enough to address changing needs. Continue to invest in people, training and education of general support for older people, this includes supporting the management of long-term conditions and supporting people with complex conditions or who are frail as part of the multidisciplinary team supporting older people. Page 162
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PROJECT/WORKSTREAM PROPOSAL APPENDIX 2 HSCM initial outline v0.01 PROPOSAL FORM Title Flexible Day Opportunities Service(s) involved Provider Services, Social Enterprises, Social Work, SDS, Volunteering, Shared Lives Impact Assessment (H/M/L) (See APPENDIX A) Medium/High Strategic Fit: Moray Partners in Care 2019-2029 Identify which theme(s) and outcome(s) your proposal meets Theme(s): 1) Building Resilience: Taking greater responsibility for our health & wellbeing X 2) Home First: Being supported at home or in a homely setting as far as possible X 3) Partners in Care: Making choices and taking control of decisions affecting our care and support X Expected Outcome(s): a) Lives are healthier X b) Experiences of services are positive X c) Carers are supported x d) People live more independently X e) Quality of life is improved X f) People are safe X g) Health inequalities are reduced X h) The workforce continually improves X i) Resources are used effectively and efficiently X What needs to be done? (bullet points – main requirements) Develop a multi-agency Community led model of flexible support to delivering placed based, outcomes focussed flexible day opportunities. This will: • Increase access to day opportunities; • Prevent negative outcomes; • Be resource efficient; • Provide empowerment; • Have person centred design at the centre of a flexible approach; and • Provide strength in community. Provide a 6 month test of change for Day opportunities with permanent service structure changes for enabler posts. To employ a team of 2 permanent SDS Enablers and 5 temporary Care Assistants to assess and deliver outcome focussed support in the community as part of a new model of day opportunities. Page 163
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PROJECT/WORKSTREAM PROPOSAL APPENDIX 2 HSCM initial outline v0.01 Why does it need to be done? (bullet points – main drivers; current issues) Evidence demonstrates the new approaches characterised by collaboration between organisations and partnerships with people and communities are making a real difference and can provide positive models for the future – this is a test of change to collect evidence for the successful rollout in Moray. When does it need to be done? (only include known critical timescales here – e.g. legislative, contractual etc.) • As soon as possible, to fill gap created by previous model/provision ending; • Would want to get adverts out for recruitment by 21 Oct 2021 in order to provide 6 month test of change for day opportunities workers with permanent posts for Grade 7 Enablers. What are the risks of not doing this? (compared with current situation) • Miss the opportunity to find effective and efficient ways of working; • Miss the opportunity to align day opportunities to SDS and 3 conversation model; • We fail to recognise the local context; and • We are unable to provide services to those with assessed need. What are the main likely benefits of doing this? (bullet points – including any likely financial and non-financial savings) • Leadership [both local through valuing community partners and external from partners such as i-hub]; • Partnership with Communities [Building capacity of community organisations, sharing responsibility with local partners, collaborating to shape new approaches and design services]; • Incremental change [starting small and growing with local needs]; • Understanding local contexts [planning with multi-agencies, signposting, identifying assets]; • Promoting home first and care/support in the community; and • Reducing cost for delivery in the long term. How will we know we have been successful? (bullet points – what are the targets / what measures will be used to demonstrate the change?) • People will be empowered; • Improved community wellbeing; • Provide radical change in design of service delivery; • Self-Directed Support is aligned with community led health and social care; • Collaboration is achieved in the delivery of day opportunities; • Community groups take greater responsibility using local resources; Page 164
