Agenda Document Pack - Midlothian Integration Joint Board - 22/06/2023
Midlothian Council · 22 June 2023
Back to Midlothian Integration Joint Board — 22 June 2023 and its agenda
Text extracted from the council's PDF. Layout and reading order may differ from the original.
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Notice of Meeting and Agenda Midlothian Integration Joint Board Venue: Council Chambers/Hybrid, Midlothian House, Dalkeith, EH22 1DN Date: Thursday, 22 June 2023 Time: 14:00 Morag Barrow Chief Officer Contact: Clerk Name: Mike Broadway Clerk Telephone: 0131 271 3160 Clerk Email: mike.broadway@midlothian.gov.uk Further Information: This is a meeting which is open to members of the public. Page 1 of 302
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1 Welcome, Introductions and Apologies 2 Order of Business Including notice of new business submitted as urgent for consideration at the end of the meeting. 3 Declaration of Interest Members should declare any financial and non-financial interests they have in the items of business for consideration, identifying the relevant agenda item and the nature of their interest. 4 Minute of Previous Meeting 4.1 Minutes of the MIJB held on 13 April 2023 for Approval 5 - 12 4.2 Minutes of the Strategic Planning Group held on 27th April 2023 - for Noting 13 - 20 5 Public Reports 5.1 Chair's Update - Val de Souza, Chair Review of Proposed Board Meeting Dates 2024 21 - 26 5.2 Chief Officer Report - Morag Barrow, Chief Officer 27 - 34 5.3 Draft Annual Accounts - Paper presented by Claire Flanagan, Cheif Finance Officer 35 - 76 5.4 2022 Financial Recovery Options Report - Paper presented by Morag Barrow, Cheif Officer & Claire Flanagan, Chief Finance Officer 77 - 106 5.5 Analogue to Digital Transition - Paper presented by Matthew Curl, Digital Programme Manager Please note item carried over from April 2023 MIJB meeting. 107 - 124 5.6 Integrated Impact Assessment Process Approval - Paper presented by Gill Main, Integration Manager 125 - 176 5.7 IJB Performance Report - Paper presented by Elouise Johnstone, Performance Manager 177 - 192 5.8 Integrated Assurance Report - Paper presented by Fiona Stratton, Chief Nurse Please note item carried over from April 2023 MIJB meeting 193 - 262 5.9 Midlothian Response to Director of Public Health Annual Report - Paper presented by Jim Sherval, Consultant in Public Health Please note item carried over from April 2023 MIJB meeting 263 - 298 Page 2 of 302
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5.10 Interim Lerning Disabilty Service Review - Paper submitted by Nick Clater, Head of Adult Services 299 - 302 6 Private Reports 7 Date of Next Meeting The next meeting will be held on Thursday August 24th 2023 at 14:00-16:00. Page 3 of 302
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Midlothian Integration Joint Board Meeting Date Time Venue Midlothian Integration Joint Board Thursday 13 April 2023 2.00pm Virtual Meeting held using Microsoft Teams. Present (voting members): Val de Souza (Chair) Andrew Fleming Peter Knight (Proxy for Nadin Akta) Angus McCann Cllr Connor McManus Cllr Derek Milligan Cllr Kelly Parry Cllr Pauline Winchester Present (non-voting members): Morag Barrow (Chief Officer) Joan Tranent (Chief Social Work Officer) Claire Flanagan (Chief Finance Officer) Rebecca Green (Clinical Director) Wanda Fairgrieve (Staff side representative) Fiona Stratton (Chief Nurse) Keith Chapman (User/Carer) Miriam Leighton (Third Sector) James Hill (Trade Union Representative) Substitute for Grace Chalmers In attendance: Andrew Fleming (NHS Lothian) Nick Clater (Head of Adult & Social Care) Grace Cowan (Head of Primary Care and Older Peoples Services) Gill Main (Integration Manager) Emma-Jane Gunda (Assistant Strategic Program Manager) Matthew Curl (Digital Program Manager) Lynn Freeman (OT team lead) Fiona MacKinnon (Epilepsy Specialist Nurse) Jim Sherval (Consultant in Public Health) Andrew Henderson (Democratic Services Officer) Apologies: Nadin Akta Grace Chalmers (Trade Union Representative) Kevin Dick (Audit Scotland) Midlothian Integration Joint Board Thursday 22 June 2023 Item No 4.1 Page 5 of 302
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2 Midlothian Integration Joint Board Thursday 13 April 2023 1. Welcome and introductions The Chair, Val de Souza, welcomed everyone to this virtual Meeting of the Midlothian Integration Joint Board. 2. Order of Business With regard to the order of business the Chair outlined that item 5.10 in advance of item 5.9 to allow for more in depth discussion. 3. Declarations of interest Peter Knight made a point of transparency in relation to telecare confirming he was undertaking consultancy work. 4. Minute of previous Meetings 4.1 The Minutes of the MIJB held on 09 February 2023 were approved subject to the following amendment – Andrew Fleming was noted as not being in attendance. 4.2 The Minutes of the Special MIJB held on 16 March 2023 were approved as a correct record. 4.3 The Minutes of the Strategic Planning Group held on 26 January 2023 were noted. 5. Public Reports Report Title/Summary Decision Action Owner Date to be Completed/Comments 5.1 Chair’s Update - Presented by Val de Souza Val de Souza made reference with regard to the self evaluation survey issued by the improvement service, confirming that an extension had been issued until the 19th of April for completion. Val De Souza took the opportunity to urge all board members to respond. To note the Chair’s update All To Note Page 6 of 302
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3 Midlothian Integration Joint Board Thursday 13 April 2023 Report Title/Summary Decision Action Owner Date to be Completed/Comments 5.2 Chief Officers Report – Presented by Morag Barrow, Chief Officer Morag Barrow provided a brief overview of the report making reference to the directions for 2023/24, Hybrid IJB meetings, the appointment of a Clinical Lead Physiotherapist, progress of the governance assurance framework, workforce planning, third sector partners and anticipatory care planning. In response to comments regarding when feedback from the third sector summit would be available, Morag Barrow confirmed that an overview would be presented at a future meeting. To note the content of the Chief Officer’s Report. All to Note. 5.3 Proposed Meeting Schedule and Development Session Dates for 2023 and 2024 - Presented Andrew Henderson, Democratic Services Officer Andrew Henderson provided a brief overview of the report making reference to the schedule of meeting dates for 2023-24 and the approach to be taken with regard to service visits. Following a brief discussion, it was agreed that the report would be resubmitted with consideration to school holiday dates being given. The board agreed for the report to be resubmitted with consideration to school holiday dates. Democratic Services Ongoing Page 7 of 302
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4 Midlothian Integration Joint Board Thursday 13 April 2023 Report Title/Summary Decision Action Owner Date to be Completed/Comments 5.4 Finance Update – Budget Offers from Partners for 2023/24 - Presented by Claire Flanagan, Chief Finance Officer Claire Flanagan provided a brief overview of the report making reference to the formal budget offer from NHS Lothian, the reduced offer from Midlothian Council and provided further details in relation to recovery plans and reserves. A discussion ensued in relation to the paper with reference being made to the financial challenges faced by both Midlothian Council and the MIJB, the possible impacts to the MIJB in the event of accepting or not accepting the Council’s offer, the possibility of writing to the Scottish Government, the use of non-recurrent funding to cover the funding gap and possible service transformation. Claire Flanagan took the opportunity to clarify that Midlothian Council have historically provided budget offers to the MIJB which were above the minimum requirement. After further discussion, board members unanimously agreed to accept the budget offer from NHS Lothian. Val De Souza, seconded by Andrew Fleming, moved to not accept the IJB budget offer from Midlothian Council for 2023/24. Councillor Parry, seconded by Councillor Milligan, moved to amend the report to accept the budget offer from Midlothian Council for 2023/24. Thereafter, a vote The MIJB agreed; (a) To accept the budget offer from NHS Lothian; and (b) To not accept the IJB budget offer from Midlothian Council for 2023/24 and; (c) Letter to Scottish Government to be circulated to board members in advance of sending. (d) To otherwise note the update from Midlothian Council on the support from their Capital Planning Board with capital funding for the one- off purchase of digital alarms, subject to Council. Claire Flanagan Claire Flanagan Val De Souza Claire Flanagan Page 8 of 302
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5 Midlothian Integration Joint Board Thursday 13 April 2023 Report Title/Summary Decision Action Owner Date to be Completed/Comments ensued in which 5 votes were received for the motion and 3 for the amendment. 5.5 Financial Recovery options following reduced budget offer from Midlothian Council - Presented by Morag Barrow, Chief Officer Morag Barrow provided a brief overview of the report making reference to the different options as outlined. Morag Barrow highlighted that the recommendation was for the board to approve recovery options 1, 2 and 7. A discussion ensued with board members querying the possible cost implications and timescale requirements for option 1. Morag Barrow took the opportunity to clarify that a decision would be required in advance of June 2023 as staff would need to be recruited. Clare Flanagan further clarified that in 2024/25 £6.5 million in savings would be required. Members then took the opportunity to highlight the lack of equalities impact assessment and requested that further details be provided in relation to possible benefits to providing care within a single complex. After further discussion, members agreed to pause the progression of extra care housing at Normandy Court pending further discussion. (a) To defer the paper to the June board meeting for further consideration; and (b) Pause the progression of extra care housing at Normandy Court pending further discussion; and (c) A briefing for board members to be set up exploring possible recovery options. Chief Officer Chief Officer Chief Officer/Democ ratic Services Page 9 of 302
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6 Midlothian Integration Joint Board Thursday 13 April 2023 Report Title/Summary Decision Action Owner Date to be Completed/Comments 5.10 IJB Performance Report - Presented by Elouise Johnstone, Performance Manager Elouise Johnstone provided a brief overview of the report making reference to the move from monthly to quarterly performance reporting. Board members took the opportunity to recommend that the Performance Assurance and Governance Group looks forward to developing a small number of local improvement goals. (a) Members noted the performance against the IJB Improvement Goals for 2022/23 (Appendix 1). (b) Noted the change in the Public Health Scotland (PHS reporting schedule) from monthly to quarterly (c) Noted the ongoing requirement to report on the goals set by the Scottish Government Ministerial Strategic Group for Health and Community Care and consider if additional local performance goals may be more useful for regular IJB review. (d) Approved commissioning the Performance, Assurance and Governance Group (PAGG) to develop more locally set performance goal options for the Boards consideration. All to note All to note All to note Elouise Johnstone 5.6 Analogue to Digital Transition 2023/24 – Presented by Matthew Curl, Digital Programme Manager 5.7 Midlothian IJB Mainstreaming Equalities Report and Action Plan - presented by Gill Main, Integration Manager 5.8 Integrated Governance Report - presented by Fiona Stratton, Chief Nurse 5.9 Director of Public Health Annual Report and Planned Midlothian Response - Presented by Jim Sherval, Consultant in Public Health Board members agreed to drop Items 5.6 – 5.9 of (a) Board members agreed; to drop the papers from the agenda due to time constraints; and (b) To note that urgent business would be dealt with in accordance to standing order 15.1 which states: If a decision which would normally be made by the Integration Joint Board or one of its committees, requires to be made urgently between meetings of the Integration Joint Board or committee, the Chief Officer, in consultation with the Chair, Vice-Chair and Standards Officer, may take action, subject to the matter being reported to the next meeting of the Integration Joint Board Morag Barrow All to note Page 10 of 302
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7 Midlothian Integration Joint Board Thursday 13 April 2023 Report Title/Summary Decision Action Owner Date to be Completed/Comments the agenda due to time constraints, to be heard at the next meeting whilst noting that any urgent business would be dealt with in accordance to standing order 15.1. Which states: If a decision which would normally be made by the Integration Joint Board or one of its committees, requires to be made urgently between meetings of the Integration Joint Board or committee, the Chief Officer, in consultation with the Chair, Vice-Chair and Standards Officer, may take action, subject to the matter being reported to the next meeting of the Integration Joint Board or committee. or committee. 6. Private Reports No private business to be discussed at this meeting. 7. Any other business No additional business had been notified to the Chair in advance. 8. Date of next meeting The next meetings of the Midlothian Integration Joint Board would be held on: • Thursday 11 May 2023 2pm Development Workshop (Members only) • Thursday 1 June 2023 • Thursday 22 June 2023 2pm 2pm MIJB Audit and Risk Committee Midlothian Integration Joint Board (Action: All Members to Note) The meeting terminated at 4.05 pm. Page 11 of 302
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Midlothian Integration Joint Board Meeting Date Time Venue Strategic Planning Group Thursday 27 April 2023 14.00 Virtual Meeting held using MS Teams. Chair: Gill Main (Integration Manager) Vice Chair: Vacant Present (MIJB members): Keith Chapman Angus McCann Present (HSCP): Nick Clater (Head of Adult Services) Fiona Kennedy (Group Service Manager) Chris King (Finance) Elouise Johnstone (Programme Manager, Performance) Kevin Dickson (Programme Manager) Wanda Fairgrieve (Lead Partnership Representative) Emma-Jane Gunda (Assistant Strategic Programme Manager) In attendance: Laura Hill Saty Kaur Colin Cassidy Strategic Planning Group Thursday 27 April 2023 Page 13 of 302
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2 Strategic Planning Group Thursday 27 April 2023 Lesley Crozier Graeme McGuire Rachael Honeyman Jim Sherval Apologies: Claire Flanagan Fiona Stratton Morag Barrow James Hill Laura Hutchison Miriam Leighton Rebecca Green Lynne Douglas Pat Wynne Annette Laing Joan Tranent 1. Welcome and introductions Gill Main (Chair) welcomed everyone to the meeting. 2. Order of Business The order of business was as set out in the agenda. 3. Minutes of Meeting The Minutes of Meeting of the Strategic Planning Group held on 23 February 2023 were reviewed and approved. 4. Public Reports Report Title/Summary Decision Action Owner Date to be Completed/Comments 4.1 Chairs Update GM reported the Board approved and Issued Directions for 2023-24s. GM also noted that Directions were available on Page 14 of 302
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3 Strategic Planning Group Thursday 27 April 2023 Report Title/Summary Decision Action Owner Date to be Completed/Comments the Midlothian Health and Social Care webpage and thanked Nick McDowell and Caroline Shilton for their work on this. GM acknowledged continuing service pressures and recognised the good quality planning work underway in spite of ongoing capacity challenges. GM advised that the first iteration of the Group Service Specification, Service/Programme Plans, and Team Plans have been submitted for 2023-24 and SMT are reviewing these. 4.2 Finance and Performance Update – Chris King CK confirmed the HSCP position for the year end is now closed. The Council’s position due to close next week. CK is waiting for the IJB to close and described the extremely tight position resulting in a 15k underspend for Health. CK reported the 3 key areas of pressure are Midlothian Community Hospital, Nursing, and GP prescribing. 4.3 PAGG update – Elouise Johnstone EJ reported that the last meeting of the Performance and Assurance Group took place on 9th March where they reviewed the IJB performance framework. EJ advised that, following the IJB on 27th April, the PAGG has been commissioned to review and suggest local improvement goals for the IJB in 2023-24. The next meeting is on the 4th of May. Page 15 of 302
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4 Strategic Planning Group Thursday 27 April 2023 Report Title/Summary Decision Action Owner Date to be Completed/Comments 4.4. Workforce Governance Group update – Gill Main GM advised the first Board of the ongoing work to prepare for the Midlothian HSCP Workforce Governance Board scheduled for the 5th of September 2023. This includes a series of discovery sessions to shape the two subgroups that will progress the work of the Board. The two subgroups are proposed to be Workforce Planning, chaired by GM and Workforce Engagement, chaired by FK. 5. Reports 5.1 Topic in Focus Set-Aside Financial Update: Q3 Position – Graeme McGuire GMcG provided an overview of a prepared slide-deck describing the Q3 position and then took questions and supported discussion. EJ questioned the agency spend and whether this was due to buying more agency hours or if the costs have increased. GMcG confirmed the answer is a combination of both and stated sickness levels have risen to 6-7%. GMcG stated the patient safety is at the centre of decision making. Angus McCann asked Graeme for his view on the 3% target savings in cancer drugs. GMcG said it is a frustrating process and is looking at skill mixing within vacancies. Page 16 of 302
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5 Strategic Planning Group Thursday 27 April 2023 Report Title/Summary Decision Action Owner Date to be Completed/Comments GM reminded the group of the discussion during GMcG last presentation to SPG regarding the potential to explore the Midlothian usage of set aside and the power of the 2023-24 Directions 5.1 and 9.1 in this regard. GM also asked GMcG what his ask would be of the group and GMcG confirmed a better connection between primary and secondary care. GM suggested taking a focused strategic and collaborative approach to Directions 5.1 and 9.1 Action: The group agreed it would be helpful for a session with Midlothian and NHSL Finance, Planning, and Performance to consider Direction 5.1 and 9.1 GM also suggested working with Midlothian and NHSL finance, Planning and Performance as part of the planning in relation to Midlothian IJB Strategic Commissioning Plan 2025-28. The group agreed Action: GM to liaise with GM GM September 2023 October 2023 5.2 Items for Decision Integrated Impact Assessment Process – Kevin Dickson KD summarised the legislative duty if the IJB to give consideration to the quality impact for all Strategies, policies, plans, provision and activities of the Board, including that of the HSCP in delivering the ambitions of the Page 17 of 302
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6 Strategic Planning Group Thursday 27 April 2023 Report Title/Summary Decision Action Owner Date to be Completed/Comments Midlothian IJB Strategic Commissioning Plan 2022-25. SG and the EHRC required Midlothian IJB to create and implement a process to screen, identify, complete and monitor the impact of IIAs by the end of March 2023. The first draft of a process to screen, identify, complete and monitor the impact of IIAs came to the meeting of the SPG in February 2023 and the recommended changes have been adopted. KD asked the group to recommend this process for approval to the June Board EJ commented this process will greatly improve the performance reporting in this area. KD also noted the oversight implications for SPG in regards to the reviewing the HSCP mechanism to also record and report to the Board using a similar process. GM reiterated that the Equality Duty and requirement for the IJB to give due consideration to equality issues could not be delegated and that this meant the HSPC is required to report to the IJB on how it is considering equality issues as it delivers on the ambition of the Strategic Commissioning Plan. LC confirmed this was the correct interpretation of the Public Sector Equality Duty. Noting this, GM noted this would now suggest a similar process was adopted for SPG and a request for SMT to report to SPG on the HSCP consideration to equality issues The group agreed to recommend this process for approval to the June Board. The group agreed for a similar process to be implanted for SPG. Action: The Planning team will implement and oversee this process Action: The group agreed a paper should now go to SMT regarding the requirement to adopt a similar process and report GM GM GM 22nd June 2023 For 29th June SPG July 2023 Page 18 of 302
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7 Strategic Planning Group Thursday 27 April 2023 Report Title/Summary Decision Action Owner Date to be Completed/Comments in its screening, identification, completion and monitoring of impact in relation to equalities in operational planning work. biannually to SPG 5.3 Annual Performance Review Skeleton Draft – Elouise Johnstone EJ asked the group to consider the proposed skeleton draft, make any comments and note the publication dates. Due to the release of PHS management data in Mid-May, the first draft will come to SPG on 29th June 2023, the data scrutinised by PAGG on 29th July 2023, and the final version going to Midlothian IJB Board on 26th August. GM thanks EJ and the APR Writing Group for the work completed to date. GM then commented that it will be impossible to meet the Scottish Government deadline due to data release dates but noted Midlothian IJB has contacted Scottish Government and asked for an extension to the deadline. GM noted the recommendations for review and scrutiny via SPG, and PAGG prior to the August Board and advised inviting MIJB Board Members to join SPG on 29th of June 2023, and PAGG on 20th of July 2023. The group agreed for Board members to join SPG and PAGG. Action: Invites to be circulated to Board Members EJG / JK / Democratic Services End of May 2023 Page 19 of 302
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8 Strategic Planning Group Thursday 27 April 2023 Report Title/Summary Decision Action Owner Date to be Completed/Comments EJ reported that a focus on the ‘looking forward’ section required some input from Heads of Service and Professional Leads to better understand the planned main thrust of operational activity in 2023-24. GM suggested a short and targeted discussion with SPG leads (40 mins). Angus commented that a session would be valuable with directed questions on each key issues helpful. The group agreed to commission EJ to lead a session to establish the areas Heads of Service and Professional Leads would like to be included in the ‘Looking Forward’ section of the APR EJ End of May 2023 6. Any other business Report Title/Summary Decision Action Owner Date to be Completed/Comments None raised. 7. Date of next meeting The next meeting of the Strategic Planning Group will be held on 29 June 2023 at 2.00pm. Actions: All Members please note and progress the actions detailed in this document The meeting terminated at 4.00pm Page 20 of 302
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Midlothian Integration Joint Board Thursday, 22nd June, 14:00-16:00 Proposed Meeting Schedule and Development Workshops Dates for 2023 and 2024 Executive summary The purpose of this report is to set the dates for the meetings and development workshops of the Midlothian Integration Joint Board for 2023 and 2024 including meetings of the Midlothian Integration Joint Board which take into account Midlothian School Holidays; Members are asked to: a) To note the Meeting Schedule and Development Workshop dates for 2023 as approved at the meeting of the MIJB on the 26 August 2022; and b) To approve the Meeting Schedule and Development Workshops dates 2023 and 2024; and c) To note the approach for Service Visits for the Members of the Midlothian Integration Joint Board. # Item number: 5.1 Page 21 of 302
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Midlothian Integration Joint Board Midlothian Integration Joint Board Proposed Meeting Schedule and Development Workshops Dates for 2023 and 2024 1 Purpose 1.1 To set the dates for meetings, groups and development workshops of Midlothian Integration Joint Board for 2023 and 2024 as prescribed by the Midlothian Integration Joint Board Standing Orders – 5.2. 2 Recommendations 2.1 To note the Meeting Schedule and Development Workshop dates for 2023 as approved at the meeting of the MIJB on the 26 August 2022. 2.2 To approve the Meeting Schedule and Development Workshops dates for 2024 as set out in Appendix to the report. 2.3 To note the approach for Service Visits for the Members of the Midlothian Integration Joint Board as set out in the report. 3 Background and main report 3.1 The proposed schedule follows the current existing pattern of Board meetings and Development Workshops held on alternative months, with quarterly Audit & Risk Committee meetings and Special Board meetings in March and September to consider the budget and annual accounts respectively. 3.2 The proposed schedule of meetings for 2023 and 2024 is shown in detail in Appendix A. 3.3 Members are reminded that the facility exists under Standing Orders for special meetings to be called if and when required. 3.4 Appropriate arrangements are to be made where applicable to allow for the access of the public and press to attend. 3.5 Any Service Visits will continue to be scheduled as required or at the request of Members of the Midlothian Integration Joint Board. 4 Policy Implications 4.1 There are no policy implications arising from any decisions made in this report. Page 22 of 302
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Midlothian Integration Joint Board 5 Directions 5.1 There are no implications on Directions arising from any decisions made in this report. 6 Equalities Implications 6.1 There are no equalities issues arising from any decisions made in this report. 7 Resource Implications 7.1 There are no implications on Directions arising from any decisions made in this report. 8 Risk 8.1 The availability of the schedule of meeting dates contributes to the mitigation of risk by: • facilitating forward planning for meetings; contributing to the governance • framework which allows the Board to conduct its business; and • providing a timetable to which Officers can work to ensure that reports are submitted timeously. 9 Involving people 9.1 There are no implications for involving people as a result of this report. 10 Background Papers 10.1 There are no background papers in relation to the content of this report AUTHOR’S NAME Democratic Services DESIGNATION Democratic Services Officer CONTACT INFO democratic.services@Midlothian.gov.uk DATE 30/03/2023 Appendices: Appendix 1: Proposed MIJB schedule of meetings and workshop dates 2023 and 2024 Page 23 of 302
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Midlothian Integration Joint Board Page 1 Midlothian Integration Joint Board Proposed Meeting Schedule and Development Session Dates 2023 and 2024 2023 Submitted for noting. Day/Date Time Meeting August Thursday 24th August 2023 September 2pm MIJB Board Thursday 7th September 2023 2pm MIJB Audit and Risk Committee Thursday 21st September 2023 2pm Special MIJB and Development Session (Annual Accounts) Thursday 28th September 2023 October 2pm MIJB Strategic Planning Group Thursday 12th October 2023 Thursday 26th October 2023 November Thursday 9th November 2023 Thursday 30th November 2023 December Thursday 7th December 2023 Thursday 21st December 2023 2pm 2pm 2pm 2pm 2pm 2pm MIJB Board MIJB Strategic Planning Group Development Session MIJB Strategic Planning Group MIJB Audit and Risk Committee MIJB Board 2024 Submitted for Approval Day/Date Time Meeting January Thursday 18th January 2024 2pm Development Session Thursday 25th January 2024 February 2pm MIJB Strategic Planning Group Thursday 8th February 2024 2pm MIJB Board Thursday 29th February 2024 March Thursday 7th March 2024 2pm 2pm MIJB Strategic Planning Group MIJB Audit and Risk Committee Thursday 21st March 2024 2pm Special MIJB and Development Session Page 25 of 302
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Midlothian Integration Joint Board Page 2 April Thursday 18th April 2024 Thursday 25th April 2024 2pm 2pm MIJB Board MIJB Strategic Planning Group May Thursday 16th May 2024 2pm Development Session Thursday 23rd May 2024 June 2pm MIJB Strategic Planning Group Thursday 6th June 2024 2pm MIJB Audit and Risk Committee Thursday 20th June 2024 2pm MIJB Board Thursday 27th June 2024 2pm MIJB Strategic Planning Group Summer Recess August Thursday 22nd August 2024 2pm MIJB Board September Thursday 5th September 2024 Thursday 19th September 2024 2pm 2pm MIJB Audit and Risk Committee Special MIJB Board and Development Session Thursday 26th September 2024 October 2pm MIJB Strategic Planning Group Thursday 17th October 2024 2pm MIJB Board Thursday 24th October 2024 MIJB Strategic Planning Group November Thursday 21st November 2024 2pm Development Session Thursday 28th November 2024 2pm MIJB Strategic Planning Group December Thursday 5th December 2024 2pm MIJB Audit and Risk Committee Thursday 19th December 2024 2pm MIJB Board Service Visits Further service visits will be scheduled as required or at the request of members of the Midlothian Integration Joint Board. Page 26 of 302
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Midlothian Integration Joint Board Chief Officer Report Thursday 22nd June 2023, 14:00 – 16:00 Executive summary The paper sets out the key strategic updates for Midlothian IJB Board meeting June 2023. Board members are asked to: • Note the content of the report # Item number: 5.2 Page 27 of 302
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Midlothian Integration Joint Board Midlothian Integration Joint Board Chief Officer Report 1 Purpose 1.1 The paper sets out the key strategic updates for Midlothian IJB Board meeting June 2023. 2 Recommendations 2.1 As a result of this report Members are asked to: • Note the content of the report 3 Background and main report 3.1 Chief Officer System pressure The Health and Social care system remains under pressure. Patients experiencing a delayed discharge remain a focus nationally, with only a slight improvement in national numbers. Midlothian Health and Social Care Partnership (HSCP) delays are currently low, with us seeing the benefit of the significant investment in leadership and capacity to support Flow service redesign. Discharge Without Delay (DWD) is well underway, with the introduction of Rapid Rundown Meetings each morning in Midlothian Community Hospital (MCH). This multi-disciplinary proactive planning meeting has supported the average length of stay decline steadily each month since its introduction, from 55.7 to 27.95 days. The MCH team presented to Scottish Government colleagues, as well as the wider NHS, on the experience of implementing the process. Similarly, Multi Agency Discharge Events (MADE) have been instigated to support improved processes to enable person centred discharge planning. Minister for Social Care, Mental Health and Sport The Midlothian Allied Health Professionals (AHP) team hosted a visit for Maree Todd (Minister for Social care, Mental Health, and Sport) to MCH on 23rd May. This was to focus on the contribution of AHPs and rehabilitation to the patient journey. In a thank you letter Ms Todd wrote: “I thoroughly enjoyed hearing about how the team support people across Midlothian to live well in the community for as long as possible and how you reduce prolonged stays in hospital. I found your references to the ADL Life Curve particularly interesting. The points made about preventing people from reaching crisis through early intervention in the community were particularly pertinent. The discussion gave me a lot to think about and it’s really important that the voices and experience of Allied Health Professionals, and the people they support, feed into the development of the National Care Service.” Page 28 of 302
