Agenda Document Pack - Moray Integration Joint Board - 26/01/2023
Moray Council · 26 January 2023
Back to Moray Integration Joint Board — 26 January 2023 and its agenda
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Moray Integration Joint Board Thursday, 26 January 2023 Council Chambers NOTICE IS HEREBY GIVEN that a Meeting of the Moray Integration Joint Board, Council Chambers, Council Office, High Street, Elgin, IV30 1BX on Thursday, 26 January 2023 at 10:00 to consider the business noted below. AGENDA 1. Sederunt 2. Declaration of Member's Interests 3. Minute of Meeting of 24 November 2022 5 - 10 4. Action Log - 24 November 2022 11 - 12 5. Minutes of Committees for Noting 5a. Minutes of AP&R meeting of 30 June 2022 - am 13 - 14 5b. Minute of AP&R Meeting of 30 June 2022 - pm 15 - 18 5c. Minutes of AP&R meeting of 25 August 2022 19 - 20 5d. Minute of CCG Meeting of 25 August 2022 21 - 24 6. Chief Officer Report 25 - 32 7. Membership of Board and Committees 33 - 38 8. External Auditors Report to Those Charged with Governance Report 39 - 72 9. Audited Annual Accounts 2021-22 73 - 138 Page 1
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10. Aberdeenshire Hosted Services 139 - 154 11. Lossiemouth Locality Community Consultation 155 - 238 12. Moray Scheme of Integration Report 239 - 336 13. Recruitment Challenges and Opportunities in Moray 337 - 346 14. Reserves Policy Review 347 - 356 Page 2
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MORAY INTEGRATION JOINT BOARD SEDERUNT Mr Dennis Robertson (Chair) Councillor Tracy Colyer (Vice-Chair) Professor Siladitya Bhattacharya (Voting Member) Mr Derick Murray (Voting Member) Mr Sandy Riddell (Voting Member) Councillor Peter Bloomfield (Voting Member) Councillor John Divers (Voting Member) Councillor Scott Lawrence (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) Ms Jane Ewen (Non-Voting Member) Mr Stuart Falconer (Non-Voting Member) Mr Graham Hilditch (Non-Voting Member) Dr Paul Southworth (Non-Voting Member) Mrs Val Thatcher (Non-Voting Member) Mr Simon Bokor-Ingram (Non-Voting Member) Ms Sonya Duncan (Non-Voting Member) Ms Deborah O'Shea (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, 24 November 2022 Council Chambers, Council Office, High Street, Elgin, IV30 1BX PRESENT Mr Ivan Augustus, Professor Siladitya Bhattacharya, Councillor Peter Bloomfield, Mr Simon Bokor-Ingram, Mr Sean Coady, Councillor Tracy Colyer, Councillor John Divers, Ms Sonya Duncan, Mr Stuart Falconer, Mr Graham Hilditch, Councillor Scott Lawrence, Mr Derick Murray, Ms Deborah O'Shea, Mr Sandy Riddell APOLOGIES Mr Roddy Burns, Ms Karen Donaldson, Ms Jane Ewen, Professor Caroline Hiscox, Mr Dennis Robertson, Dr Paul Southworth, Mr Neil Strachan, Mrs Val Thatcher IN ATTENDANCE Also in attendance at the above meeting were the Interim Strategy and Performance Lead, Interim Chief Financial Officer, Mrs Laura Sutherland - Home First Programme Team, Lead Occupational Therapist, Mr Adam Coldwells, Director of Strategy and Deputy Chief Executive, Mrs Tracey Sutherland, Committee Services Officer. 1. Chair The meeting was chaired by Councillor Tracy Colyer. 2. Order of Business The Chair advised the Board that Item 15 on the agenda had been withdrawn. 3. Declaration of Member's Interests Councillor Divers declared that he was an unpaid carer, however advised that he had sought advice and would remain in the meeting during the discussion of the Draft Strategy for Unpaid Carers as this did not preclude him from the consideration of the item. Item 3. Page 5
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The Board noted that there were no other declarations noted. 4. Minute of meeting of 29 September 2022 The minute of the meeting of 29 September 2022 was submitted and agreed as an accurate record of the meeting. 5. Action Log - 29 September 2022 The Action Log of the meeting of 29 September 2022 was discussed and updated accordingly. Mr Riddell raised concerns about the transparency of discussing Staffing Pressures at a Development Session and felt that given the coverage in the press nationally and the impact the pressures have on people's lives it is important that the Board can give assurances to the public on the measures being put in place to lessen the impact. In response, the Chief Officer confirmed that a report can be brought to the next meeting of the Board following the development session to allow the discussion to take place in a public forum. 6. Dr Grays Hospital Strategy Report A report by the Chief Officer informed the Board of the current progress in the development of a strategy for Dr Gray's Hospital in Elgin, Moray as part of NHS Grampian's overall strategy plan for the future. Following consideration the Board agreed to note the progress on the development of a strategy. 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. Councillor Bloomfield sought clarification on the increased figures for non consent for pupils included in the Schools Vaccination Programme and the possible reasons for the lower uptake. In response, the Chief Officer confirmed that he did not have the figures or reasons at hand, but would provide them following the meeting. 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 a focus on key objectives as we mobilise from the Covid-19 pandemic, along with a look ahead as the IJB continue to develop its strategic planning. Page 6
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Sean Coady, Head of Service joined the meeting during the consideration of this item. 8. Moray Integration Joint Board Revenue Budget Qtr 2 2022-23 Report A report by the Interim Chief Financial Officer updated the Board on the current Revenue Budget reporting position as at 30 September 2022 and provide a provisional forecast position for the year end for the Moray Integration Joint Board budget. The Interim Chief Officer apologised to the Board and advised that there was an error in the recommendations at 2.1 (ii) and it should read, note the provisional forecast position for 2022/23 of an overspend of £3,156,966. She further added that the table at para 3.3 was also incorrect and would circulate the amended table and appendix following the meeting. Following consideration the Board agreed to: i) note the financial position of the board as at 30 September 2022 is showing an overall overspend of £1,454,162; ii) note the provisional forecast position for 2022/23 of an overspend of £3,156,966; iii) note the progress against the approved savings plan in paragraph 6, and update on Covid-19 and additional funding in paragraph 8; iv) note the revisions to staffing arrangements dealt with under delegated powers and in accordance with financial regulations within the Council and NHS Grampian for the period 1 July to 30 September 2021 as shown in Appendix 3; and v) approve for issue, the Directions arising from the updated budget position shown in Appendix 4. 9. Draft Strategy for Unpaid Carers in Moray 2023-26 A report by the Lead Officer for Carers presented a draft Health and Social Care Moray Carers Strategy 2023-26 and sought approval to consult with stakeholders on the draft strategy. Following consideration the Board agreed: i) to note the draft all-ages strategy for unpaid carers in Moray (Appendix 1) ii) to note the engagement work that has taken place to date (Appendix 2) iii) that as the strategy covers young carers, it will be presented to Moray Council's Education, Chidlren's and Leisure Services Committee on 14 December 2022 for comment; iv) that the draft strategy is published for consultation in January 2023; and v) to instruct the Lead Officer for Carers to present the final version of the strategy at the meeting of the Board on 30 March 2023 for approval prior to it being launched in April 2023. Page 7
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10. Home First in Moray Report A report by the Head of Service provided the Board with an update on the current status and priorities for Home First in Moray. Following consideration the Board agreed: i) to note the progress towards delivering the identified aims for Home First in Moray and that this programme should remain a priority activity to meet the objectives of the Strategic Plan; and ii) that further reports will be brought to the Board as specific decisions are required. 11. Home First Discharge to Assess Report A report by the Head of Service updated the Board on the impact of Discharge to Assess (D2A) on system flow and capacity across the Moray Health and Social Care portfolio. Following consideration the Board agreed to note: i) the performance evaluation of the D2A Service with an emphasis on impact across system flow and capacity; and ii) the actins identified in section 4 as an update on progress as requested by the Board on 26 May 2022. 12. Moray Integration Joint Board Meeting Dates 2023-24 A report by the Corporate Manager asked the Board to consider future arrangements for holding meetings of the Board, Audit, Performance and Risk Committee and the Clinical and Care Governance Committee going forward and to agree the meeting dates for 2023/24. Following consideration the Board agreed the schedule of meetings for MIJB, Audit Performance and Risk and Clinical and Care Governance Committees for 2023/24. 13. Public Sectors Climate Change Duties Reporting 2021-22 A report by the Chief Officer presented the draft Moray Integration Joint Board Climate Change Duties Report submission for 2021/22. Following consideration the Board agreed to approve the draft submission to Sustainable Scotland Network (Appendix 1) for the reporting year 2021/22. 14. Strategic Plan Report A report by the Interim Strategy and Planning Lead informed the Board on the developments of the revised Strategic Plan 2022-2032. Page 8
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Following consideration the Board agreed: i) the revised IJB Strategic Plan 2022-32 ii) to delegate authority to Officers to action minor amendments to the Plan; and iii) to endorse the Moray Wellbeing Pledge. 15. Moray Winter Surge Action Plan 2022-23 A report by the Chief Officer informed the Board of the Health and Social Care Moray Winter/Surge Action Plan for 2022/23. Mr Riddell sought clarification on what the leadership oversight arrangements are for the plan and could updates be included in the Chief Officer reports to the Board. In response, the Chief Officer confirmed that he would be happy to include leadership oversight arrangements for the plan in his report going forward. Following consideration the Board agreed to note: i) that Health and Social Care Moray, including GMED (the NHS out of hours service) have robust and deliverable plans in place to manage the pressures of surge at any time of the year including the festive period; and ii) that the Moray Winter/Surge Action Plan 2022/23 has been submitted to the NHS Grampian for inclusion in the Grampian Health and Social Care Winter (Surge) Plan. 16. Delegation of Children and Families and Justice Social Work to MIJB Report This item was withdrawn. 17. Moray Annual Performance Report 2021-22 A report by the Chief Officer presented the Board with the draft Annual Performance Report 2021/22. Following consideration the Board agreed to: i) note the draft Annual Performance report 2021/22 at Appendix 1; and ii) approve the publication of the Annual Performance Report 2021/22 by 30 November 2022. 18. Health and Social Care Moray - Annual Complaints Report 2021-22 A report by the Corporate Manager provided the Board with the Health and Social Care Moray Annual Complaints Report for 2021/22. Page 9
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Following consideration the Board agreed to: i) note the contents of the annual report; and ii) approve the annual report for publication on the Health and Social Care Moray website. 19. Civil Contingencies Resilience Assurance Report A report by the Corporate Manager provided the board with the first annual assurance report on the Moray Integration Joint Board's resilience arrangements in fulfilling its duties as a Category 1 responder under the Civil Contingencies Act 2004. Following consideration the Board agreed to note the progress to date and note the risk highlighted in this report and the contents of this report alongside the Health and Social Care Moray Civil Contingencies Group Action Plan (Appendix 1). Page 10
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MEETING OF MORAY INTEGRATION JOINT BOARD Thursday 24 November 2022 ACTION LOG ITEM NO. TITLE OF REPORT ACTION REQUIRED DUE DATE ACTION BY UPDATE FOR 26 JANUARY 2022 1. Lossiemouth Locality Community Engagement Final report to be submitted summarising the outcomes of the public consultation and seeking agreement to proceed with recommendations. January 2023 Locality Manager Additional time required due to impact of Omicron wave – to be reported in January 2023 along with final report Scheduled 2. 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 3. Reserves Policy Review Next review will be no later than March 2023 March 2023 Chief Financial Officer Scheduled 4. Chief Officer Report Brief to be drafted on current recruitment pressures and how the IJB are attempting to recruit and retain staff. Mid November 2022 Chief Officer Brief to focus initially on recruitment to social care 5. Locality Planning Update Local Councillors to be invited to meet with Locality Managers – progress update at January IJB January 2023 Locality Manager Scheduled Item 4. Page 11
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ITEM NO. TITLE OF REPORT ACTION REQUIRED DUE DATE ACTION BY UPDATE FOR 26 JANUARY 2022 6. Action Log – 29 September 2022 A report to be brought to IJB following the Development Session on Staffing Pressures within HSCM. Chief Officer 7. Chief Officer Report Reasons for the increased non consent for pupils included in the Schools Vaccination Programme to be circulated Chief Officer 8. Moray Winter Surge Action Plan 2022-23 A section in the Chief Officer report to be included on the leadership oversight arrangements for the plan Chief Officer Page 12
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MINUTE OF MEETING OF THE AUDIT, PERFORMANCE AND RISK COMMITTEE Thursday, 30 June 2022 Remote Locations via Video Conference, PRESENT Simon Bokor-Ingram, Councillor John Divers, Councillor Scott Lawrence, Mr Steven Lindsay, Mr Derick Murray, Jeanette Netherwood, Mr Sandy Riddell APOLOGIES Mr Sean Coady, Ms Jane Mackie, Mr Neil Strachan IN ATTENDANCE Also in attendance were the Interim Chief Financial Officer, Internal Audit Manager and Tracey Sutherland, Committee Services Officer. 1. Welcome and Apologies Sandy Riddell as Chair of the meeting welcomed everyone and apologies were noted. 2. Declaration of Member's Interests There were no declarations of Members' Interest in respect of any item on the agenda. 3. Unaudited Annual Accounts Report A report by the Interim Chief Financial Officer informed the Committee of the Unaudited Accounts of the Moray Integration Joint Board (MIJB) for the year ended 31 March 2022. Item 5a. Page 13
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Mr Riddell explained to the Committee that due to timings, the special meeting had been called to allow the Committee to consider the unaudited accounts prior to the consideration by the main Integration Joint Board. Following consideration the Committee agreed: i) 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. Page 14
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MINUTE OF MEETING OF THE AUDIT, PERFORMANCE AND RISK COMMITTEE Thursday, 30 June 2022 remote locations via video conference, PRESENT Simon Bokor-Ingram, Mr Sean Coady, Councillor John Divers, Councillor Scott Lawrence, Mr Derick Murray, Jeanette Netherwood, Mr Sandy Riddell APOLOGIES Mr Steven Lindsay, Ms Jane Mackie, Mr Neil Strachan IN ATTENDANCE Also in attendance were Interim Chief Financial Officer, Internal Audit Manager and Tracey Sutherland, Committee Services Officer. 1. Welcome and Apologies Sandy Riddell as Chair of the meeting welcomed everyone to the meeting and apologies were noted. 2. Declaration of Member's Interests Mr Riddell declared that he is Chair of the Mental Welfare Commission, there were no further declarations. 3. Minute of Meeting of 31 March 2022 The minute of the meeting of 31 March 2022 was submitted and approved. 4. Action Log of Meeting of 31 March 2022 The Action Log of the meeting of 31 March 2022 was considered and updated accordingly. Item 5b. Page 15
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5. Quarter 4 Performance Report A report by the Corporate Manager updated the Committee on performance as at Quarter 4 (January to March 2022) Mr Riddell expressed concern about the increase in staff absences, particularly within Moray Council. In response, the Corporate Manager assured him that managers are following the appropriate sickness procedures within each organisation. Following consideration, the Committee agreed to note: i) the performance of local indicators for Quarter 4 (January to March 2022) as presented in the Performance Report at APPENDIX 1; ii) the analysis of the local indicators that have been highlighted and actions being undertaken to address performance that is outside of acceptable target ranges as detailed in APPENDIX 1; iii) the performance of the indicators reported to the Ministerial Strategic Group (MSG) for Health and Community Care (latest published data) as presented at APPENDIX 2; and iv) the performance of the Health and Social Care Integration: core indicators for the reporting year 2021/22 as presented at APPENDIX 3. 6. Internal Audit Completed Projects A report by the Chief Internal Auditor provided an update on audit work completed since the last meeting of the Committee. Following consideration the Committee agreed to note the audit update. 7. Internal Audit Annual Report 2021-22 A report by the Chief Internal Auditer provided the Committee with details of internal audit work undertaken relative to the Moray Integration Joint Board (MIJB) for the financial year ended 31 March 2022, and the assurances available on which to base the internal audit opinion on the adequacy of the MIJB’s systems of internal control. Following consideration the Committee agreed to note the contents of the annual report given as Appendix 1 to the report. 8. Strategic Risk Register Report A report by the Chief Officer, Health and Social Care, provided an overview of the current strategic risks, along with a summary of actions which are in place to mitigate those risks, updated June 2022. Following consideration the Committee agreed to: i) note the updated Strategic Risk Register included in APPENDIX 1; and ii) note the Strategic Risk Register will be further refined to align with the transformation and redesign plans as they evolve. Page 16
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MINUTE OF MEETING OF THE AUDIT, PERFORMANCE AND RISK COMMITTEE Thursday, 25 August 2022 Council Chambers, Council Office, High Street, Elgin, IV30 1BX PRESENT Simon Bokor-Ingram, Mr Sean Coady, Councillor John Divers, Mr Graham Hilditch, Councillor Scott Lawrence, Mr Derick Murray, Deborah O'Shea, Mr Sandy Riddell APOLOGIES Sonya Duncan, Mr Steven Lindsay, Ms Jane Mackie, Mr Neil Strachan IN ATTENDANCE Also in attendance were the Chief Internal Auditor and Tracey Sutherland, Committee Services Officer. 1. Welcome and Apologies Sandy Riddell as Chair of the meeting welcomed everyone and apologies were noted. 2. Declaration of Member's Interests Mr Riddell declared that he is Chair of the Mental Welfare Commission. There were no other declarations of Members' interests in respect of any items on the agenda. 3. Minutes of meeting of 30 June 2022 - am The minute of the meeting of 30 June 2022 was submitted and approved. 4. Minute of Meeting of 30 June 2022 - pm The minute of the meeting of 30 June 2022 was submitted and approved. Item 5c. Page 19
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5. Action Log of Meeting of 30 June 2022 The Action Log of the meeting of 30 June 2022 was considered and updated accordingly. 6. Quarter 1 Performance Report A report by the Corporate Manager updated the Committee on performance as at Quarter 1 (April to June 2022) Following consideration the Committee agreed to note: i) the performance of local indicators for Quarter 1 (April to June 2022) as presented in the Performance Report as at Appendix 1; and ii) the analysis of the local indicators that have been highlighted and actions being undertaken to address performance that is outside of acceptable target ranges as detailed in Appendix 1. 7. Internal Audit Section - Update Report A report by the Chief Internal Auditor provided the Committee with an update on progress against the 2022/23 Audit Plan. Following consideration the Committee agreed to note the audit update. 8. Strategic Risk Register Report A report by the Chief Officer provided the Committee with an overview of the current strategic risks, along with a summary of actions which are in place to mitigate those risks, updated August 2022. Following consideration the Committee agreed to: i) note the updated Strategic Risk Register included in Appendix 1; and ii) note the Strategic Risk Register will be further refined to align with the transformation and redesign plans as they evolve. 9. Internal Audit Section - Completed Projects Report A report by the Chief Internal Auditor provided the Committee with an update on audit work completed since the last meeting of the Committee. Following consideration the Committee agreed to note the audit update. Page 20
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MINUTE OF MEETING OF THE CLINICAL AND CARE GOVERNANCE COMMITTEE Thursday, 25 August 2022 Council Chambers, Council Office, High Street, Elgin, IV30 1BX PRESENT Professor Siladitya Bhattacharya, Mr Simon Bokor-Ingram, Mr Sean Coady, Mr Graham Hilditch, Councillor Scott Lawrence, Mr Derick Murray, Ms Samantha Thomas, Councillor Kathleen Robertson (for Councillor Peter Bloomfield) APOLOGIES Mr Ivan Augustus, Councillor Peter Bloomfield, Ms Karen Donaldson, Ms Sonya Duncan, Ms Jane Ewen, Ms Jane Mackie, Ms Deborah O'Shea, Mr Neil Strachan, Mrs Val Thatcher IN ATTENDANCE Also in attendance at the above meeting were Sammy Robertson, Consultant Practitioner, Chris Wiles, Consultant Clinical Psychologist, Laura Sutherland, Acting Locality Manager/Home First Programme Lead, Alison Smart, Service Manager and Tracey Sutherland, Committee Services Officer. 1. Chair The meeting was chaired by Mr Derick Murray. 2. Welcome and Apologies The Chair welcomed everyone to the meeting and apologies were noted. Item 5d. Page 21
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3. Declaration of Member's Interests There were no declarations of Members' Interests in respect of any item on the agenda. 4. Minute of Meeting of 26 May 2022 The minute of the meeting of 26 May 2022 was submitted and approved. 5. Action Log - 26 May 2022 The Action Log for the meeting of 26 May 2022 was discussed and updated. 6. Complaints Report Quarter 1 A report by the Chief Nurse informed the Committee of complaints reported and closed during Quarter 1 (1 April 2022 - 30 June 2022). Following consideration the Committee agreed to: i) note the totals, lessons learned, response times and action taken for complaints completed within the last quarter; and ii) note that a draft Health and Social Care Moray (HSCM) Annual Complaints Report for 2021/22 will be presented tot he October meeting. 7. Clinical and Care Governance Group Escalation Q1 Report A report by the Chief Nurse informed the Committee of progress and exceptions reported to the Clinical and Care Governance Group during quarter 1 of 2022/23 (1 April to 30 June 2022). Following consideration the Committee agreed to note the contents of the report. 8. Out Of Hours Mental Health Service Provision for 16 to 18 year olds A report by the Service Manager, Child and Adolescent Mental Health Services (CAMHS) updated the Committee on progress towards addressing the previous gaps in out-of-hours mental health service provision for young people aged 16-18 years in Moray, the current risk mitigation plan and longer terms plans. Following consideration the Committee agreed: i) to note the contents of this update report; and ii) agreed that a further update report should be presented to the next meeting. 9. Three Conversations Approach A report by the Head of Service/Chief Social Work Officer informed the Committee of progress made regarding the initial implementation of the Three Conversation Model within Health and Social Care Moray (HSCM). Page 22
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Following consideration the Committee agreed to note: i) the impact of the implementation of the Three Conversations Approach thus far; and ii) the future plans and next steps for this approach in Moray. 10. Unmet Need Report A report by the Head of Service/Chief Social Work Officer updated the Committee on the current position on unmet need within Health and Social Care Moray (HSCM). Following consideration the Committee agreed to: i) note the current situation within HSCM and the mitigation actions that have been introduced; ii) note the continuing additional pressures placed upon HSCM staff; and iii) recognise the fragility of any improvements and the long term impact on staff. 11. Strategic Risk Register Report A report by the Chief Officer provided the Committee with an overview of the current strategic risks, along with a summary of actions which are in place to mitigate those risks, updated August 2022. Following consideration the Committee agreed to note: i) note the updated Strategic Risk Register included as Appendix 1; and ii) the Strategic Risk Register will be further refined to align with the transformation and redesign plans as they evolve. 12. Items for Escalation to MIJB The Chair proposed escalating the Unmet Need Report to the Moray Integration Joint Board as it is an ongoing issue. In response the Chief Officer, suggested that whilst this persists that there is coverage in his Chief Officer Report to provide a regular update on the Unmet Needs situation. The Committee agreed that this would be a good resolution. Page 23
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REPORT TO: MORAY INTEGRATION JOINT BOARD ON 26 JANUARY 2023 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. 1.2 Strategic planning needs to maintain a focus on transformational change to deliver services to our community within the resources we have available. 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-19 pandemic, along with a look ahead as we continue to develop our strategic planning. 3. BACKGROUND Home First and Hospital without Walls 3.1 Work continues to develop the Home First portfolio of projects with a focus on ensuring projects are sustainable, scalable and meet the strategic objectives of HSCM. A minor revision will see the portfolio broadened ensuring it emphasises a whole system approach with work stream specific key performance indicators (KPIs) a requirement going forward. Recent efforts have also concentrated on tackling delayed discharges, with a two-phase plan currently in operation, phase 1 completed in October (to reduce Delayed Discharges to March 2022 levels). Phase 2 is underway (to reduce delayed Item 6. Page 25
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discharges to 10 or below).Hospital without Walls continues to be developed and there will be opportunities for testing new concepts within the framework of the Moray Growth deal and specifically with the Digital Health and Care Innovation Centre. There are also opportunities for concept testing through non-recurrent funding agreed through the NHS Grampian Unscheduled Care Programme Board, with GMED planning a trial of in hours support to primary care in Moray due to commence January 2023. Remobilisation and winter planning 3.2 To date the healthcare system has responded to 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 significant 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, other pressures remain. Demand for unscheduled hospital care has not diminished, and Dr Gray’s 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 Gray’s as soon as beds are available. A risk of high staff absence continues as flu and Covid continue to circulate within communities. 3.4 Waiting times for inpatient elective surgical procedures at Dr Gray's Hospital continue to increase during the post pandemic period. A combination of continued higher than desirable volumes of delayed transfers of care, plus an incident in our theatre suite on the 10 August 2022 that has only recently been resolved, has meant that most inpatient elective surgery has been cancelled for a period of time. As we now look to ramp up the levels of elective activity that will need to be managed alongside significant bed occupancy for emergency medicine. 3.5 The significant pressure on Social work/Social care continues with limited signs of any sustained improvement. Homecare staff consistently have absence rates of over 8% and some weeks more than 10%. The internal home care service is successfully recruiting staff, but these gains are offset by numbers of staff leaving. The backlog of social care (the weekly number of people awaiting assessments is consistently between 150 and 165) and inability to meet demand, with over 1,100 unmet care hours, is resulting in family carers having to shoulder an increased burden, and in its turn this leads to high demand for carer support, combined with concern from community members at levels of unmet need. The inability to meet care needs also impacts upon our ability to reduce delays from hospital. The sustained pressure on care staff is impacting on the quality of care that some providers can deliver. Interim care beds, designed to increase movement within the system, are monitored daily. 3.6 There has been extensive planning for winter, and for over the festive season, with the IJB approving surge plans at its November 2022 meeting. These have been put into use, and early on in 2023 we will start to evaluate the effectiveness of the plans, in order to refine current plans and learn any Page 26
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lessons. The period over Christmas and New Year saw significant pressure at the front door of Dr Gray’s Hospital, with demand in excess of predictions. High patient acuity led to increased lengths of stay. Surge beds remain open in Dr Gray’s Hospital and the community hospitals. Our planning and the response to pressures is scrutinised by the senior management team within the Portfolio. The NHS Grampian daily system connect (meeting at least twice daily) evaluates the daily updates from each Portfolio on how they are responding to the escalation plan, with specific actions described for Moray. The weekly NHS Grampian Chief Executive Team meeting has an overview of the whole system and directs any further response that is needed. COVID VACCINATION PROGRAMME Schools 3.7 Pupils have never been vaccinated with Covid vaccines within school premises, only the flu vaccine (Education Board request). While there have been more flu non consents this year (1079) than in the previous year (992), the (flu) programme went well with 76% vaccinated in school. It is believed that the majority of non-consents were due to vaccine fatigue. School staff, who were in an eligible cohort, could receive both the flu and Covid vaccines within the school premises, with an uptake 67.8%. This cohort was completed at the beginning of December, due to rescheduling with the strikes causing school closures. Opportunities to receive the nasal flu vaccine will be offered in the Centre until the end of January, or in local participating Pharmacies. Care Homes (583 individuals) 3.8 This cohort was completed within the first few weeks of the Programme beginning, with very few people not being able to be vaccinated at that point, due to the time frame of 12 weeks, since last vaccination, not being reached yet. A follow up service for those who were not yet eligible has been provided, and this has now been completed. We have had minimal non consents - less than in previous years. We have also provided 1st doses for people who have recently moved into a care home. Care home uptake is 92.6%. This cohort has now been completed, but we will still offer the vaccine to those who move into a care home who have not yet been vaccinated. Care home staff have also been offered their vaccines during our visits. Housebound Residents (1221 individuals) 3.9 This is a large cohort in respect of time and distance to be travelled. We were contacting people first to ascertain their housebound status and reduce unnecessary visits, thus managing to reduce this from 1717 individuals. We have had a good uptake with only 2.1% not consenting to receiving the vaccines so far, with 97.9% of those on our list having now received their vaccine. The remaining percentage have been postponed, due to illness or timings from previous vaccine. We have also came across people who are needing more support, so have been liaising with GPs and Quarriers. This cohort is completed, except for those postponed, as explained above. Page 27
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Health and Care Workforce (5722 individuals) 3.10 There were extensive communications to encourage people to come forward for vaccination, prior to the start of the Autumn/Winter Programme and throughout. However, there has been a poor uptake of 40.2% NHS staff and 20% Social Care staff. We had two Community Treatment and Care (CTAC) nurses delivering peer-to-peer vaccines within the GP Practices across Moray. They had a good response with over 100 people vaccinated. We have also provided 3 clinics at Dr Gray’s hospital in the Mobile Information Bus which proved more worthwhile. The health and care workforce cohort can attend the Fiona Elcock Vaccination Centre (FEVC) Mon-Sat 10-5 for vaccination until the end of March. No appointment is necessary. We are currently in talks with a community hospital that has a significantly low Healthcare Support Worker uptake, to agree a further visit for vaccinations. Over 80s (5719 individuals) 3.11 We commenced the over 80s cohort week starting 19 September 2022, with outreach venues and clinics within the FEVC, this has now been completed with a percentage uptake of 88.4%. Opportunities are still available for those who still wish the vaccine at FEVC. Other Groups 3.12 Over 65s (16673 individuals) has now been completed with an 85.5% uptake. At risk (12902 individuals) commenced 24 October 2022 with an uptake of 57.7% to date. Their household contacts were also eligible to receive the vaccines. Over 50s (14720 individuals) letters were sent with appointments available to book from 24th October 2022 with an uptake so far of 61.3%. Opportunity for vaccination will continue to be provided for all eligible cohorts, up until the end of March. 3.13 Recognition and huge thanks to the Vaccination Team for their continued work in relation to all eligible groups within the community to ensure an effective and accessible vaccination service supporting vaccination preventable disease and completion of the Autumn / Winter programme. Whilst the Health and Care Workforce uptake remained poor, the team worked hard to encourage vaccination and offered many opportunities to allow access to vaccination in order to support uptake. Asylum and Humanitarian Protection Schemes 3.14 The pressures associated with the various schemes have become particularly acute in recent months across Scotland, especially in relation to the Super Sponsorship Scheme for Ukrainians, the roll out of full dispersal model for Asylums, and the National Transfer Scheme for Unaccompanied Asylum- Seeking Children. 3.15 Moray continues to offer a Warm Scots Welcome to 115 Ukrainian Displaced Persons (UDPs). The arrival rate has steadied for Moray, with families settling into more permanent accommodation or continuing to be accommodated by host families across Moray. On 14 December 2022, the UK government announced that the tariff funding would be reduced from £10.5k to £5.9k for arrivals entering the UK after 01 January 2023. This does not pose any financial risk to the Local Authority. Guidance from Scottish Government has been created through collaborative work across the Ukrainian Resettlement Directorate. This guidance will support displaced Page 28
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people from Ukraine including information on visas, travel, accommodation, and life in Scotland. This is due for publication early 2023. This will complement the local data handbook in circulation for Ukrainians who reside in Moray. 3.16 In addition, the roll out of full dispersal for Asylum Seekers in Scotland is being overseen by a Local Government-led Asylum Partnership Board (APB). This is currently being expanded to involve strategic leads from all 32 councils. It is proposed that the conversations with Mears and the Home Office about the detail of widening dispersal in each local authority area will take place at a ‘regional level’ across Scotland based on the Housing Options Hub model. These meetings will be coordinated by COSLA and progress reported back to the APB. At a UK level, a new Asylum and Resettlement Council Senior Engagement Group (ARCSEG) is seeking to bring coherence to asylum dispersal and the other UK Government-led schemes. Chief Officer, Glasgow City HSCP chairs the former and is the Scottish representative on the latter, with support from COSLA on both. The Refugee Resettlement Team are refocusing to identify the support and requirements for this model. Members will be briefed on any developments pertinent to Moray when further information is available. 3.17 Through the National Transfer Scheme for Unaccompanied Asylum- Seeking Children, Moray currently supports 6 young people and are awaiting the arrival of a further 2 in the next few weeks. The numbers of young people allocated to Moray via the National Transfer Scheme will continue to increase in line with the increasing numbers entering the United Kingdom. This will have significant resource implications for the local authority in relation to housing and support; it will also have an impact on other services such as health and education. Young people are currently accommodated either via a Supported Lodgings placement or dual occupancy accommodation provided via the Housing Department. With dual occupancy accommodation support is provided via social work staff. All Unaccompanied Asylum-Seeking Children via the National Transfer Scheme are supported with an allocated social worker from the Through Care and After Care Team (TCAC). There is a commitment to support these young people effectively and to help them establish settled and successful lives in the United Kingdom. Ward 4 anti-ligature work and installation of MRI scanner at Dr Gray’s Hospital 3.18 A dedicated workstream is in place to manage the programme of works on the Dr Gray’s hospital site that involves completing the anti-ligature work on Ward 4 alongside the planned installation of a MRI scanner on the hospital site. Both the anti-ligature work and the MRI installation will directly affect the ability of Ward 4 to maintain a safe environment for patients while the works are being carried out, and alternative accommodation on a temporary basis will need to be sourced. This is proving to be challenging and a key risk to the two pieces of work being able to commence. Dr Grays Strategy 3.19 A period of stakeholder engagement has begun to inform the strategic direction for the Plan for the Future for Dr Gray’s Hospital (2023-2033). After initial high level engagement to inform the process in June, staff workshops have been taking place in September and October, using a principal element Page 29
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of the Scottish Approach to Service Design Framework, otherwise known as the Double Diamond approach. This engagement has been extended during September to November to include patient and service users, partner organisations and the wider public. As engagement progresses, feedback is being grouped thematically, consulted upon and will inform the Plan for the Future’s strategic direction. Dr Gray’s Plan for the Future is expected to go to the NHS Grampian Board in February 2023 for approval. Further information can be found here: Plan For The Future - Dr Gray’s Hospital 2023-2033 (nhsgrampian.org). Portfolio arrangements 3.20 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 was a desire to transition from an organisational leadership and management model to a system leadership and management approach. The portfolio leadership arrangements continue to embed and mature. Further opportunities for the alignment of services around pathways will be led by the Chief Officer. 3.21 Two posts will become vacant at the start of 2023, being the Chief Nurse post and the Strategy and Planning Lead post. Both posts are being reviewed to ensure that succession arrangements meet the needs of the business. Both posts are covered on an interim basis. The role of designated Deputy Chief Officer is now uncovered following the departure of the previous incumbent to hold this role, and the Chief Officer is completing the process to identify a successor. 3.22 The Chief Finance Officer post continues to be covered on an interim basis. The Chief Officer is working with the Council Head of Finance to put in place arrangements which support a longer term interim arrangement. The arrangement will be reviewed in Quarter 1 of 2023/34. Budget Control 3.23 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 and report an ongoing balanced position for 2022/23 to the MIJB, savings will continue to be required to ensure sustainability in the years beyond. 3.24 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 particularly in preparation for entry to 2023/24. Page 30
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Payment Verification 3.25 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-19 pandemic. 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-19 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. 5. SUMMARY OF IMPLICATIONS (a) Corporate Plan and 10 Year Plan (Local Outcomes Improvement Plan (LOIP)) and Moray Integration Joint Board Strategic Plan “Partners in Care 2022 – 2032” 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-19 related supplier relief ends in June this year, and we will monitor Page 31
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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. (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 32
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REPORT TO: MORAY INTEGRATION JOINT BOARD ON 26 JANUARY 2023 SUBJECT: MEMBERSHIP OF BOARD AND COMMITTEES BY: CORPORATE MANAGER 1. REASON FOR REPORT 1.1. To inform the Board of changes to Membership. This is due to the appointment to the vacancies of Chief Social Work Officer, Non Primary Medical Services Lead and ongoing recruitment of the GP Vacancy. 2. RECOMMENDATION 2.1. It is recommended that the Moray Integration Joint Board (MIJB) notes the: i) confirmation of appointment of members to the Integration Joint Board; ii) confirmation of members to the Clinical and Care Governance Committee; and iii) updated membership of Board and committees attached at APPENDIX 1 3. BACKGROUND 3.1. At the meeting of the Board on 29 August 2019 (para 9 of the minute refers) the Board approved the rotation of Chair from a Council to a Health Board Member in October 2019. 4. KEY MATTERS RELEVANT TO RECOMMENDATION 4.1. Ms Tracy Stephen was appointed to the role of Chief Social Work Officer and commenced in post from October 2022. Ms Stephen also accepted the role of Clinical and Care Governance Committee member. 4.2. The Chief Social Work Officer has a defined role in professional and clinical and care leadership and has a key role in Clinical and Care Governance. The Chief Social Work Officer is responsible for providing professional leadership for social workers and staff in social work services. Item 7. Page 33
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4.3. Professor Duff Bruce was appointed to the role of Clinical Director and also accepted the role of Non Primary Medical Services Lead in December 2022. An induction will be organised for early 2023. Professor Bruce will also be a member of the Clinical and Care Governance Committee. 4.4. The recruitment process is progressing for the position of GP Lead. 5. SUMMARY OF IMPLICATIONS (a) Corporate Plan and 10 Year Plan (Local Outcomes Improvement Plan (LOIP)) and Moray Integration Joint Board Strategic Plan “Partners in Care 2022 – 2032” 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 the report is to inform the Board of changes required to membership of the Board and CCG Committee. (h) Climate Change and Biodiversity Impacts None arising from this report. (i) Directions None arising from this report. (j) Consultations Consultation on this report has taken place with Sean Coady, Head of Service, Nick Fluck, Medical Director and Simon Bokor-Ingram, Chief Officer, who are in agreement with the report. 6. CONCLUSION 6.1. This paper sets out the position in relation to the membership of MIJB. Page 34
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Author of Report: Sonya Duncan, Corporate Manager Background Papers: None Date: 9 January 2023 Page 35
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APPENDIX 1 Moray Integration Joint Board Vacancies – as at 9 January 2023 Moray Integration Joint Board 4 Council voting members Tracy Colyer (Vice-Chair) John Divers Peter Bloomfield Scott Lawrence 4 NHS Grampian voting members Dennis Robertson (Chair) Derick Murray Sandy Riddell Prof Siladitya Bhattacharya Third Sector Stakeholder Graham Hilditch NHS Grampian Staff Representative Stakeholder Member Stuart Falconer 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 Tracy Stephen Lead Nurse Jane Ewen GP Lead To be confirmed Non Primary Medical Services Lead Prof Duff Bruce 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 (Chair) 2 Health Board voting members Sandy Riddell Derick Murray Third Sector Stakeholder Graham Hilditch NHS Grampian Staff Representative Stakeholder Member Stuart Falconer Clinical and Care Governance Members 2 Council voting member Cllr Peter Bloomfield Cllr Scott Lawrence 2 Health Board voting member (Chair) Derick Murray (Chair) Prof Bhattacharya 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 Tracy Stephen Lead Nurse Jane Ewen GP Lead To be confirmed Non Primary Medical Services Lead Prof Duff Bruce Additional Member Dr Paul Southworth Item 7. Page 37
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REPORT TO: MORAY INTEGRATION JOINT BOARD ON 26 JANUARY 2023 SUBJECT: EXTERNAL AUDITORS’ REPORT TO THOSE CHARGED WITH GOVERNANCE BY: INTERIM CHIEF FINANCIAL OFFICER 1. REASON FOR REPORT 1.1 To request the Moray Integration Joint Board (MIJB) consider and note the reports to those charged with governance from the Board’s External Auditor for the year ended 31 March 2022. 2. RECOMMENDATION 2.1 It is recommended that the MIJB considers and notes the reports from the External Auditor within Appendices 1 and 2. 3. BACKGROUND 3.1 The responsibilities of Audit Scotland as the independent auditor are established by the Local Government (Scotland) Act 1973, the code of Audit Practice (2016), which can be found at https://www.audit- scotland.gov.uk/uploads/docs/report/2016/code_audit_practice_16.pdf and supplementary guidance, and are supported by the auditing profession’s ethical guidance. 4. KEY MATTERS RELEVANT TO RECOMMENDATION 4.1 The work carried out by Audit Scotland during 2021/22 has produced two reports that are subject to the consideration of those charged with governance. The reports are attached as follows: • Independent Auditors Report to those charged with governance (APPENDIX 1) • The Annual Audit Report 2021/22 (APPENDIX 2) 4.2 The audit opinions expressed were all unqualified and are reported within the ‘independent auditors report’ included within APPENDIX 1. 4.3 The Annual Audit Report included at APPENDIX 2 provides an Action Plan where recommendations for improvement are made, based on the findings of Item 8. Page 39
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the review. These recommendations have been discussed with management and corresponding actions have been agreed, together with timescales for completion. 4.4 The Annual Audit Report provides a summary of the significant audit risks identified during planning. The results and conclusions of this work are noted within the report. 5. SUMMARY OF IMPLICATIONS (a) Corporate Plan and 10 Year Plan (Local Outcomes Improvement Plan (LOIP)) and Moray Integration Joint Board Strategic Plan “Partners in Care 2022 – 2032” The work of the external auditor and the production of these reports for those charged with governance have been completed within the specified timescales agreed. (b) Policy and Legal The Public Bodies (Joint Working ) (Scotland) Act 2014 requires that the Moray Integration Joint Board (MIJB) is subject to the audit and accounts provisions of a body under Section 106 of the Local Government (Scotland) Act 1973. (c) Financial implications There are no direct financial implications arising from this report. (d) Risk Implications and Mitigation The external auditor, Audit Scotland, through the audit process, provides assurance to the Board that the Annual Accounts for 2020/21 give a true and fair view of the financial position. The Annual Audit Report highlights risks identified during the audit process and recommendations for action that have been agreed by management. (e) Staffing Implications None arising directly from this report. (f) Property None arising directly from this report (g) Equalities/Socio Economic Impact None arising directly from this report as there has been no resultant policy change. (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 Consultation has taken place between Audit Scotland and the Chief Financial Officer of the MIJB in preparation of the Annual Audit Report. Any comments received have been considered in writing this report. Page 40
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6. CONCLUSION 6.1 The External Auditor has issued an unqualified opinion for the 2021/22 Annual Accounts. The Annual Audit Report, Independent Auditors’ Report and the Letter of Representation present the full findings. Author of Report: Deborah O’Shea, Interim Chief Financial Officer Background Papers: with author Ref: Page 41
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102 West Port Edinburgh EH3 9DN 8 Nelson Mandela Place Glasgow G2 1BT The Green House Beechwood Business Park North Inverness IV2 3BL T: 0131 625 1500 E: info@audit-scotland.gov.uk www.audit-scotland.gov.uk Moray Integration Joint Board C/o Moray Council High street Elgin IV30 1BX 26 January 2023 Moray Integration Joint Board Audit of 2021/22 annual accounts Independent auditor's report 1. Our audit work on the 2021/22 annual accounts is now substantially complete. Subject to [the satisfactory conclusion of the outstanding matters referred to later in this letter and - delete if no outstanding matter] receipt of a revised set of annual accounts for final review, we anticipate being able to issue unqualified audit opinions in the independent auditor's report on 26 January 2023. The proposed report is attached at Appendix A. Annual audit report 2. Under International Standards on Auditing in the UK, we report specific matters arising from the audit of the financial statements to those charged with governance of a body in sufficient time to enable appropriate action. We present for the Integration Joint Board’s consideration our draft annual report on the 2021/22 audit. There are no significant findings from our audit of the financial statements to bring to your attention. 3. The report also sets out conclusions from our consideration of the four audit dimensions that frame the wider scope of public audit as set out in the Code of Audit Practice. 4. This report will be issued in final form after the annual accounts have been certified. Unadjusted misstatements 5. We also report to those charged with governance all unadjusted misstatements which we have identified during the course of our audit, other than those of a trivial nature and request that these misstatements be corrected. 6. We have no unadjusted misstatements to be corrected Fraud, subsequent events and compliance with laws and regulations 7. In presenting this report to the Audit Committee we seek confirmation from those charged with governance of any instances of any actual, suspected or alleged fraud; any subsequent events that have occurred since the date of the financial statements; or material non- compliance with laws and regulations affecting the entity that should be brought to our attention. APPENDIX 1 Item 8. Page 43
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Representations from Section 95 Officer 8. As part of the completion of our audit, we are seeking written representations from the Interim Chief Financial Officer on aspects of the annual accounts, including the judgements and estimates made. 9. A draft letter of representation is attached at Appendix B. This should be signed and returned to us by the Section 95 Officer with the signed annual accounts prior to the independent auditor’s report being certified. Page 44
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Appendix A: Proposed Independent Auditor’s Report Independent auditor’s report to the members of Moray Integration Joint Board and the Accounts Commission Reporting on the audit of the financial statements Opinion on financial statements I certify that I have audited the financial statements in the annual accounts of Moray Integration Joint Board for the year ended 31 March 2022 under Part VII of the Local Government (Scotland) Act 1973. The financial statements comprise the Comprehensive Income and Expenditure Statement, Movement in Reserves Statement, Balance Sheet and notes to the financial statements, including significant accounting policies. The financial reporting framework that has been applied in their preparation is applicable law and UK adopted international accounting standards, as interpreted and adapted by the Code of Practice on Local Authority Accounting in the United Kingdom 2021/22 (the 2021/22 Code). In my opinion the accompanying financial statements: • give a true and fair view in accordance with applicable law and the 2021/22 Code of the state of affairs of the body as at 31 March 2022 and of its income and expenditure for the year then ended; • have been properly prepared in accordance with UK adopted international accounting standards, as interpreted and adapted by the 2021/22 Code; and • have been prepared in accordance with the requirements of the Local Government (Scotland) Act 1973, The Local Authority Accounts (Scotland) Regulations 2014, and the Local Government in Scotland Act 2003. Basis for opinion I conducted my audit in accordance with applicable law and International Standards on Auditing (UK) (ISAs (UK)), as required by the Code of Audit Practice approved by the Accounts Commission for Scotland. My responsibilities under those standards are further described in the auditor’s responsibilities for the audit of the financial statements section of my report. I was appointed under arrangements approved by the Accounts Commission on 10 April 2017. The period of total uninterrupted appointment is six years. I am independent of the body in accordance with the ethical requirements that are relevant to my audit of the financial statements in the UK including the Financial Reporting Council’s Ethical Standard, and I have fulfilled my other ethical responsibilities in accordance with these requirements. Non-audit services prohibited by the Ethical Standard were not provided to the body. I believe that the audit evidence I have obtained is sufficient and appropriate to provide a basis for my opinion. Conclusions relating to going concern basis of accounting I have concluded that the use of the going concern basis of accounting in the preparation of the financial statements is appropriate. Page 45
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Based on the work I have performed, I have not identified any material uncertainties relating to events or conditions that, individually or collectively, may cast significant doubt on the body’s ability to continue to adopt the going concern basis of accounting for a period of at least twelve months from when the financial statements are authorised for issue. These conclusions are not intended to, nor do they, provide assurance on the body’s current or future financial sustainability. However, I report on the body’s arrangements for financial sustainability in a separate Annual Audit Report available from the Audit Scotland website. Risks of material misstatement I report in my Annual Audit Report the most significant assessed risks of material misstatement that I identified and my judgements thereon. Responsibilities of the Interim Chief Financial Officer and Moray Integration Joint Board for the financial statements As explained more fully in the Statement of Responsibilities, the Interim Chief Financial Officer is responsible for the preparation of financial statements that give a true and fair view in accordance with the financial reporting framework, and for such internal control as the Interim Chief Financial Officer determines is necessary to enable the preparation of financial statements that are free from material misstatement, whether due to fraud or error. In preparing the financial statements, the Interim Chief Financial Officer is responsible for assessing the body’s ability to continue as a going concern, disclosing, as applicable, matters related to going concern and using the going concern basis of accounting unless there is an intention to discontinue the body’s operations. The Moray Integration Joint Board is responsible for overseeing the financial reporting process. Auditor’s responsibilities for the audit of the financial statements My objectives are to obtain reasonable assurance about whether the financial statements as a whole are free from material misstatement, whether due to fraud or error, and to issue an auditor’s report that includes my opinion. Reasonable assurance is a high level of assurance, but is not a guarantee that an audit conducted in accordance with ISAs (UK) will always detect a material misstatement when it exists. Misstatements can arise from fraud or error and are considered material if, individually or in the aggregate, they could reasonably be expected to influence the decisions of users taken on the basis of these financial statements. Irregularities, including fraud, are instances of non-compliance with laws and regulations. I design procedures in line with my responsibilities outlined above to detect material misstatements in respect of irregularities, including fraud. Procedures include: • obtaining an understanding of the applicable legal and regulatory framework and how the body is complying with that framework; Page 46
