Agenda Document Pack - Moray Integration Joint Board - 30/05/2024
Moray Council · 30 May 2024
Back to Moray Integration Joint Board — 30 May 2024 and its agenda
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Moray Integration Joint Board Thursday, 30 May 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, 30 May 2024 at 09:30 to consider the business noted below. AGENDA 1. Welcome and Apologies 2. Declaration of Member's Interests 3. Minute of meeting of 28 March 2024 5 - 10 4. Action Log of 28 March 2024 11 - 12 5. Chief Officer Report 13 - 26 6. Revenue Budget Outturn for 2023-24 27 - 48 7. Revenue Budget and Recovery Plan 2024-25 49 - 68 8. Strategic Risk Register Report 69 - 80 9. Annual Report of the Chief Social Work Officer 2023-24 81 - 116 10. Moray Alcohol and Drug Partnership Scottish Government Annual Reporting Survey Report 117 - 152 11. Analogue to Digial Telecare Transition Report 153 - 160 12. Recruitment and Selection Process for an Interim and Subsequent Permanent Chief Officer Report 161 - 164 Page 1
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13. Membership of Board and Committees Report 165 - 170 14. General Adult Mental Health Secondary Care Pathway Review Report 171 - 262 Item(s) which the Board may wish to consider with the Press and Public excluded 15. Financial Recovery Plan 2024-25 - Confidential • 1. Information relating to staffing matters; Page 2
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MORAY INTEGRATION JOINT BOARD SEDERUNT Councillor Tracy Colyer (Chair) Mr Dennis Robertson (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) Mrs Sheila Brumby (Non-Voting Member) Mr Sean Coady (Non-Voting Member) Ms Jane Ewen (Non-Voting Member) Ms Deirdre McIntyre (Non-Voting Member) Ms Janette Topp (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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MORAY COUNCIL Minute of Meeting of the Moray Integration Joint Board Thursday, 28 March 2024 Council Chambers, Council Office, High Street, Elgin, IV30 1BX PRESENT Mr Ivan Augustus, Councillor Peter Bloomfield, Mr Simon Bokor-Ingram, Mr Sean Coady, Councillor Tracy Colyer, Ms Sonya Duncan, Ms Jane Ewen, Councillor Scott Lawrence, Dr Robert Lockhart, Mr Derick Murray, Ms Deborah O'Shea, Mr Sandy Riddell, Mr Dennis Robertson, Dr Malcolm Simmons, Ms Tracy Stephen, Mr Kevin Todd, Councillor Ben Williams APOLOGIES Professor Duff Bruce, Mr Roddy Burns, Mr Adam Coldwells, Ms Deirdre McIntyre, Ms Elizabeth Robinson IN ATTENDANCE Ms Sheila Brumby, Third Sector Representative substitute; General Manager, Dr Gray's Hospital; Director of Planning and Performance, Digital Health and Care Innovation Centre (DHI) Scotland; Lead Pharmacist Primary Care, Moray Health and Social Care Partnership (HSCP); Consultant Psychiatrist and Clinical Lead; Primary Care Development Manager, Aberdeen City HSCP; Locality Manager; Service Manager, Provider Services; 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. Councillor Williams stated for transparency a member of his family was employed by an organisation involved in Item 5 on the agenda, however this did not relate to the aspects included in the report and would therefore remain in the meeting. The Board noted that there were no other declarations of member's interests. 3. Minute of meeting of 25 January 2024 The minute of the meeting of 25 January 2024 was submitted and approved. 4. Action Log of 25 January 2024 The Action Log of the meeting of 25 January 2024 was discussed and updated accordingly. Page 5
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5. 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. 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 for delivering within the budget, with our two funding partners, Moray Council and NHS Grampian, under considerable financial pressure as well. The Chair asked, in relation to the pausing of Ward 4 anti-ligature work project, what immediate mitigations were in place for those requiring the services from Ward 4 to meet the needs in the interim in order to provide assurance to the Board. In response the General Manager, Dr Gray's advised there are range of environmental control measures already in place which have reduced the risk of ligature related safety incidents, noting further work was required to reach the level required by the Health and Safety Executive. He further advised the team are keen to develop a community model to enhance and support patients to reduce reliance on hospitalisation and this would form part of the risk assessment and investment considerations by the Short Life Working Group. Mr Riddell asked for assurance on behalf of the Board in relation to both the anti- ligature work and development of mental health pathways, that the Mental Health Welfare Commission, Health and Safety Executive and relevant department of the Scottish Government are fully sighted on what can be done within the funding network. In response the General Manager, Dr Gray's advised part of the asset management process will be clearly communicating what cannot be done along with the risks to the Scottish Government, key stakeholders and patients. Councillor Lawrence asked, in relation to Moray Growth Deal and Rural Centre of Excellence (RCE) for digital health care and innovation, for feedback on how Living Lab 5 (Mental Wellbeing) will assist with early intervention given that issues often start at an early age. In response and during the course of an update from the Director of Planning and Performance, DHI-Scotland, she advised Living Lab 5 is the least developed project and relates to all other Living Labs and is about preventing mental health escalating as far as possible. LL5 will commence in mid 2024. DHI are working with the wellbeing communities in Moray and a further update will be provided when more developed. 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. 6. Order of Business Page 6
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The Chair sought agreement from the Board that Item 7 would be taken after Item 8 on the agenda to allow the Lead Pharmacist Primary Care, MHSCP to join the meeting to present the report. This was unanimously agreed. 7. Revenue Budget Monitoring Quarter 3 for 2023-24 The meeting had before it a report by the Chief Financial Officer updating the Board of the current Revenue Budget reporting position as at 31 December 2023 for the Moray Integration Joint Board budget. Mr Riddell expressed concern relating to the approved savings plan where savings achieved were far less than the target. In response the Chief Financial Officer advised there had been some ambitious targets set at the start of the year which had not come to fruition however other targets had been exceeded. Following lengthy consideration the Board unanimously agreed to:- 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 show in Appendix 3; and vi) approve for issue, the Directions arising from the updated budget position shown in Appendix 4. 8. Revenue Budget 2024-25 The meeting had before it a report by the Chief Financial Officer outlining the budget allocations to the Moray Integration Joint Board (MIJB) and considering the revenue budget for 2024/25, the estimated funding gap and the charges. Mr Murray expressed concern that the Board was not meeting its legal obligations to set a balanced budget. In response the Chief Financial Officer advised it is acceptable to have a working budget to identify how the savings will be made to balance the budget which will come back to the Board in May. Concern was raised by a number of members of Board regarding how realistic the timescales were for implementing significant change to deliver savings. In response the Chief Officer advised there are gateways in place which have already generated savings and the time will be used between now and May to engage with stakeholders to inform impact assessments. Page 7
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Following lengthy consideration the Board unanimously agreed to:- 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 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 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. 9. Primary Care Prescribing Budget for 2024-25 The meeting had before it a report by the Lead Pharmacist, Health and Social Care Moray informing the Board of the predicted prescribing budget resource requirements for 2024-2025, alongside key drivers of growth and mitigations regarding costs. Following consideration the Board unanimously agreed to note:- i) the recommendations made in the paper regarding volume, costs, risks and the net predicted need for a budget source 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. 10. Mental Health Pathway Mapping The meeting had before it a report by the Interim Integrated Service Manager, Mental Health and Drug and Alcohol Service updating the Board on progress on the Mental Health Pathway Mapping exercise and implementation of the Moray Page 8
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Mental Health Strategy as discussed at the Moray Integration Joint Board (MIJB) development session on 26 October 2023. Mr Riddell raised a number of concerns he had with the report, namely there being no timescale stated as to when the Strategic Oversight Group would report back to the Board, confusion around the role of Board as he would expect that experts in adult and children's services would draft a model and transitions for discussion at the Board and lastly, the details relating to waiting times at 3.15 were at odds with what was reported to the last Audit and Performance Review Committee asking for clarification regarding the figures provided to provide assurance to the Board. In response the Consultant Psychiatrist and Clinical Lead agreed with the points raised and agreed clarity would be provided in an updated report back to the Board. Councillor Bloomfield asked what the actions and outcomes are from the five key themes and principles as it was unclear from the report and asked for the reason for the age range of 25-64 in para 3.8 as the needs of individuals at either end of the ranges were very different. In response the Consultant Psychiatrist and Clinical Lead advised he would ensure these points would be addressed in the updated report. In response to a query from Dr Lockhart as to why there was no mention of adult Attention Deficit Hyperactivity Disorder (ADHD) in the report, the Consultant Psychiatrist and Clinical Lead confirmed he would ensure this was added to the updated report. The Chair noted the report was disappointing and asked for a more detailed report providing clarity on the points raised be prepared for the Board meeting on 27 June and the author of the report attend the meeting to answer any questions. There being no one otherwise minded the Board unanimously agreed, given members of the Board felt it was a disappointing paper and did not provide the clarity the Board would seek, that a full report providing clarity on all the points raised be prepared for the Board meeting on 27 June. 11. General Practice Vision and Objectives The meeting had before it a report by the Programme Manager, GP Vision Programme informing 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. Following consideration the Board unanimously agreed to:- i) approve the vision and objections for General Practice in Grampian as set out in Appendix A; and ii) instruct the Chief Officer to report back to the MIJB by the end of March 2025 with a progress update on the implementation of the vision and objectives. 12 Care at Home Service in Moray Page 9
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The meeting had before it a report by the Service Manager, Provider Services providing the Board with an update on the delivery of the Care at Home Service in Moray and the current demands faced. Following consideration the Board unanimously agreed to:- i) endorse the actions being taken to continue to deliver Care at Home in Moray; and ii) note the increasing demand on the Care at Home Service. Page 10
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MEETING OF MORAY INTEGRATION JOINT BOARD Thursday 28 March 2024 ACTION LOG ITEM NO. TITLE OF REPORT ACTION REQUIRED DUE DATE ACTION BY UPDATE FOR 30 MAY 2024 1. 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 2. 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. Balanced budget to be reported to Board on 30 May. 30 May 2024 SBI/DO 3. Mental Health Pathway Mapping Detailed report to be prepared for June Board meeting providing clarify on all issues raised by the Board and author to attend June Board meeting. 27 Jun 24 KK Page 11
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ITEM NO. TITLE OF REPORT ACTION REQUIRED DUE DATE ACTION BY UPDATE FOR 30 MAY 2024 4. Care at Home In Moray More detail/context to be added relating to graphs in future reports, clarity to be provided re planned care hours being double the number of hours available in the budget and further data on the reasons for employees leaving to be distributed to the Board. JC Page 12
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REPORT TO: MORAY INTEGRATION JOINT BOARD ON 30 MAY 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 is 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 Efforts continue to reduce people delayed in their discharge from hospital. A Day of Care audit was carried out for community hospitals, showing a reduction in patients in community hospitals who were medically fit for discharge. In last year’s audit 72% of patients were medically fit for discharge but were still in a community hospital bed, with this year’s audit showing a result of 61%. 3.2 The two Nurse Practitioners have been dividing their time between acute and community work and are working closely with GP’s and community teams. The Strategic Flow Multi-disciplinary Team continues to meet daily, allowing for collective decision making to ensure patients with complex needs transition Page 13
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appropriately through our services. There have been some excellent examples of multi-disciplinary working that have enabled patients who would have previously been delayed, to move seamlessly through the system. Care at Home Workshops continue on a monthly basis. Vaccination Programme 3.3 The Autumn / Winter Vaccination Programme for Covid-19 and Flu completed at the end of March 2024. The final uptake for the Covid-19 Vaccination for Moray was 60% which was above the Scottish average of 56.5% with Flu Vaccination uptake for Moray being 58.3%, again this was above the Scottish average of 53.7%. 3.4 The Covid-19 Spring 2024 Programme commenced as of 2 April 2024 and will run until 30 June 2024. The schedule for this programme commenced with Care Home Residents and those citizens that are house bound and eligible for the booster. Those citizens that are 75years and over will be offered clinic or outreach appointments. Those aged 6 months to 74years and identified as having a weakened immune system, will also be allocated appointments or prompted to book appointments. The Vaccination Team across Moray are working hard to deliver the Spring Programme across all the eligible cohorts with a current 27.2% update in Moray which is currently exceeding the national uptake of 22.1% across Scotland. 3.5 The aim of the Covid-19 vaccination Programme has to date been the prevention of severe Covid-19 disease and hospitalisation in this most at risk within our population. For 2024 this remains the same aim however, moving forward the programme will start to transition from a pandemic response to that of routine immunisation. 3.6 The recent Health and Social Care Workforce survey results have been shared with the Scottish Vaccination and Immunisation Programme with final analysis underway and a draft national report awaited. Once this is finalised it is envisaged that local management information reports will be available and shared. The final report will also be published on the Public Health Scotland website. 3.7 Apart from the Spring Covid-19 vaccination programme there are other vaccination programmes currently running including: - Shingles Vaccination with a revised two dose schedule for eligible cohorts. - Pneumococcal Vaccination Programme - Pre-school and School aged Vaccination Programme 3.8 The Vaccination Team continue to receive new advice from the Joint Committee on Vaccination and Immunisation (JVCI), recommending the introduction of new programmes including the Respiratory Syncytial Virus (RSV) vaccination with a programme planned for order adults and infants. Ward 4 anti-ligature work and installation of MRI scanner at Dr Gray’s Hospital 3.9 Following discussion at the January 2024 MIJB meeting, and further to the Scottish Government announcement in December 2023 in relation to their Page 14
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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. With the anti-ligature work planned to be carried out concurrently to the MRI installation, and funded as part of that project, this now puts the completion of the ligature reduction work at risk. 3.10 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 that process, and the expectation is that there will be a decision by the end of May 2024. Annual Whistleblowing update 3.11 The Independent National Whistleblowing Officer (INWO) introduced the standards in April 2021. They provide clear guidelines for raising concerns and protecting those who come forward with information. All HSCP staff, including those from local authorities and the NHS, as well as students, trainees, agency staff, and volunteers, should be able to raise concerns through this procedure. 3.12 NHS Grampian and Moray Council, as employing organisations, have a duty to report to the INWO annually. These reports also pass through their own staff governance structures. Additionally, HSCM includes updates and data in their annual performance report, and any cases are reported to MIJB (Moray Integration Joint Board) quarterly. 3.13 In the 2023/24 financial year, Health and Social Care Moray recorded 2 contacts under the Whistleblowing policy. One of these contacts was with NHS Grampian, with the other being with Moray Council. 3.14 The issue raised with NHS Grampian was a matter of concern, emphasising the need for focus on process improvement. HSCM upheld this concern, and the identified improvements are currently being implemented. This process did not involve patient care or contact. 3.15 The report to Moray Council is currently being expedited and is not yet concluded. Aberlour Medical Centre Update 3.16 Health and Social Care Moray (HSCM) has taken over the running of Aberlour Medical Practice to ensure continued access to primary care services for the community. 3.17 HSCM took over the management of Aberlour Health Centre as a 2C practice on the19 February 2024 after the GMS contract was handed back. The contract for Aberlour Health Centre will now be advertised as part of the NHS Grampian tendering process. This is to be progressed as a Note of Interest Request to all Grampian practices, and once we have received responses to Page 15
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this, we will ask interested parties to submit a detailed business case outlining how they would intend to deliver services to the Aberlour population. 3.18 A panel will be set up to review these business cases. We anticipate this piece of work will take a minimum of 3-6months to bring to conclusion. In the meantime, the HSCM continue to run the Health Centre with a team making improvements and managing the day to day running of the practice. 3.19 We held an engagement event with approximately 180 patients attending on 18 March. Following this event, we have 46 completed questionnaires returned, which has given us valuable insights into what it has been like to be a patient at the Aberlour Practice, and what is important to people as we progress on the improvement journey and the tender process. Lossiemouth Locality update 3.20 The Cabinet Sectary for Health and Social Care commissioned a review to seek learning from the process of engagement and consultation carried out by HSCM in relation to the closure of the Burghead and Hopeman Branch Surgeries. In the last Chief Officer report there was an update on the process undertaken to date. A draft report has been developed, and once finalised and issued this will then be shared with the MIJB. We still await the finalised report. Management capacity 3.21 In the last Chief Officer report we had started a recruitment process for the Chief Nurse post. That post has been successfully recruited to, and the post holder will commence on the 3 June 2024. 3.22 The recruitment to the Chief Officer post is the subject of a separate report on today’s meeting agenda. 3.23 A number of internal moves are being enacted to provide capacity for the budget challenge. A programme office approach is being taken to support and monitor the achievement of savings. The budget is the subject of a separate report on today’s meeting agenda. External Inspections of our services 3.24 A number of inspections of our services have taken place and were reported to the last meeting of the Clinical and Care Governance Committee on the 28 March 2024, which the Committee wished to highlight to the Board. 3.25 The inspection for Children at Risk of Harm had many elements assessed, with Inspectors using a six-point scale to provide a formal evaluation of just one quality indicator, 2.1 impact on children and young people. This indicator focuses solely on the experience and feelings of children and young people at risk of harm. It relates to the differences services are making to their lives and future life chances. It includes measuring the impact of services aimed at optimising the wellbeing of children and young people against the wellbeing indicators. This indicator was rated as Adequate. 3.26 In December 2023, the Care Inspectorate carried out an unannounced inspection of the Moray Council’s Care Home at the Residential Child Care Service located at CALA. There were no new areas identified for improvement for the service in this report. All areas for improvement from previous Page 16
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inspection reports had been met, demonstrating that the service is actively reviewing and improving practices through listening to those receiving a service (including their families), and those providing it. The inspection focused on how well we support children and young people’s rights and wellbeing, with a rating of 5 being awarded, which is “very good”. 3.27 In November 2023, Care Inspectors carried out a full unannounced inspection of the Moray Council Care at Home Service. A number of areas of strength were cited in the report, including the service being commended for having several projects ongoing, looking at innovative solutions to the difficulties facing the care sector and improving peoples’ outcomes. The focus was on the following themes, with ratings awarded: How well do we support people's wellbeing? 5 – Very Good How good is our leadership? 5 – Very Good How good is our staff team? 5 – Very Good How well is our care and support planned? 5 – Very Good Moray Growth Deal and the Rural Centre of Excellence (RCE) for digital health and care innovation 3.28 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. Page 17
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5. SUMMARY OF IMPLICATIONS (a) Corporate Plan and 10 Year Plan (Local Outcomes Improvement Plan (LOIP)) and Moray Integration Joint Board Strategic Plan “Partners in Care 2022 – 2032” 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 Chief Finance Officer continues to report regularly. There is an ongoing requirement to find efficiencies and to demonstrate best value for money. (d) Risk Implications and Mitigation The risk of not redesigning services will mean that HSCM and the Moray Portfolio cannot respond adequately to future demands. (e) Staffing Implications Staff remain the organisation’s greatest asset, and 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. Page 18
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(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. Author of Report: Simon Bokor-Ingram, Chief Officer, Moray Portfolio Page 19
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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 May 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 1 Page 21
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Digital Health & Care Innovation Centre, 1st Floor, Suite B, Inovo Building, 121 George Street Glasgow, G1 1RD RCE Activity Update March 2024 to May 2024 Living Lab Updates LL1 Supported Self-Management and LL2 Long Term Condition Management (NHS), have now been aligned to share a common infrastructure while retaining their individual outputs. These will now be delivered over three campaigns with campaign 1 offering patients (Initially from Elgin Health Centre) living with high BMI and/or type 2 diabetes access to trusted digital tier 1 self-management information via the Community Connections @ Moray (CC@M) platform, with the option to self-refer to community facilities for non- clinical weight management and lifestyle support (Initially Moray Leisure Centre) as shown in figure 2. Campaigns 2 and 3 will continue to develop clinically guided pathways ready for testing once campaign 1 is completed and evaluated. These will focus on the management and support of the campaign 1 cohort directing them to the most appropriate service at any given point in their journey across dietetic and diabetic clinical services, and community or online based non-clinical support based on personal data store information. LL2 Long Term Condition Management (Community): This pathway focuses on the development of digital tools to support the Community Occupational Therapy Service via self and supported self-management assets. The steering group will commence in May and a working group will be set up to design and create the content for self-management via the CC@M platform. The current call to industry will close on 27/5/24 and seeks a development partner to support triage of referrals to the OT service, and the option of digital assessment Page 22
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Digital Health & Care Innovation Centre, 1st Floor, Suite B, Inovo Building, 121 George Street Glasgow, G1 1RD where appropriate for lower-level need aimed at reducing waiting times for basic equipment provision. LL3 Care in Place: Final iteration of the R&D Community Connections platform and Personal Data Store assets are nearing completion with both R&D assets now live. This lab will move to a phased real world evidence stage in the next few weeks for a minimum of 6 months across the Forres and Lossiemouth areas with a focus on unpaid carers and frailty. An evaluation framework is being implemented to support this. LL4 Smart Housing/Smart Communities: The first steering group was held on 7th of May, with a broad group of stakeholders representing health and social care, digital office, RCC, housing and third sector. Working groups will now be set up to manage each of the following R&D pathways: • Development of smart housing specification for new builds and telecare services • Population stratification platform for holistic data collection, analysis, and alerting • Development of an exemplar smart enabled, low-carbon, low-cost modular house The RCE continues to work closely with the Moray Analogue to Digital(A2D) project and aims to collaboratively develop, test, and evaluate alternative device and platform options to achieve improved proactive/predictive outcomes for citizens and services. This will allow the partnership to consider innovative service redesign and procurement opportunities as part of the required replacement of the remaining Moral Lifeline analogue Telecare devices with digital devices by December 2025. RCE are also exploring R&D opportunities with the 5G Smart Rural project based in Hunty, which aims to evidence the effectiveness of a connectivity infrastructure in rural/ poor signal areas for transmission of data via Internet of Things (IOT) enabled devices which can be used to gather data related to activity, health, and environment. LL5 Mental Wellbeing: Engagement is ongoing with statutory, and third sector services to agree most beneficial scope for this living lab. Skills and Workforce Development The University of Oxford have now completed their review of workforce training tools to identify gaps in Moray, with a focus on innovation skill and needs. The findings are now being reviewed and will inform the next skills grant scope in order to publish an academic call later this year. Health and Social Care VR Learning Grant application was successful. This grant provides 12 weeks of free access to the FLO platform which comprises a range of immersive learning content tailored specifically for the health and social care sector. Page 23
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Digital Health & Care Innovation Centre, 1st Floor, Suite B, Inovo Building, 121 George Street Glasgow, G1 1RD Micro-credentials (Digital Essentials for Carers) - Delivery of Unit 3 (Digital Care: the Moray Context) has been agreed for 17th May 2024. Robertson Trust Internship (to support Moray RCE team) - officially starting on a 3-day a week basis from early June – 9th Aug. Potential collaboration opportunities with Young Minds Saves Lives: Scottish Ambulance Service (SAS) project aimed at teaching S3 students about responding to medical emergencies (such as CPR) and raising awareness about healthcare career options and volunteering opportunities. Comms and Engagement A ‘U ’ partners; Mydex CIC & Archangel, with the win announced at the annual conference on the 1 M B . UK’ herefore provided great exposure for the RCE programme. An exclusive for P&J newspaper was published on the 16th of March 2024, which also received front page coverage on other local news outlets. A Facebook/Instagram campaign was launched in tandem to the P&J article to target people to sign up to citizen panel alongside four information events which took place w/c 18th March which were well received. Fortnightly GSA Led co-design sessions scheduled; Burghead on 27th May, Buckie on 21st June 2024 for general theme topics such as delegated access and digital security. A full schedule is being developed. RCE also has a space in GSA summer show on 14/15th June and will treat as a pop-up engagement Evaluation Page 24
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Digital Health & Care Innovation Centre, 1st Floor, Suite B, Inovo Building, 121 George Street Glasgow, G1 1RD A logic model 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 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 25
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REPORT TO: MORAY INTEGRATION JOINT BOARD ON 30 MAY 2024 SUBJECT: REVENUE BUDGET OUTTURN FOR 2023/2024 BY: CHIEF FINANCIAL OFFICER 1. REASON FOR REPORT 1.1 To inform the Moray Integration Joint Board (MIJB) of the unaudited financial outturn for 2023/24 for the core budgets and the impact this outturn will have on the 2024/25 budget. 2. RECOMMENDATIONS 2.1 It is recommended that the MIJB: i) consider and note the unaudited revenue outturn position for the financial year 2023/24, ii) consider and note the impact of the 2023/24 outturn on the 2024/25 revenue budget; and iii) approve for issue, the Directions shown in APPENDIX 4 to NHS Grampian and Moray Council. 3. BACKGROUND 3.1 The overall position for the MIJB is that core services were overspent by £10,023,949 as at 31 March 2024. The MIJB’s unaudited financial position for the financial year ending 31 March 2024 is shown at APPENDIX 1. This is summarised in the table below. Annual Budget £ Actual Expenditure £ Variance to date £ MIJB Core Service 169,844,600 179,868,549 (10,023,949) MIJB Strategic Funds & other resources 13,898,336 6,897,942 7,000,394 Set Aside Budget 14,665,000 14,665,000 0 Total MIJB Expenditure 198,407,936 201,431,491 (3,023,555) Page 27
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A list of services that are included in each budget heading are shown in APPENDIX 2 for information. 4. KEY MATTERS/SIGNIFICANT VARIANCES FOR 2022/23 Community Hospitals and Services 4.1 The Community Hospital budget is overspent by £337,024 to the year-end. This predominantly relates to non pay variances totalling £175,492, which mainly includes increased energy and medical supplies costs alongside increased administration and ancillary domestic services costs. The Community Hospitals were overspent overall by £69,357 with overspend in Buckie and Keith. The medical staffing position was overspent by £78,890 after community hospital contract changes and £13,285 costs relating to change in a GP contract provision. 4.2 Efforts are ongoing to mitigate or minimise risk to service delivery, including the deployment of available staffing in the most effective manner. 4.3 The outturn for Community Hospitals & Services is overspent by £24,904 more than previously forecast due to the costs mentioned above continuing to increase. Learning Disabilities 4.4 The Learning Disability (LD) service is overspent by £2,617,513 at the year- end. The overspend is essentially due to the purchase of care for people with complex needs which resulted in an overspend of £2,727,867, client transport of £13,589. This is offset by more income received than expected of £109,728 (partly due to deferred payments); an underspend in clinical Speech and Language services, physiotherapy and psychology services of £10,544 and other minor underspends totalling £3,671. 4.5 This budget has been under pressure for a number of years due to demographic pressures, transitions from Children’s services and people living longer and getting frailer whilst staying at home. The biggest overspends was for domiciliary care and day services this enables people to stay living at home or in a homely setting for as long as possible. 4.6 The outturn for the LD service is overspent by £330,474 less than previously forecast due purchase of care and support being less than forecasted.and forecasting is difficult to do on this volatile budget as client needs can change and therefore costs can fluctuate. Mental Health 4.7 Mental Health services are overspent by £459,363 at the year end. This overspend includes senior medical pays £731,858 attributable to medical locum cover and purchase of care for people £50,101 along with other combined variances of £16,483 offset in part by additional income from NES Scotland £203,086 and other NHS Scotland income £135,993 which relates to doctors in training placed in Moray. 4.8 Over the last couple of years the Mental Health budget has seen an increase in referral numbers of young people with complex needs including elements of autistic and ADHD symptoms in addition to, or causing mental health Page 28
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challenges. The impact of Covid both in terms of isolation and on community resources are being realised and the Mental Health Social Work team have had some high cost packages transfer from both children and families Social Work and Learning Disability services. There are no local residential/ accommodated mental health resources for under 65’s in Moray, which means out of area placements are required, using facilities in Highland. 4.9 The outturn for Mental Health is overspent by £20,923 more than the previous forecast reflecting continuance of additional costs within the budget. Care Services Provided In-House 4.10 This budget is underspent by £1,567,455 at the end of the year. This relates to underspend in staffing across all the services in this budget totalling £2,146,703 which is being reduced by overspends of £366,317 in day care services due mostly to transport costs and other overspends across the services comes to £212,931 for energy costs, software licences, uniforms for staff and transport costs. 4.11 Unfilled vacancies have been the main reason for the underspend throughout the year and the issue of recruitment has been an ongoing problem. 4.12 The outturn for this budget is £302,137 better than previously forecast which is due to the ongoing vacancies and recruitment challenges. Older People and Physical Sensory Disability (Assessment and Care) 4.13 This budget is overspent by £2,834,016 at the end of the year. This primarily relates to overspends for domiciliary care in the area teams £1,715,375, which includes the Hanover very sheltered housing complexes, permanent care at £1,039,794 due to the increase in the number of clients receiving nursing care rather than residential care and other overspends of £78,847 which includes £69,158 on agency staff to provide care and support at Loxa Court. The variances within this overall budget heading reflect the shift in the balance of care to enable people to remain in their homes for longer. 4.14 Due to the increase in need and complexity – increase in double up care at home packages. Limited resource availability through our internal provider and limited availability with Allied partnership provider means a reliance on external providers to continue to support the demand/need. The overspend on this budget is related to the underspend in Care Services provided in-house budget above. 4.15 The outturn for this budget is £607,676 more overspent than the previous forecast due to less income than expected and more spend on care than expected. Intermediate Care and Occupational Therapy 4.16 This budget is overspent by £240,628, this primarily relates to spend on aids, minor adaptations and stairlifts of £201,990. Other overspends are for Jubilee Cottages and Hanover Loxa Court at £45,725, this is reduced by minor underspends of £7,087. 4.17 The outturn for this budget is £18,211 less than previously forecast due to the difficulties in forecasting for this volatile budget. Page 29
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Other Community Services 4.18 This budget is overspent by £273,042 at the end of the year. This includes cost pressure within Physiotherapy £189,957, Dietetics £131,389 relating to staff costs and Continence Service £129,692 relating to cost of supplies, offset by underspend in Speech and language therapy £165,701 caused by recruitment challenges and other combined underspends of £12,295. 4.19 The outturn for this budget is £24,922 more overspent than the previous forecast due to the continuing impact of cost pressures. Admin and Management 4.20 This budget is overspent by £231,122 at the year end. This is due to not fully achieving the vacancy target by £188,206 and additional costs within Moray Management & Administration amounting to £42,916 for costs for medical staffing pay supporting Primary Care services in Moray. 4.21 The outturn for this budget is £80,574 less overspent than previously forecast due to achieving more of the vacancy target in final quarter. Primary Care Prescribing 4.22 The primary care prescribing budget is reporting an over spend of £2,688,390 for the twelve months to 31 March 2024. The overall continuing high price has been attributed in part to the impact of short supply causing an increase in costs being sustained. This is spread across a range of products. The actual volume of items to January has been lowering compared to prior year and is estimated to continue at this level to March 2024.The estimated position has been adjusted to include an overall 4.00% volume increase for the year to March 2024. This overall volume increase is less than previously anticipated. 4.23 This has a positive impact on estimated outcome and outturn is £1,061,610 better than previously forecast for this budget. This takes into account volume increase continuing at reduced level and price remaining stable in the final months of the year. Hosted Services 4.24 This budget is overspent by £576,494 at the end of the financial year. This is due to increased costs relating to the Moray share a number of hosted services including Intermediate Care £125,600, Sexual Health Services £189,561, Retinal Screening £186,017 and Heart Failure £110,831 offset by combined other variances of £35,515. 4.25 The outturn is £145,864 more overspent than previously forecast. This is due to increased costs being incurred for Moray services delivered in final quarter. Out of Area Placements 4.26 This budget is overspent by £1,057,271 at the year end. This is due to the continuing number of high cost individual specialised placements. 4.27 The outturn for this budget is £60,598 less overspent than previously forecast, due to the current pattern of expenditure and placements. Page 30
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5. STRATEGIC FUNDS 5.1 Strategic Funds is additional Scottish Government 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); and • Provisions for earmarked reserves has been made to fund unutilised allocation for Primary Care Improvement Funds, Action 15 additional investment funding, identified budget pressures, new burdens, and savings that were expected at the start of the year. 5.2 At the end of the financial year there was slippage on Strategic Funds of £7,000,394 which has resulted in an overall overspend of £3,023,555. 5.3 During the 2023/24 financial year, Scottish Government continued to commit to the additional winter funding, to help support continuing system pressures. However, the Scottish Government did not make the full allocation of funding aligned to the Primary Care Improvement Plan (PCIP), Moray Alcohol & Drug Partnership (MADP) and Multi-disciplinary teams. Allocations made during the year, which remain unspent are considered as earmarked funding and to be used for these specific purposes in future years. This has contributed to the MIJB reserves. 5.4 After consideration of funding received, earmarked reserves and application of slippage on Strategic Funds, the MIJB financial position resulted in an overspend of £3,023,555, which the partners had to make additional funding available to break even. The reserves are detailed below in paragraph 9. 6. CHANGES TO STAFFING ARRANGEMENTS 6.1 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. 6.2 The staffing arrangements are noted in APPENDIX 3 as dealt with under delegated powers for the period 1 Jan to 31 March 2024. 7. IMPACT ON 2024/25 BUDGET AND RISK 7.1 The actual out-turn for the 2023/24 Core Services budget year is an overspend of £10,023,949. The Scottish Government also reduced payments for PCIP, MADP and for the Multi-Disciplinary team funding, thus reducing any balance on reserves for these areas it is difficult to ascertain with certainty the 2024/25 variances to budget and the likely impact moving into the next financial year. However, the variances against the budget have been reviewed and classified as one-off or likely to be recurring. Impact in 2024/25 will be monitored continuously and reported regularly to the MIJB. The overall position is summarised below: Page 31
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Area Para Ref Recurring Non-Recurring £ £ OVERSPEND Staff 7.2 (1,277,993) (1,506,583) Purchasing of Care 7.3 (6,385,905) (1,070,478) Income 7.4 (305,320) (54,000) Supplies & Services 7.5 (527,967) 0 Property costs 7.6 (354,926) 0 Client transport 7.7 (355,651) 0 Aids & Adaptations 7.8 (211,640) 0 Prescribing & hosted 7.9 (3,052,129) 0 Other 7.10 (144,647) 0 Sub-total (12,616,178) (2,631,061) UNDERSPEND Staff 7.2 2,991,854 91,639 Purchasing of Care 7.3 236,997 299,144 Income 7.4 732,370 191,750 Supplies & Services 7.5 293,595 100,000 Property costs 7.6 29,753 0 Client transport 7.7 149,656 0 Other 7.10 106,532 0 Sub-total 4,540,757 682,533 TOTAL (8,075,421) (1,948,528) Net Overspend (10,023,949) 7.2 Staff turnover can incur both under and overspends. Underspends can be attributed to the process of recruitment, which adds a natural delay, with posts being filled by new staff at lower points on the pay scale and in some circumstances the nature of the positions have been challenging to recruit to. The Council has recognised this turnover and had set as part of the budget process a vacancy factor saving, which has been met for numerous years. NHS Grampian also put in a vacancy factor saving in 2023/24. Overspends can be due to the use of bank staff/locum to provide required cover for vacancies/sickness and from the historic incremental drift and efficiency targets imposed. 7.3 The purchasing of care overspend relates to the purchase of domiciliary care by the area teams and the underspend relates to ceased contract. There is a direct correlation with the underspend in internal care at home service. The demographics show that Moray has an ageing population and the spend on external domiciliary care is increasing in relation to both increasing hours of commissioned care, the number of packages of care and complexity. This also reflects the shift in the balance of care to enable people to remain in their own homes for longer. 7.4 The under recovery of income budgets is apparent across a number of service headings. It is exceedingly difficult to predict the level of income accurately as client income is subject to the contributions policy which is based on a client’s financial assessment. Income recovery on all care at home services continues Page 32