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PROJECT/WORKSTREAM PROPOSAL APPENDIX 2 HSCM initial outline v0.01 • Greater use of community based health services; and • A renewed focus on a rights based approach which empowers people Resource requirements (detail any financial outlay/ staffing resources required – requirements only – specific costings not required at this stage) Initial six month cost for providing this test of change is to provide 5 day service care assistants at Grade 4 funded from COVID reserves to support the remobilisation of OP day services. Temporary Posts 5 x grade 4 Care Assistant (13,557) £67,785 Total £67,785 Permanent Posts 2 x grade 7 DCO (38,998) £77,996 To support the system change to embed a flexible framework for SDS option 2 in line with the national SDS standards and taking into consideration the national recommendations from the Independent Review of Adult Social Care Who needs to help make this happen? (bullet points – key stakeholders) • Re-Mobilisation group [Sponsor] • Provider Services [Employer] • SDS [enabler] • Social Enterprise [Partner] • Social Wok [Partner] • Volunteer Co-ordinator [Partner] • Shared Lives [Partner] If appropriate, detail any preliminary discussions with identified stakeholders above Request for change has been driven by the Re-mobilisation Group within Health and Social Care Moray in order to provide a test of change in the delivery of day opportunities. Completed by John Campbell Date 16 June 2021 Reviewed 7 Oct21 Contact for queries john.campbell@moray.gov.uk Email/ Telephone No. 07527387515 Submit to Gram.moraycontrolcentre@nhs.scot Page 165
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PROJECT/WORKSTREAM PROPOSAL APPENDIX 2 HSCM initial outline v0.01 To be returned to originator once form reviewed at appropriate forum – ideally within fortnight of submission. Feedback from Date General comments Status (strike out as appropriate) Approved to proceed to next stage Not approved at this stage Decision not to proceed at this point (provide basis of decision) Further work required to develop proposal (provide specifics and date for resubmission) Proceed to next stage (detail appropriate governance route and dates of submission where appropriate) Contact for queries or further information Name: Contact details: Page 166
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PROJECT/WORKSTREAM PROPOSAL APPENDIX 2 HSCM initial outline v0.01 APPENDIX A – PROPOSAL CATEGORISATION GUIDANCE Each proposal is to be given a low / medium / high assessment in accordance with the criteria for Organisational Impact and Complexity. This will provide guidance to whether the proposal is categorised as Basic, Intermediate or Strategic: • Organisational Impact assessment Low Medium High Organisational Impact (Business Criticality and Scale of Project) • Activity relevant to an individual service or team within a Department • Some Political interest in project • Contributes to delivery of a Government initiative • Maybe linked to statutory requirements / compliance with legislation • Cross cutting activity within a Department affecting most services or teams • Strong Political interest in the project • Critical to delivery of a key Government Initiative • Essential to statutory requirements / compliance with legislation • Critical to delivery of a ‘flagship’ Organisational activity AND/OR critical to the running of the Organisation Level of investment < £3,000 Investment value of greater than £3,000 (over lifecycle of the project and any resulting contracts. • Complexity assessment Low Medium High Complexity • Low degree of inter dependency with other Organisational Projects • Impact on staff felt mainly within a business unit or team • Medium degree of inter dependency with other Organisational projects • Impact on staff felt mainly within a service • High degree of inter dependency with other Organisational projects • High impact on staff across the Organisation • High degree of business process change Page 167
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PROJECT/WORKSTREAM PROPOSAL APPENDIX 2 HSCM initial outline v0.01 • Minimal innovation required (tried and tested solution(s) for the project in place • Small number of internal stakeholders affected (e.g. within a service/team only) • Some degrees of business process change • Some innovation required (solution(s) for project new to Organisation but established in the market) • Internal stakeholders affected across at least one Department • High level of innovation required (solution(s) new to the market untested by the Organisation) • Multiple stakeholders affected across several Departments and external partners The Impact and Complexity assessments are applied to the Category matrix. Classification Outcomes • BASIC Category - Change can be implemented as BAU. [SLG/SMT] provide governance and agree reporting requirements direct with nominated project/work-stream lead. Semi-regular (as agreed) progress updates to be provided to [other governance structure?] • INTERMEDIATE Category – Full Project Management provided by service. Project lead to provide regular progress updates for information (as agreed) to [who/where?]. Issues/slippages etc. identified by [governance] reported back to [SLG/SMT]. • STRATEGIC Category – Full Project governance required. Progress reported back to [SLG/SMT] as agreed. Page 168
