Agenda Document Pack - Moray Integration Joint Board - 30/11/2023
Moray Council · 30 November 2023
Back to Moray Integration Joint Board — 30 November 2023 and its agenda
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Moray Integration Joint Board Thursday, 30 November 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, 30 November 2023 at 09:30 to consider the business noted below. AGENDA 1. Welcome and Apologies 2. Declaration of Member's Interests 3. Minutes of meeting of 28 September 2023 4 - 9 4. Action Log of 28 September 2023 10 - 10 5. Minutes of Special Meeting dated 26 October 2023 11 - 12 6. Chief Officer Report 13 - 24 7. Grampian Vaccination and Immunisation Annual Report 2023 25 - 64 8. Revenue Budget Monitoring Quarter 2 2023-24 65 - 85 9. Adult and Older Adult Mental Health Medical Workforce 86 - 90 10. Moray Winter Surge Action Plan 2023-24 91 - 124 11. Review of Financial Regulations 125 - 146 12. Care for People Plan - Moray Arrangements 147 - 150 Page 1
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13. Annual Report of the Chief Social Work Officer 2022-23 151 - 183 14. Moray Integration Joint Board Meetings 2024-25 184 - 188 15. Realignment of Services [Para 6.2.5] Page 2
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MORAY INTEGRATION JOINT BOARD SEDERUNT Mr Dennis Robertson (Chair) Councillor Tracy Colyer (Vice-Chair) Mr Derick Murray (Voting Member) Mr Sandy Riddell (Voting Member) Councillor Peter Bloomfield (Voting Member) Councillor Scott Lawrence (Voting Member) Councillor Ben Williams (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 Jane Ewen (Non-Voting Member) Mr Stuart Falconer (Non-Voting Member) Mr Graham Hilditch (Non-Voting Member) Dr Paul Southworth (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) Mr Kevin Todd (Non-Voting Member) Clerk Name: Caroline O'Connor Clerk Telephone: 07779 999296 Clerk Email: committee.services@moray.gov.uk Page 3
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MINUTE OF MEETING OF THE MORAY INTEGRATION JOINT BOARD Thursday, 28 September 2023 Council Chambers, Council Office, High Street, Elgin, IV30 1BX PRESENT Mr Ivan Augustus, Councillor Peter Bloomfield, Mr Sean Coady, Councillor Tracy Colyer, Mr Stuart Falconer, Mr Graham Hilditch, Councillor Scott Lawrence, Mr Derick Murray, Ms Deborah O'Shea, Mr Sandy Riddell, Mr Dennis Robertson, Ms Elizabeth Robinson, Ms Tracy Stephen Councillor Sandy Keith (for Councillor John Divers) APOLOGIES Professor Siladitya Bhattacharya, Mr Simon Bokor-Ingram, Professor Duff Bruce, Mr Roddy Burns, Councillor John Divers, Ms Sonya Duncan, Ms Jane Ewen, Professor Caroline Hiscox, Dr Robert Lockhart, Dr Malcolm Simmons, Dr Paul Southworth, Mrs Val Thatcher, Mr Kevin Todd IN ATTENDANCE Iain MacDonald, Locality Manager, General Manager, Dr Gray's Hospital, Jenna Young, Planning Manager, Chief Nurse Moray, Chaloner Chute, DHI, Interim Strategy, Planning and Performance Lead, Interim Primary Care Development Manager, Carl Campbell, Service Manager HSCM, Patricia Morgan, Service Manager HSCM, Democratic Services Manager and Caroline O'Connor, Committee Services Officer. 1. Declaration of Member's Interests Mr Ivan Augustus declared an interest in Item 16 - Childrens Services Social Work Review of Spend for Self Directed Support in respect of his wife. Mr Sandy Riddell declared that he was Chair of the Mental Welfare Commission Scotland. The board noted that there were no other declarations of member's interests. Item 3. Page 4
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2. Minutes of meeting of 29 June 2023 The minute of the meeting of 29 June 2023 was submitted and approved, subject to correction of a typo on page 8 from 'send' to 'sent'. 3. Action Log of 29 June 2023 The Action Log of the meeting of 29 June 2023 was discussed and updated acccordingly. 4. 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. Mr Riddell welcomed the update in relation to older age psychiatry staffing and asked that in terms of public scrutiny, an update on key thoughts from the development session be included as a report for the November Board meeting. Following consideration the Board agreed: i. to note the content of the report; and ii. that transforming services to meet the aspirations of the MIJB's Strategic Plan remains a priority, with a focus on key objectives as we mobilise from the Covid- 19, along a look ahead as we continue to develop our strategic planning. 5. Revenue Budget Monitoring Quarter 1 for 2023-24 A report by the Interim Chief Financial Officer updating the Board of the current Revenue Budget reporting position as at 30 June 2023. Councillor Keith asked what was going to be done about the four headings showing no progress on the efficiencies table and queried if they were realistic targets. In response the Interim Chief Financial Officer advised the targets were realistic however increasing prescribing costs was a national issue. Management costs are in hand for the next quarter and a recovery plan is being worked on to achieve savings. Mr Coady advised work is being done on prescribing practice and in order to provide assurance, agreed that an update report be brought back to Clinical and Care Governance Committee which would then be presented to the Board. Following consideration the Board agreed to: i. note the financial position of the Board as at 30 June 2023 is showing an overall overspend of £2,306,993; ii. note the progress against the approved savings plan in paragraph 6; Page 5
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iii. note the budget pressures and emerging budget pressure as detailed in paragraph 7; iv. approve the virements in budgets from Care Services provided by external contractors to the Learning Disability Services, Mental Health Services and Older People and PSD services, as detailed in paragraph 8; v. note the revisions to staffing arrangements dealt with under delegated powers and in accordance with financial regulations within the Council (MC) and NHS Grampian (NHSG) for the period 1 April to 30 June 2023 as shown in APPENDIX 3; and vi. approve for issue, the Directions arising from the updated budget position shown in Appendix 4. 6. MRI Scanner and Ligature Reduction Integrated Programme - Dr Gray's Hospital A report by Dr Gray's Hospital General Manager and Integrated Programme Senior Responsible Officer informing the Board of the programme status and associated requirements of the MRI scanner and Ligature Reduction Integrated Programme. Following consideration the Board agreed to note the report. 7. Ministerial Strategic Group Improvement Action Plan Update A report by the Interim Chief Financial Officer updating the Board on progress of the delivery of the actions in the Ministerial Strategic Group (MSG) Improvement Action Plan as at September 2023. Following consideration the Board agreed to approve the progress made on delivery of the actions within the MSG Improvement Action Plan. 8. Lossiemouth Locality Health and Social Care Services Progress Update A report by the Locality Manager updating the Board on matters relating to the provision of health and social care within the Lossiemouth locality. Following consideration the Board agreed to note:- i. that the Moray Coast Medical Practice had formally notified the landlord of the Burghead Branch Surgery premises that they are terminating the lease as of 31 December 2023; ii. that the Moray Coast Medical Practice had formally notified Health and Social Moray that they do not intend to reopen the Hopeman Branch Surgery premises. Moray Coast Medical Practice own the premises; and iii. the mitigating actions that are in place as a result of the closure of the Burghead and Hopeman branch surgery premises are now incorporated into the wider Forres and Lossiemouth Locality Planning procedures. Page 6
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9. Keith and East Locality Project A report by the Primary Care Development Manager informing the Board of progress regarding the current Keith (and east) Locality Project position. Following consider the Board agreed to note the current position regarding to the Keith (and east) Locality Project and the further gateways that the project will need to move through. 10. Out of Hours Nursing Service A report by the Chief Nurse, Moray informing the Board of the current situation regarding the Out of Hours Rapid Response Nursing Service currently hosted by Aberdeenshire and delivered by Marie Curie across Moray and Aberdeenshire. Following consideration the Board agreed to note: i. that notice has been given by Marie Curie in relation to the cessation of the Rapid Response Out of Hours Nursing Service aspect of the current contract as of 30 September 2023; ii. the requirement for NHS Grampian to deliver an Out of Hours Nursing Service across Aberdeenshire and Moray in a two phased approach with the first priority being to ensure that we have a continuity of service provision beyond the notice period of 30 September 2023 for a 6 month period to allow a full review of the service delivery model; iii. Phase 1 – the proposal that NHS Grampian deliver the joint Moray and Aberdeenshire model as an “in- house” service with the addition of a nursing triage support aligned with the Grampian Medical Emergency Department (GMED) to support right care, right time, and right person approach thereby improving the current Out Of Hours Nursing Service; and iv. Phase 2 – the proposal hat NHS Grampian, during Phase 1, review the full service delivery model and consider a standalone Moray Out of Hours Nursing Care Service based on population need, geographical spread and how this would align with a full 24 hour Nursing Care Service. 11. NHS Grampian Three Year Delivery Plan 2023-2026 A report by the Chief Officer informing the Board of the linkages with the NHS Grampian Three Year Delivery Plan (2023-2026) and the compatibility with the Moray Integration Joint Board's strategic aims and objectives, and to promote the partnership working necessary to achieve improved health and well-being for the population of Moray and the wider Grampian region. Following consideration the Board agreed to: i. note the priorities set out within the NHS Grampian Three Year Delivery Plan (2023-2026) for the period up to March 2026; ii. note the arrangements for reporting on progress of the NHS Grampian Delivery Plan as complementary to existing MIJB reporting; and Page 7
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iii. the MIJB continuing to support the NHS Grampian Delivery Plan priorities through the local work in Moray of the MIJB. 12. Health and Social Care Moray Strategic Delivery Plan 2023-26 A report by the Interim Strategy, Planning and Performance Lead asking the Board to agree the delivery plan that supports meeting the aims and objectives of the Moray Integration Joint Board Strategy. Mr Murray, whilst happy to agree the Plan in its current form, felt the actions were quite generic and asked if future plans could be more specific describing what will be done. In response the Interim Strategy, Planning and Performance advised that to provide assurance a comprehensive update based on key performance indicators will be reported to Audit and Performance Risk Committee and also how the generic actions will be achieved. The Board joined the Chair in paying tribute to the Interim Strategy, Planning and Performance Lead who is leaving the IJB to take up a new post with NHS Grampian and thanked Carmen for her contribution to the delivery of services in Moray and wished her well for the future. Following consideration the Board approved Health and Social Care Moray's (HCSM) Three Year Delivery Plan (2023-2026). 13. Annual Performance Report 2022-23 A report by the Chief Officer presenting the Board with the Final Annual Performance Report 2022/23. Councillor Keith delayed discharges remain a concern and asked if there was anything in the pipeline to bring the figures under control Mr Coady agreed it remains a ongoing challenge and advised measures are continually being scrutinised. Some measures in place are a daily discharge action plan, a Care at Home Strategic Group has been set up and going intopartnership with Aberdeen City to share good practices. Following consideration the Board agreed to note the Final Annual Performance Report 2022/23 at Appendix 1, which is published on the Health and Social Care Moray webpage. 14. Moray Care for People Plan A report by the Corporate Manager presenting the Board with the Care for People Plan prepared by Health and Social Care Moray and Moray Council. Mr Riddell asked, while the plan states training will be undertaken on a three yearly basis, as there are regular staff changes wondered if there was any training planned in terms of process testing, exercises and training to ensure the Plan is robust and secure. In response Mr Coady advised a session was held with all those who would be involved along with a proposed practical table top session for an incident. Page 8
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Ms Morgan confirmed as well as the three individual plans within the Grampian area, a Grampian Plan is also being considered with a further tabletop exercise planned in the next few months. Following consideration the Board noted the Care for People Plan. 15. Childrens Services Social Work Review of Spend for Self Directed Support A report by the Head of Service and Chief Social Work Officer and Chief Officer providing a review of spend for Self Directed Support. Following consideration the Board agreed to note the review of spend for Self Directed Support. 16. Health and Social Care Moray Annual Complaints Report 2022-23 A report by the Chief Nurse, Moray providing the Board with the Health and Social Care Moray (HSCM) Annual Complaints Report for 2022/23. Following consideration the Board agreed to: i. note the contents of the annual report; and ii. approve the publication of the annual report on the Health and Social Care Moray webpage. 17. Public Sector Climate Change Duties Reporting Submission 2022-23 A report by the Chief Officer presenting the draft Moray Integration Joint Board (MIJB) Climate Change Duties Report submission for 2022/23. Following consideration the Board approved the draft Public Sector Climate Change submission to Sustainable Scotland Network (Appendix 1) for the reporting year 2022/23. 18. Thanks In noting that this would be the Professor Bhattacharya's last meeting before moving to Aberdeen City IJB, the Board joined the Chair in thanking him for his wisdom, knowledge and experience to both the Clinical and Care Governance Committee and the Moray Integration Joint Board. Page 9
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MEETING OF MORAY INTEGRATION JOINT BOARD Thursday 28 September 2023 ACTION LOG ITEM NO. TITLE OF REPORT ACTION REQUIRED DUE DATE ACTION BY UPDATE FOR 30 NOVEMBER 2023 1. Minute of 29 June 2023 Mr Macdonald to discuss with Transport Unit whether the M-Connect service operating hours could be extended during school holiday periods. 30 Nov 23 IM Mr Macdonald confirms there is flexibility based on specific routes and vehicles. 2. Revenue Budget Monitoring Quarter 1 for 2023-24 Update on work being done to reduce prescribing costs to be prepared for CCG Cttee before coming to future IJB meeting. 30 Nov 23 SC Paper to be presented to the next CCG Cttee in March 2024. 3. Chief Officer Report A report to be brought back to the November meeting to update the Board on the key thoughts from the development day being held to discuss Mental Health Services within Moray. 30 Nov 23 SBI Paper on today’s agenda. Item 4. Page 10
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MORAY COUNCIL Minute of Special Meeting of the Moray Integration Joint Board Thursday, 26 October 2023 Council Chambers, Council Office, High Street, Elgin, IV30 1BX PRESENT Mr Ivan Augustus, Councillor Peter Bloomfield, Mr Simon Bokor-Ingram, Mr Sean Coady, Councillor Tracy Colyer, Ms Sonya Duncan, Councillor Scott Lawrence, Mr Derick Murray, Ms Deborah O'Shea, Mr Sandy Riddell, Dr Malcolm Simmons, Councillor Ben Williams APOLOGIES Professor Duff Bruce, Mr Roddy Burns, Ms Jane Ewen, Mr Stuart Falconer, Mr Graham Hilditch, Professor Caroline Hiscox, Dr Robert Lockhart, Mr Dennis Robertson, Ms Elizabeth Robinson, Dr Paul Southworth, Ms Tracy Stephen, Mr Kevin Todd IN ATTENDANCE Public Sector Audit Director - Scotland, Grant Thornton UK LLP, Caroline O’Connor, Committee Services Officer and Lissa Rowan, Committee Services Officer. 1. Chair The meeting was chaired by Councillor Tracy Colyer. 2. Welcome and Apologies The Board joined the Chair in welcoming Councillor Ben Williams, who was replacing Councillor John Divers, to his first meeting of the Board. 3. Declaration of Member's Interests The Board noted there were no declarations of member's interests. 4. External Auditors Report to Those Charged with Governance The meeting had before it a report by the Chief Financial Officer requesting the Board consider the reports to those charged with governance from the Board’s External Auditor for the year ended 31 March 2023. Councillor Bloomfield asked in relation to the wider scope and given that the Council is responsible for a large portion of the deficit, what is being done to reduce the deficit in the audit. In addition, he asked for clarification on what steps are being taken to upscale the pace of transformation in the audit recommendations and sought assurance that NHS Grampian would strengthen their reporting process. In response to the question regarding the deficit, the Chief Officer advised a similar question had been asked at the Moray Integration Joint Board (MIJB) Audit & Performance Review (APR) Committee held prior to the Board. The Chief Officer acknowledged the deficit Item 5. Page 11
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related to a historical annual structural budget deficit from implementation of the Integration with inflationary costs since and is now compounded with the huge pressures facing both funding partners, namely NHS Grampian and Council. He noted there required to be a focus on joint programme efficiencies and further work requires to be undertaken to achieve savings. In response to the question regarding monitoring the pace of transformation and NHS Grampian audits being shared with the Board/APR Committee, Councillor Lawrence, as Chair of APR Committee, confirmed both had been discussed at the APR Committee meeting held prior to the Board and the Internal Auditor had provided assurance work was progressing to provide a resolution to both matters. Following consideration the Board agreed to note the reports from the External Auditor within Appendices 1 and 2. 5. 2022-23 Audited Annual Accounts Report The meeting had before it a report by the Chief Financial Officer submitting to the Board the Audited Annual Accounts for the year then ended 31 March 2023. Following consideration the Board agreed to approve the Audited Annual Accounts for the financial year 2022/23 and the letter of Representation. 6. Membership of Board and Committees The meeting had before it a report by the Corporate Manager informing the Board of changes to Membership of the Moray Integration Joint Board (MIJB), Audit, Performance and Risk Committee and Clinical and Care Governance Committee (CCG). Following consideration the Board noted:- i. the confirmation of appointment of a new member to the MIJB following changes to Moray Council’s committee appointments; ii. the vacancies in National Health Service (NHS) voting membership and Service User Stakeholder position; and iii. the updated membership of Board and Committees attached at Appendix 1. Page 12
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REPORT TO: MORAY INTEGRATION JOINT BOARD ON 30 NOVEMBER 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 presented in a separate paper at today’s 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. 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 MIJB. 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, which has been very challenging to achieve despite the significant work of the team. To maximise opportunities to support patient flow a Moray wide Strategic Multidisciplinary Team meets to prioritise resource. A strategy group and operational group reviewing the challenges of Care at Home provision have both met with action plans developed. A Item 6. Page 13
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workshop has been arranged for end of November for Health and Social Care Moray (HSCM) staff and Aberdeen City Health and Social Care Partnership (HSCP) staff to come together to work on initiatives in line with care at home. 3.2 Initiatives in line with Hospital at Home principles continue to be developed and there will be opportunities to bid for further resources. The Unscheduled Care team of Scottish Government put out a call for bids to expand Hospital at Home initiatives, and we made a submission, seeking funding to improve what we can develop locally. An offer of funding has been made, and we will now firm up our plan and recruit to expand our local provision, using a multi- disciplinary team approach and how we can build a flexible model that reacts to varying need and demand. Collaborative funding has been secured to enhance data gathering, and this will help inform and support future programme development. 3.3 Value improvement funds have supported the establishment of Realistic Medicine Community Healthpoint Advisor roles, which aim to improve awareness and promote support available for older people, their families and carers living with frailty and pre-frailty conditions. These programmes will contribute to key priorities within Home First, The Frailty Collaborative and performance monitoring. 3.4 Moray HSCP is part of a national initiative to improve the frailty pathway, having bid successfully to be part of the Focus on Frailty programme being run by Healthcare Improvement Scotland ihub. The overall aim of the programme is to ensure people living with or at risk of frailty have improved experience of and access to person centred, co-ordinated health and social care. This will be realised by early identification and assessment of frailty; people living with frailty, carers and family members access person-centred health and social care services: and health and social care teams report improved integrated working. 3.5 We are engaging with Scottish Government officers for GIRFE (Getting It Right For Everyone) and have submitted a bid to join the national programme, and have a further discussion arranged with Scottish Government Officials this month. Remobilisation and winter planning 3.6 To date the health and social care 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 is receiving a particular focus to work through the backlog of referrals. 3.7 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 discernibly diminished, and Dr Gray’s Hospital is having to manage a very tight capacity position on a daily basis. Community hospital beds, and intermediate options are being fully utilised, with expedient discharge from Dr Gray’s and Aberdeen Royal Infirmary as soon as beds are available. Demand for social care, and in particular care at Page 14
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home, has continued with hours of care that cannot be met. Primary care continues to operate with a high level of demand and acuity. 3.8 The pressure on the bed base from predominantly unscheduled presentations creates a challenge, within a fixed bed base, to carry out a level of planned operations, and a plan is being developed to return to pre-covid levels of elective activity at Dr Gray’s Hospital. Recognising that every part of the system is connected, and the potential for patients on waiting lists to develop worsening or more complex medical problems, patients are likely to need additional and more frequent support from general practice, adding further to the pressure they are experiencing. 3.9 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 specialties where waiting times for elective 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. The National Treatment Centre in Inverness has already started hip and knee replacement surgery for Grampian residents. 3.10 Planning continues across Grampian for winter 23/24. A separate paper reporting on the partnerships planning is on today’s agenda. Vaccination Programme 3.11 The Autumn Winter programme for Covid and Flu vaccinations commenced on 4 September 2023 and will run until 31 March 2024 with the majority of eligible cohorts offered vaccinations by 11 December 2023, including Health and Care staff. As of 31 October 2023, 606,933 Covid and Flu vaccinations were delivered by NHS Grampian, which is above the Scottish average for both vaccinations. The Health and Care staff uptake for vaccinations is slightly below the Scottish average, with further focus on this group to continue to support the messaging to encourage uptake. There is ongoing review of the uptake by job family and location to support this messaging with a National Survey planned for early 2024 to understand why some Health and Care Staff have not taken up the offer of the vaccinations and any barriers to this. NHS Grampian have published an annual report for vaccinations, which is the subject of a separate paper on today’s agenda. 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 those seeking asylum, and the National Transfer Scheme for Unaccompanied Asylum-Seeking Children. 3.13 Moray will continue to support the 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. The Refugee Resettlement Team and associated budget were never delegated to the IJB, but were hosted as part of an arrangement linking Page 15
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to the interim strategy and planning lead. With the Interim Strategy and Planning Lead Officer having moved post to an NHS Grampian team, the Head of Housing in Moray Council is now leading the Refugee Resettlement Team. HSCM continue to work closely with the Head of Housing to ensure that health and care needs are met for those coming to Moray. Ward 4 anti-ligature work and installation of MRI scanner at Dr Gray’s Hospital 3.14 A dedicated work stream 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, the Mental Health inpatient ward, alongside the planned installation of an MRI scanner on the hospital site. The Standard Business Case (SBC) with Addendum requested by the NHS Grampian Board in August 2022 detailing the enabling works plan, costs and timescales, as well as the Ligature Reduction schedule and cost, has been finalised and approved by the NHS Grampian NTC (National Treatment Centre) Programme Board and Asset Management Group. The SBC has been submitted to Scottish Government for consideration and dialogue continues with officials on the SBC and timing of funding. Given the pressure on the NHS Scotland capital budget HSCM are advised that any decision on funding allocation should be expected towards the end of December 2023. Primary Care Strategy 3.15 The 3 Chief Officers (City, Shire and Moray) have commissioned work to develop a vision for general practice across Grampian. The fragility of primary care and GP Practices in particular is well understood, and MIJB have led local discussions on the challenges we face. In Grampian, the delivery of the 2018 General Medical Services (GMS) contract and the Memorandum of Understanding (MoU) has been challenging, due to a number of factors, including recruitment and retention, the application of multi-disciplinary teams across a rural geography resulting in teams being spread too thinly, and a region with diverse populations, communities and needs. Whilst the number of practices and General Practitioners (GPs) has reduced in number during the last ten years, the list size per GP has increased. 3.16 A structure is in place to take this work forward, with a timescale of completion by the end of the calendar year. The vision for general practice will recognise the uniqueness of the three different local authority areas in Grampian, and bring together the commonalties of the challenges we collectively face, and how we deal with those challenges. The national primary care team are supportive of this work, and this creates an opportunity for the north-east region to influence the national GP contract and create a path specific to the north-east on how we meet the challenges. The aim is to develop a local vision with strategic objectives and an associated implementation plan to address the challenges, with a desired outcome of creating a more resilient and sustainable service. 3.17 The second and third of three workshops occurs in November, with a wider participation including patient representatives and service users. Lossiemouth Locality update 3.18 Between October 2021 and January 2023 a period of community engagement and consultation took place on the future of health and social care provision Page 16
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within the Lossiemouth Locality Area. There has been a focus on the Hopeman and Burghead branch surgery premises. 3.19 HSCM was informed by Moray Coast Medical Practice on 29 October 2023 that it had sold the vacated Hopeman branch surgery premises to a private buyer. As the practice was no longer providing a service from the premises and owned the site, no approval from HSCM or the Moray IJB was required. 3.20 Mitigating actions remain in place to address any impact from the closure of the buildings. These actions are incorporated into the Forres and Lossiemouth Locality Plan which is reported to the MIJB on a six monthly basis. 3.21 An undertaking has also been given that representatives from the Save our Surgeries Group will be invited to take part in the Primary Care Visioning work being taken forward, and locally to include the Glasgow School of Art in our locality work. Out of hours Nursing 3.22 As a result of the notice period served by Marie Curie detailing their being unable to continue to delivering the current Rapid Response Out Of Hours Community Nursing contract, NHS Grampian took this service over as of the 1 October 2023. The revised service to date is working well with positive feedback regarding the induction, support, and leadership that has been provided to the staff who transferred from Marie Curie to NHS Grampian. The recruitment of new staff for this service has also been positive for both Health Care Support Worker posts as well as Registered Nurses. These positive developments have improved our ability to deliver care out of hours with the increased workforce. Shifts are covered better and this supports the delivery of nursing care out of hours to patients across both Moray and Aberdeenshire. Budget Control 3.23 Transformational change that meets the test of quality and safety must also be efficient, making the best use of available resources. The Senior Management Team (SMT) for the Portfolio are meeting regularly to review spend and consider areas for efficiency. A plan for 24/25 will be presented to the MIJB in January 2024 that begins the process of developing a balanced budget for 24/25. The challenge of reducing an in-year deficit in 23/24 remains and has a focus from the team. Payment Verification 3.24 National Services Scotland (NSS) process contractor payments and during the pandemic their focus had been to maintain protective payments each month. The payment verification meetings have now recommenced for all groups. Once sufficient data is available a report will be presented to the Audit, Performance and Risk Committee. Moray Growth Deal and the Rural Centre of Excellence (RCE) for digital health and care innovation 3.25 Appendix 1 sets out the latest position on progress. The Moray Portfolio continues to work closely with RCE as part of the transformation programme for the Portfolio. These updates will now be a regular feature on the Chief Officers reports. Page 17
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Mental Health Service update on Older Age Psychiatry staffing 3.26 For a number of years there has been difficulty in recruiting to one of the two Consultant posts within the Older Adult Mental Health team. This is due to a national shortage of suitably qualified staff, numerous rounds of advertising have proven to be unsuccessful. Due to the inability to recruit to the substantive consultant vacancy the service have had to continue to use high cost agency locums to support the existing service model. 3.27 The Integrated Mental Health Management Team based at Pluscarden Clinic have been working with the existing staffing resource to explore options to mitigate the challenges in light of the financial risk of continued locum consultant costs. The Interim Integrated Service Manager commenced in post on 1 August 2023 and has held discussions with the team around service redesign in order to progress to a more sustainable service model. Alternative options are being worked up to deliver essential care and support to the Older Adult population. A separate paper is on today’s agenda that sets out a proposal to mitigate this risk. Updating Governance 3.28 As we continue to evolve our governance, work is now completed in refreshing the original governance processes approved by the MIJB in 2019. A report will be presented to the Clinical Care Governance Committee today. Work continues across the health system in Grampian, considering the governance frameworks as the Portfolio structure continues to develop. Should any amendments be necessary to reflect this work, they will be presented to Committee. Staff Wellbeing - Culture Collaborative and Whistleblowing 3.29 HSCM are piloting the use of the Culture Collaborative resource pack created by NHS Grampian. Two roadshows were held, one in Dr Gray’s and the other in Seafield Community Hospital. Members of the Senior Management Team were on site to discuss any of the resources with staff. Work continues to encourage teams to utilise the resources provided, promoting the ethos of a values based culture across the partnership. A further piece of work will be to link in the Whistleblowing policies of NHS Grampian and Moray Council, to ensure we have a culture that supports staff to feel safe in speaking up if they have concerns. A member of SMT has just completed training as a ‘Speak Up Ambassador’ to support this. In 2022/23 there were no concerns raised under Whistleblowing for HSCM, either through Council or NHS routes. 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 challenge of finance persists and there remains the need to address the underlying deficit in core services. Funding partners are also under severe financial pressures and are unlikely to have the ability to cover overspends going forwards. Page 18
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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 HSCM 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. HSCM 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 the ability to maintain performance and continuity of care. HSCM 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 HSCM are not disadvantaging any section of our community. Page 19
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HSCM will continue to work closely with all our partners to ensure that we contribute to the health and well-being of the community and support the recovery phase of the Covid-19 pandemic. (h) Climate Change and Biodiversity Impacts Care closer to and at home, delivered by teams working on a locality basis, will reduce HSCM’s 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, the Legal Services Manager and Caroline O’Connor, 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. 6.2 The size of the financial challenge facing the IJB, and also its two funding partners, means that redesign and transformation is not an option but a necessity. HSCM’s approach will be to prioritise quality, safety and good outcomes in all service redesigns. Author of Report: Simon Bokor-Ingram, Chief Officer, Moray Portfolio Page 20
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Digital Health & Care Innovation Centre, 1st Floor, Suite B, Inovo Building, 121 George Street Glasgow, G1 1RD This paper is presented to the November 2023 Moray IJB to give an update on the progress of the Moray Growth Deal, Rural Centre of Excellence for Digital Health and Care Innovation This £5 million UK Government funded programme of the Rural Centre of Excellence (RCE) Research and Development (R&D) programme as part of Moray Growth Deal, commenced in late 2021 with the ambition to create a unique ecosystem in the Moray region to foster economic development and create jobs through the creation of a physical Demonstration and Simulation environment (DSE) at UHI Moray, underpinned by a virtual R&D infrastructure, five living labs and a robust skills and workforce development programme. Working closely with the citizens, health and social care Moray, NHS Grampian and third sector organisations, the living labs methodology uses co-design approaches to validate and address key national and local strategic priorities in order to release clinical and care capacity and make services more accessible enabled by digital to meet targeted demand, and to improve the health and wellbeing outcomes for the citizens of Moray. http://www.moray.gov.uk/moray_standard/page_114144.html The image below provides a visual representation of the R&D infrastructure, assets and Living Lab (LL) R&D themes and the skills programme being progressed within the RCE. APPENDIX 1Item 6. Page 21
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Digital Health & Care Innovation Centre, 1st Floor, Suite B, Inovo Building, 121 George Street Glasgow, G1 1RD Image 1: Key R&D assets and the 5 Living Lab (LL) Themes RCE Activity Update October-November 2023 Programme Update DHI are progressing an options appraisal to mitigate the accruing underspend in year three of the programme due to timeline delays across the three early stage living labs. Emerging opportunities and learning through stakeholder engagement support a review of the original scope of LL4- Smart Housing and LL5 Mental Wellbeing, and the development of a unique platform that would integrate the full RCE infrastructure and assets to support health and social care services globally. This opportunity would require a no cost project programme extension but would have the potential for a significantly greater economic impact. Living Lab Updates LL1 Supported Self-Management: Final iterations and user testing via the Dietetic service are being completed for the weight management platform. A Data Protection Impact Assessment (DPIA) has been submitted to NHS Grampian and subject to its approval, the project will move to the real-world evidence stage in February 2024. A working group has been established to take forward the delivery plan, and an evaluation framework has been drafted. LL2 Long Term Condition Management (NHS): The first call on the Dynamic Purchasing System (DPS) seeking industry partners to develop a solution to tackle access deprivation with an initial clinical focus of Type 2 Diabetes will close on the 15th of November. It is Page 22
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Digital Health & Care Innovation Centre, 1st Floor, Suite B, Inovo Building, 121 George Street Glasgow, G1 1RD anticipated that following tender evaluation, an award can be made to allow simulation work to commence in January 2024. LL2 Long Term Condition Management (Community): This pathway will focus on the development of digital tools to support the Community Occupational Therapy Service via self and supported self-management assets. Initiate stage workshops have now been completed with stakeholders, and subject to approval, a call will be published in December 2023 via the DPS. LL3 Care in Place: User testing has now been completed, with a final iteration of the community connections platform and personal data store assets in progress. This lab will move to a phased real world evidence stage in February 2024 for a minimum of 6 months, and an evaluation framework has been drafted to support this. LL4 Smart Housing: Define and initiate work is underway for this living lab, with work commenced on developing an asset for the DSE in Elgin to demonstrate the benefits of the proactive and preventive use of combined telehealth and digital telecare/activity monitoring. This will be used as the basis to develop a state-of-the-art specification for new build smart enabled properties and prototype for testing ahead of the deployment into Leanchoil Trust site properties by the MGD Housing Mix project team in 2027/28. LL5 Mental Wellbeing: Engagement discussions are ongoing with statutory, and third sector services to agree most beneficial scope at this time. It is likely that the following two distinct pathways will be developed, if capacity within H&SC and budget allow: 1. Mental wellbeing (MWB) pathway to develop tools and social prescribing linked to the early Connected Communities platform and personal data store to support early intervention and self-management 2. Mental health (MH) pathway to develop digital tools to support an aspect of statutory clinical services to be confirmed Additional Scope Being Explored (Smart Communities) Potential rescope and extension of RCE will use collective stakeholder feedback, emerging learning, and new opportunities to develop an international, multi sector collaboration to develop a unique innovative platform utilising holistic person-centred data gathered through the RCE infrastructure, assets and health and social care integration. This would enable population stratification and resource management at both an individual and population level to reduce waiting lists, increase capacity and alert to early indicators of decline to reduce hospital admissions and unscheduled care. The development of such an asset will require a timeline beyond June 2025 due to its complexity and need for inward investment, however the increased industry inclusion in the project would support RCE’s Page 23
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Digital Health & Care Innovation Centre, 1st Floor, Suite B, Inovo Building, 121 George Street Glasgow, G1 1RD sustainability and economic growth contribution to the region through its international relevance and scalability. Skills and Workforce SkillsFest will be hosted by the RCE on 23rd November 2023 at UHI Moray, with a packed agenda featuring keynote speakers and a series of workshops, it will also include a soft launch of the recently developed micro credential courses for carers. An academic call has been published seeking a partner to undertake a review of workforce training tools and identify gaps. This will inform the scope of a further skills development call in 2024. Communication and Engagement A refreshed communication strategy and sector specific plans have been developed and a working group has been set up to progress the delivery plan. A key area of the strategy outlines the need for a partnership approach between DHI, H&SCM, NHS G and third sector to develop workforce and citizen readiness for adoption of digital assets. A full schedule of events to build awareness of the demographic need for change, and opportunities to participate in codesign to shape future assets is being finalised for 2024. Evaluation A framework for the academic evaluation is being developed by UHI to capture the integrative and living lab specific outcomes across the whole programme. Qualitative data and evidence. Sustainability The sustainability of the RCE is being considered early, with a working group set up and a range of bids underway to ensure further funding is leveraged into the RCE in preparation for the end of the UK Gov funding period for RCE (June 2025). Preparation and discussion around service readiness and needs for asset adoption is now being progressed with H&SCM and NHS Grampian. Page 24