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Midlothian Integration Joint Board Morag Barrow, Chief Officer - Morag.barrow@nhslothian.scot.nhs.uk 3.2 Head of Adult Services Physical Disabilities Strategic Inspection The HSCP have received notification of a forthcoming Strategic inspection from the Care Inspectorate and Healthcare Improvement Scotland. The inspection will focus on Physical Disabilities and commenced at the end of May. There is a newly established Inspection Activity Board chaired by Nick Clater that will provide governance and assurance around the various workstreams associated with inspection work. To date, there has been benchmarking activity (against other published inspection reports) in Physical Disabilities and Adult Support and Protection with a significant focus around the recent Edinburgh City Council Social Work inspection report. Fiona Kennedy (Group Service manager) is leading on this work and is currently conducting a workforce survey for Social work/Social care and Occupational Therapy teams to share their views. Reviewing and updating operational policies and procedures is a priority. Timeously, there is Council wide commitment to review all procedural documents, and this will incorporate all relevant adult social care procedures. Other areas of progress include developing system wide service and team plans, shaping a digital system (Outnav) that allows the team to collate and map evidence in relation to outcomes for people who use services in Midlothian, as well as a continuing commitment to the HSCP ‘Staff Communication, Engagement and Experience Delivery plan’. Midlothian Dementia Team The Midlothian Dementia Team has been nominated in the Team of the Year Award category in the 2023 NHS Lothian Celebrating Success Awards. The team has been shortlisted and will be invited to attend the Awards ceremony on the 7th September 2023. The nomination is in recognition of the team's dedication over the last year to integrated working to enhance and develop the service by improving individuals' journey, by improving their person-centred care and treatment along with improving the experience of families and carers. Together the team have developed new ways of working, introduced new evidence-based therapies, for example a Home-Based Memory Rehabilitation and Cognitive Stimulation Therapy group, developing new groups such as Journey Through Dementia, along with implementing carer support groups. The team has also taken the opportunity to enhance and develop further their Post Diagnostic Support (PDS) service which has reduced their waiting list considerably to ensure people are getting the right support at the right time and in a timely manner. Midlothian’s Implementation of Medication Assisted Treatment Standards Midlothian HSCP have submitted the final submission of evidence on the implementation of MAT Standards 1- 5 which focuses on access, choice, and support. The MAT Implementation Support Team (MIST) have projected a RAG rating of green both for theoretical process and numerical data, which secures Midlothian as completed on target for March 2023. During this submission process Midlothian had to rate its current position for MAT standards 6-10 which must be fully implemented by March 24. Page 29 of 302
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Midlothian Integration Joint Board The Substances use services are also pleased to report over quarter 4 the waiting times target (HEAT) A11 has also improved and has exceeded the target standard of 90% (Midlothian 95%) of individuals being seen within 21 days. Nick Clater, Head of Adult Services - nick.clater@midlothian.gov.uk 3.3 Head of Primary Care and Older People Pharmacotherapy Ongoing implementation of the Primary Care Improvement Plan now delivers access to Pharmacy services for all GP practices in Midlothian. An HSCP Pharmacy Medicines Reconciliation Hub has been established and has now been scaled up to provide access to all practices; technicians have been trained to lead on this process and escalate appropriately to pharmacists when needed. Several Pharmacists have completed their independent prescribing course, so there is now have Pharmacy-led clinics for cardiovascular disease, respiratory, and mental health in some practices with the intention to extend the service as more Pharmacists complete their training. Celebrating success MCH has two members of the team nominated for NHS Lothian Celebrating Success awards. Maisie Davidson (Activities coordinator in Roselane ward), and Angie Neal (Clinical Educator) have been selected in top 3 for their respective categories, and will attend the awards ceremony on 7th September, where winners will be announced. Grace Cowan, Head of Primary Care & Older People Grace.cowan@nhslothian.scot.nhs.uk 3.4 Planning, Performance and Programme The Midlothian Health and Social Care Contribution to the Midlothian Community Planning Partnership The first draft of the Single Midlothian Plan that describes the work of the Community Planning Partnership from 2023-27 has been submitted to the Community Planning Partnership Board. Health and Social Care are legislatively required to contribute to this key agenda and officers of Midlothian HSCP have taken a more intention approach to ensure that whole system transformation is delivered through targeted prevention, early interventions and self-management service offers and supports. The HSCP is confident that by taking a partnership approach and working with a range of the Community Planning partners, we will achieve more together than we can alone. The HSCP has planned and designed 4 project-based pieces of work that are anticipated to maximise and accelerate whole system change. 1. Explore and define the demand for and the benefit of Midlothian Care and Support Community Co-operative that facilitates personalised support for carers, identifies local assets, and enhances local economic value 1.1 2. Increase falls prevention and support to reduce the rate of falls for people in Midlothian over the age of 85. The rate of falls for this age group is currently 86.1 per 1000 population. This is much higher than the national rate of 72 per 1000 population, or the Lothian rate of 78.9 per 1000 population. Page 30 of 302
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Midlothian Integration Joint Board 3. Scope and develop a digital self-management platform to support people have more choice and control in how they access information, exercises, and activities, then take positive action to set personal goals and measure progress in their health and wellbeing. 4. Provide an individualised approach to Early Identification and Support for People Living with Frailty that helps people to thrive and avoid crisis Measuring Personal Outcomes and Impact The Planning, Performance, and Programme Team was asked to present our innovative and ground-breaking work on evidencing population outcomes at the ‘Towards Relational Public Services’ conference 2023, held at Newcastle University. The team has designed a methodology that triangulates the contribution analysis approach of the Matter of Focus software, ‘OutNav’, with activity and experience data to measure and visualise the progress being made towards the 6 strategic aims of our Strategic Commissioning Plan 2022-25. The team and Matter of Focus are looking forward to sharing this work at the next IJB Development session on 21st September 2023. Annual Performance Report (APR) The Planning, Performance, and Programme team are writing the first draft of Midlothian IJBs Annual Performance Report (APR) 2022-23. As part of the governance process to approve the report for publication, Midlothian IJB Board Members are invited to attend the following sessions Strategic Planning Group: 6th July 2023 14.00- 16.00 Performance, Assurance & Governance Group: 20th July 2023,14.00 – 16.00 Celebrating Success Caroline Shilton (Public Engagement Lead) has also been nominated within the top three for the ‘Respect for Others’ category. Gill Main, Integration Manager - Gill.main3@nhslothian.scot.nhs.uk 3.5 Chief Allied Health Professional Long Covid Supported Self-Management Pathway The Lothian Long COVID Supported Self-Management (Digital) Pathway launched on 17th March 2022. The first phase included a trial of 26 GP surgeries from across The Lothians with the aim of rolling out to the remaining GPs in NHS Lothian by region. On the 31st of January 2023, Midlothian were the first HSCP to fully implement the pathway across all GP practices. A total of 36 GP surgeries are involved in the pathway as of March 2023. An example of the weekly report detailing outputs from the pathway is provided below. Page 31 of 302
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Midlothian Integration Joint Board The Midlothian Implementation Group used the rollout into Midlothian as an opportunity to review the established information regarding Long COVID. In January 2023 key information was identified by the MHSCP Equality Impact Assessment. This report highlighted population groups who are more likely to be affected by Long COVID and therefore more likely to be positively impacted by the implementation of this pathway. By identifying people who are more likely to be affected by Long COVID, the Midlothian Project team and Lothian Steering Group are considering if the needs of these people are being met and ensure they are at the forefront of the pathway’s aims and future development. Midlothian has been very influential in the development of the pathway and a formal Statement of Progress has been developed in conjunction with all partners and is due to be released as the plan for scale up to the other regions in Lothian is progressed. Hannah Cairns, Chief AHP - hannah.cairns@nhslothian.scot.nhs.uk 3.6 Primary Care Activity (clinical contacts with patients) remain consistently high across Midlothian even though winter viral illness is now behind us. Access at Danderhall Medical Practice has improved since the Newbattle Medical Practice team took over management, and all practice teams continue to work hard to meet demand. The HSCP is supporting this work via the provision of an add-on digital access platform, and improved Communications with patients regarding services available. The Legionella Species detection in Bonnyrigg Health Centre has been challenging for both HSCP and practice teams alike. All three Bonnyrigg GP practices have been able to remain operational and providing emergency appointments on site, as well as routine and nursing appointments from Midlothian Community Hospitals, demonstrating impressive agility and flexibility, as well as their commitment to providing general medical services to their patients. HSCP teams have shown similar resilience adapting to remote working, or alternative bases. Prescribing The Pharmacy team achieved 130% performance against their 2022-23 efficiencies target, with 19% of that coming from initiatives in GP practices. While much of the current unprecedented increase in the cost per item of medications is outwith the HSCP’s control, the pharmacy team have a strong efficiencies plan in place for the forthcoming year and are aggressively pursuing all available options to reduce prescribing costs. Page 32 of 302
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Midlothian Integration Joint Board Hospital at Home The HSCP is pleased to have been able to recruit a full-time Clinical Fellow to the medical team in Hospital at Home who will start in August 2023. This additional resource will increase capacity for accepting referrals from GPs in the community and avoid hospital in-patient admissions for more patients where safe and appropriate. The team appeared in a recent BBC news item which showcased the service in a very positive way. Rebecca Green, Clinical Director – Rebecca.green@nhslothian.scot.nhs.uk 3.7 Nursing NHS Lothian’s Nursing and Midwifery Strategic Plan (2023 – 2028). Realising our Ambitions; Reimagining Nursing and Midwifery for NHS Lothian was launched on 12th May on International Nurses’ Day. The plan aims to address the key challenges face by the professions and to ensure NHS Lothian is equipped with a strong, compassionate, and highly skilled workforce to deliver the best outcomes for people. It provides a roadmap to make NHS Lothian a great place to work and a great place to be cared for. The document can be accessed at Nursing and Midwifery Strategic Plan 2023-2028 (scot.nhs.uk) National controls on the use of agency staffing within nursing will be introduced from the 1st June 2023. The changes to policy are being made to support patient safety, as required by the Health and Care (Staffing) (Scotland) Act 2019, and to address the value and sustainability relating to the use of flexible workforce. Communication has been distributed to all nursing staff within NHS Lothian to ensure awareness of the changes, and comprehensive escalation and risk management processes have been developed based on the National Principles. Agency usage will be monitored at all levels with any continued high use of agency staffing requiring a service model or workforce review to be brought forward to the NHS Lothian CMT. Fiona Stratton, Chief Nurse – Fiona.stratton@nhslothian.scot.nhs.uk 4 Policy Implications 4.1 The issues outlined in this report relate to the integration of health and social care services and the delivery of policy objectives within the IJBs Strategic Plan. 5 Directions 5.1 The report reflects the ongoing work in support of the delivery of the current Directions issued by Midlothian IJB. 6 Equalities Implications 6.1 There are no specific equalities issues arising from this update report. 7 Resource Implications 7.1 There are no direct resource implications arising from this report. Page 33 of 302
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Midlothian Integration Joint Board 8 Risk 8.1 The key risks associated with the delivery of services and programmes of work are articulated and monitored by managers and, where appropriate, reflected in the risk register. 9 Involving people 9.1 There continues to be ongoing engagement and involvement with key stakeholders across the Partnership to support development and delivery of services. 10 Background Papers AUTHOR’S NAME Morag Barrow DESIGNATION Chief Officer CONTACT INFO 0131 271 3402 DATE June 2023 // Page 34 of 302
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Midlothian Integration Joint Board Thursday 22nd June 2023, 14:00 – 16:00 Midlothian IJB Draft Unaudited Annual Accounts 2022/23 Item number: 5.3 Executive summary This report presents the IJB’s draft (unaudited) Annual Accounts for 2022/23. The IJB is required to prepare a set of annual accounts each year a draft of these accounts must be agreed by committee before 30 June whereupon the draft must be published on the IJB’s website and presented to the IJB’s auditors for review. Board members are asked to: • Consider the IJB’s draft unaudited annual accounts • Note the IJB’s Audit & Risk Committee will have the accounts presented to them on 28th June 2023 Page 35 of 302
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Midlothian Integration Joint Board Page 2 Midlothian Integratiom Joint Board 1. Purpose 1.1 This report presents the IJB’s draft (unaudited) Annual Accounts for 2022/23 2. Recommendations 2.1 Committee members are asked to • Consider the IJB’s draft annual accounts • Note the IJB’s Audit & Risk Committee will have the accounts presented to them on 28th June 2023 3. Background and main report 3.1 The IJB is constituted under section 106 of the local government (Scotland) Act and as such must prepare a set of annual accounts. These accounts must be presented in draft for approval to either the IJB or a committee of governance of the IJB by 30th June whereupon the accounts will be presented for audit by the IJB’s auditors. 3.2 The annual accounts contain a range of sections but breakdown into three main areas :- • The Management Commentary. This provides a statement of the IJB’s purpose and its performance against that purpose in the financial year along with a reflection on the challenges facing the IJB in the next financial year. • A range of financial statements showing the financial position of the IJB. 3.2 The Audit and Risk Committee will be asked to approve the draft annual accounts reflecting on the Management Commentary, the Annual Governance Statement and the financial position at their meeting 28 June 2023. 4. Policy Implications 4.1 The framework focuses on supporting the implementation of the Public Bodies (Joint Working) (Scotland) Act 2014. 5. Equalities Implications 5.1 There are no equalities implications arising from this report 6. Resource Implications Page 36 of 302
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Midlothian Integration Joint Board Page 3 6.1 There are no resource implications arising from this report. 7 Risks 7.1 There are no risks associated. 8 Involving People 8.1 There are no direct implications for involving people as a result of this report. 9 Background Papers 9.2 None AUTHOR’S NAME Claire Flanagan DESIGNATION Chief Finance Officer CONTACT INFO Claire.flanagan@nhslothian.scot.nhs.uk DATE June 2023 Appendices: Appendix 1: Midlothian IJB Unaudited Annual Accounts 2022/23 Page 37 of 302
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1 Midlothian Integration Joint Board (IJB) Unaudited Annual Accounts 2022/23 The Annual Accounts of Midlothian Integration Joint Board for the period from 1 April 2022 to 31 March 2023, prepared pursuant to Section 105 of the Local Government (Scotland) Act 1973 and in accordance with the terms of the CIPFA/LASAAC Code of Practice on Local Authority Accounting in the United Kingdom 2022/23. Page 39 of 302
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2 Contents Audit Arrangements ............................................................................................... 3 Management Commentary ..................................................................................... 4 Plans for Next Year and beyond ............................................................................ 12 The IJB’s Financial Position: 31 March 2023 ............................................................ 14 Statement of Responsibilities ................................................................................ 21 Remuneration Report ........................................................................................... 23 Annual Governance Statement 2022/23 ................................................................. 26 Independent Auditor’s Report ............................................................................... 27 Comprehensive Income and Expenditure Statement ................................................ 28 Movement in Reserves Statement ......................................................................... 29 Balance Sheet ..................................................................................................... 30 Notes to the Financial Statements ......................................................................... 31 Page 40 of 302
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3 Audit Arrangements Under arrangements approved by the Accounts Commission of Local Authority Accounts in Scotland, the auditor with responsibility for the audit of the accounts of Midlothian Integration Joint Board for the period 1 April 2022 to 31 March 2023 is Audit Scotland, 102 West Port, Edinburgh EH3 9DN. Page 41 of 302
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4 Management Commentary Introduction The management commentary considers the work that the IJB has undertaken during the financial year 2022/23, and then describes the financial performance for the financial year ended 31 March 2023. It provides an overview of the key messages relating to the role, remit, members, objectives, and the strategy of the Midlothian Integration Joint Board (IJB). The IJB’s Operations for the Year 2022/23 The Role and Remit of the IJB The IJB is an Integration Authority set up under the Public Bodies (Joint Working) Act (2014). It is a ‘body corporate’, that is a separate legal entity. The IJB is constituted through its Integration Scheme which was prepared by Midlothian Council and NHS Lothian and presented to Scottish Ministers in March 2015. The Integration Scheme was approved by the Scottish Parliament in June 2015 and the first meeting of the IJB took place on 20 August 2015. A review of the integration scheme was undertaken during 2022 and approved by Midlothian Council and NHS Lothian in June 2022. The scheme is currently awaiting Scottish Parliament approval. The IJB’s role and responsibility is to plan for the delivery of the functions that have been delegated to the IJB by Midlothian Council and NHS Lothian. These functions are - • Adult Social Care • Primary Care Services (GP Practices, Community Dentists, Community Pharmacies and Community Opticians) • Mental Health Services • Physical and Learning Disabilities Services • Community Health Services • Community Hospital Services • Unscheduled Care Services (services that are generally delivered from the Royal Infirmary of Edinburgh, the Western General Hospital and St. John’s Hospital). The IJB assumed formal responsibility for these functions in April 2016 including the budgets for the delivery of these functions. The strategic plan of each IJB must be reviewed and approved by the IJB every 3 years. The IJB, during March and April 2022 considered and approved its third Strategic Plan which covers April 2022 to March 2025. Membership of Integration Joint Board The IJB met virtually 8 times in 2022/23 for formal business meetings, there were two virtual workshops. The members of the IJB as of March 2023 were: Page 42 of 302
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5 Member Nominated/Appointed by Role Val de Souza Nominated by NHS Lothian Voting Member, Chair Colin Cassidy Nominated by Midlothian Council Voting Member, Vice Chair and Chair of Audit and Risk Committee Pauline Winchester Nominated by Midlothian Council Voting Member Derek Milligan Nominated by Midlothian Council Voting Member Kelly Parry Nominated by Midlothian Council Voting Member Angus McCann Nominated by NHS Lothian Voting Member Andrew Fleming Nominated by NHS Lothian Voting Member Nadin Akta (currently Peter Knight acting as substitute) Nominated by NHS Lothian Voting Member Morag Barrow Appointed by the IJB Chief Officer Claire Flanagan Appointed by the IJB Chief Finance Officer Joan Tranent Nominated by Midlothian Council Chief Social Worker Fiona Stratton Nominated by NHS Lothian Chief Nurse Johanne Simpson Nominated by NHS Lothian Medical Practitioner Rebecca Green Nominated by NHS Lothian General Practitioner Grace Chalmers Appointed by the IJB MLC Staff Side Representative Hannah Cairns Appointed by the IJB Head Allied Health Professional Miriam Leighton Appointed by the IJB Voluntary Sector Representative Keith Chapman Appointed by the IJB User Representative/Carer Representative Wanda Fairgrieve / Jordan Miller Appointed by the IJB NHS Staff Side Representative Page 43 of 302
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6 COVID-19 During the pandemic, Midlothian, in line with Scottish Government guidance, stepped up a range of services to support the continued system wide response to Covid. The cost projections associated with these services, through the Scottish Government Local Mobilisation Plan (LMP), were reported to the IJB and during the 2020/21 to 2022/23 financial years the associated costs were funded by designated Covid funding. The Scottish Government confirmed the funding would not be available in the 2023/24 financial year. In response, a Covid decommissioning assessment and reprioritisation of funding exercise was undertaken. The result of this exercise has allowed funding streams to be assessed and reprioritised to ensure both clinical and financial sustainability of these services. IJB’s Vision and Objectives The IJB’s vision and objections are laid out in the IJB’s Integration Scheme, and these reflect the national agreed Health and Wellbeing outcomes. These are: 1. People are able to look after and improve their own health and wellbeing and live in good health for longer. 2. People, including those with disabilities or long-term conditions or who are frail are able to live, as far as reasonably practicable, independently and at home or in a homely setting in their community. 3. People who use health and social care services have positive experiences of those services, and have their dignity respected. 4. Health and social care services are centred on helping to maintain or improve the quality of life of people who use those services. 5. Health and social care services contribute to reducing health inequalities. 6. People who provide unpaid care are supported to look after their own health and wellbeing, including to reduce any negative impact of their caring role on their own health and wellbeing. 7. People using health and social care services are safe from harm. 8. People who work in health and social care services feel engaged with the work they do and are supported to continuously improve the information, support, care and treatment they provide. 9. Resources are used effectively and efficiently in the provision of health and social care services. The IJB also contributes to the achievement of the national criminal justice outcomes because the Parties have elected to delegate criminal justice social work. Page 44 of 302
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7 Delivery of the IJB’s current Strategic plan The Strategic Plan is delivered through the IJB’s directions to the partners (Midlothian Council and NHS Lothian) and the IJB considered the delivery of these directions in detail at its April 2022 meeting and approved the directions in June 2022. The IJB’s Strategic Planning Group has met regularly during the financial year to reflect on and develop the IJB’s Strategic Plan and this is discussed further below in the IJB’s plan for future years. The IJB categorises its services into three broad areas: Core Services These are the local Health and Social Care services within Midlothian and are operationally managed by the Health and Social Care Partnership which is a joint arrangement between Midlothian Council and NHS Lothian. Hosted Services These being delegated functions that are operationally managed by other parts of NHS Lothian – for example in-patient mental health services provided at the Royal Edinburgh Hospital in Edinburgh Set Aside Services These being delegated functions operationally managed by NHS Lothian in its Acute Division. Details of all the functions delegated to the IJB by NHS Lothian and Midlothian Council are laid out under the Role of the IJB below. Within each of these areas the following developments have been driven forward during the year. Core Services Primary Care The IJB is ongoing in supporting the delivery of the Primary Care Implementation Plan in the twelve GP Practices within Midlothian. The HSCP and the GP Practices continue to work closely together to deliver an integrated local care service and the work to progress the memorandums of understanding (MOU) between the Scottish Government and the GP Practices is key in delivering the IJB’s Primary Care Strategy. Examples of this are: Pharmacotherapy: Ongoing implementation of the Primary Care Improvement Plan (via the Scottish Government Primary Care Improvement Fund) now delivers access to Pharmacy services for all GP practices in Midlothian. A wide range of pharmacotherapy is provided, dependent on current need in each practice. Page 45 of 302
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8 A Pharmacy Medicines Reconciliation Hub has been established and scaled up to provide access to all practices. In Addition, Pharmacy-led clinics have been established for cardiology, respiratory, and mental health. The aim is to extend the service as more Pharmacists complete their training. Community Treatment and Care (CTAC) Community Treatment and Care Services are now established and embedded in all GP Practices across Midlothian. Additionally, the service has been extended to 7-day cover. This year’s increased investment from the Primary Care Improvement Fund has increased workforce capacity in the team, with all practices now been offered Phlebotomy, and most practices with chronic disease, wound care, and ear irrigation. MSK-APP (First contact physiotherapy) Advanced Practitioner Physiotherapy (APP) service is now fully established across all Midlothian GP Practices. The service has demonstrated a significant impact in reducing GP workload, with 93% of cases requiring no GP input once seen by an APP. Mental Health Mental Health and Resilience service (MHARS) The Mental Health and Resilience Service (MHARS) is a joint collaborative approach between Midlothian HSCP and Penumbra. The service is open to anyone aged 18 to 65 across Midlothian, 7 days a week, 8am-10pm. MHARS has been designed to be a self-referral service which aims to reduce barriers, offer support around an individual’s specific needs and tailor support around what matters most to them. The service offers a single point of access to support adult residents of Midlothian who are experiencing mental health crisis and distress offering an adaptive approach that provides both Distress Brief Intervention (DBI) and intensive home treatment. This allows MHARS to provide a range of person-centred support options that are customised to each person's needs. DBI has been shown to be a highly effective tool for reducing distress for individuals experiencing a mental health crisis providing immediate support to those in crisis, helping them to develop coping strategies and promote long term resilience. The intensive home treatment offers a more specialist mental health assessment for those at higher risk which includes using assertive outreach to provide support in the person’s own home. There has been a positive impact of the new service in Midlothian, and since launching on the 1st of August 2022. Page 46 of 302