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REPORT TO: MORAY INTEGRATION JOINT BOARD ON 30 JUNE 2022 SUBJECT: UNMET NEED IN HEALTH AND SOCIAL CARE MORAY BY: HEAD OF SERVICE/CHIEF SOCIAL WORK OFFICER 1. REASON FOR REPORT 1.1. To escalate the issues raised in this report, previously submitted to the Clinical and Care Governance Committee on 26 May 2022, on the current position on unmet need in Health and Social Care Moray. 2. RECOMMENDATION 2.1. It is recommended that the Moray Integration Joint Board (MIJB) considers and notes: i) the current situation within Health and Social Care Moray and the mitigation actions that have been introduced; ii) the continuing additional pressures placed upon Health and Social Care Moray staff; and iii) the recovery being achieved, but recognises the fragility of the improvement and the long-term impact on staff. 3. BACKGROUND 3.1. The impact of the COVID-19 pandemic continues to place a significant burden on health and social care staff. Patients, particularly the elderly and frail, are facing delays before they can leave hospital to receive appropriate care elsewhere, be that back at home, at a community hospital or residential care. The surge in cases this spring appears to be waning at last; although the highest number of cases recorded in a day was almost half the January peak, this outbreak lasted longer than previous surges (Figure 1). The impact has been felt across Scotland with a corresponding increase in hospital admissions, which are now reducing rapidly, but are still high (Figure 2). The pressure on hospitals noted in the previous report continues and there has been little or no chance for health and social care staff to recuperate and recover. Note that data for hospital admissions due to COVID-19 is only published for Scotland as a whole and is not publicly available for individual health boards or local authorities. Page 169
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Figure 1: Positive PCR cases in Moray 1 Feb 21 – 25 Apr 22 (Public Health Scotland COVID-19 data) Figure 2: Hospital admissions in Scotland due to COVID-19 between 1 Apr 20 – 25 Apr 22 (Public Health Scotland COVID-19 data) 3.2. Nationally there has been higher than usual staff absence rates amongst both council and NHS employed staff over this winter period (Figure 3).Moray Council staff absences have averaged 6.6% since May 2020, which is above the national average of 5.9%. However, for the week ending 28 January 2022, the latest data published by SOLACE, the figure for Moray has risen to 10%. Figure 3: NHS Scotland Covid-19 staff absences since April 2020 (TURAS data intelligence) and Scottish Council staff absences since May 2020 (SOLACE) These percentages suggest that the impact of COVID-19 on staff absences will continue to be a factor in reducing the ability of the Health & Care Service in Moray to meet the demands being placed on it. The trends aren’t clear, but with relatively high sickness rates for non-COVID-19 related illnesses and some care staff reducing their contracted hours, it is not going to be easy, or quick, to meet the demand. 3.3. Demand for health and social care service are likely to continue to grow as Moray’s population continues to age. Figure 4 is taken from the National Records of Scotland principal population projection for Moray and is based on Page 170
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2018 data. It will be interesting to see the impact of the current census on this population projection when the data become available. Figure 4: NRS principal population projection for Moray in 2033 by age and sex 3.4. There are 6 categories of unmet need that are routinely monitored that provide an overview of the number of people waiting for a social care assessment, a package of care, or a statutory social care review. Additionally, the number of hours of care not yet provided are also monitored. A weekly summary of trends is provided for managers (see Appendix 1). Overall, the level of unmet need is much higher than it was before the pandemic, and there is nothing to suggest that unmet need will be back to more typical values in the near future. The latest trends for each measure are summarised below: Number of people waiting for a social care assessment 3.5 The number of people waiting for a social care assessment overall has been static at between 140 and 150 since last autumn. Cases classified as URGENT reduced from a high of 36 in January to a low of 15 in March, but rose again and are static (28). These numbers are well above the numbers waiting in September last year (8). Cases classified as HIGH are half what they were in August (73). Since mid-December there have been between 34 and 39 people in this category each week waiting for an assessment, although there was a blip in February and March when the number of people waiting rose to 54. The East Team have just taken over responsibility for assessing the people classified as MEDIUM and LOW priority through the innovation site that they have set up as part of the roll-out of the 3-conversations model. In the first week they were able to reduce the waiting list for people in the MEDIUM and LOW priority groups from 80 to 49; the largest reduction for this measure since recording began in September last year. Number of people assessed and waiting for a package of care 3.6 During 2022 there have been between 154 and 169 people each week who have received a social care assessment but have yet to be provided with a package of care. Approximately 85% of people are waiting in the community and the other 15% are in hospital. The numbers appear to be static at more than one and a half times larger than last August. Number of people in receipt of a care package and waiting for a statutory social care review 3.7 For most of 2022 the number of people who are receiving a care package, but who are waiting for a statutory social care review, has remained fairly constant at between 290 and 300. While lower than the number waiting for a review last Page 171