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• identifying which laws and regulations are significant in the context of the body; • assessing the susceptibility of the financial statements to material misstatement, including how fraud might occur; and • considering whether the audit team collectively has the appropriate competence and capabilities to identify or recognise non-compliance with laws and regulations. The extent to which my procedures are capable of detecting irregularities, including fraud, is affected by the inherent difficulty in detecting irregularities, the effectiveness of the body’s controls, and the nature, timing and extent of the audit procedures performed. Irregularities that result from fraud are inherently more difficult to detect than irregularities that result from error as fraud may involve collusion, intentional omissions, misrepresentations, or the override of internal control. The capability of the audit to detect fraud and other irregularities depends on factors such as the skilfulness of the perpetrator, the frequency and extent of manipulation, the degree of collusion involved, the relative size of individual amounts manipulated, and the seniority of those individuals involved. A further description of the auditor’s responsibilities for the audit of the financial statements is located on the Financial Reporting Council's website www.frc.org.uk/auditorsresponsibilities. This description forms part of my auditor’s report. Reporting on other requirements Opinion prescribed by the Accounts Commission on the audited part of the Remuneration Report I have audited the part of the Remuneration Report described as audited. In my opinion, the audited part of the Remuneration Report has been properly prepared in accordance with The Local Authority Accounts (Scotland) Regulations 2014. Other information The Interim Chief Financial Officer is responsible for other information in the annual accounts. The other information comprises the Management Commentary, Annual Governance Statement, Statement of Responsibilities and the unaudited part of the Remuneration Report. My responsibility is to read all the other information and, in doing so, consider whether the other information is materially inconsistent with the financial statements or my knowledge obtained in the course of the audit or otherwise appears to be materially misstated. If I identify such material inconsistencies or apparent material misstatements, I am required to determine whether this gives rise to a material misstatement in the financial statements themselves. If, based on the work I have performed, I conclude that there is a material misstatement of this other information, I am required to report that fact. I have nothing to report in this regard. Page 47
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My opinion on the financial statements does not cover the other information and I do not express any form of assurance conclusion thereon except on the Management Commentary and Annual Governance Statement to the extent explicitly stated in the following opinions prescribed by the Accounts Commission. Opinions prescribed by the Accounts Commission on the Management Commentary and Annual Governance Statement In my opinion, based on the work undertaken in the course of the audit: • the information given in the Management Commentary for the financial year for which the financial statements are prepared is consistent with the financial statements and that report has been prepared in accordance with statutory guidance issued under the Local Government in Scotland Act 2003; and • the information given in the Annual Governance Statement for the financial year for which the financial statements are prepared is consistent with the financial statements and that report has been prepared in accordance with the Delivering Good Governance in Local Government: Framework (2016). Matters on which I am required to report by exception I am required by the Accounts Commission to report to you if, in my opinion: • adequate accounting records have not been kept; or • the financial statements and the audited part of the Remuneration Report are not in agreement with the accounting records; or • I have not received all the information and explanations I require for my audit. I have nothing to report in respect of these matters. Conclusions on wider scope responsibilities In addition to my responsibilities for the annual accounts, my conclusions on the wider scope responsibilities specified in the Code of Audit Practice, including those in respect of Best Value, are set out in my Annual Audit Report. Use of my report This report is made solely to the parties to whom it is addressed in accordance with Part VII of the Local Government (Scotland) Act 1973 and for no other purpose. In accordance with paragraph 120 of the Code of Audit Practice, I do not undertake to have responsibilities to members or officers, in their individual capacities, or to third parties. Brian Howarth ACMA CGMA Audit Director Audit Scotland Page 48
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Appendix B: Letter of Representation (ISA 580) Brian Howarth, Audit Director Audit Scotland 4th Floor 8 Nelson Mandela Place Glasgow G2 1BT 26 January 2023 Dear Brian Moray Integration Joint Board Annual Accounts 2021/22 1. This representation letter is provided in connection with your audit of the annual accounts of Moray Integration Joint Board for the year ended 31 March 2022 for the purpose of expressing an opinion as to whether the financial statements give a true and fair view in accordance with the financial reporting framework, and for expressing other opinions on the remuneration report, management commentary and annual governance statement. 2. I confirm to the best of my knowledge and belief and having made appropriate enquiries of the Chief Officer and Senior Management Team, the following representations given to you in connection with your audit of Moray Integration Joint Board's annual accounts for the year ended 31 March 2022. General 3. Moray Integration Joint Board and I have fulfilled our statutory responsibilities for the preparation of the 2021/22 annual accounts. All the accounting records, documentation and other matters which I am aware are relevant to the preparation of the annual accounts have been made available to you for the purposes of your audit. All transactions undertaken by Moray Integration Joint Board have been recorded in the accounting records and are properly reflected in the financial statements. 4. I confirm that I am not aware of any uncorrected misstatements. Financial Reporting Framework 5. The annual accounts have been prepared in accordance with the Code of Practice on Local Authority Accounting in the United Kingdom 2021/22 (2021/22 Code), mandatory guidance from LASAAC, and the requirements of the Local Government (Scotland) Act 1973, the Local Government in Scotland Act 2003 and The Local Authority Accounts (Scotland) Regulations 2014. 6. In accordance with the 2014 regulations, I have ensured that the financial statements give a true and fair view of the financial position of the Moray Integration Joint Board at 31 March 2022 and the transactions for 2021/22. Page 50
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Accounting Policies & Estimates 7. All significant accounting policies applied are as shown in the notes to the financial statements. The accounting policies are determined by the 2021/22 Code, where applicable. Where the Code does not specifically apply, I have used judgement in developing and applying an accounting policy that results in information that is relevant and reliable. All accounting policies applied are appropriate to Moray Integration Joint Board’s circumstances and have been consistently applied. 8. The significant assumptions used in making accounting estimates are reasonable and properly reflected in the financial statements. Judgements used in making estimates have been based on the latest available, reliable information. Estimates have been revised where there are changes in the circumstances on which the original estimate was based or as a result of new information or experience. Going Concern Basis of Accounting 9. I have assessed Moray Integration Joint Board's ability to continue to use the going concern basis of accounting and have concluded that it is appropriate. I am not aware of any material uncertainties that may cast significant doubt on Moray Integration Joint Board's ability to continue as a going concern. Fraud 10. I have provided you with all information in relation to • my assessment of the risk that the financial statements may be materially misstated as a result of fraud • any allegations of fraud or suspected fraud affecting the financial statements • fraud or suspected fraud that I am aware of involving management, employees who have a significant role in internal control, or others that could have a material effect on the financial statements. Laws and Regulations 11. I have disclosed to you all known instances of non-compliance or suspected non- compliance with laws and regulations whose effects should be considered when preparing financial statements. Related Party Transactions 12. All material transactions with related parties have been appropriately accounted for and disclosed in the financial statements in accordance with the 2021/22 Code. I have made available to you the identity of all the Moray Integration Joint Board's related parties and all the related party relationships and transactions of which I am aware. Remuneration Report 13. The Remuneration Report has been prepared in accordance with the Local Authority Accounts (Scotland) Regulations 2014, and all required information of which I am aware has been provided to you. Page 51
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Management commentary 14. I confirm that the Management Commentary has been prepared in accordance with the statutory guidance and the information is consistent with the financial statements. Corporate Governance 15. I confirm that the Moray Integration Joint Board has undertaken a review of the system of internal control during 2021/22 to establish the extent to which it complies with proper practices set out in the Delivering Good Governance in Local Government: Framework 2016. I have disclosed to you all deficiencies in internal control identified from this review or of which I am otherwise aware. 16. I confirm that the Annual Governance Statement has been prepared in accordance with the Delivering Good Governance in Local Government: Framework 2016 and the information is consistent with the financial statements. There have been no changes in the corporate governance arrangements or issues identified, since 31 March 2022, which require to be reflected. Balance Sheet 17. All events subsequent to 31 March 2022 for which the 2021/22 Code requires adjustment or disclosure have been adjusted or disclosed. Yours sincerely Interim Chief Financial Officer Page 52
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Prepared for Moray Integration Joint Board and the Controller of Audit January 2023 Moray Integration Joint Board DRAFT 2021/22 Annual Audit Report APPENDIX 2 Item 8. Page 53
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Moray Integration Joint Board DRAFT 2021/22 Annual Audit Report | 2 Contents Key messages 3 Introduction 4 1. Audit of 2021/22 annual accounts 7 2. Financial management and sustainability 10 3. Governance, transparency, and Best Value 14 Appendix 1. Action plan 2021/22 17 Appendix 2. National reports and briefing papers 19 Page 54
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Key messages | 3 Key messages 2021/22 annual accounts 1 Our audit opinions on the annual accounts of the Moray Integration Joint Board are unmodified and there were no significant issues. Financial management and sustainability 2 The IJB reported an overall underspend of £10.7 million against a revised budget of £170.8 million. 3 Covid-19 funding of £11.7 million was received in 2021/22; £6.7 million was unspent at 31 March 2022 and is included in reserves 4 Medium term financial plans were updated during 2021/22. The IJB is projecting a budget deficit of £12.1 million over the period from 2023-27. Governance, Transparency and Best Value 5 The IJB has yet to develop processes to evaluate and measure Best Value 6 The IJB effectively monitors performance and indicators show mixed performance Page 55
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Key messages | 4 Introduction 1. This report summarises the findings arising from the 2021/22 audit of Moray Integration Joint Board (the IJB). 2. The scope of the audit was set out in our 2021/22 Annual Audit Plan which was presented to the Board on 26 May 2022. 3. This report comprises the findings from: • the audit of the Moray IJB’s annual accounts • consideration of the four audit dimensions that frame the wider scope of public audit set out in the Code of Audit Practice 2016 • a review of the arrangements put in place by the IJB to secure Best Value. 4. The global coronavirus pandemic has had a considerable impact on the IJB during 2021/22. We did not identify any significant audit risks related to the pandemic for 2021/22. Adding value through the audit 5. We add value to the IJB, through the audit by: • identifying and providing insight on significant risks, and making clear and relevant recommendations • sharing intelligence and good practice through our national reports (Appendix 2) and good practice guides • providing clear and focused conclusions on the appropriateness, effectiveness and impact of corporate governance, performance management arrangements and financial sustainability. Responsibilities and reporting 6. The IJB has primary responsibility for ensuring the proper financial stewardship of public funds. This includes preparing annual accounts that are in accordance with proper accounting practices. The IJB is also responsible for compliance with legislation and putting arrangements in place for governance and propriety that enable it to successfully deliver its objectives. 7. Our responsibilities as independent auditor appointed by the Accounts Commission are established by the Local Government in Scotland Act 1973, the Page 56
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Key messages | 5 Code of Audit Practice 2016 and supplementary guidance, and International Standards on Auditing in the UK. 8. As public sector auditors we give independent opinions on the annual accounts. Additionally, we conclude on: • the effectiveness of the IJB’s performance management arrangements, • the suitability and effectiveness of corporate governance arrangements, • the financial position and arrangements for securing financial sustainability, and • Best Value arrangements. 9. Further details of the respective responsibilities of management and the auditor can be found in the Code of Audit Practice 2016. and supplementary guidance. 10. This report raises matters from our audit. Weaknesses or risks identified are only those which have come to our attention during our normal audit work and may not be all that exist. Communicating these does not absolve management from its responsibility to address the issues we raise and to maintain adequate systems of control. 11. Our annual audit report contains an agreed action plan at Appendix 1 setting out specific recommendations, responsible officers, and dates for implementation. It also includes outstanding actions from last year and the steps being taken to implement them. Auditor Independence 12. Auditors appointed by the Accounts Commission or Auditor General must comply with the Code of Audit Practice and relevant supporting guidance. When auditing the financial statements auditors must comply with professional standards issued by the Financial Reporting Council and those of the professional accountancy bodies. 13. We can confirm that we comply with the Financial Reporting Council’s Ethical Standard. We can also confirm that we have not undertaken any non- audit related services and the 2021/22 audit fee of £27,960 as set out in our 2021/22 Annual Audit Plan remains unchanged. We are not aware of any relationships that could compromise our objectivity and independence. 14. This report is addressed to both the IJB and the Controller of Audit and will be published on Audit Scotland's website www.audit-scotland.gov.uk. Audit appointment from 2022/23 15. The Accounts Commission is responsible for the appointment of external auditors to local government bodies. External auditors are usually appointed for a five-year term either from Audit Scotland’s Audit Services Group or a private firm of accountants. The current appointment round was due to end in 2020/21 Page 57
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Key messages | 6 but this was extended for a year so that 2021/22 is the last year of the current appointment round. 16. The procurement process for the new round of audit appointments was completed in May 2022. From financial year 2022/23 Grant Thornton will be the appointed auditor for Moray Integration Joint Board. We are working closely with the new auditors to ensure a well-managed transition. 17. We would like to thank Board members, Audit, Performance and Risk Committee members, the Chief Officer and the Interim Chief Finance Officer for their co-operation and assistance over the last six years. Page 58
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1. Audit of 2021/22 annual accounts | 7 1. Audit of 2021/22 annual accounts The principal means of accounting for the stewardship of resources and performance Main judgements Our audit opinions on the annual accounts of the Moray Integration Joint Board are unmodified and there were no significant issues. Our audit opinions on the annual accounts are unmodified 18. The IJB’s annual accounts for the year ended 31 March 2022 were approved by the Integration Joint Board on 26 January 2023. As reported in the independent auditor’s report: • the financial statements give a true and fair view and were properly prepared in accordance with the financial reporting framework • the audited part of the Remuneration Report, Management Commentary and the Annual Governance Statement were all consistent with the financial statements and properly prepared in accordance with the relevant regulations and guidance. The annual accounts were submitted for audit by the statutory dates 19. The unaudited annual accounts were received in line with our agreed audit timetable on 30 June 2022. 20. The working papers provided with the unaudited accounts were of a good standard and finance staff provided support to the audit team during the audit. There were no objections raised to the annual accounts 21. The Local Authority Accounts (Scotland) Regulations 2014 require local government bodies to publish a public notice on its website that includes details of the period for inspecting and objecting to the accounts. This must remain on the website throughout the inspection period. There were no objections to the 2021/22 annual accounts. Page 59
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1. Audit of 2021/22 annual accounts | 8 Overall materiality is £1.4 million 22. We apply the concept of materiality in both planning and performing the audit and in evaluating the effect of identified misstatements on the audit and of uncorrected misstatements, if any, on the financial statements and in forming the opinion in the auditor’s report. We identify a benchmark on which to base overall materiality, such as gross expenditure, and apply what we judge to be the most appropriate percentage level for calculating materiality values. 23. The determination of materiality is based on professional judgement and is informed by our understanding of the entity and what users are likely to be most concerned about in the annual accounts. In assessing performance materiality, we have considered factors such as our findings from previous audits, any changes in business processes and the entity’s control environment including fraud risks. 24. Our initial assessment of materiality for the annual accounts was carried out during the planning phase of the audit. This was reviewed on receipt of the unaudited annual accounts and is summarised in Exhibit 1. Exhibit 1 Materiality values Materiality level Amount Overall materiality £1.4 million Performance materiality £1.1 million Reporting threshold £75,000 Source: Audit Scotland We have no significant findings to report on the audited annual accounts 25. International Standard on Auditing (UK) 260 requires us to communicate significant findings from the audit to those charged with governance, including our view about the qualitative aspects of the body’s accounting practices. We have no issues to report from the audit. We have obtained assurance over the significant risks identified in our Annual Audit Plan 26. Exhibit 2 sets out the significant risks of material misstatement to the financial statements we identified in our 2021/22 Annual Audit Plan. It summarises the further audit procedures we performed during the year to obtain assurances over these risks and the conclusions from the work completed. Page 60
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1. Audit of 2021/22 annual accounts | 9 Exhibit 2 Significant risks of material misstatement in the financial statements Audit risk Assurance procedure Results and conclusions 1. Management override of controls As stated in International Standard on Auditing 240, management is in a unique position to perpetrate fraud because of management’s ability to manipulate accounting records and prepare fraudulent financial statements by overriding controls that otherwise are operating effectively. Agreement of balances and transactions to Moray Council and NHS Grampian financial reports / ledger / correspondence Service auditor assurances obtained from the external auditors of Moray Council and NHS Grampian over the completeness, accuracy and allocation of income and expenditure. Review of adjustments at year end. Review of financial monitoring reports during the year. Results & Significant Judgements: We agreed the figures in the CIES, Balance Sheet and Movement in Reserves Statement to ledger information. We obtained the relevant assurances from the auditors of Moray Council and NHS Grampian. We undertook detailed testing of year-end adjustments. We reviewed financial monitoring reports that were prepared throughout the year. Conclusion: We did not identify any incidents of management override of controls. There were no identified misstatements in the audited annual accounts 27. It is our responsibility to request that all misstatements, other than those below the reporting threshold, are corrected. However, the final decision on making the correction lies with those charged with governance considering advice from senior officers and materiality. There were no misstatements identified that exceeded our reporting threshold. The IJB has made limited progress in implementing our prior year audit recommendations. 28. Limited progress has been made in implementing our prior year audit recommendations with two out of three still outstanding. For actions not yet implemented, revised responses and timescales have been agreed with management, and are set out in Appendix 1. Page 61
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2. Financial management and sustainability | 10 2. Financial management and sustainability Financial management is about financial capacity, sound budgetary processes and whether the control environment and internal controls are operating effectively. Financial sustainability looks forward to the medium and long term to consider whether the council is planning effectively to continue to deliver its services or the way in which they should be delivered. Main judgements The IJB underspent by £10.7 million in 2021/22. Covid-19 funding of £11.7 million was received in 2021/22; £6.7 million was unspent at 31 March 2022 and is included in reserves. Medium -term financial plans have been developed and these have been updated to reflect the impact of Covid-19. The IJB has identified a cumulative budget deficit of £12.1 million over the period from 2023-27. The 2021/22 budget included planned savings and contributions from reserves 29. The IJB approved its 2021/22 budget on 25 March 2021. The budget was set at net expenditure of £140.7 million with a funding gap of £1.5 million. Plans to address the gap included efficiency savings of £0.4 million and use of reserves of £1.1 million. The IJB underspent by £10.7 million in 2021/22 and received £11.7 million Covid-19 funding 30. The final 2021/22 budget was £170.8 million. The increase was due to additional non-recurring funding received from NHS Grampian during the year, with the most significant increase relating to £11.7 million of Covid-19 grants. 31. The IJB returned an underspend of £10.7 million against a budgeted breakeven position (Exhibit 3). The underspend was made up of an overspend of £2.5 million on core services and an underspend of £13.2 million on Strategic Fund schemes funded by the Scottish Government. Page 62
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2. Financial management and sustainability | 11 Exhibit 3 Performance against budget IJB budget summary Budget £m Actual £m Variance £m Gross Core Expenditure 170.8 153.8 (17.0) Total Income (169.7) (164.5) 5.2 In-year expenditure met from reserves 1.1 0.0 1.1 (Surplus)/Deficit in annual accounts 0.0 (10.7) (10.7) Source: MIJB 2021/22 budget monitoring reports and annual accounts Budget processes were appropriate 32. Detailed budget monitoring reports were submitted to the IJB Board throughout the year. The outturn to date and projected year-end outturn position, alongside revisions to the budget were clearly stated in these reports while the actual year-end outturn position was in line with expectations. 33. The content of the budget monitoring reports was updated to reflect the financial impact of Covid-19 and an additional section was included in the outturn report that highlighted spend on the Local Mobilisation Plan developed in response to Covid-19. This ensured the IJB were aware of how Covid-19 impacted on the overall financial position and outturn. 34. We observed that senior management and members receive regular and accurate financial information on the IJB’s financial position and have concluded the IJB has appropriate budget monitoring arrangements. 75% of savings were achieved but it is becoming increasingly challenging to identify further savings 35. The IJB is required to make efficiency savings to maintain financial balance. The total savings target for 2021/22 was £0.4 million. The IJB achieved £0.3 million (75%) of planned savings. The Scottish Government provided additional Covid funding that covered the £0.1 million of savings not achieved. 36. The 2022/23 Revenue Budget Report was presented to the IJB on 31 March 2022. The budget was set at £155.2 million and includes £12.6 million Set Aside and £4.9 million to support commitments in relation to the Carers Act and ring-fenced investment to support increasing demand. There is excess Page 63
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2. Financial management and sustainability | 12 funding over planned expenditure of £0.2 million. The budget includes planned efficiencies of £0.1 million. The IJB considers this to be achievable but has acknowledged the challenges it faces in identifying further savings. Total reserves are £17 million at the year end with most of this earmarked for specific purposes 37. With the £10.7 million surplus achieved in 2021/22, the balance on the General Fund was £17 million at 31 March 2022. The majority of the year end reserves balance (£15.8 million) is held as earmarked reserves for specific purposes. These include £9 million to be spent on Covid-19 and £2.3 million for the Primary Care Improvement Plan. The remaining £1.3 million has been included in uncommitted reserves and will be used as part of the 2022/23 budget. The IJB has a medium-term financial plan but has yet to develop a longer-term plan 38. Financial sustainability looks forward to the medium and longer term to consider whether the body is planning effectively to continue to deliver its services or the way in which they should be delivered. 39. During 2021/22, the IJB updated its Reserves Policy. While the Policy does not set a minimum level of reserves the IJB should hold, it does require that a prudent amount should be held and should be reviewed annually considering the prevailing financial environment. 40. As part of the 2022/23 budget setting process, the Medium-Term Financial Framework was updated and presented the Board in March 2022. This covers the period from 2022/23 to 2026/27. The updated framework identified Covid-19 as a significant risk around its budgeting in coming years, as well as the challenges of the current economic climate and labour market challenges. The plan forecasts an increasing deficit over the five years, with a cumulative deficit of £12.1 million forecast over the five years to 2026/27. 41. The IJB’s Strategic Plan 2022-2032 was presented to the Board in November 2022. The Medium-Term Financial Framework is currently being reviewed to ensure financial planning is aligned with the Strategic Plan. Financial systems of internal control operated effectively 42. The IJB does not have its own financial systems and instead relies on partner bodies’ financial systems. All financial transactions are therefore processed under the partner bodies’ internal controls. 43. As part of our audit approach, we sought assurances from the external auditor of NHS Grampian and Moray Council. Some control weaknesses were identified within Moray Council and the auditors undertook additional audit procedures to obtain the assurances required for their audit opinions. No issues were identified from completion of these additional procedures that affect our overall opinion on the IJB accounts. Page 64
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2. Financial management and sustainability | 13 Standards of conduct and arrangements for the prevention and detection of fraud and error were appropriate 44. The IJB does not maintain its own policies relating to the prevention and detection of fraud and error but instead depends on those in place at its partner bodies. We reviewed the arrangements in place at Moray Council and NHS Grampian and found them to be adequate. The IJB has a Code of Conduct in place to which members subscribe and the Members’ Registers of Interest are publicly available on the IJB’s website. 45. Appropriate arrangements are in place for the prevention and detection of fraud and error. We are not aware of any specific issues we require to bring to your attention. Page 65
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3. Governance, transparency, and Best Value | 14 3. Governance, transparency, and Best Value The effectiveness of scrutiny and oversight and transparent reporting of information. Using resources effectively and continually improving services. Main Judgements The governance arrangements are appropriate and operate effectively The IJB has yet to develop processes to evaluate and measure Best Value The IJB effectively monitors performance and indicators show mixed performance Governance arrangements are appropriate and operate effectively 46. Board and Audit, Performance and Risk Committee meetings were held remotely while restrictions were in place as a result of the Covid 19 pandemic. This continued through 2021/22 but in person meeting resumed in September 2022. Full details of the meetings held by the IJB are available on the IJB’s website. Committee papers and minutes of meetings are publicly available. Public notice of each meeting is available via the IJB’s website. 47. CIPFA has produced a good practice guide on audit committees which recommends these committees should report annually on their performance to those charged with governance. The good practice guide includes a self- assessment checklist for audit committees to help them do this. We reported previously that the IJB’s Audit, Performance and Risk Committee had not completed this assessment. The assessment has still not been completed and this is reflected in Appendix 1 and our follow up of prior year actions. 48. We consider that governance arrangements are appropriate and support effective scrutiny, challenge and decision making. The IJB has yet to develop processes to evaluate and measure Best Value 49. Integration Joint Boards have a statutory duty to have arrangements to secure Best Value. To achieve this, IJBs should have effective processes for Page 66
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3. Governance, transparency, and Best Value | 15 scrutinising performance, monitoring progress towards their strategic objectives, and holding partners to account. 50. The IJB clearly recognises the importance of securing best value, with this being highlighted in its ten-year Strategic Plan. A self-evaluation exercise on the importance of securing best value, reported in June 2019, highlighted the need to ‘develop better processes to evaluate and measure outcomes in line with Best Value’. This self-evaluation and the resulting action plan were revisited in April 2021 and an updated improvement action plan was approved in June 2021. Progress against this plan was reported to the IJB meeting in January 2022 and a development session was held for members in February 2022. 51. In prior years we have recommended that the IJB should develop its own assessment of Best Value. We have been advised that this work progressed during 2021/22 but was not completed due to changes in key staff. A revised action and timescale for completion have been agreed with management, and are set out in Appendix 1 in our follow-up of prior year recommendations. The IJB effectively monitors performance and indicators show mixed performance 52. The Public Bodies (Joint Working) (Scotland) Act 2014 requires the IJB to produce an annual performance report covering areas such as assessing performance in relation to national health and wellbeing outcomes, financial performance and best value, reporting on localities, and the inspection of services. The 2021/22 Annual Performance Report was presented to the Audit, Performance and Risk Committee on 24 November 2022 and, following approval, has been published on the IJB’s website. 53. The Board has continued to monitor key performance targets throughout the year with quarterly performance reports presented to the Audit, Performance and Risk Committee during 2021/22. Performance is measured using a RAG (red / amber / green) system against each of the IJB’s ten local indicators which are aligned to its Strategic Plan. 54. The most recent quarterly performance report (presented to the committee in August 2022) showed three of the indicators as being green, two amber and five red. 55. The five red indicators relate to: • A&E attendance rate per 1,000 of the population • number of delayed discharges at the end of the quarter • number of beds days occupied by delayed discharges • rate of emergency occupied bed days for over 65s per 1,000 of the population • percentage of patients commencing Psychological Therapy Treatment within 18 weeks of referral. Page 67
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3. Governance, transparency, and Best Value | 16 56. Delayed discharge indicators are showing an increasing trend. Work is ongoing to reduce these numbers and action taken in 2021/22 includes the introduction of twice weekly meetings to scrutinise the delayed discharge workflow and a new contract for Care at Home service provision being put in place. The IJB recognises the significant challenges in addressing issues around delayed discharges. National performance audit reports 57. Audit Scotland carries out a national performance audit programme on behalf of the Accounts Commission and the Auditor General for Scotland. During 2021/22 we published some reports which may be of interest to the IJB as outlined in Appendix 2. Page 68
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Appendix 1. Action plan 2021/22 | 17 Appendix 1. Action plan 2021/22 Follow-up of prior year recommendations Issue/risk Recommendation Agreed management action/timing B/F 1. Audit, Performance and Risk committee 2020/21 AAR CIPFA recommends that audit committees report annually on their performance to those charged with governance. CIPFA’s good practice guide includes a checklist for audit committees to use as part of their assessment of performance. The IJB’s Audit, Performance and Risk Committee has yet to assess its performance. Risk: the Audit, Performance and Risk Committee is not complying with good practice and cannot evidence its effectiveness. The Audit, Performance and Risk Committee should assess its performance using the CIPFA self-assessment checklist and report annually to the IJB on its performance. Outstanding The assessment has still not been completed Revised action: Complete self-assessment at year end and then embed this as part of business cycle. Responsible officer: Corporate Manager Revised date: 30 April 2023 B/F 2. Medium-term financial plan The IJB now has a medium- term financial plan that spans the period 2019/20 to 2023/24 but this will need to be updated to reflect the impact of Covid-19 and EU withdrawal. Risk: the financial planning assumptions in the medium- term plan may now be inaccurate. The IJB’s medium-term financial plan should be reviewed due to the impact of Covid-19 and EU withdrawal. 2020/21 Update: the IJB’s Strategic Plan and suite of other supporting documents should also be reviewed. Complete An updated medium-term financial framework has been completed and identified Covid-19 as a significant risk with assumptions made to include recurring SG funding in the figures. EU withdrawal isn’t specifically mentioned but labour challenges and wider economic challenges are. Page 69
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Appendix 1. Action plan 2021/22 | 18 Issue/risk Recommendation Agreed management action/timing A new Strategic Plan covering the period 2022 to 2032 was approved at the November 2022 meeting of the Board. B/F 3. Self-evaluation exercise A self-evaluation exercise was undertaken and presented to the Board in June 2019. It included 11 areas for improvement, including the need to ‘develop better processes to evaluate and measure outcomes in line with Best Value’. There has been no update provided to the Board on the progress against implementing these areas for improvement. Risk: the IJB is unable to demonstrate how it delivers Best Value. The IJB should develop its own assessment of Best Value. Outstanding Work to develop the IJB’s assessment of Best Value progressed during 2021/22 but was not completed due to changes in key staff. Revised action: Seek out examples of good practice from other IJBs and shape for use for Moray, presenting the model to the IJB. Responsible officer: Interim Chief Finance Officer Revised date: 31 March 2023 Page 70
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Appendix 2. National reports and briefing papers | 19 Appendix 2. National reports and briefing papers May Local government in Scotland Overview 2021 June Covid 19: Personal protective equipment July Community justice: Sustainable alternatives to custody September Covid 19: Vaccination programme January Planning for skills Social care briefing February NHS in Scotland 2021 March Local government in Scotland: Financial Overview 20/21 Drug and alcohol: An update Scotland’s economy: Supporting businesses through the Covid 19 pandemic Page 71
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Appendix 2. National reports and briefing papers | 20 Moray Integration Joint Board Draft 2021/22 Annual Audit Report Audit Scotland’s published material is available for download on the website in a number of formats. For information on our accessibility principles, please visit: www.audit-scotland.gov.uk/accessibility For the latest news follow us on social media or subscribe to our email alerts. Audit Scotland, 4th Floor, 102 West Port, Edinburgh EH3 9DN Phone: 0131 625 1500 Email: info@audit-scotland.gov.uk www.audit-scotland.gov.uk AS.4.0 Page 72
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REPORT TO: MORAY INTEGRATION JOINT BOARD ON 26 JANUARY 2023 SUBJECT: 2021/22 AUDITED ANNUAL ACCOUNTS BY: INTERIM CHIEF FINANCIAL OFFICER 1. REASON FOR REPORT 1.1 To submit to the Moray Integration Joint Board (MIJB) the Audited Annual Accounts for the year then ended 31 March 2022. 2. RECOMMENDATION 2.1 It is recommended that the MIJB consider and approve the Audited Annual Accounts for the financial year 2021/22. 3. BACKGROUND 3.1 The Unaudited Annual Accounts for 2021/22 were submitted to the meeting of the Moray Integration Joint Board (MIJB) on 30 June 2022 prior to submission to external audit (paragraph 8 of the Minute refers). 3.2 The Annual Accounts have been prepared in accordance with International Financial Reporting Standards and the Local Government (Scotland) Act 1973, The Local Authority Accounts (Scotland) Regulations 2014 and the Local Government in Scotland Act 2003. 4 KEY MATTERS RELEVANT TO RECOMMENDATION 4.1 The audit undertaken by the Board’s External Auditors, Audit Scotland is now complete. The External Auditors have expressed unqualified opinions in respect of the financial statements, the remuneration report, the management commentary and the annual governance statement. The Independent Auditor’s Report to the Members of the MIJB and the Accounts Commission is included within the audited Annual Accounts and can be found on page 41. The audited Annual Accounts are attached at APPENDIX 1. 4.2 The audit process highlighted changes to be made to the accounts which in the main were presentational and in parallel with expectation following external audit inspection. Item 9. Page 73
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4.3 The Auditor’s Annual Audit Report to the MIJB and the Accounts Commission is the subject of a separate report to this meeting. The report sets out the responsibilities of Audit Scotland as the independent auditor and presents a summary of the findings arising from the 2021/22 audit. The report confirms there are no unadjusted misstatements in the annual accounts to report to those charged with governance. 4.4 The Audited Annual Accounts are presented to this meeting for consideration and approval. Thereafter, the Chief Officer, Interim Chief Financial Officer and the Chair of the Board will sign the accounts prior to submission to Audit Scotland prior to publication. 5 SUMMARY OF IMPLICATIONS (a) Corporate Plan and 10 Year Plan (Local Outcomes Improvement Plan (LOIP)) and Moray Integration Joint Board Strategic Plan “Partners in Care 2022 – 2032” The Audited Annual Accounts have been completed within the statutory timescales permitted under the Coronavirus (Scotland) Act 2021 and are being presented for consideration and sign off. (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. In addition, the Coronavirus (Scotland) Act 2021 has been adhered allowing statutory reporting deadlines to be flexed. (c) Financial implications The adjustments and revisions made to the Annual Accounts following the external audit had no financial impact on the MIJB. (d) Risk Implications and Mitigation There are no risk issues arising directly from this report. The work undertaken by Audit Scotland provides assurance to the Board that the Annual Accounts for 2021/22 give a true and fair view in accordance with applicable law and the 2021/22 Code of the state of affairs of the MIJB as at 31 March. (e) Staffing Implications None arising directly from this report. (f) Property None arising directly from this report. (g) Equalities/Socio Economic Impact None arising directly from this report as there is no resultant change in policy. (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 Page 74
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(j) Consultations In preparation of the Annual Accounts, consultations have taken place between finance staff of both Moray Council and NHS Grampian who are in agreement within their areas of responsibility. The Chief Officer has been consulted and comments have been considered. 6 CONCLUSION 6.1 Following a completed external audit process and an unqualified opinion being received. The Audited Annual Accounts are presented here for approval and formal sign off. Author of Report: Deborah O’Shea, Interim Chief Financial Officer Background Papers: With author Ref: Page 75
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Moray Integration Joint Board Annual Accounts 2021/22 AUDITED ANNUAL ACCOUNTS FOR THE YEAR ENDED 31 MARCH 2022 Moray Integration Joint Board Item 9. Page 77
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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 مط ب 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: Interim Chief Financial Officer to the Moray Integration Joint Board, High Street, Elgin, IV30 1BX 01343 563125 accountancy.support@moray.gov.uk Page 78
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Moray Integration Joint Board Annual Accounts 2021/22 Table of Contents MORAY INTEGRATION JOINT BOARD MEMBERS ............................................................ 1 MANAGEMENT COMMENTARY .......................................................................................... 2 STATEMENT OF RESPONSIBILITIES ............................................................................... 24 REMUNERATION REPORT ............................................................................................... 26 ANNUAL GOVERNANCE STATEMENT ............................................................................. 30 INDEPENDENT AUDITOR’S REPORT............................................................................... 41 COMPREHENSIVE INCOME AND EXPENDITURE STATEMENT ..................................... 46 MOVEMENT IN RESERVES STATEMENT ........................................................................ 47 BALANCE SHEET .............................................................................................................. 48 NOTES TO THE FINANCIAL STATEMENTS ..................................................................... 49 Note 1 Significant Accounting Policies ............................................................................. 49 Note 2 Critical Judgements and Estimation Uncertainty .................................................. 50 Note 3 Events after the Reporting Period ........................................................................ 51 Note 4 Expenditure and Income Analysis by Nature ........................................................ 51 Note 5 Taxation and Non-Specific Grant Income ............................................................. 52 Note 6 Debtors ................................................................................................................ 52 Note 7 Usable Reserve: General Fund ............................................................................ 53 Note 8 Agency Income and Expenditure .......................................................................... 54 Note 9 Related Party Transactions .................................................................................. 55 Note 10 VAT .................................................................................................................... 57 Note 11 Accounting Standards That Have Been Issued but Have Yet To Be Adopted .... 57 Page 79
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Moray Integration Joint Board Annual Accounts 2021/22 1 MORAY INTEGRATION JOINT BOARD MEMBERS 2021/22 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 Note * were in position until 31 March 2022 Page 80
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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 81
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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 82
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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 83
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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 84
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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 85
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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 86
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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 87
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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 88
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Moray Integration Joint Board Annual Accounts 2021/22 10 MANAGEMENT COMMENTARY (continued) 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. 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. Page 89
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Moray Integration Joint Board Annual Accounts 2021/22 11 MANAGEMENT COMMENTARY (continued) 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 90
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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 £5.2m, this included £0.11m for the underachievement of the approved savings plan. The largest element of spend was £3.18m 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. Page 91
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Moray Integration Joint Board Annual Accounts 2021/22 13 MANAGEMENT COMMENTARY (continued) Additional detail on the areas of spend supported through Covid-19 funding is highlighted in the table below: 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 Page 92
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Moray Integration Joint Board Annual Accounts 2021/22 14 MANAGEMENT COMMENTARY (continued) 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) 6 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 93
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Moray Integration Joint Board Annual Accounts 2021/22 15 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 46. At 31 March 2022 there were usable reserves of £17.02m available to the MIJB, compared to £6.34m at 31 March 2021. These remaining reserves of £17.02m 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 94
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Moray Integration Joint Board Annual Accounts 2021/22 16 MANAGEMENT COMMENTARY (continued) 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. Page 95
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Moray Integration Joint Board Annual Accounts 2021/22 17 MANAGEMENT COMMENTARY (continued) 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. 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. Page 96
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Moray Integration Joint Board Annual Accounts 2021/22 18 MANAGEMENT COMMENTARY (continued) 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. Note 6 Primary Care Prescribing - This budget was overspent by £894,000. The budget to March includes 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 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. Page 97
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Moray Integration Joint Board Annual Accounts 2021/22 19 MANAGEMENT COMMENTARY (continued) 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 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 Interim 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 98
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Moray Integration Joint Board Annual Accounts 2021/22 20 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 99
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Moray Integration Joint Board Annual Accounts 2021/22 21 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 100
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Moray Integration Joint Board Annual Accounts 2021/22 22 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. Page 101
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Moray Integration Joint Board Annual Accounts 2021/22 23 MANAGEMENT COMMENTARY (continued) Home First whilst also considering unscheduled care, primary and secondary care services 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 Disability. ………………………… ……………………… ……………………… Dennis Robertson Simon Bokor-Ingram Deborah O’Shea Chair of Moray IJB Chief Officer Interim Chief Financial Officer Page 102
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Moray Integration Joint Board Annual Accounts 2021/22 24 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 Interim 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 2022, 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. I confirm that the Annual Accounts were approved by the MIJB at its meeting on 26 January 2023. Signed on behalf of the Moray Integration Joint Board Dennis Robertson Chair of Moray IJB Page 103
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Moray Integration Joint Board Annual Accounts 2021/22 25 STATEMENT OF RESPONSIBILITIES (continued) Responsibilities of the Interim Chief Financial Officer The Interim 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 Interim 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 Interim 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 Page 104
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Moray Integration Joint Board Annual Accounts 2021/22 26 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 £ £ - Dennis Robertson Vice-Chair 29/04/21 to date Chair 24/09/20 to 29/04/21 Grampian Health Board - - Cllr Shona Morrison Chair 29/04/21 to 31/03/2022 Vice-Chair 01/10/19 to 29/04/2021 Moray Council - Page 105
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Moray Integration Joint Board Annual Accounts 2021/22 27 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 106
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Moray Integration Joint Board Annual Accounts 2021/22 28 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) 22,954 Pension 43 5 Lump Sum 87 7 Tracey Abdy Chief Financial Officer 18,075 18,562 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 - - £90,000 - £94,999 1 1 £95,000 - £99,999 - - £105,000 - £109,999 1 Page 107
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Moray Integration Joint Board Annual Accounts 2021/22 29 REMUNERATION REPORT (continued) Exit Packages There were no exit packages agreed by the MIJB during 2021/22 financial year, or in the preceding year. ……………………….. ……………………… Dennis Robertson Simon Bokor-Ingram Chair of Moray IJB Chief Officer Page 108
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Moray Integration Joint Board Annual Accounts 2021/22 30 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/ . Page 109
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Moray Integration Joint Board Annual Accounts 2021/22 31 ANNUAL GOVERNANCE STATEMENT (continued) 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 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 Page 110
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Moray Integration Joint Board Annual Accounts 2021/22 32 ANNUAL GOVERNANCE STATEMENT (continued) 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 111
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Moray Integration Joint Board Annual Accounts 2021/22 33 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 112
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Moray Integration Joint Board Annual Accounts 2021/22 34 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 113
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Moray Integration Joint Board Annual Accounts 2021/22 35 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, Interim 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 114
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Moray Integration Joint Board Annual Accounts 2021/22 36 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 115
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Moray Integration Joint Board Annual Accounts 2021/22 37 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 116
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Moray Integration Joint Board Annual Accounts 2021/22 38 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 117
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Moray Integration Joint Board Annual Accounts 2021/22 39 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 118
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Moray Integration Joint Board Annual Accounts 2021/22 40 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. • Continue to implement the recommendations of internal audit to further improve key controls and engage with KPMG on the audit of Commissioned services. 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. ………………………… ……………………… Dennis Robertson Simon Bokor-Ingram Chair of Moray IJB Chief Officer Page 119