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9 Midlothian Medicated Assisted Treatment (MAT) Implementation Plan Scottish Government’s MAT standards aim to ensure safe, effective, acceptable, accessible, and person-centred care by improving access, choice and care for people affected by problematic substance use across Scotland. Midlothian achieved MAT standards 1-5 (which focus on access, choice, and support) and are on target to achieve MAT standards 6-10 by the March 2024 deadline. Justice The Justice Team have continued to deliver a range of interventions that fulfil Midlothian’s statutory requirements throughout the financial year. This has included making progress to implement the national outcomes outlined in the Scottish Government’s Vision for Justice in Scotland. To ensure the provision of early interventions at the Court stage the service continue to liaise with colleagues locally and nationally to offer and provide a range of bail services to people in Midlothian. As evidenced by the updated performance measures Midlothian have made good progress against the performance indicators, this has been supported by close partnership working to ensure that positive outcomes are achieved for service users. Home First Midlothian have had a continued focus on Home First throughout the year, embedding a continuous improvement approach to help balance capacity and demand. Home first encompasses services such as Discharge to Assess, Rapid Response, Community Respiratory Team, Flow Team, and In-reach Social Work. The services work in close collaboration with Midlothian Community Hospital, Highbank, District Nursing, Care at Home, Primary and Secondary Care. The teams have linked closely with the Scottish Government Discharge Without Delay workstream, using the tools available to embed its' principles system wide. This includes training, developing staff and services, embedding new systems and processes, building relationships across the system, collaborating, and having clear points of escalation. Midlothian are now beginning to see the benefits of their sustained efforts, with performance improving. Learning Disabilities Within Learning Disability Services one of the key areas of success has been the promotion of Positive Behaviour Support where integrated working between staff in health and social care and with external care providers has enhanced the support for people with complex needs. In addition, wider planning activities continue to be driven by the aspiration that all Midlothian learning-disabled citizens feel confident to take part in our community life free from fear, harassment, and abuse. The work is supported and implemented by Expert Panels Page 47 of 302
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10 designed to give people with lived experience of a learning disability direct participation as drivers of our work and implementing a series of measures to promote people’s human rights. In 2022/23, the IJB agreed a strategic review of the learning disabilities service, the review is set to be completed in 2023/24 and will involve a review of the full model of care including day services, commissioned services, and transport. Avoiding patient falls Significant scoping work has been undertaken by the Falls Project Team to map the current processes for falls. This has resulted in a comprehensive programme of work with short, medium, and long-term goals to implement a more preventative approach to falls in Midlothian. This work is underway and will be undertaken by a Falls Implementation Team in the next 6-9 months. Given the high personal and financial cost of falls across the health and social care system, it is anticipated this work results in a reduction in falls and a consequential reduction in demand for services and improved outcomes for people living in Midlothian. Self-Management Approach In the last year, the partnership has tested, developed, and scaled -up a variety of early intervention and self-management approaches for people living with a range of long-term conditions including: • The approach to Long-Covid which is a digital pathway that has been developed in collaboration with partners in NHS Lothian, Chest Heart and Stroke Scotland (CHSS) and POGO Healthcare. • The approach to the management of Chronic obstructive pulmonary disease (COPD) which has been tested and there has been a scale-up of a digital self-management platform in collaboration with NHS Greater Glasgow & Clyde and National Services Scotland; and • The Neurological Pathway which is an early intervention approach in collaboration with the Thistle Wellbeing Service, ArtLink, Cerebral Palsy Scotland and Queen Margaret University. It is anticipated that in 2023/24, the partnership will bring all these approaches together to scope and develop a cohesive approach to all long-term conditions involving a single digital platform embedded within a robust pathway. Hosted Services Dietetics Dietetics is a pan Lothian service hosted by Midlothian HSCP, the service provide both inpatient and community support. During the year there have been several developments: Page 48 of 302
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11 Enteral Feeding – The service explored ways to support the Royal Edinburgh Hospital (REH) wards to manage the dietetic intervention of enteral feeding. The dietetic team have worked with the nursing staff to support training in all aspects of enteral feeding to support the ongoing care of a patient. This has facilitated the right care in the right place for that patient and has meant that an acute hospital admission has been avoided. Community - Prescribing Support Dietitians have worked on the development of information videos to support patients on the use of Food First advice and appropriate use of Oral Nutritional Supplements (ONS) as part of the Dietetics Malnutrition care pathway. Care Home training has also been delivered to support delivery of nutritional care within the care home setting and on appropriate use of ONS in care homes. Inpatient Mental Health The IJB continues to support phase II of the Royal Edinburgh Hospital (REH) business case. The Royal Edinburgh Hospital is an in-patient facility for Mental Health patients in Edinburgh. NHS Lothian have been working on rebuilding this hospital and providing modern fit-for purpose accommodation and services for patients. As part of the overall IJB’s Mental Health Strategy, the IJB has been successful in reducing the in-patient bed usage at the REH and now requires fewer beds than it used previously. Set Aside Services As in previous years, there are significant pressures on the Acute Hospitals which support Midlothian patients (the Royal Infirmary of Edinburgh and the Western General Hospital). During the year, work has been undertaken to review the use of acute beds, identify the drivers influencing the system and reduce attendances at the Emergency Department. In response to the system pressures NHS Lothian’s Unscheduled Care programme board established the Same Day Emergency Care (SDEC) service, following a successful pilot, at the Western General Hospital (WGH). The service is designed to maximise the flow and throughput of patients who can be seen and treated without the need for hospital admission. Using scheduled appointment slots, the care is provided by a combination of Advanced Nurse Practitioner (ANP) and medical staff, supported by Clinical Support Workers (CSW) and admin staff. A full, detailed examination of the work of the IJB in 2022/23 will be published in August 2023 as part of the IJB’s Annual Performance Report. This will be on the IJB’s website; https://www.midlothian.gov.uk/mid-hscp/ Page 49 of 302
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12 IJB’s Financial Performance in 2022/23 For the financial year ending 31st March 2023, the IJB had a deficit of £10,355,000 as reported in the accounting statements on page 14. This position was driven by a significant use of earmarked reserves in 2022/23. This includes £9,703,000 of Covid funding being utilised to offset Covid costs during the year with the unrequired balance being reclaimed by the Scottish Government. The use of these funds is detailed in the analysis of reserves below. The IJB’s financial performance against its in year delegated budgets (excluding earmarked reserves) reported a surplus of £404,000. This is further detailed below in the section describing the IJB’s financial performance in 2022/23. Plans for Next Year and beyond Strategic Commissioning Plan 2022-2025: Year One In June 2022, The IJB published a new Strategic Commissioning Plan for 2022-25. This plan directs on how to manage the available resources and design services that contribute to people in Midlothian living longer and healthier lives. To do this we know we will need to provide more support, treatment, and care for people in their homes, communities, or a homely setting rather than in hospital and work with people as partners in their health and social care. Midlothian IJB looks to ensure services contribute to building a healthier future and continue to meet people’s needs. This will require us to design more service offers and supports that help people take action to prevent ill or worsening health while still provide care, treatment and support when required. The three areas of focus in the Strategic Commissioning Plan for 2022-25 are: • early intervention and prevention, • support and treatment, and • crisis and emergency Our Strategic Aims The Strategic Commissioning Plan for 2022-25 has 6 strategic aims 1. Increase people’s support and opportunities to stay well, prevent ill or worsening health, and plan ahead. 2. Enable more people to get support, treatment and care in community and home- based settings. 3. Increase people’s choice and control over their support and services. 4. Support more people with rehabilitation and recovery. 5. Improve our ability to promote and protect people's human rights, including social and economic rights and meet our duties under human rights law through our services and support. Page 50 of 302
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13 6. Expand our joint working, integration of services, and partnership work with primary care, third sector organisations, providers, unpaid carers, and communities to better meet people’s needs. During the first year of this plan, services have made significant progress in improving how services are planned and delivered, found opportunities to work together in new ways, and strengthened our community connections. Midlothian IJBs Annual Performance Report for 2022/23 will be available on the HSPC website in late August 2023. Directions Directions are the mechanism by which Midlothian IJB sets out the main priorities for the services delegated to the IJB, instructs to NHS Lothian and Midlothian Council on how to approach this, and allocates financial resources. Midlothian IJB has continued to actively improve how progress is measured and recognises the individual and collective contribution made by our partners to see better outcomes for people in Midlothian. A log of Directions was created in 2022/23 to ensure compliance with the Statutory Guidance on Directions from Scottish Government. The log has ensured that all issued Directions continue to be monitored and allowed for more effective reporting of progress. In 2022/23, Midlothian IJB used this log to review progress against the delivery of Directions issued from 2020 and help inform strategic planning. In 2022/23, Midlothian IJB also reviewed how to set Directions for its NHS Lothian and Midlothian Council partners to ensure grip and control around strategic planning, financial allocation, performance monitoring and review of priority actions. This work allowed the Board to reappraise the value of issuing high numbers of operational Directions and resulted in a decision to move towards a more strategic approach for 2023/24. The Planning and Performance Teams conducted a series of workshops with the Officers of the HSCP and Board Members. This process supported the development of a strategic set of Directions that reflected the Boards best hopes for the people and communities of Midlothian, and gave operational services to explore, design, and catalyse the transformation required. A new Midlothian IJB Performance Framework developed in 2022/23 and progress towards Directions continues to be reported to the IJB every six months within this. The Midlothian Performance Framework sits alongside the Midlothian HSCP Performance Framework and brings together the strategic ambitions of the organisation with operational activity captured in the Midlothian HSCP Governance and Assurance Framework. Looking forward, Midlothian IJB Directions for 2023/24 are aligned to the nine National Health and Wellbeing Outcomes and share the overarching strategic vision of the Lothian Strategic Development Framework, the Midlothian Council 5-Year Plan, and the ambitions of the Midlothian Community Planning Partnership. This integrated approach is designed achieve the greatest change in the shortest time possible to improve the outcomes that matter most to people and communities. Directions for 2023/24 were issued on 30th March to the Chief Executives of NHS Lothian and Midlothian Council. Page 51 of 302
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14 The IJB’s Financial Position: 31 March 2023 Summary For the year ending 31 March 2023, the IJB recorded a deficit of £10,355,000. The costs incurred in delivering the IJB’s functions, by Midlothian Council and NHS Lothian, were more than the income that the IJB received from NHS Lothian and Midlothian Council. Income £000’s Expenditure £000’s Variance £000’s Midlothian IJB £172,830 £183,185 (£10,355) This position should be seen in the context of: • The IJB generated a surplus in 2021/22. The surplus was the result of funding being allocated by the Scottish Government during 2021/22 for use in 2022/23. A significant proportion of this equated to the Covid funding allocation. Therefore, the deficit is a result of the IJB incurring expenditure against its earmarked reserve. • The IJB’s financial performance against its “in year” delegated budgets (excluding earmarked reserves) resulted in a surplus of £404,000 within Social Care. • The health budgets of the IJB generated an overspend of £1,480,000 and as a result non-recurring financial support was provided by NHS Lothian to ensure a balanced financial position. Reserves The movement in the IJB’s reserves and the makeup of that reserve is detailed below. Opening Movement Closing £000's £000's £000's Covid £9,703 (£9,703) £0 Other Earmarked £7,939 (£964) £6,975 General £5,870 £312 £6,182 Total £23,512 (£10,355) £13,157 In summary the balance in the IJB’s reserves on 31st March 2023 is £13,157,000. This is made up of £6,975,000 for earmarked reserves and £6,182,000 of general reserves. The IJB no longer holds any COVID reserves. The earmarked reserves are for very specific projects and the IJB will be encouraging the partners to progress these projects, however some elements will support broader work and the IJB is committed to ensuring that the earmarked funds which can be appropriately used to develop the IJB’s services are used in that way. More detail on the earmarked reserves is shared below and within the notes to the accounts. Page 52 of 302
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15 2023/24 Financial Outlook The IJB did not have a balanced budget for 2023/24 at its March and April 2023 meetings. This was due to a reduced budget offer from Partner Midlothian Council, as such the IJB voted to not accept this offer from the Council. The IJB with Midlothian Council are looking at other methods of financial support to the IJB and the IJB is considering options to mitigate the £1,333,000 budget reduction. There are clearly a significant range of financial pressures impacting on the IJB’s partners and the IJB is committed to working with the partners in so far as the Integration Scheme allows. Analysis of the Financial Statements The financial statements are all presented on a net basis. Therefore, budget and expenditure values below include both income and expenditure. Health Social Care Health Social Care Variance Note Budget Budget Expenditure Expenditure £000’s £000’s £000’s £000’s £000’s Direct Midlothian Services Community AHPS 2,234 2,101 133 Community Hospitals 6,206 6,563 (358) District Nursing 6,085 5,858 227 General Medical Services 17,276 17,512 (236) Health Visiting 2,398 2,506 (108) Mental Health 3,031 2,849 182 Other 1,384 1,167 217 1 Prescribing 19,660 20,328 (668) Resource Transfer 7,112 7,109 3 2 Older People 26,304 25,552 752 Learning Disabilities 18,229 18,984 (755) Mental Health 1,134 1,189 (55) Physical Disabilities 3,829 3,847 (18) Assessment & Care Management 3,616 3,583 33 Other 3,499 3,053 446 3 Midlothian Share of Pan Lothian Set Aside 21,495 22,586 (1,091) 4 Mental Health 2,802 3,051 (249) Learning Disabilities 1,338 1,353 (15) GP Out of Hours 1,328 1,397 (69) Rehabilitation 948 783 165 Sexual Health 759 774 (15) Psychology 1,283 1,184 99 Page 53 of 302
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16 Substance Misuse 518 497 21 Allied Health Professions 1,781 1,658 123 Oral Health 1,355 1,305 51 Other 3,826 3,717 109 Dental 6,348 6,348 0 5 Ophthalmology 1,744 1,744 0 5 Pharmacy 3,830 3,830 0 5 Sub Totals 114,738 56,612 116,218 56,208 (1,076) Nonrecurring funding support from NHS Lothian 1,480 1,480 Grand Total 116,218 56,612 116,218 56,208 404 Notes 1. Other includes £4.816m for the Social Care Fund. These are resources which the Scottish Government has directed to the IJB through NHS Lothian and are shown as health; however, these funds are then transferred to the Council and used to support the delivery of social care services. 2. Resource Transfer are funds for specific purposes which are transferred from health to social care. However, these remain part of the health budget and are reported there. 3. Other includes care for non-specific groups, substance misuse services and other management and performance costs. 4. Set Aside are the budgets for those functions delegated to the IJB which are managed by the Acute Services management teams within NHS Lothian. These services are: ▪ Accident and Emergency ▪ Cardiology ▪ Diabetes ▪ Endocrinology ▪ Gastroenterology ▪ General Medicine ▪ Geriatric Medicine ▪ Rehabilitation Medicine ▪ Respiratory Medicine ▪ Various ancillary support services for the above These services are delivered at the Royal Infirmary of Edinburgh, the Western General Hospital and St. John’s Hospital. 5. In the Health system, expenditure to support the delivery of community dentistry, community opticians and community pharmacists is termed as ‘noncash limited’ (NCL) but is clearly part of the delivery of primary care services and these functions are delegated to the IJB. However, being NCL there is no budget as such, but any expenditure incurred is supported in its entirety by the Scottish Government. The NCL values are not part of the budget setting process, there being no budget, but NHS Lothian has matched the NCL expenditure with income to cover this expenditure. Page 54 of 302
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17 The charges (shown as expenditure above) made by Midlothian Council to the IJB are the net direct costs incurred in the delivery of social care services in Midlothian. The charges from NHS Lothian are based on the health budget setting model as agreed by the IJB. That is, charges for the core services (those services specifically for and delivered by the Midlothian partnership) are based on the net direct actual costs incurred in Midlothian. However, charges for hosted and set aside services (those services which are not generally managed by the Midlothian Partnership and are delivered on a pan-Lothian basis) are based on the total actual costs for these service shared across four IJBs per the budget setting model. The IJB share of the total actual costs incurred in 2022/23 for hosted services is 10% and, generally, 10% of the Lothian element of the set aside budgets and the non-cash limited budgets. Reserves The IJB has reserves at the end of 2022/23 of £13,157,000, compared to reserves of £23,512,000 in March 2022. The movement can be described as follows: Opening Balance Movement Closing Balance £000’s £000’s £000’s Earmarked Reserves COVID-19 Funding 9,703 (9,703) 0 Local Programmes 2,274 (1,663) 611 Primary Care Investment Fund 889 (677) 212 Alcohol and Drug Strategy 619 (529) 90 Community Support Fund 312 (3) 309 Technology Enabled Care 208 124 332 Integrated Care Fund 399 7 406 Wellbeing Service 248 42 290 Action 15 140 (100) 40 Unscheduled Care 0 1,313 1,313 Mental Health Recovery & Renewal 0 242 242 Unpaid Carers PPE 0 2 2 EGIERDA Project 49 0 49 Autism Strategy 12 0 12 Interim Care 603 (145) 458 Care at Home 934 91 1,025 Multi-disciplinary Teams 302 (302) 0 Older People's Transformation Board 22 0 22 Carers Act 679 558 1,237 Equally Safe Fund 29 (14) 15 Trauma Informed Practice 50 40 90 Additional MHO Capacity 80 0 80 DBI/Penumbra Funding 90 50 140 Total Earmarked Reserves 17,642 (10,667) 6,975 General/Contingency Reserve 5,870 312 6,182 Total Reserves 23,512 (10,355) 13,157 Page 55 of 302
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18 It should be noted that of the total reserve of £13,157,000 at the end of the 2022/23 financial year, these earmarked funds should be expended in 2023/24 and will not be available to the IJB for any other purpose. Key risks, challenges, and uncertainties The three main pressures faced by Midlothian are: • The growing demand for services, both locally and in Acute sites, driven by population growth and the changing needs of the population. • the lack of available workforce; and • the challenging financial landscape. Health and Social Care will regularly update the IJB with detailed transformations plans on reshaping services to meet the needs of the population. The challenge for the IJB is to transform the delivery of its delegated functions to ensure both clinical and financial sustainability. A growing and ageing population Midlothian’s population is one of the fast growing in Scotland, this was evidenced by the population estimates released by the National Records of Scotland (NRS). The published findings projected that between 2018 and 2028, the population of Midlothian is to increase from 91,340 to 103,945. This is an increase of 13.8%, which compares to a projected increase of 1.8% for Scotland as a whole. Midlothian is projected to have the highest percentage change in population size out of the 32 council areas in Scotland. The average age of the population of Midlothian is projected to increase. The 75 and over age group is projected to see the largest percentage increase (+40.9%). As people live longer many more people will be living at home with frailty and/or dementia and/or multiple health conditions. This will pose challenges for all our health and social care services whilst also changing the face of some of the local communities. Source Information - Link to NRS. Higher rates of long-term conditions Managing long-term conditions is one of the biggest challenges facing health care services worldwide, with approximately 60% of all deaths attributable to them. There are a range of long-term conditions that impact the population of Midlothian, but a particular challenge for Midlothian is the prevalence chronic obstructive pulmonary disease (COPD). The number and prevalence of COPD has been increasing over the last decade. Midlothian ranks 10th highest out of the 31 HSCPs for COPD prevalence, has the highest prevalence rate among the Lothian HSCPs, and a higher prevalence rate than the Scotland average. Page 56 of 302
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19 Workforce pressures Both the NHS and the Local Authority are experiencing a shortage of care professionals. The pressure spans over various disciplines, including medical staff, nurses, allied health professionals, social workers, and carers. The demand for services often exceeds the available workforce, leading to increased workloads and potential strains on the system. Addressing these challenges requires a multifaceted approach, including robust workforce planning, recruitment, and retention strategies. In response, Midlothian is piloting new approaches and has held recruitment days to provide a better understanding of services and promote working in Midlothian. Acute hospitals The Acute hospitals that support the population of Midlothian (The Royal Infirmary of Edinburgh and the Western General Hospital) remain under significant demand pressures as do other social care and health services, in a financially challenging environment. The IJB will continue to support community-based alternatives that will minimise avoidable admissions and facilitate discharges to help improve system flow. The challenging financial landscape The Scottish Government, in setting its budget, highlighted that there is significant financial challenge ahead with limited resources available. The challenge impacts across the whole of the Public Sector and the IJB understands the pressures faced by NHS Lothian and Midlothian Council with increasing costs and constrained funding. The IJB must ensure its own financial sustainability, reported through the IJB’s medium term financial plan. The plan shows signification financial gaps therefore a focus will need to be put on financial recovery to ensure the sustainability of services – tough decisions, service redesign and transformation will be critical. Mitigation and management of the risks, challenges, and uncertainties Midlothian will continue to pursue innovative solutions to mitigate risk and maximise the opportunities available. Midlothian will manage this through its risk management system, it’s Directions and the Strategic Plan. As stated, the population is increasing however the Scottish Government’s distribution model of resource allocation to both Councils and the NHS does take account of changes in population. There is a lag between the distribution model changing and the movement in population, but this is not a new issue and both Midlothian Council and NHS Lothian continue to escalate this issue. The other uncertainties have been and will continue to be managed through the IJB’s Strategic Plan (and the supporting Medium Term Financial Plan) and the IJB’s Strategic Planning Group discusses and develops transformational change and new integrated models of delivery of both social and health care. Page 57 of 302
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20 Val de Souza, IJB Chair. Date: Morag Barrow, Chief Officer. Date: Claire Flanagan, Chief Finance Officer. Date: Page 58 of 302
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21 Statement of Responsibilities Responsibilities of the Integration Joint Board The Integration Joint Board is required to: • Make arrangements for the proper administration of its financial affairs and to secure that the proper officer of the board has responsibility for the administration of those affairs (section 95 of the Local Government (Scotland) Act 1973). In this authority, that officer is the chief finance officer • Manage its affairs to secure economic, efficient, and effective use of resources and safeguard its assets • Ensure the Annual Accounts are prepared in accordance with legislation (The Local Authority Accounts (Scotland) Regulations 2014), and so far, as is compatible with that legislation, in accordance with proper accounting practices (section 12 of the Local Government in Scotland Act 2003) • Approve the Annual Accounts I confirm that these Annual Accounts were approved for signature at a meeting of the Audit & Risk Committee. Signed on behalf of Midlothian Integration Joint Board. Val de Souza, IJB Chair. Date: Page 59 of 302
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22 Responsibilities of the Chief Finance Officer The chief finance officer is responsible for the preparation of the IJB’s Annual Accounts in accordance with proper practices as required by legislation and as set out in the CIPFA/LASAAC Code of Practice on Local Authority Accounting in the United Kingdom (the Accounting Code). In preparing the Annual Accounts, the chief finance officer has: - • Selected suitable accounting policies and then applied them consistently • Made judgements and estimates that were reasonable and prudent • Complied with legislation • Complied with the local authority Code (in so far as it is compatible with legislation) The chief finance officer has also: - • Kept proper accounting records which were up to date • Taken reasonable steps for the prevention and detection of fraud and other irregularities. I certify that the financial statements give a true and fair view of the financial position of the Midlothian Integration Joint Board as at 31 March 2023 and the transactions for the year then ended. Claire Flanagan, Chief Finance Officer Date: Page 60 of 302
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23 Remuneration Report Introduction This Remuneration Report is provided in accordance with the Local Authority Accounts (Scotland) Regulations 2014. It discloses information relating to the remuneration and pension benefits of specified IJB members and staff. The information in the tables below is subject to external audit. The other sections of this report will be reviewed by Audit Scotland and any apparent material inconsistencies with the audited financial statements will be considered as part of their audit report. Remuneration: IJB Chair and Vice Chair The voting members of the IJB are appointed through nomination by Midlothian Council and NHS Lothian Board. Nomination of the IJB Chair and Vice Chair post holders alternates between a Councillor and a Health Board representative. The IJB does not provide any additional remuneration to the Chair, Vice Chair or any other board members relating to their role on the IJB. The IJB does not reimburse the relevant partner organisations for any voting board member costs borne by the partner. Neither the Chair nor the Vice Chair appointments had any taxable expenses paid by the IJB in 2022/23 (PY: nil). The IJB does not have responsibilities, either in the current year or in future years, for funding any pension entitlements of voting IJB members. Therefore, no pension rights disclosures are provided for the Chair or Vice Chair. NHS Lothian remunerates its non-executive members on a notional day basis. Those non- executive members of the NHS Lothian Board who are also Chairs or Vice Chairs of IJBs are given an additional notional day’s remuneration in recognition of the additional time required to undertake those roles. This remuneration is £9,030 per annum (PY £8,842). Val de Souza took the Chair of the IJB from 01 September 2022, replacing Carolyn Hirst who was the Chair of the IJB until 31 August 2022. Remuneration: Officers of the IJB The IJB does not directly employ any staff; however specific post-holding officers are non- voting members of the Board. Chief Officer Under section 10 of the Public Bodies (Joint Working) (Scotland) Act 2014 a Chief Officer for the IJB has to be appointed and the employing partner has to formally second the officer to the IJB. The employment contract for the Chief Officer will adhere to the legislative and regulatory framework of the employing partner organisation. The remuneration terms of the Chief Officer’s employment are approved by the IJB. Page 61 of 302