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summer (340) there is no clear indication that the numbers waiting for a social care review will reduce significantly. Number of hours of care yet to be provided for individuals in hospital 3.8 The number of hours not yet provided for people in hospital varies weekly, but has gradually risen over time from 226 hours in August to over 450 hours in March, but has now reduced to 373 hours. If this trend continues then within the next 4 to 5 weeks the outstanding hours would be back to August 2021 levels. Number of hours of care yet to be provided for individuals in the community 3.9 Similarly, there has been an increase for people in the community over the same period from 266 hours to 778 hours at the end of January. Since then the number of hours not provided have reduced to 517, but the rate of reduction has slowed down and is likely to take several weeks or months to be back to the August 2021 figure. Number of hours of care assessed as needed and not provided for those in receipt of a care package 3.10 Since the start of February the number of hours of care not delivered to residents receiving a care package has risen steadily from 385 to 417 hours. This figure is much higher than in September 2021 when for 4 weeks this figure was consistently below 250 hours. 3.11. The status of care homes and care at home services, both internal and external are monitored regularly each week by the Care Homes Oversight Group. A RAG (Red/Amber/Green) rating is used to identify the ability to accept clients or deliver services. For the most recent data (4 May 2022) 13 out of the 14 care homes in Moray were assessed as Green, and just 1 as Red and unable to accept patients. This demonstrates a marked improvement from 18 January 2022 when there were only 4 care homes rated Green, 4 rated Amber and 6 at Red. 3.12. There were 29 Care at Home external providers rated Green on 4 May 2022, 1 at Amber and 7 at Red with either a member of staff or a client with a positive confirmation for COVID-19. Again, this represented an improvement on the situation as reported on 18 January 2022, with 17 external providers rated Green, 5 at Amber and the remaining 13 at Red. Day Services had one location at Red on 18 January due to positive test results for a member of staff and a client, but all locations are now green. The Care @ Home team remain Red but due to non-COVID-19 illnesses and vacancies, whereas in January there were 6 positive cases reported and 2 people were self-isolating. In January there was a member of staff on START who tested positive that put the team at Red. The team is currently Red due to absences and vacancies. 3.13. Overall, the situation is showing improvements compared to just a few weeks ago, and the service is closer to capacity. However, it is likely capacity shortfalls will continue to be faced in the short-term. Furthermore, the continuing levels of unmet need noted above has contributed to high numbers of patients facing delays in being discharged from hospital. 3.14. The impact of all of the above factors is illustrated by the rising numbers of delayed discharges being reported since April 2021, which remain well above historic levels (Figure 5). At the end of February 2022 the data suggested that Page 172
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the winter peak may have been reached, but then the prevalence of the Omicron variant in the local population rose rapidly and the numbers of people delayed in hospital waiting for discharge rose to a new peak. However, there was a gradual reduction in numbers in early April, which has since stagnated at 38 people per day. There is still some way to go to reach the target of 10 people per day, and the Omicron variant outbreak highlighted the fragility of the recovery. Any further pressure on the system could quickly reverse the gains. Figure 5: Average number of delayed discharged patients in Moray per week (1 Jan 2021 to present) 3.15. Delayed discharges remain high across Scotland. In February there were 57% more days spent in hospital than in February 2021 (47,713 days compared to 30,450 days)1. The PHS data also indicate that across Scotland health and social care reasons account for 69% of the delays, complex needs for 29% and 2% are due to patient and family related reasons. 