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Moray Integration Joint Board Annual Accounts 2021/22 41 INDEPENDENT AUDITOR’S REPORT Independent auditor’s report to the members of Moray Integration Joint Board and the Accounts Commission Reporting on the audit of the financial statements Opinion on financial statements I certify that I have audited the financial statements in the annual accounts of Moray Integration Joint Board for the year ended 31 March 2022 under Part VII of the Local Government (Scotland) Act 1973. The financial statements comprise the Comprehensive Income and Expenditure Statement, Movement in Reserves Statement, Balance Sheet and notes to the financial statements, including significant accounting policies. The financial reporting framework that has been applied in their preparation is applicable law and UK adopted international accounting standards, as interpreted and adapted by the Code of Practice on Local Authority Accounting in the United Kingdom 2021/22 (the 2021/22 Code). In my opinion the accompanying financial statements: • give a true and fair view in accordance with applicable law and the 2021/22 Code of the state of affairs of the body as at 31 March 2022 and of its income and expenditure for the year then ended; • have been properly prepared in accordance with UK adopted international accounting standards, as interpreted and adapted by the 2021/22 Code; and • have been prepared in accordance with the requirements of the Local Government (Scotland) Act 1973, The Local Authority Accounts (Scotland) Regulations 2014, and the Local Government in Scotland Act 2003. Basis for opinion I conducted my audit in accordance with applicable law and International Standards on Auditing (UK) (ISAs (UK)), as required by the Code of Audit Practice approved by the Accounts Commission for Scotland. My responsibilities under those standards are further described in the auditor’s responsibilities for the audit of the financial statements section of my report. I was appointed under arrangements approved by the Accounts Commission on 10 April 2017. The period of total uninterrupted appointment is six years. I am independent of the body in accordance with the ethical requirements that are relevant to my audit of the financial statements in the UK including the Financial Reporting Council’s Ethical Standard, and I have fulfilled my other ethical responsibilities in accordance with these requirements. Non-audit services prohibited by the Ethical Standard were not provided to the body. I believe that the audit evidence I have obtained is sufficient and appropriate to provide a basis for my opinion. Page 120
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Moray Integration Joint Board Annual Accounts 2021/22 42 INDEPENDENT AUDITOR’S REPORT (Continued) Conclusions relating to going concern basis of accounting I have concluded that the use of the going concern basis of accounting in the preparation of the financial statements is appropriate. Based on the work I have performed, I have not identified any material uncertainties relating to events or conditions that, individually or collectively, may cast significant doubt on the body’s ability to continue to adopt the going concern basis of accounting for a period of at least twelve months from when the financial statements are authorised for issue. These conclusions are not intended to, nor do they, provide assurance on the body’s current or future financial sustainability. However, I report on the body’s arrangements for financial sustainability in a separate Annual Audit Report available from the Audit Scotland website. Risks of material misstatement I report in my Annual Audit Report the most significant assessed risks of material misstatement that I identified and my judgements thereon. Responsibilities of the Interim Chief Financial Officer and Moray Integration Joint Board for the financial statements As explained more fully in the Statement of Responsibilities, the Interim Chief Financial Officer is responsible for the preparation of financial statements that give a true and fair view in accordance with the financial reporting framework, and for such internal control as the Interim Chief Financial Officer determines is necessary to enable the preparation of financial statements that are free from material misstatement, whether due to fraud or error. In preparing the financial statements, the Interim Chief Financial Officer is responsible for assessing the body’s ability to continue as a going concern, disclosing, as applicable, matters related to going concern and using the going concern basis of accounting unless there is an intention to discontinue the body’s operations. The Moray Integration Joint Board is responsible for overseeing the financial reporting process. Auditor’s responsibilities for the audit of the financial statements My objectives are to obtain reasonable assurance about whether the financial statements as a whole are free from material misstatement, whether due to fraud or error, and to issue an auditor’s report that includes my opinion. Page 121
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Moray Integration Joint Board Annual Accounts 2021/22 43 INDEPENDENT AUDITOR’S REPORT (Continued) Reasonable assurance is a high level of assurance, but is not a guarantee that an audit conducted in accordance with ISAs (UK) will always detect a material misstatement when it exists. Misstatements can arise from fraud or error and are considered material if, individually or in the aggregate, they could reasonably be expected to influence the decisions of users taken on the basis of these financial statements. Irregularities, including fraud, are instances of non-compliance with laws and regulations. I design procedures in line with my responsibilities outlined above to detect material misstatements in respect of irregularities, including fraud. Procedures include: • obtaining an understanding of the applicable legal and regulatory framework and how the body is complying with that framework; • identifying which laws and regulations are significant in the context of the body; • assessing the susceptibility of the financial statements to material misstatement, including how fraud might occur; and • considering whether the audit team collectively has the appropriate competence and capabilities to identify or recognise non-compliance with laws and regulations. The extent to which my procedures are capable of detecting irregularities, including fraud, is affected by the inherent difficulty in detecting irregularities, the effectiveness of the body’s controls, and the nature, timing and extent of the audit procedures performed. Irregularities that result from fraud are inherently more difficult to detect than irregularities that result from error as fraud may involve collusion, intentional omissions, misrepresentations, or the override of internal control. The capability of the audit to detect fraud and other irregularities depends on factors such as the skilfulness of the perpetrator, the frequency and extent of manipulation, the degree of collusion involved, the relative size of individual amounts manipulated, and the seniority of those individuals involved. A further description of the auditor’s responsibilities for the audit of the financial statements is located on the Financial Reporting Council's website www.frc.org.uk/auditorsresponsibilities. This description forms part of my auditor’s report. Page 122
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Moray Integration Joint Board Annual Accounts 2021/22 44 INDEPENDENT AUDITOR’S REPORT (Continued) Reporting on other requirements Opinion prescribed by the Accounts Commission on the audited part of the Remuneration Report I have audited the part of the Remuneration Report described as audited. In my opinion, the audited part of the Remuneration Report has been properly prepared in accordance with The Local Authority Accounts (Scotland) Regulations 2014. Other information The Interim Chief Financial Officer is responsible for other information in the annual accounts. The other information comprises the Management Commentary, Annual Governance Statement, Statement of Responsibilities and the unaudited part of the Remuneration Report. My responsibility is to read all the other information and, in doing so, consider whether the other information is materially inconsistent with the financial statements or my knowledge obtained in the course of the audit or otherwise appears to be materially misstated. If I identify such material inconsistencies or apparent material misstatements, I am required to determine whether this gives rise to a material misstatement in the financial statements themselves. If, based on the work I have performed, I conclude that there is a material misstatement of this other information, I am required to report that fact. I have nothing to report in this regard. My opinion on the financial statements does not cover the other information and I do not express any form of assurance conclusion thereon except on the Management Commentary and Annual Governance Statement to the extent explicitly stated in the following opinions prescribed by the Accounts Commission. Opinions prescribed by the Accounts Commission on the Management Commentary and Annual Governance Statement In my opinion, based on the work undertaken in the course of the audit: • the information given in the Management Commentary for the financial year for which the financial statements are prepared is consistent with the financial statements and that report has been prepared in accordance with statutory guidance issued under the Local Government in Scotland Act 2003; and • the information given in the Annual Governance Statement for the financial year for which the financial statements are prepared is consistent with the financial statements and that report has been prepared in accordance with the Delivering Good Governance in Local Government: Framework (2016). Page 123
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Moray Integration Joint Board Annual Accounts 2021/22 45 INDEPENDENT AUDITOR’S REPORT (Continued) Matters on which I am required to report by exception I am required by the Accounts Commission to report to you if, in my opinion: • adequate accounting records have not been kept; or • the financial statements and the audited part of the Remuneration Report are not in agreement with the accounting records; or • I have not received all the information and explanations I require for my audit. I have nothing to report in respect of these matters. Conclusions on wider scope responsibilities In addition to my responsibilities for the annual accounts, my conclusions on the wider scope responsibilities specified in the Code of Audit Practice, including those in respect of Best Value, are set out in my Annual Audit Report. Use of my report This report is made solely to the parties to whom it is addressed in accordance with Part VII of the Local Government (Scotland) Act 1973 and for no other purpose. In accordance with paragraph 120 of the Code of Audit Practice, I do not undertake to have responsibilities to members or officers, in their individual capacities, or to third parties. Brian Howarth ACMA CGMA Audit Director Audit Scotland 4th Floor 8 Nelson Mandela Place Glasgow G2 1BT Page 124
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Moray Integration Joint Board Annual Accounts 2021/22 46 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 125
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Moray Integration Joint Board Annual Accounts 2021/22 47 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 126
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Moray Integration Joint Board Annual Accounts 2021/22 48 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 - Short Term Creditors - Current Liabilities - Provisions - 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 and the audited annual accounts were authorised for issue on 26 January 2023. . The Annual Accounts present a true and fair view of the financial position of the MIJB as at 31 March 2022 and its income and expenditure for the year then ended. Deborah O’Shea FCCA Interim Chief Financial Officer Page 127
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Moray Integration Joint Board Annual Accounts 2021/22 49 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 128
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Moray Integration Joint Board Annual Accounts 2021/22 50 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 129
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Moray Integration Joint Board Annual Accounts 2021/22 51 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 and the audited accounts were authorised for issue on 26 January 2023. 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. In December 2022 the IJB was notified of costs relating to two out of area placements. Following receipt of the Scottish Government decision on ordinary residence for the first placement, the IJB is due to pay £0.7 million covering the period from October 2018 to 31 March 2022. The surplus on provision of services and reserves are overstated by this amount but the annual accounts have not been adjusted as this amount is not considered material. The IJB has not accepted responsibility for the second placement and this is considered to be a contingent liability until the individual’s ordinary residence is agreed or determined by the Scottish Government. Note 4 Expenditure and Income Analysis by Nature 2020/21 2021/22 £000 £000 60,984 Services commissioned from Moray Council 65,020 84,391 Services commissioned from The Grampian Health Board 88,760 Page 130
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Moray Integration Joint Board Annual Accounts 2021/22 52 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) NOTES TO THE FINANCIAL STATEMENTS (continued) Note 5 Taxation and Non-Specific Grant Income 2020/21 2021/22 £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 Page 131
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Moray Integration Joint Board Annual Accounts 2021/22 53 182 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. 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 - 187 - - 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 2021/22 (341) - - - (341) Transfers in 2021/22 - 664 6,291 4,065 11,020 Balance at 31 March 2022 1,257 2,331 9,016 4,417 17,021 Page 132
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Moray Integration Joint Board Annual Accounts 2021/22 54 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. 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) - Net Agency Expenditure excluded from the CIES - Page 133
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Moray Integration Joint Board Annual Accounts 2021/22 55 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 2022 £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 134
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Moray Integration Joint Board Annual Accounts 2021/22 56 NOTES TO THE FINANCIAL STATEMENTS (continued) Note 9 Related Party Transactions (continued) Transactions with Moray Council 2020/21 2021/22 £000 £000 (45,060) Funding Contributions received from the Council (50,549) 60,945 Expenditure on Services Provided by the Council 64,970 66 Key Management Personnel: Non-Voting Board Members 78 15,951 Net Transactions with Moray Council 14,499 Balances with Moray Council 31 March 2021 31 March 2022 £000 £000 182 Debtor balances: Amounts due from Moray Council 1,282 - Creditor balances: Amounts due to Moray Council - 182 Net Balance due from Moray Council 1,282 Page 135
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Moray Integration Joint Board Annual Accounts 2021/22 57 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 136
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REPORT TO: MORAY INTEGRATION JOINT BOARD ON 26 JANUARY 2023 SUBJECT: ABERDEENSHIRE HOSTED SERVICES REPORT BY: LOCATION MANAGER AND CHIEF NURSE, ABERDEENSHIRE HEALTH AND SOCIAL CARE PARTNERSHIP 1. REASON FOR REPORT 1.1. To inform the Board of the current position in relation to the services where Aberdeenshire Integration Joint Board are the ‘host’ Integration Joint Board (IJB). 2. RECOMMENDATION 2.1. It is recommended that the Moray Integration Joint Board consider and note the current position in relation to the services where Aberdeenshire Integration Joint Board are the ‘host’ IJB. 3. BACKGROUND 3.1 Hosted Services are services which have been delegated to Integration Joint Boards (IJB’s) but are operated and managed on a Grampian wide basis. Hosting arrangements describe the situation where an IJB within the Grampian Health board area hosts a service on behalf of all three IJB’s (Moray, Aberdeen City and Aberdeenshire). Operational oversight and management responsibility is held by the ‘host’ IJB. Strategic Planning for the use of these services should be undertaken by the three IJB’s for their respective population. Provision for these hosted services is included within each IJB’s Integration Scheme. 3.2 The services currently hosted by Aberdeenshire IJB all have a budget of less than £3m. This includes: • His Majesty’s Prison and Young Offenders Institution (HMP&YOI) Grampian (£2.7m) – the health centre at HMP Grampian provides a range of health care including on-site nursing teams (Substance Use, Mental Health and Primary Care). Consultant Clinical Psychology, Allied Health Professionals, medical cover (provided by Peterhead Health Centre) and visiting specialists. • Forensic and Custody Healthcare Service (£1.7m) – Provision of a full range of forensic and custodial medicine services, including all paediatric and sexual assault examinations, in sites in Aberdeen, Elgin Item 10. Page 139
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2 and Fraserburgh. Since April 2022 this has also included delivery of the Sexual Assault Self-Referral Service. • Marie Curie Nursing Service (836k) – Managed Care Service and out of hours service for Moray and Aberdeenshire HSCP’s, including rapid response. • Specialist Nursing Service for continence care/bladder and bowel health (£706k) • Community Diabetes Specialist Nursing Team and Diabetic Eye Screening Service (£1.014m) • Heart Failure Specialist Nursing Service (£313k) • Chronic Oedema Service (£240k) - Specialist Therapy Service 3.3 Health and Social Care Partnership’s have been tasked to develop a Service Level Agreement (SLA) for the services currently hosted by them based on the principle of Quality, Safety and Efficiency. Progress on this will be reviewed through the North East Scotland Planning Group, with the intention to submit SLA’s to IJB budget setting meetings in March 2023. 3.4 The main part of this report will provide an update on healthcare provision at HMP&YOI Grampian and the Forensic and Custody Healthcare Service. Reports on the other hosted services are attached to this report from page 7 onwards. HMP&YOI Grampian 3.5 Management responsibility for prison healthcare sits within the North Aberdeenshire locality management team and updates on key themes and issues are reported on a monthly basis through the north management team meeting. Starting in November we are also reporting monthly to the Clinical and Adult Social Work Governance Group on the risks identified on the risk register, in particular around recruitment and retention of staff. The team also report daily into the Daily Situation Update meeting and the staffing/bed huddle to ensure we have a clear picture of staffing levels across the service. 3.6 Inspections of prison health care are carried out jointly by His Majesty’s Inspector of Prisons in Scotland (HMIPS) and Healthcare Improvement Scotland (HIS) using the Standards for Inspecting and Monitoring Prisons in Scotland. Outcomes of inspections and subsequent improvement plans are reported to the HSCP Clinical and Adult Social Work Governance Committee and to the Integration Joint Board where appropriate. 3.7 In the last year we have worked alongside Scottish Prison Service (SPS) colleagues to review and agree the best structure for ensuring joint oversight and reporting in relation the delivery of health care within the prison. The Governor at HMP Grampian chairs the Health Care Oversight Group and below that the Primary Care, Mental Health and Substance Use Strategic Groups meet once a month with a structure below that for operational and weekly meetings. This reporting structure ensures resolution or escalation of issues as required. 3.8 The recruitment and retention of staff (particularly prison nursing) remains a key challenge. We have been undertaking workforce planning sessions on a regular basis to work towards a staffing model that is fit for purpose and reflects the changes to prison health care and to ensure that we have a model in place that will meet the changing needs of the prison population. We will be looking to take Page 140
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3 forward a strategic review of the prison workforce in the near future. The issues with prison health care staffing is a national issue and we continue to be part of the discussions through national forums. 3.9 In recent years there have been a number of achievements within prison health care, and listed below are a few of those: • Progress made against improvement actions as identified by previous inspections (Controlled Drug Licence in place and funding for a pharmacy team in place) • Development of joint oversight arrangements with SPS partners • Staffing compliment has increased as a result of Action 15 funding to include additional psychology posts and OT posts on a permanent basis, this is to provide interventions for those prisoners presenting with lower level mental health issues. We have also secured temporary funding through Action 15 to support a pathway’s for prisoners with brain injury and for older adults within the prison setting • Funding via Aberdeenshire Alcohol and Drug Partnership to recruit 2 FTE Band 4 nurses to take on the role of Harm Reduction Workers and provide assertive outreach for those prisoners who are at risk of harm from Substance Use. We have successfully recruited into 1.5 of these posts and the other 0.5 has gone out to recruitment • Given our challenges in recruiting nursing staff we are in the process of recruiting Band 4 Wellbeing and Enablement Workers to each of our core nursing teams. These workers will be supported through training at Robert Gordon University Forensic and Custody Healthcare 3.10 Operational Management sits within the North Aberdeenshire locality management and report in through the daily situation update. There is also attendance at monthly national meetings with Police Scotland and other custody healthcare colleagues to ensure consistency of practice across Scotland 3.11 The main custody healthcare site is at Kittybrewster Custody Suite where there is 24-hour nursing and forensic medical cover. There are a further two custody suites in Aberdeenshire (Fraserburgh and Elgin). Teams at Elgin and Fraserburgh were given additional resource to provide nurse cover for these sites. In Fraserburgh staff from the Minor Injury Unit provide the cover and in Elgin there have recently been appointed a team of custody nurse practitioners who are based at the Dr Gray’s Emergency Department. Both sites link into Kittybrewster if Forensic Medical cover is required. With regards the model at Elgin, Aberdeenshire Health and Social Care Partnership and Moray Health and Social Care Partnership have worked together in the last year to ensure there is a robust staffing model in place for delivery of custody healthcare services in Elgin as the previous model based with GMED presented significant challenges for both services. 3.12 A Nurse Manager post is currently being introduced on a temporary basis with dedicated time to focus on Custody Healthcare. This will allow the provision of the governance and assurance from a nursing perspective and provide that link across all the custody sites to ensure consistency of practice across Grampian. Page 141
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4 3.13 In addition to all custody medical services the team also deliver the Sexual Assault Response Coordination Service (SARC’s). Until April this year this was for police referrals only but the implantation of the Forensic Medical Services (Victims of Sexual Offences) (Scotland) (Act) 2021 on 1 April 2022 also extended this to survivors who choose to self-refer for an examination. The service is required as part of this work to attend quarterly performance meetings with the Scottish Government to review and monitor performance around the SARC and implementation of the legislation. 3.14 The setting up of the self-referral pathway has been a significant achievement for the service. This legislation means that survivors of sexual assault can choose to self-refer without contacting the police. This allows for a forensic medical examination to take place and evidence gathered to allow the survivor the choice of when or if they want to proceed with a prosecution. Most importantly it allows survivors to access healthcare following an assault and we are working with colleagues in the Sexual Health Service to ensure we have the appropriate throughcare pathways in place so that survivors can access the necessary health and support services. 3.15 The service is not without it’s challenges and is currently experiencing gaps in the Forensic Medical Examiner (FME) rota due to an FME leaving and another reducing hours as part of a phased retirement. This has resulted in the use of agency to ensure 24/7 coverage for forensic services. The Service is currently working with HR to move the current FME group onto a salaried contract and this piece of work is near completion with a final agreement to be reached on a job plan. Historically the FME role has been difficult to fill but it is hoped that the move to a salaried form of payment will improve recruitment. 3.16 The next 6-12 months will be focused on the continued implementation of the SARC service in line with the HIS Standards and ensuring that there are the correct skill mix of staff to be able to deliver this service and to ensure that there is no impact on the delivery of custody healthcare as a result. 3.17 Please see additional updates as per APPENDIX 1 on the following services: • Marie Curing Nursing Service • Bowel and Specialist Service • Diabetes Specialist Nursing and Diabetic Eye Screening • Heart Failure Specialist Nursing • Chronic Oedema Service (COS) 4. KEY MATTERS RELEVANT TO RECOMMENDATION 4.1 As highlighted in the report the main challenges for prison healthcare and custody healthcare are around the workforce and ensuring that we have a sustainable workforce model for both services. We have already taken steps to address this by looking at a strategic review for the workforce at HMP&YOI Grampian and there is work ongoing to look at staffing for custody healthcare to include covering the SARC service. Page 142
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5 4.2 It is also acknowledged that there have been considerable challenges in terms of the delivery of the Marie Curie Service and this will be addressed by the service review currently being undertaken. 4.3 Key matters to note from the other hosted services are: • Bladder and Bowell – as noted in the update there is an overspend on this service and currently this is sitting with the Chief Financial Officers to address. • Diabetic Specialist Nursing – There have also been workforce challenges with this service, this is due to an increase in caseload, and also movement in the workforce due to retirals. • Diabetic Eye Screening – The team have successfully recruited additional screening staff and this has made a significant impact on the backlog of cases. • Heart Failure Specialist Nursing Service – This service has also experienced workforce challenges due to reduced staffing because of maternity leave/long term sickness and increasing referrals workload. • Chronic Oedema Service – staff within this service were successfully redeployed and have adapted to new ways of working such as the use of technology which has allowed them to keep waiting times to a minimum. 5. SUMMARY OF IMPLICATIONS (a) Corporate Plan and 10 Year Plan (Local Outcomes Improvement Plan (LOIP)) and Moray Integration Joint Board Strategic Plan “Partners in Care 2022 – 2023” This report sets out the principles that will support the delivery of the above plans, highlighting its challenges. (b) Policy and Legal There are no policy or legal implications as a result of this report. (c) Financial implications There are no financial implications as a result of this report. (d) Risk Implications and Mitigation All risks associated to this service are managed via Aberdeenshire Health and Social Care Partnership Risk Register and Clinical and Adult Social Work Governance Group. (e) Staffing Implications There are no staffing implications as a result of this report. (f) Property There are no property implications as a result of this report. (g) Equalities/Socio Economic Impact There are no equality or socio ecomonica impacts as a result of this report. Page 143
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6 (h) Climate Change and Biodiversity Impacts There are no climate change of biodiversity impacts as a result of this report. (i) Directions There are no directions as a result of this report. (j) Consultations No other parties require to be consulted. 6. CONCLUSION 6.1. This report is to provide information to Moray IJB on the positon of the Grampian wide services which are hosted by Aberdeenshire IJB and will be presented to all 3 IJB’s. Author of Report: Corinne Millar (Location Manager, Aberdeenshire Health and Social Care Partnership Background Papers: N/A Ref: Page 144
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APPENDIX 1 Service: Marie Curie Nursing Service Hosted: Aberdeenshire Budget: £836k Description of Services: • Provision of managed care service and out of hours service for Moray and Aberdeenshire HSCPs, providing palliative nursing care to patients in the community including rapid response. Current Governance/Management Arrangements: Operational management through Aberdeenshire HSCP Chief Nurse. Service agreement in place with Marie Curie for provision of service - regular meetings held with Marie Curie with representation from HSCPs and NHSG Finance. Regular activity reports provided by the service – further analysis presently being undertaken around detail of type of visits and interactions with patients. Regular meetings held cross sector including GMED to ensure concerns re service provision are addressed. Current Issues: Marie Curie increased the cost of their contract at the end of 2020 which led to discussions across Shire and Moray to look at alternative models of service delivery. Due to pressures as a result of COVID this work remains ongoing. Relationships have improved greatly with the service and joint working to progress a sustainable model for future service delivery. Marie Curie attend daily the Shire Bed/Staff huddle to promote joint working and problem solving of service gaps. Joint working to relook at a more streamlined service with a reduction from 3 pods to 2 and the introduction of a Senior Nurse to Triage all calls. This will provide a more sustainable service over winter and allow planning and progress to review the service in more detail in 2023. Project Manager support has been identified to undertake this work in 2023. Achievements: Strong working relationships Attendance daily for Pod cover update Good use of data to determine plans for service delivery Ongoing work across both Moray and Shire to look at Out of Hours Redesign options and costs Improvement Areas for consideration: There is the risk that any options for redesign will be out with the available financial envelope. Therefore if this is not an option to progress then support will be required from the Commissioning team to ensure a robust and measurable contract going forward. Item 10. Page 145
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2 Service: Bladder and Bowel Specialist Service Description of Services: • Specialist nursing team in bladder and bowel health, providing education and training to both patients and NHS Grampian staff; voluntary staff; Agency staff; 3rd sector support, health care workers in residential and care home settings; Schools, students at university and colleges and AHPs across NHS Grampian. • Advisory phone line 5 days per week • Around 6500 patients currently prescribed containment products for bladder and bowel incontinence, patients reassessed annually • Specialist nurse led clinics in Elgin, Aberdeen city, Inverurie, Peterhead, Stonehaven • Advisory service for Children’s bladder and bowel health • MDT with colorectal, neuro rehab, Gynae, Urology, Urogynae, Paediatrics, Social work • Representation of NHSG at national level, tender negotiation, formulary development, national guideline development • Support to NHS Orkney provided by Band 8A Current Governance/Management Arrangements: Operational management through Aberdeenshire HSCP Chief Nurse. Line manages Nurse Manager (Band 8A). Current Issues: 22/23 budget overspend of £115,321 due to national contract extension agreed by National Procurement and 15% cost increase. Ongoing issues with national contract impacting service ability to provide high standard of care to patients. Official letter of complaint has been submitted to National Procurement by NHSG and National leads group. Demand to service has increased out with current staffing capacity due to changes in community nursing workforce/Health visiting/School nursing post Covid19 Increased demand on service due to impact of secondary care waiting lists, Gynae, Urology, Gastro. Health point have highlighted increase in referrals they are directing to BB service as a result. Up skilling new staff members in each nursing base Moving from paper records to electronic, progress is slow and fragmented. Achievements: Current staffing allocation full, admin team vacancy recently recruited to. iMatter and Culture survey results show positive team environment and happy team members. Motivation and moral is high. High engagement with service teaching program across disciplines and IJBs Nursing staff have completed training to allow service to host student nurses. Collaborative working with Practice Education team to deliver NHSG catheterisation clinical skills learning pathway BB Service and PE invited to provide professional review of NES learning material to be used nationally. Currently working with Practice Education to develop clinical skills pathway for HCSWs Currently working with local and national procurement to update catheter formulary and identify cost savings. Page 146
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3 Building service on Trakcare to allow electronic referrals so self-referral route can be removed due to inappropriate use in primary care as a result of demand on GP services and access to appointments and community nursing workforce tasks. Service specialist clinic waiting lists around 24 weeks for new patients Availability of clinical space in City and Shire to allow us to increase clinical capacity Availability of office space in Inverurie to allow us to add staff to nursing team if staffing budget funds were found in order to develop the service. Community nursing/HV/SN workload could be reduced if service had additional staffing to take all continence assessment in house. I would also predict a budget saving as all patients would be prescribed a 12 week treatment plan before provision of products leading to better patient outcomes and service savings. Catheter project with Transformation team looking to reduce acute and community catheter workload Collaborative working with NHS Orkney to support them through an options appraisal of current service provision there and what support can be given by the Grampian service. Improvement Areas for consideration: Budget review, NP571/22 Continence pads and garments currently in tender process, initial indication from National Procurement is that next 5 year contract is likely to incur >15% increase in cost. Review of service delivery • Increase in nursing staff – Service would benefit from a band 7 post to allow band 8A to take a fully operational role. Additional band 5 in City/Shire team and HCSW and Admin support in Moray team would provide more equitable service pan Grampian. • Increase in clinic capacity • Moving all continence assessment in house • Increasing teaching program, possibly working with other disciplines to deliver this • Fully move to electronic records to provide more efficiency • Develop service level agreement to formalise clinical support we provide to NHS Orkney once the review of their service and options appraisal is completed. Page 147
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4 Service: Diabetes Specialist Nursing and Diabetic Eye Screening Hosted: Aberdeenshire Budget: £1.014m Description of Services: Community Diabetes Specialist Nurse Team (DSN) provides advice, guidance and support to health and social care professionals and people with diabetes across NHS Grampian to support self-management. Diabetic Eye Screening Service provides screening to all patients with diabetes who are aged 12 years and older, with aim of detecting and offering timeous treatment for sight threatening diabetic retinopathy. Current Governance/Management Arrangements: Operational and Professional Management through Aberdeenshire HSCP Chief Nurse. Line manages Nurse Manager (Band 8A). Diabetes Specialist Nursing Current Issues: Staff retirement and reduction of hours/staffing issues Change to service delivery - education to Heath Care Professionals and service users. Up skilling new staff members New technologies and how they will be rolled out to our patients, Increase in Freestyle libre 2, CGM Increased workload due to steroid therapies being used for treatment for Covid 19 Dr Grays (DHG) have no Inpatient DSN Service ( test of change being done with Inpatient DSN from ARI remote working) DSN support for pregnancy patients DGH patients. Increase in workload for DSN with reduction in Consultant support in Moray Achievements: Appointment of new Staff member SANDRA course getting through to the QIC Diabetes Awards (Quality in Care Diabetes) and been Commended for this piece of work. Staff engagement is excellent post Covid 19 – open to thinking about what works well, what we can stop, start and keep in relation to the results of the Culture Survey DSN education training currently being offered across NHSG Virtually Staff have worked very conscientiously to provide a high quality service to patients and Primary care colleagues DSN outreach support sessions provided across NHSG Improvement Areas for consideration: Education delivery moving away from some online education into the classroom where it is felt that people learn and engage more Consideration on business plan for part time Practice Educator for the Diabetes Specialist Nurse Team which would be of great benefit to the team, HCP and services users. Page 148
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5 Working with the third sector more in relation to the Diabetes Improvement Plan. Staffing levels to be reviewed to take into consideration the Increased demand for CGM/ Technology, Pre-pregnancy and Maternity services Inpatient DSN to improve patient care across NHSG Inpatient DSN plan currently under a test of change being implementation in November, Ultimately looking at having a NHSG wide inpatient service. Diabetic Eye Screening Current Issues: Additional screening resource has greatly contributed to recovery and reducing the current backlog, however this has added further pressure onto the administration team regarding workload increase relating to telephone call volumes, increased mailing volume, referrals to ophthalmology A concern that has been highlighted, by most boards who provide mobile screening, is that when problems/issues present with the mobile trollies there is no support as regards manufacturer to provide new replacements. This matter has been raised at service manager meetings of all 14 boards which the action it was noted as a procurement concern with National Services Division (NSD). Grampian currently have 3 trollies in operation of which the local medical physics team are on hand to support with what resource they can offer, the trollies have been in use in excess of fifteen years and adapted over this time to accommodate newer, varying models of cameras Achievements: Successful recruitment of screening staff to replace staffing hours reduced due to changed working hours following return of maternity leave, staff role progression within the service Additional camera secured at David Anderson building to aid higher volume of appointments to support recovery and to allow further sustainability of screening long term Until the end of October 2022 a mobile camera has been utilised at David Anderson building to aid recovery, now with additional resource, all mobile cameras can be fully operational across Aberdeenshire and Moray to aid further recovery beginning November 2022 With the further relaxing of covid 19 restrictions, this has allowed the service to increase the amount of appointments that can be honoured within sustainable parameters i.e time allocated per appointment within the time available to screen in a day. All screening locations have been recovered, with some sites granted pre bookings throughout the year Waiting list for optical coherence tomography for people living within the Moray area has now been cleared New public health consultant in post as of September 2022, John Mooney. Page 149
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6 Improvement Areas for consideration: Although DES is now beginning to change trajectory towards a positive recovery, there remains areas to improve. Through support of the lead clinician and nurse manager, ways of creating a more robust administration team will be explored. The specialised screening software, Optomize, has a next software release in November 2022 which will include functions to provide a text message reminder, may support with increasing attendance uptake and reduce DNA rates which creates further administration; there will also be the option to offer people an online booking service with the added support for people to change their appointment online – these are optional features of the system for health boards to opt in to use. Further action is to note tasks undertaken by each role and who can support as a backfill during episodes of absence. Aim of this task is to identify fragility within roles and how these can be strengthened to avoid detriment to service. Page 150
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7 Service: Heart Failure Specialist Nursing Service Hosted: Aberdeenshire Budget: £313k Description of Services: Provision of nurse led interventions and improving self-management for patients across Grampian with moderate to severe Left Ventricular Systolic Dysfunction (LVSD) from diagnosis, through exacerbations to stabilisation and deterioration, including supportive and palliative care for terminally ill patients. Current Governance/Management Arrangements: Operational management through Aberdeenshire HSCP Chief Nurse. Line manages Nurse Manager (Band 8A). Current Issues: Reduced staffing due to maternity leave/long term sick leave Increasing referrals/workloads The service secured permanent funding in 2013 and despite considerable service expansion, the staffing level is unchanged and does not align with current service expectation/sustainability. Delay in patient review due to reduced staffing levels and increasing workloads Components; acute sector are actively pursuing funding (through various routes) for two acute HF nurses / revamped inpatient service with early supported discharge pathway which will further increase service referrals. Achievements: Service adaption and remobilisation following the pandemic Improved integrated working across NHSG along the continuous change journey, aligning patient care with Hospital at Home/CTAC/Urgent Care services – preventing hospital admissions and delivering right time/right place/right person care Established Student Nurse Placement programme – supporting the future workforce Working towards securing funding for two acute HF nurses Improvement Areas for consideration: Increase Band 6 staffing level to 6.62 WTE (currently WTE: 4.62) Aim to have all Heart Failure Specialist Nurses as Independent Nurse Prescribers Support the set-up of the acute HF Service; navigating new pathways and staff development opportunities/support systems, so both services complement one another to streamline Heart Failure coordinated care/treatment planning and staff engagement Heart Failure Digital Infrastructure; pursuing a common digital infrastructure across Scotland for heart failure. The idea is that across Scotland we procure, at national level, a digital platform to facilitate diagnostic pathways for heart failure, as well as downstream monitoring, follow-up and management of patients diagnosed with heart failure. We would have the opportunity to tailor the functionality of the platform to our required specification. This approach would hopefully streamline the diagnostic process and allow us to work Page 151
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8 towards common standards of care whilst maintaining flexibility for individual boards to tailor their pathway as they see fit according to local resources and service pressures. Page 152
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9 Service: Chronic Oedema Service (COS) Hosted: Aberdeenshire Budget: £267k Description of Services: Specialist service providing assessment and management of patients with chronic oedema. Education of other health care professionals to enable them to undertake or support self-management within their patient group. Treatment provided within outpatient clinics, hospitals and domiciliary visits. Main clinical base in Aberdeen Health Village with satellite clinics in Stonehaven, Aboyne, Inverurie and commencement of a service in Moray This is a to be a 2 day a week service and is currently operating one day a week. Out of the Oaks in Elgin. Referrals accepted via Consultants, GPs, Breast Care Nurses. 65% of caseload is cancer related. Current Governance/Management Arrangements: Operational management of service through Chronic Oedema Specialist reporting to HSCP Partnership Manager (South). Hosted service includes the staffing budget for all of Grampian and the consumables (garments). . The staffing budget for Moray HSCP transferred from 1st April 2022 into the Grampian service. Current Issues: Staffing: 1WTE 8b Oedema Specialist 0.4 WTE Band 6 Keyworker 0.4 WTE Band 7 to cover Moray 0.53 WTE Band 4 Admin support Current active caseload - 1045 patients New Referrals October 2021 - November 2022 - 279 January 2022 - November 2022 - 247 Achievements: Staff were redeployed from March 2020 – October 2020, since returning to COS staff have had to adapt to alternative ways of working as clinical space is still limited. The use of technology has been a vital part of enabling waiting times to be kept at a minimum (currently 3 week for non-urgent referrals). During the 6 months of redeployment no reviews other than urgent reviews took place, to date all patients have now been reviewed and ongoing appointments are up-to-date. Improvement Areas for consideration: Funding of the money for the service in Moray has happened and there is active work underway to recruit to this post and while this happens, the services is being supported a day week from the main team. Succession planning – as this is a small service, succession planning is vital for continuity of the service. Page 153
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REPORT TO: MORAY INTEGRATION JOINT BOARD ON 26 JANUARY 2023 SUBJECT: LOSSIEMOUTH LOCALITY COMMUNITY CONSULTATION REPORT BY: IAIN MACDONALD, LOCALITY MANAGER 1. REASON FOR REPORT 1.1. To inform the Board of the outcome of the community consultation 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. 2. RECOMMENDATION 2.1. It is recommended that the Moray Integration Joint Board (MIJB): i) note the position statement of Moray Coast Medical Practice on not returning to work in the branch surgeries; ii) note the community Consultation Report and the community views on the continued closure of the branch surgeries; iii) note the sustainable model of service delivery recommended by Health and Social Care Moray iv) approve the model of health and care provision incorporating the permanent closure of the branch surgeries. Further reports will be provided that describe the development of health and care provision across the Lossiemouth Locality in partnership with the local community. 3. BACKGROUND 3.1 General Practice is at the heart of our vision for primary care with Scotland’s GPs as the expert medical generalists in our communities providing clear leadership in response to the increasingly complex care needs of Scotland’s population. The core values of general practice – generalist care; care for the whole person, mind and body, throughout the whole life course; continuity of care – have never been more important. Effective, sustainable and accessible Item 11. Page 155
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general practice is needed by everyone – so we all start well, live well, age well and indeed die well. As we seek to meet the challenges of more complex care in the community, general practice and the role of Scotland’s GPs will need to be strengthened. The GP practice patient list and consultation will remain at the heart of GP provision but GPs will be supported by, and be the clinical leaders of, an expanded multi-disciplinary team of health professionals who can help patients to access the right treatment, by the right professional at the right time. 3.2. Discussion in relation to health and social care provision within the Lossiemouth locality has been ongoing for several years, both at a community and at a strategic level. In the main these discussions have focused on the requirement for increased clinical space, for GPs and Health Care Professionals, within the main surgery building in Lossiemouth and the long term future of the two branch surgeries in Burghead and Hopeman. Various factors such as a different medical model highlighted in the General Medical Services Contract 2018, Covid-19; renewed questions regarding whether the branch surgery buildings meet current health care standards; imminent renewal of building leases and the vacated Laich Dental Suite have led to a decision now requiring to be made. 3.3. It was agreed at the MIJB on 30 September 2021 (para 10 of the minute refers) that such a decision required to be made within the broader context of health and wellbeing provision within the Lossiemouth locality, in line with good practice and following an engagement and consultation process with all key stakeholders. 3.4. A draft Community Engagement Plan was shared with the MIJB on 30 September 2021 (para 10 of the minute refers). The engagement plan was then shared with, and endorsed by, Health Care Improvement Scotland and the NHS Grampian Engagement Team. The engagement activity formally began in October 2021 and was completed in April 2022. Detailed information on the outcome of the engagement activity is contained within the MIJB report 26 May 2022 (sections 3.3 to 3.37 of the report refers). 3.5. It was agreed at the MIJB meeting on 26 May 2022 (par 11 of the minute refers) to approve a formal consultation with patients of Moray Coast Medical Practice on the future model of health and social care provision, including permanent closure of the branch surgeries. 3.6. The Lossiemouth Engagement and Consultation Steering Group has met on monthly basis throughout the engagement and consultation period. A terms of reference for the Steering Group was agreed at the outset and this governed the operation of the group throughout. The purpose of the steering group was to plan and oversee the engagement and consultation process; members were not tasked to reach a final conclusion on recommendations on the future of the branch surgery buildings. 3.7. The steering group membership included representation from: • Burghead Community Council • Hopeman Development Trust • Lossiemouth Community Council • Hopeman Community Minibus Page 156
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• Lossiemouth 2 to 3 Group • Burghead Community Representative • Moray Coast Medical Practice Manager • Moray Coast Medical Practice GP • Health and Social Care Moray • Moray Council • NHS Grampian Primary Care • Public Health 3.8. Once a plan was drawn up for the consultation process a meeting took place with Health Improvement Scotland and the NHS Grampian Public Engagement Team to seek independent feedback on the consultation process being considered. Both groups endorsed the proposed consultation plan. 3.9. All patients, aged 16 years or older, of the Moray Coast Medical Practice were sent a letter informing them of the consultation on the 30 August 2022. The letters included an overview of the consultation process, a frequently asked questions document and a consultation survey response form. In total 8,390 letters were sent. The consultation started on the 8 September 2022 and ran until 16 December 2022. 3.10. Heldon and Laich Councillors, and Moray members of the Scottish and UK parliament were briefed prior to the consultation letters going out. 3.11. The consultation was publicised through various social media channels, via the Health and Social Care Moray website and via the steering group members. Consultees were provided with contact details should they wish to discuss any details of the consultation in person and local groups were given the opportunity to have a member of the steering group attend one of their meetings. There was a small uptake in relation to requested attendance at local groups. 3.12. A total of 653 people completed a consultation response. 251 responses were submitted electronically and 402 responses were submitted via post. A detailed Consultation Report is included in Appendix 1. • 57% of responses were from women • 39% of people said they had a long term condition or disability • 15% of people identified as being an unpaid carer • 34% were aged 45-64 • 51% were aged 65 and over 3.13. The age profile of respondents is outlined in the graphs below. Page 157
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3.14 Two public consultation meetings were facilitated by the steering group. These events took place during October and November 2022 • Hopeman Memorial Hall, 6.30-8.00pm, 27 October 2022 • Burghead Community Hall, 6.30-8.00pm, 14 November 2022 3.15 The events took the form of a brief introductory presentation by the Locality Manager, Health and Social Care Moray, followed by a question/answer session between the public and a panel. The panel consisted of: • Chairperson for Evening: Vice Chair of the MIJB • Chief Officer or Head of Service, Health and Social Care Moray • Locality Manager, Health and Social Care Moray • Practice Manager, Moray Coast Medical Practice • Public Information Officer, Health and Social Care Moray Support was available for individuals to complete the consultation questionnaire. In total approximately 140 people attended the consultation events. At each event two people were tasked with taking a written record of the discussions; this information is incorporated within the detailed consultation Report in Appendix 1. 3.16 Direct access to medical appointments via public transport was a key issue raised during early community engagement activity. Therefore several meetings have taken place with the three key transport providers within the Lossiemouth Locality. i. In total during the engagement and consultation phase there has been six meetings with the Council Public Transport Manager and/or the Public Transport Officer for the ‘Dial M for Moray’ bus service. As a test of change, from April 2022 a dedicated door to door bus service was put in place between 10.00am and 2.30pm to transport patients requiring to travel from the coastal villages to the Lossiemouth Surgery. The use of this service was monitored between April and November 2022 to determine potential demand. The Moray Coast Medical Practice tried where practically possible to arrange appointments for patients during these times. ii. In total during the engagement and consultation phase there has been four meetings with the Commercial Director of Stagecoach buses. The 0 5 10 15 20 25 30 35 40 Under 16 16 - 24 25 - 44 45 - 64 65 - 75 Over 75 n/a Age Profile Page 158
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company continue to be willing to engage in discussions with local partners about the possibility of introducing a coastal service which would assist in providing access to the medical practice for appointments. However, at this stage, Stagecoach would suggest that such a service would not be commercially viable on its own merit as the passenger journeys generated would be unlikely to cover the costs of operation. Consequently, Stagecoach would need to work collaboratively with NHS Grampian, Moray Council and others to explore potential funding options or alternative ways of providing a service at a lower cost (such as off-peak only or only on certain days of the week). iii. There have been several meetings with members of the Hopeman Community Mini Bus Committee. As a third sector registered charity, ran solely by community volunteers, the community minibus has offered an invaluable service pre and post Covid-19 to provide a vital source of transport for patients to access a range of health and wellbeing activities and to attend medical appointments across the Lossiemouth Locality and beyond. The committee have innovative ambitious plans to develop a community led transport provision for the coastal villages and Health and Social Care Moray would aim to work alongside the committee to help them achieve this. 3.17 Lossiemouth Locality has four Pharmacies: Lossiemouth Pharmacy (Lossiemouth), Lloyds Pharmacy (Lossiemouth) and Duthie GF Pharmacy (Burghead and Hopeman). The Pharmacies in Burghead and Hopeman provide a wide range of services including care within the NHS Pharmacy First and Pharmacy First Plus Service and are well attended by the local communities. The Pharmacy First model enables Pharmacists to treat a range of minor ailments and offer where appropriate an alternative to the use of general practice or other health care environments. There is potential to utilise the vacated Burghead branch surgery premises to develop a Pharmacy First Plus model which would allow a broader range of treatments to be provided by the pharmacy, however this would be a business decision for the Pharmacy to consider. 3.18 Moray Coast Medical Practice traditionally provided a part time service from the two roomed branch surgeries in Burghead and Hopeman for the past 30 years. The buildings have never had enough space to sustain the multi-disciplinary team working that is recognised as Primary Care today (section 3.1 above) and as such the patients being seen in the branch surgeries were hugely disadvantaged with limited options, often having to have a second appointment in Lossiemouth to meet their needs. The Practice is keen to provide equitable care to all its patients and the support of a full team of clinical staff is needed for this work - this cannot be replicated across three sites. The Practice is keen to maintain a long term sustainable service in the current climate of health and care services under pressure, remaining in one building as one team allows for maximum use of available personnel on any given day. Diluting the team across three sites would not ensure that patients are seen by the right clinician at first contact. The Moray Coast Medical Practice support the premises recommendations that the branch surgeries are not fit for purpose. Our priority is the ability to maintain a sustainable multi-disciplinary team primary health care service for the patient population. Page 159