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24 The Chief Officer of the IJB is Morag Barrow, who is also the Director of Health and Social Care for Midlothian Council and the Joint Director of the Midlothian Partnership. It has been agreed that 50% of her total remuneration is to be shown in the accounts of the IJB as her remuneration as the Chief Officer of the IJB. Chief Finance Officer Although the costs of the Chief Finance Officer are not included in the charges made to the IJB by either partner, given the S95 role of the Chief Finance Officer and in the interests of transparency, the remuneration of the Chief Finance Officer is included below. The Chief Finance Officer is employed by NHS Lothian and has three roles – the IJB’s Chief Finance Officer, the Chief Finance Officer of East Lothian IJB and an operational role in the NHS Lothian finance team as a Finance Business Partner. On that basis, one third of the total remuneration for Claire Flanagan is shown below. Other Officers No other staff are appointed by the IJB under a similar legal regime. Other non-voting board members who meet the criteria for disclosure are included in the disclosures below. Senior Employees: Salary, Fees & Allowances: Name 2021/22 £ 2022/23 £ Morag Barrow 53,805 52,699 Claire Flanagan (Note 1) 22,640 25,901 David King (Note 2) 14,047 1,436 Note 1: Chief Finance Officer (Claire Flanagan) returned from maternity leave in May 2022, while off her role was fulfilled on an interim basis by David King. Note 2: David King is retired but was paid on the NHS Lothian Staff bank (by NHS Lothian) on an ad hoc basis. David King also undertook the role of CFO in East Lothian IJB but did not undertake any duties as a finance business partner. NHS Lothian have provided the total costs of having employed David King during this time and half of these costs will be shown here (the other half shown in East Lothian IJB). David King is no longer an active member of the SPPA. In respect of officers’ pension benefits the statutory liability for any future contributions to be made rests with the relevant employing partner organisation. On this basis there is no pensions liability reflected on the IJB balance sheet for the Chief Officer or any other Officers. The IJB however has responsibility for funding the employer contributions for the current year in respect of the officer time spent on fulfilling the responsibilities of their role on the IJB. The following table shows the IJB’s funding during the year to support officers’ pension benefits. The tables also shows the total value of accrued pension benefits which may include benefits earned in other employment positions and from each officer’s own contributions. Page 62 of 302
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25 In year Pension Contributions: For Year to 2022 £ For year to 2023 £ Claire Flanagan £5,504 £5,873 Accrued Pension Benefits: Pension (Difference from 31 March 2022) £000’s Lump Sum (Difference from 31 March 2022) £000’s Pension (as at 31 March 2023) £000’s Lump Sum (as at 31 March 2023) £000’s Morag Barrow 21 54 9 19 Claire Flanagan 18 27 21 29 Disclosure by Pay Bands Pay band information is not separately provided as all staff pay information has been disclosed in the information above. Exit Packages The IJB did not support nor did it direct to be supported by its partners, any exit packages during 2022/23 (2021/22: nil). Val de Souza, IJB Chair. Date: Morag Barrow, Chief Officer. Date: Page 63 of 302
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26 Annual Governance Statement 2022/23 Annual Governance Statement 2022/23 Page 64 of 302
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27 Independent Auditor’s Report Independent auditor’s report to the members of Midlothian Integration Joint Board and the Accounts Commission Page 65 of 302
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28 Comprehensive Income and Expenditure Statement This statement shows the cost of providing services for the year according to accepted accounting practices. Where the impact on the General Fund is amended by statutory adjustments, this is shown in both the Expenditure and Funding Analysis and the Movement in Reserves Statement. IJB Comprehensive Income and Expenditure Statement 2021/22 Net Expenditure £000’s 2022/23 Net Expenditure £000’s Health Care Services - NHS Lothian £121,552 £122,663 Social Care Services - Midlothian Council £46,352 £60,522 Cost of Services £167,904 £183,185 Taxation and Non-Specific Grant Income (£178,423) (£172,830) Surplus on Provision of Services £10,519 (£10,355) The Integration scheme lays out that the partners will provide corporate and other support to the IJB as required and will not charge for these services. These costs are not, therefore, included above. Page 66 of 302
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29 Movement in Reserves Statement The movement in reserves statement shows the value of the IJBs reserve and how this has grown during 2022/23, a large proportion of this reserve is earmarked for future projects and commitments. Movements in Reserves during 2022/23 General Fund Balance £000’s Total Reserves £000’s Opening Balance at 1 April 2022 £23,512 £23,512 Total Comprehensive Income and Expenditure (£10,355) (£10,355) Increase or decrease in 2022/23 (£10,355) (£10,355) Closing Balance at 31 March 2023 £13,157 £13,157 Page 67 of 302
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30 Balance Sheet The Balance Sheet shows the value of the IJB’s assets and liabilities as at the balance sheet date. The net assets (assets less liabilities) of the IJB are matched by the reserves held by the IJB. IJB Balance Sheet 31 March 2022 £000’s 31 March 2023 £000’s Note Current Assets Debtors £23,512 £13,157 7 Creditors: amounts falling due within one year 0 0 8 Total assets less current liabilities £23,512 £13,157 Capital and Reserves Earmarked Reserve £17,642 £6,975 General Reserve £5,870 £6,182 Total Reserves £23,512 £13,157 See Notes 7 and 8 at end of document in Notes to the Financial Statements. Claire Flanagan, Chief Finance Officer. Date: Page 68 of 302
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31 Notes to the Financial Statements 1 Significant Accounting Policies General Principles The Financial Statements summarise the IJB’s transactions for the 2022/23 financial year and its position at the year-end of 31 March 2023. The IJB was established under the requirements of the Public Bodies (Joint Working) (Scotland) Act 2014 and is a Section 106 body as defined in the Local Government (Scotland) Act 1973. The Financial Statements are therefore prepared in compliance with the Code of Practice on Local Authority Accounting in the United Kingdom 2022/23, supported by International Financial Reporting Standards (IFRS), unless legislation or statutory guidance requires different treatment. The accounts are prepared on a going concern basis, which assumes that the IJB will continue in operational existence for the foreseeable future. The historical cost convention has been adopted. Basis of Preparation The IJB financial statements for 2022/23 have been prepared on a going concern basis. The IJB was established under the requirements of the Public Bodies (Joint Working) (Scotland) Act 2014 and is a Section 106 body as defined in the Local Government (Scotland) Act 1973. In accordance with the CIPFA Code of Local Government Accounting (2022/23), the IJB is required to prepare its financial statements on a going concern basis unless informed by the relevant national body of the intention for dissolution without transfer of services or function to another entity. The accounts are prepared on the assumption that the IJB will continue in operational existence for the foreseeable future. The IJB’s funding from and commissioning of services to partners has been confirmed for 2023/24, and a medium-term financial plan has been prepared through to 2026. The Scottish Government allocation has met all costs associated with the pandemic in 2022/23. Therefore, the IJB considers there are no material uncertainties around its going concern status. Accruals of Income and Expenditure Activity is accounted for in the year that it takes place, not simply when settlement in cash occurs. In particular: • Expenditure is recognised when goods or services are received, and their benefits are used by the IJB • Income is recognised when the IJB has a right to the income, for instance by meeting any terms and conditions required to earn the income, and receipt of the income is probable Page 69 of 302
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32 • Where income and expenditure have been recognised but settlement in cash has not taken place, a debtor or creditor is recorded in the Balance Sheet • Where debts may not be received, the balance of debtors is written down Funding The IJB is wholly funded through funding contributions from the statutory funding partners, Midlothian Council and NHS Lothian. Expenditure is incurred in the form of net charges by the partners to the IJB. Cash and Cash Equivalents The IJB does not operate a bank account or hold cash. Transactions are settled on behalf of the IJB by the funding partners. Consequently, the IJB does not present a ‘Cash and Cash Equivalent’ figure on the balance sheet. Debtors and Creditors The funding balance due to or from each funding partner as at 31 March is represented as a debtor or creditor on the IJB’s Balance Sheet. Where income and expenditure have been recognised but settlement in cash has not taken place, a debtor or creditor is recorded in the Balance Sheet. Employee Benefits The IJB does not directly employ staff. Staff are formally employed by the partners who retain the liability for pension benefits payable in the future. The IJB therefore does not present a Pensions Liability on its Balance Sheet. The IJB has a legal responsibility to appoint a Chief Officer. More details on the arrangements are provided in the Remuneration Report. Provisions, Contingent Liabilities and Contingent Assets Provisions are liabilities of uncertain timing or amount. A provision is recognised as a liability on the balance sheet when there is an obligation as at 31 March due to a past event; settlement of the obligation is probable; and a reliable estimate of the amount can be made. Recognition of a provision will result in expenditure being charged to the Comprehensive Income and Expenditure Statement and will normally be a charge to the General Fund. A contingent liability is a possible liability arising from events on or before 31 March, whose existence will only be confirmed by later events. A provision that cannot be reasonably estimated, or where settlement is not probable, is treated as a contingent liability. A contingent liability is not recognised in the IJB’s Balance Sheet but is disclosed in a note where it is material. A contingent asset is a possible asset arising from events on or before 31 March, whose existence will only be confirmed by later events. A contingent asset is not recognised in the IJB’s Balance Sheet but is disclosed in a note only if it is probable to arise and can be reliably measured. The IJB has none of the above. Page 70 of 302
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33 Reserves The IJB’s reserves are classified as either Usable or Unusable Reserves. The IJB’s only Usable Reserve is the General Fund. The balance of the General Fund as at 31 March shows the extent of resources which the IJB can use in later years to support service provision. As noted above, the IJB has reserves of £13,157,000 at 31 March 2023. The IJB’s only Unusable Reserve is the Employee Statutory Adjustment Account. This is required by legislation. IJB’s useable reserve 2022/23 Closing Balance £000’s COVID-19 Funding 0 Local Programmes 611 Primary Care Investment Fund 212 Alcohol and Drug Strategy 90 Community Support Fund 309 Technology Enabled Care 332 Integrated Care Fund 406 Wellbeing Service 290 Action 15 40 Unscheduled Care 1,313 Mental Health Recovery & Renewal 242 Unpaid Carers PPE 2 EGIERDA Project 49 Autism Strategy 12 Interim Care 458 Care at Home 1,025 Multi-disciplinary Teams 0 Older People's Transformation Board 22 Carers Act 1,237 Equally Safe Fund 15 Trauma Informed Practice 90 Additional MHO Capacity 80 DBI/Penumbra Funding 140 General Reserves 6,182 Total 13,157 Indemnity Insurance The IJB has indemnity insurance for costs relating primarily to potential claim liabilities regarding Board member and officer responsibilities. NHS Lothian and Midlothian Council have responsibility for claims in respect of the services that they are statutorily responsible for and that they provide. The IJB holds separate indemnity insurance through its membership of the CNORIS scheme, the charge for this in 2022/23 was £3,000 (PY £3,000). Page 71 of 302
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34 Unlike NHS Boards, the IJB does not have any ‘shared risk’ exposure from participation in CNORIS. The IJB participation in the CNORIS scheme is therefore analogous to normal insurance arrangements. Known claims are assessed as to the value and probability of settlement. Where it is material the overall expected value of known claims taking probability of settlement into consideration is provided for in the IJB’s Balance Sheet. The likelihood of receipt of an insurance settlement to cover any claims is separately assessed and, where material, presented as either a debtor or disclosed as a contingent asset. There are no outstanding claims or any indications that any claims are to be made against the IJB. 2 Critical Judgements and Estimation Uncertainty The critical judgements made in the Financial Statements relating to complex transactions are: • The partner organisations have considered their exposure to possible losses and made adequate provision where it is probable that an outflow of resources will be required, and the amount of the obligation can be measured reliably. Where it has not been possible to measure the obligation, or it is not probable in the partner organisations’ options that a transfer of economic benefits will be required, material contingent liabilities have been disclosed (there are none). • The Annual Accounts contains estimated figures that are based on assumptions made by the IJB about the future or that are otherwise uncertain. Estimates are made taking into account historical experience, current trends and other relevant factors. However, because balances cannot be determined with certainty, actual results could be materially different from the assumptions and estimates. • There are no items in the IJB’s Balance Sheet at 31 March 2023 for which there is a significant risk of material adjustment in the forthcoming financial year. Provisions The IJB has not created any provisions in respect of compensation claims. It is not certain that all claims have been identified or that the historic level of settlement payments is a reliable guide for future settlements. 3 Subsequent Events In accordance with the requirements of International Accounting Standards 10, events after the reporting period are considered up to the date on which the accounts are authorised for issue. This is interpreted as the date that the accounts were certified by the Chief Financial Officer following approval by the Audit and Risk Committee. Page 72 of 302
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35 Events after the Balance Sheet date are those events, both favourable and unfavourable, that occur between the end of the reporting period and the date when the Annual Accounts are authorised for issue. Two types of events can be identified. • Adjusting events: Those that provide evidence of conditions that existed at the end of the reporting period. The Annual Accounts is adjusted to reflect such events. • Non-adjusting events: Those that are indicative of conditions that arose after the reporting period and the Statements are not adjusted to reflect such events. Where a category of events would have a material effect, disclosure is made in the notes of the nature of the events and their estimated financial effect. 4 Expenditure and Funding Analysis Services specifically for Midlothian 2021/22 £000’s 2022/23 £000’s Health 75,000 72,439 Social Care 46,352 60,522 Midlothian’s share of Lothian Health Services (Hosted) 25,853 27,638 Midlothian’s share of Lothian Health Services (Set Aside) 20,698 22,586 Total 167,903 183,185 Funded by: Midlothian Council 50,598 56,612 Funded by: NHS Lothian 127,825 116,218 Total Funding 178,423 172,830 Surplus 10,519 (10,355) Expenditure above has been split into three main areas: • Expenditure on those services delivered specifically for the population of Midlothian. These services are managed locally by the Midlothian Partnership • Hosted Services – these are health services managed either by the Edinburgh, East Lothian and West Lothian Partnerships or managed by NHS Lothian on a pan-Lothian basis. These services included Mental Health Services, Learning Disability Services, Substance Misuse Services, Rehabilitation services, General Dental Services, General Pharmaceutical Services and General Ophthalmic Services. This is the IJB’s agreed share of these services • Set Aside Services – these are services delivered in the main acute hospitals (Royal Infirmary of Edinburgh, Western General Hospital and St. John’s Hospital) and managed by NHS Lothian. This is the IJB’s agreed share of these services. 5 Corporate Service Included in the above costs are the following corporate services: Page 73 of 302
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36 2021/22 £000’s 2022/23 £000’s Staff (Chief Officer) 54 53 CNORIS 3 3 Audit Fee 28 32 Total 85 88 As noted above, the Chief Finance Officer is not charged to the IJB. 6 Related Party Transactions As partners with the Integration Joint Board, both Midlothian Council and NHS Lothian are related parties and the material transactions with these bodies are disclosed in these accounts. There are elements of expenditure which are shown against the NHS Lothian above but where the resources are used by the social care services delivered by Midlothian Council. 2021/22 £000’s 2022/23 £000’s NHS Lothian 121,552 122,663 Resource Transfer (7,173) (7,109) Social Care Fund (4,816) (4,816) Net NHS Lothian Expenditure 109,563 110,738 Midlothian Council 46,352 56,612 Resource Transfer 7,173 7,109 Social Care Fund 4,816 4,816 Gross Social Care Expenditure 58,341 72,447 Both Resource Transfer and the Social Care Fund are resources which are part of the NHS Lothian budget, but these funds are used to deliver social care service supplied by Midlothian Council. 7 Short Term Debtors 2021/22 £000’s 2022/23 £000’s Funding due from NHS Lothian 11,899 5,454 Funding due from Midlothian Council 11,613 7,703 Total 23,512 13,157 8 Short Term Creditors 2021/22 £000’s 2022/23 £000’s Funding due to NHS Lothian 0 0 Funding due to Midlothian Council 0 0 Total 0 0 Page 74 of 302
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37 9 VAT The IJB is not VAT registered. The VAT treatment of expenditure in the IJB’s accounts depends on which of the Partner agencies is providing the service as these agencies are treated differently for VAT purposes. Where the Council is the provider, income and expenditure excluded any amounts related to VAT, as all VAT collected is payable to H.M. Revenue & Customs and all VAT paid is recoverable from it. The Council is not entitled to fully recover VAT paid on a very limited number of items of expenditure and for these items the cost of VAT paid is included within service expenditure to the extent that it is irrecoverable from H.M. Revenue and Customs. Where the NHS is the provider, expenditure incurred will include irrecoverable VAT as generally the NHS cannot recover VAT paid as input tax and will seek to recover its full cost as income from the Commissioning IJB. Page 75 of 302
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Midlothian Integration Joint Board Midlothian Integration Joint Board Thursday 22nd June 2023, 14:00-16:00 Financial Recovery options following reduced budget offer from Midlothian Council Executive summary On the 21st February 2023, Midlothian Council agreed a budget that led to a reduced budget offer to Midlothian IJB. As previously noted in finance reports to the IJB in February and March 2023, Local Authorities must pass over the full allocations from Scottish Government to IJBs. “The funding allocated to Integration Authorities should be additional and not substitutional to each Council’s 2022-23 recurring budgets for services delegated to IJBs and, therefore, Local Authority social care budgets for allocation to Integration Authorities must be at least £95 million greater than 2022-23 recurring budgets.” As a result, additional financial recovery plans are now required to support the extra £1.33m budget gap, over and above the core budget financial planning from officers to deliver a balanced budget for IJB for 2023/24. As Midlothian Council did not follow the Scottish Government parameters, Midlothian IJB chose to defer a decision on the budget offer, pending HSCP officers bringing back an options paper on recovery actions available. In April 2023 the IJB decided not to accept the Midlothian Council budget offer, and requested further consideration be given to options for financial recovery options. The IJB also requested that a formal letter be drafted to send on to Scottish Government, stating that the full allocation was not passed over to the IJB. This was actioned in May 2023 with a letter from the Chair of the IJB being sent to Cabinet Secretary for Health and Social Care, which was shared with voting members of the IJB prior to sending, and subsequently with the wider Board as requested. A response to this letter is contained within the Appendix to this report. The Chief Financial Officer for the IJB also formally advised Midlothian Council of the IJB decision not to accept the budget offer. This paper details options available for discussion, and decision, to advise Officers which actions should be taken forward. Item number: 5.4 Page 77 of 302
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Midlothian Integration Joint Board Members are asked to: • Note the financial gap incurred by a reduced budget offer from Midlothian Council • Agree which recovery actions should be progressed by Officers to support the subsequent funding gap. The Board should note that failure to make a decision will have a further detrimental impact on the IJB financial position, as already full year effect savings will not be realised. Page 78 of 302
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Midlothian Integration Joint Board Midlothian Integration Joint Board Additional Financial Recovery options following reduced budget offer from Midlothian Council 1 Purpose 1.1 The purpose of this paper is to present additional financial recovery actions required to support a reduced budget offer to the IJB from Midlothian Council. This equates to £1.33m. 2 Recommendations As a result of this report, Members are asked to: • Note the financial gap incurred by a reduced budget offer from Midlothian Council • Agree which recovery actions should be progressed by officers to support the subsequent funding gap, noting the preferred recurring Recovery Actions 1b and 2, with a minimum of £100k being utilised from IJB General Reserves, supported by non-recurring Recovery Action 5, being the recommended actions. (Please note that Recovery Action 5 requires full Council sign off on 27th June) 3 Background and main report 3.1 Midlothian Council agreed their budget at Council on the 21st February 2023 following which a formal budget offer letter was issued to the IJB. 3.2 This position is the formal offer from Midlothian Council for 2023/24 and it should be noted is not in line with the parameters set by Scottish Government. As reported to the IJB at its February meeting these parameters were: “The funding allocated to Integration Authorities should be additional and not substitutional to each Council’s 2022-23 recurring budgets for services delegated to IJBs and, therefore, Local Authority social care budgets for allocation to Integration Authorities must be at least £95 million greater than 2022-23 recurring budgets.” Page 79 of 302
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Midlothian Integration Joint Board £m 2022/23 56.438 In year changes through distributional changes 0.155 Base 23/24 allocation 56.593 Scottish Government Funding Changes: Living wage uplift 1.436 Free personal & nursing care 0.202 End of NR interim care funding -0.305 Total 57.926 Less -1.333 2023/24 MIJB allocation 56.593 Fig 1: Midlothian Council budget offer to the IJB 3.2 Officers have now reviewed further options to support a break-even position. Details of these are noted below. Options have been developed to minimise impact on care and/or workforce and have been assessed against a matrix to support decision making. This is contained within the appendix of this report. All have Equality Impact assessments completed which can be accessed via the appendices attached to this report. • Recovery Action 1a Fully withdraw from Extra Care Housing development The HSCP Extra Care Housing (ECH) Draft Action Plan 2019-2022 highlighted the benefits and extra care housing agenda prior to Covid. It is noted that the further expansion of Extra Care Housing was approved as formal Midlothian policy at a meeting of the full Council in November 2016 when it agreed to include additional extra care housing in Phase 3 of the housing programme. The Normandy Court ECH Development is currently part of Midlothian Council’s Local Housing Strategy 2021- 2026 and relevant to IJB Directions 8.12 and 8.13, which call for increased intermediate care provision and a reshaped model of care through provision of new purpose-build accommodation. The site consists of 40 x 1-bedroom flats within ECH complex, and 8 ECH bungalows (one is adapted for bariatric use). The anticipated handover date to the Council is June 2023. No additional funding was received from Midlothian Council for the additional care provision, and initial budget plans had been around re-alignment of Care at Home contract funding. Due to the reduction in budget offer, it is no longer financially viable for Midlothian HSCP to deliver this development. The cost of delivering this service was £647k. If this recovery action were not to be chosen, it would place significant financial pressure on the budget in 2023/24. As Page 80 of 302
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Midlothian Integration Joint Board this is a new and additional service, there would be no workforce implications, or material change in care provision to Midlothian residents. • Recovery Action 1b Support Midlothian Council to allocate ECH properties to Older people on Housing waiting list, with care provision from existing care infrastructure. Following the April IJB meeting, discussion has taken place with Midlothian Council to ascertain opportunity to allocate the adapted ECH properties to older people currently awaiting rehousing. A significant amount of these people will currently be receiving care from current care model, but in a geographically diverse map across the county. Care would be “re-mapped” to provide more efficient service delivery with an identified team of carers supporting this new complex. As further service transformation takes place to review all “bed” provision in Midlothian, extra care could be “switched on” moving the model to the full extra care model of care when finance is available. This would allow a current recurring saving of £647k, as no additionality/new services would be put in place now but would allow the opportunity to add at a future point in time. This would ensure that the IJB and Midlothian Council continue to support our growing older population, with the provision of additional adapted housing options. • Recovery Action 2 Transition to a Care at Home model with only 30% care delivered from internal Care at Home team, moving to 70% via External providers. Currently the Midlothian HSCP Care at home service operates 3 Externally provided block contracts for care across Midlothian, delivering 62% of current care at home service provision. The remaining 38% is provided by an internal HSCP Care at Home service. Transitioning to a 70% external service provision, will provide a more cost-effective model, supporting a saving of £200k once fully implemented. This relates to a more efficient cost per hour relating to terms and conditions. This is also full year effect, so would not be fully realised in 2023/24. It is anticipated that the move to a 70%/30% model can be achieved through minimal workforce disruption. This would be delivered though natural turnover, and a reduced spend in locum and overtime use. Should this be sustainable, the IJB could consider a move in 2024/25 to 75% external care provision, yielding a saving of circa £600k (£400k additional for that year), and a further move in 2025/26 to 80% external care delivery yielding circa £900k (£500k additional for that year). This would provide some options for the IJB to consider for financial planning beyond this year. There is a risk that local providers may not be able to provide additional care hours given the national workforce challenges across social care. With this noted, the maintenance of a percentage of internal service allows the HSCP to safeguard around statutory responsibility to provide care if any of the external providers are unable to deliver on contracts. It should be re-emphasised that a full year effect would not be realised in 2023/24, due to the planning and contracting processes that will be required, and consideration should be given to supporting this utilising IJB General Reserves of a minimum of £100k. Page 81 of 302
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Midlothian Integration Joint Board • Recovery Action 3 Raise all social care Eligibility criteria to critical only The provision of social care support is governed by Eligibility Criteria in line with the 2009 National Guidelines. The eligibility criteria are graded into four bands which describe the seriousness of risk to independence or the consequences if needs are not addressed. The bands are, Critical, Substantial, Moderate and Low. Currently care packages are provided to meet Critical and Substantial criteria, but consideration could be given to meeting critical care needs only. Further detailed work would be required to fully quantity the consequential reduction in expenditure however initial analysis indicates this could be in the region of £1.5m. There would need to be programme of work including public consultation to progress changes to eligibility criteria. It needs to be noted that changing eligibility criteria may mean a reduction in the support for many people we support. For some individuals it will mean a reduction in support that has been provided for significant periods of time. Without prejudging the outcome of detailed analysis, it is anticipated that changing to critical only care provisions will likely mean: • Higher thresholds for funding for care home placements • Individuals will not be receiving care at home support unless they are at significant (critical) risk without this support • A reduction in the annual amounts of respite care being provided • Reduced day service provision for people with Learning Disabilities • Less time being provided to housing support people with housing support for people who need assistance to manage housing and finances There are two key risks associated with changing eligibility criteria. Firstly, there is likely to be strong reputational risk to the HSCP and a resistance to any reduction to current packages care. Secondary there is a risk the by not providing support in relation to substantial risks situations can deteriorate to the extent that risks become critical and additional expenditure is required in the long run to mitigate these risks. Midlothian HSCP charges for care in line with COSLA guidance and therefore care charges (except telecare and transport) are financially assessed. The financial assessment is tied to benefit income and is updated annually to take into consideration changes in benefits. As a result of welfare benefits increasing by 10.1% it is anticipated that there will be a corresponding increase in charging income resulting in additional income of approx. £104k. Consideration can also be given to increasing charging rates (excluding telecare) which would increase income by a further £20k to £30k but further work is required on this to determine the efficacy. • Recovery Action 4 Use of IJB General Reserves The IJB does hold a general reserve and has an approved reserves policy in place, this has the minimum level of general reserves held set at 2% of net expenditure (circa Page 82 of 302