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to reduce. The income will continue to reduce due to the legislation in relation to the Carers Act and free personal care for under 65’s as well as the impact of Covid. The Independent Review of Adult Social Care will likely impact in the longer term. During 2023/24 additional income was received from permanent care placements for deferred income and income recoveries from the review of Direct Payments/ SDS contingency funds for clients. 7.5 The Supplies and services overspend includes purchases of medical supplies, medical equipment, uniforms, system licenses and maintenance cost of equipment which is expected to be recurring. The non-recurring underspend relates to Forres Varis community team which is not expected to continue. 7.6 The recurring overspend in property costs primarily relates to the rising cost of energy and non pay costs for domestics. The non recurring underspend relates to rents and rates for a closed office and repairs and maintenance for a block contract. . 7.7 Client transport costs are recurringly overspent for internal day services transport. The non recurring underspend is due to an external day services closure. 7.8 Aids and Adaptations overspend relates to Occupational therapy aids, servicing and stair lifts. There is also an overspend in the improvement grants, due to the timing of works. 7.9 Prescribing costs relate to the increased volumes and price factors which are expected to be sustained alongside increased cost for Moray shares of hosted services and others which again are mainly expected to recur. 7.10 Other category relates to minor variances across the services but also includes recurring overspends relating to admin costs, recurring underspends included staff transport and printing for which are already identified as a saving in 2023/24. This also includes bad debt for permanent care which has significantly decreased in 2023/24. 7.11 The financial results for 2023/24 show that underlying financial pressures on both the NHS and Council budgets remain, with the MIJB assuming responsibility for the budgets of the delegated functions and are expected to prioritise services within the budgets directed to it by Moray Council and NHS Grampian. 7.12 Through in-year reporting of the savings plan progress it was evident that the saving of £4,141,000 for 2023/24 would be partly achieved, £2,739.000 was saved at the end of the financial year. The MIJB has committed to continue to identify further efficiencies that will be reported throughout the year, recognising the significant pressure on the budget and the required transformation and disinvestment to allow the programmes of transformation to develop. 7.13 Whilst the 2023/24 revenue budget position as reported to the Board on 30 March 2023 (para 7 of the minute refers) presented a balanced budget position, through the use of reserves, and a challenging savings plan, there is Page 33
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still the recurring overspend to be addressed. The recurring outturn position was as forecasted all year except for prescribing, which had a significant improvement in the last quarter. 7.14 This additional recurring cost reduces the level of reserves going into 2024/25. There are minimal reserves of £2,023,898 for ear marked reserves and no general reserve. With no general reserves the additional cost and any emerging budget pressure will have to be funded from additional savings or from recommissioning other activities. The Senior Management Team are actively addressing the situation to implement alternative measures to limit the financial pressure. Updates on the recovery and transformation process and further savings will be provided to the Board for approval during 2024/25 through the financial reporting processes. 8. UPDATED BUDGET POSITION 8.1 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. 8.2 The MIJB, for the 2023/24 has concluded the financial year in an overspend position. The additional funding contributions during the year are also show in the table below: £’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 2 6,520,716 Revised funding at start of Qtr 3 195,030,065 Adjustments in Qtr 3 2,294,977 Revised funding at start of Qtr 4 197,325,042 Budget adjustments M10-M12 Increase in Set Aside 748,000 NCARE allocation 23.24 748,159 Action 15 adj 633,870 Moray PCIF alloc 529,495 Dental Public Health Funding (Childsmile) 204,968 MADP 23-24 tranche 2 153,980 Allocation letter 138,000 District Nurse Fund 61,000 Prison HEPC 57,528 Page 34
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Open University 40,000 Moray Child Weight 15,000 Pay award (Exe &Snr man) 13,298 Virtual Bed Recruit 6,078 SARC funding 4,605 Hosted services recharge 5,444 Prescribing adj global sum (77,260) IFRS16 Adj (4,989) IJB impr grant (91,747) Moray TMC ADP Payment (183,517) Ear marked reserves c/fwd (2,023,898) Self directed support transformation 6,000 Children & Justice services adj 98,880 Revised 2023/24 Financial Year Funding 198,407,936 8.3 In accordance with the updated budget position, revised Directions have been included at APPENDIX 4 for approval by the Board to be issued to NHS Grampian and Moray Council. 9. RESERVES 9.1 The MIJB Reserves Policy, was most recently approved on 25 January 2024 (para 16 of the minute refers). The next review date should be no later than March 2025. The closing financial position on Reserves for 2023/24 is £2,023,898. This reserve is wholly for earmarked reserves, there is no usable general reserve to carry forward. The earmarked reserve will be called upon during the year in line with their specific purpose. The earmarked reserves detail is provided in the table below: Reserve Detail Type £’s Primary Care Improvement Plan Earmarked 33,264 GP Premises Earmarked 228,447 Community Living Change Fund Earmarked 319,463 National Drugs MAT Earmarked 267,878 OOH Winter Pressure funding Earmarked 171,841 Moray Cervical screening Earmarked 35,504 Moray hospital at home Earmarked 4,584 Moray Psychological Earmarked 314,741 MHO Funding Earmarked 138,000 Adult protection funding for CA Earmarked 18,000 Adult disability payment Earmarked 45,000 National Trauma training services Earmarked 100,000 Moray ADP Earmarked 22,089 Page 35
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Moray School Nurse Earmarked 27,789 Moray Winter Fund HCSW & MDT Earmarked 225,995 LD Annual Health Checks Earmarked 69,188 Community Planning partnership Earmarked 2,115 TOTAL 2,023,898 10. 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’ This report is consistent with the objectives of the Strategic Plan and includes budget information for services included in the MIJB Revenue Budget 2023/24. (b) Policy and Legal It is the responsibility of the organisation receiving the direction to work with the Chief Officer and Chief Financial Officer to deliver services within the resources identified. The Moray Integration Scheme (para 12.7 of the 2023 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 unaudited financial outturn for 2023/24 for the MIJB core budgets is £10,023,949 overspend. The financial details are set out in sections 3-9 of this report and in APPENDIX 1. The estimated recurring overspend of £8,075,421 as detailed in para 7 will impact on the 2024/25 budget. The movements in the 2023/24 budget as detailed in paragraph 8 have been incorporated in the figures reported. (d) Risk Implications and Mitigations The most significant risk arising from this report is the control and management of expenditure to provide the Health and Social Care services required for the Moray Area, within budget. Due to the ongoing financial challenges, the financial circumstances of the partners and Scottish Government, the amount of reserves have reduced. There is significant pressure on the budget for 2024/25 along with increasing demands on the services and cost of living pressures. Considerations are being given to alternative measures that can be established to support the recurring overspends and to achieve the savings target set for 2024/25. There is a big risk for 2024/25 onwards Page 36
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to achieve a financial balance. There is a need for constant scrutiny around this rapidly changing situation and reporting to the Board will inform throughout 2024/25. (e) Staffing Implications There are no direct implications in this report. (f) Property There are no direct implications in this report. (g) Equalities/Socio Economic Impact An Equality Impact Assessment is not required because there are no changes to policy resulting from this report. (h) Climate Change and Biodiversity Impacts There are no direct climate change and biodiversity implications as there has been no change to policy. (i) Directions Directions are detailed in para 9 above and in Appendix 4. (i) Consultations The Chief Officer, the Senior Management Team, Corporate Manager, Service Managers, Chief Finance Officer (Moray Council) and the Finance Officers from Health and Social Care Moray have been consulted and their comments have been incorporated in this report as appropriate. 11. CONCLUSION 11.1 This report identifies MIJB’s unaudited final out-turn position on the Core Budget of an overspend of £10,023,949 at 31 March 2024 and identifies major areas of variance between budget and actual for 2023/24. 11.2 The impact of the provisional outturn on the 2024/25 budget, of a recurring overspend of £8,075,421 is detailed in paragraph 7. 11.3 NHS Grampian and Moray Council have both carried forward ear marked reserves into 2024/25 which total £2,023,898. Author of Report: D O’Shea Chief Finance Officer & B Sivewright Finance Manager (NHSG) Background Papers: Papers held by respective Accountancy teams. Ref: Page 37
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APPENDIX 1MORAY INTEGRATION JOINT BOARD JOINT FINANCE REPORT APRIL 2023 - March 2024 Para Annual Budget (Net) Actual Ref Net Budget To Date To Date Variance £'s £'s £'s £'s 2023-24 2023-24 2023-24 2023-24 Community Hospitals 4.1 7,605,270 7,605,270 7,942,294 (337,024) Community Nursing 5,543,544 5,543,544 5,701,401 (157,857) Learning Disabilities 4.4 15,748,195 15,748,195 18,365,708 (2,617,513) Mental Health 4.7 11,046,780 11,046,780 11,506,143 (459,363) Addictions 1,848,791 1,848,791 1,726,000 122,791 Adult Protection & Health Improvement 197,394 197,394 212,524 (15,130) Care Services provided in-house 4.10 23,298,067 23,298,067 21,730,612 1,567,455 Older People & PSD Services 4.13 22,356,428 22,356,428 25,190,444 (2,834,016) Intermediate Care & OT 4.16 1,640,076 1,640,076 1,880,704 (240,628) Care Services provided by External Contractors 1,833,373 1,833,373 1,808,195 25,178 Other Community Services 4.18 9,739,039 9,739,039 10,012,081 (273,042) Admin & Management 4.20 2,559,495 2,559,495 2,790,617 (231,122) Primary Care Prescribing 4.22 18,650,502 18,650,502 21,338,891 (2,688,390) Primary Care Services 19,776,283 19,776,283 19,939,412 (163,130) Hosted Services 4.24 5,359,323 5,359,323 5,935,816 (576,494) Out of Area 4.26 720,131 720,131 1,777,402 (1,057,271) Improvement Grants 939,600 939,600 949,249 (9,649) Childrens Services 19,761,623 19,761,623 19,761,623 0 Total Moray IJB Core 169,844,600 169,844,600 179,868,549 (10,023,949) Other non-recurring Strategic Funds in the ledger 5,980,480 5,980,480 5,980,769 (290) Total Moray IJB Including Other Strategic funds in the ledger 175,825,080 175,825,080 185,849,319 (10,024,239) Other resources not included in ledger under core and strategic: 5 7,917,856 7,917,856 917,172 7,000,684 Total Moray IJB (incl. other strategic funds) and other costs not in ledger 183,742,936 183,742,936 186,766,491 (3,023,555) Set Aside Budget 14,665,000 14,665,000 14,665,000 - Overall Total Moray IJB 198,407,936 198,407,936 201,431,491 (3,023,555) Funded By: NHS Grampian 114,689,538 Moray Council 83,718,398 IJB FUNDING 198,407,936 Page 39
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APPENDIX 2 Description of MIJB Core Services 1. Community Hospitals includes community hospitals, community administration and community Medical services in Moray. 2. Community Nursing related to Community Nursing services throughout Moray, including District Nurses and Health Visitors. 3. Learning Disabilities budget comprises of:- • Transitions, • Staff – social work and admin infrastructure, • External purchasing of care for residential & nursing care, • External purchasing of care for respite, day care and domiciliary care, • Medical, Nursing, Allied Health Professionals and other staff. 4. Mental Health budget comprises of:- • Staff social work and admin infrastructure, • External purchasing of care for residential & nursing care, • External purchasing of care for respite, day care and domiciliary care, • In patient accommodation in Buckie & Elgin. • Medical, Nursing, Allied Health Professionals and other staff. 5. Addictions budget comprises of:- • Staff – social work and admin infrastructure, • Medical and nursing staff • External purchasing of care for residential & nursing care, • External purchasing of care for respite, day care and domiciliary care, • Moray Alcohol & Drugs Partnership. 6. Adult Protection and Health Improvement 7. Care Services provided in-house Services budget comprises of:- • Employment Support services, • Care at Home service/ re-ablement, • Integrated Day services (including Moray Resource Centre), • Supported Housing/Respite and • Occupational Therapy Equipment Store. 8. Older People & Physical Sensory Disability (PSD) budget comprises of:- • Staff – social work infrastructure (including access team and area teams), • External purchasing of care for residential & nursing care, • External purchasing of care for respite, day care and domiciliary care and • Residential & Nursing Care home (permanent care), 9. Intermediate Care & Occupational Therapy budget includes:- • Staff – OT infrastructure • Occupational therapy equipment • Telecare/ Community Alarm equipment, • Blue Badge scheme Page 41
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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 42
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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 Page 43
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APPENDIX 2 • Criminal Justice Services i) Children Services Admin and Management budget comprises of:- • Central management staffing • Target for staffing efficiencies from vacancies j) Additional grant funding • Unaccompanied asylum seeking children • Corra Foundation • Mental Health and Wellbeing Fund • Whole Family Wellbeing Fund Other definitions: Tier 1- Help to help you (information and advice), universal services to the whole community and an emphasis on prevention. Tier 2- Help when you need it (immediate help in a crisis, re-ablement) and regaining independence. Tier 3- Ongoing support for those in need through the delivery of 1 or more self- directed support options. Page 44
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HEALTH & SOCIAL CARE MORAY DELEGATED AUTHORITY REPORTS - PERIOD January to March 2024 Title of DAR Summary of Proposal Post(s) Permanent/ Temporary Duration (if Temporary) Effective Dates Funding Speech and Language Therapist Required for Moray HSCP to fulfil it's statutory duties for these children. Band 6 26.25 hours Temporary to 31/03/26 As appointed Funded in full by a contract with Moray council in place until end of March 2026. Health Care Support Worker Required for Moray HSCP to fulfil it's statutory duties for these children. Band 3 30 hours Temporary to 31/03/26 As appointed Funded in full by a contract with Moray council in place until end of March 2026. Desk Top Publishing - Relocation of G6 Transfer post from Desk top publishing to performance and quality team Grade 6 36.25 hours Permanent N/A ASAP Budget already in place Page 45
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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 20240530GHB11 20240530MC11 2. Date Direction issued by the Moray Integration Joint Board 30.05.2024 3. Effective date of the Direction 01.04.2023 4. Direction to: NHS Grampian and Moray Council 5. Does the Direction supersede/update a previous Direction? If yes, include the reference number(s) of previous Direction Yes budgeting monitoring report on 28.03.2024 and budget report for 23/24 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 - £90.02 million, of which £0.5 million is ring fenced for Housing Revenue Account aids and adaptations and £19.8 for Children Services & Criminal Justice which is in the shadow year. NHS Grampian associated budget - £88.2 million, of which £5.3 million Page 47
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relates to Moray’s share for services to be hosted and £18.7 million relates to primary care prescribing. An additional £14.6 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 48
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REPORT TO: MORAY INTEGRATION JOINT BOARD ON 30 MAY 2024 SUBJECT: REVENUE BUDGET & RECOVERY PLAN 2024/25 BY: 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 MIJB: 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) approves the 2024/25 proposed savings plan at 4.23 and detailed in APPENDIX 2; iv) formally approve the Revenue Budget for 2024/25 as detailed in APPENDIX 1, following consideration on risks highlighted in 4.30 and v) approve Directions for issue as set out at APPENDIX 3 to NHS Grampian and Moray Council. 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. Page 49
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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. The 2023/24 out turn report is also on this meetings agenda, the unaudited position was a deficit of £3.02 million as previously forecasted, which was funded by the partner organisations as per the Scheme of Integration. The 2024/25 working budget was brought to the IJB meeting on 28 March 2024 (para 8 of the minute refers), which reported a funding gap of £3.8 million which was to be found and brought back to this meeting with a balanced budget. 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. 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 funding to the Council was reduced from 2023/24 and so no further uplift is passed on to the MIJB for adult services. 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. Page 50
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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. The Board’s 2024/25 Finance Plan was considered by the NHS Grampian Board on 11th April in conjunction with the Board’s Annual Delivery Plan. Both the Finance Plan and the Annual Delivery Plan have now been submitted to the Scottish Government. 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: Page 51
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£’000 NHS Grampian (recurring 2024/25) 89,662 NHS Grampian – Set Aside Services 14,665 NHS Grampian – SG Multi-Disciplinary Team Funding 740 NHS Grampian – SG MDT Health Care Support Workers 560 NHS Grampian – Immunisation funding 108 NHS Grampian – School nurses 180 NHS Grampian – District nurses 196 Moray Council - Core 61,339 Moray Council – reduction in pension contribution (1,169) Moray Council Childrens & Justice Services – Core ** 19,157 Moray Council Childrens & Justice Services reduction in pension contribution (360) 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 2024/25 190,997 * Improvement Grants includes £0.707 million which requires to be ring- fenced as it relates to council house tenants. ** Childrens services includes £3.133 million which required to be ring-fenced as it relates to the joint Out of Area budget which remains in the Council. 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 Page 52
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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 responsibility in the joint strategic planning of these services in partnership with the Acute Sector. £’000 General Medicine 7,389 Geriatric Medicine 1,152 Rehabilitation Medicine 94 Respiratory Medicine 236 Palliative Care 30 A & E Inpatient 65 A & E Outpatient 4,850 Learning Disabilities 50 Psychiatry of Old Age 106 General Psychiatry 693 TOTAL SET ASIDE BUDGET 14,665 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 we continue 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: Page 53
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£’000 BUDGET PRESSURES Pay Inflation 966 Contractual Inflation & Scottish Living Wage 2,404 Prescribing & Community Pharmacy 3,002 Children in Transition 855 Learning Disability & Mental Health complex clients 1,518 Recurring Deficit 8,075 Hosted services 9 National Care Home Contract (NCHC) uplift 826 Free Personal & Nursing Care (FPNC) uplift 215 Funding pressures carried forward 300 TOTAL BUDGET PRESSURES 18,171 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. 4.12 £0.826 million is included as a budget pressure for the NCHC however it is not yet finalised 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 £13.721 million. Page 54
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SAVINGS PLAN 4.16 It is the Moray IJB strategy that sets out the programme of transformation, operation and improvement. The vision for Moray IJB Strategy 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. The 3 themes within the strategy are: • Homefirst – developing locality planning approach with the development of multidisciplinary teams and initiatives including discharge to assess, crises support, rehabilitation, re-ablement and recovery, housing, adaptations and technology. Building based to community services. • Building resilience – developing Making Every Opportunity Count, self management, prevention, personal responsibility, social prescribing. • Partners in care- developing care and support planning, support for unpaid carers, self directed support, realistic medicine, long term conditions, palliative/end of life, market – shaping strategies. 4.17 Our outcomes continue align with the National Health and Wellbeing Outcomes (9): • Lives are healthier • People live more independently • Experiences of services are positive • Quality of life is improved • Health inequalities are reduced • Carers are supported • People are safe • The workforce continually improves 4.18 The Moray Joint Strategic Needs Assessment (JSNA) has been refreshed to analyse the needs of the local population to inform and guide the commissioning of health, wellbeing and social care services within Moray. The main goal of the JSNA is to accurately assess the care needs of a local population in order to improve the physical, mental health and wellbeing of individuals and communities. 4.19 We understand that the building blocks of health and wellbeing include: employment, housing, education and skills, childhood experiences, economic stability, healthcare, social and community requirements. We also are working with competing priorities - cost savings, reducing demand on hospitals, better experiences and outcomes for people who use health and care services, improved service alignment/integration, developing population health and prevention at scale, including wellbeing and tackling inequalities. Page 55
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4.20 A change in focus for Moray is required to deliver improved care and better outcomes, ensuring sustainability for the future, rather than to deliver cost savings only in the short term. The health and care system is often seen as hospital focused, however an integrated and holistic response is required that encompasses community assets. This requires a system with increased generalism and multidisciplinary teamworking, with practitioners able to hold risk and enable people to live healthily in their communities, with a focus on prevention and reablement. A community focused health and care system prioritised to local need and individualised support is most effective where that support maximises independence. 4.21 The budget setting for 2024/25 includes an indicative saving plan totalling £8.297 million. Continuous 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 followed on from 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. 4.22 There is still a focus and commitment 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. The savings have been RAG with the basis of the savings being achieved with particular reference to political environment; staff and changes in services; capacity; engagement and processes i.e. HR, procurement etc. With this in mind 24 are green status, 4 are amber status and 5 are red status. 4.23 The table below summarises the progress made by the Health and Social Care Moray management team in identifying opportunities for efficiency/savings, which fall under the 3 themes of the MIJB strategy and a 4th heading of savings already implemented. Areas under each theme are detailed in APPENDIX 2. 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 Building resilience 4.17 3,299 Home first 4.18 685 Partners in care 4.19 2,713 Savings already implemented 4.20 1,600 Total Projected Efficiencies 8,297 Page 56
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4.24 Building resilience covers 9 proposals, predominantly with a RAG status of green. These proposals cover review and redesign of services: Internal care at home; vaccination programme; Ward 4; GMED (hosted service for Grampian, led by Moray); relocation/ reduction of lease of buildings; use of pool cars; ceasing outsourcing of projects and Children & Justice Service efficiency. There is 1 proposal that has a RAG status of red for the review of care and care purchasing, this is reducing the care home bed base by 10, reviewing all care packages and the use of spot purchasing. These proposals although challenging will be achievable, a total of £4.462 million is the expectation over the next 2 financial years, with £3.299 million being achievable in 2024/25. 4.25 Home first covers 5 proposals; 3 proposals have a RAG status of green and relate to the review of respite provision; use of proportionate care model and the review/redesign of the Learning disability nighttime model of care delivery. There are 2 proposals that have a RAG status of red and these relate to redesign of models of care, in conjunction with our home first priority to ensure people are looked after in their own homes as safely as possible and relates to redesign of ward 4 inpatient services and the redesign of community hospitals, to ensure services are fit for purpose. These proposals although challenging will be achievable, a total of £1.932 million is the expectation over the next 2 financial years, with £0.685 million being achievable in 2024/25. 4.26 Partners in care covers 9 proposals, 6 of which have a RAG status of green and relate to review of day services; review of complex and challenging behaviour units; review of step down building based facilities, prescribing efficiencies, use of digital support; review of charging policy & SDS pay points (including recovery of income through reviews). There is 1 proposal that has an amber RAG status which relates to review of Learning disability service and review of care home bed usage. There are 2 proposals that have a red RAG status these relate to commissioning and contracts review and review of the transport contract for children’s & justice service and adult services. These proposals although challenging will be achievable, a total of £4.238 million is the expectation over the next 2 financial years, with £2.713 million being achievable in 2024/25. 4.27 There are 10 plans that have already been implemented and savings taken in 2024/25. These relate to review of weekend working; equipment budgets being combined, vacant posts that have been difficult to recruit and are now given up from redesign of workloads; vacancy target agreed in the last financial year for NHS budgets (based on natural turnover). There are also 3 proposals that are for 1 year initially, which will be reviewed for the next financial year, which relate to no non-essential travel, no non-essential training and no backfill for secondments. These proposals total £1.6 million all achievable in 2024/25. Page 57
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BUDGET OVERVIEW 4.28 The MIJB Revenue Budget for 2024/25 is £200.641 million which includes £14.665 million Set Aside. The detail is provided in APPENDIX 1 and summarised below: £’000 BUDGET Recurring Budget 167,563 Inflationary and Demand Led Pressures 7,155 Recurring Deficit 8,075 SLW & FPNC 4,413 2023/24 commitments to be funded 300 Set Aside 14,665 Reduction for pension contributions (1,529) TOTAL BUDGET 200,641 FUNDED BY NHS Grampian Recurring (inc Set Aside) 104,327 Moray Council (inc Improvement Grants) 81,702 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 reduction for pension contributions (1,529) Savings identified 8,297 TOTAL FUNDING 199,295 BUDGET DEFICIT (1,346) FUNDED FROM EARMARKED RESERVES 1,346 4.29 Earmarked reserves carried forward into 2024/25 were £2.02 million, this included reserves relating to PCIF and Moray Action 15 which will be exhausted in 2024/25. Page 58
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FINANCIAL RISKS 4.30 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 by Scottish Government. 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 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. There is no provision for increases over and above the SLW payments for providers. • 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 Page 59
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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. • The savings identified is particularly challenging to be fully achieved in the year, the risk of achieving the savings has been calculated based on the RAG status, with green assuming will be 90% achieved, amber 80% and red 70% respectively. Using this assumption the savings for 2024/25 could be £6.817 million, leaving a risk of a potential funding gap, which would have to be borne by the partners of £1.48 million. The implementation of savings also presents an opportunity to redesign services collaborating with staff and communities. 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 £185.976 million. The funding allocated to the MIJB by Moray Council and NHS Grampian and through the Partner bodies from Scottish Government totals £176.332 million (excluding Set Aside). In addition, the indicative savings plan for the forthcoming year totals £8.297 million. Page 60
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The notional Set Aside budget for Moray’s share of the Large Hospital Services is currently £14.665 million. The Set Aside budget is provided by NHS Grampian. A balanced budget is presented displaying use of slippage in ear marked reserves of £1.346 million, this will need to be funded in 2025/26. (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. • 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 although are now forecast to decrease continuing cost increases 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 achieved in line with expectations for 2024/25. Based on the rag status as in para 4.23, there is a risk of not achieving the savings in this financial year of £1.48 million, which will require to be borne by the partners of the MIJB. Page 61
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(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 4.28 above and in APPENDIX 3. (j) Consultations The Chief Officer, Health and Social Care Moray Senior Management Team, Operational Management Team, Corporate Manager, Chief Finance Officer (Moray Council), Deputy Director of Finance NHS Grampian, 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 its Revenue Budget for the forthcoming year by 31 March each year. A working budget was approved on 28 March 2024, with the budget gap to be closed for this meeting. The budget displays a balanced position. The Section 95 Officer as Chief Financial Officer to the Board recommends the budget as presented at APPENDIX 1. 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, Chief Financial Officer Background Papers: with author Ref: Page 62
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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 16,105,087 Mental Health 10,875,617 Addictions 1,204,261 Adult Protection & Health Improvement 197,875 Care Services provided in-house 23,906,043 Older People & PSD Services 22,745,439 Intermediate Care & OT 1,845,077 Care Services provided by External Contractors 2,209,707 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 19,156,625 Total Moray IJB Core 167,302,651 Other recurring Strategic Funds in the ledger 260,046 Total Moray IJB Including Other Strategic funds in the ledger 167,562,697 Other resources not included in ledger under core and strategic: 18,413,581 Total Moray IJB (incl. other strategic funds) and other costs not in ledger 185,976,278 Set Aside Budget 14,665,000 Overall Total Moray IJB 200,641,278 Funded By: NHS Grampian 106,111,000 Moray Council 84,886,256 Savings identified 8,297,470 Use of ear marked reserves 1,346,552 IJB FUNDING 200,641,278 Page 63
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Progress to MIJB proposed savings 35% 100% 65% Ref Service Brief Description Full year effect £000s Effect amended Progress towards Implementation Planned Implementation Date Implementation Date Risk Level Risk Description Apr-24 May-24 Jun-24 Jul-24 Aug-24 Sep-24 Oct-24 Nov-24 Dec-24 Jan-25 Feb-25 Mar-25 Total in year 2025/26 BUILDING RESILIENCE 4,462.00 3,299.47 26.32 234.65 247.15 250.65 250.65 250.65 338.15 338.25 340.75 340.75 340.75 340.75 3,299.47 1,162.53 Internal Care at Home review Review of Internal care at home including redesign 238.00 76.00 0% 01/4/2024 & 1/4/2025 Green Timeline 6.33 6.33 6.33 6.33 6.33 6.33 6.33 6.33 6.33 6.33 6.33 6.33 76.00 162.00 Vaccination Programme redesign Redesign 110.00 110.00 100% Apr-24 Apr-24 Green Workforce implications Could impact on contingency for another pandemic Timeframe may be too short 9.17 9.17 9.17 9.17 9.17 9.17 9.17 9.17 9.17 9.17 9.17 9.17 110.00 - Outsourcing of staff for projects etc Cease outsourcing for projects - use existing staff for development 100.00 100.00 100% Mar-24 Apr-24 Green Limited capacity within our own workforce 8.33 8.33 8.33 8.33 8.33 8.33 8.33 8.33 8.33 8.33 8.33 8.33 100.00 - Ward 4 redesign of service Cease locum use - gradual & implement 2 CESR fellows 1,044.00 522.00 Oct-24 Green Recruitment 87.00 87.00 87.00 87.00 87.00 87.00 522.00 522.00 GMED redesign & health village relocation Relocation from Health Village, redesign of clinical & admin staffing model, Ad astra Ehealth system 133.00 36.80 Apr 24, july 24 & Apr 25 Green Workforce Impact Parking Footfall dependent on location 0.40 0.40 0.40 3.90 3.90 3.90 3.90 4.00 4.00 4.00 4.00 4.00 36.80 96.20 Pool car vs expenses review Review into all teams transport and expenses to evalaute best options 30.00 10.00 0% Dec-24 Green Time and capacity – will be spend to save in the first instance 2.50 2.50 2.50 2.50 10.00 20.00 Cessation of leases and relocation FEVC, Southfield, Strathisla dental proactice 282.00 128.00 0% June 24, Oct 24 & Apr 25 Green none 12.50 12.50 12.50 12.50 13.00 13.00 13.00 13.00 13.00 13.00 128.00 154.00 C&F additional efficiencies Additional budget efficiency 25.00 25.00 100% Apr-24 Apr-24 Green Impact on SW ASP CP 2.08 2.08 2.08 2.08 2.08 2.08 2.08 2.08 2.08 2.08 2.08 2.08 25.00 - Review of Care & Care Purchasing Reduction of care home bed base by 10 , spot purchasing & review care packages 2,500.00 2,291.67 May-24 Red 208.33 208.33 208.33 208.33 208.33 208.33 208.33 208.33 208.33 208.33 208.33 2,291.67 208.33 HOME FIRST 1,932.00 685.00 - - - - 46.25 46.25 69.33 69.33 94.33 94.33 94.33 170.83 685.00 1,247.00 Respite provision Review into planned and emergency respite - change in model 450.00 37.50 0% Mar-25 Green Time to implement fully Care home bed shortage Care Home Provider monopoly Competition from other boards Time heavy paperwork for care homes 37.50 37.50 412.50 Proportionate care Redesign model 555.00 370.00 0% Aug-24 Green Time to fully implement Needs full EQIA Service user safety 46.25 46.25 46.25 46.25 46.25 46.25 46.25 46.25 370.00 185.00 Night Time Responder (LD) Redesign LD nighttime model of care delivery 277.00 138.50 0% Oct-24 Green Organisational change 23.08 23.08 23.08 23.08 23.08 23.08 138.50 138.50 Ward 4 redesign of service Redesign of mental health inpatient services 350.00 39.00 0% Mar-25 Red Reputational damage RCH pressure Pan Grampian impact and decision PotentIal OOA 39.00 39.00 311.00 Community hospital redesign Redesign of inpatient services supporting Home First 300.00 100.00 0% Dec-24 Red Contentious – public opinion (KELP) etc Reputational damage Impact on secondary care 25.00 25.00 25.00 25.00 100.00 200.00 PARTNERS IN CARE 4,238.00 2,712.50 95.50 95.50 145.50 187.17 187.17 187.17 218.75 270.15 331.44 331.44 331.44 331.30 2,712.50 1,525.50 Commissioning and contracts review Review of all contracts and redesign of provisions 807.00 551.00 0% Apr 24, july 24 & oct 24 Red Time and capacity, reputational damage Balance of needs versus costs 3.75 3.75 3.75 45.42 45.42 45.42 67.25 67.25 67.25 67.25 67.25 67.24 551.00 256.00 Day Services review Review into day services and provsion, including building based: co-location options, MRC catering & infrastructure 220.00 161.50 0% Apr 24 & Oct 24 Green Reputational damage Impact on Unpaid carers Downstream impact Impact on MH of service user 8.58 8.58 8.58 8.58 8.58 8.58 18.33 18.33 18.34 18.34 18.34 18.34 161.50 58.50 Complex & challenging behaviour unit Review Review into Woodview and change management 657.00 498.00 100% Apr-24 Apr-24 Green Organisational change 41.50 41.50 41.50 41.50 41.50 41.50 41.50 41.50 41.50 41.50 41.50 41.50 498.00 159.00 LD review & review of care home bed usage Internal review and redesign, review care home bed utilitsation 736.00 245.00 0% Dec-24 Amber Any care package savings has implications for safety. Requires care home registration change and agreed costings 61.25 61.25 61.25 61.25 245.00 491.00 Review of step down building based facilities Review into model of care 118.00 49.00 0% Nov-24 Green Lack of step down facility Impact on acute /secondary care/ primary care 9.80 9.80 9.80 9.80 9.80 49.00 69.00 Prescribing efficiencies Medication cessation and switches within GP services 600.00 500.00 0% Jun-24 Green Pan Grampian approach may take tme to implement 50.00 50.00 50.00 50.00 50.00 50.00 50.00 50.00 50.00 50.00 500.00 100.00 Digital Support efficiencies - NO TEMPLATE REQUIRED As part of DHI (Moray Growth Deal and Analogue To Digital Proposal) 100.00 Requires further consideration Green Pan Grampian approach may take tme to implement - 100.00 Charging policy & SDS pay points review Review charges and SDS points, increase recovery 500.00 500.00 100% Apr-24 Apr-24 Green SG shift away from charging 41.67 41.67 41.67 41.67 41.67 41.67 41.67 41.67 41.70 41.70 41.70 41.57 500.00 (0.00) Transport contract Review fo how we contract for transport for childrens and adult services 500.00 208.00 Nov-24 Red 41.60 41.6 41.6 41.6 41.6 208.00 292.00 Page 65
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ALREADY IMPLEMENTED 1,600.00 1,600.00 133.33 133.33 133.33 133.33 133.33 133.33 133.33 133.33 133.33 133.33 133.33 133.33 1,600.00 - Service delivery B7 w/end working Cease use of band 7 nurses for weekend working community hospitals and FNCT 50.00 50.00 100% Apr-24 Apr-24 Green Could leave all decision making to Mon –Fri Workforce impact 4.17 4.17 4.17 4.17 4.17 4.17 4.17 4.17 4.17 4.17 4.17 4.17 50.00 - Equipment & Supplies Shift of budget to education 100.00 100.00 100% Mar-24 Apr-24 Green Implemented 8.33 8.33 8.33 8.33 8.33 8.33 8.33 8.33 8.33 8.33 8.33 8.33 100.00 - Remove TL Older adult comm(temp)MH No replacement of post 61.00 61.00 100% Apr-24 Apr-24 Green Risk to existing staff 5.08 5.08 5.08 5.08 5.08 5.08 5.08 5.08 5.08 5.08 5.08 5.08 61.00 - Lead Nurse- reduction in hours No backfill of seconded post 17.00 17.00 100% Apr-24 Apr-24 Green Risk to existing staff 1.42 1.42 1.42 1.42 1.42 1.42 1.42 1.42 1.42 1.42 1.42 1.42 17.00 - No non-essential travel (I year) Non essential travel ban (out of area) 30.00 30.00 100% Apr-24 Apr-24 Amber Impact on staff development 2.50 2.50 2.50 2.50 2.50 2.50 2.50 2.50 2.50 2.50 2.50 2.50 30.00 - No non-essential training (I year) Non essential training ban (conference attendance etc) 20.00 20.00 100% Apr-24 Apr-24 Amber Impact on staff development 1.67 1.67 1.67 1.67 1.67 1.67 1.67 1.67 1.67 1.67 1.67 1.67 20.00 - No backfill for secondments (1 year) Maternity leave- case by case consideration via RMG 150.00 150.00 100% Apr-24 Apr-24 Amber Displacement of some staff, service pressures 12.50 12.50 12.50 12.50 12.50 12.50 12.50 12.50 12.50 12.50 12.50 12.50 150.00 - Vacancy target NHS - NO TEMPLATE REQUIRED Already implemented 1,000.00 1,000.00 100% Apr-24 Apr-24 Green 83.33 83.33 83.33 83.33 83.33 83.33 83.33 83.33 83.33 83.33 83.33 83.33 1,000.00 - Cessation of Weekend working OT (NHS) Cease weekend working DGH NO FUNDING 86.00 86.00 100% Mar-24 Mar-24 Green Implemented - OT wait list 7.17 7.17 7.17 7.17 7.17 7.17 7.17 7.17 7.17 7.17 7.17 7.17 86.00 - Cessation of Weekend working physio Cease weekend physio DGH (NO FUNDING) 86.00 86.00 100% Mar-24 Mar-24 Green Implemented - Physio wait list 7.17 7.17 7.17 7.17 7.17 7.17 7.17 7.17 7.17 7.17 7.17 7.17 86.00 - TOTAL 12,232.00 8,296.97 255.15 463.48 525.98 571.15 617.40 617.40 759.56 811.06 899.86 899.86 899.86 976.22 8,296.97 3,935.03 Page 66
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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 20240530GHB12 20240530MC12 2. Date Direction issued by the Moray Integration Joint Board 30.05.2024 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 working budget report 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 - £89.9 million, of which £0.5 million is ring fenced for Housing Revenue Account aids and adaptations and £3.1 for Children Services & Criminal Justice OOA ring fenced shared budget. NHS Grampian associated budget - £77.7 million, of which £5.3 million Page 67
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relates to Moray’s share for services to be hosted and £18.7 million relates to primary care prescribing. An additional £14.6 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 68
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REPORT TO: MORAY INTEGRATION JOINT BOARD ON 30 MAY 2024 SUBJECT: STRATEGIC RISK REGISTER – FINANCIAL – MAY 2024 BY: CHIEF OFFICER 1. REASON FOR REPORT 1.1 To provide the Board with an overview of the strategic financial risks, along with a summary of actions which are in place to mitigate those risks, updated May 2024. 2. RECOMMENDATION 2.1 It is recommended that the Board notes the updated Financial Strategic Risk Register included in APPENDIX 1. 3. BACKGROUND 3.1 The strategic risk register is reviewed regularly by the Senior Management Team as part of a robust risk monitoring framework, to identify, assess and prioritise risks related to the delivery of services in relation to delegated functions, particularly any which are likely to affect the delivery of the Strategic Plan. 3.2 The Moray Integration Joint Board (MIJB) Financial Strategic Risk Register is attached to this report at APPENDIX 1 and sets out the increasing risks being faced by the MIJB, together with a current assessment on the level of the risks and mitigating actions being taken to reduce the impact of the risks. 3.3 Risk scores are weighted, based on assessment according to their likelihood and corresponding impact, as per Section 5 of the MIJB Risk Policy. 3.4 The Strategic Risks received an initial review to ensure they align to the Moray Partners in Care 2022-2032 strategic plan which was agreed at MIJB on 24 November 2022 (para 14 of the minute refers). 3.5 As agreed at Audit, Performance and Risk Committee 26 October 2023 (para 8 of the minute refers), amendment was approved to report on the Strategic Risk Register from quarterly to biannually unless any significant change required to be informed to committee. As agreed the Financial Strategic Risks are presented to the Board today. Page 69
