Agenda Document Pack - Moray Integration Joint Board - 25/05/2023
Moray Council · 25 May 2023
Back to Moray Integration Joint Board — 25 May 2023 and its agenda
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Moray Integration Joint Board Thursday, 25 May 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, 25 May 2023 at 09:30 to consider the business noted below. AGENDA 1. Welcome and Apologies 2. Declaration of Member's Interests 3. Minute of meeting of 30 March 2023 5 - 10 4. Action Log of 30 March 2023 11 - 12 5. Membership of Board and Committees Report 13 - 18 6. Chief Officer Report 19 - 28 7. Primary Care Pharmacy Budget 2023-24 Report 29 - 52 8. MRI Scanner and Ligature Reduction Integrated Programme Dr Gray's Hospital Report 53 - 58 9. Demand for Housing and the Impact Plan for Future GP Resources Report 59 - 64 10. General Practice Sustainability in Moray Report 65 - 80 11. Implementation Plan Relating to Strategy for Unpaid Carers in Moray Report 81 - 98 Page 1
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Committee Minutes for Noting Minutes of Meeting of Audit Performance and Risk on 24 November 2022 99 - 100 Minutes of Special meeting Audit Performance and Risk on 26 January 2023 101 - 102 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) Professor Duff Bruce (Non-Voting Member) Ms Sonya Duncan (Non-Voting Member) Dr Robert Lockhart (Non-Voting Member) Ms Deborah O'Shea (Non-Voting Member) Ms Elizabeth Robinson (Non-Voting Member) Dr Malcolm Simmons (Non-Voting Member) Ms Tracy Stephen (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, 30 March 2023 Remote Locations via Video Conference, PRESENT Mr Ivan Augustus, Professor Siladitya Bhattacharya, Councillor Peter Bloomfield, Mr Simon Bokor-Ingram, Mr Sean Coady, Councillor Tracy Colyer, Councillor John Divers, Mr Graham Hilditch, Councillor Scott Lawrence, Dr Robert Lockhart, Mr Derick Murray, Ms Deborah O'Shea, Mr Sandy Riddell, Mr Dennis Robertson, Dr Malcolm Simmons APOLOGIES Professor Duff Bruce, Mr Roddy Burns, Ms Karen Donaldson, Ms Sonya Duncan, Ms Jane Ewen, Mr Stuart Falconer, Professor Caroline Hiscox, Dr Paul Southworth, Ms Tracy Stephen, Mrs Val Thatcher IN ATTENDANCE Also in attendance at the above meeting were the Head of Governance, Strategy and Performance, Interim Strategy and Planning Lead, Lizette Van Hal, Service Manager Education and Social Care, Charles McKerron, Service Manager Education and Social Care, Self-Directed Support and Carers Officer, Locality Manger Speyside and Keith, Locality Manager Elgin, Locality Manger Forres and Lossiemouth, and Lindsey Robinson, Committee Services Officer as clerk to the meeting. 1. Chair The meeting was chaired by Mr Dennis Robertson. 2. Declaration of Member's Interests Councillor Divers declared that he was an unpaid carer, however advised that he would remain in the meeting during the discussion of item 11 "the Draft Strategy for Unpaid Carers" as this did not preclude him from the consideration of the item. Mr Riddell declared that he was the Chair of the Mentall Health Welfare Commission. Item 3. Page 5
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The Board noted that there were no other declarations. 3. Minute of Meeting of 26 January 2023 The minute of the meeting of 24 November 2022 was submitted and approved, subject to a point of accuracy raised by Councillor Divers. He was of the opinion that, in reference to Item 11 of the minute, that the feelings of Members should be recorded. After discussion, the Chair asked that the following wording be added to the minute: "Discussion took place around the local impact" This was agreed by the Board. 4. Action Log of 26 January 2023 The Action Log of the meeting of 26 January 2023 was discussed and updated accordingly. 5. 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 (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. During consideration, the Chief Officer confirmed that the Scheme of Integration was agreed on 16 March 2023 and that Children's, Families and Justice Services were now part of the MIJB. Councillor Divers sought clarification on the impact on primary care in Elgin and how it was progressing. In response the Interim Strategy and Planning Lead confirmed that the Moray Portfolio Infrastructure Board had been established and will use the data from the Housing Needs assessment to bring in enablers. The Chair asked that a more informed report be brought to the next meeting. This was agreed. Thereafter the Board agreed: i. to note the content of the report; 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 remobilise from the Covid- 19 pandemic, along with a look ahead as we continue to develop our strategic planning; and iii. that a further report on primary care in Elgin be brought to the next meeting. 6. Quarter 3 Revenue Budget Monitoring 2022-23 Page 6
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A report by the Chief Financial Officer updated the Moray Integration Joint Board (MIJB) on the current Revenue Budget reporting position as at 31 December 2022 and provide a provisional forecast position for the year-end for the MIJB budget. During consideration Mr Riddell sought clarification on the recruitment to older adult psychiatry, stating that long term use of locums would be a financial risk to the IJB. He asked what was going to be done as the current model of recruitment has failed. In response, the Chief Officer advised he would go back to the service and see what needs to be done. He was of the opinion that the recruitment process needs to be redesigned now. He further advised that this would be included in his next report to the Board. Thereafter the Board agreed to: i. note the financial position of the Board as at 31 December 2022 is showing an overall overspend of £1,297,158; ii. note the provisional forecast position for 2022/23 of an underspend of £4,616,187 on total budget; iii. note the progress against the approved savings plan in paragraph 6 of the report, and an update on Covid-19 and additional funding in paragraph 8 of the report; iv. approve the repayment to NHS Grampian of £6,239,000 of the unused ear marked Covid reserve, as detailed in paragraph 8.3 of the report; v. 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 October to 31 December 2022 as shown in Appendix 4 to the report; and vi. approve for issue, the Directions arising from the updated budget position shown in Appendix 5 to the report. 7. Revenue Budget 2023-24 and Medium Term Financial Framework 2023-24 to 2027-28 A report by the Chief Financial Officer asked the Board to agree the Moray Integration Joint Board's (MIJB) revenue budget for 2023/24 and consider the updated Medium Term Financial Framework 2023/24 to 2027/28. Following consideration the Board agreed to: i. note the funding allocations proposed by NHS Grampian and Moray Council, detailed at paragraph 4.6 in the report; ii. note the anticipated budget pressures detailed in paragraph 4.10 of the report; iii. approve the 2023/24 proposed savings plan at paragraph 4.14 of the report; iv. formally approve the uplift to social care providers as set out in paragraph 4.5 of the report, as part of the continued policy commitment made by Scottish Government in November 2021; Page 7
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v. consider and approve the updated Medium Term Financial Framework as set out in paragraph 4.18 and Appendix 2 to the report and that a full review be carried out and presented to the MIJB before 30 September 2023; vi. formally approve the Revenue Budget for 2023/24 as detailed at Appendix 1 to the report following consideration of the risks highlighted in paragraph 4.23 of the report; and vii. approve Directions for issue as set out at Appendix 5 to the report to NHS Grampian and Moray Council. 8. Membership of Board and Committees A report by the Corporate Manager informed the Board of changes to Membership. The Head of Service confirmed that Dr Robert Lockhart and Dr Malcolm Simmons have been jointly appointed to the role of GP Lead. He further confirmed that Karen Donaldson had stepped down from the role of Moray Council Staff Representative on both the MIJB and the Clinical and Care Governance Committee and that this set would be taken by Kevin Todd. Following consideration, the Board agreed to note 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 the Board and committees attached at Appendix 1 to the report. 9. Strategic Commissioning Plan A report by the Interim Strategy and Planning Lead informed the Board of the collaborative strategic planning approached to further enhance health and social care services. Following consideration, the Board agreed to note the work being undertaken to support collaborative strategic planning. 10. Localities Planning Update A report by the Locality Manager informed the Board on the work done to date in relation to the Health and Social Care Moray Locality Planning model. Following consideration, the Board agreed: i. to note the progress made on locality plans since the previous report on 29 September 2022; and ii. that further progress reports be brought to the MIJB on a six monthly basis. 11. Draft Strategy for Unpaid Carers in Moray 2023-26 Page 8
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A report by the Lead Officer for Unpaid Carers presented the final version of Health and Social Care Moray Carers Strategy 2023-26 and sought approval of the Board to publish the strategy on 1 April 2023. During consideration, Mr Augustus sought clarification on how the implementation would be progressed. In response it was agreed that it would be a standing item on the Clinical and Care Governance committee agenda, where it could be monitored by the Committee and passed to the Board as necessary. It was further agreed that, initially, the reports would be on a six monthly basis and then changed to annually as necessary. Professor Bhattacharya and Dr Simmons left during the discussion of this item. Thereafter, the Board agreed to: i. note the engagement work that has taken place to date on the Strategy; ii. instruct the Lead Officer for Unpaid Carers to launch the strategy proposed in April 2023; and iii. instruct the Lead Officer for Unpaid Carers to report back to the Clinical and Care Governance committee on a six monthly basis, to monitor the progress of the actions within the strategy. 12. Housing for People with a Learning Disability A report by the Service Manager informed the Board of progress on the development of housing for people with a learning disability and asked the Board to continue their support for the projects noted. During consideration, Mr Hilditch sought clarification on the reasons behind all of the developments being in the east of Moray, and if there would be any consideration given to locations in Forres. In response the Service Manager advised that there had been a questionnaire and the majority of the respondents stated Elgin was their preferred location, but that he would refresh the list to see if that was still the case. In addition the Interim Strategy and Planning Lead confirmed that they are looking at needs for all different client groups by feeding into the Housing Need and Demand Assessment (HNDA) and that would be used as an evidence based approach for planning. Thereafter, the Board agreed to support the housing projects to be utilised by people with a Learning Disability as noted in the report in paragraph 4.7 to 4.11 as approved and funded by the Scottish Government in accordance with Moray Council Housing Strategy and Moray HNDA document. In noting that Charles McKerron, Service Manager Education and Social Care, would be retiring in May 2023, the Board joined the Chair in thanking him for his work in supporting people with learning disabilities over the year and wished him a long and happy retirement. 13. Annual Report of the CSWO 2021-22 Page 9
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A report by the Chief Social Work Officer (CSWO) informed the Board of the annual report of the CSWO on the statutory work undertaken on the Council's behalf during the period 1 April 2021 to 31 March 2022 inclusive. Following consideration, the Board agreed to note the contents of the report. Page 10
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MEETING OF MORAY INTEGRATION JOINT BOARD Thursday 30 March 2023 ACTION LOG ITEM NO. TITLE OF REPORT ACTION REQUIRED DUE DATE ACTION BY UPDATE FOR 25 MAY 2023 1. Chief Officer Report Report on primary care planning in Elgin to be brought to next meeting May 2023 Chief Officer On today’s agenda 2. Q3 revenue budget monitoring 2022-23 Update sought on recruitment to older adult psychiatry post / alternative models – to be added in to next Chief Officer report. May 2023 Chief Officer 3. Draft strategy for unpaid carers in Moray 2023-26 This is to be a standing item on the CCG committee agenda with reports on a 6 monthly basis May 2023 Lead Officer for Unpaid Carers Draft implementation plan on today’s agenda for approval. Progress of plan to be monitored at future CCG Committee meetings Item 4. Page 11
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REPORT TO: MORAY INTEGRATION JOINT BOARD ON 25 MAY 2023 SUBJECT: MEMBERSHIP OF BOARD AND COMMITTEES BY: CORPORATE MANAGER 1. REASON FOR REPORT 1.1. To inform the Board of changes to Membership of the Moray Integration Joint Board (MIJB) and Clinical and Care Governance Committee. 2. RECOMMENDATION 2.1. It is recommended that the Board notes: i) the confirmation of appointment of a new member to the MIJB; ii) the confirmation of a new member to the Clinical and Care Governance Committee; and iii) the updated membership of Board and committees attached at APPENDIX 1 3. BACKGROUND 3.1 The Public Bodies Joint Working (Scotland) Act 2014 (“the Act”) and the Public Bodies (Joint Working) (Integration Joint Boards) (Scotland) Order 2014 (“the Order”) make provisions about various matters including the membership of the MIJB. As a minimum this must comprise voting members nominated from the NHS Board and Council; co-opted non-voting members who are holders of key posts with the NHS and Council or the MIJB; and co-opted non-voting members who are representatives of groups who have an interest in the MIJB. There is flexibility to appoint additional non-voting members as the Board sees fit. The Moray Health and Social Care Integration Scheme (“Integration Scheme”) outlines certain agreed provisions re membership (and includes the specific provisions taken from the Act and the Order). 4. KEY MATTERS RELEVANT TO RECOMMENDATION 4.1. Elizabeth Robinson was appointed to the role of Public Health Representative in April 2023. Item 5. Page 13
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4.2. Ms Robinson will represent Public Health on Moray Integration Joint Board and Clinical Care Governance Committee. 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 2022-32” 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 Chief Officer – Health and Social Care Moray, Interim Chief Financial Officer and Tracey Sutherland, Committee Services 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. Author of Report: Sonya Duncan, Corporate Manager Background Papers: None Ref: Page 14
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Moray Integration Joint Board Vacancies – as at 30 April 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 Kevin Todd Chief Officer Professional Simon Bokor-Ingram Chief Social Work Officer Tracy Stephen Lead Nurse Jane Ewen GP Lead Dr Robert Lockhart Dr Malcolm Simmons Non Primary Medical Services Lead Prof Duff Bruce Additional Member Elizabeth Robinson 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 Kevin Todd Chief Officer Professional Simon Bokor-Ingram Chief Social Work Officer Tracy Stephen Lead Nurse Jane Ewen Item 5. Page 17
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GP Lead Dr Robert Lockhart and Dr Malcolm Simmons Non Primary Medical Services Lead Prof Duff Bruce Additional Member Elizabeth Robinson Page 18
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REPORT TO: MORAY INTEGRATION JOINT BOARD ON 25 MAY 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. The MIJB has agreed a refreshed Strategic Plan, and the delivery plan is being developed and will be brought to the next MIJB meeting for approval. 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 the Health and Social Care Partnership. Work is being undertaken in a Portfolio approach, pulling on the strengths and assets at a whole system level. Efforts include a focus on reducing delayed discharges, with a plan in Item 6. Page 19
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place to reduce delayed discharges to 10 or below. Appendix 1 shows the range of the work being undertaken. 3.2 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 supporting a trial of in hours support to primary care in Moray between January and March 2023, which will be fully evaluated and reported on in Q1 of 23/24. 3.3 As part of the response to the nationally predicted pressures in January, a day of care audit was carried out across all inpatient beds at Dr Gray’s Hospital and all community hospitals in Moray. The audit was led by the professional leads for health and social work, and has provided a valuable insight for further improvement work. The survey reports the percentage of patients in Dr Grays and in Community Hospitals that do not need hospital care and highlights why they have not been transferred/discharged. 3.4 In addition to completing the Day of Care Survey the team conducted qualitative informal interviews with staff to further understand the impact of current system pressures on staff and patients and to identify potential solutions to improve patient flow through our systems. This work will now be extended to take a more in-depth analysis for Adult Social Work, led by the Chief Social Work Officer. Remobilisation and winter planning 3.5 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. 3.6 Whilst the service is 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 Grays is having to manage a very tight capacity position on a daily basis. Community hospital beds, and intermediate options are being fully utilised, with expedient discharge from Dr Grays as soon as beds are available. A risk of high staff absence continues as flu and Covid continue to circulate within communities. 3.7 The last Chief Officers report set out the way in which the system of health and care can be given a measurement score that reflects the level of pressure being experienced. Our daily G-OPES (Grampian Operational Pressures Escalation System) level had not changed for community services for a considerable period of time, and remained at level 3. 3.8 This number relates to overall system pressure in the Moray community services, and takes account of parameters including service capacity and staffing levels across the range of health and care services. Since the last report to the MIJB, there has been a decrease to level 2. Dr Gray’s Hospital Page 20