3.16. In Moray the average number of people experiencing delays in being discharged from hospital at the end of January was 38, below the national average of 53, continuing the trend that goes back to the start of the pandemic apart from a blip (Figure 6). Since Moray has a higher proportion of residents aged 65 years and older compared to the Scottish average, it is not unexpected that the rate per 1,000 of the population in this age group in Moray is above the Scottish average with 1.8 cases per 1,000 people (Figure 7). Figures 6 and 7 suggest the number of people facing a delay in being discharged is levelling-off nationally, or rising much more slowly than previously, but there is no clear indication of the numbers starting to reduce. Due to the small population size of Moray there is a much larger daily variation in numbers, but the trend appears to be increasing for both the number of daily delayed discharges and the rate per 1,000 for 65 year olds and older. 1 Delayed discharges in NHS Scotland monthly (PHS) - Figures for February 2022 https://publichealthscotland.scot/publications/delayed-discharges-in-nhsscotland-monthly/delayed- discharges-in-nhsscotland-monthly-figures-for-february-2022/#section-1 Page 173
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Figure 6: Delayed discharge patients each day, May 2020 to April 2022 (SOLACE data) Figure 7: Delayed discharge patients (65 and over) each day, May 2020 to April 2022 (SOLACE data) 3.17. For Moray residents aged 18 years old and over the majority of reasons for discharge being delayed is social care place availability (10 out of 29 in February 2022, 34%) and care arrangements (14 out of 29, 48%). There were 4 patients with incapacity and one for whom HSCM were unable, for reasons beyond their control, to secure a patient’s safe, timely and appropriate discharge. Figure 8 suggests health and social care reasons may still be increasing, and the data for the March and April will be vital before the trend can be clearly understood. Page 174
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Figure 8: Delayed discharge census by delay reason for Moray residents (PHS data) 4. KEY MATTERS RELEVANT TO RECOMMENDATION 4.1. As in the previous report the numbers being reported represent real people whose quality of life is being diminished either through remaining in hospital longer than necessary, or from not receiving the care that they require. The data suggest that the situation may starting to improve, albeit from a higher level than before, and is likely to take some time before returning to pre- pandemic levels. 4.2. The previous report included the observations made by Dr Gray’s Hospital emergency department that patients were more acutely unwell or their condition had deteriorated more than was the case prior to the pandemic. Data are now available that demonstrates that the hours of care required from the Homecare Team by individuals are rising with frailer people regularly requiring more than one carer, and or more visits each day. Over the past 12 months the average number of hours of care provided to individuals by the Care at Home team has risen by 17% from 13.1 to 15.3 hours (see Figure 9). Figure 9: Average number of hours of care per person – Care at Home (April 2021- March 2022) 4.3. Mitigation measures have been put in place and were described in the previous report. The following sections provide brief updates. 4.4. Discharge 2 Assess team (D2A) is meeting its aim of enabling people meeting specific criteria to leave hospital as soon as possible. A report on the impact of D2A is being prepared by the HSCM project manager. Page 175
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4.5. A request for volunteers from Moray Council to provide short-term support to the health and social care team had limited success with just 12 volunteers identified for possible re-deployment. The complexity of arranging the required training, setting-up job-shadowing sessions, and incorporating the volunteers into rotas proved challenging, particularly as managers were having to deal with a considerably high workload and trying to meet constantly changing demands. If volunteers are requested from other parts of Moray Council in the future a robust process will need to be developed with input from across the HSCM team. 4.6. The recruitment cell has worked closely with Moray Council Human Resources team to bring people into HSCM, and is working well. Since April 2020 167 staff have been recruited into Provider Services, of which 47 were new to the care sector and the retention rate for staff over that period is close to 80%. The retention rate for the new employees is over 85% (Figures 10 and 11). Figure 10: Provider Services recruitment and retention since April 2020 Figure 11: Provider Services retention of new staff since April 2020: 4.7. The previous report identified the adoption of the three-conversation model to reduce bureaucracy and increase our responsiveness to people who approach us for support. Two of the innovation hubs have been formed: a Hospital Team innovation site, and as noted above at 3.4.1 the East Team, who are using this approach to reduce the number of people waiting for a social care assessment. Updates on their progress will be provided at future meetings. Page 176