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4. KEY MATTERS RELEVANT TO RECOMMENDATION 4.1 The Risk Management Framework review was completed and outcome was approved by the Board on 25 June 2020 (para 9 of the minute refers). The approved Risk Appetite Statements have been included in APPENDIX 1. 4.2 A report is presented to MIJB with a financial update and savings plan for 2024/25 on 30 May 2024. 4.3 The financial position poses a significant complexity to service planning. 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 MIJB requires effective governance arrangements for those services and functions delegated to it and Risk Management systems are integral to this. (b) Policy and Legal As set out in the terms of reference, the Board has responsibility to provide assurance of the adequacy of the risk management framework. There are no legal implications arising from this report. (c) Financial implications There are no direct financial implications arising from this report however the Board should note the failure to manage risks effectively could have a financial impact for the MIJB. (d) Risk Implications and Mitigation This report forms part of the governance arrangements for identifying and managing strategic risks of the MIJB. The risks are outlined in the body of the report in section 4. (e) Staffing Implications There are no additional staffing implications arising from this report. (f) Property There are no property implications arising from this report. (g) Equalities/Socio Economic Impact An Equalities Impact Assessment is not required because there are no service, policy or organisational changes being proposed. However, Impact Assessments will be core to any financial decision making. (h) Climate Change and Biodiversity Impacts There are no impacts arising from this report. (i) Directions None arising from this report. Page 70
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(j) Consultations Consultation on this report has taken place with the Chief Finance Officer and Senior Management Team. 6. CONCLUSION 6.1 This report and appendix outlines the current position and recommends the Committee note the revised and updated Strategic Risk Register. Author of Report: Sonya Duncan, Corporate Manager Background Papers: held by HSCM Ref: Page 71
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APPENDIX 1 RISK SUMMARY 1. The Moray Integration Joint Board (MIJB) does not function as set out within the Integration Scheme, Strategic Plan and in-line with Standing Orders and fails to deliver its objectives or expected outcomes. 2. There is a risk of MIJB financial failure in that the demand for services outstripping available financial resources. Financial pressures being experienced by the funding Partners will directly impact on decision making and prioritisation of MIJB. 3. Inability to recruit and retain qualified and experienced staff to provide safe care and providing capacity to deliver on planned strategic aims. 4. Inability to demonstrate effective governance and effective communication and engagement with stakeholders. 5. Inability to cope with unforeseen external emergencies or incidents as a result of inadequate emergency and resilience planning. 6. Risk to MIJB decisions resulting in litigation/judicial review. Expectations from external inspections are not met. 7. Inability to achieve progress in relation to national Health and Wellbeing Outcomes. Performance falls below acceptable level. 8. Inability to progress with delivery of Strategic Objectives and Transformation projects as a result of inability to resolve data sharing and data security requirements. 9. Requirements for support services are not prioritised by NHS Grampian and Moray Council. Risk Assessment Table – Multiply likelihood score by impact score to determine the risk rating (score). Risk Heading Lead Officer Current Risk Rating Target Risk Rating Last Reviewed Position Change Financial Sustainability Chief Finance Officer 20 9 23/1/24 Key Risk improvement No change to risk Risk deterioration Page 73
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APPENDIX 1 Description of Risk: Financial There is a risk of MIJB financial failure in that the demand for services outstrips available financial resources. Financial pressures being experienced both by the funding Partners and Community Planning Partners will directly impact on decision making and prioritisation of MIJB. Consequence: MIJB is unable to deliver its strategic priorities, statutory services and identified projects. Rationale for Risk Appetite The Board recognises the financial constraints all partners are working within. MIJB has a low risk appetite to financial failure and recognises the significance of achieving a balanced budget. The Board also acknowledges the statutory requirements to provide services within the allocated budget. The cost of current service delivery is higher than available budgeted resources. Those risks will only be considered: • Where a clear business case or rationale exists for exposing ourselves to the financial risk • Where we can protect the long term sustainability of health & social care in Moray Rational for Risk Rating If the IJB's strategic plan and medium term financial plan are not prepared on a sustainable basis, there is a risk that the recurring cost base could exceed future funding allocations resulting in an underlying deficit. This will adversely affect both current and future service provision and will impact on the IJB's ability to deliver its strategic priorities and vision. Given the current level of uncertainty associated with civil unrest across the globe, cost of living crisis, tight financial settlements for local government and health and the impact of increasing demand, the magnitude of the potential costs involved represent a continuing significant financial risk. Additional consequentials have ceased and any recurring costs will have to be met from existing baseline budgets. National Care Service legislation also introduces a new area of financial uncertainty Mitigations / Current controls in place 5 5 25 1. Budgets delegated and managed by Service Managers with Head of Service oversight. 2. Vacancy controls via the Resource Management Group (RMG), High cost packages are now reviewed by an oversight group with recommendations made to RMG 3. Chief Finance Officer (CFO) and Senior Management Team (SMT) working to continuously identify additional savings. 4 5 20 Untreated Likelihood Untreated Impact Untreated Score Current Likelihood Current Impact Current Score Page 74
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APPENDIX 1 Assurances: MIJB and Audit, Performance and Risk oversight and scrutiny of budget Reporting through MIJB, NHS Grampian and Moray Council Gaps in Assurance: Some of the financial savings will take planning, engagement and implementation. SMT and OMT are in the process of identifying capacity within the current workforce to support this work. Capacity to manage the redesign work required has yet to be realised. Releasing capacity to manage the work required to realise the financial savings could impact on other service delivery / priorities. Financial savings need to be aligned to the themes set out in Partners in Care 2022-2032 Whilst prioritising the financial savings there is a risk that other commitments may need to be paused. Further Controls Required Further Controls Owner Target Date Regular financial workshops with Service Leads to identify further savings Chief Financial Officer 2/2/24 - Completed Financial development session with MIJB members Chief Officer 7/3/24 - Completed Reporting from RMG to SMT for oversight of agreed spend Chief Officer 4/3/24 - Completed Financial workshops with OMT looking at savings options Head of Service 2/2/24 - Completed Additional Drop in finance sessions have been arranged for managers to speak with senior leaders and the CFO regards any proposed savings plans. Chief Finance Officer 31/5/24 4. A reviewed Financial Framework was presented to MIJB on 30 March 2023, and a further update will be presented in June 2024. 5. Financial information is reported regularly to MIJB, SMT and Operational Management Team (OMT). 6. The CO and CFO continue to regularly engage in finance discussions with key personnel of both NHS Grampian and Moray Council. 7. The CO and CFO will continue to engage with partner organisations in respect of the financial position throughout the year. Cross partnership performance meetings are with partner CEOs, Finance Directors and Chair/Vice Chair of MIJB. Page 75
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APPENDIX 1 Capacity within current staffing has been identified to support the collation and oversight of the financial savings plan for 2024/25 SMT 31/5/24 Engagement and consultation with stakeholders is required before any decisions are made SMT 31/10/24 Engagement and consultation is required with stakeholders where interdependencies may exist SMT 31/10/24 Review Date Review Notes / Decisions 8/3/24 A Recovery plan was submitted to IJB in January 2024, a development session took place to discuss options in 7/3/24 with the recovery plan going back to IJB in March 2024. 29/4/24 A Development Session was held with Service Managers, SMT and MIJB members (hybrid) on 18/4/24 to discuss the proposed savings plan, some topics were discussed with Q&A session for MIJB Likelihood – What is the likelihood of the risk occurring? Assess using the criteria below. Rare (1) Unlikely (2) Possible (3) Likely (4) Almost Certain (5) Don’t believe this event would happen Will only happen in exceptional circumstances Not expected to happen but definite potential exists Unlikely to occur May occur occasionally Has happened before on occasions Reasonable chance of occurring Strong possibility that this could occur Likely to occur This is expected to occur frequently/ in most circumstances more likely to occur than not Impact – What could happen if the risk occurred? Assess for each category and use the highest score identified. The impact scale is from an organisational level perspective. It reflects the key areas that if impacted could prevent the organisation achieving its priorities and objectives. The scale is a guide and cannot cover every type of impact therefore judgement is required. Category Negligible (1) Minor (2) Moderate (3) Major (4) Extreme (5) Page 76
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APPENDIX 1 Patient or Service user Experience Reduced quality patient experience/clinical outcome not directly related to delivery of clinical care Unsatisfactory patient experience/clinical outcome directly related to care provision – readily resolvable Unsatisfactory patient experience/ clinical outcome, short term effects – expect recovery less than 1wk Unsatisfactory patient experience /clinical outcome, long term effects - expect recovery over more than 1week Unsatisfactory patient experience/clinical outcome, continued ongoing long term effects Objectives/ Project Barely noticeable reduction in scope/quality/ schedule Minor reduction in scope/quality/schedule Reduction in scope/quality/project objectives or schedule Significant project overrun Inability to meet project/corporate objectives, reputation of organisation seriously damaged Injury /illness (physical and psychological) to patient/service user/visitor/staff/carer Adverse event leading to minor injury not requiring first aid Minor injury or illness, first aid treatment required Agency reportable, e.g. Police (violent and aggressive acts) Significant injury requiring medical treatment and/or counselling Major injuries/long term incapacity /disability (e.g. loss of limb), requiring, medical treatment and/or counselling Incident leading to death(s) or major permanent incapacity Complaints/Claims Locally resolved verbal complaint Justified written complaint peripheral to clinical care Justified complaint involving lack of appropriate care Claim above excess level. Multiple justified complaints Multiple claims or single major claim Complex Justified complaint Service/ Business Interruption Interruption in a service which does not impact on the delivery of patient care or the ability to continue to provide service Short term disruption to service with minor impact on patient care/service provision Some disruption in service with unacceptable impact on patient care Temporary loss of ability to provide Service. Sustained loss of service which has serious impact on delivery of patient care resulting in major contingency plans being invoked Permanent loss of core service/ facility Disruption to facility leading to significant “knock on” effect -- to function Staffing and Competence Short term low staffing level temporarily reduces service Ongoing low staffing level reduces service quality Late delivery of key objective/service /care due to lack of staff Uncertain delivery of key objective/service/care due to lack of staff Non-delivery of key objective/ service/care due to lack of staff. Page 77
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APPENDIX 1 quality (less than 1 day) Short term low staffing level (>1 day), where there is no disruption to patient care Minor error due to lack of/ ineffective training/ implementation of training Moderate error due to lack of/ ineffective training / implementation of training Ongoing problems with staffing levels Major error due to lack of/ ineffective training / implementation of training Loss of key staff Critical error due to lack of/ ineffective training/ implementation of training Financial (including Damage/Loss/Theft/ Fraud Negligible organisational/ personal financial loss up to £1k Minor organisational/ personal financial loss of £1-10K Significant organisational/personal financial loss of £10- 100k Major organisational/personal financial loss of £100k- 1m) Severe organisational financial loss of more than £1m Inspection/ Audit Small number of recommendations which focus on minor quality improvement issues Recommendations made which can be addressed by low level of management action Challenging recommendations that can be addressed with appropriate action plan Improvement Notice Enforcement/prohibition action Low Rating Critical report Prosecution Zero rating Severely critical report Adverse Publicity/ Reputation Rumours, no media coverage Little effect on staff morale Local media coverage – short term. Some public embarrassment Minor effect on staff morale/public attitudes Local media – long term adverse publicity Significant effect on staff morale/public perception of the organisation National media adverse publicity less than 3 days Public confidence in the organisation undermined Use of services affected National/International media/ adverse publicity, more than 3 days MSP/MP/SEHD concern (Questions in Parliament) Court Enforcement/Public Enquiry/FAI Likelihood Consequences/Impact Negligible Minor Moderate Major Extreme Almost Certain Medium High High V High V High Likely Medium Medium High High V High Possible Low Medium Medium High High Unlikely Low Medium Medium Medium High Rare Low Low Low Medium Medium Page 78
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APPENDIX 1 Review Timescales – When a risk rating has been assigned the criteria below should be used to assess the review timescales. Very High or High Requires monthly monitoring and updates. Medium Requires quarterly monitoring and updates. Low Requires 6 monthly monitoring and updates. Page 79
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REPORT TO: MORAY INTEGRATION JOINT BOARD ON 30 MAY 2024 SUBJECT: ANNUAL REPORT OF THE CHIEF SOCIAL WORK OFFICER 2023-2024 BY: CHIEF SOCIAL WORK OFFICER 1. REASON FOR REPORT 1.1. To inform the Board of the annual report of the Chief Social Work Officer on the work undertaken on the Council’s behalf during the period 1 April 2023 to 31 March 2024 inclusive. 2. RECOMMENDATION 2.1. It is recommended that the Moray Integration Joint Board consider the contents of this report. 3. BACKGROUND 3.1. In compliance with their statutory functions under the Social Work (Scotland) Act 1968, all local authorities have a Chief Social Work Officer (CSWO). Chief Social Work Officers are requested to complete annual reports detailing the performance, challenges and successes experienced by their respective social work services and taken through their own governance structures alongside submission to Scottish Government. 3.2. The Office of the Chief Social Work Adviser in the Scottish Government (OCSWA) collates an overview Summary Report based on the key content of the reports from all local authorities in Scotland. This summary would: • Be of value to CSWOs and also support OCSWA in their role of raising the profile and highlighting the value and contribution of social work services; and • Be a useful addition to the set of information available to aid understanding of quality and performance in social work services across Scotland. Page 81
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3.3. The Council’s Social Work Services require to support and protect people of all ages as well as contributing to community safety by reducing offending and managing the risk posed by known offenders. Social Work has to manage this together with the implications of significant demographic change and financial constraint whilst fulfilling a widening array of legal obligations and duties. 3.4. The annual report is attached at APPENDIX 1. 4. SUMMARY OF IMPLICATIONS (a) Corporate Plan and 10 Year Plan (Local Outcomes Improvement Plan (LOIP)) and Moray Integration Joint Board Strategic Plan “Partners in Care 2022 – 2032” This report is in line with Moray 2026 Plan – healthier citizens, ambitious and confident young people, adults living healthier, sustainable independent lives safeguarded from harm and Council priority 4 – More of our children have a better start in life and are ready to succeed. (b) Policy and Legal The services referred to in this report fall within the scope of a number of important pieces of legislation including: • Social Work (Scotland) Act 1968 • The Adult Support & Protection (Scotland) Act 2007 • The Community Care & Health (Scotland) Act 2002 • The Children (Scotland) Act 1995 • The Joint Inspection of Children’s Services & Inspection of Social Work Services (Scotland) Act 2006 • Adoption and Children (Scotland) Act 2007 • Looked After Children (Scotland) Regulations 2009 • The Public Bodies (Joint Working) (Scotland) Act 2014 • Children & Young People (Scotland) Act 2014 Significant policies and white papers that relate to these services include: • Changing Lives, the Future of Unpaid Care in Scotland (2006) • Delivery for Health (2005) • All our Futures: Planning for a Scotland with an Ageing Population (2007) • Better Health, Better Care: Action Plan for a Healthier Scotland (2007) • Better Outcomes for Older People: Framework for Joint Services (2005) • National Guidance for Child Protection in Scotland, The Scottish Government 2021 • The Promise: Scotland’s Independent Care Review 2020 (c) Financial implications There are no direct financial implications arising from this report. Future priorities will be addressed within the context of the financial planning process. Page 82
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(d) Risk Implications and Mitigation There are no risk implications associated with or arising from this report. (e) Staffing Implications There are no staffing implications directly relating to this report. (f) Property There are no property implications arising from this report. (g) Equalities/Socio Economic Impact There are no issues directly arising from this report. (h) Climate Change and Biodiversity Impacts There are no issues directly arising from this report. (i) Consultations The following have been consulted in the preparation of this report: MIJB Senior Management Team; Simon Bokor-Ingram, Chief Officer 5. CONCLUSION 5.1. The report outlines the performance, challenges and opportunities experienced across social work in Moray through the year. Author of Report: Tracy Stephen CSWO/Head of Service Background Papers: Attached at Appendix 1 Ref: Page 83
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Appendix 1 Annual Report by Moray Chief Social Work Officer Introduction I am pleased to present the Chief Social Work Officer (CSWO) report for the period spanning 1st April 2023 to 31st March 2024. This year has brought about a different set of challenges, chiefly related to the financial position of Moray IJB and the continuing difficulties in recruitment across social work and social care. There has continued to be a lot of policy change across the wider system and staff wellbeing has come into much sharper focus as staffing levels and resources became scarce. That said, the staff across the health and social care partnership have been extraordinary and their commitment and relentless efforts are keenly felt by the members of our community who they are supporting. This was the first year of children, families and justice services social work being in the Health and Social Care Partnership as a delegated service into Moray Integration Joint Board. This created a year of many changes and adjustments for everyone across the partnership but it has felt like a positive step forward in being able to work in an integrated way with adult social work and social care, amongst others. Governance, accountability, and statutory functions The CSWO chairs a Practice Governance Board both within children and justice and adult services. The CSWO reports into the Integration Joint Board and related Audit, Risk and Performance and Clinical and Care Governance Committees as well as the Education, Children’s and Leisure Services Council Committee, as necessary. There is also requirement to attend and support both the Adult and Child Protection Committees. The CSWO chairs the GIRFEC Leadership Group and attends a wide range of partnership meetings across the health and social care partnership, children’s services, wider NHS Grampian partnership and across adults and justice services. The CSWO also attends a regular national CSWO meeting, as well as linking into Social Work Scotland Standing Committee and related subgroups. The governance and accountability arrangements for Moray remain chiefly unchanged throughout this period. Work will continue around trying to better align the governance structures across health and social care. This year saw a joint inspection of children at risk of harm which created an amount of additional activity, between July 23 and January 24. The partnership worked well together to support the process and the inspection report was as expected, where partners were aware of the areas still requiring development. Page 85
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Appendix 1 There was a Fostering, Adoption and Adult Placements inspection in July 2023 which resulted in an improved grading of Good. There was also a nationwide thematic inspection in relation to children’s disability services which included Moray. There were many challenges experienced across adult services, with the continued issue of delayed discharges and care at home and there have been transformational ideas and a high level of commitment from staff to find solutions to the situation. Reducing resources and a requirement to find savings created opportunities to approach challenges in a different way and rethink the way people are provided with support to best meet their needs. There have been challenges with recruitment of social workers and social care staff across this year and this has had an impact on staff who continue to work increasing caseloads. Although this is a national issue, it is felt keenly in Moray as a rural area as recruitment can be a challenge at any time, with this year being particularly difficult. Within Health and Social Care Moray the CSWO is part of the Senior Management Team that meets on a weekly basis. The Chief Social Work Officer relies on reporting from Service Managers, Consultant Practitioners and the development and performance staff to have oversight of the wider system and the quality of social work practice. Developments in this area are required to ensure that the right information is being collected and scrutinised. The data dashboard using Microsoft Power BI has now been developed for children’s and justice services and it is hoped that not only will this provide much more relevant reporting to stakeholders, but there may in the future be opportunities to publish recent data. Children and families This year has seen a number of significant challenges within children and families social work, mainly pertaining to recruitment and retention of staff, similar to many other areas. This led to increased workloads for staff and some failed recruitment drives. The recruitment of agency workers was also a challenge, as Moray can be a difficult place to attract people to, due to the rurality and geography of the authority, despite the fact that when people come here to work and live, they tend to remain. Work is ongoing related to the partnership’s efforts to progress with the Whole Family Wellbeing Fund and both staff absence and capacity impacted progress. The commitment shown to making improvements across the Children’s Services Partnership has been inspiring and with everyone working together, the children’s services plan came together cohesively. Services across the partnership, in place to protect children and young people at risk of harm, were inspected between July and December 2023. Services were assessed as adequate and the key inspection findings were: Page 86
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Appendix 1 - The partnership’s approach to identification and initial response to risk was helping to keep children and young people safe. - The majority of children and young people were benefitting from caring and trusting relationships with key staff, but not all felt that staff spent the time with them that they needed. - Where available, specialist services were helping children and young people recover from abuse and neglect. - Young people at risk of harm from themselves or to others, or from risk in the community did not always receive the help they needed to make a positive difference in their lives. - Children and young people and parents and carers were contributing to decisions about their lives, though not all had access yet to independent advocacy. - Children and young people at risk of harm were not yet routinely influencing service planning and delivery. - The child protection committee had not yet fully developed the mechanisms necessary to understand and communicate the difference that services were making to the lives of children and young people at risk of harm. Alongside partners, social work services are now engaged in an improvement plan to develop and improve the service and practice for children and young people at risk of harm. Positively, the Children’s Services Plan 2023-2026 was launched in October 2023, setting out the vision for children, young people and their families. The social work service has incorporated the aims of this plan into a Social Work Plan for 2024-2027. Central to this plan is reducing the number of children going into care, developing best practice and transforming our culture. Page 87
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Appendix 1 Population of approx. 94,280 (NRS Mid-Year Population Estimates data released on 26 March 24) 18.8% of those are under 18 Approx. 95% of young people under 16 identify as White -Scottish 14% of families have two children or less 0.97% of children and young people have a ‘looked after’ status 95% 5% Nationality White Scottish other Page 88
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Appendix 1 Overall at the end of March 2024 there were 1185 open cases to the Children and Families and Justice Social Work department. Excluding aftercare cases 23% of the people using all other services had previous care experience. • Access Team 172 • West Area Team 233 • East Team 136 • Youth Justice 45 • Throughcare and Aftercare 87 • Disability Pod 90 • Justice Service 422 There were 2614 referrals into the Access Team in the year 23/24 which is an overall decrease of 13.27% on the previous year. 136 233 17290 4537 50 422 Cases open as at 31 March 2024 East SW West SW Access Disability Pod Youth Justice Throughcare Aftercare Justice Services Page 89
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Appendix 1 Of these 624 were Child Protection referrals which is a 14.4% decrease in Child Protection referrals on the previous year. There was also a decrease of 26 referrals relating to domestic abuse which is a decrease 6.9%. Area Teams West and East Area Teams had an average of 18% child protection cases open across the services. Both area teams also struggled with similar staffing challenges putting the teams under additional pressure. There were 173 looked after and accommodated children. 71 children’s names were placed on the North East Child Protection Register at the end of March 24. 0 100 200 300 400 Referrals -Year on Year 21-22 22-23 23-24 Page 90
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Appendix 1 *Numbers exclude justice services and aftercare services Overall there was a slight increase in children being received into local authority care in Moray from March 23 until November 23, there is been evidence of social workers finding creative solutions to support families to stay together and keep children remaining within their families which resulted in an overall decrease in numbers at the end of March 24. Of the children and young people who were leaving care (no longer formally looked after) there were 58 who left care and this was also a decrease of 26.7% from the previous year. The Promise During this period developments were focussed on keeping The Promise to Moray’s children and young people. Our Champion’s Board was refreshed and we launched Moray’s Children’s Services Plan which incorporated the Promise Plan for Moray, Child Poverty plan and the Corporate Parenting Plan. Staff absences impacted our ability to progress the activity we hoped, but a new structure to support the priorities of the plan helped to continue towards our goals. Bairn’s hoose conversations took us to consider our current building at Hamilton Drive, which is a shared unit for police, social work and health colleagues and has the potential to become a format of Bairn’s hoose. Those conversations will continue within the Child Protection Committee. This year has seen the first annual review of the Scottish Child Interview Model (SCIM). The design and implementation of the model has brought accolade to the North East of Scotland with the model winning the Chief Constable’s Excellence Award 2023 under category of Service Improvement. The SCIM is now firmly embedded and well-established across the North East. The proposed hybrid model allowing central coordination supported by local management and structures has been implemented, along with the successful delivery of ‘soft boundaries’ and a single North East IRD process. 173 71469 Categories of Open Cases Looked After Child Child Protection Registration Child In Need Page 91
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Appendix 1 The Implementation Group continues to provide oversight, support, and direction of the SCIM with quarterly reports developed and considered by the group and reported to the three associated CPCs. Total Number of JIIs (SCIM) During 2023, a total of 676 JIIs were completed by the SCIM team with an additional 108 requiring to be completed out with the team utilising the 5-Day model. As such, over the course of the review period, 87% of interviews were conducted under the SCIM, far exceeding the team’s initial commitment of 60%. Children’s Services Learning Reviews — Child I (Irvine) The circumstances pertaining to Irvine were felt to be similar in nature to the recent learning review the partnership undertook for Haddon. While the partnership agreed there would be benefit for a smaller review and support for practitioners the learning is reflected in the wider action plan from both reviews. The Strategic Manager learning event held 22nd January 2024 and A practitioner Feedback Event held 5th February 2024. Both reviews of Flora and Hadden were undertaken internally and were noted as excellent examples of learning reviews by the Care Inspectorate. As such both were presented to the Care Inspectorate Knowledge Hub to disseminate the wider learning, both presentations generated lots of interest and questions, we were thanked for sharing the learning widely. Out of Area Placements In April of 2024 there were 23 agency placements which was a decrease of 4 from the start of the financial year. For residential care the number of placements reduced from 18 to 15, there was 1 secure care placement and for foster care there was a decrease from 9 to 7. 279 41% 253 38% 144 21% 2023 - Number of Interviews Aberdeen City Aberdeenshire Moray Page 92
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Appendix 1 Reduction in the overall number of placements related to young people becoming adults or a change in the practice model. In 2023/24 the Placement Oversight Meeting has continued to have oversight of agency placements and supports care planning. This is with a view to ensuring that high cost care options are only used when necessary and to support young people returning to placements in Moray. The carer recruitment campaign for foster care and supported lodgings has continued to broaden placement options and reducing the need for agency/out of area placements. Placement Services Placement Services comprises Fostering, Adoption, Kinship, Supported Lodgings, Continuing Care and Throughcare & Aftercare. The Fostering Service experienced an increase in the number of foster carers from 34 to 37. This was an increase of 8.87% and followed increased activity with the Marketing Plan and a focus placed on recruitment within the Carer Recruitment Campaign. The Adoption Service undertook one assessment which was due to be heard at panel in May 2024. Two young people from outwith Moray were placed with Moray Adopters where four young people achieved legal permanence by each being made subject to a Permanence Order with Authority to Adopt. In Kinship Care the number of kinship household moved from 28 to 30 which was an increase of 7%. Linked with this, the number of kinship placements formalised via a legal order moved from 38 to 36 during the year which was a decrease of 5%. Two placements ended as the young people returned to parental care. In Supported Lodgings the number of households moved from 4 to 7 where the number of being offered placements increased from 5 to 10. This reflected a move by Supported Lodgings carers to provide more than one placement. It also reflected some applicants wishing to provide a supported lodgings placement to unaccompanied asylum seeking children. As with the Fostering Service a Marketing Plan and Business Plan resulted in a more targeted recruitment campaign as part of the Carer Recruitment Campaign. In Continuing Care the number of placements increased from 7 to 9, a rise of 28%, providing young people with placement stability and continuity as they transitioned into adulthood. This also reflected the effectiveness of the Continuing Care Policy and the degree to which it was embedded within practice. Champion’s Board Moray Champions Board continues to thrive and during the last year has been the driving force behind events which have enabled young people to connect with their peers, develop Page 93
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Appendix 1 new and valuable skills, and be involved in the co-production and decision making of services. Key achievements include- • Care Leavers Event supported by 15 Corporate Parents from across the partnership. • Care Day Celebrations hosted by 10 care experienced young people and attended by 50 Corporate Parents. • Participation in Moray Council Recruitment Process. • 8 young people hosted a Summer BBQ which provided peer support opportunities for young care experienced children. • Co-produced a new Care Leavers Housing Protocol. • 3 young people created and launched a video addressing stigma in Education. • 8 young people supported the joint inspection of children’s services by developing a welcome video for inspectors and hosting an engagement event with young inspectors from the Care Inspectorate. • Moray Champions Board took a lead role in the commissioning including service design and delivery of the new advocacy provider for Moray. • 5 young people worked with Morays Promise Team to co-produce and submit a successful funding bid to Corra, to develop a local maintaining relationships project. During the last year 10 young people are active members of the Champions Board attending weekly sessions and have been supported by 4 multiagency facilitators including adults from the Through Care After Care Team, Morays Youth Team, and Police Scotland. The group has been supported regularly by 7 Corporate Parents from across the partnership. Next steps for the group include developing a care leavers drop in hub and a Champions Board weekly podcast. Unaccompanied children and young people seeking asylum In 2023/24 there was a significant increase in the number of unaccompanied asylum seeking children (UASC) supported by Placement Services via the National Transfer Scheme. The number of young people increased from 6 to 10 UASC who were under 18 and for the over 18’s, still being supported, increased from 3 to 7. They were placed in Supported Lodgings, college accommodation or Local Authority housing supported by staff from the Throughcare & Aftercare Team. This highlights the commitment by Moray Council to support those unaccompanied asylum seeking children via the National Transfer Scheme. Youth Justice There have been 67 referrals into Youth Justice over the last year, with 45 young people actively engaging with the team at the end of this reporting period. These numbers have remained fairly consistent throughout this period. At this time 8% of open cases within Justice Social work and Youth Justice are care experienced young people. This relates to 31% within Youth Justice and 6% in Justice Social Work. Page 94
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Appendix 1 There remains a continued commitment to reducing the number of care experienced young people open to Justice Services and the early identification of individuals so that appropriate supports and early interventions can be offered. There have been 61 children and young people referred to the Scottish Children’s Reporter Administration during this period. 5 of those individuals were female indicating that it continues to be young males who require the highest level of support in respect of being in conflict with the law. The most common offence reported is vandalism with threatening or abusive behaviour next highest, it is evident that these behaviours have a significant impact on the local community and other young people. Targeted interventions are used to address these types of behaviour working with the young people and their care givers. Multi-agency working with education, police and fire service continues to address risks and provide information and safety advice to young people and their families. Youth Justice staff have undertaken training in relation to criminal exploitation and young people which has enhanced their knowledge in relation to contextual safeguarding and particular risks faced by young people within the community. There has also been further training completed in relation to completing risk assessments for young people displaying sexually harmful behaviour which ensures that young people are provided with the right care and support alongside addressing behaviours that are of concern. The Youth Justice team carry out interventions for all 16 and 17 year olds who are assessed as suitable for diversion from prosecution and continue to provide a support role to young people who appear from Court. During this period the team have supported two individuals who have been remanded by the Court to a secure care placement and supported the Justice Social work team in ensuring that approaches when working with younger people within the criminal justice system are appropriate and upholding the rights of children. Justice Services Justice services supported 324 requests for a Justice Social Work Report which converted into 249 community payback orders over the reporting period. The service was able to provide some bespoke and creative supports to people who need it the most in the community, whilst also maintaining contact with individuals in custody who will be released 39 25 14 467 422 45 JSW/YJ COMBINED JUSTICE SW YOUTH JUSTICE CEYP Total case load Page 95
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Appendix 1 on statutory measures. During this period there were 6 individuals who were released from prison on statutory measures and 16 who were offered support through voluntary throughcare. Work has been undertaken through the Community Justice partnership to improve the voluntary provision offered with partners as the uptake on this support remains quite low. At the end of reporting period there were 92 individuals being subject to MAPPA in the community, 2 of these were MAPPA level 2 and none at MAPPA level 3. During this period there was a CAT 3 referral into MAPPA which was managed until transfer of the case to another local authority area. Stats as of 31 March 2024: Moray Cat 1's Total: 126 In prison: 34 In hospital: 0 In community: 92 Police owned: 54 JSW owned: 38 NHS owned: 0 Cat 3's In community: 0 SPS - due for release 1 Restricted Patients Total: 2 In community: 0 In hospital: 2 Bail supervision and electronic monitoring assessments allow an opportunity for early intervention work to take place and early identification of support needs whilst offering a robust alternative to remand. Assessments are completed in all cases where bail is being opposed and there has been a significant increase in these over this period. Bail supervision clinics have now been set up by the support work team in Justice to ensure that contact levels meet the requirements, and practical and emotional support is available in addition to referrals to other agencies. We continue to prioritise women, parents or those with caring responsibilities, individuals who may be more vulnerable due to addiction or mental health issues and under 25’s. Page 96
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Appendix 1 12551 hours of unpaid work have been completed over this reporting period covering the majority of areas in Moray. Whilst most of this work is undertaken by the unpaid work squads in the community, at the end of this period 14 individuals were being supported in individual placements. These placements include charity and third sector organisations which does not take away employment opportunities for other people. This has meant we have been able to support a female who was pregnant to compete her hours and has also resulted in on-going voluntary placements following individuals completing their hours. Improved links have been made between Unpaid Work staff and Moray Pathways in order to link people with employment support at the earliest opportunity. This also allows the individuals to maximise the potential for ‘other activity’ hours that can make up to 30% of hours on an Order. This approach has resulted in increased access to funding for training courses for individuals alongside support to gain employment. The team also continue to work in partnership with Moray Food Plus in the growing and distribution of fresh produce to the local community from our polytunnel, we also utilise this space for group work activities. During this reporting period we have continued to run a men and women’s group which is open to anyone within the service. An 8-week health and wellbeing programme was run in partnership with the NHS Health Promotions team, with sessions also supported by Moray Arts Development Engagement. There are a number of other interventions used within the team aimed at reducing reoffending including structured programme work targeting particular offences i.e. sexual or domestic offending which is delivered in a group, 2:1 or 1:1 depending on the programme and individuals risks and needs. 11 122 8 29 0 20 40 60 80 100 120 140 2022/2023 2023/2024 Bail Supervision Disposal Assessment Page 97
