Agenda Document Pack - Moray Integration Joint Board - 28/03/2024
Moray Council · 28 March 2024
Back to Moray Integration Joint Board — 28 March 2024 and its agenda
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Moray Integration Joint Board Thursday, 28 March 2024 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, 28 March 2024 at 09:30 to consider the business noted below. AGENDA 1. Sederunt 2. Declaration of Member's Interests 3. Minute of meeting of 25 January 2024 5 - 12 4. Action Log of 25 January 2024 13 - 14 5. Chief Officer Report 15 - 28 6. Revenue Budget Monitoring Quarter 3 for 2023-24 29 - 50 7. Primary Care Prescribing Budget for 2024-25 51 - 78 8. Revenue Budget 2024-25 79 - 98 9. Mental Health Pathway Mapping 99 - 148 10. General Practice Vision and Objectives 149 - 222 11. Care at Home Service in Moray 223 - 244 Committee Minutes for Noting Minute of Meeting of Audit, Performance and Risk Committee on 26 October 2023 245 - 248 Page 1
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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) Mr Adam Coldwells (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) Ms Deirdre McIntyre (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, 25 January 2024 Council Chambers, Council Office, High Street, Elgin, IV30 1BX PRESENT Councillor Peter Bloomfield, Mr Simon Bokor-Ingram, Professor Duff Bruce, Mr Sean Coady, Councillor Tracy Colyer, Ms Sonya Duncan, Councillor Scott Lawrence, Dr Robert Lockhart, Ms Deirdre McIntyre, Mr Derick Murray, Ms Deborah O'Shea, Mr Sandy Riddell, Mr Dennis Robertson, Ms Elizabeth Robinson, Ms Tracy Stephen, Mr Kevin Todd, Councillor Ben Williams APOLOGIES Mr Ivan Augustus, Mr Roddy Burns, Mr Adam Coldwells, Ms Jane Ewen, Dr Malcolm Simmons IN ATTENDANCE General Manager, Dr Gray's Hospital; Marie Simpson, Programme Manager, Digital Health and Care Innovation Centre (DHI) Scotland; Transformation Programme Manager, Aberdeen City Health and Social Care Partnership; Lead Pharmacist Primary Care, Moray Health and Social Care Partnership (MHSCP); Lead Pharmacy Technician, MHSCP; Head of Governance, Strategy and Performance and Caroline O'Connor, Committee Services Officer. 1. Chair The meeting was chaired by Mr Dennis Robertson. 2. Declaration of Member's Interests Mr Riddell stated for transparency 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 5
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3. Minutes of meeting of 30 November 2023 The minute of the meeting of 30 November 2023 was submitted and approved. 4. Action Log of 30 November 2023 The Action Log of the meeting of 30 November 2023 was discussed and updated accordingly. 5. Thanks The Board, in noting that Mr Graham Hilditch had resigned due to other commitments, joined the Chair in paying tribute to Mr Hilditch for his contribution to the Board and wished him well for the future. 6. Congratulations The Board joined the Chair in congratulating Ms Deborah O'Shea, Interim Chief Financial Officer on her permanent appointment to the post of Chief Financial Officer with effect from 1 April 2024. 7. Chief Officer Report The meeting had before it a report by the Chief Officer informing 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 Moray Health and Social Care Partnership (HSCP) includes the continuation of a shift in the balance of care through implementing a Home First approach; remobilisation from the covid pandemic; supporting measures for the reduction of local covid transmission; and budget control. The Chief Officer provided a further update to the Board in relation to the Ward 4 anti- ligature work and installation of MRI scanner at Dr Gray's Hospital, advising that Scottish Government funding was no longer available for the MRI scanner at this time which would also impact on the Ward 4 anti-ligature work as it was part of the same project. The General Manager, Dr Gray's Hospital advised the Ward 4 work was paused and further discussions on funding streams would require to be held. In response the Chair asked for an update to be prepared for the next meeting of the Board to provide reassurance regarding discussions and the process for continuation of the work. Mr Riddell expressed concern about the budget pressures relating to Care at Home service and sought assurance that there was strategic direction with full understanding how the budget pressures have been manifested. In response the Deputy Chief Officer confirmed the current delivery model is not working and a new outcome focussed delivery model is required. He confirmed he would prepare an update for the next meeting of the Board to provide assurance on the current position and actions undertaken. Page 6
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Mr Murray sought an update on the trends in relation to unmet demand and delayed discharge. In response the Chief Officer agreed a report would be prepared for the next Clinical and Care Governance Committee. Following consideration the Board unanimously 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. 8. Strategic Review of Neuro-Rehabilitation Pathway The meeting had before it a report by the Lead for Allied Health Professionals and Specialist Rehabilitation Services and Transformation Programme Manager informing the Board of the findings and recommendations of a strategic review undertaken to identify the most effective delivery of Neurorehabilitation across Aberdeen City, Aberdeenshire and Moray. Following consideration the Board unanimously agreed:- i. to note the findings of the strategic review of the neurorehabilitation pathway; ii. that Aberdeen City Integration Joint Board (IJB) as host IJB for this service implements the proposed changes to the neurorehabilitation pathway in collaboration with Health and Social Care Moray (HSCM) and in a phased manner as set out in section 5; iii. agrees that an evaluation of Phase 1 will be shared with MIJB in September 2024 before Phase 2 commences; and iv. to note the engagement to date with the Aberdeenshire and Moray Health and Social Care Partnerships (HSCPs) and support the continuation of the engagement to help ensure the redesign continues to met the needs of all three Partnerships. 9. Membership of Board and Committees The meeting had before it a report by the Corporate Manager informing the Board of changes to the Membership of the Moray Integration Joint Board (MIJB), Audit, Performance and Risk (APR) Committee and Clinical and Care Governance (CCG) Committee. Following consideration the Board unanimously agreed to note:- i. the Chair and Vice Chair are due to rotate on 1 April 2024; ii. the appointment of Sandy Riddell as Chair of the APR Committee from 1 April 2024; iii. the update regarding vacancies in National Health Service (NHS) voting membership, noting the temporary appointment of Sandy Riddell to the CCG Committee until such time as the new Health Board voting member is appointed, Page 7
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and Service User Stakeholder position; iv. the appointment of Deirdre McIntyre as the new NHS Staff Partnership representative; and v. the updated membership of the Board and Committee attached at Appendix 1. Councillor Williams left the meeting at this juncture. 10. Locality Planning Update The meeting had before it a report by the Interim Deputy Head of Service informing the Board on the work done to date in relation the Health and Social Care Moray Locality Planning model. Mr Riddell stated it would be useful in terms of providing assurance and understanding the potential for transformation if evidence was available to support the test of change in respect of successes shared across localities. Councillor Lawrence agreed such evidence would be useful to highlight positive examples and to evidence change against possible savings. In response the Deputy Chief Officer agreed to include examples of evidence in the report to be presented to the Board on 29 August 2024. Following consideration the Board unanimously agreed to:- i. note the progress made on locality plans since the previous report on 30 March 2023; and ii. agree that further progress reports be brought to the MIJB on a six monthly basis. 11. Lossiemouth Locality Health and Social Care Provision Update The meeting had before it a report by the Deputy Head of Service (Interim) informing the Board on the progress made in relation to the development of health and social care provision within the Lossiemouth Locality, in partnership with the local community and practitioners. Following consideration the Board unanimously agreed to:- i. note the current position in relation to Hopeman and Burghead branch surgery buildings; ii. note the request from the Cabinet Secretary for NHS Recovery, Health and Social Care that an officer from another Health and Social Care Partnership (HSCP) meet with representatives from Health and Social Care Moray (HSCM) to discuss the engagement and consultation process undertaken regarding the Burghead and Hopeman branch surgery premises; and iii. agrees the role of Glasgow School of Art in supporting General Practice visioning work within Moray. Page 8
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12. Carefirst Replacement The meeting had before it a report by the Chief Social Work Officer informing the Board of the requirement for a replacement Social Work services client based recording system. Concern was raised by a number of members of the Board on how the replacement system would be funded. In response the Chief Officer advised funding streams would be part of the scoping exercise which would be reported back to the Board. Following consideration the Board unanimously agreed to:- i. note the requirement for a replacement Social Work services client based recording system; and ii. agree the initiation of a process to begin scoping a replacement system. 13. Reappointment of Chief Internal Auditor The meeting had before it a report by the Chief Officer asking the Board to consider the reappointment of the Chief Internal Auditor, whose current terms of appointment are due to expire on 31 March 2024. Following consideration the Board unanimously agreed to appoint Dafydd Lewis, Audit and Risk Manager, Moray Council, as the Chief Internal Auditor of the MIJB, for a further period of two years to 31 March 2026. 14. Reappointment of Standards Officer and Depute Standards Officer The meeting had before it a report by the Chief Officer asking the Board to consider the reappointment of its Standards Officer and one Depute, whose current terms of appointment are due to expire on 1 April 2024. Following consideration the Board unanimously agreed to:- i. formally nominate for approval by the Standards Commission, Alasdair McEachan, Head of Governance, Strategy and Performance, Moray Council, as the Standards Officer of the MIJB, for a further period of two years until 1 April 2026; ii. formally nominate for approval by the Standards Commission, Aileen Scott, Legal Services Manager, Moray Council, for a further period of two years until 1 April 2026; iii. task the Chief Officer with writing to the Standards Commission with the relevant information; and iv. note that the arrangements will be reviewed period to April 2026. Page 9
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15. Care for People Plan - Moray Arrangements The meeting had before it a report by the Corporate Manager providing assurance to the Board that Health and Social Care Moray (HSCM) have developed an operational framework to deliver the Care for People Strategy. Following consideration the Board unanimously agreed to:- i. note that a Care for People Operational Framework has been developed in conjunction with its partners, as set out in the operational document (Appendix A); and ii. note that continued improvement and implementation of the Care for People Plan is now business as usual. 16. Reserves Policy - Review The meeting had before it a report by the Chief Financial Officer seeking approval from the Board on its reserves policy. Following consideration the Board unanimously agreed:- i. to approve the Reserves Policy as at Appendix 1; and ii. that the next review will be no later than March 2025. 17. Budget Update and Financial Recovery Plan [Para 6.2.1] The meeting had before it a report by the Chief Financial Officer providing the MIJB with a budget update in preparation for the 2024/25 financial year, along with a financial recovery action plan that begins to address the 2024/25 budget gap between income and expenditure. Concern was raised by members of the Board that there was not enough information in the recovery plan for a decision to be made at the meeting as the proposed savings were not sufficiently radical or transformational to address the budget deficit as set out in the report. The Chief Officer advised that a report on MIJB Scrutiny had been considered by Moray Council at their meeting on 24 January 2024. The Head of Governance, Strategy and Performance confirmed that the purpose of the report was to provide Councillors with assurance and clarification of the Council’s scrutiny arrangements and reporting arrangements for MIJB. The Chair moved that a workshop be arranged with the Board and, if appropriate, community planning partners, to discuss detailed costed options including risks and for the outcomes from the workshop be reported back to Board for approval. Following further lengthy consideration theBoard unanimously agreed:- i. a workshop be held as soon as practicable to consider detailed and costed options with associated risks for transformational change to address the budget deficit; and Page 10
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ii. the outcomes from the workshop be reported back to the Board at the earliest opportunity for approval in order to set a balanced budget. Page 11
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MEETING OF MORAY INTEGRATION JOINT BOARD Thursday 25 January 2024 ACTION LOG ITEM NO. TITLE OF REPORT ACTION REQUIRED DUE DATE ACTION BY UPDATE FOR 28 MARCH 2024 1. 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 MIJB meeting. 30 Nov 23 SC Paper to be presented to CCG Cttee this afternoon 2. Action Log of 30 November 2023 Request for further reports to be brought to the Board addressing the wider aspects of mental health in Moray. 28 Mar 2024 SBI On today’s agenda 3. Chief Officer Report: Update on how the Ward 4 anti-ligature work is to be progressed to be provided to next MIJB meeting. 28 Mar 2024 SBI/AP Included in Chief Officer report on today’s agenda 4. Chief Officer Report: Paper to be prepared for next MIJB meeting detailing the current position relating to Care at Home and actions undertaken to progress new outcome focused delivery model. 28 Mar 2024 SC Report on today’s agenda 5. Chief Officer Report Paper on the unmet demand and delayed discharge trends to be prepared for CCG Cttee. 28 Mar 2024 SBI Included in the Care at Home report on today’s agenda Item 4. Page 13
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ITEM NO. TITLE OF REPORT ACTION REQUIRED DUE DATE ACTION BY UPDATE FOR 28 MARCH 2024 6. Carefirst Replacement Following scoping exercise being undertaken, paper to be prepared for MIJB detailing costs of team recruitment, replacement system and how it is proposed to fund it. TBC TS 7. Budget Update and Financial Recovery Plan Report from 25/01 deferred to allow workshop on detailed and costed options with associated risks to be held as soon as possible and outcomes reported back to IJB at earliest opportunity for approval. ASAP SBI/DO On today’s agenda Page 14
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REPORT TO: MORAY INTEGRATION JOINT BOARD ON 28 MARCH 2024 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. 1.2 Strategic planning needs to maintain a focus on transformational change to deliver services to our community within the resources we have available. 2024/25 will be a very challenging year for delivering within the budget, with our two funding partners, Moray Council and NHS Grampian, under considerable financial pressure as well. 2. RECOMMENDATION 2.1 It is recommended that the Board: 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. Additional resource has been allocated with two Band 6 Nurse Practitioners joining the Hospital Without Walls Team and an addition of a Career Start GP working one day a week working with the Geriatric team at DGH and Home First Team. To maximise opportunities to support patient flow, a Moray wide Strategic Multidisciplinary Team meets to prioritise resource. A strategy group and operational group Item 5. Page 15
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reviewing the challenges of Care at Home provision have both met with action plans developed. 3.2 The current Care at Home Contract with external providers ends in October 2024. Senior Managers within the partnership are therefore reviewing the Care at Home Service. 3.3 A Care at Home Workshop was held on 4th March 2024; involving both internal and external stakeholders with a view to identifying the aspirations and actions required to progress Care at Home Delivery in Moray. The workshop facilitated discussion between a wide range of partners to develop key themes to support the overall plan. 3.4 In order to do this the service will require a change in the operational culture, embedding a need for service improvement and change management to ensure delivery against an outcomes focussed care at home delivery model. 3.5 Social care providers will work in partnership to develop a collaborative approach to the delivery of care. With a focus on developing improved communications with the third sector, working in collaboration to seek solutions for the increasing demands. 3.6 Communication with communities requires transparency in relation to the availability of care at home services and a move towards different models of care. Vaccination Programme 3.7 The autumn / winter vaccination programme for Covid and Flu commenced in September 2023 and will run until the end of March 2024. 3.8 As of 7 March 2024 Covid-19 vaccination uptake for Moray was 60% which is above the Scottish average of 56.6% with the Flu vaccination uptake over the same period across Moray being 58.3%, again above the Scottish average of 53.7% with the final autumn / winter uptake being published in April 2024. 3.9 The uptake within Health and Care Staff will also be available in April 2024. A recent staff survey to understand the reasons for Health and Care staff not taking up the offer of vaccinations has been widely distributed and closed at the beginning of March 2024 with the outcome of the survey awaited. 3.10 The priorities for Spring 2024 include the commencement of the Covid-19 spring booster programme which will commence on 2 April 2024 for eligible cohorts. The shingles vaccination programme commenced in January 2024 which now requires 2 doses, with the 2nd dose offer commencing in March. The uptake of the shingles vaccine for priority groups as of 7 March detailed 65 year olds (68.3%) 70 year olds (72%) 50 year olds and those who are immunosuppressed (52.85%). Those between 71-79 years who have not been offered shingles vaccine previously have now been offered this but has to date had a lower uptake of 13.19%. 3.11 The pneumococcal program was brought forward to February 2024 commencing with those who are immunocompromised and the outcome of the uptake for this is not yet available. Page 16
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3.12 Pre School and childhood immunisation schedule is continuing and now delivered within the vaccination centre. 3.13 There has been additional planning within the vaccination service to support requests for the MMR vaccination given the recent concerns related to measles. Ward 4 anti-ligature work and installation of MRI scanner at Dr Gray’s Hospital 3.14 Following discussion at the January 2024 MIJB meeting, and further to the Scottish Government announcement in December 2023 in relation to their budget, which outlined a very challenging picture for public sector spending, in particular Capital spending, Scottish Government have now confirmed that, based on budget allocation for 2024/25 and the medium term funding outlook, work on the National Treatment Centre - Grampian Project, including an MRI scanner for Dr Gray's Hospital, will not progress further at this time and all project activity will stop. This will be the position until there is certainty on funding. 3.15 Plans to concurrently refurbish the mental health ward at Dr Gray's Hospital, will now be reviewed alongside wider NHS Grampian infrastructure risks and investment plans. 3.16 The NHS Grampian Asset Management Group are developing a process through which they will prioritise the allocation of funding over the next 5 year period informed by both the Scottish Government budget letter guidance and a weighted risk and benefit assessment of all of its infrastructure liabilities. The mental health ward ligature reduction project will be considered in this process. GP Vision 3.17 The 3 Chief Officers (Aberdeen City, Aberdeenshire 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 faced. 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. The Vision is on today’s agenda and seeks to address the challenges. Aberlour Medical Centre Update 3.18 Health & Social Care Moray (HSCM) has taken over the running of Aberlour Medical Practice to ensure continued access to primary care services for the community. 3.19 A letter has been sent to patients by the Health and Social Care Partnership (HSCP) confirming that Dr Annabel Ross has ended the practice’s contract to provide General Medical Services (GMS) with immediate effect. Dr Ross, the independent contractor and sole partner, made the difficult decision after her efforts to recruit additional permanent GPs to the practice were unsuccessful. Page 17
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The Aberlour practice, which has just over 3,000 patients, will be managed and operated by Health and Social Care Moray (HSCM) on an interim basis while plans are developed to secure a robust and sustainable service to the community going forward. As soon as HSCM are satisfied with the position of the practice then a tendering process will be put in place to return the practice to independent practice arrangements. Lossiemouth Locality update 3.20 Evan Beswick, Head of Primary Care Argyll and Bute HSCP was tasked by the Cabinet Sectary for Health and Social Care to review and seek learning from the process of engagement and consultation carried out by the Moray HSCP in relation to the closure of the Burghead and Hopeman Branch Surgeries. As part of his review on 15 January 2024, Evan met with members of the Save our Surgeries group and then later that day with members of the HSCP. Evan also reviewed a range of documentation provided to him by both the Save our Surgeries Group and the HSCP. A final draft of the commissioned report was duly produced and shared for comment at a joint meeting of all stakeholders on 22 February 2024. 3.21 The draft report identifies areas of strength and also areas of learning for the HSCP, and most importantly recommends ongoing dialogue between the Partnership and the local community through the locality planning process; recently two further members of the Save our Surgeries group have been inducted into the Lossiemouth Locality Planning Group which should aid this process. 3.22 In terms of the community engagement and consultation process the report notes: 'having considered both the clear process, rigorous documentation and the rationale as described by HSCM representatives, and noting the best- practice approach of consultation with Healthcare Improvement Scotland, I find that a rigorous engagement and decision making process has been adhered to. Indeed, HSCM Moray have gone beyond the minimal requirements of the regulations. This is supported by clear and transparent decision making through MIJB'. 3.23 Once finalised the report and associated recommendations will be shared in full with Moray IJB members. Management capacity 3.24 There are a number of competing priorities; a system that is constantly under pressure; and an urgent requirement to decrease expenditure. In order to retain a balance between these priorities MIJB will need to be innovative about how to retain a management capacity that can satisfy all these demands. With the loss of a strategy and planning lead; a lead for performance; and an imminent retiral, the three Grampian HSCPs have discussed how to progress a “once for Grampian” approach where it is appropriate to do so. An agreement with Aberdeen City Partnership has been formulated, and we are now in the implementation stage. The arrangement will deliver an effective strategy, planning and performance function, at less cost and with more resilience. 3.25 The Chief Finance Officer role is permanently recruited to and the start in post date is 1 April 2024. Page 18
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3.26 A recruitment process is underway for the Chief Nurse post, which covers the Portfolio (HSCP and Dr Gray’s Hospital) as the current post holder retires at the end of May. A 12 month fixed term post funded by NHS Grampian for a Senior Nurse has been recruited to and will support the nursing structure particularly at a time of transition for the Chief Nurse role. Moray Growth Deal and the Rural Centre of Excellence (RCE) for digital health and care innovation 3.27 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 continue to be a regular feature on the Chief Officer reports. 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. 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 Page 19
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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 engagement with all sectors must continue to ensure full involvement, which will create the best solutions to the challenges faced. HSCM staff are facing continued pressures on a daily basis, and effort into ensuring staff well-being must continue. (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. 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 MIJB, 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. Page 20
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Author of Report: Simon Bokor-Ingram, Chief Officer, Moray Portfolio Page 21
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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 March 2024 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. Image 1: Key R&D assets and the 5 Living Lab (LL) Themes APPENDIX 1Item 5. Page 23
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Digital Health & Care Innovation Centre, 1st Floor, Suite B, Inovo Building, 121 George Street Glasgow, G1 1RD RCE Activity Update February 2024 to March 2024 Programme Update Following a change control submission to the MGD board in November 2023, the RCE received approval from UKG and SG in January to extend the programme to May 2026 and to reprofile the current budget. This has allowed the team to review scope and timelines for all R&D living labs and to explore future inward investment under the sustainability work package to enable maturation of developing assets, additionality, and integration to achieve increased impact as shown in figure 2. Figure 2: Revised Scope of the RCE Living Lab Updates LL1 Supported Self-Management and LL2 Long Term Condition Management (NHS), will now be aligned to share a common infrastructure while retaining their individual outputs. LL1 will continue to focus on a tier 2 weight management service programme, supported by the Moray NHS Dietetic Service, with eligible citizens enabled to self-refer via a Personal Data Store (PDS). Once onboarded, individuals will be able to share data collected from approved apps and personal devices such as Fitbit’s with the clinician and to communicate using two-way asynchronous messaging via shared access platform. Revised iterations and user testing will be completed over the next few months, and it is expected to move to real world evidence stage in summer 2024. A working group has been established to take forward the delivery plan, and an evaluation framework has been drafted. Page 24
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Digital Health & Care Innovation Centre, 1st Floor, Suite B, Inovo Building, 121 George Street Glasgow, G1 1RD LL2 Long Term Condition Management (NHS) will utilise the infrastructure developed in LL1 with the aim of developing digital solutions to address access deprivation, with an initial clinical focus of Type 2 Diabetes. Through consented sharing, these assets will enable the citizen, the clinical team and community facilities such as leisure/sport centres or libraries with health and wellbeing capability, to view and monitor relevant data to ensure needs are met by the right person at the right time. This will bring additional capacity and support to clinical services through utilisation of community-based resources, while releasing some clinical time through digital monitoring in place of face-to-face review of stable cases. 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, with call to industry is expected to be published in the next few weeks. LL3 Care in Place: User testing has now been completed, with a final iteration of the R&D community connections platform and personal data store assets in progress with both R&D assets now live. This lab will move to a phased real world evidence stage in spring 2024 for a minimum of 6 months, and an evaluation framework has been drafted to support this. Interest in this model has been shown from the Improving Cancer Journey project and Moray Children and Family Services, although not in current scope, further development and funding opportunities are being explored. LL4 Smart Housing: Definition stage has now been completed 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, digital telecare, activity monitoring, IOT and consumer devices through a single AI enabled platform. This will be used as the basis to develop a state-of-the-art specification for new build smart enabled properties, alternative housing options, and future community alarm/ responder provision. The assets developed will be tested within live services in Moray ahead of the deployment into the Leanchoil Trust site properties by the MGD Housing Mix project team in 2027/28. Enabled by the additional year of the project, under LL4, the RCE aims to develop a population stratification tool to pull data from the smart housing devices along with other holistic data gathered from relevant health, care, environment, and about me sources via a PDS. This universally unique platform based on the social determinants of health will allow data to be viewed and shared at the citizen’s discretion with the services that support them. At a later stage, it is intended to integrate AI analysis to the holistic data in the platform, to enable alerting to change, based on personalised baselines and protocols to provide smart self-management suggestions and/or, to trigger a health or care intervention. Through these alerts it is envisaged that a more proactive and predictive approach can be adopted to maintain independence and wellbeing which will enable population stratification and resource management at both an individual and population level to reduce waiting lists, Page 25
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Digital Health & Care Innovation Centre, 1st Floor, Suite B, Inovo Building, 121 George Street Glasgow, G1 1RD increase capacity and alert to early indicators of decline to reduce hospital admissions and unscheduled care. 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) Other Moray Workstreams • The RCE continues to contribute to the Moray HIS frailty project through attendance at Moray meetings, update reports and presentations. • Research report has been competed by DHI RKM team to identify international self- assessment frailty baselining tools and information related to effectiveness and will be used to inform potential future inclusion in the PDS. • Meeting held with Grampian NHS GP Vision project lead, and alignment with programme identified, including frailty. Collaborative opportunities are now being scoped further. • The RCE team are working closely with the analogue to digital telecare project team with some R&D work being taken forward together under living lab 4. Skills The University of Oxford were appointed as the academic partner to undertake a review of workforce training tools and identify gap, with a focus on innovation skill and needs. Two pop events were held at Dr Gray’ and the Glassgreen Centre in February along with several online interviews, to gain insights from all levels of the health and socials care workforce. A report will follow, and this will inform the scope of further skills development calls in 2024. Micro-credentials (Digital Essentials for Carers) Three digital courses have been developed, with the initial review phase nearing completion. Further iteration will follow based on feedback, with modules to be developed in to more engaging and interactive courses by incorporating case studies, interviews with local carers/ care staff, video demonstrations etc. Page 26
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Digital Health & Care Innovation Centre, 1st Floor, Suite B, Inovo Building, 121 George Street Glasgow, G1 1RD Communication and Engagement RCE in parentship with H&SCM will deliver a multi-media campaign in March aimed at increasing community understanding of the challenges facing health and social care, the need to shift the balance of care, and the contributory opportunity presented by the RCE. This will commence with an exclusive feature run over two days in the Press and Journal newspaper, followed by a general press release and social media posts. Four in person events across Moray will be delivered between the 20th and 23rd of March to give attendees the opportunity to ask questions and participate in codesign activities with GSA colleagues. It is hoped that through this campaign the broader community will register for project updates and opportunities to participate in regular co-design and information events. The monthly DSE drop-in sessions in The Alexander Graham Centre will commence on the afternoon of Tuesday the 9th of April 2024, with the first session offered to IJB members and strategic partners to provide an update on the living lab assets developed. Further details and a registration link will be sent to members in due course. The RCE team along with two industry partners, are delighted to be one of three entrants shortlisted for the upcoming innovation award at the national TSA ITEC conference on the 18th of March. As a key national industry event this will be a significant opportunity to spotlight the work being done in Moray. ITEC Awards Finalists 2024 : TSA Conference (itecconf.org.uk) Evaluation A framework for the academic evaluation continues to be developed by UHI to capture the integrative and living lab specific outcomes across the whole programme. Qualitative data is also being collated to evaluate the impact of the RCE on the Moray region to evidence increased service, technology and business readiness for R&D and innovation. Sustainability Page 27
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Digital Health & Care Innovation Centre, 1st Floor, Suite B, Inovo Building, 121 George Street Glasgow, G1 1RD The sustainability of the RCE continues to be a key focus, supported by a working group with 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. Preparation and discussion around service readiness and needs for asset adoption continues to be progressed with H&SCM and NHS Grampian. Page 28
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DRAFT REPORT TO: MORAY INTEGRATION JOINT BOARD ON 28 MARCH 2024 SUBJECT: REVENUE BUDGET MONITORING QUARTER 3 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 31 December 2023 for the MIJB budget. 2. RECOMMENDATIONS 2.1 It is recommended that the Board: i) note the financial position of the Board as at 31 December 2023 is showing an overall overspend of £7,110,508 on core services; ii) note the updated provisional forecast position for 2023/24 of an overspend of £11,210,917 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 pressures as detailed in paragraph 7; v) note the revisions to staffing arrangements dealt with under delegated powers and in accordance with financial regulations within Moray Council (MC) and NHS Grampian (NHSG) for the period 1 October to 31 December 2023 as shown in APPENDIX 3; and vi) approve for issue, the Directions arising from the updated budget position shown in Appendix 4. Item 6. Page 29
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3. BACKGROUND 3.1 The financial position for the MIJB services at 31 December 2023 is shown at Appendix 1. The figures reflect the position in that the MIJB core services are currently over spent by £7,110,508. This is summarised in the table below. Annual Budget £ Budget to date £ Expenditure to date £ Variance to date £ MIJB Core Service 167,896,497 125,561,421 132,862,729 (7,110,508) MIJB Strategic Funds 15,511,545 5,355,047 4,861,771 577,815 Set Aside Budget 13,917,000 - - - Total MIJB Expenditure 197,325,042 130,916,467 137,724,500 (6,617,232) 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 £11,210,917 by the end of the financial year. This is summarised in the table below: Annual Budget £ Forecast expenditure to 31 Mar 24 £ Variance to 31 Mar 24 £ MIJB Core Service 167,896,497 179,107,414 (11,210,917) MIJB Strategic Funds 15,511,545 7,324,184 8,187,361 Set Aside Budget 13,917,000 13,917,000 0 Total MIJB Expenditure 197,325,042 200,348,598 (3,023,556) 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 £87,024 to date, this predominantly relates to cost pressure within community hospital and community admin in the Buckie area including property costs. 4.2 This budget is forecast to be £392,800 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 final confirmed allocation alongside additional costs for community hospitals including medical and energy costs. Learning Disability 4.3 The Learning Disability (LD) service is overspent by £1,604,879. The overspend is predominantly due to care purchased at £1,693,016 this is being reduced by more income received than expected of £83,627 and other minor underspends totalling £4,511. 4.4 The overspend primarily relates to domiciliary care to support individuals in their own home, day care which allows clients to do meaningful activities, social opportunities and a chance to learning new skills and housing support Page 30
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to help people to live as independently as possible in the community. The LD service has found this year that Children who are transitioning into adult services, are transitioning with higher than usual levels of complex and challenging need. In addition, the staffing challenges in care provision has led to instability in care packages. For the people LD support, who need consistency, structure and routine, the instability leads to behavioural challenges and an escalation in need, requiring increases in care hours or a reliance on specialist services that come at greater cost. Moray has a growing and ageing population that means year on year, more individuals are received into the service than those who leave, and those who are ageing will require the same or increased levels of care than in their younger years. 4.5 There is currently work taking place to monitor and support external care providers to enable them to deliver high quality care packages. It is hoped this will achieve the stability required to maintain care packages at their current levels. The team also regularly look to ‘smart’ solutions that would enable greater independence and less reliance on care provision, or that would enable economies of scale in care provision. Each new or changing package of support is considered within a resource management group ensuring careful consideration of all factors and options available and examination of costs including both expenditure and income. 4.6 This budget is forecast to be £2,934,736 overspent by the end of the financial year, due to the issues above remaining to the end of the financial year. Mental Health 4.7 The Mental Health service is overspent by £125,905. This includes Clinical Nursing and other services which are overspent by £199,567. The overspend is primarily due to staffing and non-pay overspends for Clinical nursing and other services of £422,289, mainly in medical services. This is partly offset by continuing underspends across other staffing including Psychology and Allied Health Professionals (AHP’s), additional staffing income £222,722 from NHS Scotland and assessment and care £73,622 mainly due to a ceased mental health contract that is currently under review. 4.8 The staffing overspends continues to relate to consultant vacancies to December 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. 4.9 This budget is forecast to be £438,440 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 7.8 below). Care Services Provided In-House 4.10 This budget is underspent by £1,068,500 due to vacancies in the service which are still encountering issues with recruitment and retention. Page 31
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4.11 This budget is forecast to be £1,265,318 due the above issues remaining and also the reduction in use of overtime. Older People and Physical Sensory Disability (Assessment & Care) 4.12 This budget is overspent by £1,899,883 to 31 December 2023. This primarily relates to overspends for care purchased in the area teams of £1,083,117 and permanent care £948,599. This is being reduced by income received more than budgeted £116,070 and other minor underspends totalling £15,763 4.13 This budget is forecast to be £2,226,340 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. Intermediate Care & Occupational Therapy 4.14 This budget is overspent by £167,987 to date. This is due to purchase of equipment £183,044, other minor overspends totalling £16,633 which is being reduce by more income received than budgeted £31,690. To enable people to stay independently in their own home they require specialist equipment and adaptations these include ramps, grab rails, stair lifts, bath lifts, walk-in showers and community alarms. 4.15 This budget is forecast to be £258,839 overspent by the end of the financial year due to the reasons above continuing. Other Community Services 4.16 This budget is £228,434 overspent to date. This includes the impact of overspends within Allied Health Professionals for Dietetics and Physiotherapy alongside Pharmacy and Specialist Nurses. This remains primarily due to staff costs, loss of income, increase costs of medical supplies and other non-pay expenditure. 4.17 This budget is forecast to be £248,121 overspent by the end of the financial year. This is primarily due to these cost pressures continuing to be incurred as services redesign. Admin & Management 4.18 This budget is overspent by £35,475 as at 31 December 2023, this primarily is due to overspend in Management services relating to salary costs 4.19 This budget is forecast to be overspent by £311,696 by the end of the financial year. This is due to the above factors remaining for the whole financial year and the vacancy target is not expected to be fully achieved by the end of the financial year. Primary Care Prescribing 4.20 The primary care prescribing budget is overspent by £2,708,198 to 31 December 2023. This estimated position is based on five month’s actuals and an accrued for September to December due to difficulties implementing a new national prescribing processing system whereby information for NHS Boards has been delayed. The budget to month 9 includes allocation from MIJB core uplift to mitigate position. For 2022/23 the overall prescribing volume of items Page 32
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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 with the increase to December estimated at 5.5%. Work continues at a local level and through Grampian wide Primary Care Prescribing Group to pursue efficiency. 4.21 This budget is forecast to be £3,750,00 overspent by the end of the financial year taking into account the volume increase continuing and impact of price changes relating to short supply being maintained. Primary Care Service 4.22 This budget is overspent by £218,557 to 31 December 2023, and includes exceptional costs not anticipated for supporting Primary Care services delivered in Moray. This includes continuing support for Aberlour GP practice through a period of challenge which is continuing and locum costs being incurred during this support. 4.23 This budget is forecast to be £291,410 overspent by the end of this financial year, as the need for support costs are anticipated to continue Hosted Services 4.24 This budget is overspent by £273,273 due to continuing cost pressures within recharged hosted services including Intermediate Care, Marie Curie services, Continence services, HMP Grampian and Police Forensic Services. 4.25 This budget is forecast to be £430,630 overspent by the end of the financial year due to cost pressures above anticipated to continue, as well as additional winter costs expected particularly in GMED service. Out of Area Placements 4.26 This budget is overspent by £896,146. 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 has not been uplifted. There are now additional patients with complex needs for which there is no budget. This coupled with increased unit costs are producing a continuing overspend. 4.27 This budget is forecast to be £1,117,869 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. Page 33
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5.2 Within the strategic funds are earmarked reserves totalling £4,682,794. However, there are not enough reserves to cover the overspend in total with the current level of spend forecast till 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. Efficiencies Para Ref Full Year Target Expected progress at 31 Dec 2023 Actual Progress against target at 31 Dec 2023 £’000 £’000 £’000 External Commissioning 6.3 500 375 544 Vacancy target 6.5 1,400 1,050 1,461 Reduction in prescribing costs 6.6 400 300 0 Reduction in overspending budgets 6.7 600 450 0 Reduction in management costs 6.8 300 225 33 Reduction in overtime 6.9 800 600 0 Staff transport 6.4 136 102 77 Postages 6.4 5 4 5 Additional savings achieved 6.3 0 0 123 Total Projected Efficiencies 4,141 3,106 2,243 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, the balance of £96,000 savings are partially achieved with £37,214 underspend on travel and Subsistence achieved to December within Core services. 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, savings of £442,000 in quarter 2 and £370,000 savings achieved in quarter 3. This has exceeded the vacancy target and is expected to over achieve by the end of the financial year. Page 34