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had been moving between G-OPES level 3 and 4, with the move up to level 4 being largely when demand at the Emergency Department had been significantly high and a commensurate pressure on the inpatient bed base. Since the last report to the MIJB Dr Grays has been moving between level 2 and 3. 3.9 Primary care and social care are key to the successful implementation of Home First and Hospital without Walls. There are significant risks being faced by these crucial services. 3.10 Two Moray GP Practices are currently receiving additional support from the health and social care partnership, and there is a picture on a Grampian basis of practices under significant pressure, which presents a risk to the whole system of health and care. 3.11 There are inextricable links between primary care, secondary care and social care which means that pressure and high levels of demand in any one part of the system will have an impact elsewhere. The current GOPES system does not fully reflect the demand and pressures in primary care, and a new system (GPAS) is being developed with the Grampian Local Medical Committee to better reflect workload trends, and to be a better barometer that helps forward planning. 3.5 Waiting times for inpatient elective surgical procedures at Dr Gray's Hospital continue to increase during the post pandemic period. As well as the physical infrastructure challenges experienced in Dr Gray's theatres, there has also been some staffing challenges that has limited our theatre capability and therefore the volume of surgical activity provided locally. As this is set to improve over the coming weeks and months, we now look to increase the levels of elective activity, however, that will need to be managed alongside continued bed occupancy demands for acute and general medical patients. 3.6 A range of initiatives are being introduced and tested as part of the wider portfolio Urgent and Unscheduled Care Improvement Plan that focuses on avoiding unnecessary hospital admissions and improving patient flow through the system. In parallel, in specialties where waiting times for surgery are long, e.g., Orthopaedics, General Surgery and Ophthalmology, alongside the small volume of cases we are providing locally we are also offering Moray residents the opportunity to have their surgery provided in other regional and national centres where staffed theatre and bed capacity is available. 3.7 There had been extensive planning for winter, and for over the festive season, with the MIJB approving surge plans at its November 2022 meeting. These have been put into use, and we are starting to evaluate the effectiveness of the plans, in order to refine current plans and learn any 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. 3.8 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. Page 21
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3.9 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 required. 3.10 Planning is now taking place at a Grampian level for winter 23/24, and as part of that planning bed base across all Moray hospitals will be looked at, Dr Grays and community hospitals, and the balance between allocations for specialities, and scheduled and unscheduled care. This will compliment work being undertaken at Aberdeen Royal Infirmary to look at the most effective use of the bed base in preparation for next winter. Covid Vaccination Programme 3.11 There is no change to the forward programme from the last Chief Officers report to the MIJB. Asylum and Humanitarian Protection Schemes 3.12 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. 3.13 Moray will continue to support many resettlement and refugee schemes including the Asylum Dispersal Model and the Afghan Relocation and Assistance Policy (ARAP) Scheme when required. The Refugee Resettlement Team will continue to coordinate and facilitate all partners to be active contributors. Moray will host up to 50 people seeking asylum at a hotel in Elgin starting in May 2023. The hotel facility is managed through a contract from the Home Office with the private sector. The Refugee Resettlement Team will be very active in supporting any health and care needs, and working with partner organisations to maximise the overall well-being of individuals. Ward 4 anti-ligature work and installation of MRI scanner at Dr Gray’s Hospital 3.14 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. A separate report is on today’s MIJB agenda. Dr Gray’s Strategy 3.15 Dr Gray’s Plan for the Future was approved by the NHS Grampian Board in February 2023. An implementation plan was presented to the NHS Grampian Board and approved in April 2023. Further information can be found here: Plan For The Future - Dr Gray’s Hospital 2023-2033 (nhsgrampian.org). Implementation will be monitored at both a Dr Grays and Portfolio level, and there are a number of strands of work that span across the Portfolio. Page 22
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New build housing in Elgin and impact on primary care 3.16 At the January 2023 MIJB meeting a number of concerns were raised about the capacity of primary care to absorb additional patients as the population of Elgin increases as a result of new house building. Maryhill and Linkwood practices in particular, with already large list sizes, will come under increasing pressure. A planning team has been created utilising a project management approach to address the future needs of citizens accessing primary care services and to explore future models of service delivery. The team outputs will be governed through Morays Infrastructure Programme Board. A separate report is on today’s MIJB agenda. Budget Control 3.17 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. 3.18 Ongoing work will be required, led by the Chief Officer, with the Senior Management Team and wider System Leadership Group, to implement proposals that were presented to the last MIJB meeting that will align the budget to available resources during 2023/24. Payment Verification 3.19 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. Page 23
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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. There is an ongoing requirement to find efficiencies and to demonstrate best value for money. (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. The threat of industrial action by Junior Doctors will have an impact on our ability to maintain performance and continuity of care. We will use a Portfolio approach and full use of the Portfolio teams to mitigate risks. (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. Page 24
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(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 and Tracey Sutherland, Committee Services Officer have 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 recovery, and the drive to create resilience and sustainability through positive change. Author of Report: Simon Bokor-Ingram, Chief Officer, Moray Portfolio Page 25
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Moray Redesign of Urgent Care Action Plan APPENDIX 1 Executive Lead: Simon Boker-Ingram SROs: Sean Coady and Alasdair Pattison Programme Lead: Tori Higgins Clinical Lead: Robert Lockhart Report Date: 27/04/23 Overall Status: On Track Key Deliverables & Status Deliverable Progress Update RAG Mapping Services Across Moray Mapping Session 24/03/23. Planning meeting tomorrow for follow up session in June Ambulatory Emergency Care Ambulatory Emergency Care launched on 09/01/23. DGH Strategy update and DGH footprint update (Future strategy of DGH – stabilising transfer and SAS boundaries) Flash report and poster to be shared. Launch of Daytime Urgent Care Service (DUCS) Launched 30/01/23 - Collected data on reason for request to visit and outcome of visit. Update on clinical discussions between hospital team and GP required. PMcLean to update on linking this with Primary Care Escalation Score. Evaluation date due 2nd week of May. Documented description of FNC function and service model with agreed shared vision and plan to progress to this Update: all decision makers to be in the same location. GMED NHS 24 co location. Discussions remain underway regarding FNC model and next steps – UUC Programme Board reviewing priorities from March 2023. Optimising Patient Flow Sharing of work form this group (Planned Date of Discharge, Criteria Led Discharge, Simulation Training, Discharge Tab, Patient Navigators and Whole System Flow Hub) workshop being planned for 23/05/23 – liaise with Susan Flannery (ask LB to facilitate Moray end). Pilot for discharge tab launched end of May but maybe June. Primary Care Access to Secondary Care Data Progressing with IG and HI – Ben working on report format. IG confirmed position and agreed to proceed with Maryhill in first instance. Some already underway such as Boxi report on upcoming discharges – CY and AB Paperwork being finalised for submission. Report with recommendations on improved system of communication between primary care and DGH Community teams meeting – locality plans and activity already ongoing, PCIP. Report on number of patients who would benefit from ACP with plan in place to support development where there are gaps Overlaps with the LES. Work progressing with a TEPS/ReSPECT/ACP mapping session on 17/04/23 for a collective work streams discussion by Realistic Medicine Team. AG to come to meeting 11/05 to discuss output from this. Reduction in turn around time for blood test results to support patients to remain at home where appropriate JM to give update Pathways Only a small portion of patients with ENT and Vascular conditions can receive assessment and treatment at DGH before transfer to Raigmore (ENT) and ARI (Vascular). Currently SAS convey patients to DGH ED prior to onward transfer to Raigmore or ARI in these circumstances therefore clinical discussions around pathway have been suggested. Key Risks/Issues & Mitigations (expanded in Project Charter) Key Risks Mitigations Staff capacity due to ongoing service pressures Shortened meeting with focussed discussions on key progress and challenges Action plan focus too much on single part of system Bespoke engagement with community colleagues Industrial Action Will develop through cells and be communicated. Agreed Scope Unscheduled activity across the Moray system Objectives 1. To develop and implement a Moray Redesign of Urgent Care Action plan. 2. Decrease pressure points in the system by controlling, coordinating and collaborating Key Progress Action Plan drafted and agreed by stakeholder group Great engagement from community providers for USC MDT discussion linked challenge to actions already underway and well progressed Action plan to be endorsed by Moray Portfolio SLT Comms plan KPIs/Improvement Trajectory Measures Reduction in ambulance stacking Reduction in 12hourwaits fromED Reduction in attendance in ED Reduction in G-OPESlevel forMoray and DGH Reduction in Delayed Dischargeand Delayed Transfer of Care Reduced Length of Stay Patientsatisfaction levels Staff satisfaction levels Staff absences/capacity Elective CareActivity Occupancy Levels Snap Auditof Bloods Numberof ACPsin place CALUMANDDUNCANTOPROGRESSDISCUSSIONS Next Steps • Sharing of up to date LIVE AP • Evaluation progression • Movement of actions from the system pressures plan to USC plan • Stock take and summary paper of this to be written for planning beyond March 2023 Item 6. Page 27
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E.g. Staffing shortages E.g. Care Homes already at capacity E.g. Increased demand for health and care services MorayUSC Programme–Theoryof Change PRIMARY DRIVERS ACTIONS (activities) KEY OUPUT (acting as proxy) Proposal A We have awareness of system pathways and pressure points A1 –Mapping services INDICATIVE ALIGNED IMPACT -Staff satisfaction (A2; B5) -Staff capacity (A2; B5) -Reduced delayed discharges (A3; A4; C1) -Reduced length of stay (A3; A4; C1) -Reduced A&E attendances (B2; C1; C2) -Reduced hospital admissions (C1; C3; C4) -Increased elective activity (C2) -Reduction in ambulance stacking (E2) -Reduction in 12 hour waits from ED (E2) IMPACT (Complex KPIs)AIM Develop and deliver a sustainable unscheduled care model in Moray MACRO MESO MICRO CONFOUNDING VARIABLES (external influences that could jeopardise progress) Proposal B Flow can be effectively navigated throughout the system Proposal C Increase triage prior to admission Proposal D The Moray system connects daily regarding patient placement Proposal E Clinical activity is directed away from DGH when appropriate A2 –Review GOPES A3 –MDT comms to support hospital flow A4 –Reset DGH medical footprint / SOP B1 –GMED redirection test of change B2 –FNC enhanced understanding B3 –Reduce DDs B5 –DUCS C1 –Redesign H@H C2 –Review and strengthen ACP C3 –Use MDT at front door C4 –rapid access to blood testing / results D1 – Review comms systems E1 – Mvmt of MI activity from DGH E2 – Alt location for SAS Systems map of services % Practices completing G-OPES level MDT established %age patients admitted to appropriate ward within 24hrs SOP of pathways Reduced delayed discharge Service Usage Proportion of patients assessed at home ACPs Uptake Number of redirections from ED & AMAU % samples returned within 24 hours TBC No. DATIX related to ambulance stacking KEY METRIC (acting as proxy) B4 –Improved comms TBC Page 28
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REPORT TO: MORAY INTEGRATION JOINT BOARD ON 25 MAY 2023 SUBJECT: PRIMARY CARE PRESCRIBING BUDGET FOR 2023-24 BY: LEAD PHARMACIST 1. REASON FOR REPORT 1.1 To inform the Board of the predicted prescribing budget resource requirements for 2023-2024, alongside key drivers of growth. 1.2 To inform the Board of mitigations regarding costs. 2. RECOMMENDATION 2.1. It is recommended that the Moray Integration Joint Board (MIJB) consider and note: i) the recommendations made in this paper regarding volume, costs, risks and the net predicted need for a budget resource of £20,414,000, as part of the overall Health and Social Care Partnership (HSCP) budget setting process for 2023-24; ii) efficiency savings of £400,000, detailed in para 5.7, takes the net budget from £20,414,000 to £20,014,000 iii) the estimated budget requirements; and iv) mitigations regarding cost efficiencies. 3. BACKGROUND 3.1 Current forecasting indicates that Moray will end the 2022-23 year with a prescribing deficit of -£1,190,000, which will be further affected by identified factors and estimates for these factors. 3.2 Resource assessment for prescribing has been undertaken for 2023-24. This was done using the approach adopted in previous years, which estimates growth in volume and spend in the coming year, and also offsets these with generic savings and approved efficiency plans. The key themes and data presented here are taken from the more comprehensive ‘Health and Social Care Prescribing Budget Supporting Information and Data for 2023/2024’, which has been scrutinised and approved by the multidisciplinary / cross sector Grampian Area Drug and Therapeutics Committee (GADTC) and NHS Grampian Primary Care Prescribing Group. 4.3 A breakdown of the components of the requested budget for 2023-24 is provided in Appendix 1. Item 7. Page 29
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4.4 During 2022-23, there have been variations in prescription volume still related to COVID-19 impact. Covid continues to have a significant effect on prescribing within the changed patient pathways. Volume growth for 2023-24 is still highly variable due to multiple factors, including changes in volumes and treatments, and post-Covid variation in operating levels across Primary and Secondary care. 4.5 Following Grampian’s increasing trend over time, the number of items and cost trends per financial quarter show an increase, as does the cost per item (detailed in Appendix 2). 4.6 A growing and ageing population demographic: NRS figures for mid-2021 showed an increase of 700 people (+0.72%), with 22% of Moray population now over age 65. Mitigation is to offer Primary and Secondary prevention and adopt Realistic Medicine approaches to care. 4.7 Scottish Drug Tariff Pricing and Medicine Shortages: Volatility within pricing of several widely used medications means that prices are likely to remain high in 2023-24. 4.8 Generic costs are being affected by rebalancing Community Pharmacy payment, and national changes regarding remuneration as a consequence of the Pharmaceutical Price Recommendation Scheme. Generic shortages also continue to be a significant problem. Some examples of generic medication shortages that have had significant cost increases are Alendronic acid (70mg) tablets with price rising from £0.85 to £11.99 at peak, and Temazepam (20mg) tablets rising from £1.18 to £34.93 at peak. 4.9 Antibiotic costs have also increased due to shortages driving pricing during an increased incidence of Group A Strep in December 2022. Shortages cannot be predicted or mitigated for. 4.10 Many new medicines and new indications for existing medicationa, as well as changes to existing medications, are likely to have a financial impact. Examples are: Direct Oral Anticoagulants (DOACs) 4.11 Due to the availability of a reversal agent, Apixaban is now the DOAC of choice, with Rivaroxaban as a second choice. This move from the use of Edoxaban represents an increase in cost per patient. In addition, greater patient acceptability has meant there is a continuing increase in prescribing of DOACs and over 70% of patients on anticoagulation are on a DOAC rather than the more cost-effective option, Warfarin (detailed in Appendix 3). Sodium Glucose Co-Transporter (SGLT2) Inhibitors 4.12 Extension of licence to include chronic heart failure and chronic kidney disease has accelerated the growth in prescribing of these agents; it is expected that SGLT2 prescribing in Grampian will cost approximately £2million in 2023-24 (detailed in Appendix 4). 4.13 Mental Health Prescribing such as: Page 30