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3.19 A meeting was held with representatives of the Maryhill Medical Practice to consider what impact the permanent closure of the Hopeman and Burghead branch surgeries might have on the Maryhill Medical Practice. This is particularly pertinent to Maryhill Medical Practice as people living within the coastal villages west of Lossiemouth have the option to register at either Moray Coast or Maryhill Medical Practices. Currently 37% of the population living within the IV30 5 post code area which includes the coastal villages are registered at Maryhill Medical Practice. Maryhill Medical Practice highlighted their concern regarding the potential movement of additional patients from Moray Coast to Maryhill at this time as their current available consulting room space is very limited to meet its current registered patients. Discussions have taken place, (costs for this have been returned and it is now a case of identifying the funding to support this) within the NHS Grampian Primary Care Premises Group to reconfigure the Maryhill Medical Practice building by a further 3 consulting rooms. Maryhill Medical Practice also indicated they would not consider a branch surgery in the coastal area at this time. 3.20 The Scottish Governments ‘Fourth National Planning Framework – Position Statement’ (2020) outlines the vision for 20 minute neighbourhoods. ‘Our spatial strategy and policies will reflect the needs and aspirations of people living throughout Scotland by building quality places that work for everyone. 20 minute neighbourhoods have the potential to reduce emissions and improve our health and wellbeing’. ‘The 20 minute neighbourhood concept doesn’t exist in isolation but scales up to include larger geographies and networked areas providing access and opportunities for the wide range of facilities and services that communities require’. The document offers a useful reference source in relation to locality planning and the development of local service provision within each locality. 3.21 An updated and revised Equality Impact Assessment (EQIA) document was independently completed by the Equality and Diversity Manager, NHS Grampian and is included as Appendix 2. 4. KEY MATTERS RELEVANT TO RECOMMENDATION 4.1. The Moray Coast Medical Practice Lossiemouth premises was built on RAF land utilising considerable NHS Grampian and private investment funding with a 25 year lease which is due to expire in 2033. 4.2. Patients registered with Moray Coast Medical Practice are also served by two branch surgeries in Hopeman and Burghead respectively. Both of these branch surgeries have been closed since the start of the Covid-19 pandemic in March 2020, due to inadequate space to allow social distancing and an inability to meet other risk mitigation measures such as wipeable flooring and seating materials, zoning areas and entrance/exit points. Burghead branch surgery is rented from the Pharmacy; the lease is due to expire in December 2023; and is 7.8 miles from the main branch surgery in Lossiemouth, resulting in a vehicle travel time of approximately 15 minutes. Hopeman branch surgery is a GP owned property which is 5.5 miles from the main branch surgery in Lossiemouth, resulting in a vehicle travel time of approximately 10 minutes. 4.3. The Lossiemouth Locality has a very active and effective Health and Social Care Multi-Disciplinary Team. The Lossiemouth premises house the Multi- Disciplinary Team which includes GPs, Advanced Nurse Practitioners, Practice Page 160
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Nurses, Community Treatment and Care Team, District Nurses, Health Visitors, School Nurses, Pharmacists, Pharmacy Technicians, First Contact Physiotherapy, Minor Surgery Services, Community Care, Care at Home, Mental Health and Wellbeing Practitioners, Family Planning Services including Cervical Screening, Electrocardiograms (routine and acute), Health Point Services, Joint Injections, Doppler examinations, Bladder and Catheter changes, Periphery Inserted Central Catheter Line Maintenance, Dementia Nurse Specialist and many other procedures. Visiting services include; Midwife/Antenatal and Postnatal Clinics, Baby Clinics, Baby Massage sessions, Community Psychiatric Nurses, Drug and Alcohol Counsellors, Retinal Screening, Health Improvement, Citizen’s Advice. 4.4. The Moray Coast Practice patient population has increased year upon year; the patient population at 31 March for the last three years is illustrated in the graph below. The overall population numbers are expected to stabilise, however there is predicted to be an increase in the proportion of older people and a decrease in the proportion of young people within the locality. 4.5. The current age profile of the patient population is illustrated in the graph below: 4.6. The patient population is predominantly resident in Lossiemouth or in the larger coastal villages of Burghead, Hopeman, Cummingston and Duffus. Of the total 10,195 Moray Coast Medical Practice patient population 3,026 (32%) live in the post code area linked to the coastal villages. 4.7. The spread of patients, living in the post code area and which Moray GP Practice they are registered at is illustrated in the graph below: 9800 9900 10000 10100 10200 2020 2021 2022 Patient Population 0% 5% 10% 15% 20% 25% 30% 35% 0 to 4 5 to 14 15 - 24 25 - 44 45 - 64 65 to 74 75 - 84 85+ Age Profile Page 161
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4.8. A total of 5289 residents live within the area 57% of whom choose to register with Moray Coast Medical Practice (3026) and 37% with the Maryhill Practice in Elgin (1952). There has been no significant movement of patient registrations between Moray Coast and Maryhill over the past 12 months. The direct bus route to Elgin and place of employment are key factors in coastal village patients registering with the Elgin practice. 4.9. A summary of the patient population living in the coastal villages would indicate; That male life expectancy rates are similar to those of other areas of Moray and higher than the national average. Female life expectancy rates are higher than both the Moray and national average. Mortality rates are lower than both the Moray and National average. 4.10 In relation to long term conditions Asthma rates are higher than both the Moray and National Average, however, Arthritis, Coronary Heart Disease, Cancer and Diabetes are all lower than both the Moray and the National Average. Emergency hospital admissions, and readmissions, are lower than both the Moray and the National Average. However admissions due to falls are higher than the Moray average. 4.11 The last reported Census (2011) indicated that: • Within the IV30 5 post code area 12% of households had no car, 46% of households had 1 car and 42% of households had more than 1 car. • There were 1582 families of which 61.5% had no children and 38.5% had children. • 29% of the overall population identified as having 1 or more long term condition. Of that 29% grouping - 28.5% had a ‘hearing/sight’ health condition, 16.9% a ‘physical’ related health condition, 11.7% a ‘learning disability’, 10.9% as a ‘mental health’ related condition, 2% as a ‘developmental disorder and 30% were noted as ‘other’. 4.12 A report titled Local Poverty: Painting a picture of Moray was recently produced using both local and national benefits data, children in low-income families’ data and SIMD 2020 data. The report determined that the intermediate data zone of ‘Burghead, Roseisle and Laich’ is placed 21/24 in terms of estimated poverty. With 1 being highest levels of poverty and 24 been lowest. Additional local profile information is included in Appendix 3 0 1000 2000 3000 4000 Moray Coast Maryhill Varis Culbin Linkwood Other Number of Patients in IV30 5 Post Code Registered at GP Practice Page 162
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4.13 A summary of the points raised through the various components of the community consultation are included below. A detailed Consultation Report is included in Appendix 1. 4.14 The majority of respondents to the consultation questionnaire (75%) did not support the proposed closures of the Burghead and Hopeman branch surgeries. 15% were unsure and 10% were supportive; 4.15 The majority of respondents (84% for Burghead and 82% for Hopeman) felt the proposed closures would have a negative impact. Reasons included: • Fears that residents’ health and wellbeing will be at risk if they experience barriers to accessing a GP service. • The impact on community life of losing a key local service at a time of population growth due to new housing developments. • Particular difficulty getting to Lossiemouth surgery for the elderly, disabled and parents with young children. • Transport concerns for all patients given the lack of a direct service bus connecting Burghead, Hopeman and surrounding communities with Lossiemouth. • Concern over increased patient list at Lossiemouth surgery putting additional pressure on the practice, resulting in longer waiting times for appointments. Key themes from the public consultations meetings included: • The impact on communities with a growing population of losing an important local service. Residents not receiving the local healthcare service they are entitled to. • The time, cost and stress for patients in having to get a service bus from Burghead and Hopeman to Elgin and then to Lossiemouth for a short appointment, followed by the return journey. This can take as long as four hours. • The limited time the Dial a Bus service is available and the need to book a day in advance. • Concern that transport is a barrier to accessing health care for many, particularly more vulnerable residents including the elderly, those with health conditions and children, and the impact this will have on their health and wellbeing. • Non-acceptance that the branch surgery buildings are not fit for purpose or could not be ungraded to meet requirements. • Patients are not seeking an equivalent building or service as that offered in Lossiemouth but seeking to retain some form of health service. • Consideration of the option of keeping one of the two branch surgeries open or of a new build funded through developer contributions. • The offer made by the landlord of the Burghead building to fund improvements. • Concern as to whether Moray Coast Medical Practice is prepared to return to working in the branch surgeries. Page 163
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• The difficulties is getting through to Moray Coast by phone and in accessing an appointment for a face-to-face GP consultation. • A decision having already been made on the future of the two branch surgeries and the consultation being a meaningless exercise as peoples’ concerns were not being listened to. 4.16 A small number of emails and letters were received. Key themes from these echoed those from the consultation questionnaire and public meetings. 4.17 One submission was received from Hopeman Community Minibus Committee. This highlighted the continued efforts of volunteers to support patients to attend health appointments at Lossiemouth and elsewhere, and requested consideration of funding towards the sustainability of community transport scheme which is available at the times when the council’s Dial a Bus is not. 4.18 Health and Social Care Moray require to deliver services that are sustainable in terms of staffing, resourcing, facilities and financing. We believe that to have one well-staffed and resourced building and a process in place that coordinates prevention and self-management approaches, primary care provision, and adheres to the principles of HomeFirst will provide the most sustainable service at this current time. 4.19 We greatly value the discussions that have taken place with community members within the Lossiemouth Locality and acknowledge the concerns that have been raised and where possible have tried to mitigate these concerns as outlined in Section 4.36 below. We believe that working from one fixed location can complement a community based approach where: • Housebound patients are seen as a priority. • Community pharmacy and community organisations are supported to develop local services. • Digital technology is embraced providing convenience for the patient, low impact on the environment and effective use of staffing. • Digital hubs are created within communities where people can access digital devices and can be supported to utilise the technology. • Transport to appointments is provided for those who do not have/cannot access a vehicle. • Health and Social Care staff outreach into the community for specific individuals/groupings. • Community clinics are facilitated on a needs basis utilising local community facilities. Health and Social Care Moray believe this is the best use of public funding to meet the health and social care needs of the local population. 4.20 Key points of discussion relevant to the recommendation are outlined in section 4.21 to 4.37 below. 4.21 Transport: Community members overwhelmingly felt that transport provision between the Moray coast villages and Lossiemouth town centre was inadequate. There is a connecting bus service but this involves travelling via Elgin and changing bus. The transport issue was raised not only in relation to challenges faced by patients travelling to appointments at the Lossiemouth Medical Centre but also for residents to access broader health and wellbeing Page 164
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activities such as sport, leisure and community events as well as enabling access to beaches and forest walks. As a test of change from April 2022 onwards patients from the coastal villages had the option to book a Moray Council Dial a Bus vehicle to transport them to and from their appointment. This was a dedicated bus providing a door to door service between 10.00am and 2.30pm. The service is free for concessionary card holders and has a comparative price to Stagecoach services for paying customers. The uptake of the service has been very minimal with an average of only 1 resident in total using the service per week. The consultation highlighted that the service could be promoted more broadly and that patients had concerns about being left at the Lossiemouth Medical Centre if their appointment ran over time. There will therefore be an enhanced promotion of the service in January 2023 with an emphasis on reassuring patients that travel home will be provided by the Dial a Bus or by a funded taxi. 4.22 The low uptake of the dedicated service has made it difficult to present a case to Moray Council for extending the length of day of the service, or to put forward a case to Stagecoach to consider a timetabled bus service. Historically the uptake of Dial a Bus in the Lossiemouth area has been lower than in other areas of Moray; we continue to try and promote the service as Dial a Bus could provide the answer to the current transport concerns and with a move towards electric vehicles could provide a future enhanced low carbon solution. The Community Mini Bus provides a vital role in supporting residents to travel a wide range of appointments and activities. Health and Social Care Moray would like to help support this service develop further. 4.23 Digital Technology: The use of digital technology for assessment and consultations has generated interesting discussion and comment throughout the engagement and consultation activity. Responses were split in terms of the benefits of remote patient consultation versus face to face consultation. There was a similar mixed split in relation to respondents’ preference to be assessed by a GP rather than another Healthcare Professional. This split is reflected nationally as well as locally in Moray. In part the split can be related to the age of the respondent in terms of younger people being more comfortable with remote consultations and seeing a broader range of health professionals but this over simplifies the situation. Particularly in relation to digital technology where accessibility, cost and support are also key factors. Interestingly 98% of the respondents to the Lossiemouth Locality engagement questionnaire (2021) stated they had a device that allowed access to the internet at home; of which 83% had unlimited access and 15% had limited access. Of the total number of respondents 9% stated they would like support to use their digital device. The intention would be to work widely with the broad community grouping of Medical Practice patients to utilise the online platforms and to carry out more specific support/coaching with the 9% of patients who would value specific support. Where possible we will work with the local community/third sector providers to facilitate this support and develop capacity locally. 4.24 Access to GP’s: A number of respondents raised concerns about access to GPs and equated this in part due to the temporary closure of the branch surgery buildings. There was a sense that when the buildings were open it was possible to book an appointment with a specific GP and that appointments were readily available. The branch surgeries actually carried a very small proportion of the GP workload, though they did operate at capacity. A number of respondents also commented on the GPs moving to part time contracts and Page 165
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this decreasing the number of GPs available. Although it is correct that a greater number of GPs are on part time contracts the ‘working time equivalent’ of GPs at the Moray Coast Medical Practice has increased slightly over the past 6 years as has the number of Advanced Nurse Practitioners. A key influencing factor has been availability of suitably trained staff and subsequent recruitment. A key factor in public perception is the need to see a GP as opposed to another more suitability skilled and experienced health care worker. Following the introduction of the 2018 General Medical Services (GMS) Contract in Scotland GMS contract: 2018 - gov.scot (www.gov.scot), there has been a refocusing on the role of the GP as the 'expert medical generalist.' The role of the GP has evolved over the years, and people are living longer with more complex health needs which has increased demand on GP services. To enable the GP to focus on those with complex care needs, the GMS 2018 contract aims to increase the wider Primary Care multi-disciplinary team providing a highly skilled team who can support the GP in their role and a redistribution of workload. In Moray, we have already made good progress on implementing the Primary Care multi-disciplinary teams, and the majority of local practices now benefit from Pharmacotherapy teams, Musculoskeletal (MSK) Physiotherapist, Primary Care Occupational Therapists, Treatment room staff and visiting vaccination teams. 4.25 Multi-disciplinary Teams: A Multi-disciplinary Team (MDT) is a group of health and social care staff who are members of different organisations and professions (e.g. GPs, social workers, nurses), that work together to make decisions regarding the treatment of individual patients and service users. Multi-disciplinary Teams are used in both health and care settings. Moray Coast Medical Practice have an extremely well-staffed and resourced Multi- disciplinary Team as outlined in section 4.3 above. Having the team all based at one location increases staff and patient safety, improves the quality of decision making and increases patients access to the right person at the right time. 4.26 Buildings: Much of the discussion understandably has focused on the two branch surgery buildings; which healthcare standards they meet, potential refurbishment options, and the potential for new builds. At the centre of the recommendation within this report is the opportunity to develop a modern sustainable model of service provision for the Lossiemouth locality based on having one well-resourced building which is staffed with an extensive multi- disciplinary team and provides a safe environment for staff and patients. It should be noted that the recommendation of the permanent closure of the branch surgery buildings does not provide a direct cost saving to the MIJB, however it does reduce additional spend through a reduction in leased buildings and their associated running and maintenance costs. A question raised on several occasions was the availability of developer obligations to fund work. Developer obligations can only be used to increase capacity at a medical practice to accommodate the additional patients from any new housing development. It cannot be used for maintenance, nor can it be used to make good any existing deficiencies. Moray as a whole are only securing developer obligations towards the main premises not branch surgeries. Therefore for Moray Coast any monies secured for housing developments in Burghead or Hopeman would be secured against the Lossiemouth building. The reasoning being that the branch surgeries only provided limited services and in the case of Burghead and Hopeman were never open full time. However the Lossiemouth premises can provide a wide range of services and is open full Page 166
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time. Current developer obligations for the Lossiemouth locality amount to £57,964. A number of respondents suggested that if the two branch surgeries cannot remain open then could a new build be planned. The Property and Planning team estimate the costs for a 2 clinic surgery to be £2.6 million pounds and £4.2 million for a four clinic surgery. Understandably the community have questioned these figures, however they are conservative estimates based on recent new builds of a similar size. The Burghead landlord did offer to part pay refurbishment costs for the expansion of the current Burghead premises on renegotiation of the current lease. This would however require Health and Social Care Moray to take on a new lease and a proportion of the refurbishment, refit and the ongoing maintenance costs whilst still facing the challenges of staffing an additional premises and the associated staff and patient safety concerns. 4.27 Safety: Safety of staff and patients is paramount. GP’s or nurses working in isolated situations will experience greater risk in terms of decision making in a crisis situation. Discussions during the consultation phase suggested that a GP, nurse, and receptionist could be on site at the same time however there is not the staffing establishment to make this achievable. It is not possible to provide the same level and breadth of expertise to patients visiting a branch surgery. 4.28 Sustainability: Recruitment and retention of health and social care staff has never been more difficult. This coupled with high sickness rates in part due to the impact of the pandemic makes staffing a medical practice incredibly challenging at this current time. Therefore offering services from one location ensures the most effective use of available staff, and ensure those patients most in need can be assessed and treated as promptly as possible. 4.29 Place: A sense of place, and of community, came through strongly in peoples’ responses; in terms of residents connecting themselves to specific coastal villages, and those respondents not feeling particularly connected to Lossiemouth town or indeed the other nearby coastal villages. A number of people felt that the branch surgeries were an integral part of the community and that many people had moved to the villages, in part, because these provisions were available locally. This at a time when other businesses such as banks and post offices are also closing their branch services. In terms of Health and Social Care there is an opportunity to relook at the provision of services within a community through utilising community building on a needs basis and working with local groups and business to coproduce future services. 4.30 Patient Population: With the projected population increase for the coastal villages a small number of respondents highlighted the need for increased community provision and questioned the rationale for the buildings to remain closed given potential housing developments. On the whole people were unaware that all planned housing developments have been incorporated into the current calculation to determine the appropriate amount of clinic space for the Lossiemouth Locality. It is not envisaged that the patient population would outgrow the capacity of the current Lossiemouth building in the near future. 4.31 Equity of Provision: On the theme of Equity of Service Provision there was equal support for differing models. The convenience of attending the branch surgeries was offset by the benefit of attending a modern building with a vast multi-disciplinary team on site to cater for a wide range of patient needs. Respondents noted that benefits could be seen in both models. A number of Page 167
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respondents indicated they would be happy to use the current buildings in their current state and with current staffing levels and would be willing to accept the risks. This is not a risk however that Health and Social Care Moray can endorse for patients or staff. 4.32 Vulnerable Groups: A theme that emerged through the questionnaire responses and face to face sessions was respondents speaking on behalf of individuals from vulnerable groups. Many people responding noted their own ability to travel at this time but acknowledged that others in the community are less able to do so. Respondents also acknowledged that they may not be able to travel when they grow older so they were planning for a service that they perceived others needed now and that they may need later. To this end 41% and 36% of respondents had never used the Burghead or Hopeman Branch Surgery respectively. 4.33 Community Provision: The engagement and consultation events provided some useful discussion regarding the potential to bring more services out into communities but not necessarily from one fixed location such as a branch surgery building. There is potential to support the most vulnerable within their own home and to utilise community locations for specific events such as vaccination clinics and health improvement activity. This concept is referred to as pop up hubs/clinics. This model has had success in other areas of Moray but a number of respondents from the coastal villages indicated it difficult to move beyond the concept of a fixed specific building based provision and the convenience this provides. There has been an increase in nursing and health care support worker provision available within the community settings to support individuals with long term conditions, patients returning from hospital and palliative patients. This continues to be a key focus for Health and Social Care Moray. 4.34 Financial Implications: Historically leases for GP Practice buildings and branch surgeries would be held by the GP Practice. However this has recently changed and any new leases would require to be held by the NHS, and in this specific case Health and Social Care Moray, alongside all associated costs for the term of the new lease. Therefore considering a branch surgery of any description would be committing Health and Social Care Moray/NHS to a long- term lease for premises without assurance of any staffing or service provision. The basis of this proposal is about the long-term sustainability of a primary care service for the Lossiemouth Locality. 4.35 Work to refurbish the vacated Dental Suite at the Lossiemouth building was approved at the MIJB on 30 September 2021 (para 10 of the minute refers). A report will require to be submitted to the NHS Grampian Premises Group and then to the Asset Management Group to finalise this. 4.36 Mitigating Actions: The decision to recommend the permanent closure of the Burghead and Hopeman Branch Surgeries has not been an easy one, and in reaching this recommendation HSCM acknowledge the community response to the engagement and consultation process. However we believe permanent closure is required to ensure a sustainable health and social care service for the Lossiemouth Locality. We have listened to the concerns raised by the community members and will put a range of actions in place to mitigate the risks/concerns raised and also to mitigate impact on protected groups as Page 168
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outlined in the Equalities Impact Assessment. Timescales for completion are in brackets: i. Extensive public information campaign on the closure of the branch surgeries and current transport options to appointments at Lossiemouth (Jan – Feb 2023) ii. Completion of the review and updating of the phone/appointment system (Jan 2023) iii. Promote, through publicity and community sessions, how best to access the appropriate health and social care professional (Feb – Apr 2023) iv. Monitor effectiveness of systems to access a local health and social care professional (Feb – July 2023) v. Increased promotion of the Dial a Bus Service within communities (Jan – Feb 2023) vi. Provide reassurance to communities that patients will be transported home, by bus or taxi, if their appointment runs over time (Jan – Feb 2023) vii. Update briefing information on Dial a Bus Service for all administration staff at Moray Coast Medical practice (Jan 2023) viii. Further discussion with Moray Council to extend Dial a Bus Service if need can be identified (Feb - July 2023) ix. Support provided to the Community Mini Bus Project to develop services (Jan 2023 onwards) x. IT/Digital platforms further developed to enable remote communication with GP/health and social care professionals and support provided to community members to develop their digital skills (Feb – June 2023) xi. Locations sought for shared IT/Digital technology within local communities and subsequent support provided to access these platforms (Feb – June 2023) xii. Housebound patients to continue to receive GP/Health and Social Care professional home visits. It is a contractual requirement to receive the full range of General Medical Services (Jan 2023 onwards) xiii. Locality Manager to attend the Moray Transport Forum (Jan 2023 onwards) xiv. Social prescribing model to be introduced to Moray Coast Medical Practice (Jan 2023) xv. Promote the Multi-Disciplinary Team serving the Lossiemouth Locality through publicity and community sessions, (Feb to July 2023) xvi. Nurse/Health Professional led community provision is reviewed (Jan - Jun 2023 and onwards) 4.37 The above mitigating actions will be reviewed through the Forres and Lossiemouth Locality Planning process. The Lossiemouth Steering group for this process meets every two months. Actions can be reported back to the MIJB through the Locality Planning Process reporting cycle. 5 SUMMARY OF IMPLICATIONS (a) Corporate Plan and 10 Year Plan (Local Outcomes Improvement Plan (LOIP)) and Moray Integration Joint Board Strategic Plan “Partners in Care 2022 – 2032” The policy and approach set out in this report is consistent with the ambitions of the MIJB Strategic Plan in providing care at home or close to home with a particular emphasis on the needs of older people. This locality approach is Page 169
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also consistent with the ambitions of the Moray Council Corporate Plan and the Moray Community Planning Partnership LOIP. (b) Policy and Legal A number of policy and legal implications require to be considered (c) Financial implications Financial implications relating to building leases, potential construction/refurbishment, resourcing and staffing costs (d) Risk Implications and Mitigation Risks and mitigating factors are outlined within the report (e) Staffing Implications There are implications on staffing provision and on staff health and wellbeing (f) Property Implications relating to the Moray Coast Medical Practice surgery premises in Lossiemouth, Hopeman and Burghead (g) Equalities/Socio Economic Impact Equality Impact Assessment (EQIA) completed and attached as Appendix 2 (h) Climate Change and Biodiversity Impacts Potential increase in carbon emissions due to patients travelling further to access facilities. This is offset to a degree by availability of a dedicated Dial a Bus service and the decrease in energy usage following the reduction from 3 buildings to 1 building (i) Directions None arising directly from this report. (j) Consultations Sean Coady, Head of Service, Health and Social Care Moray Simon Bokor-Ingram, Chief Officer, Health and Social Care Moray Gerry Donald, Head of Property and Asset Development, NHS Grampian Carmen Gillies, Interim Strategy & Planning Lead, Health and Social Care Moray Allan Robertson, Property Planning Manager, NHS Grampian Sheila Roberts, Primary Care Resources Manager, NHS Grampian Gareth Evans, Property Transactions Manager, NHS Grampian Bob Sivewright, Finance Manager, NHS Grampian Nigel Firth, Equality and Diversity Manager, NHS Grampian Alison Frankland, Practice Manager, Moray Coast Medical Centre Eileen Rae, Practice Manager, Maryhill Medical Practice Peter Maclean, Service Manager for Primary Care Contracts, NHS Grampian Christine Thomson, Lead Pharmacist Primary Care, Health and Social Care Moray Rosemary Reeve, Primary Care Development Manager, NHS Grampian Fiona McPherson, Public Involvement Officer, Health and Social Care Moray Tracey Sutherland, Committee Services Officer, Moray Council Who are in agreement with the contents of this report as regards their respective responsibilities. Page 170
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6 CONCLUSION 6.1 The MIJB are asked to note the content of the report and approve the permanent closure of the Burghead and Hopeman Branch Surgeries. Author of Report: Iain Macdonald, Locality Manager Background Papers: Appendix 1 Consultation Response Summary Appendix 2 Equality Impact Assessment Appendix 3 Community Profile Ref: Page 171
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Appendix 1 Health & Social Care Moray Report on the consultation for the proposed permanent closure of the Moray Coast Medical Practice branch surgeries in Burghead and Hopeman 8 September – 16 December 2022 Date of report: 4 January 2023 Item 11. Page 173
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Consultation report - Moray Coast Medical Practice branch surgeries 2 1. Background Moray Coast Medical Practice is an independent contractor which provides services under the General Medical Services contract to a patient population of 10,195. Services are provided from the main building at Lossiemouth and two-roomed branch surgeries in Burghead and Hopeman which are 7.8 miles and 5.5 miles away. The COVID-19 pandemic meant that Moray Coast Medical Practice - like all GP practices in the UK – had to rapidly change the way it delivered consultations. In March 2020, the UK and Scottish Government instructed GP practices to conduct consultations remotely unless there was urgent need for a face-to-face appointment. As a result, the practice stopped using face-to-face appointments as the first point of contact. Instead, most patients were offered telephone or video consultations. The Lossiemouth surgery has continued to be used when in-person appointments are required. Both branch surgeries, which have operated on a part-time basis for the past 30 years, temporarily closed in March 2020 due to inadequate space to allow social distancing and an inability to meet other risk mitigation measures. Patients on the housebound register and those who are too ill to attend Lossiemouth medical centre are visited at home. The Lossiemouth premises was built on Ministry of Defence land with a 25 year lease which is due to expire in 2033. The Burghead branch surgery is rented from a private landlord and the lease is due to expire in December 2023. Hopeman branch surgery is a GP owned property. 2. Executive summary The case for change The future of the branch surgeries had been discussed by Moray Coast Medical Practice and Health & Social Care Moray for many years prior to the COVID-19 pandemic. Consideration as to whether the premises at Burghead and Hopeman can be safely reopened have been based on the following key points: • Inspections shows neither of the buildings in Burghead and Hopeman are fit for the purpose of running a modern medical branch surgery. They fail to meet legislation and standards for the delivery of modern, high quality healthcare, particularly for patients with a disability. This is due to their size, layout and condition (internal and structural). • Even with significant investment, the failures cannot be resolved due to the limited space to extend and improve the buildings. • Moray Coast Medical Practice does not support a return to working in the buildings. They have concerns for the safety and welfare of patients and staff. Page 174
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Consultation report - Moray Coast Medical Practice branch surgeries 3 • The practice is not able to deliver services to patients at Burghead and Hopeman at the same standard as in the Lossiemouth medical centre. Health & Social Care Moray has recommended the permanent closure of the Burghead and Hopeman branch surgeries for the following reasons: • Lossiemouth is a modern, fit for purpose medical centre. It provides high quality facilities for patients and staff. It is fully wheelchair accessible. There are opportunities to expand and improve the clinical space. • Patients attending at Lossiemouth have access to a wider range of services and different members of the practice team. They also have access to the full multi-disciplinary team of health and care professionals who are based together in the Lossiemouth building. • Concentrating services at Lossiemouth will support Moray Coast Medical Practice to secure a sustainable, effective and equitable model of service provision for the broader Lossiemouth Locality. • Recognising there is no direct Stagecoach bus service between Burghead, Hopeman and Lossiemouth, a bookable Dial M for Moray on demand bus service is currently in place Monday to Friday between 10.00am and 2.30pm to take people from the coastal villages and surrounding communities to Lossiemouth for health care appointments and any other journeys. This is bookable a day in advance. Consultation activity A total of 653 consultation questionnaire response forms were received (both online and in hard copy). Seven emails/letters were received. Two public consultation meetings took place with around 140 attendees. Questionnaire responses • The majority of respondents to the questionnaire (75%) do not support the proposed closures of the Burghead and Hopeman branch surgeries. 15% were unsure and 10% were supportive; • The majority of respondents (84% for Burghead and 82% for Hopeman) felt the proposed closures would have a negative impact. Reasons included: • Fears that residents’ health and wellbeing will be at risk if they experience barriers to accessing a GP service. • The impact on community life of losing a key local service at a time of population growth due to new housing developments, • Particular difficulty getting to Lossiemouth surgery for the elderly, disabled and parents with young children, Page 175
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Consultation report - Moray Coast Medical Practice branch surgeries 4 • Transport concerns for all patients given the lack of a direct service bus connecting Burghead, Hopeman and surrounding communities with Lossiemouth. • Concern over increased patient list at Lossiemouth surgery putting additional pressure on the practice, resulting in longer waiting times for appointments. Consultation events Key themes from the public consultations meetings included: • The impact on communities with a growing population of losing an important local service. Residents not receiving the local healthcare service they are entitled to. • The time, cost and stress for patients in having to get a service bus from Burghead and Hopeman to Elgin and then to Lossiemouth for a short appointment, followed by the return journey. This can take as long as four hours. • The limited time the dial-a-bus service is available and the need to book a day in advance. • Concern that transport is a barrier to accessing health care for many, particularly more vulnerable residents including the elderly, those with health conditions and children, and the impact this will have on their health and wellbeing. • Non-acceptance that the branch surgery buildings are not fit for purpose or could not be ungraded to meet requirements. • Patients are not seeking an equivalent building or service as that offered in Lossiemouth but seeking to retain some form of health service. • Consideration of the option of keeping one of the two branch surgeries open or of a new build funded through developer contributions. • The offer made by the landlord of the Burghead building to fund improvements. • Concern as to whether Moray Coast Medical Practice is prepared to return to working in the branch surgeries. • The difficulties is getting through to Moray Coast by phone and in accessing an appointment for a face-to-face GP consultation. • A decision having already been made on the future of the two branch surgeries and the consultation being a meaningless exercise as people’s concerns were not being listened to. Email and letters in response to the consultation A small number of emails and letters were received. Key themes from these echoed those from the consultation questionnaire and public meetings. One submission was received from Hopeman Community Minibus Committee. This highlighted the continued efforts of volunteers to support patients to attend health appointments at Lossiemouth and elsewhere, and requested consideration of Page 176
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Consultation report - Moray Coast Medical Practice branch surgeries 5 funding towards the sustainability of community transport scheme which is available at the times when the council’s dial-a-bus is not. Key points for consideration Local concern and anxiety expressed should the proposed closure of the branch surgeries go ahead is apparent in the following: • The response to the consultation questionnaire where the majority of respondents (75%) do not support the closure of the branch surgeries in Burghead and Hopeman; • The attendance at the two public consultation meetings where residents expressed strong concerns for the proposed closure • Consistency of concern expressed across all channels of feedback into the consultation and consistency of themes. 3. The consultation process The aims and objectives of the consultation were: • To ensure the patient population was aware of the proposal. • To ensure the patient population had the opportunity to have their say on the proposal. • To provide sufficient evidence and information for the Moray Integration Joint Board to make a decision on the proposal; • If appropriate, to ensure that any issues and themes raised are taken into account and any potential mitigating actions are considered. The consultation process was overseen by Health & Social Care Moray’s Lossiemouth Locality Engagement and Consultation Steering Group. To inform patients of the consultation on the proposed permanent closure of the branch surgeries at Burghead and Hopeman and to let them know how to feedback their views, a letter, frequently asked questions sheet and consultation response form was sent to all patients of Moray Coast Medical Practice aged 16 and over (8,390). The letter provided details on the two public consultation meetings and additional ways for people to respond, including using an online consultation form, by email and telephone. Copies of the response form were also made available at the meetings. The consultation opened on 8 September 2022 and closed after 12 weeks on 16 December 2022. It was promoted on Health & Social Care Moray’s social media platforms and through the issue of a press release which secured media coverage. All information, Page 177
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Consultation report - Moray Coast Medical Practice branch surgeries 6 including previous Board papers, were available on the Health & Social Care Moray website: https://hscmoray.co.uk/branch-surgeries-consultation.html 4. Response to the consultation This section details the response received to the consultation. Consultation form 251 online response + 402 hard copy responses = total of 653 responses. • More women than men responded • The highest number of responses came from people aged 45-64 • Over a third identified as being a person with a disability or long-term health condition Do you support the proposed permanent closure of the branch surgeries in Burghead and Hopeman? The majority of respondents (75%) did not support the proposal. This question was answered by 651 respondents. Answer choices Responses Yes 10.29% 67 No 75.12% 489 Not sure 14.58% 96 Answered 651 Skipped 4 10% 75% 15% 0% 10% 20% 30% 40% 50% 60% 70% 80% Yes No Not sure Do you support the proposed permanent closure of the branch surgeries in Burghead and Hopeman? Page 178
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Consultation report - Moray Coast Medical Practice branch surgeries 7 Have you ever used the Burghead branch surgery? Answer choices Responses Yes 58.84% 366 No 41.16% 256 Answered 622 Skipped 33 Thinking about the proposed permanent closure of the Burghead branch surgery, what impact do you consider this will have? The majority of respondents (83.65%) felt the proposed closure would have a negative impact compared to 12.22% who felt it would have no impact. A further 4.13% considered it would have a positive impact. Answer choices Responses No impact 12.22% 77 A positive impact 4.13% 26 A negative impact 83.65% 527 Answered 630 Skipped 25 Respondents were asked to tell us more about the impact they considered permanent closure of the Burghead branch surgery would have. 473 people answered. Issued raised included: Loss of a local service and transport This theme was mentioned in 346 responses. The branch surgeries have been an integral part of village life for decades. Axing them will lead to their decline. 12% 4% 84% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% No impact Positive Negative Thinking about the proposed permanent closure of the Burghead branch surgery, what impact do you consider this will have? Page 179
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Consultation report - Moray Coast Medical Practice branch surgeries 8 Patients highlighted the need for a GP surgery in Burghead and the importance of health care services being available in rural communities which were already losing many other services. People valued having health care provision close to home, meaning they did not have to make travel arrangements or rely on others for help. Not having to travel saved time, money and reduced the impact on the environment. It was felt that some type of provision, no matter how limited the branch surgery may have been, was better than nothing. Traditional coastal villages were said to have higher proportions of older residents who relied on easy access to services. People were concerned they would have greater difficulty getting to Lossiemouth as they got older. When patients had been unable to be seen at Burghead, they were able to access the surgery at Hopeman and vice versa. People had reassurance that came from having a surgery on their doorstep if they suddenly became unwell. The population is rising due to new houses being built and closure of the service was seen as a backward step when demand for appointments was increasing. Burghead was said to deserve a surgery just the same as other communities and patients should not be expected to travel. Their choice was being removed. It should not be assumed that everybody has their own transport. Public transport in the area is very limited. Expecting people to take four buses to Lossiemouth and return, which is via Elgin and can take up to four hours, was branded unfair. People do not want to travel when they are unwell. Conditions in winter can make the journey and waiting times particularly difficult. People did not feel the council’s dial-a-bus service was a suitable replacement. Journeys have to be booked a day in advance which mean it cannot be used for on the day appointments, and operates for a limited period. Patients felt it would be too stressful to try to co-ordinate appointments with the bus times and were worried about what would happen if their appointment time over ran. There is a bus service between Burghead and Hopeman which supports patients getting to one surgery or the other. Impact of permanent closure on more vulnerable residents This theme was mentioned in 74 responses and was closely linked to access to transport. It was considered the elderly, people with a disability or mobility issue and parents with young children would be hardest hit by the loss of the branch surgeries as they would struggle more than other groups of patients to travel to Lossiemouth. The extended journey time via Elgin and the wait for connections would be detrimental to their health when they were already feeling unwell. People unable to access public transport would be hit financially if they had to pay for a taxi. Page 180
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Consultation report - Moray Coast Medical Practice branch surgeries 9 There were concerns that not being able to access GP services without support would impact on people’s feelings of independence. They need the reassurance of having medical help close by. Older people were worried what would happen when they could no longer drive themselves to appointments. It was again put forward that the worry and stress of getting to Lossiemouth would make people reluctant to try to get an appointment, impacting negatively on their health and wellbeing and adding to levels of health debt. Access to and capacity at Moray Coast Medical Practice This theme was mentioned in 81 responses. People said they had never had difficulty in getting an appointment in Burghead. They considered the proposal would result in a poorer service. Patients were concerned there would be increased demand for appointments at the Lossiemouth surgery, leading to longer waiting times and a delay in diagnosis and treatment. Respondents felt the practice was already struggling to cope with the existing workload and they highlighted the difficulties experienced in getting through to the practice by phone and in getting to see a doctor. This view was shared by patients in Lossiemouth as well as those in Burghead and Hopeman. People saw the branch surgeries as benefitting Lossiemouth by supporting capacity. Respondents were worried people would be put off trying to make an appointment and that their health and wellbeing would deteriorate as a consequence. They pointed to the increasing elderly population in Burghead and Hopeman who would have a greater need to be able to access GP services in a timely way. Concern was expressed for the pressure on existing practice staff and it was questioned whether more staff would be recruited to respond to the increased demand. Respondents highlighted the difficulties patients experience in using technology to access services such as eConsult. Branch surgery buildings This theme was mentioned in 11 responses. People questioned why the current buildings could not continue to be used, highlighting that they have served patients well for many years and the communities were content to make do with what had had before, rejecting the position of Health & Social Care Moray that they are not fit for purpose. Page 181
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Consultation report - Moray Coast Medical Practice branch surgeries 10 The costs of a new build surgery were also questioned, with patients stating they were not seeking a facility which replicated what was available at Lossiemouth. Decision already made This theme was mentioned in nine responses. A small number of people questioned the validity of the consultation process, expressing the view that a decision to close had already been taken and that this was a “tick box exercise”. It was stated that as no funding had been identified for a new build or refurbishment of the existing buildings, closure was a “done deal.” Supportive and neutral Points made among the 10 supportive and 18 neutral responses were that as the branch surgeries were already shut they may as well stay shut, and that patients would continue to be seen at the Lossiemouth building where they have access to a larger practice team. It would be more efficient for the practice to provide services from one building rather than three. Have you ever used the Hopeman branch surgery? Answer choices Responses Yes 63.61% 395 No 36.39% 226 Answered 621 Skipped 34 Thinking about the proposed permanent closure of the Hopeman branch surgery, what impact do you consider this will have? The majority of respondents (81.94%) felt the proposed closure would have a negative impact compared to 12.10% who felt it would have no impact. A further 5.97% considered it would have a positive impact. Answer choices Responses No impact 12.10% 75 A positive impact 5.97% 37 A negative impact 81.94% 508 Answered 620 Skipped 35 Page 182
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Consultation report - Moray Coast Medical Practice branch surgeries 11 Respondents were asked to tell us more about the impact they considered permanent closure of the Hopeman branch surgery would have. 417 people answered. 93 said their comments with regard to Hopeman were the same as they had expressed for Burghead. Issued raised were very similar and included: Loss of a local service and transport This theme was mentioned in 154 responses. The population of the village is growing but has access to fewer services. Village life is being eroded and having a local surgery was the reason some people moved to Hopeman. Not having easy access to health care support would put additional stress on people who were unwell. Savings were being put before patient care and at the cost of leaving residents with a much poorer service than they deserve. People are more likely to stay healthy if the doctor’s surgery is nearby as they will more likely go if they have a concern or feel ill rather than ignore or put off making an appointment. They feel more comfortable being seen in a small surgery. Not everyone has the option to take their own transport and the limitations in public transport and the dial-a-bus service were echoed from previous comments. People cannot always rely on relatives or community transport volunteers to take them to appointments. There is a bus service between Burghead and Hopeman which supports patients getting to one surgery or the other. Many elderly or less mobile patients would not be able to travel by bus causing them financial hardship if having to travel by taxi. 12% 6% 82% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% No impact Positive Negative Thinking about the proposed permanent closure of the Burghead branch surgery, what impact do you consider this will have? Page 183
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Consultation report - Moray Coast Medical Practice branch surgeries 12 Closure does not support the push towards people undertaking fewer journeys by car. Impact of permanent closure on more vulnerable residents This theme was mentioned in 29 responses and was closely linked to access to transport. There are many older people and parents of young children who do not have access to transport. Frailer residents who do not qualify for home visits will have reduced access to medical care. There was also concern there are not enough staff to meet increasing demand for home visits. The loss of the local service would have a greater impact on patients with serious medical conditions and people with limited mobility. People on low income would be impacted by increased travel costs. Access to and capacity at Moray Coast Medical Practice This theme was mentioned in 39 responses. People said they had never experienced difficulty getting an appointment at Hopeman. They considered the proposal would result in a poorer service. Patients considered closure would put more pressure on the practice’s provision at Lossiemouth, with more patients meaning fewer available appointments. Many had not had a positive experience of accessing GP services since the start of the COVID- 19 pandemic and were concerned waiting times would increase and the Lossiemouth surgery would be too busy. Branch surgery building This theme was mentioned in five responses. Repairs and improvements to the Hopeman surgery should have been carried out previously so that it remained fit for purpose, rather than being allowed to be run down leading to the current closure. It was considered improvement work to meet legislation could easily be carried out at reasonable cost when compared to overall health budgets. Decision already made This theme was mentioned in 11 responses. Valid points were made at the public meeting but the panel was not prepared to listen. The consultation materials made it appear a decision had already been taken to close the surgeries. Page 184