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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 accurately quantified. Provisions to meet budget pressures totalling £927,830 was released in quarter 1, £2,670,042 was released in quarter 2 and £2,390,493 was released in quarter 3. 7.2 Provisions still held centrally at the end of quarter 3 total £5,367,281 and are detailed in the table below. Description Para Ref £’000 Pay & inflation 7.3 104 Contractual inflation & Scottish Living Wage 7.3 906 Prescribing & Community Pharmacy 7.4 1,605 Children in Transition 7.3 398 Learning Disability Clients 7.3 (119) Recurring Deficit 7.5 2,473 TOTAL BUDGET PRESSURES 5,367 7.3 These budget pressures have partially been drawn down as they have 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 be done in quarter 4. 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: Page 35
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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 7.10 547 Total emerging budget pressures 1,787 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 cost is now showing under mental health services and is part of the reason for the increase in overspend as detailed in para 4.9. 7.9 Out of Hours nursing service is the budget pressure that was reported to Clinical and Care Governance committee on 31 August 2023 (para 10 of minute refers). 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 that was agreed in December 2023, was £1,619,000 more than estimated at the start of the financial year, which was £586,000. Some funding from Scottish Government was received totalling £1,072,000 which has left a budget pressure of £547,000. 8. CHANGES TO STAFFING ARRANGEMENTS 8.1 At the meeting of the Board on 30 November 2023, the Financial Regulations were approved (para 12 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 October to 31 December 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. Page 36
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9.2 In addition, the MIJB, concluded the financial year 2022/23 in an underspend position following the application of reserves. The audited reserves totalling £4,682,793 were carried forward into 2023/24, all of which are ear-marked with no general reserves. 9.3 £’s Approved Funding 30.3.23 148,673,460 Set aside funding 13,466,000 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 Childrens Service 19,202,132 Amendment to Set Aside 451,460 Revised funding at start of Quarter 1 186,796,563 Adjustments in Qtr 1 1,712,786 Revised funding at start of Quarter 2 188,509,349 Adjustments in Qtr 3 6,520,716 Revised funding at start of Qtr 4 195,030,065 Budget adjustment M7 - M9 Pay awards NHS 370,659 Prescribing Tariff increase 334,668 Primary Care GP vision 128,688 Moray OOH 25,921 Hosted Recharges (56) IFRS16 amendments (203,435) MAMHS Moray 63,564 DPDS Allocation 60,541 Misc (619) MDT reduction in funding (22,208) Moray Council pay award 1,072,000 Childrens Service budget amendment 465,254 Revised Funding to Quarter 4 197,325,042 9.4 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. Page 37
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(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 31 December 2023, a total overspend is reported to the Board of £6,617,233. 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 £3,023,555 overspend. There is also the assumption that not all the savings will be achieved by the end of the financial year. The potential impact to the partners has been communicated and a recovery plan to mitigate this overspend in the next financial year forms part of the Budget setting report to this Committee. 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 an overspend position, this has been communicated to both partners, this also sees the use of all ear marked reserves to reduce the overspend for 2023/24 as both partners are also under severe financial pressures. (e) Staffing Implications There are no direct implications in this report. Page 38
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(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. (j) Consultations The 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 31 December 2023 has an over spend of £7,110,509 and the updated provisional forecast position of £11,323,636 on core services. This is reduced by underspends in Strategic funds to give a total overspend position of £3,023,555, Managers will continue to monitor the financial position closely. 11.2 The financial position to 31 December 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 39
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APPENDIX 1 JOINT FINANCE REPORT APRIL 2023 -DECEMBER 2023 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 7,315,495 5,788,921 5,875,945 (87,024) (1) 7,708,295 (392,800) (5) Community Nursing 5,637,620 4,241,012 4,279,052 (38,040) (1) 5,618,065 19,556 0 Learning Disabilities 4.3 15,693,433 11,352,799 12,957,678 (1,604,879) (10) 18,641,420 (2,947,987) (19) Mental Health 4.7 11,065,642 8,292,726 8,418,632 (125,905) (1) 11,504,082 (438,440) (4) Addictions 1,843,901 1,385,469 1,347,025 38,444 2 1,801,679 42,222 2 Adult Protection & Health Improvement 191,678 131,201 140,059 (8,858) (5) 202,416 (10,738) (6) Care Services provided in-house 4.10 23,446,506 17,417,152 16,348,652 1,068,500 5 22,181,188 1,265,318 5 Older People & PSD Services 4.12 22,419,784 16,982,228 18,882,110 (1,899,883) (8) 24,646,124 (2,226,340) (10) Intermediate Care & OT 4.14 1,671,483 1,232,285 1,400,272 (167,987) (10) 1,930,322 (258,839) (15) Care Services provided by External Contractors 1,924,114 1,440,379 1,421,599 18,780 1 1,922,812 1,302 0 Other Community Services 4.16 9,616,575 7,263,556 7,491,990 (228,434) (2) 9,864,695 (248,121) (3) Admin & Management 4.18 2,128,372 2,005,276 2,040,750 (35,475) (2) 2,440,068 (311,696) (15) Other Operational Services 1,153,644 869,370 869,370 0 0 1,343,321 (189,677) (16) Primary Care Prescribing 4.20 18,054,158 13,675,345 16,383,543 (2,708,198) (15) 21,804,158 (3,750,000) (21) Primary Care Services 4.22 19,119,871 14,339,903 14,558,460 (218,557) (1) 19,411,281 (291,410) (2) Hosted Services 4.24 5,291,746 3,987,999 4,261,272 (273,273) (5) 5,722,376 (430,630) (8) Out of Area 4.26 720,131 478,204 1,374,349 (896,146) (124) 1,838,000 (1,117,869) (155) Improvement Grants 939,600 737,586 871,963 56,424 6 864,368 75,232 8 Childrens Services 19,662,743 13,940,008 13,940,008 0 0 19,662,743 0 0 Total Moray IJB Core 167,896,497 125,561,420 132,862,729 (7,110,509) (173) 179,107,414 (11,210,917) (7) Other non-recurring Strategic Funds in the ledger 4,358,873 4,306,634 4,278,375 28,259 0 5,262,765 (903,892) (21) Total Moray IJB Including Other Strategic funds in the ledger 172,255,370 129,868,053 137,141,104 (7,082,250) 184,370,178 (12,114,808) (7) Other resources not included in ledger under core and strategic: 5 11,152,673 1,048,413 583,396 465,017 0 2,061,419 9,091,253 222 Total Moray IJB (incl. other strategic funds) and other costs not in ledger 183,408,042 130,916,466 137,724,500 (6,617,233) 0 186,431,598 (3,023,555) (2) Set Aside Budget 13,917,000 - 13,917,000 0 0 Overall Total Moray IJB 197,325,042 130,916,466 137,724,500 (6,617,233) ,0 200,348,598 (3,023,555) (2) Funded By: NHS Grampian 113,410,524 Moray Council 83,914,518 IJB FUNDING 197,325,042 Item 6. Page 41
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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 6. Page 43
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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 • HMP Grampian – provision of healthcare to HMP Grampian. Page 44
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APPENDIX 2 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 • Community Justice Reform • Criminal Justice Services Page 45
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APPENDIX 2 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 46
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APPENDIX 3 HEALTH & SOCIAL CARE MORAY DELEGATED AUTHORITY REPORTS - PERIOD October to December 2023 Title of DAR Summary of Proposal Post(s) Permanent/ Temporary Duration (if Temporary) Effective Dates Funding Macmillan Project Manager – improving the cancer journey Create a grade 10 position for 4.5 years that will be recharged to MacMillan Grade 10 36.25 hours Temporary 4.5 years As appointed Recharged to MacMillan Direct Payments financial reviews Create 4 temporary grade 4 positions Grade 4 36.25 hours x 4 Temporary 9 months As appointed Funding will come from the monies reclaimed Day centre officer – Moray Resource Centre Reduce one position by 6.25 hours and increase one position by 6.25 hours Grade 7 6.25 hours Permanent N/A ASAP Funding already in place Clinical Administrator Podiatry Internal re-design as a consequence of recruitment. Band 3 22.5 hours Temporary 12 months As appointed Podiatry Primary Care Pharmacist (Home First) New post hospital at home 2023 Band 6 18.75 hours Temporary To 31 March 2024 As appointed Pharmacy Item 6. Page 47
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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 20240328GHB09 20240328MC09 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 30.11.2023 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 - £89.9 million, of which £0.5 million is ring fenced for Housing Revenue Account aids and adaptations and £19.7 for Children Services & Criminal Justice which is in the shadow year. NHS Grampian associated budget - £99.8 million, of which £5.3 million Item 6. Page 49
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relates to Moray’s share for services to be hosted and £18.1 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 50
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REPORT TO: MORAY INTEGRATION JOINT BOARD ON 28 MARCH 2024 SUBJECT: PRIMARY CARE PRESCRIBING BUDGET FOR 2024-25 BY: LEAD PHARMACIST, HEALTH AND SOCIAL CARE MORAY 1. REASON FOR REPORT 1.1 To inform the Board of the predicted prescribing budget resource requirements for 2024-2025, alongside key drivers of growth and mitigations regarding costs. 2. RECOMMENDATION 2.1 It is recommended that the Moray Integration Joint Board (MIJB) consider and note: (i) the recommendations made in this paper regarding volume, costs, risks and the net predicted need for a budget resource of £23,799m, as part of the overall Health and Social Care Partnership budget setting process for 2024-25; (ii) the estimated budget requirements; and (iii) mitigations regarding cost efficiencies. 3. BACKGROUND 3.1 Current forecasting indicates that Moray will end the 2023-24 year with a prescribing deficit of -£3,703,000 which will be further affected by identified factors and estimates for these factors. Historic limited budget uplifts have resulted in significant historic overspends. 3.2 Appendix 1 highlights a trend of increasing void between actual budget and actual spend. 3.3 There has been unprecedented growth in items and costs across all boards in Scotland (Appendix 2). This has been further impacted also by the increase in acute prescription requests by patients. There are wide ranging factors affecting performance. 3.4 Resource assessment for prescribing has been undertaken for 2024-25. This was done using the approach adopted in previous years, which estimates growth in volume and spend in the coming year, and also offsets these with generic savings and approved efficiency plans. The key themes and data Item 7. Page 51
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presented here are taken from the more comprehensive ‘Health and Social Care Prescribing Budget Supporting Information and Data for 2024/2025’, which has been scrutinised and approved by the multidisciplinary / cross sector Grampian Area Drug and Therapeutics Committee (GADTC) and NHS Grampian Primary Care Prescribing Group. 3.5 A breakdown of the components of the Moray requested budget for 2024-25 is provided in Appendix 3. 3.6 A growing and ageing population demographic has had an effect on prescribing volumes and subsequent costs: (i) NRS figures for mid-2021 showed an increase of 700 people (+0.72%), and 2023 figures now show that 22% of Moray population are now over age 65 which carries much higher cost per patient (Appendix 4). Mitigation is to offer Primary and Secondary prevention and adopt Realistic Medicine approaches to care. 3.7 Volume growth for 2023-24 is still highly variable due to multiple factors, including changes in volumes and treatments, and post-Covid variation in operating levels across Primary and Secondary care. Pre-Covid Grampian annual growth of prescription items was steady at 1% but 2022/23 growth exceeded this at 4.4% items with 6.6 % costs. In 2023/24 we have unprecedented growth in items and costs. Many drivers of growth are out with our HSCP control. 3.8 Following Grampian’s increasing trend over time, the number of items and cost trends per financial quarter show an increase, as does the cost per item (detailed in Appendix 5). 3.9 The need for sustainable and environmentally friendly prescribing is a consideration. 4. KEY MATTERS RELEVANT TO RECOMMENDATION The following are the main financial risks: 4.1 Scottish Drug Tariff Pricing and Medicine Shortages: Volatility within pricing of several widely used medications means that prices are likely to remain high in 2024-25. 4.2 There is a risk in that the future prices for generic medicines, and associated reimbursement levels set within the Scottish Drug tariff, remain high and difficult to predict. The Scottish Government has committed to rebalancing Community Pharmacy contractor payments by reducing the emphasis on margin share and moving these payments to within the guaranteed global sum. 4.3 Generic shortages arise from increase in demand, lack of active ingredient, quality control and manufacturing delay, etc. These result in more costly prescribing e.g. more expensive sometimes unlicensed medication choices, as well as impacting pharmacy admin and clinician time required. Page 52
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4.4 The global supply chain of medication remaining fragile continues to be a significant sourcing problem for Community Pharmacy within a wide range of medicines for a variety of conditions. Such shortages can lead to unpredictability in the cost per item during the year. 4.5 The growth in consumption of medicines had been stabilising. Anecdotally this has been linked to the end of Quality and Outcomes Framework (QOF) pressure to prescribe preventative medication, strengthened approaches to medication review and associated reductions in polypharmacy. The variations in volume since 2020 are partially related to COVID-19 and changes in patient behaviours, as well as changes in capacity within Primary Care. Repeat prescribing increase has continued, and acute prescribing and outpatient/medication requests are variable corresponding to service provision and patient flow. 4.6 In terms of Primary Care rebates, the system that provides the NHS in Scotland with post-use discounts on spend on specific medicines has remained generally stable, but there remains a risk that these rebates may change or are removed. N.B. these discounts accrue to the individual Health and Social Care Partnerships (HSCPs) based on spend. 4.7 Sustained and increased pressures within GP practices and expectation of workload by Pharmacotherapy teams to deliver Pharmacotherapy Memorandum of Understanding (MOU) work has reduced time availability for medicines management cost efficiency work by Pharmacists and GPs. 4.8 National/international research, change to evidence based guidance or change to government policy. Many new medicines and new indications/licensing change for existing medications, from new protocols, are likely to have a significant clinical and subsequent financial impact e.g. HRT/Testosterone treatment in women and Attention Deficit Hyperactivity Disorder (ADHD ) treatment in adults. Appendix 6 highlights examples of medicines predicted to cause impact of an additional £4.3m in Grampian. The list is not exhaustive and difficult to predict. 4.9 Changes in delivery of local services and patient pathways, some following COVID, have the potential to affect medicine use e.g. transfer of prescribing from secondary care to primary care has a financial impact. 4.10 Extended hospital procedure waiting lists also requires extended prescribing time while patients are on the waiting list. 4.11 In addition, Appendix 7 lists medicines with unknown financial impact in the near future. 5. SUMMARY OF RISK MITIGATION Patent Expiry 5.1 On expiry of a drug patent, increasing competition can drive down market prices where there are alternative manufacturers. On patent expiry there is also opportunity to review the preparation prescribed and change to generic or more cost effective drug. Page 53
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Prescribing Cost Efficiencies and Cost Avoidance 5.2 There is an urgent need and opportunity to deliver several cost efficiencies. An actionable tracker (in line with Grampian Primary Care Prescribing Group) holds some drug therapeutic switches, and other appropriate cost efficiency work for the pharmacy team to complete. Moray Pharmacotherapy staff annotate work when completed. This work has been challenging in terms of workforce capacity and workload pressures. We aim to deliver measurable efficiencies but would require protected “invest to save” in this area. Grampian Medicines Management support us in this area also. Appendix 8 details a summary of some work which could be delivered. Spend to Save Initiative 5.3 Opportunities remain to achieve considerable cost savings by increased dedicated focused work if we allocated capacity. As well as therapeutic switches prescribing of items of low clinical value could be looked at .This does require some Clinician input as well as Pharmacy Technician input. Recent targeted cost efficiency drug therapeutic switches work was carried out by a Moray Pharmacy Technician on 20 medications, and this realised measurable savings of £21,606 per annum on therapeutic switches from 35 hours of Technician time with additional Pharmacist support. 5.4 A Grampian primary care prescribing efficiencies agreement has been put in place with the aim of medication review interventions which will involve drug therapeutic switches and generic switches. There will be 3 levels of work stream and GPs have been identified as suitable to sign up to do level 3 aspects. The plan may be that pharmacy technicians will be identified to enable level 1 and 2 work. Scriptswitch 5.5 This is a communication tool providing electronic advice messages to the prescriber. We continually review these messages to ensure that Scriptswitch underpins and delivers many cost saving initiatives. This can be in the form of a targeted therapeutic drug switch, reducing waste by dose optimising, as well as safety alerts. In 3 months Moray generates approximately £48,215 savings via Scriptswitch, as well as influencing prescribing for future. Generic Savings Work 5.6 On our actionable tracker, we include work from the Practice Generic Savings Quarterly Report, and all teams are given details on medications not prescribed generically and the costs involved, although admittedly this is less than previous impact. The teams are requested to review and annotate changes made. Extraordinary Prescribing Report 5.7 Moray Pharmacotherapy Team Management check reports and request copies of prescriptions in order to identify where pricing and reimbursement overpayments may require to be claimed. This can be from specials medications or normal prescribing. Time capacity more recently prevents much of this work, however in 2022, we claimed back £23,545 via pricing recovery. Page 54
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Tighter Control of Specials Items 5.8 Automatic authorisation of specials items of £100 or less has now been removed to allow more scrutiny of the specials prescribing and payments. Medicine Care and Review – Serial Prescribing 5.9 Use of this serial prescription service, and now also in care homes, has the potential to reduce wastage as prescriptions are issued at correct intervals, which prevents any unnecessary stock piling. The Grampian Formulary 5.10 A Grampian Formulary tool is installed in all Moray GP Practices to steer the appropriate cost-effective prescribing choices. There remains opportunity to identify and amend non formulary prescribing. 6. SUMMARY OF IMPLICATIONS (a) Corporate Plan and 10 Year Plan (Local Outcomes Improvement Plan (LOIP)) and Moray Integration Joint Board Strategic Plan “Partners in Care 2022-2032” As set out within Moray’s Integration Scheme. (b) Policy and Legal There are no policy or legal implications arising from this report. (c) Financial implications Primary Care prescribing remains a material financial risk area and this paper identifies the anticipated requirements for additional investment. This is described in Appendix 3. (d) Risk Implications and Mitigation There is a risk of financial failure; the risk is that demand for medicines outstrips the budget and the MIJB cannot deliver priorities, statutory work, and therefore project an overspend. Risk will be mitigated by actions set out in this report to manage the budget, but the key financial risks are highlighted above. (e) Staffing Implications There is a risk of Pharmacotherapy time capacity implications arising from this report. (f) Property There are no property implications arising from this report. (g) Equalities/Socio Economic Impact There are no equalities/socio economic implications arising from this report. (h) Climate Change and Biodiversity Impacts There are positive benefits to environment included in some therapeutic switches where inhalers are changed to lower Global Warming Potential impact devices. Page 55
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(i) Directions None arising directly from this report. (j) Consultations Consultations have been undertaken with the following partnership members, who are in agreement with the content of this report where it relates to their area of responsibility: • Chief Financial Officer, Moray Integration Joint Board • GP Clinical Leads, Health and Social Care Moray • Clinical and Care Governance Group 7. CONCLUSION 7.1 The Board are asked to consider the recommendations made in this paper with regard to volume, costs, risks and the net predicted need for budget resource of £23,799m, as part of the overall HSCP budget setting process for 2024-25 and taking into account new and existing cost pressures and historic overspends. 7.2 Also to consider mitigations to address some rising costs. Author of Report: Christine Thomson, Moray HSCP Lead Pharmacist Background Papers: with author References: - Health and Social Care Prescribing Budget Supporting Information and Data for 2024-2025 - NHS Grampian Pharmacy & Medicines Directorate, Grampian Area Drug &Therapeutics Committee & Finance Directorate. - BNF Sep 2023 - Pharmaceutical Journal - NHS Inform - SP3A The Impact of COVID on GP Prescribing - Scottish Drug Tariff - www.cps.scot/nhs-services/remuneration/drug-tariff/adjusted-prices - NRS council profiles accessed at https://www.nrscotland.gov.uk Page 56
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APPENDIX 1 Moray Budget Predictions, Budget Allocation and Actual Spend Item 7. Page 57
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APPENDIX 2 NHS Grampian vs Other Health Boards Figure 1 – Items Trends, NHS Scotland Mainland Health Boards Item 7. Page 59
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Figure 2 – Cost Trends, NHS Scotland Mainland Health Boards Page 60
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APPENDIX 3 Moray Health and Social Care Partnership: Summary and Budget Estimates Tables A and B: Estimates for Prescribing Table A: Growth, Expenditure and Savings – Primary Care Prescribing Item 7. Page 61
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Table B: Overall Moray HSCP Suggested Primary Care Prescribing Budget Requirement 2024/25 Table C: Moray HSCP Suggested Primary Care Core HSCP Service Requirements 2024/25 Table D: Hosted Services Impact by IJB Page 62
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APPENDIX 4 Population Calculations Rationale for Financial Updates Associated for Population Changes Increases in spend across each HSCP relating to population growth and demographic changes was calculated using the following steps: 1. Population projection figures were obtained from National Records of Scotland (NRS). These projections were based on 2018 data. 2. Costs for financial year 2022/2023, split by 4-year age bands (0-4, 5-9, 10-14, 15, 19…...85-90, 90+), were obtained from Prescribing Information System (PIS) for each HSCP. 3. Using the cost per age band, and 2022 population numbers per age band (obtained from 2022 census data - https://www.scotlandscensus.gov.uk/documents/scotland-s-census-2022-rounded-population-estimates-data/) cost per age band was calculated for each age band in each HSCP. 4. The calculated cost per patient, per age band was then used alongside predicted population numbers to calculate the potential financial impact of changes in both absolute population numbers and demographics. Item 7. Page 63
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Table 1 – Moray Estimated Costs based on Population Predictions using Cost per Patient per Age Band Page 64
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APPENDIX 5 Items and Cost Performance Trends Figure 1 – Number of Items Prescribed in General Practice (GP10, GP10N, GP10P (practice pharmacist) and GP10A) Item 7. Page 65
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Figure 2 – Cost of Items Prescribed in General Practice (GP10, GP10N, GP10P (practice pharmacist) and GP10A) Page 66
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APPENDIX 6 Primary Care Growth of Medicines Predictions (existing and new medicines) Item 7. Page 67
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APPENDIX 7 Medicines with Potential to Impact on Primary Care with no Financial Prediction Item 7. Page 73
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APPENDIX 8 Potential Medicines Management Work Streams to Deliver Prescribing Efficiencies Activities Requiring Pharmacy Technician Level Input to Deliver Item 7. Page 75
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Activities Requiring Pharmacy Technician Level Input and Pharmacist/Clinician Support to Deliver Page 76
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Activities Requiring Clinical Input to Deliver Page 77
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REPORT TO: MORAY INTEGRATION JOINT BOARD ON 28 MARCH 2024 SUBJECT: REVENUE BUDGET 2024/25 BY: INTERIM CHIEF FINANCIAL OFFICER 1. REASON FOR REPORT 1.1 To outline the budget allocations to the Moray Integration Joint Board (MIJB) and to consider the revenue budget for 2024/25, the estimated funding gap and the charges. 2. RECOMMENDATION 2.1 It is recommended that the Board: i) note the funding allocations proposed by NHS Grampian and Moray Council, detailed at 4.6; ii) note the anticipated budget pressures detailed in 4.10; iii) note and endorse the 2024/25 proposed savings plan at 4.16 and to progress to full integrated impact assessments and to commence staff and user consultation; iv) formally approve the uplift to social care providers as set out in 4.5 as part of the continued policy commitment made by Scottish Government since November 2021; v) note the increase in charges agreed by Moray Council for 2024/25 as detailed in Appendix 2 and that the review of the contributions policy will be brought back to the next meeting; vi) accept that the Revenue Budget for 2024/25 as detailed at Appendix 1 will be used as a working document to allow services to continue to be delivered and a robust recovery plan to be developed for the next meeting of the Board on 30 May 2024, following consideration of the risks highlighted in 4.33; vii) approve Directions for issue as set out at Appendix 3 to NHS Grampian and Moray Council; and Item 8. Page 79
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viii) note the Medium Term Financial plan will be updated for the meeting in May 2024 to reflect the recent amendments from both partner organisations and the details from this report. 3. BACKGROUND 3.1 On 19 December 2023 following the announcement of the Scottish Government’s indicative budget for 2024-25 by the Cabinet Secretary for Finance, the Director of Health Finance and Governance wrote to Health Board Chief Executives providing details of the funding settlement for Health Boards. In Parliament on 19 December, the Cabinet Secretary set out that 2024/25 delivered a worst-case scenario for Scotland’s finances, with financial pressures across health and social care being, by far, the most challenging since devolution. 3.2 The letter outlined that NHS payments uplift to Integration Authorities for delegated health functions would only cover pay awards following the outcome of the pay negotiations in the new financial year. 3.3 In addition and separate to Health Board funding uplifts, the health and social care portfolio, will transfer to Local Government additional funding of £230 million to support retention by beginning to embed improved pay and conditions for care workers, with Scottish Government considering that this funding requires local government to deliver a £12.00 minimum pay settlement for adult social care workers in commissioned services, in line with the equivalent commitment being made in the public sector pay policy. In addition to this, further additional funding of £11.5 million will support the uprating of Free Personal and Nursing Care rates. 3.4 Scottish Government stipulated that the funding allocation to Integration Authorities should be additional and not substitutional to each Council’s 2023/24 recurring budgets for social care services and therefore, Local Authority social care budgets for allocation to Integration Authorities should be £241.5 million greater than 2023/24. 3.5 As reported in the quarter 3 Budget monitoring report in a separate paper to this meeting of the Board, the forecast position for 2023/24 is a deficit of £3.024 million. This is then a liability for both partner organisations that will need to provide additional resources to balance the MIJB as at 31 March 2024, in the ratio as per the Scheme of Delegation. The current ratio will have to be revised for 2024/25 due to the full delegation of Children and Justice Services. 4. KEY MATTERS RELEVANT TO RECOMMENDATION MIJB BUDGET 4.1 The MIJB is required to consider its budget in the context of economic uncertainty in relation to the ongoing increase in the cost of living and high interest rates. It is fair to say that the impact of these circumstances remains a challenge and cannot yet be fully assessed. 4.2 Following the announcement of the Scottish Budget, NHS Grampian and Moray Council have notified the MIJB Chief Officer and Chief Financial Officer of the funding allocation for the forthcoming financial year. Page 80
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4.3 On 28 February 2024, a meeting of Moray Council agreed its 2024/25 budget for the forthcoming financial year. The Local Government settlement is for one year only, but the budget was set in the context of longer term planning. The paper presented referred to the Moray share of the additional funding that is required to be passed through from the Council to the MIJB. This is the Moray share of the reported investment in health and social care of £230 million and £11.5 million relating to free nursing and personal care, which equates to £4.413 million for Moray. 4.4 The NHS Grampian budget setting process is based on the principle that funding allocations to the 3 Grampian IJB’s will be uplifted in line with the increase in baseline funding agreed through the Scottish Government budget settlement, with the total to each IJB being made on the National Resource Allocation Committee (NRAC) share. The draft Scottish Government budget was announced on 19 December 2023. It provides for a no baseline funding uplift for 2024/25. Given the rate of inflation in the UK is currently 4.2% (Office of National Statistics at January 2024), this contributes to the challenging financial settlement. However, Scottish Government confirmed that Boards should assume that pay awards which have yet to be agreed for the 2024/25 financial year will be fully funded by additional Scottish Government resources. Formal agreement of the 2024/25 NHS Grampian financial plan will be sought at its Board on 11 April 2024. 4.5 The table below summarises the additional funding provided to Integration Authorities by Scottish Government that is passported through both Moray Council and NHS Grampian. Route Moray Share Scotland Wide Allocation £’000 £m £12.00 – uplift for Adult Social Care Staff * Council (full year effect) 4,198 230.0 Free Personal & Nursing Care * Council 215 11.5 Total via Council 4,413 241.5 *this is yet to be distributed and as such is not included in the Moray Council contribution MIJB FUNDING 2024/25 4.6 The MIJB has a responsibility under the Public Bodies (Joint Working) (Scotland) Act 2014 to set its revenue budget by 31 March each year. The funding of the MIJB revenue budget in support of the delivery of the Strategic Plan is delegated from NHS Grampian and Moray Council. The allocated funding is summarised below: £’000 NHS Grampian (recurring 2024/25) 89,662 NHS Grampian – Set Aside Services 13,917 NHS Grampian – SG Multi-Disciplinary Team Funding 740 NHS Grampian – SG MDT Health Care Support Workers 560 NHS Grampian – Immunisation funding 108 Page 81
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NHS Grampian – School nurses 180 NHS Grampian – District nurses 196 Moray Council - Core 61,339 Moray Council – reduction in pension contribution (660) Moray Council Childrens & Justice Services - Core 19,663 Moray Council Childrens & Justice Services reduction in pension contribution (227) Moray Council Childrens & Justice Services reduction in funding (703) Moray Council Childrens & Justice Services pay award 300 Moray Council – Improvement Grants* 1,207 Moray Council – SG additional funding (share of £241.5M) 4,413 PARTNER MIJB FUNDING 2024/25 190,695 * Improvement Grants includes £0.707 million which requires to be ring- fenced as it relates to council house tenants. HOSTED SERVICES 4.7 Within the scope of services delegated to the MIJB are hosted services. Budgets for hosted services are primarily based on NRAC. Hosted services are operated and managed on a Grampian-wide basis. Hosting arrangements mean that one IJB within the Grampian Health Board area would host the service on behalf of all 3 IJB’s. Strategic planning for the use of the hosted services is undertaken by the IJB’s for their respective populations. 4.8 The 2024/25 budget for Moray’s share of all hosted services is £5.269 million as detailed below. £’000 Hosted by Aberdeen City IJB Intermediate Care 926 Sexual Health Services 529 Hosted by Aberdeenshire IJB Marie Curie Nursing 199 Heart Failure Service 66 Continence Service 145 Diabetes MCN including Retinal Screening 221 Chronic Oedema Service 49 HMP Grampian 572 Police Forensic Examiners 349 Hosted by Moray IJB GMED Out of Hours 2,101 Primary Care Contracts 113 TOTAL MORAY HOSTED SERVICES 5,269 LARGE HOSPITAL SERVICES (SET ASIDE) 4.9 Budgets for Large Hospital Services continue to be managed on a day to day basis by the NHS Grampian Acute Sector and Mental Health Service, however the MIJB has an allocated set aside budget, designed to represent the consumption of these services by the Moray population. The MIJB has a Page 82
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responsibility in the joint strategic planning of these services in partnership with the Acute Sector. BUDGET PRESSURES 4.10 Budget pressures are a major consideration for the MIJB and are an intrinsic part of the budget setting process. The additional funding highlighted in the Scottish Government budget for health and social care is welcomed and will be required to support expected budget pressures arising for adult social care uplift of £12.00 for externally commissioned services and free personal and nursing care. In previous years, both Moray Council and NHS Grampian would have supported some elements of inflation through their budget setting process, taking cognisance of the budget setting protocol agreed by the MIJB on 14 December 2017 (para 15 of the minute refers). Given the difficult budget settlement for Local Authorities and the financial pressures facing NHS Grampian, there has been no additional funding aligned to MIJB for adult social care in addition to the requirement to transfer the share of the additional investment as determined by Scottish Government. There is also an expectation as the MIJB continues to re-mobilise and transform, there will be budget pressures arising in relation to what is described as the recurring deficit. It is important that any investment in building capacity is viewed in the context of historical cost pressures. The identified cost pressures below are based on estimates and remains an ongoing consideration in the financial planning. The table below outlines the anticipated budget pressure the MIJB needs to address in the forthcoming financial year: £’000 BUDGET PRESSURES Pay Inflation 966 Contractual Inflation & Scottish Living Wage 2,474 Prescribing & Community Pharmacy 3,002 Children in Transition 855 Learning Disability & Mental Health complex clients 1,518 Recurring Deficit 8,891 Hosted services 9 National Care Home Contract (NCHC) uplift 826 Free Personal & Nursing Care (FPNC) uplift 215 Funding pressures carried forward 2,243 TOTAL BUDGET PRESSURES 20,999 4.11 In March 2024 following agreement at COSLA Leaders, the Scottish Government wrote to Integration Authorities providing details of the pay uplift that would apply to staff providing direct care within Adult Social Care in commissioned services. The Scottish Government settlement for 24/25 includes funding to support retention and to begin to embed improved pay and conditions for care workers, requiring local government to deliver a £12.00 minimum pay settlement for adult social care workers in commissioned services. This will cost in the region of £4.198 million and is included within the budget pressures for the forthcoming year in the table above. Page 83
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4.12 Budget pressure for the NCHC is not yet quantified as Scottish Government and COSLA are still in negotiations around the increase for 2024/25. This will be partly funded from the additional funding mentioned above for the £12.00 per hour. 4.13 Budget pressure for FPNC is also to be funded from the Scottish Government as part of the £11.5 million additional funding agreed as part of the settlement for 2024/25. 4.14 Budget pressure for NHS Pay award, estimated at £0.869 million is excluded in the pay award figure above since there will be additional funding from the Scottish Government to fund this once the increase is agreed. 4.15 With funding being provided by Scottish Government for some elements listed above, the net budget pressure is £16.586 million. SAVINGS PLAN 4.15 The budget setting for 2024/25 includes an indicative saving plan totalling £9 million. Regular meetings of the Chief Officer, Chief Financial Officer and the two Heads of Service, along with service managers have been the focus, albeit being extremely challenging, to identify additional savings to support the 2024/25 budget setting process. The indicative savings being presented today at were agreed at the Senior Managers Team meeting and formed the main focus of the recent MIJB Finance event on 7 March 2024. Given that each separate decision made when setting the budget may impact on the lives of people with protected characteristics, the importance of the cumulative impact on the decisions being taken is recognised, including the cumulative impact of service changes and unintended consequences on communities where multiple organisations might have reduced savings. Some of these savings identified will be extremely challenging and to ensure a decision can be made Integrated Impact Assessments are being carried out as part of the savings proposals and will be brought to the next MIJB meeting to allow for decisions to be made. There is still a budget gap of £3.763 million to be identified and the focus and commitment must be around identifying further in-year savings and savings for future years that will be brought back before the MIJB for approval to ensure future years budgeting is robust. MIJB is acutely aware of the challenges it faces surrounding both its people and financial resources which remains a focus within its decision making. Financial and staffing impacts will be monitored on an individual savings basis and scrutiny will be provided through the agreed governance structure. 4.16 The table below summarises the progress made by the Health and Social Care Moray management team in identifying opportunities for efficiency/savings. All services involved in the following efficiency reviews and actions will need to provide comprehensive Integrated Impact Assessment prior to the MIJB’s approval. Close monitoring of progress will be considered and will be reported on a quarterly basis during 2024/25. Para Ref 2024/25 £ 000’s Projected Efficiencies/Savings Provider Services 4.17 984 Page 84
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Localities & prevention 4.18 1,755 Allied Health Professionals (AHP) 4.19 232 Mental Health & Learning Disabilities 4.20 2,271 Hosted Services 4.21 721 Commissioning, transport, equipment & supplies and infrastructure 4.22 538 Additional considerations 4.23 2,029 NHS vacancy target 4.24 1,000 Total Projected Efficiencies 9,530 4.17 Provider services comprises of full reviews of Older Person’s day services, Internal Care at Home service and a review of social and therapeutic project. 4.18 Localities and prevention comprise of service redesign for the Vaccination programme, full reviews into the respite provision, risk assessed internal and external care facility, as well as ceasing all project management outsourcing and utilising lower bands for weekend working. In addition, a full contracts review will be held within each of the four localities. 4.19 AHP efficiencies involves a relocation of equipment expenditure to the appropriate service (out with MIJB) and the cessation of weekend working within Dr Gray’s hospital for Occupational Therapy and Physiotherapy, where there is no identified budget for these services. 4.20 Mental Health and Learning Disabilities comprises of review of current staffing models, which will reduce the use of locums which is a considerable cost to the MIJB, as well as staffing reconfiguration within teams for some posts. 4.21 Hosted services involve a relocation of the Out of Hours service as well as full service redesign and a systems realignment of expenditure across the 3 partnerships. 4.22 Commissioning, Transport, Equipment & Supplies and Infrastructure includes a review of the Council transport policy as well as scoping of lease/pool cars versus staff expenses; centralisation of equipment to reduce wastage and enhanced monitoring of equipment purchase and replacement. For infrastructure includes the cessation of leased accommodation, repurposing of buildings and co-location. 4.23 Additional considerations include risks, partnership actions, Childrens and Justice Services and Primary Care Prescribing. These efficiencies include prescribing scrutiny and review, and along with working collaboratively across Grampian with the other IJB’s, NHS Grampian Pharmacy team, primary care teams, GP clusters, Local Medical Committee, other prescribers, and the community. Maximising use of digital support, a full review into unrecovered debts and charging policy/contributions policy; Ward 4: additional savings over and above the Council savings taken as part of the Council budget for 2024/25; Review of Community Hospitals and reviewing existing care packages to ensure they are the right size. Page 85
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4.24 Inclusion of a vacancy target for NHS employees, in line with the target for Council employees. This is based on natural turn over and savings will be taken from vacant posts that have not yet been filled. BUDGET OVERVIEW 4.25 The MIJB Revenue Budget for 2024/25 is £203.988 million which includes £13.917 million Set Aside. The detail is provided in Appendix 1 and summarised below: £’000 BUDGET Recurring Budget 167,288 Inflationary and Demand Led Pressures 7,236 Recurring Deficit 8,891 SLW & FPNC 4,413 2023/24 commitments to be funded 2,243 Set Aside 13,917 TOTAL BUDGET 203,988 FUNDED BY NHS Grampian Recurring (inc Set Aside) 103,579 Moray Council (inc Improvement Grants) 81,506 Scottish Government Additional Funding (£241.5m) 4,413 Childrens & Justice services pay award funding 300 MDT additional funding * 1,300 Scottish Government Additional Funding (including Ring-Fenced) * 484 One year reduction for pension contributions (887) Savings identified 9,530 TOTAL FUNDING 200,225 BUDGET DEFICIT (3,763) 4.26 Earmarked reserves carried forward into 2023/24 were £4.6 million, this included reserves relating to PCIF and Moray Action 15 which will be exhausted in 2023/24. As part of the quarter 3 revenue budget monitoring, (also on this agenda) makes the assumption that all reserves will be exhausted in 2023/24. CHARGING FOR SERVICES 4.27 Integration Authorities do not currently have statutory powers to set charges for the services aligned to delegated functions. Moray Council, therefore, has the legal responsibility to set social care charges on behalf of the MIJB. The review of charges is undertaken annually as an integral part of the budget process. Page 86