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4.8. In addition, the Hospital Innovation Site are now also taking people from the waiting list (any category) who are admitted to hospital. This was previously an informal arrangement but has now been formalised through the innovation site. These people will now be seen by the hospital team, using the three- conversation approach. Data is being collected by the innovation site as an interim measure before being transferred into CareFirst and will be reported at future meetings. 5. SUMMARY OF IMPLICATIONS (a) Corporate Plan and 10 Year Plan (Local Outcomes Improvement Plan (LOIP)) and Moray Integration Joint Board Strategic Plan “Moray Partners in Care 2019 – 2029” This report highlights the pressures on delivering the Corporate Plan 2024 priority of “Adults and older people”. In particular the aim of ensuring that people are supported at home or in a homely setting as far as possible through a HomeFirst approach and multi-professional teams at a local level. The LOIP priority “Improving wellbeing of our population” recognises that “health and wellbeing make a significant contribution to life experiences and can be adversely affected by many factors, including mental…health.” This report identifies additional pressures that HSCM staff are now facing and that will need to be addressed if the LOIP priority is to be met. “Theme 2: Home First” of the Moray Integration Joint Board Strategic Plan “Moray Partners in Care 2019 – 2029” notes that older people very quickly lose their independence through loss of confidence and often reduced mobility when admitted to hospital. The current situation is causing people to be delayed in hospital and is likely to prevent some residents from functioning as they did prior to admission. (b) Policy and Legal None directly associated with this report. (c) Financial implications None directly associated with this report, although the cost of providing care packages may rise due to patients presenting with higher morbidity than previously. (d) Risk Implications and Mitigation The risks to the service from the pandemic, and the winter period, have been realised. The mitigation measures are discussed in the report. There continues to be a risk of harm to individuals who are not receiving support that has been identified they require and also for those awaiting to be assessed. (e) Staffing Implications Staffing levels, availability of staff and their health and wellbeing are core factors at the heart of this report. Support for staff continues to be a vital role for managers. Page 177
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(f) Property None directly arising from this report. (g) Equalities/Socio Economic Impact An Equality Impact Assessment is not required because there will be no impact, as a result of the report, on people with protected characteristics. However, it should be noted that Public Health Scotland have identified that people who live in poorer areas in Scotland are more likely to die early from disease and have more years of ill health, including mental wellbeing and depression. Although no data are available it is likely that the additional time spent in hospital waiting for suitable care packages to be put in place will have a greater impact on Moray residents from deprived areas. (h) Climate Change and Biodiversity Impacts No climate change or biodiversity implications have been determined for this policy/activity. (i) Directions None directly arising from this report. (j) Consultations Consultations have been undertaken with the following staff and their comments have been included where appropriate: Corporate Manager (HSCM) and Head of Service/Chief Social Work Officer. 6. CONCLUSION 6.1. Unmet need levels in Moray remain higher than pre-pandemic levels, both for the number of people affected and the hours of care required to be provided. The indications are that the worst may be over and the levels are gradually reducing. However, the recovery is fragile and could easily be reversed by another outbreak of COVID-19. 6.2. The statement made about the dedication of the Health and Social Care staff and their commitment to support their clients in the previous report bears repeating. They have been exceptional throughout the pandemic ensuring basic care continued to be provided. However, the long-term position on staffing and recruitment is less clear. HSCM will need to understand the long-term impact of COVID-19 on demand, the increasing number of elderly residents forecast for Moray, and a potentially frailer community. A strategic assessment of future staff numbers to meet demand, and an appropriate recruitment strategy is suggested. Author of Report: Carl Bennett, Senior Performance Officer Health and Social Care Moray Background Papers: Ref: Page 178
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APPENDIX 1 Care Homes Oversight Group Weekly Unmet Needs Report - Week ending: 13 February 2022 Page 179
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