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Appendix 1 Policy, Development and Commissioning There was significant work undertaken by the Policy, Development and Commissioning team to develop and implement procedures and resources to support staff across the partnership in their practice. Procedures developed this year include: • Revised Multi-agency Child Protection Procedure incorporating Protection From Serious Harm The National Guidance for Child Protection 2023 is translated into the Moray context and the procedure ensures that our approach to safeguarding young people who may be at risk of significant harm is firmly anchored in child protection practice. Further to this, where there is actual or potential risk of serious harm, the procedure introduces Protection for Serious Harm Planning to support the partnership manage risk. • Multiagency Reflective Case Discussion Procedure Reflective Case Discussions have been written into practice to support practitioners to reflect upon the barriers to positive outcomes for families • Multiagency Escalation Procedure Where there is a variance in, for example, the assessment of risk or approach to planning between partners to a plan, the Escalation Procedure will support practitioners to resolve the problem and make progress for children and their families. • Secure Care Procedure When secure care may be an option for a young person, to prevent risk of harm to themselves or others, the Secure Care Procedure outlines the potential routes to secure acre and the efforts which must be made to prevent this options form being utilised. • Moray Support in Pregnancy Pathway A revision of the Moray Vulnerable Pregnancy Pathway, the Support in Pregnancy Pathway, sets out the duties, roles and responsibilities to women whose pregnancy is considered vulnerable. • Graded Care Profile 2 Procedure The Graded Care Profile 2 was introduced to Moray to support the assessment and response to neglect. This procedure sets out the response to the assessment to ensure that were neglect is assessed as present, children, young people and their families can rely on a consistent approach across the partnership. • Induction Procedure Mirroring the national picture, the recruitment and retention of qualified social work staff has been a challenge in Moray. The Induction Procedure was introduced to welcome new staff. Page 98
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Appendix 1 Child Protection materials: A series of leaflets relating to child protection practice (Inter-agency Referrals Discussion, Child Protection Planning Meetings, Child Protection Investigations) were developed to support practitioners to help children, young people and their families understand the service and support their participation in planning. Training and Development In the dates between April 2023 and April 2024, the following training has been received by staff: Safe and Together The multi-agency roll out of Safe & Together has been ongoing during this period and over 60 staff members attended the four day CORE sessions. In total, 82% staff members are now licensed to use the tool with the remainder scheduled to be trained over summer 2024. This is a total increase of 54% over the period. 3 social work staff members are trained as trainers. In addition to this, a series of quarterly Practitioner Forums have been introduced to support trained staff. Safer Sleep The multi-agency Safer Sleep training delivered by the Cot Death Trust has now been attended by 71% of children and families social work staff. This training was specifically in relation to Sudden and Unexplained Death of an Infant and/or Child giving staff a good understanding of potential causes, as well as how to interact with families who may face this awful situation. This increase equates to a further 16% of staff receiving training. Our Family Story The assessment paperwork ‘Our Family Story’ introduced in the previous period was still being trained in the past 12 months and 76% of children & families staff have now received training in its use, an increase of 17%. Solution-Orientated Practice/Meetings Moray is continuing to embrace the multi-agency use of Solution Oriented Practice/Meetings. This way of working ties in directly with child protection planning meetings, the Our Family Story assessment and soon to be launch Child Planning paperwork suite. 76% of staff are familiar with this model, which is a 17% increase during this period. Graded Care Profile 2 As of October 2023, 18 members of staff across the partnership were prepared to become Graded Care Profile 2 trainers, 5 of which are from the children & families social work department. To date, 11 training sessions have been scheduled and a total of 31 staff members becoming licensed practitioners, alongside multi-agency colleagues. This equates to 30% of the eligible workforce, with a further 40% to be captured over the remainder of the year. Page 99
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Appendix 1 Short briefings have also been delivered to individuals who would have little use for the licensed tool, but would benefit from a general understanding. These have been well attended and attendees span across the HSP, Council employees and third sector staff. In addition to the aforementioned sessions, the department has come together with the CSWO at multiple sessions to assist with the creation of a Social Work Plan. This are designed to work alongside the existing Children’s Services Plan 23-26. These sessions have allowed for collaborative working, critical thinking, and the introduction of appropriate Team performance indicators. Furthermore, Senior Social Workers now have their own mentoring sessions with a representative from HR, covering staffing related issues, like the FARM process. Parallel to the delivery of the above training, further learning opportunities have been being developed. Over the summer months, staff are due to receive training in newly developed topics such as: Child Criminal Exploitation, Child Sexual Exploitation, Contextual Safeguarding, and Court Skills. Adult Services Challenges were keenly felt across adult services, with the pressures of delayed hospital discharge continuing. There are many examples of staff pulling together to find creative solutions to support different parts of the system to enable support to be focussed in the correct areas. Plans to progress the MRI scanner for Moray and the related decant of Ward 4, Mental Health services to complete necessary anti-ligature works was making good progress and many practitioners came together to carefully plan how the works could happen concurrently and in the least intrusive way possible both for patients of Ward 4 but also of Dr Grays Hospital. Unfortunately, despite making good progress towards finding an ultimate solution, Scottish Government advised that it was unlikely to be able to fund this project and so an alternative route to making support to people both safe and sustainable, with a focus on community supports and maintaining people at home where possible and in their best interests. Page 100
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Appendix 1 Community Care Referrals to Community Care NHS24 Public Protection Referral - Adult Police Concern Report - Adult Referral to Community Care Team+ Scottish Ambulance Service Referral - Adult Scottish Fire & Rescue Service Referral - Adult 2023/24 205 1332 2136 120 52 2022/23 187 1645 2042 74 16 2021/22 12 1333 2227 23 11 Need in the community continues to rise as the age of the population does in Moray with reducing resources across the board. This gives rise to a need to work relentlessly to support people in need to access family and community assets and third sector supports first and foremost, also supporting people to remain at home and be independent. Care at Home The Care at Home Service 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. 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. 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. 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). Weekly monitoring of the unmet need in CAH has been in place since August 2021. In Spring 2023, a strategic review of current CAH arrangements was commissioned by HSCM Senior Management Team. There is an ongoing review of the current contract with a focus on service improvement and sustainability. 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.” Care at Home Position 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. As of 25th February 2024, the planned weekly hours of care were 4752. Page 101
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Appendix 1 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% 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. 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. 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. Recruitment/Retention/Training: Since April 2023, 58 new staff have started in the service as shown in Figure 1. It also shows 48 staff have left, the reasons for this are shown in figure 1 below. Page 102
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Appendix 1 Figure 1 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. 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. There has been significant work from Health and Social Care Moray with the help of internal services, to support the external partner. It was hoped that we will see substantial improvements during 2024. The partner provider had a moratorium placed upon the service leading to a reduction in almost 60 packages of care since September. CAH have devised a Self-assessment tool based on the Care Inspectorate framework, which was highly commended as part of the Inspection process. A forum was established 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. From the Quarter 2 and 3 performance report, the number of delayed discharges at the December 2023 snapshot was 37, this was 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. 0 2 4 6 8 10 12 14 16 18 20 Reasons employees have left Care at Home Service 23/24 Page 103
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Appendix 1 Total Number of hours of care not provided each week – those waiting in community and hospital Mental Health Mental Health Officer Workforce There are currently 13.8FTE Mental Health Officers practicing in Moray. Only 1 MHO has a dedicated MHO role with the remaining having substantive posts. Two of the FTE work in Out of Hours Social Work. A recent workload measurement exercise indicated that daytime MHOs with substantive posts spend on average 1 day per week on MHO work. As with the situation throughout Scotland there are challenges in growing the MHO workforce to meet demand. One Mental Health Officer (MHO) qualified in 2023. There are currently two MHO candidates in training who are expected to qualify towards the end of 2024. However, it is possible retirements will reduce the workforce in the near future given the age profile of MHOs, with 5 being over the age of 60 (see table 1) and some seriously considering retirement. Table 1 MHOs ≤25 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+ Female 0 0 0 0 4 2 2 1 3 0 Male 0 0 0 0 0 0 0 1 2 0 Total 0 0 0 0 4 2 2 2 5 0 Moray seconded an Advanced Practitioner in 2022 attached to the Mental Health Team to focus solely on Adults with Incapacity work to mirror the MHO who had a dedicated MHO role focussing largely on Mental Health Act work. Because the funding was a one-off payment with no further funding forthcoming we were only able to recruit for two years, Page 104
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Appendix 1 starting in July 2022. The seconded post holder left that post early due to being recruited to a permanent post and the social work secondment post was ended on maternity leave. The AWI dedicated role was instrumental in almost clearing the MHO report waiting list but this has since grown again with 20 being on the waiting list as of 31st March 2024. Mental Health Act Comparative data 2021-2024 Table 2 Order 2021- 2022 2022- 2023 2023- 2024 EDC 17(8) 23(10) 21(8) STDC 66 60 85 CTO 18 11 26 CO 2 1 0 EDC = Emergency Detention Certificate; STDC= Short Term Detention Certificate; CTO = Compulsory Treatment Certificate; CTO6 = CTO extension; CO = Compulsion Order. Numbers of EDCs in brackets show attributable to there being no MHO on duty Out of Hours. There is an upward trend in both Short Term Detention Certificates (STDCs). This represents a 42% increase from previous year. For CTOs there has been an increase of 44% increase since 2021-2022. It is not possible to draw conclusions from this given the natural annual fluctuations and the small numbers involved. Data collection and reporting is an area for improvement in the coming year. The gateway into Mental Health compulsory treatment is expected to be through Short Term Detention Certificates rather than Emergency Detention. In total in 2023-2024 there were 21 EDCs, 8 EDCs of which had no MHO consent were attributable to no MHO being available. All EDCs were converted to an STDC the following two days or revoked. Scrutiny into the reason for EDCs in the past year indicated that some EDCs had been incorrectly attributed to there not being an MHO available and clarification of availability of MHOs was sent to the Clinical Director for distribution. The number of EDCs should decrease during the coming year when the remaining social worker in Out of Hours Social Work qualifies as an MHO in Autumn of 2024. Page 105
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Appendix 1 Adult’s with Incapacity In 2022-2023 referrals for an MHO Adults with Incapacity report was 79 which was more than a 100% increase compared to pre-pandemic levels. In 2023-2024 numbers of referrals fell to 62 after a 3-year trend of increasing referrals, a decrease of 27%. Unfortunately, the waiting list for an MHO report has increased to 20. During 2023 -2024 there were 46 welfare guardianships granted in Moray. Table 3 Applicant Learning Disability Dementia Head injury Mental Health ARBD Total Private 24 12 2 0 0 38 CSWO 2 4 0 1 1 8 There are 50 CSWO welfare guardianships in existence, each overseen by a delegated guardian. Adult Commissioning In the last year the team have been focusing on the improvements identified in the external audit from KPMG in February 2023. This process has ensured that the governance surrounding commissioning decisions has been approved and the role that Commissioning has within Health and Social Care Moray has been strengthened. To maintain the processes around commissioning, contracts and monitoring, the team has created a procedure with a number of process maps underpinning the content. These process maps identify governance routes, monitoring processes and internal ways of working. The team have also been working hard to ensure that contracts are current, and they have awarded 13 contracts and undertaken 5 letters of extension. The team is currently working on 12 contracts which are at various stages of the commissioning cycle. Within this, the voice of the citizens of Moray gets stronger as they are included in the commissioning cycle, from consultation stage to sitting on a tender panel. A particular strength of the Adult Social Care Commissioning team is with the proactive and reactive monitoring of contracts. The proactive element of the monitoring of contracts involves a weekly submission of staffing absences, a monthly submission of Comments, Complaints and Incidents, an annual site visit by a Commissioning Co-ordinator, a 6 monthly finance meeting and an annual contract meeting. This ensures that relationships with providers are strong, and they are well supported. This information is then detailed to the Lead Officer. The Commissioning Team also meet weekly with Social Work and Health colleagues as well as with the Care Inspectorate to identify any potential issues. Where there are issues, the Commissioning Team lead on reactive monitoring which is a three-tiered approach: Page 106
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Appendix 1 Supportive Monitoring, Enhanced Monitoring and Social Work led Large Scale Investigations. The approach to be used is authorised through the Collaborative Care Meeting and is a well-received way of monitoring that is supportive, whilst also holding all internal and external colleagues to account for improvement actions. This way of monitoring has been praised by colleagues in the Care Inspectorate as it supports their inspections and any improvements that they agree with providers. Over the next year, the Commissioning Team will be focussing largely on ensuring that Health and Social Care Moray have contracts that are current and appropriate. They will also take the work on commissioning processes from the last year and undertake shared learning within Health and Social Care Moray to upskill and teach colleagues about ethical commissioning. Learning Disability Following the management changes in relation to the Service Manager and Social Work Team manager roles in 2023, there have been further changes in 2024 with the current Health Team Manager retiring from this position at the end of May 2024. Recruitment is ongoing in relation to this role. Approximately 450 people with a Learning Disability are supported and receive a wide spectrum of services from a multi-disciplinary team, to promote their safety, health and wellbeing, and ensure that they have access to full and independent lives. Implementing the Dynamic Support Register has been a significant area of development within the service over the last year. This is in line with the Coming Home Implementation Memorandum of Understanding between the Scottish Government and COSLA and aims to improve monitoring of the experiences of people with learning disabilities and complex care needs who are in hospital, who are in out-of-area placements and/or whose current support arrangements are at risk of breaking down. In the last year there have been 3 people supported through this process to return to their homes in Moray following discharge from a Learning Disability or Mental Health hospital bed, and 9 people supported to stabilise support arrangements which had been at risk of breaking down. There continue to be 5 people living out of area or in hospital and 7 people whose current support arrangements are at risk of breaking down that are being proactively supported through this process. Housing has been an area of significant development within the service over recent years and it is imperative this momentum continues in order to meet the needs of those on the Dynamic Support Register and to proactively prevent people being added to the register. The service is working in partnership with Moray Council Housing Department as well as external providers to achieve this. This includes the continued plan to increase our provision Page 107
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Appendix 1 within the Woodview service which offers independent living to some of the most vulnerable adults who have complex and challenging needs. There has been significant progress over the last year in planning for implementation of Annual Health Checks for adults with Learning Disabilities. These checks have been introduced by the Scottish Government to address and reduce health inequalities experienced by those with a Learning Disability. Working in partnership with one GP practice, the service is soon to commence a pilot involving 20 people with Learning Disabilities with a view to rolling this out more widely thereafter. The transition workers within the Health and Social Care Partnership continue to work closely with the children and families disability pod, ensuring that planning for young adults begins at the earliest possible opportunity. Our Adult Learning Disability service has continued to experience challenges in recruiting into vacant posts, particularly within Social Work and Psychiatry however the team have worked exceptionally hard to provide continuous support to people despite the aforementioned challenges around Covid and recovery. Unpaid Carers Carers UK predicts 3 in 5 of us will be a carer at some point in our lives. There are approximately 800,00 carers in Scotland, with an estimated 16,200 unpaid carers in Moray. Not all unpaid carers in Moray require formal support from statutory services to assist them to meet the demand of the role, or to receive formal support for the person they care for, however, carers rights are enshrined in the Carers (Scotland) Act 2016, and alongside the national Carers Strategy, our local Moray Carers strategy 2023-2026 “Recognised, Valued and Supported” for both adult and young carers was launched on 1st April 2023. Our strategy has three key priorities: Priority 1 Recognition for Carers Priority 2 Valuing Carers Priority 3 Supporting Carers A local action plan has been developed to support us to embed our key priorities over the coming years, with work underway in line with our strategic aims. We have a commissioned service who provide information, support, advice and to offer both Adult Carer Support Plans and Young Carer Statements. Our Carers team is working alongside the Carers Support Service and our Commissioning team to ensure that the key outcomes are delivered in line with strategy. We are continuing to support unpaid carers through the work undertaken by the Day Opportunities team, with the SDS Enablers focussing on building relationships, taking a strength based, asset-based approach, and acknowledging the need for place-based support in people’s own communities. Through the team ensuring that the support delivered Page 108
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Appendix 1 is focussed on meeting the needs of the unpaid carer, but also providing a meaningful outcome for the cared for person, short breaks and respite can be a positive experience for both individuals. The work of the team supports Strategic Outcome Three, Supporting Carers. Adult Protection Committee The adult protection committee continues to be an effective meeting and meets each quarter – chaired by the Independent Chair of both adult and child protection committees. Several developments have taken place in the last year within Adult Support and Protection. These have included: • Trauma informed approach to Case Conferences • Multi-agency training events • Multi-Agency Quality Assurance • The embedding of the Moray Integrated Vulnerable Adults process (MIVA) • ASP National Implementation Subgroup – Chronologies The trauma informed approach to Case Conferences is highlighted as a particular area of good practice with the team working alongside multi-agency practitioners and supported individuals to ensure that the Adult Support and Protection Case Conference Agenda and flow of the meeting was mindful of the trauma experienced by the people they support. One such example of the changes that have taken place included the support provided prior, during and after the meeting to individuals as well as ensuring that the meeting was as person-centred as possible, with professionals entering only after the individual and their representatives had arrived and had time with the Chair. This has proved successful, and we have seen a rise in individuals attending and contributing to their Case Conference. In relation to training the APC agreed a subgroup for ASP Learning and Development. The subgroup links to the Grampian Learning and Development ASP Group. The multi-agency group will work to support developments and awareness on local issues relating to ASP work. Including • Hoarding and Self-Neglect • Referrals and local threshold awareness • Identifying areas of interest and further development • Undertaking a training needs analysis (TNA) Following the revision of the Adult Support and Protection Codes of Practice in 2022 a National Implementation Group was formed supported by the Scottish Government to support the embedding of the codes and changes to practise. A series of smaller Subgroups were then created to support this with participants from a breadth of services and organisations across Scotland (SWS, IRISS, Scottish Government, Care Inspectorate, Police, NHS, Health Improvement Scotland, Local Authorities, and the 3rd Sector). These subgroups cover 4 areas. Page 109
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Appendix 1 • Chronologies • Self-Evaluation • Advocacy and Voice of the Service User • Inquiry, investigative powers, and the role of the Council Officer The Adult Support and Protection Lead Officer for Moray currently facilitates the Chronology Group, with representation on a Grampian basis to all four of the Subgroups from the Pan Grampian Partnership. Following discussion, further presentation and partnership working, as well as agreement and interest from several Scottish Government Ministers who are responsible for Public Protection areas and workstreams the remit of the Chronology Subgroup will now be widened to include all areas across the lifespan. This is an exciting development in which can lead to real transformational change in relation to Chronologies across the Lifespan and how we move forward collaboratively in tackling this challenging subject. The Subgroup will now work to • Develop and amend the draft tools alongside Iriss to ensure its relevance across the life span of an individual. • Discuss and plan communication and learning and development messaging. • Move forward to Championing Chronologies within Partnerships and Organisations • Plan involvement and consultation with lived experienced individuals in their information and what this means for them. • Agree governance and oversight on a national basis (currently this is via the National Adult Protection Strategic Forum) • Test the agreed draft tools within Pilot areas across Scotland. Throughout the period 2023 – 2024 Moray has received 2 requests for Learning Review. One referral progressed to Adverse Event Review (AER). The further referral resulted in decision by the Learning Review Subgroup to not proceed with Learning Review but hold a Practitioners Event in relation to the case to enable any learning to be extracted and shared. The Practitioner Event is due to take place in May 2024. Moving forward into 2023/2024 the APC are revising their Multi-Agency Improvement Plan in consultation with front-line practitioners as well as revision of the Lead Agency Operational Guidance which will assist in bringing further clarity and support the embedding of this workstream. Adult Support and Protection A total of 920 Adult Support and Protection referrals have been received from April 2023 – March 2024. It is apparent that the significant rise we observed in 2022/2023 appears to have reached a plateau. The table below gives a further insight into this and shows the unprecedented rise in referrals witnessed last year and over the last 3 years. Page 110
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Appendix 1 Figure 1 – number of ASP referrals received. Following receipt of an ASP referral a formal ‘screening’ process takes place to ascertain if the individual concerned could be at risk of harm. Instances where a screening is not required include should the referral be a duplicate; individual is already open to ASP process, or the referral is an ‘update’ of information already known for example. Below is a breakdown of the outcome of the ASP referrals received. Screening outcome Number of Screenings Percentage of all screenings Further Social Work Intervention 379 52.20% No Support Required 154 21.21% Proceed to IRD 131 18.04% Referral to External Agencies 26 3.58% Social Work Team Referral 32 4.41% No outcome recorded 3 0.41% Outcome overdue 1 0.14% Figure 2: Screening outcomes Between April 2023 and March 2024 there have been 726 screenings completed, with 379 (52.2%) requiring further social work intervention. 154 (21.2%) did not require support, and a further 131 (18.0%) proceeded to IRD. The remaining 62 (8.54%) were referred to external agencies or social work team or have no outcome recorded. The use of an Inter-Agency Referral Discussion (IRD) for ASP has been in place in Moray since December 2021. Since commencement this process has provided better working 0 20 40 60 80 100 120 April May June July August Sep Oct Nov Dec Jan Feb March ASP Referrals 2021/22 2022/23 2023/24 Page 111
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Appendix 1 relationships between partners, and feedback provided from practitioners has been favourable. The number of IRD’s held during the period April 2023 and March 2024 averaged 10 adults per month with 74 progressing to Adult Support and Protection Investigation compared to 58 the year prior. The advent of the Adult Support and Protection Minimum Dataset in conjunction with Iriss, who led the project alongside five learning partners commenced in April 2023. This mandatory dataset was welcomed in Moray and a step in the right direction in relation to generating meaningful and comparable data nationally. The implementation of this has not been without challenge for Moray in aligning our CareFirst System to capture the data required, but one that we see value in. Challenges and improvements We have faced a number of challenges across this year, getting used to the addition to the HSCP of children and justice social work. There were also challenges around reducing resources, increases in need in the community and staffing issues, both retention and recruitment and staff sickness. Staff have been extremely resilient this year when there have been a number of vacancies across the system but no let-up in need. There has been high levels of commitment to providing quality services to individuals who need support across the board and an improvement in how people consider the views of those they are supporting. Undoubtedly, there is an increased need for justice social work and increasing prison population and recognition that community based sentences are most likely to allow the right conditions for change but this creates additional pressure on justice services and this has been an extremely busy year for the team. The cost of care is increasing along with the cost of living, so third sector partners, commissioned services and the general public have all been impacted by this and it creates unmet need at a time where we have an aging population and families are living under stressful conditions, particularly related to poverty. We have had to work closely with providers to recognise where they require additional support, and where we have had to look creatively at service provision to ensure we are helping the right people at the right time. There has been a significant increase in young people arriving in Moray through the UASC scheme and our teams have done an amazing job in helping the young people settle and have opportunities to reach their potential. Our mental health officers are declining in numbers and this creates additional requests for support from the officers we have in place, with less interest from staff in completing their Page 112
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Appendix 1 mental health certificate, which perhaps reflects the pressures on the social work roles across the system. Delayed discharges continue to be a wicked issue but teams have worked relentlessly to shift the position related to this and to allow people to get home from hospital at the soonest opportunity, in line with our priority of home first. This has to be done in a way that balances people’s need for protection and support with being discharged from a disempowering hospital setting. Resources The Health and Social Care Partnership in Moray faced the same financial challenges as many other areas of the country. There is an increasing overspend and need to pull back in line with reducing budgets. Work has been ongoing throughout the year to identify where savings can be made and where efficiencies can be created by doing things differently. Children’s services commissioned a prevention of care service to work with families whose children were on the edge of care to enable more young people to remain at home with support on an intensive basis. Functional Family Therapy are now embedded and form part of the children’s services resource panel, to ensure the correct children and young people are given this service as a priority. The Whole Family Wellbeing Fund has allowed for continuation of some key posts, not least the Wellbeing Co-ordinators whose function it is to work with universal services to ensure that the GIRFEC process is working well in Moray, with the child’s plan being developed by universal services to reduce the pressures on social work’s front door and to ensure that families are not elevated to third tier services unnecessarily. Plans are now in place to develop services that will help whole family support and reduce some of the difficulties that young people are experiencing within education, by providing a multi-agency team to pool all skills together to wrap around families. The resources to support children and young people is in high demand, with numbers of foster carers not meeting demand and the use of Out of Area placements continues to be a challenge as a number of social work departments compete for the same few placements available at times. There are also challenges around resources within care at home and care homes, as well as community care and the pressures of providing safe bespoke care on tightening purse strings is ever present and continues to be a source of stress for social workers. Moray also has a limited number of third sector and community organisations and there is a low presence of social care agencies to enable good competitive and ethical commissioning practices. We continue to try and find creative ways to ensure our commissioning processes allow us the best possible services for our communities. Page 113
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Appendix 1 Adult Social Work and Social Care 2020/21 £m 2021/22 £m 2022/23 £m 2023/24 £m Total Budget 49.6 58.5 60.4 63.9 Services for Children, Young People & Families 2020/21 £m 2021/22 £m 2022/23 £m 2023/24 £m Total Budget 19.383 19.791 18.334 16.147 Justice Services 2020/21 £m 2021/22 £m 2022/23 £m 2023/24 £m Total Budget -0.106 -0.106 -0.109 -0.109 Workforce Number of front line social work posts: Adult Services: 46.8 FTE Children and Families: 57.08 FTE Justice: 13.5 FTE There continues to be a number of vacancies across social work, in particular around children and families, as with other parts of the country, with work happening alongside HR to try and find creative ways to fill posts and support succession planning. Looking ahead Moray will see the introduction of a new CSWO and Head of Service this year, as I will be leaving the post in June. This coincides with the departure of the Chief Nurse and the Chief Officer at the same time as a new Chief Executive comes into the council. This will create some change for the workforce, it will be important to ensure services remain as stable as possible during this time of transition, with an opportunity for a fresh look at how we are doing and where we need to go. This next year should see the development of the Youth Pod within children’s services, bringing together our throughcare and youth justice services into one specialised team. This helps us meet the requirements of our improvement plan which followed the joint inspection of children at risk of harm. There should also be an improved performance reporting within children’s services as we have set out KPIs and developed the data dashboard to provide a better sense of how children’s and justice social work is performing. Page 114
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Appendix 1 Overall the key feature of the next year will be realising challenging savings plans and ensuring that services to our most vulnerable citizen’s remain appropriate, proportionate and that we are upholding the rights and best interests of those we are charged with supporting. Tracy Stephen Moray Health and Social Care Partnership Chief Social Work Officer and Head of Service May 2024 Page 115
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REPORT TO: MORAY INTEGRATION JOINT BOARD ON 30 MAY 2024 SUBJECT: THE MORAY ALCOHOL AND DRUG PARTNERSHIP (MADP) – SCOTTISH GOVERMENT ANNUAL REPORTING SURVEY BY: MADP COORDINATOR 1. REASON FOR REPORT 1.1 To inform the Board of the results of the MADP Annual reporting survey 2023/2024 and request approval to submit the survey. 2. RECOMMENDATION 2.1 It is recommended that the Board: i) considers and notes the completed annual reporting survey and agrees submission to the Scottish Government as required; and ii) notes the progress of the Moray Drug and Alcohol Partnership in delivering services to Moray as documented in Appendix 1. 3. BACKGROUND 3.1 The Scottish Government conducts an annual survey to gather information from Alcohol and Drug Partnerships (ADPs) throughout Scotland on an annual basis. 3.2 The survey contents, as gathered by the Scottish Government, serve to enhance insights into local progress, shaping national mission monitoring. The deadline for submission is 28 June 2024, with annual survey sign off required from the MIJB and MADP. 4. KEY MATTERS RELEVANT TO RECOMMENDATION 4.1 In 2023/24 the Moray ADP has used allocated funding to support lived experience. Work undertaken has included: • The forming of an independent lived experience panel. • Charter of rights engagement groups and peer support groups. Page 117
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• Peer support training, independent advocacy, and rights training as well as Motivational Interview training. • Lived experience involvement is the design of the specification of the direct access service contract. • Lived experience part of the scoring panel on the direct access service tender. • Funding and supporting the employment of a lived experience development worker. 4.2 The Moray ADP has carried out work on tackling stigma and ensuring the human rights of the people the service supports. Work undertaken has included: • Lived experience pathways into employment. • 80 Percent of the team now working in the direct access service have lived or family experience of substance use. • Lived experience substance use talks in all the schools in Moray. • Shared care in GP practices. • Lived experience contribute and support the ADP through local improvement plans. • Lived experience has supported Police Scotland on assertive outreach, cuckooing and county lines (Operation Protector) which has led to innovative projects like our recovery football. 4.3 Moray ADP has made strides in building a Resilient and Skilled Workforce. Work undertaken has included: • New staff training plans put together by both specialist and direct access Third Sector service to support staff training and wellbeing. • Streamlined software recording systems to support staff to ensure recording is simple. • ADP training to support staff with trauma informed practice. • Protected time for staff training, reflective practice, group supervision and individual supervisions. • Lived experience team members have peer support events that support networking with other peers, training, and mental health support. 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 delivery plan for the MADP aligns to the Moray Integration Joint Board Strategic Plan and the Local Outcomes Improvement Plan. (b) Policy and Legal The MADP works to both National and Local Policy and within the agreed Legal Framework. (c) Financial implications There are no financial implications arising from this report. (d) Risk Implications and Mitigation None arising directly from this report. Page 118
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(e) Staffing Implications There are no staffing implications. (f) Property There are no property implications. (g) Equalities/Socio Economic Impact This report does not require an Equality Impact Assessment as there is no change to policy. (h) Climate Change and Biodiversity Impacts None arising directly from this report. (i) Directions There are no directions. (j) Consultations Simon Bokor-Ingram, Chief Officer Tracy Stephen, CSWO/Head of Service Children and Adult Social Work Service – Locality/Service and Team Managers Public Protection Areas Moray Drug and Alcohol Partnership members 6. CONCLUSION 6.1 In the 2023/24 period, the Moray ADP diligently aligned our strategies to the National mission and Medication Assisted Treatment (MAT) standards. The Board is asked to acknowledge and approve the survey detailed in Appendix 1 and to endorse ongoing updates from the ADP upon request. Author of Report: Justin Jansen, ADP co-ordinator Background Papers: https://www.gov.scot/publications/national-drugs-mission-plan- 2022-2026/ Ref: Page 119
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1 Alcohol and Drug Partnership (ADP) Annual Reporting Survey: 2023/24 This survey is designed to collect information from all ADPs across Scotland on a range of aspects relating to the delivery of the National Mission on drugs during the financial year 2023/24. This will not reflect the totality of your work but will cover areas where you do not already report progress nationally through other means. The survey is composed of single option and multiple-choice questions with a limited number of open text questions. We want to emphasise that the multiple-choice options provided are for ease of completion and it is not expected that every ADP will have all of these in place. We do not expect you to go out to services in order to respond to questions relating to activities undertaken by them in your area. Where questions refer to service level activities, we are interested in the extent to which you are aware of these at an ADP level. We are conscious that some of the data we are now asking for may appear to have been supplied through other means (e.g. MAT Standards reporting). After careful review, we found the data supplied via these means is not in a form that allows for consistently tracking change over time at a national level and so have included a limited number of questions on these topics. The data collected will be used to better understand progress at local level will inform: • National monitoring of the National Mission on Drugs; • The work of advisory groups including the Whole Family Approach Group, the Public Health Surveillance Group and the Residential Rehabilitation Working Group, amongst others; and • The work of national organisations which support local delivery. The data will be analysed and findings will be published at an aggregate level as Official Statistics on the Scottish Government website. You can find the report on the 2022/23 ADP survey responses here. All data will be shared with Public Health Scotland to inform drug and alcohol policy monitoring and evaluation, and excerpts and/or summary data may be used in published reports. It should also be noted that the data provided will be available on request under freedom of information regulations and so we would encourage you to publish your return. The deadline for returns is Friday 28 June 2024. Your submission should be signed off by the ADP and the IJB. We are aware that there is variation in the timings of IJB meetings so please flag if this will be an issue. If you require clarification on any areas of the survey or would like any more information, please do not hesitate to get in touch by email at substanceuseanalyticalteam@gov.scot. APPENDIX 1 Page 121
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2 Cross-cutting priority: Surveillance and Data Informed Question 1 Which Alcohol and Drug Partnership (ADP) do you represent? Mark with an ‘x’. [single option] Aberdeen City ADP Aberdeenshire ADP Angus ADP Argyll & Bute ADP Borders ADP City of Edinburgh ADP Clackmannanshire & Stirling ADP Dumfries & Galloway ADP Dundee City ADP East Ayrshire ADP East Dunbartonshire ADP East Renfrewshire ADP Falkirk ADP Fife ADP Glasgow City ADP Highland ADP Inverclyde ADP Lothian MELDAP ADP X Moray ADP North Ayrshire ADP North Lanarkshire ADP Orkney ADP Perth & Kinross ADP Renfrewshire ADP Shetland ADP South Ayrshire ADP South Lanarkshire ADP West Dunbartonshire ADP West Lothian ADP Western Isles ADP Page 122
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3 Question 2 Which groups or structures were in place at an ADP level to inform surveillance and monitoring of alcohol and drug harms or deaths? Mark all that apply with an ‘x’ – if drug and alcohol deaths are reviewed at a combined group, please select both ‘Alcohol death review group’ and ‘Drug death review group’. [multiple choice] X Alcohol death review group X Alcohol harms group X Drug death review group X Drug trend monitoring group/Early Warning System None Other (please specify): MARS Group which Covers Alcohol and Substance use risk and harms Question 3 3a. Do Chief Officers for Public Protection receive feedback from drug death reviews? Mark with an ‘x’. [single option] X Yes No Don’t know 3b. If no, please provide details on why this is not the case. [open text – maximum 500 characters] Question 4 Please describe what local and national structures are in place in your ADP area for the monitoring and surveillance of alcohol and drug harms and deaths, and how these are being used to inform local decision making in response to emerging threats (e.g. novel synthetics)? [open text – maximum 2,000 characters] In Moray we currently have the following structures in place to monitor alcohol and drug harms and deaths: Drug related death review group Multi Agency risk and harm group ADP Strategic Group Grampian Radar Group DRD Data Review Group MAT Implementation and Support Meeting Daily Huddle meeting between 3rd sector and specialist services Page 123