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REPORT TO: MORAY INTEGRATION JOINT BOARD ON 30 NOVEMBER 2023 SUBJECT: GRAMPIAN VACCINATION AND IMMUNISATION ANNUAL REPORT 2023 BY: VACCINATION PLANNING MANAGER 1. REASON FOR REPORT 1.1 To inform the Board on the development of the first Grampian Vaccination and Immunisation Annual Report 2023. 2. RECOMMENDATION 2.1 It is recommended that the Moray Integration Joint Board (MIJB) acknowledge the findings of the Vaccination and Immunisation Annual Report 2023. 3. BACKGROUND 3.1 The World Health Organisation (WHO) describes vaccines as one of the two public health interventions that have the greatest impact on the world’s health, the other being clean water. Vaccination can prevent or reduce the severity of disease, minimise disability and save lives, often in many of the most disadvantaged people in society. It offers excellent value for money by reducing current and future public expenditure on health and social care provision. 3.2 Effective control of vaccine preventable disease requires action across the whole health and care system, and this aligns with the drive to improve outcomes and reduce inequalities. 3.3 The annual report discusses vaccination in the national and local context including; Vaccination Uptake; Equity in Grampian; Quality Improvement in vaccination and Horizon Scanning. 4. KEY MATTERS RELEVANT TO RECOMMENDATION 4.1 There has been declines in childhood vaccination uptakes in both Grampian and Scotland. Moray continue to meet the WHO 95% uptake for all childhood routine schedules at 24 months. At 12 months of age, Moray does not meet the Item 7. Page 25
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95% uptake for the Rotavirus (94.4%) and at 5 years of age, Moray does not meet the 95% uptake for the 4 in 1 (91.4%) and Measles, Mumps and Rubella (MMR) dose 2 (90.1%) programme. Table 1: Completed primary immunisations by 12 months of age, 2022 – 23 by Moray and NHS Grampian Number in % completed primary course by 12 months Cohort 6-in-1 PCV Rotavirus3 MenB No. % No. % No. % No. % Moray 872 842 96.6 840 96.3 823 94.4 839 96.2 Grampian 5,494 5,257 95.7 5,240 95.4 5,050 91.9 5,124 93.3 Source: SIRS 15th May 2023 Table 2: Completed primary immunisations by 24 months of age, 2022-23 by Moray and NHS Grampian Number in % completed primary and booster course by 24 months Cohort 6-in-1 MMR1 Hib/MenC PCVB MenB (Booster) No. % No. % No. % No. % No. % Moray 820 803 97.9 784 95.6 785 95.7 785 95.7 785 95.7 Grampian 5,269 5,115 97.1 4,932 93.6 4,898 93.0 4,829 91.6 4,858 92.2 Source: SIRS 15th May 2023 Table 3: Completed primary immunisations and boosters by 5 years of age, 2022-23 by Moray and NHS Grampian Number in % completed primary and booster course by 5 years Cohort 6-in-1* MMR1 Hib/MenC 4-in-1 MMR2 No. % No. % No. % No. % No. % Moray 886 855 96.5 843 95.1 842 95.0 810 91.4 798 90.1 Grampian 6,223 5,974 96.0 5,848 94.0 5,762 92.6 5,528 88.8 5,469 87.9 Source: SIRS 15th May 2023 4.2 Uptake in the teenage (school based) programme saw disruption during 2020– 21 due to the covid-19 pandemic. Teams have been carrying out catch up during 2021–22 with Moray. A vaccines for young people national campaign is planned to commence in November to raise awareness and encourage uptake of the Human Papilloma Virus (HPV), Meningococcal groups A, C, W and Y (MenACWY) and combined Diphtheria, Tetanus and Polio (DTP) vaccines Table 4: HPV immunisation coverage rates of dose 1 by the end of the school year 2021/22 at S1 and S2 by Moray and NHS Grampian S1 Coverage Rate (%) Dose 1 S2 Coverage Rate (%) Dose 1 Female Male Female Male Moray 87.1 72.4 87.4 86.8 Grampian 83.7 74 88.4 85.3 Source: CHSP School/SIRS Table 5: Vaccination with Td, IPV and Men ACWY by the end of the school year 2021/22 by Moray and NHS Grampian Page 26
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S3 Coverage Rate (%) S4 Coverage Rate (%) Td/IPV MenACWY Td/IPV MenACWY Moray 77.6 77.8 82.0 82.2 Grampian 77 77.2 86.7 86.4 Source: CHSP School/SIRS 4.3 The adult routine programmes were paused during the pandemic and were subsequently transferred to health board/Health and Social Care Partnership (HSCP) delivery. Moray has made good progress in ensuring all eligible cohorts are offered the vaccines. The shingles coverage is currently 75% which is above Grampian average. The pneumococcal cohort is currently at 47.3% for 65 years and over and 33.1% for 2 -64 at risk cohort which is below Grampian average. Table 6: Shingles Zostavax vaccination coverage amongst eligible routine and catch-up cohorts (70 – 79 years). Moray and NHS Grampian 2021-22 and 2022 – 23 70 – 79 years % coverage 2021 - 22 2022-23 Moray 69.8 75.0 Grampian 53.9 69.5 Source: National Clinical Data Store/SEER Table 7: Pneumococcal vaccination coverage amongst aged 65+ and 2-64 at Risk cohorts 1 April 2022 – 31st March 2023 by Moray and NHS Grampian % coverage Aged 65+ 2 – 64 at risk Moray 47.3 33.1 Grampian 55.5 36.9 Source: National Clinical Data Store/SEER 4.4 Uptake of seasonal flu and covid-19 vaccinations in Winter 2022/23 was similar in Grampian to elsewhere in Scotland and highest in the oldest age groups. Uptake shows a socioeconomic gradient with highest uptake amongst those identified as least deprived. 4.5 Within Grampian we continue to improve the delivery of all the vaccination programmes. This includes monitoring the proportion of our eligible population who are vaccinated. 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. (b) Policy and Legal None directly associated with this report. Page 27
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(c) Financial implications None directly associated with this report. (d) Risk Implications and Mitigation None directly associated with this report. (e) Staffing Implications None directly associated with this report. (f) Property None directly associated with this report. (g) Equalities/Socio Economic Impact An Equality Impact Assessment is not required as there are no changes to policy arising from this report and therefore there will be no differential impact on people with protected characteristics. However, individual strategies will comply with the need for an Equalities Impact Assessment and is considered as part of our service planning process. (h) Climate Change and Biodiversity Impacts None directly associated with this report. (i) Directions None directly associated with this report. (j) Consultations Chief Officer; Heads of Services; Chief Financial Officer and Caroline O’Connor, Committee Services Officer have been consulted in the drafting of this report. 6 CONCLUSION 6.1 The Grampian Vaccination and Immunisation annual report (Appendix 1) is an opportunity to reflect on the varied activities and improvements that have been achieved over the year. Author of Report: Jo Hall, Vaccination Planning Manager, Public Health, NHS Grampian Background Papers: Appendix 1 Grampian Vaccination and Immunisation Annual Report 2023 Ref: Page 28
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1 Grampian Vaccination and Immunisation Annual Report 2023 NHS Grampian Grampian Vaccination and Immunisation Programme Annual Report 2023 APPENDIX 1 Item 7. Page 29
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2 Grampian Vaccination and Immunisation Annual Report 2023 Contents Abbreviations and Glossary 2 1. Executive Summary 3 2. Introduction 5 3. Why is vaccination important as part of Population Health 6 4. National and Local Context of vaccination 7 5. Vaccine Preventable disease 7 6. Vaccination Uptake 17 7. Equity In Grampian 28 8. Quality improvement 28 9. Horizon Scanning 30 10 Conclusions 31 11. Acknowledgements 31 12. References 31 13. Appendix 1. Routine childhood and adult immunisation schedule 2. Outcome of Aberdeen City Preliminary Assessment Group 32 Abbreviations CMO Chief Medical Officer (for Scotland) GBMSM Gay, Bisexual and Men who have sex with Men GREC Grampian Regional Equality Council HSCP Health and Social Care Partnership IJB Integrated Joint Board JCVI Joint Committee on Vaccinations and Immunisation MSM Men who have Sex with Men NHSG NHS Grampian PAG Preliminary Assessment Group PHS Public Health Scotland SIMD Scottish Index of Multiple Deprivation SIRS Scottish Immunisation & Recall System SLWG Short Life Working Group VMT Vaccination Management Tool VTP Vaccination Transformation Programme WHO World Health Organisation Vaccine and disease abbreviations BCG Bacillus Calmette-Guerin FVCV Influenza vaccine (Flu) and covid-19 Vaccine Hib Haemophilus influenzae type B HPV Human Papilloma Virus IPD Invasive pneumococcal disease MenACWY Meningococcal groups A,C,W and Y MenC Meningitis C MMR Measles, Mumps and Rubella Mpox Mpox (Previously Monkeypox) PPV Pneumococcal Polysaccharide Vaccine Td Tetanus and Diphtheria vaccine IPV Inactivated Polio Virus Page 30
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3 Grampian Vaccination and Immunisation Annual Report 2023 1. EXECUTIVE SUMMARY 1.1. This is the first Annual Vaccination and Immunisation Report for NHS Grampian. The purpose of the report is to provide an annual monitoring report of vaccine preventable disease surveillance data, along with uptake data for each vaccine delivered within Grampian. 1.2. Immunisation provides protection against a range of infections across the life course, enabling our population to live longer, healthier lives, reducing inequalities, and releasing health service capacity. Vaccination can prevent or reduce the severity of disease, minimise disability and save lives, often in many of the most disadvantaged people in society. It offers excellent value for money by reducing current and future public expenditure on health and social care provision. The European Region of WHO recommend coverage of 95% in a population is required to control or eliminate disease. 1.3. The Vaccination Transformation Programme (VTP) was created because of the 2018 Scottish General Medical Services (GMS) Contract (4). Since 2022, NHS Grampian has been responsible for coordination of vaccination programmes with operational delivery being the responsibility of our three Health and Social Care Partnerships (HSCPs) in Aberdeen City, Aberdeenshire, and Moray. The programme delivers the pregnancy, pre-school, school age, adult routine, non- routine, seasonal and travel vaccinations to the population of Grampian. 1.4. The report discusses vaccination in the national and local context including; Vaccination Uptake; Equity in Grampian; Quality Improvement in vaccination and horizon scanning. 1.5. There have been declines in vaccination uptake across childhood vaccinations in both Grampian and Scotland. Uptake rates at 12 months of age were below the 95% target for rotavirus and meningitis B. Work is ongoing to identify challenges and areas for improvement from a Grampian and HSCP perspective to support increased uptake. 1.6. Uptake in teenage (school based) vaccination programme saw disruption during 2020 – 21 due to covid-19 pandemic which resulted in catch up programmes. Our Grampian uptake during 2021-22 is above Scotland average, however, remains below the WHO target of 95%. 1.7. The adult routine shingles programme was paused during the pandemic and was subsequently transferred to health board/HSCP delivery as part of the VTP. This resulted in a significant catch-up programme being delivered during 2022-23. The health and social care partnerships have made good progress to ensure all those eligible have been offered. In 2022/23 the coverage in Grampian for the 70 – 79 cohort was 69.5% which is a 15.5% increase from 21/22 position. 1.8. Young children, the elderly and people in a clinical risk group are most at risk of severe pneumococcal disease, and so all these groups are currently offered a pneumococcal immunisation During 2022-23, 14,328 pneumococcal vaccines were administered to citizens turning 65 as well as those under 65 in an at-risk group. 1.9. Uptake of seasonal flu and covid-19 vaccinations in Winter 2022/23 was similar in Grampian to elsewhere in Scotland and highest in the oldest age groups. Uptake shows a socioeconomic gradient with highest uptake amongst least deprived. 1.10. Non routine vaccinations cover a range of situations where citizens require vaccination out with the usual population vaccination schedules. NHSG has processes by which services may refer a citizen for vaccinations that are required Page 31
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4 Grampian Vaccination and Immunisation Annual Report 2023 out with normal vaccination schedules. There remain outstanding operational and clinical questions to be worked through and we are collaborating with specialist services on a local and national level to achieve clarity and strong clinical governance in this most flexible of programmes. 1.11. Travel risk assessments, advice, and vaccinations (if required) are provided to reduce the risk of transmission of diseases amongst patients travelling to countries where these diseases are still prevalent. The travel health service in Grampian has been delivered by community pharmacy since October 2021 and is available to all travellers who reside in Grampian and require advice and /or vaccinations for travelling to a destination considered at risk of tropical disease. 1.12. We are currently undertaking a Needs Assessment focussing on families with children under 6 years of age to identify concerns and practical barriers to accessing vaccinations for uptake of vaccinations and improve engagement, along with engaging with Grampian Regional Equality Council (GREC). 1.13. Priorities for improvement have been identified including Work with PHS and health intelligence to develop quality assured statistical reporting which will provide live data to allow us to better understand variance in programme and monitor these more effectively. 1.14. Conclusion: We are delivering the vaccination programme and continue to develop ways of working to promote a consistent approach across NHS Grampian in line with national and local policy, guidelines and priorities. Page 32
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5 Grampian Vaccination and Immunisation Annual Report 2023 2. INTRODUCTION 2.1. This is the first Annual Vaccination and Immunisation Report for NHS Grampian. The purpose of the report is to provide an annual monitoring report of vaccine preventable disease surveillance data, along with uptake data for each vaccine delivered within Grampian. 2.2. The most recently published data has been used throughout the report. Variation in data release timings and reporting intervals mean that the period covered in this report varies by programme. 2.3. Within Grampian we continue to improve the delivery of all the vaccination programmes. This includes monitoring the proportion of our eligible population who are vaccinated. Within Scotland we have adopted the recommendations made by the World Health Organisation (WHO) that at least 95% of children should be immunised against vaccine preventable diseases on the routine schedule. 2.4. The routine childhood and adult schedules in the UK (appendix 1) are based on advice from the independent Joint Committee of Vaccination and Immunisation (JCVI) and provides protection against the following vaccine preventable infections: Covid-19 Diphtheria Haemophilus influenza type b (Hib) Hepatitis B Human Papilloma Virus (HPV) Influenza Measles Meningococcal disease Mumps Pertussis (whooping cough) Pneumococcal disease Polio Rotavirus Rubella Shingles Tetanus Tuberculosis 2.5. The Director for Public Health has the accountability and governance oversight for vaccination and immunisation at NHS Grampian Board Level and undertakes the role of executive lead. 2.6. The operational delivery of vaccination is through the 3 HSCPs with the Chief Officers being accountable to their respective Integrated Joint Boards (IJBs). The Vaccination Transformation Programme Board (VTPB) is chaired by the Director of Public Health with the 3 HSCP Chief Officers, Finance, Primary Care, Nursing, Pharmacy and property and asset colleagues as members. The Programme Board has oversight of the whole vaccination programme, oversees progress, and ensures the national agreed outcomes are delivered within Grampian, taking decisions on a Grampian wide basis on complex issues that are common to Grampian or issues which are escalated. Page 33
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6 Grampian Vaccination and Immunisation Annual Report 2023 2.7. Reporting into the VTPB, the Grampian Vaccination and Immunisation Clinical and Care Governance Group meets monthly to be assured that all appropriate governance arrangements are in place, to identify actions where required and to provide support and advice and share learning across NHS Grampian. This group reviews quality of service delivery, complaints and feedback, adverse events along with the review of the vaccination programme risk register. This groups provides reports to the Vaccination programme board. 3. WHY VACCINATION IS IMPORTANT AS PART OF POPULATION HEALTH 3.1. The World Health Organisation (WHO) describes vaccines as one of the two public health interventions that have the greatest impact on the world’s health, the other being clean water. It is also considered as one of the most impactful and cost- effective public health interventions available to communities and populations across the world. Vaccination can prevent or reduce the severity of disease, minimise disability and save lives, often in many of the most disadvantaged people in society. It offers excellent value for money by reducing current and future public expenditure on health and social care provision. The European Region of WHO recommend coverage of 95% in a population is required to control or eliminate disease. 3.2. Effective control of vaccine preventable disease requires action across the whole health and care system, and this aligns with the drive to improve outcomes and reduce inequalities. Vaccination has for the first time become included in the annual delivery plan process for health boards. 3.3. Surveillance data demonstrate low incidence rates of vaccine preventable disease during 2022 in Grampian. Many of the vaccine preventable diseases are also notifiable diseases because of their potential to cause harm to public health. The information in table 1 was taken from disease notifications to Public Health Protection Team in 2022. Table 1: Notifiable organism/ disease controllable by vaccination in Grampian 2022 Notifiable Organism/Diseases controllable by vaccination in Grampian (2022) Infectious disease Number reported Bordetella pertussis (Whooping cough) 0 Mumps <5 Rubella (German Measles) 0 Measles 0 Meningococcal disease <5 Hepatitis B 48 Tuberculosis 20 Corynebacterium diphtheria (Diphtheria) 0 Hepatitis A 0 Source: HP Zone Page 34
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7 Grampian Vaccination and Immunisation Annual Report 2023 3.4. Hepatitis B and Tuberculosis (TB) have numerically the highest number of notified cases. Tuberculosis vaccination is a targeted, risk-based programme, not a population-based vaccination programme. Grampian’s rates are low regionally and internationally. Hepatitis B became a population-based programme in October 2017 as part of the childhood programme and we would predict these numbers to fall as the children grow to adulthood. More information on both programmes is given below. 4. National and Local Context - Immunisation Programmes 4.1. Immunisation policy in Scotland is set by the Scottish Government Health Directorate who take advice from the UK Joint Committee on Vaccinations and Immunisation (JCVI). JCVI provide advice on immunisations for the prevention of infections and/or disease following consideration of evidence on the burden of disease, vaccine safety and efficacy and on the impact and cost effectiveness of immunisation strategies (1). The UK immunisation schedule is continually reviewed and updated (2). Immunisation against infectious disease (commonly known as the Green Book) reflects the current policies and procedures as advised by the JCVI and provides essential guidance on vaccines and vaccination procedures for all vaccine preventable diseases that may occur in the UK (3). 4.2. The Vaccination Transformation Programme (VTP) was created as a result of the 2018 Scottish General Medical Services (GMS) Contract (4). The Contract aims to improve access for patients in General Practice (GP) with the expansion of multi- disciplinary teams to share the delivery of care and ease workload pressures. 4.3. Since 2022, NHS Grampian has been responsible for coordination of vaccination programmes with operational delivery being the responsibility of our three Health and Social Care Partnerships (HSCPs) in Aberdeen City, Aberdeenshire, and Moray. This has meant local changes in how members of the public access services. In Grampian, vaccinations are administered in a range of settings. 4.4. General Practice staff retain important roles in continuing to promote and advise on vaccinations; responding to vaccination status enquiries; and signposting and referring to Immunisation Teams in Health Boards for vaccine delivery. 5. VACCINE PREVENTABLE DISEASES 5.1. Data for vaccine preventable diseases are summarised at both a national and Grampian level where data is available. 5.2. The following section contains background information about the agents, diseases, and vaccinations for reference. 5.3. Graphs showing Scottish data aim to illustrate the effect of vaccination on vaccine preventable diseases Covid-19 5.4. Covid-19 is an acute respiratory viral infection caused by SARS-Cov-2 and spread primarily through respiratory droplets and aerosol. The 2020 Covid-19 pandemic resulted in a significant increase in mortality both worldwide and in the United Kingdom, particularly in people aged over 75, and led to several lockdowns and accelerated vaccine development. Mortality has subsequently fallen, believed to be due to increased natural and vaccine-mediated immunity, but rapid emergence Page 35
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8 Grampian Vaccination and Immunisation Annual Report 2023 of new strains has led to concerns regarding immune escape. Evidence shows that protection provided by both vaccination and previous natural infection wane as new strains become prevalent – this has led to several adaptions of vaccines by manufacturers. 5.5. Initial national programmes in the UK aimed to offer primary vaccination prioritised by risk category as capacity allowed. The lowest risk group, children aged 5 to 11 years, were offered vaccination by late 2021. Seasonal booster programmes are now only offered to certain populations including those aged over 65; clinically at- risk individuals; close contacts of immunocompromised individuals; residents of care homes, and frontline healthcare staff. There are currently five vaccinations against Covid-19 available in the UK, all of which target the S protein of the original SARS-Cov-2 strain. These vary in their mechanism of action using either mRNA, adenovirus vectors or recombinant S protein to induce immunity. Diphtheria 5.6. Diphtheria is caused by Corynebacterium diphtheriae and closely related bacteria and classically presents with swollen neck glands and a pseudo membrane in the throat which obstructs the airways or sore throat or pharyngitis in immunised or partially immunised individuals. It is now rare in Scotland following the vaccination programme which began in 1941/2. In 1940 there were nearly 16,000 cases in Scotland with 675 deaths. Haemophilus influenza type b (Hib) 5.7. Haemophilus influenzae can cause serious invasive disease, especially in young children. There are six subtypes but prior to vaccination Type B was the dominant subtype. The usual presentation of invasive disease was meningitis with around 10% of children having long term complications of the disease. Cases from Hib have fallen dramatically since the introduction of vaccination. Protection is achieved from 4 doses given in multivalent preparations as part of the childhood programme. Figure 1: Laboratory reports of invasive Haemophilus influenzae type b disease in Scotland, 1988 to 2023 (week 13) - Source: PHS Hepatitis A Page 36
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9 Grampian Vaccination and Immunisation Annual Report 2023 5.8. Hepatitis A is caused by the Hepatitis A virus and spread through the faecal-oral route. Hepatitis A infection tends to be mild and does not result in chronic infection or liver impairment, though can lead to significant morbidity or mortality in older people and those with hepatic co-morbidities. Given its faecal-oral spread, Hepatitis A is comparatively rare in high-income countries with adequate standards of sanitation and vaccination. At-risk categories include individuals travelling to Hepatitis A-endemic areas; patients with chronic liver disease; patients with haemophilia; men who have sex with men (MSM); people who inject drugs, and individuals with occupational exposure. Several Hepatitis A vaccinations are available – both monovalent and combined with Hepatitis B or Typhoid vaccinations – and these are given either IM or subcutaneously (in the case of haemophilic patients) in two or three doses. Hepatitis B 5.9. Hepatitis B is caused by the Hepatitis B virus and spread through exposure to infected blood or bodily fluids. Hepatitis B causes an acute flu-like illness with jaundice and may sometimes lead to complete liver failure. While infection resolves in most patients following the acute illness, chronic infection persists in a proportion of cases. Risk of chronic infection is increased in young people and immunocompromised individuals, and chronic infection can lead to cirrhosis and hepatocellular carcinoma. 5.10. Hepatitis B vaccination is included in the routine childhood immunisation programme - 3 doses in 1st year (with extra doses at 4 weeks and 1 year to babies at risk) as well as selective pre- and post-exposure vaccination programmes for at- risk individuals. At risk categories include neonates with maternal Hepatitis B exposure; travellers to endemic countries; people who inject drugs; MSM; sex workers; close family contacts of individuals with chronic Hepatitis B infection; individuals living in custodial institutions or residential accommodation; individuals with certain renal or hepatic comorbidities, and those at risk of occupational exposure. Table 2: Hepatitis B case in Grampian 2011-2020 Hepatitis B cases (acute and chronic) in Grampian 2011-2020 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 75 49 58 59 50 39 22 39 29 14 23 48 Human Papilloma Virus (HPV) 5.11. Vaccination against HPV is part of WHO’s global Cervical Cancer Elimination Initiative. There is a causal pathway from infection with particular HPV subtypes and development of squamous cell carcinomas of the cervix, anus, vulva, vagina, penis and head and neck cancers. By vaccinating young people and older people at higher risk, this pathway can be disrupted. From 1 August 2019, the HPV immunisation programme in Scotland became universal when males in first year of secondary school (S1) became eligible alongside females. The routine HPV schedule was a full course of two doses of vaccine given predominantly in schools. The second dose was given no sooner than six months and no later than two years after the first dose. Page 37
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10 Grampian Vaccination and Immunisation Annual Report 2023 5.12. From 1 January 2023, following a review of evidence by JCVI showing one dose conferred similar levels of immunity to two doses, the HPV vaccine moved to a one-dose schedule for immunocompetent individuals before their 25th birthday. 2 doses are required for citizens aged 25 – 45 years in the MSM programme and 3 doses for immunosuppressed or known to be HIV positive. Figure 2: Incidence rate amongst women aged 20-24, Scotland 1991 - 2017 Source: ISD Scotland Influenza 5.13. Influenza is an acute viral respiratory infection caused by influenza A, B or C – symptoms include fever, myalgia, malaise, headache and coryzal symptoms. Influenza is normally self-limiting in otherwise healthy patients but can lead to significant morbidity in young children, older people, immunocompromised individuals, those with respiratory or cardiac co-morbidities and pregnant women. Influenza is highly seasonal, and a vaccination programme has been in place in the United Kingdom since the late 1960s. Periodic antigenic drift in the virus means that individuals frequently lose immunity between influenza seasons, necessitating at-risk individuals being re-vaccinated each year against likely dominant strains. Measles 5.14. Measles is one of the most transmissible infectious diseases. It can lead to serious and potentially life-threatening complications even years after the original infection. Catching measles when pregnant can result in complications for baby. However, the MMR vaccine, which also provides protection against mumps and rubella, is highly effective - after two doses around 99% of people will be protected against measles. The number of notifiable cases within Grampian over the past ten years is detailed below: Table 3: Measles cases in Grampian 2011 – 2020 Measles cases in Grampian 2011-2020 Page 38
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11 Grampian Vaccination and Immunisation Annual Report 2023 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 <5 <5 <5 <5 0 0 0 <5 0 0 0 0 Figure 3: Number of laboratory-confirmed cases of measles in Scotland by year, 1988 to end of March 2023 – Source: PHS Figure 4: Number of laboratory-confirmed cases of measles in Scotland by month and year, 2015 to March 2023 – Source: PHS Meningococcal disease (Men B) 5.15. Men B vaccination is given as 3 doses in the first year of life with Men C also currently given at 1 year as part of the childhood programme. The Meningococcal groups A,C,W and Y (Men ACWY) vaccine protects against meningococcal disease caused by four groups of meningococcal bacteria A, C,W and Y. The Men ACWY vaccine is offered to all young people in S3 at school. Young people in S4 to S6 who missed the opportunity to be immunised the previous year are offered vaccination at subsequent visits. 5.16. Due to the success of the adolescent MenACWY vaccination programme in controlling meningococcal disease across the population, from 2025 a dose of meningococcal C containing vaccine will no longer be recommended at 12 months. (This would have been delivered via the Hib/MenC vaccination at this time.) Page 39
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12 Grampian Vaccination and Immunisation Annual Report 2023 5.17. The number of notifiable cases of meningococcal disease in Grampian over the past ten years is detailed below: Table 4: Meningococcal cases in Grampian 2011 – 2022 Figure 5: Meningococcal disease cases reported to MIDAS by serogroup, 2003 to 2022 (week 13) - Source: PHS Mpox 5.18. Mpox (previously known as Monkeypox) is a rare viral infection usually associated with travel to West Africa and has only, until recently, rarely been reported out with this region. Mpox can be transmitted through close physical contact with a person who already has the infection or contact with their bedding, towels, etc. It does not spread easily in the general population. Mpox is usually a self-limiting illness, with most people making a complete recovery within a few weeks. The Mpox virus is similar to the smallpox virus and the smallpox vaccine gives effective protection against Mpox. The vaccine is given in two doses a minimum of 28 days apart. 5.19. The 2022–2023 Mpox outbreak represents the first incidence of widespread community transmission outside of Africa. This was initially identified in the United Kingdom in May 2022, with subsequent cases confirmed in 111 countries as of May 2023. During the recent outbreak, all those in NHS Grampian (NHSG) who were considered at high risk of Mpox were offered vaccination in line with national guidance via sexual health clinics. 5.20. There remains a level of clinical discretion when deciding to offer vaccination to those who are attending sexual health services for other sexual health care or treatments. Opportunistic Mpox vaccination are included as part of a holistic approach to care for those attending sexual health services. This may include those who are attending for other vaccinations given at sexual health services, such as the adult HPV vaccine. Efforts have been made to offer vaccination to those who are newly eligible through sexual health services. Eligible healthcare workers have been vaccinated through occupational health services. Mumps Meningococcal cases in Grampian 2011-2022 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 8 5 7 6 11 11 7 8 5 <5 0 <5 Page 40
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13 Grampian Vaccination and Immunisation Annual Report 2023 5.21. Mumps, caused by paramyxovirus, is spread by airborne or droplet transmission and classically causes bilateral parotid swelling, fever, and myalgia. In addition, mumps can cause a variety of significant complications such as meningitis, encephalitis, orchiditis, oophoritis and pancreatitis. These complications, if developed, may be associated with sensorineural hearing loss and subfertility. Vaccination against mumps in the United Kingdom commenced with the introduction of the MMR vaccine in 1988, leading to a significant decrease in the prevalence of mumps in the years following due to high levels of uptake. Subsequent decreases in uptake, as well as supply issues with the MMR in certain years, have led to increasing cases since the late 1990s. Figure 6: Number of laboratory-confirmed cases of mumps in Scotland by year, 2000 to March 2023 – Source: PHS Figure 7: Number of laboratory-confirmed cases of mumps in Scotland by age group and year, 2015 to March 2023 – Source: PHS Pertussis (Whooping cough) 5.22. Pertussis, or whooping cough, is a highly infectious bacterial disease affecting the respiratory system. Infants and young children are particularly at risk of severe disease and/or death. The number of notifiable cases in Grampian over the past 10 years is detailed below: Table 5: Pertussis cases in Grampian 2011- 22 Page 41
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14 Grampian Vaccination and Immunisation Annual Report 2023 Pertussis cases in Grampian 2011-2022 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 6 219 193 47 146 143 80 98 143 11 0 0 5.23. Protection against disease is conferred via vaccination, From October 2012 pregnant women in Scotland are offered a pertussis vaccine typically between 16- and 32-weeks’ gestation. This is to protect infants in the first eight weeks of life who are too young to receive their routine immunisations. Figure 8: Incidence of Bordetella pertussis per 100,000 population in Scotland by age group, 2016 to 2022 – Source: PHS Pneumococcal disease 5.24. Pneumococcal disease can present as non-invasive or invasive infections caused by the bacterium Streptococcus pneumoniae (also called pneumococcus). Non- invasive disease includes middle ear infections (otitis media), sinusitis and bronchitis, whilst invasive pneumococcal disease (IPD) includes septicaemia, pneumonia, and meningitis. 5.25. Young children, the elderly and people in a clinical risk group are most at risk of severe pneumococcal disease, and so all these groups are currently offered a pneumococcal immunisation. Polio 5.26. Poliomyelitis is now rare in the UK following national vaccination programmes. It is an acute illness caused by the poliovirus entering the body through the gut and giving rise to a range of symptoms from gastrointestinal disturbance, fever and paralysis. During UK epidemics in the 1950s up to 8000 notifications of paralytic polio were received in a year. 4 doses via the 6 in 1 vaccine are offered during the childhood programme, with a booster dose delivered at age 14 (S3). Rotavirus 5.27. Rotavirus is an extremely infectious cause of gastroenteritis through both the faecal-oral and occasionally respiratory route and can require hospitalisation in severe cases due to dehydration. Incidence follows a seasonal pattern, with the majority of cases in winter and early spring, and most symptomatic cases are in Page 42
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15 Grampian Vaccination and Immunisation Annual Report 2023 young children. A national infant rotavirus vaccination programme was commenced in Scotland in 2013, leading to a significant reduction in both overall cases and peak incidence in winter. Rotarix, the licensed vaccine for rotavirus, is given orally in two doses at 8 and 12 weeks. Figure 9: Laboratory reports of rotavirus in Scotland from 2011 to end of March 2023 – Source: PHS Rubella 5.28. Rubella is a viral illness caused by togavirus and spread by droplet transmission. The symptoms of acute rubella infection tend to be mild and include fever, coryzal symptoms, malaise and rash – though it may be associated with more serious complications such as post-infectious encephalitis and thrombocytopenia. The primary concern regarding rubella is the potential for foetal loss and birth defects in cases of maternal infection in pregnancy. Up to 90% of infants exposed to rubella at 8 to 10 weeks' gestation will develop congenital rubella syndrome (CRS). As such, the primary aim of vaccination programmes is to reduce exposure of pregnant women to rubella. Targeted vaccination began in the UK in 1970, and universal vaccination began in 1988 with the introduction of MMR leading to significant decreases in rates of rubella. This is delivered during the childhood programme via the MMR vaccine. Figure 10: Number of laboratory-confirmed cases of rubella in Scotland by year, 1988 to end of March 2023 – Source: PHS Page 43
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16 Grampian Vaccination and Immunisation Annual Report 2023 Shingles 5.29. Shingles (Herpes zoster) is caused by the reactivation of a latent varicella zoster virus (VZV) infection, sometimes decades after initial infection. Shingles can occur at any age, with the highest incidence seen in older people. The severity of shingles generally increases with age and can lead to Post Herpetic Neuralgia (PHN) that may require hospitalisation. 5.30. The shingles vaccine programme for older adults was introduced in Scotland in September 2013 following recommendation by JCVI in 2009 and a Scottish policy. The JCVI recently recommended changes to the shingles programme and these will be implemented from 1st September 2023. The vaccine offered will switch from Zostavax to the non-live vaccine Shingrix requiring a 2-dose schedule. There will also be a change to eligibility so that individuals are protected from a younger age. 5.31. The eligible age for immunocompetent individuals will change from 70 to 60 years of age for the routine cohort in a phased implementation over a 10-year period. In addition, from 1st September 2023, eligibility will expand to all those who are severely immunosuppressed aged 50 years and over, with no upper age limit. Tetanus 5.32. Tetanus is caused by the release of tetanus toxin during infection with the bacterium Clostridium tetani. It causes symptoms such as fever, muscle spasms, lockjaw, difficulty breathing and swallowing problems. Tetanus can never be eradicated as its bacterial spores are commonly present in the environment, including soil. This vaccine is given at 8, 12 and 16 weeks via the 6-1 vaccine and at 3 years 4 months via the 4-1 vaccine. Tuberculosis 5.33. The BCG immunisation programme was introduced into the UK in 1953 to protect against Tuberculosis (TB), a serious bacterial disease which affects the lungs and other parts of the body including brain, bones, kidneys, and joints. The programme has undergone several changes in response to changing trends in TB epidemiology. Following a continued decline in TB incidence in the UK-born population, the universal school-based programme for adolescents was stopped in 2005. The BCG immunisation programme is now risk-based; the key part being a neonatal programme targeted at those children most at risk of exposure to TB, aiming to protect them from the more serious childhood forms of the disease. Page 44
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17 Grampian Vaccination and Immunisation Annual Report 2023 Babies are offered the vaccine if they or their parents or others close to the baby have lived in an area with high levels of tuberculosis. Figure 11: Number of tuberculosis cases and incidence per 100,000 population in Scotland, 2000–2021 – Source: PHS Figure 12: Tuberculosis incidence per 100,000 population and case numbers by NHS board, 2021 – Source: PHS Typhoid 5.34. Typhoid fever is caused by Salmonella enterica typhi and is spread through the faecal-oral route. Typhoid fever varies significantly in severity from isolated gastrointestinal symptoms and fever to multi-organ failure and has a mortality rate of up to 20% if untreated. Given its faecal-oral spread, typhoid fever is comparatively rare in high-income countries with adequate standards of sanitation - the United Kingdom averaged 393 cases of typhoid fever a year between 2008 and 2017 and 93% of cases were determined to have been contracted abroad. As such, vaccination against typhoid fever is typically only carried out on individuals Page 45
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18 Grampian Vaccination and Immunisation Annual Report 2023 travelling to endemic areas. Increasing antibiotic resistance noted in typhoid- endemic countries increases the importance of vaccination of at-risk travellers. There are currently two typhoid vaccines licensed in the United Kingdom - a polysaccharide vaccine given in one oral dose, and a live attenuated vaccine given in three oral doses. 6. VACCINE UPTAKE 6.1. The Grampian Vaccination and Immunisation Programme is organised into the following work streams, largely mirroring the structure in figure 13 below. Uptake data within this annual report will be reported according to this structure. Pregnancy Pre-school children School age children Adults Non routine vaccinations Figure 13: Vaccination and Immunisation workstreams 6.2. The summary of the reporting period covered in this report is as follows: Cohort Reporting Period Pregnancy Routine April 2022 – March 2023 Childhood Routine April 2022 – March 2023 Teenage Routine School year 2021 – 22 *22-23 will be published at end November 2023 Adult Routine April 2022 – March 2023 September 2022 – August 2022 Flu and Covid-19 September 2022 – March 2023 Travel health September 2022 – August 2023 Page 46
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19 Grampian Vaccination and Immunisation Annual Report 2023 Pregnancy Pertussis 6.3. Prenatal pertussis vaccination uptake surveillance started in Scotland in 2014, however, a decision was taken to stop publishing this data in 2021 as data held nationally (taken from General Practice IT systems) was underestimating local figures. 6.4. Across Grampian the pertussis vaccine in pregnancy programme is delivered by the midwifery teams from 16 weeks’ gestation. Midwives have an important role in promoting the vaccine, ensuring pregnant women are informed and administering the vaccine. 6.5. In 2022 – 23, coverage in Grampian from locally held data was 81.7%. The data is reported according to NHS Board of delivery and therefore excludes those who choose to receive their maternity care in other Board areas. Flu and Covid-19 Programme 6.6. Pregnant women are eligible for both Flu and Covid-19 vaccinations however uptake is low. 802 (14.8%) covid-19 vaccinations were given in the year 22-23 and 986 (18.2%) Flu vaccinations. 6.7. During the summer of 2023, a study was undertaken in Grampian to help to understand vaccine hesitancy in pregnant women. This included a literature review and engagement with key stakeholders, comprising a survey to all health boards in Scotland and midwifery teams in NHS Grampian. Overall, this review highlighted the need for targeted engagement, tailored interventions, and clear communication to address barriers to vaccine acceptance among pregnant individuals. This ran concurrently with a short life working group (SLWG) to identify solutions to increase engagement and vaccine uptake with pregnant women in Grampian. A number of recommendations were identified, some of which have been implemented for the start of the winter vaccination programme, with the aim of increased vaccine uptake. This will be reviewed and appraised at the end of the programme to identify impact. Childhood routine immunisations 6.8. Over the past 10 years, there has been a gradual decline in the uptake of childhood immunisations across the UK and globally. While Scotland’s uptake has continued to perform well by comparison with the other UK nations, this trend is observed here too. 6.9. The reporting ages for childhood vaccine completion rates in the UK are 12 months, 24 months, and five years of age. The data presented is based on the published data from PHS and relates to year end to March 2023. 6.10. There are time lags between when a vaccination is first offered within the routine childhood schedule and when uptake is evaluated, for example MMR2 appointments are scheduled from 3 years 4 months but uptake is evaluated based on the cohort of children who reach 5 years. Therefore, uptake data in a particular reporting year reflect delivery practices over a longer period. Vaccinations up to 12 months of age 6.11. The 95% target is met on a Grampian basis for all vaccinations up to 12 months of age except Rotavirus and Men B. The Rotavirus course requires two vaccinations Page 47