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4.28 Not all charges are within the control of Moray Council, some charges levied by the Council are set by statute, some are limited by statute and some have the method of calculation prescribed by statute. 4.29 In prior years Moray Councils methodology for proposing charges has been in line with the Consumer Price Index (CPI). Moray Council on 12 December 2023 (para 7 of minute refers) agreed the default increase for charges for services for the period 2024/25 to 2026/27 is the CPI including owner occupiers’ housing costs (CPIH) plus 1% as measured for October of the year before the increase takes effect. Moray Council has set the charges for 2024/25 on 24 January 2024 (para 8 of minute refers), with an increase based on the default increase of 5.7%. Where appropriate the charges have been increased as detailed in Appendix 2. 4.30 It is necessary for the MIJB to consider its approach to income maximisation within the context of its existing policies and the broader context of social care, which is within the contributions policy. As part of the savings identified above, a look at the contributions policy is now required and will be brought back to the next MIJB meeting in May 2024. MEDIUM TERM FINANCIAL FRAMEWORK 4.31 The current Medium Term Financial Framework covers the period 2023/24 – 2027/28 that was presented to the IJB on 30 March 2023 (para 7 of minute refers). 4.32 The review of the MIJB Medium Term Financial Framework takes account of information currently available, however it is recognised that assumptions and applied methodology will be subject of ongoing review and refinement as additional information becomes available (notably the updated Scottish Government Medium Term Health and Social Care Financial Framework) and information relating to the National Care Service / Independent Review of Adult Social Care. Given the current uncertainty, the updates from both partners it is therefore considered necessary to review the medium term financial framework and will be presented to the IJB in May 2024. FINANCIAL RISKS 4.33 The budget assumptions made within this report carry a degree of financial risk, meaning that variations that may arise will impact on financial performance. Acceptance of risk is a necessary part of the budget setting process. The main risks are summarised: • Financial Settlement – the 2024/25 financial settlement is for one year only and the increased level of funding is required to meet policy commitments as determined by Scottish Government. There is no inflationary increase for adult social care provided by Moray Council, but for NHS Grampian there is the agreement that the pay inflation will be fully funded. Whilst a provision has been made for Local Authority and NHS Grampian pay increases, the NHS Public Sector Pay Policy or Local Authority pay award negotiations has not yet been agreed and there is a risk that this will exceed the provision. Whilst the benefits of longer-term financial planning are well documented in assisting the delivery of strategic priorities, at this stage, financial planning is subject Page 87
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to continuous change and there is a need to adapt to the changing landscape. • The budget pressures identified in paragraph 4.5 are based on continued discussion and assessment and through monitoring, this process is reasonably accurate. However, there remains the risk in the event that inflationary increases and demand driven pressures may exceed the anticipated cost. • Prescribing costs are a large and volatile part of the MIJB budget with demographic changes a material contributing factor. Whilst the decisions to prescribe are made locally, the costs of drugs and agreements to introduce new drugs are made on a national basis. Provision in the budget has been made based on analysis undertaken by NHS Grampian with a range of options provided from Best Case to Best Prediction and Worst Case scenario. MIJB are proposing the inclusion of the Best Prediction scenario with the associated pressure of this option. There is a risk associated with this option and the IJB will closely monitor this budget through regular reporting to the IJB throughout financial year 2024/25 and appropriate action taken to mitigate the pressure in year through continued close working with NHS Grampian, this is being reviewed not only across Grampian but nationally. • Demographic changes, the demographic profile of Moray continues to show a general rise in population with a specific increase in the age profile of the population. The associated challenges of providing care for a rising population where people live with multiple conditions are well known. These challenges manifest themselves in a financial sense when we experience issues such as rising numbers for social care packages and rising demand for aids, adaptations, and equipment. The increasing level of complexity of need for some of our clients means that high-cost care packages may arise during the year for which we have not budgeted. The same applies to patients who need out of area care and where a clinical decision has been made that this is in their best interests. • In Primary Care there continues to be a number of continuing challenges around sustainability of some of our GP Practices with inability to recruit General Practitioners a common issue. This has necessitated the Partnership providing support and investment to maintain GP services in some parts of Moray. We will continue to use the Primary Care Improvement Fund and other funding streams to support General Practices and wider Primary Care teams across Moray. • The MIJB must also ensure preparedness for the implementation of national policy and legislation in particular the Health and Care (Staffing) (Scotland) Act 2019 ensuring safe and appropriate staffing with implementation from 1 April 2024 and full compliance by March 2025. Page 88
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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 2022-2032, ‘Partners in Care’ The approval of a balanced budget for the MIJB is key to the delivery of health and social care services in Moray in accordance with the Strategic Plan. (b) Policy and Legal In accordance with the Public Bodies (Joint Working) (Scotland) Act 2014, MIJB is subject to the audit and accounts regulations and legislation of a body under Section 106 of the Local Government (Scotland) Act 1973 and is classified as a local government body for accounts purposes by the Office for National Statistics. (c) Financial implications The 2024/25 revenue budget (excluding Set Aside) as detailed in Appendix 1 is £190.071 million. The funding allocated to the MIJB by Moray Council and NHS Grampian and through the Partner bodies from Scottish Government totals £176.778 million (excluding Set Aside). In addition, the indicative savings plan for the forthcoming year totals £9.530 million, with a savings gap still to be found of £3.763 million. The notional Set Aside budget for Moray’s share of the Large Hospital Services is currently £13.917 million. The Set Aside budget is provided by NHS Grampian. A balanced budget is not yet presented and the budget detailed is a working budget with a requirement to identify how the budget gap will be met. (d) Risk Implications and Mitigation The revenue budget for 2024/25 is subject to the following risks: • GP Prescribing – represents around 10% of the MIJB core budget. It is well documented that the Prescribing budget can be extremely volatile in nature with volume and price increases potentially leading to substantial adverse variances. • Growth and demand in the system, together with service users with complex care needs are attracting additional financial challenge. These issues require to be managed within the overall resource of the MIJB. • The need to transform at pace and drive forward opportunities arising through changes to working practice experienced through the pandemic. The risk being the ability to capture and embed in a timely manner. Page 89
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• National Care Home Contract for 2024/25 has not yet been agreed and whilst this will be partly funded from Scottish Government funding for the £12.00 per hour, this will not fully fund the increase once agreed. • The implications of the cost of living crisis and current levels of inflation, which are still forecast to rise may mean the provision for inflation may not cover all the calls upon it. Price inflation may impact on areas where no provision has been made for inflationary increases and this will add pressure to budgets. Budget managers will need to control their expenditure to absorb such pressure if possible and may have to reduce service levels or identify further savings. • This report highlights the anticipated budget pressures at paragraph 4.10. It will be necessary to note that budget pressures may exceed allocation. This will be closely monitored and reported accordingly to the MIJB as part of the budget monitoring reports. • With the level of savings required to balance the budget there is a risk that the budget may not be developed in time for implementation in 2024/25. (e) Staffing Implications There are no direct implications in this report. (f) Property None arising directly from this report. (g) Equalities/Socio Economic Impact None arising directly from this report as there is no change to policy. Any subsequent changes to policy arising from proposals made within this paper will be considered and Impact assessed as appropriate. (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 4.25 above and in Appendix 3. (j) Consultations The Chief Officer, Health and Social Care Moray Senior Management Team, Operational Management Team, the finance teams of both Moray Council and NHS Grampian, and Caroline O’Connor, Committee Services Officer. 6. CONCLUSION 6.1 Legislation requires the MIJB to set a balanced budget and a recovery plan to reduce the budget shortfall of £3.763 million requires to be developed. The Chief Financial Officer to the Board recommends using Page 90
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the indicative budget attached in APPENDIX 1 as a working document and that an update of progress in reducing the funding gap are shared with the Board at the next meeting in May 2024. 6.2 Close monitoring of the continuing effects of the increasing demands on services will be required in order to ensure the MIJB can remain within the funding allocation provided by NHS Grampian and Moray Council. Author of Report: Deborah O’Shea, Interim Chief Financial Officer Background Papers: with author Ref: Page 91
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APPENDIX 1MORAY INTEGRATION JOINT BOARD JOINT FINANCE REPORT APRIL 2024 -MARCH 2025 Para Approved Annual Ref Net Budget £'s 2024-25 Community Hospitals 6,253,310 Community Nursing 6,060,235 Learning Disabilities 16,105,309 Mental Health 10,794,964 Addictions 1,204,261 Adult Protection & Health Improvement 197,875 Care Services provided in-house 23,981,726 Older People & PSD Services 22,745,439 Intermediate Care & OT 1,845,077 Care Services provided by External Contractors 2,136,650 Other Community Services 9,610,235 Admin & Management 1,214,961 Other Operational Services 1,128,760 Primary Care Prescribing 18,727,506 Primary Care Services 18,865,380 Hosted Services 5,269,365 Out of Area 720,131 Improvement Grants 1,207,037 Childrens Services 18,960,000 Total Moray IJB Core 167,028,221 Other recurring Strategic Funds in the ledger 260,046 Total Moray IJB Including Other Strategic funds in the ledger 167,288,267 Other resources not included in ledger under core and strategic: 22,782,897 Total Moray IJB (incl. other strategic funds) and other costs not in ledger 190,071,164 Set Aside Budget 13,917,000 Overall Total Moray IJB 203,988,164 Funded By: NHS Grampian 114,893,000 Moray Council 85,331,631 IJB FUNDING 200,224,631 BUDGET GAP 3,763,533 Item 8. Page 93
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APPENDIX 2 SECTION B: SOCIAL CARE – MIJB REF SERVICE CHARGE 2023/24 CHARGE 2024/25 DATE OF LAST CHANGE B1. Moray Lifeline / Telecare £41.80 per quarter inc VAT £44.18 per quarter inc VAT April 2023 B4. Blue Badge £20 per badge – badge valid for 3 years £20 per badge – badge valid for 3 years April 2021 B6. Meals at Day Care Centres (Older People) and Shared Lives: B6a. Meal £5.20 per meal £5.50 per meal April 2023 B6b. Tea & Biscuits £0.80 per cup £0.85 per cup April 2023 B6c. Light meal (Shared Lives Service only) Per Shared Lives carer Per Shared Lives carer April 2021 B6d. Packed lunches (Murray Street) £5.20 £5.50 April 2023 B10. Stair lift maintenance £17.22 per quarter inc VAT No VAT if registered disabled £18.20 per quarter inc VAT No VAT if registered disabled April 2023 B10 a Wash / dry toilet maintenance Nil Nil April 2022 B11. Occupational Therapy Aids and Equipment None (per CoSLA recommendati on) None (per CoSLA recommendati on) October 2005 B12. Hire of Day Centre rooms £5.71 per hour £6.00 per hour April 2023 B14. Speyside Lunch Club £6.50 inc VAT £6.87 inc VAT April 2023 B16 Case review carried out on behalf of another local authority £104.43 £110.38 April 2023 Item 8. Page 95
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APPENDIX 3 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 20240328GHB10 20240328MC10 2. Date Direction issued by the Moray Integration Joint Board 28.03.2024 3. Effective date of the Direction 01.04.2024 4. Direction to: NHS Grampian and Moray Council 5. Does the Direction supersede/update a previous Direction? If yes, include the reference number(s) of previous Direction Yes last budget monitoring report for Quarter 3 of 23/24 budget outturn to MIJB on 28.03.2024 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 - £89.6 million, of which £0.7 million is ring fenced for Housing Revenue Account aids and adaptations. NHS Grampian associated budget - £78 million, of which £5.3 million relates to Moray’s share for services to be hosted and £18.7 million relates to primary care prescribing. Item 8. Page 97
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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 2024/25 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 98
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REPORT TO: MORAY INTEGRATION JOINT BOARD ON 28 MARCH 2024 SUBJECT: MENTAL HEALTH PATHWAY MAPPING BY: INTERIM INTEGRATED SERVICE MANAGER, MENTAL HEALTH AND DRUG AND ALCOHOL SERVICE 1. REASON FOR REPORT 1.1 To update the Board on progress on the Mental Health Pathway Mapping exercise and implementation of the Moray Mental Health Strategy as discussed at the Moray Integration Joint Board (MIJB) development session on 26 October 2023. 2. RECOMMENDATION 2.1 It is recommended that the Board: i) note the content of the report, the mapping of services that has been completed to date, and the outline plan for delivery of the Moray Mental Health and Wellbeing strategy; and ii) provide comment on how this plan could connect with children and young people’s mental health and wellbeing work across Moray. 3. BACKGROUND 3.1 The Scottish Government Mental Health and Wellbeing Strategy outlines nine outcomes that Health and Social Care Partnerships should work towards and ultimately deliver. These include increased availability of timely, effective support, care and treatment that support people’s mental health and wellbeing; meeting individual needs and having better equipped communities to support people’s mental health and wellbeing and providing opportunities to connect with others. 3.2 Other frameworks which are relevant to the Mental Health and Wellbeing agenda include: • Core Mental Health Standards • Adult Mental Health Standards • Self-harm prevention Item 9. Page 99
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• Medical Assisted Treatments for Drug and Alcohol use (MAT Standards) • Suicide Prevention strategy • Psychological Therapies Specification • Dementia Strategy • Mental Health and Wellbeing Workforce Plan • Public Health Scotland Waiting Times • Health & Social Care Standards • Review of the Mental Health Act 3.3 The Moray Mental Health Strategy covers the period 2016-2026 (Appendix 1). The strategy is intended to provide a framework for future action as well as contribute to an ongoing discussion about the best direction for mental health policy and services in Moray incorporating the above. 3.4 This strategy fits with the aspirations of health and social care integration to improve the quality and consistency of services and to provide seamless, joined-up, high quality health and social care services which focuses on the prevention of mental illness. 3.5 Health and Social Care Moray’s vision and strategic priorities are underpinned by five key themes and principles. These are: • A whole systems integrated approach to mental health and wellbeing that brings health and social models together; • A life-course approach that considers the differential experiences and conditions throughout life in which people are born, grow, live, work, play and age; • An upstream approach that is focused upon protection, promotion, prevention, and early intervention, as well as treatment and care services; • A strengths-based perspective which is focused upon recovery, assets, improving quality of life, ambition and hope, and not wholly on the deficits and problems of individuals and communities; • A human rights-based approach which ensures that international human rights standards are put at the centre of policies and practice that impact on people with mental health problems. These key cross cutting themes and principles bring together what people in Moray said was important with good practice and evidence in mental health promotion, prevention, care and recovery. 3.6 The community and third sector partners are essential partners in the prevention, health promotion and recovery of mental illness. Local communities, including all the stakeholders within the Community Planning Partnership, have a key role in encouraging local communities to work together to improve the environment, particularly in deprived areas and use this as a lever to improve health and wellbeing. 3.7 Austerity, the COVID-19 pandemic and the cost-of-living crisis have combined to increase the levels of poor mental health within the population. Following a Page 100
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dip in early 2020, levels of referrals in mental health services have been increasing steadily to above pre-COVID levels, and there has been a larger increase in referral rates amongst females than males, particularly in the most deprived areas of Grampian. 3.8 People in the most deprived areas of Grampian have a referral rate of more than double that in the least deprived areas (1,470 referrals per 100,000 population in the last quarter of 2022 compared with 738); the inequalities were most marked among those aged 25-64; less so among younger and older populations. 3.9 Depression is fourth in the list of the ten greatest burdens of disease in Moray for both men and women. Anxiety disorders are within the top ten for women. 3.10 The Primary Care Disease Register (PCDR) provides data extracted from General Practices in Moray through the Scottish Primary Care Information Resource (SPIRE). Depression is recorded as the second highest Long-Term Condition in Moray (4005 patients), second only to hypertension at 6,947 patients. 3.11 For several 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. 3.12 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 areas 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 this can continue without the use of expensive locum staff and build sustainable services for the future. 3.13 There is also an opportunity to redesign Nursing and Allied Health Professional roles and how we can support Primary Care in the further development of Mental Wellbeing and Practitioner Posts. There is commitment from the Primary Care service to work collaboratively with secondary care to improve the interface. 3.14 The Mental Health Service is committed to investing in the prevention of mental illness and the promotion of positive mental health. A mapping exercise will allow the service to identify already well-established provision whilst also identifying any gaps in service that need attention. This then provides an opportunity to redesign services. 3.15 Any redesign will give the service an opportunity to work more efficiently. The only service that is required to meet national waiting times is the Psychological Therapies service and the service is well within the 18 week referral to treatment. There are no waiting times to have an assessment from a Psychiatrist. Page 101
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3.16 At the MIJB Development session on 26 October 2023, the Interim Integrated Service Manager for Mental Health Services was asked to provide a report to the MIJB on the mapping of current services to identify strengths and gaps, and to update on progress towards delivery of the Moray Mental Health and Wellbeing Strategy. 3.17 In parallel to this, a Grampian-wide Mental Health Delivery Plan is also under development, which will complement the Moray strategy and service development. 4. KEY MATTERS RELEVANT TO RECOMMENDATION 4.1 In order to deliver on the Moray Mental Health and Wellbeing Strategy, improve mental health within Moray and provide timely and appropriate treatment to those in need, the focus must be on preventing future poor mental health as well as building the capacity of our current treatment services. 4.2 A range of effective public mental health interventions exist which result in broad impacts and associated economic savings across different sectors, even in the short term. Such interventions can be implemented by different sectors including primary care, secondary care, social care, public health and local authorities, third sector providers, education providers, employers and community justice. 4.3 Actions to improve public mental health practice include (an overview is also provided in Appendix 2): • Understanding of local public mental health intervention coverage and size of unmet need, as well as an assessment of impact and associated economic savings from improved coverage • Improved population understanding about public mental health • Training on population mental health for professionals and trainees in public health, primary care, secondary mental health care, social care, community justice and commissioning including: - Impact of mental disorder and wellbeing - Risk and protective factors - Evidence for effective public mental health interventions • Evaluation of coverage and outcomes • Targeting certain settings such as antenatal/ postnatal settings, schools, workplaces, neighbourhoods, gardens, primary care, older people’s care homes and libraries. • Prioritising childhood and adolescence since most lifetime mental disorder has arisen by early adulthood. • Use of digital technology to improve mental health literacy and provide evidence based public mental health interventions • Maximising existing resources including through self-help, improved concordance with treatment and less intense intervention Page 102
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• Addressing socioeconomic inequalities • Specific interventions including parenting programmes, addressing parental mental disorder and child adversity, and promoting physical activity 1 . • The communities our citizens live in play a central role in their wellbeing. Strong, cohesive and inclusive communities can provide their members with psychological and emotional support; increase and widen the range of resources (material and intangible) people can access; improve people’s sense of belonging; and empower people to take collective action on those things that matter most to them.2 3 A challenge for existing public sector organisations in supporting community empowerment is one of transfer of power from these organisations to communities. 4.4 Action on prevention is most effective when systems work together and address the causes of mental health problems at multiple levels. It is also recognised the need to maximise the impact that can be made while making use of scarce resources. The Conceptual Framework for Public Mental Health developed by the National Institute for Health Research, provides a helpful map of the factors affecting mental health across all stages of a person’s life, including links to key evidence and lived experiences. 4.5 Initial desk-based mapping of services and projects that support mental health and wellbeing in Moray is a work in progress (Appendix 3 and 3a). This work has been mapped against the above framework. This should help to think about where the current focus is as a system, and where focus should be in the future. This is a whole system mapping exercise which has identified provision established in Moray and will identify any gaps. Included in the mapping exercise is a description of the Tier 1 to Tier 4 service provision. It is appreciated that not everything happening in communities will be captured here, and a key part of this work will be to improve understanding of what is working and ensure there is an awareness of this at a strategic level. The Discover Pathways Wellness in Moray website has been used to inform this mapping exercise www.disoverpathwaysmoray.org.uk 4.6 A short-life Strategic Oversight Group will have been established by 25 March. The membership of the group will be reflective of the broader partnership and the various stages of the Moray Mental Health and Wellbeing Pathway. For example; partners from primary and secondary care as well as 3rd sector and lived experience. 4.7 The Strategic Oversight Group will understand in more detail the numbers in service, capacity and sustainability of services, any gaps or pinch points, and the extent to which Moray takes a population health approach to supporting good mental health and preventing poor mental health. It will then report back to MIJB with appropriate recommendations. 1 Campion J (2019) Public mental health: Evidence, practice and commissioning. Royal Society for Public Health 2 Southworth and Potts (2021) A public mental health approach to mental health and wellbeing in Grampian 3 Akhter et al (2023) Community empowerment and mental wellbeing: longitudinal findings from a survey of people actively involved in the big local place-based initiative in England, Journal of Public Health Page 103
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4.8 Consideration should also be given as to how this work will align with the mental health and wellbeing strategic work currently underway within children and young people’s services. It is recognised that most mental health problems first present before the age of 24, which presents a compelling case for intervening at these early stages of life. 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 None at present. (d) Risk Implications and Mitigation This work aims to increase the capacity, resilience and sustainability of the service for patients in the adult and older adult mental health service. The mapping exercise will identify any gaps in the provision of a high- quality Mental Health Service and will support the delivery of the right care at the right time by the right people. At the same time, services will seek to reduce levels of poor mental health within the population of Moray. (e) Staffing Implications None arising directly from this report. (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 The service has consulted with the following people: Simon Bokor-Ingram, Chief Officer Iain MacDonald, Deputy Head of Service Pete Matthews, Advanced Public Health Practitioner Elizabeth Robinson, Consultant in Public Health Corrine Lackie, Interim Lead Nurse Tracy Stephen, Chief Social Worker/Head of Service Dr Robert Lockhart, Clinical Lead/GP Page 104
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Dr Malcolm Simmons, Clinical Lead/GP Dr Bruce Davidson, Consultant Psychiatrist/Clinical Lead Kirsteen Pyett, Team Lead Social Work/Mental Health Officer Julie McKay, Lead Nurse 6. CONCLUSION 6.1 The MIJB are asked to note the content of the report and the mapping of services that has been completed to date. The Moray Mental Health Strategy covers the period 2016-2026 and fits with the aspirations of health and social care integration to improve the quality and consistency of services and to provide seamless, joined up, high quality services which focus on the prevention of mental illness. Author of Report: Kathryn Kinnear, Interim Integrated Service Manager, Mental Health and Drug and Alcohol Service. Elizabeth Robinson, Consultant in Public Health Pete Matthews, Advanced Public Health Practitioner Background Papers: Ref: Page 105
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Good Mental Health for all in moray2016-2026 APPENDIX 1 Item 9. Page 107
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This document is available on the Council’s website www.moray.gov.uk. For alternative formats including large print, Braille, BSL, audio, other languages or for further information, please contact us. Jeżeli chcieliby Państwo otrzymać informacje w innym formacie, języku lub dodatkowe informacje, mówiący po angielsku znajomy lub członek rodziny może do nas: Para outros formatos, idiomas ou para obter mais informações, peça para um amigo ou parente que fale a língua inglesa entrar em contato conosco: Phone: 01343 567187 Email: involvement@moray.gov.uk Write to: Public Involvement Officer The Moray Health and Social Care Partnership Spynie Hospital Duffus Road Elgin IV30 5PW 2 || Good Mental Health for All in Moray 2016-2026 Page 108
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Our Vision Working together we will enable people to achieve the best possible mental health and wellbeing. We will do this through promoting choice and control, and by developing resilient communities and responsive services that contribute towards a mentally healthy, happy, stigma free Moray. 2 || Good Mental Health for All in Moray 2016-2026 Moray community Planning Partnership|| 3Page 109
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Contents Our shared vision for Good Mental Health for ALL in Moray 5 Introduction 6 Background 8 Mental Health and why it’s important 9 Key Mental Health Facts 12 Achieving good mental health & wellbeing in Moray 13 A picture of mental health services in Moray 16 How we will make this change happen 18 Governance & Accountability – How will we know we are making a difference? 25 Appendix 1 – Moray Community Planning landscape 26 Appendix 2 – Mental Health and Wellbeing Services 28 References 32 Further involvement 35 Good Mental Health for all in moray2016-2026 A joint Mental Health & Wellbeing Strategy developed by people with lived experience of mental health, their family members and people involved in health and social care all working together. 4 || Good Mental Health for All in Moray 2016-2026 Page 110
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Our shared vision for Good Mental Health for ALL in Moray Working together we will enable people to achieve the best possible mental health and wellbeing. We will do this through promoting choice and control, and by developing resilient communities and responsive services that contribute towards a mentally healthy, happy, stigma free Moray. This strategy emphasises the cross cutting nature of mental health and how our mental health and wellbeing can be put at risk and protected by a wide range of factors. It reinforces the key message that a mentally healthy Moray can be achieved by a wide range of effective policy and practice, not only in health but across a wide range of other sectors and partners. The strategy asks us to consider how people with lived experience of mental health, their family members, carers, communities and people involved in health and social care can all work together to contribute to a mentally healthy Moray. The strategy provides exciting opportunities for developing and innovating service re-design and improvement by maximising existing resources and new investment in the modernisation of mental health services in Moray. I am delighted to endorse this strategy and look forward to working with partners and communities in its delivery over the next ten years to help create good mental health for all in Moray. Improving mental health can help us create a Moray where children have the best start in life, communities are resilient, life chances are improved and we live longer, healthier, happier and stigma free lives. This strategy provides a valuable opportunity to refocus local attention on mental health and wellbeing to provide opportunities for better promotion, prevention, protection and early intervention in mental health while creating more responsive and effective recovery focused services for those with mental health problems. Pam Gowans Chief Officer (Moray Joint Integration Board) Laurence Findlay Corporate Director (Education & Social Care) 4 || Good Mental Health for All in Moray 2016-2026 Moray community Planning Partnership|| 5Page 111
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Introduction Welcome to the Moray Joint Mental Health and Wellbeing Strategy 2016-2026. Mental health affects us all. It is often said that there is no health without mental health. Mental health is important at every stage of life from childhood and adolescence through adulthood. Our mental health and wellbeing affects how we think and feel, and how we respond to events. It affects our ability to learn, communicate and form relationships and play a full part amongst our family, friends, community and workplace. It influences our ability to manage change and life events and to lead a happy and fulfilling life. It’s also closely linked with our physical health. Mental health is facing major challenges and opportunities across Scotland. In the current public spending climate and with a renewed focus on outcomes and the integration of health and social care, it is important that mental health is at the forefront of our work in Moray. This strategy represents a valuable opportunity to refocus local attention on mental health and wellbeing. It sets out a shared vision of change that has been developed by people with lived experience of mental health, their family members and people involved in health and social care all working together. It has been written for everyone in Moray to provide opportunities for better promotion, prevention, protection and early intervention in mental health while creating more responsive and effective recovery focused services for people with mental health problems. The strategy has been informed by what people have said is important, an analysis of available evidence about mental health needs and issues, as well as best practice and evidence of what works in addressing mental health and wellbeing. It sets out clear priorities for what a new mental health strategy should aim to achieve over the next decade and where mental health issues need to be considered in a range of other local policy areas. It is intended to provide a framework for future action as well as contribute to an ongoing discussion about the best direction for mental health policy and services in Moray. It supports the joint working of the Moray Community Planning Partnership in delivering Moray 2026: A Plan for the Future to improve life for all in Moray. Our aspiration for mental Health in Moray Improving mental health can help us create a Moray where children have the best start in life, communities are resilient, life chances are improved and we live longer, healthier, happier and stigma free lives. 6 || Good Mental Health for All in Moray 2016-2026 Page 112
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By working with the existing community planning structures and the emerging locality planning groups for health and social care integration, this strategy aspires to: • Improve population mental health through the promotion and protection of mental wellbeing, prevention of mental health problems, and improving the quality of life and recovery of those experiencing mental ill health. • Promote human rights and equality of access to information and services to ensure that all people receive the right care, at the right time, in the right place regardless of background and circumstances, mental health status, age, sex, race, religion, disability or sexual orientation. • Improve the quality and consistency of services and to provide seamless, joined-up, high quality integrated health and social care services. • Invest in a healthy start in life that is directed towards positive development in childhood, adolescence and adulthood. • Ensure that families, carers and communities remain at the heart of quality mental health service delivery and recovery. • Retain a focus on high quality specialist services available locally for those who have high and complex support needs. • Promote a collaborative primary and community care approach with General Practitioners (GPs) to widen access to a range of community-based psychological and social supports. • Strengthen the role of the third sector and communities in mental health and recovery – a partnership approach. • Build capacity and capability within the wider health and social care workforce to deliver upon mental health and recovery. • Raise the educational, employment and housing aspirations and opportunities for people with mental ill health. • Support social inclusion and the role of supporting relationships with family, friends and the wider community. • Embed the principles and values of recovery in policy, commissioning, and service planning and delivery. • Shift the power from services to people by giving people greater choice and control. • Redefine user involvement – accepting the value of ‘lived experience’. • Support collaboration between service providers and service users in the planning, design, delivery and improvement of services – a commitment to co-production. • Reduce the stigma and discrimination associated with mental health problems. • Widen the choice of community peer to peer work and support. • Help change the culture of seeking services to one of self-management support. • Plan and deliver services tailored to local need and in line with existing evidence and best practice. • Make best use of sources of funding such as the Integrated Care Fund to try out new ways to improve the system. • Ensure the Mental Health & Wellbeing Partnership, supported by its sub-groups, retains an overview of the progress of the strategy and is accountable for its delivery. 6 || Good Mental Health for All in Moray 2016-2026 Moray community Planning Partnership|| 7Page 113
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Background Mental illness is one of the major public health challenges in Scotland. One in four of us will experience a problem with our mental health at some stage in our lives. (1) Improving mental health is a key priority for the Scottish Government. Scotland’s Mental Health Strategy (2016) (2) sets out a population-wide approach, combining the benefits of universal support with focused and targeted action to improve the mental health of particular groups and communities. It is organised around life stages that are concerned with starting well, living well and ageing well. Infant and child mental health is now firmly embedded in Scottish public policy with its promotion forming an important part of the national mental health strategy. The Scottish Government has made a priority of starting well and the need to focus upon prevention, early intervention and early years approaches as well as supports for child and adolescent mental health and mental wellbeing. Scottish Government policy frameworks, including The Early Years Framework, Achieving Our Potential and Equally Well (2008) (3,4,5), all seek to address disadvantage and improve the life chances of children by tackling social, health and educational inequalities. Good Mental Health for All (2015) (6) promotes a broad approach to promoting and protecting mental health and wellbeing through a wide range of effective policy and practice which works to address the social, environmental and individual determinants of mental health and wellbeing. National priorities broadly reflect the issues raised by individuals and communities in Moray during the development of this strategy. This is reflected in the strategy’s shared vision, cross cutting themes, and strategic priorities for local action. The economic cost of mental health problems in Scotland is estimated at £10.7 billion. For Moray this equates to around £172 million. (7) 8 || Good Mental Health for All in Moray 2016-2026 Page 114
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Mental Health and why it’s important Our starting point for a mental health and wellbeing strategy for Moray is to develop a shared understanding of mental health, wellbeing and recovery. A common understanding and language is important as it provides the basis for our strategic thinking and actions. This understanding is based upon current thinking and evidence in mental health, as well as discussions with communities and those with lived experience of mental health problems. Mental health is an important but often misunderstood concept. Understanding of mental health and wellbeing is influenced by people’s experiences, expectations, and cultural and religious beliefs, as well as by age, class and gender. The World Health Organisation defines mental health as: “a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community.” (2014) (8) In this positive sense mental health is more than the absence of mental illness or mental health problems. Mental health is the foundation for the wellbeing and effective functioning of individuals, families and communities. Mental health problems are wide-ranging, from the worries and stresses that we all experience as part of everyday life to serious long-term conditions. Mental health problems are very common. Around one in four of us will experience a problem with our mental health at some stage in our lives. (1) Anxiety and depression are the most common problems, with around one in ten affected at any one time. Anxiety and depression can be severe and enduring and have a large impact on people’s ability to function and get on with life. (9) Between one and two in every 100 people experience a severe mental illness such as bi-polar disorder or schizophrenia. (9) Many factors contribute to mental health problems at the environmental, social and individual level. The determinants of mental health, risk and protective factors are explored in more detail in Part 5. There are many different ideas about the way mental health problems are diagnosed, what causes them and which treatments are most effective. Although certain symptoms are common in specific mental health problems, no two people behave in exactly the same way when they are unwell. People can and do recover from even the most serious and long-term mental health problems. Recovery is a unique and individual experience and while there may be common experiences, no two people’s recovery journeys will be the same. For some, recovery is about working towards goals and having hope for the future, but for others, it is about a return to a normal or healthy condition and benefiting from treatment and support in a timely way. (10) Many of the causes of mental health problems are socially determined, and many of the changes that can lead to better mental health and recovery also lie in actions which are concerned with the wider social environment. (6) Recovery is a unique and individual experience and while there may be common themes and experiences, no two people’s recovery journeys will be identical. 8 || Good Mental Health for All in Moray 2016-2026 Moray community Planning Partnership|| 9Page 115
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Child and Adolescent Mental Health The early years provide the first and best opportunity to set children off on the right trajectory and reduce the need for later interventions that are more costly in both financial and social terms. The early years play a significant part in determining mental health through childhood and beyond. In the early years, infants make emotional attachments and form relationships that lay the foundations for future mental health and wellbeing through the development of resilience, learning skills and social and emotional abilities. There is increasing evidence that early years settings and schools have an indispensable role to play in promoting and protecting children’s social and emotional wellbeing, and being able to intervene effectively with those children experiencing problems. (11) Mental health and emotional problems in children and young people are wide and varied. Problems range from emotional, conduct, developmental and attachment disorders to other mental health problems such as stress, anxiety, depression, self-harm, eating disorders and psychotic disorders such as schizophrenia and bipolar. Many of these problems will be experienced as being mild, moderate and temporary to children and their families, whereas others will have more adverse and longer term effects. (12) The Mental Health of Working Age Adults The transition from adolescence into adulthood is extremely important in terms of making life choices and establishing behaviours that have a major impact throughout the lifespan. This transition is often difficult and challenging for those with mental health problems moving between adolescent and adult services. (13) Mental health in emerging and later adulthood presents a wide range of challenges, particularly for those with a history of childhood problems. Research has found that children who experience bouts of anxiety, depression and other behavioural problems are more likely to be susceptible to having serious issues when they grow up and are six times more likely to have difficulties in their adult life compared to those who did not have any psychiatric issues in childhood. (14,15) Women are more likely to have been treated for a mental health problem than men and are almost twice as likely to be diagnosed with anxiety disorders. Depression is more common in women than men. (15) UK research indicates that around 50% of women with perinatal mental health problems are not identified or treated and that there is a huge economic cost associated with not properly identifying mothers’ mental health needs or treating them effectively. (16) There is a strong association between mental illness and suicide risk. Suicide remains the most common cause of death in men under the age of 35. In 2014, 696 suicides were registered in Scotland (497 males and 199 males). (17,18) Suicide prevention is a key strategic priority of this strategy (see page 30). There are strong links between physical health and mental health problems. The King’s Fund (2012) found that 46% of people with a mental health problem had a long-term physical health problem and that 30% of people with a long-term physical health problem also had a mental health problem. (19) Those who experience mental ill health often have poor physical health, lower life expectancy, inequitable access to services and increased risk of social deprivation. (15) 10 || Good Mental Health for All in Moray 2016-2026 Page 116