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Antidepressant Medication 4.14 The graph in Appendix 5 shows a continually increasing trend in antidepressant items prescribed and this is expected to continue, owing to the economic downturn and lasting Covid effects. In addition there is volatility due to SDT pricing e.g. in 2022, Fluoxetine (28 tablet) cost was £0.90 in April, £1.80 in July, £1.60 September, then £1.25 in December. Attention Deficit Hyperactivity Disorder (ADHD) 4.15 There remains a steady increase in prescribing items and costs in the last 5 years, together with an increase in prescribing for younger adult age groups (detailed in Appendix 6). 4.16 A number of new licenced melatonin products with higher costs than previously unlicensed preparations represent a significant financial burden, with an additional £58,000 required on top of existing Grampian costs already approaching £250,000 (detailed in Appendix 7). 4.17 Buvidal® Injectable Prolonged Release Buprenorphine (i-PRB): Buvidal® in place of methadone offers a choice for patients and the advantages in use particularly are: stabilisation of treatment, reduced risk of diversion, reduced pharmacy attendance, and reduced drop-out or treatment failure. It is predicted that in Moray we will require an extra £50,337 in 2023-24 for this change of treatment. Continuous glucose monitoring 4.18 Following evolved technology, blood glucose measurement has changed in the management of Diabetes (Type 1 and Type 2) over the next 24 months. Use of continuous glucose monitoring has been successful, and the Grampian Diabetes Specialist Service intend to expand the use of Freestyle LIBRE to an additional 900 patients at a cost of £819,000 (detailed in Appendix 8). Hormone Replacement Therapy (HRT) 4.19 Prescribing of HRT medication items increased 156% from 2021 to 2022 (detailed in Appendix 9). This increasing trend may be due to increased awareness and also Scottish Governments Women’s Health Plan. It is anticipated that the upward trend of patient numbers and prescribing costs will continue and is estimated to cost £2,525,121 in Grampian. 5 KEY MATTERS RELEVANT TO RECOMMENDATION 5.1 The following are the main financial risks: 5.2 There is a risk in that the future prices for generic medicines, and associated reimbursement levels set within the Scottish Drug tariff, remain difficult to predict. The Scottish Government has committed to rebalancing Community Pharmacy contractor payments by reducing the emphasis on margin share and moving these payments to within the guaranteed global sum. 5.3 The global supply chain remains fragile. Shortages in supply continue to be a significant problem for Community Pharmacy with the most recent examples including a wide range of medicines for a variety of conditions. Such shortages can lead to unpredictability in the cost per item during the year. 5.4 The growth in consumption of medicines had been stabilising. Anecdotally this Page 31
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has been linked to the end of Quality and Outcomes Framework (QOF) pressure to prescribe preventative medication, strengthened approaches to medication review and associated reductions in polypharmacy. The variations in volume since 2020 are related to COVID-19 and changes in patient behaviours, as well as changes in capacity within Primary Care. Repeat prescribing increase has continued, however acute prescribing and outpatient/medication requests are variable corresponding to service provision and patient flow. 5.5 In terms of Primary Care rebates, the system that provides the NHS in Scotland with post-use discounts on spend on specific medicines has remained generally stable, but there remains a risk that these rebates may change or are removed. N.B. these discounts accrue to the individual Health and Social Care Partnerships (HSCPs) based on spend. 5.6 Sustained and increased pressures within GP practices and expectation of workload by pharmacotherapy teams has reduced time availability for medicines management cost efficiency work. 5.7 At the March meeting of the MIJB, efficiency savings of £400,000 were approved to be achieved. 6 SUMMARY OF RISK MITIGATION Patent Expiry 6.1 On expiry of a drug patent, increasing competition can drive down market prices where there are alternative manufacturers. 6.2 One example is Sitagliptin, where cost will potentially be reduced to 80%, yielding a potential £112,320 saving if we ensure we are prescribing appropriately. Prescribing Cost Efficiencies and Cost Avoidance 6.3 The Moray Pharmacotherapy Team are delivering several cost efficiencies. An actionable tracker (in line with Grampian Primary Care Prescribing Group) holds some drug therapeutic switches, and staff annotate work when completed. This work is challenging in terms of workforce capacity and workload pressures. Spend to Save Initiative 6.4 Opportunities remain to achieve cost savings focused work, but this does require Clinician input as well as Pharmacy Technician input. Recent targeted cost efficiency work was carried out by Moray Pharmacy Technicians on 20 medication, and this realised measurable savings of £21,021 per annum. Scriptswitch 6.5 This is a communication tool providing electronic advice messages to the prescriber. We continually review these messages to ensure that Scriptswitch underpins and delivers many cost saving initiatives. This can be in the form of a targeted therapeutic drug switch, reducing waste by dose optimising, as well as safety alerts. Generic Savings Work 6.6 On our actionable tracker, we include the Practice Generic Savings Quarterly Report and all teams are given details on medications not prescribed generically and the costs involved. The teams are requested to review and annotate changes made. Page 32
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Extraordinary Prescribing Report 6.7 Moray Pharmacotherapy Team Management check reports and request copies of prescriptions in order to identify where pricing and reimbursement overpayments may require to be claimed. This can be from specials medications or normal prescribing. Time capacity prevents much of this work, however in January to September 2022, the team claimed back £17,448. Tighter Control of Specials Items 6.8 Automatic authorisation of specials items £100 or less has now been removed. The Grampian Formulary 6.9 A Grampian Formulary tool is installed in all Moray GP Practices to steer the appropriate cost-effective prescribing choices. 6.10 Further Efficiencies Regarding the £400,000 efficiencies to be realised, a further spend to save initiative could be considered to allow further cost savings. 7 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” As set out within Moray’s Integration Scheme. (b) Policy and Legal There are no policy or legal implications arising from this report. (c) Financial implications Primary Care prescribing remains a material financial risk area and this paper identifies the anticipated requirements for additional investment. This is described in Appendix 1. (d) Risk Implications and Mitigation There is a risk of financial failure; the risk is that demand for medicines outstrips the budget and the MIJB cannot deliver priorities, statutory work, and therefore project an overspend. Risk will be mitigated by actions set out in this report to manage the budget, but the key financial risks are highlighted above. (e) Staffing Implications There is a risk of Pharmacotherapy time capacity implications arising from this report. (f) Property There are no property implications arising from this report. (g) Equalities/Socio Economic Impact There are no equalities/socio economic implications arising from this report. (h) Climate Change and Biodiversity Impacts None arising directly from this report. Page 33
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(i) Directions None arising directly from this report. (j) Consultations Consultations have been undertaken with the following partnership members, who are in agreement with the content of this report where it relates to their area of responsibility: Chief Officer, Health and Social Care Moray Lead Pharmacist, Health and Social Care Moray Interim Chief Financial Officer, Moray Integrated Joint Board Tracey Sutherland, Committee Services Officer 8 CONCLUSION 8.1 This report recommends the MIJB consider the volume, costs, risks and the net predicted need for budget resource of £20,414,000, as part of the overall HSCP budget setting process for 2023- 24; 8.2 Efficiency savings of £400,000 were approved for 2023/24. 8.3 Mitigations are detailed in paragraph 6, which addresses some rising costs. Author of Report: Christine Thomson, Moray HSCP Lead Pharmacist Background Papers: - Health and Social Care Prescribing Budget Supporting Information and Data for 2022-2023 - NHS Grampian Pharmacy & Medicines Directorate, Grampian Area Drug &Therapeutics Committee & Finance Directorate. - BNF Sep 2022 - Pharmaceutical Journal - NHS Inform - SP3A The Impact of Covid on GP Prescribing - Scottish Drug Tariff - www.cps.scot/nhs-services/remuneration/drug-tariff/adjusted-prices Ref: Page 34
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Appendix 1: Moray HSCP Estimates for Prescribing Table A – Growth, Expenditure and Savings – Primary Care Prescribing Factor Best Case £000’s Best Guess £000’s Worst Case £000’s Level of Level of Level of Remove under accrual impact from 2022/23 -2 -2 -2 Buvidal further impact 0 0 0 Organisational and Development claw back to Scottish Government 0 0 0 Demographic impact 0 0 0 Volume estimate movement 0 395 395 Price impact from 2022- 23 movement 148 148 148 Price impact further movement -456 0 456 ScriptSwitch allocation and communications 43 43 43 Discount income -6 -19 -27 New Medicines affecting Primary care 0 0 0 Existing Medicines affecting Primary Care 246 246 246 Medication Attention Deficit Hyperactive Disorder 34 34 34 Glucose monitor 141 141 141 Melatonin usage 10 10 10 HRT 157 157 157 Pharmacy 1st & Pharmacy 1st plus 66 66 66 Non-Medical devices 29 29 29 Further Prescribing Efficiencies -27 -27 -27 Patent loss and savings -34 -34 -34 Total Movements 352 1190 1639 Item 7. Page 35
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Table B - Overall Moray HSCP Suggested Primary Care Prescribing Budget Requirement 2022-23 Factor Best case Best guess Worst case £000’s £000’s £000’s Full year Budget 2022-23 17400 17400 17400 Predicted Year End Outturn 2022-23 18876 18876 18876 Total Movements 806 1285 1575 Suggested Total budget 2023-24 19576 20414 20863 % increase on 2022-23 budget 12.5 17.3 19.5 % increase on predicted 2022-23 expenditure 1.8 6.2 8.5 Table C – Hosted Services Impacted by IJB Hosted Sector 2023/24 Total uplift £000’s Moray IJB impact 2023/24 £000’s Shire IJB % shares Moray GMED 54 9 18% Page 36
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Appendix 2: Items, Cost and Cost per Items Trend (2016–2022) Graph A – NHS Grampian & HSCP Quarterly Item Trend 2016–2022 Graph B - NHS Grampian & HSCP Quarterly Cost Trend 2016–2022 Item 7. Page 37
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Graph C - NHS Grampian & HSCP Quarterly Cost per Item Trend 2016–2022 Page 38
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Appendix 3: NHS Grampian and HSCP DOAC – Costs (£) Item 7. Page 39
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Appendix 4: NHS Grampian and HSCP SGLT2 – Cost (£) Item 7. Page 41
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Appendix 5: NHS Grampian and HSCP Anti-Depressant Graph A: NHS Grampian Anti-Depressant – Items Graph B: NHS Grampian Anti-Depressant – Cost (£) Item 7. Page 43
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Appendix 6: NHS Grampian and HSCP ADHD Medications Graph A: NHS Grampian ADHD Medications – Items Graph B: NHS Grampian ADHD Medications – Distinct Patient Count per Age Group (January – September, 2018 - 2022) Item 7. Page 45
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Appendix 7: NHS Grampian and HSCP Melatonin Figure 17. NHS Grampian – Melatonin – Items Figure 18. NHS Grampian – Melatonin – Costs (£) Item 7. Page 47
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Appendix 8 - NHS Grampian Freestyle Libre® and Freestyle Libre® 2 Sensor Cost (£) Item 7. Page 49
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Appendix 9: NHS Grampian and HSCP HRT Graph A: NHS Grampian HRT – Cost (£) Graph B: NHS Grampian – Distinct Patient Count of HRT Prescriptions Item 7. Page 51
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REPORT TO: MORAY INTEGRATION JOINT BOARD ON 25 MAY 2023 SUBJECT: MRI SCANNER AND LIGATURE REDUCTION INTEGRATED PROGRAMME - DR GRAYS HOSPITAL BY: DR GRAY’S HOSPITAL GENERAL MANAGER AND INTEGRATED PROGRAMME SENIOR RESPONSIBLE OFFICER 1. REASON FOR REPORT 1.1. To inform the Board of the programme status and associated requirements of the MRI Scanner and Ligature Reduction Integrated Programme. 2. RECOMMENDATION 2.1. It is recommended that the Moray Integration Joint Board (MIJB) consider and note this report. 3. BACKGROUND 3.1 NHS Grampian (NHSG) Board approved the Standard Business Case (SBC) for the development of a dedicated Magnetic Resonance Imaging (MRI) service at Dr Gray’s Hospital (DGH) in Elgin at its August 2022 meeting as part of its National Treatment Centre programme. 3.2 They confirmed a requirement to bring an addendum to the SBC back to a future NHSG Board meeting for final agreement on price and programme prior to proceeding to construction. This remains outstanding and was due to a number of risks to programme delivery. 3.3 These included: i) MRI Workforce Planning and Recruitment ii) Timeline and impact on Programme: Mental Health Services - inpatient/out- patient/community teams/management and administration teams in Ward 4 and Pluscarden Clinic – adjacency to MRI construction site and requirement to relocate due to noise disruption. iii) Timeline and impact on Programme: Procurement and Cost – uncertainty in construction market place and procurement of specialist equipment. This is dependent on a solution to risk ii). Item 8. Page 53
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Activity to address Risk ii) 3.4 Prior to MRI plans mental health services have been seeking a relocation/decant solution for many years since the Health and Safety Executive (HSE) notice of contravention to Royal Cornhill Hospital (RCH) in June 2017. Various options have been considered over many years, none without challenge and most ruled out due to not being considered a realistic or safe possibility. 3.5 This work was revisited in July 2022 in light of the MRI development with a brief options appraisal/risk assessment reconsidering 4 options for the inpatient service (Ward 4) temporary relocation: a) Muirton Ward, Seafield Hospital in Buckie, b) Ward 7 Dr Gray’s Hospital (under refurbishment and vacant at time of consideration), c) RCH in Aberdeen, and d) a bespoke modular ward option. 3.6 Option d) was removed as the product wasn’t readily available on the market as well as there being known infrastructure and planning challenges on the Dr Grays campus. 3.7 The Bolton Ligature Risk Assessment was undertaken for Muirton Ward and Ward 7 in order to understand minimum changes required for both settings. 3.8 Muirton was ruled out again due to risks associated with mixing adults with acute mental disorder with patients experiencing complex symptoms of dementia. There was also a lack of facilities such as bathrooms and toilets to separate the two patient groups. 3.9 Ward 7 was considered a potential option, as it was vacant at the time, due to protracted refurbishment works and identified water safety issues, and would have required additional ligature reduction works. The risks of this option were further delays for the patient group the refurbishment was intended for as well as cost and reputation of the organisation given it had newly been developed for a frail elderly population. The business continuity arrangements in place during the refurbishment of Ward 7 became protracted and generated a number of patient and staff safety issues in other ward areas. 3.10 Of the three options, RCH was considered the best option due to being the only facility in Grampian that could provide a ligature reduced environment to the same level as Ward 4 in its current state. 3.11 A further option was then considered which was to do nothing i.e. leave mental health services in situ during the MRI construction as whilst option c was preferred it still was not felt to be deliverable. 3.12 A session with the Mental Health team, wider DGH, RCH, project and technical teams and the MRI construction team was facilitated to assess the relative risks with this option and it became very clear for reasons of noise, vibration and dust pollution that services remaining in situ would be untenable. 3.13 Services remaining in situ would also prolong the duration of the construction programme. Page 54
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3.14 Recognising the need for services to vacate facilities adjacent to the proposed MRI construction site, planning to progress the outstanding ligature reduction works in Ward 4 was reconsidered and it was agreed that given the inter- dependency of both projects that an ‘integrated’ planning and governance approach to this would improve delivery. 3.15 An MRI Construction and Ligature Reduction Integrated Programme Board is now in place. Description of Service 3.16 Ward 4 is an 18 bedded in patient acute adult mental health assessment ward based on the Dr Gray’s Hospital site. Average occupancy for the last calendar year was 91.2% which has increased to 97.6% in the April – December 2022 period. Although the ward at times have patients who are classed as delayed discharges this is a very small number compared to the overall bed base. There are 29.15 whole time equivalent (WTE) staff aligned to the inpatient ward. 3.17 There are currently 8 detained patients on Ward 4 all of whom would require to be accommodated in an in-patient setting. There is a concern about movement of patients and that there may be no availability to admit people assessed locally as requiring admission. 3.18 Pluscarden Clinic houses approximately 87 WTE staff employed by both NHS Grampian and Moray Council as the service is managed in an integrated model. The building provides a mixture of office accommodation and clinical space, including a Place of Safety assessment room. Outpatient clinics are delivered 5 days per week in 4 dedicated clinical rooms. 3.19 Office accommodation for staff unable to work due to the disruption caused by the construction and installation of the MRI scanner requires to be identified. Planning Considerations for Temporary Provision of Mental Health Services 3.20 The integrated programme of work, actions and decision points to date are as follows: • Integrated Programme Board (IPB) decision following multi-stakeholder engagement sessions confirmed that the Royal Cornhill Hospital is not a workable alternative temporary location for the provision of Ward 4, Mental Health Inpatient beds. • The development of Enhanced Community Mental Health Pathway (Home Treatment Team) over the duration of the service decant period, supported by mental health & primary care leads, is no longer felt to be critically dependent on Ward 4 ligature reduction and refurbishment works. This will be taken forward as part of mental health service planning business. • Muirton Ward (Seafield Hospital, Buckie) has been identified as a suitable site for decant of mental health inpatients and high-level costs for associated green-works are being confirmed. Early assessment and estimates of preparation of the environment suggests both feasible, given the existing physical space and also ‘palatable’ in relation to cost – approx. £350-500K. • Agreed that 18 beds are required for Moray’s Inpatient Mental Health Service during any temporary re-location. This can be achieved in Muirton Ward. Page 55