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Midlothian Integration Joint Board £3.7m). The IJBs general reserves position for 2022/23 closed at £6.1m, subject to external audit. There is scope to utilise the general reserve to balance the budget during 2023/24 but this should be on the understanding of the reserve being non-recurring in nature and the significant financial challenges facing the IJB over the next 5 years as shared in the IJBs medium term financial plan. • Recovery Action 5 Request Analogue to Digital telecare support from Midlothian Council Capital Planning Board to purchase technology as a non-recurring cost/benefit By 2025 the UK telephony network will complete a transformation to a fully digital network, many telephony service providers expect to complete by a stretch target of 2023. This deadline has been communicated widely. Scotland’s telecare providers community has been aware of it for several years and has been working to understand the implications and consequences. Since 2017 the Local Digital Government Office (LDGO) has led a national programme of work to ensure a smooth, safe transition to digital services is achieved and support a Once for Scotland approach. There is no national funding for this transition, and it is estimated to cost Midlothian HSCP £1m on a non-recurring basis. Actual costs won’t be known until purchasing begins. Midlothian HSCP were looking to request to utilise the IJBs general reserve for this purchase given its one-off nature. From discussion at the March IJB meeting it was recommended that the paper for this transition be taken to the Council capital planning committee, to be considered for non- recurring support this year. This was supported and will be presented at Midlothian Council meeting for agreement on 27th June. This would provide the IJB with one off financial support for 2023/24 to allow time for any other financial recovery actions to be implemented. 3.3 Transformation The HSCP is committed to transformation to support larger and longer-term change. It should be noted that working already underway in the following areas which will realise future efficiencies though new models of care. This will be largely multi-agency change and will be delivered with partners. These include; • Falls • Frailty • Self-management • Carers co-operative/Carers support 3.4 Recommended Recovery actions It is recommended that Recovery Actions 1b and 2 are progressed, with non-recurring support from Midlothian Council capital funding for Recovery action 5. Use of a minimum of £100k from General reserves should be considered to support non-realisation of full year effect for Option 2, as well as any financial gap at end of the financial year. Page 83 of 302
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Midlothian Integration Joint Board These options are recommended to minimise impact on the people of Midlothian, and adverse impact on staff, supporting the longer-term planning and transformation required both locally, and in the context of the challenges for the wider health and social care system. 4 Policy Implications 4.1 The reduced budget offer from Midlothian Council will impact on delivery of the IJB Strategic Plan 2022-25 and the IJB Mainstreaming Equalities Report and Action Plan 2021-25. 5 Directions 5.1 The reduced budget offer from Midlothian Council will directly impact on the HSCPs ability to successfully operationalise a number of Directions 2023-24. Generalised financial pressure will not necessarily mean a Direction cannot be delivered but will significantly limit progress. In this case, there is a high potential for operational risk to become strategic risk and threaten the IJBs ability to achieve its own strategic aims. 5.2 Each of the six strategic aims of the IJB are: • Increase people’s support and opportunities to stay well, prevent ill or worsening health, and plan ahead. • Enable more people to get support, treatment and care in community and home-based settings • Increase people’s choice and control over their support and services • Support more people with rehabilitation and recovery • Improve our ability to promote and protect people's human rights, including social and economic rights and meet our duties under human rights law through our services and support • Expand our joint working, integration of services, and partnership work with primary care, third sector organisations, providers, unpaid carers, and communities to better meet people’s needs 5.3 The options described above have the potential to create challenge in relation to ensuring fair access to services (Direction 2.1), improve personal outcomes (4.2), support the equitable provision of service offers and support across our communities, minimise disadvantage where possible, meet different needs, and encourage participation (5.1), and our ability to deliver on the HSCP Workforce Plan (8.1; 8.2). Any reduction in statuary service provision will increase the burden on unpaid carers and the impact will be significant (6.1; 6.2) 6 Equalities Implications 6.1 Equality Impact Assessments have been completed and are within the Appendices of this paper. Page 84 of 302
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Midlothian Integration Joint Board 6.2 The IJBs ambitions to improve equality and to reduce disadvantage will be more difficult to realise, and particularly in relation to group of people with protected characteristics. 6.3 Should the Board agree with Officers’ recommendations for Recovery Actions 1b and 2 to be implemented, with recovery action 5 being supported by Midlothian Council on a non-recurring basis from their capital budget, and the utilisation of General Reserves, this would minimise impact. 7 Resource Implications 7.1 Should the Board decide not to progress with any recovery actions recommended, there will be budget pressure likely to replicate the reduced offer. 8 Risk 8.1 There is significant additional financial risk related to reduced budget offer. It is recommended to the Board that risk can be supported by a clear decision to progress on the suggested recovery actions, with a decision made at the Board meeting. 9 Involving people 9.1 The Board and included Trade Union representatives have been fully briefed on the position. Three briefing sessions have been facilitated by officers. No further consultation has taken place at present until a decision and direction of travel is agreed. 10 Background Papers 1. 2023 04 13 Board Paper: Financial Recovery options following reduced budget offer from Midlothian Council 2. 2023 04 13 Board Paper: Finance Update – Budget Offers from Partners for 2023/24 Please note these papers are contained in the appendices below for your reference. AUTHOR’S NAME Morag Barrow DESIGNATION Chief Officer CONTACT INFO Morag.barrow@nhslothian.scot.nhs.uk DATE 8th June 2023 Appendices 1. EQIA Extra Care Housing (ECH): Recovery Action 1/1b 2. EQIA Care at Home: Recovery Recovery Action 2 3. EQIA Adult Social Care Recovery Action 3 4. EQIA Allied Health Professions and Digital Programme 5. Response letter from Michael Matheson Page 85 of 302
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Midlothian Integration Joint Board Appendix 1: EQIA Extra Care Housing Recovery Action 1/1b Midlothian Health and Social Care Equality Impact Assessment (EqIA) of Recovery Actions Recovery Action Extra Care Housing (ECH): Recovery Action 1/1b Group Service Primary Care and Older Adults Service Area Older Adults Lead Officer Melissa Goodbourn Completion Date 08.06.23 Aims and Objectives • Not expanding the ECH Model (Normandy Court) • MLC to provide Housing to Older people on waiting list and provide care business as usual. 1. Does the proposed recovery action affect people? Yes No 2. What is/are the reason(s) for your proposed recovery action? • There was no additional funding attached to ECH. The initial budget plans had been a re-alignment of Care at Home block funding and possible use of Physical Disability funding. This is no longer possible due to the financial position. A reduced budget from Midlothian Council requires financial planning in place to mitigate the subsequent budget gap. 3. Impact Which of the protected characteristics* will the proposed recovery action have an impact upon? Page 86 of 302
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Midlothian Integration Joint Board Equality Target Group* Positive Impact Negative Impact Relevant evidence/ information Age Housing is still available but without extra care package Care package will need to be sourced through traditional models which could exclude certain individuals from accessing these housing opportunities. Potential reduction in choice and control over living situation. Potential impact on individuals’ mental and physical wellbeing. In terms of overall size, the 45 to 64 age group was the largest in 2021, with a population of 25,243. In contrast, the 75 and over age group was the smallest, with a population of 7,740. Between 2018 and 2028, each age group increased in size. The 75 and over age group is projected to see the largest percentage increase (+40.9%). In terms of size, however, 25 to 44 is projected to become the largest age group. [Reference: National Records of Scotland Midlothian Council Area Profile (nrscotland.gov.uk)] Disability Housing is still available but without extra care package. Care provided under current care model. Care package will need to be sourced through traditional models which could exclude certain individuals from accessing these housing opportunities. Potential reduction in choice and control over living situation. Potential increase in pressure on other services Potential impact on individuals’ mental and physical wellbeing. In the 2011 census, the National Records of Scotland report that in Midlothian 6.9% people identified themselves as living with a physical disability that had lasted or was expected to last at least 12 months. This was close to the Scottish average of 6.7%. In Midlothian in 2023, records show that 3,179 adults (18 and over) known to the Adults and Social Care team have physical disability recorded as their primary care group, 5,681 people have a blue badge and 1,200 people are recorded as wheelchair users. [Reference: Midlothian Council Internal Data: Mosaic, accessed Feb 2023] 785 adults with a Learning Disability are known to Social Care service in Midlothian. [Reference: Midlothian Council Internal Data: Mosaic, accessed Feb 2023] Midlothian has a higher prevalence rate of adults with a Learning Disability known to Social Care (6.3 per 1,000) in comparison to the Scottish average (Scottish Page 87 of 302
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Midlothian Integration Joint Board Commission for Learning Disability, 2019). In Midlothian, 66.4% of adults with learning disabilities live in mainstream accommodation without support (Scottish Commission for Learning Disability, 2019). This is slightly greater than in the whole of Scotland where it was 61.8% in 2019. Gender Reassignment No disproportionate affect identified. No disproportionate affect identified. We do not have reliable local figures for Trans and other gender identities. Scotland’s Census 2022 will include a voluntary question asking whether individuals consider themselves to be trans or have a trans history. [Reference: Stage 2: Data and evidence gathering, involvement and consultation - Gender Recognition Reform (Scotland) Bill: equality impact assessment - gov.scot (www.gov.scot)] Marriage & Civil Partnership No disproportionate affect identified. Care package will need to be sourced through traditional models which could exclude certain individuals and/or partners/families from accessing these housing opportunities. (No overnight care needs met) Marriages have declined in Midlothian, from 701 in 2005 to 319 in 2021. Civil Partnerships have also declined since introduced in 2005, averaging 5 per year from 2006-2014 and recording 5 in total from 2015-2021. [Reference: Marriages and Civil Partnership - Time Series Data | National Records of Scotland (nrscotland.gov.uk)] Pregnancy and maternity No disproportionate affect identified. No disproportionate affect identified. In 2021, there were 1,071 births in Midlothian. This is an increase of 9.4% from 979 births in 2020. In Midlothian, the standardised birth rate increased from 10.8 per 1,000 population in 2020 to 11.7 in 2021. In comparison, the rate in Scotland overall increased from 8.6 to 8.7. In 2021, Midlothian was the council area with the highest standardised birth rate. [Reference: National Records Scotland Midlothian Council Area Page 88 of 302
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Midlothian Integration Joint Board Profile (nrscotland.gov.uk)] Race No disproportionate affect identified. No disproportionate affect identified. The 2011 census provides the most recent data, 1.8% of the Midlothian population belonged to a Minority Ethnic Community. This compared with 4% of the Scottish population. [Reference: 2011 Census National Records of Scotland] Religion or Belief No disproportionate affect identified. No disproportionate affect identified. In 2011 in Midlothian the most common religion was Church of Scotland (33.7%), followed by Roman Catholic (9.8%), other Christian (4%), Muslim (0.6%), other religion (0.5%). 45.2% of people reported no religion and 6.2% didn’t state their religion. [Reference: 2011 Census National Records of Scotland] Sex No disproportionate affect identified. No disproportionate affect identified. In 2021, more females than males lived in Midlothian in 4 out of 6 age groups, from 25 years to 75 years and over. [Reference: National Records Scotland Midlothian Council Area Profile (nrscotland.gov.uk)] Sexual Orientation No disproportionate affect identified. No disproportionate affect identified. We do not have reliable local figures for sexual orientation. Scotland’s Census 2022 will include a voluntary question. Socio-economic Deprivation No disproportionate affect identified. Potential reduction in job and business opportunities locally In 2020, Midlothian had 8.7% share of 20% most deprived data zones. [Reference: Scottish Government, 2023] Whilst all areas in the most deprived 20% were around Dalkeith, Mayfield, Easthouses and Gorebridge, areas in the most deprived 20-30% were spread more widely including Thornybank, Penicuik and Newtongrange. [Reference: Joint Needs Assessment, 2019] Page 89 of 302
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Midlothian Integration Joint Board 4. How will the implementation of the proposed recovery action be communicated to those affected by any changes? Nobody currently allocated accommodation in ECH. Communication with potential residents as required dependant on model agreed. Information published by Midlothian Council can be provided on request in many languages and in large print, Braille, audio tape or BSL. For more information, please contact the Equality, Diversity & Human Rights Officer on 0131 271 3658 or email equalities@midlothian.gov.uk 5. H5. How will you monitor the impact of the changes proposed? When is the budget due to be reviewed? Continue consultation and involvement of potential residents, families, carers and other partners as an ongoing process throughout the proposed change. Continue to monitor impact on equalities groups in relation to procuring and staffing the proposed service through existing policy and procedure. The budget is monitored routinely throughout the year. 6. 6. Please use the space below to detail any other matters arising from the Equality Impact Assessment (EqIA) process. Ensure that residents already accessing ECH and were scheduled to move to Normandy Court are risked assessed appropriately. Page 90 of 302
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Midlothian Integration Joint Board Appendix 2: EQIA Care at Home Recovery Action 2 Midlothian Health and Social Care Equality Impact Assessment (EqIA) of Recovery Actions Recovery Action Care at Home: Recovery Action 2 Group Service Primary Care and Older Adults Service Area Care at Home Lead Officer Melissa Goodbourn Completion Date 08.06.23 Aims and Objectives • Proposal to move to a 70/30 Care at Home model. • Currently 62% of Care at Home services are delivered externally by 3 providers on a block contract format. • Maintaining an internal provision allows us to safeguard around our statutory responsibility to provide care if any of the external providers collapsed. • The transition could be undertaken in a phased approach: e.g., move to 70/30 and then review the model in 12 months. 1. Does the proposed recovery action affect people? Yes No 2. What is/are the reason(s) for your proposed recovery action? • An increase in the external provision would provide a financial saving to the IJB to support a reduced budget for 2023/24 from Midlothian Council. 3. Impact Which of the protected characteristics* will the proposed recovery action have an impact upon? Equality Target Group* Positive Impact Negative Impact Relevant evidence/ information Page 91 of 302
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Midlothian Integration Joint Board Age No disproportionate affect currently identified as care should remain the same as long as external providers can sustain the additional hours. No disproportionate affect currently identified as care should remain the same as long as external providers can sustain the additional hours. In terms of overall size, the 45 to 64 age group was the largest in 2021, with a population of 25,243. In contrast, the 75 and over age group was the smallest, with a population of 7,740. Between 2018 and 2028, each age group increased in size. The 75 and over age group is projected to see the largest percentage increase (+40.9%). In terms of size, however, 25 to 44 is projected to become the largest age group. [Reference: National Records of Scotland Midlothian Council Area Profile (nrscotland.gov.uk)] Disability No disproportionate affect currently identified as care should remain the same as long as external providers can sustain the additional hours. No disproportionate affect currently identified as care should remain the same as long as external providers can sustain the additional hours. In the 2011 census, the National Records of Scotland report that in Midlothian 6.9% people identified themselves as living with a physical disability that had lasted or was expected to last at least 12 months. This was close to the Scottish average of 6.7%. In Midlothian in 2023, records show that 3,179 adults (18 and over) known to the Adults and Social Care team have physical disability recorded as their primary care group, 5,681 people have a blue badge and 1,200 people are recorded as wheelchair users. [Reference: Midlothian Council Internal Data: Mosaic, accessed Feb 2023] 785 adults with a Learning Disability are known to Social Care service in Midlothian. [Reference: Midlothian Council Internal Data: Mosaic, accessed Feb 2023] Midlothian has a higher prevalence rate of adults with a Learning Disability known to Social Care (6.3 Page 92 of 302
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Midlothian Integration Joint Board per 1,000) in comparison to the Scottish average (Scottish Commission for Learning Disability, 2019). In Midlothian, 66.4% of adults with learning disabilities live in mainstream accommodation without support (Scottish Commission for Learning Disability, 2019). This is slightly greater than in the whole of Scotland where it was 61.8% in 2019. Gender Reassignment No disproportionate affect identified. No disproportionate affect identified. We do not have reliable local figures for Trans and other gender identities. Scotland’s Census 2022 will include a voluntary question asking whether individuals consider themselves to be trans or have a trans history. [Reference: Stage 2: Data and evidence gathering, involvement and consultation - Gender Recognition Reform (Scotland) Bill: equality impact assessment - gov.scot (www.gov.scot)] Marriage & Civil Partnership No disproportionate affect identified. No disproportionate affect identified. Marriages have declined in Midlothian, from 701 in 2005 to 319 in 2021. Civil Partnerships have also declined since introduced in 2005, averaging 5 per year from 2006-2014 and recording 5 in total from 2015-2021. [Reference: Marriages and Civil Partnership - Time Series Data | National Records of Scotland (nrscotland.gov.uk)] Pregnancy and maternity No disproportionate affect identified. No disproportionate affect identified. In 2021, there were 1,071 births in Midlothian. This is an increase of 9.4% from 979 births in 2020. In Midlothian, the standardised birth rate increased from 10.8 per 1,000 population in 2020 to 11.7 in 2021. In comparison, the rate in Scotland overall increased from 8.6 to 8.7. In 2021, Midlothian was the Page 93 of 302
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Midlothian Integration Joint Board council area with the highest standardised birth rate. [Reference: National Records Scotland Midlothian Council Area Profile (nrscotland.gov.uk)] Race No disproportionate affect identified. No disproportionate affect identified. The 2011 census provides the most recent data, 1.8% of the Midlothian population belonged to a Minority Ethnic Community. This compared with 4% of the Scottish population. [Reference: 2011 Census National Records of Scotland] Religion or Belief No disproportionate affect identified. No disproportionate affect identified. In 2011 in Midlothian the most common religion was Church of Scotland (33.7%), followed by Roman Catholic (9.8%), other Christian (4%), Muslim (0.6%), other religion (0.5%). 45.2% of people reported no religion and 6.2% didn’t state their religion. [Reference: 2011 Census National Records of Scotland] Sex No disproportionate affect identified. No disproportionate affect identified. In 2021, more females than males lived in Midlothian in 4 out of 6 age groups, from 25 years to 75 years and over. [Reference: National Records Scotland Midlothian Council Area Profile (nrscotland.gov.uk)] Sexual Orientation No disproportionate affect identified. No disproportionate affect identified. We do not have reliable local figures for sexual orientation. Scotland’s Census 2022 will include a voluntary question. Socio-economic Deprivation Extra provision for external providers can increase job opportunities on a limited market. Each provider is a living wage employer. Transition period means that job loss is limited to Changes in provision externally can cause changes in market economy for care at home which could impact on staff shifting/changing jobs which could affect the sustainability of the care provision. In 2020, Midlothian had 8.7% share of 20% most deprived data zones. [Reference: Scottish Government, 2023] Whilst all areas in the most deprived 20% were around Dalkeith, Mayfield, Easthouses and Gorebridge, areas in the Page 94 of 302
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Midlothian Integration Joint Board 4. How will the implementation of the proposed recovery action be communicated to those affected by any changes? Clients who are directly affected will be written to in advance of any changes in provider being applied to inform them. Information published by Midlothian Council can be provided on request in many languages and in large print, Braille, audio tape or BSL. For more information, please contact the Equality, Diversity & Human Rights Officer on 0131 271 3658 or email equalities@midlothian.gov.uk 5. How will you monitor the impact of the changes proposed? When is the budget due to be reviewed? The budget is monitored routinely throughout the year. The transition could be undertaken in a phased approach: e.g., move to 70/30 and then review the model in 12 months. Following the review, a decision could be made on further splits (e.g., 75/25 or 80/20) to examine which would be the most appropriate model. 6. Please use the space below to detail any other matters arising from the Equality Impact Assessment (EqIA) process. Continue consultation and involvement of potential residents, families, carers and other partners as an ongoing process throughout the proposed change and further review of the Care at Home Service. Continue to monitor impact on equalities groups in relation to procuring and staffing the proposed service through existing policy and procedure. Continue to monitor external provider sustainability through the multi-agency care and home group. vacant posts only. most deprived 20-30% were spread more widely including Thornybank, Penicuik and Newtongrange. [Reference: Joint Needs Assessment, 2019] Page 95 of 302
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Midlothian Integration Joint Board Appendix 3: EQIA Adult Social Care Recovery Action 3 Midlothian Health and Social Care Equality Impact Assessment (EqIA) of Recovery Actions Recovery Action Review of Eligibility Criteria: Recovery Action 3 Group Service Adult Social Care Service Area Learning Disability, Physical Disability / Long Term Conditions, Mental Health, Older People, Substance Use Lead Officer Nick Clater Completion Date 17/5/23 Aims and Objectives Review of Eligibility Criteria to consider: • Provision of support to only meet critical risk (currently substantial and critical) • More prescriptive guidance on application of Eligibility Criteria 1. Does the proposed recovery action affect people? Yes x No 2. What is/are the reason(s) for your proposed recovery action? Financial constraints as a result of a reduced budget allocation to IJB from Midlothian Council, has resulted in Midlothian HSCP is progressing work to review the eligibility criteria that must be met for the provision of support and the need for more prescriptive guidance on the application of Eligibility Criteria. The likely outcome, necessary for a balanced budget is a reduction in the overall amount of social care support provided to population within Midlothian. This will affect individuals with care needs that meet substantial risks that may no longer be eligible for social care 3. Impact Which of the protected characteristics* will the proposed recovery action have an impact upon? Equality Target Group* Positive Impact Negative Impact Relevant evidence/ information Page 96 of 302
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Midlothian Integration Joint Board Age Older people are more likely that the general population to require social care support and therefore changes in eligibility criteria will impact this group. In terms of overall size, the 45 to 64 age group was the largest in 2021, with a population of 25,243. In contrast, the 75 and over age group was the smallest, with a population of 7,740. Between 2018 and 2028, each age group increased in size. The 75 and over age group is projected to see the largest percentage increase (+40.9%). In terms of size, however, 25 to 44 is projected to become the largest age group. [Reference: National Records of Scotland Midlothian Council Area Profile (nrscotland.gov.uk)] Disability People with Disabilities are more likely that the general population to require social care support and therefore changes in eligibility criteria will impact this group. In the 2011 census, the National Records of Scotland report that in Midlothian 6.9% people identified themselves as living with a physical disability that had lasted or was expected to last at least 12 months. This was close to the Scottish average of 6.7%. In Midlothian in 2023, records show that 3,179 adults (18 and over) known to the Adults and Social Care team have physical disability recorded as their primary care group, 5,681 people have a blue badge and 1,200 people are recorded as wheelchair users. [Reference: Midlothian Council Internal Data: Mosaic, accessed Feb 2023] 785 adults with a Learning Disability are known to Social Care service in Midlothian. [Reference: Midlothian Council Internal Data: Mosaic, accessed Feb 2023] Midlothian has a higher prevalence rate of adults with a Learning Disability known to Social Care (6.3 Page 97 of 302
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Midlothian Integration Joint Board per 1,000) in comparison to the Scottish average (Scottish Commission for Learning Disability, 2019). In Midlothian, 66.4% of adults with learning disabilities live in mainstream accommodation without support (Scottish Commission for Learning Disability, 2019). This is slightly greater than in the whole of Scotland where it was 61.8% in 2019. Gender Reassignment Changes to eligibility criteria will not have a disproportionate impact individuals (relative to the whole population) on the basis of Gender Reassignment. We do not have reliable local figures for Trans and other gender identities. Scotland’s Census 2022 will include a voluntary question asking whether individuals consider themselves to be trans or have a trans history. [Reference: Stage 2: Data and evidence gathering, involvement and consultation - Gender Recognition Reform (Scotland) Bill: equality impact assessment - gov.scot (www.gov.scot)] Marriage & Civil Partnership Changes to eligibility criteria will not have a disproportionate impact individuals (relative to the whole population) on the basis of Marriage & Civil Partnership. Marriages have declined in Midlothian, from 701 in 2005 to 319 in 2021. Civil Partnerships have also declined since introduced in 2005, averaging 5 per year from 2006-2014 and recording 5 in total from 2015-2021. [Reference: Marriages and Civil Partnership - Time Series Data | National Records of Scotland (nrscotland.gov.uk)] Pregnancy and maternity Changes to eligibility criteria will not have a disproportionate impact individuals (relative to the whole population) on the basis of pregnancy and maternity. In 2021, there were 1,071 births in Midlothian. This is an increase of 9.4% from 979 births in 2020. In Midlothian, the standardised birth rate increased from 10.8 per 1,000 population in 2020 to 11.7 in 2021. In comparison, the rate in Scotland overall increased from 8.6 to 8.7. In 2021, Midlothian was the Page 98 of 302
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Midlothian Integration Joint Board council area with the highest standardised birth rate. [Reference: National Records Scotland Midlothian Council Area Profile (nrscotland.gov.uk)] Race Changes to eligibility criteria will not have a disproportionate impact individuals (relative to the whole population) on the basis of race. The 2011 census provides the most recent data, 1.8% of the Midlothian population belonged to a Minority Ethnic Community. This compared with 4% of the Scottish population. [Reference: 2011 Census National Records of Scotland] Religion or Belief Changes to eligibility criteria will not have a disproportionate impact individuals (relative to the whole population) on the basis of religion or belief. In 2011 in Midlothian the most common religion was Church of Scotland (33.7%), followed by Roman Catholic (9.8%), other Christian (4%), Muslim (0.6%), other religion (0.5%). 45.2% of people reported no religion and 6.2% didn’t state their religion. [Reference: 2011 Census National Records of Scotland] Sex Changes to eligibility criteria will not have a disproportionate impact individuals (relative to the whole population) on the basis of sex. In 2021, more females than males lived in Midlothian in 4 out of 6 age groups, from 25 years to 75 years and over. [Reference: National Records Scotland Midlothian Council Area Profile (nrscotland.gov.uk)] Sexual Orientation Changes to eligibility criteria will not have a disproportionate impact individuals (relative to the whole population) on the basis of sexual exploitation. We do not have reliable local figures for sexual orientation. Scotland’s Census 2022 will include a voluntary question. Socio-economic Deprivation People affected by social economic deprivation are more likely that the general population to receive social care support and therefore changes in eligibility criteria will impact this group. In 2020, Midlothian had 8.7% share of 20% most deprived data zones. [Reference: Scottish Government, 2023] Whilst all areas in the most deprived 20% were around Dalkeith, Mayfield, Easthouses and Page 99 of 302