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Consultation report - Moray Coast Medical Practice branch surgeries 13 Positive and neutral Points made among the six supportive and nine neutral comments were that having three surgeries close together was not a sensible model and having GPs working from a central locations would increase the availability of appointments. What action could be taken to reduce any negative impact resulting from the proposed closure of the branch surgeries? 401 respondents provided comment. Retain the existing branch surgeries This theme was mentioned in 146 responses. The overwhelming comment was not to close such vital resources. It was important to people that at least one branch surgery was retained although any closure would result in a negative impact. Patients do not feel the branch surgeries need to be equivalent to the main surgery at Lossiemouth – being able to see a doctor or nurse locally was more important to them and most people have no issue with the size, layout and condition of the buildings. Transport This theme was mentioned in 140 responses. Improvements would have to be made in transport links, with a frequent, reliable direct bus service between Burghead, Hopeman and Lossiemouth which also linked in with smaller communities. An on demand shuttle bus could run on days dedicated for Burghead and Hopeman patients. A volunteer car share scheme could be set up or a reduced rate taxi service made available. People would need more information on dial-a-bus and operating times would need to increase. It should be easier to book transport for on the day appointments. Waiting facilities should be provided at Lossiemouth, with a suggestion that the empty unit next to the surgery be utilised. A safe cycle and walking route along the B9040 should be created. Existing buildings and new build This theme was mentioned in 40 responses. One or both of the existing branch surgeries could be adapted and upgraded to meet requirements. Both are in good locations. The funding proposed for increasing the clinical space at Lossiemouth should be spent at Burghead and Hopeman instead. Page 185
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Consultation report - Moray Coast Medical Practice branch surgeries 14 If the buildings do not meet disability requirements they should be adapted rather than closed and disabled patients forced to travel to Lossiemouth instead. A new surgery could be built in either Burghead or Hopeman or a location in between the two communities. These would be accessible using the current service bus. Developer contributions could contribute to the cost or a local developer could be approached to construct a new surgery. The costs put forward by Health & Social Care Moray for a new build were disputed. The offer by the Burghead landlord to improve the building should be taken up. Moray Coast Medical Practice – access and capacity This theme was mentioned in 37 responses. Patients shared their negative experiences of accessing services since March 2020. There are concerns people are in poorer health because they have not been able to access health care. They called for improvements to the practice telephone system and a return to being able to see a GP without having to go through a difficult triage process. Patients want better continuity of care – being able to see the same GP who knows them so they do not have to repeat their story all the time. More should be done to reduce waiting times. The practice should recruit more staff such as nurse practitioners and for part-time GPs to increase their hours to be able to offer more appointments. Walk-in slots should be offered at the end of the day. Alternative premises and increased provision This theme was mentioned in 19 responses. Surgeries and clinics could be run from other buildings in the villages such as halls or schools or use could be made of a mobile clinic. Other health care practitioners as well as a GP could be made available. Home visits should be provided on request. Local facilities and IT support should be provided to help patients’ access virtual appointments. Consultation meetings Two public consultation meetings were facilitated by the steering group. These events took place during October and November 2022 • Hopeman Memorial Hall, 6.30-8.00pm, 27 October 2022 • Burghead Community Hall, 6.30-8.00pm, 14 November 2022 The events were chaired by the Vice Chair of the Moray Integration Joint Board and took the form of a brief introductory presentation by the Locality Manager, Health and Page 186
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Consultation report - Moray Coast Medical Practice branch surgeries 15 Social Care Moray, followed by a question/answer session between the public and panel which also included the Practice Manager of Moray Coast Medical Practice; the Chief Officer or Head of Service Health of Social Care Moray and the Public Involvement Officer. Attendance at the two meetings was around 140. The feedback recorded from the events included: Hopeman meeting • When is dial-a-bus going to be available? Can you guarantee it is going to be available? • What’s the point if you can’t get the bus to take you to your appointment? • Dial-a-bus is only available for a short period during the day. Lots of people will be trying to access appointments during that time and the wait will be longer and longer. No credence has been given to having one surgery to serve both communities. The decision has been made. Has there been any consideration of developer funding the replacement of the surgery with a new building? • I thought the consultation was to look at the possibility of one or both buildings would be open. I live in Hopeman and never expect the service in Lossie to be replicated. It will never be equitable. I am interested if Stagecoach are now open to enhancing the service. When people need to see a GP or healthcare professional they need to see them and need to get there. There is no pharmacy attached to GP practice (at Lossie). Where am I going to go and get prescription? It will never be equal if you are looking at removing a service and that’s what it is about. • Buses are a mitigation. You are looking to manage the closure. You are closing the surgery because you can’t staff it. What is the purpose of the consultation? You are recommending action against what has been said in the engagement. We were asked about access to healthcare. All the recommendations are against it. • This is totally about cutting the service. What you are deciding is not fulfilling the Government of UN access to healthcare. If you are talking about equity you would need to keep it open. People are not using dial-a-bus because you can’t get an appointment during the time. • Prior to Covid both were open. People made do and managed. Was there talk of closing prior to Covid? • Are you not going against the Scottish Government’s directive on 20 minute communities? The owner of the surgery at Burghead offered to upgrade the building at no cost to the doctors and it was turned down. • What people really want to hear is the truth so we can deal with it. People use the pharmacist and he does not have access to anybody’s (medial) records. He can say go and see the doctor and they don’t know what (pharmacist) has been prescribing. There is no link up with district nurses. You have to start linking up so all your professionals know what is happening or there is going to be an accident. • Amazed Covid nurses don’t have a direct link to the surgery. Page 187
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Consultation report - Moray Coast Medical Practice branch surgeries 16 • You want to take doctor’s surgery away. I feel we are taking away lots of things but we need to have a system in place so there will not be an accident • You are going to the IJB and saying the rebuild cost is going to be £1.5m but no one in here wants duplication. What people here want a doctor, nurse and receptionist. I believe what you are asking the IJB for should be reassessed without the issue of duplication. We are not asking for that. If it goes to NHS Grampian (for capital budget) we are not looking for duplication. • The desire from the community is to see the facility replaced with something locally and the obstacle is money. The doctors said they would not support a satellite surgery. With the growth of the community we should warrant it but it appears you are not going to get support to man it anyway. • This is a ticking the box exercise, telling us what you plan to do. Lots of people are here tonight with valid questions. I think your mind is made up. There was a plan for Burghead surgery which was offered the facility to do it up. Was that spoken about? This is a very sad time for the community. Hopeman had 2 surgeries at one point. The village has doubled in size with developments and we are going to have nothing. Go back and go round the table and listen to what the community are looking for. Take on board what people have replied. It is not just about yourselves. You have got to think about our community. • We have very big hearts in our community. Why don’t we have a surgery here and have 60% of the population travel here. Would it be acceptable? 40% of the community wants to help you. What do we need to do to support you? Is there any other facility available? • You are telling us where we have to go because you don’t have the staff • You are missing the views of the population who have had to register with Maryhill • Having a surgery is a great asset. 6,000 of a population – is there anywhere else in Moray (of that size) that doesn’t have direct access to healthcare? You must give us something back. Surely you can get the bus route to link up, something concrete we could rely on all the time. Otherwise it means you have to be a car owner to access the service • There is enough demand for an hourly bus if you joined the route to divert to Lossie. • We are talking about a lot of people in the village who can’t use technology. People can’t use eConsult. • If we are going to run the community minibus we will need finance. We are servicing something you should be funding. • The community bus is working but dial-a-bus is not working. • The community minibus was won by the people of Hopeman. It was not provided to transport people to a facility in Lossiemouth because Burghead had closed. I don’t believe that is what the community minibus is for. You mention Stagecoach and there is still no resolution. With dial-a-bus, if I take ill at 3pm in Burghead, what do I do? New houses are being built – where are people going to go to see a doctor? Page 188
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Consultation report - Moray Coast Medical Practice branch surgeries 17 • The opinion of young people is being missed. They scrapped the maternity unit, A&E has a lack of beds and there is an issue with recruitment. How long before we are sitting here talking about the closure of Dr Gray’s? • Are you saying this is the end of the discussion? • You want us all to go to Lossie for a better service. You said you could fill the gap yet you are going to have extra staff. • Taking Hopeman and Burghead population together, what level of service does it justify? Was the survey only sent to patients and excluded those who are registered elsewhere? • Our community is growing yet there doesn’t seem to be any plan to provide services. It is going to put more pressure on Lossie. • There is new housing in Elgin and 2,300 extra in Hopeman and Burghead. Services can’t cope. Developer contributions could be used for a new build. • Are we being singled out but Aberlour and Dufftown are being kept open. Should be equitable across the whole of Moray. • You are taking from this community. • How many GPs working full time and how many work part-time? A number of people are trying to see a GP but are seeing a nurse practitioner instead. • Can you confirm a decision has not been made? • It seems the capacity at the medical centre is not there. Long working is not an excuse. Why can’t you recruit? We must be a high priority. How are you going to get us to the medical practice? • If you open the (branch) surgery there will not be this issue. • They (the practice) are being paid by the NHS to provide a service but are not providing a service to our community. • The buildings were fit for purpose before they were inspected. • Have you taken on board what the community are shouting out for – to keep their surgeries? Hopefully we can come to a better conclusion. Burghead meeting • Are you going to give iPads to all the old people? • Risk of infection if a number of people with flu were travelling on dial-a-bus at same time • People are not aware of dial-a-bus • Timing of dial-a-bus is restrictive. Are receptionists aware of issues when patients are trying to make an appointment? What if an appointment is running late? • Dial-a-bus is not being used as appointments are not being given at the right time. • Is there not a Scottish Government directive on 20 minute journeys? This is a 2 ½ hour journey. • Why all of a sudden are they (buildings) not suitable for purpose when they have been there for years and years? Page 189
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Consultation report - Moray Coast Medical Practice branch surgeries 18 • I have read some of the reasons you are claiming (for the buildings not being fit for purpose) and I thought they were very trivial and things that could be easily sorted. Nothing substantial. • 20 minute neighbourhoods – if you remove what is there now we will no longer be a 20 minute neighbourhood. You talk about good health. You are taking that away. You are going against the Scottish Government. The Practice is responsible for the upkeep of the buildings and there was no money invested. You are saying MDT can’t come out to branch surgeries. It must be the only place in Scotland (that doesn’t happen). You are causing overspill of people in to Elgin by to many people taking over practice in Elgin. You can expand Burghead and grow your practice • Money to extend Burghead was turned down. Why was the man turned down who offered to improve the building? • You are saying Burghead and Hopeman don’t exist. • Will you be publishing the results of the consultation? • What happens if you take Lossiemouth out of the equation? • 3 mornings, 27 individuals. Every slot was full. It was fully utilised when it was open. You say only 27 people seen – that is misleading • There have been problems with the building over the years. Why not fix it in 2008, 2010? Why have you let them build up? Feels like you have let the problem build up • In the previous report to the IJB it was said 54 patients were seen in a week. You are not comparing like for like when Lossie is open 9 hours a day. Hopeman and Burghead are more efficient and more productive than Lossiemouth. • We can argue every single point you make. You do your questionnaire and consultation and it will all say you need to keep the surgery open. Hopeman said keep the surgery open and same result here tonight. Your recommendation is to close. How do you come to that recommendation? Is it true that Moray Coast would not come back? We can do everything else right but if they are not willing to come back it is useless. • Everything is concentrated on Lossiemouth. We are saying there are other options. Your own 10 year Strategic Plan says very clearly you are putting the patient at the heart of every decision. We want you to do that so let’s work together to put the service back. We are not looking at equality – we want the right care at the right time and in the right place. I might have something that does not the whole team (MDT). We need to talk about equity. To be able to address the issue of disabled access you want to remove access to everybody else. Let’s make everybody else go to Lossie! • Is Lossie the right place for everybody? • How is patient supposed to get there (Lossie) quickly when can’t get dial-a-bus? I was at the Lossie surgery and over 45 minutes I saw a maximum of 6 people going in. Are all appointments on line? • The report is biased. Refused to put in what had been offered (by Burghead landlord). Are you (Practice) willing to go back? Urge Iain to put in all the counter arguments so a decision can be made. Why did you refuse to put the plan (for Burghead) in the report? Page 190
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Consultation report - Moray Coast Medical Practice branch surgeries 19 • You are going to have to take his offer. You are stabbing him in the back. • We have an obligation as the community to air our views. It is so easy to take a vote on something that does not affect you. They have kindly offered to get the surgery up and running in Burghead. We in Hopeman will support the community from Burghead 100%. • It’s a money saving exercise, not to help people. No one wants all the fancy things coming here. We don’t have to have it all in one place. • The decision has been made. Are you advertising dial-a-bus in the right way? Make people understand. People may give up (calling the practice) and call 999. Is it closed for now or 5 years down the line? • I had concerns about the IJB meeting. How do you check the IJB’s understanding of what is important? Do they really read the document and understand it and the implications of what they are voting for? They have got to take a balanced view and they have to understand the loss potentials. • How many people are served by Moray Coast Medical Practice? • A quarter of the population are paying their money and have not been getting the same quality of service for years. • Patients are having to go somewhere else. Not all stakeholders are here – half of our community is served by Maryhill. We have the biggest community in Moray without a practice. Maryhill is going to have to take the strain. We are the biggest community without doctors. We need to come to a middle ground. You have people here who will build a building for you. You don’t have the capacity to serve us. • Will Maryhill give us the service we want? You don’t want to come here. You have enough to do in Lossie. • Is it not the case this is a done deal? You turned down the offer of a free surgery. You are going to spend £167,000 on five surgery rooms. For 2 years you have been talking to Stagecoach. The community is growing. It appears you can’t cope. Closing Burghead and Hopeman is the wrong choice. • Where did developer contributions go? • If the Board decided that yes, they are going to back NHS Grampian, does the community have a route to appeal the decision? • Hearing about MDT. Don’t understand why they need to be in the building at the same time. GPs are able to work at home. Why can’t they communicate from branch surgeries? • Face to face is what patients want. Everyone has the ability to take notes and communicate so I don’t get that as an argument Submissions from community organisations One submission was received from Hopeman Community Minibus Committee. “Since the end of the initial Covid lockdown, a new volunteer minibus committee was formed from across Burghead, Cummingston, Duffus and Hopeman. Together with a team of volunteer drivers they have supported 591 appts so far that are either to the Moray coastal practice or for flu/Covid jabs which in the past they would have gone Page 191
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Consultation report - Moray Coast Medical Practice branch surgeries 20 to the surgery for. Together with hospital runs they make up to 54% of our journeys. The need for transport is increasing with more people becoming unable to drive or financially not affording the journey costs. Going forward are you prepared to financially contribute to make this community transport sustainable as demand continues as the dial a bus service does not meet peoples appointment times or the social connect they are seeing from our service?” 5. Equality data As part of this consultation equality data was collected from the responses gathered via the online and hard copy form to ensure patient views from all areas and communities were recorded. Gender: Answer choices Responses Male 40.15% 261 Female 57.08% 371 Prefer not to say 2.77% 18 Answered 650 Skipped 5 Is the gender you identify with the same as the sex you were assigned at birth? Answer choices Responses Yes 96.39% 614 No 0.16% 1 Prefer not to say 3.45% 22 Answered 637 Skipped 18 Age: Answer choices Responses Under 16 0% 0 16-24 2.77% 18 25-44 10.02% 65 45-64 33.74$ 219 65-74 25.12% 163 75 and over 26.19% 170 Prefer not to say 2.16% 14 Answered 649 Skipped 6 Page 192
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Consultation report - Moray Coast Medical Practice branch surgeries 21 Which of the following options best describes how you think of yourself? Answer choices Responses Bisexual 0.8% 5 Gay man 0.48% 3 Gay woman 0.48% 3 Heterosexual/straight 87.64% 546 None of these 2.89% 18 Prefer not to say 7.70% 48 Answered 623 Skipped 32 Do you identify as being a person with a disability of long-term health condition? Answer choices Responses Yes 39.03% 249 No 56.43% 360 Prefer not to say 4.55% 29 Answered 638 Skipped 17 Are you responsible for caring for a family member, friend or neighbour who needs support because they are ill, frail or have a disability? Answer choices Responses Yes 15.44% 99 No 80.34% 515 Prefer not to say 4.21% 27 Answered 641 Skipped 14 Are you currently pregnant or have you been pregnant in the last year? Answer choices Responses Yes 1.11% 7 No 96.04% 606 Prefer not to say 2.85% 18 Answered 631 Skipped 24 Page 193
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Consultation report - Moray Coast Medical Practice branch surgeries 22 Ethnic identity: Answer choices Responses Asian or Asian British 0.31% 2 Mixed or multiple ethnic groups 0.16% 1 White 93.86% 596 Prefer not to say 5.67% 36 Answered 635 Skipped 20 Religious identity: Answer choices Responses None 28.68% 183 Christian 60.5% 386 Buddhist 0.63% 4 Prefer not to say 7.68% 49 Other 2.51% 16 Answered 635 Skipped 20 Page 194
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NHS Grampian 1 Full EQIA Impact Assessment of the Moray Coast Medical Practice Proposed Closure of the Part-Time Burghead and Hopeman GP Sub Branches, Impact Assessment begun 4th August 2022, completed 10th November 2022 Organisation: Full EQIA carried out by NHS Grampian on behalf of the Moray Integration Joint Board Department carrying out the full EQIA: Equality and Diversity Section of the NHS Grampian Corporate Communications Department Person undertaking Full EQIA: Nigel Firth Title: Equality and Diversity Manager, NHS Grampian, NHS Orkney and NHS Shetland Date EQIA Started: Thursday 4th August 2022 Date completed: Tuesday 10th November 2022 Name of Policy, Strategy, or re-organisational proposal: Proposed closure of the Burghead and Hopeman GP Sub Branches by Moray Coast Medical Practice Item 11. Page 195
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NHS Grampian 2 Summary of Main issue(s) The Moray Coast GP Practice has its main base in Lossiemouth. It also operates two GP Sub Branches, one in Burghead and one in Hopeman. Both Sub Branches are located in accommodation which is considered too small and below an acceptable standard for the provision of modern healthcare. The Burghead Sub Branch building is too small and cannot be brought up to an acceptable standard within its present footprint. The Hopeman building has serious structural faults and is deemed uneconomic to repair. The Sub Branches also involve lone working for a GP and a nurse which poses a potential risk to the staff involved. The Practice have proposed the closure of both Sub Branches. It is proposed that patients who currently access GP services in the Burghead and Hopeman Sub Branches, would travel to Lossiemouth in future. The Sub Branches are popular with patients. Before their temporary closure due to COVID-19 in March 2020, on average there were 54 consultation per week in each locations, half with GP’s, half with Practice nurses A final decision now requires to be made on the way forward. However, due to GP shortages across Grampian, it is important to establish at the outset whether the Moray Coast GP Practice have the GP capacity to re-open these two Sub Branches. If not, would there be any other viable alternative for the provision of GP services in these two locations. Has the re-organisational proposal being Impact Assessed in terms of current equality and diversity legislation? Yes, an Equality and Diversity Impact Assessment has been carried out on the Proposed closure of the Burghead and Hopeman GP Sub Branches by Moray Coast Medical Practice. This was carried out using the Rapid Impact Assessment Checklist methodology. Page 196
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NHS Grampian 3 A copy of the Rapid Impact Assessment Checklist (RIC) is attached at Appendix I. A copy of the RIC Summary Sheet is attached at Appendix II. List any associated NHS Grampian policies or functions None List any other bodies involved Moray Coast Medical Practice Moray Health and Social Care Partnership (Integration Joint Board) Any associated policies or functions from the associated bodies which are relevant to the policy, strategy or re- organisational proposal NHS Reform (Scotland) Act 2004 Equality Act 2010 Equality Act 2010 (Specific Duties) (Scotland) Regulations 2012, as amended The Fairer Scotland Duty 2018 NHS Circular CEL 4 (2010) entitled: Informing, Engaging and Consulting People in Developing Health and Community Care Services Scottish Health Planning Note (SHPN) 36, Part 1 which sets out the design guidance for General Medical Practice Premises in Scotland. Page 197
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NHS Grampian 4 Moray Health and Social Care partnership Strategic Plan 2019-2029. Scottish Health Facilities Note 30: ‘Infection control in the built environment’ Version 2 and Healthcare Associated Infection System for Controlling Risk in the Built Environment (HAI Scribe) 1. Aim/Status (a) What is the aim/purpose of the policy/function? To establish the best way forward for GP provided healthcare in the Burghead and Hopeman areas. (b) Who is intended to benefit from this policy/function and in what way? Patients Patients who currently access GP services in Burghead and Hopeman, by travelling to Lossiemouth, would have access to a wider range of healthcare services. These include women’s health screening, child health screening, minor surgery and tests, all carried out in better facilities. This may result in fewer visits and quicker diagnosis. There is also access to other supporting services in-site. If the decision is taken to retain and upgrade or re-provide the Burghead and Hopeman Sub Branches, this would be a popular decision with most patients in these areas. Page 198
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NHS Grampian 5 However, retaining the Burghead and Hopeman Sub Branches would mean that patients using the Sub Branches or re-provided facilities would not reap the benefits of accessing a much wider range of services in Lossiemouth. Staff will benefit by having: A more efficient use of GP time and nursing staff therefore help to reduce waiting times. Safer working. A lone GP and one lone nurse working in unsuitable premises poses safety risks to the staff concerned. There was no information provided at the time of compiling the FULL EQIA on whether the Lossiemouth GP Practice are actually able to sustain the Sub Branches with their current level of GP staffing. If not, are there any other alternatives for the provision of GP services in these two areas. (c) How have they been involved in the development of this policy/function? Patients and the general public A Healthier Lives, Healthier Communities questionnaire was drafted on Survey Monkey and sent out in November 2021 via social media and the Moray Health and Social Care website and through partner agencies. It was also made available in hard copy and widely distributed. The survey highlighted the community concern that the temporary closure of the Burghead and Hopeman GP Sub Branches might become permanent. The Moray integration Joint Board at a meeting on 26th May 2022 initiated a formal consultation with patients of Moray Coast GP Practice on the future model of healthcare provision, including the permanent closure of the two Sub Branch Surgeries. Page 199
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NHS Grampian 6 Staff Moray Coast Practice staff have been closely involved throughout the discussion process. There was no information provided at the time of compiling the FULL EQIA on whether the Lossiemouth GP Practice are actually able to sustain the GP Sub Branches with their current level of GP staffing. If not, are there any other alternatives for the provision of GP services in these two areas? (d) How does it fit into broader corporate aims? (i) Moray Integration Join Board Moray Integration Joint Board in their Strategic Plan 2019-2029, highlighted their wish to: Improve the patient experience Improve the efficient use of healthcare resources Provide health and social care services in an integrated manner Provide services in premises fit for purpose. Provide all possible support to GP Practices. Avoid overcrowding The only inconsistency is a commitment in the Strategic Plan to provide the services closer to the patient’s home. Page 200
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NHS Grampian 7 (e) What outcomes are intended from this policy/function If the outcome is closure: Patients who currently access GP services in Burghead and Hopeman, by travelling to Lossiemouth, would: have access to a wider range of healthcare services such as women’s health screening, child health screening, minor surgery and tests Better facilities, compliant with current healthcare accommodation standards Have fewer visits and quicker diagnosis Access to other supporting services on-site Closure of the Burghead and Hopeman Sub Branches would also: Be a more efficient use of GP and Practice nurse time and therefore help to reduce overall GP waiting times for the Lossiemouth Practice patients. Provide a safer working. A lone GP or a lone nurse working in unsuitable premises poses safety risks to the GP and any other staff concerned. (f) What resource implications are linked to this policy and/or functions? If would be a good idea as part of the consultation process, to establish any likely savings in both staff travelling time and revenue and capital building costs if the Burghead and Hopeman GP Sub Branches close. This could include: Opportunity cost saving of GP time and Practice nurse time used more efficiently? Cost saving of closing Burghead Sub Branch? Costs associated with termination of lease before November 2023? Page 201
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NHS Grampian 8 Savings on heat light and power? Any capital cost savings? Has the availability of more suitable accommodation in Burghead been explored and possible costs? The Burghead Sub Branch accommodation is leased from a private landlord. A survey carried out by the NHS Grampian Estates Department identified an estimated cost of £116,000 +VAT to address immediate issues. However, these would be issues within the existing building footprint. It would not address the space issues such as: • Inadequate disabled access • Room sizes do not comply with current design standards • Toilet facilities require to be shared between patients and staff • No available staff rest/changing facilities • Inadequate utility/cleaning areas • Fire escape strategy for one direction of travel The Hopeman Sub Branch accommodation is owned by the Lossiemouth GP Practice. To address the immediate issues identified by an NHS Grampian Estates Department Survey would require expenditure of £142,000 + VAT. However, these would be issues within the existing building footprint. It would not address the space issues. In addition, the NHS Grampian Estates Department Survey identified cracking throughout the building and recommended a structural survey be carried out. This was carried out by Cameron and Ross, Consulting Engineers from Aberdeen in February 2022. Their survey identified: Extensive cracking suggesting ongoing structural movement Over stressed roof timbers which are deflecting. The side elevations appear to be dropping relative to the central portion of the building Page 202
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NHS Grampian 9 Historical cracks which have been repaired, are e-opening There is anecdotal evidence of subsidence in the adjacent car park In the view of the Consulting engineers, repairs to the building would not be economically viable Complete (g) to (i) for new policies/functions/re-organisational proposals only. (g) What research or consultation has been done? Research The Burghead and Hopeman buildings have both been surveyed by NHS Grampian Estates Department staff and Reports produced. The Hopeman Sub Branch has been the subject of a Structural Survey carried by Cameron and Ross, Consulting Engineers from Aberdeen in February 2022. A Healthier Lives, Healthier Communities questionnaire was drafted on Survey Monkey and sent out in November 2021 via social media and the Moray Health and Social Care website and through local organisations. Consultation Engagement activity took place with the local population, community groups and key stakeholders between November 2021 and January 2022. Formal consultation, as required by NHS Circular CEL 4 (2010) entitled: Informing, Engaging and Consulting People in Developing Health and Community Care Services commenced on 16th September 2022, until 26th January 2023. Page 203
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NHS Grampian 10 h) What stage is the policy/function/re-organisational proposal at? Awaiting a formal consultation process as required by NHS Circular CEL 4 (2010) before the Integration Joint Board arrive at a final decision. (i) What is the target date for completion? Formal consultation began on 16th September 2022 until 26th January 2023. 2. Examination of Available Data Data (data collection could include consultations, surveys, databases, focus groups, in-depth interviews, pilot projects, complaints made, user feedback, academic publications, consultants` reports, citizens juries etc) Information available for consideration in the EQIA includes: A Report to Moray Integration Joint Board dated 26th May 2022 A Paper Entitled: Do I Need an EIA? Undated An NHS Grampian Estates Survey of the Burghead Sub Branch Building with an estimate of costs to improve the building, but it would not meet current minimum standards for a clinical building An NHS Grampian Estates Survey of the Hopeman Sub Branch Building with an estimate of costs to improve the building, but it would not meet current minimum standards for a clinical building A Structural Engineers Report on the Hopeman Sub Branch Building, carried out in February 2022 A Healthier Lives Survey carried out in the Burghead, Hopeman and Lossiemouth areas in late 2021. Page 204
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NHS Grampian 11 (a) Are there any experts/relevant groups whom you can/should approach to explore their views on the issues? All relevant experts have been involved at the appropriate stages. No additional input is required. (b) What do we know from existing data, research, consultation, focus groups and analysis in-house? Quantitative: The in-house quantitative data shows: That both the Burghead and Hopeman Sub Branch buildings are not fit for purpose That patients who use the Burghead and Hopeman GP Sub Branches greatly value their ready access to GP and community nursing care, averaging 54 consultation per location per week prior to the temporary closure. There is no direct public transport links between Burghead and Hopeman to Lossiemouth. Burghead to Lossiemouth surgery is 7.8 miles. Hopeman to Lossiemouth surgery is 5.5 miles. A much wider range of health and social care services is provided at the main Lossiemouth GP Practice. These Include: o women’s health screening o child health screening o minor surgery o on-site tests o The facilities are compliant with current building, hygiene and healthcare standards. o There is also access to other supporting services in-site. Closure of the two Sub Branches would enable a more efficient use of GP and community nurse time. Page 205
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NHS Grampian 12 No information was submitted for the FULL EQIA process on whether the Lossiemouth GP Practice are actually able to sustain the Sub Branches with their current level of GP staffing or if alternative GP resources are available. Qualitative: As stated above. (c) What do we know from existing data, research, consultation, focus groups and analysis available externally? Any proposed closure of a GP Sub Branch causes great concern to members of the communities from which the Sub Branches are removed. Most perceive the removal as downgrading the status of their community and making the location a less attractive place for inward migration. There is a great deal of empirical evidence to prove the benefits of providing care close to a patient’s home. (d) What gaps in knowledge are apparent? The main gap is a lack of information about the population who use the Burghead and Hopeman Sub Branches. In these circumstances, it would be usual to have information on: How many people who use the Sub Branches in each location are o elderly o have a limiting long term illnesses o are disabled o are families with young children o car owners o Morbidity data At the time this FULL EQIA was being carried out, none of this information was available. Page 206
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NHS Grampian 13 Accordingly, it was necessary to scrutinise the information which was available. Public Health Scotland Locality Profile, Lossiemouth Sub-Locality August 2022 On page 11 of the profile is an illustration showing the Scottish Index of Multiple Deprivation (SIMD) for the Lossiemouth area. SIMD 1 is the most deprived, SIMD 5 is the least deprived. The Lossiemouth area is generally prosperous. Most locations are shown to be in SIMD 4. The Lossiemouth town area is shown to be SIMD 5, while the Burghead and Hopeman areas are SIMD 4. Scottish Health and Well Being Profiles For Lossiemouth Data Zones The data shows that: People living in the Burghead, Roseisle and Laich are living in the 15% most “access deprived” areas People in the Burghead, Roseisle and Laich areas are overall, healthier than people living in Lossiemouth, East and Seatown and Lossiemouth West. The Moray Coast GP Practice There is no indication as to whether the Moray Coast GP Practice are actually able to sustain the Burghead and Hopeman Sub Branches with their current level of GP staffing. If the Practice are unable to sustain the Sub Branches, are there alternative suppliers of GP services? Page 207
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NHS Grampian 14 Fairer Scotland Duty 2018 The Fairer Scotland Duty came into force in Scotland from 1st April 2018 and places a legal duty on public bodies to consider how they can reduce inequalities of outcome caused by socio-economic disadvantage, when making strategic decision. Specifically: “An authority to which this section applies must, when making decisions of a strategic nature about how to exercise its functions, have due regard to the desirability of exercising them in a way that is designed to reduce the inequalities of outcome which result from socio-economic disadvantage.” If the proposed closure of the Sub Branches goes ahead, steps should be taken to mitigate any potential negative health impacts in Burghead and Hopeman. The main issues being: the absence of any direct public transport links the associated additional travel costs additional travel time for patients. If the GP Sub Branches close, this will have a negative impact on geographical equity of access to GP services. (e) If there appears to be any potential difficulties of access or compliance with the aims of the policy/function/re-organisational proposal, please describe these. As at (d) above. Page 208
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NHS Grampian 15 3. Rapid Impact Assessment Checklist (RIC) After completing the RIC screening process, answer the following questions: Have potential negative impacts been identified for people with a “protected characteristic”, as defined by the Equality Act 2010? Yes No If yes, has a full EQIA process been recommended? Yes No If no, are you satisfied that the conclusions of the RIC are accurate and comprehensive? Yes No Signature of Impact Assessor: Nigel Firth Date: 10th November 2022 Page 209
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NHS Grampian 16 4. Compliance with the Socio-Economic Duty (in Scotland called the Fairer Scotland Duty) enacted in April 2018 “Fairer Scotland Duty: Socio- economic deprivation The Fairer Scotland Duty requires public bodies such as NHS Grampian and Health and Social Care Partnerships, when making strategic decisions, to take account of the need to improve equity of health and social care outcomes for area of multiple deprivation. If a decision is made by the Integration Joint Board to allow the closure of the Sub Branches, all possible steps must be taken to mitigate any adverse effects. Things to consider would be: A mini bus service free to Scotland-wide concession card holders for patients in the Burghead and Hopeman locations to the Lossiemouth GP Practice. Consideration of other properties in the Burghead and Hopeman areas which might make suitable replacement Sub Branch buildings? Is an extended role of nurse post appropriate in both the Burghead and Hopeman areas? Can additional support be provided to patients in the Burghead and Hopeman locations to access digital healthcare from Lossiemouth? However, it is acknowledged that digital communication and information is not suitable for all patients in all circumstances. Page 210
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NHS Grampian 17 5. Impacts (a) What is the likely impact (whether intended or unintended), positive or negative of the initiative on individual service users or on the public at large? Positive Impacts: Patients will benefit by having: A much wider range of health and social care services provided at the main Lossiemouth GP Practice. These Include: women’s health screening child health screening minor surgery on-site tests The facilities are compliant with current building, hygiene and healthcare standards. There is also access to other supporting services in-site. Staff will benefit by having: Provide a safer working. A lone GP or a lone nurse working in unsuitable premises poses safety risks to the GP and any other staff concerned. A working environment compliant with NHS building and hygiene standards Negative Impacts: There are three main potential negatives: Patients who use the Burghead and Hopeman GP Sub Branches greatly value their ready access to GP and community nursing care, averaging 54 consultation per location per week prior to the temporary closure due to COVID-19. If the Sub Branches close, patients will have to travel further to access GP and nursing services. Page 211
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NHS Grampian 18 There is no direct public transport links between Burghead to Lossiemouth and Hopeman to Lossiemouth. Burghead to Lossiemouth is 9 miles. Hopeman to Lossiemouth is 6.3 miles. A risk of a widening of health outcomes between people in Burghead and Hopeman and patients in Lossiemouth. (b) Is there likely to be any differential impact on people with a “protected characteristic” as defined by the Equality Act 2010? If yes, please state if this impact may be adverse and give further details (e.g. which specific groups are affected, in what ways and why do you believe this to be the case?) (i) Race Yes No Adverse? Please give details The size of local ethnic communities in the Burghead and Hopeman areas is small. (ii) Disability Yes No √ Adverse? √ Please give details The latest figures for Grampian show that 20% of the population have a limiting long term disability. Many people have a communication disability. If a patient and their family members and carers have to travel further to access GP and nursing healthcare, this could seriously disadvantage disabled people. There would also be a cost implication. Page 212
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NHS Grampian 19 (iii) Age Yes No √ Adverse? √ Please give details As per disability above. (iv) Sex (male or female) Yes No Adverse? Please give details (v) Sexual orientation Yes No Adverse? Please give details (vi) Gender reassignment Yes No Adverse? Please give details (vii) Pregnancy and maternity Yes No Adverse? Please give details Mothers with young children who do not have their own personal transport may find it much harder to access GP and nursing services if the GP Sub Branches close. Appointments in Lossiemouth might incur child care costs. Page 213
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NHS Grampian 20 (viii) Marriage and civil partnership Yes No Adverse? Please give details (ix) Religion or belief Yes No Adverse? Please give details (x) Other grounds (e.g. poverty, mental health, homelessness, immigration status, involvement in the criminal justice system) Yes No Adverse? Please give details Already covered in Section 5 (a) above. (c) Is the policy directly discriminatory?) Yes No (d) Is the policy indirectly discriminatory? Yes No If yes, is this objectively justifiable or proportionate in meeting a legitimate aim? Yes No Yes, provided mitigating steps ae put in place. Page 214
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NHS Grampian 21 (e) Is this policy intended to increase equality of opportunity by permitting positive action or action or redress inequalities Yes No Please give details The proposed closure of the Burghead and Hopeman GP Sub Branches Is being proposed due to the current poor accommodation in these two locations. If this policy/function/re-organisational proposal is unlawfully discriminatory, you must decide how to ensure the organization acts lawfully. The proposed closure of the Burghead and Hopeman GP Sub Branches is not unlawfully discriminatory, provided mitigating steps are put in place to avoid widening any existing health inequalities and there is no disproportionate impact on patients with a “protected characteristic”. (f) If this policy/function/re-organisational proposal is not directly or indirectly discriminatory, does it still have an adverse impact? Yes No √ As detailed at 5 (a) above. Page 215
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NHS Grampian 22 6. Modifications In your consideration of the next questions, you should think about the following: How does each option further or hinder equality of opportunity? How does each option challenge or reinforce stereotypes which influence equality of opportunity? What are the consequences for the group(s) and the public authority/organisation of not adopting an option more favourable to equality of opportunity? What are the social and economic costs and benefits of implementing each option? For the group? For the authority/organisation? Will the benefits of implementing the change outweigh the costs? (a) If you answered yes to Question 5(f) and the policy/function/re- organisational proposal could have an adverse impact on any new group, could you modify the initiative to reduce or eliminate any identified negative impacts, or to create or accentuate positive parts of the development? Can the Lossiemouth GP Practice sustain the GP cover to the Burghead and Hopeman GP Sub Branches? If not, is GP provision from another sources possible? If the GP cover can be sustained, is there alternative accommodation available in Burghead and Hopeman of a better quality which could be developed to provide alternative accommodation of the required standard? Page 216
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NHS Grampian 23 If the outcome of the review is the closure of the Burghead and Hopeman GP Sub Branches, mitigating steps should be put in place. These should include consideration of: o A minibus service free to Scotland-wide concession card holders between Burghead and Lossiemouth and between Hopeman and Lossiemouth. and/or o Consideration of the provision of an “extended role of nurse” service to the Burghead and Hopeman areas o Additional patient IT support to access the GP practice in Lossiemouth remotely (b) If you make these modifications, would there be any impacts on other groups in society or on the ability of the initiative to achieve its purpose? No 7. Further Research (a) Given the analysis so far, what additional research or consultation is desirable to investigate the impacts of the proposals on diverse groups? (i) New primary data? Yes No √ Describe:: Ideally, the data described at 2(d) above should be obtained to enable the Integration Joint Board to make a fully informed decision. If this is not possible, the Integration Joint Board must accept that they may be making a final decision based on extensive but incomplete information. Page 217
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NHS Grampian 24 (i) Secondary analysis of existing data? Yes No √ Describe:: (b) What steps do you need to take to ensure that the right people are involved in this research? The correct people are already involved. The input of the NHS Grampian Public Involvement Team would be a sensible step for the consultation process. 8. Consultation (i) The National Health Service Reform (Scotland) Act 2004 requires the involvement of the public in service change. (ii) Involvement is also a legal requirement the Disability Discrimination Act 2005, the Equality Act 2010 and the Equality Act 2010 (Specific Duties) (Scotland) Regulations 2012. (iii) There is also a Scottish Health department Circular giving Guidance on this topic: Circular CEL 4 (2010) entitled: “Informing, Engaging and Consulting the Public in Developing Health and Community Care Services”. This circular sets out how the public should be informed, engaged and consulted when health and community services are developed. It also re-states the important role of the Scottish Health Council in ensuring that the informing, engaging and consulting process has been carried out appropriately. The importance of Equality and Diversity Impact Assessment in this process is also re-stated. The formal consultation process began on 26th May 2022, with a target date for completion of 26th January 2023. Page 218
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NHS Grampian 25 (a) What will be the aims of the consultation and involvement? For Patients and the general public in the Burghead and Hopeman areas who access healthcare at the GP Sub Branches Involvement of patients and the general public in the Burghead and Hopeman areas in identifying possible solutions to the problems Encourage patients and the general public to contribute their knowledge and expertise Identify the issues which would be faced by patients should the Integration Joint Board take the decision to allow the closure of the Burghead and Hopeman GP Sub Branches Identify any mitigating arrangements required to minimise the impact of the closure of the Sub Branches For Moray Integration Joint Board The aims will be to: Identify all of the current problems with the current arrangements which require to be addressed Involve all of the stakeholders in identifying possible solutions to the problems Encourage all stakeholders to contribute their knowledge and expertise Compliance with Circular CEL 4 (2010) and the NHS Reform (Scotland) Act 2004. (b) What is the planned timescale? 26th May 2022 to 26th January 2023. Page 219
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NHS Grampian 26 (c) What is the managing the consultation? The consultation will be managed by Iain Macdonald Locality Manager Moray HSCP, in co-operation with Louise Ballantyne Public Involvement Manager NHS Grampian. The consultation will be managed on behalf of Moray Integration Joint Board. (d) What methods of consultation will be used? (These should be appropriate to the groups being consulted) To be decided. (e) What steps will be taken to ensure information was accessible so participants could contribute fully? As a public body, Moray Integration Joint Board must be an exemplar of good practice. Accordingly, In compliance with the Equality Act 2010, the Disability Discrimination Act 2005 and the Royal National Institute for the Blind (RNIB) Good Practice Guidelines, Moray Integration Joint Board will make available any of its published material, in any other language or format, upon request. This offer is contained at the front of our policies, strategies and re-organisational proposals. √ Accessible formats? √ Community languages? √ Oral information? √ Taking account of different needs? √ Taking account of different customs? √ Accessible venues? E.g. acoustics, transport, wheelchair access, loops, signing, interpreter facilities? √ Use of advocate? Page 220
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NHS Grampian 27 √ Training of other support for potential participants? √ Social Media √ √ Other- please give details Online Online Patient and Public Reference Group (f) What other consultation exercises are planned? (Can they be joined up?) None. (g) How will consultation outcomes be fed back into the process? Through the media outlets described above and through local groups and organisations. (h) Following consultation what is the Recommendation? Consultation has not concluded. 9. Decision making and reports to Line Management/Health Board (a) Who will make the decision? The Moray Integration Joint Board Page 221
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NHS Grampian 28 (b) Following consultation, what is the decision? The consultation process has not yet concluded. Therefore no decision has been made. Reject the policy/function Introduce the policy function Amend the policy function Other, please explain Formal consultation began on 26th May 2022 until 26th January 2023. 10. Public availability of Report/Results (a) What are the arrangements for publishing the Impact Assessment? A communication/media campaign is now underway. (b) The results of the Impact Assessment? This Full EQIA does not contain sensitive financial information. Accordingly, it can be listed on the Moray Integration Joint Board website. The Impact Assessment will be made available, upon request, as required by the Equality Act 2010 (Specific Duties) (Scotland) Regulations 2012. It will also be made available to stakeholders. (c) The results of the consultation? Formal consultation has not yet concluded. No decision has been made. Page 222
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NHS Grampian 29 (d) Employment monitoring outcomes? As highlighted in the Rapid Impact Assessment Checklist (RIC) service relocations and re-configurations always cause concern to the staff concerned. The changes may have implications for employment prospects. Any staff changes will be carefully monitored to ensure that they do not impact disproportionately on any group with a “protected characteristic”, as defined by the Equality Act 2010. (e) Other monitoring outcomes? (E.g. service users, non-users, stakeholder views) A formal monitoring and review process involving all stakeholders will require to be put in place to check that the objectives intended, have been achieved and to determine what further steps might be required. A more formal review should take place after the new arrangements have been in place one year. NGF/Full EQIA/10th November 2022 Page 223
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NHS Grampian 31 1. Rapid Impact Checklist Moray Integration Joint Board and NHS Grampian An Equality and Diversity Impact Assessment Tool: Appendix I Moray Coast Medical Practice: Proposed Closure of the Part-Time Burghead and Hopeman Sub Branches, Impact Assessment carried out in August 2022 Which groups of the population do you think will be affected by this proposal? Other groups: Minority ethnic people (incl. Gypsy/travellers, refugees & asylum seekers) Women and men People with mental health problems People in religious/faith groups Older people, children and young people People of low income Homeless people Disabled people People involved in criminal justice system Staff Lesbian, gay, bisexual and transgender Patients of the Moray Coast Medical Practice who access GP services in the Part Time Burghead and Hopeman Sub Branches. Staff who work in the Burghead and Hopeman Sub Branches. These individuals may be members of several of the above groups. N.B The word proposal is used below as shorthand for any policy, procedure, strategy or proposal that might be assessed What positive and negative impacts do you think there may be? Which groups will be affected by these impacts? What impact will the proposal have on lifestyles? For example, will the changes affect: Diet and nutrition None. Page 225
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NHS Grampian 32 Exercise and physical activity Substance use: tobacco, alcohol and drugs? Risk taking behaviour? √ Positive. Patients who currently access GP services in Burghead and Hopeman, by travelling to Lossiemouth, would have access to a wider range of healthcare services. These include women’s health screening, child health screening, minor surgery and tests, all carried out in better facilities. This may result in fewer visits and quicker diagnosis. There is also access to other supporting services. √ Positive. The proposal, if implemented would result in a more efficient use of GP time and therefore help to reduce waiting times. √ Positive. Single handed GP working in unsuitable premises poses safety risks for the staff concerned. Negative. Patients who currently access GP services in the Burghead and Hopeman Sub Branches would have to travel to Lossiemouth to access GP services. Burghead to Lossiemouth is 8.5 miles. Hopeman to Lossiemouth is 6.3 miles. This would: Be a problem for patients who do not have their own transport because there are no direct public transport links between Burghead/ Hopeman and Lossiemouth Travel may pose a problem in Winter and inclement weather. Page 226
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NHS Grampian 33 Education and learning or skills? Additional problems may be faced by patients who are: elderly have a limiting long term illnesses are disabled families with young children √ Positive. The proposal is a learning opportunity for the Patients of the Moray Coast Medical Practice who access GP services in the Burghead and Hopeman Sub Branches. It is also a learning opportunity for the staff of Moray Coast Medical Practice who work in the Burghead and Hopeman Sub Branches. Will the proposal have any impact on the social environment? Things that might be affected include: Social status Employment (paid or unpaid) Social/Family support Negative. A loss of a part-time GP Sub Branches may be perceived by many residents in Burghead and Hopeman as making these areas less attractive for existing residents and potential new residents. None, if the staff who currently work in the Sub Branches were redeployed on a “no detriment” basis. Negative. Patients who use the Burghead and Hopeman Sub Branches who do not have their own personal transport or who are elderly or have with limiting long term illnesses, or hare a disability or are families with young children, may require more Page 227