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• There are two potential options for providing an alternative site for the Care of the Elderly patients currently occupying Muirton Ward. These are; use of an existing Community Hospital facility in Moray currently used for a range of outpatient services, and, procurement of space in an independent care home facility. Both options are currently being assessed for feasibility with an outcome expected by the end of May. • Decant of Pluscarden Clinic; out-patient services; community team’s offices; and the management and administration team’s accommodation is being reviewed. Assessment of decant options for these services and teams on both the DGH campus and in the wider Moray Portfolio estate is underway. • NHS Grampian Asset Management Group (AMG) approved the request to appoint a design team via measured terms for the feasibility cost and programme for associated programme enabling works. • A Critical Path including key decision point milestones has been developed and is under continuous review. Next Decision Points • Confirm decant option for care of the elderly patients from Muirton Ward – by 31 May 2023. • Confirm and agree requirements for decanting Pluscarden building based services / teams – by 31 May 2023. • Recognise and document associated risks. National Treatment Centre Dr Gray’s Hospital (NTC DGH) MRI: 3.21 Pre-construction phase of NTC DGH MRI completed. • Development of service storyboards, aligned to NHS Grampian radiology strategy and linking in with the National Imaging Alliance. • Workforce plan in place and external scrutiny complete. • Project remains ‘paused’ pending decant arrangements being finalised for mental health services. • Ongoing interaction with Scottish Government – indications remain positive in terms of project delivery. Encouragement to continue to develop and refine project and to include requirements for Mental Health Ligature Reduction plans. 4. KEY MATTERS RELEVANT TO RECOMMENDATION Risks 4.1 Quality/Patient Care - Patient care will be improved through the refurbishment of the Ward 4 environment. However, in the short term patients and their carers/families will be adversely affected with any travel out with the Elgin area for their in-patient care. 4.2 Workforce - Ward 4 staff have been consulted about this process. An organisational change steering group has been set up to work with and support staff employed within the service through these temporary and significant changes to working arrangements. 4.3 Financial - The scope, quality assurance, timeline and cost relating to the enabling works, ligature reduction works in Ward 4 and the MRI Scanner are still to be finalised. Page 56
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Considerations 4.4 It has been confirmed that the construction and installation of the MRI scanner cannot commence until Ward 4 is vacated. 4.5 Final costs for the MRI facility cannot be confirmed until alternative arrangements for mental health inpatient, out-patient and admin accommodation are secured. 4.6 A number of co-dependencies exist and careful coordination of these is required. 4.7 A ‘critical path’ has been drafted to describe and manage these via the agreed programme governance arrangements. 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” As set out in the Strategic Plan ‘Our Vision’ is to come together as equal and value partners in care to achieve the best health and wellbeing possible for everyone in Moray throughout their lives. (b) Policy and Legal Ligature reduction work requires to be addressed to comply with the improvement notice issued to NHS Grampian in relation to Adult Inpatient Admission Ward in June 2017. (c) Financial implications None arising directly from this report. (d) Risk Implications and Mitigation Set out in 4.1 – 4.3 of this report. (e) Staffing Implications Accommodation for staff unable to work due to the disruption caused by the construction and installation of the MRI scanner requires to be identified. (f) Property The construction and installation of the MRI scanner cannot commence until Ward 4 is vacated. (g) Equalities/Socio Economic Impact Not required as no change to policy. (h) Climate Change and Biodiversity Impacts Potential impact in the short term due to increase in travel for patients and their carers/families due to travelling out with the Elgin area for their in- patient care. (i) Directions None arising as a direct result of this report. Page 57
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(j) Consultations The Integrated Programme Board. 6. CONCLUSION 6.1. The MRI Scanner and Ligature Reduction programme are major capital investments and provide significant improvements in the quality of care delivered for the Moray population and more regionally. 6.2. A complex set of enabling works are required in order to deliver the improvement programme which will create temporary disruption to patients, families and staff. 6.3. An Integrated Programme Board approach is in place to manage the planning and associated communication and engagement. Author of Report: Alasdair Pattinson. Hospital General Manager, Dr Gray’s and Integrated Programme SRO Background Papers: with author Ref: Page 58
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REPORT TO: MORAY INTEGRATION JOINT BOARD ON 25 MAY 2023 SUBJECT: THE DEMAND FOR HOUSING AND THE IMPACT / PLAN FOR FUTURE GP RESOURCES BY: PRIMARY CARE DEVELOPMENT MANAGER 1. REASON FOR REPORT 1.1. To inform the Board of the demand for housing across Moray and the resultant impact on current and future plans for GP Premises. 2. RECOMMENDATION 2.1 It is recommended that the Moray Integration Joint Board (MIJB) consider and note: i) the demand for housing across Moray; and ii) the impact on current and future plans for Moray GP Practices 3. BACKGROUND 3.1. The Moray Local Development Plan (MLDP) for 2020, which sets the planning direction for Moray, has proposed that there will be significant housing development in Moray over the next 10 years and beyond. Plan can be found here: http://www.moray.gov.uk/moray_standard/page_133431.html 3.2. MLDP Settlement Statements details what is planned for Moray in its entirety over the above noted period, which is subject to planning permission and therefore not guaranteed. 3.3. All four localities in Moray are impacted. However due to the volume of housing demands particularly in the Elgin locality, there needs to be a particular focus on that Locality. Impact for Moray per Locality (subject to Planning Permission for any future developments in all localities) is as follows: • Elgin locality - over 8,000 additional housing units which equates to over 17,000 additional patients. Item 9. Page 59
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• Buckie Locality - over 1,000 additional housing units which equates to over 3,000 additional patients. • Forres Locality (including Lossiemouth) - over 2,400 additional housing units which equates to 6,000 additional patients. • Speyside and Keith Locality - over 800 additional housing units which equates to 1,800 additional patients. Practice Potential additional patients Ardach medical practice 813 Seafield & Cullen Medical Practice 1269 Maryhill Medical Practice 7912 Linkwood Medical Practice 9309 Forres Health & care Centre 4806 Keith Medical Practice 736 Moray Coast Medical Practice 1124 Fochabers Medical Practice 1044 Table 1: MLDP overview of housing developments 3.4. Approval is being sought from Moray Infrastructure Program Board to undertake a scoping exercise which will provide the necessary information/data to realise current and future health and social care service provision for Moray - i.e. what these services could and should look like and what is required from a service point of view for the next 10-20 years. 3.5. This scoping exercise will facilitate determinations as to the infrastructure necessities required across Moray. Therefore identify opportunities to alter/extend/create additional premises and/or space to accommodate increasing patient numbers, as a result of the housing demands. 3.6. Solutions for the Elgin Locality need to factor in the land at the old Spynie hospital site, which remains an NHS Grampian asset. 3.7. Currently all premises issues across Moray General Practices are being identified to ensure early engagement with the practices to establish solutions. This information is being collated for future project work, if/when solutions are not straight away obtainable. 4. KEY MATTERS RELEVANT TO RECOMMENDATION 4.1. Current healthcare and social care providers, including GP Practices across Moray are struggling to provide services to the current patient base due to various circumstances but particularly as a result of infrastructure restrictions/issues. The impact of additional patients, particularly to the Elgin locality where it is anticipated there will be an additional 17,000 patients, over the next 10 years, will put an extensive burden on current GP Practice infrastructure. Page 60
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4.2. There is work on going with every GP Practice in Moray to improve/enhance premises in a bid to increase capacity, as it has been recognised that they have insufficient space to deliver the services they are required to/need to deliver to Moray patients. This is not possible in the majority of practices without substantial investment, including capital investment. 4.3. The two practices in Buckie are classified as the opposite, as it is deemed that their property allowance exceeds their floor area. However the current premises directive does not enact the requirement for additional professional teams as per 2018 Memorandum of Understanding (MoU) i.e. Primary Care Improvement Plan (PCIP) Multi Disciplinary Teams (MDTs). There is nothing in the premises directive that allocates property allowance for PCIP services. . 4.4. In reality all Moray GP practices are struggling to accommodate the MDTs. This is a daily struggle for the Practice Managers who manage room allocation for all services being delivered from their practice. 4.5. All GP Practices are aware that they can apply for funding via Improvement Grants, to increase their premises capacity. The work that can be approved for development is very dependent on the availability of the Improvement Grant funding. 4.6 During 2022/23 this was problematic due to rising costs for existing NHS Grampian projects - with costs increasing this resulted in construction costs increasing by a third, which eroded funds that could have normally been used towards other projects. This trend is expected to continue. Currently awaiting details from the NHS Grampian Property and Assets Development Team regarding the 2023/24 budget and the plans for the spend of these monies. 4.7 In Moray, HSCM have received confirmation that vital work to provide increased space at Maryhill GP Practice will commence in 2023/24 and continue into 2024/25. The spread over 2 financial years is purely due to this financial situation. 4.8 In Moray, the following are outstanding Improvement Grants works to date: o Moray Coast Medical Practice - To transform disused dental centre into useable clinical space to expand the GP practice o Rinnes Medical Practice - to transform a non-clinical room into a useable space; o Seafield & Cullen Medical Practice - Refurbishment of former Podiatry Room to Treatment Room to meet current Healthcare standards; o Linkwood Medical Centre - to create additional clinical/office space; o Forres Health and Care Centre - to re-purpose records rooms into hot desk/office/admin space following removal of medical records 4.9 For some Moray GP Practices, the infrastructure requirement has progressed beyond Improvement Grants to capital funding, in particular: • Keith Medical Practice; • Moray Coast Medical Practice; • Maryhill Medical Practice, and Page 61
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• Fochabers Health Centre. 4.10 Developers Obligations are financial contributions sought from planning applicants to mitigate the impact of their development on existing infrastructure and facilities to ensure there is no negative impact on existing residents. The mitigations that Developers Obligations are collected for are stated in the S75 and cannot be spent on other projects out with what they have been collected for. 4.11 NHS/HSCM can only access these monies via discussions with Moray Council and by ensuring that criteria are met. 4.12 There is an agreed 15 year deadline for the spend of developer obligations, (this was previously 10 years which will impact on some of the earlier monies taken through planning). The earliest deadline for spend within Moray is 2026. It is important that plans/projects are progressed to the point of accessing these monies. 4.13 Some Moray GP Practices are in leased accommodation. When a lease is due for renewal there is set guidance that needs to be adhered to which is detailed in the Scottish Government guidance on Acquisition of property. 4.14 In short what happens is 5 years in advance of a lease expiry, NHS Grampian Property Department will discuss the lease with the contractor and make them aware of the options. It is anticipated that contractors may/will want NHSG/HSCM to take on future leases. If this is the case then an Options Appraisal and Outline Business Case will need to be developed. The 5 year timescale will allow for this to happen. 4.15 Current lease position: • Rinnes Medical Practice confirmed in 2021 that they would like NHSG/HSCM to take on the lease for the Tomintoul Medical Practice. The practice cancelled their lease with the premises owner as of 31 March 2022. Work is still on-going via NHS Grampian on the new lease. • Burghead Sub branch lease expires 30 December 2023 - this is part of the Moray Coast discussions. • Next lease due to expire is in January 2033 for Moray Coast Medical Practice then Linkwood Medical in September 2034. 4.16 Back-scanning of patient records: 2021/22 GP Premises funding meant monies were allocated to assist with premises improvement. Across NHS Grampian it was agreed that these monies would be utilised to back-scan patient records and free up space within the practices which would then be transformed into usable clinical and/or admin space. 4.17 There have been some extenuating circumstances, which has resulted in the commencement of a second tendering process to procure a contractor to undertake this work. Page 62
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4.18 The submissions for this tender were evaluated week commencing 8 May 2023. Once a contractor has been procured, work will commence with that supplier i.e. completion of Data Protection Impact Assessment (DPIA), timeline for rolling out practices etc. 4.19 Work has already commenced with Moray GP Practices to ascertain what work needs to be undertaken when the patients records have been removed. A programme of work is being developed alongside NHS Grampian Property Department. 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. This locality approach is 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 but these are very dependent on a diversity of aspects. (c) Financial implications Financial implications relating to building leases, potential construction and/or refurbishment costs. (d) Risk Implications and Mitigation Increase in GP registrations would, for example, lead to cancellations of appointments, reduce preventative health care and increase pressure of community services, in turn reducing the service delivery within existing infrastructure. To mitigate the examples stated and discover the whole impact, a detailed study will be undertaken with governance through the Moray Infrastructure Board. (e) Staffing Implications There are implications on staffing provision and on staff health and wellbeing which are unclear at this point until all information / data is gathered. (f) Property Implications relating all Moray GP Practice premises. (g) Equalities/Socio Economic Impact None arising directly from this report. But likely dependent on whether or not any developments are capital investment projects. (h) Climate Change and Biodiversity Impacts None arising directly from this report. But likely dependent on whether or not any developments are capital investment projects. Page 63
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(i) Directions None arising directly from this report. (j) Consultations Sean Coady, Head of Service, HSCM Simon Bokor-Ingram, Chief Officer, HSCM Carmen Gillies, Interim Strategy & Planning Lead, HSCM Robert Lockhart, Moray GP Clinical Lead Tracey Sutherland, Committee Services Officer Aileen Scott, Legal Services Manager, Moray Council Katrina Martin, Senior Infrastructure Officer, Moray Council Have all been consulted and their comments taken into account in the report. 6 CONCLUSION 6.16 The MIJB are asked to consider and note the contents of this report. Author of Report: Rosemary Reeve, Interim Primary Care Development Manager Background Papers: None Ref: Page 64
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REPORT TO: MORAY INTEGRATION JOINT BOARD ON 25 MAY 2023 SUBJECT: GENERAL PRACTICE SUSTAINABILITY IN MORAY BY: HEAD OF SERVICE 1. REASON FOR REPORT 1.1. To inform the Board of sustainability issues in general practice across Moray. 2. RECOMMENDATION 2.1. It is recommended that the Moray Integration Joint Board (MIJB): i) considers and notes the contents of this report; and ii) agrees the actions and risk mitigation as detailed in section 4 of the report. 3. BACKGROUND 3.1. General Practice nationally are facing a serious and prolonged sustainability challenge. These challenges are felt acutely in Moray, with long standing recruitment and retention issues across Grampian. Some practices are struggling to maintain services, and there is the threat of more practices handing back contracts. 3.2. We have a decreasing number of practices and a falling GP headcount dealing with an increasing ageing population that has more complex health needs. Society as a whole is also becoming more challenging in expectations of services. There has not been a corresponding increase in investment in General Practice 3.3. Total number of practices in Grampian: Item 10. Page 65
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Practice numbers in Grampian have gradually declined from 84 in 2007 to 69 in 2023, a decrease of just under 18%. Practice numbers in Moray have decreased from 16 in 2007 to 12 in 2023, a decrease of 25%. 0 10 20 30 40 50 60 70 80 90 2007 2010 2013 2016 2019 2023 Total number of practices in Grampian 0 2 4 6 8 10 12 14 16 18 2007 2010 2013 2016 2019 2023 Total number of practices in Moray Page 66
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3.4 GP Headcount . GP Headcount in Moray appears to have increased by 12%, against an overall population increase of around 3%. However local information about equivalent Whole Time Equivalent GPs in not accurately available, but has decreased across the 10 year period due to GPs choosing to work less sessions. 74 76 78 80 82 84 86 88 90 92 94 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 GP Headcount in Moray Page 67