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Mental Health and Older Adults Mental health and well-being is as important amongst older adults as at any other time of life. Many 50+ year olds are in a state of change, both physically and with respect to life circumstances and areas such as employment conditions. There is often an assumption that mental health problems are a ‘normal’ part of ageing but most older adults don’t develop mental health problems and have good mental health. (20) However, there are a number of factors which can compromise older people’s mental health and put them at risk of developing mental and neurological disorders as well as physical illness or disability. A UK inquiry (20016) into mental health and wellbeing in later life identified five key factors that affect the mental health and wellbeing of older adults. These factors include – relationships, physical health, poverty, discrimination and participation in meaningful activities. (21) The demographic and social changes facing Scotland and Moray are well documented. As our population ages there is a projected 50% increase in the number of people with dementia. Dementia is a major cause of disability in people aged 60 and over. It is estimated that only 40% of people in Moray with dementia have a diagnosis. (22) Non-prescribed Drugs & Alcohol Misuse Substance misuse and other mental health issues, such as psychological distress and suicide, are often interrelated. Those who have both mental health problems and problems with drug or alcohol use may be described as having ‘dual diagnosis’. There is no standardised treatment for dual diagnosis, largely because it includes a large number of problems, and often involves both substance misuse services and mental health services. (23) The relationship between drug / alcohol misuse and mental health is wide ranging: • There may be a range of risk factors (such as family or financial problems) that contribute to both alcohol/drug and mental health problems. • A person with a mental health condition or problem such as anxiety, stress and depression may use alcohol and/or drugs to cope with or relieve symptoms. • Sometimes alcohol and/or drug use may aggravate or exacerbate a mental health condition or problem and lessen the efficiency of available treatments. • Alcohol/drug use may ‘trigger’ or directly cause mental health conditions or problems. • An individual’s alcohol/drug misuse can have a negative impact on the health and wellbeing of others such as children and other family members. (24) People of all ages with mental health problems report experiencing stigma, disadvantage and discrimination when accessing services. The populations affected by drug/alcohol misuse and mental health problems are known to overlap significantly, as do the risk and protective factors that impact upon each area. 10 || Good Mental Health for All in Moray 2016-2026 Moray community Planning Partnership|| 11Page 117
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Key Mental Health Facts: • Mental health problems are common. Around one in three people are estimated to be affected by mental illness in any one year. One in four people will experience mental health problems at some stage in their lives. (1) • Those with severe and enduring mental health conditions such as Schizophrenia and Bipolar disorder die on average 16-25 years younger than the general population, mainly due to physical health problems. (25) • People experiencing mental health problems are at increased risk of poorer social, educational, health and employment outcomes. (26) • Mixed anxiety and depression is the most common mental disorder in Britain. There are no specific anxiety or depression statistics for Moray but anxiety overall estimated prevalence is about 9.2% of the UK population and depression overall estimated prevalence is about 10% in UK adults. (27,28) • 20% of children have a mental health problem in any given year, and about 10% at any one time. (14) • Depression affects one in five older people living in the community and two in five living in care homes. (29) • Women are more likely to have been treated for a mental health problem than men (29% compared to 17%). (30) • Suicide remains the most common cause of death in men under the age of 35. In Moray there have been 24 male suicides aged under 35 in the years 2006 to 2014 inclusive and mental illness or poor mental health is known to be an associated risk factor. (18) • Anxiety is one of the most prevalent mental health problems in the UK and elsewhere, yet it is still under-reported, under-diagnosed and under- treated. (31) • Nine out of ten people affected by mental health problems report having experienced stigma and discrimination. (32) • People in pain due to physical illness or who have long term conditions are up to five times more likely to have significant clinical depression than their healthy peers. (33) People with mental disorders have a much higher mortality than the general population, dying on average more than 10 years earlier. (34) 12 || Good Mental Health for All in Moray 2016-2026 Page 118
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Achieving good mental health & wellbeing in Moray These key cross cutting themes bring together what people in Moray told us was important with good practice and evidence in mental health promotion, prevention, protection, care and recovery. We will take a whole systems integrated approach to mental health and wellbeing that is concerned with bringing health and social models together in the delivery of national health and wellbeing outcomes. A whole systems approach is one that recognises the contribution that ‘all partners’ make to the promotion and protection of mental health and wellbeing, and the delivery of high quality care and recovery services. A whole systems integrated approach should incorporate an understanding of risk and protective factors as they relate to the wider determinants of mental health and the impact of the broader environments in which people are born, grow, live, work and play and age. (6) This understanding demands actions across multiple areas and levels’, ensuring that mental health is everyone’s business. We can see from the health determinants model (Fig 1.) (35) that this requires ‘multi-sectoral community planning partnership’ activity across all sectors that include communities, children’s services, health and social care, education, employment, economic development, housing etc. to all work together as part of a strategic, joined up and co-ordinated approach to improving and protecting mental health and wellbeing in Moray. See also Appendix 1. Which outlines the current Moray community planning policy and planning landscape. Fig 1. We have developed a shared vision for the direction of travel for tackling mental health and wellbeing in Moray. Working together we will enable people to achieve the best possible mental health and wellbeing. We will do this through promoting choice and control and by developing resilient communities and responsive services that contribute towards a mentally healthy, happy, stigma free Moray. Delivering against our vision and strategic priorities will be underpinned by five key cross cutting themes. These are: • A whole systems integrated approach to mental health and wellbeing that brings health and social models together; • A life-course approach that takes into account the differential experiences and conditions throughout life in which people are born, grow, live, work, play and age; • An upstream approach that is focused upon protection, promotion, prevention, and early intervention, as well as treatment and care services; • A strengths based perspective which is focused upon recovery, assets, improving quality of life, ambition and hope, and not wholly on the deficits and problems of individuals and communities; • A human rights based approach which ensures that international human rights standards are put at the centre of policies and practice that impact on people with mental health problems. Individual lifestyle factors Social and community influences Living and working conditionsGeneral socioeconomic, cultural and environmental conditions Age, gender and hereditary factors Moray community Planning Partnership|| 13Page 119
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Determinants can either be protective so promoting mental health, or have a negative impact by contributing to poor mental health. Risk and protective factors for mental health and wellbeing exist in multiple contexts and act at several different levels, interacting to influence a person’s overall mental health and wellbeing (Fig 2.) Knowing what kind of factors put children and adults at risk of mental health difficulties as well as those that can promote and protect mental health, form the basis for guiding service improvements and actions for promoting, protecting and supporting optimal health and wellbeing. (6) Feedback from community consultation broadly reflects these recognised protective factors for promoting positive mental health and wellbeing where people have highlighted areas that they feel are important and where action is required. An understanding of risk and protective factors and the determinants of mental health and wellbeing therefore underpins the focus of this strategy and its delivery plan. Fig 2: An illustrative list of things that determine our mental health Protective factors Risk factors Environmental factors • Social protection and active labour market programmes against economic downturn • Equality of access to services • Safe secure employment • Positive physical environment, including housing, neighbourhoods and green space • High unemployment rates • Economic recession • Socio-economic deprivation and inequality • Population alcohol consumption Exposure to trauma Social circumstances • Social capital and community cohesion • Physical safety and security Good nurturing parental/ care relationships • Close and supportive partnership/family interaction • Educational achievement • Social fragmentation and poor social connections • Social exclusion • Isolation • Childhood adversity (neglect, abuse, bullying) • (Gender based) violence and abuse • Family conflict • Low income/poverty Protective factors Risk factors Individual factors • Problem solving skills • Ability to manage stress or adversity • Communication skills • Good physical health and healthy living (physical activity, nutrition) • Spirituality • Age, sex, genetics • Low self esteem • Loneliness • Difficulty in communicating • Substance misuse • Physical ill health, impairment, injury • Work stress • Unemployment • Debt • Age, sex, genetics (Adapted from Good Mental Health for All 2015) 14 || Good Mental Health for All in Moray 2016-2026 Page 120
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community. We will ensure that all people receive the right care, at the right time, in the right place regardless of background and circumstances, age, sex, race, religion, disability or sexual orientation. (38,39) We will take a life-course approach that takes into account the differential experiences and conditions throughout life in which people are born, grow, live, work, play and age. All policies, plans and services need to take account of mental health and wellbeing at all stages of the life course including infancy, childhood, adolescence, adulthood and older age. Taking a life- course perspective recognises that the influences that operate at each stage of life can impact upon mental health and wellbeing, and that shared and broad actions are required to improve the conditions that influence mental health and wellbeing. (2) Whilst it is recognised that comprehensive action across the life course is required, there is considerable evidence and scientific consensus that ‘action to give every child the best possible start in life will generate the greatest societal and mental health benefits’. (3) We will take an upstream approach that has a focus on prevention, promotion and protection, as well as high quality recovery focused treatment and care services. Scottish Government Mental Health Strategy 2012- 2015 brings mental health improvement work and work to improve mental health services together in a single strategy covering the full spectrum of mental health improvement, prevention, care, services, and recovery. It advocates actions which impact upon the layers of influence on mental health that are concerned with: ‘promoting good mental wellbeing in the general population; reducing the prevalence of common mental health problems; and that improve quality of life for those experiencing mental health problems or mental illness.’ (34) This Moray strategy and its delivery plan will ensure that actions and resources are appropriately balanced across these key areas of influence. We will take a strengths based perspective which is focused upon recovery, assets, improving quality of life, ambition and hope, and not wholly on the deficits and problems of individuals and communities. Many health systems have traditionally adopted a view of mental disorders based on pathologies, deficits and problems as a means of identifying successful treatment of illness. Recovery based practice is based upon a strengths and assets based approach to supporting people where the capacity, skills, knowledge, connections and potential in individuals and communities is valued and allows people to achieve better or more satisfying outcomes. Implementing and embedding a recovery and strengths based perspective into policy and practice involves a significant reorientation of mental health services and practices. Available evidence indicates that this requires a broad holistic approach with a focus on multiple recovery initiatives acting on different parts of the system in order to bring about meaningful and sustainable change. (36,37) We will take a human rights based approach that ensures that international human rights standards are put at the centre of policies and practice that impact on people with mental health problems. Human rights refer to the basic rights and freedoms to which all humans are entitled. Many situations experienced by people living with mental health problems involve human rights. All of the human rights protected by the European Convention belong to and may be relevant for people living with mental health problems. Human rights can empower people to make choices about their lives, they can provide legal protections and they can ensure inclusion and participation in the 14 || Good Mental Health for All in Moray 2016-2026 Moray community Planning Partnership|| 15Page 121
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A picture of mental health services in Moray This strategy is concerned with the wider influences upon mental health and wellbeing such as the impact of social and economic circumstances and the broader environments in which people are born, grow, live, work, play and age. Community planning provides the context for this broad approach which recognises the importance of not only mental health services but also the multi- sectoral partnership activity across all policy and service sectors as part of a strategic and co-ordinated approach to improving mental health and wellbeing in Moray. This broad policy and planning landscape is set out in Appendix 1. Mental health services in Moray are delivered primarily through the NHS and local authority in partnership with communities and the voluntary (e.g. charities and other not-for-profit organisations) and independent sectors. General Practitioners are often the consistent and visible face of the health and social care system and play a pivotal role in the promotion and treatment of mental health and wellbeing. NHS boards are responsible for the treatment of those with mental illness and poor mental health either in community or in acute settings, whilst local authorities are responsible for securing social care and support services (e.g. housing, social work, day care services etc.) in the community, as well as providing a range of mainstream universal services that support people’s health and wellbeing. From April 2016 responsibility and resources for planning and delivering these adult services will move to the Moray Health and Social Care Partnership led by an Integrated Joint Board. The integration of specialist clinical interventions within a wider framework of support is necessary as those that experience mental health problems face many barriers to their full inclusion in the social and economic life of the community in Moray. There are many valuable community and voluntary organisations and groups in Moray that contribute to people’s mental health and wellbeing. The type of work that community projects and groups do is hugely varied and is known for its diversity and flexibility. Whilst this sector and its activities make a significant contribution to mental health and wellbeing outcomes in Moray, many of these activities and programmes are not necessarily identified as being ‘mental health’ services. Families and carers play a valuable role in helping people to recover and deal with a wide range of mental health problems. The support of carers in mental health, as well as supporting the mental health and wellbeing of carers themselves is important. A key role of statutory services is to help build community capacity by supporting the voluntary and community sector to create choice and diversity in the provision of local services, programmes and activities that contribute to mental health and wellbeing. This strategy recognises the enormous and valuable contribution that all services, communities, and volunteers can make to the promotion of positive mental health and wellbeing, and the prevention and support of mental health problems. The Mental Health and Wellbeing Tier framework below is intended to capture this broad spectrum of activity and to help inform future planning, service and programme delivery – where do you fit in? See also the Community Care Moray Partners in Care Policy. (40) Mental Health & Wellbeing Tiers Tier 0 Early intervention, prevention and education: Includes a wide range of universal and third sector agencies and services (children, families, young people, adults) and protective services which impact upon the determinants of mental health; public health and mental health awareness campaigns; lifestyle information & advice (being active, alcohol, nutrition); working with the media, information and signposting; schools education and PSHE & Curriculum for Excellence; parenting programmes; informal education & youth work; the natural environment (outdoors, parks, green spaces); social networks; volunteering; health in the workplace programmes; mental health training in the community (e.g. ASIST, Mental Health 1st Aid). 16 || Good Mental Health for All in Moray 2016-2026 Page 122
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Tier 1 People with low support needs (help to help you) who: • Require low level monitoring and support or intervention of one agency or discipline; • Are likely to self-manage their mental health problems with minimal support and/or prompting; • Have an established informal support network; • On assessment are deemed to pose reduced or little risk to themselves or others; • Are likely to have been signposted to community self-care & management supports and maintain contact with their GP, mental health and other services with minimal support and / or prompting. Tier 2 People with medium support needs (help when you need it). Includes individuals with a history of serious and enduring mental health needs, including personality disorder and/or a high degree of clinical complexity who: • Require higher levels of support, intervention and monitoring services from more than one agency or discipline compared to Tier 1; • Require a ‘stepping stone’ from residential care / higher level supported accommodation or in-patient services to independent living in the community; • May only have poor or partially established informal support networks; • On assessment, poses identified risk(s) to self or others as a result of their mental health needs. Tier 3 People with high and complex support needs (ongoing support for those that need it). Includes individuals with a history of serious and enduring mental health needs, including severe personality disorder with a very high degree of clinical complexity, who: • Require active co-ordinated support from multiple agencies, including housing, physical health, substance misuse, employment training, criminal justice, voluntary sector and other agencies; • Require a 24-hour accommodation-based support service; • Will be receiving care co-ordination from a statutory provider e.g. community mental health team or similar service; • On assessment poses significant risk to self or others as a result of mental health needs, forensic history or other reason. Mental health and wellbeing is not a fixed state and people will move across tiers as their wellbeing is influenced by a wide range of factors and influences. Tier 1, for example, will include people with a history of serious and enduring mental health needs and who may have previously met the criteria for Tiers 2 and/or 3 but will have been supported to develop the recovery skills and tools to manage their wellbeing – recognising signs of relapse and crisis and managing these situations with minimal support. Adapted from Look Ahead Care and Support (2013) (40, 41) 16 || Good Mental Health for All in Moray 2016-2026 Moray community Planning Partnership|| 17Page 123
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How we will make this change happen Moray’s shared vision for change will be achieved through the delivery of seven key strategic priorities and a wide range of related actions. These priorities have been identified via a process of consultation with individuals, communities and services and reflect the areas that people felt to be most important. Our seven strategic priorities: 1. Promote and sustain good mental health and wellbeing 2. Decrease mental health inequality, stigma and discrimination 3. Improve the quality of life of those experiencing mental health problems via a strength based recovery orientated mental health system and services 4. Develop, strengthen and maintain supporting relationships, and increase social inclusion 5. Increase financial security, maximise employment / employability opportunities and increase access to housing 6. Reduce suicide, suicidal behaviour and self-harm 7. Support a professional workforce which Includes robust staff training Promote and sustain good mental health and wellbeing This priority is directed at promoting good mental health, preventing mental ill health and ensuring early intervention when mental health problems occur (Tier 0/1). The focus on prevention, anticipation and supported self-management is identified by Scottish Government as central to promoting mental health and wellbeing in Scotland. (34) People in Moray have told us that these areas matter and that mental health is more than just the absence of mental ill health and disorders and that a broad holistic approach to the promotion of mental health and wellbeing is required. Mental health improvement (sometimes called mental health promotion) is any action taken to enhance the mental health and wellbeing of individuals, families, carers, organisations or communities and is relevant to the whole population, individuals at risk, vulnerable groups and people with mental health problems. (42,43) Mental health promotion works at three levels – strengthening individuals, strengthening communities and removing structural barriers to positive mental health and wellbeing. (42) There is now a growing body of evidence on the effectiveness of interventions, covering both prevention and promotion. Continuity between childhood and adult life is particularly important in the context of mental health promotion and prevention. Many forms of emotional and behavioural response are formed in the early years and may be difficult to alter in later life. Fostering the development of appropriate emotional and social skills from the outset is therefore likely to be more effective than later intervention. (3,14) Examples of interventions: • Early years work • Schools based PSHE / Curriculum for Excellence / Anti- bullying • Youth work provision • Targeted mental health promotion campaigns • Working with the media • Stress management • Self-Management / Self-Help approaches • Social prescribing • National helplines – Breathing Space, Samaritans • Lifestyle & health behaviours (diet, activity, alcohol) • Mental Health Impact Assessments (public policies, programmes and plans) • Domestic violence work • Signposting / access to information • Health in the workplace / Healthy Working Lives (see priority 7.) • Information & Communication Technologies / beb based supports • CBT programmes 18 || Good Mental Health for All in Moray 2016-2026 Page 124
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Decrease mental health inequality, stigma and discrimination We know that people with mental health problems are amongst the least likely of any group with a long- term health condition or disability to: find work; be in a steady, long-term relationship; live in decent housing, and be socially included in mainstream society. (45,46) These types of inequality are often exacerbated by society’s stereotyped views about mental illness and how it affects people. Research indicates that significant numbers of young people with mental health problems experience stigma and discrimination in the school setting and in the community, often from peers, family and friends. Young people with mental health problems are often treated differently, and even bullied. This can affect their education and self-esteem with knock-on effects for the rest of their life. (44, 47) We will ensure that all people receive the right care, at the right time, in the right place regardless of background and circumstances, mental health status, age, sex, race, religion, disability or sexual orientation. Examples of interventions: • Anti-bullying work • Anti-stigma work • Public mental health awareness • Training & education • Peer support • Promotion of recovery focused principles & practice • Promotion of human rights • Recovery narratives and stories • Intergenerational work • Work with the media • Public mental health campaigns • Role models community champions • Positive discrimination • Workplace campaigns • Addressing barriers to access • Schools work / campaigns People with mental health problems told us that they often experienced stigma and discrimination in their daily lives. They said the social stigma attached to mental ill health and the discrimination can make their difficulties worse and make it more difficult to recover. Stigma not only affects the individual with the mental health problem but can also impact on their family. Stigma and discrimination can often trap people in a cycle of illness and social exclusion. One of the most damaging aspects of stigma is when it is internalised and people believe they are of less value than a ‘normal’ person’, impacting on the individual’s sense of self, self-esteem, self-value and confidence’. (44) Inequality in mental health means the unequal distribution of factors that promote and protect positive mental health and factors that are detrimental to mental health. 18 || Good Mental Health for All in Moray 2016-2026 Moray community Planning Partnership|| 19Page 125
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Improve the quality of life of those experiencing mental health problems via a strength based recovery orientated mental health system and services People told us that recovery focused principles and practice should be at the heart of our mental health policy and services. As previously highlighted this strategy also has an underlying cross cutting theme which relates to taking a strength based and recovery focused approach across the strategy as a whole. Recovery focused principles and actions will therefore cut across all of our identified strategic priorities. Our new Making Recovery Real in Moray programme (2015) in conjunction with the Scottish Recovery Network and other local partners will be responsible for developing a Making Recovery Real in Moray delivery and action plan which will seek to support improved and sustainable recovery orientated practice and outcomes. It will primarily be concerned with influencing organisational culture and ways of working with the aim of embedding the principles and values of recovery in policy and practice. Examples of interventions: • Recovery focused practice – whole system approach • Recovery indicators & standards • Recovery focused commissioning • Co-production • GP / primary care focused interventions • Community mental health services • CAMHS services • Community outreach • Inpatient services • Intensive home treatment services and crisis prevention approaches • Recognition & treatment of first episode psychosis • Psychological therapies • Workforce development • Community development • Health improvement for people with severe and enduring mental illness • Community Wellbeing Hub / Recovery College • Virtual online hub / single point of access • Peer Support and link workers • Recovery narratives / stories • Recovery/lifestyle coaches • Veterans peer support • Environmental Education / Therapy • Role of the voluntary / 3rd sector • Criminal justice work 20 || Good Mental Health for All in Moray 2016-2026 Page 126
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Develop, strengthen and maintain supporting relationships, and increase social inclusion There is a strong link between the recovery process and social inclusion – ‘a key role for services is to support people to regain their place in the communities where they live and take part in mainstream activities and opportunities along with everyone else. There is a growing body of evidence that demonstrates that taking part in social, educational, training, volunteering and employment opportunities can support the process of individual recovery.’ (49) Available evidence recommends that there is a need for more interventions and policies that promote social relationships and psychological wellbeing. Strengthening levels of social support and identifying structural barriers to social contact is likely to involve action across many different areas including education, transport, housing, regeneration and residential care. (50) Examples of activities: • Early years work & family support • Perinatal mental health • Looked after children • Volunteering • Community peer support groups • Community facilities such as libraries and community halls • Role of the voluntary / 3rd sector • Befriending, mentoring and buddying initiatives • Men’s focused work (sheds and groups) • Women’s groups • Community clubs and groups • Dementia Friendly Communities • Arts & mental health When it comes to wellbeing, people have told us that other people matter. This is backed up by evidence that shows that social isolation is a key trigger for mental illness and that supportive relationships with family, friends and the wider community are beneficial to the mental health and wellbeing of individuals and the population. Work relationships are known to be a protective factor amongst working age people. (6) Other forms of social interaction such as volunteering are also known to boost wellbeing amongst older people. Supporting parents during the early years of child development is known to be beneficial for both parents and children. Attachment theory suggests that people with secure childhoods may be better at forming relationships at school, work and in social situations. (48) 20 || Good Mental Health for All in Moray 2016-2026 Moray community Planning Partnership|| 21Page 127
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Increase financial security, maximise employment / employability opportunities and increase access to housing Work plays a vital part in all of our lives. Employment can have distinct effects on mental health. It can be protective - providing financial security as well as the value that is placed upon employment opportunities such as work relationships and skills development. Employment provides social status and identity, a sense of achievement and a way of structuring people’s time’. Poor working environments can however be detrimental to mental health. (53,54) Mental health and housing are closely interlinked. Good quality, affordable, safe housing is essential to all of our wellbeing. For those with mental health problems the security of a safe and stable environment in supporting people’s recovery cannot be underestimated. Without a settled place to live, access to treatment, enabling genuine recovery and encouraging social inclusion can be impeded. (55) Having secured and settled accommodation, with the right kind of support, can have a positive impact on people’s recovery and mental health. Examples of activities: • Debt advice and management • Personalised and targeted employment & education interventions • Improved joint working and sharing of knowledge across health, housing and related services and sector • Mental Health Awareness amongst housing sector staff and housing providers • Supported accommodation • Individual placement and support (DWP/NHS) People told us that many wider social issues impacted upon and influenced their mental health and wellbeing. People identified protective factors such as financial security, employment and access to good affordable housing. Many people with mental health problems highlighted a number of barriers to employment opportunities. Financial security is recognised as a social determinant of health. There is a relationship between money problems and mental ill-health. One in two adults with debts also has a mental health problem. There is a link between ‘financial capability’ and psychological wellbeing - moving from low to average levels of financial capability leads to an improvement in psychological wellbeing. Increases in financial capability decreases the risk of anxiety and depression and increases life satisfaction. (51,52) 22 || Good Mental Health for All in Moray 2016-2026 Page 128
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Reduce suicide, suicidal behaviour and self-harm People told us that our Choose Life suicide prevention work was important. People emphasised the importance of suicide prevention as a cross-cutting theme and that all of our mental health activities should have an impact on suicide outcomes. Many factors put individuals at risk of suicide, with four key groups of risk factors identified: • Risks and pressures within society, including poverty and inequalities, access to methods of suicide, prevalence of alcohol problems and substance misuse, and changing trends in society such as marital breakdown; • Risks and pressures within communities, including neighbourhood deprivation, social exclusion, isolation, and inadequate access to local services; • Risks and pressures for individuals, including socio- demographic characteristics, previous deliberate self-harm, lack of care, treatment and support towards recovery from serious mental illness, loss (e.g. bereavement or divorce), and experience of abuse; • Quality of response from services, including insufficient identification of those at risk. (56, 57) The relationship between these factors is complex. Scotland’s suicide prevention strategy (2013) (56) states that such factors should not be addressed in isolation, emphasising the need for a shared responsibility for suicide prevention. Self-harm - The Moray Choose Life programme includes activities which set out to develop and implement responses to reduce suicidal ideation, repetition, severity and risk of harm associated with self-harm. Most episodes of self-harm are not directly related to suicide behaviours. Suicide is a way of ending life, but many people who self-harm do so as a way of coping with life and being able to continue with living. Links between self-harming and suicide risk do however exist. While the majority of people who self-harm do not go on to take their own lives, people who harm themselves are at increased risk of future suicide. It is therefore important to ensure that self- harm and suicide are addressed as related issues in organisational policies, planning and protocols. Examples of activities: • A broad policy and partnership approach to suicide prevention • Identify and intervene to reduce suicidal behaviour in high risk groups • Working with media and public mental health campaigns • Actions to reduce suicides at locations of concern • Education and training about suicidal behaviour and promote awareness about the help available • Supporting those affected / bereaved by suicidal behaviour • Self-harm awareness and management 22 || Good Mental Health for All in Moray 2016-2026 Moray community Planning Partnership|| 23Page 129
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Support a professional workforce which includes robust staff training. Examples of activities: • Broad competency framework for mental health and recovery focused learning and development • Mental health awareness for all staff groups • Specialist mental health training • Mental Health 1st Aid training • Recovery College approach • Healthy workplaces / healthy working lives • Anti-stigma work Identified competencies and associated training design and delivery would reflect the different roles of the broad mental health improvement workforce (58,59) i.e. • People who may come into contact with people with mental health problems as part of their day to day work; • Staff who are not mental health specialists, but who work with people who may have a mental health problem, and/or people who may be experiencing a mental health crisis, as part of a wider client group; • Staff working with people with mental health problems – either as a main client group or as a significant part of a wider client group; • Local Human Resources (HR), workforce and training leads. Improved mental health also reduces sickness absence and increases performance / productivity. (60) Making mental health everyone’s business requires ensuring that many diverse sectors are competent in delivering that business. This requires both expertise within the public health specialist workforce and increased capability within the wider health and social care workforce. The aim is to build the capacity and capability of leaders and staff in understanding and integrating mental health, recovery and wellbeing into all policy and practice. This strategy recognises the importance of developing a common and shared understanding and language in relation to mental health and recovery as the basis for the effective delivery of this strategy. A framework for mental health competencies would help to identify training needs within and across the wider health and social care workforce and to enable organisations to design and provide training to a consistent model. A competency framework also articulates the means by which the aspirations of the strategy can be achieved. (58) 24 || Good Mental Health for All in Moray 2016-2026 Page 130
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Governance & Accountability – How will we know we are making a difference? We have identified what we need to do and what we want to achieve. We need to know who will do it, what resources we need and when we will achieve them, as well as being able to measure success. This will form part of a Mental Health and Wellbeing Delivery and Action Plan for Moray – both for children & young people, and adults. Local strategic partnerships will have a key role in providing leadership and a coordinated approach to achieving good mental health for all people in Moray. These partnerships will have a key role to play in working with individuals, families, communities and partners to deliver this joint strategy for Moray. We will adopt recognised good practice that advocates that local partnerships should have ‘a vision of the mental health gains across a range of local policy and service provision, a key plank for Single Outcome Agreements and central to preventative spend.’ A new mental health joint partnership group has been set up to provide leadership and strategic direction in the delivery of this mental health and wellbeing strategy. A sub group structure will be responsible for taking forward our strategic priorities and for developing a wide programme of actions and activities in the delivery of this strategy and its outcomes. These groups will be accountable to the overarching leadership group which in turn will report to the Integration Joint Board for adult health and social care and the Children and Young People’s Partnership. They will report to the Moray Community Planning Partnership. The ongoing engagement of national agencies in mental health improvement and recovery such as NHS Health Scotland and the Scottish Recovery Network will ensure that current evidence, research and good practice informs an effective response to delivering our shared vision for mental health and wellbeing in Moray. During the lifetime of the strategy the group will continue to engage and consult with anyone who has an interest in mental health and wellbeing to review progress in delivering on the strategy and its outcomes. Moray community Planning Partnership|| 25Page 131
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Moray Community Planning landscape • Moray Economic Strategy Community Engagement Group • Community Engagement 6 Point Action Plan • Community Learning & Development Plan Moray Economic Partnership • Cultural Strategy 2014 • Curriculum for Excellence • Employability Action Plan • HIE Operating Plan • Housing Strategy • LEADER Local Development Strategy • Modern Apprenticeships • Moray Economic Strategy • Moray Local Development Plan • Moray Social Enterprise Plan • Regional Skills Investment Plan • Strategy for Tourism Development in Moray Health & Social Care Partnership • Moray Health & Social Care Strategic Plan 2016-19 • 3 Tier Policy (Moray Partners in Care) • Business Case for Redesign of Adult Community Care Services 2011 • Moray Mental Health and Wellbeing Strategy and Delivery Plan 2016-2026 • Choose Life Partnership Strategy/Delivery Plan • Recovery Partnership Strategy/Delivery Plan • Change Fund Older People • Community Safety Strategy • Director of Public Health Annual Report 2014/15 • Fostering & Adoption Smoking Policy • HEAL Strategic Framework • Joint Grampian Adult Support & Protection Policy • Living Longer Living Better (Joint Commissions Strategy for Older People 2013/23) • Living Streets Plan • Long Term Conditions Plan • Moray Alcohol & Drug Partnership Strategy • Moray Autism Strategy • Moray Carers Strategy (currently under review) • Moray Learning Disability Strategy • Moray Local Tobacco Alliance Delivery Plan • Moray Physical Activity & Sports Health Strategies (Under Review) • Moray Physical and Sensory Disability Strategy • Morinfo • NHS Grampian Strategic Framework & Delivery Plan • NHS Grampian Tobacco Control Plan 2020 Action Plan • Reablement Policy • Self Directed Support Policy • Sport, Leisure & Recreation Plan • Trading Standards Operational Plan 2014/15 • Unscheduled Care (NHS Grampian) • Volunteering Policy Appendix 1 – Moray Community Planning landscape 26 || Good Mental Health for All in Moray 2016-2026 Page 132
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Public Protection Partnership • Child Protection • Community Safety Strategy • Criminal Justice Strategy • English as a Second Language Strategy • Local Fire & Rescue Operational Plan for Aberdeenshire & Moray • Moray Alcohol & Drug Partnership Delivery Plan • Moray Alcohol & Drug Partnership Strategy • Moray Council Housing & Registered Social Landlords ASB Strategies • Moray Local Fire & Rescue Multi-Member Ward Plans • Moray Local Fire & Rescue Plan 2014/17 • Police Scotland Moray Local Policing Plan • Police Scotland Moray Multi Member Ward Plans • Public Protection Strategy • Scottish Fire and Rescue Service Strategic Plan • Youth Justice Strategy Children & Young People’s Partnership • Mental Health & Wellbeing Strategy – Children & Young People’s Delivery Plan • Autism Strategy • Child Protection • Community Learning & Development Plan • Early Years & Parenting Strategies • GIRFEC Group Improvement Plan • Implementation of Developing Scotland’s Young Workforce 1+2 Languages • Lifelong Learning Strategy • Moray Children’s & Young People’s Services Plan 2013/16 • Moray Corporate Parenting Plan • Moray Council Integrated Children’s Services Annual Service Improvements Plan • Moray Council Strategy for Raising Attainment & Achievement • NHS Grampian Child Health 2020 – A Strategic Framework for Children & Young People’s Health Action Plan • Opportunities for All Action Plan • Physical & Sensory Strategy • Schools & Curriculum for Excellence Five Year Plan Employability Moray • Community Learning & Development Plan • Curriculum for Excellence • Developing the Young Workforce • HIE Operating Plan • Libraries Service Plan • Modern Apprenticeships • Moray Community Planning Partnership Employability Strategy 2013 • Moray Economic Strategy • Regional Skills Investment Plan • Schools and Curriculum Development Plan • Skills Development Scotland Plans • UHI Strategic Plan Sustainability & Communities Partnership • Affordable Housing Supplementary Planning Guidance • Cairngorms National Park Partnership Plan • Empty Homes Strategy • Energy Plan (the Moray Council) • Flood Alleviation Schemes • Homelessness Strategy • Housing Needs & Demand Assessment • Kerbside Collection Policy • Local Housing Strategy • Moray Climate Change Plan • Moray Council Waste Strategy • Moray Home Energy Efficiency Programme • Strategic Housing Investment Programme • The Housing Investment Strategy • The Tenant Participation Strategy 26 || Good Mental Health for All in Moray 2016-2026 Moray community Planning Partnership|| 27Page 133
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BREATHING SPACE (NHS 24) Feeling down or depressed. Breathing Space can help if you need someone to talk to, experienced advisors will listen and provide confidential information and advice. tel: 0800 838587 (freephone) web: www.breathingspace.scot Opening hours: Weekdays: Monday – Thursday 6pm to 2am Weekend: Friday 6pm – Monday 6am SAMARITANS Confidential emotional support for people who are experiencing feelings of distress, despair or suicidal thoughts. Also if you need support with helping someone you are worried about. tel: 116123 (freephone) email: joe@samaratins.org web: www.samaritans.org.uk Opening hours: 24 hours a day LIVING LIFE (NHS 24) Living Life is a free and confidential phone service for anyone aged 16 and over experiencing low mood, mild/moderate depression and/or anxiety. Offering telephone support with either a Guided Self Help Coach or fully trained CBT professional. tel: 0800 328 9655 (freephone) web: www.nhs24.com/usefulresources/livinglife/ Opening hours: Monday-Friday 1pm to 9pm NHS 24 NHS 24 is Scotland’s national telehealth and telecare organisation. We’re an online and telephone-based service. We can answer your questions about your health and offer advice. Call us free if you are ill and it can’t wait until your regular NHS service reopens tel: 111 (freephone) web: www.nhs24.com Opening hours: 24 hours a day NHS INFORM NHS inform is Scotland’s health information service. NHS inform provides a single source of online health and care information. web: www.nhsinform.co.uk Appendix 2 – Mental Health and Wellbeing Services 28 || Good Mental Health for All in Moray 2016-2026 Page 134