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20 Grampian Vaccination and Immunisation Annual Report 2023 in a narrow time window (8 and 12 weeks) and must be completed before 24 weeks. The consequence of this schedule is if the first dose is missed or delayed for some reason it may not be possible to have the second dose within this time window. 6.12. Aberdeen City coverage is under the 95% threshold for all vaccinations. Investigation has shown that there has been an influx of new to area children with incomplete vaccination history, greater than in other parts of Grampian and Scotland as a whole. Table 6: Completed primary immunisations by 12 months of age, 2022 – 23, Local Authority, NHS Grampian and Scotland. April ‘22 - March ‘23 Number in % completed primary course by 12 months Cohort 6-in-1 PCV Rotavirus3 MenB No. % No. % No. % No. % Aberdeen City 2,316 2,173 93.8 2,159 93.2 2,041 88.1 2,055 88.7 Aberdeenshire 2,195 2,141 97.5 2,139 97.4 2,087 95.1 2,129 97.0 Moray 872 842 96.6 840 96.3 823 94.4 839 96.2 Grampian 5,494 5,257 95.7 5,240 95.4 5,050 91.9 5,124 93.3 Scotland 49,583 47,376 95.5 47,328 95.5 45,919 92.6 46,716 94.2 Source: SIRS 15th May 2023 Immunisations up to 24 months of age 6.13. The second year of life introduces the vaccines for Men C, Hib, Men B booster and MMR. In common with Scotland as a whole NHS Grampian achieves the 95% mark for 6 in 1 only. Table 7. Completed primary immunisations by 24 months of age, 2022-23, Local Authority, NHS Grampian and Scotland April ‘22 - March ‘23 Number in % completed primary and booster course by 24 months Cohort 6-in-1 MMR1 Hib/MenC PCVB MenB (Booster) No. % No. % No. % No. % No. % Aberdeen City 2,209 2,112 95.6 1,982 89.7 1,953 88.4 1,895 85.8 1,922 87.0 Aberdeenshire 2,137 2,100 98.3 2,068 96.8 2,061 96.4 2,050 95.9 2,053 96.1 Moray 820 803 97.9 784 95.6 785 95.7 785 95.7 785 95.7 Grampian 5,269 5,115 97.1 4,932 93.6 4,898 93.0 4,829 91.6 4,858 92.2 Scotland 48,462 46,747 96.5 45,268 93.4 45,165 93.2 45,056 93.0 44,885 92.6 Source: SIRS 15th May 2023 Immunisations up to five years of age 6.14. Grampian’s uptake of vaccinations up to five years of age are all below 95% except for the 6 in 1 and are all below those seen for the Scotland average. There is Page 48
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21 Grampian Vaccination and Immunisation Annual Report 2023 variation in uptake across the HSCPs which lead to quality improvement work discussed in later sections. Table 8. Completed primary immunisations and boosters by 5 years of age, 2022-23, Local Authority, NHS Grampian and Scotland. April ‘22 - March ‘23 Number in % completed primary and booster course by 5 years Cohort 6-in-1* MMR1 Hib/MenC 4-in-1 MMR2 No. % No. % No. % No. % No. % Aberdeen City 2,488 2,339 94.0 2,256 90.7 2,180 87.6 2,043 82.1 2,018 81.1 Aberdeenshire 2,711 2,655 97.9 2,624 96.8 2,615 96.5 2,553 94.2 2,531 93.4 Moray 886 855 96.5 843 95.1 842 95.0 810 91.4 798 90.1 Grampian 6,223 5,974 96.0 5,848 94.0 5,762 92.6 5,528 88.8 5,469 87.9 Scotland 55,071 53,156 96.5 52,455 95.2 52,130 94.7 50,029 90.8 49,701 90.2 Source: SIRS 15th May 2023 Immunisations up to six years of age 6.15. By the age of 6, first MMR, MMR2 and 4 in 1 remain lower than the Scottish average and below the 95% coverage mark and uptake is decreasing over time. This is of concern as MMR requires two doses for protection and 95% coverage for population protection. Measles is a particular concern because it is highly infectious, and the disease can have significant short- and long-term health complications. 6.16. At the time of writing in August 2023, the Chief Medical Officer has written to Health Boards to highlight the risks from Measles and NHS Grampian has responded with an updated action plan. Table 9. 4 in 1, MMR and MMR2 vaccination uptake rates at 6 years of age, April 2022 – March 2023, NHS Grampian and Scotland. April ‘22 - March ‘23 Number in % completed primary and booster course by 6 years Cohort MMR1 4-in-1 MMR2 No. % No. % No. % Aberdeen City 2,664 2,390 89.7 2,280 85.6 2,232 83.8 Aberdeenshire 2,680 2,558 95.4 2,511 93.7 2,500 93.3 Moray 991 952 96.1 929 93.7 924 93.2 Grampian 6,472 6,018 93.0 5,837 90.2 5,773 89.2 Scotland 56,759 53,799 94.8 52,476 92.5 52,118 91.8 Source: SIRS 15th May 2023 Uptake and Coverage of School-based Immunisation Programmes Human Papilloma Virus (HPV) 6.17. Coverage is higher in girls than boys. This may be a legacy of the programme starting as a female only programme. Further work is needed to see how uptake in boys can be improved. 6.18. Coverage consistently improves with each school year showing the importance of offering vaccination at each opportunity. Page 49
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22 Grampian Vaccination and Immunisation Annual Report 2023 6.19. A process has been developed to ensure any child who has left school without the opportunity to receive routine vaccinations is contacted with the offer of vaccination. Table 10: HPV immunisation coverage rates of dose 1 by the end of the school year 2021/22 at S1 and S2 by local authority area, NHS Grampian and Scotland S1 Coverage Rate (%) Dose 1 S2 Coverage Rate (%) Dose 1 Female Male Female Male Aberdeen City 79 68 84.3 78 Aberdeenshire 85.6 78.6 91.6 89.4 Moray 87.1 72.4 87.4 86.8 Grampian 83.7 74 88.4 85.3 Scotland 77.5 69.6 86.4 80.9 Source: CHSP School/SIRS Vaccination with Td, IPV and Men ACWY 6.20. Coverage shows that Grampian as a whole and HSCPs individually exceed the Scottish average for diphtheria, polio, and the ACWY meningococcal subtypes. Rates continue to improve in S4. 6.21. However, when coverage is analysed by Scottish Index of Multiple Deprivation (SIMD) there is a marked disparity between those in the most deprived and least deprived. Coverage among the least deprived is as much as 30% higher. 6.22. Updated figures for pupils will be published for school year 2022/23 in November 2023 Table 11: Td/IPV and MenACWY uptake rates by end of S3 and end of S4, Local Authority Area, NHS Grampian and Scotland. School year 2021 – 22. S3 Coverage Rate (%) S4 Coverage Rate (%) Td/IPV MenACWY Td/IPV MenACWY Aberdeen City 72.2 72.5 84.1 83.9 Aberdeenshire 79.9 79.9 89.8 89.3 Moray 77.6 77.8 82.0 82.2 Grampian 77 77.2 86.7 86.4 Scotland 71.6 71.7 74.9 73.8 Source: CHSP School/SIRS Table 12: Td/IPV and MenACWY by NHS board of school and Scottish Index of Multiple Deprivation Quintile S3 Coverage Rate (%) S4 Coverage Rate (%) Scottish Index of Multiple Deprivation quintile Td/IPV MenACWY Td/IPV MenACWY 1= Most deprived 55.6 55.3 67.7 67.7 2 65.3 65.5 77.1 76.5 Page 50
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23 Grampian Vaccination and Immunisation Annual Report 2023 3 74.3 74.6 86.5 85.8 4 80.6 80.6 88.6 88.6 5 85.0 85.2 93.2 92.9 Source: CHSP School/SIRS Uptake and Coverage in Adult Immunisation Programmes Shingles 6.23. This programme was paused during the pandemic and was subsequently transferred to health board/HSCP delivery as part of the VTP. This resulted in a significant catch-up programme being delivered during 2022-23. The health and social care partnerships have made good progress to ensure all those eligible have been offered and this is evident in the progress in table 13. 6.24. In 2022/23, 13,600 shingles vaccines were administered covering routine (age 70 years) and catch-up (age 71 – 79 years) cohorts. 6.25. Uptake of adult vaccination programmes experience seasonal fluctuations as a result of the alignment in delivery models. 6.26. Planning has been ongoing, and we will move to the 2-dose shingles schedule offer to the eligible groups from start of 2024. Table 13: Shingles Zostavax vaccination coverage amongst eligible routine and catch-up cohorts (70 – 79 years). Local Authority area and NHS Grampian. 1 September to 31 August 70 – 79 years % coverage 2021 - 22 2022-23 Aberdeen City 52.3 68.4 Aberdeenshire 49.7 68.2 Moray 69.8 75.0 Grampian 53.9 69.5 Source: National Clinical Data Store/SEER Pneumococcal 6.27. Young children, the elderly and people in a clinical risk group are most at risk of severe pneumococcal disease, and so all these groups are currently offered a pneumococcal immunisation. 6.28. During 2022-23, 14,328 pneumococcal vaccines were administered to citizens turning 65 as well as those in the 2 – 64 at risk cohort and good progress has been made to offer the vaccine to eligible groups. Table 14: Pneumococcal vaccination coverage amongst aged 65+ and 2-64 at Risk cohorts 1 April 2022 – 31st March 2023 % coverage Aged 65+ 2 – 64 at risk Aberdeen City 56.6 22.3 Aberdeenshire 57.8 51.2 Moray 47.3 33.1 Grampian 55.5 36.9 Source: National Clinical Data Store/SEER Page 51
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24 Grampian Vaccination and Immunisation Annual Report 2023 Uptake and Coverage in Seasonal Immunisation Programmes Influenza 6.29. For the 2022/23 flu season adults aged 50 and over, health and social care workers and individuals at risk aged 18 years or over were eligible to receive the flu vaccine. The programme ran from the 5th of September 2022 until the 31st of March 2023. Citizens were invited to attend clinics with most vaccines being co-administered with the COVID-19 winter booster vaccine (89.9%). 6.30. Grampian outperforms the Scottish average for both flu and Covid-19 vaccinations. Table 15: % Uptake Seasonal Flu Vaccine adults 2022/23 18 – 64 at risk 50 - 64 65+ Grampian 57.7 57.2 85.8 Scotland 56.9 55.5 85.5 (Source: PHS FVCV Delivery and planning flash report) Map 1: Cold spot map of influenza autumn winter ‘22 vaccination uptake for citizens aged 65 years and over Covid-19 6.31. As with the seasonal flu vaccine the COVID-19 winter booster programme ran from the 5th of September 2022 to the 31st of March 2023. Eligible groups for the 2022/23 COVID-19 winter booster programme included adults aged 50 years or over, frontline health and social care workers, and at-risk individuals aged 5 years and over. 6.32. A total of 197,720 vaccines were administered during the programme, 73.7% uptake among the total eligible cohort, which is around 1% higher than the uptake reported for the rest of Scotland. Page 52
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25 Grampian Vaccination and Immunisation Annual Report 2023 6.33. During the 2022/23 season overall the uptake rates in Grampian were higher than for the rest of Scotland for individuals aged 5 – 64 at risk, 50-64 years and those aged 65 and over. 6.34. Uptake is lower in areas which are most deprived. Uptake is also lower in some ethnic minority groups, specifically the Polish and African communities. Table 16: % Uptake COVID-19 Booster Vaccine 2022-23 5 – 64 at risk 50 - 64 65+ Grampian 64.2 67.8 91.2 Scotland 63.8 66.0 90.6 (Source: PHS FVCV Delivery and planning flash report) Map 2: Cold spot map of covid-19 autumn winter ‘22 vaccination uptake for citizens aged 65 years and over Table 17: Uptake of COVID-19 winter booster vaccine by SIMD decile for eligible groups 2022/23 programme SIMD Decile (1 = Most Deprived - 10 = Least Deprived) NHS Grampian Page 53
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26 Grampian Vaccination and Immunisation Annual Report 2023 Number Uptake Population Percentage Uptake 1 1,465 2,718 53.9 2 6,088 10,121 60.2 3 10,195 15,628 65.2 4 15,214 22,292 68.2 5 17,129 24,249 70.6 6 23,974 32,848 73 7 29,054 38,402 75.7 8 33,678 44,547 75.6 9 29,476 38,457 76.6 10 31,296 38,962 80.3 Uptake and delivery of other selective and non- routine vaccines 6.35. Non routine vaccinations cover a range of situations where citizens require vaccination out with the usual population vaccination schedules. These include individuals recently treated for cancer or who have had a stem cell transplant and require their full course of vaccinations again; bat handlers or travellers who have been scratched or bitten by rabid animals; certain travel vaccinations etc. 6.36. With no national scheduling, call or recall system for non-routine vaccinations, Boards have been working to put in place processes which support the delivery of these vaccines. NHSG has processes by which services may refer a citizen for vaccinations that are required out with normal vaccination schedules. There remain outstanding operational and clinical questions to be worked through and we are collaborating with specialist services on a local and national level to achieve clarity and strong clinical governance in this most flexible of programmes. A local working group has been established to improve and further develop a system- wide approach to non-routine vaccinations in NHSG with the aim to protect the health of the local population and reduce inequalities. Post Exposure treatment of infectious disease 6.37. Health protection investigations regularly identify persons who have been exposed to infectious disease. Post-exposure treatment with vaccines is recommended in some cases including Diphtheria, Hepatitis A and B, Measles, Meningococcus and Pertussis. Immunoglobulin may also be indicated for some infections. Health and Social Care Partnerships (HSCP) now arrange and administer vaccinations, with referrals made in line with the non-routine vaccine pathway. An updated national Post Exposure protocol is under development. Babies born to mothers with Hepatitis B 6.38. Mothers are offered screening for Hepatitis B in pregnancy and their babies can be offered their first vaccination within 24 hours of birth. Page 54
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27 Grampian Vaccination and Immunisation Annual Report 2023 6.39. During 2022 - 23, a total of 11 babies were born to mothers' resident in Grampian infected with Hepatitis B. Because of the small numbers involved the breakdown of this data is not given. However, babies were not receiving all their doses in a timely way. 6.40. To support improvement work in Grampian we reviewed processes implemented to improve offer and uptake. A Catch-up programme was undertaken and to date all those who have consented to vaccination have received the required doses. Ongoing audit and analysis of vaccinations is discussed at the Grampian Vaccination Programme Board. Table 18. Hepatitis B screening status of all mothers delivering in Grampian during the period April 2022 – March 2023. Screening result: negative Screening result: positive No screening results Total Grampian 4,649 9 78 4,736 Total registerable births in NHS Grampian during this timeframe was 4,958 BCG for newborns at risk 6.41. In 2021, 643 babies in Grampian were identified as meeting the national selective criteria for requiring BCG vaccination. Of these 599 (93%) received the vaccine within the first 12 months of life. 6.42. The BCG uptake levels in at risk infants in Grampian exceeds the 2018 Scottish TB Framework Key Performance Indicator level (set at 85% uptake level) [3] Table 19: Uptake levels of BCG for eligible infants. August ‘21 – September ‘22 Care Location of Birth Total Babies (Live Births) Parent or Grandparent Born in high prevalence area At Risk Babies Offered BCG At Risk Babies Given BCG Total BCG Given NHS Grampian 2021 5313 668 (12%) 550 (82%) 554 (100%) 554 (100%) NHS Grampian Up to 30/09/2022) 3826 547 (14%) 476 (87%) 468 (85%) 468 (85%) Total 9139 1215 1026 1022 1022 Source: Badgernet Vaccinations delivered in Sexual Health Clinics 6.43. A small number of vaccinations are carried out in sexual health clinics as part of their specialist assessment and treatment. 6.44. Since the Mpox outbreak in 2022/23 NHS Grampian sexual health clinics vaccinated 487 individuals, with all those eligible having been offered an appointment to attend for 1st and 2nd doses. Opportunistic vaccination continues. 6.45. A further breakdown is detailed below in Table 20. Table 20: Vaccinations delivered to GBMSM, Source: NaSH Page 55
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28 Grampian Vaccination and Immunisation Annual Report 2023 Vaccine Year Number of patients HPV April 21-March 22 74 April 22- March 23 46 Hep A April 21-March 22 74 April 22- March 23 46 Hep B April 21-March 22 28 April 22- March 23 28 Hep A&B April 21-March 22 279 April 22- March 23 239 Travel health 6.46. Travel risk assessments, advice, and vaccinations (if required) are provided to reduce the risk of transmission of diseases amongst patients travelling to countries where these diseases are still prevalent. 6.47. The travel health service in Grampian has been delivered by community pharmacy since October 2021 and is available to all travellers who reside in Grampian and require advice and /or vaccinations for travelling to a destination considered at risk of tropical disease. 6.48. The following travel vaccines are offered free as part of the NHS service: Hepatitis A, Typhoid, Cholera, and polio / diphtheria / tetanus. 6.49. In person travel health advice is supported by a digital offer. The Fit for Travel website is available to citizens and the Travax specialist website is available to health professionals. 6.50. Since July 2023, Travel risk assessments and vaccines are only offered to citizens residing in the Grampian health board area. Table 21: Number of NHS travel vaccines administered by Local authority and Health board. September ‘22 - August ‘23 Hepatitis A Chlora Typhoid Polio, diphtheria/ Tetanus Aberdeen City 867 21 867 774 Aberdeenshire 1018 102 1131 973 Moray 180 34 211 153 Grampian 2,065 157 2,209 1,900 Source: Seer vaccination dashboard 7. Equity in Grampian 7.1. “Health inequalities are the unjust and avoidable differences in people’s health across the population and between specific population groups. Health inequalities go against the principles of social justice because they are avoidable. They do not occur randomly or by chance. They are socially determined by circumstances largely beyond an individual’s control. These circumstances disadvantage people and limit their chance to live longer, healthier and fulfilled lives. The existence of health inequalities in Scotland means that the right of everyone to the highest attainable standard of physical and mental health is not being enjoyed equally across the population.” 7.2. The above statement is taken from the NHS Grampian Health Inequalities Action Plan. We know from the limited information we have that those suffering Page 56
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29 Grampian Vaccination and Immunisation Annual Report 2023 socioeconomic deprivation and some ethnic groups are less likely to come forward for preventative healthcare. NHS Grampian Vaccination Programme is taking action to investigate and reduce health inequalities in vaccination for the Grampian population. As part of the overarching plan, we are working with colleagues in screening, academia, and community representatives to improve engagement and ultimately to increase uptake of preventative medicine offers within our underserved populations. 7.3. We are currently undertaking a Needs Assessment focussing on families with children under six years of age. Amongst other work to collate what engagement activities are ongoing, we are asking about families’ concerns and beliefs about vaccination and the practical barriers to accessing vaccination. As part of this work, we are trying to reach ethnic communities through the support of HSCP and GREC (Grampian Regional Equality Council) to have their voices heard. This report will be completed for January 2024 and its insights will be used to improve services. 7.4. We are working with the University of Aberdeen on evidence collation and messaging around screening in the Polish community and this will give us insights that we can generalise to the vaccination programme. To support the delivery of programme we are also developing a vaccine inclusivity plan that will complement the screening inequality plan. This will provide a joined-up approach towards addressing inequalities in Grampian. 8. Quality improvement in Vaccination 8.1. Aberdeen City have an Improvement Action Plan. Progress against this plan was reported to their HSCP’s IJB Clinical Care Governance Committee in their August update paper. 8.2. An updated Measles Elimination Plan for Grampian has been written in response to the CMO’s letter. 8.3. We continue to work with boards across Scotland and national colleagues on non- routine vaccination and post exposure treatment pathways. 8.4. Issues are identified and discussed at the Vaccination and Immunisation Clinical and Care Governance Group. Staff participate in shared learning events across the programme at least 2 times per year, along with relevant short life working groups convened to develop improved processes. 8.5. Two PAGs (Preliminary Assessment Group) and a short life working group have been instigated in the 2022-23 timeframe to look at vaccination of newborns born to mothers with Hepatitis B, the decline of childhood vaccination uptake in Aberdeen City and vaccine uptake in pregnancy. A summary of the work undertaken by these groups is as follows: 8.4.1 Vaccination of newborns born to mothers with Hep B Audit showed that babies were not completing their full course of vaccinations. The first vaccination is offered within 24 hours of birth and is usually given in hospital, whereas subsequent vaccinations require referral to the vaccination services. Training has been given to staff and processes improved to ensure this first vaccination takes place and onward referral happens. A catch-up plan was implemented for those babies who have missed their full course. Audits are ongoing to ensure processes are robust and remain under regular review. 8.4.2 Aberdeen City – Vaccination and Child Health Review Annual and quarterly pre-school child vaccination uptake rates for Aberdeen City and NHS Grampian highlight that uptake remains below the 95% necessary to preserve Page 57
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30 Grampian Vaccination and Immunisation Annual Report 2023 herd immunity. There is an ongoing downward trend in vaccine uptake over recent years. A need to ensure accurate, consistent reporting of pre-school vaccine uptake has also been recognised. Our assessment group established that the decline in vaccination uptake identified for Grampian is clear, reflecting the wider decline in pre-school vaccination uptake across NHS Boards in Scotland. However, there are areas where the local vaccination process could be improved, and an action plan has been developed to address these. These include scheduling systems, reporting systems and completeness of data. Further information is available in appendix 2. Progress against these actions will be reported to the Programme Board and will be included in the Annual Report for 2024. 8.4.3 Short Life Working Group - Vaccine hesitancy in pregnant women This work identified the need for targeted engagement, tailored interventions, and clear communication to address barriers to vaccine acceptance among pregnant individuals. Solutions to increase engagement and vaccine uptake with pregnant women in Grampian were identified and recommendations made. Some of which have been implemented for the start of the winter vaccination programme, with the aim of increasing vaccine uptake. This includes making it easier for pregnant women to access an appointment and sharing information with midwifery colleagues to ensure positive information sharing. Priorities for improvement Work with PHS and health intelligence to develop quality assured statistical reporting which will provide live data to allow us to better understand variance in programme and monitor these more effectively. Ensure that we maintain and improve vaccination rates. We will do this by better understanding variance of programmes as well as attitudes and barriers to vaccination. Improve the availability and accessibility of up-to-date resources for all health professionals. This will include development of bespoke training resources for harder to reach groups to highlight the importance of vaccines. Contribute to the digital discovery work being led by NHS National Services Scotland to ensure that we have digital systems to support the delivery of all vaccination programmes. Work with a range of organisations to improve accessibility of vaccination programmes to those that need through targeted interventions. We will develop a Vaccination and Immunisation strategic framework for Grampian to provide governance and assurance around uptake rates and improvement required. 9. Planned changes and Horizon Scanning for Programme 9.1. The below table provide a summary of forthcoming planned and proposed schedule changes which will require teams to adapt delivery models. Programme Changes (proposed/approved) Page 58
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31 Grampian Vaccination and Immunisation Annual Report 2023 Childhood The JCVI advised that the following changes should come into effect nationally once the current supply of the Hib/MenC vaccine has been used: a. an additional dose of Hib-containing multivalent vaccine such as the 6in1 should be given at 18 months (to replace the Hib dose at 12-13 months). b. From 2025, JCVI are recommending the second dose of MMR vaccine be brought forward from 3 years 4 months to 18 months of age. The rationale for delivering the vaccine earlier is to complete the course at an earlier age and therefore further reduce the likelihood of measles outbreaks. c. Due to the success of the adolescent MenACWY programme in controlling meningococcal C disease across the population a dose of meningococcal C containing vaccine is no longer recommended at 12 months. JCVI advises that a Respiratory Syncytial Virus (RSV) immunisation programme, that is cost effective, should be developed for both infants and older adults. JCVI varicella subcommittee continue to assess chickenpox as a target for vaccination. New child health system to replace Scottish Immunisation Recall systems has been brought forward to winter 2024. School MMR review and catch up to take place from S1 rather than S3. Adult 1 September 2023 change of vaccine in Shingles programme to Shingrix, and extended eligibility. If uptake remains the same or improves this will require at least a doubling of capacity within the same financial resources for an extended period of time. Seasonal Poultry workers to be eligible for influenza vaccination in the Autumn winter programme for 2023/24 as a response to Avian Influenza. 10. Conclusions 10.1. This report has highlighted the findings from the surveillance data on vaccine preventable disease in Grampian, as well as vaccine uptakes across childhood, school age and adult programmes in Grampian. The data within the report demonstrates low incidence rates of most vaccine preventable diseases in Scotland and Grampian. 10.2. We continue to achieve good coverage in our vaccination programmes, however there is a growing concern in relation to a decline in childhood uptake trends. 10.3. We have an ambitious plan of quality improvement with a number of priorities being highlighted in section 8. We will conclude and evaluate work around inequalities and improving uptake and we will commence to develop a vaccination and immunisation strategic framework during 2024. This will provide a framework to ensure the monitoring of uptakes across all programmes and ensure that delivery models are accessible and can adapt to the needs of our populations within Grampian. Page 59
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32 Grampian Vaccination and Immunisation Annual Report 2023 11. Acknowledgements The NHS Grampian public health directorate would like to thank everyone who works so hard across the Grampian system to ensure that the population is protected against vaccine preventable diseases by working to ensure that we maintain a high vaccine coverage. Feedback As this is our first annual report, we would welcome feedback on the content of this report so that we can make improvements for future reporting. Please contact us directly with any feedback at: gram.vaccineenquiries@nhs.scot 12. References 1. Joint Committee on Vaccination and Immunisation Code of Practice, June 2013 2. Complete schedule (children & adults) available here: https://www.gov.uk/government/publications/the-complete-routine-immunisation- schedule 3. Immunisation Against Infectious Disease, Immunisation against infectious disease - GOV.UK (www.gov.uk) 4. GMS contract: 2018 - gov.scot (www.gov.scot) 13. Appendix 13.1. Appendix 1: Routine childhood and adult immunisation schedule Page 60
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33 Grampian Vaccination and Immunisation Annual Report 2023 Source: The complete routine immunisation schedule from September 2023 (publishing.service.gov.uk) Page 61
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34 Grampian Vaccination and Immunisation Annual Report 2023 Appendix 2 – Outcome of Aberdeen City PAG The SIRS Appointment System: The system is outdated and is inflexible in its approach to appointment calls and recalls. Appointments are allocated to one specific clinic location according to registered GP. Transfer to a more convenient location is not supported by the system. This creates capacity issues with some locations over capacity and others under used. The management of children not brought for vaccination is equally inflexible. Page 62
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35 Grampian Vaccination and Immunisation Annual Report 2023 Consequently, local vaccination waiting lists are formed and the local child health team and health and social care partnerships continue to contact families/carers on the waiting list to locally manage reappointments to ensure vaccination. This is problematic when local child health teams need to function across HSCP boundaries where children are registered with GP practices out with the HSCP of residence. As a replacement system for SIRS is not expected to be operational before 2025, these issues will remain for the foreseeable future. The SIRS Reporting System: Information cannot be extracted by postcode area which does not allow easy identification of low uptake areas by GP Practice / Postcode. Again, the Grampian vaccination team manually collate data by postcode area to understand any local variation to mitigate this issue through, for example, organising additional clinics. Completeness of data: Data from PHS for the year ending 14th February 2023 was extracted from SIRS and has been analysed locally. As table below shows, during 2022 a total of 1,271 children aged 0-16 were recorded as “new to area” within Grampian and for whom there are no recorded vaccinations. The data do not tell us when the children newly arrived in Grampian, only that a child was coded as new to area at some point. PHS report that this number of new to area children is an outlier compared with other NHS Boards. A child new to area but previously registered within SIRS will have its vaccination history recorded. Children from elsewhere in the UK or from outside the UK will not get an automatic transfer of vaccination history. Once registered with a GP, a child will be entered within the child health system (and therefore SIRS), but it is not automatic that vaccination history is captured. Once captured, it must be manually updated. Within Aberdeen City, the local perception is that children new to area are a mix of those linked to international students attending Higher Education institutes, those arriving as part of asylum and resettlement arrangements, as well as families relocating to Grampian for work. SIRS Data for Children New to Grampian with No Recorded Vaccinations for the year ending 14th February 2023 Age Group Locality Aberdeen City Aberdeenshire Moray Grampian Pre-school (0-4y) 177 (72%) 50 (20%) 20 (9%) 247 School (5-16y) 699 (68%) 239 (23%) 86 (8%) 1024 All ages (0-16y) 876 (69%) 289 (23%) 106 (8%) 1271 Completeness of data: The denominator figures used within SIRS to identify uptake rates does not exclude those children whose families that have notified the service they do not wish to take up the offer of vaccine. This is also a consideration in relation to the data for new to area children, as this may also contain children for whom there is no record of vaccination due to the child having been withdrawn from the vaccination programme by parents/guardians. Page 63
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36 Grampian Vaccination and Immunisation Annual Report 2023 Quality assuring statistical reporting: Ensuring that there is consistency of reporting data relating to vaccination uptake is desirable, as a number of organisations across Grampian use pre-school vaccination uptake rates as part of their organisational reporting. This has led to circumstances where there are discrepancies in the uptake data reported. This can occur because of more recently reported data having become available or when data from national sources has been locally analysed. Page 64
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DRAFT REPORT TO: MORAY INTEGRATION JOINT BOARD ON 30 NOVEMBER 2023 SUBJECT: REVENUE BUDGET MONITORING QUARTER 2 FOR 2023/24 BY: CHIEF FINANCIAL OFFICER 1. REASON FOR REPORT 1.1 To update the Moray Integration Joint Board (MIJB) of the current Revenue Budget reporting position as at 30 September 2023 for the MIJB budget. 2. RECOMMENDATIONS 2.1 It is recommended that the MIJB: i) note the financial position of the Board as at 30 September 2023 is showing an overall overspend of £5,068,191 on core services. ii) note the provisional forecast position for 2023/24 of an overspend of £10,615,345 on total budget for core services; iii) note the progress against the approved savings plan in paragraph 6, iv) note the budget pressures and emerging budget pressure as detailed in paragraph 7, v) note the revisions to staffing arrangements dealt with under delegated powers and in accordance with financial regulations within the Council (MC) and NHS Grampian (NHSG) for the period 1 July to 30 September 2023 as shown in Appendix 3; and vi) approve for issue, the Directions arising from the updated budget position shown in Appendix 4. vii) note that a recovery and transformation plan will be brought to the MIJB Committee in January 2024. Item 8. Page 65
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3. BACKGROUND 3.1 The financial position for the MIJB services at 30 September 2023 is shown at Appendix 1. The figures reflect the position in that the MIJB core services are currently over spent by £5,068,191. This is summarised in the table below. Annual Budget £ Budget to date £ Expenditure to date £ Variance to date £ MIJB Core Service 163,540,354 82,115,057 86,726,473 (5,068,191) MIJB Strategic Funds 17,572,711 3,584,186 3,358,045 226,141 Set Aside Budget 13,917,000 - - - Total MIJB Expenditure 195,030,065 85,699,243 90,084,518 (4,842,050) 3.2 The updated provisional forecast outturn to 31 March 2024 is included in Appendix 1. The figures reflect the overall position in that the MIJB core services are forecast to be overspent by £10,615,345 by the end of the financial year. This is summarised in the table below: Annual Budget £ Forecast expenditure to 31 Mar 23 £ Variance to 31 Mar 23 £ MIJB Core Service 163,540,354 174,155,699 (10,615,345) MIJB Strategic Funds 17,572,711 11,102,775 6,469,936 Set Aside Budget 13,917,000 13,917,000 0 Total MIJB Expenditure 195,030,065 199,175,474 (4,145,409) 3.3 A list of services that are included in each budget heading are shown in Appendix 2 for information. 4. KEY MATTERS/SIGNIFICANT VARIANCES FOR 2023/24 Community Hospitals & Services 4.1 The Community Hospitals & Services is overspent by £21,841 to date, this predominantly relates to cost pressure within community hospital and community admin in the Buckie area. 4.2 This budget is forecast to be £213,711 overspent by the end of the financial year. This is mainly due to forecast expenditure relating to winter vaccinations programme including flu campaign costs in excess of confirmed allocation and additional costs for community hospitals including energy costs. Learning Disability 4.3 The Learning Disability (LD) service is overspent by £1,083,056. The overspend is predominantly due to care purchased at £1,172,230 with income received more than expected reducing this overspend by £76,679 and other minor underspends totalling £1,417. 4.4 The overspend primarily relates to domiciliary care to support an individual in their own home, day care which allows clients to do meaningful activities, Page 66
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social opportunities and a chance to learning new skills and housing support to help people to live as independently as possible in the community. 4.5 This budget is forecast to be £3,473,308 overspent by the end of the financial year, due to the issues above remaining to the end of the financial year and an additional 6 children are due to transition to adults services this financial year. Mental Health 4.6 The Mental Health service is overspent by £63,557. This includes Clinical Nursing and other services which are overspent by £159,243. The overspend is primarily due to staffing in medical services which is overspent by £312,586 partly offset by continuing underspends of £43,679 across Nursing Psychology and Allied Health Professionals (AHP’s) and additional staffing income £165,975 from NHS Scotland alongside other adverse movements totalling £56,311. 4.7 The staffing overspends continues to relate to consultant vacancies to September and junior medical staff within the department being covered by locums. This remains a continuing financial risk to MIJB, which has been reported previously, due to high costs of locums compared to NHS substantive medical staff. 4.8 Assessment and care is £95,687 underspent primarily due to a ceased mental health contract that is currently under review. 4.9 This budget is forecast to be £409,955 overspent by the end of the financial year due to the issues mentioned above being expected to continue to the end of the financial year and there are two mental health clients transitioning from a hospital setting to a community setting, forecast to be in place until the end of the financial year (as detailed in emerging budget pressures paragraph 7.6 below) Care Services Provided In-House 4.10 This budget is overspent by £183,900 due to an accrual relating to the costs from November to March for the staff regrading at Woodview, staff overtime at Woodview and also client transport for internal transport. 4.11 This budget is forecast to be £244,720 underspent by the end of the financial year due to the regrading being paid in December and also the reduction in use of overtime. Older People and Physical Sensory Disability (Assessment & Care) 4.12 This budget is overspent by £724,401 to 30 September 2023. This primarily relates to overspends for care purchased in the area teams of £870,713 and permanent care £709,787. This is being reduced by income received more than budgeted £79,372 and other minor underspends totalling £20,689. The overall overspend is further reduced by the underspend of £756,038 in Care Service provided in-house, there is a direct link between internal and external homecare, hence the offset of this variance. Page 67
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4.13 This budget is forecast to be £1,136,001 overspent by the end of the financial year due to the issues with care purchased continuing to the end of the financial year. The population is ageing and more complex care is now required and projected to continue and most elderly prefer to live in their own home. Other Community Services 4.14 This budget is £166,647 overspent to date. This includes the impact of overspends within Allied Health Professionals for Dietetics, Physiotherapy, Pharmacy and Specialist Nurses. Primarily due to staff costs, loss of income increase costs of medical supplies and other non-pay expenditure. 4.15 This budget is forecast to be £337,337 overspent by the end of the financial year. This is primarily due to continuing cost pressure anticipated in Dietetics, Physiotherapy, Pharmacy and Specialist Nurses. Primary Care Prescribing 4.16 The primary care prescribing budget is overspent by £1,913,000 to 30 September 2023. This estimated position is based on only one month’s actuals for April and an accrued position for May to September due to difficulties implementing a new national prescribing processing system whereby information for NHS Boards has been delayed. The budget to month 6 include allocation from MIJB core uplift of £319,000 to mitigate position. For 2022/23 the overall prescribing volume of items in total was 4.44% higher than in 1921/22. The prescribing volumes overall are now greater than pre Covid levels and are expected to continue to grow. Locally work is ongoing to look at prescribing and a test of change looking at therapeutic drug switches recently achieved £22,000 saving. 4.17 This budget is forecast to be £3,442,842 overspent by the end of the financial year taking into account the volume increase continuing and impact of price changes relating to short supply. Primary Care Service 4.18 This budget is overspend by £117,691 to 30 September 2023, and includes exceptional costs which could not be anticipated for supporting Primary Care services delivered in Moray. This includes support for Aberlour GP practice through a period of extended absence which is continuing and locum costs incurred during this support. 4.19 This budget is forecast to be £235,383 overspent by the end of this financial year, as the need for support costs are anticipated to continue Hosted Services 4.20 This budget is overspent by £154,896 due to continuing cost pressures within recharged hosted services including Marie Curie services, Continence services, HMP Grampian and GMED Out of Hours service Page 68
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4.21 This budget is forecast to be £409,267 overspent by the end of the financial year due to cost pressures above anticipated to continue, as well as additional winter costs expected. Out of Area Placements 4.22 This budget is overspent by £502,807. This relates primarily to Mental Health, Learning Disability and Acquired Brain Injury (ABI) Placements for specific individuals agreed on a case by case basis. This budget remains at the original transfer value in 2016/17. There are an additional 4 patients who have been admitted since that date for who there is no budget, which along with increase in unit costs are producing an overspend. 4.23 This budget is forecast to be £970,869 overspend by the end of the financial year due to the above expected to continue for the rest of the financial year. 5. STRATEGIC FUNDS 5.1 Strategic Funds is additional funding for the MIJB, they include: • Additional funding received via NHS Grampian and Moray Council (this may not be fully utilised in the year resulting in a contribution to overall MIJB financial position at year end which then needs to be earmarked as a commitment for the future year. • Provisions for earmarked reserves has been made to fund unutilised allocation for Primary Care Improvement Funds, Action 15, additional investment funding & others in 2023/24, identified budget pressures, new burdens, savings and general reserve that were expected at the start of the year. 5.2 Within the strategic funds are earmarked reserves totalling £4,682,794. However there will not be enough reserves to cover the overspend in total if the level of spend continues till the 31 March 2024. 5.3 By the end of the financial year, the Strategic Funds will reduce as the commitments and provisions materialise and the core budgets will increase correspondingly. 6. PROGRESS AGAINST THE APPROVED SAVINGS PLAN 6.1 The Revenue Budget 2023/24 was presented to the MIJB 30 March 2023 (para 12 of the minute refers). The paper presented a balanced budget through the identification of efficiencies through savings and the use of general reserves. 6.2 The progress against the savings plan is reported in the table below and will continue to be reported to the Board during the 2023/24 financial year. The table details progress during the first quarter against the original recovery plan. Page 69