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3.5 Population Growth Moray’s practice list size increases are similar to those in the rest of Grampian and Scotland. Page 68
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3.6 Patients per GP The Grampian average patients per GP in 2022 was 1164 The corresponding Moray figure is lower at 1033, but there appears to have been a similar increase over the past 10 year period, and the Whole Time Equivalent (WTE) reduction will further influence this. 3.7 An aging population equals increased morbidity and complexity 980 1000 1020 1040 1060 1080 1100 1120 1140 1160 1180 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 Average patients per GP Average patients per GP Page 69
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3.8 Expenditure - GP funding over time as total of NHS expenditure 3.9 GP funding has actually decreased from 7.8% to 7.0% as a proportion of NHS Grampian operating cost, while spending on other services has increased by 18%. This is despite 90% of all NHS contacts occurring in Primary care with GPs seeing close to 10% of the population every week. General practice is good value for money seeing a large number of patients for a small proportion of NHS Grampian’s total spend on healthcare. Impact on Emergency Attendance and Admissions 3.10 General Practice is a successful gatekeeper for secondary care services, with Grampian having some of the lowest ED and admission rates in Scotland. Within Grampian, Moray has the lowest figures. Page 70
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3.11 G-OPES Performance The GPAS (General practice Alert System) practice metric is currently under test and is anticipated to provide further data beyond the Grampian Operational Pressure Escalation System (G-OPES) which is shown above. G-OPES has not accurately captured Primary Care activity. 3.12 Practices returning contracts: 1 1.5 2 2.5 3 3.5 4 4.5 Primary Care G-OPES Score 22-23 G-OPES Page 71
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This is the extreme scenario when a practice feels unable to continue to meet its General Medical Services (GMS) contractual requirements, so hands back its contract to the Health Board. The graph above indicates just over 7% of Grampian practices felt the need to do this in the past 12 months. 3.13 Morale and Wellbeing - May 2021 BMA wellbeing survey indicates low levels of morale: • 66.8% responders described workload as unmanageable with 57.1% of responders saying it had got worse since the pandemic. • 73.3 % stated –“struggling to cope and my work is having a negative impact on my physical and mental wellbeing”. • 70.2% stated the last year had made them more likely to take early retirement. • 87.7% stated they had been subjected to verbal or physical abuse within the last month. Recruitment and retention 3.14 As illustrated above the total head count is falling for General practitioners. Clinical and workload pressures, long working hours and work related stress together with comparatively higher numbers of female GPs has meant full time equivalent GP numbers are also reduced. Those working full time often have a more diverse work portfolio to provide variety of work and importantly guard against burn out. This, combined with lower numbers of GPs overall decreases patient facing time. There is a rise in Advanced Clinical Practitioners that has filled in some of the created shortfall. However this pool of workforce has latterly become increasingly hard to recruit to as well. The need for their skills is well recognised across the whole health system and not enough are being trained to meet the demand. There are the same recruitment challenges for attracting new staff to come to the Grampian region as experienced for GPs. Often the populations with the highest levels of need associated with deprivation are the same areas that can find it hardest to recruit. Page 72
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The Primary Care Improvement Plan (PCIP) 3.15 PCIP has not fully delivered locally – the 2018 contract was agreed to address the recognised sustainability issues in General Practice. It aimed to achieve this by removing workload from GPs and widening the primary care workforce. However the combination of funding shortfalls which have limited the ability to fulfil the objectives of memorandum of understanding and the recruitment issues highlighted above means that the PCIP has fallen well short of its full potential. From the outset local GPs were concerned that the new contract was not suitable for a more rural population such as ours in Grampian and Moray, and the vast majority Grampian GPs did not vote for this contract. Subsequent claw back of underspend payments and lack of agreed national flexibility for using this money has meant NHS Grampian General Practice has been adversely and disproportionally affected by recruitment problems and funding clawbacks, and therefore not had the same access to the resource and funding when compared with other areas of the country who have been better able to recruit PCIP staff. Pulled funding streams 3.16 As well as the claw back of PCIP underspend general practice has also seen a reduction and removal of transitionary/sustainability payments, initially cut by 1/3 in the second half of the 22/23 financial year and then stopped altogether in 23/24 financial year. These payments were meant to help support practices who had not had the full PCIP staff delivered. In a further cut mental health support funding planned for 22-23 was cancelled. This has meant practices have not had the support of additional staff and have also lost funding – leaving practices to face increasing patient demand with fewer staff and reduced financial support. Population demographic changes 3.17 These are illustrated in the graphs in sections above. As our local population becomes more elderly, our patients have a greater number of chronic disease conditions and their health needs become more complex. They need to use practice services more often, needing more clinical time and often needing higher levels of input and support. If we are to treat patients at home and in their own communities (rather than hospital), and remembering the important Gatekeeper role of GPs, we need to be able to manage our aging population (and the associated clinical demand) effectively in General Practice. There has not been an equivalent increase in funding to recognise this change. 3.18 Population behavioural changes and expectation and demand of patients has increased over the last decade. The rise of the internet and political promises has all meant that as a population we expect our demands to be met more quickly. The number of times on average a patient consults their general practices has increased significantly. Although alternative flexible modes of access such as telephone and video consultations and online eConsultations have provided access to those that choose this method, increasing levels of demand have not been matched with an equivalent increase in funding to recognise this change. Page 73
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Increase in clinical activity at Maryhill Practice over past 4 years. This includes taking over of Elgin Community Surgery, but there has not been a corresponding increase in clinical staff due to recruitment challenges. Transfer of work 3.19 There is a national drive to provide more medical care closer to a patient’s home than ever before. This is laudable but has meant a further transfer of work from secondary to primary care. The funding to resource this work transfer has usually not followed. Impact of waiting lists in Secondary care 3.20 Many hospital departments already had long waiting times however the impact of the covid-19 pandemic has significantly lengthened many of these. Whilst waiting for hospital treatments and investigations, patients suffer worsening health problems and need to consult their GPs more often, reducing available appointments for other patients, for support with these symptoms as they await the surgery or outpatient clinics that will definitively address these issues. The additional work generated is currently poorly recognised by the wider system and is unresourced. Premises 3.21 There has been minimal significant investment in the General practice estate. Central funding has led to several large capital projects on the Foresterhill site. However despite 90% of all health contacts taking place in Primary Care there has not been an equivalent investment in the primary care estate. This has led to several practices working in unsatisfactory conditions including porta cabins well beyond their expiry date. It can be difficult to attract new staff to work in these surroundings. Some practices have also seen their reimbursement for providing health services from privately owned buildings fall at the same time as borrowing costs are rising. Utility costs Page 74
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3.22 A more recent concern is a dramatic rises in utility costs. Some practices are reporting a 3x increase in their bills. Some of these costs were already high due to the lack of heat efficiency in many out dated buildings. At the time of writing there is not a way for NHS Grampian practices to on-board onto the national reduced tariff that support secondary care costs and primary care in other parts of the country. The rising business and running costs for practices is not resourced and, unless addressed, will impact on practices’ ability to employ more staff and expand services to patients. Pension costs 3.23 Similar to the situation facing hospital doctors, the tax penalties for GP’s relating to the NHS pension annual allowance (AA) and life time allowance (LTA) have proven to be a disincentive for practitioners to increase their working hours or continue to work in the latter stages of their career and has led in many cases to early retirements. This issue has been partially addressed and reversed in the most recent UK budget but future governments may choose to backtrack on these decisions, and so further uncertainty remains at a time when we need to retain and maximise our GP workforce. The recent changes have focussed on LTA over AA, and in future years the degree of relief could fall away quickly. Locum costs 3.24 The costs of backfilling for illness, pregnancy or an inability to recruit permanent staff has escalated. Twenty years ago a day’s GP locum would cost £250-£300. Now the costs can be anything from £600 to £1200 due to market forces. Locums often restrict what they will do (for example, no house visits and minimal administration) and do not provide the same continuity of care as a permanent GP or member of staff. There is little financial incentive for locums to take on permanent positions which also has a negative impact on the continuity of patient care. Falling profit 3.25 The above impact on costs has impacted on the profits associated with the current majority independent practice model. As income falls and business costs increase, taking into account the additional workload and responsibility involved, the gap in earnings associated with being a partner and the earnings of a salaried GP have narrowed. Ultimately, this means fewer GPs want to be GP Partners and rising costs and workload pressures have been a major factor in some recent contracts being handed back. Changing GP expectations 3.26 There has been fairly consistent feedback that the majority of the current newly qualifying GPs do not want to commit to the traditional partnership model due to the expectations and risk that is involved in taking on that responsibility. This has destabilised practices that can’t recruit new partners and leads to a fear of “the last man standing” scenario for existing GP partners. Page 75
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Agenda for Change (AfC) Uplift 3.27 The recent significant pay uplift awarded to health board (PCIP) employed staff via AfC has not been matched by a pay uplift to staff working in general practice (awarded via the DDRB). The effect on practices has been significant, creating inequity and discord between staff members often doing the same job. Due to current workload pressures, even very stable and well run practices will be at risk if staff chose to leave and cannot be replaced. This presents a real and current danger to the sustainability of many GP practices. 4. KEY MATTERS RELEVANT TO RECOMMENDATION Sustainability working group (SWG) 4.1 This was formed in March 2022 and originally focused on General practice but now with the wider remit of all Primary care. It meets regularly and has a well spread representation including clinical leads from General Practice, Optometry, Pharmacy and Dental and Primary Care Managers and officer bearers from the GP representative groups. It has a broad agenda covering the key topics outlined in this paper and often leads onto smaller action groups on specific areas of interest. Early warning systems 4.2 The SWG developed a document to standardise the relationship between Health and Social Care Partnerships (HSCPs) and practices. It also covered the important role of the Local Medical Committee (LMC) in supporting practices. These relationships are key in ensuring early warning and early support to areas that might be struggling. It also outlined to practices what types of support would be available in which circumstances. It is now utilised by HSCPs in planning their practice visits and communications and has been shared with all practices via the GP bulletin. Escalation Plan 4.3 Since beginning of covid this national document has been widely used locally to allow practices, upon successfully applying for permission through primary care contracts, to temporarily reduce their level of service provision in situations where they did not have the full capacity to deliver the whole breath of the GMS contract and any enhanced services. Continuity Plan 4.4 In a situation where the above escalation plan was not robust enough due to a large number of practices being impacted threatening the ability to provide even essential urgent care NHS Grampian is developing a plan to allow this care to be delivered by a centralised approach akin to a day time GMED-style service. Unscheduled Care (USC) Teams 4.5 A potential solution to day time general practice workload has been seen as having separate unscheduled care teams. Moray used winter pressure money to pilot a Daytime urgent care service project (DUCs) - this will be fully evaluated and then an assessment done of costs and staffing to see if would benefit continuing in Moray and being rolled out to the other partnerships. Page 76
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Future of General practice workshop/new models of working 4.6 It is clear to most that continuing to do the same with the changing demographics and increasing population demands is not going to result in a sustainable service. HSCM have therefore began conversations locally about what a future sustainable model of general practice could look like. Advertising vacancies 4.7 The Grampian section of the GP jobs has been updated to make more relevant but above and beyond that Jo Raine-Mitchell is leading a piece of working to make a proposal to chief officers to commission some market research to lead to a more targeted advertising campaign for primary care in General practice and a more bespoke website to attract those who may be interested to work in Grampian. Issues with medical student places not being offered to local candidates 4.8 Current medical school funding arrangement incentivise non UK students due to higher revenue. These students will often not remain in the UK and further pressure the recruitment / retention difficulties outlined above. Pressures in General Practice also offer a barrier to a rewarding training experience to medical students that promotes a career in General Practice. There are challenges here with medical students numbers locally increasing by 50% to 300 per year, with no apparent plan for the infrastructure involved. Education/training/management resources for practices shared 4.9 A factor in many failing practices is the loss of senior experience/leadership. There is therefore promotion of relevant courses to GPs and practice managers and other senior staff. Webinar series 4.10 Similar to above there are a variety of topics that practices are less knowledgeable including premises, statements of financial entitlement. So a series of webinars are planned to help better inform. Twice weekly bulletin to all practices 4.11 This initiative was started as a response to Covid-19 but has continued to better highlight relevant issues to practices in one document rather than a series of emails. Patient engagement and communication group 4.12 This group now meets across all 4 primary care contractor groups having initially started as a general practice initiative to look at how best to engage and communicate with patients and elected members. It has led to radio campaigns, a patient facing website and a number of resources for practices to share physically in their practices and on social media to promote better functioning of the practice and patient understanding of how practices have had to adapt. Page 77
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Wellbeing 4.13 General practice wellbeing resources are now regularly shared in the bulletin. An all-encompassing document is also being prepared to bring them all together in one resource. Endowment fund is being explored to see if we can provide a primary care arm of the successful We Care programme for NHS employed staff and associated counselling. National sustainability conversations 4.14 A number of Grampian primary care leaders engage with national meetings around sustainability – regularly sharing the tools and thoughts from local discussions. Utility bills 4.15 Pushing for a local or national solution to practices being able to sign up to the reduced rate negotiated for public service energy supply. Data Gathering 4.16 As illustrated above the importance of good quality data is now recognised by GP leaders and a number of initiatives are put in place to improve this. 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” Functional Primary Care is crucial to the wider Moray system, and issues within this will be felt in all other sectors and impede Strategic delivery aims. In addition the Moray Portfolio has overall operational responsibility for Primary Care in Grampian, so wider Grampian sustainability issues will impact operationally on the Moray Portfolio. (b) Policy and Legal None (c) Financial implications Additional backfill and support costs for Practices needing help, and the risk of increased costs if we have 2C Practices. (d) Risk Implications and Mitigation Sections 3 highlights issues across the system. Section 4 indicates mitigations in place. (e) Staffing Implications None (f) Property None (g) Equalities/Socio Economic Impact Lowest SIMD quintile areas have decreased access to Primary Care across Scotland, and sustainability issues in Primary Care would be expected to exacerbate this. Page 78