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NHS Grampian 34 Stress Income family support. This is due to the lack of direct public transport links between Burghead/Hopeman and Lossiemouth. Negative. The closure of the Burghead and Hopeman Sub Branches would cause stress and anxiety to vulnerable groups in these areas and the wider community. None. Will the proposal have any impact on the following? Discrimination? Equality of opportunity? Negative. The move could potentially discriminate against patients who use the Sub Branches: who do not have their own personal transport. There are no direct public transport links between Burghead/ Hopeman and Lossiemouth. are elderly have a limiting long term illnesses are disabled residents who are families with young children. It is important to carry out research to quantify the numbers in each vulnerable category in Burghead and Hopeman and the healthcare needs and morbidity of the patients concerned. An assessment of car ownership in these locations would also be helpful. Negative. Sub Branch users would require to travel further. This will have a negative impact on geographical equity of access to GP services. Page 228
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NHS Grampian 35 Relations between groups? Fairer Scotland Duty? Any proposed formal consultation process must be full and fair to avoid possible enmity developing between the patients who access GP services in Burghead and Hopeman and the GP Practice staff. The Fairer Scotland Duty came into force in Scotland from 1st April 2018 and places a legal duty on public bodies to consider how they can reduce inequalities of outcome caused by socio- economic disadvantage, when making strategic decision. The proposed closure of the Burghead and Hopeman Sub Branches requires: (i) An assessment of the socio-economic standing of Burghead and Hopeman compared to Lossiemouth. (ii) An assessment of relative health outcomes in the Burghead and Hopeman areas compared to Lossiemouth. (iii) An assessment of car ownership in the Burghead and Hopeman areas. (iv) If the proposal goes ahead, steps should be taken to mitigate any potential health impacts in Burghead and Hopeman. The main issue being transport. Page 229
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NHS Grampian 36 Will the proposal have an impact on the physical environment? For example, will there be impacts on: Living conditions? Pollution or climate change? Accidental injuries or public safety? Transmission of infectious disease? Negative. The proposed closure of the Sub Branches may make Burghead and Hopeman less attractive areas in which to live. Negative. If the proposal goes ahead, patients in Burghead and Hopeman will have to travel further to access GP services, leading to more vehicle pollution. √ Positive. Single handed GP working in unsuitable premises poses safety risks for the staff concerned. Following an expert assessment of both Sub Branch buildings, both buildings have been deemed unfit for purpose. The Lossiemouth premises meet modern healthcare standards. None. Will the proposal affect access to and experience of services? For example, Health and social services Negative. The proposal will be perceived by most people living in Burghead and Hopeman as a negative step. √ Positive. The co-location of social services with healthcare service at the Lossiemouth GP Practice is a positive advantage to patients in terms of integrated care. Page 230
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NHS Grampian 37 Transport Housing services Education √ Positive. The Lossiemouth facility provides an environment more conducive to the provision of modern health care and is compliant with current standards. The Lossiemouth facility is assessed as fit for purpose Negative. Patients who use the Sub Branches in Burghead and Hopeman will have to travel further to access GP service if the proposal goes ahead. This will take up more time and incur cost. Negative. The proposal could potentially discriminate against patients who use the Sub Branches who do not have their own personal transport. There are no direct public transport links between Burghead/ Hopeman and Lossiemouth. None. √ Positive. The proposal is a learning opportunity for the Patients of the Moray Coast Medical Practice who access GP services in the Burghead and Hopeman Sub Branches. It is also a learning opportunity for the staff of Moray Coast Medical Practice who work in the Burghead and Hopeman Sub Branches. For further information contact: Nigel Firth, Equality and Diversity Manager NHS Grampian, by email on: Nigel.firth@nhs.scot Page 231
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NHS Grampian 38 Moray Integration Joint Board and NHS Grampian Appendix II Rapid Impact Checklist: Summary Sheet Moray Coast Medical Practice: Proposed Closure of the Part-Time Burghead and Hopeman Sub Branches, Impact Assessment carried out August 2022 Positive Impacts (Note the groups affected) The Proposal would: Give patients who access GP services in Burghead and Hopeman access to a wider range of healthcare services in Lossiemouth. These include women’s health screening, child health screening, minor surgery and tests, all carried out in better facilities. This may result in fewer visits and quicker diagnosis. There is also access to other supporting services. Result in a more efficient use of GP time and therefore help to reduce waiting times. Avoid single handed GP working. Avoid healthcare being provided in unsuitable premises. Enable patients attending Lossiemouth Medical Practice to access the co-located of social services. Be a learning opportunity for the Patients of the Moray Coast Medical Practice who access GP services in the Burghead and Hopeman Sub Branches. It is also a learning opportunity for the staff of Moray Coast Medical Practice who work in the Burghead and Hopeman Sub Branches Negative Impacts (Note the groups affected) The Proposal would: Require patients who use the Burghead and Hopeman GP Sub Branch to travel 8.5 miles and 6.3 miles respectively, to Lossiemouth. There is no direct public transport link between Burghead and Hopeman for people without their own transports. This is a serious issue for patients who use the Burghead and Hopeman Sub Branches who do not have their own personal transport or who are elderly or have with limiting long term illnesses, or hare a disability or are families with young children. Travelling to Lossiemouth will take time and incur cost. Be perceived by many residents in Burghead and Hopeman as making these areas less attractive for existing residents and potential new residents. Additional Information and Evidence Required To explore the negative issues highlighted above, a FULL EQIA is required. Recommendations A FULL EQIA is required. Page 232
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NHS Grampian 39 Signature(s) of Level One Impact Assessor(s) ............................................................................. ............................................................................ Date: ...................................... Signature(s) of Level Two Impact Assessor(s) Nigel Firth, Equality and Diversity Manager, NHS Grampian Date: Friday 4th August 2022 From the outcome of the RIC, have negative impacts been identified for race or other equality groups? Has a full EQIA process been recommended? If not, why not? Yes, but if a FULL EQIA is carried out, this should generate the additional information required to explore the issues highlighted above more fully. A FULL EQIA is required. Page 233
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Appendix 3. Lossiemouth Locality Profile Information 1) Scotland Census (2011) data for the IV30 5 post code indicated: Cars or Vans within households 12% of households had no car, 46% of households had 1 car and 42% of households had more than 1 car. Families with children At the point of the 2011 Census there were 1582 families of which 61.5% had no dependent children and 38.5% had dependent children. Term Conditions 29% of the population identified as having 1 or more long term condition. Of that overall 29% - 28.5% had a ‘hearing/sight’ health condition, 16.9% identified as having a ‘physical’ related health condition, 11.7% as a ‘learning disability’, 10.9% as a ‘mental health’ related condition, 2% as a ‘developmental disorder and 30% were noted as ‘other’. 0% 10% 20% 30% 40% 50% No Car 1 Car 2+ Cars No. of Cars in Household 0% 10% 20% 30% 40% 50% 60% 70% No Dependant Children 1 or More Dependant Children Families with Dependant Children Item 11. Page 235
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2) The Scottish Public Health Organisation Data indicates: The number of alcohol related hospital admissions are significantly below the Moray or National average. (2021) The number of asthma related hospital admissions are higher than both the Moray and National average. (2021) The number of children in low income families are significantly lower than both the Moray and National average. (2016) The number of Chronic Obstructive Pulmonary Disease hospitalisations are lower than both the Moray and National average. (2021). The number of deaths in the 15-44 age group are significantly below both the Moray and National average. (2020) The number of deaths ‘all ages’ are significantly below both the Moray and National average. (2020) The number of deaths from Coronary Heart Disease are significantly lower than both the Moray and National average. (2021) The number of Emergency Hospitalisations are lower than both the Moray and National average. (2020) The number of Multiple Emergency Hospital Admissions for >65 years are higher than the Moray but lower than the National average. (2020) The number of Working Population Employment Deprived are lower than both the Moray and National average. (2017) Immunisations uptake ‘6 in 1’ is higher than both the Moray and National average. (2020) Immunisations uptake MMR is lower than both the Moray and National average. (2020) 3) The Lossiemouth Locality Profile collated by NHSG (2021) indicated that for the Lossiemouth Locality as a whole: Life expectancy of males was equal to the Moray and higher than the National Average. 0% 5% 10% 15% 20% 25% 30% 35% Long Term Conditions Page 236
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Life expectancy of females was higher than the Moray and the National Average. Mortality rate was lower than the Moray and the National average. The percentage of the population with Long Term Conditions was lower than the Moray and the National Average. Asthma rates were higher than the Moray or National Average. Arthritis, Coronary Heart Disease, Cancer Diabetes rates were all lower than the Moray and the National Average. Unscheduled Acute Hospital Bed Days rates were lower than the Moray and the National average. A&E attendances were lower than the Moray average and similar to the National average. Emergency Hospital admissions were lower than the Moray and the National Average. Emergency Hospital Readmissions were lower than the Moray and the National Average. Emergency Admissions from falls are higher than the Moray average and similar to the National average. Potentially Preventable Emergency Hospital Admissions were lower than the Moray and the National Average. Mental Health Hospital Admissions were lower than the Moray and the National Average. Unscheduled bed days for Mental Health conditions were lower than the Moray and the National Average. Population Time Trend and Projection 4) LOCAL POVERTY: Painting a picture of Moray using both local and national benefits data, children in low-income families and SIMD2020 data (Moray Council, 2022) indicated: That the intermediate data zone of ‘Burghead, Roseisle and Laich’ is placed 21/24 in terms of estimated poverty. With 1 being highest levels of poverty and 24 been lowest. Page 237
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REPORT TO: MORAY INTEGRATION JOINT BOARD ON 26 JANUARY 2023 SUBJECT: MORAY SCHEME OF INTEGRATION BY: INTERIM STRATEGY AND PLANNING LEAD 1. REASON FOR REPORT 1.1. To inform the Board of progress in relation to updating the Scheme of Integration to reflect the decision to delegate Children and Families and Justice Social Work Services to Moray Integration Joint Board (MIJB). 2. RECOMMENDATION 2.1. It is recommended that the MIJB: i) consider and approve the amendments to the Integration Scheme; ii) agree the submission of the Integration Scheme to the Scottish Government for final approval subject to approval by Moray Council and NHS Grampian at their meetings on 2 February 2023; and iii) agree the implementation of the transition of the statutory responsibility of Children’s Services from Moray Council to the MIJB following the final Scottish Government approval. 3. BACKGROUND 3.1. Section 2(3) of the Public Bodies (Joint Working) (Scotland) Act (2014) requires each Local Authority and the Health Board to jointly prepare an Integration Scheme for the area of the local authority. Section 7(1) requires the Local Authority and the Health Board to jointly submit an Integration Scheme to the Scottish Ministers for approval. 3.2. On 6 April 2022 Moray Council agreed to progress with delegation of Children and Families and Justice Social Work Services. NHS Grampian Board approval was gained on 2 June 2022, with MIJB approval on 30 June 2022 (para 9 of the minutes refers). 3.3. The functions which are delegated by the Local Authority to the Integration Joint Board are set out in the Scheme of Integration; Part 2 of the Annex 2 Item 12. Page 239
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within Appendix 1. These functions are delegated to the extent that the functions are exercisable in relation to the following service areas: • Social care services provided to children and families • Fostering and adoptions services • Child protection • Justice services 3.4. Changes to the Scheme of Integration have been overseen by Brodies Solicitors and areas of change are highlighted in Appendix 2 for ease of viewing. 4. KEY MATTERS RELEVANT TO RECOMMENDATION 4.1 Discussions are progressing with Scottish Government (as the statutory approval body) over the formal amendments required to the Integration Scheme to enable the delegation to legally proceed and to aid ministerial approval. 4.2 The timeline for revision of the current scheme aims to complete approvals and publish by March 2023. Following consideration by the MIJB, the draft Scheme of Integration will also be considered by Moray Council and NHS Grampian Board, simultaneously on 2 February 2023. Thereafter it will be submitted to Scottish Ministers allowing time for their review within the required timescale. 5. SUMMARY OF IMPLICATIONS (a) Corporate Plan and 10 Year Plan (Local Outcomes Improvement Plan (LOIP)) and Moray Integration Joint Board Strategic Plan “Partners in Care 2022 – 2032” 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 Boards) (Scotland) Act 2014, ensures that affairs are administered in accordance with the law, probity and proper standards. (c) Financial implications In preparation for the delegation of additional function to the MIJB, it will be necessary to closely monitor the financial resources to allow to carry of the function delegated and to assess the risks associated with this. The MIJB Chief Financial Officer with both Council Section 95 Officer and the Health Board Director of Finance established the arrangement that financial accountability for the delegated functions remains with the Council until to 31 March 2024. (d) Risk Implications and Mitigation To continue at pace and to recognise the benefits of delegating children and families and justice social work services, workforce engagement is essential to a successful transition. Not only for opportunities for efficiencies and professional development across the Social Work Page 240
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workforce, but more importantly the lost opportunity for improved workforce alignment which will offer better outcomes for our most vulnerable children and families. (e) Staffing Implications Proposals for change to team structures and lines of responsibility will be documented through a change management plans 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 at this point (i) Directions Formal directions will continue to be in place relating to delegated functions. (j) Consultations Chief Executive Moray Council, Chief Officer MIJB, Chief Executive NHS Grampian, Interim Chief Financial Officer HSCM, Head Governance Strategy and Performance, Chief Financial Officer Moray Council and NHS Grampian, Heads of Service Health and Social Care Moray (Sean Coady and Tracy Stephen) have been consulted. 6. CONCLUSION 6.1. Approvals from all three bodies (NHS Grampian, Moray Council and MIJB) have been gained to formally delegate Children and Families and Justice Social Work services to MIJB. 6.2. This paper sets out the position in relation to delegating function to MIJB and the revisions required to the Scheme of Integration Author of Report: Carmen Gillies, Interim Strategy and Planning Lead Background Papers: Ref: Page 241
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1 APPENDIX 1 Health and Social Care Integration Scheme for Moray [ ] 2022 This document is also available in large print and other formats and languages, upon request. Please call NHS Grampian Corporate Communications on (01224) 551116 or (01224) 552245. Item 12. Page 243
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2 Introduction This document outlines revised arrangements for how adults and older people care services will be integrated and delivered by The Moray Council and NHS Grampian and is prepared in line with the requirements of the Public Bodies (Joint Working) (Scotland) Act 2014 (the “Act”) In revising the 2018 Integration Scheme we have engaged with carers, people who currently use health and social care services in Moray, and our joint workforce. We have also subjected the draft revised Scheme to an extensive consultation exercise and have made further changes to the document based on the views and comments expressed both by people and the organisations who took the opportunity to respond. During the consultation exercise we also informed people that the contents of this revised Integration Scheme will be final, and it shall not be possible to make any modifications to the revised Integration Scheme without a further consultation and approval by Scottish Ministers. We also explained that the revised Integration Scheme will set out the parameters of our Strategic Plan which will present in more detail the changes to the way we propose to deliver integrated care services in Moray in the future. At a time when the health and social care system is facing significant demographic and financial challenges, we consider that this Integration Scheme will provide a strong foundation to how we can best improve the quality of care we deliver to the people of Moray. Page 244
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3 Aims and Outcomes of the Integration Scheme The main purpose of integration is to improve the wellbeing of people who use health and social care services, particularly those whose needs are complex and involve support from health and social care at the same time. The Integration Scheme is intended to achieve the National Health and Wellbeing Outcomes prescribed by the Scottish Ministers in Regulations under section 5(1) of the Act, 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 towards 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. Page 245
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4 Our Vision, Purpose, Local Principles and Values In aiming to fulfil the above 9 National Health and Wellbeing Outcomes, the following Vision, Purpose, Local Principles and Values have been developed by listening to the views of people who presently use health and social care services in Moray or who are involved in the delivery of care and support. Our Vision • To enable the people of Moray to lead independent, healthy and fulfilling lives in active and inclusive communities, where everyone is valued, respected and supported to achieve their own goals. Our Purpose • Through health, social care and third sector professionals and commercial providers working together with patients, unpaid carers, service users and their families, we will promote choice, independence, quality and consistency of services by providing a seamless, joined up, high quality health and social care service. When it is safe to do so, we will always do our utmost to support people to live independently in their own homes and communities for as long as possible. We will strive to ensure resources are used effectively and efficiently to deliver services that meet the needs of the increasing number of people with longer term and often complex care needs; many of whom are older. Our Local Principles • A single point of contact. We will make it easier for people to access information and support by having a single point of contact for accessing health and social care services where it is appropriate to do so. Page 246
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5 • Continuity of care. We will appoint a single lead professional across health and social care to facilitate improved communication with people in need of support and when possible we will aim to provide continuity of care. • Health and social care professionals share information. We will work to ensure that people will have to tell their story only once and that their information is shared with all relevant professionals. • Signposting. Information and advice should be provided in a format that is right for the person and is readily available in their community. • Personalisation. Our vision means that we do not provide the same service for everyone but the right service for each person. We will always aim to provide choice and control. • Community outcomes. We will aim to support local communities to determine their own health and well-being priorities and we will work in partnership towards the realisation of these agreed outcomes. • The conversation is at the heart of what we do and is the key to meaningful action. Identifying positive outcomes that matter to people is based on a conversation with the service user, patient, unpaid carer and sometimes the whole community. This level of engagement is the essential first step in delivering an outcomes-based service. • Best value. We will always endeavour to make the best use of public money by ensuring that our services are efficient, effective and sustainable. Our values • We will always work to support people to achieve their own outcomes and goals that improve their quality of life. • We will always listen and treat people with respect. • We will always value the support and contribution provided by unpaid carers. • We will respect our workforce and give them the support and trust they need to help them achieve positive outcomes for the people of Moray. Page 247
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6 Integration Scheme The parties: MORAY COUNCIL, established under the Local Government etc. (Scotland) Act 1994 and having its principal offices at Council Offices, High Street, Elgin, Moray IV30 1BX (hereinafter referred to as “the Council” which expression shall include its statutory successors); And GRAMPIAN HEALTH BOARD, established under section 2(1) of the National Health Service (Scotland) Act 1978 (operating as “NHS Grampian”) and having its principal offices at Summerfield House, 2 Eday Road, Aberdeen AB15 6RE (hereinafter referred to as “NHS Grampian” which expression shall include its statutory successors) (together referred to as “the Parties”, and each being referred to as a “Party”) Page 248
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7 1. Definitions and Interpretation 1.1 In this Integration Scheme, the following terms shall have the following meanings:- “Accountable Officer” means the National Health Service (“NHS”) officer appointed in terms of section 15 of the Public Finance and Accountability (Scotland) Act 2000; “Chief Officer” means the Officer appointed by the Integration Joint Board (IJB) in accordance with section 10 of the Act; “Chief Social Work Officer” means the officer appointed by Moray Council in terms of Section 3 of the Social Work (Scotland) Act 1968 “Clinical, Care and Governance Committee” means the IJB committee thatsupports and assists" the Board in achieving their clinical and care governance responsibilities in compliance with the Health and Social Care Integration, Clinical and Care Governance Framework Version 1 (Scottish Government published October 2015). “Clinical Lead” means the registered medical practitioner who delivers primary care services or some other registered health care professional who delivers services within a community context who is appointed by the Chief Officer and the Medical Director of NHS Grampian; “Community Planning Board” means the Moray Community Planning Board established in terms of the Community Empowerment (Scotland) Act 2015 to consider the strategic development and monitor the performance of the partner agencies within Moray (which include both Moray Council and NHS Grampian ) in delivering Locality Plans, the Local Outcomes Improvement Plan and any wider CPP national matters. Page 249
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8 “Direction(s)” means an instruction(s) from the Integration Joint Board in accordance with section 26 of the Act; “Executive Director of Nursing and Midwifery” means the post that is accountable for professional leadership for Nurses, Midwives and Allied Health Professionals within the organisation; setting standards and enuring the delivery of compassionate, caring and effective patient and family centred services. “IJB” means the Moray Integration Joint Board established by an Order made in accordance with section 9 “IJB Order” means the Public Bodies (Joint Working) (Integration Joint Boards) (Scotland) Order 2014; “Integrated Budget” means the budget for the delegated resources for the functions set out in the Scheme; “Integrated Services” means the functions and services listed in Annexes 1 and 2 of this Scheme; “Joint Performance Management Plan” means a resource which provides a list of targets and measures for use within a performance framework; “Integrated Workforce Plan” means the three year plan for workforce resources, produced collaboratively with Moray Council and NHS Grampian, aligned to the objectives of IJB and in accordance with the guidance from Scottish Government. “NHS Grampian Clinical and Care Governance committee” means the committee that is responsible for demonstrating compliance with statutory requirements in relation to clinical governance, authorising an accurate and honest annual clinical governance statement and responding to scrutiny and Page 250
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9 improvement reports by external bodies such as Healthcare Improvement Scotland (or any successor) “Organisational Development Strategy” means the overarching planned and systematic approach to developing the culture and improving the effectiveness of the organisation, through engagement, communication, training and development of staff. It aligns strategy, individuals processes and values. “Outcomes” means the Health and Wellbeing Outcomes prescribed by the Scottish Ministers in Regulations under section 5(1) of the Act; “Payment” means all of the following: a) the Integrated Budget contribution to the Integration Joint Board; b) the resources paid by the Integration Joint Board to the Parties for carrying out a Direction or Directions, in accordance with section 27 of the Act and c) does not require that a bank transaction is made; “Section 95 Officer” means the statutory post under the Local Government (Scotland) Act 1973 being the Accountable (Proper) Officer for the administration and governance of the financial affairs of the Council; “Strategic Plan” means the plan which the Integration Joint Board is required to prepare and implement in relation to the delegated provision of health and social care services to adults in accordance with section 29 of the Act; “Strategic Planning and Commissioning Group” means the forum that assists the IJB and Chief Officer through the development of key strategic outcomes and oversees, drives and strengthens strategic planning and commission of health and social care services across Moray. “Strategic Risk Register” means the register that outlines the identified risks to the implementation and achievement of the outcomes contained in the strategic plan, showing the controls, mitigation actions and potential impacts if the risk materialises.(17) Page 251
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10 “The act” means the Public Bodies (Joint Working) (Scotland) Act 2014; “The Administration Scheme” means the document that sets out the governance and structure by which the MIJB conducts its affairs. It details the structure of its Committees and the functions referred to these Committees; “the Integration Scheme Regulations” means the Public Bodies (Joint Working) (Integration Scheme) (Scotland) Regulations 2014; “the Scheme” means this Integration Scheme; 1.2 In implementation of their obligations under the Act, the Parties hereby agree as follows: 1.3 In accordance with section 1(2) of the Act, the Parties agreed that the integration model set out in sections 1(4)(a) of the Act would be put in place for the IJB, namely the delegation of functions by the Parties to a body corporate that is to be established by an Order made in accordance with section 9 of the Act. The Moray Integration Joint Board was established by a Parliamentary Order on 6 February 2016. 2. Local Governance Arrangements 2.1 Requirements are contained in the Act including the detail of the remit and constitution of the IJB but for context the following is repeated here: 2.1.1 The remit of the IJB is to prepare and implement a Strategic Plan in relation to the provision of health and social care services to adults in their area in accordance with sections 29-39 of the Act. Page 252
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11 2.1.2 The regulation of the IJB’s procedure, business and meetings and that of any Committee of the IJB will follow the IJB Order and the standing orders which will be agreed by the IJB, and which may be amended by the IJB. The Standing Orders will be set out in a separate document. 2.1.3 NHS Grampian and the Council will continue to have in place an appropriate governance structure to ensure effective delivery of any functions or services not delegated as part of this scheme. 2.1.4 NHS Grampian and the Council and any of their Committees will positively support through productive communication and interaction the IJB and its Committees to allow it to achieve its Outcomes and Vision. The IJB will similarly support through productive communication and interaction NHS Grampian and the Council and any of their Committees in their delivery of integrated and non-integrated services. 2.1.5 The IJB has a distinct legal personality and the autonomy to manage itself. There is no role for NHS Grampian or the Council to independently sanction or veto decisions of the IJB. 2.1.6 The IJB will create such Committees that it requires to assist it with the planning and delivery of Integrated Services. 2.1.7 The IJB is a statutory partner in the Community Planning Partnership in terms of s.4(1) and Schedule 1 of the Community Empowerment (Scotland) Act 2015 and as such will be a member of the Community Planning Board and shall, along with the other statutory partners, report to the Community Planning Board. The IJB shall assist in the identification of priorities for the Community Planning Board’s strategic partnerships as appropriate. Page 253
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12 3. Board Governance 3.1 The arrangements for appointing the voting membership of the IJB in accordance with the IJB Order are as follows:- 3.1.1 The Council shall nominate four councillors; and 3.1.2 NHS Grampian shall nominate four non-executive directors (if unable to do so then it must nominate a minimum of three non-executive directors and one executive director). 3.2 The voting membership of the IJB shall be appointed for a term of up to 3 years. 3.3 Provision for the disqualification, resignation and removal of voting members is set out in the IJB Order. 3.4 The IJB is required to co-opt non-voting members to the IJB. 3.5 The non-voting membership of the IJB is set out in the IJB Order and includes (subject to any amendment of the IJB Order): a) the chief social work officer of the local authority; b) the Chief Officer, once appointed by the IJB; c) the proper officer of the integration joint board appointed under section 95 of the Local Government (Scotland) Act 1973; d) a registered medical practitioner whose name is included in the list of primary medical services performers prepared by NHS Grampianin accordance with Regulations made under section 17P of the National Health Service (Scotland) Act 1978; e) a registered nurse who is employed by NHS Grampian or by a person or body with which NHS Grampian has entered into a general medical services contract; f) a registered medical practitioner employed by NHS Grampian and not providing primary medical services; and g) a professional representative from Public Health Page 254
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13 and at least one member of each of the following groups: h) staff of the constituent authorities engaged in the provision of services provided under integration functions; i) third sector bodies carrying out activities related to health or social care in the area of the local authority; j) service users residing in the area of the local authority; and k) persons providing unpaid care in the area of the local authority. 3.6 NHS Grampian will determine the non-voting representatives listed in d)-f) above, in accordance with the terms of the IJB Order. 3.7 The arrangements for appointing the Chair and Vice Chair of the IJB are as follows:- 3.7.1 The first Chair was nominated by the Council. 3.7.2 The first term of the Chair began on the date the IJB was established and continued until 30 September 2016 and second term of the Chair commenced 1 October 2016.. 3.7.3 Further terms of the Chair are for a period of 18 months., 3.7.4 The Parties are entitled to change the person appointed by them as Chair or Vice Chair during the appointed period via the appropriate governance procedures within the Parties. 3.7.5 After the term of the first Chair came to an end, the Vice Chair became the next Chair and the outgoing Chair’s organisation then nominated the next Vice Chair, which the IJB appointed. 3.7.6 The Parties must alternate which of them is to appoint the Chair in respect of each successive appointing period. The organisation which has not nominated the Chair shall nominate the Vice Chair. Page 255
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14 4. Delegation of Functions 4.1 The functions that are to be delegated by NHS Grampian to the IJB are set out in Part 1 of Annex 1 and are subject to the exceptions and restrictions specified or referred to. The services to which these functions relate, which are currently provided by NHS Grampian and which are to be integrated, are set out in Part 2 of Annex 1. For the avoidance of doubt the functions listed in Part 1 of Annex 1 are delegated only to the extent that they relate to the services listed in Part 2 of Annex 1 and there are certain services in respect of which functions are delegated for all age groups and certain services in respect of which functions are delegated for people over the age of 18 only. 4.2 The functions that are to be delegated by the Council to the IJB are set out in Parts 1 and 2 of Annex 2 and are subject to the exceptions and restrictions specified or referred to. The services to which the functions set out in Part 1, which are currently provided by the Local Authority and which are to be integrated, are set out in Part 3 of Annex 2. For the avoidance of doubt the functions listed in Part 1 of Annex 2 are delegated only to the extent that they relate to the services listed in Part 3 of Annex 2 and are provided to persons of 18 years and over. The functions listed in Part 2 of Annex 2 are delegated to the extent that they relate to the functions listed in part 4 of Annex 2. 4.3 In the delegation of functions, the Parties recognise that they will require to work together, and with, the IJB, to achieve the Outcomes. Through local management, the Parties will put arrangements in place to avoid fragmentation of services provided to persons under 18 years. In particular, the community health services for persons under 18 years of age set out in Part 3 of Annex 1 shall be operationally devolved by the Chief Executive of NHS Grampian to the Chief Officer of the IJB who will be responsible and accountable for the operational delivery and performance of these services. Page 256
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15 4.4 In exercising its functions, the IJB must take into account the Parties requirements to meet their respective statutory obligations, standards set by government and other organisational and service delivery standards set by the Parties. Apart from those functions delegated by virtue of the Scheme, the Parties retain their distinct statutory responsibilities and therefore also retain their formal decision-making roles. 4.5 The delegation of functions from the Parties to the IJB shall not affect the legality of any contract made between either of the Parties and any third party, which relates to the delivery of integrated or non-integrated services. The IJB shall be mindful of the Parties’ contracts and will enter into a joint commissioning strategy with the Parties. 4.6 Some Integrated Services may be hosted by the IJB on behalf of other integration authorities, or some integrated services may be hosted by another integration authority on behalf of the IJB. The IJB will consider and agree the hosting arrangements. Page 257
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16 5. Local Operational Delivery Arrangements 5.1 The local operational arrangements agreed by the Parties are: 5.2 The following responsibilities of the membership of the IJB in relation to monitoring and reporting on the delivery of Integrated Services on behalf of the Parties are as follows:- 5.2.1 The IJB is responsible for the planning of Integrated Services and achieves this through the Strategic Plan. It issues Directions to the Parties to deliver services in accordance with the Strategic Plan. 5.2.2 The IJB will continue to monitor the performance of the delivery of Integrated services using the Strategic Plan on an ongoing basis and the Parties will report to the IJB regularly on performance in implementation of Directions to enable it to do so. 5.2.3 The IJB is required to publish an annual performance report on performance to deliver the Outcomes and will share this with the Parties. The IJB makes decisions on matters of strategy, policy and the annual budget as well as having oversight of, and obtaining assurance on, the performance of delegated services, including services that it hosts but not including the health services listed in Annex 4 or services which are hosted by another integration authority. NHS Grampian will be responsible for the operational oversight of the services listed in Annex 4 and already has in place an existing mechanism for the scrutiny and monitoring of delivery of these services. Appropriate links will be made between this structure and any governance framework to be put in place by the IJB in terms of paragraph 5.6 below. 5.3 The IJB will take decisions in respect of Integrated Services for which it has operational oversight. Page 258
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17 5.4 The IJB shall ensure that resources are managed appropriately for the delivery of Integrated Services for which it has operational oversight, in implementation of the Strategic Plan. 5.5 The Parties expect the IJB to develop a governance framework to provide itself with a mechanism for assurance and monitoring of the management and delivery of Integrated Services. This will enable scrutiny of performance and appropriate use of resources. If required, the Parties will support the IJB in the development of this framework. 5.7 The Chief Officer is accountable to the IJB for the planning and operational delivery of the delegated services and the outcomes they achieve. The Chief Officer will make decisions which, in their opinion, is required to discharge their responsibilities for the planning and operational delivery of these delegated services. The Parties acknowledge that the Chief Officer’s role in operational delivery will represent an important means by which closer integration of services, in accordance with the integration delivery principles specified in the Act, can be achieved. For the avoidance of doubt, the Chief Officer's role shall not displace: (a) the responsibilities of each Party regarding compliance with Directions issued by the IJB; or (b) the principle that each Party’s governance arrangements must allow that Party to manage risks relating to service delivery. 5.8 For Integrated Services that the IJB does not have operational oversight of, the IJB shall be responsible for the strategic planning of those services. The IJB shall monitor performance of those services in terms of Outcomes delivered by comparison against the Strategic Plan 5.9 NHS Grampian and the Council will be responsible for the operational delivery of Integrated Services in implementation of Directions of the IJB. The Parties shall provide such information as may be required by the Chief Officer, the IJB Page 259
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18 and the Strategic Planning and Commissioning Group to enable the planning, monitoring and delivery of Integrated Services. 5.10 NHS Grampian will provide such information as may be reasonably required by the Chief Officer or the IJB in respect of the delivery of Integrated Services provided within hospitals that the IJB does not have operational oversight of. 5.11 NHS Grampian and the IJB will work together to ensure that the planning and delivery of integrated (and non-integrated) hospital services are consistent. Page 260
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19 6. Corporate Support Services 6.1 The Parties recognise that the IJB requires various corporate support services in order to fully discharge its duties under the Act. 6.2 The Parties shall identify, and may review, the corporate resources required for the IJB, including the provision of any professional, technical, or administrative services for the purpose of preparing a Strategic Plan and carrying out integration functions. This assessment shall be made available to the IJB. 6.3 The Parties shall be responsible for ensuring that the IJB has provision of suitable resources for corporate support to allow it to fully discharge its duties under the Act. 6.4 The Parties and the IJB shall reach an agreement in respect of how these services will be provided to the IJB which will set out the details of the provision. 6.5 The Parties shall identify and keep under regular review suitable resources for corporate support for the IJB to allow it to fully discharge its duties under the Act. The Parties and the IJB shall agree on the arrangements for future provision, including specifying how these requirements will be built into the IJB’s annual budget setting and review process. 6.6 7. Support for Strategic Planning 7.1 The Parties shall share, with such other relevant integration authorities, the necessary activity and financial data for services, facilities or resources that relate to the planned use of services provided in the Moray area by those integration authorities for people who live within Moray. 7.2 The Strategic Plan is written for the residents of Moray. A number of individuals may be resident in the area of one integration authority but receive services in Page 261
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20 the area of another integration authority. NHS Grampian will provide support to enable the appropriate planning of such services for these individuals. This shall be done in pursuance of the duty prescribed by s30(3) of the Act. 7.3 The Parties shall consult with the IJB on any plans to change service provision of non-integrated services which may have a resultant impact on the Strategic Plan. Page 262
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21 8. Targets and Performance Measurement 8.1 The Parties shall inform the IJB what performance targets and improvement measures it considers the IJB should take account of, in the planning and delivery of delegated functions for which responsibility should transfer exclusively to the IJB. 8.2 Where the responsibility for achieving the targets span delegated and non- delegated services, the Parties and the IJB will work together to deliver these. 8.3 A set of shared principles for targets, measures and indicators known as a Performance Framework, will be maintained and agreed by the Parties and the IJB. This will take into account the Scottish Government’s Guidance on the Outcomes and the associated core suite of indicators for integration. 8.4 The performance framework will be underpinned by the Outcomes and will drive change and improve effectiveness. The framework will be informed by an assessment of current performance arrangements and the development of a set of objectives which the framework is intended to achieve. . Page 263
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22 9. Clinical and Professional Governance 9.1 Outcomes 9.1.1 The IJB will improve and provide assurance on the Outcomes through its clinical and professional governance arrangements. The Outcomes are as follows: • People are able to look after and improve their own health and wellbeing and live in good health for longer. • People, including those with disabilities or long-term conditions or who are frail are able to live, as far as reasonably practicable, independently and at home or in a homely setting in their community. • People who use health and social care services have positive experiences of those services, and have their dignity respected. • Health and social care services are centred on helping to maintain or improve the quality of life of people who use those services. • Health and social care services contribute to reducing health inequalities. • People who provide unpaid care are supported to look after their own health and wellbeing, including to reduce any negative impact of their caring role on their own health and wellbeing. • People using health and social care services are safe from harm. • People who work in health and social care services feel engaged with the work they do and are supported to continuously improve the information, support, care and treatment they provide. • Resources are used effectively and efficiently in the provision of health and social care services. 9.1.2 The Parties and the IJB will have regard to the integration planning and delivery principles and will determine the clinical and professional governance assurances and information required by the IJB to inform the development, monitoring and delivery of its Strategic Plan. The Parties will provide that assurance and information to the IJB. Page 264
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23 9.2 General Clinical and Professional Governance Arrangements 9.2.1 The Parties and the IJB are accountable for ensuring appropriate clinical and professional governance arrangements for their duties under the Act. 9.2.2 The Parties remain responsible for the clinical and professional governance of the services which the IJB has instructed the Parties to deliver. 9.2.3 The Parties remain responsible for the assurance of the quality and safety of services commissioned from the third and independent sectors in line with the requirements set out in the Strategic Plan. 9.2.4 The IJB will have regard to healthcare and social care governance quality aims and risks when developing and agreeing its Strategic Plan and its corresponding Directions to the Parties. These risks may be identified by either of the Parties or the IJB and may include professional risks. 9.2.5 The Parties and the IJB will establish an agreed approach to measuring and reporting to the IJB on the quality of service delivery, organisational and individual care risks, the promotion of continuous improvement and ensuring that all professional and clinical standards, legislation and guidance are met. This will be set out in a report to the IJB for it to approve. 9.3 Clinical and Professional Governance Framework 9.3.1 NHS Grampian seeks assurance in the area of clinical governance, quality improvement and clinical risk from the NHS Grampian Clinical Governance Committee, through a process of constructive challenge. The NHS Grampian Clinical Governance Committee is responsible for demonstrating compliance with statutory requirements in relation to Page 265
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24 clinical governance, authorising an accurate and honest annual clinical governance statement and responding to scrutiny and improvement reports by external bodies such as Healthcare Improvement Scotland (or any successor). To achieve this, the Committee oversees a governance framework including a strategy, annual work programme, infrastructure of governance groups and an annual report. 9.3.2 The Council is required by law to appoint a Chief Social Work Officer to oversee and make decisions in relation to specified social work services, some of which are delegated in relation to integration functions, and to report to and alert the Council and elected members of any matters of professional concern in the management and delivery of those functions. He or she has a duty to make an annual report to the Council in relation to the discharge of the role and responsibilities. The Chief Social Work Officer will be a non-voting member of the IJB. If required, he or she shall make an annual report to the IJB in relation to the aspects of his or her position which relate to the delivery of integrated functions. The Chief Social Work Officer will retain all of the statutory decision-making and advisory powers given by statute and guidance, and the Medical Director and Executive Director of Nursing and Midwifery shall not be entitled to countermand or over-rule any decisions or instructions given by the Chief Social Work Officer in carrying out that statutory role. 9.3.3 External scrutiny is provided by the Care Inspectorate (Social Care and Social Work Improvement Scotland) (or any successor), which regulates, inspects and supports improvement of adult social work and social care. 9.3.4 The Scottish Government’s Clinical and Care Governance Framework for Integrated Health and Social Care Services in Scotland, 2014 (or any updated version or replacement) outlines the proposed roles, responsibilities and actions that will be required to ensure governance arrangements in support of the Act’s integration planning and delivery principles and the required focus on improved Outcomes. Page 266
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25 9.4 Staff Governance 9.4.1 The Parties will ensure that staff working in Integrated Services have the right training and education required to deliver professional standards of care and meet any professional regulatory requirements. 9.4.2 The IJB and the Parties shall ensure that staff will be supported if they raise concerns relating to practice that endangers the safety of service users and other wrong doing in line with local policies and regulatory requirements. There are three main Whistleblowing policies relevant to the IJB: the National Whistleblowing Standards, the Council’s Whistleblowing Policy and the IJB’s Whistleblowing Policy: ▪ National Whistleblowing Standards have been produced by the Independent National Whistleblowing Officer’s Department and came into effect on 1 April 2021. Whistleblowing Concerns can be raised by anyone who is (or has been) providing services for the NHS or working to provide services with NHS staff. ▪ Moray Council Whistleblowing Policy -This policy applies to all employees and workers, including agency staff, workers who are self-employed, sub-contractors and workers employed by an outsourced contractor providing Council services. ▪ IJB Whistleblowing Policy - This Policy relates to all IJB Members and Office Holders of the Board and is committed to dealing responsibly, openly and professionally with any genuine concerns held by staff of the Moray Health and Social Care Partnership, Members of the Board or Office Holders, encouraging them to report any concerns about wrongdoing or malpractice within the IJB, which they believe has occurred. The aim of this policy is to ensure that staff and Members are fully aware of the types of matters that they should report and the reporting procedure they Page 267
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26 should follow to raise any genuine concerns about any possible wrongdoing or malpractice, at an early stage, without fear of penalty or victimisation. 9.4.3 Staff employed by NHS Grampian are bound to follow the NHS Staff Governance Standard. This standard is recognised as being very laudable and the IJB will encourage it to be adopted for all staff involved in the delivery of delegated services. The Staff Governance Standard requires all Health Boards to demonstrate that staff are: • Well informed; • Appropriately trained and developed; • Involved in decisions which affect them; • Treated fairly and consistently, with dignity and respect, in an environment where diversity is valued; and • Provided with a continuously improving and safe working environment, promoting the health and wellbeing of staff, patients, and the wider community. 9.4.4 The Standard places a reciprocal duty on staff to: • Keep themselves up to date with developments relevant to their job within the organisation; • Commit to continuous personal and professional development; • Adhere to the standards set by their regulatory bodies; • Actively participate in discussions on issues that affect them either directly or via their trade union/professional organisation; • Treat all staff and patients with dignity and respect while valuing diversity; and • Ensure that their actions maintain and promote the health, safety and wellbeing of all staff, patients, carers and those with lived experience. Page 268
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27 9.5 Interaction with the IJB, Strategic Planning Commissioning Group and Localities 9.5.1 The IJB has established a Clinical and Care Governance Committee to oversee the clinical and professional governance arrangements for Integrated Services. The Clinical and Care Governance Committee brings together senior professionals representative of the range of professional groups involved in delivering health and social care services. This includes at least one lead from each of the Parties senior professional staff, the Chief Social Work Officer and Executive Director of Nursing and Midwifery. 9.5.2 The three professional advisors of the IJB listed at 9.5.5 b)-d) are members of the Clinical and Care Governance Committee. These advisors will continue to report to the Medical Director and Executive Director of Nursing and Midwifery. 9.5.3 The role, remit and membership of the IJB Clinical and Care Governance Committee is set out in the IJB’s Scheme of Administration, which may be reviewed and amended by the IJB. 9.5.4 The Clinical and Care Governance Committee will provide clinical health care and professional social work advice to the IJB, the Strategic Planning and Commissioning Group, the Chief Officer and any professional groups established in localities as and when required. This can be done through the Chair of the Committee (or such other appropriate members) informing and advising the IJB, the Strategic Planning Group, the Chief Officer and any other Group, Committee or locality of the IJB as and when required. 9.5.5 The IJB and the Chief Officer shall also be able to obtain clinical and professional advice from the IJB non-voting membership, which shall include (subject to any amendment of the IJB Order): Page 269
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28 a) The Chief Social Work Officer; b) A registered medical practitioner whose name is included in the list of primary medical services performers prepared by NHS Grampian in accordance with Regulations made under section 17P of the National Health Service (Scotland) Act 1978; c) A registered nurse who is employed by NHS Grampian or by a person or body with which the Health Board has entered into a general medical services contract; and d) A registered medical practitioner employed by NHS Grmapian and not providing primary medical services. 9.5.6 The Clinical and Care Governance Committee will be represented on the established clinical and professional forums/groups of both the Council and NHS Grampian to address matters of risk, safety, and quality. The Clinical and Care Governance Committee is aligned with both Parties arrangements. 9.5.7 The Chief Social Work Officer is a member of the Clinical and Care Governance Committee. The Chief Social Work Officer may report to the Council to provide any necessary assurance as required. 9.5.8 The NHS Grampian Area Clinical Forum (and clinical advisory structure), Managed Clinical and Care Networks, Local Medical Committees, other appropriate professional groups, and the Adult and Child Protection Groups and Committees will be available to provide clinical and professional advice to the IJB. 9.6 Professional Leadership 9.6.1 The Act does not change the professional regulatory framework within which health and social care professionals work, or the established professional accountabilities that are currently in place within the NHS and local government. The Act through drawing together the planning Page 270