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4 All of these structures are being used to influence our ADP strategy and local improvement plans on how we support people affected by substance use harm and how we commision our substance use services in Moray. The data influences our assertive outreach support and how we support areas and people in Moray at highest risk. Our daily huddle support meeting proactively identifies people at highest risk and supports our fieldworking team to proactively support NFOs, MAT support and those at highest risk of harm on a daily basis. Question 5 5a. In response to emerging threats, e.g. novel synthetics, have you made specific revisions to any protocols? Mark with an ‘x’. [single option] X Yes No 5b. Please provide details of any revisions [open text – maximum 500 characters] Revisions have been made through our Pan Grampian Substance Use network to our RADAR program and response to emerging threats, this has been led by our public health consultant with a remit for substance use and lead Pharmacist in Grampian. Our Rapid alert program was revised in January 2024 and is in an advanced draft stage. Page 124
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5 Cross-cutting priority: Resilient and Skilled Workforce Question 6 6a. What is the whole-time equivalent1 staffing resource routinely dedicated to your ADP Support Team as of 31 March 2024. [numeric, decimal] Total current staff (whole-time equivalent including fixed-term and temporary staff, and those shared with other business areas) 2.00 Total vacancies (whole-time equivalent) 0 6b. Please list the job title for each vacancy in your ADP Support Team as at 31 March 2024 (if applicable). [open text – maximum 500 characters] Question 7 1 Note: whole-time equivalent (WTE) is a unit of measurement that indicates the total working hours of employees in relation to a full-time position. It helps to standardise and compare staffing resource across different teams or organisations. A full-time employee is equal to one whole-time equivalent. For part-time employees, divide their hours by the whole-time equivalent. For example, if a part-time employee is required to work 7.5 hours per week and a ‘full-time’ position is considered to be 37.5 hours, the WTE would be 0.2 (7.5 hours / 37.5 hours). Page 125
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6 Please describe any initiatives you have undertaken as an ADP, or are aware of in the services you commission, that are aimed at improving employee wellbeing (volunteers as well as paid staff). [open text – maximum 2,000 characters] In our new 3rd sector direct access service specification, special emphasis was made towards staff wellbeing. We asked for streamlined software recording systems to support staff to ensure recording is simple, streamlined and has no duplicate recording practices. Our reasoning for this ask was due to staff feedback that the sytems were not conducive to staff wellbeing and caused the most frustration in working within services. We have added specific training to our ADP training calender to support staff with trauma informed practice and have worked as an ADP to have protected time for staff training, reflective practice, group supervision and individual supervisions. There are staff training plans put together by both our specialist and direct access service to support staff training and wellbeing. Both our services have staff wellbeing structures in place that offer wellbeing benefits, counselling and have an appointed wellbeing staff member for organising staff events and team building activities for our teams. Lived experience team members have peer support events that support networking with other peers, training and mental health support delivered by Moray wellbeing Hub and our direct access service. Cross cutting priorities: Lived and Living Experience Question 8 Do you have a formal mechanism at an ADP level for gathering feedback from people with lived/living experience who are using services you fund? Mark all that apply with an ‘x’. [multiple choice] X Experiential data collected as part of MAT programme X Feedback / complaints process X Lived / living experience panel, forum and / or focus group Page 126
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7 X Questionnaire / survey No formal mechanism in place Other (please specify): Question 9 How do you, as an ADP, use feedback received from people with lived/living experience and family members to improve service provision? Mark all that apply with an ‘x’. [multiple choice] Lived/living experience Family members Feedback is integrated into strategy X X Feedback is presented at the ADP board level X X Feedback used in assessment and appraisal processes for staff X Feedback used to inform service design X X Feedback used to inform service improvement X X Other (please specify) Question 10 10a. In what ways are people with lived and living experience able to participate in ADP decision-making? Mark all that apply with an ‘x’. [multiple choice] X Through ADP board membership X Through a group or network that is independent of the ADP X Through an existing ADP group/panel/reference group X Through membership in other areas of ADP governance (e.g. steering group) Not currently able to participate Other (please specify): 10b. In what ways are family members able to participate in ADP decision-making? Mark all that apply with an ‘x’. [multiple choice] X Through ADP board membership X Through a group or network that is independent of the ADP X Through an existing ADP group/panel/reference group X Through membership in other areas of ADP governance (e.g. steering group) Not currently able to participate Page 127
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8 Other (please specify): Question 11 What mechanisms are in place within your ADP to ensure that services you fund involve people with lived/living experience and/or family members in their decision making (e.g. the delivery of the service)? Mark all that apply with an ‘x’. [multiple choice] X Prerequisite for our commissioning X Asked about in their reporting X Mentioned in our contracts None Other (please specify): Question 12 Please describe how you have used your ADP’s allocated funding for lived/living experience participation2 in the last financial year. Within your answer please indicate which activities have been most costly. [open text – maximum 2,000 characters] We have used our allocated funding to support the forming of our independent lived experience panel. ADP funding has been made available to support lived experience to attend recovery walks, charter of rights engagement groups, experiential interviews and vouchers to support the interviews. Funding has been used for peer support training, independent advocacy and rights training as well as Motivational Interview training. We have also used funding to support lived experience in supporting our commisioning team when tendering and scoring for our new direct access service contract. Our most costly expenditure has been to employ a lived experience development worker funded by the ADP who supports within our direct access service. Cross cutting priorities: Stigma Reduction Question 13 2 The funding letter specified that “£0.5 million is being allocated to ADPs to ensure the voices of people with lived and living experience are heard and acted upon in service design and delivery at a local level. This includes decisions about prioritisation, commissioning and evaluation of services.” Page 128
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9 Within which written strategies or policies does your ADP consider stigma reduction for people who use substances and/or their families? Mark all that apply with an ‘x’. [multiple choice] X ADP strategy, delivery and/or action plan X Alcohol deaths and harms prevention action plan X Communication strategy X Community action plan Drug deaths and harms prevention action plan X MAT standards delivery plan X Service development, improvement and/or delivery plan None Other (please specify): Question 14 14a. Please describe what work is underway in your ADP area to reduce stigma for people who use substances and/or their families. [open text – maximum 2,000 characters] Through our frontline services we have developed lived experience pathways into employment, this has come through support to volunteer and then progress into paid employment. 80 Percent of the team now working in our direct access service have lived or family experience of substance use. We are delivering lived experience substance use talks in all the schools in Moray. Through our partners and lived experience community we have peer development events. People can now access substance use support in some of the GP practices in Moray with lived experience supporting within those GP practices. Fieldworking and outreach have been instrumental in removing barriers to people accesing support, we operate a no barriers policy to supporting people in the community they live in as opposed to a policy of people need to come into services for appointments. Lived experience contribute and support our ADP through local improvement plans, commisioning and are part of our newly formed strategic development group. Our commisioning contract for our direct access service was developed with lived experience input, stigma and support for lived experience/families is central to our contract. Lived experience has supported police Scotland on assertive outreach, cuckooing and county lines (Operation Protector) which has led to innovative projects like our recovery football which is supported by Police Scotland as a partner. We have supported SAS in training new ambulance technicians by having lived experience deliver part of the training and within our drugs education for other services training we have lived experience and family members deliver their stories as part of the training. 14b. What data does your ADP have access to that could be used to capture the impact of the work described in 14a? (Please indicate if this is not currently possible). [open text – maximum 500 characters] Page 129
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10 School Talk Data, Peer development attendance and event data, Fieldworking and outreach visit data, GP practice attendance data, Lived experience Local improvement plan feedback, Lived experience contract commisioning feedback, Operation Protector data and Football attendance data and feedback from attendees. Page 130
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11 Fewer people develop problem substance use Question 15 How is information on local treatment and support services made available to different audiences at an ADP level (not at a service level)? Mark all that apply with an ‘x’. [multiple choice] In person (e.g. at events, workshops, etc) Leaflets / posters Online (e.g. websites, social media, apps, etc.) Non-native English speakers (English Second Language) X People from minority ethnic groups People from religious groups People who are experiencing homelessness X X People who are LGBTQI+ X People who are pregnant or peri-natal People who engage in transactional sex People with hearing impairments and/or visual impairments People with learning disabilities and literacy difficulties Veterans X Women X X X Page 131
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12 Question 16 Which of the following education or prevention activities were funded or supported3 by the ADP? Mark all that apply with an ‘x’. [multiple choice] 0-15 years (children) 16-24 years (young people) 25 years+ (adults) Campaigns / information X X X Harm reduction services X X Learning materials X X X Mental wellbeing X X Peer-led interventions X X Physical health X X X Planet Youth Pregnancy & parenting X X Youth activities X X X Other (please specify) 3 Note: ‘supported’ refers to where the ADP provides resources of some kind (separate from financial, which is covered by “funded”). This could take the form of knowledge exchange, staffing, the supply of materials (e.g. learning templates, lending them a physical location), etc. Page 132
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13 Risk is reduced for people who use substances Question 17 In which of the following settings are selected harm reduction initiatives delivered in your ADP area? Mark all that apply with an ‘x’. [multiple choice] Supply of naloxone Hepatitis C testing Injecting equipment provision Wound care Community pharmacies X X X Drug services (NHS, third sector, council) X X X X Family support services X X General practices X X X Homelessness services X X Hospitals (incl. A&E, inpatient departments) X X Justice services X Mental health services Mobile/outreach services X X X Peer-led initiatives X X Prison Sexual health services X Women support services Young people’s service X None Other (please specify) Page 133
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14 Question 18 19a. Which of the following harm reduction interventions is there currently a demand for in your ADP area? (Either where the intervention is not currently provided or where demand exceeds current supply). Mark all that apply with an ‘x’. [multiple choice] Drug checking Drug testing strips Heroin Assisted Treatment Safer drug consumption facility X Safer inhalation pipe provision Safe supply of substances Other (please specify): 19b. Please provide details, e.g. scale of the demand. [open text – maximum 500 characters] None of the above are available in our area, safer pipe provision would see an uptake if provided with our IEP. Moray is rural in nature and some of the above would need to be delivered on outreach support which makes it complex to be able to deliver and support. Page 134
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15 People most at risk have access to treatment and recovery Question 19 Which partners within your ADP area have documented pathways in place, or in development, to ensure people who experience a near-fatal overdose (NFO) are identified and offered support? Mark all that apply with an ‘x’. [multiple choice] NFO pathway in place NFO pathway in development Community recovery providers X Homeless services X Hospitals (including emergency departments) X Housing services X Mental health services X Police Scotland X Primary care X Prison Scottish Ambulance Service X Scottish Fire & Rescue Service Specialist substance use treatment services X Third sector substance use services X Other (please specify) Question 20 Which, if any, of the following barriers to implementing NFO pathways exist in your ADP area? Mark all that apply with an ‘x’. [multiple choice] X Further workforce training required X Insufficient funds X Issues around information sharing Lack of leadership Lack of ownership X Workforce capacity None Other (please specify): Page 135
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16 Question 21 In what ways have you worked with justice partners4? Mark all that apply with an ‘x’. [multiple choice] Strategic level X ADP representation on local Community Justice Partnership X Contributed to strategic planning X Coordinated activities between justice, health or social care partners X Data sharing X Justice organisations represented on the ADP (e.g. COPFS, Police Scotland, local Community Justice Partnership, local Justice Social Work department, prison) X Provided advice and guidance Other (please specify): Operational level X Provided funding or staff for a specialist court (Drug, Alcohol, Problem Solving) X Raised awareness about community-based treatment options (partners involved in diversion from prosecution or treatment-based community orders) X Supported staff training on drug or alcohol related issues Other (please specify): Service level Funded or supported: Navigators for people in the justice system who use drugs X Services for people transitioning out of custody X Services in police custody suites X Services in prisons or young offenders institutions Services specifically for Drug Treatment and Testing Orders (DTTOs) X Services specifically for people serving Community Payback Orders with a Drug or Alcohol Treatment Requirement Other (please specify): 4 Note: ‘justice partners’ includes Community Justice Partnerships (CJPs), Justice Social Work departments, Prisons and Young Offender Institutes, Police, Crown Office and Procurator Fiscal Service (COPFS), Scottish Courts and Tribunals Service (SCTS), Sacro, and third sector organisations that specifically serve people involved with the criminal justice system. Page 136
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17 Question 22 Which activities did your ADP support at each stage of the criminal justice system? Mark all that apply with an ‘x’. [multiple choice] Pre- arrest5 In police custody6 In courts7 In prison8 Upon release9 Advocacy or navigators Alcohol interventions X X X X X Drug and alcohol use and treatment needs screening X X X X X Harm reduction inc. naloxone X X X X Health education & life skills X X X Medically supervised detoxification X X X Opioid Substitution Therapy X X Psychosocial and mental health based interventions X X X Psychological and mental health screening X X X Recovery (e.g. café, community) X X X X Referrals to drug and alcohol treatment services X X X X X Staff training X X X X X None Other (please specify) 5 Pre-arrest: Services for police to refer people into without making an arrest. 6 In police custody: Services available in police custody suites to people who have been arrested. 7 In courts: Services delivered in collaboration with the courts (e.g. services only available through a specialist drug court, services only available to people on a DTTO). 8 In prison: Services available to people in prisons or young offenders institutions in your area (if applicable). 9 Upon release: Services aimed specifically at supporting people transitioning out of custody. Page 137
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18 Question 23 24a. Does your ADP fund or support any residential services that are aimed at those in the justice system (who are who are subject to Community Payback Orders, Drug Treatment and Testing Orders, Supervised Release Orders and other relevant community orders)? Mark with an ‘x’. [single option] Yes X No Don’t know 24b. If yes, please list the relevant services. [open text – maximum 500 characters] Question 24 24a. For individuals who have had a court order given to them in relation to their substance use, do you have testing services available in your ADP area10? Mark with an ‘x’. [single option] X Yes No Don’t know 24b. If yes, please describe the type of monitoring that takes place (e.g. sampling with handheld devices, spit tests, electronic monitoring) and who provides these services (e.g. private, third sector, statutory). [open text – maximum 500 characters]. Sampling with handheld devices - Statutory 10 We are including this question on behalf of Scottish Government Justice colleagues to better understand substance testing for orders and licences in Scotland. Page 138
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19 People receive high quality treatment and recovery services Question 25 What screening options are in place to address alcohol harms? Mark all that apply with an ‘x’. [multiple choice] X Alcohol hospital liaison X Arrangements for the delivery of alcohol brief interventions in all priority settings X Arrangement of the delivery of alcohol brief interventions in non-priority settings X Pathways for early detection of alcohol-related liver disease None Other (please specify): Question 26 What treatment options are in place to address alcohol harms? Mark all that apply with an ‘x’. [multiple choice] X Access to alcohol medication (e.g. Antabuse, Acamprase, etc.) X Alcohol hospital liaison Alcohol related cognitive testing (e.g. for alcohol related brain damage) X Community alcohol detox (including at-home) In-patient alcohol detox X Pathways into mental health treatment X Psychosocial counselling X Residential rehabilitation None Other (please specify): Page 139
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20 Question 27 27a. Which, if any, of the following barriers to residential rehabilitation exist in your ADP area? Mark all that apply with an ‘x’. [multiple choice] Availability of aftercare X Availability of detox services X Availability of stabilisation services X Current models are not working X Difficulty identifying all those who will benefit X Further workforce training required X Insufficient funds X Insufficient staff X Lack of awareness among potential clients Lack of capacity Lack of specialist providers X Scope to further improve/refine your own pathways Waiting times None Other (please specify): 27b. What actions is your ADP taking to overcome these barriers to residential rehabilitation? [open text – maximum 500 characters] Our ADP has been working with HIS to action an audit on our residential treatment pathway. We have a working group set up to address the barriers we have with our residential treatment pathway and are currently in process of adopting the National flexible framework for residential treatment. We have initiated meetings with most of the residential treatment providers and have further explored how the dual housing benefit can support people needing residential treatment. Question 28 28a. Have you made any revisions in your pathway to residential rehabilitation in the last year? Mark with an ‘x’. [single option] No revisions or updates made in 2023/24 Yes - Revised or updated in 2023/24 and this has been published X Yes - Revised or updated in 2023/24 but not currently published 28b. If yes, please provide brief details of the changes made and the rationale for the changes. Page 140
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21 [open text – maximum 500 characters] The residential treatment pathway needed updating to align with all the changes currently taking place in this area, it will need further updating to align with the National Flexible Framework. As an ADP this is an area that we feel needs improvement, funding and staff capacity to get the full benefit of this treatment option for those in our community. The funding we receive for residential treatment does not meet the demand but equally our pathway was not comprehensive. Page 141
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22 Question 29 29a. Which, if any, of the following barriers to implementing MAT exist in your area? Mark all that apply with an ‘x’. [multiple choice] X Accommodation challenges (e.g. appropriate physical spaces, premises, etc.) X Availability of stabilisation services Difficulty identifying all those who will benefit Further workforce training is needed Geographical challenges (e.g. remote, rural, etc.) Insufficient funds Insufficient staff Lack of awareness among potential clients Lack of capacity Scope to further improve/refine your own pathways Waiting times None Other (please specify): 29b. What actions is your ADP taking to overcome these barriers to implementing MAT in your ADP area? [open text – maximum 500 characters] Our specialist service is in need of appropriate accomodation to meet the MAT requirements, we do not have enough treatment rooms and the space is not trauma informed as accomodation is shared with community justice. we have set funding aside to support this but lack of appropriate accomodation and costs being higher than available funds. Availability of stabilisation services in the NE and Moray is an issue. In support of MAT 6 and 10 Psychological staff and recruitment is a challenge. Page 142
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23 Question 30 Which of the following treatment and support services are in place specifically for children and young people using alcohol and / or drugs? Mark all that apply with an ‘x’. [multiple choice] Up to 12 years (early years and primary) 13-15 years (secondary S1-4) 16-24 years (young people) Alcohol-related medication (e.g. acamprosate, disulfiram, naltrexone, nalmefene) X Diversionary activities X X Employability support X Family support services X X X Information services X X Justice services X X Mental health services (including wellbeing) X X Opioid Substitution Therapy X Outreach/mobile (including school outreach) X X Recovery communities X X School outreach X X X Support/discussion groups (including 1:1) X X Other (please specify) Question 31 Please list all recovery groups11 in your ADP area that are funded or supported12 by your ADP. [open text – maximum 2,000 characters] Bow Café- Recovery Café and Hub Real Recovery Group 11 ‘Recovery group’ includes any group that supports recovery and/or wellbeing in your local area. This could be local recovery cafés; peer support groups; wellbeing groups that support people affected by substance use; or more established recovery networks, hubs or organisations. If some of these are covered by umbrella groups, please list both. 12 Note: ‘supported’ here refers to where ADP provides resources of some kind (separate from financial, which is covered by “funded”). This could take the form of knowledge exchange, staffing, the supply of materials (e.g. learning templates, lending them a physical location), etc. Page 143
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24 Active Recovery Moray- football and womens walking group Narcotics Anonymous and Alcoholics Anonymous SMART Recovery Wellbeing Group Mental Health Drop in Group Cooking Group Crystal Sound Bath Recovery Art Group Quality of life is improved by addressing multiple disadvantages Question 32 Do you have specific treatment and support services in place for the following groups? Mark all that apply with an ‘x’. [multiple choice] Yes No Non-native English speakers (English Second Language) X People from minority ethnic groups X People from religious groups X People who are experiencing homelessness X People who are LGBTQI+ X People who are pregnant or peri-natal X People who engage in transactional sex X People with hearing impairments and/or visual impairments X People with learning disabilities and literacy difficulties X Veterans X Women X Question 33 33a. Are there formal joint working protocols in place to support people with co-occurring substance use and mental health diagnoses to receive mental health care? Mark with an ‘x’. [single choice] X Yes No 33b. Please provide details. [open text – maximum 500 characters] Page 144
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25 Our weekly allocations Multi disciplinary meeting is supported by our mental health colleagues. We have a pathway that supports co-occuring diagnosis and are hopeful that with MAT 9 we will be able to build and improve on the pathway and support offered to people. Question 34 What arrangements are in place within your ADP area for people who present at substance use services with mental health concerns for which they do not have a diagnosis? Mark all that apply with an ‘x’. [multiple choice] Dual diagnosis teams X Formal joint working protocols between mental health and substance use services specifically for people with mental health concerns for which they do not have a diagnosis X Pathways for referral to mental health services or other multi-disciplinary teams X Professional mental health staff within services (e.g. psychiatrists, community mental health nurses, etc) None Other (please specify): Question 35 How do you as an ADP work with support services not directly linked to substance use (e.g. welfare advice, housing support, etc.) to address multiple disadvantages? Mark all that apply with an ‘x’. [multiple choice] X By representation on strategic groups or topic-specific sub-groups X By representation on the ADP board X Through partnership working Via provision of funding Not applicable Page 145
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26 Other (please specify): Page 146
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27 Question 36 Which of the following activities are you aware of having been undertaken in ADP funded or supported13 services to implement a trauma-informed approach? Mark all that apply with an ‘x’. [multiple choice] X Engaging with people with lived/living experience X Engaging with third sector/community partners Provision of trauma-informed spaces/accommodation X Recruiting staff X Training existing workforce Working group None Other (please specify): Question 37 37a. Does your ADP area have specific referral pathways for people to access independent advocacy? Mark with an ‘x’. [single option] X Yes No Don’t know 37b. If yes, are these commissioned directly by the ADP? Mark with an ‘x’. [single option] X Yes No Don’t know 13 Note: ‘supported’ refers to where the ADP provides resources of some kind (separate from financial, which is covered by “funded”). This could take the form of knowledge exchange, staffing, the supply of materials (e.g. learning templates, lending them a physical location), etc. Page 147
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28 Children, families and communities affected by substance use are supported Question 38 Which of the following treatment and support services are in place for children and young people affected by a parent’s or carer’s substance use? Mark all that apply with an ‘x’. [multiple choice] Up to 12 years (early years and primary) 13-15 years (secondary S1-4) 16-24 years (young people) Carer support X X X Diversionary activities X X Employability support X X Family support services X X X Information services X X Mental health services X X Outreach/mobile services X Recovery communities X School outreach X X Support/discussion groups X X Other (please specify) Question 39 Which of the following support services are in place for adults affected by another person’s substance use? Mark all that apply with an ‘x’. [multiple choice] X Advocacy X Commissioned services X Counselling X One to one support Mental health support X Naloxone training X Support groups X Training None Other (please specify): Page 148
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29 Question 40 40a. Do you have an agreed set of activities and priorities with local partners to implement the Holistic Whole Family Approach Framework in your ADP area? Mark with an ‘x’. [single option] X Yes No Don’t know 40b. Please provide details of these activities and priorities for 2023/24. [open text – maximum 500 characters] We have an agreed contract with our direct access provider to imbed the whole family support framework into the service. We also have a 5 year Corra funded intensive whole family support program running. Question 41 Which of the following services supporting Family Inclusive Practice or a Whole Family Approach are in place in your ADP area? Mark all that apply with an ‘x’. [multiple choice] Family member in treatment Family member not in treatment Advice X X Advocacy X X Mentoring X Peer support X X Personal development X Social activities X X Support for victims of gender based violence and their families X X Youth services X X Other (please specify) Question 42 42a. Are any activities in your ADP area currently integrated with planned activity for the Whole Family Wellbeing Funding in your Children’s Service’s Planning Partnership area? Mark with an ‘x’. [single option] X Yes No Don’t know 42b. If yes, please provide details. [open text – maximum 500 characters] Page 149
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30 The whole family wellbeing fund supported our Direct Access Service Childrens and family team over the last financial year with funding to support families affected by substance use. We would be looking to further that support for families over the next year. Page 150
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31 Additional question Question 43 Please list all services / organisations commissioned by your ADP during 2023/24 and the amount of funding provided for 2023/24. If the final year-end position is not yet known, please include the projected spend amount. For part-funding, please only include the amount contributed by your ADP. Service / organisation name [open text] Amount of funding provided £ [number] NHSG Data Analyst 64965.00 NHSG MIDAS (clinical input) 337460.00 NHSG MIDAS (prescriber/team lead) 143485.00 MC - Advocacy - Circles Network 35000.00 MC - Quarriers Arrows 663540.00 MC - staffing 86040.00 MC - Quarriers test of change 13846.00 MC - Arrows Children Service 50016.00 MC - Rehab beds 41108.00 MC - Aberlour Youth Point 10000.00 MC - Arrows bus hire 85.00 Page 151
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32 Confirmation of sign-off Question 44 Has your response been signed off at the following levels? [multiple choice] ADP IJB Not signed off by IJB (please specify date of the next meeting in dd/mm/yyyy format): Thank you Thank you for taking the time to complete this survey, your response is highly valued. The results will be published in the 2023/24 ADP Annual Survey Official Statistics report, scheduled for publication in autumn 2024. Please do not hesitate to get in touch via email at substanceuseanalyticalteam@gov.scot should you have any questions. [End of survey] Page 152
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REPORT TO: MORAY INTEGRATION JOINT BOARD ON 30 MAY 2024 SUBJECT: ANALOGUE TO DIGITAL TELECARE TRANSITION BY: DEPUTY CHIEF OFFICER/HEAD OF SERVICE 1. REASON FOR REPORT 1.1 To seek approval from the Board to proceed with the proposed approach for replacing current analogue community alarm/telecare devices in the community, in preparation for the UK-wide switchover from analogue to digital phone lines. 2. RECOMMENDATION 2.1 It is recommended that the Board: i) note the requirement to fully transition devices from analogue to digital by December 2025; ii) approve the budget of £150k as outlined in 4.5 for the procurement of appropriate digital devices; iii) approve the additional recurring revenue cost of £65k as outlined in 4.5 as a result of using digital technology; iv) note a future report will be brought to the Board regarding the revised costs for the Alarm Response Centre; and v) note the programme of replacement of current analogue community alarms. 3. BACKGROUND 3.1 In 2017 Telecommunications providers (CPs), announced the intention to upgrade all existing copper-based analogue phone lines to digital fibre lines across the UK, by December 2025. 3.2 Switching from analogue to digital phone lines means that analogue-based community alarm/telecare systems currently in place for people using the Telecare service will no longer function across a digital phone line. Page 153
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3.3 Following the announcement at 3.1 above, the Digital Office for Scotland was set up to oversee and support Local Authorities with their transition from analogue to digital Telecare (A2DT). 3.4 A hiatus in progressing the transition in Moray was experienced during the Covid-19 pandemic and the project was picked up again late in 2023. 3.5 As well as the absolute deadline of December 2025 to complete this work, some CPs have also adopted a stop-sell policy from September 2023. This means that they will no longer sell analogue phone lines from this date, therefore people changing phone, TV or broadband providers or packages, for example, may already have been migrated to a digital phone line. The obvious impact of this is being mitigated by the following – • CPs signed up to a Government Charter in December 2023, which states that no vulnerable people (including people with community alarm devices), will be migrated to digital without prior consultation; and • A data-sharing agreement has been signed on behalf of Health and Social Care Moray (HSCM), to allow HSCM to share peoples’ landline numbers (no directly identifiable personal information) with BT. This will afford them prior knowledge of vulnerable clients and will allow them to highlight to HSCM, any numbers that have already been migrated to digital lines. 3.6 As well as having to replace all current analogue community alarm devices in the community, Aberdeen City Council who currently provide our 24/7 monitoring of alarms, will also have to upgrade to a digital platform. We will have to bear a financial share of any increase in running costs because of this. 3.7 Planning is now underway to – • Procure a digital Alarm Receiving Centre (ARC) – the intention is to remain with Aberdeen City Council if costs and user requirements are acceptable. • Replace circa 1,200 analogue community alarms across Moray, with digital devices. 4. KEY MATTERS RELEVANT TO RECOMMENDATION Procurement and installation of digital Telecare devices 4.1. Digital devices send alarm signals in a completely different way to traditional analogue methods, which was simply via a landline phone connection. Some rely on mobile phone signals; some on Internet Protocol (IP) via a broadband connection; and some use a mix of both connections for failover purposes. 4.2. Not all clients will have home broadband (although many do – the Scottish Household Survey in 2022 showed this to be true of 91% of all households in Scotland). Also, not all clients will live in strong mobile signal areas (note: external signal strength can also be reduced by environmental factors such as thick property walls - and certain types of building insulation). 4.3. Due to the variable nature of required connectivity, it is proposed to procure a range of different devices to provide optimum effectiveness of alarm activation Page 154
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in the event of an emergency. Over the past 5 to 6 years, the Digital Office has been working with telecare suppliers and has documented an assessed suppliers list, to assist Local Authorities in making informed decisions around procurement. APPENDIX 1 shows devices proposed to support the transition from analogue to digital in Moray, and the basic rationale for these choices against each. Of course, the market is ever-changing and will continue to be monitored. All devices noted are available for call-off from Scotland Excel’s telecare dynamic purchasing system (DPS). It should be noted that this projection is based on known facts as of 2 April 2024. Budget 4.4. An assessment and breakdown of how many of each device has been undertaken to inform Moray’s replacement strategy. It should be noted that this plan is based on the number of known connections as of 2 April 2024, which provides only a snapshot due to the fluid nature of the service (changes in users of the services, location and peripherals required), but nevertheless provides a sound basis for an initial plan and budget provision. 4.5. The outline calculations indicate that a total commitment of £250K to ensure that all devices are replaced and digitally ready by December 2025 is required. There is currently a flat-rate client charge of £44.18 per quarter for the provision of community alarm/telecare (with exemption for terminal illness). Based on current connections. The budget net income is £51k and if this sum can be utilised to implement the replacement strategy over two financial years (2024/25 and 2025/26) the shortfall to complete implementation is £148k. In addition, the introduction of digital technology will incur revenue costs of around £65K p.a. in relation to SIM charges, which were not required previously with analogue devices. 4.6. To procure and install digital devices, there will be a requirement for preliminary and secondary technical input, including testing activities, development and delivery of staff training and exploration of service redesign. Funding was secured from (Technology Enabled Care) TEC Scotland which is being used to fund temporary technician and service redesign posts to support the project. 4.7. With the advent of digital technology, which can collect and pass data quickly and regularly, there is a potential for sensors to use algorithms related to daily living activity to predict the onset of a crisis before the crisis actually occurs. This is an area warrants further investigation, as there are likely to be different ways of providing services with increased savings and benefits in the future. To this end officers are linked in and working closely with the Digital Health and Care Institute’s (DHI) work, under the Moray Growth Deal. Procurement of digital Alarm Response Centre (ARC) 4.8. HSCM already have an existing relationship with Aberdeen City Council (ACC), who have provided our alarm monitoring services since 1996, at a current charge of £40k. Remaining with a pan-Grampian approach with potential economies of scale the intention would be to remain as a customer, providing the proposed costs and contractual requirements represent best value. ACC have opted for the shared ARC for Scotland platform, procured by the Digital Office and provided by Chubb/Skyresponse. At the time of writing, we are still Page 155
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awaiting details around the costs and contract from Aberdeen City Council and a further report will be brought to the Board on this matter. Proposed timeline 4.9. The key milestones to be achieved to deliver analogue to digital switchover by December 2025 is shown in Table 1 below: - Function Delivery Budget approval May 2024 Recruitment of staff June 2024 Liaison with Aberdeen City regarding ARC April to Aug 2024 Initial procurement of devices for 2024/25 Commencing June 2024 Urgent replacement of end-of-life devices (88 devices) July/Sept 2024 Replacement of other end of life devices (to budget) Sept to Mar 2025 Process reviews and procedure updates July to Dec 2024 Procurement of remaining required devices April 2025 Continued replacement of end-of-life devices April to Nov 2025 Table 1 5. SUMMARY OF IMPLICATIONS (a) Corporate Plan and 10 Year Plan (Local Outcomes Improvement Plan (LOIP)) and Moray Integration Joint Board Strategic Plan “Partners in Care 2022 – 2032” The aims of the A2DT Transition Project, align with 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 There are significant financial implications related to the mandatory requirement to ensure our entire Telecare estate is digitally enabled and linked to a digital ARC, by December 2025, as outlined in this report in section 4.5. These costs amount to £148k for replacement devices and recuring costs circa £65k. (d) Risk Implications and Mitigation If we do not have digitally enabled devices connected to a digital ARC by the time phone lines switch from analogue to digital, then there is a risk to life for people unable to raise an alarm in the event of an emergency. If there are adverse events reported in relation to the risk outlined above because of the failure to invest, plan, and implement in time, then this will result in significant reputational damage. (e) Staffing Implications The project currently has 1.0 FTE Project Manager, with support from the Digital Office for Scotland. Page 156
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0.68 FTE Telecare-specific technician will be employed for 1 year to provide local technical and installation support (TEC Scotland funding). 0.80 FTE Service redesign post will be employed for 1 year to provide support around service redesign potential and updating existing policies/guidance/training etc. (TEC Scotland funding). There will be limited implications at present, for existing staff, apart from general communications and targeted training/guidance. This may change as the project matures. (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, because of the report, on people with protected characteristics. This will be closely monitored and considered at key stages of the project, particularly where processes and guidance are being reviewed/updated. (h) Climate Change and Biodiversity Impacts There will be a need to visit homes across Moray to install new devices. However, digital devices have improved capability to provide things such as software updates remotely, without the need for further visits for that specific purpose. (i) Directions No directions associated with this report. (j) Consultations Chief Officer, Chief Financial Officer, Head of Service, Service Manager, Provider services, A2D Board, Operational Management Team, HSCM and Caroline O’Connor, Committee Services Officer, Moray Council have been consulted and comments have been incorporated into this report. 6. CONCLUSION 6.1 This report outlines the proposed approach for ensuring that the current analogue Telecare estate in Moray is replaced with digital devices in readiness for the switch-off of analogue phone lines by December 2025. Author of Report: Lorna Bernard, Project Manager Background Papers: None Ref: Page 157