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(h) Climate Change and Biodiversity Impacts None (i) Directions None (j) Consultations The Chief Officer, Health and Social Care Moray, GP Clinical Lead, Primary Care Contract Manager, Clinical Director Primary Care, Locality Managers, Interim Chief Financial Officer, Chief Nurse and Tracey Sutherland, Committee Services Officer were all consulted in the preparation of this report and any comments have been included. 6. CONCLUSION 6.1. General Practice in both Grampian and Moray are experiencing an unprecedented period of sustainability pressure that is impacting on operational delivery. 6.2 The impact of this instability in General Practice will be felt across the entire Moray Health and Social Care system. Author of Report: Stuart Reary and Peter Maclean Background Papers: Ref: Page 79
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REPORT TO: MORAY INTEGRATION JOINT BOARD ON 25 MAY 2023 SUBJECT: IMPLEMENTATION PLAN RELATING TO STRATEGY FOR UNPAID CARERS IN MORAY 2023-26 BY: LEAD OFFICER FOR UNPAID CARERS 1. REASON FOR REPORT 1.1. The Carers (Scotland) Act 2016 requires the Moray Integration Joint Board (IJB) to prepare and review a local carer strategy. The associated implementation plan is to be agreed and monitored by the IJB. 2. RECOMMENDATION 2.1. It is recommended that the Moray Integration Joint Board: i) Agree the associated implementation plan relating to the Moray Carers Strategy 2023-2026; and ii) Instruct the Lead Officer for Unpaid Carers to report back to the MIJB Clinical and Care Governance Committee in six months’ time to monitor progress on the plan and the actions within. 3. BACKGROUND 3.1. The Carers (Scotland) Act 2016 requires local carer strategies to be developed which set out plans to identify carers, provide information about local support, and provide support and services. The duty to prepare local carer strategies applies to local authorities and relevant health boards but is delegated to integration joint boards. 3.2. Moray’s local carer strategy was developed through engagement with unpaid carers in Moray, and approved at IJB on 31 March 2023. 3.3. The local strategy supports the national vision of Valuing, Recognising and Support Carers. The key strategic outcomes for Scotland include: • Carers are recognise and their contribution is understood and valued by society • Carer’s voices are heard and their views and experiences are taken into account in decisions which affect them. Item 11. Page 81
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4. KEY MATTERS RELEVANT TO RECOMMENDATION 4.1. Health and Social Care Moray’s Carers Strategy has three strategic priorities to be delivered on over the next three years. These are: • Recognition for Carers • We want carers to be able to say, ‘I can identify as a carer. I am able to access the information and advice I need as a carer and I know and understand my rights’. • Valuing Carers We want carers to be able to say, ‘I am listened to and valued as an equal and expert partner by people working in health and social care. I am involved in the planning and delivery of services and support for myself and for the person/s I am caring for’. • Supporting Carers Involving Carers as Equal, Expert and Valued, we want carers to be able to say, ‘I am able to manage my caring role and reduce any negative impact on my health and wellbeing. I can access the support and services which are right for me. I am able to take a break from my caring role when I need to. I am not disadvantaged because I am a carer. I am able to achieve my own goals and maintain my education and/or employment’. 4.2. The high-level actions set out in the strategy have been developed into the implementation plan (Appendix 1). This is intended to be a live document with new actions added as they are identified and indicators in place to support performance reporting. .Project plans are currently being developed in greater detail to deliver on key areas and will sit under the overarching implementation plan. 4.3. The plan directly links to the three key priorities identified within the strategy. It also supports Health and Social Care Moray’s Partners in Care strategy, namely Theme 1: Building Resilience, Objective 2. The plan will be further refined to evidence where it links with the Carers (Scotland) Act 2016 and also with the national Carers Strategy. 4.4. Key priorities for year one have been identified following the engagement with unpaid carers as noted within the plan. These will be further refined to ensure it is reflective of the current pressures and the potential for further actions being identified as the work is progressed. This will support the review and refinement of the Carers Strategy on an annual basis. 4.5. The first Carer Voice Group is due to take place in July 2023 and will further support the delivery of the implementation plan, ensuring it is reflective of the current landscape for carers. 4.6. Regular monitoring of the delivery plan that will accompany the strategy will be monitored through the Carers Strategy Implementation Group, as a standing item at the Clinical Care Governance Committee, and with regular updates to the IJB, the first being in 6 months’ time. Page 82
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5. SUMMARY OF IMPLICATIONS (a) Corporate Plan and 10 Year Plan (Local Outcomes Improvement Plan (LOIP)) and Moray Integration Joint Board Strategic Plan “Moray Partners in Care 2022– 2032” Carers who are supported to carry out their role in a way that supports their own health and wellbeing and their educational and economic potential, are key to achieving the ambitions of the Moray IJB Strategy Plan, the Corporate Plan and LOIP. The strategy will support Theme 1 Objective 2 of the Moray Partners in Care strategy and supports HSCM to demonstrate impact on Outcome 6 of the National Health and Wellbeing Outcomes. (b) Policy and Legal Having a local carer strategy in place meets the legal obligation on the Moray IJB as prescribed in the Carers (Scotland) Act 2016. It also supports carers’ right to: • Access a local information and advice service • Be included in the hospital discharge of the person they are caring for • Request and Adult Carer Support Plan (if over the age of 18) or a Young Carer Statement (if under aged 18 or younger) • Access Support if they have eligible needs • Be consulted on services for them and the person they are caring for (c) Financial implications Annual Carer Act funding is in place to support delivery of the strategy. The actions outlined within the Strategy and Action Plan, including the commissioning of the local information and advice service, require to be delivered within the existing resource envelope and through additional, applied for, funding streams where available. (d) Risk Implications and Mitigation The provisions of the Act are considered to contribute to overall risk management across the responsibilities of the health and social care partnership. Demand for support is likely to increase significantly as more people are identified as carers. A local eligibility criteria is in place to determine whether a carer should receive formal support. (e) Staffing Implications The strategy will be delivered by the workforce in partnership with unpaid carers, the public, third and independent sectors, and the wider community. The plan currently highlights risks due to current staffing resources. (f) Property None arising directly from this report. Page 83
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(g) Equalities/Socio Economic Impact Carers are more likely to experience inequality of outcome and more likely to be in poor health than people who do not undertaken a caring role. The strategy aims to enhance equality of opportunity for all carers. (h) Climate Change and Biodiversity Impacts None arising directly from this report. (i) Directions No Direction required. (j) Consultations Consultations have taken place with Chief Officer, Health and Social Care Moray, Interim Chief Financial Officer, the Carer Representative and Tracey Sutherland, Committee Services Officer. 6. CONCLUSION 6.1 The implementation plan must be monitored to ensure progress is made to deliver on the Carers Strategy. 6.2 The plan must be monitored and reviewed by all stakeholders, include carers to ensure it is reflective of the current landscape, noting that priorities may change as a result. This is in turn will support the review and update of the Carers Strategy on an annual basis to ensure it remains a live document. 6.3 The plan will be monitored through the Carers Strategy Implementation Group, Clinical Care Governance Committee and the Moray Integrated Joint Board. Author of Report: Michelle Fleming, Self-Directed Support & Carers Officer Background Papers: Carers Strategy Implementation Plan 2023-2026 Ref: Page 84
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Objectives from Moray Carers Strategy 2023 - 2026 Ref Activities Ref Actions Target Achievement Date Reference To Separate Project Plan Associated Risks (see Risk Log for detail on Med and High Risks) Low , Medium, High Lead Person(S) Supported by/Additional Resources Required Progress Notes Status - (Completed, In Progress, Not Started) Reference to Carers (Scotland) Act 2016 Reference to National Carers Strategy Reference to Strategic Plan Health & Social Care Moray “Moray Partners in Care 2022- 2032" 1.1.1 Provide a programme of information/awareness to Social Work Teams and Home Care Teams in Adult Services, highlighting carer issues, the referral process to the commissioned service, and the supports available, as well as the statutory requirements under the Carers (Scotland) Act 2016 Year 1 Adult Carers Officer Assistant Adult Carers Officer, Commissioned Carers Service, Staffing Information, materials, Online Campaigns, Promotion & Marketing Not Started 1.1.2 Provide a programme of information to MIDAS and MADP members, highlighting carer issues, the referral process to commissioned services, and the support available, as well as statutory requirements under the Carers (Scotland) Act 2016 Year 1 Adult Carers Officer Assistant Adult Carers Officer, Commissioned Carers Service, Staffing Information, materials Not Started 1.1.3 Provide a programme of information to Social Work Teams in Children’s Services, highlighting carer issues, the referral process to the commissioned service, and the supports available, as well as the statutory requirements under the Carers (Scotland) Act 2016 Year 1 Young Carers Officer Assistant Young Care Officer, Commissioned Carers Service, staffing information and associated materials Not Started 1.1.4 Provide a programme of information/awareness to GP practice staff, highlighting carer issues, the referral process to the commissioned service, and the supports available, as well as the statutory requirements under the Carers (Scotland) Act 2016 Year 1 Adult Carers Officer/Young Carers Officer Assistant Adult Carer Officer, Assistant Young Carer Officer, Commissioned Carers Service, Staffing information and associated materials Not Started 1.1.5 Provide a programme of information/awareness to colleges/universities highlighting carer issues, the referral process to the commissioned service, and the supports available. Year 2 Adult Carers Officer/Young Carers Officer Assistant Adult Carer Officer, Assistant Young Carer Officer, Commissioned Carers Service, Contacts within college/university, information and awareness materials Not Started 1.1.6 Support and promote the creation of Carer Champions in colleges/universities Year 2 Adult Carers Officer/Young Carers Officer Assistant Adult Carer Officer, Assistant Young Carer Officer, Commissioned Carers Service, resources within colleges/universities, Carer Champion Role Documentation, Support Materials Not Started 1.1.7 Include Young Carer Awareness sessions in PSE lessons in schools 50% of schools within Year 2, 100% of schools by end Year 3 Young Carers Officer Assistant Young Carer Officer, Commissioned Carers Service, Young Carer awareness resources/pack for school use Not Started 1.1.8 Promote and encourage, with a view to establish Carer Champions in schools in Moray 50% of schools within Year 2, 100% of schools by end Year 3 Young Carers Officer Assistant Young Carer Officer, Commissioned Carers Service, Young Carer awareness resources/pack for school use Not Started 1.1.9 Facilitate a programme of carer awareness for third sector and business/community providers in Moray, highlighting the needs of carers, the referral process to the commissioned service, and the supports available Year 1 and 2 Adult Carers Officer/Young Carers Officer Assistant Adult Carer Officer, Assistant Young Carer Officer, Commissioned Carers Service, Third Sector Provider contacts, appropriate information and awareness materials. Not Started 1.1.10 Consider and research the introduction of a Carer Passport scheme to support awareness, understanding and recognition of carers across our communities in Moray Year 3 To be developed Adult Carers Officer/Young Carers Officer Assistant Adult Carer Officer, Assistant Young Carer Officer, Commissioned Carers Service, Development of a working group to progress. Use learning from implementation of Hospital Carer Passport Not Started 1.2.1 Include online Carer Aware training in induction for all new NHS staff Year 1 Hospital Project Adult Carers Officer In Progress 1.2.2 Include online Carer Aware training in ongoing professional development programmes for all existing NHS staff Year 2 Hospital Project Adult Carers Officer In Progress We want carers to be able to say, ‘I can identify as a carer. I am able to access the information and advice I need as a carer and I know and understand my rights’. 1.1 1.2 Priority 1 – Recognition for carers - To raise the profile of all carers of all ages in Moray, and support individuals to both recognise carers, and be recognised as carers, as early as possible in their caring role as the first step to support. Theme 1 - Building Resilience, Objective 2 - Value and Support Unpaid Carers Develop and deliver an awareness raising programme to NHS staff, Adult Social Care, Children’s Social Care, Schools and UHI, wider Moray Council and NHS staff, third sector and other community/business providers across Moray Embed Turas Carer Aware training in the core skills requirement for all NHS staff Item 11. Page 85
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1.2.3 Establish Carer Champions in NHS public facilities: hospital wards, out-patient clinics, A&E, to enable regular circulation of carer aware information for staff, patients and carers Year 2 Hospital Project Adult Carers Officer Carer Champion identified in Stephen Hospital In Progress 1.3.1 Identify a lead to progress Carer Positive within Moray Council Year 1 Carer Positive Project Adult Carers Officer Lead (to be determined) Not Started 1.3.2 Achieve Level 2 Carer Positive in Moray Council Year 3 Carer Positive Project Adult Carers Officer Carer Positive Lead, Assistant Adult Carers Officer, HR, promotional materials, Not Started 1.3.3 Identify a lead within HSCM to support the progress of Carer Positive in all hospitals in Moray Year 1 Carer Positive Project Adult Carers Officer Lead (to be determined) Not Started 1.3.4 Complete - see "completed actions" Completed 1.3.5 Complete - see "completed actions" Completed 1.3.6 Carers Team (Moray Council) to support NHS Grampian in achieving Level 2 (established) Carer Positive Award in hospitals within Moray Year 3 Carer Positive Project HSCM Hospital Carer Positive Lead (to be determined) To be determined Not Started 1.4.1 Review and enable online, in-person and paper- based referral processes within the commissioned Carer Support Service Year 1 and 2 N/A Adult Carer Officer, Young Carer Officer Commissioned Carer Service, Unpaid Carers Social Worker, Assistant Adult and Young Carer Officers, IT In Progress 1.4.2 Promote commissioned Carer Support Service referral processes widely across Moray and all stakeholders Year 2 N/A Adult Carer Officer, Young Carer Officer Commissioned Carer Service, Unpaid Carer Social Worker, Assistant Adult and Young Carer Officers, IT, Communications, PR Not Started 1.5.1 Establish an application, recording and issuing process for carer ID cards in Moray Year 2 To be developed Adult Carer Officer, Young Carer Officer Commissioned Carer Service, Assistant Adult and Young Carer Officers, Carers Voice Group, Card machine Blank cards Staffing/admin Not Started 1.5.2 Promote the Carer ID card initiative widely across Moray, to carers, communities, businesses and service providers Year 2 To be developed Adult Carer Officer, Young Carer Officer Commissioned Carer Service, Unpaid Carer Social Worker, Assistant Adult and Young Carer Officers, PR, Comms, Social Care Teams Not Started 1.5.3 Secure discounts and other benefits for carers in Moray linked to the Carer ID card Year 3 To be developed Adult Carer Officer, Young Carer Officer Assistant Adult and Young Carer Officers, PR, Comms, Not Started 1.5.4 Support carers to obtain a Carer ID card Year 2 To be developed Adult Carer Officer, Young Carer Officer Commissioned Carer Service, Unpaid Carer Social Worker, HSCM Social Care Teams Not Started 1.6.1 Enable early identification and support for YC transitioning from Secondary School to higher/further education Year 2 To be developed Young Carers Officer To be determined Not Started 1.6.2 Enable early identification and support for YC making choices about employment – link to Developing the Young Workforce and other initiatives able to provide targeted support Year 3 To be developed Young Carers Officer To be determined Not Started 1.6.3 Review and enable early identification and support for carers of someone moving, or considering moving, into residential or nursing care Year 2 To be developed Adult Carer Officer Assistant Adult Carer Officer, Unpaid Carer Social Worker, Commissioned Carer Service, HSCM Social Care Teams Not Started 1.6.4 Enable early identification and support for carers in work, to support decisions in relation to balancing work and caring, and the potential for reducing or ceasing work Year 2 To be developed Adult Carer Officer Assistant Adult Carer Officer, Unpaid Carer Social Worker, Commissioned Carer Service, HSCM Social Care Teams Not Started 1.6.5 Review and enable early identification and support for carers wishing to return to work, to support decisions in relation to balancing work and caring Year 2 To be developed Adult Carer Officer Assistant Adult Carer Officer, Commissioned Carer Service, Unpaid Carer Social Worker Not Started 1.6.6 Enable early identification and support for parent carers of disabled children approaching adulthood/independent living Year 2 To be developed Adult Carer Officer Assistant Adult Carer Officer, Commissioned Carer Service, Unpaid Carer Social Worker, HSCM Social Care Teams Not Started 1.6.7 Review and enable early identification and support for former carers on the death of the person they care for or if their caring role reduces suddenly because the cared-for has moved into long term care. Year 2 To be developed Adult Carer Officer Assistant Adult Carer Officer, Commissioned Carer Service, Unpaid Carer Social Worker, HSCM Social Care Teams Not Started 1.6.8 Research, develop & facilitate peer support groups for carers whose caring role has ended or significantly reduced for different reasons. Year 2 To be developed Adult Carer Officer Assistant Adult Carer Officer, Commissioned Carer Service, Carers Voice Group. Not Started 1.3 1.6 Support carers during periods of transition: age and circumstance related We want carers to be able to say, ‘I can identify as a carer. I am able to access the information and advice I need as a carer and I know and understand my rights’. 1.2 1.4 1.5 Theme 1 - Building Resilience, Objective 2 - Value and Support Unpaid Carers Embed Turas Carer Aware training in the core skills requirement for all NHS staff Enable easy referral and registration for carers to the commissioned Carer Support service, including online, in- person and paper processes Develop and make easily available a carers ID card, recognised across Moray Support take-up of the Carer Positive award in HSCM, Moray Council and NHS Grampian provision in Moray Page 86