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Midlothian Integration Joint Board 4. How will the implementation of the proposed recovery action be communicated to those affected by any changes? A detailed communication plan will be developed relating to any changes to eligibility criteria. 5. How will you monitor the impact of the changes proposed? When is the budget due to be reviewed? A review process will be developed within the implementation phase of the review or eligibility criteria work. 6. Please use the space below to detail any other matters arising from the Equality Impact Assessment (EqIA) process. A more detailed EQIA will be developed within the implementation phase of the review or eligibility criteria work. Gorebridge, areas in the most deprived 20-30% were spread more widely including Thornybank, Penicuik and Newtongrange. [Reference: Joint Needs Assessment, 2019] Page 100 of 302
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Midlothian Integration Joint Board Appendix 4: EQIA Analogue to Digital Recovery Action 4 Midlothian Health and Social Care Equality Impact Assessment (EqIA) of Recovery Actions Recovery Action Analogue to Digital Transition Group Service Allied Health Professions and Digital Programme Service Area Digital Programme and Services Lead Officer Matthew Curl and Hannah Cairns Completion Date 08-06-23 Aims and Objectives Secure capital funding for analogue to digital switchover to ensure continuity or reliable telecare alarm provision to existing and new service users in Midlothian because of the UK national telecoms infrastructure switchover from analogue to digital signalling. 1. Does the proposed recovery action affect people? Yes No 2. What is/are the reason(s) for your proposed recovery action? Telecare works by transmitting alerts across the UK's telephony network. This network is largely analogue and is nearing obsolescence. By 2025 the UK telephony network will complete a transformation to a fully digital network. Telecare alarms transmit a series of tones to place a call and open a voice connection. An analogue network can transmit these without conversion. When an analogue alarm is connected to a digital network, once the alarm call reaches the exchange it will be converted into a digital form to allow it to be sent over the supplier’s internal network. The process of conversion appears to distort the tones such that they do not place the call properly anymore. The expected outcome of this on the telecare industry is that analogue alarms will cease to provide a reliable connection to the alarm response centres which received the calls resulting in loss of service client harm. Funding has been requested from Midlothian Council capital fund to support this, to prevent utilisation of IJB General reserves. This relates to a reduced budget offer from Midlothian Council to IJB for 2023/24. 3. Impact Which of the protected characteristics* will the proposed recovery action have an impact upon? Page 101 of 302
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Midlothian Integration Joint Board Equality Target Group* Positive Impact Negative Impact Relevant evidence/ information Age This change will ensure that we are able to provide continued, safe, and reliable telecare provision. No disproportionate affect identified. We provide telecare services to around 1700-1800 clients across a range of service user groups. In the last few years, Midcare has needed to significantly grow the number of alarms SIM based alarms to manage a growing decline in landline ownership. New digital alarms will operate via SIM connection so we will anticipate this trend, ensure best practice cyber security standards are met and support more flexible management of the service to clients going forward. Disability This change will ensure that we are able to provide continued, safe, and reliable telecare provision. No disproportionate affect identified. Gender Reassignment No disproportionate affect identified. No disproportionate affect identified. We do not have reliable local figures for Trans and other gender identities. Scotland’s Census 2022 will include a voluntary question asking whether individuals consider themselves to be trans or have a trans history. Stage 2: Data and evidence gathering, involvement and consultation - Gender Recognition Reform (Scotland) Bill: equality impact assessment - gov.scot (www.gov.scot)] Marriage & Civil Partnership No disproportionate affect identified. No disproportionate affect identified. Marriages have declined in Midlothian, from 701 in 2005 to 319 in 2021. Civil Partnerships have also declined since introduced in 2005, averaging 5 per year from 2006-2014 and recording 5 in total from 2015-2021. [Reference: Marriages Page 102 of 302
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Midlothian Integration Joint Board and Civil Partnership - Time Series Data | National Records of Scotland (nrscotland.gov.uk)] Pregnancy and maternity No disproportionate affect identified. No disproportionate affect identified. In 2021, there were 1,071 births in Midlothian. This is an increase of 9.4% from 979 births in 2020. In Midlothian, the standardised birth rate increased from 10.8 per 1,000 population in 2020 to 11.7 in 2021. In comparison, the rate in Scotland overall increased from 8.6 to 8.7. Race No disproportionate affect identified. No disproportionate affect identified. The 2011 census provides the most recent data, 1.8% of the Midlothian population belonged to a Minority Ethnic Community. This compared with 4% of the Scottish population. [Reference: 2011 Census National Records of Scotland] Religion or Belief No disproportionate affect identified. No disproportionate affect identified. In 2011 in Midlothian the most common religion was Church of Scotland (33.7%), followed by Roman Catholic (9.8%), other Christian (4%), Muslim (0.6%), other religion (0.5%). 45.2% of people reported no religion and 6.2% didn’t state their religion. Sex No disproportionate affect identified. No disproportionate affect identified. In 2021, more females than males lived in Midlothian in 4 out of 6 age groups, from 25 years to 75 years and over. Midlothian Council Area Profile (nrscotland.gov.uk)] Sexual Orientation No disproportionate affect identified. No disproportionate affect identified. We do not have reliable local figures for sexual orientation. Scotland’s Census 2022 contains a Page 103 of 302
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Midlothian Integration Joint Board 4. How will the implementation of the proposed recovery action be communicated to those affected by any changes? Clients who are directly affected will be written to in advance of any changes being applied to inform them. Information published by Midlothian Council can be provided on request in many languages and in large print, Braille, audio tape or BSL. For more information, please contact the Equality, Diversity & Human Rights Officer on 0131 271 3658 or email equalities@midlothian.gov.uk 5. How will you monitor the impact of the changes proposed? When is the budget due to be reviewed? A review process will be developed as part of the A2D transition project. It is necessary to note that SIM alarms require a SIM connection which landlines don’t currently require. Historically, clients paid for the line rental and the calls to the ARC. The growth in analogue SIM alarms has been absorbed to date in the service but this cannot extend to absorb the full cost of the revenue impact post transition (£45-60/annum/client). Having secured the capital funding there will be an urgent need for the HSCP to consider how this revenue pressure will be mitigated to ensure an expedient start to the transition programme which needs to complete by end of 2025. If the full cost is passed on to clients, then there will be negative impacts to all users and the systemic impact could be significant if clients decide to respond to the increase charge by cancelling their service as their needs will have to picked up elsewhere in the system. voluntary question on this. Socio-economic Deprivation No disproportionate affect identified. No disproportionate affect identified. In 2020, Midlothian had 8.7% share of 20% most deprived data zones. [Reference: Scottish Government, 2023] Whilst all areas in the most deprived 20% were around Dalkeith, Mayfield, Easthouses and Gorebridge, areas in the most deprived 20- 30% were spread more widely including Thornybank, Penicuik and Newtongrange. [Reference: Joint Needs Assessment, 2019] Page 104 of 302
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Midlothian Integration Joint Board 6. Please use the space below to detail any other matters arising from the Equality Impact Assessment (EqIA) process. A more detailed EQIA will be developed as part of the A2D transition project. Page 105 of 302
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Midlothian Integration Joint Board Appendix 5: Response from Matthew Matheson Page 106 of 302
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Midlothian Integration Joint Board Thursday 22nd June 2023, 14:00-16:00 Analogue to Digital Transition 2023/24 Executive summary The purpose of this report is to provide background on the requirement for investment to implement the Analogue to Digital (A2D) transition and estimated associated funding required. It should also provide an update on the progress of securing the necessary funding. Members are asked to: • Note the non-recurring funding requirement to support the A2D transition and the associated risks that may result without appropriate resourcing. • Note the positive update from Midlothian Council Capital Plan and Asset Management Board that provided support for provision of the funding with formal approval anticipated following full Council on 9 May 2023. Item number: 5.5 Page 107 of 302
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Midlothian Integration Joint Board Midlothian Integration Joint Board Analogue to Digital Transition 1 Purpose 1.1 This report sets out to provide background on the requirement for investment to implement the Analogue to Digital (A2D) transition and estimated associated funding required. 1.2 Update the IJB following the discussion at the March IJB meeting where it was recommended that a paper (see Appendix 1) for this transition be taken to the Midlothian Council Capital Plan and Asset Management Board, to be considered for non-recurring support this year. 2 Recommendations 2.1 As a result of this report, Members are asked to: • Note the non-recurring funding requirement to support the A2D transition and the associated risks that may result without appropriate resourcing. • Note the positive update from Midlothian Council Capital Plan and Asset Management Board that provided support for provision of the funding with formal approval anticipated following full Council on 9 May 2023. 3 Background and main report 3.1 In 2017 it was announced by all the main telephony providers in the UK that their existing analogue telephone infrastructure would be decommissioned and replaced with a digital internet protocol (IP) service by 2025. Updates provided by these suppliers indicate acceleration of these timescales in some cases with an end date of 2023. Although many users will be unaware of any change to their telephony service following this transition, this announcement causes significant implications for telecare service providers, and for citizens in Scotland who are currently in receipt of these essential services within their home. 3.2 Over the past few years, the Local Government Digital Office (LGDO) has been working in partnership with Technology Enabled Care (TEC) and COSLA to develop best practice, strategic guidance, and operational support to Scottish telecare service providers for the planned transition from analogue to digital telecare. 3.3 The LGDO worked collaboratively with a group of telecare service providers to identify the requirements to ensure a smooth, safe, transition to a digital service delivery model. This learning and collaboration has been captured and collated and now forms the basis of the Digital Telecare Playbook which provides a Once for Page 108 of 302
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Midlothian Integration Joint Board Scotland approach to transformation, reducing effort, time and costs, and streamlining the process. 3.4 Midlothian Health and Social Care Partnership (HSCP) elected to work collaboratively with the Scottish Borders and East Lothian HSCP’s to carry out the required A2D transition. The tri-partite arrangement successfully applied for 2-year funding for a Project Manager, hosted and managed by Midlothian HSCP. The project manager has begun work and a project team and project steering group have been established with representatives from the three areas and led by the HSCP Digital Programme Manager and overseen by the Digital SRO. Work is underway with Midcare (Midlothian’s telecare service) to safely transition the service over to digital technology. 3.5 In carrying out the exploratory work within the A2D project, there is clear evidence of a need for a large capital spend programme (for replacement alarms and peripherals) to mitigate the effect of the digital telecom’s switchover. 3.6 Considering a discussion at the IJB Special Meeting on 16 March 2023 in relation to the Council’s resource allocation to the IJB for 2023/24, it was suggested that a request for this funding from the Capital Plan and Asset Management Board be submitted. 3.7 The anticipated costs and risks of not approving funding are outlined below in sections 7 and 8. 4 Policy Implications 4.1 There are no policy implications arising from this report. 5 Directions 5.1 This report does not relate to any specific directions. 6 Equalities Implications 6.1 There are no equalities implications from this report at this stage. Page 109 of 302
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Midlothian Integration Joint Board 7 Resource Implications Clients Alarm Cost Peripherals Package Cost Total Client Base 1776 60% Basic 'average package (Alarm + pendent + falls detector) 1066 £200 £144 35% Full 'average package' (BASIC + 3 Smokes + Heat + CO + 2xFlood, + Chair Occupancy + Bed Occupancy) 622 £200 £744 5% Enhanced 'average' package (FULL + Property Exit Sensor, PIR) 89 £200 £1,049 Basic 'Average' package 1066 £213,120 £153,446 Full 'average package' 622 £124,320 £462,470 Enhanced 'average' package 89 £17,760 £93,151 £355,200 £709,068 £1,064,268 Total Estimated Equipment Cost The estimated costs are based on the current service data and are subject to change based on the ‘actual’ requirements when works gets underway and needs of individuals, and real-time demand is realised. Page 110 of 302
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Midlothian Integration Joint Board 8 Risk 8.1 Not approving funding would present significant risks to the Council and Health and Service Care Partnerships ability to maintain the safety of the most vulnerable people in our society as outlined below. Risk Description Consequence Risk of alarm failure Call failing due to progression digitalisation for the network. There is a risk that an emergency call fails to connect when required due to loss of service. This could result in the most severe injury to a person and ultimately potential litigation and compensation costs to the organisation. Finance Wasting public resources While we continue to buy alarms that we expect to become obsolete before the end of their serviceable life, we are wasting resource. Risk of inaction Procuring equipment from a nascent supplier marketplace The global supply chain issues with technological kit is impacting suppliers adding to scarcity at a time with the whole UK industry is needing to react. Cost and availability are considerations here. Risk of not establishing a foundational infrastructure Developing a model of Digital Telecare With the arrival of digital equipment there is a convergence of Telecare and smart home/assisted living/consumer tech. There are likely to be increasing cases where, through the convergence of Midcare with Home Care, Reablement, Home first, proactive frailty support, etc, that we see opportunities to support technology adoption to facilitate connection and communication, or environmental control, or active monitoring. Risk of telecare system failure Midcare is unable to provide a proactive maintenance programme. Installation workflow and alert response demand high – & the service carries a waiting list. If the system does not report a fault but rather a component (door exist senor, movement sensor, bed sensor, etc) goes ‘off-line’ then the telecare package is no longer providing care. Page 111 of 302
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Midlothian Integration Joint Board 9 Involving people 9.1 Internal stakeholders have been consulted during the preparation of this report. 10 Background Papers None. AUTHOR’S NAME Hannah Cairns and Matthew Curl DESIGNATION Chief AHP and Digital Programme Manager CONTACT INFO Hannah.Cairns@nhslothian.scot.nhs.uk Matthew.Curl@nhslothian.scot.nhs.uk DATE 04 April 2023 Appendices: Appendix 1: Analogue to Digital (A2D) Transition Capital Plan and Asset Board Report 2023 Appendix 2: Analogue to Digital (A2D) Transition slide pack April 2023 Page 112 of 302
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Capital Plan and Asset Management Board 04 April 2023 Item No Analogue to Digital (A2D) Transition 2023/24 Report by Hannah Cairns, Chief AHP and Digital SRO, Health and Social Care Report for Decision 1 Recommendations That Capital Plan and Asset Management Board: Note the report and endorse the recommendation to approve capital funding or capital receipt flexibility for 2023/24 in light of the Integration Joint Board (IJB) discussion on the 16 March 2023 in relation to the 2023/2024 resource allocation. 2 Purpose of Report/Executive Summary The purpose of this report is to provide background on the requirement for investment to implement the A2D transition and estimated associated funding required. Date: 24-03-23 Report Contact: Name: Hannah Cairns Tel No: 07929 078782 Hannah.Cairns@nhslothian.scot.nhs.uk Page 113 of 302
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2 3 Background In 2017 it was announced by all the main telephony providers in the UK that their existing analogue telephone infrastructure would be decommissioned and replaced with a digital internet protocol (IP) service by 2025. Updates provided by these suppliers indicate acceleration of these timescales in some cases with an end date of 2023. Although many users will be unaware of any change to their telephony service following this transition, this announcement causes significant implications for telecare service providers, and for citizens in Scotland who are currently in receipt of these essential services within their home. Over the past few years, the Local Government Digital Office (LGDO) has been working in partnership with TEC and COSLA to develop best practice, strategic guidance and operational support to Scottish telecare service providers for the planned transition from analogue to digital telecare. The LGDO worked collaboratively with a group of telecare service providers to identify the requirements to ensure a smooth, safe, transition to a digital service delivery model. This learning and collaboration has been captured and collated and now forms the basis of the Digital Telecare Playbook which provides a Once for Scotland approach to transformation, reducing effort, time and costs, and streamlining the process. Midlothian Health and Social Care Partnership (HSCP) elected to work collaboratively with the Scottish Borders and East Lothian HSCP’s to carry out the required A2D transition. The tri-partite arrangement successfully applied for 2-year funding for a Project Manager, hosted and managed by Midlothian HSCP. The project manager has begun work and a project team and project steering group have been established with representatives from the three areas and led by the HSCP Digital Programme Manager and overseen by the Digital SRO. Work is underway with Midcare, Midlothian’s telecare service, to safely transition the service over to digital technology. In carrying out the exploratory work within the A2D project, there is clear evidence of a need for a large capital spend programme (for replacement alarms and peripherals) to mitigate the effect of the digital telecom’s switchover. Considering a discussion at the IJB Special Meeting on 16 March 2023 in relation to the Council’s resource allocation to the IJB for 2023/24, it was suggested that a request for this funding from the Capital Plan and Asset Management Board be submitted. There is a requirement for the IJB Meeting of 13 April 2023 to set a budget for 2023/24 and agreement regarding the A2D project is important within this context. The anticipated costs and risks of not approving funding are outlined below. Page 114 of 302
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3 4 Report Implications (Resource, Digital and Risk) 4.1 Resource Clients Alarm Cost Peripherals Package Cost Total Client Base 1776 60% Basic 'average package (Alarm + pendent + falls detector) 1066 £200 £144 35% Full 'average package' (BASIC + 3 Smokes + Heat + CO + 2xFlood, + Chair Occupancy + Bed Occupancy) 622 £200 £744 5% Enhanced 'average' package (FULL + Property Exit Sensor, PIR) 89 £200 £1,049 Basic 'Average' package 1066 £213,120 £153,446 Full 'average package' 622 £124,320 £462,470 Enhanced 'average' package 89 £17,760 £93,151 £355,200 £709,068 £1,064,268 Total Estimated Equipment Cost The estimated costs are based on the current service data and are subject to change based on the ‘actual’ requirements when works gets underway and individuals needs and real-time demand is realised. Page 115 of 302
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4 4.2 Digital It is not anticipated that resource would be required from Digital Services and Business Applications to contribute to the A2D transition. 4.3 Risk Not approving funding would present significant risks to the Council and Health and Service Care Partnerships ability to maintain the safety of the most vulnerable people in our society as outlined below. Risk Description Consequence Risk of alarm failure Call failing due to progression digitalisation for the network. There is a risk that an emergency call fails to connect when required due to loss of service. This could result in the most severe injury to a person and ultimately potential litigation and compensation costs to the organisation. Finance Wasting public resources While we continue to buy alarms that we expect to become obsolete before the end of their serviceable life, we are wasting resource. Risk of inaction Procuring equipment from a nascent supplier marketplace The global supply chain issues with technological kit is impacting suppliers adding to scarcity at a time with the whole UK industry is needing to react. Cost and availability are considerations here. Risk of not establishing a foundational infrastructure Developing a model of Digital Telecare With the arrival of digital equipment there is a convergence of Telecare and smart home/assisted living/consumer tech. There are likely to be increasing cases where, through the convergence of Midcare with Home Care, Reablement, Home first, proactive frailty support, etc, that we see opportunities to Page 116 of 302
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5 support technology adoption to facilitate connection and communication, or environmental control, or active monitoring. Risk of telecare system failure Midcare is unable to provide a proactive maintenance programme. Installation workflow and alert response demand high – & the service carries a waiting list. If the system does not report a fault but rather a component (door exist senor, movement sensor, bed sensor, etc) goes ‘off-line’ then the telecare package is no longer providing care. 4.4 Ensuring Equalities (if required a separate IIA must be completed) Not required. 4.5 Additional Report Implications (See Appendix A) Not applicable. Appendices Page 117 of 302
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6 APPENDIX A – Report Implications A.1 Key Priorities within the Single Midlothian Plan Not applicable. A.2 Key Drivers for Change Key drivers addressed in this report: Holistic Working Hub and Spoke Modern Sustainable Transformational Preventative Asset-based Continuous Improvement One size fits one None of the above A.3 Key Delivery Streams Key delivery streams addressed in this report: One Council Working with you, for you Preventative and Sustainable Efficient and Modern Innovative and Ambitious None of the above A.4 Delivering Best Value Based on the recommendations above, approving capital funding would help maintain and secure on premise business critical applications. A.5 Involving Communities and Other Stakeholders Internal stakeholders have been consulted during the preparation of this report. A.6 Impact on Performance and Outcomes Page 118 of 302
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7 Based on the recommendations above, approving capital funding would help maintain and secure on premise business critical applications. A.7 Adopting a Preventative Approach Based on the recommendations above, approving capital funding would support those living with long term conditions and frailty and reduce the need for hospital admission and long-term care. A.8 Supporting Sustainable Development Not applicable. Page 119 of 302
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Analogue to Digital Transition (A2D) Midcare / Telecare Situation Midlothian HSCP has recently brought together the operational (Midcare) element of telecare provision with the strategic requirement to manage the A2D transition. During the exploratory work within the A2D project, there is evidence of a need for a large capital spend programme (for replacement alarms and peripherals) to mitigate the effect of the digital telecom’s switchover. Background In 2017 it was announced by all the main telephony providers in the UK that their existing analogue telephone infrastructure would be decommissioned and replaced with a digital internet protocol service by 2025. Updates provided by these suppliers indicate acceleration of these timescales in some cases with an end date of 2023. Although many users will be unaware of any change to their telephony service following this transition, this announcement causes significant implications for telecare service providers, and for citizens in Scotland who are currently in receipt of these essential services within their home. Page 121 of 302
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Risk of alarms failure (digitisation of network) Inefficient use of resources Risk of inaction (global supply chain issues) Risk of not establishing a foundational infrastructure Risk of telecare system failure(maintenance) Analysis Page 122 of 302
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Clients Alarm Cost Peripherals Package Cost Total Client Base 1776 60% Basic 'average package (Alarm + pendent + falls detector) 1066 £200 £144 35% Full 'average package' (BASIC + 3 Smokes + Heat + CO + 2xFlood, + Chair Occupancy + Bed Occupancy) 622 £200 £744 5% Enhanced 'average' package (FULL + Property Exit Sensor, PIR) 89 £200 £1,049 Basic 'Average' package 1066 £213,120 £153,446 Full 'average package' 622 £124,320 £462,470 Enhanced 'average' package 89 £17,760 £93,151 £355,200 £709,068 £1,064,268 Total Estimated Equipment Cost Anticipated Capital Request Page 123 of 302
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Midlothian Integration Joint Board Thursday, 22nd June 2023, 14:00-16:00 Midlothian IJB Integrated Impact Assessment Process Executive summary This report sets out a proposed system to support Midlothian IJB ensure it meets the statutory requirement to completion an Integrated Impact Assessment (IIA) for all new and revised strategies, policies and plans, provisions, practices, and activities. The EHRC requested all Integration Authorities agree and implement a system for the identification, completion, publication, monitoring, and review of all Integrated Impact Assessments (IIAs) by the end of March 2023. A first draft of a proposed process was presented to SPG on 23rd February 2023 for review and discussion. Recommendations were adopted and represented to the Strategic Planning Group on 27th April 2023 where SPG agreed to recommend this process to the Board for approval The proposed system includes the identification of the requirement to complete an Integrated impact Assessment (IIA), and the completion, review, publication, and monitoring arrangements. Members are asked to: • Note the proposed process to identify the requirement to complete an Integrated impact Assessment (IIA), and the completion, review, publication, and monitoring arrangements • Agree to adopt this process for all Board business • Note the equality oversight implications for the Strategic Planning Group in relation to HSCP delivered activity Item number: 5.6 Page 125 of 302
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Midlothian Integration Joint Board Midlothian Integration Joint Board Midlothian IJB Integrated Impact Assessment Process 1 Purpose 1.1 This report sets out the proposed system to support Midlothian IJB ensure it meets the statutory requirement to complete an Integrated Impact Assessment (IIA) for all new and revised strategies, policies and plans, provisions, practices, and activities. 2 Recommendations 2.1 As a result of this report, Members are asked to: • Note the proposed process to identify the requirement to complete an Integrated impact Assessment (IIA), and the completion, review, publication, and monitoring arrangements • Agree to adopt this process for all Board business • Note the equality oversight implications for the Strategic Planning Group in relation to HSCP delivered activity 3 Background and main report 3.1 The Equalities and Human Rights Commission (EHRC) requested all Integration Authorities agree and implement a system for the identification, completion, publication, monitoring, and review of all Integrated Impact Assessment (IIA) by the end of March 2023. This has been delayed due to the prioritisation of essential discussion relating to the 2023-24 budget offers. 3.2 The proposed process includes the identification of the requirement to complete an Integrated impact Assessment (IIA), and the completion, publication, review, and impact monitoring arrangements. 3.3 A first draft of a proposed process was presented to SPG on 23rd February 2023 for review and discussion. Recommendations were adopted and represented to the Strategic Planning Group on 27th April 2023 where SPG agreed to recommend this process to the Board for approval. 3.4 It is proposed that, a IIA Screening Tool (appendix 1) should accompany all Board papers record any decisions and provide evidence. 3.5 A record of decisions relating to the screening of Board papers and reports and the identification of the requirement to complete an IIA should be recorded on the IIA IJB Paper & Report Record Form (appendix 2). This will be maintained and monitored by the HSCP Equality Lead. Data entered should be reviewed by the Integration Manager and the Standards Officer prior to presenting to the Chair for review ahead of each Board meeting. Page 126 of 302