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Efficiencies Para Ref Full Year Target Expected progress at 30 Sept 2023 Actual Progress against target at 30 Sept 2023 £’000 £’000 £’000 External Commissioning 6.3 500 250 544 Vacancy target 6.5 1,400 700 1,091 Reduction in prescribing costs 6.6 400 200 0 Reduction in overspending budgets 6.7 600 300 0 Reduction in management costs 6.8 300 150 33 Reduction in overtime 6.9 800 400 0 Staff transport 6.4 136 68 40 Postages 6.4 5 3 5 Additional savings achieved 6.3 0 0 123 Total Projected Efficiencies 4,141 2,071 1,836 6.3 Savings have been achieved in quarter 1 for the full year effect. 6.4 Savings of £45,000 have been taken during quarter 2, but the balance of £96,000 savings will be taken and achieved in full by quarter 3. 6.5 Savings of £400,000 for the full year have been achieved in quarter 1, with savings of £249,000 relating to the period to 30 June 2023 and savings of £442,000 in quarter 2, the rest of the vacancy target is expected to be achieved and progress will be reported each quarter. 6.6 Reduction in the prescribing costs has not been achieved and with the increasing cost pressure on prescribing there is a high chance the overspend will still increase. 6.7 Reduction in overspending budgets has not been achieved and with the current level of overspend on the core budgets is not looking likely to be achieved. 6.8 Reduction in management costs of £33,000 has been achieved in quarter 2, this budget is currently under review but is not expected to be fully achieved. 6.9 Reduction in overtime has not been achieved in quarter 2, with the current level of vacancies and recruitment issues facing the MIJB, it is unlikely this will be achieved. 7 BUDGET PRESSURES 7.1 Budget pressures recognised when the budget was approved on 30 March 2023 are released when the pressure crystallises to the extent that it can be Page 70
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accurately quantified. Provisions to meet budget pressures totalling £927,830 was released in quarter 1 and £2,670,042 was released in quarter 2. 7.2 Provisions still held centrally at the end of quarter 2 total £5,817,099 and are detailed in the table below. Description Para Ref £’000 Pay & inflation 7.3 927 Contractual inflation & Scottish Living Wage 7.3 332 Prescribing & Community Pharmacy 7.4 1,605 Children in Transition 7.3 599 Learning Disability Clients 7.3 (119) Recurring Deficit 7.5 2,473 TOTAL BUDGET PRESSURES 5,817 7.3 These budget pressures have not yet been drawn down as they have not yet materialised in the budgets. At this stage these are all intended to be fully required in this financial year. 7.4 The budget for prescribing has not yet been drawn down but will done in quarter 3. At this early stage in the financial year it is not looking like this will be sufficient to cover all the overspend and pressures in this financial year. 7.5 The budget pressure for recurring deficit is used against the bottom line in the budget and is not allocated out during the financial year. 7.6 Emerging budget pressures have materialised since the budget was set and these are detailed in the table below: Description Para Ref £’000 National Care Home Contract 7.7 823 Mental Health out of area clients 7.8 317 Out of Hours nursing service 7.9 100 Pay award 7.10 1,555 Total emerging budget pressures 2,795 7.7 National care home contract was included in the budget but was also the assumption that funding would be provided for this nationally agreed uplift. The uplift agreed by the care homes with Scottish Government and COSLA was 6.9% however, this was to be funded from existing resources and no additional funding was received and is showing in the core services budgets. 7.8 Emerging budget pressure has arisen for mental health clients that were in a hospital setting, where this is no longer the best place for them and as such the responsibility for these clients are to be under the care of the health and social care partnership. This additional costs is now showing under mental health services and is part of the reason for the increase in overspend as detailed in para 4.6 Page 71
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7.9 Out of Hours nursing service is the budget pressure that was reported to Clinical and Care Governance committee on 31 August 2023. This budget pressure relates to the cessation of the Marie Curie contract and this is phase 1 of the service to replace that contract. This budget pressure is now showing as an additional cost in the core budget under hosted services. 7.10 The cost of the pay award based on the latest offer is expected to be £1,555,000 more than included at the start of the financial year, which was £586,000. This offer has not been agreed and is likely that the cost will increase. Some funding from Scottish Government is expected but the amount is not yet known. 8. CHANGES TO STAFFING ARRANGEMENTS 8.1 At the meeting of the Board on 28 March 2019, the Financial Regulations were approved (para 11 of the minute refers). All changes to staffing arrangements with financial implications and effects on establishment are to be advised to the Board. 8.2 Changes to staffing arrangements as dealt with under delegated powers through appropriate Council and NHS Grampian procedures for the period 1 July to 30 September 2023, are detailed in Appendix 3. 9. UPDATED BUDGET POSITION 9.1 During the financial year, budget adjustments arise relating in the main to the allocation of non-recurring funding that is received via NHS Grampian. In order to establish clarity of these budget allocations a summary reconciliation has been provided below. 9.2 In addition, the MIJB, concluded the financial year 2022/23 in an underspend position following the application of reserves. The unaudited reserves totalling £4,682,793 were carried forward into 2023/24, all of which are ear-marked with no general reserves. £’s Approved Funding 30.3.23 148,673,460 Set Aside Funding 13,465,540 Balance of IJB reserves c/fwd to 23/24 4,682,793 Amendment to Moray Council core (84,698) Amendment to NHS Grampian core 405,876 Children Services & Criminal Justice 19,202,132 Amendment to set aside 451,460 Revised funding at the start of Qtr 1 186,796,563 Adjustments in Qtr 1 1,712,786 Revised funding at the start of Qtr 2 188,509,349 Budget adjustments M04-M06 Moray IJB Uplift 25,000 Moray Vaccination Transformation Programme 60,535 Page 72
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AFC One Off Payment (6,000) Primary Care 63,714 Hosted Recharges 6,186 Arrears of Pay 1,154 Public Health 2,967,972 HCSW Funding 146,195 ADP Funding 496,376 Moray Care Home 8,829 Mental Health Capacity 59,860 LD Annual Health Check 34,594 Mental Health Psychological Therapy 156,835 Mental Health Bundle Funding 67,121 Mental Health Innovation 34,977 PCIF Funding 2,344,000 Community Pathways of Care - Physio in Dr Grays ED 57,900 School nurse funding 26,111 Childrens Service budget amendment (4,643) MC funding adjustment for RLW (26,000) Revised Funding to Quarter 3 195,030,065 9.3 In accordance with the updated budget position, revised Directions have been included at Appendix 4 for approval by the Board to be issued to NHS Grampian and Moray Council. 10. 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’ This report is consistent with the objectives of the Strategic Plan and includes budget information for services included in the MIJB Revenue Budget 2023/24. (b) Policy and Legal It is the responsibility of the organisation receiving the direction to work with the Chief Officer and Chief Financial Officer to deliver services within the resources identified. The Moray Integration Scheme (para 12.8 of the 2015 Integration Scheme) makes provision for dealing with in year variations to budget and forecast overspend by reference to agreed corrective action and recovery plans. It also makes provision for dealing with year-end actual overspend where such action and plans have been unsuccessful in balancing the relevant budget by reference to use of MIJB reserves and additional payments from NHS Grampian and Moray Council. (c) Financial implications The financial details are set out in sections 3-8 of this report and in Appendix 1. For the period to 30 September 2023, a total overspend is reported to the Board of £4,842,050. Page 73
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The updated provisional forecast to end March 2024 has been included in section 3 and Appendix 1, which gives the provisional year end position of £4,145,409. There is also the assumption at this early stage that not all the savings will be achieved. The potential impact to the partners has been communicated however, a recovery plan will be brought to a future meeting of this Committee to mitigate the overspend. The staffing changes detailed in paragraph 9 have already been incorporated in the figures reported. The movement in the 2023/24 budget as detailed in paragraph 10 have already been incorporated in the figures reported. (d) Risk Implications and Mitigations The most significant risk arising from this report is the control and management of expenditure to provide the Health and Social Care services required for the Moray Area, within budget. There are earmarked reserves brought forward in 2023/24. Additional savings continue to be sought and service redesign are under regular review. Progress reports will be presented to this Board throughout the year in order to address the financial implications the MIJB is facing. The claw back of reserves during 2022/23 vastly reduced the amount of reserves carried forward into 2023/24 as well as additional pressures arising from the cost of living crisis, increasing energy bills, emerging budget pressures and inflation puts a risk on the budget. The updated provisional forecast is a potential overspend position, this has been communicated to both partners and a recovery plan will be produced to counteract and potentially reduce this position as both partners are also under severe financial pressures. (e) Staffing Implications There are no direct implications in this report. (f) Property There are no direct implications in this report. (g) Equalities/Socio Economic Impact There are no direct equality/socio economic implications as there has been no change to policy. (h) Climate Change and Biodiversity Impacts There are no direct climate change and biodiversity implications as there has been no change to policy (i) Directions Directions are detailed in para 10 above and in Appendix 4. Page 74
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(j) Consultations Chief Officer, the Health and Social Care Moray Senior Leadership Group and the Finance Officers from Health and Social Care Moray have been consulted and their comments have been incorporated in this report where appropriate. 11. CONCLUSION 11.1 The MIJB Budget to 30 September 2023 has an over spend of £5,068,191 and the updated provisional forecast position of £10,615,345 on core services. This is reduced by underspends in Strategic funds to give a total overspend position, Managers will continue to monitor the financial position closely and will report on the Recovery and Transformation Plan at the next meeting. 11.2 The financial position to 30 September 2023 reflects the updated budget position and revised Directions have been prepared accordingly, as detailed in Appendix 4. Author of Report: D O’Shea Interim Chief Financial Officer (MC) Background Papers: Papers held by respective Accountancy teams Ref: Page 75
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MORAY INTEGRATION JOINT BOARD JOINT FINANCE REPORT APRIL 2023 -SEPTEMBER 2023 APPENDIX 1 Para Annual Budget (Net) Actual Most recent Variance Forecast Ref Net Budget To Date To Date Variance Variance Forecast To Budget Variance £'s £'s £'s £'s % £'s £'s % 2023-24 2023-24 2023-24 2023-24 2023-24 2023-24 2023-24 2023-24 Community Hospitals 4.1 7,028,448 3,915,912 3,937,753 (21,841) (0) 7,242,159 (213,711) (3) Community Nursing 5,600,085 2,805,546 2,873,757 (68,210) (1) 5,638,159 (38,074) (1) Learning Disabilities 4.3 15,312,835 7,158,816 8,241,872 (1,083,056) (7) 18,786,143 (3,473,308) (23) Mental Health 4.7 10,891,080 5,448,240 5,511,796 (63,557) (1) 11,301,035 (409,955) (4) Addictions 1,653,267 832,932 831,247 1,684 0 1,665,120 (11,853) (1) Adult Protection & Health Improvement 184,750 85,820 90,744 (4,924) (3) 194,316 (9,566) (5) Care Services provided in-house 4.11 21,978,772 10,800,685 10,984,585 (183,900) (1) 21,734,052 244,720 1 Older People & PSD Services 4.13 22,235,172 10,541,818 11,266,219 (724,401) (3) 23,371,173 (1,136,001) (5) Intermediate Care & OT 1,644,387 800,462 909,911 (109,449) (7) 1,781,261 (136,874) (8) Care Services provided by External Contractors 1,862,287 917,513 907,778 9,735 1 1,857,977 4,310 0 Other Community Services 4.15 9,467,678 4,814,758 4,981,405 (166,647) (2) 9,804,915 (337,237) (4) Admin & Management 1,637,429 1,299,227 1,299,083 145 0 1,821,783 (184,354) (11) Other Operational Services 1,205,337 610,966 595,968 14,998 1 1,060,418 144,919 12 Primary Care Prescribing 4.17 17,719,490 8,868,166 10,781,166 (1,913,000) (11) 21,162,332 (3,442,842) (19) Primary Care Services 4.19 19,053,956 9,526,978 9,644,669 (117,691) (1) 19,289,339 (235,383) (1) Hosted Services 4.21 5,208,161 2,634,719 2,789,615 (154,896) (3) 5,617,428 (409,267) (8) Out of Area 4.23 720,131 308,302 811,109 (502,807) (70) 1,691,000 (970,869) (135) Improvement Grants 939,600 492,700 570,977 19,625 2 939,600 0 0 Childrens Services 19,197,489 10,251,496 10,251,496 0 0 19,197,489 0 0 Total Moray IJB Core 163,540,354 82,115,057 87,281,151 (5,068,191) (105) 174,155,699 (10,615,345) (214) Other non-recurring Strategic Funds in the ledger 2,973,505 2,820,810 2,821,398 (589) 0 3,292,625 (319,120) (11) Other resources not included in ledger under core and strategic: 14,599,206 763,377 536,647 226,730 0 7,810,149 6,789,057 26 Total Moray IJB (incl. other strategic funds) and other costs not in ledger 181,113,065 85,699,243 90,639,196 (4,842,050) 0 185,258,474 (4,145,409) (2) Set Aside Budget 13,917,000 - 13,917,000 0 0 Overall Total Moray IJB 195,030,065 85,699,243 90,639,196 (4,842,050) ,0 199,175,474 (4,145,409) (2) Funded By: NHS Grampian 112,652,801 Moray Council 82,377,264 IJB FUNDING 195,030,065 Item 8. Page 76
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APPENDIX 2 Description of MIJB Core Services 1. Community Hospitals includes community hospitals, community administration and community Medical services in Moray. 2. Community Nursing related to Community Nursing services throughout Moray, including District Nurses and Health Visitors. 3. Learning Disabilities budget comprises of:- • Transitions, • Staff – social work and admin infrastructure, • External purchasing of care for residential & nursing care, • External purchasing of care for respite, day care and domiciliary care, • Medical, Nursing, Allied Health Professionals and other staff. 4. Mental Health budget comprises of:- • Staff social work and admin infrastructure, • External purchasing of care for residential & nursing care, • External purchasing of care for respite, day care and domiciliary care, • In patient accommodation in Buckie & Elgin. • Medical, Nursing, Allied Health Professionals and other staff. 5. Addictions budget comprises of:- • Staff – social work and admin infrastructure, • Medical and nursing staff • External purchasing of care for residential & nursing care, • External purchasing of care for respite, day care and domiciliary care, • Moray Alcohol & Drugs Partnership. 6. Adult Protection and Health Improvement 7. Care Services provided in-house Services budget comprises of:- • Employment Support services, • Care at Home service/ re-ablement, • Integrated Day services (including Moray Resource Centre), • Supported Housing/Respite and • Occupational Therapy Equipment Store. 8. Older People & Physical Sensory Disability (PSD) budget comprises of:- • Staff – social work infrastructure (including access team and area teams), • External purchasing of care for residential & nursing care, • External purchasing of care for respite, day care and domiciliary care and • Residential & Nursing Care home (permanent care), 9. Intermediate Care & Occupational Therapy budget includes:- • Staff – OT infrastructure • Occupational therapy equipment • Telecare/ Community Alarm equipment, • Blue Badge scheme Item 8. Page 77
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APPENDIX 2 10. The Care Services provided by External Contractors Services budget includes:- • Commissioning and Performance team, • Carefirst team, • Social Work contracts (for all services) • Older People development, • Community Care finance, • Self Directed support. 11. Other Community Services budget comprises of:- • Community services for each locality (Allied Health Professionals (AHP’s), Dental services, Public Health, Pharmacy and other specialist nursing roles). 12. Admin & Management budget comprises of :- • Admin & Management staff infrastructure • Target for staffing efficiencies from vacancies 13. Other Operational Services - range of operational services including – • Community Response • Team • Child Protection • Winter Pressures • Clinical Governance • International Normalised Ratio (INR) blood clotting test Training • Moray Alcohol and Drug Partnership (ADP) 14. Primary Care Prescribing includes cost of drugs prescribed in Moray. 15. Primary Care Services relate to General Practitioner GP services in Moray. 16. Hosted Services, comprises of a range of Grampian wide services. These services are hosted and managed by a specific IJB on a Grampian wide basis and costs are re-allocated to IJB budgets. These services include:- Moray IJB Hosted & Managed services: • GMED out of Hours service. • Primary Care Contracts Team Aberdeen City/Aberdeenshire IJB Hosted & Managed services: • Intermediate care of elderly & rehab. • Marie Curie Nursing Service – out of hours nursing service for end of life patients • Continence Service – provides advice on continence issues and runs continence clinics • Sexual Health service • Diabetes Development Funding – overseen by the diabetes Network. Also covers the retinal screening service • Chronic Oedema Service – provides specialist support to oedema patients • Heart Failure Service – provided specialist nursing support to patients suffering from heart failure. • Police Forensic Examiner Service Page 78
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APPENDIX 2 • HMP Grampian – provision of healthcare to HMP Grampian. 17. Out of Area Placements for a range of needs and conditions in accommodation out with Grampian. These are managed centrally within NHS Grampian and charged to IJB’s. 18. Improvement Grants managed by Council Housing Service, budget comprises of:- • Disabled adaptations • Private Sector Improvement grants • Grass cutting scheme 19. Children Services & Criminal Justice budget was delegated to the MIJB from 1 April 2023 and is in its shadow year during 2023/24. The budget includes the following areas: a) Children Services area teams budget includes:- • Staff – social work (including access team, area teams, disability team, SCIM and Child Protection Unit) • Self directed support • Fostering home to school transport • Support to families b) Quality Assurance team budget includes:- • Staff – social work • Locality management groups funding c) Reviewing Team d) Commissioned Services budget includes:- • Commissioning team • Contracts for all services e) Out of Area Placements for children placed with external fostering agencies or in residential accommodation out with Moray. f) Placement Services budget includes:- • Staff – social work (including fostering, adoption and throughcare/aftercare) • Continuing care payments, income maintenance, supported lodgings and throughcare/aftercare grants • Fostering/kinship fees and allowances • Adoption allowances • Adoption fees to other local authorities g) Children Services Residential Unit h) Justice Services budget includes:- • Staff – social work • Youth Justice services • Out of Hours team Page 79
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APPENDIX 2 • Community Justice Reform • Criminal Justice Services i) Children Services Admin and Management budget comprises of:- • Central management staffing • Target for staffing efficiencies from vacancies j) Additional grant funding • Unaccompanied asylum seeking children • Corra Foundation • Mental Health and Wellbeing Fund • Whole Family Wellbeing Fund Other definitions: Tier 1- Help to help you (information and advice), universal services to the whole community and an emphasis on prevention. Tier 2- Help when you need it (immediate help in a crisis, re-ablement) and regaining independence. Tier 3- Ongoing support for those in need through the delivery of 1 or more self- directed support options. Page 80
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APPENDIX 3 1`HEALTH & SOCIAL CARE MORAY DELEGATED AUTHORITY REPORTS - PERIOD July to September 2023 Title of DAR Summary of Proposal Post(s) Permanent/ Temporary Duration (if Temporary) Effective Dates Funding Geriatrician Support - Nurse Practitioner - Frailty Team x 2 Realignment of band 7 budget to band 6 hours. Band 6 – 60 hours Permanent n/a asap Realignment of existing budget Primary Care Pharmacist (Band 6) PCIP pharmacy regrade 8a to 6 Band 6 – 37.5 hours Permanent n/a asap This is funded out of the B8A money from Maryhill as the 8A cluster lead; is paid from N36349 (PCIP Core/recurring) and is leaving post 30/09/2023. Admin support NHS volunteer services To create a new post providing administrative support to the Volunteer Coordinator. Band 3 – 30 hours Permanent n/a asap MDT Funding Volunteer services monies - has made efficiency Access Team SW hours to East and West team Transfer hours from the Access team to the East and West teams 36.25 grade 9 hours to East Team 18 hours grade 9 to West Team Permanent n/a Asap Posts already in budget Item 8. Page 81
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APPENDIX 3 Title of DAR Summary of Proposal Post(s) Permanent/ Temporary Duration (if Temporary) Effective Dates Funding Refresh the job description of the vacant public engagement post and creation of communications officer Regrade grade 8 to grade 9 Create grade 5 post Transfer posts to sit under Corporate Manager 36.25 hours grade 9 26.50 hours grade 5 Permanent n/a Asap Budget for grade 8 already in place. Funding for regrade from 8 to 9 and creation of grade 5 post will come from MDT funding East Team Resource Re-Distribution To use some social work hours already held within team to increase AP and ACCO hours. Also to reduce 1 part time vacant ACCO post to make other post full time. Current Vacant hours 32.5 hours Grade 10 36.25 hours Grade 9 27.5 hours Grade 5 Create 36.25 hours Grade 10 29 hours Grade 9 21.75 hours Grade 5 Permanent n/a Asap Budget already in place Business Manager to Head of Service HSCM Temporary Post to be make Permanent Band 7 – 37.5 hours Permanent n/a asap Budget identified in Moray Management for difference between band 6/7 Page 82
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APPENDIX 3 Title of DAR Summary of Proposal Post(s) Permanent/ Temporary Duration (if Temporary) Effective Dates Funding Page 83
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APPENDIX 4 MORAY INTEGRATION JOINT BOARD DIRECTION Issued under Sections 26-28 of the Public Bodies (Joint Working) (Scotland) Act 2014 1. Title of Direction and Reference Number MIJB Updated Budget Position 20231130GHB08 20231130MC08 2. Date Direction issued by the Moray Integration Joint Board 30.11.2023 3. Effective date of the Direction 01.04.2023 4. Direction to: NHS Grampian and Moray Council 5. Does the Direction supersede/update a previous Direction? If yes, include the reference number(s) of previous Direction Yes budgeting monitoring report on 28.09.2023 and budget report for 22/23 to MIJB on 30.03.2023 6. Functions covered by Direction All functions listed in Annex 1, Part 1 of the Moray Health and Social Care Integration Scheme and all functions listed in Annex 2, Part 1 of the Moray Health and Social Care Integration Scheme. 7. Direction Narrative Directed to deliver for the Board, the services noted below in pursuance of the functions noted below and within the associated budget noted below 8. Budget Allocation by MIJB to deliver on the Direction Moray Council associated budget - £86.5 million, of which £0.5 million is ring fenced for Housing Revenue Account aids and adaptations and £19.2 for Children Services & Criminal Justice which is in the shadow year. NHS Grampian associated budget - £98.8 million, of which £5.2 million Item 8. Page 84
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relates to Moray’s share for services to be hosted and £17.7 million relates to primary care prescribing. An additional £13.9 million is set aside for large hospital services . All details contained in APPENDIX 1 to the report 9. Desired Outcomes The direction is intended to update and reflect the budget position for 2023/24 10. Performance monitoring arrangements and review Directions will be reviewed by the Audit Performance & Risk Committee on a six monthly basis for assurance. Any concerns should be escalated at the first available opportunity to the MIJB. An annual report of all current Directions will be presented to the MIJB Page 85
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REPORT TO: MORAY INTEGRATION JOINT BOARD ON 30 NOVEMBER 2023 SUBJECT: ADULT AND OLDER ADULT MENTAL HEALTH MEDICAL WORKFORCE BY: INTERIM INTEGRATED SERVICE MANAGER, MENTAL HEALTH & SUBSTANCE MISUSE 1. REASON FOR REPORT 1.1 To inform the Board of progress and expectations for the Adult and Older Adult Mental Health Medical team and to seek approval on a proposal to solve a long standing issue of vacancies in the team. 2. RECOMMENDATION 2.1 It is recommended that the MIJB: i) note the content of the report; and ii) approve that the funding is utilised differently and that we employ Specialty Doctors on the Certificate of Eligibility for Specialist Registration (CESR) program. 3. BACKGROUND 3.1 For a number of years there has been difficulty in recruiting to Consultant posts within both the older adult and adult mental health service. This is due to a national shortage of suitably qualified staff. Numerous rounds of advertising have proven to be unsuccessful. 3.2 Medical workforce and recruitment are issues that are not unique to NHS Grampian. There are several complex national and political factors that have influenced this in recent times and although all of us have faced the impact of this, it is particularly deeply felt in the more remote and rural areas of Scotland. Health care services in Scotland are being increasingly forced to be dependent on a temporary agency workforce which further affects clinical, professional and financial governance. The priority for the mental health service is the continuation of high quality, safe and affordable patient care, therefore options are being explored as to how we can continue to deliver this without the use of expensive locum staff. Item 9. Page 86
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3.3 The Mental Health Service is funded for 10.6 whole time equivalent (WTE) Consultant staff. Based on ten sessions each per week, this equates to 106 sessions. This covers Adult Mental Health, Older Adult Mental Health and the Substance Misuse Service. The Royal College of Psychiatrists’ recommendation is, based on population, Moray should have two Consultant Psychiatrists for its inpatient service within both the older adult and adult mental health service. The Moray medical model is an inpatient/outpatient model, therefore Consultants cover both inpatient and outpatient work which would indicate three Consultants to each specialty. 3.4 Currently the service has six substantive Consultants, with one due to retire in February 2024. One Consultant is part time, therefore out of 106 sessions, 58 are covered. This leaves 48 sessions uncovered, which equates to 4.8 WTE Consultants. The service currently has two Locum Consultants covering 12 sessions each which still leaves 24 sessions uncovered. The remaining Consultants are covering some of these sessions which is leading to fatigue, with increased instances of sick leave. The service is seeing increased patient acuity with around 46% of patients being detained under the mental health act, and there are larger caseloads in the catchment area (caused by increased house building in the area) which creates extra demand on services. Patients are presenting with complex mental illness, with some having never presented to the secondary care service before. 3.5 The service is challenged with the geographical nature of Moray. It has proven challenging to retain trainees in the area and even more challenging to attract new people to come and work in Moray. The majority of the workforce have ties to the area and have either come back or have lived here all their life. 3.6 Locums are a valuable part of the service, however they are an expensive resource. From 1 April 2022 – 31 March 2023 the service spent £705,058 on locums. From 1 April 2023 – 30 September 2023 (6 months) the service spent £358,606 on locums. The nature of the locum appointment and the recruitment challenges mean that the locums become a long term commitment. This is unsustainable for a number of reasons, including financially, but also for continuity of patient care. 3.7 To try and mitigate these challenges the service has explored more permanent and sustainable options, such as a nurse led service, however this will take time to develop. The service is also reviewing catchment areas with a view to ensuring equity amongst Consultants. Caseload management is ongoing to ensure patients are not on lists when they do not need to be. 3.8 The service is committed to reducing the use of locums. One option is the Certificate of Equivalence for Specialist Registration (CESR). This is an alternative route for Doctors, both internationally and UK resident to gain a route to development into a Consultant post. 4. KEY MATTERS RELEVANT TO RECOMMENDATION 4.1 The Mental Health Service are looking to appoint two CESR fellows, one to the older adult mental health service and one to the adult mental health service. These posts are open to International applicants who wish to come to the UK to Page 87
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develop into a Consultant post. CESR fellows are allocated a mentor from the Substantive Consultants and are developed into working at a Consultant level. 4.2 The CESR program is a three year development program where at conclusion the member of staff should have collated enough evidence to present, and be awarded, the Certificate of Eligibility to the Specialist Register and thus be able to secure a Consultant post. CESR fellows are a less expensive resource for the Health and Social Care Partnership. There is a risk that after the three year program the Consultant could leave, but that is true for any post. 4.3 In 2021, the Grampian Mental Health and Learning Disability Service launched the first ever sponsored CESR Fellowship programme in Scotland. There are two intakes per year, one that commences in January and one in August. The application process is rigorous and competitive. A portfolio should be submitted for every applicant which should be the presentation of at least 10 anonymised case histories in a combination of new outpatient assessment letters, tribunal reports, medico legal reports, discharge letters, Care Program Assessment (CPA) reports and urgent assessments. Primary evidence is the backbone, and often central deciding point of a CESR application. Good clinical letters and reports are key in a CESR application and the recording skills of the doctor need to be assessed carefully before admitting them to a CESR fellowship scheme. In addition, an application should include a detailed CV. The doctors also need to convince the interview panel that they are committed to a CESR application and the reasons for choosing this route. They need to demonstrate both some understanding of CESR, have some knowledge of application requirements and motivation to work towards CESR through the portfolio they present. 4.4 As senior international specialists, these doctors are keen to work in the U.K. and gain specialist registration. The sponsored route provides access to General Medical Council (GMC) registration and work visa sponsorship. The entire application process can be completed from their home country so they arrive in Scotland with the security of employment. They also benefit from local Grampian-based training that provides a bespoke CESR orientated programme of support and mentoring. They are also able to draw support from the Scottish Deanery and access a variety of resources for their professional development. 4.5 The CESR Fellows bring rich cultural diversity and expertise in psychiatry to local teams. The process for international recruitment is fiercely competitive and the candidates already have excellent skills in communication, knowledge and experience within the field. With the right intensive onboarding and support, these doctors will become an asset to our services. As the CESR application requires evidencing of expertise at a ‘near consultant’ level, the CESR Fellows will be proactive in gaining not only clinical expertise but also engaging with non-clinical activities including teaching, research, quality and governance activities. This will provide a chance to support the service in many ways whilst keeping a clear supervisory structure for professional assurance. It is hoped that most CESR Fellows will complete a successful application for CESR within the 3 years of the Fellowship and some may choose to additionally pursue the Member of the Royal College of Psychiatry (MRCPsych) examinations. 4.6 Locum Consultants hourly rates can fluctuate depending on which agency the locum is recruited from. The rates can be upwards of £99 per hour. CESR fellows are paid as Specialty Doctors which attract a rate of £43.78 per hour. Page 88
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4.7 CESR fellows are paid as a Specialty Doctor despite covering work of a Consultant, including on-call commitments. The starting salary for an NHS Consultant is £91,474 based on a 40 hour per week contract. Salary for a locum depends on the hourly rate, however taking £99 per hour on a 40 hour per week contract would mean a yearly salary of £190,080 (minus tax, national insurance and agency costs). 4.8 Specialty Doctor starting salary is £40,995, which is a saving of £50,479. The service is looking to appoint to two CESR fellow posts at a cost of £81,990. Should this be approved, the service will cease the use of the two locum Consultants three months post recruitment of the CESR fellows. This would give sufficient time for the induction of the Speciality Doctors. 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 approach set out in this report is consistent with the MIJB Strategic Plan. (b) Policy and Legal There are no implications for policy or legal. (c) Financial implications There are positive financial implications if the proposal is agreed, with the potential for a more stable staff group and patient continuity. (d) Risk Implications and Mitigation The priority is continuation of the service for patients in the adult and older adult mental health service. This model would support the delivery of the right care at the right time by the right people. This model would bring consistency to the medical team as the nature of locum staff mean they can leave their post without giving any notice. (e) Staffing Implications There are staffing implications as the CESR fellows would need a substantive Consultant to mentor them through the program. (f) Property There are no implications on property provision. (g) Equalities/Socio Economic Impact None arising directly from this report. (h) Climate Change and Biodiversity Impacts None arising directly from this report. (i) Directions None arising from this report. (j) Consultations Simon Bokor-Ingram, Chief Officer, HSCM Page 89
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Iain Macdonald, Deputy Head of Service, HSCM Dr Bruce Davidson, Clinical Lead, Moray Mental Health and Substance Misuse Lynne Clark, Business Manager, Moray Mental Health Team Isla Whyte, Interim Support Manager, HSCM Caroline O’Connor, Committee Services Officer, Moray Council Have all been consulted and their comments have been incorporated into this report where appropriate. 6. CONCLUSION 6.1 The MIJB are recommended to approve the proposal in this report and agree that the short term 3 month cost of induction for Speciality Doctors is more efficient than not proceeding with this initiative. Author of Report: Interim Integrated Service Manager, Mental Health & Substance Misuse Service. Background Papers: https://www.rcpsych.ac.uk/news-and- features/blogs/detail/rcpsych-in-scotland-blog/2022/11/25/cesr- fellowship-in-psychiatry-first-for-scotland Guidance for CESR Fellowships (rcpsych.ac.uk) Page 90
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REPORT TO: MORAY INTEGRATION JOINT BOARD ON 30 NOVEMBER 2023 SUBJECT: MORAY WINTER/SURGE ACTION PLAN 2023/24 BY: CHIEF OFFICER 1. REASON FOR REPORT 1.1 To inform the Board of the Health and Social Care Moray Winter/Surge Action Plan for 2023/24. 2. RECOMMENDATION 2.1 It is recommended that the Moray Integration Joint Board (MIJB) considers and notes: i) that Health and Social Care Moray (HSCM), including GMED (the NHS out of hours service) have robust and deliverable plans in place to manage the pressures of surge at any time of the year including the festive period; and ii) that the Moray Winter/Surge Action Plan 2023/24 has been submitted to NHS Grampian for inclusion in the Grampian Health and Social Care Winter (Surge) Plan. 3. BACKGROUND 3.1 Winter / surge planning is a critical part of operational business to ensure business continuity during a potentially pressured time of the year. It is anticipated that the winter period 2023/24 will bring significant pressure to the health and care system across Grampian. 3.2 Moray’s Winter Plan key themes have been created from the nationally agreed Scottish Government and COSLA Winter Priorities and Actions Workshop in August 2023. 3.3 Services are requested to review their business continuity plans annually and review prioritisation of critical functions in order to respond during periods of surge winter activity. Item 10. Page 91
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3.4 Regular cross system meetings are held to learn from previous experience and ensure progress against the Grampian wide action plan. 4. KEY MATTERS RELEVANT TO RECOMMENDATION 4.1 There have been various debrief sessions to identify lessons learned from the previous year’s winter/surge. The attached winter/surge action plan (Appendix 1) has been informed from lessons learned and the remobilisation plan. 4.2 GMED have a Surge Plan for Out of Hours Urgent Care and continue to review / amend as necessary throughout the year to ensure robust, effective and agreed plans for the delivery of primary care out-of-hours services during surge. 4.3 Work will continue to be developed with the Civil Contingencies teams in Moray Council and NHS Grampian, around how HSCM develop and link plans together. Sharing of plans across the three Health and Social Care Partnerships allows discussion about partner support. 4.4 The winter/surge plan is supported by The Scottish Government’s Winter Preparedness Checklist which is attached at Appendix 2. 5. SUMMARY OF IMPLICATIONS (a) Corporate Plan and 10 Year Plan (Local Outcomes Improvement Plan (LOIP)) and Moray Integration Joint Board Strategic Plan “Partners in Care 2022 – 2032” In line with the strategic themes set out in MIJB Strategic Plan. (b) Policy and Legal None arising directly from this report. (c) Financial implications Additional funding is made available by Scottish Government to support additional pressures presented by the winter period. The senior management team will assess and discuss where the funds should be applied for greatest benefit and approvals will be sought as appropriate. The interim Chief Financial Officer continues to report regularly. (d) Risk Implications and Mitigation Any risks relating to the surge plans will be considered and recorded on the Strategic Risk Register and escalated where appropriate. (e) Staffing Implications None arising directly from this report, however staffing is of significant relevance throughout this period as winter ailments will also affect staff. Staff levels will be under constant review and actions taken as appropriate to mitigate risk. Staff are being offered the flu and Covid-19 vaccination to help reduce the risk of severe illness. (f) Property None directly arising from this report. However, HSCM is mindful of the impact of property issues over the winter period i.e. access due to weather. Contingency plans are in place to mitigate risk. Page 92
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(g) Equalities/Socio Economic Impact An Equalities Impact Assessment is not required as there are no changes to policy as a direct result of this report. (h) Climate Change and Biodiversity Impacts An Equality Impact Assessment is not required as there are no changes to policy arising from this report and therefore there will be no differential impact on people with protected characteristics. (i) Directions None directly associated with this report. (j) Consultations Consultation on this report has taken place with the following staff who are in agreement with the content in relation to their area of responsibility: • Chief Financial Officer • Heads of Service • Service Managers • GMED Manager 6. CONCLUSION 6.1 HSCM have worked closely with all key stakeholders under the guidance of NHS Grampian to establish local plans in line with national guidance and good practice. Author of Report: Alison Smart, Clinical Lead Home First/Operational Lead Nurse Moray Background Papers: with author Ref: Page 93
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APPENDIX 1 INFORMATION Draft Winter Priorities and Actions – August 2023 (Scottish Government and Cosla) This is a draft, for discussion, of proposed priorities to help guide planning and delivery of services through the surge period of winter. This builds upon the close partnership developed between the Scottish Government and COSLA in managing the Health and Social Care System throughout winter 22/23 and would seek to ensure that we continue and strengthen that collaboration. To that end, we have drawn from the priorities agreed in October 2022 between SG and COSLA to frame our approach for 2023/24, which aim to put people and prevention at the heart of our work, and provide a focus for local systems to maintain resilient services. These priorities and actions will be incorporated into the Scottish Government and COSLA joint Health and Social Care Plan to be published in early October, following agreement of priorities and actions with COSLA and Scottish Ministers. Summary of resilience priorities 1. Where clinically appropriate, ensure people receive care at home, or as close to home as possible. 2. Through clear and consistent messaging, we will have a strong focus on prevention and give people the information and support they need to manage their own health and care, and that of their families, better. 3. Support delivery of health and social care services that are safe and sustainable. 4. Maximising capacity and supporting our valuable workforce to meet demand. 5. Protect planned care with a focus on continuing to reduce long waits. 6. Prioritise care for the most vulnerable in our communities. 7. Work in partnership to deliver this Plan. VERSION DISCUSSED AT WINTER SUMMIT PRIORITIES AND ACTIONS (To note that those marked with an * are still being explored at this stage) 1. Where clinically appropriate, ensure people receive care at home, or as close to home as possible. a. Through the Urgent and Unscheduled Care Collaborative Programme, improve urgent care pathways in the community and improving links across the primary and secondary care interface. b. We will work with NHS 24 to consider additional outcomes for patients through the urgent care pathway to ensure patients receive the right care in the right place. c. *We will continue to ensure that Community Pharmacy are able to deliver core services; both in and out of hours d. We will through the Expert Panel, increase use of Flow Navigation Centres to reduce avoidable visits to A&E, optimising use of Call Before You Convey and Near Me video consultations and increasing direct access to Flow Navigation Centres from Professionals with a focus on primary and community settings. e. *We will continue to drive improvement to the mental health unscheduled care response to allow people to access care in the most accessible setting. f. *We will scale up remote monitoring for long term conditions to enable people, and those who care for them, to proactively manage acute and chronic conditions. As an example, Accelerator programme for hypertension diagnosis and management in development. g. *We will further expand the Hospital at Home service this financial year to enable patients to be treated at home, where appropriate, and to expand access to care. Item 10. Page 94