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STEPS FOR STRESS A simple online guide to stressing less and enjoying life more. Take our online Stress Quiz and access our simple tips for dealing with typical symptoms of stress. You can also download a free Steps for Stress booklet and order a free relaxation CD all online at: web: www.stepsforstress.org HOPELine UK – Prevention of Young Suicide A service provided by PAPYRUS UK which exists to give young people hope and to prevent suicide. HOPELine UK is a free confidential helpline, staffed by trained professionals who give non-judgemental support, practical advice and information. Are you worried about yourself or someone you know? depressed or not coping with life? Hurting… or hurting yourself? tel: 0800 068 4141 (freephone) email: pat@papyrus-uk.org txt: 07786 209697 web: www.papyrus-uk.org/help-advice/about- hopelineuk Opening hours: Weekdays: 10am till 10pm Weekends: 2pm till 10pm Bank Holidays: 2pm till 5pm 24 hour Dementia Helpline (Alzheimer Scotland) The 24 hour Dementia Helpline is a freephone Scottish service for people with dementia, carers, relatives, professionals, students and anyone concerned about dementia. Experienced call handlers provide: • Information and emotional support • Help you, your family and friends plan for the future • Put you in touch with local sources of support tel: 0808 808 3000 (freephone) email: helpline@alzscot.org GP’s Ask your GP - who can provide advice and information, referral and signpost to local mental health and wellbeing services, supports and self-help publications and resources. They also provide treatments. Community Care – Mental Health Services Day Services Day services with nursing support - the purpose of this service is to provide intensive day care with skilled and qualified support staff as an alternative to admission to hospital. You must be referred to this service by your GP or through the Community Mental Health Team. This service is free. Community Mental Health (NHS & Local Authority) The Community Mental Health team provide specialist assessment, treatment and care services. There are 3 teams each covering a geographical area of Moray. Each team comprises Psychiatrist and other medical staff, Community Psychiatric nurses, Social Worker/Care Manager, Occupational Therapist, Psychotherapist. You must be referred by your GP to this service. The team has a number of professionals - each with different skills and experience. You will receive a service to meet your individual needs. This service is for adults under 65 years. Mental Health Supported Tenancies The Moray Council, through the Community Mental Health Team, offers furnished, supported tenancies across Moray to people recovering from mental illness. Support can also be offered to people in their own tenancies. This is available if you are able to live independently but require some support to keep on your own tenancy. The level of support will depend on your individual needs and will decrease as you become more able to live independently. Charges – you will have to pay rent, or have these costs met through your benefits. 28 || Good Mental Health for All in Moray 2016-2026 Moray community Planning Partnership|| 29Page 135
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Access Care Team tel: 01343 563999 Out of Hours emergency service: 08457 565656 email: accesscareteam@moray.gov.uk WELLNESS RECOVERY ACTION PLANNING (Moray) Wellness Recovery Action Planning (WRAP) is a community led course delivered by people with lived experience of mental health problems. The course will provide you with the tools to: • develop a wellness action plan • anticipate and overcome crisis • build confidence & self-esteem • take control & manage your emotional health and wellbeing • realise your aspirations and potential For information on WRAP and upcoming courses contact: Heidi Tweedie, Community Recovery & Wellbeing Champion. tel: 07989 331651 email: info@wrapmoray.org LIVING LIFE TO THE FULL (Moray) Living Life to the Full (LLTTF) is a life skills course designed to help you: • overcome stress and anxiety • relax • build confidence • overcome reduced activity • tackle difficult situations • change unhelpful thinking • understand why we feel as we do • recognise helpful and unhelpful behaviour • solve problems • live healthily In Moray you can access LLTTF in a variety of ways: • Community LLTTF courses. Contact: Heidi Tweedie – heidi@moxiemedia.co.uk • Via LLTTF workbooks available through your local library and NHS Healthpoint service • DVD – available through your local library and NHS Healthpoint service • Online course – www.llttf.com and www. actionondepression.org/services/cbt-online GINSBERG Be in control of your health and wellbeing. One place to track and understand your emotional and physical wellbeing. Ginsberg is an online interactive tool for anyone that wants to improve their health and wellbeing by understanding themselves better. Ginsberg is a completely private space for you to keep track of how you’ve been feeling and what’s been going on around you. web: www.ginsberg.io/ PREVENT SUICIDE APP (NE Scotland) A free Grampian and Moray suicide prevention App to find help with emergency situations, finding local advice and services, supporting others. Available for download on your phone and hand held device via Apple Store, Google Play, Amazon App store, Windows & Microsoft Store. Also available to access: www.preventsuicideapp.com MORAY CHOOSE LIFE: Suicide Prevention & Self-Harm Awareness Training A range of free suicide prevention and self-harm awareness training courses for professionals and communities i.e. ASIST, SafeTALK, SuicideTalk, Self- Harm Awareness, Mental Health 1st Aid. email: martin.kirwan@moray.gov.uk Choose Life info: steve.mccluskey@moray.gov.uk 30 || Good Mental Health for All in Moray 2016-2026 Page 136
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MORAY MENTAL HEALTH Community Support Group A community led peer support group run for and by individuals with experience of mental health problems, including carers. Provides advice, information, support meetings and outings. email: moraymentalhealth@outlook.com CRUSE BEREAVEMENT CARE (Moray) If you live in Moray and have been bereaved Cruse Scotland can help. We offer confidential individual support for both bereaved adults and children and young people. We can also offer group support for those bereaved by suicide. Once you have given your details they will be input to our secure database and the local team will then contact you. tel: 0845 600 2227 email: moray@crusescotland.org.uk LIVING IT UP (Moray) For help to get and share information for a healthier lifestyle in Moray go to the Living it Up portal website. web: www.livingitup.scot NHS Grampian HEALTHPOINT (Moray) Healthpoint is a NHS Grampian walk in service which offers free advice or information on: • information, advice & resources on mental health & wellbeing • practical ways to improve your health • support groups and organisations • long term conditions e.g. diabetes, asthma • access to smoking cessation services • access to free condoms • how to access NHS services drop in: Dr Gray’s Hospital, Foyer, Elgin tel: 0500 202030 (freephone) txt ‘info’ to 82727 an advisor will call you back email: healthpoint@nhs.net Moray libraries HEALTH-MATTERS Healthy Reading Collection A collection of healthy reading books, resources, DVD’s to help you make healthy choices. Including many publications on emotional health and wellbeing. Look out for the dedicated Health-Matters section in your local library and online. web: capitadiscovery.co.uk/moray For information on leisure & sports facilities, community groups: web: morinfo.moray.gov.uk Quarriers Carer Support Service (Moray) Advice, information and support which best meet your needs to cope with your caring responsibilities whether you are young or old. This includes support and information to support carers emotional health and wellbeing. tel: 01343 556031 web: www.quarrierscarersservice.org.uk ARROWS – Quarriers Drug and Alcohol Service (Moray) Access point for all drug and alcohol services in Moray. If you require access to a service this is your first point of call. Arrows offers assessment and referral to services that meet your needs as well as information, support and guidance. tel: 01343 610500 email: arrows@quarriers.org.uk 30 || Good Mental Health for All in Moray 2016-2026 Moray community Planning Partnership|| 31Page 137
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References (1) The Health & Social Care Information Centre (2009). Adult Psychiatric Morbidity in England: results of a household survey. NHS The Information Centre. (2) The Scottish Government (2016). Scotland’s Mental Health Strategy. Mental Health in Scotland a 10 year vision (consultation draft). The Scottish Government. Edinburgh. (3) The Scottish Government and COSLA (2008). The Early Years Framework: Part 1 and 2. The Scottish Government. Edinburgh. (4) The Scottish Government (2008). Achieving Our Potential: A framework to tackle poverty and income inequality in Scotland. The Scottish Government. Edinburgh. (5) The Scottish Government and COSLA (2008). Equally Well: report of the ministerial taskforce on health inequalities. The Scottish Government. Edinburgh. (6) NHS Health Scotland (2015). Good Mental Health for ALL. NHS Health Scotland. Edinburgh. (7) Scottish Association for Mental Health (2011). What’s it Worth Now? SAMH. Glasgow. (8) World Health Organisation. Factfiles Mental Health [online]. WHO. Available at: www.who. int/features/factfiles/mental_health/en/. (updated 2014). [Accessed 27th June 2016]. (9) Mental Health Foundation. Mental Health Statistics [online]. Mental Health Foundation. London. Available at: www.mentalhealth.org.uk/ statistics [Accessed 10th August 2015] (10) Pilgrim, D. & Corry, P. (2013). Strategic Review of Anti-Stigma Approach in Scotland: final report. University of Liverpool. (11) NICE Public Health Guidance 40. (2012). Social and Emotional Wellbeing: early years. National Institute for Health and Clinical Excellence. Manchester. (12) Rethink Mental Illness [online]. Rethink. Available at: www.rethink.org/living-with- mental-illness/young-people/what-is-mental- health. [Accessed 14 Sept. 2015]. (13) NICE Draft Guideline: Transition from children’s to adults’ services [online]. NICE. London. Available at: www.nice.org.uk/guidance/NG43/ documents/transition-from-childrens-to-adults- services-full-guideline2. [Accessed 14th March 2016]. (14) Mental Health Foundation (2004). Childhood and Adolescent Mental Health: understanding the lifetime impacts. Mental Health Foundation. London. (15) Mental Health Foundation (2015). Fundamental Facts about Mental Health. Mental Health Foundation. London. (16) Bauer, A., Parsonage, M., Knapp, M., Lemmi, V., and Adelaja, B. (2014). The costs of perinatal mental health problems [online]. Centre for Mental Health. London. Available at: www. centreformentalhealth.org.uk/costsof-perinatal- mh-problems [Accessed 14 Sept. 2015]. (17) Samaritans (2012). Men, Suicide & Society. Samaritans. Surrey. (18) ScotPHO Public Health Information for Scotland. Suicide Key Points [online]. ScotPHO. Edinburgh. Available at: www.scotpho.org.uk/health- wellbeing-and-disease/suicide/key-points. [Accessed 14 Sep. 2015]. (19) Naylor, C., Parsonage, M., McDaid, D., Knapp. M., Fossy, M., and Galea, A. (2012). Long Term Conditions and Mental Health: the cost of co- morbidities. The King’s Fund and Centre for Mental Health. London. (20) World Health Organisation. Mental Health and Older Adults Fact Sheet [online]. WHO. Available at: www.who.int/mediacentre/factsheets/fs381/ en/. [Accessed 9th Feb. 2016]. (21) Lee, M. (2006). Promoting Mental Health and Well-being in Later Life: A first report from the UK inquiry into mental health and well-being in later life. Age Concern and the Mental Health Foundation. London. 32 || Good Mental Health for All in Moray 2016-2026 Page 138
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(22) The Moray Council (2013). Moray Joint Commissioning Strategy for Older People 2013- 2023. The Moray Council. Elgin. (23) Mind (2004). Understanding Dual Diagnosis. Mind (National Association for Mental Health). London. (24) Rethink (2016). Drugs, Alcohol and Mental Health Factsheet. Rethink Mental Illness. London. (25) NICE Briefing paper [online]. Available at: www.nice.org.uk/Media/Default/Standards- andindicators/QOF%20Indicator%20Key%20 documents/NM15%20NM20%20Briefing%20 paper%20to%20the%20committee%20on%20 mental%20health.pdf. [Accessed 12th April 2016]. (26) World Health Organisation (2012). Risks to Mental Health: an overview of vulnerabilities and risk factors [online]. Available at: www.who. int/mental_health/mhgap/risks_to_mental_ health_EN_27_08_12.pdf [Accessed 9th Feb. 2016]. (27) The Office for National Statistics (2001). Psychiatric Morbidity Report [online]. Available at: www.mentalhealth.org.uk/help-information/ mental-health-statistics/common-mental-health- problems/. [Accessed 12th April 2016]. (28) SPICe Briefing Mental Health in Scotland [online]. Available at: www.scottish.parliament. uk/ResearchBriefingsAndFactsheets/S4/SB_14- 36.pdf. [Accessed 12th April 2016]. (29) Mental Health Foundation (2002). Adults in Later Life with Mental Health Problems, quoting Psychiatry in the Elderly, 3rd edition, Oxford University Press [online]. Available at: www. mentalhealth.org.uk/help-information/mental- health-statistics/older-people/. [Accessed 14th Sep 2015]. (30) National Statistics (2003). Better Or Worse: A longitudinal study of the mental health of adults in Great Britain [online]. Available at: www. mentalhealth.org.uk/help-information/mental- health-statistics/men-women/. [Accessed 12th April 2016]. (31) Mental Health Foundation. Statistics [online]. Available at: www.mentalhealth.org.uk/help- information/mental-health-statistics/anxiety- statistics/. [Accessed 14th Sep. 2015]. (32) Mental Health Foundation. Stigma and Discrimination [online]. Available at: www. mentalhealth.org.uk/help-information/mental- health-a-z/s/stigma-discrimination/. [Accessed 14th Sep. 2015]. (33) Naylor, C., and others (2012). Long Term Conditions and Mental Health: the cost of co- morbidities. The King’s Fund. London. (34) Scottish Government (2012). Mental Health Strategy for Scotland: 2012-2015. The Scottish Government. Edinburgh. (35) Dahlgren and Whiteheads Model. Introducing the Wider Determinants of Health [online]. Available at: www.bridgingthegap.scot.nhs.uk/ understanding-health-inequalities/introducing- the-wider-determinants-of-health.aspx. [Accessed 14th Sep. 2015]. (36) Centre for Mental Health. Recovery Publications [online]. Available at: www. centreformentalhealth.org.uk/Pages/Category/ recovery-pubs. [Accessed 9th Feb. 2016]. (37) Brown, W., and Kandirikirira, N. (2007). Recovering Mental Health in Scotland. Report on narrative investigation of mental health recovery. Scottish Recovery Network. Glasgow. (38) SAMH. Know YOUR Rights [online]. Available at: www.samh.org.uk/our-work/public-affairs/know- your-rights. [Accessed 14th Sep 2015] (39) The British Institute of Human Rights (2014). Mental Health Advocacy and Human Rights: Your guide. The British Institute of Human Rights. London. (40) The Moray Council. (2013). Moray Partners in Care: introducing the Moray community care model. The Moray Council. Elgin. 32 || Good Mental Health for All in Moray 2016-2026 Moray community Planning Partnership|| 33Page 139
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(41) Look Ahead Care and Support (2013). Mental Health Service Tiers. Look Ahead Care and Support. London. (42) Pollett, H. (2007). Mental Health Promotion: a literature review. Mental Health Promotion Working Group of the Provincial Wellness Advisory Council. Canada. (43) World Health Organisation (2005). Promoting Mental Health: concepts, emerging evidence, practice: report of the World Health Organization, Department of Mental Health and Substance Abuse in collaboration with the Victorian Health Promotion Foundation and the University of Melbourne. WHO. Denmark. (44) Young Minds (2011). Stigma a Review of the Evidence. Young Minds. London. (45) The Scottish Government (2008). Equally Well the report of the ministerial task force on health inequalities. Scottish Government. Edinburgh. (46) Friedli, L. (2009). Mental Health, Resilience and Inequalities. World Health Organisation. Denmark. (47) Time to Change (2011). Children and Young People’s Programme Development: summary of research and insights. Time to Change. London. (48) Haslett, B.,B., & Samter, W. (2015). Parent-Infant Communication. The International Encyclopaedia of Interpersonal Communication, 1-5. DOI: 10.1002/9781118540190.wbeic03. (49) Mental Health Foundation. Recovery [online]. Available at: www.mentalhealth.org.uk/a-to-z/r/ recovery. [Accessed 12th April 2016]. (50) Mental Health Foundation (2016). Relationships in the 21st Century: the forgotten foundation of mental health and wellbeing. Mental Health Foundation. London. (51) Mental Health Network NHS Confederation (2011). Managing Money and Mental Health. The NHS Confederation. London (52) Fitch, C., Hamilton, S., Basset, P., and Davey, R. (2010). Debt and Mental Health: what do we know? what should we do? Royal College of Psychiatrists. London. (53) Jahoda, M. (1981). Work, Employment and Unemployment: Values, theories and approaches in social research. American Psychologist 36: 184-191. (54) Centre for Mental Health. Employment [online]. Available at: www.centreformentalhealth.org. uk/Pages/Category/employment. [Accessed 15th Sep 2015]. (55) Alakeson, V., and Perkins, R. Implementing Recovery Through Organisational Change: Recovery, Personalisation and Personal Budgets. Centre for Mental Health. London. (56) Scottish Government (2013). Scottish Government Suicide Prevention Strategy 2013- 2016. The Scottish Government. Edinburgh. (57) McLean, J., Maxwell, M., Platt, S., Harris, F., and Jepson, R. (2008). Risk and Protective Factors for Suicide and Suicidal Behaviour: A literature review. Scottish Government Social Research. Edinburgh. (58) Mental Health Models of Care (2013). Competency Framework. NHS London. London. (59) NHS Knowledge and Skills Framework [online]. Understanding KSF Dimension. Available at: www.ksf.scot.nhs.uk/understanding-ksf- dimension. [Accessed 15th Sep. 2015]. (60) Mind (2011). Taking Care of Business: Employers guide to mentally healthy workplaces. Mind. London. 34 || Good Mental Health for All in Moray 2016-2026 Page 140
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Further involvement Would you like to be involved in helping to deliver this strategy in Moray? If so please tell us your name, how best to contact you and in what way you would you like to be involved. You can return this page to us separately if you wish your comments to remain anonymous. Your personal details will be stored securely and only used to connect you about future health and social care involvement opportunities. 34 || Good Mental Health for All in Moray 2016-2026 Moray community Planning Partnership|| 35Page 141
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D-01676 - Produced by the Moray Council for the Moray Community Planning Partnership Page 142
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APPENDIX 2 Item 9. Page 143
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Name of intervention/service Name of organisation delivering Type of intervention Coverage Target Group Factor (1st Level) NIHR Findhorn Bay Arts – In The Mix Findhorn Bay Arts – In The Mix Social activities and befriending Moray Wide Children and young people Community Step by Step in Moray Step by Step in Moray Practical help and assistance Moray Wide Children and young people Community Children and Young People Forum tsiMoray Policies, strategies, funding and networks Moray Wide Children and young people Community Avenue Avenue Counselling Moray Wide Children and young people Community Aberlour Options – Moray Aberlour Practical help and assistance Moray Wide Children and young people Community Moray Council Income maximisation team Moray Council Practical help and assistance Moray Wide Children and young people Community Moray School Bank Moray School Bank Practical help and assistance Moray Wide Children and young people Community Earthtime Earthtime Animal and green space interventions Moray Wide Children and young people Community Outfit Moray Outfit Moray Animal and green space interventions Moray Wide Children and young people Community REAP (Rural Environmental Action Project) REAP (Rural Environmental Action ProjAnimal and green space interventions Moray Wide Children and young people Community Wild Things! Wild Things! Education, training and workshops to expand skillsets Moray Wide Children and young people Community Quarriers Carers Support Service (Moray) Quarriers Practical help and assistance Moray Wide Young carers Family Who Cares? Scotland Who Cares? Scotland Signposting, information, referral, advice services Moray Wide Young carers Family Website Parent Network Scotland Signposting, information, referral, advice services Moray Wide Parents Family Scottish Centre for Conflict Resolution Resource Hub Scottish Centre for Conflict ResolutionSignposting, information, referral, advice services Scotland Wide Parents Family Loneparentline Loneparentline Signposting, information, referral, advice services Scotland Wide Parents Family Youthpoint Moray Aberlour Practical help and assistance Moray Wide Children and young people Individual Children 1st Children 1st Practical help and assistance Moray Wide Children and young people Individual Cruse Bereavement Care Cruse Bereavement Care Practical help and assistance Moray Wide Children and young people Individual Families Outside Families Outside Practical help and assistance Moray Wide Children and young people Individual Grampian Child Bereavement Network Grampian Child Bereavement Network Practical help and assistance Grampian Wide Children and young people Individual Information Moray Rape Crisis Signposting, information, referral, advice services Moray Wide TBC Individual Advocacy support Moray Rape Crisis Advocacy and legal support Moray Wide TBC Individual Longer term support Moray Rape Crisis Practical help and assistance Moray Wide TBC Individual Rise Up: Support for young people aged 11-18 Moray Rape Crisis Practical help and assistance Moray Wide Children and young people Individual Side by side: Spport for people with a learning disability or need Moray Rape Crisis Practical help and assistance Moray Wide TBC Individual Stop przemocy seksualnej Moray Rape Crisis Practical help and assistance Moray Wide TBC Individual Moray Women’s Aid Moray Women’s Aid Practical help and assistance Moray Wide Women Individual Quarriers Arrows Quarriers Practical help and assistance Moray Wide TBC Individual Barnardo’s Works Barnardos Practical help and assistance Moray Wide TBC Individual Young Minds Young Minds Signposting, information, referral, advice services Scotland Wide Children and young people Individual Anna Freud Centre Anna Freud Centre Signposting, information, referral, advice services Scotland Wide Children and young people Individual CAMHS CAMHS Signposting, information, referral, advice services Moray Wide Children and young people Individual Mood Juice Mood Juice Signposting, information, referral, advice services Scotland Wide Children and young people Individual Getselfhelp Getselfhelp Signposting, information, referral, advice services Scotland Wide Children and young people Individual Aye Mind Aye Mind Signposting, information, referral, advice services Scotland Wide Children and young people Individual Young Scot Young Scot Signposting, information, referral, advice services Scotland Wide Children and young people Individual The Mix The Mix Signposting, information, referral, advice services Scotland Wide Children and young people Individual LBGTQ Scotland LBGTQ Scotland Signposting, information, referral, advice services Scotland Wide Children and young people Individual Samaritans Samaritans Signposting, information, referral, advice services Scotland Wide Children and young people Individual Childline Childline Signposting, information, referral, advice services Scotland Wide Children and young people Individual Sleep Scotland Sleep Scotland Signposting, information, referral, advice services Scotland Wide Children and young people Individual Papyrus Papyrus Signposting, information, referral, advice services Scotland Wide Children and young people Individual Breathing Space Breathing Space Signposting, information, referral, advice services Scotland Wide Children and young people Individual Children 1st Parentline Children 1st Parentline Signposting, information, referral, advice services Scotland Wide Parents Individual Prevent Suicide App Prevent Suicide App Signposting, information, referral, advice services Moray Wide All ages Individual Home School Link Worker Moray Council Practical help and assistance Moray Wide Children and young people Individual Inclusion worker Moray Council Practical help and assistance Moray Wide Children and young people Individual Educational Psychologist Moray Council Practical help and assistance Moray Wide Children and young people Individual Social, Emotional and Behavioural Needs Service Moray Council Practical help and assistance Moray Wide Children and young people Individual The Moray Sonas Service Action for Children Practical help and assistance Moray Wide Children and young people Community Appendix 3 Item 9. 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tsi Moray tsi Moray Policies, strategies, funding and networks Moray Wide Children and young people Community Child and Adult Mental Health Service (CAMHS) NHS Grampian Practical help and assistance Moray Wide Children and young people Community Me Time GREC Practical help and assistance Moray Wide Children and young people Individual Crossreach Crossreach Practical help and assistance Moray Wide Children and young people Individual Children and Families Social Work Teams Moray Council Practical help and assistance Moray Wide Children and young people Community Parent Club Parent Club Signposting, information, referral, advice services Moray Wide Children and young people Family Stop it now! Scotland Stop it now! Scotland Practical help and assistance Scotland Wide All ages Individual Grampian Autistic Society Grampian Autistic Society Practical help and assistance Grampian Wide All ages Community James Support Group James Support Group Peer support and mentoring Scotland Wide Children and young people Community Scottish Domestic Abuse and Forced Marriage Helpline Scottish Domestic Abuse and Forced MPractical help and assistance Scotland Wide Children and families Individual Scottish families affected by alcohol and drugs Helpline Scottish families affected by alcohol aPractical help and assistance Scotland Wide Children and families Individual Living life to the full Moray Wellbeing Hub Education, training and workshops for mental health awareMoray Wide Adults Community Living life Living life Psychological therapy Moray Wide Adults Community Breathing Space Breathing Space Practical help and assistance Scotland Wide Adults Community NHS 24 NHS 24 Practical help and assistance Scotland Wide Adults Community NHS Inform NHS Inform Signposting, information, referral, advice services Scotland Wide Adults Community The Samaritans The Samaritans Practical help and assistance Scotland Wide Adults Community Psychological therapies Health and Social Care Moray Psychological therapy Moray Wide Adults Community Community mental health team (CMHT) Health and Social Care Moray Practical help and assistance Moray Wide Adults Community Circles Advocacy Circles Advocacy and legal support Moray Wide Adults Community Moray Wellbeing Hub Moray Wellbeing Hub Peer support and mentoring Moray Wide Adults Community Moray Wellness College Moray Wellbeing Hub Education, training and workshops for mental health awareMoray Wide Adults Community tsi Moray tsi Moray Policies, strategies, funding and networks Moray Wide Adults Community The Moray Arts Centre The Moray Arts Centre Education, training and workshops to expand skillsets Moray Wide Adults Community North East Suicide Prevention SAMH Education, training and workshops for mental health awareGrampian Wide All ages Community Mental Health and Wellbeing Practitioners Health and Social Care Moray Signposting, information, referral, advice services Moray Wide Adults Community Page 146
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Cateogory Description Name of intervention/service As described Name of organisation delivering As described Type of intervention Brief description of intervention/service Coverage Where this can be accessed in Moray Target group Age range covered by intervention/service Prevention level Level of prevention: Primary (population level); Secondary (early intervention); and/or Tertiary (staying well) Factor (1st Level) NIHR See IJB paper for more detail Factor (2nd Level) NIHR See IJB paper for more detail Funding Source Who funds the intervention/service Cost How much the intervention/service costs Level of useage How many people use the intervention/service Sustainability How sustainable the service is Any other relevant information? As described Appendix 3a Item 9. Page 147
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REPORT TO: MORAY INTEGRATION JOINT BOARD ON 28 MARCH 2024 SUBJECT: GENERAL PRACTICE VISION AND OBJECTIVES BY: PROGRAMME MANAGER, GP VISION PROGRAMME 1. REASON FOR REPORT 1.1 To inform the Board of the outcomes and recommendations of the NHS Grampian GP Vision Programme, and seek endorsement of the vision and Specific, Measurable, Attainable, Realistic, Time-Bound (SMART) objectives related to this programme. 2. RECOMMENDATION 2.1 It is recommended that the Board: i) approves the vision and objectives for General Practice in Grampian as set out in Appendix A; and ii) instructs the Chief Officer to report back to the MIJB by end of March 2025 with a progress update on the implementation of the vision and objectives. 3. BACKGROUND Health and Social Care Partnership (HSCP) Chief Officer Objective 3.1 The three HSCP Chief Officers held a shared objective for 2023/24 to design and create a delivery plan for a Grampian Primary Care Strategy. This was in response to the challenging implementation of the 2018 General Medical Services (GMS) contract. There are a number of relevant factors, many of which are particularly relevant to Moray and Grampian. These include challenges around recruitment and retention, the application of multi- disciplinary teams across a wide and rural geography resulting in teams being spread too thinly, and a large region with diverse populations, communities and needs. All of which have an impact on the sustainability of general practice and the ability for General Practice to play a key role in preventing ill health in our communities. 3.2 General Practice became the focus of the project due to the particular acute challenges faced by General Practice with primary care providers acting as key Item 10. Page 149
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stakeholders in the process of determining the vision and associated objectives. 3.3 As a programme we are aware of the cost pressure relating to primary care prescribing and savings plan for 2024/25. Having sustainable general practices in the medium to longer term will facilitate continuity of patient care which will contribute to medication reviews and effective prescribing. 4. KEY MATTERS RELEVANT TO RECOMMENDATION Programme Summary 4.1 A Programme Initiation Document was developed which set out three aims: • a shared vision for General Practice across Grampian; • identification of the challenges to achieving that vision; and • a set of strategic objectives to address those challenges in order to realise the vision. 4.2 In July 2023, a programme board was set up for the General Practice Vision Programme, which includes representation from NHS Grampian, the Health and Social Care Partnerships (HSCP’s), General Practice Sub Committee (GP Sub) and the Local Medical Committee (LMC). 4.3 A series of facilitated workshop sessions were organised to develop the vision and strategic objectives. The first workshop was for General Practice staff (166 attendees). The second and third workshops included wider stakeholders such as other primary care services (pharmacy, dental, ophthalmology), acute and secondary care representation, patient representation, and Scottish Government representation (208 and 209 attendees respectively). These were held on: - Wednesday 27 September 2023; - Wednesday 8 November 2023; and - Wednesday 22 November 2023. General Practice Engagement 4.4 A Service Level Agreement (SLA) between NHS Grampian and practices was agreed to ensure appropriate practice staff were able to engage in and co- design the development of a strategic direction and vision of General Practice across Grampian. Patient Engagement 4.5 A patient engagement plan was developed to ensure that a co-production approach was used, and patients from across the Grampian were involved in the development of the vision and strategic objectives. 4.6 A wider patient engagement survey has been circulated via multiple sources including; Locality Empowerment Groups (LEG); Patient Participation Groups (PPG’s); Social Media and GP practices. A total of 1293 responses were submitted. 4.7 A patient stakeholder group to attend the facilitated stakeholder was created. The aim was to have a cross section of patients from across various Page 150
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communities and age ranges. There were around 25 members of the public on this group from across the Grampian areas. 4.8 The patient stakeholder group attended the facilitated events on 8 and 22 November. There were a total on 24 and 22 patient’s representatives at the two workshops respectively. 4.9 Feedback from the patient participation group was overall positive. The themes from the patient feedback was that there was a good mix of roles on the table, the sessions were interactive and there was time for good discussions. Young Persons Engagement 4.10 Output of the patient survey showed that there was limited input from young people age 16 – 34. Therefore the programme planned and completed further work to reach out to this age range. This included a series of focus groups with senior high school pupils, engagement with university and college students. 4.11 Focus groups at 4 high schools were arranged to ascertain views of the younger generation in relation to ‘what matters to them’ in general practice. In addition to this a drop in session at Aberdeen University was arranged to engage with students. A survey was also shared via QR code to allow for further views to be sought at these sessions. Further Stakeholder Engagement 4.12 NHS Grampian Groups - Presentations were given to various groups across the , this includes the NHS Grampian Clinical , NHS Grampian Pharmacotherapy Group and the Clinical Interface group to provide an overview of progress to date and emerging key themes. Please see Appendix D. 4.13 MP / MSP briefing - a presentation was given to the NHS Grampian MP / MSP Briefing group, including what the current strengths and challenges are, what the summary output from the facilitated sessions was and what local and national action and support is required. GP Vision and Objectives 4.14 In response to current sustainability challenges and evolving needs within the NHS Grampian area, we have articulated a new vision statement and strategic objectives that capture the changes required to move towards a more sustainable general practice sector within the area. 4.15 The proposed Vision Statement, ‘A sustainable General Practice across Grampian which enables people in their communities to stay well through the prevention and treatment of ill health’, encapsulates a commitment to fostering health and well-being within our communities. It signifies a commitment to providing comprehensive and accessible healthcare services that not only address illness but also promote preventive care and empower individuals to lead healthier lives. 4.16 The Vision is underpinned by 10 Key themes (Appendix C) that were highlighted during the stakeholder engagement programme as a problem or challenge to achieving the Vision. Page 151
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4.17 An initial objective has been identified against each of the key themes. Table 1 outlines the 10 Objectives. Table 1 THEME OBJECTIVES Data Through the Grampian Data Gathering Group, develop a programme of work to: • identify and define necessary data sets; • create data gathering processes which enables consistent and consolidated data to be collected across General Practice in a standardised way; and • develop data sharing arrangements with relevant partners where necessary. Models of Contract Develop a flexible approach to the delivery of the existing GMS contract, using currently available levers, following consultation with relevant stakeholders, including: • NHSG Primary care and Contracts representatives; • General Practices; • Scottish Government; • Scottish General Practitioners Committee (SGPC); • Local Medical Committee; • Advisory Committees to the Health Board; and • other relevant stakeholders. Keeping the population well Develop, in consultation with community planning partners, a programme to deliver targeted and comprehensive health interventions for at risk communities to offer proactive preventative care and empower communities to participate in their own healthcare and wellbeing. Digital Support the development of a regional Grampian Digital plan, which includes General Practice. This will help to develop a coherent approach to the development of a prioritised set of digital solutions to ensure the wider system is best placed to meet the needs of communities within available resource. Pathways Review pathways to explore the opportunities, risks and challenges to these pathways. A priority-based implementation plan will be created to improve these pathways. It is anticipated that the plan will include a solution to empower service users to track progress of their situation across the pathways and offer help and advice while on the pathway. This will promote effective communication, collaboration and coordination, ensuring staff and patients are well informed about the pathways. Multi- Disciplinary Team Initiate and complete an evaluation and review of PCIP services that are in place across NHS Grampian. Where best practice is identified, learn from this, and facilitate its rollout to other areas if appropriate. Continuity of Care Create pathways that achieve continuity of care for those who will benefit most from continuity of care. In the context of flexible models of contract, identifying areas that can be used for a test of change to support practices to improved models to support meeting complex care. Premises Via the Primary Care Premises Group, each HSCP, in consultation with practices and relevant partners, will develop an estate plan to meet the needs of our communities. Regard will be had to buildings (where required) being well-equipped, accessible, patient- centred, conducive to partnership working, integrated with advanced and standardised technologies, and in the right place to meet the needs of the communities. Mental Health & Wellbeing • Improve mental health and wellbeing support for schools / young people; making use to technology formerly adoption and engagement • encourage better wellbeing across patient groups through, for example, supporting social prescribing and realistic medicine where appropriate; and • Identify improvements that will help ensure patients see the most appropriate person the first time to minimise delays in appropriate treatment. Page 152
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Recruitment Retention & Education Develop and implement comprehensive training initiatives that will inspire individuals to enter careers in General Practice and wider MDT and administrative Roles to encourage the retention of talent in Grampian. Future colleagues will have the knowledge and technical and digital skills necessary to meet the vision for General Practice in Grampian. This objective will be delivered in consultation with relevant stakeholders, including: • local authorities; • colleges; • universities; • NHS Education for Scotland (NES); and • Royal College of General Practitioners (RCGP). Contribution to other National and Local Priorities 4.18 The new vision for General Practice will contribute to both local, regional and national initiatives including: • The National Health and Wellbeing Outcomes; • NHS Grampian Vision, Values and Strategic Themes; • Aberdeen City, Aberdeenshire and Moray HSCPs; and • Local Outcome Improvement Plans across Grampian. Delivery Plan 4.19 It is anticipated that implementation of the vision and objectives will be delivered via the creation of a new programme board which in turn will be supported by project sub groups. Monitoring and evaluation of the programme delivery will be through the programme board structure with annual updates to the three integration joint boards anticipated. This would include updates against, for example, progress against the objectives, the development of new objectives to support the delivery of the vision, and the impact of the objectives as they are delivered. Moray HSCP’s contribution to the delivery of the vision will be outlined in future iterations of its Strategic Plan and associated Strategic Delivery Plan. 4.20 Key Metrics have been identified to determine if the programme has had a positive impact on the sustainability of general practice within Grampian. These include: • Number of 2C practices within Grampian • % of total 2C practices within NHS Grampian • Number of GPs / GP head count • Full Time Equivalent of GPs • GP headcount by designation • Practice list size • Average number of patients per GP • Inpatient waiting list size • Outpatient waiting list size • ED attendance rates • Emergency admission rates • General Practice Alert System (GPAS) • Grampian Operational Pressure Escalation System (GOPES) • Number of GP List closures • % of List Closures • Practices Managing List Informally • % of practices Managing List Informally • Number of contracts returned • % of contracts returned • British Medical Association staff survey Page 153
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Next Steps Lessons Learned 4.21 A lessons learned process will be carried out post consideration of the new General Practice Vision and Objectives. The lessons learned process is crucial for continuous improvement in the development and optimisation of future projects. Project Closure 4.22 Following on from the IJB meetings in March 2024, the programme in its current state will commence the project closure process to ensure that all aspects of the project are completed, documented, and handed over appropriately into the delivery phase. 4.23 As the programme of work moves forward, we are fully committed to realising the vision and objectives outlined, with confidence in the ability to drive positive change and enhance General Practice within NHS Grampian, fostering a renewed sense of purpose and determination among all stakeholders involved. 4.24 A focus will be placed on balancing financial pressures, clinical governance, patient safety and staff governance with a spotlight on prevention and services to some of the most deprived communities. 4.25 This programme of work provides the foundations of which the next steps of true aspirational transformational change can flourish from. It will enable partners across all sectors to be able to collectively identity the future model of what is ‘the possible’ and work towards implementation to create long term sustainability of general practice services for residents of Grampian. 4.26 Deep appreciation is extended to all stakeholders for their vital contributions, commitment, and ongoing support in our collective pursuit of enhancing patient- centred care and improving health outcomes across the community and look forward to working with those with the vision for ‘the possible’. 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” Moray HSCP vision is: ‘We come together as equal and valued partners in care to achieve the best health and wellbeing possible for everyone in Moray throughout their lives’. This is underpinned by three strategic priorities, the vision and objectives will support the delivery of these as shown in the below table. Moray HSCP Strategic Priorities Moray council LOIP NHSG GP Vision Objectives Improve the health and wellbeing of the population (Better Health) Building a better future for our children and young people in Moray. Improving wellbeing of our population ✓ Data ✓ Pathways ✓ Keeping the Population well ✓ Models of Contract ✓ MDT ✓ Mental Health & Wellbeing Page 154
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✓ Continuity of Care ✓ Digital Improve the quality of care people receive (better Care Empowering and connecting communities ✓ Data ✓ Digital ✓ Models of Contract ✓ MDT ✓ Mental Health & Wellbeing ✓ Continuity of Care ✓ Premises Improve the efficient of health and social care services to ensure we spend public money on services that get good outcomes for people (better value) Developing a diverse, inclusive and sustainable economy ✓ Data ✓ Models of Contract ✓ MDT ✓ Mental health & Wellbeing ✓ Continuity of care ✓ Premises ✓ Digital (b) Policy and Legal There are no direct policy or legal implications arising from the recommendations of this report. (c) Financial implications There are no direct financial implications arising from the recommendations of this report. (d) Risk Implications and Mitigation Category Description Mitigation RAG Status Sustainability There is a risk that if the project is not delivered, General Practice within Grampian will continue on an unsustainable basis. This will further exacerbate the challenges outlined above. As the first point of access to healthcare for 90% of the population General Practice delivers early intervention and preventative measures for the whole system and therefore the consequences will not be limited to GP services. Failure to deliver the project will increase the prospect of further increasing demand on secondary care services, unscheduled and urgent care (including PC & OOH), a reduction in NHS performance and poorer The development of a project to deliver a shared vision and strategic objectives for General Practice in Grampian. Adequate funding support from the Scottish Government to build the necessary capacity to deliver this project (which is preventative in nature) to March 2024 and anticipated support to deliver the implementation plan beyond March 2024. Working with public health colleagues to Amber Page 155