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Midlothian Integration Joint Board 3.6 It is further proposed that the IJB will review IIAs and record any decisions made on the Decision Making Log (appendix 3) 3.7 Finally work on IIAs should be tracked and a log of decisions along with details of the IIAs publication and future monitoring arrangements recorded on the IIA Tracker and Monitor Log (appendix 4) 4 Policy Implications 4.1 The action proposed in this report does not have any direct policy implications. 5 Directions 5.1 This action proposed in this report does not have any implications for Directions. 6 Equalities Implications 6.1 The actions outlined in this report are designed to support Midlothian IJB meet its Public Sector Equality Duty and improve the IJBs progress towards greater equality in our communities. 7 Resource Implications 7.1 The resource implications arising from this report are limited to the time required for the Board and officers of the HSCP to undertake specific actions. 8 Risk 8.1 A lack evidence demonstrating due regard to the impact of all new and revised strategies, policies and plans, provisions, practices, and activities on people with protected characteristics could result in non-compliance with the Public Sector Equality Duty (PSED) and EHRC referral for legal action. 9 Involving people 9.1 The completion of Integration Impact Assessments (IIAs) support engagement with people, communities and the health and social care workforce to effectively progress equality mainstreaming. There is recognition that engagement and consultation with people who have protected characteristics, and the impact of work to improve equality requires improvement. Page 127 of 302
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Midlothian Integration Joint Board 10 Background Papers None. AUTHOR’S NAME Gill Main DESIGNATION Integration Manager CONTACT INFO Via email or MS Teams DATE 08/05/2023 Appendices: Appendix 1: Midlothian IJB IIA Process Information v4 Appendix 2: Midlothian IJB IIA Process_Screening Tool Appendix 3: Midlothian IJB IIA Process_IIA Paper & Report Record Form Appendix 4: Midlothian IJB IIA Process_Decision Making Log Appendix 5: Midlothian IJB IIA Process_IIA Tracker and Monitor Log Page 128 of 302
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Midlothian Integration Joint Board Integrated Impact Assessment (IIA) Process Introduction In Midlothian, equality assessments are called Integrated Impact Assessments (IIAs). This assessment is designed to support consideration to equality issues, health inequalities, socio- economic inequalities, needs assessments for care experienced people, human rights, and environmental impact. An IIA should be considered for all new and revised strategies, policies and plans, provisions, practices, and activities. Completed well, an IIA should highlight how we can avoid discrimination against groups of people and to remove or minimise disadvantage where possible. A regional equalities working group ensures our NHS and Local Authority partners work together to improve how we are identifying equality issues. The Duty of Integration Authorities Integration authorities must ensure that a system is in place for carrying out, using, and publishing IIAs for all new and revised strategies, policies and plans, provisions, practices, and activities relating to IJB activity. The following process will be used for the identification, completion, publication, monitoring, and review of IIAs. Screening and Identification The decision to conduct and Integrated Impact Assessment should be made when a Board paper or report is conceptualised and before development. The IJB report templates include a ‘Equality Implications’ section which asked authors to consider if a report either • has implication for groups of people with protected characteristics, or • results in the requirement to revise or develop a new strategy, policy, plan, provision, practice, and • if an IIA is required All new and revised Midlothian IJB strategies, policies and plans, provisions, practices, and activities will be identified through the screening of all IJB Board papers and reports. This activity includes, but is not limited to » Midlothian IJB Strategic Commissioning Plan » Midlothian IJB Engagement and Public Involvement Plans » Midlothian IJB Policies (including Sottish Government Model Schemes) All Board papers will be submitted with the IIA Screening Tool (appendix 1). This should be completed by the HSCP Officer presenting the paper and reviewed by the HSCP Equality Lead and Integration Manger. This will serve as a record and provide evidence of any decisions. Page 129 of 302
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A record of decisions relating to the screening of Board papers and reports and the identification of the requirement to complete an IIA should be recorded on the IIA IJB Paper & Report Record Form (appendix 2). This will be maintained and monitored by the HSCP Equality Lead. Data entered should be reviewed by the Integration Manager and the Standards Officer prior to presenting to the Chair for review ahead of each Board meeting. The Midlothian IJB Chair will then alert Members to the potential requirement for an IIA either before or during IJB Board meetings. Midlothian IJB must then agree whether an IIA should be completed, record this decision, and nominate an Officer of the Board who will act as the responsible lead to oversee the completion of an IIA. Completion The Nominated Officer should be the person responsible for the strategy, policy or plan, provision, practice, or activity. The completion of the IIA may be delegated but responsibility for ensuring IIA preparation, information gathering, engagement with services and relevant personnel, and completion of assessment for submission to Strategic Planning Group (SPG) for scrutiny, and subsequently Midlothian IJB for review lies with the Nominated Officer. Review Midlothian IJB will review the submitted IIA, consider the strength of the assessment and associated implications before delivering a decision on whether this EIA is robust and accepted by the Board as sufficient to meet its duties. The details of Midlothian IJBs decision making process and the decision must be recorded on the IIA Decision Making Log (appendix 3). Publication Publication of all IIAs must be in good time following Midlothian IJB decision. The IIA report must be published at the same time as either the strategy, policy or plan is published, or the provision or practice is approved. This must be within a month of final IJB Approval, and within 14 days of the Boards approval. Confirmation of the online publication of the IIA must be communicated to the Chair of Midlothian IJB by the Integration Manager. IIA Log and Monitoring Arrangements A log of decisions along with details of the IIAs publication and future monitoring arrangements and with the progress of IIAs should be logged in the IJB IIA Tracker and Monitor Log (appendix 4) and submitted to each IJB meeting with a succinct update paper for noting. The impact of IIAs will be recorded within the Midlothian IJBs Performance Framework. As part of Midlothian IJBs performance framework, assurance regarding equality assessment from all core and delegated services within operational planning is required. The HSCP must provide assurance to Midlothian IJB regarding the adequate and appropriate consideration of equality issues via the HSCP Governance and Assurance Framework and the HSCP Performance Framework. This will allow annual reporting from the HSCP Senior Management Team (SMT) to the Strategic Planning Group (SPG) on an HSCP operational log that records the identification, completion, review, publication, and monitoring arrangements for IIAs. Page 130 of 302
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Midlothian Integration Joint Board Integrated Impact Assessment (IIA) Screening Tool This Screening Tool should accompany all Midlothian IJB reports and papers. Decisions about whether an impact assessment should be completed must happen as early as possible in the planning of a new, or revision of an existing, initiative. This tool will help you record any decisions made and provide evidence. Title of Midlothian IJB Report: Presenting Officer: Does an IIA Accompany this Report? Yes √ No √ If yes, please attach the IIA to the report If no, please complete the screening tool below Type of Initiative: New √ Revised √ Aim / purpose of new or revised initiative: Comments: e.g., Strategy, Policy, Plan, Provision, Practice, or Activity Implications Identification & Screening: Does the content of this report affect service users, employees of the wider community, & therefore potentially have an effect in terms of equality? Please note the relevance of a policy will depend not only on the number of people affected, but also the significance of the effect on them. Yes / No √ Information on potential impact: Positive / Negative / Requires further investigation Comments: Please state any reasons for deciding if not relevant. Is it a major policy, significantly affecting how functions are delivered? Yes / No √ Additional Comments: Will it have a significant effect on how other organisations operate? (For example, criteria for funding) Yes / No √ Additional Comments: Page 131 of 302
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Does it have an impact on health inequalities, socio-economic inequalities, needs assessments for care experienced people, human rights, or the environment? Please note the relevance of a policy will depend not only on the number of people affected, but also the significance of the effect on them. Yes / No √ Additional Comments: Does it relate to functions that have previously been identified as being important to particular protected groups? Yes / No √ Additional Comments: Does it relate to an area where Midlothian IJB has set equality outcomes? Yes / No √ Additional Comments: Does it relate to an area where there are known inequalities? (For example, disabled people’s access to services offers and supports; the gender pay gap; racist or homophobic behaviour, etc.) Yes / No √ Additional Comments: Does it relate to a policy where there is significant potential for reducing inequalities or improving outcomes? (For example, improving access to health services for transsexual people, or increasing take-up of apprenticeships by female students) Yes / No √ Additional Comments: If you answered “yes” to any of the questions above, a full Integrated Impact Assessment (IIA) must be considered. If an IIA is not required, please state the reasons why here. Screening Completed by: Screening Reviewed & Signed off by Integration Manager: Date: Date: Page 132 of 302
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Midlothian Integration Joint Board Integrated Impact Assessment (IIA) Decision Making Log Title of IIA: Lead Officer: Type of Initiative: New √ Revised √ IJB Decision: Approved √ Returned √ e.g., Strategy, Policy, Plan, Provision, practice, or activity Comments: Date of Board: Date of Next IJB Review: Identified Impact on Equality Has the IIA identified all relevant protected characteristics groups likely to be impacted by this proposed activity? Yes √ No √ Further info required √ Does the IIA demonstrate that the necessary equality evidence has been collected & used, including engagement with protected characteristics groups to address any gaps in knowledge & understanding? Yes √ No √ Further info required √ Does the IIA give due consideration to the risk of unlawful discrimination, harassment, or victimisation against each relevant PC group? Yes √ No √ Further info required √ Does the IIA explore how the policy can help to advance equality of opportunity (meet different needs and reduce/ remove disadvantage) for each relevant protected characteristic? Yes √ No √ Further info required √ Appendix 2: Decision Making Log Page 147 of 302
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Does the IIA explore how the policy can help to foster good relations between different protected characteristic groups? Yes √ No √ Further info required √ Is it clear how the findings of this IIA have been used in the development of the final proposed activity? Yes √ No √ Further info required √ Is an implementation plan included, with details on how the implementation of this proposed activity will be reviewed & monitored? Yes √ No √ Further info required √ Page 148 of 302
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Has the IIA identified all protected characteristics groups likely to be impacted by this policy? Board Agreement to Complete an IIA If No, Rationale Midlothian Integration Joint Board Integrated Impact Assessments: Action and Impact Date of IJB Review Impact on Equality Type of Initiative Page 155 of 302
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Does the IIA detail adequate consultation & engagement with these groups? Has the impact (positive, negative, negligible) for identified groups been fully explored & justified Is it clear how the finding of this IIA has influenced the planning and decision making relating to the proposed activity? Midlothian Integration Joint Board Integrated Impact Assessments: Action and Impact Impact on Equality Page 158 of 302
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Is an implementation plan included, with details on how the implementation of this proposal will be reviewed & monitored? Has the IIA identified all protected characteristics groups likely to be impacted by this policy? Midlothian Integration Joint Board Integrated Impact Assessments: Action and Impact Outcome Date of IJB Review Impact on EqualityImpact on Equality Page 161 of 302
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Does the IIA detail adequate consultation & engagement with these groups? Has the impact (positive, negative, negligible) for identified groups been fully explored & justified Is it clear how the finding of this IIA has influenced the planning and decision making relating to the proposed activity? Midlothian Integration Joint Board Integrated Impact Assessments: Action and Impact Impact on Equality Page 164 of 302
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Is an implementation plan included, with details on how the implementation of this proposal will be reviewed & monitored? Midlothian Integration Joint Board Integrated Impact Assessments: Action and Impact Method of Impact Assessment and Monitoring Date Published on Website Impact on Equality Outcome Page 167 of 302
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Midlothian Integration Joint Board Thursday 22nd June 2023, 14:00-16:00 IJB Performance Report Executive summary The purpose of this report is to update the IJB on progress towards the IJB performance goals set for the financial year 2022/23. Due to the processes required to validate these data, the full reporting year is not yet complete. A report describing progress against each improvement goal is attached in Appendix 1. There is an inbuilt reporting delay (noted above). More recent management data are available for a number of the improvement goals but as they have not been validated, they cannot be published. In order to support the Board’s understanding of the current position regarding progress towards the improvement goals, a brief summary is provided. Following the Midlothian IJB meeting on 13th April 2023, the Performance, Assurance, and Governance Group (PAGG) was commissioned to consider a local improvement goal(s) for the IJB. The group met on 4th May and collaboratively produced one improvement goal with 8 locally relevant process measures. Following the Strategic Planning Group (SPG) meeting on 27th April 2023, it was agreed that all Board members be invited to join the next meeting of SPG to consider the full draft of the Annual Performance Report (non-validated management data). This meeting will take place on 6th July, and an invitation to Board members will follow. Due to Public Health Scotland timelines for publication of validated data, an additional meeting of the Performance, Assurance, and Governance Group (PAGG) has been scheduled. This will take place on the 20th July and an invitation to Board members will follow. Members are asked to: • Note the performance against the IJB Improvement Goals for 2023/24 (Appendix 1). • Discuss and approve the proposed local Improvement Goal and associated measures. • Note the additional meetings for scrutiny of the Annual Performance Report. Item number: 5.7 Page 177 of 302
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Midlothian Integration Joint Board Midlothian Integration Joint Board IJB Performance Report 1 Purpose 1.1 The purpose of this report is to update the IJB on progress towards the IJB performance goals set for the financial year 2022/23. Due to the processes required to validate these data, the full reporting year is not yet complete. 2 Recommendations 2.1 As a result of this report, Members are asked to: • Note the performance against the IJB Improvement Goals for 2022/23 (Appendix 1). • Discuss and approve the proposed local Improvement Goal and associated measures. • Note the additional meetings for scrutiny of the Annual Performance Report. 3 Background and main report 3.1 The IJB has previously identified improvement goals to monitor progress on reducing unscheduled hospital activity and use of institutional care. They are based on goals recommended by the Scottish Government Ministerial Strategic Group for Health and Community Care). 3.2 At the IJB meeting in June 2022 the Performance Assurance & Governance Group recommended that the improvement goals for 2022/23 were set to prioritise an increase in system stability, focussing on workforce recovery and wellbeing. 3.3 An updated report describing progress against each improvement goal is attached in Appendix 1. This report is produced by the Local Intelligence Support Team (LIST) on behalf of the Midlothian HSCP. Members are asked to note the information in Appendix 1, specifically regarding data completeness. Due to the processes required to validate these data for publication, there is an inbuilt reporting delay, and this information is not taken from a “live” system. This means that we are not yet able to calculate the full year performance for some measures. 3.4 Members are asked to note that Public Health Scotland (PHS) has moved to a schedule of quarterly, rather than monthly, updates. This means that Appendix 1 does not include any updated data compared with the Performance Report submitted to the Board in February 2023. 3.5 The Midlothian HSCP Performance Manager and the Principal Information Analyst (PHS Local Intelligence Support Team) have been supporting the NHS Lothian Performance Business Unit with plans to progress development of a local Tableau dashboard. This would permit more recent management data to be available to Lothian HSCPs in a way that better informs understanding of whole-system activity. 3.6 More recent management data are available for a number of the improvement goals but as they have not been validated, they cannot be published. In order to Page 178 of 302
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Midlothian Integration Joint Board support the Board’s understanding of the current position regarding progress towards the improvement goals, a brief summary is provided below. 3.7 A&E Attendances 2022/23 Target Rate per 100,000 people 2,629 / month 2022/23 Running Average 2,851 / month The validated data are only available up to December 2022. Based on this information, the target is not currently being met. The most recent non-validated management information data indicate a slight improvement. 3.8 Emergency Admissions 2022/23 Target Rate per 100,000 767 / month 2021/22 Rate 799 / month The validated data are only available up to March 2022. Based on this information, the target is not currently being met. The most recent non-validated management information data indicate a slight improvement. 3.9 Unplanned Bed Days 2022/23 Target Rate per 100,000 5,074 / month 2021/22 Rate 4,779 / month The validated data are only available up to March 2022. Based on this information, the target is currently being met. 3.10 Delayed Discharge Occupied Bed Days 2022/23 Target Rate per 100,000 820 / month 2022/23 Running Average 1,077 / month The validated data are only available up to December 2022. Based on this information, the target is not currently being met. The most recent non-validated management information data indicate that system activity levels continue to present a significant challenge to achieving the target set. 3.11 End of Life – Percentage of Last Six Months Spent in Large Hospitals 2022/23 Target Rate <8.7% 2020/21 Rate 7.5% The validated data are only available for 2020/21. Based on this information, the target is currently being met. It is not possible to refer to management information as these data are not held locally. 3.12 Balance of Care 2022/23 Target Rate >96.4% 2020/21 Rate 97% (provisional data) The validated data are only available on a provisional basis for 2020/21. Based on this information, the target is currently being met. It is not possible to refer to management information as these data are not held locally. 3.13 IJB Local Improvement Goal Following the Midlothian IJB meeting on 13th April 2023, the Performance, Assurance, and Governance Group (PAGG) was commissioned to consider a local improvement goal(s) for the IJB. 3.14 The group met on 4th May and collaboratively produced one improvement goal with 8 locally relevant process measures: Goal: The balance of care from hospital to community-based care in Midlothian will have shifted by x% by March 2025 (percentage to be defined). Outcome Measure: % of shift from hospital to community-based care Process Measures (collected monthly): • Number of people in hospital • Number of people working with services across community health and / or Page 179 of 302
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Midlothian Integration Joint Board social care • Number of people who saw a GP • Number of people who saw a primary care practitioner within a GP practice • Number of people who did not receive any health or social care • Number of admissions prevented • Number of supported discharges • IJB delivers on budget. Balancing Measures: (quarterly from PHS) Our recommendation is to use the MSG indicators here as we already report on these. 3.15 The Performance, Assurance, and Governance Group (PAGG) met on the 8th June and all Board Members were invited for a short and focused discussion to review this proposal ahead of the June Board meeting. 3.16 Annual Performance Report Following the Strategic Planning Group meeting on 27th April 2023, it was agreed that all Board members be invited to join the next meeting of the Strategic Planning Group, to consider the full draft of the Annual Performance Report (based on non- validated management data). This meeting will take place on 6th July, and an invitation to Board members (from Democratic Services) will follow. 3.17 It was also agreed that all Board members be invited to join a meeting of the Performance Assurance and Governance Group to participate in the review of the validated data that will be published within the Annual Performance Report. 3.18 Due to Public Health Scotland timelines for publication of validated data, an additional meeting of the Performance, Assurance, and Governance Group (PAGG) has been scheduled. This will take place on the 20th July and an invitation to Board members (from Democratic Services) will follow. 4 Policy Implications 4.1 There are no policy implications arising from this report. 5 Directions 5.1 This report does not directly impact upon service ability to deliver existing Directions. 5.2 It is acknowledged that there will be a requirement for ongoing review and revision to the Performance Report, in alignment with any revisions to existing Directions / issue of new Directions at any stage in the reporting period. 6 Equalities Implications 6.1 There are no equality implications from focussing on these goals but there may be implications in the actions that result from work to achieve them. The focus of most of the goals is on reducing hospital activity and hospitals are not used equally by the population. There are groups of people that make more use of hospitals than others – for example older people, people living in areas of deprivation or people who live alone. Page 180 of 302
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Midlothian Integration Joint Board 7 Resource Implications 7.1 There will be resource implications resulting from further action to achieve these improvement goals. 8 Risk 8.1 The main risk is that the IJB fails to set improvement goals that take cognisance of the continued instability of health and care systems, the significant operational system pressures, and the ongoing challenges of supporting workforce wellbeing. 9 Involving people 9.1 The Performance Assurance & Governance Group (PAGG) meet monthly to review and discuss these measures as part of wider data assurance. Membership of the group will be expanded to ensure increased representation of elected officials, the third sector and public health. 10 Background Papers No background papers. AUTHOR’S NAME Elouise Johnstone DESIGNATION Programme Manager for Performance CONTACT INFO elouise.johnstone@nhslothian.scot.nhs.uk DATE 4th June 2023 Appendices: Appendix One: Local Intelligence Support Team (LIST) Report describing progress against the IJB improvement goals 2022/23. Page 181 of 302
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Midlothian HSCP MSG Indicators Performance from April 2019 to December 2022, with 2020/21 MSG targets and trends Local Intelligence Support Team (LIST), May 2023 Page 183 of 302
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Data completeness Source: MSG data release Mar-23, PHS 2 Indicator Published until Provisional until Data completeness issues 1. A&E attendances Dec-22 n/a - 2. Emergency admissions Mar-22 Dec-22 (SMR01) Nov-20 = 93%, Nov-21 = 95%, Nov-22=89% 3a. Unplanned bed days (acute) Mar-22 Dec-22 (SMR01) Nov-20 = 93%, Nov-21 = 95%, Nov-22=89% 3b. Unplanned bed days (GLS) n/a Dec-22 (SMR01E) Quarters ending: Mar-22 = 98%; Jun-22 = 92%; Sep-22 = 96%; Dec-22 = 91% 3c. Unplanned bed days (MH) Mar-21 Dec-22 (SMR04) Quarters ending: Jun-22 = 91% 4. Delayed discharges occupied bed days Dec-22 n/a - 5. Last 6 months of life (% in community setting) 2020/21 2021/22 - 6. Balance of care (% at home) n/a 2020/21 - Page 184 of 302
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2020/21 targets and actuals Source: MSG objectives 2020-21 template - Midlothian IJB; MSG data release Mar-23, PHS • Indicators 3b and 6 are still provisional. 3 Indicator 2020/21 target Annual Monthly Annual Monthly 1. A&E attendances Maintain 31,543 2,629 26,391 2,199 ✓ 2. Emergency admissions 5% decrease 9,207 767 9,208 767 ✓ 3a. Unplanned bed days (acute) 10% decrease 60,888 5,074 57,459 4,788 ✓ 3b. Unplanned bed days (GLS) Decrease <13,733 <1,144 14,122 (p) 1,177 (p) X 3c. Unplanned bed days (MH) Decrease <15,910 <1,326 12,932 1,078 ✓ 4. Delayed discharges occupied bed days 20% decrease 9,836 820 9,779 815 ✓ 5. Last 6 months of life (% in large hospital) Decrease <8.7% - 7.9% - ✓ 6. Balance of care (% at home) Increase >96.4% - 97.% - ✓ 2020/21 target (rate per 100,000) 2020/21 (rate per 100,000) Target met (p) = provisional Page 185 of 302
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Data Sources 2020/21 MSG Targets • Source: MSG data release v1.62, Mar-23; Public Health Scotland • These are official monthly figures released by PHS and will be nationally published (some data is provisional and not yet published) • Next data release: ?Jun-23 4Page 186 of 302
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A&E Attendances Source: MSG data release Mar-23; data published up to Dec-22 • The rate of attendances in 2020/21 was 21% lower than 2019/20, and 17% lower than the 2017/18 baseline year. Much of this may be due to covid-19. • The rate of attendances had increased back to typical levels by Aug-20, but steadily decreased again until Mar-21 when it started increasing. • From May-21 – Nov-21 it exceeded the 2020/21 target level. Between Dec- 21 and Feb-22 it dipped below the target again. • The 2020/21 target was met 5 Target = maintain Annual Monthly 2020/21 Target Rate (per 100,000) 31,543 2,629 2019/20 Rate (per 100,000) 33,319 2,777 2020/21 Rate (per 100,000) 26,391 2,199 2021/22 Rate (per 100,000) 33,153 2,763 2022/23 Running average (Dec) 2,851 Page 187 of 302
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Emergency Admissions Source: MSG data release Mar-23; data published up to Mar-22 • The rate of emergency admissions dropped in Apr- 20 due to Covid-19, but quickly returned to more typical levels – although remained lower than 2019/20 until March-21 • In the first quarter of 2021/22 the admissions rate increased above the 2020/21 target level and above 2020/21 levels; this discrepancy has reduced since • The 2020/21 target was met 6 Target = 5% decrease Annual Monthly 2020/21 Target Rate (per 100,000) 9,207 767 2019/20 Rate (per 100,000) 10,969 914 2020/21 Rate (per 100,000) 9,208 767 2021/22 Rate (per 100,000) 9,586 799 Page 188 of 302
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Unplanned Bed Days - Acute Source: MSG data release Mar-23; data published up to Mar-22 • The rate dropped drastically in Apr-20 due to Covid-19, but was back to a more typical level by Jul-20. • The rate has remained stable since then • The 2020/21 target was met 7 Target = 10% decrease Annual Monthly 2020/21 Target Rate (per 100,000) 60,888 5,074 2019/20 Rate (per 100,000) 64,683 5,390 2020/21 Rate (per 100,000) 57,459 4,788 2021/22 Rate (per 100,000) 57,351 4,779 Page 189 of 302
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Delayed Discharges Occupied Bed Days Source: MSG data release Mar-23; data published up to Dec-22 • The rate of delayed discharge occupied bed days in Apr-20 was about 80% lower than the previous April’s rate due to Covid-19 • The rate has remained mostly lower than the previous year ever since; during much of 2021/22 it was lower than the 2020/21 target level, although it has now exceeded it since Feb- 22 and has risen substantially over the last few months • The 2020/21 target was met 8 Target = 20% decrease Annual Monthly 2020/21 Target Rate (per 100,000) 9,836 820 2019/20 Rate (per 100,000) 14,336 1,195 2020/21 Rate (per 100,000) 9,779 815 2021/22 Rate (per 100,000) 8,249 687 2022/23 Running average (Dec) 1,077 Page 190 of 302
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End of Life - Percentage of Last Six Months Spent in Large Hospitals Source: MSG data release Mar-23; data published up to 2020/21 9 • The 2020/21 target was met • The provisional percentage for 2021/22 is below the target but is higher than the 2020/21 level Target = decrease Annual 2020/21 Target <8.7% 2019/20 9.1% 2020/21 7.5% Page 191 of 302