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APPENDIX 1 2. Through clear and consistent messaging, we will have a strong focus on prevention and give people the information and support they need to manage their own health and care, and that of their families, better. a. We will continue to encourage Boards and, where appropriate, Partnerships to redirect/ signpost people to the appropriate service for their needs, through national guidance and strong clear local messaging (as seen in NHS Lothian). b. We will ensure the public are made aware of key services that will support them with their care needs for example NHS inform and direct them to right place at the right time c. We will continue to promote the use of the NHS 24 online app and its increased number of self- help guides which signpost people to the right place, at the right time and the national medicines management app that supports people to access and self-manage medicines d. We will continue to build more preventative messaging into health and care communications activity for Winter and throughout the year. e. *We will continue to raising awareness of the mental health and wellbeing resources available on the new Mind to Mind website f. *Campaigns to increasing awareness and uptake of Power of Attorney, to enable people to be discharged from hospital as quickly as possible to the best setting for their ongoing care. 3. Support delivery of health and social care services that are safe and sustainable. a. We will continue with support for sustainability of General Practice to deliver general medical services. This includes developing a capacity and pressures sustainability tool, and continued support for planned increase in GP recruitment and MDTs. b. *We will continue to support Boards to provide a resilient Out of Hours service through the work of the Primary Care Out of Hours Short Life Working Group. c. We will work with Boards on the implementation of Principles of Safe Transfer to Hospital. These principles are designed to reduce the risk of harm to patient’s experiencing extended waits at hospital, improve the health and wellbeing of staff and improve the availability of ambulance resources to respond to patients waiting in the community. d. We will work with NHS 24 and SAS in the development of digital handover ambulance requests and referrals between NHS 24 and SAS to improve the patient and staff experience. e. *We will continue to work with Boards to improve NHS Dental Services and complete the payment reform of the Statement of Dental remuneration f. We will work with Boards to ensure that Community Pharmacy are able to deliver core services; both in and out of hours g. We will support Boards with workforce recruitment, for example in international recruitment. h. We will support an international recruitment pilot started with the aim to improve the experience of providers in undertaking ethical recruitment from abroad. i. * We will maximise social care workforce capacity through recruitment and retention – national campaign and working with local Partnerships j. We will work with Boards to achieve optimal use of staff bank and other supplementary staffing routes k. We will work with Boards to improve delayed discharge data relating to forensic mental health patients. l. We will continue to strengthen workforce retention, such as Retire and Return policy and enable healthcare students to work flexibly alongside study m. National adult social care recruitment campaign running three times during 2023-24 n. *We will continue to work with Fair Work in social care on our commitment to develop a timetable towards £12/hour 4. Maximising capacity and supporting our valuable workforce to meet demand. Page 95
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APPENDIX 1 a. We will reduce time spent in the Emergency Department by working with Boards to deliver rapid assessment and care; enhanced triage and signposting / redirection; short stay b. We will work with Boards to ensure Dentistry and Optometry capacity to support referrals from NHS 24 and OOH/unregistered patient care and holiday cover. c. We will make improvements to reporting and performance dashboards that will support “visibility” of capacity in social care d. We will reduce the time people need to spend in hospital by promoting early and effective discharge planning and robust and responsive operational management. e. We will work with the National Volunteers Hub to explore how volunteers can provide support in discharge. f. We will ensure all eligible workers including non-frontline NHS HSCWs have access to their flu and Covid-19 vaccine. g. We will focus on preventative wellbeing for all health and care staff 5. Protect planned care with a focus on continuing to reduce long waits. a. We will strive to protect cancer care with a focus on continuing to prioritise new urgent suspicion of cancer patients and protect theatres for cancer operating. b. We will deliver the actions contained in Endoscopy and Urology Diagnostic Plan. c. We will work with Boards to maximise capacity through Pooled Lists: locally for high volume specialties (new and return patients) and pooled lists regionally/nationally for longest waits/specific specialities. d. We will work with Boards to maximise theatre capacity including NTCs through expanded sessions in evenings and weekends, e.g., Hot Clinics / Super Saturdays. e. We will support Boards to maximise national automated and administrative validation including clinical validation, for TTG/NOP, cancer and endoscopy waiting lists. f. We will continue to support Boards in the adoption of ACRT and PIR to reduce demand and release capacity. g. *We will continue to encourage the optimisation of digital solutions, standardise pre-operative assessment to reduce unnecessary appointments and cancellations releasing capacity. 6. Prioritise care for the most vulnerable in our communities. a. We will continue to scope options for increasing creation and review of Anticipatory Care Plans (including renaming as Future Care Plans) focusing on specific population groups. Future Care Planning aims to support people to think and plan ahead for changes in their health and care that might happen when they are living with a serious illness; have a longer-term condition or disability that could get worse, or getting older and frailer, focusing on what matters to them. This can include treatments and care they want and don’t want, and could avoid hospital admissions when not wanted or of benefit to the patient. b. *We will continue to support Adults with Incapacity to live well in the community; improve delays incurred by AWI processes [ c. We will provide Covid-19 booster for those at higher risk, as JCVI statement of August-23 and explore access for older/ frailer groups to receive their Flu and Covid-19 vaccines in their home in partnership with local agencies and third sector. d. We will work with Partnerships and NHS Boards across the country to reduce delayed discharges for patients with learning disabilities and complex care needs moving from inpatient treatment to the community. e. We will continue to link with third and voluntary sectors to support older and frailer people who may need practical help to keep them safe and well. 7. Work in partnership to deliver this Plan. Page 96
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APPENDIX 1 a. To deliver on our commitments, we have put in place a national governance system with strategic oversight across health and care to recognise and mitigate evolving risks (including system pressures); maintain a flexible approach; and enable an effective response and support to whole-system winter pressures. b. The Chief Operating Officer NHS Scotland (COO) and Director, Social Care Resilience and Improvement, supported by Health and Social Care Directors and COSLA Officials, will report to Ministers and COSLA Leaders on progress of addressing whole-system pressures throughout the winter period. c. Enhanced monitoring and improvement - A National Oversight Group National Whole System Oversight and Planning Group (WSOPG) will be in place and have strategic oversight of health and social care pressures and be in place to monitor and support health and care systems through the winter period. Working on a subsidiarity basis, local monitoring will continue and health and care organisations will utilise their established governance and response structures to manage pressures. In addition to the WSOPG, Health Emergency Preparedness, Resilience & Response (EPRR) Division will continue to support NHS Boards to respond to any Emergency / Major Incidents through established procedures. The Scottish Government and COSLA will continue to support NHS Boards and Health and Social Care Partnerships to respond to Emergency/Major Incidents and surge pressures through established procedures. This will also include appropriate governance and assurance mechanisms. d. A shared escalation plan between the Scottish Ambulance Service and NHS 24 for early identification and management of surge and risks. Page 97
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APPENDIX 1 MORAY PRIORITY 1 1. Where clinically appropriate, ensure people receive care at home, or as close to home as possible. Link Key Action Date Started Delivery Deadline Lead Officer RAG Status Progress/Comments a Intermediate Care - CRT, D2A, FNCT can adapt during times of increased activity, improve responsiveness to include actions when system GOPES 4 12/10/2023 01/12/2023 Locality Managers Teams able to adapt during recent increase in system pressures, demonstrated responsiveness when DGH GOPES at 4. Escalation document to be produced a Hospital Occupancy, DGH and CH to monitor daily at Response Group 12/10/2023 01/12/2023 Home First Occupancy for DGH and CH noted daily at Response Group a, b End of Life pathway - can adapt at times of increased activity, actions when GOPES 4 12/10/2023 01/12/2023 LA EOL pathway able to adapt during recent increase in system pressures. a, b Outpatient Parenteral Antibiotic Therapy using day hospital services in Community Hospitals 12/10/2023 01/12/2023 DGH IV day case therapy is available in all community hospitals on a day case basis. Plan to have OPAT or DGH referrals to CH's rather than DGH, pathway being developed a, b Rapid Access to Assessment for Frail Elderly for community, ED and Acute 12/10/2023 01/12/2023 DGH This is a development and part of the Frail Elderly collaborative ongoing work Page 98
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APPENDIX 1 c Continue Pharmacy Medicines Review for Frail Elderly 12/10/2023 01/12/2023 Home First Funding secured for CH pharmacy input and Medicines Management Frail Elderly reviews will continue d Flow Navigation and DGH 12/10/2023 01/12/2023 DGH Linked to Unscheduled Care Work g Frail Elderly Identification at ED, identification of complex discharge in ED 12/10/2023 01/12/2023 DGH Plans progressing, IT requirements holding up progress (frail elderly icon on TRAK) g Surge plans for core teams working within Hospital without Walls, (DN's OT/PT, CPN SW etc) for times of increased activity 12/10/2023 01/12/2023 Locality Managers Included in Business Continuity Plans a Realistic Medicine winter Strategy 12/10/2023 01/12/2023 LS Roll out of programme to those attending Vaccination Clinics a Implement Public Health Initiatives and public messaging 12/10/2023 01/12/2023 Health Improvement Roll out via NHSG Health Improvement Team a Review all Anticipatory Care Plans, SPARRA for highlighting those at risk in the absence of other tools 12/10/2023 01/12/2023 Locality Managers Work Ongoing, should complete by delivery deadline a Monitor ASP referrals, report weekly to response group 12/10/2023 01/12/2023 ASP Team Work Ongoing, should complete by delivery deadline a Managers aware and can use Moving On policy 12/10/2023 01/12/2023 SMT Moving on Policy available to all a Aim Frail Elderly Discharge within 48hrs, MDT in ED 12/10/2023 01/12/2023 Home First Work Ongoing, part of longer term actions from the Frail Elderly Collaborative Page 99
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APPENDIX 1 a Monitor the number of patients who are discharged with care in line with their PDD and report at daily response group 12/10/2023 01/12/2023 Hospital SW Team Monitoring this information weekly a, b, d, e, GMED Surge Plan and OOH's provision 12/10/2023 01/12/2023 GMed Management Surge Plan in Place. Resilient out of hours service from GMED. The reintroduction of ‘tough books’ will enhance this service once ICT issues are resolved. GM b, c,. d, g Review Workforce for Winter and Festive Periods, surge plan for times of increased activity 12/10/2023 01/12/2023 SMT All services are now required to provide rota cover for public holiday weekends which are uploaded to SMOC channel. Some services still do not have cover on PH e Mental Health Teams (Liaison Nurses) to establish links with Community Hospitals and Community Teams 12/10/2023 01/12/2023 Mental Health Links made at Care at Home workshop, work commenced to improve communication in particular around the referral of high risk patients needing Mental Health Support a Physical bed surge plan 12/10/2023 01/12/2023 DGH Beds identified for surge a Review of Care Home Intermediate Care Beds (EOL, Respite etc), identify demand 12/10/2023 01/12/2023 Home First Discussed daily at 11.30 meeting a Care at Home Strategy Completion 12/10/2023 01/12/2023 Care at Home Group Work ongoing, strategic group in place, working through actions a Determine need and funding for Interim Beds and possibilities to commission beds if required. 12/10/2023 01/12/2023 SMT HSCM currently have patients in 9 Interim care beds within the community. These beds are used when required. Page 100
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APPENDIX 1 a Plan for winter safety packs to be available for relevant staff 12/10/2023 01/12/2023 Moray Health and Wellbeing care/We Care Team Local health and wellbeing group which links with We Care Team are leading on this. a Remind all staff re Adverse Weather Policy 12/10/2023 01/12/2023 SMT/Service Managers Control room email is now in operation all year. This email will issue relevant policies (MC/NHSG) for onward distribution to staff. a Moray control room reinstated Nov - Feb 12/10/2023 01/12/2023 SMT Rota now in place during office hours, excluding public holidays. Moray HSC Website and Facebook page to be used for sharing of information 12/10/2023 01/12/2023 SMT Public Comms and Engagement Officer now in post. Officer also sits on National Comms Groups for planning, event response etc. Close links with all partners. Page 101
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APPENDIX 1 MORAY PRIORITY 2 2. Through clear and consistent messaging, we will have a strong focus on prevention and give people the information and support they need to manage their own health and care, and that of their families, better. Priority Linked Key Action Date Started Delivery Deadline Lead Officer RAG Status Progress/Comments a Make Every Opportunity Count and Public Messaging, NHS Inform 12/10/2023 01/12/2023 Health Improvement Team Established programmes a b c d e f Continued delivery of targeted Stay Well Stay Connected and Public Health initiatives. 12/10/2023 12/10/2023 Health Improvement Team Established programmes a b c d e f Plan public safety messages with statutory partners (vaccinations, walk like a penguin etc.) 12/10/2023 12/10/2023 SMT/Service Managers Established programmes a b c d e f Ensure communication channels are available with commissioned providers 12/10/2023 12/10/2023 Commissioning Lead Allied invited to system wide meetings, communication channels established Page 102
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APPENDIX 1 a-f Repetition of ‘know who to turn to’ messages to divert demand from hospital and prevent system becoming overwhelmed. 12/10/2023 12/10/2023 SMT/Service Managers Partnership will continue to assist the issue of public safety messages alongside partners. Including repeating any messages being sent out by statutory partners, including Scottish Government. The Partnership will provide links to statutory messages on website/Twitter and social media sites. a-f Moray HSC Website and Facebook page to be used for sharing of information 12/10/2023 12/10/2023 SMT Public Comms and Engagement Officer now in post. Officer also sits on National Comms Groups for planning, event response etc. Close links with all partners. a-f Corporate Communications Teams 12/10/2023 12/10/2023 SMT Moray Portfolio has active and robust links with all Corporate Comms teams for proactive messaging to the public and staff. Page 103
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APPENDIX 1 MORAY PRIORITY 3 3. Support delivery of health and social care services that are safe and sustainable. Priority Linked Key Action Date Started Delivery Deadline Lead Officer RAG Status Progress/Comments b Robust Out of Hours service, plans in place for times of high activity 12/10/2023 01/12/2023 GMed Management Work Ongoing to update plans c Embed principles of Safe Transfer to Hospital 12/10/2023 01/12/2023 NHSG/DGH Work Ongoing, should complete by delivery deadline Dental winter and festive surge plans completed 12/10/2023 01/12/2023 PDS Work Ongoing, should complete by delivery deadline Pharmacy winter and festive surge plans completed 12/10/2023 01/12/2023 CT Work Ongoing to secure local pharmacy opening over festive period - plans to IW for collation All recruitment completed by 01/12/23 12/10/2023 01/12/2023 Locality Managers Work Ongoing, should complete by delivery deadline Ensure all managers can access bank staff 12/10/2023 01/12/2023 Locality Managers Bank access information available on intranet Page 104
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APPENDIX 1 Care at Home winter and festive surge plans completed 12/10/2023 01/12/2023 Work Ongoing, should complete by delivery deadline Social work winter and festive surge plans completed 12/10/2023 01/12/2023 JC SW festive on call plans being developed Festive Staffing Plans collated 12/10/2023 01/12/2023 IW All plans to IW to collate for Festive Plan Ensure managers are aware of HR policies relating to recruitment and retention, Retire and Return etc 12/10/2023 01/12/2023 Service Managers The Partnership will work with both NHS Grampian (NHSG) and MC on any redeployment requirements, within the employers’ policies if required. Working Groups will be stood up to discuss this if required during periods of severe staff shortages as agreed across sectors. Page 105
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APPENDIX 1 MORAY PRIORITY 4 4. Maximising capacity and supporting our valuable workforce to meet demand. Priority Linked Key Action Date Started Delivery Deadline Lead Officer RAG Status Progress/Comments a MDT assessment in ED 12/10/2023 01/12/2023 GH Part of Frail Elderly collaborative work b Dental and Optometry surge winter and festive surge plans in place 12/10/2023 01/12/2023 PDS/Optom etry Lead Plans to IW for collation for Festive Plan d Early effective Discharge planning 12/10/2023 01/12/2023 Home First Monitored via Portfolio meeting, barriers to discharge discussed and managed. Access to short term care (START) challenging, work to be completed around accessing other intermediate services during the winter period c Agree performance dashboard 12/10/2023 01/12/2023 Home First Weekly and Daily Dashboard available on Illuminate, attach both weekly (Monday) at Daily Response Group for review f Promote and Deliver Covid and flu Vaccinations 12/10/2023 01/12/2023 Public Health and Lead Nurse Operational delivery of autumn/winter vaccination ongoing – public and staff. f Staff Absence Reporting 12/10/2023 01/12/2023 SMT/PM Managers’ report any staffing issues at Daily Response meetings. Page 106
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APPENDIX 1 e Develop Volunteer Protocol including a list of tasks with associated risk assessments 12/10/2023 12/10/2023 Care for People Group and Volunteer Coordinator ? A new Volunteer Coordinator has been recruited at DGH. Volunteer protocols with the 3rd and Voluntary Sectors were in place during the pandemic response. This is part of a larger Moray project. They continue to work with NHSG Volunteer Oversight Group to ensure risk assessments and roles are consistent etc. Funding in place to increase the Social Care (MC) Volunteer department to 2 WTE coordinators and plans are underway to review the roles, paperwork and align/compliment both the NHS and Social Care volunteer services where appropriate to meet need and demand. The Oaks (NHS) also has Part -time Volunteer Coordinator. MC is doing a separate piece of work regarding non HSCM volunteers and groups who supported services during the pandemic response. Policies and protocols for HSCM Volunteers will be both MC and NHSG, alongside insurance cover etc. e Promote volunteer register 12/10/2023 01/12/2023 Care for People Group and ? If utilising non NHSG/MC (HSCM) volunteers, it is worth noting there is no information sharing agreement in place with NHSG yet to allow the sharing of personal information. All current HSCM volunteers are recruited to specific roles, but there would be scope, with additional resource to support, to recruit volunteers specifically to support resilience. Page 107
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APPENDIX 1 e Deliver volunteer training if required 12/10/2023 01/12/2023 Volunteer Coordinator All HSCM Volunteers undertake induction training via NHSG or MH and then role specific training before commencing Page 108
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APPENDIX 1 MORAY PRIORITY 5 5. Protect planned care with a focus on continuing to reduce long waits. Priority Linked Key Action Date Started Delivery Deadline Lead Officer RAG Status Progress/Comments a Escalation of risk of cancellation of surgery for patients with cancer 12/10/2023 01/12/2023 DGH Work Ongoing, should complete by delivery deadline c Waiting list plan 12/10/2023 01/12/2023 DGH Work Ongoing, should complete by delivery deadline d Maximising theatre sessions 12/10/2023 01/12/2023 DGH Work Ongoing, should complete by delivery deadline e Cancer waiting lists 12/10/2023 01/12/2023 DGH Work Ongoing, should complete by delivery deadline f ACRT and PIR to reduce demand and release capacity 12/10/2023 01/12/2023 DGH Work Ongoing, should complete by delivery deadline g Optimising digital solutions, reduce unnecessary appointments and cancellations releasing capacity 12/10/2023 01/12/2023 DGH Work Ongoing, should complete by delivery deadline Page 109
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APPENDIX 1 MORAY PRIORITY 6 6. Prioritise care for the most vulnerable in our communities. Priority Linked Key Action Date Started Delivery Deadline Lead Officer RAG Status Progress/Comments a Identification of frailty in ED, in acute and in primary care 12/10/2023 01/12/2023 GH/Home First Part of Frail Elderly Collaborative Action Plan b Monitor ASP referrals, monitor AWI delays 12/10/2023 01/12/2023 ASP Team Monitored by ASP team c Monitor COVID 19 booster and flu uptake for vulnerable groups, ensure system wide knowledge of data 12/10/2023 01/12/2023 Vaccination Team Programme commenced d Monitor the delays in discharge for patient with LD 12/10/2023 01/12/2023 LD Team Monitored at 11.30 meeting e Develop links with third and voluntary sectors to support older and frailer people who may need practical help to keep them safe and well 12/10/2023 01/12/2023 Volunteer Co- ordinator Action Completed Page 110
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APPENDIX 1 MORAY PRIORITY 7 7. Work in partnership to deliver this Plan. Priority Linked Key Action Date Started Delivery Deadline Lead Officer RAG Status Progress/Comments a Ensure a mechanism that provides governance and strategic oversight to recognise and mitigate evolving risks (including system pressures). Develop a surge plan for periods of high activity 12/10/2023 01/12/2023 SMT Daily Response Group and Daily Portfolio Meeting. b Ensure escalation of whole system pressures to NHSG, MC and SG and other appropriate organisations/departments 12/10/2023 01/12/2023 SMT Escalation of information to relevant departments in place c Ensure monitoring and improvement activity over the winter period, this includes emergency preparedness 12/10/2023 01/12/2023 SMT Monitored at OMT and SMT d Ensure that there are mechanisms in place to identify when SAS and NHS 24 are under pressure 12/10/2023 01/12/2023 SMT In place Nationally Page 111
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Scottish Government Health & Social Care: Winter Preparedness Self-Assessment Checklist 2023/24 Page 1 of 13 Health & Social Care Winter 23/24 Preparedness Checklist The Winter Preparedness Checklist sets out key areas of resilience preparedness to provide both local systems and Scottish Government with an understanding of the level readiness of winter plans. If there are any areas within this checklist that have not been considered, it remains the responsibility of the respective Board /HSCP to develop an action plan to ensure that appropriate action is taken to improve resilience. As a further line of defence, local systems may wish to engage internal audit in the review of this checklist. Return due: 22-Sep-23 APPENDIX 2Item 10. Page 112
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Scottish Government Health & Social Care: Winter Preparedness Self-Assessment Checklist 2023/24 Page 2 of 13 NHS Scotland Chief Operating Officer Director for Social Care Resilience and Improvement 6th September 2023 Dear Colleagues, WINTER PREPAREDNESS CHECKLIST Ahead of our Winter Plan for health and social care in Scotland, we are taking a state of readiness check across systems, Health Boards, and Health and Social Care Partnerships for service resilience, similar to the approach we have taken in previous years. The Winter Preparedness Checklist (this document) sets out key areas against which we asked you to provide an assessment of preparedness for your local systems. We are taking a further step this year in that preparedness view through a whole-system approach. We have reflected a number of health and social care assurance statements throughout the document, albeit there are health-specific sections as per previous years. We will continue to develop this approach each year. For 2023/24, we are asking that this checklist is completed as a collaboration between Health Board and associated Partnerships. For Health Boards, we will seek to align follow-up of the checklist responses with the quarterly ADP reviews (covering Q1 and Q2) to avoid duplication where possible. This will be further supported by regular meetings between Directors of Planning and the Health Planning Team. Boards will receive funding letters this week for unscheduled care, which should be targeted towards improvement measures that support delivery of the Four Hour Target. This includes measures which will support winter resilience and implementation of the actions outlined in the checklist. For partnerships, we are aware that this ask comes alongside other returns such as the quarterly Whole System Discharge Planning Self-Assessment Tool that will be issued this week. In Page 113
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Scottish Government Health & Social Care: Winter Preparedness Self-Assessment Checklist 2023/24 Page 3 of 13 recognition of this we have extended the return date of the self-assessment to 6th October. We also want to offer reassurance that these returns will be considered holistically and not in isolation. If there are any areas within this checklist that have not been fully considered, it would be expected that Boards and local systems develop an action plan to ensure that appropriate action is taken to maintain and improve resilience. We request all areas return the completed checklist by 22-Sep-23, for review and engagement with you, as appropriate, over the course of October. If you have any questions, please contact the Health Planning team at healthplanning@gov.scot Yours sincerely John Burns Angie Wood NHS Scotland Chief Operating Officer Director for Social Care Resilience and Improvement Page 114
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Scottish Government Health & Social Care: Winter Preparedness Self-Assessment Checklist 2023/24 Page 4 of 13 The Winter 23/24 Resilience Priorities The winter resilience priorities are consistent with last year: key system resilience areas for supporting patients, citizens and staff through seasonal increase in demand. The delivery and implementation is year-round improvement and development to support ongoing resilience and capacity across the systems, alongside targeted prevention and early-intervention work. 1. Where clinically appropriate, ensure people receive care at home, or as close to home as possible. 2. Through clear and consistent messaging, we will have a strong focus on prevention and give people the information and support they need to better manage their own health and care, and that of their families. 3. Support delivery of health and social care services that are safe and sustainable. 4. Maximising capacity and support wellbeing of our workforce to meet demand. 5. Protect planned care with a focus on continuing to reduce long waits. 6. Prioritise care for the most vulnerable in our communities. 7. Work in partnership to deliver this Plan. Completing the Self-Assessment Winter Checklist There are four sections to the self-assessment checklist: 1. Overview of Preparedness & Business Continuity 2. Urgent & Unscheduled Health and Social Care, Planned Care 3. Primary Care, Mental Health and Social Care 4. Health and Social Care Workforce and Staff Wellbeing Whole System Response As outlined at the recent Winter Summit, the approach we are taking is to strengthen our whole- system planning. Please complete the checklist as a joint response between Board and Partnerships. It is appreciated that for some areas this requires increased logistics; please be in touch with the team if this is not possible. Where necessary, supplementary information can be provided that outlines your Board/Partnership position. Financial Note Boards have submitted financial plans for 2023-24 and this would have included costs over the winter period. All areas in this document are assumed to be included already in plans and no further funding is anticipated, unless otherwise stated. As noted above, Boards will shortly receive funding letters for unscheduled care which should be targeted towards improvement measures that support delivery of the Four Hour Target. This includes measures which will support winter resilience and implementation of the actions outlined in the checklist. Checklist statements For each assurance statement, please provide a current state level of readiness alongside a short statement on the rationale for that classification. The statement should be high-level and concise. Statements which are showing as ‘Yes’ (or green in the Excel format) will be assumed to require no further action. Areas showing as ‘Partial’ or ‘No’ may require a follow-up discussion to gain greater understanding of the classification and any mitigations that can be put in place. Current level classification Page 115
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Scottish Government Health & Social Care: Winter Preparedness Self-Assessment Checklist 2023/24 Page 5 of 13 There are four possible responses; this provides a high-level status for the readiness statement. Classification Definition Yes The statement is true for your Board / Partnership Partial The statement is mostly true for your Board Partnership; minor issues still to be resolved but it is estimated that this area will be ready ahead of winter No This statement is not true for your Board / Partnership; major issues still to be resolved and it is estimated with current plans this area will not be ready for winter n/a This statement is not applicable for your Board / Partnership Example The table below provides an example of classification with associated response statement. 1.1 There are sufficient mechanisms in place to support the collaboration and co-operation with other Boards and Partnerships in the delivery of health and care. Yes Our health board and HSCP has regular meetings with a joint winter plan. Partial Our health board is part of our regional winter readiness group which is working across our partnerships; it has not met yet to agree plans yet. No Our health board and HSCP has not yet met to discuss winter and we have no meeting scheduled. n/a Our health board does not have formal partnership agreements. Deadline and return of form Please return the completed checklist by 22-Sep-23. We have provided an Microsoft Excel version of the return responses to support completion of the checklist; this has dropdown boxes and summary dashboard. Excel is the preferred return format. However, if you would prefer a Word version, please contact the team. The Excel has a “Submit Return” button which will automatically generate an email to return. To manually send the return, please send to healthplanning@gov.scot Page 116
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Scottish Government Health & Social Care: Winter Preparedness Self-Assessment Checklist 2023/24 Page 6 of 13 Section 1: Overview of Preparedness & Business Continuity * Indicates additional information provided. Subsection # Readiness Statement Overarching principles 1.1 There are sufficient mechanisms in place to support the collaboration and co- operation with other Boards and Partnerships in the delivery of health and care. 1.2 Plans have been developed through joint working between the Board, associated HSCPs, and other key partners (i.e. Primary Care practitioners, SAS, Scottish Prison Service, care at home and care home providers etc.). It is clear to all parties how plans will be delivered through joint mechanisms. 1.3* Winter Planning includes demand, capacity, and activity plans across all health and care delivery (including urgent, unscheduled, social care and planned care provision). 1.4 Planning for winter reflects identification of surge capacity to ensure capacity is made across the health and care system to allow new emergency admissions to be accommodated. Resilience preparedness 1.5 Business Continuity Management arrangements are in place and regularly reviewed, exercised, and updated. These are in accordance with Civil Contingencies Act 2004 for Category 1 and 2 organisations and other guidance including: • NHS Scotland Standards for Organisational Resilience 2018. • Preparing For Emergencies: Guidance for Health Boards in Scotland. 1.6* Plans have identified potential disruptive risks to service delivery and associated mitigation responses. These incorporate lessons identified from Winter 2022/23 in addition to concurrent risks. Resilience Teams are involved in winter preparedness to ensure that business continuity management principles are embedded as part of year-round capacity and service continuity planning. 1.7* Business Continuity plans take into account critical activities across the NHS Board / HSCPs spectrum of activity and include analysis of the risks of disruption and their actual effects and demonstrate that planning has been based upon the likelihood and impact of worst-case scenarios. 1.8* Business continuity plans include response(s) if a clinical system outage occurs and the steps required to ensure continuity of services. Communications 1.9* Local communication plans: A review has been undertaken of communication channels to ensure that key messages about winter planning are clearly and consistently delivered to all parties, involved. This includes : a) Key partner communication protocols b) OOH information including four day festive period c) Surgery hours & access arrangements General practices contingency plans for respiratory disease outbreaks d) Signposting to Scottish Government assistance for households struggling to meet their energy bills. Step up / Step down care 1.10* Boards and HSCPs can evidence plans to increase the provision of intermediate care to impact positively on patients and services over the winter; and work towards building sustainability for the future. Page 117
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Scottish Government Health & Social Care: Winter Preparedness Self-Assessment Checklist 2023/24 Page 7 of 13 Section 2: Urgent & Unscheduled Health and Social Care, Planned Care * Indicates additional information provided. Subsection # Readiness Statement Urgent and Unscheduled Care 2.1* To ensure Right Care is provided in the Right Place, a 24/7 Health Board Flow Navigation Centre is in place to offer rapid access to a senior clinical decision maker as well as the option of appointments via Near Me. 2.2* Effective communication protocols are in place to support whole-system situational awareness of emerging pressures. Monitoring of key indicators across the system forms the basis of huddle discussions. This ‘early warning system’ should highlight areas of concern and drive action to maintain or regain a balanced system. 2.3* Robust communication processes are in place across each hospital site, following Discharge Without Delay (DWD principles) including morning hospital-safety huddles, focusing on the day's activity and current status, and afternoon huddles, setting Planned Date of Discharge and using this to predict capacity and demand for the next day. 2.4 Emergency Physician in Charge (EPIC), Flow Co-Ordinator roles are in place where possible to provide dedicated leadership in Emergency Departments. A Discharge Co-ordinator is in place in each ED to act as a single point of contact (SPOC) to arrange rapid discharge from ED and take responsibility for co- ordinating community support. 2.5* Pathways are in place which provide care closer to home through pathways such as Hospital at Home for Older People; Respiratory Rapid Response and Out- patient Parental Antibiotic Therapy (OPAT); and supported by appropriate digital interventions such as Remote Consultation by phone and Near Me and Remote Monitoring, call before convey with SAS and flow navigation hub working to maximise virtual/remote Monitoring. 2.6 Boards and Partnerships have effective organisation of care across between primary and secondary care so that patients receive high-quality care and the best use is made of clinical time and resources in both settings. This could be through a mechanism such as an Interface Group. 2.7* Escalation procedures are directly linked to a plan which encompasses the full use of step-down community facilities. 2.8 Boards and HSCPs have additional festive arrangements, over the four-day public holiday, planned in collaboration with partner organisations such as Local authorities, Police Scotland, SAS and the local Voluntary Sector and in line with recommendations from the Four Day Public Holiday Review. 2.9 Patients identified as being at high risk of admission from both the SPARRA register and local intelligence, and who have a care manager allocated to them, will be identifiable on contact with OOH and acute services to help prevent admissions and facilitate appropriate early discharge. 2.10* Processes are in place to enable patients with respiratory conditions and those who are frail are given the opportunity to have an anticipatory or future care plan. There should be a system in place for identifying these individuals and it should be clear which professional clinical groups will take a lead on having these care planning conversations depending on the persons circumstances. 2.11* Pathways are in place for patients who are identified as ‘frail’ and those with respiratory or cardiac exacerbations, and these are embedded within primary care services, in and out of hours, as alternatives to admissions. 2.12* People living with a respiratory condition have access to a respiratory team 7 days a week, should they become unable to self-manage their condition from home. People with heart failure and those who are living with frailty should be given the opportunity to have an anticipatory or future care plan. Page 118
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Scottish Government Health & Social Care: Winter Preparedness Self-Assessment Checklist 2023/24 Page 8 of 13 2.13 Care Homes will be supported with timely access to professional support and clinical advice to enable admission prevention and more planned interventions to keep residents safe in their own home. This includes proactive contact on at least a weekly basis to discuss any residents the care home staff are concerned about and agree a plan of care and interventions if these should be required. Remote consultations via phone or Near Me video consultation should be available. 2.14* For Health Boards with Major Trauma Centres (Grampian, GGC, Lothian, Tayside), to incorporate into their winter surge plans, assurance of sufficient safe staffing on MTCs (both adult and paediatric) to ensure Scottish Trauma Network MTCs will continue to deliver high quality, integrated, multi-speciality care to severely injured patients. Further consideration is also required for those Boards with Major Trauma Units to similarly support safe staffing. 2.15 Where admission is necessary, ensure there is a mechanism and/or agreements in place with primary care and secondary care clinicians to minimise delays in pathway, and avoid multiple discussions that can lead to delays; recognising that in periods of increased demand, general practice may not have the functional capacity to follow the usual processes such as pathways for admission. Planned Care 2.16* Plans are in place to maintain activity over winter for planned care, including outpatients and inpatient / daycase, diagnostics, imaging and cancer, with plans considering the impact of increased unscheduled admissions on planned care activity. Planned care activity will not be paused or cancelled routinely – if Health Boards need to consider this as part of their business continuity / escalation plans it needs to be discussed and agreed in advance with Scottish Government. 2.17 Health Boards are considering opportunities to maximise capacity through Pooled Lists - locally for high volume specialties and pooled lists regionally / nationally for those patients waiting the longest. 2.18 Health Boards are making use of the National Elective Coordination Unit (NECU) to support admin and clinical validation. 2.19 For those Health Boards with National Treatment Centres (NTCs), plans are in place to enhance and maximise use of the NTCs through winter and beyond. 2.20* Discharge – close partnership working is in place, including the third and independent sector, to ensure that adequate care packages are in place in the community to meet all discharge levels. Digital assets 2.21 Plans are in place to support the availability of Near Me video consultations to optimise estate and workforce capacity. Section 3: Primary Care, Mental Health and Social Care * Indicates additional information provided. Primary Care: Primary Care Independent Contractors (including General Practice, Dentistry, Optometry and Pharmacy and including Health Board provided Primary Care Services e.g. 2C practices and Health Board employed MDT). Subsection # Readiness Statement Primary Care 3.1* Plans are in place to support General Practice (and where necessary other independent contractors) to manage provision of core General Medical Services (and sustainability more widely) over the winter period. Specific reference should be made to contingency arrangements where practices are unable to open (or provide General Medical Services) due to staffing or other reasons. Health Boards and HSCPs should ensure that where services are Page 119