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APPENDIX 1 – Proposed Replacement Devices In view of the additional variables at play compared to analogue devices (connectivity options, mobile network signals etc.), it is good practice to have a range of devices to suit various scenarios. The following devices are from suppliers with whom we have a previous relationship and are available via Scotland Excel’s Telecare Dynamis Purchasing System (DPS). Scotland Excel’s Telecare Framework is currently under review and is expected to be updated later in 2024. Device Provider A Provider B Provider C Device cost £195 £331 £165 Ongoing costs (SIMs) TBC No cost for first 2 years - £5 per month, per connection thereafter. £36 per connection, p.a. Support Poor – from experience Good – from experience (Anecdotal) Good - Assigned dedicated account manager Functionality (future proof) Testing has so far proved the Lifeline Digital Unit to provide reliable connections to a digital ARC Testing has so far proved the Lifeline Digital Unit to provide reliable connections to a digital ARC Testing has so far proved the Lifeline Digital Unit to provide reliable connections to a digital ARC Use of peripherals Inter-operable only with Tunstall peripherals Less risk to match Possum units with Possum peripherals Inter-operable with other devices Ease of installation Moderate – should be similar to current analogue installation, but some added time to start with for familiarisation Moderate – already installing these devices (Anecdotal) – potential to reduce installation time as devices arrive pre-programmed and has voice-prompt set-up guides. Connectivity resilience Can connect via broadband router or via SIM. Could be issues in areas with poor/no mobile signal Can only connect via one mobile SIM at present – presents an issue in no/poor mobile signal areas Dual SIM, so better chance of picking up a mobile network to connect on. Can also be connected via broadband router Recommendation Preferred for those with existing Provider A peripherals as peripherals will remain in place (additional cost saving). On Digital Office Assessed Suppliers’ list. Preferred for those with existing Provider B peripherals as peripherals will remain in place (additional cost saving). Not on Digital Office assessed suppliers’ list, as Provider B are a third-party provider. The devices themselves however, (LeGrand NEAT), are on the list. Anecdotal evidence only. On Digital Office assessed suppliers’ list Previous relationship having completed a test of change with one of their products in 2019. Preferred For non peripheral requirements for replacement purposes On Digital Office assessed suppliers’ list. Page 159
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REPORT TO: MORAY INTEGRATION JOINT BOARD ON 30 MAY 2024 SUBJECT: RECRUITMENT AND SELECTION PROCESS FOR AN INTERIM AND SUBSEQUENT PERMANENT CHIEF OFFICER BY: JOHN MUNDELL, INTERIM CHIEF EXECUTIVE, MORAY COUNCIL AND ADAM COLDWELLS, INTERIM CHIEF EXECUTIVE, NHS GRAMPIAN 1. REASON FOR REPORT 1.1 To recommend the proposed approach to recruiting a replacement for the outgoing Chief Officer of the Moray Integration Joint Board (MIJB) (Moray Health and Social Care Partnership), and includes a number of recommendations for approval by the MIJB relating to the interim appointment for the role, the recruitment selection process and the constitution of an appointment panel for the final selection panel interview. 2. RECOMMENDATIONS 2.1 It is recommended that the Board: i) agree to delegate authority to the Interim Chief Executives of Moray Council and NHS Grampian to make an appointment of an Interim Chief Officer in consultation with the Chair and Vice Chair of MIJB for a period until the new Chief Officer takes up post (approximately 6 months), to allow the recruitment process of the permanent post to proceed; ii) notes the indicative timeline for the recruitment and selection process for the permanent position; iii) establishes a temporary Committee of the MIJB, to be called an Appointment Panel for the permanent appointment, constituting the Chair and Vice Chair of the MIJB and Chairs of the Audit, Performance and Risk and Clinical and Care Governance Committees, with the Interim Chief Executives of Moray Council and NHS Grampian as principal advisors to the Panel, to interview Page 161
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candidates and make a recommendation to MIJB in terms of recommendation; iv) agrees that the appointment of the Chief Officer shall be determined by MIJB on the recommendation of the Appointment Panel; and v) instructs the Interim Chief Executives of Moray Council and NHS Grampian to report back to the MIJB on any interim appointment. 3. BACKGROUND 3.1 The current Moray Health and Social Care Partnership’s Chief Officer formally tendered his intent to stand down from the role on health grounds and will end his Chief Officer role on 31 May 2024. 3.2 Section 10 of the Public Bodies (Joint Working) Scotland Act 2014, states that the MIJB is to appoint the Chief Officer and notes that it must consult with both Moray Council (MC) and NHS Grampian (NHSG). The Moray Scheme of Integration (an agreement between MC and NHSG in respect of functions each delegated to the MIJB) provides more detail on the responsibilities of the Chief Officer. 4. KEY MATTERS RELEVANT TO RECOMMENDATION 4.1 The Chief Officer leads the development and implementation of the MIJB’s Strategic and Financial Plans, and as such, the recruitment of a Chief Officer is integral to the continued delivery of the aims and objectives of the Strategic Plan. It will take approximately six months to recruit a permanent Chief Officer and with current workloads and limited management capacity coupled to financial pressures, it is necessary to appoint a suitably experienced interim Chief Officer to cover this critical period. Selection Process for permanent Chief Officer appointment 4.2 A robust selection process will be arranged to assess candidates against the requirements of the job profile. In accordance with the selection processes facilitated by the Human Resource (HR) Teams of MC and NHSG for senior leadership appointments, it is recommended that an assessment centre be arranged comprising a number of sessions, each designed to test different elements of the job requirements. The assessment centre outcomes will be provided to the Appointment Panel convened to undertake a final selection panel interview. Appointment of Chief Officer 4.3 As noted above, the appointment of the Chief Officer shall be made by the MIJB. However, the entire composition of the MIJB as an appointment panel is unlikely to be practicable, or best practice from a candidate perspective. It is Page 162
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recommended that the MIJB establish a Committee, to be known as the “Appointment Panel”, under Standing Order 14.1 of MIJB’s Standing Orders. That Committee will be temporary and will be disestablished once MIJB have appointed a Chief Officer. 4.4 The Appointment Panel shall comprise the Chair and Vice Chair of the MIJB and the Chairs of the Risk, Audit & Performance and Clinical & Care Governance Committees, with the Chief Executives of MC and NHSG as principal advisers to the Panel. The Chief Executives line manage the Chief Officer and so bring that expertise to the panel. The Panel will also be supported by HR advisers from both MC and NHSG. 5. SUMMARY OF IMPLICATIONS (a) Corporate Plan and 10 Year Plan (Local Outcomes Improvement Plan (LOIP)) and Moray Integration Joint Board Strategic Plan “Partners in Care 2022-2032” The aims of this document link with the themes of the MIJB strategic plan; Partners in Care, Home First and Building Resilience. Ensuring that our systems are as simple and efficient as possible, working with partners, to keep people safe from harm during an emergency response as required by legislation. (b) Policy and Legal The role of the Chief Officer is a statutory requirement. To not make plans to appoint an incumbent Chief Officer would result in non-compliance with the Public Bodies (Joint Working) Scotland Act 2014. The National Care Service Bill is currently being progressed and will bring further change to the Integration of Health and Social Care. The role and remit of the Chief Officer may be subject to review to ensure it meets the requirements of any future legislative change. Where this is necessary, the matter will be brought to the MIJB’s attention. (c) Financial implications The Chief Officer together with the Senior Leadership Team is responsible for the delivery of the Strategic Plan for the MIJB. The Strategic Risk Register sets out all of the potential risks and mitigations associated with delivery of the Strategic Plan. The risk of failure to deliver on the Strategic Plan is mitigated by the appointment of a Chief Officer (d) Risk Implications and Mitigation As above, all strategic risks set out of the Strategic Risk Register help to manage and mitigate delivery of the Strategic Plan. Page 163
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(e) Staffing Implications None directly associated with this report. (f) Property None directly associated with this report. (g) Equalities/Socio Economic Impact As with all public bodies, the MIJB has an equalities duty under the Equality Act 2010. Public Bodies such as the MIJB must, when making decisions of a strategic nature about how to exercise its functions, have due regard to reducing discrimination and advancing equality of opportunity, with the purpose to reduce inequality of outcomes. (h) Climate Change and Biodiversity Impacts None directly associated with this report. (i) Directions None directly associated with this report. (j) Consultations The following partners were also consulted in the writing of this report and views incorporated: Chair and Vice Chair of MIJB, and Interim Chief Executives of NHS Grampian and Moray Council, Head of Governance, Strategy and Performance Moray Council, Head of HR, ICT & Organisational Development Moray Council and Committee Services Moray Council. 6. CONCLUSION 6.1 This report requests that MIJB should consider and approve the proposed recruitment process for the role of Chief Officer as per Section 10 of the Integration Scheme for MIJB. Author of Report: Sonya Duncan, Corporate Manager, HSCM Background Papers: Health and Social Care Integration Scheme for Moray Page 164
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REPORT TO: MORAY INTEGRATION JOINT BOARD ON 30 MAY 2024 SUBJECT: MEMBERSHIP OF BOARD AND COMMITTEES BY: CORPORATE MANAGER 1. REASON FOR REPORT 1.1 To inform the Board of changes to Membership of the Moray Integration Joint Board (MIJB), Audit, Performance and Risk (APR) Committee and Clinical and Care Governance (CCG) Committee. 2. RECOMMENDATION 2.1 It is recommended that the Board notes: i) the Chair and Vice-Chair rotated position on 1 April 2024; ii) the appointment of a new Chair to the APR Committee from 1 April 2024; iii) the temporary update to the CCG Committee membership whilst awaiting the update of National Health Service (NHS) voting membership; iv) the vacancy of NHS Voting member; v) the appointment of Sheila Brumby as the Service User Stakeholder; vi) the appointment of Janette Topp as the Third Sector Stakeholder; and vii) the updated membership of Board and committees attached at Appendix 1. 3. BACKGROUND 3.1 The Public Bodies Joint Working (Scotland) Act 2014 (“the Act”) and the Public Bodies (Joint Working) (Integration Joint Boards) (Scotland) Order 2014 (“the Order”) make provisions about various matters including the membership of the MIJB. As a minimum this must comprise voting members nominated from the NHS Board and Council; co-opted non-voting members who are holders of key Page 165
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posts with the NHS and Council or the MIJB; and co-opted non-voting members who are representatives of groups who have an interest in the MIJB. There is flexibility to appoint additional non-voting members as the Board sees fit. The Moray Health and Social Care Integration Scheme (“Integration Scheme”) outlines certain agreed provisions re membership (and includes the specific provisions taken from the Act and the Order). 4. KEY MATTERS RELEVANT TO RECOMMENDATION 4.1 The MIJB agreed to note, at their meeting on 25 January 2024 (para 9 of minute refers), the rotation of MIJB Chair and Vice Chair and the appointment of Sandy Riddell as Chair of APR Committee, from 1 April 2024. 4.2 Following two resignations from the NHS Grampian Board a realignment of NHS Grampian members on Integration Joint Boards (IJBs) in Aberdeen City, Aberdeenshire and Moray took place to manage these vacancies in IJB membership until their replacements are appointed by Scottish Government. As of 17 October 2023, Professor Bhattacharya moved to Aberdeen City IJB. This means MIJB is currently reduced to 3 NHS voting members. NHSG are waiting to hear from Scottish Government regards the appointments. The timetable for the process estimated appointments by mid-June 2024. Until an appointment is made, Sandy Riddell will take up the NHS voting member seat at Clinical and Care Governance Committee. 4.3 Ms Sheila Brumby has been appointed to the position of Service User Stakeholder. 4.4 Ms Janette Todd has been appointed to the position of Third Sector Stakeholder. 5. SUMMARY OF IMPLICATIONS (a) Corporate Plan and 10 Year Plan (Local Outcomes Improvement Plan (LOIP)) and Moray Integration Joint Board Strategic Plan “Partners in Care 2022-32” Effective governance arrangements support the development and delivery of priorities and plans. (b) Policy and Legal The Board, through its approved Standing Orders for Meetings, established under the Public Bodies (Joint Working) (Integration Joint Board) (Scotland) Order 2014, ensures that affairs are administered in accordance with the law, probity and proper standards. (c) Financial implications There are no financial implications arising as a direct result of this report. (d) Risk Implications and Mitigation There are no risk implications arising as a direct result of this report. (e) Staffing Implications There are no staffing implications arising as a direct result of this report. Page 166
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(f) Property There are no property implications arising as a direct result of this report. (g) Equalities/Socio Economic Impact An Equalities Impact Assessment is not required as the report is to inform the Board of changes required to membership of the Board and CCG Committee. (h) Climate Change and Biodiversity Impacts None arising from this report. (i) Directions None arising from this report. (j) Consultations Consultation on this report has taken place with Simon Bokor-Ingram, Chief Officer HSCM and Caroline O’Connor, Committee Services Officer, Moray Council, who are in agreement with the report. 6. CONCLUSION 6.1 This paper sets out the position in relation to the membership of MIJB. Author of Report: Sonya Duncan, Corporate Manager Background Papers: None Date: May 2024 Page 167
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APPENDIX 1 Moray Integration Joint Board – as at 30 May 2024 Moray Integration Joint Board 4 Council voting members Tracy Colyer (Chair) Ben Williams Peter Bloomfield Scott Lawrence 4 NHS Grampian voting members Dennis Robertson (Vice- Chair) Derick Murray Sandy Riddell Vacancy Third Sector Stakeholder Janette Topp NHS Grampian Staff Representative Stakeholder Member Deidre McIntyre Carer Stakeholder Ivan Augustus Service User Stakeholder Sheila Brumby Moray Council Staff Representative Kevin Todd Chief Officer Professional Simon Bokor-Ingram Chief Social Work Officer Tracy Stephen Lead Nurse Jane Ewen GP Lead Dr Robert Lockhart Dr Malcolm Simmons Non Primary Medical Services Lead Mr Duff Bruce Additional Member Elizabeth Robinson Audit, Performance and Risk Members (note chair needs to be alternate partnership member to the Chair of MIJB) 2 Council voting members John Divers Scott Lawrence 2 Health Board voting members Sandy Riddell (Chair) Derick Murray Third Sector Stakeholder Janette Topp NHS Grampian Staff Representative Stakeholder Member Deirdre McIntyre Clinical and Care Governance Members 2 Council voting member Cllr Peter Bloomfield Cllr Scott Lawrence 2 Health Board voting member (Chair) Derick Murray (Chair) Vacancy (Sandy Riddell 25/1/24 temporary) Carer Stakeholder Ivan Augustus Service User Stakeholder Sheila Brumby Third Sector Stakeholder Janette Topp Moray Council Staff Representative Kevin Todd Chief Officer Professional Simon Bokor-Ingram Chief Social Work Officer Tracy Stephen Page 169
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APPENDIX 1 Lead Nurse Jane Ewen GP Lead Dr Robert Lockhart and Dr Malcolm Simmons Non Primary Medical Services Lead Mr Duff Bruce Additional Member Elizabeth Robinson Page 170
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REPORT TO: MORAY INTEGRATION JOINT BOARD ON 30 MAY 2024 SUBJECT: GENERAL ADULT MENTAL HEALTH SECONDARY CARE PATHWAY REVIEW BY: LEAD FOR MENTAL HEALTH AND LEARNING DISABILITY (MHLD) INPATIENT, SPECIALIST SERVICES AND CHILD AND ADOLESCENT MENTAL HEALTH SERVICES (CAMHS) 1. REASON FOR REPORT 1.1 This report provides an update to Health and Social Care Moray (HSCM) on the review of the General Adult Mental Health Secondary Care Pathway, providing an overview of the findings and recommendations. This report is being shared with the other two Integration Joint Boards within Grampian, Aberdeen City Health, and Social Care Partnership (ACHSCP) and Aberdeenshire Health and Social Care Partnership (AHSCP). 2. RECOMMENDATION 2.1 It is recommended that the Board: i) note the update of the General Adult Mental Health Secondary Care Pathway Review, provided in the Summary Report (Appendix 1) with supporting appendices (Appendix 2); and ii) consider and comment on the findings and recommendations of the General Adult Mental Health Secondary Care Pathway review as outlined in Section 4 of the report. 3. BACKGROUND 3.1 The Chief Officers of the three Integration Joint Boards in Grampian, ACHSCP, AHSCP and HSCM commissioned a review of the General Adult Mental Health (AMH) Secondary Care pathway to improve outcomes, efficiency, and governance. 3.2 NHS Grampian have structured their services into Portfolio arrangements. There is a Grampian cross system Mental Health Portfolio Board, to which the Chief Officer from AHSCP holds role of Portfolio Executive Lead for oversight and delivery of strategic transformation projects. All three HSCPs within Grampian have operational responsibility for community Mental Health Page 171
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Learning Disability Service (MHLDS), including the pathway within this report, i.e. the Adult Mental Health pathway. ACHSCP also has responsibility for hosting Specialist, pan Grampian Mental Health and Learning Disability Services to which the report author is the Senior Operational Manager and Lead, (inpatient, specialist services, and Child and Adolescent Mental Health Services (CAMHS)) this also includes tertiary provision of inpatient and outpatient services to NHS Orkney and NHS Shetland. 3.3 The review included various teams and services within AMH; Unscheduled Care, Adult Liaison Psychiatry, AMH Inpatient Wards, Intensive Psychiatric Care Unit (IPCU), Community Adult Mental Health Teams, and Social Work. 3.4 Key stakeholders were identified and participated in the project through the creation of a Steering Group and associated subgroups e.g., lived experience. A range of methods of engagement were used including meetings, service information forms, workshops, and regular updates. Lived experience participants also contributed to this review through public and inpatient surveys. 3.5 The Scottish Mental Health and Wellbeing Strategy was published in June 2023. This strategy sets out the long-term vision and approach to improving the mental health and wellbeing of everyone in Scotland. It is intended that the Adult Mental Health Secondary Care Pathway review, and any recommendations for improvement, will allow for better delivery of the Scottish Mental Health and Wellbeing Strategy. 4. KEY MATTERS RELEVANT TO RECOMMENDATION 4.1 The intention of the AMH Secondary Care Pathway review was to identify improvement opportunities which impact positively on patients, staff, and governance. To meet this aim process and governance mapping of in scope services was undertaken. All three Health & Social Care Partnerships, and their services within the scope of this project, have now completed process maps and Service Information forms. These have assisted in outlining the associated governance structures and how they are connected. This gives a clearer picture of AMH Secondary Care, across Grampian. 4.2 The review has identified key themes arising from engagement with staff and individuals with lived experience. The key themes have been developed into improvement opportunities with 40 actions which, if taken forward, may realise changes to AMH Secondary Care. These actions align with Scotland’s Mental Health Core Standards, Health & Social Care Standards and the national Mental Health and Wellbeing Strategy. 4.3 The key themes arising from staff engagement can be summarised as follows: lack of recruitment and/or poor staff retention, poor communication/change management, partner/service relationships, lack of funding, lack of clear processes and resource limitations. The key themes arising from engagement with people with lived experience were related to staff, access to support, service delivery, moving on/reviewing treatment, and how staff, services and patients work together. 4.4 Feedback suggests that in relation to governance staff want more clarity on it, across the system, as well as policies and strategies. Most staff understand Page 172
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their local governance but not necessarily where that governance sits within the wider system. The governance pathway is complex when viewed across the system (HSCPs and portfolio level). 4.5 As a part of the review process, a delivery plan summarising the key actions to be undertaken has been developed. The Delivery Plan maps the creation of 5 workstreams, cognisant of the Mental Health Core Standards, under which the 40 actions identified within the review are aligned. These workstreams will be taken forward as Task and Finish Working Groups. Each group will develop and deliver a workshop by September 2024. These workshops aim to fully identify priority actions and develop how these will be taken forward and implemented; part of this will be identifying which actions are business as usual, to embed these in services, and those which are local or Grampian-wide. Progress on each of these workshops will be reported to the Grampian-wide MHLD Portfolio Board, and in turn the IJBs as required. 4.6 The AMH Steering Group intends to share the final summary report and delivery plan with those who contributed to the Lived Experience engagement by June 2024 i.e., those who contributed to the Lived Experience Survey who have requested follow-up. 4.7 The workstreams of the Delivery Plan will be managed as subgroups under the MHLD Portfolio Board. The Responsible, Accountable, Consulted, and Informed (RACI) model will be applied across all actions: • Responsible: Cross System Strategic Delivery Team • Accountable: MHLD Portfolio Board • Consulted: Frontline Teams, Lived Experience, Public, Partners • Informed: Frontline Teams, Lived Experience, Public, Partners 4.8 There are identified risks in the implementation of the AMH Delivery Plan, in that the MHLD Portfolio Board is currently undertaking an evaluation of its role and function, in addition to the wider Chief Executive Team (CET) review of all portfolios. The current programme plan for the MHLD Portfolio contains pressing priorities for 2024/2025 and beyond. Additionally, there are a large number (24) of national strategies, standards, and specifications in place for MHLD, services are already struggling with capacity because of the necessary work these bring. 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 recommendations set out in this report are consistent with the MIJB Strategic Plan. (b) Policy and Legal There are no direct policy or legal implications arising from the recommendations of this report. Page 173
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(c) Financial implications There are no direct financial implications arising from the recommendations of this report. (d) Risk Implications and Mitigation Risk: Prioritisation of AMH Secondary Care Pathway Review Delivery Plan Impact: High: The 24 national strategies/ specifications aligned to the Grampian Mental Health Portfolio Board may mean the AMH pathway work may have to be reprioritised to accommodate the recommendations, which may impact staff, patients, and services, depending on how these are prioritised. Mitigation: AMH actions are to be reviewed and prioritised by each workstream’s Task and Deliver Working Group in line with service capacity and pressures. Likelihood following Mitigation: Low Risk: Priority of the AMH Secondary Care Pathway Review Impact: Medium: While changes to communication and approach were made to ensure stakeholders were engaged and/or actively involved, this was a challenge that persisted throughout the review. Key information and problems have been missed in this review due to how stakeholders participated in this work i.e. it was not necessarily work stakeholders would have chosen as a priority. Mitigation: All stakeholders have had an opportunity to: • Review the AMH Summary Report • Provide their feedback to help shape the report • Ensure actions are accurate to the issues gathered throughout the review • Agree/Disagree with how actions will be progressed. Consideration may need to be given to involving staff early in the prioritising of work. Likelihood following Mitigation: Low (e) Staffing Implications There are no direct workforce implications arising from the recommendations of this report. (f) Property There are no implications to property arising from the recommendations of this report. (g) Equalities/Socio Economic Impact At this time, no Integrated Impact Assessment has been undertaken for this review. The nature of the review has been to find opportunities to improve outcomes for people in Grampian, improve efficiency and strengthen governance, within the pathway. Improvement opportunities have been identified, but how these will be addressed, and the implications of any changes have yet to be realised. Therefore, an Integrated Impacted Assessment is not necessary at this stage but would be undertaken as part of the above mentioned workstreams. Page 174
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(h) Climate Change and Biodiversity Impacts There are no direct environmental implications arising from the recommendations of this report for HSCM. (i) Directions There are no directions arising from the recommendations of this report for HSCM. (j) Consultations HSCM Senior Management Team 6. CONCLUSION 6.1 The review of the Adult Mental Health Secondary Care Pathway across Grampian has now concluded, with the recommended next steps to address the actions identified from the review, to be undertaken by September 2024. 6.2 The most significant risk to undertaking the next steps relates to the number of strategies, specifications and reviews aligned to the Grampian MHLD Portfolio Board, which need to be actioned, and may need to be reprioritised to support this work. Author of Report: Judith McLenan, Lead for Mental Health & Learning Disability (MHLD) Inpatient, Specialist Services and Child and Adolescent Mental Health Services (CAMHS) Background Papers: None Ref: Page 175
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0 | P a g e General Adult Mental Health Secondary Care Pathway Review Summary Report Judith McLenan; Lead for Mental Health & Learning Disability (MHLD) Inpatient, Specialist Services and Child and Adolescent Mental Health Services (CAMHS) APPENDIX 1 Page 177
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1 | P a g e Overview This document provides a pan-Grampian overview of the current, general adult mental health secondary care pathway. This includes process and governance mapping as well as recommendations and delivery plan for improvement to this pathway. The recommendations will support the implementation of actions outlined in the Scottish Government Mental Health & Wellbeing Strategy: Delivery Plan 2023 - 2025. Page 178
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2 | P a g e Contents Overview ................................................................................................................ 1 Introduction............................................................................................................. 3 Stakeholder Involvement ........................................................................................ 5 Lived Experience of Secondary Care Pathway ...................................................... 6 Main Points............................................................................................................. 7 Recommendations ................................................................................................. 9 Delivery Plan ..................................................................................................... 11 Project Delivery .................................................................................................... 14 Systems Mapping.............................................................................................. 14 Further Mapping Workshops ............................................................................. 16 Problem Statements/ How Might We Statements ............................................. 20 Adult Mental Health Governance Mapping ........................................................ 23 Adult Mental Health Lived Experience Engagement ......................................... 25 Summary of Workstreams .................................................................................... 27 Evaluation ......................................................................................................... 32 Page 179
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3 | P a g e Introduction The Chief Officers of Aberdeen City, Aberdeenshire and Moray Health and Social Care Partnerships were asked to carry out a review of the General Adult Mental Health (AMH) Secondary Care pathway. The review intended to find any opportunities to improve outcomes for residents, improve efficiency and strengthen governance, within the pathway. Options to re- design the pathway were discussed within the Adult Mental Health Secondary Care Pathway Steering Group and its key recommendations are outlined within this report. It is important to acknowledge that this review sits within a landscape of varying strategies and initiatives, it is not an isolated activity. The recommendations and actions outlined within this report may link to other activities taking place locally and nationally e.g. the Barron Report therefore, the actions of this review will be considered holistically. There are many teams and services in Adult Mental Health, but this review looked at the Secondary Care Pathway, which included: • Unscheduled Care including the Flow Team • General Adult Mental Health Liaison Psychiatry • Adult Mental Health Inpatient Wards • Intensive Psychiatric Care Unit (IPCU) • Community Adult Mental Health Teams (CMHTs) • Social Work Process and governance maps for each of these areas were produced. These maps are visual diagrams of how patients' access, move through and leave this pathway. As well as who is responsible for making decisions about the pathway and its population. Page 180
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4 | P a g e The Scottish Mental Health and Wellbeing Strategy: Delivery Plan 2023 - 2025 was published in June 2023. This strategy tells us about the long-term vision and approach to improving the mental health and wellbeing of everyone in Scotland. This review and any recommendations for improvement will allow for better delivery of the Scottish Mental Health and Wellbeing Strategy. Page 181
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5 | P a g e Stakeholder Involvement There were several different ways stakeholders were involved in this review: • Joining the Steering Group of key stakeholders who were responsible for reviewing the findings of the review and informing the recommendations and 2024/25 delivery plan. • Joining a subgroup for Lived Experience; sharing research of recent engagement or supporting the development of inpatient and outpatient engagement, to capture lived experience of this pathway. • Meeting with members of the project team to help them understand a service or how its team works, so a process map can be created. • Completing a Service Information Form to help the project team understand more about the service or team and how it functions. • Participating in workshops to deepen the project team’s understanding of shared experiences/issues/opportunities across the pathway. • Receiving regular updates about the progress of the review and providing feedback on findings as and when it was needed. Stakeholders were kept informed of the progress of this review through a singular SharePoint communication point, monthly newsletter, 1-2-1 or team meetings, as well as at, monthly General Adult Mental Health (AMH) Secondary Care Pathway Steering Group meetings. Page 182
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6 | P a g e Lived Experience of Secondary Care Pathway Individuals with Lived Experience added to this review in several ways. • By participating in the review’s Lived Experience subgroup and sharing how best to involve more Lived Experienced individuals in this review. • Through a survey which asked a series of questions relating to an individual’s experience accessing and using mental health secondary care pathways. This survey was carried out using Citizen Space, an Aberdeen City Council online consultation tool, and was promoted through the Steering Group and other key stakeholders. • Through participation in the Royal Cornhill Hospital’s Mental Health Inpatient Survey for Quarter 4 in 2023. As a recent review of inpatient experiences this provided valuable insight to the experiences of those residing in hospital. Individuals who have contributed to this review with their lived experience, and who have requested they be provided with the outcome of this review and kept up to date with its next steps, will be provided with a copy of this Summary Report once all appropriate governance steps have been completed. Page 183
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7 | P a g e Main Points The following are the summary points gathered from this review and across the range of research and data collected as part of this work including the recommendations to move this work forward: 1. Each Health & Social Care Partnership and the services in those Partnerships, within the scope of this review, have associated process maps and Service Information forms. Process maps can be viewed in General Adult Mental Health Secondary Care Pathway Review Appendices – Appendices A - M. 2. Each Health & Social Care Partnership has outlined its Governance Structure and how these are connected. These can be viewed in General Adult Mental Health Secondary Care Pathway Review Appendices – Appendix O: MHLD Grampian Governance Pathways. 3. The themes arising as problems or issues within the secondary care pathway are lack of recruitment and/or poor staff retention, poor communication/change management, partner/service relationships, lack of funding, lack of clear processes and resource limitations. 4. The review has identified 40 actions (‘How Might We’ statements) which are both directly and indirectly impacting the AMH secondary care pathway; as shared by stakeholders (staff, partners, lived experience). These can be viewed in General Adult Mental Health Secondary Care Pathway Review Appendices – Appendix N: Problem Statements/How Might We Statements. 5. The themes arising as problems or improvement opportunities from the Adult Mental Health Secondary Care pathway survey, and Royal Cornhill Hospital’s Mental Health Inpatient Survey for Quarter 4 in 2023, were related to staff, access to support, service delivery, moving on/reviewing treatment, and how staff, services and patients work together. These can be seen in Adult Mental Health Lived Experience Engagement 6. Feedback on the AMH governance suggests that staff want more clarity on it (i.e. role and purpose of groups/ boards), across the system, as well as policies and strategies. Most staff understand the governance impacting their own service but not necessarily where that governance sits within the Page 184
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8 | P a g e wider system. The governance pathway is complex when viewed across the system (HSCPs & Portfolio Board level). This can be viewed in General Adult Mental Health Secondary Care Pathway Review Appendices – Appendix O: MHLD Grampian Governance Pathways. 7. There is a risk to undertaking this work, largely relating to resource availability, and competing workstreams. The MHLD Portfolio Board is currently undertaking an evaluation of itself and maintains pressing priorities for 2024/2025. Across MHLD, services are struggling with capacity because of the necessary work around 24 national strategies, specifications, and standards. 8. The review itself was requested through the Chief Officers from the North East Partnership Steering Group (NEPSG). As this review wasn’t initiated through staff, there were challenges keeping stakeholders engaged and/or actively involved. Changes to communication and approach were made to support the involvement of stakeholders but this largely persisted throughout the review. There is the risk that key information and problems have been missed in this review due to how stakeholders participated in this work i.e. it was not necessarily work stakeholders would have chosen as a priority. Page 185
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9 | P a g e Recommendations General Actions: 1. Initial steps to implement the April 2024 – March 2025 Delivery Plan outlined below begin as of 1st April 2024. 2. The General AMH Secondary Care Pathway Review is taken as an update to the Aberdeen City, Aberdeenshire, and Moray Health & Social Care Partnerships’ IJBs in May 2024. 3. The final Summary Report is shared with contributing Lived Experience by June 2024 i.e., those who contributed to the Lived Experience Survey who have requested follow-up. April 2024 – March 2025 Delivery Plan: 1. The actions identified within this review will fall under five workstreams which are cognisant with the Mental Health Core Standards; Access, Workforce, Moving Between and Out of Services; Governance & Accountability, and Assessment, Care Planning, Treatment & Support. 2. The 40 actions have been initially prioritised by: a. Stakeholders, as part of the review’s workshops b. By using the How, Wow & Now Matrix as a tool, and the complexity of the action as a guide, to help prioritise actions c. By understanding which actions are likely to be met within an existing or upcoming project or workstream. 3. The above workstreams will be undertaken as Task and Finish Working Groups which will be established by June 2024. 4. A workshop will be developed and delivered by each Task and Finish Working Group by September 2024. The purpose of the workshop will be: a. To allow the Task and Finish Working Groups to make a more informed decision on the priority of each action within their workstream. Page 186
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10 | P a g e b. For each Task and Finish Working Group to identify actions it would consider ‘Business As Usual’ (BAU) and to pass these actions back, to be embedded, in services. c. For each Task and Finish Working Group to identify which actions it would consider pan-Grampian or local. d. Of the remaining, and prioritised actions, for each Task and Finish Working Group to develop how these actions will be achieved. e. For each Task and Finish Working Group to provide an update through the agreed governance structure on the outcomes of the Task and Deliver Workshop by September 2024. 5. Any changes to be implemented as agreed within these workshops are to be delivered by March 2025 or beyond if this is need is specifically identified. 6. These actions will be considered in line with priority activities identified by the MHLD Portfolio Board. Therefore, the above workstreams should be managed as a programme under the MHLD Portfolio Board as outlined in General Adult Mental Health Secondary Care Pathway Review Appendices - Appendix N: MHLD Grampian Governance Pathways, Cross System Strategic Delivery Team pathway. 7. The RACI model to be applied across all actions are: a. Responsible: Cross System Strategic Delivery Team b. Accountable: MHLD Portfolio Board c. Consulted: Frontline Teams, Lived Experience, Public, Partners d. Informed: Frontline Teams, Lived Experience, Public, Partners A Delivery Plan has been outlined below which will provide an ‘at a glance’ view of: • All actions to the undertaken • The workstream each action corresponds to • Actions considered a priority. • Actions that may be delivered through other projects/ workstreams Page 187
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11 | P a g e Delivery Plan Adult Mental Health Secondary Care: Workstreams Access Assessment, Care Planning, Treatment And Support Moving Between And Out Of Services Workforce Governance And Accountability Improving access and understanding of services available across Grampian. Developing consistency of approach and clear processes. Build capacity within services and processes to enable person centred approaches to care, from prevention and early intervention to response. Create a holistic approach to person centred care, supporting the movement between and from services in a right care, right time, right service approach. Create a caring skilled workforce which is supported to provide safe, high-quality person-centred care and provided with opportunities for development. Establish and promote clear governance routes which are accessible and promote accountability within service delivery and design. Enabling Themes Relationships Funding Recruitment & Retention Communication/ Change Resources Processes This primarily focused on the relationship between Primary and Secondary care services; and the difficulty for patients to access services in either primary or secondary care based on where the patient’s referral was initially made and what criteria is being met. This primarily focused on the use of locums and the impact this has on staff morale i.e. pay differences; as well as the pause on project funding and the difference in primary and secondary care funding. This primarily focused on the morale of staff, work absorption due to staff shortages and the ability to recruit and to retain staff. The impact of not having enough nurses, consultants, retirement and the loss of experience or significant roles e.g. MHO status. The inconsistency in patient/service delivery due to the use of locums. This primarily focused on the need for improved communication between primary and secondary care. It also highlighted that a lot of staff are unaware of the governance structures of MH and its relevant strategies (that strategies are not clear). The lack of clarity about what programme/project work is taking place across Grampian that should have Grampian- wide input. This primarily focused on the tools to provide services and support, e.g. supported accommodation, service provision (self- directed support packages). It also looked at the inability to better share or access information across partner services to aid patients. It also highlighted the increase in referrals and diagnosis in specific areas e.g. autism spectrum disorder. This primarily focused on the lack of clear process mapping, clinical pathways, operational policies and referring across areas. Page 188