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1.7.1 Enable and encourage family members to explore their role and its impact on them, in the context of the Carers (Scotland) Act 2016 and their rights to support as a carer Year 1 To be developed Adult, Carer Officer, Young Carer Officer, Assistant Carer Officers, Commissioned Carer Service, Unpaid Carer Social Worker, Specialist Service Providers, In Progress 1.7.2 Involve carers of people who have an alcohol and/or drug dependency in the review of the ACSP template and process, to ensure relevance and accessibility for their circumstances Year 2 To be developed Adult Carer Officer Assistant Carer Officers, Commissioned Carer Service, Specialist Service Providers, Working Group consisting of Carers with experience. Not Started 1.7.3 Enable early identification and support for children of those with an alcohol and/or drug dependence, who may be taking on a caring role that isn’t recognised or acknowledged within the family Year 2 To be developed Young Carer Officer Assistant Young Carer Officer, Commissioned Carer Service, Specialist Service Providers, Education, GP's Not Started 1.7.4 Create targeted materials for use with carers and family members of people who have an alcohol and/or drug dependence, to help improve understanding of the caring role Year 2 To be developed Adult Carer Officer, Young Carer Officer Assistant Carer Officers, Commissioned Carer Service, Specialist Service Providers, Education, GP's, PR, Comms Not Started 2.1.1 Establish a Carers Voice Group enabling engagement by adult carers in regular discussion and decision making linked to implementation of the Carers Strategy and ongoing identification and prioritising of carer unmet needs Year 1 N/A Adult Carer Officer Assistant Adult Carer Officer, Commissioned Carers Service, HSCM Carer Team, PR, Comms Promotion and Invitations to join first meeting taking place in and around Carers Week in June. Initial meeting Mid July In Progress 2.1.2 Support and promote the developing Young Carer Reference Group initiated by the commissioned service, enabling young carer engagement in regular discussion and decision making linked to the implementation of the Carers Strategy and ongoing identification and prioritising of carer unmet need Year 2 N/A Young Carer Officer Assistant Young Care Officer, Commissioned Carers Service, Young Carers, Education, PR, Comms In Progress 2.1.3 Enable targeted feedback opportunities for all carers, with specific focus on parent carers, Young Adult Carers, older carers, carers of adults in recovery from/dependence of alcohol and/or drugs, carers of Long Term Conditions, carers of adults in residential/nursing care, and other such groups as may be identified by carers themselves, enabling ongoing identification and prioritising of carer unmet need Year 3 but commencing from Year 1 N/A Adult Carer Officer Assistant Adult Carer Officer, Commissioned Carers Service, PR, Comms, Carer Voice Groups. Not Started 2.1.4 Provide admin/co-ordination to enable effective two-way communication between Carer Voice activity and appropriate platforms – e.g. IJB, Carers Steering Group, and others that may be developed during the lifetime of this strategy Year 1 N/A Adult Carer Officer, Young Carer Officer Assistant Adult Carer Officer, Assistant Young Carer Officer Not Started 2.2.1 Identify a Lead for the hospital project, as well as resources and support required. Year 1 Hospital Project Adult Carer Officer In Progress Section 28 2.2.2 Establish a dedicated staff presence in all hospitals in Moray, enabling early identification of carers and easy access to the full range of supports available. Commencing Year 1 Hospital Project Not Started Section 28 2.2.3 Develop and support a network of Carer Champions in hospitals, able to promote carer awareness amongst staff, and maintain information displays for carers in wards and clinics Year 2 Hospital Project Carer Champion identified in Stephen Hospital In Progress Section 28 2.2.4 Offer regular staff information sessions in hospitals, to maintain carer awareness and support early identification and referral Year 1, 2 and 3 Hospital Project Not Started Section 28 2.2.5 Develop carer information packs for wards and clinics, ensuring carers are able to access relevant and timely information as easily and quickly as possible Year 1 Hospital Project Information Pack in progress of being pulled together In Progress Section 28 2.3 Introduce the Carer Passport process in Moray hospitals, to aid carer access and information when the cared for is admitted 2.3.1 Initiate a Carer Passport scheme in Moray hospitals Year 2 Hospital Project Passport work commenced 2022. Draft prepared - currently under further review and amendment In Progress Section 28 2.4.1 Consider extending the Carer Passport scheme to other areas of life in Moray, including employment and education Year 3 Hospital Project Not Started 2.4.2 Deliver Triangle of Care awareness sessions to NHS and HSCM staff involved in the care and support of people with poor mental health Year 2 Hospital Project Need to ascertain current position as Triangle of Care approach apparent in Muirton Ward, Buckie. In Progress 2.4.3 Seek endorsement of the Triangle of Care principles within mental health support providers in Moray Year 3 Hospital Project As above In Progress Priority 2 – Valuing carers - To involve, respect and listen to carers in planning the care and support of the person they care for, and themselves Theme 1 - Building Resilience, Objective 2 - Value and Support Unpaid Carers Support the development of appropriate Carer Voice opportunities for carers of all ages, enabling effective feedback on strategic outcomes progress and carer experience in Moray 2.1 Build on the Test of Change work in hospitals in Moray, to seek Carer Champions on wards and easy links to the commissioned Carers Support Service 2.2 Adopt the Triangle of Care to support carers of people with poor mental health 2.4 We want carers to be able to say, ‘I am listened to and valued as an equal and expert partner by people working in health and social care. I am involved in the planning and delivery of services and support for myself and for the person/s I am caring for’. Improve identification and support for carers of family members who have an alcohol and/or drug dependence, recognising the sensitivities around identifying as a carer and the impact of cared for non-engagement. We want carers to be able to say, ‘I can identify as a carer. I am able to access the information and advice I need as a carer and I know and understand my rights’. Theme 1 - Building Resilience, Objective 2 - Value and Support Unpaid Carers 1.7 Page 87
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2.4.4 Consider the role of a Carer Passport scheme in improving carer awareness and engagement in support for people with poor mental health Year 3 Hospital Project In Progress 2.5.1 Collate data from ACSPs and YCSs to inform carer access to condition-specific awareness sessions to help increase understanding and confidence Year 2 To be developed Adult Carer Officer, Young Carer Officer Social Worker Unpaid Carers, Assistant Adult and Young Carers Officer, Commissioned Carers Service Not Started 2.5.2 Engage a wide range of condition-specific providers in awareness raising opportunities for carers of all ages Year 2 To be developed Adult Carer Officer, Young Carer Officer Assistant Carers Officers, Commissioned Carers Service, Relevant Providers across Moray Not Started 2.5.3 Evaluate provision and access to training/awareness linked to conditions of the cared for person to inform future development and commissioning needs Year 3 To be developed Adult Carer Officer, Young Carer Officer Assistant Carers Officers, Commissioned Carers Service, Social Worker Unpaid Carers Not Started 2.6 Improve carer access to self- management support in their role 2.6.1 Provide skills development and information opportunities to carers of all ages that meet the self-management needs identified via ACSP/YCS Year 2 To be developed Adult Carer Officer, Young Carer Officer Assistant Carers Officers, Commissioned Carers Service, Social Worker Unpaid Carers Not Started 3.1.1 Establish the parameters and arrangements for the Adult and Young Carers Contract from April 2023 and subsequent contract tendering process which is responsive to local need/risks and statutory requirements. April 2023 N/A Carers Service Commissioning Officer, Service Manager Adult Carer Officer, Young Carer Officer, Social Worker Unpaid Carers, Assistant Adult and Young Carer Officers, Commissioned Carers Service In Progress 3.1.2 Ensure relevant, timely and accessible information is available to carers of all ages in a variety of formats, and is widely promoted Year 2 Adult Carer Officer, Young Carer Officer Commissioned Carers Service, Assistant Adult and Young Carer Officers See Risk Log 3.1.3 Maintain social media and online communications that are flexible and responsive, to ensure carers have easy access to the most up-to-date information Year 2 Adult Carer Officer, Young Carer Officer Commissioned Carers Service, Assistant Adult and Young Carer Officers See Risk Log 3.1.4 Enable face to face information and advice sessions for carers, in response to direct enquiry or collation of unmet need via ACSP/YCS Year 1 Adult Carer Officer, Young Carer Officer Commissioned Carers Service, Assistant Adult and Young Carer Officers See Risk Log 3.1.5 Create effective referral pathways to Welfare Rights support and other financial management/life event services Year 1 Adult Carer Officer Commissioned Carers Service, Assistant Adult Carer Officer See Risk Log 3.2.1 Complete a desktop review of a sample group of ACSPs completed in the last 12 months, the support enabled as a result, and any review monitoring, to establish the accuracy of ACSP data gathering in relation to outcomes sought and achieved Year 2 To be developed Adult Carer Officer Assistant Adult Carer Officer, Social Worker Unpaid Carers, Commissioned Carers Service Not Started 3.2.2 Engage adult carers from a variety of caring circumstances and demographics in a review process to identify areas for improvement/change in the ACSP template and process Year 2 To be developed Adult Carer Officer Assistant Adult Carer Officer, Social Worker Unpaid Carers, Commissioned Carers Service Not Started 3.2.3 Refresh the ACSP template and process, and test with a sample group of adult carers, seeking feedback on the experience to inform the final model Year 2 To be developed Adult Carer Officer Assistant Adult Carer Officer, Social Worker Unpaid Carers, Commissioned Carers Service Not Started 3.2.4 Implement any revised ACSP template and process, ensuring appropriate data recording and reporting for local stats and Carers Census input Year 2 To be developed Adult Carer Officer Assistant Adult Carer Officer, Social Worker Unpaid Carers, Commissioned Carers Service Not Started 3.3.1 Provide counselling for adult carers Year 2 Adult Carer Officer Commissioned Carer Service See Risk Log 3.3.2 Enable peer support for carers of all ages and circumstances Year 1 Adult Carer Officer, Young Carer Officer Commissioned Carer Service See Risk Log 3.3.3 Provide targeted support to Young Adult Carers Year 2 Adult Carer Officer, Young Carer Officer Commissioned Carer Service See Risk Log 3.3.4 Provide targeted support to Parent Carers Year 2 Adult Carer Officer Commissioned Carer Service See Risk Log 3.3.5 Provide targeted support to carers in specific circumstances/roles as indicated by unmet need in ACSP/YCS Year 1 Adult Carer Officer, Young Carer Officer Commissioned Carer Service See Risk Log 3.3.6 Provide Young Carer Groups in schools Year 2 Young Carer Officer Commissioned Carer Service See Risk Log 3.3.7 Provide easy access to breaks that help prevent the breakdown of the caring relationship Year 1 Adult Carer Officer Commissioned Carer Service, Social Worker Unpaid Carers See Risk Log 3.4.1 Support carers to plan for emergencies Year 1 Adult Carer Officer, Young Carer Officer commissioned Carer Service, Social Worker Unpaid Carers See Risk Log 3.4.2 Provide support for working carers, to help them stay in work and, where necessary, make informed decisions about their employment Year 2 Adult Carer Officer Commissioned Carer Service, Social Worker Unpaid Carers See Risk Log Theme 1 - Building Resilience, Objective 2 - Value and Support Unpaid Carers Priority 3 - empower carers to manage their caring role, to enable them to look after their own health and wellbeing, and maintain a life of their own alongside caring. For young carers, provide support to learn, develop and thrive, and where appropriate maintain an appropriate caring role Theme 1 - Building Resilience, Objective 2 - Value and Support Unpaid Carers We want carers to be able to say, ‘I am able to manage my caring role and reduce any negative impact on my health and wellbeing. I can access the support and services which are right for me. I am able to take a break from my caring role when I need to. I am not disadvantaged because I am a carer. I am able to achieve my own goals and maintain my education and/or employment’. 3.2 3.3 3.4 Review and improve the Adult Carer Support Plan and Young Carer Statement templates and process to best support identification of carer support needs and services/support required to achieve personal outcomes Provide practical support to help carers manage the impact of their caring role Ensure carers of all ages are supported to plan for the future (their own and that of the person they care for), by identifying them and working together to consider long term needs and preferences Provide a fully accessible Information and Advice service for carers of all ages 3.1 Adopt the Triangle of Care to support carers of people with poor mental health 2.4 We want carers to be able to say, ‘I am listened to and valued as an equal and expert partner by people working in health and social care. I am involved in the planning and delivery of services and support for myself and for the person/s I am caring for’. Ensure carers have access to skills development and training/awareness opportunities linked to the condition of the person they care for, to help them best support their care 2.5 Page 88
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3.4.3 Support for employers to understand the needs of working carers – flexible working, communication while at work, time off for dependents Year 3 Adult Carer Officer Commissioned Carer Service, Social Worker Unpaid Carers, Assistant Adult Carer Officer Not Started 3.5 Develop targeted Carer Respite policies, for adult, parent and young carers 3.5.1 Engage carers in discussions about how respite could look for them, and what’s needed to make that happen Year 2 Adult Carer Officer Commissioned Carer Service, Social Worker Unpaid Carers, Assistant Adult Carer Officer, Carer Voice Group Not Started 3.6.1 Provide regular peer support opportunities, offering short breaks from the caring role Year 2 Adult Carer Officer, Young Carer Officer Commissioned Carer Service, Assistant Adult and Young Carer Officers, Social Worker Unpaid Carers See Risk Log 3.6.2 Enable relationship building with local activity and break providers to increase the opportunities for carers to benefit from a range of local breaks Year 2 To be developed Adult Carer Officer, Young Carer Officer Commissioned Carer Service, Assistant Adult and Young Carer Officers, Social Worker Unpaid Carers Not Started 3.6.3 Enable Moray’s participation in the Respitality programme to increase Moray carers’ opportunities to access breaks in Moray and beyond Year 1 To be developed Adult Carer Officer Commissioned Carer Service, Assistant Adult and Young Carer Officers, Social Worker Unpaid Carers Not Started 3.6.4 Offer small grants opportunities to enable carer breaks from their role as part of an agreed personalised action plan arising from ACSP/YCS Year 3 To be developed Adult Carer Officer, Young Carer Officer Commissioned Carer Service, Assistant Adult and Young Carer Officers, Social Worker Unpaid Carers Not Started 3.6.5 Ascertain a true budget for Carers SDS Year 1 To be developed Adult Carer Officer, Young Carer Officer Assistant Adult and Young Carers Officers, Social Worker Unpaid Carers, Social Care Teams, CareFirst, Finance In Progress 3.6.6 Review and develop Carer SDS provision inline with SDS Legislation Year 1 To be developed Adult Carer Officer, Young Carer Officer Assistant Adult and Young Carers Officers, Social Worker unpaid Carers, Social Care Teams, CareFirst, Finance In Progress 3.7.1 Include young carer awareness in induction and professional development programmes for school staff Year 2 To be developed Young Carer Officer Commissioned Carer Service, Assistant Young Carer Officer, Moray School Contacts Not Started 3.7.2 Conduct annual surveys of school staff to measure awareness of young carers and the impact of their caring role on their lives and education Year 3 To be developed Young Carer Officer Commissioned Carer Service, Assistant Young Carer Officer, Moray School Contacts Not Started 3.8.1 Re-establish a Strategy Implementation Group - review membership and Terms of Reference. Set meeting dates for Strategy term. May 2023 N/A Service Manager Adult Carer Officer, Young Carer Officer, Assistant Adult and Young Carer Officers In Progress 3.8.2 