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Scottish Government Health & Social Care: Winter Preparedness Self-Assessment Checklist 2023/24 Page 9 of 13 reduced or unavailable they support the practice with communications to patients including alternative arrangements. 3.2* Maximising Multi-Disciplinary Teams (MDTs) Plans explicitly reference the use of MDTs within OOH services; indicate where increased use of MDTs are in place. This includes increasing capacity of senior clinical and non- clinical leadership, use of multidisciplinary teams and availability of professional-to-professional advice across acute and community. 3.3 Executive level overview and oversight for Out of Hours (OOH) A Primary Care OOH winter plan has been signed off at Executive level, with clear escalation processes in place. There is Board Executive level oversight of OOH to support resilience, explore other operational solutions and agree appropriate escalation plans during the winter period given its essential role as a “front door” service 3.4* Link with wider winter plans and engagement with SAS and NHS 24 to improve system resilience. The plan puts Primary Care OOH within the context of winter readiness preparedness, as part of the urgent/unscheduled care landscape and whole system local planning, including community and social care responses through urgent care resource hubs/flow navigation centres (FNCs), or equivalent. 3.5 NHS Board Directors of Dentistry engage with NHS 24 to ensure they have sufficient capacity in place to meet any potential increased demand for out of hours care during the winter period 3.6 Provision of OOH dental services Plans reference provision of dental services; services are in place either via general dental practices or out of hours centres. This should include an agreed escalation process for emergency dental cases, i.e. trauma, uncontrolled bleeding and increasing swelling. 3.7 Working with mental health services HSCPs should have clear arrangements in place to enable access to mental health crisis teams/services 24/7, including availability of professional to professional advice for out of hours services, particularly during the festive period. 3.8 Increased level of professional-to-professional advice Boards and HSCPs have increased, where possible, the availability of professional to professional advice across acute and the community to ensure the patient receives right care in the right place at the right time. 3.9 Working with social care OOH Plans demonstrate consideration to social care services and where possible close links are in place for emergency respite, community alarm services and home care provision. OOH Plans will identify how Care Homes will be supported with timely access to professional support and clinical advice (particularly in the OOH period) to enable admission prevention and more planned interventions to keep residents safe in their own home. Mental Health 3.10* Winter readiness plans consider the needs of those living with a mental health, learning disability, neurodiverse or dementia diagnosis, including the needs of carers. 3.11 Plans to ensure appropriate staffing levels include consideration of mental health services and the need to maintain support for service provision and patient Page 120
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Scottish Government Health & Social Care: Winter Preparedness Self-Assessment Checklist 2023/24 Page 10 of 13 rehabilitation (such as suspension of detention), including for forensic mental health patients. 3.12 The discharge partnership working plans include consideration of those requiring mental health supports and/or being discharged from a mental health setting, including the unique support package needs of those leaving forensic inpatient settings or with complex care needs. 3.13 Plans ensure continued access to dementia diagnosis services for both inpatients and those in the community, ensuring people have care and treatment appropriate to their needs and any potential dementia-related issues are recognised and addressed. 3.14* Plans are in place to ensure data is available to monitor the performance of mental health services throughout the winter. Prisons 3.15 Plans are in place to ensure that the delivery of prison healthcare, including mental healthcare, is maintained and that that there are appropriate levels of healthcare staff in prisons to deliver efficient and effective patient care. Social care 3.16 Care at home assurance boards and care home assurance arrangements are in place to ensure all risks in care provision are recorded and appropriate mitigating actions are put in place. 3.17 Capacity to deliver key public protection functions is in place e.g. child and adult protection, MAPPA (Multi Agency Public Protections Arrangements) Section 4: Health and Social Care Workforce and Staff Wellbeing * Indicates additional information provided. Subsection # Readiness Statement Workforce 4.1 Appropriate steps are being taken to support recruitment of staff on an ongoing basis within recognised financial parameters, utilising the full range of potential contractual arrangements including (but not limited to) Permanent, Sessional Worker, Bank or Fixed Term contracts (or a combination of these). Work undertaken with local college and HEI student workforce to offer holiday shifts and regular part time contracts can be evidenced. 4.2 Boards and HSCPs are continuously deploying the range of tools available to them to support efforts aimed at staff retention. For Boards, this is including but not limited to those set out through DL (2022) 30: DL(2022)30.pdf (scot.nhs.uk) to enable those staff who have retired to return to work on a part time basis should they wish to do so. 4.3 Plans are in place for appropriate levels of staffing across the whole system to facilitate efficient and effective patient care, ensuring consistent effective discharge planning takes place over 7 days and the holiday periods. This requires sufficient senior medical and other senior clinical decision makers to facilitate decision-making, and pharmacists to prepare timely discharge medications. For HSCPs, this includes sufficient social work staff and others associated with discharge planning. 4.4 A strategy is in place for the deployment of volunteers over winter, making appropriate use of established local and national partnerships. Investment in and funding of local voluntary and third sector organisations to support care@home teams and provide practical support to people who are ready for discharge, and across the wider community can be evidenced. Page 121
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Scottish Government Health & Social Care: Winter Preparedness Self-Assessment Checklist 2023/24 Page 11 of 13 4.5 Staff are appropriately supported to access the range of available local and national staff wellbeing resources. This includes Primary Care independent contractor staff. 4.6 In relation to potential adverse weather, Boards and Partnerships have contingency plans in place covering staff disruption to manage the impacts – for NHS this is specifically according to DL(2022)35.pdf (scot.nhs.uk). Staff are fully aware of the contingency plan. Seasonal outbreak 4.7 COVID -19, RSV, Norovirus, Seasonal Flu, Staff Protection & Outbreak Resourcing All patient-facing Health and Social Care Staff (and this includes Primary Care independent contractor staff) have easy and convenient access to the Covid-19 and seasonal flu vaccines and that: i. clinics are available at the place of work and include clinics during early, late and night shifts, at convenient locations. ii. drop-in clinics are also available for staff unable to make their designated appointment. iii. peer vaccination is facilitated, where possible, to bring vaccine as close to the place of work for staff as possible. iv. information and guidance is provided to staff on how to book appointments via the online portal or the National Vaccination Helpline. v. Information and guidance/ promotional materials are provided to staff specific to the benefits for HC staff in receiving the vaccine. 4.8* Plans take into account the predicted surge of Covid-19 as well as other viruses including seasonal flu, RSV and Norovirus activity that can happen between October and March and have adequate resources in place to deal with potential outbreaks and the impact these have on services (health and social care inclusive of primary care) across this period. 4.9* Adequate resources are in place to manage all potential increases in Covid-19 including possible new variants with increased severity, RSV and seasonal flu that might coincide with norovirus, severe weather and festive holiday periods. Debriefs should be undertaken following significant outbreaks or end of season outbreaks to identify lessons and ensure system modifications to reduce the risk of future outbreaks 4.10 To help detect early warnings of imminent surges in activity, Boards routinely monitor PHS weekly publications, showing the current epidemiological picture on COVID-19, RSV, Norovirus and influenza infections across Scotland, and PHS Whole System Model Winter outputs. 4.11 Boards must ensure that staff have access to and are adhering to the national guidelines on Preparing for and Managing Norovirus in Care Settings Page 122
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Scottish Government Health & Social Care: Winter Preparedness Self-Assessment Checklist 2023/24 Page 12 of 13 Additional Notes Section 1 Overview of Preparedness & Business Continuity 1.3 These projections are reviewed at least weekly to assess fullness and drive balancing actions across the whole system to prevent overcrowding and maintain safe front-door pathways. 1.6 Concurrent risks include but not exclusive to: i. Industrial Action, including risk of strike action in other services, such as public transport and/or education, and risk of concurrent action across the public sector. ii. Power Outage (national, localised, planned) iii. Severe Weather iv. NHS Supply Chain v. Cyber security attack and plans in place to mitigate any impact of an attack 1.7 Risk assessments account staff absences including those likely to be caused by a range of scenarios and are linked to a business impact analysis to ensure that essential staff are in place to maintain key services. Critical activities and actions required are included on the corporate risk register and are actively monitored by the risk owner and the Executive Team. 1.8 Plans include process, equipment and staffing to operate under Business Continuity. 1.9 Consideration is given to highlighting: • www.readyscotland.org as one stop shop for information and advice on how individuals and communities can prepare for and mitigate against the consequences from a range of risks and emergencies. • The Met Office National Severe Weather Warning System for information on the localised impact of severe weather events. • Use of NHS Inform to support people to look after themselves and identify alternative pathways for care. Communications plans a) Effective communication protocols are in place between key partners, particularly across unscheduled and planned care provision, local authority housing, equipment and adaptation services, Mental Health Services and the independent sector. b) Information about OOH services is routinely available to the public at evenings and weekends, and includes community pharmacy NHS Pharmacy First, optometry first port of call and, information on advance planning for the 4-day Festive Periods, including pre-stocking of repeat prescriptions. c) There is a public communications strategy covering surgery hours, access arrangements, location and hours of PCECs, MIUs, pharmacy opening, etc. Arrangements are in place to ensure that general practices have robust contingency plans in place for outbreaks of respiratory diseases. 1.10 Plans include: • continued implementation of the following to enable step up and step down care and prevent admission: Home First, Discharge without Delay, Discharge to Assess and effective End of Life pathways to prevent an increase in patients who are delayed in the health and care system • increase in community capacity to enable patients to be discharged to their own home (or as homely a setting as possible) as the default ambition. This increase in capacity will be context specific according to need and be a mixed model of an increase in health and care community services, and/or bed based services dependent on patient and service need. Continued and swift mobilisation of their local voluntary and third sectors to maximise support to community services enabling people to be discharged and avoid readmission. This increase will also have to consider the role of General Practice and primary care out of hours services, in providing supporting services and their capacity to do so. Section 2: Urgent & Unscheduled Health and Social Care, Planned Care 2.1 This is staffed by a multi-disciplinary team, optimising digital health where possible in the clinical consultation, and should have the ability to signpost to available local services, such as MIU, Ambulatory Emergency Care, General Practice (in and out of hours), mental health services, pharmacy and ED if required. Self-care / NHS inform should be promoted where appropriate. If a face to face consultation is required, this will be a scheduled appointment with the right person and at the right time in the right place based on clinical care needs. Technology should be available to book appointments for patients and provide viable appointments / timeslots at EDs 2.2 Actions should be explicit around role and responsibility as part of a whole-system escalation plan which sets out ‘levels’ of response and is stepped up, and stepped down, as part of a 24/7 operating framework. This should include communication of potential interface issues and pressures to Primary Care Independent Contractors where appropriate. Plans should be in place to support Primary Care Independent Contractors in this situation. 2.3 Attendance and participation in the huddles includes pro-active involvement of HSCPs and Primary Care. Where HALOs are on site they are included to ensure focus on turnaround times for ambulances and SAS role in discharge etc. Winter planning includes volunteer transport as a component of discharge plans. 2.5 Pathways in place to ensure discharge to assess are in place from the front door. Page 123
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Scottish Government Health & Social Care: Winter Preparedness Self-Assessment Checklist 2023/24 Page 13 of 13 Consideration should also be given to: • General Practice rapid access to hospital investigation to maintain elderly patients at home, (for example chest x- rays) with ambulance transfer to and from hospital in a timely manner so they can be dealt with during the working day. • Faster and enhanced access for general practice to a suite of investigations such as CT scans which would decrease the demand for admission and outpatient referrals. Self-referral pathways for patients, such as physiotherapy. 2.7 If necessary, plans will consider any requirement to purchase additional capacity over the winter period. 2.10 A summary of any care plans should be on the Key Information Summary, and there should be a system in place to regularly update and review these. 2.11 Regular MDT meetings are in place to discuss patients with severe COPD. 2.12 Patients are provided with information on action to take/who to contact in the event of an exacerbation, including direct phone lines where possible. 2.14 This includes the provision of rehabilitation to enable patients to be discharged to their own home as soon as is practicably possible. 2.16 Plans are in place that focus on the reduction of long waits including diagnostic endoscopy or radiology. Systems are in place for the early identification of patients who are fit for discharge, with PDDs (planned dates of discharge) visible and worked towards to ensure patients are discharged without delay. 2.20 Where transport service is limited or there is higher demand, alternative arrangements are considered as part of the escalation process – this should include third sector partners (e.g. British Red Cross) Key partners such as: pharmacy, transport and support services, including social care services, have determined capacity and demand for services and be able to provide adequate capacity to support the discharge process over winter period. These services should be aware of any initiatives that impact on increased provision being required and communication processes are in place to support this. e.g. surge in pre-Christmas discharge. Section 3: Primary Care, Mental Health and Social Care 3.1 In particular plans should reflect that: • Measures are in place to identify and resolve issues in accessing general practice appointments (with GPs and wider multi-disciplinary team members) as soon as possible. Reference should be made to the General Practice Access Principles (to be published late Summer 2023). • To ensure issues are identified and resolved at the earliest opportunity an appropriate process to escalate issues must be established. • Specific reference should be made to contingency arrangements where practices are unable to open due to staffing or other reasons. • Any involvement of GP practices in vaccination programmes is based on the assurance that practices will continue to deliver essential primary medical services. Plans should involve Local Primary Care Leads and Cluster Leads, and where appropriate the GP Subcommittee/LMC or other independent contractor representatives. 3.2 Plans also include the requirement of HSCPs to ensure access to mental health crisis teams/services 24/7 to cover addiction and mental health needs including availability of professional to professional advice for out of hours services, particularly during the festive period. Greater use of Pharmacy First is being promoted. Sufficient community pharmacy services are open and accessible including during public holiday periods. Availability of these services is well known and information for the public is current. 3.4 This will have included engagement with SAS, NHS 24 and Primary Care OOH services and to consider what more could be done collaboratively to improve continuity of care. The plan also demonstrates how the Board will manage both predicted and unpredicted demand from NHS 24 and includes measures to ensure that pressures during weekends, public holidays are operating effectively. The plan demonstrates that resource planning and demand management are prioritised over the festive period. There is reference to direct referrals between services. 3.10 Plans support continuity of community services for those with a mental health, learning disability, neurodiverse or dementia diagnosis to keep people well and reintegrate them into the community following any inpatient stay. 3.14 This includes bed occupancy, delayed discharges, waiting lists, staffing, staff absences and bespoke system pressures data as required. Please confirm if this data is, or will be, shared with Scottish Government to assist with national planning. Section 4: Health and Social Care Workforce and Staff Wellbeing 4.8 If there are reported flu outbreaks during the season, where evidence shows that vaccination uptake rates are not particularly high, NHS Boards will consider undertaking targeted immunisation. Antiviral prescribing for seasonal influenza may also be undertaken when influenza rates circulating in the community reach a trigger level (advice on this is generated by a CMO letter to health professionals co-ordinated and issued by the Vaccinations Strategy Division). 4.9 NHS board contingency plans have a specific entry on plans to mitigate the potential impact of potential outbreaks of seasonal influenza to include infection control, staff vaccination and antiviral treatment and prophylaxis. Contingency planning is in place to also address patient management, bed management, staff redeployment and use of reserve bank staff and include plans for deferral of planned admissions and plans for alternative use of existing estate or opening of reserve capacity to offset the pressures. Page 124
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REPORT TO: MORAY INTEGRATION JOINT BOARD ON 30 NOVEMBER 2023 SUBJECT: REVIEW OF FINANCIAL REGULATIONS BY: CHIEF FINANCIAL OFFICER 1. REASON FOR REPORT 1.1 To seek the approval of the Moray Integration Joint Board (MIJB) to update the Financial Regulations in line with the proposed amendments contained within Appendix 1. 2. RECOMMENDATION 2.1 It is recommended that the MIJB: i) approves the proposed changes to the MIJB Financial Regulations as set out in Appendix 1; and ii) agrees that the reviews will be done annually. 3. BACKGROUND 3.1 Section 95 of the Local Government (Scotland) Act 1973 requires integration authorities to have adequate systems and controls in place to ensure the ‘proper administration of their financial affairs’, including the appointment of an officer with full responsibility for their governance. The MIJB Financial Regulations detail those responsibilities. 3.2 The statutory guidance produced by the Scottish Government for integration authorities stipulates the requirement for the Chief Financial Officer of the MIJB to develop Financial Regulations to include a minimum set of controls. These were developed and approved at a meeting of this Board on 31 March 2016 (para 11 of the minute refers). 3.3 The Financial Regulations were subsequently reviewed and presented to a meeting of this Board for approval on 28 March 2019 (para 11 of the minute refers). Item 11. Page 125
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4. KEY MATTERS RELEVANT TO RECOMMENDATION 4.1 It is necessary to review the Financial Regulations at regular intervals to ensure they continue to reflect policy and practice adopted by the MIJB. The updated Regulations are attached at Appendix 1 and proposed changes have been highlighted in red for ease of reference. 4.2 It is proposed that the Financial Regulations continue to be reviewed on an annual basis to reflect the pace of change and support good governance practices surrounding the MIJB financial processes. 5. SUMMARY OF IMPLICATIONS (a) Corporate Plan and 10 Year Plan (Local Outcomes Improvement Plan (LOIP)) and Moray Integration Joint Board Strategic Plan ‘Partners in Care 2022 – 2032 Effective governance arrangements will support the MIJB in providing services in line with stated priorities as outlined in its Strategic Plan. (b) Policy and Legal Approved Financial Regulations form part of the constitutional documents that provide reasonable assurance in that the decision making of the MIJB is legal, clear and accountable. Failure to observe Financial Regulations may be regarded as a breach of trust and potentially lead to disciplinary action or dismissal. (c) Financial implications None arising directly from this report. (d) Risk Implications and Mitigation Regular updating of Financial Regulations provides a reference point for staff working under the remit of the MIJB and supports the mitigation of risk in relation to inappropriate use of funds. Financial Regulations constitute an element of the governance arrangements of the MIJB, the absence of which would result in a lack of clarity regarding roles and responsibilities. (e) Staffing Implications None arising directly from this report. (f) Property None arising directly from this report. (g) Equalities/Socio Economic Impact An equality Impact Assessment is not needed because there is no change to policy as a result of this report. Page 126
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(h) Climate Change and Biodiversity Impacts There are no direct climate change and biodiversity implications as there has been no change to policy. (i) Directions None arising directly from this report. (j) Consultations The Director of Finance, Deputy Director of Finance and Finance Manager NHS Grampian; the Chief Financial Officer Moray Council and the MIJB Chief Internal Auditor have been consulted and their comments incorporated into the updated Financial Regulations. 6. CONCLUSION 6.1 Financial Regulations support the Chief Financial Officer in ensuring the proper administration of the financial affairs of the MIJB. They are also an essential point of reference for service managers in assisting day-to- day operations. Author of Report: Deborah O’Shea, Interim Chief Financial Officer Background Papers: with author Ref: Page 127
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APPENDIX 1 Owner of Policy Chief Financial Officer Author Deborah O’Shea Date of Review November 2023 Date of previous version 28 March 2019 Policy Approved 27 November 2023 Next Review Date November 2024 MORAY INTEGRATION JOINT BOARD FINANCIAL REGULATIONS Item 11. Page 128
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APPENDIX 1 MORAY INTEGRATION JOINT BOARD FINANCIAL REGULATIONS INDEX 1. INTRODUCTION and INTERPRETATION 2. CORPORATE GOVERNANCE 3. ROLES and RESPONSIBILITIES 4. FINANCIAL PLANNING and MANAGEMENT 4.1 ANNUAL REVENUE BUDGET 4.2 CAPITAL PLANNING 4.3 CAPITAL EXPENDITURE 4.4 ACCOUNTING POLICIES 4.5 BUDGET MANAGEMENT & CONTROL 4.6 BUDGET MONITORING 4.7 VIREMENT 4.8 FINAL ACCOUNTS PREPARATION 4.9 TREASURY MANAGEMENT 4.10 RESERVES 4.11 GRANT FUNDING APPLICATIONS 5. FINANCIAL SYSTEMS and PROCEDURES 5.1 INCOME 5.2 AUTHORITY TO INCUR EXPENDITURE 5.3 PROCUREMENT & COMMISSIONING 5.4 IMPRESTS 6. FINANCIAL ASSURANCE 6.1 AUDIT COMMITTEE 6.2 EXTERNAL AUDIT 6.3 INTERNAL AUDIT – RESPONSIBILITY 6.4 INTERNAL AUDIT– AUTHORITY 6.5 FRAUD, CORRUPTION & BRIBERY 6.6 INSURANCE 6.7 VAT 6.8 GIFTS and HOSPITALITY / REGISTER of INTERESTS 7. REVIEW OF FINANCIAL REGULATIONS Page 129
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APPENDIX 1 1. INTRODUCTION and INTERPRETATION 1.1 The Public Bodies (Joint Working) (Scotland) Act 2014 was passed by the Scottish Parliament on 25 February 2014 and provides a framework for the effective integration of adult health and social care services. The Act required the submission of a partnership agreement, known as the Integration Scheme for approval by the Scottish Government. Following a detailed consultation process, the scheme was submitted for approval in December 2015. Following approval by the Cabinet Secretary for Health, Wellbeing and Sport an Order was laid before the Scottish Parliament on 8 January 2016 and the Moray Integration Joint Board (MIJB) was established as an autonomous legal entity with effect from 6 February 2016. 1.2 Moray Council and NHS Grampian recognise that they each have continuing financial governance responsibilities and operate under their own Financial Regulations / Standing Financial instructions in the operational delivery of services. As this service delivery will continue to be carried out within the Council and the Health Board, these Financial Regulations relate specifically to the affairs of the MIJB and are therefore limited and focussed in scope. 1.3 The main objective of these Financial Regulations is to detail the financial responsibilities, policies and procedures that govern the MIJB. Representatives and Committees of MIJB must comply with these Financial Regulations whilst dealing with the financial affairs of MIJB. 1.4 A Chief Officer will be appointed who will be the accountable officer of the MIJB in all matters except finance where there will be joint accountability with the Chief Financial Officer. 1.5 A Chief Financial Officer will be appointed who will be the proper officer for the purposes of Section 95 of the Local Government (Scotland) Act 1973. The Chief Financial Officer has a statutory duty to ensure that proper financial administration of the financial affairs of MIJB is maintained. The MIJB will have regard to the current CIPFA guidance on the role of the Chief Financial Officer in Local Government. http://www.cipfa.org/policy-and-guidance/reports/the-role-of-the-chief-financial- officer-in-local-government 1.6 Should any difficulties arise regarding the interpretation or application of these financial regulations, individuals must seek advice from the Chief Financial Officer before any action is taken. Page 130
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APPENDIX 1 1.7 The MIJB will commission services from Moray Council and NHS Grampian. The management of services within each of these organisations will continue to be governed by the existing Standing Financial Instructions, Financial Regulations, Schedule of Reserved Decisions, Operational Scheme of Delegation and any other extant financial procedures approved by their respective Governance structures. 1.8 Any breach or non-compliance with these Regulations must, on discovery, be reported immediately to the Chief Officer or the Chief Financial Officer of MIJB who, in consultation with others as appropriate shall decide on what action should be taken. 1.9 For the avoidance of doubt the breach of, or non-compliance with these Regulations may result in disciplinary action being taken against the relevant individuals in line with the policies of the employing organisation. 2. CORPORATE GOVERNANCE 2.1 Corporate Governance is about the structures and processes for decision making, accountability, controls and behaviour throughout the MIJB. The basic principles of corporate governance are as follows: 2.1.1 Openness – Anyone with an interest in the affairs of the MIJB should have confidence in the decision making and management processes and the individuals involved in them. This confidence is gained through openness in its affairs and providing full, accurate and clear information which leads to effective and timely action and scrutiny. 2.1.2 Integrity – There should be honesty, selflessness, objectivity and high standards of conduct in how the MIJB’s funds and affairs are managed. Integrity depends on the effectiveness of the control framework and on the personal standards and professionalism of members and officers involved in the running of its affairs. 2.1.3 Accountability – There needs to be a clear understanding by everyone involved in the MIJB’s affairs of their roles and responsibilities. There should also be a process which provides appropriate independent examination of the decisions and actions of those involved in the MIJB’s affairs, including how the funds and performance are managed. 2.2 These Financial Regulations are an essential part of the corporate governance of the MIJB. 2.3 Members of the MIJB are required to follow any applicable formally agreed national codes of conduct. Page 131
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APPENDIX 1 3. ROLES and RESPONSIBILITIES 3.1 INTEGRATION JOINT BOARD MEMBERS RESPONSIBILITY 3.1.1 The Board will continuously work to secure best value for money in how the organisation directs its resources, to ensure efficiency, effectiveness, safety and quality outcomes can be achieved.The Board are responsible for ensuring that proper accounting records are kept, which disclose at any time, the true and fair financial position and enable the preparation of financial statements that comply with the applicable Code of Practice. The Board are also responsible for ensuring that procedures are in place to ensure compliance with all statutory obligations. 3.2 CHIEF OFFICER RESPONSIBILITIES 3.2.1 The Chief Officer has a direct line of accountability to the MIJB, and is jointly line managed by the Chief Executives of NHS Grampian and Moray Council for the delivery of integrated services. The Chief Officer is responsible for ensuring that progress is being made in achieving the national outcomes and for any locally delegated responsibilities for health and wellbeing and for measuring, monitoring and reporting on the underpinning measures and indicators (including financial) that will demonstrate progress. 3.2.2 The Chief Officer is responsible for ensuring that the decisions of the MIJB are carried out. 3.2.3 The Chief Officer shall ensure that the Financial Regulations and all associated procedure manuals and documents are made known to appropriate staff members and shall ensure full compliance with them. 3.2.4 The Chief Officer shall prepare budgets following consultation with the Chief Financial Officer. The Chief Officer is also responsible for the preparation of Service Plans and relevant business cases relating to the Services. The Chief Officer shall ensure that the Chief Financial Officer is informed of financial matters that will have a significant impact on the Services, seeking financial advice where necessary. 3.3 CHIEF FINANCIAL OFFICER RESPONSIBILITIES 3.3.1 The Chief Financial Officer is responsible for governance of the MIJB’s financial resources, ensuring the Partners utilise these in accordance with the Strategic Plan and the Directions issued and that the Strategic Plan delivers best value. 3.3.2 The Chief Financial Officer shall ensure that suitable accounting records are maintained and is responsible for the preparation of the MIJB’s Financial Page 132
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APPENDIX 1 Statements following the Code of Practice on Local Authority Accounting in the UK. 3.3.3 The Chief Financial Officer shall ensure that these Financial Regulations are reviewed and updated as necessarykept up to date. 3.3.4 The Chief Financial Officer shall provide the Chief Officer and the MIJB with an annual governance statement. 3.3.5 The Chief Financial Officer shall be entitled to report upon the financial implications of any matter coming before the MIJB. To allow the Chief Financial Officer to fulfil this obligation, the Chief Officer will consult with the Chief Financial Officer on all matters involving a potential financial implication that is likely to result in a report to the MIJB. 3.3.6 The Chief Financial Officer shall ensure that arrangements are in place to properly establish the correct liability, process and accounting for VAT. 3.3.7 The Chief Financial Officer will ensure that budget managers receive appropriate advice, guidance and support and appropriate information to enable them to affect control over expenditure and income. 4. FINANCIAL PLANNING and MANAGEMENT 4.1 ANNUAL REVENUE BUDGET 4.1.1 The Chief Financial Officer will report to the MIJB each year on the process, timetable, format and key assumptions in drafting the annual budget. 4.1.2 The Chief Financial Officer of MIJB, Section 95 Officer of Moray Council and the Director of Finance of NHS Grampian will agree a timetable for preparation of the annual budget of MIJB and the exchange of information between MIJB, Moray Council and NHS Grampian. This ensures that required deadlines set out within the Integration Scheme are met. 4.1.3 The MIJB will approve a Strategic Plan which sets out arrangements for planning and directing the functions delegated to it by Moray Council and NHS Grampian. The Strategic Plan will cover a three-year period and will determine the budgets required to deliver operational services in-line with the Plan, recognising the need to be indicative in years two and three. The Strategic Plan will be aligned to, and presented with alignment to the Medium Term Financial Strategy. 4.1.4 The Chief Officer and the Chief Financial Officer will develop a case for the Integrated Budget based on the Strategic Plan and present it to Moray Council and NHS Grampian for consideration and agreement as part of the annual budget setting process. Page 133
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APPENDIX 1 4.1.5 The Chief Financial Officer will prepare and issue guidance, instructions and a timetable to all involved in the preparation of the annual budget. 4.1.6 The method for determining the final payment i.e. the initial base budget as at 1 April will be contingent on the respective financial planning processes of Moray Council and NHS Grampian. The Integration Scheme stipulates that the baseline payment to the Board will be formally advised by the Partners by 28th February each year. 4.1.7 Following agreement of the Strategic Plan by the MIJB, and confirmation of the Integrated Budget by the Partners, the Chief Officer will provide the MIJB’s Directions in writing to the Partners regarding operational delivery of the Strategic Plan. The Directions will include the functions that are being directed, how they are to be delivered and the resources to be used in delivery of the Direction in accordance with the Strategic Plan. Directions will be confirmed by the Chief Officer by 31 March of the financial year proceeding the financial year under Direction. Updated Directions will be issued throughout the year. 4.1.8 The Chief Officer will hold an operational role in both Moray Council and NHS Grampian, for the management of the operational delivery of services as directed by the MIJB and a line of accountability to the Chief Executives of both organisations for the financial management of operational budgets. 4.2 CAPITAL PLANNING 4.2.1 It is unlikely that The MIJB will be is not empowered to own capital assets, and accordingly the management of assets remains the responsibility of the Partner organisation. There is a need to ensure clear planning, scrutiny and governance of assets to ensure the appropriate assets are in place to allow for the delivery of the delegated functions. 4.2.2 The MIJB has in place an Infrastructure Programme Board who’s membership includes key officers from MIJB, NHS Grampian and Moray Council. The Infrastructure Programme Board reports to the Strategic Planning and Commissioning group. 4.3 CAPITAL EXPENDITURE 4.3.1 The MIJB does not receive a capital funding allocation. Capital projects are funded by either Moray Council or NHS Grampian and expenditure will be controlled in accordance with their respective financial regulations / standing financial instructions. 4.4 ACCOUNTING POLICIES 4.4.1 The MIJB is subject to the audit and accounts provisions of a body under section 106 of the Local Government (Scotland) Act 1973. The Chief Financial Officer is responsible for the preparation of the MIJB’s Financial Statements following the Code of Practice on Local Authority Accounting in the UK. Page 134
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APPENDIX 1 4.5 BUDGET MANAGEMENT & CONTROL 4.5.1 Budget holders/managers within Moray Council and NHS Grampian will be accountable for all budgets within their control as directed by the MIJB in line with its Strategic Plan. The MIJB will ensure appropriate arrangements are in place to support good financial management and planning. 4.5.2 It is the joint responsibility of the Chief Officer and Chief Financial Officer of the MIJB to report regularly and timeously on all budgetary control matters, comparing projected outturn with the approved financial plan to the MIJB. 4.5.3 The NHS Grampian Director of Finance and the Section 95 Officer of Moray Council shall, along with the MIJB Chief Financial Officer put in place a system of budgetary control which will provide the Chief Officer with management accounting information for both arms of the operational budget and for the MIJB in aggregate. 4.6 BUDGET MONITORING 4.6.1 It is the joint responsibility of the Chief Officer and the Chief Financial Officer to report to the MIJB regularly, timeously and accurately on all matters of budget management and control. The reports should include projections for the full financial year and any implications for the following financial years. These reports will include recovery action or corrective measures proposed where a year end budget variance is identified. 4.6.2 The Director of Finance, NHS Grampian and the Section 95 Officer, Moray Council will provide the Chief Financial Officer of the MIJB with information on a monthly basis regarding the costs incurred for the services directly managed by them. Information should be provided in an agreed format. 4.6.3 The Director of Finance, NHS Grampian will provide the Chief Financial Officer of MIJB with financial information on a monthly basis regarding the hosted services. Information should be in an agreed format and produced timely to enable inclusion in the financial monitoring reports. 4.6.4 The Director of Finance, NHS Grampian will provide the Chief Financial Officer of MIJB with information regarding the use of the amounts set aside for hospital services. Reporting updates will be provided in line with the provision of activity information from NHS Information Services Division. 4.6.5 The Chief Financial Officer will report monthly to the Chief Officer on the financial performance and position. These reports will be timely, relevant and reliable and will include information, analysis and explanation in relation to: Page 135
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APPENDIX 1 • Reviewing budget savings proposals • Actual income and expenditure • Forecast outturns and annual budget • Explanations of significant variances • Reviewing action required in response to significant variances • Identifying and analysing financial risks • Use of reserves • Any adjustments to the annual budget (e.g. new funding allocations) 4.6.6 The Chief Financial Officer will work with the Section 95 Officer of Moray Council and Director of Finance of NHS Grampian to ensure managers are provided with monthly financial reports that are timely, relevant and reliable. These reports will include information and analysis in relation to: • Budget available to managers • Actual income and expenditure • Forecast outturns. 4.6.7 The Chief Financial Officer will be consulted on all reports being submitted to the MIJB to ensure that any financial implications arising have been considered. Each MIJB report should include a Financial Implications section. 4.6.8 It is a requirement of the Public Bodies (Joint Working) (Scotland) Act 2014 that an annual performance report is presented to the MIJB and the financial contents therein should comply with the requirements as set out in the Act. 4.7 VIREMENT 4.7.1 Virement is defined by CIPFA as “the transfer of an underspend on one budget head to finance additional spending on another budget head, in accordance with and Authority’s Financial Regulations”. In effect virement is the process of transferring budget between budget headings with no change to the overall net budget. 4.7.2 The Chief Officer is expected to deliver the agreed outcomes within the total delegated budget. Any virement must not create additional overall budget liability. 4.7.3 Any proposal for virement involving a new policy, or variation of existing policy, which will impact upon the strategic plans of the MIJB, will be subject to the approval of the MIJB. 4.7.4 Virement can be used in the following situations and with reference to the flow chart at APPENDIX A; • The Chief Financial Officer has been notified; and Page 136
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APPENDIX 1 • The virement does not create an additional financial commitment into future financial years. 4.7.5 The virement process cannot be used in the following situations: • for transfers between IJB and non-IJB budgets; • for expected savings on finance costs or recharges; • for recurring items of expenditure in place of non-recurring savings; • for staffing changes that would increase the establishment; • for property items such as rates and utilities; • any savings against a property which has been declared surplus under the Council’s or NHS’s surplus asset procedure; • to reinstate an item deleted by the MIJB during budget considerations unless approved by the MIJB. 4.7.6 The Chief Financial Officer must maintain separate budgets for any hosted services managed on behalf of Grampian wide partners. Virement to and from these to Integration Joint Boards requires authorisation of all the three Integration Joint Boards before being implemented. 4.7.7 To the extent that any virement would transfer budget between Partners the Chief Financial Officer is required to notify the Partner bodies and send amended Directions. 4.8 FINAL ACCOUNTS PREPARATION 4.8.1 The Public Bodies (Joint Working) (Scotland) Act 2014 requires that the MIJB is subject to the audit and accounts provisions of a body under Section 106 of the Local Government (Scotland) Act 1973 (Section 13). This will require audited annual accounts to be prepared in accordance with legislation (The Local Authority Accounts (Scotland) Regulations 2014, and so far as is compatible with that legislation, in accordance with proper accounting practices in Section 12 of the Local Government in Scotland Act 2003 and regulations under Section 105 of the Local Government (Scotland) Act 1973). 4.8.2 Financial statements will be prepared to comply with the Code of Practice on Local Authority Accounting and other relevant professional guidance. 4.8.3 The unaudited annual accounts shall be submitted to the External Auditors and to those members charged with governance for their consideration in accordance with the statutory regulations. 4.8.4 The audited annual accounts shall be submitted to those charged with governance for their consideration and approval and the Auditors report thereon shall be submitted to the MIJB for consideration in accordance with the statutory regulations Page 137