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29 and delivery of services aims to better support the delivery of improved outcomes for the individuals who receive care and support across health and social care. 9.6.2 Medical Directors and Executive Directors of Nursing and Midwifery are ministerial appointments made through health boards to oversee systems of professional and clinical governance within NHS Grampian. Their professional responsibilities supersede their responsibilities to their employer. These Directors continue to hold responsibility for the actions of NHS Grampian clinical staff who deliver care through Integrated Services. They, in turn, continue to attend the NHS Grampian Clinical Governance Committee which oversees the clinical governance arrangements of all services delivered by health care staff employed by NHS Grampian. 9.6.3 In addition to the IJB’s Clinical and Care Governance Committee, advice can be provided to the IJB and the Strategic Planning and Commissioning Group through the Clinical Executive Directors of NHS Grampian and the Chief Social Work Officer of the Council on professional / workforce, clinical / care and social care / social work governance matters relating to the development, delivery, and monitoring of the Strategic Plan, including the development of integrated service arrangements. The professional leads of the Parties can provide advice and raise issues directly with the IJB either in writing or through the representatives that sit on the IJB. The IJB will respond in writing to these issues where asked to do so by the Parties. 9.6.4 The key principles for professional leadership are as follows: • Job descriptions will reflect the level of professional responsibility at all levels of the workforce explicitly; • The IJB will name the Clinical Lead and ensure representation of professional representation and assurance from both health and social Page 271
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30 care. The Executive Director of Nursing and Midwifery and Medical Director will continue to have professional managerial responsibility; • All service development and redesign will outline participation of professional leadership from the outset, and this will be evidenced in all IJB papers; • The effectiveness of the professional leadership principles will be reviewed annually. 10. Chief Officer 10.1 The IJB shall appoint a Chief Officer in accordance with section 10 of the Act. The arrangements in relation to the Chief Officer agreed by the Parties are: 10.2 An interim Chief Officer may be appointed at the request of the IJB by arrangements made jointly by the Chief Executives of both Parties in consultation with the Chair of the IJB. 10.3 The Chief Officer will be responsible for the operational management of Integrated Services, other than the health services listed in Annex 4 or the services hosted by another integration authority. Further arrangements in relation to the Chief Officer’s responsibilities for operational management and strategic planning are set out in a separate document, which the IJB may amend from time to time. 10.4 The Chief Officer shall be accountable to the IJB for the management of Integrated Services for which the IJB has operational oversight. The Chief Officer may sub-delegate decision making powers that have been delegated by NHS Grampian and the Council where, in his/her opinion, it is appropriate and legitimate to do so. 10.5 The Chief Officer will be responsible for the development and monitoring of operational plans which set out the mechanism for the delivery of the Strategic Plan. Page 272
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31 10.6 The Chief Executive of NHS Grampian will be the Accountable Officer for the delivery of the acute services that the IJB has strategic planning responsibility for and will provide updates to the Chief Officer on the operational delivery of those services provided and the set aside budget on a regular basis. 10.8 The Chief Officer will be a member of the appropriate senior management teams of NHS Grampian and the Council. This will enable the Chief Officer to work with senior management of both Parties to carry out the functions of the IJB in accordance with the Strategic Plan. 10.9 The Chief Officer will be line managed by the Chief Executives of the Parties. The Chief Officer shall also report to the IJB. 10.10 The Chief Officer will develop close working relationships with elected members of the Council and non-executive and executive NHS Grampian board members. 10.11 The Chief Officer will establish and maintain effective working relationships with a range of key stakeholders across NHS Grampian, the Council, the third and independent sectors, communities, service users, carers and those with lived experience, the Scottish Government, trade unions and relevant professional organisations. 10.12 The Chief Officer will work with trade unions, staff side representatives and professional organisations to ensure a consistent approach to their continued involvement in the integration of health and social care. 11. Workforce 11.1 The arrangements in relation to their respective workforces agreed by the Parties are: Page 273
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32 11.2 The employment status of staff will not change as a result of the Scheme i.e. staff will continue to be employed by their current employer and retain their current terms and conditions of employment and pension status. 11.3 The Parties will develop and maintain an Integrated Workforce Plan that will be aligned to objectives set by the IJB. The Integrated Workforce Plan will relate to the development and support to be provided to the workforce who are employed in pursuance of Integrated Services and functions. The plan will cover staff communication, staff engagement, staff and team development, leadership development and the training needs for staff that will be responsible for managing integrated teams. 11.5 The Organisational Development strategy for the Parties and the IJB will be informed by Employee Engagement processes being followed as part of the Integrated Workforce Plan. This will encourage the development of a healthy organisational culture. The Parties and the IJB will work together in developing this plan along with stakeholders. 11.6 These plans will be presented to the IJB for approval in a three year cycle and will be reviewed regularly through an agreed process to ensure that it takes account of the development needs of staff. 12. Finance 12.1 Financial Governance 12.1.1 The IJB will have no cash transactions and will not directly engage or provide grants to third parties. 12.1.2 The IJB will have appropriate assurance arrangements in place (detailed in the Strategic Plan) to ensure best practice principles are followed by the Parties for the commissioned services. Page 274
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33 12.1.3 The IJB will be responsible for establishing adequate and proportionate internal audit service for review of the arrangements for risk management, governance, and control of the delegated resources. The IJB will accordingly appoint an Internal Auditor to report to the Chief Officer and IJB on the proposed annual audit plan, ongoing delivery of the plan, the outcome of each review and an annual report on delivery of the plan. 12.1.4 The Accounts Commission will confirm the external auditors for the IJB. 12.1.5 Further details of financial governance and financial regulations are contained in a separate document out with the Scheme. 12.2 Payments to the IJB – General 12.2.1 The payment made by each Party is not an actual cash transaction for the IJB. There will be a requirement for an actual cash transfer to be made between the Parties to reflect the difference between the payment being made by a Party and the resources delegated by the IJB to that Party to deliver services. Any cash transfer will take place between the Parties monthly in arrears based on the annual budgets set by the Parties and the directions from the IJB. A final transfer will be made at the end of the financial year on closure of the annual accounts of the IJB to reflect in-year budget adjustments agreed. 12.2.2 Resource Transfer – The existing resource transfer arrangements will cease upon establishment of the IJB and instead NHS Grampian will include the equivalent sum in its budget allocation to the IJB. The Council payment to the IJB will accordingly be reduced to reflect this adjustment. 12.2.3 Value Added Tax (VAT) – the budget allocations made will reflect the respective VAT status and treatments of the Parties. In general terms budget allocations by the Council will be made net of tax to reflect its status as a Section 33 body in terms of the Value Added Tax Act 1994 Page 275
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34 and those made by NHS Grampian will be made gross of tax to reflect its status as a Section 41 body in terms of the Value Added Tax Act 1994. 12.3 Payments to the IJB 12.3.1 The payment that will be determined by each Party requires to be agreed in advance of the start of the financial year. Each Party agrees that the baseline payment to the IJB for delegated functions will be formally advised to the IJB and the other Party by 28th February each year. 12.3.2 The Chief Officer and the Chief Finance Officer of the IJB will develop a case for the Integrated Budget based on the Strategic Plan and present it to the Council and NHS Grampian for consideration as part of the annual budget setting process, in accordance with the timescales contained therein. The case should be evidence based with full transparency on its assumptions and analysis of changes, covering factors such as activity changes, cost inflation, efficiencies, legal requirements, transfers to / from the “set aside” budget for hospital services and equity of resource allocation. 12.3.3 The final payment into the IJB will be agreed by the Parties in accordance with their own processes for budget setting. 12.3.4 The IJB will approve and provide direction to the Parties by 31st March each year regarding the functions that are being directed, how they are to be delivered and the resources to be used in delivery. 12.4 Method for determining the amount set aside for hospital services 12.4.1 The IJB will be responsible for strategic planning, in partnership with the hospital sector, of those hospital services most commonly associated with the emergency care pathway. 12.4.2 The IJB and the hospital sector will agree a method for establishing the amount to be set aside for services that are delivered in a large hospital Page 276
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35 as part of the emergency care pathway which will show consumption by the residents of the IJB. 12.4.3 The method of establishing the set aside budget will take account of hospital activity data and cost information. Hospital activity data will reflect actual occupied bed day and admissions information, together with any planned changes in activity and case mix. 12.5 Financial Management of the IJB 12.5.1 The Council will host the financial transactions specific to the IJB. 12.5.2 The IJB will appoint a Chief Finance Officer who will be accountable for the annual accounts preparation (including gaining the assurances required for the governance statement) and financial planning (including the financial section of the Strategic Plan) and will provide financial advice and support to the Chief Officer and the IJB. The Chief Finance Officer will also be responsible for the production of the annual financial statement (in accordance with section 39 of the Act) 12.5.3 As part of the process of preparing the annual accounts of the IJB the Chief Finance Officer of the IJB will be responsible for agreeing balances between the IJB and Parties at the end of the financial year and for agreeing details of transactions between the IJB and Parties during the financial year. The Chief Finance Officer of the IJB will also be responsible for provision of other information required by the Parties to complete their annual accounts including Group Accounts. 12.5.4 Recording of all financial information in respect of the Integrated Services will be in the financial ledger of the Party which is delivering the services on behalf of the IJB. 12.5.5 The Parties will provide the required financial administration to enable the transactions for delegated functions (e.g. payment of suppliers, Page 277
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36 payment of staff, raising of invoices etc.) to be administered and financial reports to be provided to the Chief Finance Officer of the IJB. The Parties will not charge the IJB for this service. 12.6 Financial reporting to the IJB and the Chief Officer 12.6.1 Financial reports for the IJB will be prepared by the Chief Finance Officer of the IJB. The format and frequency of the reports to be agreed by the IJB, the Council and NHS Grampian, but will be at least on a quarterly basis. The Director of Finance of NHS Grampian and the Section 95 Officer of the Council will work with the Chief Finance Officer of the IJB to ensure that the information that is required to produce such reports can be provided. 12.6.2 To assist with the above the Parties will provide information to the Chief Finance Officer of the IJB regarding costs incurred by them on a quarterly basis for services directly managed by the IJB. Similarly, NHS Grampian will provide the IJB with information on use of the amounts set aside for hospital services. This information will focus on patient activity levels and not include unit costs; the frequency will be agreed with the IJB but will be at least quarterly. 12.6.3 The Chief Finance Officer of the IJB will agree a timetable for the preparation of the annual accounts with the Director of Finance of NHS Grampian and the Section 95 Officer of the Council. 12.6.4 In order to give assurance to the Parties that the delegated budgets are being used for their intended purposes, financial monitoring reports will be produced for the Parties in accordance with timetables to be agreed at the start of each financial year. The format of such reports to be agreed by the Director of Finance of NHS Grampian and the Section 95 Officer of the Council, in conjunction with the Chief Finance Officer of the IJB. Page 278
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37 12.7 The process for addressing in year variations in the spending of the IJB 12.7.1 Increases in payment by Parties to the IJB 12.7.1.1 The Parties may increase in-year the payments to the IJB for the delegated services with the agreement of the IJB. 12.7.2 Reductions in payment by Parties to the IJB 12.7.2.1 The Parties do not expect to reduce the payment to the IJB in- year unless there are exceptional circumstances resulting in significant unplanned costs for the Party. In such exceptional circumstances the following escalation process would be followed before any reduction to the in-year payment to the IJB was agreed:- a) The Party would seek to manage the unplanned costs within its own resources, including the application of reserves where applicable; b) Each Party would need to approve any decision to seek to reduce the in-year payment to the IJB; c) Any final decision would need to be agreed by the Chief Executives of both Parties and by the Chief Officer of the IJB, and be ratified by the Parties and the IJB. 12.7.3 Variations to the planned payments by the IJB 12.7.3.1 The Chief Officer is expected to deliver the agreed Outcomes within the total delegated resources of the IJB. Where a forecast overspend against an element of the operational budget emerges during the financial year, in the first instance it is expected that the Chief Officer, in conjunction with the Chief Finance Officer of the IJB, will agree corrective action with the IJB. Page 279
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38 12.7.3.2 If this does not resolve the overspending issue then the Chief Officer, the Chief Finance Officer of the IJB and the Director of Finance of NHS Grampian and the Section 95 Officer of the Council must agree a recovery plan to balance the overspending budget. 12.7.4 IJB Overspend against payments 12.7.4.1 In the event that the recovery plan is unsuccessful and an overspend is evident at the year-end, uncommitted reserves held by the IJB, in line with the reserves policy, would firstly be used to address any overspend. 12.7.4.2 In the event that an overspend is evident following the application of reserves, the following arrangements will apply for addressing that overspend:- 12.7.4.4 In each year in respect of any overspend, either: a) A single Party may make an additional one-off payment to the IJB, or b) The Parties may jointly make additional one off payments to the IJB in order to meet the overspend. The split of one off payments between Parties in this circumstance will be based on each Party’s proportionate share of the baseline payment to the IJB, regardless of in which arm of the operational budget the overspend has occurred in. 12.7.4.5 The recovery plan may include provision for the Parties to recover any such additional one-off payments from their baseline payment to the IJB in the next financial year. Page 280
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39 12.7.4.6 The arrangement to be adopted will be agreed by the Parties. 12.7.5 IJB underspend against payments 12.7.5.1 In the event of a forecast underspend the IJB will require to decide whether this results in a redetermination of payment or whether surplus funds will contribute to the IJB’s reserves. 12.7.5.2 The Chief Officer and Chief Finance Officer of the IJB will prepare a reserves policy for the IJB, which requires the approval of the IJB and the Director of Finance of NHS Grampian and the Section 95 Officer of the Council. The reserves policy will be reviewed on a periodic basis. 12.7.5.3 In the event of a return of funds to the Parties, the split of returned payments between Parties will be based on each Party’s proportionate share of the baseline payment to the IJB, regardless of which arm of the operational budget the underspend occurred in. 12.7.6 Planned Changes in Large Hospital Services 12.7.6.1 The IJB and the hospital sector will agree a methodology for the financial consequences of planned changes in capacity for set aside budgets in large hospital services. 12.7.6.2 Planned changes in capacity for large hospital services will be outlined in the IJB Strategic Plan. A financial plan (reflecting any planned capacity changes) will be developed and agreed that sets out the capacity and resource levels required for the set aside budget for the IJB and the hospital sector, for each year. The financial plan will take account of :- Page 281
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40 - activity changes based on demographic change; - agreed activity changes from new interventions; - cost behaviour; - hospital efficiency and productivity targets; and - an agreed schedule for timing of additional resource / resource released. 12.7.6.3 The process for making adjustments to the set aside resource to reflect variances in performance against plan will be agreed by the IJB and NHS Grampian . Changes will not be made in year and any changes will be made by annual adjustments to the Strategic Plan of the IJB. 12.8 Capital 12.8.1 The use of capital assets in relation to integration functions 12.8.1.1 Ownership of capital assets will continue to sit with each Party and capital assets are not part of the payment or “set aside”. 12.8.1.2 If the IJB decides to fund a new capital asset from revenue funds, then ownership of the resulting asset shall be determined by the Parties. 12.8.1.3 The Strategic Plan will drive the financial strategy and will provide the basis for the IJB to present proposals to the Parties to influence capital budgets and prioritisation. 12.8.1.4 A business case with a clear position on funding is required for any change to the use of existing assets or proposed use of new assets. The Chief Officer of the IJB is to develop business cases for capital investment for consideration by NHS Grampian and the Council as part of their respective capital planning processes. Page 282
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41 12.8.1.5 The Chief Officer of the IJB will liaise with the relevant officer within each Party in respect of day-to-day asset related matters including any consolidation or relocation of operational teams. 12.8.1.6 It is anticipated that the Strategic Plan will outline medium term changes in the level of budget allocations for assets used by the IJB that will be acceptable to the Parties. 12.8.1.7 Any profits or loss on sale of an asset will be held by the Parties and not allocated to the IJB. 12.8.1.8 Depreciation budgets for assets used on delegated functions will continue to be held by each Party and not allocated to the IJB operations in scope. 12.8.1.9 The management of all other associated running costs (e.g. maintenance, insurance, repairs, rates, utilities) will be subject to local agreement between the Parties and the IJB. 13. Participation and Engagement 13.1 A joint consultation on the Scheme took place before it was first put in place and when it was subsequently revised. Whenever the Scheme is reviewed in future, there will be further joint consultation. 13.2 Media notifications will be issued for members of the public that reside within Moray. Staff will be alerted to the proposed revisions to the scheme. An email address will be supplied for people to send their views. 13.3 The consultation draft revised Scheme will then be presented to NHS Grampian and elected members of the Council. 13.4 Principles endorsed by the Scottish Health Council and the National Standards for Community Engagement were followed in respect of the consultation process, which included the following: Page 283
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42 13.4.1 It was a genuine consultation exercise: the views of all participants were valued; 13.4.2 It was transparent: the results of the consultation exercise were published; 13.4.3 It was an accessible consultation: the consultation documentation was provided in a variety of formats; 13.4.4 It was being led by the Chief Officer: the Chief Officer and the IJB will be answerable to the people of Moray in terms of the content of the revised Scheme; 13.4.5 It is an on-going dialogue: the revised Scheme will establish the parameters of the future strategic plans of the IJB. 13.5 The stakeholders consulted in the development of this revised Scheme were: • Health professionals; • Users of health care; • Carers of users of health care; • Commercial providers of health care; • Non-commercial providers of health care; • Social care professionals; • Users of social care; • Future users of social care; • Carers of users of social care; • Commercial providers of social care; • Non-commercial providers of social care; • Staff of NHS Grampian and the Council who are not health professionals or social care professionals; • Non-commercial providers of social housing; and • Third sector bodies carrying out activities related to health or social care and; • Other local authorities operating with the area of NHS Grampian preparing an integration scheme. Page 284
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43 13.6 The Parties enabled the IJB to develop a Communications and Engagement Strategy by providing appropriate resources and support. The Communications and Engagement Strategy ensures significant engagement with, and participation by, members of the public, representative groups and other organisations in relation to decisions about the carrying out of integration functions. The Parties will encourage the IJB to access existing forums that the Parties have established, such as Public Partnership Forums, Community Councils, groups and other networks and stakeholder groups with an interest in health and social care. 14. Information Sharing and Confidentiality 14.1 The Parties have agreed to an appropriate information sharing accord and procedures for the sharing of information in relation to Integrated Services. The information sharing accord sets out the principles, policies, procedures and management strategies around which information sharing is carried out. It encapsulates national and legal requirements. 14.2 The Parties will work together to progress the specific arrangements, practical policies and procedures, designated responsibilities and any additional requirements for any purpose connected with the preparation of an integration scheme, the preparation of a strategic plan or the carrying out of integration functions. 14.4 If the Parties consider that a further high-level accord or information sharing protocol is required, or if amendments are necessary to existing ones, they shall assist the Parties and the IJB by preparing these and making them available with their recommendation to the IJB in the first instance for comment. Page 285
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44 14.5 The information sharing accord and procedures may be amended or replaced by agreement of the Parties and the IJB. 14.6 The Parties will continue to develop information technology systems and procedures to enable information to be shared appropriately and effectively between the Parties and the IJB. Page 286
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45 15. Complaints 15.1 The Parties agree the following arrangements in respect of complaints: 15.2 Complaints should continue to be made to the Council and NHS Grampian using the existing mechanisms. 15.3 Complaints can be made to the Parties through any member of staff providing Integrated Services. Complaints can be made in person, by telephone, by email, or in writing. On completion of the complaints procedure, complainants may ask for a review of the outcome. At the end of the complaints process, complainants are entitled to take their complaint to the Scottish Public Services Ombudsman (or any such successor). Where appropriate, complainants will also be advised of their right to complain to the Care Inspectorate. 15.4 The Parties shall communicate with each other in relation to any complaint which requires investigation or input from the other organisation. This shall ensure that complaints procedures operate smoothly and in an integrated and efficient manner for the benefit of the complainant. 15.5 The Chief Officer will have an overview of complaints made about integrated services and subsequent responses. Complaints about Integrated Services will be recorded and reported to the Chief Officer on a regular and agreed basis. 15.6 Complaints will be used as a valuable tool for improving services and to identify areas where further staff training may be of benefit. 15.7 The Parties will ensure that all staff working in the provision of Integrated Services are familiar with the complaints procedures and that they can direct individuals to the appropriate complaints procedures. Page 287
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46 15.8 The complaints procedures will be clearly explained, well-publicised, accessible, will allow for timely recourse and will sign-post independent advocacy services. 15.9 The Parties will aspire to have a streamlined and integrated process for complaints and will work to ensure that any future arrangements for complaints are clear and integrated from the perspective of the complainant. When this is achieved, the Scheme will be amended using the procedure required by the Act. 15.10 In developing a streamlined and integrated process for complaints, the Parties shall ensure that all statutory requirements will continue to be met, including timescales for responding to complaints. 15.11 In developing a single complaints process, the Parties will endeavour to develop a uniform way to review unresolved complaints before signalling individuals to the appropriate statutory review authority. Page 288
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47 16. Claims Handling, Liability & Indemnity 16.1 The Parties and the IJB recognise that they could receive a claim arising from or which relates to the work undertaken on behalf of the IJB. 16.2 The Parties agree to ensure that any such claims are progressed quickly and in a manner which is equitable between them. 16.3 So far as reasonably practicable the normal common law and statutory rules relating to liability will apply. 16.4 Each party will assume responsibility for progressing and determining any claim which relates to any act or omission on the part of one of their employees. 16.5 Each party will assume responsibility for progressing and determining any claim which relates to any heritable property which is owned by them. If there are any heritable properties owned jointly by the Parties, further arrangements for liability will be agreed upon in consultation with insurers. 16.6 In the event of any claim against the IJB or in respect of which it is not clear which party should assume responsibility then the Chief Officer (or his/her representative) will liaise with the Chief Executives of the Parties (or their representatives) and determine which party should assume responsibility for progressing the claim. 16.7 If a claim is settled by either party, but it subsequently transpires that liability rested with the other party, then that party shall indemnify the party which settled the claim. 16.8 Claims regarding policy and/or strategic decisions made by the IJB shall be the responsibility of the IJB. The IJB may require to engage independent legal advice for such claims. Page 289
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48 16.9 If a claim has a “cross boundary” element whereby it relates to another integration authority area, the Chief Officers of the integration authorities concerned shall liaise with each other until an agreement is reached as to how the claim should be progressed and determined. 16.10 The IJB will develop a procedure for claims relating to hosted services with the other relevant integration authorities. Such claims may follow a different procedure than as set out above. 16.11 Claims which pre-date the establishment of the IJB will be dealt with by the Parties through the procedures used by them prior to integration. Page 290
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49 17. Risk Management 17.1 A shared risk management strategy is in place, which includes risk monitoring and a reporting process for the Parties and the IJB. This will be updated as needed and particularly when the Scheme is revised and any additional functions delegated so that it is updated by the time such functions are delegated to the IJB. In developing this shared risk management strategy, the Parties reviewed the shared risk management arrangements in operation, including the Parties own Risk Registers. 17.2 There will be shared risk management across the Parties and the IJB for significant risks that impact on integrated service provision. The Parties and the IJB will consider these risks as a matter of course and notify each other where the risks may have changed. 17.3 The Parties will provide the IJB with support, guidance, and advice through their respective Risk Managers, to enable the IJB to maintain an ongoing fit for purpose risk management strategy to ensure that the risk management of the IJB is delivered to a high standard. 17.4 Any changes to the risk management strategy shall be requested through formal paper to the IJB. 17.5 A single Risk Register has been developed for the IJB. The process used in developing a single Risk Register was to involve members of the IJB establishing a risk framework by identifying risks to the development of the Strategic Plan. This risk framework in turn was used by operational units of Integrated Services and each unit was required to contribute towards the Risk Register by identifying relevant risks and mitigation of those risks. 17.6 The single Risk Register will continue to be developed alongside the Strategic Plan, and will be modified as necessary in line with the development of the Strategic Plan. Page 291
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50 18. Dispute resolution mechanism 18.1 This provision relates to disputes between NHS Grampian and the Council in respect of the IJB or their duties under the Act. This provision does not apply to internal disputes within the IJB. 18.2 Where either of the Parties fails to agree with the other on any issue related to the Scheme and/or the delivery of integrated health and social care services, then they will follow the process as set out below: (a) The Chief Executives of NHS Grampian and the Council and the Chief Officer of the IJB will meet to resolve the issue; (b) If unresolved, NHS Grampian and the Council and the IJB will each prepare a written note of their position on the issue and exchange it with the others within 21 calendar days of the meeting in (a); (c) Within 14 calendar days of the exchange of written notes in (b) the Chief Executives and Chief Officer must meet to discuss the written positions. (d) In the event that the issue remains unresolved, the Chief Executives and the Chief Officer will proceed to mediation with a view to resolving the issue. The Chief Officer will appoint a professional independent mediator. The cost of mediation, if any, will be split equally between the Parties. The mediation process will commence within 28 calendar days of the meeting in (c); (e) Where the issue remains unresolved after following the processes outlined in (a)-(d) above and if mediation does not allow an agreement to be reached within 6 months from its commencement, or any other such time as the parties may agree, either party may notify Scottish Ministers that agreement cannot be reached; (f) Where the Scottish Ministers make a determination on the dispute, that determination shall be final and the Parties and the IJB shall be bound by the determination. Page 292
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51 Annex 1 Part 1 Functions delegated by NHS Grampian to the Integration Joint Board The functions which are to be delegated by NHS Grampian to the Integration Joint Board are set out in this Part 1 of Annex 1 and are subject to the exceptions and restrictions specified or referred to. The services to which these functions relate are set out in Part 2 of this Annex 1. Functions prescribed for the purposes of section 1(8) of the Act Column A Column B The National Health Service (Scotland) Act 1978 All functions of Health Boards conferred by, or by virtue of, the National Health Service (Scotland) Act 1978 Except functions conferred by or by virtue of— section 2(7) (Health Boards); section 2CB(1) (Functions of Health Boards outside Scotland); section 9 (local consultative committees); section 17A (NHS Contracts); section 17C (personal medical or dental services); section 17I(2) (use of accommodation); section 17J (Health Boards’ power to enter into general medical services contracts); section 28A (remuneration for Part II services); section 38(3) (care of mothers and young children); (1) Section 2CB was inserted by S.S.I. 2010/283, regulation 3(2). (2) Section 17I was inserted by the National Health Service (Primary Care) Act 1997 (c.46), Schedule 2 and amended by the Primary Medical Services (Scotland) Act 2004 (asp 1), section 4. The functions of the Scottish Ministers under section 17I are conferred on Health Boards by virtue of S.I. 1991/570, as amended by S.S.I. 2006/132. (3) The functions of the Secretary of State under section 38 are conferred on Health Boards by virtue of S.I. 1991/570. Page 293
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52 section 38A(4) (breastfeeding); section 39(5) (medical and dental inspection, supervision and treatment of pupils and young persons); section 48 (provision of residential and practice accommodation); section 55(6) (hospital accommodation on part payment); section 57 (accommodation and services for private patients); section 64 (permission for use of facilities in private practice); section 75A(7) (remission and repayment of charges and payment of travelling expenses); section 75B(8) (reimbursement of the cost of services provided in another EEA state); section 75BA (9) (reimbursement of the cost of services provided in another EEA state where expenditure (4) Section 38A was inserted by the Breastfeeding etc (Scotland) Act 2005 (asp 1), section 4. The functions of the Scottish Ministers under section 38A are conferred on Health Boards by virtue of S.I. 1991/570 as amended by S.S.I. 2006/132. (5) Section 39 was relevantly amended by the Self Governing Schools etc (Scotland) Act 1989 (c.39) Schedule 11; the Health and Medicines Act 1988 (c.49) section 10 and Schedule 3 and the Standards in Scotland’s Schools Act 2000 (asp 6), schedule 3. (6) Section 55 was amended by the Health and Medicines Act 1988 (c.49), section 7(9) and Schedule 3 and the National Health Service and Community Care Act 1990 (c.19), Schedule 9. The functions of the Secretary of State under section 55 are conferred on Health Boards by virtue of S.I. 1991/570. (7) Section 75A was inserted by the Social Security Act 1988 (c.7), section 14, and relevantly amended by S.S.I. 2010/283. The functions of the Scottish Ministers in respect of the payment of expenses under section 75A are conferred on Health Boards by S.S.I. 1991/570. (8) Section 75B was inserted by S.S.I. 2010/283, regulation 3(3) and amended by S.S.I. 2013/177. (9) Section 75BA was inserted by S.S.I. 2013/292, regulation 8(4). Page 294
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53 is incurred on or after 25 October 2013); section 79 (purchase of land and moveable property); section 82(10) use and administration of certain endowments and other property held by Health Boards); section 83(11) (power of Health Boards and local health councils to hold property on trust); section 84A(12) (power to raise money, etc., by appeals, collections etc.); section 86 (accounts of Health Boards and the Agency); section 88 (payment of allowances and remuneration to members of certain bodies connected with the health services); section 98 (13) (charges in respect of non-residents); and paragraphs 4, 5, 11A and 13 of Schedule 1 to the Act (Health Boards); and functions conferred by— (10) Section 82 was amended by the Public Appointments and Public Bodies etc. (Scotland) Act 2003 (asp 7) section 1(2) and the National Health Service Reform (Scotland) Act 2004 (asp 7), schedule 2. (11) There are amendments to section 83 not relevant to the exercise of a Health Board’s functions under that section. (12) Section 84A was inserted by the Health Services Act 1980 (c.53), section 5(2). There are no amendments to section 84A which are relevant to the exercise of a Health Board’s functions. (13) Section 98 was amended by the Health and Medicines Act 1988 (c.49), section 7. The functions of the Secretary of State under section 98 in respect of the making, recovering, determination and calculation of charges in accordance with regulations made under that section is conferred on Health Boards by virtue of S.S.I. 1991/570. Page 295
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54 The National Health Service (Charges to Overseas Visitors) (Scotland) Regulations 1989 (14); The Health Boards (Membership and Procedure) (Scotland) Regulations 2001; The National Health Service (Clinical Negligence and Other Risks Indemnity Scheme) (Scotland) Regulations 2000; The National Health Services (Primary Medical Services Performers Lists) (Scotland) Regulations 2004; National Health Service (Primary Medical Services Section 17C Agreements) (Scotland) Regulations 2018.1516 The National Health Service (Discipline Committees) (Scotland) Regulations 2006; The National Health Service (General Ophthalmic Services) (Scotland) Regulations 2006; The National Health Service (Pharmaceutical Services) (Scotland) Regulations 2009; The National Health Service (General Dental Services) (Scotland) Regulations 2010; The National Health Service (Free Prescription and Charges for Drugs and Appliances) (Scotland) Regulations 2011(17); Disabled Persons (Services, Consultation and Representation) Act 1986 (14) S.I. 1989/364, as amended by S.I. 1992/411; S.I. 1994/1770; S.S.I. 2004/369; S.S.I. 2005/455; S.S.I. 2005/572 S.S.I. 2006/141; S.S.I. 2008/290; S.S.I. 2011/25 and S.S.I. 2013/177. (15) Words substituted by National Health Service (Primary Medical Services Section 17C Agreements) (Scotland) Regulations 2018/67 (Scottish SI) Sch.8 para.6(2) (April 1, 2018) (16) As relevantly amended by S.S.I. 2004/217; S.S.I. 2010/395; and S.S.I. 2011/55. (17) S.S.I. 2011/55, to which there are amendments not relevant to the exercise of a Health Board’s functions. Page 296
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55 Section 7 (Persons discharged from hospital) Community Care and Health (Scotland) Act 2002 All functions of Health Boards conferred by, or by virtue of, the Community Care and Health (Scotland) Act 2002. Mental Health (Care and Treatment) (Scotland) Act 2003 All functions of Health Boards conferred by, or by virtue of, the Mental Health (Care and Treatment) (Scotland) Act 2003. Except functions conferred by— section 22 (Approved medical practitioners); section 34 (Inquiries under section 33: co-operation)(18); section 38 (Duties on hospital managers: examination notification etc.)(19); section 46 (Hospital managers’ duties: notification)(20); section 124 (Transfer to other hospital); section 228 (Request for assessment of needs: duty on local authorities and Health Boards); section 230 (Appointment of a patient’s responsible medical officer); section 260 (Provision of information to patients); section 264 (Detention in conditions of excessive security: state hospitals); (18) There are amendments to section 34 not relevant to the exercise of a Health Board’s functions under that section. (19) Section 329(1) of the Mental Health (Care and Treatment) (Scotland) Act 2003 provides a definition of “managers” relevant to the functions of Health Boards under that Act. (20) Section 46 is amended by S.S.I. 2005/465. Page 297
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56 section 267 (Orders under sections 264 to 266: recall); section 281(21) (Correspondence of certain persons detained in hospital); and functions conferred by— The Mental Health (Safety and Security) (Scotland) Regulations 2005(22); The Mental Health (Cross border transfer: patients subject to detention requirement or otherwise in hospital) (Scotland) Regulations 2005(23); The Mental Health (Use of Telephones) (Scotland) Regulations 2005(24); and The Mental Health (England and Wales Cross border transfer: patients subject to detention requirement or otherwise in hospital) (Scotland) Regulations 2008(25). Education (Additional Support for Learning) (Scotland) Act 2004 Section 23 (21) Section 281 is amended by S.S.I. 2011/211. (22) S.S.I. 2005/464, to which there are amendments not relevant to the exercise of the functions of a Health Board. Section 329(1) of the Mental Health (Care and Treatment) (Scotland) Act 2003 provides a definition of “managers” relevant to the functions of Health Boards. (23) S.S.I. 2005/467. Section 329(1) of the Mental Health (Care and Treatment) (Scotland) Act 2003 provides a definition of “managers” relevant to the functions of Health Boards. (24) S.S.I. 2005/468. Section 329(1) of the Mental Health (Care and Treatment) (Scotland) Act 2003 provides a definition of “managers” relevant to the functions of Health Boards. (25) S.S.I. 2008/356. Section 329(1) of the Mental Health (Care and Treatment) (Scotland) Act 2003 provides a definition of “managers” relevant to the functions of Health Boards. Page 298
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57 (other agencies etc. to help in exercise of functions under this Act) Public Services Reform (Scotland) Act 2010 All functions of Health Boards conferred by, or by virtue of, the Public Services Reform (Scotland) Act 2010 Except functions conferred by— section 31(Public functions: duties to provide information on certain expenditure etc.); and section 32 (Public functions: duty to provide information on exercise of functions). Patient Rights (Scotland) Act 2011 All functions of Health Boards conferred by, or by virtue of, the Patient Rights (Scotland) Act 2011 Except functions conferred by The Patient Rights (Complaints Procedure and Consequential Provisions) (Scotland) Regulations 2012/36(26). Functions, conferred by virtue of enactments, prescribed for the purposes of section 1(6) of the Public Bodies (Joint Working) (Scotland) Act 2014 Column A Column B The National Health Service (Scotland) Act 1978 All functions of Health Boards conferred by, or by virtue of, the National Health Service (Scotland) Act 1978 Except functions conferred by or by virtue of— Enactments listed at Column B of the foregoing list of the Scheme of functions prescribed for the purposes of section 1(8) of the Act, in respect of the National Health Service (Scotland) Act 1978; The Health Boards (Membership and Procedure) (Scotland) Regulations 200127; and (26) S.S.I. 2012/36. Section 5(2) of the Patient Rights (Scotland) Act 2011 (asp 5) provides a definition of “relevant NHS body” relevant to the exercise of a Health Board’s functions. 27 To which there are amendments not relevant to the exercise of a Health Board's functions. Page 299
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58 The National Health Service (Appointment of Consultants) (Scotland) Regulations 200928 Public Health etc. (Scotland) Act 2008 Section 2 (duty of Health Boards to protect public health) Section 7 (joint public health protection plans) Carers (Scotland) Act 2016 Section 12 (duty to prepare young carer statement) Section 31(29) (Duty to prepare local carer strategy) xx Part 2 Services currently provided by NHS Grampian which are to be delegated A Interpretation of this Part 2 of Annex 1 1. In this part— “Allied Health Professional” means a person registered as an allied health professional with the Health Professions Council; 28 To which there are amendments not relevant to the exercise of a Health Board's functions. (29) Inserted by Public Bodies (Joint Working) (Prescribed Health Board Functions) (Scotland) Amendment Regulations 2017/381 (Scottish SI) reg. 2 (December 18, 2017) Page 300
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59 “general medical practitioner” means a medical practitioner whose name is included in the General Practitioner Register kept by the General Medical Council; “general medical services contract” means a contract under section 17J of the National Health Service (Scotland) Act 1978; “hospital” has the meaning given by section 108(1) of the National Health Service (Scotland) Act 1978; “inpatient hospital services” means any health care service provided to a patient who has been admitted to a hospital and is required to remain in that hospital overnight, but does not include any secure forensic mental health services; “out of hours period” has the same meaning as in regulation 2 of the National Health Service (General Medical Services Contracts) (Scotland) Regulations 2004(30); and “the public dental service” means services provided by dentists and dental staff employed by a health board under the public dental service contract. B Provision for people over the age of 18 The functions listed in Part 1 of this Annex 1 are delegated only to the extent that: a) the function is exercisable in relation to persons of at least 18 years of age; b) the function is exercisable in relation to care or treatment provided by health professionals for the purpose of health care services listed at numbers 2 to 7 below; and c) the function is exercisable in relation to the following health services: 2. Accident and Emergency services provided in a hospital. (30) S.S.I. 2004/115. Page 301
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60 3. Inpatient hospital services relating to the following branches of medicine— (a) general medicine; (b) geriatric medicine; (c) rehabilitation medicine; (d) respiratory medicine; and (e) psychiatry of learning disability. 4. Palliative care services provided in a hospital. 5. Inpatient hospital services provided by general medical practitioners. 6. Services provided in a hospital in relation to an addiction or dependence on any substance. 7. Mental health services provided in a hospital, except secure forensic mental health services. 8. District nursing services. 9. Services provided outwith a hospital in relation to an addiction or dependence on any substance. 10. Services provided by allied health professionals in an outpatient department, clinic, or outwith a hospital. 11. The public dental service. 12. Primary medical services provided under a general medical services contract, and arrangements for the provision of services made under section 17C of the National Health Service (Scotland) Act 1978, or an arrangement made in Page 302
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61 pursuance of section 2C(2) of the National Health Service (Scotland) Act 1978(31). 13. General dental services provided under arrangements made in pursuance of section 25 of the National Health (Scotland) Act 1978(32). 14. Ophthalmic services provided under arrangements made in pursuance of section 17AA or section 26 of the National Health Service (Scotland) Act 1978(33). 15. Pharmaceutical services and additional pharmaceutical services provided under arrangements made in pursuance of sections 27 and 27A of the National Health Service (Scotland) Act 1978(34). 16. Services providing primary medical services to patients during the out-of-hours period. 17. Services provided outwith a hospital in relation to geriatric medicine. 18. Palliative care services provided outwith a hospital. 19. Community learning disability services. (31) Section 2C was inserted by the Primary Medical Services (Scotland) Act 2004 (asp 1), section 1(2) and relevantly amended by the National Health Service Reform (Scotland) Act 2004 (asp 7), schedule 1, and the Tobacco and Primary Medical Services (Scotland) Act 2010 (asp 3), section 37. (32) Section 25 was relevantly amended by the Smoking, Health and Social Care (Scotland) Act 2005 (asp 13), section 15. (33) Section 17AA was inserted by the National Health Service (Primary Care) Act 1997 (c.46), section 31(2) and relevantly amended by the Smoking, Health and Social Care (Scotland) Act 2005 (asp 13), section 25. Section 26 was relevantly amended by the Health and Social Security Act 1984 (c.48), Schedule 1, and the Smoking, Health and Social Care (Scotland) Act 2005 (asp 13) section 13. (34) Section 27 was relevantly amended by the Health Services Act 1990 (c.53), section 20; the National Health Service and Community Care Act 1990 (c.19), Schedule 9; the Medicinal Products: Prescription by Nurses etc. Act 1992 (c.28), section 3; the National Health Service and Community Care Act 1997 (c.46), Schedule 2 and the Health and Social Care Act 2001 (c.15), section 44. Page 303
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62 20. Mental health services provided outwith a hospital. 21. Continence services provided outwith a hospital. 22. Kidney dialysis services provided outwith a hospital. 23. Services provided by health professionals that aim to promote public health. C Provision for people under the age of 18 The functions listed in Part 1 of Annex 1 are also delegated to the extent that: a) the function is exercisable in relation to persons of less than 18 years of age; and b) the function is exercisable in relation to the following health services: 25. The public dental service. 26. Primary medical services provided under a general medical services contract, and arrangements for the provision of services made under section 17C of the National Health Service (Scotland) Act 1978, or an arrangement made in Page 304
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63 pursuance of section 2C(2) of the National Health Service (Scotland) Act 1978(35). 27. General dental services provided under arrangements made in pursuance of section 25 of the National Health (Scotland) Act 1978(36). 28. Ophthalmic services provided under arrangements made in pursuance of section 17AA or section 26 of the National Health Service (Scotland) Act 1978(37). 29. Pharmaceutical services and additional pharmaceutical services provided under arrangements made in pursuance of sections 27 and 27A of the National Health Service (Scotland) Act 1978(38). Part 3 Services currently provided by NHS Grampian to those under 18 years of age, which are to be operationally devolved to the Chief Officer of the Integration Joint Board. 30. Health Visiting 31. School Nursing 32. All services provided by Allied Health Professionals, as defined in Part 2A of this Annex 1, in an outpatient department, clinic, or outwith a hospital. (35) Section 2C was inserted by the Primary Medical Services (Scotland) Act 2004 (asp 1), section 1(2) and relevantly amended by the National Health Service Reform (Scotland) Act 2004 (asp 7), schedule 1, and the Tobacco and Primary Medical Services (Scotland) Act 2010 (asp 3), section 37. (36) Section 25 was relevantly amended by the Smoking, Health and Social Care (Scotland) Act 2005 (asp 13), section 15. (37) Section 17AA was inserted by the National Health Service (Primary Care) Act 1997 (c.46), section 31(2) and relevantly amended by the Smoking, Health and Social Care (Scotland) Act 2005 (asp 13), section 25. Section 26 was relevantly amended by the Health and Social Security Act 1984 (c.48), Schedule 1, and the Smoking, Health and Social Care (Scotland) Act 2005 (asp 13) section 13. (38) Section 27 was relevantly amended by the Health Services Act 1990 (c.53), section 20; the National Health Service and Community Care Act 1990 (c.19), Schedule 9; the Medicinal Products: Prescription by Nurses etc. Act 1992 (c.28), section 3; the National Health Service and Community Care Act 1997 (c.46), Schedule 2 and the Health and Social Care Act 2001 (c.15), section 44. Page 305
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64 Page 306
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65 Annex 2 Part 1 Functions delegated by the Local Authority to the Integration Joint Board The functions which are to be delegated by the Local Authority to the Integration Joint Board are set out in this Part 1 of Annex 2 and are subject to the exceptions and restrictions specified or referred to. The services to which these functions relate are set out in Part 3 of this Annex 2. Functions prescribed for the purposes of section 1(7) of the Public Bodies (Joint Working) (Scotland) Act 2014 Column A Enactment conferring function Column B Limitation National Assistance Act 1948(39) Section 48 (Duty of councils to provide temporary protection for property of persons admitted to hospitals etc.) The Disabled Persons (Employment) Act 1958(40) Section 3 (Provision of sheltered employment by local authorities) The Social Work (Scotland) Act 1968(41) (39) 1948 c.29; section 48 was amended by the Local Government etc. (Scotland) Act 1994 (c.39), Schedule 39, paragraph 31(4) and the Adult Support and Protection (Scotland) Act 2007 (asp 10) schedule 2 paragraph 1. (40) 1958 c.33; section 3 was amended by the Local Government Act 1972 (c.70), section 195(6); the Local Government (Scotland) Act 1973 (c.65), Schedule 27; the National Health Service (Scotland) Act 1978 (c.70), schedule 23; the Local Government Act 1985 (c.51), Schedule 17; the Local Government (Wales) Act 1994 (c.19), Schedules 10 and 18; the Local Government etc. (Scotland) Act 1994 (c.49), Schedule 13; and the National Health Service (Consequential Provisions) Act 2006 (c.43), Schedule 1. (41) 1968 c.49; section 1 was relevantly amended by the National Health Service (Scotland) Act 1972 (c.58), schedule 7; the Children Act 1989 (c.41), Schedule 15; the National Health Service and Community Care Act 1990 (c.19) (“the 1990 Act”), Page 307
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66 Column A Enactment conferring function Column B Limitation Section 1 (Local authorities for the administration of the Act.) So far as it is exercisable in relation to another integration function. Section 4 (Provisions relating to performance of functions by local authorities.) So far as it is exercisable in relation to another integration function. Section 8 (Research.) So far as it is exercisable in relation to another integration function. Section 10 (Financial and other assistance to voluntary organisations etc. for social work.) So far as it is exercisable in relation to another integration function. schedule 10; S.S.I. 2005/486 and S.S.I. 2013/211. Section 4 was amended by the 1990 Act, Schedule 9, the Children (Scotland) Act 1995 (c.36) (“the 1995 Act”), schedule 4; the Mental Health (Care and Treatment) (Scotland) Act 2003 (asp 13) (“the 2003 Act”), schedule 4; and S.S.I. 2013/211. Section 10 was relevantly amended by the Children Act 1975 (c.72), Schedule 2; the Local Government etc. (Scotland) Act 1994 (c.39), Schedule 13; the Regulation of Care (Scotland) Act 2001 (asp 8) (“the 2001 Act”) schedule 3; S.S.I. 2010/21 and S.S.I. 2011/211. Section 12 was relevantly amended by the 1990 Act, section 66 and Schedule 9; the 1995 Act, Schedule 4; and the Immigration and Asylum Act 1999 (c.33), section 120(2). Section 12A was inserted by the 1990 Act, section 55, and amended by the Carers (Recognition and Services) Act 1995 (c.12), section 2(3) and the Community Care and Health (Scotland) Act 2002 (asp 5) (“the 2002 Act”), sections 8 and 9(1). Section 12AZA was inserted by the Social Care (Self Directed Support) (Scotland) Act 2013 (asp 1), section 17. Section 13 was amended by the Community Care (Direct Payments) Act 1996 (c.30), section 5. Section 13ZA was inserted by the Adult Support and Protection (Scotland) Act 2007 (asp 10), section 64. Section 13A was inserted by the 1990 Act, section 56 and amended by the Immigration and Asylum Act 1999 (c.33), section 102(2); the 2001 Act, section 72 and schedule 3; the 2002 Act, schedule 2 and by S.S.I. 2011/211. Section 13B was inserted by the 1990 Act sections 56 and 67(2) and amended by the Immigration and Asylum Act 1999 (c.33), section 120(3). Section 14 was amended by the Health Services and Public Health Act 1968 (c.46), sections 13, 44 and 45; the National Health Service (Scotland) Act 1972 (c.58), schedule 7; the Guardianship Act 1973 (c.29), section 11(5); the Health and Social Service and Social Security Adjudications Act 1983 (c.41), schedule 10 and the 1990 Act, schedule 9. Section 29 was amended by the 1995 Act, schedule 4. Section 59 was amended by the 1990 Act, schedule 9; the 2001 Act, section 72(c); the 2003 Act, section 25(4) and schedule 4 and by S.S.I. 2013/211. Page 308