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12 | P a g e Workstream Actions Access Assessment, Care Planning, Treatment And Support Moving Between And Out Of Services Governance and Accountability Workforce Bring consistency to CMHT working, incorporating AMH, Older Adult (OA) MH and LD, across Grampian. Assess our care planning process, to incorporate likely patient escalations/ crisis. Ensure patients are only discharged because they are ready, they have met their milestones and because an appropriate community care plan is in place. Make better preparations, when forecasting suggests impending issues or a significant increase in MH diagnoses and any related co-morbidities impacting patients. Moving between our in- house MH training opportunities to support continuous learning in the workplace. Improve public understanding of MH services. Build on existing preventative/ proactive activities to ensure MH care, and support for impacting social issues, can be provided at the earliest opportunity. Discover what issues are arising in relation to the duty doctor system. Explore alternative models of practice. Safeguard time within MH clinical roles, to ensure that any teaching requirements they have, can be met appropriately and without risk to patient care. Expand or change how we support individuals experiencing MH distress, so their MH condition/ distress does not worsen during periods of wait. Build capacity into secondary care teams, to be able to follow up with their patients in their community. Improve the process, for assessing patients at acute sites. Identify processes or activities, which require Grampian-wide alignment, to ensure patient experiences are consistent. Minimise the use of, or more effectively make use of, locum medical support to ease the funding pressure. Reduce wait times to access secondary care services. Carry out MH assessment within Emergency Department, to improve patient experiences when also presenting with MH issues. Identify patients impacted by delayed discharge, and the challenges relating to their discharge. Determine a suitable process, which would allow for primary/secondary care, to refer to third sector organisations. Improve relationships and communication between fellow secondary care services/ teams and primary care. Patients have clear and easy access to necessary MH services/support, regardless of where their MH care originated. Provide access to important patient information, out of hours for key decision makers. Understand the challenges regarding IPCU interface with AMH. Review MH strategies, which outline the current situation for MH services and what needs to be done to deliver improvements to these services. Build interest in, or develop our MH vocations, to develop a quality recruitment pool, on which to build the MH workforce. Page 189
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13 | P a g e Provide easy access, either physically or digitally, to appropriate community resources for patients who could live independently. Identify the necessary maintenance and changes required to the IPCU. Understand the challenges regarding the transfer of IPCU patients out of area Improve the documentation of clinical pathways. Provide quality support and care to staff, to ensure they feel heard and valued. Understand the demand for hospital care, treatment, and rehabilitation. Understand the challenges regarding access to AHP for IPCU patients. Improve the process, together with [transportation services], for transporting patients to RCH for assessment/ admission. Clarify the governance structures across Grampian. Induct locum consultants, to geographical areas they are unfamiliar with, to help build strong peer relationships and maintain a high standard of patient care. Fair access to in-demand MH services, across Grampian. Implement a consistent discharge process that is visible and clear to all staff. Participate in national discussions regarding forensic pathways for females. Action identified as a priority. Action will be met through an existing or upcoming project/ workstream. Page 190
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14 | P a g e Project Delivery The General Adult Mental Health Secondary Care Pathway review began in July 2023. The aim of this review was to identify improvements within the secondary care pathway of adult general mental health which would lead to better patient and service outcomes, improve efficiency, and streamline governance. Systems Mapping A systems mapping exercise was undertaken by a subgroup of the review’s Steering Group early in the review. The aim of this activity was to create a whole system map, across the Grampian AMH Secondary Care services. This map was then shared with all stakeholders of the AMH review to help bring clarity to those participating in the review, about what parts of the pathway would be explored. The map shows: • The AMH secondary care services that exist in each area i.e., Aberdeen City, Aberdeenshire, and Moray, including Hosted services. • The AMH secondary care services that are part of the pathway review. • The scale of the review, and that this was only part of a wider AMH secondary care pathway. • The other services which impact on those within the scope of the review and/or the secondary care pathway itself. The services within the scope of this review were identified as: Service/Team No. of Teams Location Unscheduled Care 2 1 x Royal Cornhill Hospital 1 x Dr Gray’s Hospital Aberdeen City & Aberdeenshire Moray Flow Coordinator 1 Royal Cornhill Hospital Adult Liaison Psychiatry 2 1 x Royal Cornhill Hospital 1 x Dr Gray’s Hospital Aberdeen City & Aberdeenshire Moray Page 191
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15 | P a g e CMHTs 9 1 x Aberdeen City South 1 x Aberdeen City North 1 x Aberdeen City Central A 1 x Aberdeen City Central B 1 x Aberdeenshire Central 1 x Aberdeenshire South 1 x Aberdeenshire North 2 x Moray Aberdeen City Aberdeen City Aberdeen City Aberdeen City Aberdeenshire Aberdeenshire Aberdeenshire Moray Adult Mental Health Inpatient Wards 5 4 x Royal Cornhill Hospital 1 x Dr Gray’s Hospital Aberdeen City & Aberdeenshire Moray Intensive Psychiatric Care Unit (IPCU) 1 Royal Cornhill Hospital Hosted service Adult Mental Health Social Work 2 1 x Aberdeen City 1 x Moray Aberdeen City Aberdeenshire Moray Grampian-wide Systems Map Page 192
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16 | P a g e Further Mapping Workshops The review progressed to the completion of Service Information Forms for each of the services within the scope of this review. The Service Information Form aimed to capture: • Information about the individual completing the form. • Simple information about the service i.e. operating hours, primary users. • Purpose of the Service • Funding/Budget • Information Sharing • Governance • Additional Information including challenges the service is experiencing currently, and/or issues it experiences within the wider secondary care pathway. Information gathered here informed future workshops and the problem statements/’How Might We’ statements outlined in General Adult Mental Health Secondary Care Pathway Review Appendices – Appendix N: Problem Statements/How Might We Statements. Where it was identified within the Service Information Form that a service had no process map, one was developed. In addition to capturing how a patient may access, move through, and leave the service the process maps may also identify: • A stage or role within the process when there is significant information flow. • A stage within the process that is manual. • Stages within the process where there is a current limit in resources. During this time, another workshop was undertaken to add detail to the flow of information between secondary care services. This exercise echoed what was captured within the service process maps regarding information flow: Team/Role Information Flow Page 193
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17 | P a g e Unscheduled Care Significant in relation to triage, assessment, and admission Unscheduled Care: Band 7 • Flow Coordinator Information is received from: • Out of Hour GPs • Police Scotland: Custody • Police Scotland (via Emergency Department • Emergency Department • Non-Mental Health Wards • Scottish Ambulance Service • NHS24 • Self-Referrals • CMHTs Community Mental Health Teams Significant in relation to triage and assessment: • Social Work Team Manager (Aberdeenshire) • Consultants (Urgent Referrals) • CMHT Team (weekly referral meetings) Information is received from: • Unscheduled Care • Social Work • CAMHs • Self-Referrals • GP Practices • Police Scotland • Referrals within the CMHT • Additions (ADA Quarriers, ARI D & A Team) AMH Inpatient Wards Significant in relation to assessment and admission: • Inpatient Ward Consultants Information is received from: • Consultants (meeting patients at outpatient clinic) • CPN (meeting patients at outpatient clinic) • Unscheduled Care • Adult Liaison Psychiatry Page 194
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18 | P a g e Adult Liaison Psychiatry Significant in relation to triage, assessment, and admission • Practitioners • Nurse Practitioner Service (Moray) Information is received from: • Inpatient Wards • Emergency Department s • Secondary care clinicians for outpatients IPCU Significant in relation to triage, assessment, and admission • IPCU Team (assessment) • Consultants Information is received from: • Adult Mental Health Services in Grampian • Other specialist mental health services in Grampian • Out of area IPCUs for Grampian Patients • The local forensic service via the courts, PF, prison, out of area secure placements for the female forensic population. Social Work Significant in relation to triage and assessment. • Mental Health Officers (detainment) • Adult Social Work team member (assessment) • AMH Social Work team member (assessment) Information is received from: • GPs • Self-Referrals • Adult Support & Protection • Access Team • AHP: Self Directed Support • Consultant in clinic • CMHT • Police Scotland • Police Concern Report • Another Local Authority Page 195
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19 | P a g e Flow of Information Map Page 196
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20 | P a g e Problem Statements/ How Might We Statements As part of the Service Information Form completion, and process map development, services identified problems/issues impacting them or how the service was being impacted within the wider secondary care pathway. These initial problems/issues framed a workshop, where stakeholders provided further detail on these problems/issues or identified other problems/issues they wanted to capture. Six themes emerged from the Problems/Issues workshop: Theme Brief Explanation of Discussion Relationships This primarily focused on the relationship between Primary and Secondary care services; and the difficulty for patients to access services in either primary or secondary care based on where the patient’s referral was initially made and what criteria is being met. Funding This primarily focused on the use of locums and the impact this has on staff morale i.e. pay differences; as well as the pause on project funding and the difference in primary and secondary care funding. Recruitment & Retention This primarily focused on the morale of staff, work absorption due to staff shortages and the ability to recruit and to retain staff. The impact of not having enough nurses, consultants, retirement and the loss of experience or significant roles e.g. MHO status. The inconsistency in patient/service delivery due to the use of locums. Communication/ Change This primarily focused on the need for improved communication between primary and secondary care. It also highlighted that a lot of staff are unaware of the governance structures of MH and its relevant strategies (that strategies are not clear). The lack of clarity about what Page 197
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21 | P a g e programme/project work is taking place across Grampian that should have Grampian-wide input. Resources This primarily focused on the lack of community provision which would allow patients to move on from inpatient care, or that would better support them in the community e.g. supported accommodation, service provision (self-directed support packages). It also looked at the inability to better share or access information across partner services to aid patients. It also highlighted the increase in referrals and diagnosis in specific areas e.g. autism spectrum disorder. Process This primarily focused on the lack of clear process mapping, clinical pathways, operational policies and referring across areas. Themes Map Page 198
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22 | P a g e How Might We Statements Once these problem/issues were collated they were then restructured as ‘How Might We’ statements. ‘How Might We’ statements are a way to reframe problems. As an exercise, it can bring clarity to; what action needs to be taken to address the problem; who would be impacted by the action and the effect to be realised. These ‘How Might We’ statements were then aligned to the appropriate Mental Health Core Standard and Summary Outcome, which could provide a way to measure the impact of addressing a particular action. In total, 40 different actions (‘How Might We statements) were identified. These actions can be viewed in a table in General Adult Mental Health Secondary Care Pathway Review Appendices – Appendix N: Problem Statements/How Might We Statements. The table will show: • The Mental Health Core Standard the action has been aligned to • The original problem statement • The action (‘How Might We’ statement) • The theme the action falls into • The Summary Outcome the action has been aligned to A further workshop with stakeholders was undertaken to determine which of the 40 actions the stakeholders would consider a priority. The workshop also captured any ideas stakeholders had that could deliver the action, as well as sharing any known projects that may be underway or preparing to start, that may also deliver some of the actions. These actions have been grouped under each Mental Health Core Standard, which will form a workstream e.g. any actions aligned to the Mental Health Core Standard ‘Access’ will be grouped together, and this will form a workstream. Each workstream will have its own Task and Finish Working Group. These working groups will each undertake a workshop which will review all actions under that workstream and determine what changes, if any, could be undertaken to make improvements to the secondary care pathway. Page 199
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23 | P a g e Adult Mental Health Governance Mapping Captured under the Communication/Change theme of the problem statements/’How Might We’ statements is a lack of understanding of Adult Mental Health governance i.e., a lack of awareness of the pathway and a lack of knowledge of the responsibilities within the governance pathway. In short, there lacks transparency around mental health governance, as with policies and strategies, across the system. Completion of the Service Information forms highlighted that staff are very familiar with their individual services governance pathway, although less was demonstrated around its position within the wider Adult Mental Health governance pathway, either within each Health & Social Care Partnership or across the system. Therefore, less was shared within the Service Information forms and workshops regarding where improvements to the governance pathway could be made. Of course, it would be difficult for staff to share improvement opportunities or ideas for a governance pathway that they do not know enough about. Certainly, the risks raised by staff appeared to be that they could not contribute to changes taking place across the system, which may have a wider impact, because they are unaware of work taking place and who has the responsibility to oversee and collaborate on work that has a cross-system impact. As demonstrated in the image below the cross-system view of the governance pathway is complex. This is fully recognised within the MHLD Portfolio Board and, where possible, there is commitment to make improvements to this pathway. Page 200
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25 | P a g e Adult Mental Health Lived Experience Engagement Lived Experience contribution to this review was undertaken in a several ways. The first was the creation of a Lived Experience Subgroup which pulled together members from third sector organisations, advocacy groups, the Grampian Public Empowerment Group, and other key roles from across the relevant Health & Social Care Partnerships and NHS Grampian. Members of the Lived Experience Subgroup provided access to the ‘In Their Words,’ Royal Cornhill Hospital’s Mental Health Inpatient Survey for Quarter 4 in 2023/2024. This provided to the review recently gathered feedback from individuals residing within wards at the Royal Cornhill Hospital. Members also helped to create, or provided feedback on the development of, an AMH Lived Experience Survey which went live in January 2024. The survey was available to complete until the end of February 2024. A Data Protection Impact Assessment (DPIA) and Privacy Notice were completed ahead of this public engagement. In total, 38 responses were received for this survey. The primary themes arising from these Lived Experience feedback tools were: Theme Brief Explanation of Discussion Staff This primarily focused on the need for more staff and resources within the pathway. Individuals felt staff behaviours and their relationship with their patients could be improved upon. Training was also raised as an opportunity for improvement, particularly around co-morbidities and support for individuals challenged with managing multiple issues. Access to Support This primarily focused on individuals looking for support at the earliest opportunity, with suggestions that if help could have been provided earlier, it may have prevented an escalation in their mental health. Individuals felt they did not understand why they were not eligible for particular Page 202
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26 | P a g e support, that there was still stigma attached to asking for support, and that more transparency was needed here. Overall, individuals felt that wait times for support were too long. Service Delivery This primarily focused on the limited access to mental health services in rural locations and how this impacted/ impacts the individual’s life. Individuals also mentioned they would like to see the type of mental health services expand into other areas e.g. hypnotherapy, TheraPets or through the provision of drop-in mental health support. Moving On This primarily focused on medication; that it was all that was given, that it didn’t work or that the individual had been on it for considerable time with no invitation to review their mental health or medication, extended from their GP. Working Together This primarily focused on the need for person centred care. Individuals mentioned that less focus on medication was needed, that longer appointments to talk to their GPs would be helpful, faster access to assessments e.g., Autism, and to see more multi-disciplinary working. Individuals wanted to be more involved and informed about their care, to see better communication between patients and staff, to see better communication between services and be able to express their emotions/feelings freely. Please note: The outcomes of the lived experience surveys have not been included, to ensure the anonymity of those that participated in this review. Page 203
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27 | P a g e Summary of Workstreams Workstream: Access Status of Action Bring consistency to CMHT working, incorporating AMH, OAMH and LD, across Grampian. Action identified as a priority as part of the Adult Mental Health Secondary Care Pathway Review workshops. Improve public understanding of MH services. Action identified as a priority as part of the Adult Mental Health Secondary Care Pathway Review workshops. Expand or change how we support individuals experiencing MH distress, so their MH condition/ distress does not worsen during periods of wait. Action identified as a priority as part of the Adult Mental Health Secondary Care Pathway Review workshops. Reduce wait times to access secondary care services. Applying the How, Wow, Now Matrix the following action was identified as Now (Low to Medium Difficulty/ Low to Medium Innovation) Patients have clear and easy access to necessary MH services/support, regardless of where their MH care originated. Applying the How, Wow, Now Matrix the following action was identified as Now (Low to Medium Difficulty/ Low to Medium Innovation) Provide easy access, either physically or digitally, to appropriate community resources for patients who could live independently. Applying the How, Wow, Now Matrix the following action was identified as Now (Low to Medium Difficulty/ Low to Medium Innovation) Understand the demand for hospital care, treatment, and rehabilitation. Applying the How, Wow, Now Matrix the following action was identified as Now (Low to Medium Difficulty/ Low to Medium Innovation) Fair access to in-demand MH services, across Grampian. Applying the How, Wow, Now Matrix the following action was identified as How (Medium to High Difficulty/ Medium to High Innovation) Participate in national discussions regarding forensic pathways for females. Forensic Services Programme Board likely to be established to support the implementation of actions outlined within the Forensic Services Review (response to the Barron Report). Page 204
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28 | P a g e Workstream: Assessment, Care Planning, Treatment And Support Status of Action Assess our care planning process, to incorporate likely patient escalations/ crisis. Action identified as a priority as part of the Adult Mental Health Secondary Care Pathway Review workshops. Build on existing preventative/ proactive activities to ensure MH care, and support for impacting social issues, can be provided at the earliest opportunity. Applying the How, Wow, Now Matrix the following action was identified as Wow (Medium to High Difficulty/ Low to Medium Innovation) Build capacity into secondary care teams, to be able to follow up with their patients in their community. Applying the How, Wow, Now Matrix the following action was identified as Wow (Medium to High Difficulty/ Low to Medium Innovation) Carry out MH assessment within Emergency Department, to improve patient experiences when also presenting with MH issues. Applying the How, Wow, Now Matrix the following action was identified as Wow (Medium to High Difficulty/ Low to Medium Innovation) Provide access to important patient information, out of hours for key decision makers. An EPR roll out will take place this year. Data Information Governance Procedures are being explored with Caldicott Guardian Identify the necessary maintenance and changes required to the IPCU. Forensic Services Programme Board likely to be established to support the implementation of actions outlined within the Forensic Services Review (response to the Barron Report). Understand the challenges regarding access to AHP for IPCU patients. Forensic Services Programme Board likely to be established to support the implementation of actions outlined within the Forensic Services Review (response to the Barron Report). Page 205
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29 | P a g e Workstream: Moving Between And Out Of Services Status of Action Ensure patients are only discharged because they are ready, they have met their milestones and because an appropriate community care plan is in place. Action identified as a priority as part of the Adult Mental Health Secondary Care Pathway Review workshops. Discover what issues are arising in relation to the duty doctor system. Applying the How, Wow, Now Matrix the following action was identified as Now (Low to Medium Difficulty/ Low to Medium Innovation) Improve the process, for assessing patients at acute sites. Applying the How, Wow, Now Matrix the following action was identified as Wow (Medium to High Difficulty/ Low to Medium Innovation) Identify patients impacted by delayed discharge, and the challenges relating to their discharge. Optimising Patient Flow Program crosses whole Grampian system, acute, community, mental health, and other public services all members Understand the challenges regarding IPCU interface with AMH. Forensic Services Programme Board likely to be established to support the implementation of actions outlined within the Forensic Services Review (response to the Barron Report). Understand the challenges regarding the transfer of IPCU patients out of area Forensic Services Programme Board likely to be established to support the implementation of actions outlined within the Forensic Services Review (response to the Barron Report). Improve the process, together with [transportation services], for transporting patients to RCH for assessment/ admission. This action is currently included as a commitment in Finance Planning and could be actioned under this workstream. Page 206
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30 | P a g e Workstream: Governance and Accountability Status of Action Make better preparations, when forecasting suggests impending issues or a significant increase in MH diagnoses and any related co-morbidities impacting patients. Action identified as a priority as part of the Adult Mental Health Secondary Care Pathway Review workshops. Explore alternative models of practice. Applying the How, Wow, Now Matrix the following action was identified as Wow (Medium to High Difficulty/ Low to Medium Innovation) Identify processes or activities, which require Grampian- wide alignment, to ensure patient experiences are consistent. Applying the How, Wow, Now Matrix the following action was identified as Now (Low to Medium Difficulty/ Low to Medium Innovation) Determine a suitable process, which would allow for primary/secondary care, to refer to third sector organisations. Applying the How, Wow, Now Matrix the following action was identified as Now (Low to Medium Difficulty/ Low to Medium Innovation) Review MH strategies, which outline the current situation for MH services and what needs to be done to deliver improvements to these services. Applying the How, Wow, Now Matrix the following action was identified as Now (Low to Medium Difficulty/ Low to Medium Innovation) Improve the documentation of clinical pathways. Applying the How, Wow, Now Matrix the following action was identified as Now (Low to Medium Difficulty/ Low to Medium Innovation) Clarify the governance structures across Grampian. This action is a responsibility of the Cross System Strategic Delivery Team. Implement a consistent discharge process that is visible and clear to all staff. The AMH Modernisation (Hosted) was created to address this challenge and was implemented as of November 2023. There is a cross Grampian Mental Health Discharge Planning and Improvement Group who meet monthly and report into the Optimising Patient Flow Program (Government Strategic Program) Page 207
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31 | P a g e Workstream: Workforce Status of Action Moving between our in-house MH training opportunities to support continuous learning in the workplace. Action identified as a priority as part of the Adult Mental Health Secondary Care Pathway Review workshops. Safeguard time within MH clinical roles, to ensure that any teaching requirements they have, can be met appropriately and without risk to patient care. Action identified as a priority as part of the Adult Mental Health Secondary Care Pathway Review workshops. Minimise the use of, or more effectively make use of, locum medical support to ease the funding pressure. Action identified as a priority as part of the Adult Mental Health Secondary Care Pathway Review workshops. Improve relationships and communication between fellow secondary care services/ teams and primary care. Action identified as a priority as part of the Adult Mental Health Secondary Care Pathway Review workshops. Build interest in, or develop our MH vocations, to develop a quality recruitment pool, on which to build the MH workforce. Applying the How, Wow, Now Matrix the following action was identified as Now (Low to Medium Difficulty/ Low to Medium Innovation) Provide quality support and care to staff, to ensure they feel heard and valued. Applying the How, Wow, Now Matrix the following action was identified as Now (Low to Medium Difficulty/ Low to Medium Innovation) Induct locum consultants, to geographical areas they are unfamiliar with, to help build strong peer relationships and maintain a high standard of patient care. Applying the How, Wow, Now Matrix the following action was identified as Now (Low to Medium Difficulty/ Low to Medium Innovation) Page 208
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32 | P a g e Evaluation Several key themes emerged from this review, in addition to how work is prioritised by the MHLD Portfolio Board, and any actions to address these themes will be delivered in the context of other local and national strategies/initiatives and resource constraints. This is first pathway review that has taken place within MHLD and there will be learning to capture as part of delivering this review. There is commitment to do this, and to use this opportunity to develop best practice, which could help inform any future pathway reviews. Page 209
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30 | P a g e General Adult Mental Health Secondary Care Pathway Review Appendices Appendix A: Unscheduled Care & Flow (Aberdeen City & Aberdeenshire) Appendix B: Adult Liaison Psychiatry (Aberdeen City & Aberdeenshire) Appendix C: AMH Inpatient Wards (Aberdeen City & Aberdeenshire) Appendix D: Community Mental Health Teams (Aberdeen City) Appendix E: Adult Mental Health Social Work (Aberdeen City) Appendix F: Community Mental Health Teams (Aberdeenshire) Appendix G: Adult Mental Health Social Work (Aberdeenshire) Appendix H: Unscheduled Care & Flow – Nurse Practitioner Service (Moray) Appendix I : Adult Liaison Psychiatry – Nurse Practitioner Service (Moray) Appendix J: Adult Mental Health Inpatient Wards (Moray) Appendix K: Community Mental Health Teams (Moray) Appendix L: Adult Mental Health Social Work (Moray) Appendix M: Intensive Psychiatric Care Unit (Hosted) Appendix N: Problem Statements/How Might We Statements Appendix O: MHLD Grampian Governance Pathways APPENDIX 2 Page 211
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31 | P a g e Appendix A: Unscheduled Care & Flow (Aberdeen City & Aberdeenshire) Page 212
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32 | P a g e Appendix B: Adult Liaison Psychiatry (Aberdeen City & Aberdeenshire) Page 213
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33 | P a g e Appendix C: AMH Inpatient Wards (Aberdeen City & Aberdeenshire) Page 214
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34 | P a g e Appendix D: Community Mental Health Teams (Aberdeen City) Page 215
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35 | P a g e Appendix E: Adult Mental Health Social Work (Aberdeen City) Page 216
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36 | P a g e Appendix F: Community Mental Health Teams (Aberdeenshire) Page 217
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37 | P a g e Appendix G: Adult Mental Health Social Work (Aberdeenshire) Page 218
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38 | P a g e Appendix H: Unscheduled Care & Flow – Nurse Practitioner Service (Moray) Page 219
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39 | P a g e Appendix I : Adult Liaison Psychiatry – Nurse Practitioner Service (Moray) Page 220
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40 | P a g e Appendix J: Adult Mental Health Inpatient Wards (Moray) Page 221
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41 | P a g e Appendix K: Community Mental Health Teams (Moray) Page 222
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42 | P a g e Appendix L: Adult Mental Health Social Work (Moray) Page 223
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43 | P a g e Appendix M: Intensive Psychiatric Care Unit (Hosted) Page 224
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43 | P a g e Appendix N: Problem Statements/How Might We Statements Key: How (Medium to High Difficulty/ Medium to High Innovation) Wow (Medium to High Difficulty/ Low to Medium Innovation) Now (Low to Medium Difficulty/ Low to Medium Innovation) Mental Health Standard Problem Statement How Might We Statement Ideas Theme Summary Outcome Access Aberdeenshire CMHTs often work differently and separately to each other which can make working together/delivering a consistent service very difficult. How might we bring consistency to CMHT working, incorporating AMH, OAMH and LD, across Grampian? Fully Integrating teams (not relying on professional silos) so there is one referral into CMHT that could be picked up by any CMHT. Ensure that SOP's/Referral Criteria are consistent across all CMHTs whether Aberdeenshire, City or Moray. Promote team sense of ownership of the eligibility criteria and if not in place develop SOP that is shire wide. Ensure that SOP's/Referral Criteria are consistent across Teams Appreciative enquiry - assess the effectiveness of these different ways of working, draw out the best practice(s) from each and consolidate Process Better informed policy, support, care, and treatment, shaped by people with lived experience and practitioners, with a focus on quality and recovery. Page 225
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44 | P a g e Access HSCPs do not provide exactly the same services or prioritise funding exactly the same way. Depending on which area you reside within, you may have easier access to a particular service than others. This is more apparent in areas where there is a larger geographical area to cover and higher chances of patient isolation. How might we ensure fair access to in-demand MH services, across Grampian, to ensure all individuals with a need for assessment are seen based on priority/urgency of need? Create a SLWG that will explore opportunities for fairer use of resources within MH secondary care services, across Grampian, and determine whether these opportunities are viable. Funding Improved overall mental wellbeing and reduced inequalities Access If patients had easier access to MH support in their communities in the lead up to, or following a diagnosis, it may prevent patients progressing to moderate/severe MH issues that require more resource and time to resolve/ balance How might we ensure fair access to in-demand MH services, across Grampian, to ensure all individuals with a need for assessment are seen based on priority/urgency of need? Invest in peer led recovery focused support systems and social movements. These types of approaches can have big impact with small resources (funding) Correlates with some other 'How Might We' statements about having consistency in governance of access, care planning treatment & support. MH Portfolio Board to lead strategic direction for Grampian. Also need review and agree there will be local based decisions by IJBs in line with Integration agenda. Resources Better equipped communities to support people's mental health and wellbeing and provide opportunities to connect with others. Page 226
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45 | P a g e Access Patients whose needs could be met through a community provision can find it difficult to access these resources in an emergency which can often result in hospital admission. Psychology patients will only have access to secondary care services if this is where their current care originated, and this is not the care for other services e.g. OT How might we ensure fair access to in-demand MH services, across Grampian, to ensure all individuals with a need for assessment are seen based on priority/ urgency of need? Review then adhere to eligibility criteria Ensure a matched care model that is fluent across services. One could postulate that if in hours mental health support in place, there would be patient involvement in assessment, care planning, treatment and support in developing Advance Statements, Crisis Plans and Anticipatory Care Plans which would reduce burden on urgent and emergency services. Appropriate and regular use of Care Program Approach. If this is the case for Psychology services, I am happy to look at improvements to ensure a matched care model that is fluent across services. Lived experience advisory group with clear structures in place for participants Relationships Better informed policy, support, care, and treatment, shaped by people with lived experience and practitioners, with a focus on quality and recovery. Access Patients open to secondary care that don't qualify for specific support (e.g. within CMHT) cannot then access primary care services How might we ensure that patients have clear and easy access to necessary MH services/support, regardless of where their MH care originated i.e. primary or secondary? Pathway to be reviewed to incorporate a need for patients open to mental health social work, but no other secondary care discipline, being able to access primary care services, i.e. psychology. Clarity about service referral criteria, which the process mapping should present. Relationships Better informed policy, support, care, and treatment, shaped by people with lived experience and practitioners, with a focus on quality and recovery. Access The public has a differing perception of mental health How might we improve public understanding of Create a Grampian wide communication plan, using existing Change Management Improved quality of life for people with mental health Page 227
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46 | P a g e services that doesn't necessarily match with need, demand, and MH strategies. MH services, including but not limited to purpose, priorities, access, and support, to guide the public on how it functions and the resources available? resources/ mediums, with minimal cost implications, that share agreed and consistent messages about MH services and resources across the region. conditions, free from stigma and discrimination. Access The public lack understanding around secondary care services and what these services aim to deliver, which may prevent them seeking support form secondary care services which is not necessary/ can be provided elsewhere. How might we improve public understanding of MH services, including but not limited to purpose, priorities, access, and support, to guide the public on how it functions and the resources available? Public Engagement Group, IJB and NHS Executive Team can drive narrative of engagement with public. Relevant communication strategy adapted where needed (in terms of messaging and channels) to reach all demographics and look for collaboration and synergies with third sector. Public Engagement: engage with groups and organisations with a vested interested in MH services. Enter in honest conversations with people about the stress on HC systems; describe how MH systems link together; outline what they (currently) can and cannot do for people. Capture people’s concerns and try to establish what they feel are priorities within the secondary MH system. Communication Improved knowledge and understanding of mental health and wellbeing and how to access appropriate support. Page 228
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47 | P a g e Access The public has a differing perception of mental health services that doesn't necessarily match with need, demand, and MH strategies. How might we improve public understanding of MH services, including but not limited to purpose, priorities, access, and support, to guide the public on how it functions and the resources available? Public Engagement Group, IJB and NHS Executive Team can drive narrative of engagement with public. Relevant communication strategy adapted where needed (in terms of messaging and channels) to reach all demographics and look for collaboration and synergies with third sector. Public Engagement: engage with groups and organisations with a vested interested in MH services. Enter in honest conversations with people about the stress on HC systems; describe how MH systems link together; outline what they (currently) can and cannot do for people. Capture people’s concerns and try to establish what they feel are priorities within the secondary MH system. Resources Increased availability of timely, effective support, care and treatment that promote and support people's mental health and wellbeing, meeting individual needs. Moving between and out of Services Providing care in the community using resources from RCH, often leaves RCH without the resources it needs to maintain a safe? / necessary staffing level How might we improve the process, for assessing patients at acute sites, so that the time impact on RCH staff is reduced/ minimal/ removed? Having separate inpatient / outpatient medical model Can current level of bed numbers be sustained if staff are simultaneously covering both inpatient and community patients? Is the inpatient/outpatient model the correct course for the future of service delivery? Should we modernise, consider new models, and learn from previous good working across the pathway for the patient Resources Better informed policy, support, care, and treatment, shaped by people with lived experience and practitioners, with a focus on quality and recovery. Page 229
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48 | P a g e Are there any existing tools for quick, effective assessment of someone mental health to triage appropriately? This from the SCIE, for England and Wales at least, https://www.scie.org.uk/mca/dols/p ractice/assessments/mental- health) seems to suggest it is a highly specialised area. Is there a tool that could be used to assess the risks of not immediately addressing a person’s mental health difficulties? Access Pilots which have proven successful or could have a significant impact on delayed discharges, cannot go ahead due to the absence of funding. How might we provide easy access, either physically or digitally, to appropriate community resources for patients who could live independently; together with fellow public sector organisations? In order for something new to be done something old has to stop. Need to be pragmatic and see where the priorities are and focus the limited resources, we have on that Financial austerity is real. Communication about limitations upon all public sectors could be explored Funding Improved quality of life for people with mental health conditions, free from stigma and discrimination. Better informed policy, support, care, and treatment, shaped by people with lived experience and practitioners, with a focus on quality and recovery. Access Patients are unable to reside within their communities safely, and with easy access to necessary services, which can often lead to delayed discharges or patients discharged into inappropriate environments (isolation/injury). How might we provide easy access, either physically or digitally, to appropriate community resources for patients who could live independently; together with fellow public sector organisations? The issue is there is often a lack of appropriate community resources to support patients, however improved discharge planning meetings, coordinated earlier in the patient's admission journey, may assist. Resources Better equipped communities to support people's mental health and wellbeing and provide opportunities to connect with others. Page 230
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49 | P a g e Access Patients cannot receive timely access to their CMHT's secondary care psychological services which places pressures on the CMHT MH nursing and social work to provide appropriate interim support and increasing the pressure elsewhere. How might we reduce wait times to access secondary care services, so that patients can receive appropriate care more timely, and ease pressures on other MH services/roles? Consider models of working, triage app and 'homework' meantime Consider criteria and SOP's for primary/secondary care Psychology Interested again to look at this and consider criteria and SOP's for primary/secondary care Psychology Process Increased availability of timely, effective support, care and treatment that promote and support people's mental health and wellbeing, meeting individual needs. Access Partner organisations such as SAMH can often be used to provide interim support to patients waiting to access secondary care services. However, this leaves their resource strained and unable to provide support to those who perhaps do not require secondary care support. How might we reduce wait times to access secondary care services, so that patients can receive appropriate care more timely, and ease pressures on other MH services/roles? Contractual agreements? Clarifying mental health pathways with start and end point which then links with third sector might improve flow Clarifying mental health pathways with start and end point which then links with third sector might improve flow. Detail as to what service(s) this is referring to might help pinpoint direction to explore support Resources Increased availability of timely, effective support, care and treatment that promote and support people's mental health and wellbeing, meeting individual needs. Access There are more people in need of the IPCU service, than there is capacity to provide. How might we understand the demand for hospital care, treatment, and rehabilitation, so that our secondary care services are structured appropriately, to ensure access to inpatient care is accessible to those that need it? Forensic Services Programme Board likely to be established to support the implementation of actions outlined within the Forensic Services Review (response to the Barron Report). Resources Page 231