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outcomes for Grampian’s residents across the health and social care system. ensure preventative focus of workstreams and focus interventions on need. Resource The programme is required to be approved and then delivered within existing resources, therefore there is a risk that the programme is not delivered due to the financial pressures across Grampian and other competing priorities. Continued highlighting of concerns and engagement with all stakeholders to understand the importance and risks of not undertaking this project Consideration of current priorities and workforce that could be realigned to deliver some or all of the programme. As well as phasing of timelines to make workloads manageable. High Engagement – Public Reputational risk due to the potential service changes being disliked by the public Potential increased complaint due to changes to services There are also risks if changes are not made around patient expectations and experience – waiting times etc. Patient representatives as part of the Programme governance structure moving forward for co-design and engagement Patient stakeholder engagement – working with communications teams, partner agencies, and social media to make sure messages made on an ongoing basis Working with LEGS and working with elected members and community councils to increase understanding for the case to change. Amber Engagement – Workforce Risk that key stakeholder does not have the capacity Continued highlighting of High Page 156
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and therefore loose interest in implementation of priorities No dedicated resource to release General Practice to implement within an already pressured system Reputational risks with General Practice if programme not implemented concerns and engagement with all stakeholders to understand the importance and risks of not undertaking this project Consideration of current priorities and workforce that could be realigned to deliver some or all of the programme. As well as phasing of timelines to make workloads manageable. (e) Staffing Implications There are no direct staffing implications arising from the recommendations of this report. (f) Property There are no direct property implications arising from the recommendations of this report. (g) Equalities/Socio Economic Impact An Equalities Impact Assessment (EQIA) has been carried out as part of the development of the proposals set out above. It is included as Appendix B and no impact has been identified at this time. As described in the EQIA Checklist Any workstreams agreed by the IJBs and Scottish Government will ensure an EQIA specific to those workstreams will be completed. (h) Climate Change and Biodiversity Impacts There are no direct climate change or biodiversity implications arising from the recommendations of this report. (i) Directions None arising from this report. (j) Consultations For Health and Social Care Moray the Deputy Chief Officer, Clinical Leads and Locality Managers have been consulted, as well as Caroline O’Connor, Committee Services Officer, Moray Council, and their comments are incorporated in the report. Page 157
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6. CONCLUSION 6.1 The MIJB are recommended to approve the vision and objectives for General Practice in Grampian set out within the document and relevant appendices. Author of Report: Ali Chapman, Programme Manager Background Papers: Appendix A: General Practice Vision report Appendix B: Equalities Impact Assessment Appendix C: General Practice Vision One Page Summary Ref: Page 158
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General Practice Vision 2024-2030 A sustainable General Practice across Grampian which enables people in their communities to stay well through the prevention and treatment of ill health APPENDIX A Item 10. Page 159
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NHS Grampian: General Practice Vision 2 | P a g e Contents: EXECUTIVE SUMMARY ............................................................................................ 1 2 INTRODUCTION ................................................................................................. 4 3 OVERVIEW & BACKGROUND ........................................................................... 5 3.1 Current Status General Practice within NHS Grampian ........................... 5 3.2 Aims & Objectives ....................................................................................... 5 3.3 General Practice Vision Programme Methodology .................................. 6 4 NEW GP VISION AND OBJECTIVES ................................................................16 4.1 Introducing the new Vision and Objectives ...................................................16 4.2 Overview of the vision statement ..................................................................16 4.3 Overview of the Objectives ...........................................................................18 4.4 How does the vision fit with other Local, Regional and National Priorities ....22 4.5 Delivery ........................................................................................................29 4.6 Monitoring and Evaluation ............................................................................29 4.7 Implementation Risks ...................................................................................31 5 NEXT STEPS ......................................................................................................33 5.1 Establish Governance Structures .................................................................33 5.2 Release Resources ......................................................................................33 5.3 Create and action an Implementation Plan ...................................................33 5.4 Lessons learned ...........................................................................................33 5.5 Project closure ..............................................................................................34 6 CONCLUSION ....................................................................................................35 APPENDIX 1: GLOSSARY .......................................................................................37 Page 160
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NHS Grampian: General Practice Vision 1 | P a g e EXECUTIVE SUMMARY 1.1.1 Introduction In response to the evolving significant sustainability challenges within General Practice in Grampian, this report was commissioned to outline a new vision and strategic objectives that will guide our future direction This report aims to synthesise insights gathered from the broad stakeholder engagement, identify key challenges and opportunities facing General Practice, and articulate a clear vision and strategic objectives to guide us moving forward. 1.1.2 Approach A programme management approach was used to set up the project. This included the following stages: Project Initiation - This stage included: defining the project scope, objectives, and deliverables; and creation of a Programme Board. Planning - this stage included creating programme documentation such as a project plan and risk register; conducting stakeholder analysis and planning stakeholder engagement, organisation of facilitated workshops. Planning stakeholder included • Creating a Service Level Agreement (SLA) for GP practices to ensure capacity within General Practice to participate fully in the programme • Developing a patient engagement plan to ensure that a co-production approach was used. The patient engagement plan included actions to: - Develop and execute a Public Engagement Survey to ascertain views from the general public - Create a Patient Stakeholder group to represent the wider general public at the stakeholder events Execution - A series of facilitated workshop sessions were carried out to develop the vision and strategic objectives. The first workshop was for General Practice staff (166 attendees) whilst the second and third included wider stakeholders such as other primary care services (pharmacy, dental, ophthalmology), acute and secondary care representation; patient representation and Scottish Government representation (208 and 209 attendees respectively). These were held on: - Wednesday 27th September - Wednesday 8th November - Wednesday 22nd November Stakeholder engagement • Public engagement survey - To understand the views of the general public on what is important to them in General Practice. This was live from 10th - 30th October 2023. • Patient stakeholder workshop - To give an understanding of what General Practice and the Primary Care Improvement plan is, and to outline the current challenges in General Practice. The workshop also provided the Page 161
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NHS Grampian: General Practice Vision 2 | P a g e group with an understanding of views across NHS Grampian that were represented at the in person facilitated events • Young person’s engagement – this included pupil focus groups at secondary schools and drop in session at Aberdeen University to ascertain views of the younger generation in relation to ‘what matters to them’ in General Practice • Further stakeholder engagement - this included an MP / MSP briefing as well as various presentations to key stakeholder groups 1.1.3 Vision Statement & Objectives A Vision Statement has been created which captures the changes required to move towards a more sustainable General Practice sector within the area. A sustainable General Practice across Grampian which enables people in their communities to stay well through the prevention and treatment of ill health. Key themes The key themes and challenges that were identified throughout the facilitated workshop process and stakeholder analysis were consolidated. Key themes identified throughout the process were identified in response to reasons for change. An objective has been created in relation to each of these: - Data - Models of contract - Keeping the population well - Digital - Pathways - Multi-Disciplinary Team - Continuity of care - Premises - Mental health & wellbeing - Recruitment, Retention & Education The new vision for General Practice contributes to local, regional and national initiatives including: The National Health and wellbeing outcomes; NHS Grampian Vision, Values and Strategic Themes; Aberdeen City, Aberdeenshire and Moray HSCPs Vision and Priorities; and Local Outcome Improvement Plans across Grampian. Page 162
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NHS Grampian: General Practice Vision 3 | P a g e 1.1.4 Next Steps It is suggested that the following high-level actions are progressed to work towards the realisation of the outlined vision and objectives. • Establish Governance Structures • Allocate Resources • Create and action an Implementation Plan Monitoring and evaluation of the programme delivery will be through the programme board structure with annual updates to the three integration joint boards anticipated. This would include updates against, for example, progress against the objectives, the development of new objectives to support the delivery of the vision, and the impact of the objectives as they are delivered. A lessons learned process will be carried out post consideration of the new General Practice Vision and Objectives. The lessons learned process is crucial for continuous improvement in the development and optimisation of future projects. Following on from the IJB meetings in March 2024. The programme in its current state will commence the project closure process to ensure that all aspects of the project are completed, documented, and handed over appropriately into the delivery phase. 1.1.5 Conclusion After engaging in extensive stakeholder consultation, we have successfully shaped a new vision and set of strategic objectives that reflect the collective aspirations and insights of our diverse stakeholders. We emphasise the pivotal role of the newly outlined vision and strategic objectives in advancing the quality and accessibility of General Practice services within NHS Grampian. Page 163
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NHS Grampian: General Practice Vision 4 | P a g e 2 INTRODUCTION 2.1.1 In response to the growing sustainability challenges within General Practice in Grampian, this report was commissioned to outline a new vision and strategic objectives that will guide our future direction. There are ongoing recruitment and retention issues, as well as GP practices steadily having handed back their contracts, there is a need for innovative approaches to address the changing needs of our patients. 2.1.2 This report aims to synthesise insights gathered from the broad stakeholder engagement, identify key challenges and opportunities facing General Practice, and articulate a clear vision and strategic objectives to guide us moving forward. 2.1.3 The outcomes of this work will have far-reaching implications for General Practice, the wider NHS System and patients. From enhancing the quality and accessibility of General Practice services to driving innovation and efficiency in services, the vision and objectives outlined in this report will shape the future or General Practice and the impact on the communities we serve. 2.1.4 This report outlines an analysis of the current landscape, highlighting key challenges and opportunities that have been identified through stakeholder consultation. The report sets out the new vision and strategic objectives, followed by the next steps required and considerations for monitoring and evaluation. Page 164
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NHS Grampian: General Practice Vision 5 | P a g e 3 OVERVIEW & BACKGROUND 3.1 Current Status General Practice within NHS Grampian In Grampian, the delivery of the 2018 General Medical Services (GMS) contract and the Memorandum of Understanding (MoU) has been challenging. This is due to a number of factors, including, recruitment and retention, the application of multi-disciplinary teams across a wide and rural geography resulting in teams being spread too thinly, and a large region with diverse populations, communities and needs. Whilst the number of practices and General Practitioners (GP’s) has reduced in number during the last ten years, the list size per GP has increased. General Practices in Grampian also share national pressures including: High patient expectations; Newly qualifying GP’s not wishing to commit to the traditional partnership model; A decreasing gap in earnings between partner and salaried GP’s; Restrictions around the work that locums can do; Increased premises and energy costs; liability for premises which are not conducive to a modern practice and which exist in a poor commercial property market impacted by the oil & gas downturn and the lasting impact of Covid-19 restrictions; and Agenda for Change uplift to NHS staff not been mirrored in the uplift to staff within General Practice. The three HSCP Chief Officers held a shared objective for 23/24 to design and create a delivery plan for a Grampian Primary Care Strategy. This was in response to the challenging implementation of the 2018 General Medical Services (GMS) contract. There are a number of relevant factors, many of which are particularly relevant to Aberdeen and Grampian. This includes challenges around recruitment and retention, the application of multi-disciplinary teams across a wide and rural geography resulting in teams being spread too thinly, and a large region with diverse populations, communities and needs. All of which have an impact on the sustainability of general practice and the ability for General Practice to play a key role in preventing ill health in our communities. 3.2 Aims & Objectives The aim was to develop a local vision with strategic objectives and an associated implementation plan to address the above challenges with a view to creating a more resilient and sustainable sector. It is anticipated that these preventative measures will contribute to the resilience and sustainability of the wider health and social care system in Grampian. Page 165
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NHS Grampian: General Practice Vision 6 | P a g e A Programme Initiation Document was developed and it set out three aims: a shared vision for General Practice across Grampian; identification of the challenges to achieving that vision; and a set of strategic objectives to address those challenges in order to realise the vision. Beyond April 2024, it is anticipated that an implementation plan will be developed. This will consist of the actions necessary to deliver the objectives which in turn will help deliver the vision. The focus on this is specifically around General Practice and not the wider Primary care, this was due to particular challenges being faced by General Practice, difficulties meeting GMS contract and other challenges. However, key primary care providers have been key stakeholders in the process of determining the vision and associated objectives. 3.3 General Practice Vision Programme Methodology A programme management approach was used to set up the project. This included the following stages which will be outlines in further detail below: Project Initiation Planning Execution Next Steps 3.3.1 Project Initiation This stage included: defining the project scope, objectives, and deliverables. In the initiation stage there was the creation of a Programme Board which consists of Senior Responsible officers (SRO’s) from each Health and Social Care Partnership (HSCP), clinical and Primary care representation from each HSCP, NHS Grampian Primary care, Primary care Contracts (PCCT), Local Medical Committee and GP Sub Committee, NHSG Transformation team and GMED are represented. The role of the Programme Board was to ensure the required resources were available, ensuring timely progress on actions and overseeing the development and review of the project documents such as the project plan, risk register and communications plan, the Programme Board had responsibility to oversee the development of the shared vision for primary care and to prepare recommendations for the three Integrated Joint Boards (IJBs) and NHS Board. 3.3.2 Planning The planning stage included creating programme documentation such as a project plan and risk register; conducting stakeholder analysis and planning stakeholder engagement, organisation of facilitated workshops (including content). Page 166
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NHS Grampian: General Practice Vision 7 | P a g e 3.3.2.1 Stakeholder Analysis and Engagement There were a number of key audiences, with vested interests in the project, which required to be communicated and engaged with throughout the progress of the project. A Stakeholder Communications Plan was created which highlighted: the key audiences, their stake in the programme, what messages were required for each audience and the channel they would be engaged through. 3.3.2.2 General Practice Engagement A Service Level Agreement (SLA) between NHS Grampian and GP practices to ensure appropriate practice staff engagement in this programme was implemented. The SLA aimed to ensure participation in events to help set the strategic direction and vision of General Practice across NHS Grampian. The practices were expected to supply a nominated practice lead for the NHS Grampian Vision; with participation at a minimum of two out of three workshops unless extenuating pre-agreed circumstances; as well as holding local meetings to discuss the vision, i.e. at cluster meetings. 3.3.2.3 Patient Engagement A Patient engagement plan was developed to ensure that a co-production approach was used, and patients from across the Grampian were involved in the development of the vision and strategic objectives. By adopting a co- production approach, it was ensured that decisions affecting people are made with them, not for them. The patient engagement plan followed the National Standards for Community Engagement. The engagement cycle detailed below is underpinned by principles of the National Standards for Community Engagement, this was followed in to demonstrate good practice. Each stage was important and applied proportionately. Engagement Cycle Identify the issue Identify stakeholders Plan engagement Engage people potentially affected Evaluation Feedback and decision making Page 167
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NHS Grampian: General Practice Vision 8 | P a g e The patient engagement plan included: Public engagement Survey A wider patient engagement survey was circulated via multiple sources including; Locality Empowerment Groups; Patient Participation Groups (PPG’s); Social Media and GP practices. A total of 1293 responses were submitted. Patient Stakeholder Group A patient stakeholder group was created. The aim was to have a cross section of patients from across various communities and age ranges, and ensure a co- production approach. Existing networks were used to identify individuals to take part. This included: - PPG’s - IJB Membership (i.e. patient representative) - Public Involvement Team - Locality Empowerment Group / Community Planning Groups - Grampian Regional Equality Council (GREC) - Carers Representatives - Patient survey There were around 25 members of the public on this group from across the Grampian area. This group met on 1st of November 2023 for a facilitated workshop session. The aim of this was to: Provide an understanding about what General Practice is, the current challenges, an overview the Primary Care Improvement Plan (PCIP) programme and the General Practice Vision Programme. Reviewing the survey results from the public survey to determine the key outputs Provide the group with an understanding of views across NHS Grampian that can be represented at the in person facilitated events. The patient stakeholder group attended the facilitated events on 8th and 22nd November. There were a total on 24 and 22 patient representatives at the two workshops respectively. Feedback from the patient participation group was overall positive. The themes from the patient feedback was that there was a good mix of roles on the table, the sessions were interactive and there was time for valuable discussions. 3.3.3 Execution Within the execution stage all the planned activities were carried out, and the project deliverables produced. There were fortnightly Programme Board meetings as well as weekly working group meetings to ensure progress of the action plan. The group identified any key risks arising and progressed stakeholder engagement. During this phase there were 3 workshops, along with a patient stakeholder group workshop as detailed below: Page 168
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NHS Grampian: General Practice Vision 9 | P a g e 3.3.3.1 Workshop 1 Closed space for General Practice to celebrate what is going well from their perspective and to explore the challenges being faced 3.3.3.2 Public engagement Survey A wider patient engagement survey was circulated via multiple sources including; Locality Empowerment Groups (LEG); Patient Participation Groups (PPG’s); Social Media and GP practices. A total of 1293 responses were submitted. 3.3.3.3 Patient Stakeholder Workshop Provided the patient group with the current challenges in General Practice. Provided the group with an understanding of views across NHS Grampian that were then represented at the in person facilitated events. 3.3.3.4 Workshop 2 Workshop 2 brought together a larger group of stakeholders including wider primary care, Secondary Care, Scottish Ambulance Service, patients and third sector. To allow all stakeholders to reach agreement on the baseline and consolidate the information from workshop 1 and move towards defining the vision of General Practice. 3.3.3.5 Workshop 3 The purpose of this workshop was to begin to define a vision and strategic objectives in relation to themes identified at workshop 2: Pathways Data Models of contract Premises Keeping the population well IT & Technology Multi-Disciplinary Team Mental health Education Continuity 3.3.3.6 Young Persons Engagement Outputs of the Patient survey showed that there was limited input from young people, 16 – 34. Therefore, the programme included work to reach this age range, which included focus groups with senior high school pupils, engagement with university and college students. Page 169
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NHS Grampian: General Practice Vision 10 | P a g e Focus groups at 4 high schools were arranged to ascertain views of the younger generation in relation to ‘what matters to them’ in General Practice In addition to this a drop in session at Aberdeen university was arrange to engage with students. A survey at these was also shared via QR code to allow for further views to be sought. 3.3.3.7 Further Stakeholder Engagement NHS Grampian Groups - Presentations were given to various groups across the system to provide an overview of progress to date and emerging key themes. This included the NHS Grampian Clinical Board NHS Grampian Pharmacotherapy Group and the Clinical Interface group MP / MSP briefing - a presentation was given to the NHS Grampian MSP / MP Briefing group, including what the current strengths and challenges are, what the summary output from the facilitated sessions was and what local and national action and support is required. Aberdeen City HSCP Locality Empowerment groups – a presentation was given to each of the three Locality Empowerment groups to provide an overview of where this work came from, the approach taken and key emerging themes. 3.3.3.8 Workshop 4 Vision Statement and Objectives Development – this was a smaller workshop with the Programme Board. 3.3.3.9 Facilitated Workshop sessions Summary Table 1: Execution Stage Summary provides a summary overview of the objectives, content and approach as well as they key themes for each of the workshops. The table also includes the various stakeholder engagement, approach and key themes from this engagement. Page 170
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NHS Grampian: General Practice Vision 11 | P a g e 3.3.4 Table 1: Execution Stage Summary Details Key Themes / Output Workshop 1 27th September 2023 Thainstone House, Inverurie Objective of Workshop One: This workshop was designed to provide a closed space for General Practice to celebrate what is going well from their perspective and to explore the challenges being faced. Participants were provided with a variety of information in advance to aid discussions. Content and Approach With guidance from the Organisational Development Department of Aberdeen City HSCP the Working Group planned a session, endorsed by the Programme Board, which guided participants in facilitated tables of 8-10 through five activities. Facilitators were identified from the delegates with known skill set in facilitating discussions. The main themes discussed were: Workload – increased aging population with comorbidities leading to higher complex demand and long waiting times for Secondary Care leading to increased demand from patients while they wait. Premises – Insufficient space and aging infrastructure that is non-compliant with new build regulations for healthcare. IT – Aging infrastructure that slows down the pace at which GP’s can work and does not interface between systems such as with Secondary Care. Workforce – Numerous aspects: - recruitment and retention of GP’s - desire for MDT working – especially increased mental health practitioners in General Practice - variation in remuneration of practice staff and HSCP staff doing the same or similar roles leading to recruitment and retention difficulties Service Models – Numerous aspects: - Dissatisfaction with elements of PCIP in some areas such as provision of vaccination and efficacy and efficiency of Hub and Community Treatment and Care (CTAC) model - Non-consensus around suggestion of implementing an alternative service model for urgent care (of which there are various models such as top up services when practices reach saturation, hubs like GMED but in hours) - Practice contract types Key themes for a vision are: General Practice to be funded appropriately - primary care led NHS Options for Models of care and an appropriate and flexible MDT with a mix of skills and clear roles A patient centred approach with consistency of services across the area. Effective IT systems, electronic prescribing and data Education and defined career structure for GP’s Purpose built premises that are funded and fit for purpose A health aware population that are educated and understand the expectations of what General Practice is and what it is not. Effective signposting for patients so they can understand the right place, right time, right person. Collaborative, cross system working with clear pathways - sharing of staff Services embedded within the community, making use of community networks - community hubs Page 171
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NHS Grampian: General Practice Vision 12 | P a g e Details Key Themes / Output Patient Engagement Survey Live: 16th - 30th October 2023 Objective To understand the views of the general public on what is important to them in General Practice To recruit members to the Patient Stakeholder Group Content & Approach Microsoft forms survey with questions around: What’s important; What works wells; What could be improved and how we help people to understand they have a responsibility to keep themselves fit and well The survey was shared via various methods including: internally to staff, to GP Practices (including printable version) NHS Grampian daily brief, social media, and via existing networks (eg Patent Participation Groups and Locality Empowerment Groups). 1300 Responses from across Grampian The most important things in General Practice were: Being seen by the right person first time , Contact my practice with ease ; Being listened to ; Able to access same day/emergency appointments and Book an appointment in advance The key themes that worked well in General Practice were: Reception staff being helpful and supportive Triaging of appointment and the ability to have an on the day appointment Prompt responses e-Consult being a positive in some practices Being able to see the GP that have asked for Good decision making by the GP Having continuity of care, being able to see the same doctors Being listened to Key themes around what can be improved in General Practice: Getting through on the phone lines, and being able to make an appointment Not being listened to Not being able to access face to face appointment e-Consult no longer being used in some practices Need for more staff and more appointments Dissatisfaction around telling receptionist reason for appointment Unclear role of Reception Staff in relation to care navigation vs triaging Key themes around how we help people to understand they have a responsibility to keep themselves fit and well: Education – including in schools Media campaign, TV adverts Social media Signposting to appropriate services Self help Social Prescribing Annual health MOT Page 172
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NHS Grampian: General Practice Vision 13 | P a g e Details Key Themes / Output Patient Engagement Workshop 01 November 2023 Microsoft Teams Objective of Patient Stakeholder Group Workshop: The workshop provided the group with an understanding of what General Practice and the Primary Care Improvement Plan is, and outlined the current challenges in General Practice. The workshop also provided the group with an understanding of views across NHS Grampian that were then represented at the in person facilitated events Content and Approach: Provided an overview on above points Discussion and questions on content A post workshop survey showed that participants felt that: They received a clearer understanding of the GP landscape There were opportunities to bring up points for consideration and these points were adequately answered The presentations were clear and easy to understand. There was good opportunity for everyone to contribute. Seeing the statistics and the outcome from the survey helped with the following workshops Workshop 2 08 November 2023 Thainstone centre, Inverurie Objective of Workshop 2: The purpose of the workshop was enable participants from across a wider stakeholder group to get to the same baseline. Information from workshop 1 was consolidated and the group moved towards defining the vision of General Practice. Content and Approach With guidance from Buchan + Associates the Working Group planned a session, endorsed by the Programme Board, which guided participants in facilitated tables of 8-10 through five activities. Facilitators were identified from the delegates with known skill set in facilitating discussions. Key themes identified to determine a vision were: Pathways – There is a need for clear pathways and integrated systems Data – there is a need for data that will support service development and informing evidence based decision making Models of contract – There is a need for a range of diverse and adaptable models of contract that Independent General Practice providers can choose from that accommodate local needs Premises - There is a need for modern, well equipped premises that are accessible, patient centred and equipped with advanced technologies, enabling high quality healthcare services for all. Keeping the population well -There is a need for the general public to be educated about the importance of General Practice, providing resources to participate in their own healthcare, promoting preventative measures, self-care strategies and overall wellbeing. IT & Technology There is a need for integrated IT systems that allow for seamless patient journeys and workflows, facilitated data driven insights and empower patients to actively participate in their healthcare journey Multi-Disciplinary Team - There is a need for the Multi-disciplinary team (MDT) within General Practice to be adequately funded, with clear guidelines, effective training and communication and a focus on efficient use of resources and quality improvement. Mental health - There is a need or mental health practitioners to be embedded into General Practice to ensure integrated care and early intervention. Education - There is a need for comprehensive and accessible training programmes that inspire and equip individuals, to pursue careers in General Practice and other clinical roles, fostering a workforce that is rooted in their communities and committed to working where they live. Page 173
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NHS Grampian: General Practice Vision 14 | P a g e Continuity - There is a need for General Practice to be adequately resourced to allow for continuity of care to be offered where appropriate, with GP’s having the time and capacity to focus on preventative medicine and invest in Chronic Disease Management (CDM) Details Key Themes / Output Young People Engagement Objective To ascertain views of the younger generation in relation to ‘what matters to them’ in General Practice Content and Approach Pupil Focus Groups at secondary schools Drop in session at Aberdeen University Survey shared via QR code Focus Groups: Need for flexibility in appointment type GP’s need to have the ability to maintain continuity of care for ongoing conditions Patient education – when to contact a GP & awareness of MDT and appointment system Retention of talent in area Target school pupils to promote positive message of working within own community. Focus at careers fairs / via guidance teachers on how to progressing a career in General Practice Use of TikTok and messenger for communication –Facebook not used by younger generation Survey: What’s working well : Positive experiences with phone consultations, quick blood tests, and effective handling of medical issues. Easy log-in system, helpful reception, and fast appointment scheduling contribute to accessible healthcare. Patient centred approach with empathetic and understanding interactions with medical professionals. What Could be improved : Flexibility of appointment day & time and able to book in advance Improved phone systems How might we help people to understand they have a responsibility to keep themselves fit and well: Encourage early intervention in schools and ongoing health education. Implement practical measures like access to fitness classes, regular reminders, and collaborations with local health initiatives. Page 174
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NHS Grampian: General Practice Vision 15 | P a g e Details Key Themes / Output Workshop 3 22 November 2023 Thainstone centre, Inverurie Objective of Workshop 3 : The objective was to share draft vision statements derived from workshop 2 outputs, to feedback from stakeholders on draft vision statements and to begin to develop Strategic Objectives based on the draft vision statements. Content and Approach With guidance from Buchan + Associates the Working Group planned a session, endorsed by the Programme Board, which guided participants in facilitated tables of 8-10 through six activities. Facilitators were identified from the delegates with known skill set in facilitating discussions. Analysis was conducted and a series of enablers was identified on how to deliver on the 10 vision statements (see workshop 2 section above). This included the below: Integrated collaborative effective IT systems multi-agency with patient access & real-time data Resources (time; funding) Standardisation Patient access/ empowerment Support future planning E-prescribing Equitable access Effective communication to patients and across care sectors including citizen education & engagement Core element with practice- dependent modules (use templates) Cost effective Workforce flexibility Support succession planning Central support Community hubs/resources Mobile units Maximises technology Triage system . Workshop 4 - Extended Programme Board 17 January 2024 Microsoft Teams Objective of Workshop 4 : The objective of the workshop was to: - To review and agree vision statement - To review the Objectives - To Rank the Objectives in terms of priority - Review Problem Statements and Objectives in group and identify process to achieve (what/how) and leads (who) Content and Approach Presentation and breakout rooms with guidance from Buchan + Associates. Facilitated sessions reviewing the objectives and what, how and who required to deliver these. The outcome of the workshop was that there was: - Agreement to Vision – with minor amendments suggested - Agreement that ‘Data’ is an overarching objective that cross cuts other objectives and should be a priority - Agreement on Problem Statements – with minor amendments suggested - Agreement on objectives – with minor amendments suggested - Commitment to deliver on vision and objectives Page 175
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NHS Grampian: General Practice Vision V1.0 16 4 NEW GP VISION AND OBJECTIVES 4.1 Introducing the new Vision and Objectives In response to current sustainability challenges and evolving needs within the NHS Grampian area, we have articulated a new vision statement and strategic objectives that capture the changes required to move towards a more sustainable General Practice sector within the area. The key themes and challenges that were identified throughout the facilitated workshop process and stakeholder analysis have been consolidated. A problem statement for each of the key themes has been documented and a vision and objectives have been created which aims to address these challenges, and have a positive impact on the sustainability of General Practice across NHS Grampian. 4.2 Overview of the vision statement The Vision Statement ‘A sustainable General Practice across Grampian which enables people in their communities to stay well through the prevention and treatment of ill health, encapsulates the commitment to fostering health and well-being within our communities. It signifies the dedication to providing comprehensive and accessible healthcare services that not only address illness but also promote preventive care and empower individuals to lead healthier lives Our vision is to provide the foundations for transforming General Practice into a sustainable service that provides the residents of Grampian with the right services in the right place by the right person. In line with the NHSG commissioned vison work with General Practices, Grampian practices will be aligned to 10 joint objectives which aim to increase sustainability of services and improve patient and staff satisfaction, patients will be empowered to stay well; when required they will have access to tailored services through clear pathways and integrated systems. This will be supported by flexible approaches, modern premises, Integrated IT Systems, data-driven decisions, and a robust education and workforce development plan. The new vision stems from the pressing sustainability challenges facing General Practice within the Grampian region. Recognising the need for transformative action in response to resource constraints, demographic shifts, and evolving healthcare demands. The vision aims to chart a sustainable path forward for our practices. It highlights the commitment to delivering high-quality healthcare services that meet the needs of current and future generations. At the core of the vision are 10 key objectives aimed at transforming the General Practice services across Grampian which address the sustainability challenges identified, table 2 on the next page shows each of these themes, how they relate to reasons for change and what an impact of change would be: Page 176
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NHS Grampian: General Practice Vision V1.0 17 Table: 2 Reasons for Change, Key themes and Impact of Change Page 177
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V1.0 18 4.3 Overview of the Objectives Delivery of the new vison for General Practice be will through the delivery of 10 objectives which are based on the key themes identified throughout the programme. The objectives were prioritised at workshop 4 and will be documented in order of priority. These objectives represent the commitment to transforming General Practice across Grampian, fostering sustainability, resilience, and excellence in healthcare delivery for our community. Theme Objective Rationale Impact Data Through the Grampian Data Gathering Group, develop a programme of work to: identify and define necessary data sets; create data gathering processes which enables consistent and consolidated data to be collected across General Practice in a standardised way; and develop data sharing arrangements with relevant partners where necessary. There is currently no standardisation in the way data is coded and collected across General Practices and shared with relevant partners to inform resource allocation to help deliver better outcomes for our communities. By harnessing data-driven insights, we aim to optimise clinical decision- making, improve patient outcomes, and enhance operational efficiency within our practices Models of Contract Develop a flexible approach to the delivery of the existing GMS contract, using currently available levers, following consultation with relevant stakeholders, including: NHSG Primary care and Contracts representatives; General Practices; Scottish Government; Scottish General Practitioners Committee (SGPC); Local Medical Committee; Advisory Committees to the Health Board; and other relevant stakeholders. There is growing evidence that the current 2018 General Medical Services (GMS) contract is not best placed to meet patients’ needs in an efficient and effective manner in Grampian. There are significant ongoing difficulties with recruitment and retention and therefore sustainability across General Practice in the northeast of Scotland. There is evidence that the ambitions of the Primary Care Improvement Programme are yet to be fully realised. By developing flexible contract frameworks, we aim to improve sustainability, support financial viability, and foster stronger GP partnerships within the area. Page 178
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V1.0 19 Keeping the population well Develop, in consultation with community planning partners, a programme to deliver targeted and comprehensive health interventions for at risk communities to offer proactive preventative care and empower communities to participate in their own healthcare and wellbeing. Due to the increasing and more complex demands on our health service it is becoming increasingly difficult to keep our population well, and in the current system, General Practice is looking after people who are ill rather than keeping healthy in the first place. Due to an increase in demand, many GP’s are unable to dedicate time and resources to managing the effects of health inequalities or designing services that take a more proactive population based approach to the health of their patients. By prioritising preventive care and health intervention initiatives, we aim to improve population health outcomes and reduce healthcare disparities. Digital Support the development of a regional Grampian Digital plan, which includes General Practice. This will help to develop a coherent approach to the development of a prioritised set of digital solutions to ensure the wider system is best placed to meet the needs of communities within available resource. The digital programme is not meeting the requirements of General Practice or our communities. This including: inadequate resource for service design and business analysis; no uniform approach to citizen-facing digital services. There is no clear plan to integrate patient data across health and social care and there is insufficient focus on automation. There are delays in implementing agreed solutions and capacity issues in relation to data protection compliance By supporting the development of a digital plan for Grampian, we aim to improve access to care, streamline administrative processes, and enhance communication between General Practice and patients and other areas of the system alike. Standardising technologies to make best use of resource and to improve patient experience. Pathways Review pathways to explore the opportunities, risks and challenges to these pathways. A priority-based implementation plan will be created to improve these pathways. It is anticipated that the plan will include a solution to empower service users to track progress of their situation across the pathways and offer help and advice while on the pathway. This will promote effective communication, collaboration and coordination, ensuring staff and patients are well informed about the pathways.. The patient pathways between General Practice and Secondary Care are not standardised, and often unclear to the patient. There is no digital way from General Practice Clinicians and patients alike to track their progress along the pathway. There is evidence that suggests that patients often repeat contact with their General Practice while on a Secondary Care waiting list for an updated position on progress, which General Practices are unable to provide. By enhancing care pathways between acute and General Practice settings, we aim to improve patient experience and health outcomes. Page 179