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APPENDIX 1 4.8.5 The timetable for audit and publication of MIJB’s annual accounts shall be agreed in advance with the external auditors of Moray Council and NHS Grampian. 4.9 TREASURY MANAGEMENT 4.9.1 The MIJB will not undertake any cash transactions but rather these will be on a notional basis through the Direction of expenditure undertaken by the Partners. Any cash correction arising as a result of the direction by the MIJB will be undertaken directly between the Partners. 4.9.2 The MIJB will not operate a bank account. 4.10 RESERVES 4.10.1 The Public Bodies (Joint Working) (Scotland) Act 2014 empowers the Integration Joint Boards to hold reserves, which should be accounted for in the financial accounts and records of MIJB. MIJB has a Reserves Policy that is held outwith these Financial Regulations and is reviewed regularly. 4.10.2 Unless otherwise agreed, any unspent budget will be transferred into the reserves of the MIJB at the end of each financial year. 4.11 GRANT FUNDING APPLICATIONS 4.11.1 Where opportunities arise to attract external funding, relevant officers shall consider the conditions surrounding the funding to ensure they are consistent with the aims and objectives of MIJB and the Strategic Plan. 4.11.2 All grant funding to be secured by the MIJB from external bodies is required to receive approval from the MIJB prior to an application being made by the accountable body to ensure financial implications and match funding requirements are considered. 4.11.3 The Chief Financial Officer shall ensure that arrangements are in place to:- • receive and properly record such income in the accounts of the accountable body; • ensure the audit and accounting arrangements are met; and • ensure the funding requirements are considered prior to entering into any agreements, both in the present and the future. 4.11.4 The Chief Officer of the service receiving grant funding must ensure that arrangements for receiving and recording income are complied with. They must also ensure that the project progresses in accordance with the agreed terms of the funding agreement and that claims are made from the funding body timeously and in accordance with any conditions of the grant award. Page 138
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APPENDIX 1 5. FINANCIAL SYSTEMS and PROCEDURES 5.1 INCOME 5.1.1 There is no income to the MIJB by way of cash transactions. Transfer of resources will be made by NHS Grampian and Moray Council in respect of the agreed delegated functions and will be reflected in the Directions. Payment will then be made by the MIJB for the delivery of these services. The accounting for these transactions will be via book entries in the ledgers of NHS Grampian and Moray Council. 5.2 AUTHORITY TO INCUR EXPENDITURE 5.2.1 The Chief Officer shall have the authority to incur expenditure within the approved delegated resources from MIJB to Moray Council and NHS Grampian in-line with any supplementary budget that has been approved by the MIJB, and subject to the provisions of these Financial Regulations. 5.2.2 Expenditure shall be aligned with the Strategic Plan. The Chief Officer and Chief Finance Officer will make sure that MIJB only commits to expenditure that it is legally able to commit to and is within scope of the approved Integration Scheme and Strategic Plan. Where this is not clear they will consult with the section 95 Officer of the Council and the Director of Finance of NHS Grampian and seek appropriate legal advice. 5.3 PROCUREMENT and COMMISSIONING 5.3.1 The Public Bodies (Joint Working) (Scotland) Act 2014 provides that the MIJB may enter into a contract with any other person in relation to the provision to the MIJB of goods and services for the purposes of carrying out functions conferred on it by the Act. 5.3.2 Procurement activity in relation to operational delivery of services will be undertaken following the procurement procedures approved by the Partner organisations to which the MIJB has given operational Direction for the use of financial resources. 5.4 PETTY CASH IMPRESTS 5.4.1 There will be no facility for petty cash unless authorised by the MIJB Chief Financial Officer and the necessary security arrangements have been established and have been deemed adequate. 5.4.2 Petty cash imprest facilities will be operated within NHS Grampian and Moray Council and will be contained within their respective established arrangements. Page 139
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APPENDIX 1 6. FINANCIAL ASSURANCE 6.1 AUDIT COMMITTEE 6.1.1 MIJB is required to make appropriate and proportionate arrangements for overseeing the system of corporate governance and internal controls. This has resulted in the establishment of an Audit, Performance & Risk committee. The Audit, Performance& Risk Committee operates in accordance with Financial Reporting Council professional guidance for Audit Committees and has distinct, approved terms of reference set out within the MIJB’s Scheme of Administration. 6.2 EXTERNAL AUDIT 6.2.1 The Accounts Commission will appoint the external auditors to the MIJB. 6.2.2 External Audit are required to submit an annual plan to the MIJB and or its Audit, Performance & Risk Committee. 6.2.3 External Audit are required to submit a final report to MIJB and or its Audit, Performance & Risk Committee. 6.2.4 The External Auditor appointed to MIJB for the purposes of conducting their work, shall:- • Have a right of access to all records(electronic or manual), assets, personnel and premises, including those of partner organisations in carrying out their duties in relation to MIJB activity. • Have access to all records (electronic or manual), documents and correspondence relating to any financial and other transactions of the MIJB and those of partner organisations where it relates to their business with the MIJB. • Require and receive such explanations as are necessary concerning any matter under examination. 6.3 INTERNAL AUDIT - RESPONSIBILITY 6.3.1 The role of Internal Audit is to understand the key risks faced by the MIJB and to examine and evaluate the adequacy and effectiveness of the system of risk management and internal control as in support of the governance arrangements operated by the MIJB. 6.3.2 The MIJB shall secure the provision of an internal audit service to provide an independent and objective opinion on the control environment comprising risk management, governance and control of the delegated resources. The provision of internal audit services should be subject to periodic review The delivery of Page 140
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APPENDIX 1 internal audit services is currently undertaken by the Internal Audit Section of the Moray Council. . 6.3.3 The operational delivery of internal audit services within NHS Grampian and Moray Council will be contained within their respective established arrangements. 6.3.4 The Internal Audit Service provided to MIJB will undertake its work in compliance with the Public Sector Internal Audit Standards. 6.3.5 The MIJB Chief Internal Auditor, who is also the Audit and Risk Manager of the Moray Council, will prepare and submit a strategic risk based audit plan to the MIJB or Audit Performance and Risk Committee for approval on an annual basis. It is preferable that this be shared with the relevant Committees of NHS Grampian and Moray Council. This audit plan will not include systems and practices within NHS Grampian that will be subject to separate audit arrangements. 6.3.6 The Chief Internal Auditor shall report to the Audit, Performance & Risk Committee throughout the year on the outcomes of audit work completed and on progress towards delivery of the agreed annual audit plan; and provide an annual assurance opinion based on the overall findings from the audit. The Chief Internal Auditor will also provide an annual opinion on the MIJB’s systems of governance and internal control based on the findings from work carried out by Internal Audit, taken together with other sources of assurance. 6.3.7 Such Internal Audit work shall not absolve senior management of the responsibility to ensure that all financial transactions are undertaken in accordance with the Financial Regulations/ Standing Financial Instructions and Standing Orders and that adequate systems of internal control exist to safeguard assets and secure the accuracy and reliability of records. 6.3.8 It shall be the responsibility of senior management to ensure that access to relevant officers and explanations requested by the Chief Internal Auditor or their representatives are provided in a timely manner. (Operational this has been established as responding within 20 days to audit recommendations and 5 days for information requests). 6.3.9 The Chief Internal Auditor has the right to report direct to the MIJB in any instance where he or she deems it inappropriate to report to the Chief Officer, Chief Financial Officer or Audit, Performance & Risk committee. 6.3.10 Where recommendations resulting from Internal Audit work have been agreed, the Chief Officer shall ensure that these are implemented within the agreed timescale. Regular progress reports will be sought by the Chief Internal Auditor and it is the responsibility of the Chief Officer to ensure that these are provided when requested along with explanations of any recommendations not implemented within the agreed timescale. Page 141
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APPENDIX 1 6.4 INTERNAL AUDIT - AUTHORITY 6.4.1 The Chief Internal Auditor or their representatives shall have the authority, on production of identification to obtain entry at all reasonable times to any premises or land used or operated by MIJB in order to review, appraise and report on the areas detailed below:- • The adequacy and effectiveness of the systems of financial, operational and management control and their operation in practice in relation to the business risks to be addressed. • The governance arrangements in place by reviewing the systems of internal control, risk management practices and financial procedures. • The extent of compliance with policies, standards, plans and procedures approved by the MIJB and the extent of compliance with regulations and reporting requirements of regulatory bodies. • The suitability, accuracy, reliability and integrity of financial and other management information and the means used to identify, measure and report such information. 6.4.2 In addition, the Chief Internal Auditor or their representatives, for the purposes of conducting their work, shall:- • Have a right of access to all records (electronic or manual), assets, personnel and premises, when carrying out their duties in relation to Moray Integration Joint Board activity. • Have access to all records (electronic or manual), documents and correspondence relating to any activity, including financial and other transactions of the Board and those of partner organisations where it relates to their business with the Board. • Require and receive such explanations as are necessary concerning any matter under examination. 6.5 FRAUD, CORRUPTION & BRIBERY 6.5.1 Every member of MIJB and its representatives shall observe these Financial Regulations/ Standing Financial Instructions within the sphere of their responsibility. They have a duty to bring to the immediate attention of the Chief Financial Officer/ Chief Internal Auditor any suspected fraud or irregularity in any matter that would contravene these regulations. 6.5.2 All suspected fraudulent activity should be reported to the Chief Internal Auditor. However, there are a range of confidential routes available to the MIJB and its Page 142
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APPENDIX 1 representatives who wish to ask for advice regarding the reporting of an irregularity or to report a suspected fraudulent activity; • Your Line Manager • Your HR Manager • NHS Counter Fraud Services (CFS) Fraud Hotline on – 08000 15 16 28 • NHS Counter Fraud Services Website on: NHS CFS Website • NHS Grampian’s Fraud Liaison Officer – Assistant Director of Finance (Financial Services) on 01224 556211 07966 336548 • NHS Grampian’s Deputy Fraud Liaison Officer – Financial Governance Manager on 01224 556103 • The MIJB Chief Internal Auditor on 01343 563055 Fraud Hotline 01343 563003 All information provided is treated in the strictest of confidence and individuals who raise genuine concerns are protected by law, regardless of the outcome of any investigation that they initiate. The fraud policies of both NHS Grampian and Moray Council are available via their respective Intranets. 6.5.3 When a matter arises where it is suspected that an irregularity exists in the exercise of the functions of MIJB, the Chief Financial Officer in conjunction with the Chief Internal Auditor in conjunction with and the Chief Officer, will take such steps as may be considered necessary by way of investigation and report. 6.5.4 Both organisations have Whistleblowing policies and can be found on their websites here, Moray Council and NHS Grampian 6.6 INSURANCE 6.6.1 The Chief Officer in conjunction with the Chief Financial Officer will ensure that the risks faced by the MIJB are identified and quantified and that effective measures are taken to reduce, eliminate or insure against them. 6.6.2 As of 1 April 2016 the MIJB became members of the Clinical Negligence and Other Risks Scheme (CNORIS) scheme. The cover provided is in relation to indemnity for MIJB Members only. The cover provided is in respect of decisions made by Members in their capacity on the MIJB. All other cover required should be provided by NHS Grampian and Moray Council. 6.6.3 The Chief Officer is responsible for ensuring that there are adequate systems in place for the prompt notification in writing to the Chief Financial Officer of any loss, liability, damage or injury which may give rise to a claim, by or against the MIJB. Page 143
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APPENDIX 1 6.6.4 The Chief Officer in conjunction with the Chief Financial Officer shall annually or at such other period as may be considered necessary, review all insurances. Any required changes should be reported to MIJB. 6.6.5 The Chief Officer in conjunction with the Chief Financial Officer of MIJB will review the requirement for membership of the Scottish Government (CNORIS) on an annual basis. 6.7 VAT 6.7.1 HMRC have confirmed that there is no VAT registration requirement for Integration Authorites under the VAT act 1994 as it will not be delivering any services that fall within the scope of VAT. 6.7.2 Should the activities of the MIJB change in time and it becomes empowered to provide services, then it is essential the VAT treatment of any future activities or services delivered are considered in detail by the Chief Financial Officer to establish if there is a legal requirement for the Integration Authorities to register for VAT. 6.7.3 The Chief Officer and Chief Financial Officer must remain cognisant of possible VAT implications arising from the delivery of the Strategic Plan. The Partner organisations should be consulted in early course on proposals which may have VAT related implications for them. 6.8 GIFTS and HOSPITALITY / REGISTER of INTEREST 6.8.1 Members and employees should comply with their respective codes of conduct when offered gifts, gratuities and hospitality. 6.8.2 A central register of gifts and hospitality will be maintained by the MIJB. For the offers of any hospitality or gift, approval must be sought from the relevant line manager prior to acceptance and for offers exceeding £30 details must be intimated in writing for including in the register. Reference should be made to the respective codes of conduct. 6.8.3 A separate Register of Interests for members is maintained by the Clerk to the MIJB. 6.9 RETENTION OF FINANCIAL DOCUMENTS 6.9.1 The Chief Officer and Chief Financial Officer will ensure that arrangements are in place for the proper management of financial, legal and other documents and that these documents are retained in accordance with any specific statutory requirements, including the Data Protection Act (2018), the Freedom of Information (Scotland) Act (2002), and any approved MIJB management policies and procedures. The accounting records will be held by Moray Council on behalf of the MIJB. Page 144
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APPENDIX 1 7 REVIEW OF FINANCIAL REGULATIONS 7.1 These Financial Regulations shall be subject to review on a regular basis, and as a minimum of every two years by the MIJB Chief Financial Officer and where necessary, subsequent amendments will be submitted to MIJB for approval. Financial Regulations should be considered alongside other Governance documents. Page 145
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APPENDIX 1 APPENDIX A – MIJB VIREMENT APPROVAL RESPONSIBILITY CHART Does the virement involve a Y new policy or a variation of an existing policy that will MIJB to approve impact on the Strategic Plan N Y If under £20k, relevant Budget Managers& CFO to Is the virement between approve. If between £20k - Budget groupings within the £100k, Senior Same cost centre? Management Team to approve. If over £100k, Chief Officer to approve. N NOTES:- THE CFO SHOULD BE NOTIFIED OF ALL VIREMENTS OVER £20K 1. All budget virements should be advised to the relevant Finance team to ensure correct processing in the ledger. Is the virement between budget Y 2. Non-recurring savings cannot be vired to groupings within the same service fund recurring commitments. (i.e. all within Health or all within 3. Virement cannot be used to reinstate an Social Care?) item which has been previously excluded N from the MIJB Budget without agreement of the full MIJB. 4. Virements cannot be made from earmarked funding sources which are If under £20k, relevant Budget provided by the Scottish Government for Managers & CFO to approve. a specific service objective. If between £20k - £100k, Senior Management Team to approve. If over £100k, Chief Officer and the MIJB Chief Financial Officer to approve. 5. Adjustments required between MIJB and non MIJB budgets would be considered to be outside the scope of this virement process and require separate reporting to the MIJB and the Partners. 6. All virements will be reflected in monthly monitoring for reports for budget managers. 7. All virements over £100k will be reported in the financial monitoring reports to the MIJB. Page 146
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REPORT TO: MORAY INTEGRATION JOINT BOARD ON 30 NOVEMBER 2023 SUBJECT: CARE FOR PEOPLE PLAN – MORAY ARRANGEMENTS BY: CORPORATE MANAGER 1. REASON FOR REPORT 1.1 To provide assurance to the Moray Integration Joint Board that Health and Social Care Moray have developed an operational process to deliver the Care for People Strategy. 1.2 To provide assurance that the development of this framework has been in conjunction with Moray Council as its strategic partner. 2. RECOMMENDATION 2.1 It is recommended that the Moray Integration Joint Board (MIJB): i) note that a Care for People Operational Framework has been developed in conjunction with its partners; ii) note that continued improvement and implementation of the Care for People is now business as usual; and iii) note that Health and Social Care Moray (HSCM) will exercise this framework at a Moray and Grampian level to provide additional support and assurance. 3. BACKGROUND 3.1 The inclusion of IJB’s as Category 1 Responders in terms of the Civil Contingencies Act 2004 (the 2004 Act); the requirements and the arrangements in place and plans to ensure that the IJB meets its requirements under the Act. 3.2 Responsibility of the Chief Officer, as its Accountable Officer, to carry out all necessary arrangements to discharge the duties on behalf of the IJB under the 2004 Act. Item 12. Page 147
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3.3 This legislation requires MIJB to meet specific statutory requirements. The Civil Contingencies Act 2004 (CCA), is supplemented by the Contingency Planning (Scotland) Regulations 2005 and “Preparing for Scotland” Guidance. Taken together the law and guidance provides a consistent and resilient approach to emergency planning, response and recovery, which has been used to develop good practice. 3.4 The Act placed these duties on Integration Joint Boards as Category 1 Responders. It defines an emergency as: • An event or situation which threatens serious damage to human welfare; • An event or situation which threatens serious damage to the environment; • War, or terrorism, which threatens serious damage to the security of the UK. 4. KEY MATTERS RELEVANT TO RECOMMENDATION 4.1 To provide assurance to MIJB that an operational document has been developed to provide a framework to allow HSCM to activate, set-up, operate, manage and de-activate the Care for People (CfP) teams should they be deemed necessary in response to a significant or disruptive incident affecting the population of Moray area. 4.2 This framework was tested in the recent Storm Babet response to some degree, and its effectiveness will be reviewed during the upcoming debrief. 4.3 A Tabletop exercise of this framework was carried out on Monday 13 November 2023. Learning from this event will be incorporated into the ongoing development of the live framework. 4.4 A Grampian CfP exercise is planned for 5 December 2023. 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 aims of this document link with the themes of the MIJB strategic plan; Partners in Care, Home First and Building Resilience. Ensuring that our systems are as simple and efficient as possible, working with partners, to keep people safe from harm during an emergency response as required by legislation. (b) Policy and Legal The Civil Contingencies Act 2004 outlines a single framework for civil protection in the UK. Part 1 of the Act established a clearly defined set of Page 148
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roles and responsibilities for specified organisations involved in emergency preparedness and response, known as Category 1 responders. MIJB is a Category 1 responder. HSCM resilience and preparedness is the responsibility of the Chief Officer. The Corporate Manager is responsible for acting as the point of contact for Moray and for driving forward all matters relating to civil contingencies and resilience within HSCM. (c) Financial implications There are no financial implications directly associated with this report. Although during any emergency response will require financial resource from potentially both partners. (d) Risk Implications and Mitigation There is currently a High risk held on the HSCM Risk Register, detailing the lack of a Civil Contingencies Subject Matter Expert to drive this workstream. This also increases the risk of MIJB not complying, posing legislative risks for the Moray IJB. There is also a medium risk against the ability to deliver a CfP Strategy. This risk will be considered following the exercise of this plan in Moray and Grampian. (e) Staffing Implications None directly associated with this report. (f) Property None directly associated with this report. (g) Equalities/Socio Economic Impact An Equality Impact Assessment is not required as there are no changes to policy arising from this report and therefore there will be no differential impact on people with protected characteristics. (h) Climate Change and Biodiversity Impacts None directly associated with this report. (i) Directions None directly associated with this report. (j) Consultations The following partners were also consulted in the writing of this report and view incorporated: Moray Council Emergency Planning Officer and Interim Support Manager, HSCM. Page 149
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6. CONCLUSION 6.1 This report provides MIJB with assurance that HSCM has an operational framework for activating the CfP Plan and it is exercised as required. Whilst the delivery is in partnership with Moray Council, this forms part of MIJB’s responsibility as a Category 1 Responder in terms of the Civil Contingencies Act 2004. Author of Report: Sonya Duncan, Corporate Manager, HSCM Background Papers: The Civil Contingencies Act 2004 (Contingency Planning) (Scotland) Regulations 2005 Preparing Scotland, Care for people affected by emergencies Page 150
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REPORT TO: MORAY INTEGRATION JOINT BOARD ON 30 NOVEMBER 2023 SUBJECT: ANNUAL REPORT OF THE CHIEF SOCIAL WORK OFFICER 2022-2023 BY: CHIEF SOCIAL WORK OFFICER 1. REASON FOR REPORT 1.1 To inform the Board of the annual report of the Chief Social Work Officer (CSWO) on the statutory work undertaken on the Council’s behalf during the period 1 April 2022 to 31 March 2023 inclusive. 2. RECOMMENDATION 2.1 It is recommended that the Moray Integration Joint Board consider and note the contents of this report. 3. BACKGROUND 3.1 In compliance with their statutory functions under the Social Work (Scotland) Act 1968, all local authorities have a CSWO. For a number of years CSWOs have produced Annual Reports about social work services which are provided for the Scottish Government, relevant committees, full Council and Integration Joint Boards. 3.2 The Office of the Chief Social Work Adviser in the Scottish Government (OCSWA) collates an overview Summary Report based on the key content of the reports from all local authorities in Scotland. This summary would: • Be of value to CSWOs and also support the CSWA in their role of raising the profile and highlighting both the challenges and value and contribution of social work services; and • Be a useful addition to the set of information available to aid understanding of quality and performance in social work services across Scotland. 3.3 The Council’s Social Work Services require to support, protect and uphold the rights of people of all ages as well as contribute to community safety by having effective justice social work services. Social Work has to manage this together with the implications of significant demographic change and financial constraint whilst fulfilling a widening array of legal obligations and duties. Item 13. Page 151
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3.4 The annual report is attached at Appendix 1. 4. 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” This report is in line with the Moray 2026 Plan – healthier citizens, ambitious and confident young people, adults living healthier, sustainable independent lives safeguarded from harm and Council priority 4 – More of our children have a better start in life and are ready to succeed. (b) Policy and Legal The service referred to in this report falls within the scope of a number of important pieces of legislation including: • Social Work (Scotland) Act 1968 • The Adult Support & Protection (Scotland) Act 2007 • The Community Care & Health (Scotland) Act 2002 • The Children (Scotland) Act 1995 • The Joint Inspection of Children’s Services & Inspection of Social Work Services (Scotland) Act 2006 • Adoption and Children (Scotland) Act 2007 • Looked After Children (Scotland) Regulations 2009 • The Public Bodies (Joint Working) (Scotland) Act 2014 • Children & Young People (Scotland) Act 2014 Significant policies and white papers that relate to these services include: • Changing Lives, the Future of Unpaid Care in Scotland (2006) • Delivery for Health (2005) • All our Futures: Planning for a Scotland with an Ageing Population (2007) • Better Health, Better Care: Action Plan for a Healthier Scotland (2007) • Better Outcomes for Older People: Framework for Joint Services (2005) • The Independent Care Review: The Promise (2020) • The Independent Review of Adult Social Care in Scotland (2021) • National Guidance for Child Protection in Scotland, The Scottish Government (2021) (c) Financial implications There are no direct financial implications arising from this report. Future priorities will be addressed within the context of the financial planning process. (d) Risk Implications and Mitigation There are no risk implications associated with or arising from this report. (e) Staffing Implications There are no staffing implications directly relating to this report. Page 152
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(f) Property There are no property implications arising from this report (g) Equalities/Socio Economic Impact There are no issues directly arising from this report (h) Climate Change and Biodiversity Impacts There are no issues directly arising from this report (i) Directions There are no directions (j) Consultations The following have been consulted in the preparation of this report: Simon Bokor-Ingram, Chief Officer Health and Social Care Moray, Aileen Scott, Legal Services Manager 5. CONCLUSION 5.1 The report provides an update of CSWO oversight and activity. Author of Report: Tracy Stephen, Chief Social Work Officer/Head of Service Background Papers: Attached at Appendix 1 Ref: Page 153
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Moray Chief Social Work Officer Annual Report 2022 - 2023 Tracy Stephen APPENDIX 1Item 13. Page 154
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Introduction I am pleased to present the Chief Social Work Officer report for the period spanning 1st April 2022 to 31st March 2023. In what has been a particularly challenging year, with need increasing due to cost of living rises, the recovery from the Covid pandemic and the pressures on health care systems, along with recruitment challenges across all elements of Health and Social Care, it has been heartening to continue to support the achievement of improved outcomes for many vulnerable people within Moray communities. Staff have worked exceptionally hard during this period and retained a focus on getting it right for all people who come into contact with our services. Our workforce are working in unprecedented circumstances and a learning and improvement journey continues and staff are doing this with commitment, energy and tenaciousness. I came into post as Chief Social Work Officer part way through the year, with the previous incumbent retiring in 2022. That transition was managed to ensure continuity, oversight and leadership from the Chief Social Work Officer continued uninterrupted. The delegation of Children and Families and Justice Social Work came to a conclusion this year and at the end of the reporting period, delegation was agreed by the Scottish Government. This aligns Children and Families and Justice Social Work services with all other Social Work services across the Health and Social Care Partnership which creates opportunities for joined up working. Chief Social Work Officer and Head of Service Justice Children & Families Adults Page 155
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Governance, accountability, and statutory functions The Chief Social Work Officer (CSWO) holds a key leadership role within the Health and Social Care Partnership and within the council itself. The CSWO sits within the Senior Management Team of both the council and HSCP (Health and Social Care Partnership). There is a requirement for the CSWO to consult with both the Chief Executive of the Council and the Chief Officer, Health and Social Care, as the line management responsibility sits in the HSCP structure, due to both the delegation of Children’s and Justice Social Work to the Integration Joint Board (IJB), but also as a result of the previous CSWO having retired, whose substantive role was within adult services, which already sat within IJB structures. Groups Chaired by CSWO The CSWO supports both the Adult and Child Protection Committees. The CSWO also attends a national CSWO meeting, as well as linking into Social Work Scotland Standing Committee and related subgroups. The governance and accountability arrangements for Moray remain chiefly unchanged throughout this period. The CSWO recognised there was need to develop the scope of governance in relation to Practice Governance meetings with a view that Children and Families and Justice Social Work were also in the process of delegation to the IJB, which concluded in April 2023, and opportunities for alignment within these processes. This year also saw the deletion of the Head of Service role for Children and Families and Justice Social Work, as that post was earlier amalgamated with the Head of Adult Services and Chief Social Work Officer as part of efficiency savings. There will be a need to assess the impact of these changes on services as the next reporting period comes to a close. Children & Families Children, Families and Justice Social Work Practice Governance Board Community Justice Strategic Group Corporate Parenting Strategic Group GIRFEC Leadership Group Adults Adult Social Care Practice Governance Board Collaborative Care Home Support Meeting Carefor People Meeting Page 156
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A new, independent chair for Adult and Child Protection Committee has been appointed and has provided leadership, oversight and governance for some of our Public Protection work. This sits alongside the Community Justice Partnership Group, The Alcohol and Drug Partnership, Violence Against Women and Girls Partnership and a number of related sub groups. We have a structure that sits below the GIRFEC Leadership Group as reporting sub groups, such as our Corporate Parenting Strategic Group, Child Poverty Group, Child Rights and Participation, Child Planning, Wellbeing Partnership Group, for example. These groups are all created to align and report on the priorities of Moray’s Children’s Services Plan. There were a number of internal audits during this time, all of which have been reported within the Audit, Performance and Risk Committee. There was also an external audit commissioned by the Chief Officer, Health and Social Care Moray to allow for the progression of some improvements required around activity related to commissioning services. This work and related improvements are ongoing and continue to be reported against. There are a number of other meetings which are attended by leaders across both Children, Justice and Adult’s Social Work to allow managers to have connection and receive updates, make decisions and escalate concerns. There has been significant progress made by the Policy, Commissioning and Quality Assurance team within Children’s Social Work, allowing for some key processes to be formalised. This has also allowed for the management of the Consultant Practitioners to align with this team and have line management there to develop the triangulation of case file audit findings, complaints and feedback from families. There was an inspection of Placement Services work within the Children and Families team, which includes our Fostering, Adoption and Continuing Care services. The report for this inspection showed significant improvement on the inspection which took place early in 2022. We were also involved in a number of Care Inspectorate National Reviews, including a review of Diversion, Secure Care and Services to Children with a Disability. Feedback from families Case Audit FindingsComplaints Policy, Commissioning & Quality Assurance Team Consultant Practitioners Teams Page 157
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There were a number of challenges in relation to recruitment this year and as such this left services with a number of vacancies, including that of some management positions. This created additional pressures for Children and Families Social Work services alongside Community Adult Learning Disabilities teams who were most affected by these vacancies, alongside the challenges of recruiting carers for the Care at Home service. Posts of Consultant Social Work Practitioner are well established in both Adult and Children’s Services. Consultants work with Social Work practitioners and managers to support complex cases, model best practice, deliver learning and development sessions and set practice standards in their respective areas. Within Adult Services, Consultant Practitioners hold specific themes in the areas of SDS, Adult Support and Protection and Mental Health. This is on top of the practice support that the Consultant Practitioners provide to Social Work practitioners. The current governance structure brings Children’s and Justice Services in line with the Health and Social Care Partnership services. Within Health and Social Care Moray, the CSWO is part of the Senior Management Team who meet on a weekly basis. There are a number of governance meetings across the Health and Social Care Partnership, within Social Work, Practice Governance Boards report into the Governance of the IJB and related Committee Sub Groups. CSWO Reports into a number of Committees For part of the reporting period, Children and Justice Services remained as part of the governance structure of Moray Council and reported performance into the Education, Children’s and Leisure Services Committee. Children’s and Justice Social Work thereafter reports into the same structure as Adult services. •Audit and Scrutiny Committee •Education, Childrens & Leisure Services Committee Moray Council Committee •Audit, Risk and Performance Committee •Clinical and Care Governance Committee The Integration Joint Board Page 158
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As a result of changes to the Head of Children’s and Adult Services roles, there is an increase in the scope of the newly created role of Head of Service and Chief Social Work Officer. This role sits alongside another Head of Service/ Deputy Chief Officer role within the HSCP. The increase in responsibility and tasks has an impact on the ability to exercise the full scope of the role, in the main due to the increase in meetings and reporting across different systems. This also has an impact on the ability to oversee performance across both Adult and Children Services as the volume of activity is significantly more than the original posts had oversight and accountability for. This will be measured and reported against at the next reporting period progresses. The Chief Social Work Officer relies on reporting from Service Managers, Locality Managers and Consultant Practitioners in order to scrutinise data and have sufficient oversight of the wider service delivery and quality of social work practice. Developments in this area are required to ensure that the right information is being collected and scrutinised. Service Quality and Performance Children and families This year has seen a number of changes within Children and Families Social Work. An improvement plan was implemented within Placement Services as a result of an inspection by the Care Inspectorate which took place in March 2022. A further full inspection in the reporting period recognised the significant improvement work that had gone into creating changes to support positive outcomes for care experienced and children and young people who are cared for in Moray. Across the department there were a number of key personnel changes, with some retirements meaning changes in the leadership team and some challenges with recruitment resulting in teams having temporary management arrangements and requirements for creative solutions to ensure staff had the support they needed. The rollout of child protection training for practitioners continued into this period with a focus on ensuring social work staff had a robust working knowledge of the National Child Protection Guidance in Scotland (2021). Page 159
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The creation of a Commissioning, Policy and Quality Assurance team meant that areas which required policy development could be progressed and as a result policies were updated or developed in relation to: • Looked After Children • Multi-agency child protection procedures • Supervision policy and procedures • Transfer of cases procedures • Multi-agency reflective vase discussion procedures • Individual placement agreement flowchart • Data Protection Impact Assessment for social work • Commissioning procedure • Complaint handling procedure • Solution Orientated approach The team also allowed for progression in improvement work related to • The oversight and management of complaints • The development of feedback mechanisms • File audits • Feedback from families in contact with the service • Learning and development opportunities • Evaluation and monitoring of training Page 160
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Key areas of development for this reporting period; Implementation of National Guidance for Child Protection Safe And Together Model For Working With Survivors And Perpetrators Of Domestic Violence The Better Meetings Project Improvements to permanence planning for children and young people following the PACE model (Permanence and Care Excellence) New assessment paperwork including a bespoke assessment framework for throughcare and aftercare services Development of a new complaints process Training in secure care standards The 4x4x4 supervision model and training for all staff Development of a resource panel Development of disability team to ensure a focus on children and young people living with disability A refresh of a number of key strategic meetings, including Corporate Parentingategic meetings, including Corporate Parenting Previously secured reinvestment allowed for the commissioning of Functional Family Therapy and a Restorative Practice Model to increase early interventions and reduce care placements Page 161
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Moray Population of approx 96,410 Approx 95% of young people under 16 identify as White Scottish 18.8% under 18 14% of families have two children or less 1% of children and young people have a ‘looked after’ status (CSP Moray JSNA 2022) Page 162
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Overall at the end of March 2023 there were 1215 open cases to the Children and Families and Justice Social Work department. Excluding aftercare cases, 23% of the people using all other services had previous care experience. Access Team 149 West Area Team 316 East Area Team 169 Youth Justice 48 Throughcare and Aftercare 147 Justice Service 386 There were 3014 referrals into the Access Team in the year 22/23 which is an overall increase of 34.36% on the previous year. Of these 729 were Child Protection referrals which is a 68% increase in Child Protection referrals on the previous year. There was also an increase of 84 referrals relating to domestic abuse which is an increase of 26.4%. The rise in Child Protection Referrals received in within the Access Team which has placed additional pressure upon Social Work practitioners who have struggled with recruitment across this period. Agreement from Moray Council Committee in January 2022 allowed for reinvestment of savings from Children and Families Social Work for the commissioning of two new third sector services to enable families to be supported in a different way and to reduce the reliance on care placements both in and out of area. These services are still in their infancy and will be reported on at the next reporting period. Page 163
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Area Teams West and East Area Teams had an average of 4.7% Child Protection Cases open across the services. All Children and Families Social Work teams have had challenges with recruitment. There were 171 looked after and accommodated children. 23 children’s names were placed on the North East Child Protection Register at the end of March 23. *Numbers exclude justice services and aftercare services Overall there was a 20% decrease in children being placed in local authority care meaning that there were 12 fewer children and young people formally accommodated than the previous year. Of the children and young people who were leaving care (no longer formally looked after) there were 18 who left care and this Page 164
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represented a decrease of 26.7% from the previous year. Overall looked after children numbers in Moray reduced by 4% between March 22 and March 23. Out of Area Placements In April of 2022 there were 32 agency placements which moved to 27 by the end of the financial year. For residential care the number of placements reduced from 24 to 18 and for foster care there was a small increase from 8 to 9. In 2022/23 there was the development of a Placement Oversight Meeting. This allowed for oversight of agency placements and supported care planning and ensured that high cost care options were monitored. There was also work to refresh the carer recruitment campaign for foster care and supported lodgings. This was a with a view to broadening placement options and reducing the need for agency placements and there were a number of people who progressed to assessment from this activity, which continues. Placement Services Placement Services comprises Fostering, Adoption, Kinship, Supported Lodgings, Continuing Care and Throughcare & Aftercare. The Fostering Service experienced a decrease in the number of foster carers from 41 to 34. This was a decrease of 17% and reflected the national challenges in recruiting and retaining foster carers following the Covid-19 pandemic. However, the Fostering Service developed a Marketing Plan and Business Plan in 2022/23. This was an evidence based approach which resulted in a more targeted foster carer/supported lodgings recruitment campaign. The Adoption Service undertook assessments which resulted in approval of adoptive carers and four young people achieved legal permanence by each being made subject to a Permanence Order with Authority to Adopt. In Kinship Care the number of kinship household moved from 36 to 30 which was a decrease of 20%. Linked with this, the number of kinship placements formalised via a legal order moved from 33 to 38 which was an increase of 15%. This indicates that a number of kinship placements successfully move on to legal orders securing the placements for those young people. In Supported Lodgings the number of households moved from 5 to 4 where the number of being offered placements increased from 5 to 6. This reflected a move by Supported Lodgings carers to provide more than one placement. As with the Fostering Service a Marketing Plan and Business Plan was developed in 2022/23 Page 165