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50 | P a g e Access There is no established national pathway for forensic female admissions. How might we participate in national discussions regarding forensic pathways for females so that we can respond to the need of female forensic patients? Forensic Services Programme Board likely to be established to support the implementation of actions outlined within the Forensic Services Review (response to the Barron Report). Process Improved overall mental wellbeing and reduced inequalities Access Assessment, Care Planning, Treatment and Support Hours of operation are inadequate for patient need and population served Outpatient waiting list is greater than 5 months (well over 1 year for psychology) Limited hours preclude timely OOH assessments. How might we expand or change how we support individuals experiencing MH distress, so their MH condition/ distress does not worsen, while directing care and support to the most appropriate services? Develop wrap around services to include peer support from those with lived experience Are we still maximising opportunities for near me and group-based interventions? Whole system move towards extended hours, 7-day working would need modelling upon demand, workforce resource, and capacity. Disparity in some specialist services and pathways having longer waiting times than others, particularly psychological based treatments. Review of out of hours resource for liaison psychiatry (adult and older adult), and capacity in USC resource. Operational Increased availability of timely, effective support, care and treatment that promote and support people's mental health and wellbeing, meeting individual needs. Access Assessment, Care Planning, Treatment and Support There is no Psychology Crisis Service/ Early Intervention team that can support patients early in their crisis, to prevent it from becoming a larger issue. How might we expand or change how we support individuals experiencing MH distress, to ensure that their condition/ distress does not worsen during wait periods, requiring secondary care intervention? Develop robust referral screening pathways and for consideration to be given as to whether there is a role for other disciplines to support the patient whilst they are on a waiting list for psychological supports. Development of standardised letters with contact details for supports and what the patient should do if their health Resources Improved overall mental wellbeing and reduced inequalities Page 232
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51 | P a g e deteriorates (escalation protocol) Moray model of working with third sector partners as integral CMHT members allows for flexibility of service and responsiveness to emergent need Home Treatment Team with Psychology involved would be one model to address this issue. Early Intervention is Psychosis Teams are another very effective model but require significant resource. Can review hosted services (Assertive Outreach Team) function, resource, demand, and capacity. Well-resourced community-based MH services which can give people support and interventions that are proven to help alleviate psychological distress and risk - DBI's and ASIST for e.g. Also, to adopt an ethos similar to Housing First - the support is open ended/ ongoing as per an individual’s needs. Access Assessment, Care Planning, Treatment and Support Individuals experiencing MH distress, who cannot access secondary care services, often see their condition/ distress worsen with them engaging with a number of different services without How might we expand or change how we support individuals experiencing MH distress, to ensure that their condition/ distress does not worsen during wait periods, Develop robust referral screening pathways and for consideration to be given as to whether there is a role for other disciplines to support the patient whilst they are on a waiting list for psychological supports. Development of standardised letters with contact Resources Improved knowledge and understanding of mental health and wellbeing and how to access appropriate support. Page 233
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52 | P a g e receive clear or consistent support. requiring secondary care intervention? details for supports and what the patient should do if their health deteriorates (escalation protocol) Power of peer support or life skills training and facilitation e.g. WRAPS etc. Engagement with third sector who can appropriately respond to distress. Improved connections between sectors are important, but pressure on third sector also makes it difficult to address people in distress in a timely manner. CMHTs working effectively and consistently in developing Advance Statements, Anticipatory Care Plans, Crisis Plans, and or use of Care Program Approach Access Assessment, Care Planning, Treatment and Support There is pressure on other public sector services such as Police Scotland to respond and manage MH distress/episodes in the community because patients cannot yet access a service or are not yet considered in need of a service, while the MH continues to worsen. How might we expand or change how we support individuals experiencing MH distress, to ensure that their condition/ distress does not worsen during wait periods, requiring secondary care intervention? Further invest in DBI and explore models of extended DBI timeframes Need representation from social care, welfare, housing and alcohol and drug services, and third sector. Shouldn't medicalise all mental health distress when underlying social factor might be issue Relationships More effective cross- policy action to address the wide-ranging factors that impact people's mental health and wellbeing. Assessment, Care Planning, Treatment and Support Currently care planning does not cover likely escalation/crisis processes so that there is a clear step in and step out of How might we assess our care planning process, to incorporate likely patient escalations/crisis, so that it is clear where Models exist to support anticipatory care planning such as the WRAP model and this has been used within CMHT's in the past. Promote use of Advanced Statements as per MWC guidance. Resources More effective cross- policy action to address the wide-ranging factors that impact people's mental health and wellbeing. Page 234
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53 | P a g e unscheduled care/acute care. unscheduled care and acute care are needed? Tap into lived experience resource to help support and empower patients to be motivated to develop anticipatory care plans. Use any pathways that exist e.g. EUPD pathways. Encourage the wider spread use of the WRAP planning tool - involve people in thinking about what they might need in future on 'not so good days'. Assessment, Care Planning, Treatment and Support Staff feel bound to the hospital. Due to a lack of resource, they are unable to visit patients in the community. Meaning patients then have to come into travel to hospital, where a community setting would have been more appropriate. How might we build capacity into secondary care teams, to be able to follow up with their patients in their community, without impacting inpatient experiences? Separate inpatient and outpatient medical cover? In some areas of Aberdeenshire, this is the model and whilst this should make community presence / follow up easier this is not always the case. Perhaps something about cultural norms that needs addressing? Moray model of working in close partnership with third sector commissioned service for community-based resource. Audit activity of community-based facilities that could be available to host CHMT drop ins? Coordination with community- based or third sector support opportunities/spaces. Resource mapping most relevant opportunities to then explore potential collaboration? Service Improvement and Service Planning to support teams achieve Relationships Increased availability of timely, effective support, care and treatment that promote and support people's mental health and wellbeing, meeting individual needs. Page 235
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54 | P a g e Target Operating Models would uncover opportunities to develop. Perhaps links to "Community Mental Health Interventions Review" (CMHIR) headed by Jenny Rae// Also, is there a linkage here with the TEC work Tracey M was involved in? I.e. using tech to overcome some of the geographical and time restraints. Assessment, Care Planning, Treatment and Support Roles designed to prevent patient's mental health progressing to moderate/ severe, by addressing social issues impacting their mental health, are not continuing, and adding to an already stretched system. How might we build on existing preventative/ proactive activities to ensure MH care, and support for impacting social issues, can be provided at the earliest opportunity? Improve links with / awareness of the Mental Health Improvement & Wellbeing Service (Aberdeenshire) that sits under primary care. Linkage to third sector? Better coordination with and redesign of MH supports in primary care and third sector. The making recovery real in moray partnership offers an example of good co-productive work. This I think, requires really close working with third sector organisations to maximise community support for people when discharged from health. Also need include welfare, housing, addiction services. Create synergies with third sector where possible. Focus must be on real prevention before people need to access any mental support service. Extend inclusion and Recruitment & Retention Better equipped communities to support people's mental health and wellbeing and provide opportunities to connect with others. Page 236
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55 | P a g e extension of work by public health and primary care to address mental health and wellbeing issues that are not in need of secondary care mental health services. Assessment, Care Planning, Treatment and Support The lack of resource to carry out parallel assessments of MH need in Emergency Department prevents us improving acute flow. How might we carry out MH assessment within Emergency Department, to improve patient experiences when also presenting with MH issues, which would improve acute flow? Think there is a pilot whereby SAS can access Nurse Practitioners directly rather than needing to go via ED Resources More effective cross- policy action to address the wide-ranging factors that impact people's mental health and wellbeing. Moving between and out of Services There is a lot of waiting around with no decisions on who is doing what. i.e. who is escorting and at what time. How might we improve the process, together with [transportation services], for transporting patients to RCH for assessment/ admission, so that the time impact on RCH staff is reduced/ minimal/ removed? Are there adverse event reviews or debriefs available to support shared learning approach to understanding this? Process Better informed policy, support, care, and treatment, shaped by people with lived experience and practitioners, with a focus on quality and recovery. Assessment, Care Planning, Treatment and Support USC Decision makers do not have access to info from community-based support OOH which can make, making decisions OOH, much harder to do. How might we provide access to important patient information, out of hours for key decision makers, so they can make better, more appropriate decisions for patient care? EPR roll out this year. Data Information Governance Procedures are being explored with Caldicott Guardian Resources More effective cross- policy action to address the wide-ranging factors that impact people's mental health and wellbeing. Page 237
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56 | P a g e Assessment, Care Planning, Treatment and Support Individuals requiring admission to hospital are unable to because there is no suitable place for them to be accommodated safely i.e. bed/ staffing. How might we understand the demand for hospital care, treatment, and rehabilitation, so that our secondary care services are structured appropriately, to ensure access to inpatient care is accessible to those that need it? Process Increased availability of timely, effective support, care and treatment that promote and support people's mental health and wellbeing, meeting individual needs. Assessment, Care Planning, Treatment and Support RCH IPCU does not meet appropriate accommodation standards for its function, in terms of the national standards documents. How might we identify the necessary maintenance and changes required to the IPCU so that an appropriate action plan to address these changes can be implemented? Forensic Services Programme Board likely to be established to support the implementation of actions outlined within the Forensic Services Review (response to the Barron Report), which will incorporate a Forensic Services Accommodation Project Board, of which its role will be to support actions to address inpatient and outpatient accommodation. Resources Improved overall mental wellbeing and reduced inequalities Assessment, Care Planning, Treatment and Support IPCU patients cannot easily access time with Allied Health Professionals. How might we understand the challenges regarding access to AHP for IPCU patients so that we may remove any barriers to their support? Forensic Services Programme Board likely to be established to support the implementation of actions outlined within the Forensic Services Review (response to the Barron Report). Resources Increased availability of timely, effective support, care and treatment that promote and support people's mental health and wellbeing, meeting individual needs. Page 238
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57 | P a g e Assessment, Care Planning, Treatment and Support Consultants do not have enough time and capacity to contribute effectively to the care and wellbeing of IPCU patients. How might we build interest in, or develop our MH vocations, to develop a quality recruitment pool, on which to build the MH workforce. Forensic Services Programme Board likely to be established to support the implementation of actions outlined within the Forensic Services Review (response to the Barron Report). Process Increased availability of timely, effective support, care and treatment that promote and support people's mental health and wellbeing, meeting individual needs. Governance and Accountability There is project work taking place in HSCPs that is not shared with Hosted services. Staff are unfamiliar with governance structures responsible for MH secondary care or projects taking place across MH secondary care. How might we clarify the governance structures across Grampian, which support MH services and any projects impacting secondary care services, for staff to become familiar with these activities and where to find information about these activities? There is a Cross System Strategic Delivery Team (CSSDT) which incorporates senior managers and professional leads for MH cross Grampian. This team reports into Mental Health Portfolio Board and new strategic service developments should be discussed there if impacts wider system Communication More effective cross- policy action to address the wide-ranging factors that impact people's mental health and wellbeing. Moving between and out of Services The duty doctor system and how this rotates can cause issues within admin and data collection. How might we discover what issues are arising in relation to the duty doctor system, which would improve the quality of admin and data being collected? Review process also with external support to provide a more overarching view of what could be improved and most importantly connect with other NHSG areas working to improve the same issue (data collection should be reviewed and improved across the organisation) Process Better informed policy, support, care, and treatment, shaped by people with lived experience and practitioners, with a focus on quality and recovery. Page 239
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58 | P a g e Governance and Accountability We are providing services to a changing demographic within a system that is still dependent on medical leadership. How might we explore alternative models of practice, so that we can determine whether our secondary care services are structured and delivered in a way that best meets the needs/demand of the current population? We need to consider alternative models of practise Develop a strategy that makes best use of the clinical recourses available to us Train more medical staff Create a SLWG that will explore alternative models of practice and determine whether other models are viable. Psychology/Nursing/AHP's are often well placed to support MDT decision making if welcomed to do so, it may take a change in SOP where appropriate to progress. Lived experience advisory group. Resources Better informed policy, support, care, and treatment, shaped by people with lived experience and practitioners, with a focus on quality and recovery. Governance and Accountability There is no visibility of clinical pathways. How might we improve the documentation of clinical pathways, and make these visible to staff who are supporting their implementation, so that they can provide a high standard of care? Not sure what this means - Grampian Guidance, SIGN Guidelines, Royal College Guidelines, National and Local Delivery Plans Pathways, National Policy and Standards and Service Specification Process Better informed policy, support, care, and treatment, shaped by people with lived experience and practitioners, with a focus on quality and recovery. Page 240
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59 | P a g e Governance and Accountability Services such as social work are seeing a significant increase in referrals in areas such as Autism Spectrum Disorder and co-morbidities which services are not necessarily prepared to manage/support. How might we make better preparations, when forecasting suggests impending issues or a significant increase in MH diagnoses and any related co-morbidities impacting patients, to ensure that services are fit to meet the demand. Need strategic decision making around whether autism and ADHD needs can or should be met within adult mental health services. Are there other teams or parts of the system in social work that can pick this up. Can third sector offer anything Should we invest in training to increase skills and knowledge in NDD, autism, ADHD Resources Better access and use of evidence and data in policy and practice. Governance and Accountability Staff do not understand the current or proposed strategy for change or improvements to MH services. How might we review MH strategies, which outline the current situation for MH services and what needs to be done to deliver improvements to these services, so this is clear for staff of all levels? Communication Better informed policy, support, care, and treatment, shaped by people with lived experience and practitioners, with a focus on quality and recovery. Governance and Accountability The upper age boundary for acute hospital e.g. separate older adult liaison team, with a different site, which is poorly resourced, isn't an effective use of resources and isn't patient centred. How might we understand the demand for hospital care, treatment, and rehabilitation, so that our secondary care services are structured appropriately, to ensure access to inpatient care is accessible to those that need it? Liaison has three teams almost, CAMHS crisis service, Adult Liaison and Older Adult Liaison, who work across different hospital sites and departments. Perhaps workshop could be arranged to review overlaps and potential opportunities. Adult Liaison challenged in supporting ED 4hr target due to limited hours of operation. All teams handover to USC MH team and On Call team out of hours weekends where consistency of assessment, care planning and treatment may be impacted Resources More effective cross- policy action to address the wide-ranging factors that impact people's mental health and wellbeing. Page 241
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60 | P a g e Governance and Accountability Individuals requiring admission to hospital are unable to because there is no suitable place for them to be accommodated safely i.e. bed/ staffing. How might we understand the demand for hospital care, treatment, and rehabilitation, so that our secondary care services are structured appropriately, to ensure access to inpatient care is accessible to those that need it? Review of MH Bed Base in line with Executive Team commitment to consider RCH as next phase to ARI Bed Base Review Resources Increased availability of timely, effective support, care and treatment that promote and support people's mental health and wellbeing, meeting individual needs. Moving between and out of Services Interface issues with AMH. How might we understand the challenges regarding IPCU interface with AMH so that we may remove any barriers preventing an effectively relationship? Forensic Services Programme Board likely to be established to support the implementation of actions outlined within the Forensic Services Review (response to the Barron Report). Relationships More effective cross- policy action to address the wide-ranging factors that impact people's mental health and wellbeing. Page 242
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61 | P a g e Governance and Accountability There is limited access for primary care/secondary care to refer to 3rd sector i.e. DBI. These patients are then followed up internally when perhaps a non-clinical option may have been better. How might we determine a suitable process, which would allow for primary/secondary care, to refer to third sector organisations, where their care and resources are more appropriate for the patient? This happens successfully in some areas, usually referral discussed at MDT and if rejected to secondary care, social work will usually make contact with the referrer (usually GP) and the patient to signpost to third sector (social work usually best placed to identify / be familiar with what is available within the community) The third sector needs to be funded appropriately to create the capacity to accept higher number of referrals and contract to deliver the support should be closely monitored for efficiency and retendered if need be. Resource with community-based or third sector-led services, and provision of support for third sector services considered more relevant (e.g., training). Can the access be reviewed and extended to MH & ED USC? Perhaps links to "Community Mental Health Interventions Review" (CMHIR) headed by Jenny Rae// Also, is there a linkage here with the TEC work Tracey M was involved in? I.e. using tech to overcome some of the geographical and time restraints. Process Increased availability of timely, effective support, care and treatment that promote and support people's mental health and wellbeing, meeting individual needs. Page 243
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62 | P a g e Moving between and out of Services Patients are discharged too early, this may be as a result of admission pressures/other pressures, which result in patients being readmitted at a later date. How might we ensure patients are only discharged because they are ready, they have met their milestones and because an appropriate community care plan is in place? Improved discharge planning and communication between inpatient and outpatient teams. Better use of the CPA framework where appropriate. Creative joint working with third sector partners to support early but safe discharges that offer continuity of support from ward to home and also in advance of admission Home Treatment Team approach could assist in early discharge/prevent admissions but only if properly MDT resourced. Need use readmission data as reference. Clarity over aims of admission and criteria for discharge. Improve Criteria Led Discharge practice by multi professional disciplines, as currently reliance upon medical model for discharge. Operational Better informed policy, support, care, and treatment, shaped by people with lived experience and practitioners, with a focus on quality and recovery. Page 244
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63 | P a g e Moving between and out of Services There are challenges relating to the discharge of patients considered 'adults with incapacity' that cannot be resolved. How might we identify patients impacted by delayed discharge, and the challenges relating to their discharge, so that appropriate planning and resources for their discharge can be identified and implemented timely? Improved communication between inpatient and outpatient teams to ensure patients lacking capacity can be identified. Responsibility is on SW to chair AWICC's where this is needed. Improved use of delayed discharge recording. Two things here firstly to secure assessment by medical staff and MHO as a priority (dedicated time set aside) and secondly being aware of resource provision and limitations in the community i.e. lack of beds in care homes Could consider such cases as activating MDT case conference/team formulation taking a positive risk tasking approach to decision making-may be a training need here|??/ Use of CPA (care Program Approach) consistently across system. Additional level of external review of all patients delayed over 60 days (in line with Acute and Community Hospitals) Engage with people who have, or may have, been affected by delayed discharge to assess what the impact has been. Ask what might have helped to alleviate some of those impacts at any stage in their patient journey. Process More effective cross- policy action to address the wide-ranging factors that impact people's mental health and wellbeing. Page 245
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64 | P a g e Governance and Accountability There are no documented, overarching policies across Grampian services to support and guide joint service delivery e.g. responding to complaints, and where partnerships policies and systems often conflict. How might we identify processes or activities, which require Grampian- wide alignment, to ensure patient experiences are consistent are far as possible? There are national policies and procedures for managing complaints for public bodies. Quality, Safety and Assurance Clinical and Care Governance Group starts end February to bring cross Grampian issues Process Better informed policy, support, care, and treatment, shaped by people with lived experience and practitioners, with a focus on quality and recovery. Governance and Accountability There is not a consistent process for when patients are being discharged and this often results in staff not knowing that it is happening. How might we implement a consistent discharge process that is visible and clear to all staff involved in the process, so that that it is easily understood? Communication Better informed policy, support, care, and treatment, shaped by people with lived experience and practitioners, with a focus on quality and recovery. Moving between and out of Services There is no clear out of area pathway for when a patient needs to go to an out of area bed. At this stage they tend to be extremely ill, and transporting the patient can be challenging. How might we understand the challenges regarding the transfer of IPCU patients out of area so that those individuals can receive the right support and treatment in the most appropriate location? Forensic Services Programme Board likely to be established to support the implementation of actions outlined within the Forensic Services Review (response to the Barron Report). Process Increased availability of timely, effective support, care and treatment that promote and support people's mental health and wellbeing, meeting individual needs. Page 246
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65 | P a g e Workforce Lack of Consultant Psychiatrist cover which impacts on continuity of the overall service Lack of in-patient staff (Moray) Inadequate provision of senior medical staff to cover statutory Mental Health Act work in general hospitals, can be reliant on duty medical teams. How might we build interest in, or develop our MH vocations, to develop a quality recruitment pool, on which to build the MH workforce. Work should link to the Workforce Plan, Aberdeenshire HSCP (and presumably each HSCP will have similar?) and specifically the Workforce and Training Group Cesar opportunities to train our own… redesign how existing consultants time is utilised and consider developing of a senior nurse practitioner role? Freeing up consultant time to be more of a consultative role. Routine review to be managed elsewhere in system Greater use of peer support, linking people to others who have the lived experience and who understand what the ‘recovery journey’ can look and feel like – how this could fit with specialised secondary pathways, I am not sure. Recruitment & Retention Increased availability of timely, effective support, care and treatment that promote and support people's mental health and wellbeing, meeting individual needs. Workforce There are not enough [consultants/nurses] to deliver an effective MH service. There are not enough [consultants/nurses] to deliver an effective MH service. How might we build interest in, or develop our MH vocations, to develop a quality recruitment pool, on which to build the MH workforce. Work should link to the Workforce Plan, Aberdeenshire HSCP (and presumably each HSCP will have similar?) and specifically the Workforce and Training Group Need to think about the opportunities of tapping into the value of lived experience. Grow the workforce by having a training plan and invest in third sector so the statutory resource can be highly focused on their particular Recruitment & Retention A diverse, skilled, supported, and sustainable workforce across all sectors. Page 247
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66 | P a g e role. Potential to attract more Psychology graduates into mental health nursing, especially if PT pathways for career development were developed. Also potential to use EPP's to add to the skill mix in nursing which, if appropriate, could free up nursing time to focus on specific nursing duties Greater use of peer support, linking people to others who have the lived experience and who understand what the ‘recovery journey’ can look and feel like – how this could fit with specialised secondary pathways, I am not sure. Workforce There is a lack of service provision which prevents services undertaking self- directed support with patients/individuals. How might we build interest in, or develop our MH vocations, to develop a quality recruitment pool, on which to build the MH workforce. Work should link to the Workforce Plan, Aberdeenshire HSCP (and presumably each HSCP will have similar?) and specifically the Workforce and Training Group Need to think more creatively about service provision and see whole community as a resource pool that can be tapped into - move away from traditional commissioned provider model. Education within adult services about eligibility criteria for SDS Potential to attract ore Psychology graduates into mental health Resources Better informed policy, support, care, and treatment, shaped by people with lived experience and practitioners, with a focus on quality and recovery. Page 248
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67 | P a g e nursing, especially if PT pathways for career development were developed. Also potential to use EPP's to add to the skill mix in nursing which, if appropriate, could free up nursing time to focus on specific nursing duties Greater use of peer support, linking people to others who have the lived experience and who understand what the ‘recovery journey’ can look and feel like – how this could fit with specialised secondary pathways, I am not sure. Workforce There are not enough [consultants/nurses] to deliver an effective MH service. How might we build interest in, or develop our MH vocations, to develop a quality recruitment pool, on which to build the MH workforce. Work should link to the Workforce Plan, Aberdeenshire HSCP (and presumably each HSCP will have similar?) and specifically the Workforce and Training Group Resources A diverse, skilled, supported, and sustainable workforce across all sectors. Workforce Lack of understanding around Scottish legislation - how legislation was applied Impact on patient care, relationships with GPs, pressure on teams to pick up if and when locums consultants are used, as well as the locum's commitment to the service Locum Consultant - diagnosis changing often along with treatment, with How might we induct locum consultants, to geographical areas they are unfamiliar with, to help build strong peer relationships and maintain a high standard of patient care? Locums should be community based with teams (at least part of the week) which may assist with this problem area. Working more directly with teams, including MHO's would help them have a better understanding of other roles within the team Redesign use of locums to cesar training programs and have nurse led clinics for consistency develop some social supports for locums from peers and colleagues Recruitment & Retention A diverse, skilled, supported, and sustainable workforce across all sectors. Page 249
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68 | P a g e each locum, and impact on patient significant - further impact on patients mental health Locums - not embedded in the team and don't discuss changes with the wider team Locum medical cover is leading to inconsistency in quality of service. ( monthly social club ) to allow them to feel welcomed and less isolated to areas alongside work, Try to emotionally invest the locums to want to join the service. This a trickier one. Limit how long locum contracts can be extended if there are long term locums not willing to apply for the vacant posts. (need some ideas on this). virtual tours of the locale? Structured induction, regular, quick catch ups with colleagues in the region Workforce There are not enough [consultants/nurses] to deliver an effective MH service. There is an impact to patient care, relationships with GPs, pressure on teams to pick up, if and when locums consultants are used, due to disorganised handovers. How might we induct locum consultants, to geographical areas they are unfamiliar with, to help build strong peer relationships and maintain a high standard of patient care? Re: Nursing Workforce - as 5-8 above. Medical Workforce - as (14) above, additionally we need to work alongside public health strategies and primary care to ensure patients getting right care, etc, and prevent NHS G population needing the secondary care services. virtual tours of the locale? Structured induction, regular, quick catch ups with colleagues in the region Process A diverse, skilled, supported, and sustainable workforce across all sectors. Page 250
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69 | P a g e Workforce There is a lack of funding to support continuous learning in the workplace which is impacting staff development, progression, and the ability to deliver best practice as this evolves. How might we expand our in-house MH training opportunities to support continuous learning in the workplace? CPD doesn’t always have to be about workshops or training sessions but can include protected time for reflective writing and reading of free resources and materials. Identify and accurately describe the skills, knowledge and behaviours required for a particular post. Conduct a training needs analysis. Design training to focus on narrowing the gap between what is desired and what the current reality is. Develop and facilitate peer learning sessions – use of ‘solution circles’ for example. Training A diverse, skilled, supported, and sustainable workforce across all sectors. Workforce Communication between secondary care services and GPs not happening - GP not receiving communication or acting on information provided by secondary care, after patients have been provided support How might we improve relationships and communication between fellow secondary care services/ teams and primary care, so that continuing patient care is not obstructed? Aberdeenshire: Virtual Community Wards Are there regular practice meetings that secondary care staff attend at the GP? For discharge information, inpatient medical staff should adhere to PDD and full discharge summary recommendations. Clinical staff record keeping audits - are these conducted in all disciplines in community, what is record keeping standards by professional regulatory body - how is being measured and benchmarked? Communication More effective cross- policy action to address the wide-ranging factors that impact people's mental health and wellbeing. Page 251
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70 | P a g e Public Engagement: engage with groups and organisations with a vested interested in MH services. Enter in honest conversations with people about the stress on HC systems; describe how MH systems link together; outline what they (currently) can and cannot do for people. Capture people’s concerns and try to establish what they feel are priorities within the secondary MH system. Workforce The relationships between primary care and secondary care are not strong which impacts patient care. There is a lack of communication between secondary care and primary care psychology services which can result in patients fall between the cracks of these services and not receiving and care/support at all. How might we improve relationships and communication between fellow secondary care services/ teams and primary care, so that continuing patient care is not obstructed? Moray model of having interface meetings and contribution to referral discussions for psychological support between PC and SC staff Create a SLWG that would identify improvements to this situation. Relationships More effective cross- policy action to address the wide-ranging factors that impact people's mental health and wellbeing. Workforce There is a high financial pressure on partnerships through the use of locum medical cover. The disparity between locum medical cover and permanent staff is large and obvious which impacts moral amongst permanent staff. How might we minimise the use of, or more effectively make use of, locum medical support to ease the funding pressure it presents to the HSCPs? Funding Better access and use of evidence and data in policy and practice. Page 252
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71 | P a g e Workforce Staff are burnt out while they try to cover all roles and responsibilities within their team/service. There are not enough [consultants/nurses] to deliver an effective MH service. How might we provide quality support and care to staff, to ensure they feel heard and valued, during periods of change. Aberdeenshire: ensure there are service representatives on the Staff Health and Wellbeing Group (sits under the Workforce Plan 2022 - 2025). Make sure all staff support services are activated for staff at earliest opportunity, especially for those who are off sick with anxiety/depression where early access to PT's can keep people at work or allow them to return more quickly Recruitment & Retention Increased availability of timely, effective support, care and treatment that promote and support people's mental health and wellbeing, meeting individual needs. Workforce Staff are burnt out while they try to cover all roles and responsibilities within their team/service. There are not enough [consultants/nurses] to deliver an effective MH service. How might we provide quality support and care to staff, to ensure they feel heard and valued, during periods of change. Aberdeenshire: ensure there are service representatives on the Staff Health and Wellbeing Group (sits under the Workforce Plan 2022 - 2025). Communication channels to be established and support for workforce wellbeing. You said we did model within service How might we support staff during these pressurised times? Culture collaborative: We Care, good staff governance Recruitment & Retention A diverse, skilled, supported, and sustainable workforce across all sectors Workforce There is a high amount of clinical work to be undertaken, requiring significant resource which is lacking. How might we provide quality support and care to staff, to ensure they feel heard and valued, during periods of change? Values based 'supervision' or 1-to- 1's. facilitated meetings, rather than one or two voices dominating. Basic good practice for change management - make people aware of the need for change, etc, etc, Resources A diverse, skilled, supported, and sustainable workforce across all sectors. Page 253
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72 | P a g e Workforce The role that people have in teaching students, and training junior doctors aren't taken into account and there is often no space either in job plans or physically for this to be undertaken How might we safeguard time within MH clinical roles, to ensure that any teaching requirements they have, can be met appropriately and without risk to patient care? As a workforce we need to be pragmatic in evidencing what protected time is needed for such tasks in order to have a resilience sustainable workforce Training A diverse, skilled, supported, and sustainable workforce across all sectors. Workforce There is not an appropriate number of staff, with the required skills mix, within the IPCU service. How might we build interest in, or develop our MH vocations, to develop a quality recruitment pool, on which to build the MH workforce. Forensic Services Programme Board likely to be established to support the implementation of actions outlined within the Forensic Services Review (response to the Barron Report). Recruitment & Retention A diverse, skilled, supported, and sustainable workforce across all sectors. Page 254
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73 | P a g e Appendix O: MHLD Grampian Governance Pathways Page 255
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78 | P a g e NHS Grampian Board NHS Grampian Staff Governance Committee NHS Grampian Performance, Assurance, Finance & Infrastructure Committee NHS Grampian Clinical Governance Committee NHS Grampian Chief Executive Team (CET) NHS Grampian Committees: HAI Executive Committee Grampian Area Drug & Therapeutics Committee Public Protection Integration Joint Boards Health & Social Care Partnerships: Aberdeen City Aberdeenshire Moray (Annual Assurance Report) Weekly NHS Grampian Clinical Risk Meeting (CRM) Cross System Quality, Safety & Assurance Group MH & LD NHS Grampian Population Health Committee NHS Grampian Spiritual Care Committee NHS Grampian Cross System Quality, Safety & Assurance Groups Page 260
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79 | P a g e Aberdeen City Integrated Joint Board Aberdeen City Clinical & Care Governance Committee Aberdeen City HSCP Risk, Audit and Performance Committee Clinical & Care Governance Meeting Hosted Hosted MH & LD CRM MH & LD Adverse Event Review Group (Pan Grampian) IP&C Assurance Group Moray Delegated Services (Discussion ongoing) Aberdeenshire Delegated Services (Discussion ongoing) MHLDs Clinical & Care Governance Structure September 2023 Hosted MHLDS Ops Meetings MH & LD Portfolio Board Page 261
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80 | P a g e MHLD Portfolio Board Portfolio Lead Pam Milliken Established Sub-Groups Psychological Therapies Improvement Board Forensic Services Learning Disability Health Checks Learning Disability Pathways Workforce Sustainability and Modernisation Proposed Sub-Groups Older Adult Pathway ‘Review’ Working Groups aligned to projects within the Programme Plan Operational Delivery Cross System Strategic Delivery Team (CSSDT) Hosted Mental Health and Learning Disability Inpatient Services, Specialist Services and CAMHS Delegated Services – Community, Inpatient and Specialist): Aberdeen City Health and Social Care Partnership Aberdeenshire Health and Social Care Partnership Moray Health and Social Care Partnership Grampian MHLDs Cross System Strategic Delivery Team (CSSDT) Page 262