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V1.0 20 Multi- Disciplinary Team Initiate and complete an evaluation and review of PCIP services that are in place across NHS Grampian. Where best practice is identified, learn from this, and facilitate its rollout to other areas if appropriate. There have been recruitment challenges within Grampian. This has led to MDTs often being understaffed and unable to achieve the full breadth or services that they could deliver on. This has a knock on impact on General Practice and the ability to deliver proactive health care. By assessing existing PCIP services, we aim to identify opportunities for enhancing collaboration and improving patient care delivery. Continuity of Care Create pathways that achieve continuity of care for those who will benefit most from continuity of care. In the context of flexible models of contract, identifying areas that can be used for a test of change to support practices to improved models to support meeting complex care. With an increasing and ageing population, sociodemographic factors, more complex illnesses and greater comorbidities, there is increasing demand on primary care services. Urgent and unscheduled care provision often takes president over routine, longer term chronic and complex disease management, which means there is an impact on patients long term health. By prioritising continuity of care, we aim to improve care coordination, and enhance patient satisfaction. Premises Via the Primary Care Premises Group, each HSCP, in consultation with practices and relevant partners, will develop an estate plan to meet the needs of our communities. Regard will be had to buildings (where required) being well-equipped, accessible, patient- centred, conducive to partnership working, integrated with advanced and standardised technologies, and in the right place to meet the needs of the communities. There is pressure on the sustainability of General Practice which is linked to liabilities arising from GP contractors’ premises. Within the current infrastructure there is insufficient space and the internal structure of premises impedes alternative ways of working which can best meet the needs of the communities. By addressing infrastructure needs, we aim to create environments that promote patient-centred care and support the well-being of our workforce. Mental Health & Wellbeing Improve mental health and wellbeing support for schools / young people; making use of technology for adoption and engagement encourage better wellbeing across patient groups through, for example, supporting social prescribing and realistic medicine where appropriate; and Identify improvements that will help ensure patients see the most appropriate person the first time to minimise delays in appropriate treatment. A number of factors have led to a growing need for mental health and wellbeing support for our communities. This contributes to an unsustainable demand on General Practitioners, an impacting on their ability to perform proactive and preventative health care. By prioritising mental health support, we aim to improve mental health outcomes, reduce stigma, and foster a culture of well-being within our community. Page 180
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V1.0 21 Recruitment Retention & Education Develop and implement comprehensive training initiatives that will inspire individuals to enter careers in General Practice and wider MDT and administrative Roles to encourage the retention of talent in Grampian. Future colleagues will have the knowledge and technical and digital skills necessary to meet the vision for General Practice in Grampian. This objective will be delivered in consultation with relevant stakeholders, including: local authorities; colleges; universities; NHS Education for Scotland (NES); and Royal College of General Practitioners (RCGP). The total head count is falling for General practitioners. The full time equivalent (FTE) is down even further as the nature of the workforce has changed over the last few decades to more part time workers. Those working full time often have a more diverse work portfolio to provide variety of work and importantly guard against burn out. This all decreases patient facing time. There are recruitment challenges for attracting new staff to come to the Grampian region including as new and experienced for GP’s. By prioritising workforce development, we aim to address workforce shortages, enhance team cohesion, and ensure the sustainability of our General Practice workforce Page 181
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V1.0 22 4.4 How does the vision fit with other Local, Regional and National Priorities Page 182
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V1.0 23 4.4.1 How does the vision support other National and Local Priorities – detailed information National Health and wellbeing Outcomes - There are nine national health and wellbeing outcomes which apply to integrated health and social care. The General Practice Vision and objectives will contribute to the following national health and well-being outcomes as a direct result of the implementation of the objectives. National Outcome NHSG GP Vision Objectives People are able to look after and improve their own health and wellbeing and live in good health for longer. Keeping the Population Well, Pathways Data Digital Mental Health & Wellbeing Health and social care services are centred on helping to maintain or improve the quality of life of people who use those services. Keeping the Population Well Pathways, Models of Contract, MDT Continuity of Care Data Health and social care services contribute to reducing health inequalities Keeping the Population Well, Pathways, Mental Health & Wellbeing Continuity of care Data People who work in health and social care services feel engaged with the work they do and are supported to continuously improve the information, support, care and treatment they provide Recruitment, Retention & Education Data Resources are used effectively and efficiently in the provision of health and social care services Models of Contract MDT Mental Health & Wellbeing Premises Data Page 183
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V1.0 24 4.4.2 Scottish Government – 10 National Drivers of Recovery The Scottish Government has set out 10 National Driver of Recovery. The table below outlines how the vision and objectives will aid the implementation of the drivers of recovery. National Driver Improved access to primary and community care to enable earlier intervention NHSG GP Vision Objectives Keeping the Population Well, Pathways Data Digital Mental Health & Wellbeing Urgent &Unscheduled Care – Provide the Right Care, in the Right Place, at the right time Keeping the Population Well, Pathways Data Digital Premises Improve the delivery of mental health support and services Mental Health & Wellbeing Digital Data Recovering and improving the delivery of planned care Models of Contract Continuity of care MDT Mental Health and Wellbeing Enhance planning and delivery of the approach to health inequalities Keeping the Population Well, Pathways Data Digital Implementation of the Workforce Strategy Recruitment, Retention and Education Optimise use of digital and data technologies in the design and delivery of health and care services Digital Data Premises Page 184
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V1.0 25 4.4.3 NHS Grampian Vison and Strategic themes The NHS Grampian vision ‘Proudly Working Together to improve our health’ is underpinned by 3 values, which are Caring, Listening and Improving. There are 4 Strategic themes. Set out to deliver on this vision and values. These are set out in the table below along with what objectives will aid the delivery of these objectives: NHS Grampian Strategic Theme NHSG GP Vision Objectives Improving Health and reducing Inequalities Keeping the population well, Pathways Mental health and wellbeing Continuity of care Data Digital Delivering High Quality Care in the right place Continuity of care, Data Digital Premises Models of contract Improving our patients, public, staff and partners Recruitment, retention & Education Models of contract Pathways Digital Data, Developing and improving our staff Recruitment, retention & Education Data Page 185
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V1.0 26 4.4.4 Aberdeen City HSCP Strategic Priorities The Aberdeen City HCP Vision is: We are a caring partnership working in and with our communities to enable all people to achieve fulfilling, healthy lives This is underpinned by 4 strategic aims. Preventing Ill Health, Caring Together, Keeping the Population Safe at Home and Achieve Healthy Fulfilling Lives. The recommendations within this report will directly assist in the delivery of the Primary care Strategic Priority to improve primary care stability by creating capacity for General Practice improving patient experience The vision and objective will also contribute to the delivery of the Aberdeen City HSCP Strategic priorities and the Aberdeen City LOIP Key Drivers. HSCP Strategic priorities Aberdeen city LOIP - Key Drivers NHSG GP Vision Objectives Preventing Ill health 11.3 Encouraging adoption of healthier lifestyles through a whole family approach. 12.3 Enhance early intervention and preventative treatment for those at greatest risk of harm from drugs and alcohol. Keeping the population well Pathways Continuity of care Mental health and wellbeing Caring together 4.2 Improving health and reducing child poverty inequalities Models of Contract Multidisciplinary Team Mental Health and Wellbeing Pathways Digital Keeping people safe at home 5.1 Improving timely access to support. Digital keeping the population well Continuity of Care Pathways Achieve healthy Fulfilling lives. 6.1 Improving education and health outcomes for care experienced children and young people. Keeping the population well Mental health and wellbeing Digital Page 186
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V1.0 27 4.4.5 Aberdeenshire HSCP Strategic Priorities The Aberdeenshire HSCP vision is to ‘Building on a person’s abilities, we will deliver high quality person-centred care to enhance their independence and wellbeing in their own communities’, this is underpinned by 5 Strategic priorities. The table below sets out how the General Practice vision and objective are in line with the Aberdeenshire HSCP Strategic priorities as well as the Aberdeenshire Council Priorities. Aberdeenshire HSCP Strategic Priorities Aberdeenshire council Priorities NHSG GP Vision Objectives Prevention & Early Intervention Health and wellbeing Data Pathways Continuity of Care Keeping the Population well Reshaping Care Economic growth Data Premises Models of Contract, MDT Mental Health and Wellbeing Engagement Learning for life Recruitment retention and Education Data Effective use of resources Infrastructure and public assets Climate change Models of Contract MDT Mental health and Wellbeing Digital Continuity of Care Pathways Recruitment and retention & Education Data Tackling inequalities & Public Protection Resilient communities Data Pathways Continuity of Care Keeping the Population well Page 187
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V1.0 28 4.4.6 Moray HSCP Strategic Priorities Moray HSCP vision is: ‘We come together as equal and valued partners in care to achieve the best health and wellbeing possible for everyone in Moray throughout their lives’ This is underpinned by three strategic priorities, the vision and objectives will support the delivery of these as shown in the below table. Moray HSCP Strategic Priorities Moray council LOIP NHSG GP Vision Objectives Improve the health and wellbeing of the population (Better Health) Building a better future for our children and young people in Moray. Improving wellbeing of our population Data Pathways Keeping the Population well Models of Contract MDT Mental Health & Wellbeing Continuity of Care Digital Improve the quality of care people receive (better Care Empowering and connecting communities Data Digital Models of Contract MDT Mental Health & Wellbeing Continuity of Care Premises Improve the efficient of health and social care services to ensure we spend public money on services that get good outcomes for people (better value) Developing a diverse, inclusive and sustainable economy Data Models of Contract MDT Mental health and Wellbeing Continuity of care Premises Digital Page 188
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V1.0 29 4.5 Delivery The programme of work will be delivered within existing resources, with resources being released from the following teams: • NHS Grampian Primary Care Contracts Team (Contract Management) • Aberdeen City HSCP Primary Care Team (Programme Management &PCIP lead) • Aberdeenshire HSCP Primary Care Team (PCIP lead) • Aberdeen City Transformation Team (Project Management & Evaluation) With the above resources that have been identified the following priorities can commence delivery in April 2024: • Data • Models of Contract • MDT (PCIP review) In line with what resources we have there will be regular reviewed which will monitor progress and objectives will be pulled down when progress is made and resource is available. 4.6 Monitoring and Evaluation Monitoring and evaluation of the programme delivery will be through the programme board structure with annual updates to the three integration joint boards anticipated. This would include updates against, for example, progress against the objectives, the development of new objectives to support the delivery of the vision, and the impact of the objectives as they are delivered. By 2023, how will we know if we have made a difference? There will be standardised data sets, data gathering process and data sharing agreements in place to facilitate data sharing across community planning partners; General Practices will be able to utilise a flexible approach to the GMS Contract; Patients will be able to digitally track where they are on a secondary care waiting list; Increased use of automation in General practice to increase efficiency; A successful pathways test of change will be implemented improving efficiency, patient safety and wellbeing; A review and evaluation of PCIP within Grampian will be complete with recommendations implemented; A successful test of change for continuity of care will be identified and implemented; and A detailed services and estate plan will be included within the 2025 Primary Care Premises Plan; People will have access to a range of mental health and wellbeing interventions; and General Practice and other clinical roles vacancy rates will be reduced. Page 189
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V1.0 30 Key Metrics The table below outlines the key metric that will be used to review the current sustainability levels within General Practice. Data Models of Contract Keeping the population well Digital Pathways MDT Continuity of care Premises Mental Health & W ellbeing Recruitment, Retention & Education Number of 2C practice within Grampian x x x x x x x % of total 2C practices within NHS Grampian x x x x x x x Number of GPs / GP head count x x x x x x FTE of GPs x x x x x x GP headcount by designation x x x x x x Practice list size x x x x x Average number of patients per GP x x x x x Inpatient waiting list size x x x x x Outpatient waiting list size x x x x x ED attendance rates x x x x x Emergency admission rates x x x x x Genral Practcie Alert System (GPAS) x x x x x x Grampian Operational Pressure Escalation System (GOPES) x x x x x x Number of GP List closures x x x x x x x % of List Closures x x x x x x x Practices Managing List Informally x x x x x x x % of practcies Managing List Informally x x x x x x x Number of contracts returned x x x x x x x % of contracts returned x x x x x x x BMA staff survey - Low Morale x x x x Page 190
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V1.0 31 4.7 Implementation Risks Category Description Mitigation RAG Status Sustainability There is a risk that if the project is not delivered, General Practice within Grampian will continue on an unsustainable basis. This will further exacerbate the challenges outlined above. As the first point of access to healthcare for 90% of the population General Practice delivers early intervention and preventative measures for the whole system and therefore the consequences will not be limited to GP services. Failure to deliver the project will increase the prospect of further increasing demand on Secondary Care services, unscheduled and urgent care (including PC & OOH), a reduction in NHS performance and poorer outcomes for Grampian’s residents across the health and social care system. The development of a project to deliver a shared vision and strategic objectives for General Practice in Grampian. Adequate funding support from the Scottish Government to build the necessary capacity to deliver this project (which is preventative in nature) to March 2024 and anticipated support to deliver the implementation plan beyond March 2024. Working with public health colleagues to ensure preventative focus of workstreams and focus interventions on need Amber Resource The programme is required to be approved and then delivered within existing resources, therefore there is a risk that the programme is not delivered due to the financial pressures across Grampian and other competing priorities. Continued highlighting of concerns and engagement with all stakeholders to understand the importance and risks of not undertaking this project Consideration of current priorities and workforce that could be realigned to deliver some or all of the programme. As well as phasing of timelines to make workloads manageable. High Engagement – Public Reputational risk due to the potential service changes being disliked by the public Potential increased complaint due to changes to services Patient representatives as part of the Programme governance structure moving forward for co-design and engagement Patient stakeholder engagement - working with communications team and social media to make sure messages made on an ongoing basis Amber Page 191
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V1.0 32 There are also risks if changes are not made around patient expectations and experience – waiting times etc… Working with LEGS and working with elected members and community councils to increase understanding for the case to change Engagement – Workforce Risk that key stakeholders do not have the capacity and therefore loose interest in implementation of priorities No dedicated resource to release General Practice to implement within an already pressured system Reputational risks with General Practice if programme not implemented Continued highlighting of concerns and engagement with all stakeholders to understand the importance and risks of not undertaking this project Consideration of current priorities and workforce that could be realigned to deliver some or all of the programme. As well as phasing of timelines to make workloads manageable. High Page 192
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5 NEXT STEPS Based on the findings presented in this report, consideration will be given to the following high-level actions to progress towards the realisation of the outlined vision and objectives. Key actions work towards its vision and strategic objectives include: 5.1 Establish Governance Structures - Define roles, responsibilities, and decision-making processes to ensure effective coordination and accountability. - Ensure representation from all relevant stakeholders to promote shared ownership and commitment (including LMC / GP Sub and Patient representatives) - Agree a set of principles and ways of working as a system to maximise shared resource for the shared purpose Identify opportunities for pooling resources Ensure fairness and equity in resource distribution - Establish regular forums for communication, collaboration, and joint planning - Establish reporting structures and provide regular updates on progress - Agree principles for patient involvement group going forward - Agree escalation processes - Agreement on what priorities across system to pause to enable resource to be allocated to move work forward 5.2 Release Resources - Release resource allocation as per 4.5 to ensure delivery of the prioritised objectives - Clearly define roles and expectations to ensure accountability and effective coordination 5.3 Create and action an Implementation Plan - Identify specific actions required to achieve each strategic objective outlined in the vision - Establish realistic timelines for each action, including resource availability, dependencies between tasks, and external constraints - Assign actions to individuals or teams identified during resource allocation. - Make use of governance structures for monitoring progress and evaluating the effectiveness of the implementation plan. - Communicate the implementation plan clearly and transparently to all stakeholders 5.4 Lessons learned A lessons learned process will be carried out post approval of the new General Practice Vision and Objectives. The lessons learned process is crucial for continuous improvement and the optimisation of future projects. The lessons learned process and report will include the following stages: Page 193
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Define Objectives and Scope Engage Stakeholders Conduct a Comprehensive Review Document and categorise findings Share Lessons across Teams and Incorporate Lessons into Future Planning Celebrate Successes Initial work will commence in April 2024, and a full lessons learned report will be completed by the end of June 2024. 5.5 Project closure Following on from the IJB meetings in March 2024. The programme in its current state will commence the project closure process to ensure that all aspects of the project are completed, documented, and handed over appropriately. The project closure will include: Ensure all new governance arrangements are in place to deliver on the objectives Ensure all project groups have been set up and provided with appropriate information to deliver on the objectives Complete all outstanding financial activities in relation to the GP Vision budget Release any resource that is no longer required Complete lessons learned process Conduct programme closure meeting Page 194
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6 CONCLUSION After engaging in extensive stakeholder consultation, we have successfully shaped a new vision and set of objectives that reflect the collective aspirations and insights of our diverse stakeholders. A co-production approach was taken ensuring that the voice of key stakeholders was heard throughout the process. Key stakeholders included, GP’s and other GP staff such as Practice Managers, representatives from other areas of primary care, Secondary Care and other services within the NHS System (i.e. property, public health, e-heath), the LMC and GP Sub, third sector and patient representation. Delivery of the new vison for General Practice will be via by 10 objectives which are based on the following key themes identified throughout the programme: • Data • Models of Contract • Keeping the Population Well • Digital • Pathways • Multi-disciplinary team • Continuity of Care • Premises • Mental Health and Wellbeing • Recruitment, Retention & Education A sustainable General Practice across Grampian which enables people in their communities to stay well through the prevention and treatment of ill health The General Practice Vision Programme values and acknowledges the invaluable contributions of the stakeholders who contributed to this programme of work. The diverse perspectives and active participation have been instrumental in shaping the vision and strategic objectives. This exemplifies the collaborative ethos that defines the approach to healthcare delivery in the region The new vision for General Practice is in alignment with both national and local strategies and priorities including: • The National Health and wellbeing outcomes • NHS Grampian Vision, Values and Strategic Themes • Aberdeen City, Aberdeenshire and Moray HSCPs Vision and Priorities • The 3 Local Authorities plans and Locality Improvement Plans Consideration has be given to the creation of a new Programme Board and associated project sub groups that will lead the delivery of the objectives. Monitoring and evaluation of the programme delivery will be through the Programme Board structure, and quarterly reporting will be made via IJB Chief Officers reports and quarterly updates to the NHSG CET. Periodic evaluations will be conducted to ensure alignment with evolving needs and changing circumstances As we move forward with the programme of work, we are fully committed to realising the vision and objectives outlined, with confidence in the ability to drive positive Page 195
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change and enhance General Practice within NHS Grampian, fostering a renewed sense of purpose and determination among all stakeholders involved. Ongoing feedback and engagement from stakeholders is encouraged as we embark on the implementation phase, ensuring that the vision remains aligned with the evolving needs of our community. In conclusion, we emphasise the pivotal role of the newly outlined vision and strategic objectives in advancing the quality and accessibility of General Practice services within NHS Grampian. We extend our deepest appreciation to all stakeholders for their vital contributions, commitment, and ongoing support in our collective pursuit of enhancing patient-centred care and improving health outcomes across the community. Page 196
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APPENDIX 1: Glossary Glossary 17c A 17C contract is a locally-agreed alternative to the nationally agreed General Medical Services 17j A 17J contract is a GP Practice run under the General Medical Services (GMS) contract 2C NHS Board run practices AFC Agenda for Change: A framework that applies to all NHS staff (except doctors, dentists, and very senior managers) to ensure fair pay and conditions. AHP Allied Health Professional: Refers to a diverse group of healthcare professionals, excluding doctors and nurses, involved in the delivery of rehabilitation, diagnostic, technical, therapeutic, and direct patient care services. AI Artificial Intelligence: Refers to the simulation of human intelligence in machines programmed to think and learn like humans. AMIA Acute Medical Initial Assessment: The initial evaluation of patients presenting with acute medical conditions. ANP Advanced Nurse Practitioner: A registered nurse with advanced education and clinical training, allowing them to diagnose and manage common medical conditions. ARI Aberdeen Royal Infirmary Automation The use of technology and machinery to perform tasks with minimal human intervention. AWI Adults with Incapacity: Legislation in Scotland that protects the welfare and financial affairs of adults who lack capacity to make decisions for themselves. BMA British Medical Association: A professional association and trade union representing doctors and medical students in the United Kingdom. Buchan + Associates Specialist Health and Social care consultancy Care Navigator A professional who assists patients in navigating the healthcare system to access appropriate services and resources. CBT Cognitive Behavioural Therapy: A psychotherapeutic treatment that focuses on changing negative thought patterns and behaviours. CDM Chronic Disease Management: Strategies and interventions aimed at managing chronic health conditions to improve patient outcomes and quality of life. CET Chief Executive Team: The executive leadership team responsible for decision-making and strategic direction within NHS Grampian Page 197
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CIG Clinical Interface Group: A multidisciplinary group that coordinates and improves the interface between different clinical services. CMHT Community Mental Health Team: A team of healthcare professionals providing mental health services in the community. Community Nursing Nursing care provided to individuals, families, and communities in their homes or community settings. Community Pharmacist A pharmacist who provides pharmaceutical services and advice within a community setting. COPD Chronic Obstructive Pulmonary Disease: A group of progressive lung diseases, including emphysema and chronic bronchitis, characterised by airflow obstruction. Co-Production A collaborative approach where service users and providers work together to design and deliver services. CPD Continuous Professional Development: The ongoing process of learning and skill development to maintain and enhance professional competence. CPN Community Psychiatric Nurse: A mental health nurse specialising in providing care and support to individuals in community settings. CPP Community Planning Partnership: A partnership between local authorities, public sector agencies, and community representatives to plan and deliver services at the local level. CTAC Community Treatment and Care D&V Diarrhoea and Vomiting: Symptoms often associated with gastrointestinal illnesses. Dental Relating to oral health and dental care services. DES Directed Enhanced Service: Additional services provided by general practitioners (GP’s) beyond the core contract with the NHS. Developer Obligations Financial contributions sought from a developer to mitigate the impact of their development on the community DN District Nurse: A nurse who provides nursing care and support to individuals in their own homes or within the community. DNACPR Do Not Attempt Cardiopulmonary Resuscitation: A medical order indicating that cardiopulmonary resuscitation should not be attempted if a patient's heart stops beating. DWP Department of Work & Pensions: A government department responsible for welfare, pensions, and child maintenance policy in the United Kingdom. EH Extended Hours: Additional hours beyond standard working hours, often offered by healthcare providers to increase accessibility. Page 198
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e-Health Department within NHS Grampian to make best use of information and communication technologies (ICT) to support and improve healthcare delivery and patient outcomes. Emis General Practice IT System: A software system used by general practitioners (GP’s) to manage patient records, appointments, and clinical information. ES Enhanced Services - Additional healthcare services provided by general practitioners (GP’s) beyond the core contract with the NHS. Expert Medical Generalist A healthcare professional with broad expertise and experience in managing a wide range of medical conditions. FCP First Contact Physio: A physiotherapist who serves as the first point of contact for patients seeking musculoskeletal care. FTE Full-Time Equivalent: A measure of an employee's workload or unit of service expressed as the equivalent of a full-time worker. FY1 Foundation Doctor - Year 1 FY2 Foundation Doctor - Year 2 Gap Analysis A technique used to assess the disparity between current performance and desired outcomes, often used to identify areas for improvement. GMED Out of Hours Primary care Service GMS General Medical Services: A range of primary healthcare services provided by general practitioners (GP’s) under contract with the NHS. GOPES Grampian Operational Pressure Escalation System GP Cluster A grouping of general practitioner (GP) practices working together to coordinate and improve healthcare services at the local level. GPAS General Practice Alert State: A system designed to monitor and report the resilience of General Practice across a region. GP General Practitioners: Healthcare professionals who provide primary medical care to patients. GREC Grampian Regional Equality Council: An organisation promoting equality and human rights in the Grampian region of Scotland. HCP Health Care Professional: Any individual involved in providing healthcare services, including doctors, nurses, therapists, and allied health professionals. HR Human Resources: The department responsible for managing personnel, recruitment, training, and employee relations within an organisation. HSCP Health and Social Care Partnership: A collaborative partnership between local authorities and health boards to integrate health and social care services. Page 199
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HV Health Visitor: A registered nurse or midwife with additional training in public health nursing, specialising in supporting families with young children. IA Integration Agreement: A formal agreement outlining the integration of health and social care services within a region or jurisdiction. IG Information Governance: Policies and practices for managing and protecting sensitive information within an organisation. IJB Integrated Joint Board: A governing body responsible for overseeing the integration of health and social care services. Improvement Grants NHS Improvement Grants for General Practice premises are available under the National Health Service IPC Infection Prevention Control: Measures and protocols aimed at preventing the spread of infections within healthcare settings. LES Local Enhanced Service: Additional services provided by general practitioners (GP’s) to meet specific local healthcare needs. Lessons Learned Insights and knowledge gained from past experiences or projects, used to inform decision-making and improve future performance. LMC Local Medical Committee: Representative bodies for general practitioners (GP’s) at the local level, responsible for negotiating with health authorities and representing GP interests. Locum A temporary healthcare professional who fills in for regular staff during their absence or when additional support is needed. LOIP Locality Improvement Plan: A strategic plan outlining improvement priorities and objectives within a specific geographic area or locality. MCR Medicines Care & Review: A service provided by pharmacists to review patients' medications and ensure safe and effective use. MDT Multi-Disciplinary Team: A team of healthcare professionals from different disciplines collaborating to provide comprehensive care and treatment to patients. Mental Health Practioners Healthcare professionals specialising in the assessment, diagnosis, and treatment of mental health conditions. MH Mental Health: The state of psychological well-being and functioning, encompassing emotional, cognitive, and social aspects. MOU Memorandum of Understanding: A formal agreement between parties outlining mutual goals, objectives, and responsibilities. National code of practice The Code of Practice sets out the Scottish Government’s plan to facilitate the shift to a model which does not entail GP’s providing their practice premises. NES NES Education for Scotland Page 200
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NHS National Health Service: The publicly funded healthcare system in the United Kingdom, providing medical services free at the point of use. OOH Out of Hours: Healthcare services provided outside of regular working hours, often during evenings, weekends, and holidays. Optometry The healthcare profession concerned with examining the eyes for defects and abnormalities and prescribing corrective lenses or other treatments. Organisational development Strategies and initiatives aimed at enhancing organisational effectiveness, performance, and resilience. PA’s Physician Associate: A healthcare professional who works under the supervision of a doctor to provide medical care and support to patients. Pathway A structured approach or plan outlining the steps and interventions involved in the diagnosis, treatment, and management of a particular health condition or patient population. PC Primary care PCCT Primary care Contracts Team: the team responsible for managing contracts and agreements between primary care providers and NHS organisations. PCIF Primary care Improvement Funding PCIMT Primary care Information Management Team PCIP Primary Care Improvement Plan PCPG Primary Care Premises Group Pharmacotherapy The use of medications or drugs to treat diseases, alleviate symptoms, or manage health conditions. Pharmacy first A service provided by community pharmacies to offer advice, treatment, and medications for minor ailments and conditions without the need for a doctor's prescription. PLT Protected Learning Time: Designated time for healthcare professionals to engage in continuing education, training, and professional development activities. POA Power of Attorney: A legal document granting someone the authority to make decisions on behalf of another person, often used in healthcare and financial matters. POC Testing Point of Care Testing: Diagnostic tests performed at or near the point of patient care, providing rapid results to inform immediate clinical decisions. PPG Patient Participation Group: A group of patients and healthcare professionals working together to improve patient care and services within a healthcare practice or organisation. Page 201
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Practice manager An administrative professional responsible for managing the operations and business aspects of a healthcare practice or clinic. QR code Quick Response Code: A two-dimensional barcode that stores information and can be scanned using a smartphone or other devices. SAS Scottish Ambulance Service: The national ambulance service in Scotland, responsible for providing emergency medical services. Secondary Care Specialised medical services provided by hospitals and healthcare professionals for patients requiring more complex or intensive treatment. SGPC Scottish General Practitioners Committee represents all general practitioners working in Scotland. SLA Service Level Agreement SLWG Short Life Working Group: A temporary group established to address specific issues or tasks within a defined timeframe. SMART Specific, Measurable, Attainable, Realistic, Time-Bound: Criteria used for setting objectives and goals to ensure they are clear, achievable, and trackable. Social prescribing A non-medical approach to healthcare that involves connecting patients with community-based resources and activities to improve their health and well-being. SOP Standard Operating Procedures: Established protocols and guidelines for performing routine tasks and procedures in a consistent and standardised manner. SPOC Single Point of Contact: A designated individual or entity responsible for handling communications and coordination for a specific issue or service. SRO Senior Responsible Officer: An individual with overall accountability and authority for the successful delivery of a project or initiative. Sustainability loan These are government interest-free loans are intended to make GP practices that own their practice premises more viable. Qualifying practices can use these sustainability loans in any way they want, provided it is 'for the purpose of the practice Test of change A structured approach to implementing and evaluating small-scale changes or innovations within a healthcare setting before broader implementation. TOR Terms of Reference: A document outlining the scope, objectives, and responsibilities of a project, committee, or working group. TrakCare Electronic Patient Management System: A software system used for managing patient records and clinical information within healthcare organisations. Unscheduled care Healthcare services provided to patients who require immediate or urgent medical attention, often outside of scheduled appointments or clinics. Page 202
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UTI Urinary Tract Infection: An infection affecting any part of the urinary system, including the kidneys, bladder, ureters, and urethra. Vision General Practice IT System: A software system used by general practitioners (GP’s) to manage patient records, appointments, and clinical information. VTP Vaccination Transformation Programme: A program aimed at improving vaccination coverage and delivery within a healthcare system. WT Waiting Time: The length of time a patient must wait for an appointment, treatment, or service within the healthcare system. WW Waiting Well Page 203
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1 APPENDIX B Equality Impact Assessment (EQIA) Rapid Impact Checklist Completing this form will help decide whether the policy will further require a Full EQIA and/or integrated Impact Assessment. *Policy refers to service, function, policy, framework, strategy, new service, service redesign, and programmes. Title General Practice Vision Directorate, service or department Aberdeen City Primary Care Team, ACHSCP on behalf of 3 x HSCP’s Main contact of the policy* Name Ali Chapman Tel No Job Title Primary Care Development Manager Email Alison.chapman@nhs.scot Department Primary Care, ACHSCP Policy Aim In June/July 2023, the three HSCP Chief Officers were set an objective to design and create a SMART delivery plan for a Grampian Primary Care Strategy. This was in response to the challenging implementation of the 2018 GMS contract, due to a number of factors, including, recruitment and retention, the application of multi-disciplinary teams across a wide and rural geography resulting in teams being spread too thinly, and a large region with diverse populations, communities and needs. All of which have an impact on the sustainability of general practice. Purpose Due to the continuing pressure being faced across General Practice, the project brought together key stakeholders, teams and colleagues from across the system for the opportunity to help shape the future of General Practice. Intended/desired outcomes A High level strategy and vision will be created for Grampian with associated objectives and Delivery plan Part 1. Which groups of the population do you think will be affected by the proposal? People and Groups: • Staff • Patient • Minority ethnic people (incl. Gypsy/travellers, refugees & asylum seekers) • Women and men • People in religious/faith groups • People of low income • Homeless people • People involved in criminal justice system • People with mental health problems • Carers (paid or unpaid, family member) • People affected by substance misuse or addictions Item 10. Page 205
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2 • Disabled people • Older people, children and young people • Lesbian, gay, bisexual and transgender • Low literacy/health literacy • Living in deprived area, remote or rural area • Unemployed • Any other groups The proposal/policy will affect This proposal may affect all residents of the Grampian area, as well as all staff within General Practice and the wider Primary Care and NHS system. The output of the programme will be a vision and associated series of objectives that will be presented to the three IJBs. At this time we are unable to determine if there is one (or more) specific group that will be negatively impacted with any future changes, as there may be a range or programmes and projects that could be a result of this work. It is anticipated that this programme of work may allow General Practice in Grampian to deliver services differently in Grampian, in a way that is more representative of the needs of those in the north east, coupled with the local challenges around recruitment, retention and the rurality of some areas within the Grampian area. This would be seen as having a positive impact on patients across Grampian. Any workstreams agreed by the IJBs and Scottish Government will ensure an EQIA specific to that workstreams will be completed. Part 2. Identifying the impacts (in brief) on groups with protected characteristics, including economic impact and human rights. Protected Characteristic Positive or Negative Impact Social and Economic, Human Rights Additional Information [Positive impact/Negative Impact/No adverse impact has been identified. Briefly explain the impact, including any social, economic or human rights] Age (early years, children, young people, middle years, older people) At this stage no adverse impact has been identified, the EQIA will be revisited once the further detail of the delivery plan is known Disability (physical disability, learning disability, neurological, sensory loss, mental health, long term conditions) At this stage no adverse impact has been identified, the EQIA will be revisited once the further detail of the delivery plan is known Gender (male, female) At this stage no adverse impact has been identified, the EQIA will be revisited once the further detail of the delivery plan is known Page 206
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3 Gender Reassignment (people who have proposed, started, in the process or completed a process to change their sex) At this stage no adverse impact has been identified, the EQIA will be revisited once the further detail of the delivery plan is known Marriage or Civil Partnership (people who are married, unmarried or in civil partnership) At this stage no adverse impact has been identified, the EQIA will be revisited once the further detail of the delivery plan is known Pregnancy or Maternity (pregnant and/or on maternity leave, including breastfeeding) At this stage no adverse impact has been identified, the EQIA will be revisited once the further detail of the delivery plan is known Race (minority ethnic people, racial groups, national origins, gypsies/travellers, refugees, asylum seekers, migrant workers) At this stage no adverse impact has been identified, the EQIA will be revisited once the further detail of the delivery plan is known Religion or Belief (different religions or beliefs, including non- belief) At this stage no adverse impact has been identified, the EQIA will be revisited once the further detail of the delivery plan is known Sexual Orientation (e.g. lesbian, gay, bisexual, heterosexual) At this stage no adverse impact has been identified, the EQIA will be revisited once the further detail of the delivery plan is known Part 3. Any adverse or potential adverse impact identified? ☐ Yes ☒ No Briefly describe the adverse or potential impact and how it will be addressed or mitigated At the current stage of the project we are unable to determine any adverse or potential impact. Once the delivery plan has been developed the EQIA will be revisited to look at this in more detail and how this will be addressed or mitigated. Page 207