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67 Column A Enactment conferring function Column B Limitation Section 12 (General social welfare services of local authorities.) Except in so far as it is exercisable in relation to the provision of housing support services. Section 12A (Duty of local authorities to assess needs.) So far as it is exercisable in relation to another integration function. Section 12AZA (Assessments under section 12A - assistance) So far as it is exercisable in relation to another integration function. Section 13 (Power of local authorities to assist persons in need in disposal of produce of their work.) Section 13ZA (Provision of services to incapable adults.) So far as it is exercisable in relation to another integration function. Section 13A (Residential accommodation with nursing.) Section 13B (Provision of care or aftercare.) Section 14 (Home help and laundry facilities.) Section 29 (Power of local authority to defray expenses of parent, etc., visiting persons or attending funerals.) Section 59 (Provision of residential and other establishments by local authorities and maximum period for repayment of sums borrowed for such provision.) So far as it is exercisable in relation to another integration function. The Local Government and Planning (Scotland) Act 1982(42) (42) 1982 c.43; section 24(1) was amended by the Local Government etc. (Scotland) Act 1994 (c.39), schedule 13. Page 309
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68 Column A Enactment conferring function Column B Limitation Section 24(1) (The provision of gardening assistance for the disabled and the elderly.) Disabled Persons (Services, Consultation and Representation) Act 1986(43) Section 2 (Rights of authorised representatives of disabled persons.) Section 3 (Assessment by local authorities of needs of disabled persons.) Section 7 (Persons discharged from hospital.) In respect of the assessment of need for any services provided under functions contained in welfare enactments within the meaning of section 16 and which are integration functions. Section 8 (Duty of local authority to take into account abilities of carer.) In respect of the assessment of need for any services provided under functions contained in welfare enactments (within the meaning set out in section 16 of that Act) which are integration functions. The Adults with Incapacity (Scotland) Act 2000(44) Section 10 (Functions of local authorities.) Section 12 (Investigations.) (43) 1986 c.33. There are amendments to sections 2 and 7 which are not relevant to the exercise of a local authority’s functions under those sections. (44) 2000 asp 4; section 12 was amended by the Mental Health (Care and Treatment) (Scotland) Act 2003 (asp 13), schedule 5(1). Section 37 was amended by S.S.I. 2005/465. Section 39 was amended by the Adult Support and Protection (Scotland) Act 2007 (asp 10), schedule 1 and by S.S.I. 2013/137. Section 41 was amended by S.S.I. 2005/465; the Adult Support and Protection (Scotland) Act 2007 (asp 10), schedule 1 and S.S.I. 2013/137. Section 45 was amended by the Regulation of Care (Scotland) Act 2001 (asp 8), Schedule 3. Page 310
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69 Column A Enactment conferring function Column B Limitation Section 37 (Residents whose affairs may be managed.) Only in relation to residents of establishments which are managed under integration functions. Section 39 (Matters which may be managed.) Only in relation to residents of establishments which are managed under integration functions. Section 41 (Duties and functions of managers of authorised establishment.) Only in relation to residents of establishments which are managed under integration functions. Section 42 (Authorisation of named manager to withdraw from resident’s account.) Only in relation to residents of establishments which are managed under integration functions. Section 43 (Statement of resident’s affairs.) Only in relation to residents of establishments which are managed under integration functions. Section 44 (Resident ceasing to be resident of authorised establishment.) Only in relation to residents of establishments which are managed under integration functions. Section 45 (Appeal, revocation etc.) Only in relation to residents of establishments which are managed under integration functions. The Housing (Scotland) Act 2001(45) Section 92 (Assistance for housing purposes.) Only in so far as it relates to an aid or adaptation. The Community Care and Health (Scotland) Act 2002(46) Section 5 (45) 2001 asp 10; section 92 was amended by the Housing (Scotland) Act 2006 (asp 1), schedule 7. (46) 2002 asp 5. Page 311
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70 Column A Enactment conferring function Column B Limitation (Local authority arrangements for of residential accommodation outwith Scotland.) Section 14 (Payments by local authorities towards expenditure by NHS bodies on prescribed functions.) The Mental Health (Care and Treatment) (Scotland) Act 2003(47) Section 17 (Duties of Scottish Ministers, local authorities and others as respects Commission.) Section 25 (Care and support services etc.) Except in so far as it is exercisable in relation to the provision of housing support services. Section 26 (Services designed to promote well- being and social development.) Except in so far as it is exercisable in relation to the provision of housing support services. Section 27 (Assistance with travel.) Except in so far as it is exercisable in relation to the provision of housing support services. Section 33 (Duty to inquire.) Section 34 (Inquiries under section 33: Co- operation.) Section 228 (Request for assessment of needs: duty on local authorities and Health Boards.) Section 259 (Advocacy.) (47) 2003 asp 13; section 17 was amended by the Public Services Reform (Scotland) Act 2010 (asp 8), section 111(4), and schedules 14 and 17, and by the Police and Fire Reform (Scotland) Act 2012 (asp 8), schedule 7. Section 25 was amended by S.S.I. 2011/211. Section 34 was amended by the Public Services Reform (Scotland) Act 2010 (asp 8), schedules 14 and 17. Page 312
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71 Column A Enactment conferring function Column B Limitation The Housing (Scotland) Act 2006(48) Section 71(1)(b) (Assistance for housing purposes.) Only in so far as it relates to an aid or adaptation. The Adult Support and Protection (Scotland) Act 2007(49) Section 4 (Council’s duty to make inquiries.) Section 5 (Co-operation.) Section 6 (Duty to consider importance of providing advocacy and other.) Section 11 (Assessment Orders) Section 14 (Removal orders.) Section 18 (Protection of moved persons property.) Section 22 (Right to apply for a banning order.) Section 40 (Urgent cases) Section 42 (Adult Protection Committees.) Section 43 (Membership) Social Care (Self-directed Support) (Scotland) Act 2013(50) (48) 2006 asp 1; section 71 was amended by the Housing (Scotland) Act 2010 (asp 17) section 151. (49) 2007 asp 10; section 5 and section 42 were amended by the Public Services Reform (Scotland) Act 2010 (asp 8), schedules 14 and 17 and by the Police and Fire Reform (Scotland) Act 2012 (asp 8), schedule 7. Section 43 was amended by the Public Services Reform (Scotland) Act 2010 (asp 8), schedule 14. (50) 2013 asp 1. Page 313
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72 Column A Enactment conferring function Column B Limitation Section 5 (Choice of options: adults) Section 6 (Choice of options under section 5: assistances) Section 7 (Choice of options: adult carers) Section 9 (Provision of information about self- directed support) Section 11 (Local authority functions) Section 12 (Eligibility for direct payment: review) Section 13 (Further choice of options on material change of circumstances) Only in relation to a choice under section 5 or 7 of the Social Care (Self-directed Support) (Scotland) Act 2013. Section 16 (Misuse of direct payment: recovery) Section 19 (Promotion of options for self-directed support) Carers (Scotland) Act 2016(51) Section 6(52) (Duty to prepare of adult carer support plan) (51) Section 21 was inserted into the Schedule of the Public Bodies (Joint Working) (Scotland) Act 2014 by paragraph 6 of the schedule of the Carers (Scotland) Act 2016 (asp 9). (52) Inserted by Public Bodies (Joint Working) (Prescribed Local Authority Functions etc.) (Scotland) Amendment (No. 2) Regulations 2017/449 (Scottish SI) reg. 3(2) (December 13th 2017) Page 314
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73 Column A Enactment conferring function Column B Limitation Section 21(53) (Setting of local eligibility criteria) Section 24(54) (Duty to provide support) Section 25(55) (Provision of support to carers: breaks from caring) Section 31(56) (Duty to prepare local carer strategy) Section 34(57) (Information and advice service for carers) Section 35(58) (Short breaks services statements) Functions, conferred by virtue of enactments, prescribed for the purposes of section 1(7) of the Public Bodies (Joint Working) (Scotland) Act 2014 Column A Enactment conferring function Column B Limitation The Community Care and Health (Scotland) Act 2002 (53) Inserted by Public Bodies (Joint Working) (Prescribed Local Authority Functions etc.) (Scotland) Amendment Regulations 2017/190 (Scottish SI) reg. 2(2) (June 16 2017). (54) Inserted by Public Bodies (Joint Working) (Prescribed Local Authority Functions etc.) (Scotland) Amendment (No. 2) Regulations 2017/449 (Scottish SI) reg. 3(2) (December 13th 2017) (55) Inserted by Public Bodies (Joint Working) (Prescribed Local Authority Functions etc.) (Scotland) Amendment (No. 2) Regulations 2017/449 (Scottish SI) reg. 3(2) (December 13th 2017) (56) Inserted by Public Bodies (Joint Working) (Prescribed Local Authority Functions etc.) (Scotland) Amendment (No. 2) Regulations 2017/449 (Scottish SI) reg. 3(2) (December 13th 2017) (57) Inserted by Public Bodies (Joint Working) (Prescribed Local Authority Functions etc.) (Scotland) Amendment (No. 2) Regulations 2017/449 (Scottish SI) reg. 3(2) (December 13th 2017) (58) Inserted by Public Bodies (Joint Working) (Prescribed Local Authority Functions etc.) (Scotland) Amendment (No. 2) Regulations 2017/449 (Scottish SI) reg. 3(2) (December 13th 2017) Page 315
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74 Section 4(59) The functions conferred by Regulation 2 of the Community Care (Additional Payments) (Scotland) Regulations 2002(60) Functions which may be delegated by virtue of section 1(5) of the Public Bodies (Joint Working) (Scotland) Act 2014 Column A Enactment conferring function Column B Limitation Part 2 Functions delegated by the Local Authority to the Integration Joint Board The functions which are to be delegated by the Local Authority to the Integration Joint Board are set out in this Part 2 of Annex 2 and are subject to the exceptions and restrictions specified or referred to. Functions which may be delegated by virtue of section 1(5) of the Public Bodies (Joint Working) (Scotland) Act 2014 Column A Column B (59) Section 4 was amended by the Mental Health (Care and Treatment) (Scotland) Act 2003 (asp 13), schedule 4 and the Adult Support and Protection (Scotland) Act 2007 (asp 10), section 62(3). (60) S.S.I. 2002/265, as amended by S.S.I. 2005/445. Page 316
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75 Enactment conferring function Limitation Page 317
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76 National Assistance Act 1948 Section 45 (Recovery of expenditure incurred under Part III of that Act where a person has fraudulently or otherwise misrepresented or failed to disclose a material fact Matrimonial Proceedings (Children) Act 1958 Section 11 (Reports as to arrangements for future care and upbringing of children) Social Work (Scotland) Act 1968 Section 5 (Performance of functions under the guidance of the Secretary of State) Section 6B (Local authority inquiries into matters affecting children) Section 27 (Supervision and care of persons put on probation or released from prisons etc) Section 27ZA (Advice, guidance and assistance to persons arrested or on whom sentence deferred) Section 78A (Recovery of contributions) Page 318
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77 Section 80 (Enforcement of duty to make contributions) Section 81 (Provisions as to decrees for ailment) Section 83 (Variation of trusts) Section 86 (Adjustments between authority providing accommodation etc., and authority of area of residence) Children Act 1975 Section 34 (Access and maintenance) Section 39 (Reports by local authorities and probation officers) Section 40 (Notice of application to be given to local authority) Section 50 (Payments towards maintenance of children) Health and Social Services and Social Security Adjudications Act 1983 Section 21 (Recovery of sums due to local authority where persons in residential accommodation have disposed of assets) Page 319
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78 Section 22 (Arrears of contributions charged on interest in land in England and Wales) Section 23 (Arrears of contributions secured over interest in land in Scotland) Foster Children (Scotland) Act 1984 Section 3 (Local authorities to ensure well being of and to visit foster children.) Section 5 (Notification by persons maintaining or proposing to maintain foster children) Section 6 (Notification by persons ceasing to maintain foster children) Section 8 (Power to inspect foster premises) Section 9 (Power to impose requirements as to the keeping of foster children) Section 10 (Power to prohibit the keeping of foster children) Children (Scotland) Act 1995 Page 320
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79 Section 17 (Duty of local authority to child looked after by them) Section 20 (Publication of information about services for children) Section 21 (Co-operation between authorities) Section 22 (Promotion of welfare of children in need) Section 23 (Children affected by disability) Section 25 (Provision of accommodation for children, etc.) Section 26 (Manner of provision of accommodation to child looked after by local authority) Section 26A (Provision of continuing care: looked after children) Section 27 (Day care for pre-school and other children) Section 29 Page 321
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80 (After-care) Section 30 (Financial assistance towards expenses of education or training and removal of power to guarantee indentures etc.) Section 31 (Review of case of child looked after by local authority) Section 32 (Removal of child from residential establishment) Section 36 (Welfare of certain children in hospitals and nursing homes etc.) Section 38 (Short-term refuges for children at risk of harm) Section 76 (Exclusion orders) Criminal Procedure (Scotland) Act 1995 Section 51 (Remand and committal of children and young persons) Section 203 (Reports) Section 234B (Drug treatment and testing order) Page 322
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81 Section 245A (Restriction of liberty orders) Community Care and Health (Scotland) Act 2002 Section 6 (Deferred payment of accommodation costs) Management of Offenders etc. (Scotland) Act 2005 Section 10 (Arrangements for assessing and managing risks posed by certain offenders) Section 11 (Review of arrangements) Adoption and Children (Scotland) Act 2007 Section 1 (Duty of local authority to provide adoption service) Section 5 (Guidance) Section 6 (Assistance in carrying out functions under section 1) Section 9 (Assessment of needs for adoption support services) Section 10 (Provision of services) Section 11 (Urgent provision) Page 323
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82 Section 12 (Power to provide payment to person entitled to adoption support service) Section 19 (Notice under section 18: local authority's duties) Section 26 (Looked after children: adoption not proceeding) Section 45 (Adoption support plans) Section 47 (Family member's right to require review of plan) Section 48 (Other cases where authority under duty to review plan) Section 49 Reassessment of needs for adoption support services) Section 51 (Guidance) Section 71 (Adoption allowances schemes) Section 80 (Permanence orders) Section 90 (Precedence of certain other orders) Section 99 Page 324
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83 (Duty of local authority to apply for variation or revocation) Section 101 (Local authority to give notice of certain matters) Section 105 (Notification of proposed application for order) The Adult Support and Protection (Scotland) Act 2007(62) Section 7 (Visits ) Section 8 (Interviews) Section 9 (Medical Examinations) Section 10 (Examination of records etc) Section 16 (Moving adult at risk in pursuance of removal order) Children's Hearings (Scotland) Act 2011 Section 35 (Child assessment orders) Section 37 (Child protection orders) Section 42 (Parental responsibilities and rights directions) Section 44 (Obligations of local authority) Section 48 (Application for variation or termination) Section 49 (62) 2007 asp 10; section 5 and section 42 were amended by the Public Services Reform (Scotland) Act 2010 (asp 8), schedules 14 and 17 and by the Police and Fire Reform (Scotland) Act 2012 (asp 8), schedule 7. Section 43 was amended by the Public Services Reform (Scotland) Act 2010 (asp 8), schedule 14. Page 325
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84 (Notice of application for variation or termination) Section 60 (Local authority's duty to provide information to Principal Reporter) Section 131 (Duty of implementation authority to require review) Section 144 (Implementation of compulsory supervision order: general duties of implementation authority) Section 145 (Duty where order requires child to reside in certain place) Section 166 (Review of requirement imposed on local authority) Section 167 (Appeals to sheriff principal: section 166) Section 180 (Sharing of information: panel members) Section 183 (Mutual assistance) Section 184 (Enforcement of obligations on health board under section 183) Social Care (Self-directed Support) (Scotland) Act 2013 Section 8 (Choice of options: children and family members) Section 10 (Provision of information: children under 16) Carers (Scotland) Act 2016 Page 326
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85 Section 6 (Duty to prepare adult carer support plan) Section 21 (Duty to set local eligibility criteria) Section 24 (Duty to provide support) Section 25 (Provision of support to carers: breaks from caring) Section 31 (Duty to prepare local carer strategy) Section 34 (Information and advice service for carers) Section 35 (Short breaks services statements) Page 327
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86 Part 3 Services currently provided by the Local Authority which are to be integrated The functions listed in Part 1 of this Annex 2 are delegated only to the extent that a) the function is exercisable in relation to persons of at least 18 years of age; and b) the function is exercisable in relation to the following services: • Social work services for adults and older people • Services and support for adults with physical disabilities and learning disabilities • Mental health services • Drug and alcohol services • Adult protection and domestic abuse • Carers support services • Community care assessment teams • Support services • Care home services • Adult placement services • Health improvement services • Aspects of housing support, including aids and adaptions • Day services • Local area co-ordination • Respite provision • Occupational therapy services • Re-ablement services, equipment and telecare Page 328
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87 Part 4 Services currently provided by the Local Authority which are to be integrated The functions listed in Part 2 of this Annex 2 are delegated only to the extent that the function is exercisable in relation to the following services: • Social care services provided to children and families • Fostering and adoption services • Child protection • Criminal justice services. Page 329
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88 Annex 3 Hosted Services NHS Grampian has noted the services that are currently hosted across the areas of the Grampian IJBs and offer this for consideration to the IJB as they take forward strategic planning: Service Current Host Woodend Assessment of the Elderly (including Links Unit at City Hospital) Aberdeen City Woodend Rehabilitation Services (including Stroke Rehab, Neuro Rehab, Horizons, Craig Court and MARS) Aberdeen City Marie Curie Nursing Aberdeenshire Heart Failure Service Aberdeenshire Continence Service Aberdeenshire Diabetes MCN (including Retinal Screening) Aberdeenshire Chronic Oedema Service Aberdeenshire HMP Grampian Aberdeenshire Police Forensic Examiners Aberdeenshire Page 330
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89 Annex 4 This Annex lists the services provided within hospitals which the IJB will have strategic planning responsibilities for which will continue to be operationally managed by NHS Grampian: Services: • Accident & Emergency Services provided in a hospital; • Inpatient hospital services relating to: general medicine, geriatric medicine, rehabilitation medicine, respiratory medicine and psychiatry of learning disability; and • Palliative Care services provided in a hospital. In so far as they are provided within the following hospitals: • Hospitals at the Foresterhill Site, Aberdeen (which includes Aberdeen Royal Infirmary, Royal Aberdeen Childrens Hospital and Aberdeen Maternity Hospital) • Hospitals in Elgin (which includes Dr Gray’s Hospital) Page 331
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63617689v1 MORAY INTEGRATION SCHEME CHANGES (NOV 22) Page Section Amendment 14 4.2 Amended wording of 4.2 to reflect changes to annexes following delegation of functions by Moray Council. 16 5.3 Reworded for clarity. 17 5.7 Reworded for clarity. 19 6.2 Reworded to remove references to the Transitional Leadership Group 19 6.5 Reworded for clarity and 6.6 deleted. 21 8 Reworded for simplicity and clarity. 27 9.4.2 Amended to reference National Whistleblowing Standards, Council Whistleblowing Policy and IJB Whistleblowing Policy. 32 10.4 Inclusion of Chief Officer's sub-delegation powers. Removed redundant wording regarding accountability – provision already provides that the Chief Officer shall be accountable to the IJB. 33 10.7 Removed wording setting expectation that Chief Officer will have a formal relationship with service portfolio leaders across Grampian, which is no longer necessary/relevant. 34 10.11 Inclusion of "communities" in list of key stakeholders the Chief Officer will maintain effective working relationships with. 34 11.3 Added "maintain" an Integrated Workforce Plan for clarity. 34 11.4 Removed references to development of integrated teams as no longer needed. 38 12.6.2 Amendment of frequency of financial information provided from monthly to quarterly. 39 12.6.3 Deletion of reference to further guidance being issued by the Scottish Government in relation to the timetable for the production of annual accounts. 41 12.7.4.3 Deletion of reference to first financial year, and consequent changes to 12.7.4.4. Item 12. Page 333
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2 63617689v1 44 13.1 Deletion of reference to the joint consultation which took place in relation to past Scheme amendments, and further revisions for clarity. 44 13.2, 13.3 and 13.4 Changes of tense from past to future, and amendments for clarity. 45 13.5 Added in "future users of social care" as consulted stakeholder. 46 14.1 Changes of tense from future to past. 46 14.3 and 14.4 Deletion of references to Joint Information Sharing Group and consequent amendments. 47 14.5 Deletion of reference to the NHS Information Governance Toolkit. 68 Annex 2, Part 1 Substituted Part 3 for Part 2 of Annex 2 77 Annex 2, Part 1 Deleted references to Adult Support and Protection (Scotland) Act 2007 and moved to Annex 2 Part 2 to reflect delegation of social care services provided to children and families, fostering and adoption services, child protection services and criminal justice services 78 – 88 Annex 2, Part 2 Added following statutory functions to reflect delegation of social care services provided to children and families, fostering and adoption services, child protection services and criminal justice services National Assistance Act 1948 – section 45 Matrimonial Proceedings (Children) Act 1858 – section 11 Social Work (Scotland) Act 1968 – sections 5, 6B, 27, 27ZA, 78A, 80, 81, 83, 86 Children Act 1975 – sections 34, 39, 40, 50 Health and Social Services and Social Security Adjudications Act 1983 – 21, 22 and 23 Foster Children (Scotland) Act 1984 – sections 3, 5, 6, 8, 9, 10 Children (Scotland) Act 1995 – sections 17, 20, 21, 22, 23, 25, 26, 26A, 27, 29, 30, 31, 32, 36, 38, 76 Page 334
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3 63617689v1 Criminal Procedure (Scotland) Act 1995 – sections 51, 203, 234B, 245A Community Care and Health (Scotland) Act 2002 – section 6 Management of Offenders etc. (Scotland) Act 2005 – sections 10 and 11 Adoption and Children (Scotland) Act 2007 – sections 1, 5, 6, 9, 10, 11, 12, 19, 26, 45, 47, 48, 49, 51, 71, 80, 90, 99, 101, 105 Adult Support and Protection (Scotland) Act 2007 – sections 7, 8, 9, 10, 16 (see above) Children's Hearings (Scotland) Act 2011 – sections 35, 37, 42, 44, 48, 49, 60, 131, 144, 145, 166, 167, 180, 183, 184 Social Care (Self-directed Support) (Scotland) Act 2013 – sections 8 and 10 Carers (Scotland) Act 2016 – sections 6, 21, 24, 25, 31, 34, 35 89 Annex 2, Part 3 Substituted "Part 3" for "Part 2". 90 Annex 2, Part 4 Addition of wording relating to services to be delegated to the Integration Joint Board. Page 335
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REPORT TO: MORAY INTEGRATION JOINT BOARD ON 26 JANUARY 2023 SUBJECT: RECRUITMENT CHALLENGES AND OPPORTUNITIES IN MORAY BY: INTERIM STRATEGY AND PLANNING LEAD 1. REASON FOR REPORT 1.1. To inform the Board of challenges and opportunities for the recruitment and retention of staff in Moray. 2. RECOMMENDATION 2.1. It is recommended that the Moray Integration Joint Board (MIJB) consider and agree the priorities contained in section 4.21 of this report. 3. BACKGROUND 3.1. Scottish Government (SG) has set out a National Workforce Strategy for Health and Social Care in Scotland, co-produced with COSLA. This identifies five key areas which will support the creation of a sustainable, skilled workforce as the sector rebuilds from the pandemic, along with significant commitments including: • Investing £11million to establish a Centre for Workforce Supply and fund recruitment campaigns to grow the health and social care workforce. • Increase the number of undergraduate medical school places by 500. • Supporting up to 1800 training places in adult social care. • Recruiting 800 additional GPs by 2028. • Further improve staff wellbeing measures. • Increase investment to front line health and social care. 3.2. The national framework has been adopted and translated into the delivery of a Moray Health and Social Care Workforce Plan which was approved by MIJB on 29 Sep 2022 (section 12 minute refers to). Over the next three years, the local health and social care workforce plan will focus on the five key areas known as ‘pillars’; they include, Plan, Attract, Train, Employ and Nurture staff. These five pillars are designed to support a sustained and skilled workforce, futureproofing the needs for our delivery of care and support throughout Moray and Grampian as a wider networked approach to service delivery. Item 13. Page 337
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3.3. Nationally, growth has occurred in the NHS and Social Care workforce over the past decade, however, we need more than sheer numbers alone as we continue to care for patients and plan for the future. As the change in demand for services increases, our intent and focus in Moray is to continue to recover, grow and transform our health and care services, with a focus on achieving a more sustainable, skilled workforce which also makes careers in health and social care desirable at all levels. 3.4. Staff in Moray are our biggest asset, and they are at the heart of wrapping care and support around individuals. We want to ensure that staff feel confident, motivated and valued in their roles and that they can work together in the persons interests regardless of who they are employed by. Staff have encountered the most challenging times in recent years as a result of the pandemic and our staff continue to work in extremely challenging environments, facing unprecedented pressures and continue to make individual sacrifices. 3.5. As a Health and Social Care Partnership we aim to adopt a strategic approach to the growth and transformation of the workforce that not only supports the wellbeing of our workforce, but also continues the shift towards prevention and for the provision of high quality support and care for our citizens. In turn creating a more balanced system to ‘enabling wellness’ whilst ‘responding to illness’. 4. KEY MATTERS RELEVANT TO RECOMMENDATION Health 4.1. In pursuit of delivering the vision for Moray Portfolio, ‘we come together as equal and valued partners in care to achieve the best Health and Wellbeing as possible for everyone in Moray throughout their lives, will require healthcare that is more personalised and patient centred, more focused on prevention and to be delivered in the community through Multi-Disciplinary Teams, out of the hospital setting, supporting our ‘Hospital without Walls’ agenda. It will be enabled by technology and delivered by professionals from different organisations collaborating and coordinating their care for each other. As we continue to embed Discharge to Assess, work as multidisciplinary teams and keep abreast of technological advancements, with collaborations through Digital Health Institute and the opportunities from the Moray Growth Deal, our leaders also play a key role in shaping the culture to one which is positive, inclusive and supportive. One which engages and inspires all our workforce with a clear focus on improvement and advancing equality of opportunity. 4.2. There is compelling evidence that that the more engaged our workforce, the more effective and productive they are, and most importantly the higher the quality of care they deliver to our patients. Our patients tell us they want the staff who look after them to be well cared for themselves. 4.3. Through our ongoing engagement with our people they report pressures, frustration with not having enough time with patients/clients, and workplace experiences that could be improved. A comprehensive engagement study has been undertaken to support the development of the Dr Gray’s Hospital (DGH) Plan for the Future. To serve our patients and citizens in the best possible way we must act on the engagement information to support the immediate issues Page 338
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and at every level we need to pay greater attention to retaining the Moray Health and Social Care workforce. 4.4. There are workforce shortages across a wide range of NHS staff groups that we are committed to addressing. The various disciplines are all inter- connected, and recruiting to one discipline successfully does not solve the overall challenge. In the next section two disciplines are set out in more detail as examples of how we are addressing recruitment and retention. Nursing 4.5. We recognise we need to continue to support and retain our existing nurses, encourage nursing as a profession, bring in nurses from abroad and make sure we make the most of the nurses we already have. Nursing within DGH (Dr Gray’s Hospital) presently has vacancies of approximately 26 whole time equivalents (WTE) nursing staff which equates to approximately 20% nursing vacancies (registered nurses and non-registered nurses) this is largely due to retirement and staff leaving the profession or moving to another location. In order to manage the correct skill mix and reduce risk, this means that often nurses are moved to other wards within the hospital to equalise the risk. There is a high proportion of newly qualified staff across the site. 4.6. To offset these vacancies, DGH successfully recruited 18 new graduates who will be part of the new graduate process in the coming months. The Practice Education Team will work closely with new graduates with a view to making sure they have the correct skill mix to increase their impact within the hospital. 4.7. DGH was part of the NHS Grampian International recruitment drive but many of this staff cohort tend to take up positions in Aberdeen Royal Infirmary. It also recruits from other areas of the UK. The risk here is that if nurses are offered another position with substantially larger pay they are more likely to move back to nearer to where they originate from, to take advantage of the higher financial reward and avoid relocation costs. 4.8. Given the difficulties in recruitment and retention, DGH relies on agency nursing staff to supplement the workforce especially in Theatres. 4.9. Data relating to retirements in HSCM shows that there is a significant number of potential retirements in 2023 with 20 across all services. 10 of these are within Nursing and Midwifery service, and figures suggest that, although lower in years to come, those retiring are within this Service. A full breakdown of potential workforce figures for retiring in the future can be found in Appendix 2. Social Care 4.10. Social care support is as essential as Health Care and must be recognised for its unique and vital role. The Independent Review of Adult Social Care (aka Feeley Report) heard about the dedication and commitment of Social Care workers but also learned about the workforce that has been in part undervalued and poorly paid for vital and skilled work. 4.11. Recognition of the need to increase and upskill the workforce and support retention has been seen through a number of initiatives taken forward in partnership with SG; • Since 2022 Moray HSCP have funded the real living wage for social care workers with pay increased from at least £9.50 per hour to at Page 339
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least £10.50 per hour. This is inclusive of the Third and independent sector. • Recruitment campaigns continue to have a key role in attracting people into Social Care. Local social media campaigns utilising the people working in Moray are active and in line with the national ‘there’s more to caring than caring’ campaign. 4.12. There is an increasing need to support the ‘pipeline’ of workers coming into the profession, for example through highlighting the sector in schools, which takes place through career events across Moray’s high schools, not only attracting school levers but also showcasing the wider employability routes to parents and guardians who may be seeking a career change. This is coupled with the well- established Developing the Young Workforce (DYW) support workers, promoting health and social care opportunities and the availability of a range of career pathways. 4.13. Integrated approaches to recruitment are also being used to break down any perceived barriers across Health and Social Care and integrating training and leadership approaches are in place. Successful local examples are through University of Highlands and Islands (UHI) Moray continued delivery of modern apprenticeships in Social Services and Health Care along with Scottish Vocational Qualifications (SVQ) in Health and Social Care, all of which support work based awards for support workers and practitioners/key workers in a care setting. In addition to academic courses, the Moray Life Science Centre facility is located within the campus which acts as a focal point for health care education, research and life science, all offering an attractive local pathway into the health and care sector. This supports the attraction from local, national and international students to work and live in Moray. 4.14. Moray Council in partnership with Moray HSCP continue to develop new ways of working and modernising social care roles. The Care at Home team have implemented a temporary Recruitment Cell to manage all aspects of recruitment for improved information, marketing, selection, recruitment and induction training. HSCM have also worked with Human Resources (HR) and the Information Officer to use all media outlets, including social media to provide information to the public but also advertise all available posts. The team are also targeting geographical areas, addressing supply and demand. This temporary test for change was put in place in February 2022 to support recruitment across all of the service but primarily with Social Care Assistants (SCA). This “test” has proved successful in terms of numbers of SCA entering the service and raising the profile of Care at Home and the role of Care Assistants. 4.15. Since the recruitment cell was introduced 31 new members of staff have been successfully recruited to the SCA post. This is compared to 12 over the same period in 2021.The recruitment cell is also working with Department for Work and Pensions (DWP) and Moray College to take forward work to engage with students and those looking for employment. 4.16. Moray is a small county, therefore in all our actions to grow the workforce we must always carefully consider the implications of recruitment in one part of the health and social care system, recognising people are a finite resource. An area of specific growth has been through the ‘Personal Assistant’ (PA) route, which offers person centred care for the ‘cared for’ but also person centred Page 340
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outcomes for the PA (employee). This is achieved through both parties negotiating the needs and wants to maximise a mutually beneficial partnership. Moray has over 300 PAs working on packages through a Direct Payment (Option 1 Self-Directed Support). To bolster the recruitment, a temporary post was created to rapidly match and support the need for care with the recruitment of a PA coordinator with HSCM. This has proven to be highly efficient and successful in sourcing PAs to reduce the time taken for matching to take place, in turn reducing the care needs within communities across Moray and maximising outcomes for all. The post has also successfully supported PA’s in Moray, exploring the benefits and challenges to being a PA in Moray. 4.17. As Moray Council develops their Housing Demand Needs Assessment (HDNA) a study is underway to evidence base the accommodation needs for those working in the Health and Care sector. The full HDNA will be completed by Mid- 2023. This will lay the groundwork to grow the workforce and make Moray the best place to live and work. Anchor Institution 4.18. As an ‘Anchor Institution’ we contribute to community wealth building, by choosing how and where we spend our budget, how we approach employment and how we manage our land and buildings within our communities. This all contributes to addressing some of the causes of health inequalities within those communities. In addition, as a socially responsible employer, we will continue to actively consider different ways of providing support and opportunities to employment through positive messaging, flexibility in job roles, support easier access to employment and reaching out to groups currently less represented in the workforce. National Care Service (NCS) 4.19. The proposal of a NCS is under debate with Scottish Parliament, with a view to establish the NCS by the end of 2026. However, with current and recent pressures in Social Care, recovery of Adult Social Care must be taken forward now and over the coming years to 2026, and not to delay or procrastinate over the creation of the NCS, ultimately to help meet the needs of our citizens, build resilience, increase the workforce and further develop the delivery of Fair Work across the sector. Next Step 4.20. To achieve our strategic outcomes, underpinned by the tripartite ambition of Recovery, Growth and Transformation, we must do this through the five pillars of the workforce journey delivery plan. These pillars are designed to have maximum impact in their aims of recovery, growth and transformation in our services and workforce. Although we know we need to grow our workforce, we must also recognise the vacancies in the system and ensure that we consider these in understanding our workforce need into the future, this analysis of data is underway, but requires further analysis to truly understand the reasons contributing to the vacancies. 4.21. In summary, to improve the quality and effectiveness of strategic workforce planning, over the next 3 years of the delivery plan we will continue to focus on the 5 pillars with a direct focus on capacity for recovery by: Page 341
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I. Take steps to improve the quality of data, including demographic data we collect, and to progressively improve the quality of analysis we undertake from data collected, through different sources. II. Improve workforce planning capability across partners, providers, specifically focusing on shared learnings and better alignment to national and local planning, modelling the need/growth projections and improve understanding of workforce planning skills and methodologies and approaches, and a greater understanding of the barriers and solutions that reflect diversity of employers across Moray. III. Improve the accuracy of capacity planning and use workforce planning to more readily spot emerging gaps and pressure points. IV. To ensure optimal career progression and retention planning of local and national or international recruitment should remain focused on workforce demographics, aiming to have a workforce that is representative of communities we serve in Moray. 5 SUMMARY OF IMPLICATIONS (a) Corporate Plan and 10 Year Plan (Local Outcomes Improvement Plan (LOIP)) and Moray Integration Joint Board Strategic Plan “Partners in Care 2022 – 2032” The workforce plan is a key enabler to achieving the outcomes in the strategic plans for Moray Council, NHS Grampian and Health and Social care Moray. (b) Policy and Legal The development of the workforce plan and immediate next steps will support the implementation of the Health and Care (Staffing) (Scotland) Act 2019. The implementation of the above Act was delayed due to Covid-19 and will commence consultation with Partnerships mid to late March 2023. (c) Financial implications Staffing costs are projected through the forecasted annual budget. If additional funding is required, this will need to be through transformation to deliver within a finite financial resource. (d) Risk Implications and Mitigation As the population gets older, the shift towards long-term, complex and multi layered conditions will continue as will demand on our Health and Social Care services and workforce. National approaches to supporting Health and Social Care needs must continue to be complemented by place-based action at local and community levels. We must ensure that our workforce has the skills to support and care for a rights-based approach to mental health and we recognise our workforce itself requires support and care. All this has also led to sustained additional pressure on unpaid carers, many of whom also work in Health and Social Care, with significant impacts on their own health and wellbeing. The Carer Positive Kitemark is awarded to employers in Scotland who have a working environment where unpaid carers are valued and supported. Moray Council has achieved level 1 (engaged). (e) Staffing Implications Work is undertaken through existing funding resources. (f) Property Page 342
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Not applicable (g) Equalities/Socio Economic Impact An Equality Impact Assessment is not needed as there is no change to policy or procedure. (h) Climate Change and Biodiversity Impacts Through optimising the recruitment and matching ‘need’ at a community level, this will reduce the need for greater vehicle use and a reduction in transportation usage. (i) Directions None (j) Consultations Members of Moray Portfolio Senior Management Team. Jackie Andrews, University of Highlands and Islands. Michelle Fleming, Self Directed Support & Carers Officer. 6. CONCLUSION 6.1. We acknowledge that strategic action is needed both now and into the future to improve the sustainability of the Health and Social Care System 6.2. By following the next steps in the creation of the strategic workforce delivery plan, we lay effective foundations for realising more robust whole system planning in the future and create an active culture of continuous improvement. Author of Report: Carmen Gillies, Interim Strategy and Planning Lead Background Papers: with author Ref: Page 343
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APPENDIX 1 POTENTIAL RETIRALS - MORAY HEALTH & SOCIAL CARE PARTNERSHIP Data Source: eESS Staff in Post Report as at 31st March 2022, does not include fixed term posts Moray H&SCP Headcoun t as at 31st March 2022 Possible Retirals 2023 (as at 31st March 2023) Possible Retirals 2024 (as at 31st March 2024) Possible Retirals 2025 (as at 31st March 2025) Possible Retirals 2026 (as at 31st March 2026) Possible Retirals 2027 (as at 31st March 2027) Job Family Staff Count Over 65s Count 2023 % Over 65 Over 65s Count 2024 % Over 65 Over 65s Count 2025 % Over 65 Over 65s Count 2026 % Over 65 Over 65s Count 2027 % Over 65 ADMINISTRATIVE SERVICES 129 9 6.98 3 2.33 2 1.55 2 1.55 5 3.88 ALLIED HEALTH PROFESSION 135 1 0.74 1 0.74 0 0.00 0 0.00 0 0.00 AMBULANCE SERVICES 2 0 0.00 0 0.00 0 0.00 0 0.00 1 50.00 DENTAL SUPPORT 38 0 0.00 0 0.00 1 2.63 1 2.63 0 0.00 MEDICAL AND DENTAL 34 0 0.00 1 2.94 1 2.94 0 0.00 0 0.00 NURSING/MIDWIFERY 411 10 2.43 4 0.97 5 1.22 4 0.97 5 1.22 OTHER THERAPEUTIC 39 0 0.00 0 0.00 0 0.00 2 5.13 1 2.56 PERSONAL AND SOCIAL CARE 4 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 SUPPORT SERVICES 41 14 34.15 3 7.32 2 4.88 0 0.00 4 9.76 SENIOR MANAGERS 0 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 Grand Total 833 20 2.40 9 1.08 9 1.08 9 1.08 12 1.44 Item 13. Page 345
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REPORT TO: MORAY INTEGRATION JOINT BOARD ON 26 JANUARY 2023 SUBJECT: RESERVES POLICY - REVIEW BY: INTERIM CHIEF FINANCIAL OFFICER 1. REASON FOR REPORT 1.1 To seek approval from the Moray Integration Joint Board (MIJB) on its Reserves Policy. 2. RECOMMENDATION 2.1 It is recommended that the MIJB: i) approves the Reserves Policy as detailed at Appendix 1; and ii) agrees that the next review will be no later than March 2024 3. BACKGROUND 3.1 The Public Bodies (Joint Working) (Scotland) Act 2014 empowers Integration Authorities to hold reserves which should be accounted for in their financial accounts. 3.2 The MIJB is subject to the audit and accounts regulations and legislation of a body under Section 106 of the Local Government (Scotland) Act 1973 and is classified as a local government body for accounts purposes by the Office for National Statistics. 3.3 The MIJB has previously considered the purpose and use of reserves and approved its initial Reserves Policy at a meeting of the Board on 31 March 2016 (para 12 of the minute refers) with updates being prepared for consideration and approval on 25 January 2018 (para 7 of the minute refers), 31 January 2019 (para 8 of the minute refers), 30 January 2020 (para 11 of the minute refers) and 27 January 2022. A further review was due no later than March 2023, so the paper and policy at Appendix 1 is to be considered within the agreed timeframes. 3.4 Reserves are required to be considered and managed to provide security against unexpected cost pressures and financial stability. Item 14. Page 347
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4. KEY MATTERS RELEVANT TO RECOMMENDATION 4.1 The MIJB Reserves Policy has been reviewed and it remains extant with no requirement for any amendments at this current time and is presented as APPENDIX 1 to this report. 4.2 The Reserves Policy outlines the importance of holding reserves for the long term financial stability of the MIJB to manage pressures from year to year. The MIJB Integration Scheme highlights the process to be followed in circumstances where it is anticipating an overspend position in that uncommitted reserves would firstly be used to address any overspend. With the Scheme in mind, it is unlikely that by the end of the 2022/23 financial year the MIJB will hold any remaining uncommitted general reserves. 4.3 The funding announcements made in February 2021, relating to the 2021/22 financial year resulted in a further significant increase in the earmarked reserve for the MIJB of £17 million from £6.3 million in 2020/21. Primarily, this related to Covid-19, winter funding, the Primary Care Improvement Plan, Interim Care Funding and Care at Home investment. During 2022/23, funding has continued to be drawn-down from these reserves as appropriate. 4.4 In reviewing the Reserves Policy it is necessary to consider both the scale of the MIJB responsibilities and the financial climate it is operating within. The Reserves Policy approved by this Board on 31 January 2019 agreed 2% as being the prudent level of general reserve to be held (Para 8 of the minute refers). As the end of the 2022/23 financial year approaches, there is a forecast overspend position from which it is evident that 2% will not be achievable in the short-term. With this in mind, the review of the Reserves Policy has resulted in the % of general reserves to be unspecified and that over the medium term, the MIJB should be seeking to ‘hold a prudent level of general reserves’. 4.5 It will be necessary to ensure that the Reserves Policy is kept under review with the expectation that in future years, an appropriate level of reserves can be maintained. 5. SUMMARY OF IMPLICATIONS (a) Corporate Plan and 10 Year Plan (Local Outcomes Improvement Plan (LOIP)) and Moray Integration Joint Board Strategic Plan ‘Partners in Care 2022-2032’ The Integration Scheme sets out the requirement for the MIJB to determine the treatment for underspends and the necessity to detail this within an agreed policy. The Reserves Policy makes appropriate reference to the MIJB Strategic Plan. (b) Policy and Legal The Public Bodies (Joint Working) (Scotland) Act empowers the MIJB to hold reserves and in doing so requires a strategy to support the process. (c) Financial implications None arising directly from this report. Page 348
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(d) Risk Implications and Mitigation The establishment and maintenance of a Reserves Policy, promotes sound financial management practice and supports good governance. (e) Staffing Implications None arising directly from this report. (f) Property None arising directly from this report. (g) Equalities/Socio Economic Impact None arising directly from this report as there has been no change to policy. (h) Climate Change and Biodiversity Impacts None arising directly from this report. (i) Directions There are no directions arising from this report. (j) Consultations The Chief Officer has been consulted and comments have been incorporated within this report. 6. CONCLUSION 6.1 The Reserves Policy continues to be reviewed in line with published guidance and good governance principles. Author of Report: Deborah O’Shea, Interim Chief Financial Officer Background Papers: with author Ref: Page 349
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APPENDIX 1 MORAY INTEGRATION JOINT BOARD RESERVES POLICY Date Created February 2016 Date Implemented 1 April 2016 Next Review Date March 2024 Developed By Chief Financial Officer Reviewed By Chief Officer January 2023 Approved By MIJB January 2022 VERSION5.1 Item 14. Page 351
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APPENDIX 1 CONTENTS Background 3 Statutory/Regulatory Framework for Reserves 3 Operation of Reserves 4 Role of the Chief Financial Officer 4 Adequacy of Reserves 4 Reporting Framework 5 Accounting and Disclosure 5 Page 352
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APPENDIX 1 1. Background 1.1 In July 2014, CIPFA through the Local Authority Accounting Panel (LAAP) issued guidance in the form of LAAP bulletin 99 - Local Authority Reserves and Balances in order to assist local authorities (and similar organisations) in developing a framework for reserves. The purpose of the bulletin is to provide guidance to local authority chief finance officers on the establishment and maintenance of local authority reserves and balances in the context of a framework, purpose and key issues to consider when determining the appropriate level of reserves. 1.2 The Moray Integration Joint Board (MIJB) is subject to the audit and accounts regulations and legislation of a body under Section 106 of the Local Government (Scotland) Act 1973 and is classified as a local government body for accounts purposes by the Office for National Statistics (ONS). The MIJB is able to hold reserves which should be accounted for in the financial accounts of the Board. 1.3 The purpose of this Reserves Policy is to: • Outline the legislative and regulatory framework underpinning the creation, use or assessment of the adequacy of reserves; • identify the principles to be employed by the MIJB in assessing the adequacy of the its reserves; • indicate how frequently the adequacy of the MIJB’s balances and reserves will be reviewed and; • Set out arrangements relating to the creation, amendment and the use of reserves and balances. 1.4 In common with local authorities, the MIJB can hold reserves within a usable category. 2. Statutory / Regulatory Framework for Reserves Usable Reserves 2.1 Local Government bodies - which includes the MIJB for these purposes - may only hold usable reserves for which there is a statutory or regulatory power to do so. In Scotland, the legislative framework includes: Usable Reserve - Powers General Fund - Local Government (Scotland) Act 1973 2.2 For each reserve there should be a clear protocol setting out: • the reason / purpose of the reserve; • how and when the reserve can be used; • procedures for the reserves management and control; and • The timescale for review to ensure continuing relevance and adequacy. Page 353
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APPENDIX 1 3. Operation of Reserves 3.1 Reserves are generally held for three main purposes: • to create a working balance to help cushion the impact of uneven cash flows and avoid unnecessary temporary borrowing – this forms part of general reserves; • to create a contingency to cushion the impact of unexpected events or emergencies – this also forms part of general reserves; and • to create a means of building up funds, often referred to as earmarked reserves, to meet known or predicted liabilities. 3.2 The balance of the reserves normally comprise of the following elements: • funds that are earmarked or set aside for specific purposes. In Scotland, under Local Government rules, the MIJB cannot have a separate earmarked reserve within the Balance Sheet, but can highlight elements of the General Reserve balance required for specific purposes. The identification of such funds can be highlighted from a number of sources: • future use of funds for a specific purpose, as agreed by the MIJB; or • commitments made under the authority of the Chief Officer, which cannot be accrued at specific times (e.g. year-end) due to not being in receipt of the service or goods; • funds which are not earmarked for specific purposes, but are set aside to deal with unexpected events or emergencies; and • funds held in excess of the target level of reserves and the identified earmarked sums. Reserves of this nature can be spent or earmarked at the discretion of the MIJB. 4. Role of the Chief Financial Officer 4.1 The Chief Financial Officer is responsible for advising on the target level of reserves that the MIJB would aim to hold, known as the prudential target figure. The MIJB, based on this advice, should then approve the appropriate reserve strategy as part of the budget process. 5. Adequacy of Reserves 5.1 There is no guidance on the minimum level of reserves that should be held. In determining the prudential target, the Chief Financial Officer must take account of the strategic, operational and financial risks facing the MIJB over the medium term and the MIJB’s overall approach to risk management. Page 354
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APPENDIX 1 5.2 In determining the prudential target, the Chief Financial Officer should consider the MIJB’s Strategic Plan, the medium term financial strategy and the wider financial environment. Guidance also recommends that the Chief Financial Officer reviews any earmarked reserves as part of the annual budget process and continued development of the Strategic Plan. 5.3 In light of the size and scale of the MIJB’s responsibilities, over the medium term it is proposed to hold a prudent level of general reserves. This value of reserves must be reviewed annually as part of the MIJB’s Budget and Strategic Plan; and in light of the financial environment at that time. The level of other earmarked funds will be established as part of the annual financial accounting process. 6. Reporting Framework 6.1 The Chief Financial Officer has a fiduciary duty to ensure proper stewardship of public funds. 6.2 The level and utilisation of reserves will be formally approved by the MIJB based on the advice of the Chief Financial Officer. To enable the MIJB to reach a decision, the Chief Financial Officer should clearly state the factors that influenced this advice. 6.3 As part of the budget report the Chief Financial Officer should state: • the current value of general reserves, the movement proposed during the year and the estimated year-end balance and the extent that balances are being used to fund recurrent expenditure; • the adequacy of general reserves in light of the MIJB’s Strategic Plan, the medium term financial outlook and the overall financial environment; • an assessment of earmarked reserves and advice on appropriate levels and movements during the year and over the medium term; and • If the reserves held are under the prudential target, that the MIJB should be considering actions to meet the target through their budget process. 7. Accounting and Disclosure 7.1 Expenditure should not be charged direct to any reserve. Any movement within Revenue Reserves is accounted for as an appropriation and is transparent. Entries within a reserve are specifically restricted to ‘contributions to and from the revenue account’ with expenditure charged to the service revenue account. Page 355
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