Carers Voice Groups’ to report to Strategy Implementation Group Year 1, Year 2, Year 3 N/A Adult Carer Officer Assistant Adult Carer Officer, Carer Voice Group In Progress 3.8.3 Strategy Implementation Group to report progression of activities to the Clinical Care Governance Committee Year 1, Year 2, Year 3 N/A Service Manager Strategy Implementation Group members In Progress 3.8.4 Strategy Implementation Group to report progression of activities and actions detailed on the Strategy Implementation Plan to the IJB, initially 6 monthly Year 1, Year 2, Year, 3 N/A Service Manager Strategy Implementation Group members In Progress 3.8.5 Commissioned Carers Service reporting processes evidence carer support needs and trends, support provided, unmet needs, outcomes and carer satisfaction Year 1 N/A Commissioning Officer Commissioned Carer Service, Commissioning Team, Adult and Young Carer Officer, Social Worker for Unpaid Carers In Progress 3.8.6 Annual evaluation of carer experience in Moray, analysis and outcomes to be reported to the Strategy Implementation Group to determine and identify unmet need and how this will be met. Year 2/Year 3 N/A Adult Carer Officer, Young Carer Officer Assistant Adult and Young Carers Officer, Carers Voice Group, Marketing/Comms, PR, Unpaid Carers Not Started 3.8.7 Complete Carers Census submissions accurately and within required timescales As per Census Schedule N/A Adult Carer Officer, Young Carer Officer Commissioned Carer Service. Commissioning Team (HSCM) See Risk Log In Progress 3.8.8 Identify the resources currently in place and match those against those necessary to deliver the actions from the Carers Strategy. Identify and address any imbalances, taking into account funding from the Scottish Govt for the Carers Act. August 2023 N/A Service Manager Adult Carer Officer, Young Carer Officer In Progress Theme 1 - Building Resilience, Objective 2 - Value and Support Unpaid Carers We want carers to be able to say, ‘I am able to manage my caring role and reduce any negative impact on my health and wellbeing. I can access the support and services which are right for me. I am able to take a break from my caring role when I need to. I am not disadvantaged because I am a carer. I am able to achieve my own goals and maintain my education and/or employment’. Adopt a continuous improvement approach to monitoring and evaluating carer experience in Moray, aiding consistent reporting to the Scottish Carers Census and informing commissioning and development activity to improve outcomes for carers 3.8 3.4 3.7 Ensure carers of all ages are supported to plan for the future (their own and that of the person they care for), by identifying them and working together to consider long term needs and preferences Facilitate carer breaks through a variety of models, including participation in the national Respitality programme 3.6 Participate in national programmes to improve schools’ awareness of, and support for, young carers in education Page 89
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3.8.9 Establish membership and Terms of Reference for a Carer Strategy Review Group October 2023 N/A Service Manager Carers Voice Group, Strategy Implementation Group members, Social Worker for Unpaid Carers, Commissioned Carers Service, Not Started 3.8.10 Review and refresh Moray Carers Strategy 2023- 2026 on an annual basis January 2024, January 2025, January 2026, Service Manager Carers Voice Group, Carer Strategy Review Group, Strategy Implementation Group members, Social Worker for Unpaid Carers, Commissioned Carers Service, IJB Not Started 3.8.11 Establish a process and actions for the development and consultation of the Moray Carers Strategy 2026 - ? To Commence July 2025. Completion date March 2026 for launch April 2026 To be developed Adult Carer Officer, Young Carer Officer Carers Voice Group, Carer Strategy Review Group, Service Manager, Strategy Implementation Group members, Commissioned Carer Service, IJB, Not Started Theme 1 - Building Resilience, Objective 2 - Value and Support Unpaid Carers We want carers to be able to say, ‘I am able to manage my caring role and reduce any negative impact on my health and wellbeing. I can access the support and services which are right for me. I am able to take a break from my caring role when I need to. I am not disadvantaged because I am a carer. I am able to achieve my own goals and maintain my education and/or employment’. Adopt a continuous improvement approach to monitoring and evaluating carer experience in Moray, aiding consistent reporting to the Scottish Carers Census and informing commissioning and development activity to improve outcomes for carers 3.8 Page 90
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1.1.1, 1.1.4, 1.1.5, 1.1.9, 1.4.1, 1.4.2, 1.5.1, 1.5.2, 1.5.4, 1.6.1, 1.6.2, 1.6.3, 1.6.4, 1.6.5, 1.6.6, 1.6.7, 1.6.8, 1.7.3, 2.1.2, 2.5.2, 2.5.3, 2.6.1, 3.1.2, 3.1.3, 3.1.4, 3.1.5, 3.3.1, 3.3.2, 3.3.3, 3.3.4, 3.3.5, 3.3.6, 3.3.7, 3.4.1, 3.4.2, 3.6.1, 3.6.3, 3.6.4, 3.8.7, 3.8.10, 3.8.11 Lack of a substantive Carer Support Service contract. Carer service provision does not deliver Carer support that is required or compliant. HSCM failure to meet legislative requirements. Increase of Carers in "crisis". Increase in Carer unmet need. Unable to meet increases in referrals or demand for services. Inability to contribute to the progression of Carer Strategy outcomes. Unable to recruit within carer service. Satisfaction with Carer support decreases. Increase in complaints. Reduced ability to provide early help and intervention. High High Commissioning team liaising with Senior Management Team Deadline Owner Action Ref No. Risk Description Impact Countermeasures Status Overall Impact Overall Probability Page 91
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Current Social Care crisis More unpaid carers requiring practical and emotional support. Increase in carers reaching "crisis". Increase in referrals to Commissioned Carer Support Service. Increase in urgent referrals to Social Work for emergency respite. Decrease in available respite or long term care provision. Tender Specification for the Carer Support Service to be updated and made fit for purpose. Focus on early help and crisis prevention and include this in future tendering of Carer Support Service. Development of short break provision (Respitality), develop flexible and creative Carer SDS. Carers Team to provide support and represent unpaid carers in HSCM workforce planning. Unpaid Carers to be recognised as equal partners in care. 1.1.1, 1.1.4, 1.1.5, 1.1.9, 1.4.1, 1.4.2, 1.5.1, 1.5.2, 1.5.4, 1.6.1, 1.6.2, 1.6.3, 1.6.4, 1.6.5, 1.6.6, 1.6.7, 1.6.8, 1.7.3, 2.1.2, 2.5.2, 2.5.3, 2.6.1, 3.1.2, 3.1.3, 3.1.4, 3.1.5, 3.3.1, 3.3.2, 3.3.3, 3.3.4, 3.3.5, 3.3.6, 3.3.7, 3.4.1, 3.4.2, 3.6.1, 3.6.3, 3.6.4, 3.8.7, 3.8.10, 3.8.11 Lack of a substantive Carer Support Service contract. Carer service provision does not deliver Carer support that is required or compliant. HSCM failure to meet legislative requirements. Increase of Carers in "crisis". Increase in Carer unmet need. Unable to meet increases in referrals or demand for services. Inability to contribute to the progression of Carer Strategy outcomes. Unable to recruit within carer service. Satisfaction with Carer support decreases. Increase in complaints. Reduced ability to provide early help and intervention. High High Commissioning team liaising with Senior Management Team Page 92
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High1.1.3, 1.1.4, 1.1.5, 1.1.6, 1.1.7, 1.1.8, 1.1.9, 1.1.10, 1.4.1, 1.4.2, 1.5.1, 1.5.2, 1.5.3, 1.5.4, 1.6.1, 1.6.2, 1.7.1, 1.7.3, 1.7.4, 2.1.2, 2.1.4, 2.5.1, 2.5.2, 2.5.3, 2.6.1, 3.1.2, 3.1.3, 3.1.4, 3.3.2, 3.3.3, 3.3.5, 3.3.6, 3.4.1, 3.6.1, 3.6.2, 3.6.4, 3.6.5, 3.6.6, 3.7.1, 3.7.2, 3.8.1, 3.8.3, 3.8.4, 3.8.5, 3.8.6, 3.8.7, 3.8.8, 3.8.9, 3.8.10, 3.8.11 Young Carers Strategy Officer and Assistant Young Carer Officer posts currently vacant. Impact of the caring role may lead to young carers not achieving their full potential at school, entering further education or work. Aims to embed Young Carer Statements into both adult and children's services have ceased. Activities and actions identified in the Carer Strategy will not be completed. Strong links with Health and Education have ceased to be explored and progressed. Awareness raising for the support and identification of hidden young Carers is unable to progress within Moray and within HSCM. Non compliance with the young Carer aspects of the Carer legislation. Young Carers will not be represented in the review and development of the Carer Strategy or Carer Support Service contract. Development for Young Carer breaks, Young Carer transition support is not achieved. High Business case for funding has been submitted to fill the Young Carer Officer and Assistant Young Carer Officer vacancies on a permanent contract. Page 93
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3.8.8 Backlog in processing ACSPs due to Unpaid Carer Social Worker capacity leading to unpaid carers having unmet need. Unpaid carers with unmet need unable to look after own health an wellbeing. Potential for unpaid carers to reach crisis point High High Monitoring workload as early indications are that the volumes require additional resource. Review processes and structure of the unpaid carers team within HSCM. 3.6.5, 3.6.6 SDS budget allocation of £300 for those eligible for further support is not in line with the SDS legislation HSCM are not meeting their legal duties under the act to identify a personal budget. Not able to fully deliver on the SDS legislation or offer all 4 options of SDS High High Ascertain a true SDS Carers Budget. Review and develop Carer SDS provision in line with SDS Legislation. 1.1.3, 1.1.4, 1.1.5, 1.1.6, 1.1.7, 1.1.8, 1.1.9, 1.1.10, 1.4.1, 1.4.2, 1.5.1, 1.5.2, 1.5.3, 1.5.4, 1.6.1, 1.6.2, 1.7.1, 1.7.3, 1.7.4, 2.1.2, 2.1.4, 2.5.1, 2.5.2, 2.5.3, 2.6.1, 3.1.2, 3.1.3, 3.1.4, 3.3.2, 3.3.3, 3.3.5, 3.3.6, 3.4.1, 3.6.1, 3.6.2, 3.6.4, 3.6.5, 3.6.6, 3.7.1, 3.7.2, 3.8.1, 3.8.3, 3.8.4, 3.8.5, 3.8.6, 3.8.7, 3.8.8, 3.8.9, 3.8.10, 3.8.11 Young Carers Strategy Officer and Assistant Young Carer Officer posts currently vacant. Impact of the caring role may lead to young carers not achieving their full potential at school, entering further education or work. Aims to embed Young Carer Statements into both adult and children's services have ceased. Activities and actions identified in the Carer Strategy will not be completed. Strong links with Health and Education have ceased to be explored and progressed. Awareness raising for the support and identification of hidden young Carers is unable to progress within Moray and within HSCM. Non compliance with the young Carer aspects of the Carer legislation. Young Carers will not be represented in the review and development of the Carer Strategy or Carer Support Service contract. Development for Young Carer breaks, Young Carer transition support is not achieved. High Business case for funding has been submitted to fill the Young Carer Officer and Assistant Young Carer Officer vacancies on a permanent contract. Page 94
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Carers of people who are Palliative patients are to have assessments and plans all processed in 14 days. Unknown carer status if not triaged. Failure to meet Carers Act legislation. High High Mitigation - to look at each case as it comes in. Look at capacity within Commissioning review and future tendering of Carer Support Service. 1.3.1, 1.3.2, 1.3.3, 1.3.6 Carer Positive Award progression to Level 2 within Moray Council. No lead identified. Actions to progress to level 2 Carer Positive award will not be achieved without a Carer Positive Lead within the Council. Moray Council will fail to demonstrate how it is committed to valuing and supporting staff who have an unpaid caring role outside of work. Retention and recruitment of staff may be negatively affected. Medium Medium 1.2.1, 1.2.2, 1.2.3, 2.2.1. 2.2.2, 2.2.3, 2.2.4, 2.2.5, 2.3.1, 2.4.1, 2.4.2, 2.4.3, 2.4.4, Progression of the Hospital project - no lead, resources or support identified. Carers Act Legislation not met. Staff not provided with the training and awareness to support carers appropriately. Increase in Carer "Crisis". Negative experience of carers within hospital environments. Objectives within Carer Strategy not achieved. High High Work underway to identify a Lead within NHS Page 95
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3.8.4 Completion of Carers Census - no current or established accountability and formal arrangements for completion. Carers Census not completed. Legislative requirements not met. High High 3.2.4 Application of the carer support pathway detailed within the Carers (Scotland) Act is not always followed and/or evidenced. Carer outcomes not fully met/evidenced. Eligibility criteria not applied correctly. Non compliance with legislation. Documentation (Part 2 ACSP/YCS) would not show details of any increase in support arranged for the cared- for or access to universal services. Insufficient information recorded to inform annual reviews of ACSP/YCS. Unable to accurately identify true cost of spend for unpaid carers.. High High 3.8.8 Insufficient resources to successfully implement the Carers Strategy Unable to meet legislative requirements. Unable to implement the actions from the Carer Strategy. Unable to effectively support carers in Moray in their caring role. High High Page 96
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Ref Actions Target Achievement Date Reference To Separate Project Plan Associated Risks (see Risk Log for detail on Med and High Risks) Low , Medium, High Lead Person(S) Supported by/Additional Resources Required Progress Notes Status - (Completed, In Progress, Not Started) Reference to Carers (Scotland) Act 2016 Reference to National Carers Strategy 1.3.4 Agree a programme of Carer Positive take-up in all hospitals in Moray Year 1 Carer Positive Project Hospital Carer Positive Lead (to be determined) To be determined Level 1 (engaged) achieved by NHS Grampian Complete 1.3.5 Achieve Level 1 Carer Positive in all hospitals in Moray (will need to be broken down to specific hospitals/years once commitment secured) Year 3 Carer Positive Project Hospital Carer Positive Lead (to be determined) To be determined Level 1 (engaged) achieved by NHS Grampian Complete Page 98
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MINUTE OF MEETING OF THE AUDIT, PERFORMANCE AND RISK COMMITTEE Thursday, 24 November 2022 Council Chambers, Council Office, High Street, Elgin, IV30 1BX PRESENT Mr Simon Bokor-Ingram, Mr Sean Coady, 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 Neil Strachan IN ATTENDANCE Also in attendance at the above meeting were the Chief Internal Auditor and Tracey Sutherland, Committee Services Officer. 1. 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. 2. Minutes of meeting of 25 August 2022 The minute of the meeting of 25 August 2022 were submitted and approved. 3. Action Log of Meeting of 25 August 2022 The Action Log of the meeting of 25 August 2022 was considered and updated accordingly. 4. Quarter 2 Performance Report A report by the Corporate Manager updated the Audit, Performance and Risk Committee on performance as at Quarter 2 (July to September 2022). Page 99
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Following consideration the Committee agreed to note the performance of local indicators for Quarter 2 (July - September 2022). 5. Internal Audit Section - Update Report A report by the Chief Internal Auditor provided the Committee with an Internal Audit update. Following consideration the Committee agreed to note the audit update. 6. Strategic Risk Register Report A report by the Chief Officer provided an overview of the current strategic risks, along with a summary of actions which are in place to mitigate those risks, updated on November 2022. Following consideration the Committee agreed to: i) note the updated Strategic Risk Register included as Appendix 1; and ii) note the Strategic Risk Register will be further refined to align with the transformation and re-design plans as they evolve. 7. Internal Audit Section Completed Projects Report A report by the Chief Internal Auditor provided an update for the Committee on audit work completed since the last meeting of the Committee. Following consideration the Committee agreed to note the audit update. 8. Directions Monitoring Report The Interim Chief Financial Officer joined the meeting for the consideration of this item. A report by the interim Chief Financial Officer informed the Committee of the issued Directions of the Moray Integration Joint Board for the period 1 April to 30 September 2022. Following consideration the Committee agreed to note the Directions issued in the first six months of 2022/23. Page 100
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MINUTE OF MEETING OF THE AUDIT, PERFORMANCE AND RISK COMMITTEE Thursday, 26 January 2023 Council Chambers, Council Office, High Street, Elgin, IV30 1BX PRESENT Mr Simon Bokor-Ingram, 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 Sean Coady IN ATTENDANCE Also in attendance at the above meeting were Brian Howarth, Audit Scotland and Tracey Sutherland, Committee Services Officer. 1. Chair The meeting was chaired by Councillor Scott Lawrence. 2. Declaration of Member's Interests There were no declarations of Members' interests in respect of any items on the agenda. 3. External Auditors Report to Those Charged with Governance Report A report by the Interim Chief Financial Officer requested the Committee to consider the reports to those charged with governance from the Board's External Auditor for the year ended 31 March 2022. The External Auditor advised the Committee that amendments had been made to Note 3 - Events after the Reporting Period and it now read: 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 Page 101
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January 2023. Events taking place after this date are not reflected in the financial statements or notes. The Scottish Government on the 16 January 2023 advised the IJBs of the intention to request that unspent monies in the earmarked Covid reserves are to be returned as they were for specific purposes and are not to be used to fund day to day expenditure. The amount for Moray IJB is £6.2 million. The accounts have not been adjusted for this amount, as the technical advice provided by CIPFA confirms that this is not an adjusting event but a disclosure in the 2021/22 accounts. 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. Following consideration the Committee noted the reports from the External Auditor within Appendices 1 and 2. 4. Audited Annual Accounts 2021-22 A report by the Interim Chief Financial Officer submitted the Audited Annual Accounts for the year ended 31 March 2022. Following consideration the Committee agreed to recommend to the Moray Integration Joint Board the Audited Accounts for the financial year 2021/22. Page 102