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4 Part 4. Health Determinants/Health in All. Identify the positive and negative impacts and which groups will be affected? What impact will the proposal have on lifestyles? • Diet and nutrition No Impact • Exercise and physical activity No Impact • Substance use: tobacco, alcohol and drugs No Impact • Risk taking behaviour No Impact • Education and learning or skills No Impact Will the proposal have any impact on the social environment? • Social status No Impact • Employment (paid or unpaid) Possible impact to NHS and GP Staff • Social/family support Possible impact to those who provide social /family support • Stress Possible impact • Income No Impact Will the proposal have an impact on the physical environment? • Living conditions No Impact • Working conditions Possible impact to NHS and GP Staff • Pollution or climate change Possible impact • Accidental injuries or public safety No Impact • Transmission of infectious disease No Impact Will the proposal affect access to experience of services? • Health care Yes • Transport No • Social services No • Housing services No • Education No Page 208
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5 Part 5. Will it have any impact on the following? Describe or summarise how this policy will contribute to or achieve Eliminate discrimination? If you answer YES, explain if it is a positive or negative effect. It can be YES because (a) it eliminates or reduce discrimination or (b) enhance/promote discriminatory practice ☐ Yes ☐ No ☒ N/A Equality of opportunity? Does the policy offer equality to all without discrimination on the protected characteristics or other groups How does it remove or minimise disadvantages? What steps were taken to meet the needs of people who share protected characteristics? How does it encourage persons who share protected characteristics participate in the activity? ☒ Yes ☐ No ☐ N/A This programme aims to create a vision of how general practice is delivered in Grampian to meet the needs of the population. Therefore it is anticipated that there would be the potential to redesign services which would provide an opportunity to look at new ways of working, access to services and additional opportunities for improving the overall patient experience. Foster good relations between groups? Does it foster good relations between groups e.g. promote positive attitudes, having due regards to tackle prejudice, promote understanding, interactions, personal security or participation ☒ Yes ☐ No ☐ N/A The project team are taking a co-production approach in conjunction with the NHS Grampian Public Involvement Team. This will foster good relations between key stakeholders including patient groups, NHS and General Practice This will allow for a common understanding of the challenges facing general practice from a range of different perspectives with the opportunity to shape services together moving forward Page 209
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6 Part 6. Rapid Impact Checklist: Summary Sheet Positive Impacts (Note the groups affected) Negative Impacts (Note the groups affected) At this stage no adverse impact has been identified, the EQIA will be revisited once the further detail of the delivery plan is known At this stage no adverse impact has been identified, the EQIA will be revisited once the further detail of the delivery plan is known Additional Information and Evidence Required n/a Recommendations At this time this policy does not adversely impact any of the protected characteristics. It is recommended each project group re-visits the HIIA to ensure any service change is considered on a case by case basis. From the outcome of Parts 1-5, have negative impacts been identified for groups with protected characteristics or other groups? Has a full EQIA process been recommended? If not, why not? No. As above will be revisited on case by case basis for each service re-design. Part 7. Is this policy* a strategic decision? ☒ Yes ☐ No If No, go to Part 9. Page 210
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7 If Yes, go to Part 8. A policy* that has a potential to impact on health and widen health inequalities must have “due regard” for the Fairer Scotland Duty. A policy that is a “strategic decision” must take into account how they can reduce inequalities of outcome caused by socio-economic disadvantage. See page 15 of the FSD Guidance for the definition of ‘strategic decision.’ The Fairer Scotland Duty places a legal responsibility on public bodies to actively consider how they can reduce inequalities of outcome caused by socioeconomic disadvantage. The Duty applies at strategic level, which normally include decisions around setting priorities and targets, allocating resources and commissioning services. To assess if your policy is a strategic decision, please refer to: Fairer Scotland Duty: guidance for public bodies - gov.scot (www.gov.scot) Part 8. Fairer Scotland Duty. What likely will this policy have on people experiencing different kinds of social disadvantage? Socio-Economic Disadvantage Positive impact/Negative Impact/No adverse impact has been identified Low Income/Income Poverty – cannot afford to maintain regular payments such as bills, food, clothing No impact has been identified at this stage, the EQIA will be revisited once the further detail of the delivery plan is known Low and/or no wealth – enough money to meet Basic living costs and pay bills but have no savings to deal with any unexpected spends and no provision for the future No impact has been identified at this stage, the EQIA will be revisited once the further detail of the delivery plan is known Material Deprivation – being unable to access basic goods and services i.e. financial products like life insurance, repair/replace broken electrical goods, warm home, leisure/hobbies No impact has been identified at this stage, the EQIA will be revisited once the further detail of the delivery plan is known Area Deprivation – where you live (rural areas), where you work (accessibility of transport) No impact has been identified at this stage, the EQIA will be revisited once the further detail of the delivery plan is known Socio-economic Background – social class i.e. parent’s education, employment and income No impact has been identified at this stage, the EQIA will be revisited once the further detail of the delivery plan is known Page 211
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8 Part 9. Does the policy need to consider the impact on other areas? Human Rights (Human Rights Assessment) ☐ Yes ☒ No Children’s rights and welfare (Children’s Rights Impact Assessment) ☐ Yes ☒ No Environment ☐ Yes ☒ No Financial ☐ Yes ☒ No Island or Rural Communities ☐ Yes ☒ No Part 10. Children and Young People (Scotland) Act (2014) The Child Rights and Wellbeing Impact Assessment (CRWIA) is a process which you can identify, research, research and record the anticipated impact of any proposed policy on children’s human rights and wellbeing. Check the CRWIA Screening Sheet – this asks you to consider: • What aspects will affect children and young people up to 18 year • What likely impact will be • Which groups of children and young people will be ore affected Children's Rights & Wellbeing Impact Assessment (CRWIA) - Children's Rights and Wellbeing Impact Assessment guidance - gov.scot (www.gov.scot) Part 11. Has your assessment been able to demonstrate the following and why? ☒ Option 1. No major change (where no impact or potential for improvement is found, no action is required) ☐ Option 2. Adjust (where a potential or actual negative impact or potential for a more positive impact is found, make changes to mitigate risks or make improvements) ☐ Option 3. Continue (where a potential or actual negative impact or potential for a more positive impact is found but a decision not to make a change can be objectively justified, continue without making changes.) ☐ Option 4. Stop and remove (where a serious risk of negative impact is found, the plans, policies etc being assessed should be halted until these issue can be addressed) Explain decision Page 212
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9 At this time the programme is focussed on determining a high level vision and smart objectives for the delivery of general practice in Grampian. No service changes have been determined or commission at this stage. Therefore it is suggested that the programme continues with no major change. At a time that any programmes of work, including any service change are agreed by the IJBs and the Scottish Government the EQIA will be revisited, To be completed by Team Lead of the policy/proposal Name Alison Chapman Job Title Primary Care Development Manager Email Alison.chapman@nhs.scot Date 30/08/2023 Part 12. Has the policy document been checked by a Level 1 EQIA assessor? ☒ Yes ☐ No If yes, please fill in details Name Teresa Waugh Job Title Primary Care Development Manager Email teresa.waugh@nhs.scot Date 12/09/2023 Return to Equality and Diversity at roda.bird@nhs.scot • Completed form • Copy of final draft/version of any documentation To be completed by Equality and Diversity – for quality control purposes and recording Recommendations ☐ Rapid EQIA ☐ Full EQIA ☐ Fairer Scotland Duty Name Job Title Email Date Page 213
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General Practice Vision Programme Aberdeenshire / Aberdeen City/ Moray IJB Wednesday 20th March /Tuesday 26th March /Thursday 28th March 2024 APPENDIX D Item 10. Page 217
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People and Communities Increased morbidity and complexity leads to increased complexity National Recruitment challenge across the disciplines, head count up slightly but full time equivalent is down Practice list sizes growing Practices handing back their contract Decrease in GP Headcount vs unable to provide full width of services or and Aging population and long waits for out patient appointments and surgery Consultation rates increasing General Practice Challenges: Why was the work required? Page 218
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General practice Vision Programme: • Creation of a programme board • Series of facilitated workshops • Community engagement • Patient survey • Formation of a patient stakeholder group • School focus group • Engagement with various groups across the system including the Aberdeen City locality empowerment groups General Practice Vision Programme: Why was the work required & what was done? Page 219
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• Data • Models of Contract • Keeping the population well • Digital • Pathways General Practice Vision Programme: Vision & Objectives - Output ‘A sustainable General Practice across Grampian which enables people in their communities to stay well through the prevention and treatment of ill health’ Vision • Multi-Disciplinary Team • Continuity of Care • Premises • Mental Health & Wellbeing • Recruitment Retention & Education Page 220
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General Practice Vision Programme: Questions & Discussion Page 221
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REPORT TO: MORAY INTEGRATION JOINT BOARD ON 28 MARCH 2024 SUBJECT: CARE AT HOME SERVICE IN MORAY (MARCH 2024) BY: SERVICE MANAGER, PROVIDER SERVICES 1. REASON FOR REPORT 1.1 To provide the Board with an update on the delivery of the Care at Home Service in Moray and the current demands faced. 2. RECOMMENDATION 2.1 It is recommended that the Board: i) consider and endorse the actions being taken to continue to deliver Care at Home in Moray; and ii) consider and note the increasing demand on the Care at Home Service. 3. BACKGROUND 3.1 The Care at Home Service (Home Care) provides practical support and personal care, to people with an assessed need, to support them to live as independently as they can at home or in a homely setting in their community. 3.2 Care at Home (CAH) provision is one of the most challenging sectors within Health and Social Care. Social Care staff provide services to some of the most vulnerable in our communities. Citizens regularly face social isolation, difficulty with everyday tasks and mobility, long term health concerns and financial worries. 3.3 Self-Directed Support (SDS) is the way that care and support is delivered, making the principles of choice and control central to care and support, and giving individuals full opportunity to take control of their support and their lives.1 The Social Care (Self-directed Support) (Scotland) Act 2013 2 requires local authorities to offer people who are eligible for social care four choices concerning how they receive support, taking account of the amount of choice and control the supported person wants over their social care arrangements. Option 3 is the selection of support for the supported person by the local 1 https://www.gov.scot/publications/statutory-guidance-accompany-social-care-self-directed-support-scotland-act-2013- 2/pages/3/ 2 See the full 2013 Act here: https://www.legislation.gov.uk/asp/2013/1/enacted Item 11. Page 223
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authority, the making of arrangements for the provision of it by the authority and, where it is provided by someone other than the authority, the payment by the authority of the relevant amount in respect of the cost of that provision. In Moray, option 3 CAH services are delivered by the Health and Social Care Partnership’s own CAH or by our Partner, Care Quality Scotland (CQS). 3.4 Moray Integration Joint Board (MIJB) has an ongoing responsibility to ensure effective monitoring and reporting on the delivery of services and on the programme of work as set out in its strategic plan. There is also a requirement to identify any gaps in provision to inform the strategy for commissioning. 3.5 Weekly monitoring of the unmet need in CAH has been in place since August 2021. 3.6 In Spring 2023 a strategic review of current CAH arrangements was commissioned by HSCM Senior Management Team. 3.7 There is an ongoing review of the current contract with a focus on service improvement and sustainability. 3.8 As part of the review, a CAH Workshop was held on 4 March 2024 to revisit the vision “In Moray we want to empower people to live independent lives near the people and places that are important to them. We want to support people to regain their independence after a period of ill health or following a traumatic event.” 4. KEY MATTERS RELEVANT TO RECOMMENDATION Care at Home Position 4.1 Planned hours of care at home refers to the assessed package of care based on an assessment completed to assist individuals to meet their personal outcomes. 4.2 As of 25 February 2024, the planned weekly hours of care were 4752. Number of planned weekly hours (Feb 2023) Number of planned weekly hours (Feb 2024) Change % Internal Care at Home 3,550 3,871 +321 +9.04% Partner Provider 1,446 881 -565 -39.07% Total 4,996 4,752 -244 -4.88% Number of people supported (Feb 2023) Number of people supported (Feb 2024) Change % Internal Care at Home 289 325 +36 +12.46% Partner Provider 147 97 -50 -34.01% Total 436 422 -14 -3.21% Page 224
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4.3 A weekly care at home hub meeting was established in January 2023 with the aim of better understanding challenges faced in each locality and keeping track of where and how care is being provided, to understand risks faced by the service users and providers and to assist in developing strategies for improvement across the service. Performance information from these meetings is submitted weekly to the Collaborative Care Home Support Team Meeting, which oversees provision of care at home and care homes by internal and external services. An example can be seen in Appendix 1. 4.4 A Strategic Care at Home Group was set up in 2023 to look at the commissioning element of CAH and how internal services can support progress in this area. This is managed and progressed by the Commissioning Team, supported by the Locality Managers. 4.5 Internal CAH underwent an unannounced inspection between the 9-15 November 2023. This was the first inspection since 2020 and all six actions identified had been met in full, with the service being awarded the grade of five (very good) in the following categories: • How well do we support people’s wellbeing; • How good is out leadership; • How good is our staff team; and • How well is our care and support planned. The service was commended for having several projects ongoing, looking at innovative solutions to difficulties facing the care sector and improving people’s outcomes. Key Actions 4.6 Recruitment/Retention/Training: Since April 2023, 58 new staff have started in the service as shown in Appendix 1. It also shows 48 staff have left, the reasons for this are shown in figure 1 below. Figure 1 19 13 11 3 2 Family/Personal New Job Retirement Dismissal Other reason Reasons Employees have left Care at Home Service 2023/24 Page 225
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4.7 As a result of the CAH Practice Governance Forum, a new induction training programme has been developed, which is now held every 2 months, and has had excellent feedback from participants and CAH staff. This will continue to be collected after each course is completed, with a view to more formally reviewing the programme throughout 2024/25. 4.8 The retention rate in CAH remains high at 79% for staff that have joined the service since April 2023. Staff feedback gathered by the Care Inspectorate during the inspection was also incredibly positive about all aspects within the service. 4.9 External Partner: There has been significant work from Health and Social Care Moray (HSCM), with the help of internal services, to support the external partner. It is hoped that we will see substantial improvements during March and April 2024. The partner provider had a moratorium placed upon the service leading to a reduction in almost 60 packages of care since September. 4.10 Systems: The CAH service had to return to working manually after the cyber- attack in July 2022 on our IT provider, this proved resource intensive, and staff worked extremely hard to ensure continuity of service throughout. Looking forward, the service is considering the recent work of internal audit regarding Social Care & CareFirst System Information Governance Review and their recommendations to align with improved systems, which are essential to the running of a secure, efficient service for our staff and service users. 4.11 Proportional Care: HSCM are developing a model of assessment that will support safer moving and handling of people where multiple carers may be required. This will reduce the amount of resource required by better use of equipment and techniques. The expectation is that this will release capacity and efficiencies within the service. The project group aims to have started a phased roll out by the end of quarter two in 2024/25 and will update the Board in due course. 4.12 Quality Assurance: CAH have devised a Self-assessment tool based on the Care Inspectorate framework, which was highly commended as part of the Inspection process. 4.13 CAH Practice Governance Forum: A forum was established early in 2023 for internal CAH services. This is held on a weekly basis and ensures consistency, best practices, staff development, manages service and user risk and supports CAH to meet legislative requirements. 4.14 Home First: A focus group has been developed to allow the wider stakeholders to engage with the service. Once developed, further information around the Home First Project can be provided at a future date. Unmet Need in Moray 4.15 Despite taking a person-centred, outcome focussed approach to Care at Home Services, there are people who are not yet receiving their assessed package of care. 4.16 Figure 2, below, shows the number of hours of care that have not yet been provided, alongside the number of weekly hours of Social Care Assistant Page 226
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vacancies there are across the Care at Home service based on a budgetary figure. The figures show that even with a full complement of staff, there would still be a large number of hours the Health and Social Care Partnership cannot provide for. Figure 2 4.17 Included in Appendix 2 is the most recent map to show where those awaiting a care package live (or their home address if they are currently not residing at home). These figures can change daily and are summarised in the table below. HSCM Locality Number of people awaiting a care package Buckie, Cullen and Fochabers 69 Elgin 59 Forres and Lossiemouth 41 Keith and Speyside 34 4.18 From the Quarter 2 and 3 performance report which went to Audit, Performance and Risk committee on 29 February 2024 (para 5 of minute refers), the number of delayed discharges at the December 2023 snapshot was 37, this is an increase from 26 at the end of quarter 2. It was noted that delayed discharges for the winter (October – March) period showed a common trend with previous years. Daily huddles and increased multi-disciplinary team working are prioritising delayed discharge reduction work. 4.19 Moray has an aging population, according to census figures. In 2011, 18.5% of the population was over 65; in 2022, this had increased to 22.9%. On 4 March 2024, a workshop was held to look at the delivery of Care at Home in Moray. The outputs of this workshop are yet to be finalised, as they are currently being analysed and collated, however one of the themes emerging could be around better planning for the future to mitigate the rising future demand and following the Moray Model of Care shown below in Figure 3, there were discussions around upstream working and earlier engagement with communities (examples of which are detailed below). The examples described below would not be a quick fix; they would be a plan for the future of Moray and provide support to the current services that are not able to provide services due to the elevated level of demand. Page 227
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Figure 3 Care in Place Project3 - Care in Place is exploring better ways of sharing health and care information between carers, their cared for person, and anyone involved in meeting their needs. Making it easier and more efficient to access services, improve decision-making and prevent duplication. Using digital technology to relieve pressure on health and social care services and support unpaid carers. Digital Health & Care Innovation Centre (DHI) / Technology Enabled Care Assessments – With the use of a screening tool, Technology Enabled Care assessments could be introduced earlier, even prior to a need for formal services, could better support people to reduce the risk of harm and remain independent at home for longer. Communities/Active and Exercise/Social isolation/Family Support – By using the information within the joint strategic needs assessment, and by engaging Community Planning partners, GPs, local voluntary and third sector organisations, it is possible to evaluate the future needs of local communities and start to plan. Projects could range from lunch clubs to walking groups. In turn this could begin to tackle social isolation, and relieve some pressure being faced by families who are providing vital care to those close to them. Meals on Wheels – Research compiled by the University of Glasgow and Food Train4 detailed the cycle of risk for undernutrition and Household Food 3 Full details can be found at https://www.dhi-scotland.com/projects/rce-moray-living-labs-lab3/ 4 Exploring Household Food Security and Malnutrition Risk with Psychosocial Indicators of Healthy Ageing in Place: The Food Train - Eat Well Age Well Partnership Project (Kate Reid, 2020) Page 228
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Insecurity for Older Community Dwelling Older Adults (Kate Reid, 2020), shown in figure 4. Many of these risk factors can be mitigated by providing a hot meals service as Royal Voluntary Service (RVS) used to do in Moray, utilising volunteers, school meal provision, hospital canteen staff, and social care staff to little or no cost to Health and Social Care Moray but giving the community resilience and the means to remain safe and well at home. Alternatives could also be considered alongside lunch clubs or a meal makers initiative. Figure 4 Unpaid carer support/advice/groups – With further research into the current challenges faced by Moray’s unpaid carers, it would be possible to plan for local services to assist them. They provide a vital role in our local communities providing care that ensures it does not become the responsibility of Health and Social Care Services already under pressure. However, the physical and emotional toll should be recognised, and plans instigated to further support those who carry out this role. Planning for future respite provision would be essential. Page 229
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5. SUMMMARY 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 the Care at Home service align to those set out in the MIJB Strategic Plan and the Moray 10 Year Local Outcomes Improvement Plan. (b) Policy and Legal None directly associated with this report. (c) Financial implications None directly associated with this report. (d) Risk Implications and Mitigation There is a risk of potential harm to those who have been assessed as requiring care and support but who have not yet received that support. There is also a risk to families and unpaid carers whose own health and wellbeing may be impacted by the lack of care available. There is a risk of reputational damage to MIJB if these risks cannot be mitigated in some way. (e) Staffing Implications Staff absence levels are monitored on a weekly basis for both the internal CAH service and the partner provider. The internal CAH staffing retention levels are high, the feedback received by the Care Inspectorate from staff was exceptional despite the challenges faced on a daily basis. (f) Property None directly associated with this report. (g) Equalities/Socio Economic Impact An Equality Impact Assessment is not required because there will be no impact, as a result of the report, on people with protected characteristics. (h) Climate Change and Biodiversity Impacts No climate change or biodiversity implications have been determined for this policy/activity. It should be noted that extreme weather events, such as the recent storms, are expected to occur more frequently and with greater ferocity in future years. In the longer-term there are likely to be issues with the reduction in availability and increases in costs of fossil fuels that will pose challenges for the delivery of care services to people living in rural areas. (i) Directions There are no directions arising from this report. (j) Consultations For Health and Social Care Moray the Chief Officer, Corporate Officer, Head of Service, and Care at Home Team Manger have been consulted, Page 230
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as well as Caroline O’Connor, Committee Services Officer, Moray Council, and their comments are incorporated in the report. 6. CONCLUSION 6.1 This report outlines for the Board the actions being taken to continue to address the increasing demand for the Care at Home Service across Moray. It also provides members with an overview of the actions being taken in Care at Home to address the unmet need in the area and provides some information around potential for upstream working proposals. Author of Report: Aylsa Kennedy, Performance Officer Background Papers: Available on request Ref: Page 231
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In the graph below the available hours does not include any time spent not providing care, this includes, but is not limited to: - Sickness Annual Leave Any special leave (maternity etc) Breaks Travel time Collecting, refuelling and returning pool cars Any SCA admin duties Meetings Training Those only shadowing Supervisions/ERDP HSCM PS CAH Number of available hours after absences and travel v Number of planned weekly hours HSCM - PS - Care at Home Weekly reporting Number of weekly hours 3,7933,7933,793 3,7123,7123,712 3,7443,7443,744 3,7263,7263,726 3,6963,6963,696 3,7043,7043,704 3,6913,6913,691 3,6803,6803,680 3,7593,7593,759 3,7053,7053,705 3,7003,7003,700 3,7573,7573,757 3,6593,6593,659 3,6713,6713,671 3,6943,6943,694 3,7743,7743,774 3,8013,8013,801 3,8223,8223,822 3,8713,8713,871 3,9823,9823,982 3,392.4863,392.4863,392.4863,451.8423,451.8423,451.8423,554.9323,554.9323,554.932 3,372.9153,372.9153,372.9153,368.6743,368.6743,368.6743,329.3963,329.3963,329.396 3,935.6273,935.6273,935.627 4,208.6924,208.6924,208.692 3,919.5333,919.5333,919.5333,962.4813,962.4813,962.481 4,061.3074,061.3074,061.307 3,686.8913,686.8913,686.891 6,4106,4106,410 6,3686,3686,368 Planned care hours Number of available hours after breaks, absences and travel Number of hours available - budget 2022/23 WC Oct 29, 2023 WC Nov 5, 2023 WC Nov 12, 2023 WC Nov 19, 2023 WC Nov 26, 2023 WC Dec 3, 2023 WC Dec 10, 2023 WC Dec 17, 2023 WC Dec 24, 2023 WC Dec 31, 2023 WC Jan 7, 2024 WC Jan 14, 2024 WC Jan 21, 2024 WC Jan 28, 2024 WC Feb 4, 2024 WC Feb 11, 2024 WC Feb 18, 2024 WC Feb 25, 2024 WC Mar 3, 2024 WC Mar 10, 2024 2023/24 3k 4k 5k 6k 7k APPENDIX 1 Item 11. Page 233
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HSCM PS CAH Extra weekly hours and absence rate Values 7.504%7.504%7.504% 5.772%5.772%5.772% 8.081%8.081%8.081% 5.772%5.772%5.772% 5.772%5.772%5.772% 5.195%5.195%5.195% 6.927%6.927%6.927% 4.618%4.618%4.618% 1.732%1.732%1.732% 4.041%4.041%4.041% 6.35%6.35%6.35% 4.618%4.618%4.618% 2.309%2.309%2.309% 4.618%4.618%4.618% 4.618%4.618%4.618% 8.081%8.081%8.081% 8.081%8.081%8.081% 5.772%5.772%5.772% 6.927%6.927%6.927% 10.39%10.39%10.39% 12.122%12.122%12.122% 7.504%7.504%7.504% 5.772%5.772%5.772% 8.081%8.081%8.081% 5.195%5.195%5.195% 14.431%14.431%14.431% 8.405%8.405%8.405% 10.6%10.6%10.6% 11.165%11.165%11.165% 15.209%15.209%15.209% 8.464%8.464%8.464% 10.977%10.977%10.977% 8.967%8.967%8.967% 10.521%10.521%10.521% 13.191%13.191%13.191%816.96816.96816.96 968.4968.4968.4 1,073.771,073.771,073.77 1,000.731,000.731,000.73 713.22713.22713.22 893.04893.04893.04 1,037.221,037.221,037.22 1,122.381,122.381,122.38 1,244.71,244.71,244.7 1,063.61,063.61,063.6 842.2842.2842.2 974.39974.39974.39 970.79970.79970.79 834.8834.8834.8 1,068.21,068.21,068.2 822.29822.29822.29 767.3767.3767.3 831.59831.59831.59 764.51764.51764.51 1,038.171,038.171,038.17 926.76926.76926.76 773.47773.47773.47 929.14929.14929.14 860.45860.45860.45 1,012.491,012.491,012.49 846.89846.89846.89 517.69517.69517.69 351.94351.94351.94 451.1451.1451.1 539.99539.99539.99 436.75436.75436.754.041%4.041%4.041% 11.545%11.545%11.545% 13.276%13.276%13.276% 10.39%10.39%10.39% 11.545%11.545%11.545% 16.74%16.74%16.74% 8.659%8.659%8.659% 19.626%19.626%19.626% 23.089%23.089%23.089% 10.39%10.39%10.39% 16.163%16.163%16.163% 18.471%18.471%18.471% 16.163%16.163%16.163% 21.935%21.935%21.935% 14.431%14.431%14.431% 12.699%12.699%12.699% 17.431%17.431%17.431% 12.688%12.688%12.688% 7.459%7.459%7.459% 6.281%6.281%6.281% 6.069%6.069%6.069% Absence rate Number of extra hours worked Annual Leave % WC Mar 15, 2… WC Mar 22, 2023 WC Mar 29, 2023 WC Apr 5, 2023 WC Apr 12, 2023 WC Apr 19, 2023 WC Apr 26, 2023 WC May 3, 2023 WC May 10, 2023 WC May 17, 2023 WC May 24, 2023 WC May 31, 2023 WC Jun 7, 2023 WC Jun 14, 2023 WC Jun 21, 2023 WC Jun 28, 2023 WC Jul 5, 2023 WC Jul 12, 2023 WC Jul 19, 2023 WC Jul 26, 2023 WC Aug 2, 2023 WC Aug 9, 2023 WC Aug 16, 2023 WC Aug 23, 2023 WC Aug 30, 2023 WC Sep 6, 2023 WC Sep 13, 2023 WC Sep 20, 2023 WC Sep 27, 2023 WC Oct 4, 2023 WC Oct 11, 2023 WC Oct 18, 2023 WC Oct 25, 2023 WC Nov 1, 2023 WC Nov 8, 2023 WC Nov 15, 2023 WC Nov 22, 2023 WC Nov 29, 2023 WC Dec 6, 2023 WC Dec 13, 2023 WC Dec 20, 2023 WC Dec 27, 2023 WC Jan 3, 2024 WC Jan 10, 2024 WC Jan 17, 2024 WC Jan 24, 2024 WC Jan 31, 2024 WC Feb 7, 2024 WC Feb 14, 2024 WC Feb 21, 2024 WC Feb 28, 2024 WC Mar 6, 2024 1,500 300 600 900 1,200 0% 8% 16% 24% 32% Page 234
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HSCM Care at Home Hub - TMC Increases/Decreases -4-4-4 -8-8-8 000 -7-7-7 -5-5-5 000 000 -4-4-4 -1-1-1 -1-1-1 -2-2-2 -7-7-7 -47-47-47 -5-5-5 -9-9-9 -2-2-2 -4-4-4 -5-5-5 -11-11-11 -2-2-2 -2-2-2 -2-2-2 -2-2-2 -6-6-6 -7-7-7 -19-19-19 -7-7-7 000 000 000 -7-7-7 -2-2-2 -3-3-3 -5-5-5 -5-5-5 222222 999 232323 212121 111111 262626 191919 333 242424 393939 343434 393939 393939 232323 313131 181818 141414 151515 262626 272727 212121 252525 252525 141414 141414 151515 141414 222222 444 232323 464646 232323 333333 888 212121 191919 101010 404040 TMC Decreases TMC Increases WC Mar 14, … WC Mar 21, 2023 WC Mar 28, 2023 WC Apr 4, 2023 WC Apr 11, 2023 WC Apr 18, 2023 WC Apr 25, 2023 WC May 2, 2023 WC May 9, 2023 WC May 16, 2023 WC May 23, 2023 WC May 30, 2023 WC Jun 6, 2023 WC Jun 13, 2023 WC Jun 20, 2023 WC Jun 27, 2023 WC Jul 4, 2023 WC Jul 11, 2023 WC Jul 18, 2023 WC Jul 25, 2023 WC Aug 1, 2023 WC Aug 8, 2023 WC Aug 15, 2023 WC Aug 22, 2023 WC Aug 29, 2023 WC Sep 5, 2023 WC Sep 12, 2023 WC Sep 19, 2023 WC Sep 26, 2023 WC Oct 3, 2023 WC Oct 10, 2023 WC Oct 17, 2023 WC Oct 24, 2023 WC Oct 31, 2023 WC Nov 7, 2023 WC Nov 14, 2023 WC Nov 21, 2023 WC Nov 28, 2023 WC Dec 5, 2023 WC Dec 12, 2023 WC Dec 19, 2023 WC Dec 26, 2023 WC Jan 2, 2024 WC Jan 9, 2024 WC Jan 16, 2024 WC Jan 23, 2024 WC Jan 30, 2024 WC Feb 6, 2024 WC Feb 13, 2024 WC Feb 20, 2024 WC Feb 27, 2024 WC Mar 5, 2024 -100 -50 0 50 100 Page 235
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HSCM Care at Home Hub - people 444444 424242 484848 484848 454545 454545 474747 505050 525252 505050 494949 474747 474747 464646 474747 494949 505050 545454 565656 595959 595959 595959 565656 575757 555555 555555 505050 505050 515151 505050 474747 505050 494949 515151 505050 494949 494949 494949 484848 545454 656565 515151 666666 707070 666666 666666 666666 148148148 146146146 149149149 149149149 148148148 148148148 146146146 147147147 148148148 148148148 147147147 147147147 145145145 142142142 140140140 140140140 139139139 138138138 138138138 139139139 138138138 136136136 138138138 137137137 135135135 135135135 128128128 124124124 120120120 120120120 118118118 120120120 119119119 118118118 117117117 113113113 113113113 110110110 979797 969696 969696 989898 949494 939393 959595 979797 969696 304304304 307307307 307307307 307307307 308308308 311311311 312312312 313313313 311311311 316316316 316316316 318318318 312312312 313313313 311311311 312312312 309309309 308308308 307307307 309309309 311311311 308308308 310310310 308308308 311311311 311311311 315315315 318318318 315315315 314314314 311311311 307307307 305305305 305305305 307307307 313313313 310310310 309309309 308308308 301301301 306306306 308308308 314314314 317317317 320320320 325325325 326326326 START CQS Moray Council WC Apr 4, … WC Apr 11, 2023 WC Apr 18, 2023 WC Apr 25, 2023 WC May 2, 2023 WC May 9, 2023 WC May 16, 2023 WC May 23, 2023 WC May 30, 2023 WC Jun 6, 2023 WC Jun 13, 2023 WC Jun 20, 2023 WC Jun 27, 2023 WC Jul 4, 2023 WC Jul 11, 2023 WC Jul 18, 2023 WC Jul 25, 2023 WC Aug 1, 2023 WC Aug 8, 2023 WC Aug 15, 2023 WC Aug 22, 2023 WC Aug 29, 2023 WC Sep 5, 2023 WC Sep 12, 2023 WC Sep 19, 2023 WC Sep 26, 2023 WC Oct 3, 2023 WC Oct 10, 2023 WC Oct 17, 2023 WC Oct 24, 2023 WC Oct 31, 2023 WC Nov 7, 2023 WC Nov 14, 2023 WC Nov 21, 2023 WC Nov 28, 2023 WC Dec 5, 2023 WC Dec 12, 2023 WC Dec 19, 2023 WC Dec 26, 2023 WC Jan 2, 2024 WC Jan 9, 2024 WC Jan 16, 2024 WC Jan 23, 2024 WC Jan 30, 2024 WC Feb 6, 2024 WC Feb 13, 2024 WC Feb 20, 2024 WC Feb 27, 2024 WC Mar 5, 2024 WC Mar 12, 2024 0 25 50 75 100 Page 236
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HSCM PS CAH 012 Number of staff joining/leaving 666 444 888 999 131313 777 666 000 111 000 101010 000 -5-5-5 -2-2-2 -6-6-6 -4-4-4 -4-4-4 -4-4-4 -7-7-7 -3-3-3 -3-3-3 -8-8-8 -3-3-3 -4-4-4 Number of new staff Number of staff leaving March 2023 April 2023 May 2023 June 2023 July 2023 August 2023 September 2023 October 2023 November 2023 December 2023 January 2024 February 2024 -10 -5 0 5 10 15 Page 237
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HSCM PS CAH 010a/012a Number of hours lost/gained from staff joining/leaving in past 12 months 106106106 214.5214.5214.5 130130130 231.5231.5231.5 124124124 92.592.592.5 000 19.519.519.5 000 157.5157.5157.5 -19.5-19.5-19.5 -91-91-91 -94-94-94 -25.5-25.5-25.5 -97.2-97.2-97.2 -143-143-143 -39-39-39 -158.5-158.5-158.5 -47-47-47 -45.5-45.5-45.5 Hours gained from new staff appointments Hours lost from staff leaving April 2023 May 2023 June 2023 July 2023 August 2023 September 2023 October 2023 November 2023 December 2023 January 2024 February 2024 -200 -100 0 100 200 300 Page 238
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HSCM PS CAH Staff retention rate 100%100%100% 100%100%100% 100%100%100% 97%97%97% 92.5%92.5%92.5% 89%89%89% 84%84%84% 82%82%82% 82%82%82% 82%82%82% 79%79%79% CaH Staff retention rate for current financial year April 2023 May 2023 June 2023 July 2023 August 2023 September 2023 October 2023 November 2023 December 2023 January 2024 February 2024 0% 25% 50% 75% 100% Page 239
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Care at Home Staff Vacancy hours vs unmet need weekly hours Number of weekly hours Care at Home Staff Vacancy hours vs Unmet need total hours 690690690 624.5624.5624.5 741741741 689.5689.5689.5 1,5001,5001,500 1,5031,5031,503 2,0642,0642,064 1,8151,8151,815 Care at Home Staff Vacancy hours - Target Care at Home Staff Vacancy hours Total Unmet need hours Q1 2023/24 Q2 2023/24 Q3 2023/24 Q4 2023/24 0 500 1,000 1,500 2,000 2,500 Page 240
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Indicators ... Code & Title Gauge Value Target HSCM PS CAH 001x Number of available weekl… 4,297.49 HSCM PS CAH 001y Number of available weekl… 4,687.01 HSCM PS CAH 001z Number of weekly hours of… 389.52 HSCM PS CAH 010 Number of new staff 0 HSCM PS CAH 010a Number of hours gained fr… 0 HSCM PS CAH 012 Number of staff who have le… -4 HSCM PS CAH 012a Number of hours lost from … -45.5 HSCM PS CAH 012c Care at Home Staff retenti… 79% HSCM PS CAH 020 Care at Home Staff Absenc… 13.19% 4% HSCM PS CAH 020a Care at Home Staff Annual… 12.81% 13% HSCM PS CAH 021 Care at Home Staff Vacanc… 689.5 446 HSCM PS CAH 111 Number of additional weekly… 436.75 HSCM PS CAH 300a Total number of Homecare… 3,982 HSCM PS CAH 300d Number of people receivin… 326 Report Title Output Format Last Generated HSCM - CaH Weekly Rpt Word (.doc) 08 Mar 2024 HSCM - CaH Weekly Rpt HTML HTML 17 Nov 2023 Page 241
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34 41 69 59 -Unmet Service Recipient Distribution 1:375,000 @ A4 © Crown copyright [and database rights] 2024 OS AC0000806936 Moray Council. You are permitted to use this data solely to enable you to respond to, or interact with, the organisation that provided you with the data. You are not permitted to copy, sub-license, distribute or sell any of this data to third parties in any form. Third party rights to enforce the terms of this licence shall be reserved to OS. Legend Moray Boundary HSCM Locality Buckie Cullen Fochabers Elgin Forres and Lossiemouth Keith and Speyside APPENDIX 2 Item 11. Page 243
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MINUTE OF MEETING OF THE AUDIT, PERFORMANCE AND RISK COMMITTEE Thursday, 26 October 2023 Council Chambers, Council Office, High Street, Elgin, IV30 1BX PRESENT Mr Simon Bokor-Ingram, Mr Sean Coady, Ms Sonya Duncan, Councillor Scott Lawrence, Mr Derick Murray, Ms Deborah O'Shea, Mr Sandy Riddell, Councillor Ben Williams APOLOGIES Mr Stuart Falconer, Mr Graham Hilditch IN ATTENDANCE Public Sector Audit Director - Scotland, Grant Thornton UK LLP, Chief Internal Auditor, Provider Services Manager, Social Work Services Manager, Caroline O’Connor, Committee Services Officer and Lissa Rowan, Committee Services Officer. 1. Chair The meeting was chaired by Councillor Scott Lawrence. 2. Declaration of Member's Interests The Committee noted there were no declarations of member's interests. 3. Welcome and Apologies The Chair welcomed Councillor Ben Williams to his first meeting of the Audit, Performance and Risk Committee who was replacing Councillor John Divers. The Committee joined the Chair in thanking Councillor Divers for all his work over the years in relation to the Committee and Moray Integration Joint Board. 4. Minutes of meeting of 31 August 2023 The minutes of the meeting of 31 August 2023 were submitted and approved. Page 245
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5. Action Log of Meeting of 31 August 2023 The Action Log of the meeting of 31 August was discussed and updated accordingly. 6. Quarter 2 (July to September) Performance Report The meeting had before it a report by the Corporate Manager advising the Committee that due to timetabling and data release conflicts, the Quarter 2 (July to September 2023) performance report will be presented to the Committee on 29 February 2024. Mr Riddell, whilst acknowledging the timetabling issues, welcomed the detail in the report including examples of upstream initiatives and specifically the reference to the social care assessments test of change which has become business as usual. The Chief Officer, adding to Mr Riddell's comments, provided an update regarding the Scottish Government announcement on funding relating to the NHS Scotland Winter Plan which had been published and provided an opportunity to bid for funding to expand hospital at home. A pan Grampian comprehensive and cohesive final bid is being prepared for submission by the end of the week. More detail will be provided to the Moray Integration Joint Board meeting at the end of November, by which time the outcome of the bid will be known, including whether any funding is recurring. Following consideration the Committee agreed to note:- i. the performance of local indicators for Quarter 2 (July to September 2023) will be presented at APR Committee in February 2024; and ii. the update on Unmet Need data. 7. Internal Audit Section Update Report The meeting had before it a report by the Chief Internal Auditor asking Committee to consider the contents of this report; seek clarification on any points noted and otherwise note the report. Following consideration the Committee agreed to note the audit update. 8. Strategic Risk Register The meeting had before it a report by the Chief Officer providing an overview of the current strategic risks, along with a summary of actions which are in place to mitigate those risks, updated in October 2023. In response to the Chair's query regarding what mechanism would be in place for risks/issues raised in the period between biannual updates, the Chief Officer agreed focussed updates on particular risk areas with the full register attached be presented to intervening Committee meetings. Following consideration the Committee agreed to: i. note the updated Strategic Risk Register included in Appendix 1; Page 246
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ii. a change to the reporting schedule of the Strategic Risk Register, allowing to report biannually instead of quarterly with specific risk updates to be presented to intervening meetings. This will allow time for development, planning and improvement of the Register content; and iii. note that any significant changes to the register outwith the reporting cycle would be presented at the first opportunity. 9. External Auditors Report to Those Charged with Governance The meeting had before it a report by the Chief Financial Officer requesting the Committee consider the reports to those charged with governance from the Board’s External Auditor for the year ended 31 March 2023. Mr Murray noted that the audit highlights the mounting financial sustainability challenges. The Chief Officer acknowledged the deficit related to a historical annual structural deficit pre covid with inflationary costs since and is now compounded with the huge pressures facing both funding partners, namely the NHS and Council. In response to a query raised by the Chair regarding audit recommendation dates not being implemented, the Chief Internal Auditor advised there is a mechanism in place to follow up on recommendations which are reported to Committee, however appreciated the increasing demands on services which can result in slippages. In response to the Chair raising whether NHS Grampian internal audit reports will be reported to this Committee, the Chief Internal Auditor advised work is ongoing to resolve the issue. Following consideration the Committee agreed to note the reports from the External Auditor within Appendices 1 and 2. 10. 2022-23 Audited Annual Accounts The meeting had before it a report by the Chief Financial Officer submitting to Committee the Audited Annual Accounts for the year then ended 31 March 2023. Mr Murray highlighted two grammatical errors, the first on page 142 and the second on page 152 which were noted and will be be amended. The Committee joined the Chair in thanking the Chief Financial Officer for the work undertaken preparing the accounts. Following consideration the Committee agreed to approve the Audited Annual Accounts for the financial year 2022/23 and the letter of Representation. 11. Internal Audit Section Completed Projects Report The meeting had before it a report by the Chief Internal Auditor providing an update on audit work completed since the last meeting of the Committee. Following consideration the Committee agree to note the audit update. 12. Update on Improvement Plan for Adult Social Care Commissioning Page 247
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The meeting had before it a report by the Head of Service / Chief Social Work Officer updating the Committee of progress regarding the Improvement Plan for Adult Social Care Commissioning in line with the external review conducted by KPMG, finalised in February 2023 since the last Committee meeting on 31 August 2023. Following consideration the Committee agreed to:- i. approve the updated Improvement Plan attached at Appendix 1; and ii. note the progress within this report as at the end of September 2023 in relation to the recommendations detailed in the Improvement Plan. Page 248