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which resulted in a more targeted foster carer/supported lodgings recruitment campaign. In Continuing Care the number of placements increased from 2 to 5, providing young people with placement stability and continuity as they transition into adulthood. Unaccompanied children and young people seeking asylum In 2022/23 there was an increase in the number of children seeking safety and asylum in Scotland (UASC) supported by Placement Services via the National Transfer Scheme. The number of young people increased from 1 to 8 and were accommodated in Supported Lodgings or within Moray Council’s housing supported by staff from Throughcare & Aftercare services. The Promise During this period developments were focussed on keeping The Promise to Moray’s children and young people. The importance of having invested into services that help prevent children from entering the care system, by providing evidence based interventions that effectively help families find solutions to the things causing family breakdown cannot be underestimated. The outcome and impact from this work is yet to be established, however, it was an important step towards developing a different approach to Moray’s work alongside children and their families. We worked as partners towards meeting the commitments of our Children’s Services Plan and worked jointly to begin creating the new Children’s Services Plan incorporating Moray’s Promise Plan to take us up to 2026. Areas identified for improvement centred on assessment and joint planning. There continues to be a need to reduce the amount of children entering the care system and a focus on how many placement moves children experience. There is also a focus on how we endeavour to keep children together with their brothers and sisters. During this period we also developed Moray’s Scottish Child Interview Model (SCIM) team. This was a pan-Grampian project to ensure that when children and young people were victims or witnesses of a crime, that the way they are interviewed is consistent (Across Scotland) and is trauma informed at its centre. This has moved Page 166
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much of the Joint Investigative Interview work of the Access Team to the Grampian SCIM team. The SCIM social workers for Moray remain based in Moray. Justice Services and Youth Justice Justice services supported 373 requests for criminal justice social work reports which converted into 262 community payback orders over the reporting period. The service was able to provide some bespoke and creative supports to people who need it the most including 6 people who were released from prison on statutory measures and 17 who were offered support through voluntary measures. At the end of reporting period there were 87 individuals subject to MAPPA in the community. The service is working to an improvement plan in relation to a National Diversion Review which Moray Justice Services formed part of. Work has been undertaken to review the process and paperwork used and new files have been created to ensure the standards set are met. There have been a variety of training opportunities available to both Youth Justice and Justice Social work including Outcomes Star which will be primarily used in diversion from prosecution and structured deferred sentences. It is anticipated this tool will allow for improved evidence of outcomes and effectiveness of interventions whilst also hearing the voice more clearly from individuals in the service. Justice Social Work has also undertaken training in trauma informed report writing and in relation to the new Throughcare Assessment for Release on Licence report which is co-produced with prison based social work. Both teams have the majority of staff now trained in Safe and Together and undertaken Child Protection training. Within the Unpaid Work service, a Placement Projects Task Supervisor was recruited and a drive to increase the availability of placements for individuals completing hours of unpaid work. There are now placements available in East, West and Central Moray and supportive 1:1 placements are being progressed for individuals who are more vulnerable with complex needs. The Unpaid Work team continue to provide a service to the whole of Moray and recipient feedback for this work has been overwhelmingly positive. The team is currently working in partnership with Moray Food Plus in the growing and distribution of fresh produce to the local community. The bail supervision process is embedding locally and there were eight bail supervisions overseen in this period. This has allowed an opportunity for early intervention work to take place and early identification of support needs. There are a number of interventions used aimed at reducing reoffending including structured programme work targeting particular offences, for example, sexual or Page 167
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domestic offending and 1:1 work to increase individuals understanding of their pathways to offending and the impact of this on them and the wider community. In addition to this there has been the development of group work for both men and women within Justice Social Work, aimed at meeting the wider needs of individuals and supporting community based activities. The purpose of this has been to improve the mental wellbeing of individuals within the service and overcome barriers to accessing services for longer term support. There is also a good partnership representation at the Community Justice Strategic Partnership group and a focus on improving outcomes in Moray. The Lead Officer for the group retired this year and a new officer recruited, allowing for the work of the group to continue with energy. Youth Justice Referrals to Youth Justice Services have been consistent in numbers, with the following recorded. Q1 – 1st April – 30th June 2022 16 New referrals to Youth Justice for support and guidance during this period – 68 young people engaged with Service Q2 – 1st July – 30th September 2022 21 New referrals to Youth Justice for support and guidance during this period - 69 young people engaged with Service Q3 - 1st October – 31st December 2022 21 New referrals to Youth Justice for support and guidance during this period - 57 young people engaged with Service Q4 – 1st January – 31st March 2023 20 New referrals to Youth Justice for support and guidance during this period 62 young people engaged with Service Of these 78 referrals into Youth Justice over the last year. Work has been undertaken to improve the identification of those with care experience within both adult and youth justice services to ensure that additional supports are offered in terms of any identified needs, including mental wellbeing, alongside supporting them to reduce any further offending. During this period there has been an average of 33% of open cases are care experienced young people within Youth Justice and an average of 10% open to Justice Services as a whole. There remains a continued commitment to reducing the number of care experienced young people open to Justice Services. Youth Justice have additionally been trained in the new ‘Our Family Story’ assessment framework. Page 168
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Referrals REFERRALS (% Care experienced individual) Adults Challenges were keenly felt across adult services, with the pressures of delayed hospital discharge continuing. There are many examples of staff pulling together to find creative solutions to support system change. 0 10 20 30 40 Jan-21 Feb-21 Mar-21 Apr-21 May-21 Jun-21 Jul-21 Aug-21 Sep-21 Oct-21 Nov-21 Dec-21 Jan-22 Feb-22 Mar-22 Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23 No. of Care Experienced YP open to Justice Services Open to Youth Justice Open to Adult Justice Justice Social Work Q1 Q2 Q3 Q4 35(9.4%) 27(7.1%) 29(8%) 31(8%) Youth Justice Q1 Q2 Q3 Q4 14 (31%) 15 (33.3%) 18 (39%) 14 (29%) Both Q1 Q2 Q3 Q4 49(11.8%) 42(9.9%) 47(11.6%) 45(10.4%) Page 169
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There were 2,041 referrals to adult social work area teams in 22/23 down by 9.4% in comparison with the 21/22 number of 2,233. Additionally there were 1,645 police concern reports which is a rise of just over 300 from the previous year. Care at home continues to have challenges to recruitment and retention and increasing need is not reflective of increasing workforce. Social workers are working often with reduced team sizes and the complexity and number of people requiring support increases. At the end of the year there were 130 people awaiting a package of care. Of those waiting for care, 9% were in hospital. There are 14 care homes in Moray and there were 30 people waiting for a place in a care home at the end of March this year. Of those 14 were in the community, 11 were in hospital and 5 were in interim care home placements. As part of the System Pressures two week challenge, the Chief Social Work Officer along with other key leadership staff from within Health and Social Care Moray undertook the Day of Care Survey for all hospital patients in Moray, including those in community hospitals. As well as performing the Day of Care Survey, the team took the opportunity to carry out qualitative interviews with staff to understand from an operational perspective the pressure teams are under and to find barriers and possible solutions to the flow of patients through our systems in Moray. This exercise gave the partnership an insight into some of the challenges, as well as a clearer idea of the extent of delayed discharge. 72% of those in community hospital did not meet the criteria for being in a community hospital and 34% of those in Dr Gray’s Hospital did not meet the criteria. This provided an opportunity to create a plan of action, which is ongoing, to address some of the key findings of that audit. The issue of finding resource to increase care at home or care home places is not one that can be resolved easily or quickly, but Page 170
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the model of social work and social care and working in partnership with colleagues across health services are where transformative changes can take place. Our commissioned services had an external audit completed within the reporting period and related improvement plan created which allowed for some progress to be made in addressing contracts that were out of date. This presented as a risk to the partnership and the action plan allowed for focus on areas which were not being progressed. A number of key processes are now in place to allow the monitoring of contacts and escalation to Practice Governance Board should risks increase to this area of work. Work is ongoing to progress action around our mental health services in Moray. There was a requirement to improve the inpatient experience and safety for people, making the environment trauma informed, ligature safe and the ward fit for purpose. This requirement sat alongside the need to do work in the hospital site for an MRI scanner and a Programme Board was set up to plan and co-ordinate both these significant pieces of work in conjunction. These plans are still ongoing and in progress and hopefully within the next reporting period some of the necessary works will have commenced. Mental Health Officers (MHO) It can be a challenge for the MHO workforce in meeting statutory duties due to limited capacity and MHOs work exceptionally hard to provide a high quality service. In Moray there is no dedicated team and most MHOs have an established post in addition to their MHO duties. A workforce analysis showed that two MHOs should be trained each year to compensate for MHOs retiring or ceasing to undertake MHO work due to promotions or other workforce changes. Two Mental Health Officers (MHOs) qualified in 2019, for a number of reasons we had no MHO candidates in 20-21 but encouragingly there were two qualified in 2022 and there are currently two MHO candidates in training who will qualify towards the end of 2023. However it is possible retirements will feature in the near future given the age profile of MHOs, with 5 being over the age of 60 (see Table 1) and some considering retirement. Table 1 MHOs ≤25 25- 29 30- 34 35- 39 40- 44 45- 49 50- 54 55- 59 60- 64 65+ Female 0 0 0 1 5 1 2 1 4 0 Male 0 0 0 0 0 0 0 2 1 0 Total 0 0 0 0 5 1 2 3 5 0 Page 171
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The number of Compulsory Treatment Orders and Compulsion Orders have continued to decline. However the number of people requiring detention under a short term certificate has risen by 21% (16 people) on previous year. This may reflect that there are more people requiring hospital treatment but for shorter periods of time. There was less use of Emergency Detention Certificates (decrease of 48% - 11 people) to detain and more use of Short Term Detention Certificates as the gateway to mental health treatment which reflects good practice. Adults with Incapacity Guardianship and intervention order referrals (requests for MHO reports) have increased significantly between 2020 and 2023. Number of referrals for 2021-2022 was 74, a 23% increase on previous year and a 90% increase on 2019/20. In 2022- 2023 referrals have again increased by 7% on previous year. A grant to increase MHO capacity was allocated in 2021 and 2022 to each local authority from Scottish Government. In Moray an Advanced Practitioner was recruited and attached to the Mental Health Team. In addition to writing MHO reports for guardianship and intervention orders, the post holder also participates in the Mental Health Act rota, delivers AWI awareness training, supports delayed discharges for people waiting for guardianship, chairs AWI meetings, participates in auditing and improvement work and gives advice to teams on good practice. The MHO capacity grant allowed the recruitment of a social worker in the Mental Health Team to release more capacity for the MHOs covering the Mental Health Act rota in the team. Since being in post the post holder completed 23 guardianship reports by end March 2023. Because of this increased capacity there was a reduction in the waiting list for guardianship applications from 26 to 10. At end of March 2023 there were 50 welfare guardianships granted. Team Learning Disability team West Community Care team East Community Care team Mental Health/ Drug and Alcohol Total Number of LA guardianships 24 15 6 5 50 Page 172
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Quality Assurance In September 2021 the Mental Welfare Commission published their report Care and Treatment for people with alcohol related brain damage (ARBD) in Scotland. One of the findings was that not everyone on a local authority guardianship had a delegated guardian or if they did they did not receive regular visits or reviews. Each H&SCP were required to have an improvement plan. The delegated guardian audit took place in 2022 and arises from that plan. The following improvements are in progress: Delegated guardian audit and audit report produced, feedback to teams. AWI improvement plan developed Delegated guardian training being developed Guidance for delegated guardians and their manager in progress Review of templates and forms taken place, development of a 13ZA decision- making proforma. Learning Disability Our services to those with Learning Disability were also subject to changes in management, as the outgoing Service Manager retired and a new Service Manager and Team Manager recruited into their new roles. Our Learning Disability services tend to be an area of high spend and as such Quality Assurance and robust planning have been important. Approximately 450 people with a Learning Disability are supported and receive a wide spectrum of services from a multi-disciplinary team, to promote their safety, health and wellbeing, and ensure that they have access to full and independent lives. Housing has been an area of significant development within the service over the past 3 years. 22-23 has seen the building of the Greenfield Circle project, in partnership with Springfield property developers and Hanover Housing Association, creating suitable housing options for people with a Learning Disability. The service is to continue its work on further housing projects to help accommodate people who still live with parents or who want to move from supported living to live independently. In addition, there is an internal provision, Woodview, which offers independent living to vulnerable adults who have complex and challenging needs and we plan to increase our provision in this area. This is in response to the ‘Coming Home Report’ and subsequent Scottish Government directive to ensure that those in inappropriate, out of area placements, are supported in a return to Moray. There are currently 6 people who are in hospital or live out of area that will be supported back to Moray over the following year. Page 173
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The Transition Workers within the Health and Social Care Partnership are linked into the Children and Families Disability Pod, ensuring that planning for young adults begins at the earliest possible opportunity. Our Community Learning Disability Service has also experienced challenges in recruiting into vacant posts, particularly within Social Work and Psychiatry however the team have worked exceptionally hard to provide continuous support to people despite the aforementioned challenges around Covid and recovery. Adult Protection Committee The adult protection committee meets each quarter – chaired by the new Independent Chair of both Adult and Child Protection Committees. The training offered by APC is extended to the wider workforce within Moray Council, the Health and Social Care Partnership, Care Homes, Care Providers and the third and community sector. Training and Development to raise awareness of Adult Protection and how to make a referral allows the vision of the APC to be shared across a wide audience. In relation to training and development for Social Workers and Council Officers the Adult Support and Protection Training Facilitator delivers a range of sessions throughout the year. These include; • Adult Support and Protection Modules 1-4 • What to expect from a Case Conference • Hoarding and Self-Neglect • Risk Assessment and Risk Management The training delivered is documented within Health and Social Care Moray’s ASP Training Plan which provides information and guidance for employees across the Health and Social Care Partnership. The document aligns with the wider Protecting Adults in Grampian – A Learning and Development Strategic Framework and enables the reader to identify their workforce contact with regard to Adult Support and Protection and request appropriate training. The Council Officer Forum – first established in December 2021 meets on a 6- weekly basis and continues to offer a reflective space for Council Officers to meet and discuss emerging issues, learning and development, practice, and changes to guidance for example, as well as being kept up to date with National Events and news. Topics that have been covered include The New Revised Codes of Practice in Adult Support and Protection Trauma informed Practice Page 174
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Domestic Abuse and the role of MARAC Participation in Case Conferences Moray’s Interagency Vulnerable Adults Process Public Protection areas including Community Justice Partnership, Child Protection and Drugs and Alcohol Partnership Adult Support and Protection A total of 917 Adult Support and Protection referrals have been received from April 2022 – March 2023. This is an increase on last year’s figures of 557. It is apparent that the last few months appear to have remained fairly static with regard to referrals with between 81-84 with the highest rate reported in February and March this year. A further breakdown of these figures is below The advent of Morays Interagency Vulnerable Adults Procedure has been a particular area of good practice. This Procedure is a proactive and preventative work stream. This allows for cases of concern which do not meet the Adult Protection 3- point criteria to be discussed on an inter-agency basis to look at ways to further support the adult at the centre. This process does not replace any Adult Support and Protection activity, it is expected that the established procedure is followed for this. Challenges and improvements There remains to be a bedding in period of the new CSWO and a need to develop further processes to have robust oversight and data scrutiny that spans across all Social Work Services. A data dashboard is under development for Children and Families Social Work, and, if this meets the need of providing easy to read information, then it can be replicated in adult services. There will be a need to begin Page 175
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the process of replacing the current case management system over the next year as the contract expires. Resources are undoubtedly reducing in contrast to increasing need and transformation across all service areas is critical to ensure the ability to continue to support those who most need it, to achieve improving outcomes and to create good quality of life for people who come into contact with Social Work and Social Care systems. There has been a growing need to work closely as partner’s both across Moray and the wider Grampian area and take learning from other areas. Some of the challenges faced this year have been the situation in Ukraine and related sponsorship of families coming to live in Moray and an increase in people seeking asylum, including unaccompanied young people under the age of 18. We have had to be flexible in a way that we haven’t previously and come together to ensure vulnerable people are supported effectively, which was achieved through partnership working. Children and Families Social Work transformation plan centred on a Pod model, moving to a locality based social work. This process has begun with the creation of a Disability Pod, allowing for support to children with disabilities to be delivered in a more focussed way, having moved this from within the children and families team work. An evaluation of this will take place within the next reporting period, along with further Pod development. The new partnership Children’s Services Plan will incorporate Moray’s Child Poverty Plan, the Promise Plan and the Corporate Parenting Plan, alongside the Rights and Participation Plan and provide an opportunity for some clear and streamlined work to take place to meet the priorities the plan agrees. The children’s services partnership in Moray is growing in strength and the governance processes were all developed over the last year allowing for some real progress to be made in this area. Resources There are financial pressures in all areas of service delivery. There are some government investments and funding opportunities offered across the whole system, but fundamentally, core services do not form part of what is being financially supported, in the main. When savings have to be found, there is a real risk that in order to manage a budget deficit the cuts to public services only serve to cost more money in the long run as we learn where the critical thresholds for spend sit in relation to vulnerable citizens. The Whole Family Wellbeing Fund is a welcome support to early and effective interventions and create transformation, particularly linked to The Promise. The Page 176
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outcome of that investment may take time to come to fruition but in the interim, there remains a growing need to provide support, including financial support to families in need across Moray. The Whole Family Wellbeing Fund in Moray will look to increase capacity and offer intensive support to families at an earlier point. There is a significant challenge to trying to create transformation when budgets are reducing and there are staffing vacancies. So less people to do more work with less resources creates a real and present challenge to achieving positive outcomes for those seeking support from our services. The risks to budget reductions to all services remain high, but there are increasing costs and increasing need in Children and Families Social Work, Care at Home and Adult Learning Disability Services in particular. The cost of care is also increasing and this creates a dynamic where the ability to do things differently is compromised by the need to fund and support expensive and at times, existing placements for those who need it. Going forward, Moray has projected growth in the number of older adults living in the area and a reduction in the number of young people. This creates a potential issue for the future in terms of providing care to an aging population. We also have a number of adults with learning disabilities who live with elderly parents, and this will create a need for more support as we go forward into the next three years. It has been particularly pertinent to ensure that the reliance on expensive out of area placements for children and for adults with learning disabilities is reduced and that where possible internal provisions can offer best value with high quality services. The work achieved in changing the practice model in Children’s Social Work is ongoing, but has created savings. The need to ensure practice is safe and robust and that the focus and priority is on keeping children and young people with their families where possible has meant that expensive out of area and external placements have reduced. There is hope to see further savings as we embed the two newly commissioned services to help us achieve our goals in that area. Future concerns remain that reductions to budgets will continue and the risk of overspending remains high. As outlined previously, need is growing in Moray, as with other areas of Scotland and the workforce reducing also. Moray also has a limited number of third sector and community organisations and there is a low presence of social care agencies to enable good competitive and ethical commissioning practices. Adult Social Work and Social Care 2020/21 £m 2021/22 £m 2022/23 £m Total Budget 49.6 58.5 60.4 Page 177
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Services for Children, Young People & Families 2020/21 £m 2021/22 £m 2022/23 £m Total Budget 19.383 19.791 18.334 Justice Services 2020/21 £m 2021/22 £m 2022/23 £m Total Budget -0.106 -0.106 -0.109 Workforce Number of front line social work posts: Adult Services: 40.31 FTE Children and Families: 54.72 FTE Justice: 13.5 FTE There have been a number of challenges to the recruitment and retention of staff across most areas of social work as aforementioned. There has been a national movement of staff from Children and Families Social Work into other areas of social work or indeed people leaving the profession altogether. Our Social Care staff numbers have been positive in terms of recruitment but not so strong in the area of retention, with people moving on to other better paid positions outside of the caring profession with challenges in ensuring staff have the support and training they require are also contributors to people in social care moving on. A lot of work has been undertaken to help people feel Moray is an attractive opportunity, but there have been a number of hard to fill positions that we have had to absorb as part of our contingency management to ensure the continued running of services. There have also been a number of sickness absences that have further contributed to an already pressured situation and the related task of sickness management by managers who already covering a number of vacancies. Staff wellbeing has undoubtedly been impacted and at times, teams have been asked to cover other areas of social work to help minimise the risks to critical parts of the Social Work system. Service Managers attend the Workforce and Resources sub-group of Social Work Scotland Children and Families’ Standing Committee and we have spoken with universities about what steps we may take in ensuring we are looking to the future for new graduates of social work and how these posts can be secured in Moray. Page 178
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There are plans to look at how we encourage other staff to train as social workers and how we stretch or reach of adverts wider than the traditional forms of advertising, e.g. LinkedIn. We are in the process of recruiting a trauma informed lead for our partnership stretching across both adult and children’s services and so we hope going forward we can develop some strategies in relation to increasing resilience and wellbeing of our workforce. Training, Learning and Development Children and Families and Justice Social Work created and delivered child protection training for all social work staff. A large focus of this training was on the rollout of the National Child Protection Guidance 2021 to ensure social workers were well briefed and understood how the new guidance related to their practice. The plan was to implement this training every two years in order that social workers working with complex child protection cases had the training and a refresher regularly. As the year went on, it became clear that the child protection training needed to change going forward, to ensure that all practitioners understood the core elements of recognising and responding to risk using good assessment skills and clear, SMART planning and partnership working. The new child protection training is currently under development and will be rolled out across all aspects of Social Work following evaluation of delivery to Children and Families’ Social Work. Consideration will also be given to ensuring it is developed to enable partners to access this training. In recognising the need to better develop how assessments were completed and to ensure that this was anchored to the national model, new assessment paperwork was developed to help address a number of things. Firstly, it is a relational model ensuring that the assessment is done alongside children and their families. Secondly, it attempts to reduce the multiple assessment formats that were being used across the service and simplify this for staff, to ensure that time was spent with families rather than on completing lengthy documents that did not serve to create better assessments. This paperwork was designed to support families themselves to better understand the areas where support was needed and what they could expect from Social Workers to help achieve those goals. In the dates between April 2022 and April 2023, the following training has been received by staff in Moray’s Children & Family’s Social Work Service: Page 179
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Safe and Together The multi-agency rollout of Safe and Together has been ongoing during this period and over 70 staff members attended the four day CORE sessions, since they were launched in Nov 2022. In total, 28% staff members are now licenced to use the tool with a further 37% scheduled to be trained by summer 2023. A multi-agency Safe and Together Overview day was also delivered in Feb 2023. A total of six staff members are trained as trainers with another staff member finishing the training course by the end of November 2023. Safer Sleep The multi-agency Safer Sleep training delivered by the Cot Death Trust in Feb 23, was attended by 55% of children and families social work staff, with a further sweep up scheduled for Jun 23 where there is an anticipated further 10% to be captured. This training was specifically in relation to Sudden and Unexplained Death of an Infant and gave staff a good understanding of potential causes, as well as how to interact with families who may face this awful situation. 4x4x4 Supervision Model Children & Families social work use the 4x4x4 supervision model, with a supervision policy in place to reflect this. 77% of the expected workforce have attended this training in the reporting period. Our Family Story Within children and families social work, the newly created assessment paperwork ‘Our Family Story’ was introduced. This was rolled out in the beginning of 2023 and to date, 59% of staff have received training in relation to its use. A further 20% will be captured in the sweep-up training over the summer of 2023. Solution-Orientated Practice/Meetings Moray has embraced the multi-agency use of Solution-Orientated Practice/Meetings. This way of working ties in directly with child protection planning meetings, and the Our Family Story assessment. 59% of staff are familiar with this model, to date, with a further 20% scheduled to be trained over the summer. Furthermore, a number of social work staff will become trainers in the model to ensure personnel are adequately supported and training continues with a turnover of staffing. Page 180
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Graded Care Profile 2 As of January 2023, the initial stages of GCP2 implementation began. This multi- agency tool will be rolled out across all children’s services and the implementation plan is in place with 20 members of staff across the area scheduled to become trainers later in the year. Alongside the training above, there have been a number of learning and development sessions where staff are invited to hear more about certain subjects, or further develop their skills. These have included topics such as Child Protection Planning Meetings, SCIM, Functional Family Therapy and Family Group Decision Making. There are also ‘whole department service learning’ opportunities on an 8- weekly basis for the CSWO to convey any important L&D points. In between these, staff are encouraged to use these sessions in a way they direct to help them with identified learning and development needs. Learning Reviews – Children’s Services Notifications of cases to be considered for a review are made to Child Protection Committee (CPC) Case Review sub-group. The sub-group follow the National Guidance for Child Protection Committees Undertaking Learning Reviews to consider and make a recommendation about whether to proceed to a full Learning Review. When a Learning Review is recommended by this group a report is submitted to the CPC for agreement. The National Guidance is then followed and subsequent progress is reported to the CPC through the subgroup. Between April 2022 and March 2023 there was one formal notification to the subgroup for their consideration. There were three learning reviews ongoing at this time and it was felt that enough information had been gathered to identify overarching themes that reflect what we already know and what we need to improve on in Moray. Furthermore there are some plans in place to address the key themes and issues. The case review sub-group also consider all national Learning Reviews in the context of any multiagency learning that can be taken from these. The group supports reflective discussion about these cases and considered any gaps within our own structures and systems across the multi-agency in relation to the learning outcomes and recommendations from these reviews. Learning Reviews – Adults Notifications of cases to be reviewed are made using the Grampian Learning Review Procedures. Learning from Case Reviews is a standing item at each APC with the intended outcome of continuous improvement through reflection on day to day Page 181
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practice and systems. On receiving notification, the Learning Review sub-group of the APC is required to meet to discuss and recommend a course of action to the APC. Between April 2022 and March 2023, 2 cases have been discussed within the Learning Review sub-group. 1 did not meet the criteria for Learning Review 1 case did, however, due to challenges in progression and time lapsed it was agreed that it will take the guise of a detailed timeline with recommendations brought to APC for further discussion and dissemination. Learning from reviews comes not only from undertaking local case reviews, but also having oversight of case review nationally. A Grampian-wide External Learning Review Group enables discussion and reflection on case reviews from other areas of Scotland which is then passed to APCs and Chief Officers Groups (for example Angus’ Adult 018 Report). This has proved to be exceptionally useful with learning disseminated via Council Officer Forums. Looking ahead Going forward there are a number of key areas that require ongoing development. Work will be ongoing to keep The Promise in Children’s Services and beyond and using the Whole Family Wellbeing Fund work with partners to deliver holistic intensive family support to a number of families as a pilot project will come to fruition. The implementation of the Children’s Services Plan as a partnership to focus on the priority areas will be key. Work will continue to develop staff skills in relation to the assessment of risk and multi-agency planning. In Adult Services there will be the implementation of the plan arising from the Day of Care Audit and developments in relation to the Adult Support and Protection improvement plan. Looking forward over the coming year there are a number of key posts which will hopefully be filled allowing the capacity to further develop and improve across Adult and Children’s Social Work. In Justice Services, work will be ongoing to ensure diversionary activity is achieving good outcomes and support for men with mental wellbeing issues in particular will be a focus. Work will continue on the development of a secure care procedure document which will incorporate the secure care standards. This will ensure a consistent, trauma informed process for young people who might meet secure care criteria. A young people support and protection procedure is also in development to support older young people up to adulthood and those who experience extra-familial harm or who are a risk to themselves or others. To stay true to Moray’s Promise, this procedure will focus on the needs of young people rather than solely on age. Page 182
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Overall, efforts will continue to offer support to all people who require it, at the earliest opportunity. Tracy Stephen Moray Health and Social Care Partnership Chief Social Work Officer and Head of Service Page 183
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REPORT TO: MORAY INTEGRATION JOINT BOARD ON 30 NOVEMBER 2023 SUBJECT: MORAY INTEGRATION JOINT BOARD MEETINGS 2024/25 BY: CORPORATE MANAGER 1. REASON FOR REPORT 1.1 To ask the Board to consider future arrangements for holding meetings of the Moray Integration Joint Board, the Audit, Performance and Risk Committee and the Clinical and Care Governance Committee and to agree the meeting dates for 2024/25. 2. RECOMMENDATION 2.1 It is recommended that the Moray Integration Joint Board (MIJB) endorses the schedule of meetings for the MIJB, the Audit, Performance and Risk (APR) Committee and the Clinical and Care Governance (CCG) Committee for 2024/25. 3. BACKGROUND 6.1 A proposed timetable of Board and Committee meetings for 2024/25 including MIJB development sessions is attached at APPENDIX 1. 6.2 Following the Covid-19 pandemic, meetings of the MIJB, APR Committee and CCG Committee have been a hybrid model of in-person and remote attendance. The Council’s committee meeting system, Connect Remote, allows the meetings to be webcast live to members of the public, also allowing members to watch the meeting at a later date if required. There have been no requests to change this system. This hybrid system supports sustainability, reduces costs, and travel time for staff and members of the public who may need to travel to attend the meetings. 6.3 To enable APR Committee to recommend the submission of the unaudited Annual Accounts and audited Annual Accounts to MIJB for approval, it is proposed the June and September APR Committee meetings take place in the morning and the MIJB in the afternoon. 4. KEY MATTERS RELEVANT TO RECOMMENDATIONS 4.1 The meeting schedule is established with the intention to ensure key dates for formal business are accounted for and to avoid the creation of Special meetings and conducting formal business during development sessions. Item 14. Page 184
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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 “Partners in Care 2022 – 2032” The scheduling of appropriate meetings facilitates good governance arrangements and supports the delivery of the Strategic Plan. (b) Policy and Legal In terms of the Standing Orders section 4.1, approved by the Board at its meeting on 28 June 2018 (para 5 of the Minute refers), the Board is to approve annually a forward schedule of meeting dates for the following year. (c) Financial implications There are no financial implications directly arising from this report. (d) Risk Implications and Mitigation None directly arising from this report. (e) Staffing Implications There are no staffing implications directly arising from this report. (f) Property There are no implications in terms of Council or NHS property directly arising from this report. (g) Equalities/Socio Economic Impact An equalities impact assessment is not required as there is no change to service delivery arising as a result of this report. The hybrid model allows access to all members of the public and staff. It reduces the need for the cost and emissions associated with travel. (h) Climate Change and Biodiversity Impacts The hybrid system supports sustainability, reduces costs, and travel time for staff and members of the public who may need to travel to attend the meetings. (i) Directions None directly arising from this report. (j) Consultations Consultations have been undertaken with the following who are in agreement with the content of this report where it relates to their area of responsibility: • Corporate Manager • Chief Financial Officer • Caroline O’Connor, Committee Services Officer, Moray Council • HSCM Performance Team Page 185
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6. CONCLUSION 6.1 The MIJB is asked to endorse the timetable of meetings, as attached at APPENDIX 1. Authors of Report: Isla Whyte, Interim Support Manager, HSCM Background Papers: Ref: Page 186
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APPENDIX 1 Proposed Meeting Dates 2024/25 DATE MEETING TYPE TIME 25 April 2024 Moray Integration Joint Board Development Session 9:00 to 12:00 30 May 2024 Moray Integration Joint Board 9:30 to 12:00 30 May 2024 Clinical & Care Governance Committee 14:00 to 16:30 27 June 2024 Audit, Performance and Risk Committee 09:30 to 11:00 27 June 2024 Moray Integration Joint Board 14:00 to 16:00 29 August 2024 Clinical & Care Governance Committee 9:30 to 12:00 29 August 2024 Moray Integration Joint Board Development Session 14:00 to 16:00 26 September 2024 Audit, Performance and Risk Committee 9:30 to 11:00 26 September 2024 Moray Integration Joint Board 14:00 to 16:00 31 October 2024 Moray Integration Joint Board Development Session 9:00 to 12:00 28 November 2024 Moray Integration Joint Board 9:30 to 12:00 28 November 2024 Clinical & Care Governance Committee 14:00 to 16:30 Item 14. Page 187
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APPENDIX 1 30 January 2025 Moray Integration Joint Board 9:30 to 12:00 30 January 2025 Audit, Performance and Risk Committee 14:00 to 15:30 27 February 2025 Moray Integration Joint Board Development Session 9:00 to 12:00 27 February 2025 Clinical & Care Governance Committee 14:00 to 16:30 27 March 2025 Moray Integration Joint Board 9:30 to 12:00 27 March 2025 Audit, Performance and Risk Committee 14:00 to 15:30 Page 188