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Midlothian Integration Joint Board Thursday, 22nd June 2023, 14.00-16.00. Integrated Governance Report Executive summary This report is presented to provide Midlothian Integration Joint Board with assurance around the processes in place to deliver clinical and care governance and risk and resilience management by the Midlothian Health and Social Care Partnership. The structure for oversight of safe, effective, and person-centred care and professional governance consists of the Clinical Care and Governance Group and Quality Improvement Teams (QITs). A number of specialist subgroups ensure focus on identified risks and most common harms. A culture of shared learning and improvement is promoted. Previous reports advised of testing of the Governance and Assurance Framework (GAF). With issues identified during testing now resolved and Group Service, Service and Team Plans in place across the HSCP, the rollout of the GAF will proceed from April 2023. This aims to provide a consistent and complete picture of the assurance being reported. These activities support the ambition to implement a total Quality Management System (QMS) linking clinical and care governance with the management of performance and resources. Preparations for a Care Inspectorate and Healthcare Improvement Scotland joint adult inspection during 2023 are underway. These include a quality improvement framework and a streamlined system to record, analyse and articulate personal outcomes (OutNav). The report sets out the ongoing work to ensure Social Work and Social Care governance is appropriately managed so effective assurance can be given. The report confirms that the Partnership’s structures and processes for risk management, resilience and major incident planning address the requirements of Midlothian Council and the Lothian NHS Board. This includes the maintenance of the Partnership’s Risk Register and processes which support the appropriate escalation of identified risks. Board members are asked to discuss and approve the contents of this report Item number: 5.8 Page 193 of 302
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Midlothian Integration Joint Board Midlothian Integration Joint Board Integrated Governance Report 1 Purpose 1.1 This is the Integrated Governance report for Midlothian Integration Joint Board (IJB). 2 Recommendations 2.1 Board members are asked to discuss and approve the content of this report. 3 Background and main report 3.1 This report updates the IJB on the activity undertaken to provide assurance around the delivery of safe, effective, and person-centred care in Midlothian and the processes in place to cover risk and resilience. 3.2 Clinical Care and Governance and Assurance Structure and Processes The Clinical and Care Governance Group (CCGG) meets quarterly to enable assurance to be provided to the IJB around the safety, effectiveness, and person centredness of Midlothian Health and Social Care Partnership (MHSCP) services. Quality Improvement Teams (QITs) report to the CCGG around the actions services undertake to address clinical and care governance, deliver quality improvement share learning and progress innovation. The Quality Improvement Teams are expected to meet at least 4 times per year and report to the CCGG quarterly. A reporting template collates information about actions in place relating to the learning arising from investigation of adverse events and complaints, implementation of actions around safety alerts, specific standards and guidance, improvement work, action plans arising from audit and inspection activity and any other service-specific issues which could have impact on the quality and safety of care the service provides The Board have previously been advised of work underway to refresh the assurance template to support a more streamlined and consistent approach across services. From July 2023, the HSCP will begin testing the Governance and Assurance Framework adapted from the version tested by AHPs across Lothian (Appendix 1). This will support the assurance processes around clinical and care governance for all services in the HSCP. The system will provide a robust framework to enable reporting on the level of assurance being provided and will generate a system for auditing the evidence for assurance provided. Group Service, Service and Team Plans have been in place across the HSCP from April 2023. The associated rollout of the Governance and Assurance Framework and Page 194 of 302
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Midlothian Integration Joint Board a review of meeting structures mean a clear expectation is now in place that QITs will meet in alignment with the annual calendar of CCGG groups. This should provide the CCGG with a complete picture of the assurance being reported across all services at every meeting Delays in implementation arise from gaps being identified during testing of the AHP Governance and Assurance Framework. Correction has been progressed prior to finalisation of the Midlothian HSCP version of the framework. Group Service Specifications, Service Plans and Team Plans which articulate delivery against Strategic Objectives and key performance and quality measures will be finalised prior to the implementation of the framework. These elements are key in being able to provide a clear baseline from which to be able to provide a level of governance assurance on a quarterly basis. These activities will support the previously advised ambition to implement a total Quality Management System (QMS) to strengthen the links between the clinical and care governance workstreams and the management of performance and resources, ensuring all activities and tasks are delivered to a desired level of excellence. The role of Chief Social Work Officer, which carries statutory functions, sits outwith the HSCP. There is, consequently, a strong link to the Head of Adult Services who is also a Social Worker. The Head of Adult Services generally deputises for the CSWO when they are unavailable. The CSWO is a member of the IJB and pre-IJB meetings have been set up with the Chief Officer and Head of Adult Services to discuss any issues that may be particularly pertinent for professional social work. The QIT processes are integrated, and managers’ report on all HSCP business thus providing assurance regarding social work services. There remains a need to ensure the CSWO is linked in effectively to this structure. The Governance and Assurance Framework will further strengthen this level of assurance. 3.3 The Clinical and Care Governance Group The Clinical and Care Governance Group meets on a quarterly basis. Since the last report to the IJB, meetings have taken place in August, November, February and May. The HSCP’s annual report (Appendix 2) was presented at the September meeting of the NHS Lothian Healthcare Governance Committee and was positively received. 3.4 Investigating and Learning from Adverse Events and Complaints Three groups are established to provide oversight of all significant adverse events reported within Midlothian. Specific groups address patient/client falls and pressure ulcers. The Midlothian Safety and Experience Action Group (MSEAG) has oversight of all other significant adverse events (adverse events which result in harm assessed as moderate or above), including the death or suicide of patients engaged with mental health and substance misuse services. This group commissions external reviews in line with NHS Lothian protocols. The MSEAG minutes are submitted to the Lothian Patient Safety and Experience Action Group, and all Serious Adverse Events approved as complete in Midlothian require the approval of the NHS Lothian Medical Director and Executive Nurse Director before final closure. Page 195 of 302
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Midlothian Integration Joint Board The HSCP Senior Management Team (SMT) receives a fortnightly report from the Chief Nurse regarding performance around the management of complaints and the reporting and management of adverse events on the Datix system. Datix is a web- based tool accessed by NHS Lothian staff to report and learn from safety concerns such as actual adverse events and near misses and helps in the collection and analysis of information to support safety and quality improvement. The system also provides modules to support the administration of Complaints, Claims and Service Management Team level Risk Registers, to provide an integrated information system. At the time of writing 8 Significant Adverse Event (SAEs) are under investigation, two of those being Level 1 external reviews open more than 6 months. Charts 1 and 2 show the Midlothian HSCP’s performance regarding SAEs open more than 6 months 2021-23.Work continues to support actions that will enable local teams to address all adverse events within the Healthcare Improvement Scotland guidance timescales. While SAE review performance against timescales has improved, continued work is needed to maintain performance and assure the quality of the reviews and the implementation of learning gained. To support Managers across the HSCP to consistently deliver reviews within expected timescales and to the level of detail and quality required, training was delivered and well attended in Autumn 2022. Ongoing review of learning needs is undertaken and work with the Quality Improvement Support team of NHS Lothian to enable appropriate learning opportunities to be identified and delivered. Outstanding actions from previously investigated Significant Adverse Events continue to be monitored by the MSEAG. Chart 1 Midlothian Serious Adverse Events Open over 6 months at 1st May 2023 Page 196 of 302
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Midlothian Integration Joint Board Chart 2 Midlothian Significant Adverse Events Reported and Closed 2021- 2023 Processes for Council services remain less mature around adverse events and work is outstanding to bring a degree of synergy to this. Ultimately, the aspiration is that MSEAG will manage all adverse events across the HSCP. Presently, there is scope to ensure all parts of the system are involved in SAE’s where appropriate. This is most appropriate in relation to drug related deaths and suicides as it is not uncommon that staff from integrated teams have involvement in such cases. NHS Lothian recently published its Patient Experience Plan and work is underway to enhance awareness of the plan and to implement revised processes around complaints handling within Midlothian. There is an opportunity to consider the alignment of NHS Lothian and Midlothian Council complaints handling processes, and how learning from complaints and feedback has greater priority and visibility in relation to the work to improvement the quality of experience and outcome for Midlothian residents. Complaints are generally managed through the respective organisations’ complaints handling processes and whilst processes and timescales are similar, there are also a range of Elected Member, MP and MSP enquires which tend to be funnelled through a Council route. Generally, these are managed by respective Heads of Service. 3.5 Clinical and Professional Oversight of Care Homes The Scottish Government published My Health, My Care, My Home - Healthcare Framework for Adults Living in Care Homes in June 2022. An Advice Note on Enhanced Collaborative Clinical and care Support for Care Homes issued on 14 December 2022 provides guiding principles and a framework to continue cross sector Page 197 of 302
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Midlothian Integration Joint Board work to continue to improve the health and wellbeing of people living in care homes. Work is continuing at a Midlothian and Lothian basis to ensure these recommendations are met and that partners involved in the delivery of care home services are engaged in shaping the model going forward. The approach will be evolving and iterative, recognising that the role of the HSCP is different to that of the inspection and regulation responsibilities of the Care Inspectorate. 3.6 Inspections The Clinical and Care Governance Group maintains oversight of the inspections undertaken by regulatory bodies, including the monitoring of action plans for improvements. Managers log service inspection reports with their QIT submissions. The Care Inspectorate and Healthcare Improvement Scotland share a common aim that the people of Scotland should experience the best quality health and social care. They work together to deliver programmes of scrutiny and assurance activity that look at the quality of integrated health and social care services and how well those services are delivered. Midlothian’s Health and Social Care Partnership has been given indication that the Care Inspectorate and Healthcare Improvement Scotland will be undertaking a joint adult inspection within their 2023 calendar of scrutiny. Preparation for this inspection has involved incorporating the jointly produced quality improvement framework into our own agenda of a continuous improvement approach. This involves developing a more streamlined system that helps record, analyse, and articulate the HSCPs contribution to improving personal outcomes. Midlothian HSCP and Matter of Focus (Mission led company) have been working together to embed more meaningful outcome focused, evaluation, and performance management across work streams, underpinned by the Matter of Focus software, OutNav. There has been a clear intention to ensure the national indicators used by the Care Inspectorate and Healthcare Improvement Scotland are contained within the system–wide digital outcome map (OutNav). This will allow services to evidence that the support, care, and treatment they provide improves people’s outcomes and experiences. In addition, several working groups have been established to consider benchmarking activity against other recently published inspection reports, particularly in H&SCPs that are within our neighbouring localities. This allows for a self-evaluation and continuous improvement plans to be implemented, ensuring internal governance and assurance is prioritised. Through the QITs, we have begun to have a more systematic approach to managing recommendations from Mental Welfare Commission themed reports. Generally, such reports have a range of actions for Scottish Government, NHS Boards and HSCPs. These are worked into an Action Plan for later submission back to the Mental Welfare Commission. 3.7 Risk Management Midlothian HSCP is compliant with the NHS Lothian Risk Management Policy and Midlothian Council Risk Management Policy and Strategy. The Risk Management process within Midlothian was audited in 2021 and the finalised report confirmed that Page 198 of 302
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Midlothian Integration Joint Board the Risk Management processes within Midlothian provided high assurance and demonstrated best practice in several areas: • Midlothian HSCP Senior Management Team meet every 2 weeks and risk is a standing agenda item. • The Senior Management Team is supported by 4 committees (Business Management Governance, Finance and Performance, Staff Governance and Clinical and Care Governance) each of which have risk as a standing agenda item. • Service level risks registers are locally managed and brought to Business Management Governance for oversight and escalation review. • Risks are routinely monitored through these escalating levels with additional risk reviewed held with Midlothian Council and Midlothian IJB both strategically and operationally. • Each risk recorded either operationally or strategically have actions associated to mitigate the risk, these are routinely monitored through the appropriate level of monitoring as mentioned above. Impacts of actions are monitored by the outcome, where improvement is not measurable, additional actions will be assigned to further mitigate the risk. • Each risk has a risk owner identified who is the accountable person for managing the related actions and providing routine updates on the status of the risk. 3.8 Resilience and Major Incident Planning Midlothian Health and Social Care Partnership supports its partner organisations, NHS Lothian and Midlothian Council, to deliver their obligations as responders to major incidents. The Partnership provides Midlothian IJB with any relevant assurance in relation to incident management and response which supports its’ responsibilities as a Category 1 responder. Midlothian Health and Social Care Partnership maintains major incident plans in line with NHS Lothian’s Resilience Policy and provides assurance through NHS Lothian’s reporting cycle on resilience, major incident planning and business continuity. A virtual control room is in place for incident management. Service Managers are required to review and update their service-specific resilience and business continuity plans which feed into the overarching Midlothian Resilience Plan. During a major incident declared by NHS Lothian on Wednesday, 22nd March 2023, the Midlothian HSCP Resilience plan was implemented providing a robust guidance to all staff groups for relevant operational actions. In reviewing the actions taken there is confidence that no errors or oversight have been identified. Page 199 of 302
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Midlothian Integration Joint Board 3.9 Risk Register Operational risks are captured in the Partnership Risk Register, which is updated and reviewed regularly, and when required escalated to the NHS Lothian Corporate Risk Register and Midlothian Council Strategic Risk Profile. HSCP mitigation plans contribute to the following risks on the NHS Lothian Corporate Risk Register: • Hours Emergency Access Target • Hospital Bed Occupancy (Previously Timely Discharge of Inpatients) • Sustainability of Model of General Practice Council Services risks areas which form part of HSCP mitigation plans are: • Public Protection • Impact assessments of Service Closures / reassignments 4.0 Policy Implications 4.1 This report should provide assurance to the IJB that relevant clinical and care governance policies are appropriately implemented in Midlothian, and that appropriate mechanisms are in place to assess and manage risk and ensure service resilience. 5.0 Directions 5.1 Clinical and care governance and risk management and resilience planning are implicit in various directions that relate to the delivery of care. 6.0 Equalities Implications 6.1 The new Governance and Assurance Framework requires services to provide assurance that they are complying with the Equalities duties including the completion of Integrated Impact Assessments (IIA’s) where necessary. It is anticipated that this will strengthen the ability for the HSCP to comply with its equality’s duties. 7.0 Resource Implications 7.1 Resource implications are identified by managers as part of service development. and additional resource may at times be required to ensure required standards of clinical and care governance, risk management and resilience planning are met. The expectation is that these activities are embedded in service areas and teams and that staff have time built in to attend the relevant oversight groups and undertake the associated responsibilities. Page 200 of 302
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Midlothian Integration Joint Board 8.0 Risk 8.1 This report is intended to keep the IJB informed of governance arrangements and any related risks and to provide assurance to members around improvement and monitoring activity. 8.2 All risks associated with the delivery of services are monitored by managers and where appropriate they are reflected in the risk register. 9.0 Involving people 9.1 Midlothian staff are involved in the development and ongoing monitoring of processes related to clinical and care governance. Public representatives on the IJB will have an opportunity to provide feedback and ideas. 10.0 Background Papers None. AUTHOR’S NAME Fiona Stratton, Hannah Cairns, Nick Clater and Grace Cowan DESIGNATION Chief Nurse, Chief AHP, Heads of Service Adult, and Head of Service Primary Care and Older People CONTACT INFO Fiona.Stratton@nhslothian.scot.nhs.uk Hannah.Cairns@nhslothian.scot.nhs.uk Nick.Clater@midlothian.gov.uk Grace.Cowan@nhslothian.scot.nhs.uk DATE 31st May 2023 Appendices: Appendix 1: Midlothian HSCP Governance and Assurance Framework Appendix 2: Midlothian HSCP Annual Performance Report Correspondence 2022 Page 201 of 302
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NHS LOTHIAN Healthcare Governance Committee 27 September 2022 Fiona Stratton, Chief Nurse, Midlothian HSCP MIDLOTHIAN HEALTH AND SOCIAL CARE PARTNERSHIP: ANNUAL REPORT 1 Purpose of the Report 1.1 The purpose of this report is to recommend that the Committee take moderate assurance that Midlothian Health and Social Care Partnership has robust systems and processes in place to ensure the provision of safe, effective and high-quality care across the Partnership. Any member wishing additional information should contact the Executive Lead in advance of the meeting. 2 Recommendations 2.1 The Committee is recommended to: Take moderate assurance that the Midlothian Health and Social Care Partnership management team have comprehensive systems in place to deliver robust health and care governance across all services. Note the ongoing work to deliver programmes of change and improvement across the Partnership and the governance processes in place to oversee this work, including identification and mitigation of risks to patient safety. 3 Discussion of Key Issues 3.1 Scope of Services 3.1.1 The Midlothian HSCP Core Management Team is responsible for the management and oversight of a range of delegated health and social care services within Midlothian and for two hosted pan Lothian services, Dietetics and the Adults with Complex and Exceptional Needs Service (ACENS). 3.1.2 Delegated services delivered by the HSCP include: Adult Social Work Care homes and Care Home Support Community Learning Disabilities Community Treatment and Care Centres (CTACs) District Nursing Hospital at Home Intermediate care: Home First and Discharge to Assess Page 241 of 302
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2 Midlothian Community Hospital Occupational Therapy Physiotherapy Primary Care (GP, community pharmacy, dentistry and optometry services) Public Health and Health Improvement Sport and leisure Substance Use 3.2 Oversight of quality 3.2.1 The Midlothian HSCP management team have developed a governance structure to ensure that services are provided with management support and that oversight is in place for the management of clinical and care quality and governance. 3.2.2 Fortnightly Senior Management Team meetings chaired by the Joint Director provide ongoing formal oversight of service developments, discussion of emerging issues, and verbal updates are received on adverse events, complaints and performance, risk and resilience issues. 3.2.3 The Midlothian Safety and Experience Action Group (MSEAG) chaired by the Chief Nurse and attended by the Clinical Director, Heads of Service and relevant Service Managers meets fortnightly to manage and have oversight of the review of significant adverse events within Midlothian HSCP. This group undertakes initial consideration of Local Case Reviews into suicides and unexpected deaths of people engaged in mental health and substance use services and commissions external reviews in accordance with NHS Lothian . The group has oversight of performance of the performance in relation to the completion of significant adverse events within timescales and considerable improvement has been made (Chart 1) Chart 1: Significant Adverse Event Reviews Midlothian November 2020- August 2022 Page 242 of 302
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3 Subgroups are established to progress, support and quality assure local reviews of inpatient falls and pressure ulcers. An action tracker is in place to ensure that learning from adverse events is translated into action to improve patient safety. Plans are in development to strengthen the oversight of adverse events and complaints by MSEAG. There is recognition of the need to improve oversight of complaints and adverse events within Midlothian Council services, and to have regular oversight at Partnership level around the reporting of common harms to support early identification of trends and to support improvement actions. 3.2.4 Quality Improvement Teams (QITS) are organised at service level and are chaired by Service Managers. This structure includes the Primary Care Cluster Quality Network of all 12 Midlothian GP practices, chaired by the Cluster Quality Lead and attended by the Clinical Director. QITs are required to meet at least four times per year and are required to provide assurance around the safety, effectiveness and person centredness of the services delivered. This includes oversight of the inspections undertaken by regulatory bodies, including the monitoring of action plans for improvements associated with Healthcare Improvement Scotland inspections and Care Inspectorate Inspections of internally provided regulated services 3.2.5 The QITS report to the quarterly meeting of the Care and Clinical Governance group (CCGG), submitting a standard template covering the dimensions of quality, improvement activity, inspection updates and identifying service level and escalated risks. The CCGG is attended by the Clinical Director, Chief AHP, Heads of Service, Service Mangers, key staff with Quality Improvement, Risk Management and Performance roles and is chaired by the Chief Nurse. 3.2.6 Working groups are established to drive improvement work within Midlothian Community Hospital including Medicines Management, Falls and Food, Fluid and Nutrition. Infection Control is a standing item on the monthly Senior Charge Nurse meeting chaired by the Service Manager and links are maintained between the MCH team and specialist Infection Prevention and Control Nurses. 3.2.7 The NHS Lothian Accreditation and Care Assurance Standards (LACAS) provide a framework to give organisational and service user assurance that quality person- Framework has been developed to promote Quality Assurance activity which can be utilised to positively inform and drive improvement by engaging front line clinical staff in areas of focus. The 5 in-patient areas in Midlothian Community Hospital have implemented the Lothian Accreditation and Care Assurance Standards. Participation has been incremental with 2 areas having completed 3 cycles of assurance, 4 out of 5 participating in the 2nd cycle and all 5 areas completing the cycle in June 2022. The most recent LACAS review cycle identified clear themes, both in good practice and areas for improvement, which will inform quality improvement priorities at both ward and site level. A high standard of care was observed during the Ward Observations visits and a Gold Level of Assurance awarded to Seven Standards. Continuous improvement in standard attainment has been delivered across the 3 Page 243 of 302
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4 cycles, with staff reporting positive experience of involvement in the process and enthusiasm to evidence high standards of person centred and effective care. 3.2.8 Two Pan Lothian services are hosted by Midlothian HSCP, the Adults with Complex and Exceptional Needs Service (ACENS) and Dietetics. Both hosted services have direct operational management from a member of the Senior Management team. 3.2.9 ACENS is under the direct line management of the Chief Nurse who leads on the scrutiny of activity and performance and provides line management and professional support to the Team manager. Finance and performance information is provided within the HSCP and over the last year, more regular reporting to the Lothian Chief Officers has been commenced. ACENS has a local QIT and provides assurance to the Clinical and Care Governance group. ACENS has experienced a significant increase in demand over the last 18 months, and a waiting list has developed. Discussion of concerns around the growing gap between capacity and demand was undertaken with the Midlothian Joint Director/Chief Officer, the Director for Primary and Community Nursing, and the Finance Business partner outlining the complex challenges faced in growing the service to meet demand. The Chief Officers acknowledged the significant progress the service had made to meet demand and address service challenges over recent years. It was agreed that options needed to be developed around a service model and financial framework that would deliver an approach that would ensure safe and sustainable service delivery going forward. This work is being progressed with the expectation that an option paper will 3.2.10 Dietetics is a large service delivering across the 3 acute hospitals and 4 HSCPs. Dieticians work as part of the multidisciplinary teams in a range of settings. Under the new leadership team including the Head of Dietetics, and the Chief Allied Health Professional (AHP) in Midlothian HSCP, development is underway to ensure that all aspects of Dietetics Governance Assurance, Quality and Performance are robustly managed, reportable and improvement orientated. One component of this has been involvement in the initial testing period of the NHS Lothian AHP Governance and Assurance Framework. Several areas of improvement have been identified and will be monitored on an ongoing basis via the monthly Dietetics Service Leads group and more formally on a quarterly basis via the AHP Governance and Assurance Framework submissions. This information will be routinely reported internally via the Midlothian HSCP Clinical and Care Governance Group, have oversight from AHP Director in NHSL and can be made available to other HSCP areas as is necessary and helpful to support oversight of the delivery of this hosted service within their integrated services. 3.2.11 Midlothian HSCP directly manages the Health Visiting Service and the delivery of Immunisations to Children under 5 years. Clinical Governance assurance is delivered through the QIT and the Clinical Care and Governance Group. Midlothian HSCP has invested in the leadership of the service and appointed a Clinical Nurse Manager in February 2022. Improved data quality and availability is driving understanding of the delivery of the Universal Health Visiting Pathway, providing the team with opportunities to benchmark, plan and deliver improvement and developing work to report on Page 244 of 302
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5 outcomes. Midlothian Health Visiting has benefitted from significant investment in Health Visitor training to secure a workforce that aligns to population need, but it is recognised that other partnerships in Lothian continue to experience shortfalls in staffing due to the age profile of their workforce and there is recognition of the imperative to work collaboratively to ensure the wellbeing of our youngest citizens. Pan Lothian work under the oversight and direction of the Children and Young People Health and Wellbeing Board ensures demographic and epidemiological trends inform shared decision making to support workforce and service planning. Health visiting also features in the remit of the Midlothian GIRFEC Board, with managers and Services Plan. 3.2.12 Systems and processes are in place deliver oversight and assurance around the work undertaken within Midlothian HSCP services to improve the safety of people at risk of harm. Public Protection duties are delivered under the oversight of the East and Midlothian Public Protection Committee (EMPPC), and the NHS Lothian Public Protection Action Group (PPAG). The EMPPC is a multi-agency statutory committee which addresses Adult Support and Protection, Child Protection, Violence against Women and Girls and the Multiagency Public Protection Arrangements (MAPPA) for service users in East Lothian and Midlothian. The committee has a wide range of multiagency senior representatives across services and key agencies and reports to the Critical Services Oversight Group (CSOG) where the Chief Officers of core partners provide strategic leadership, scrutiny, governance and direction to the EMPPC. The Committee includes key senior officers from the statutory and third sectors who work in partnership to deliver leadership, expertise and support to scrutinise and improve public protection arrangements. Subgroups progress work around Performance and Quality improvement, Learning and Practice Development, Offender Management and Violence Against Women and Girls. The East Lothian and Midlothian Public Protection Committee and its sub-groups are supported by a team of specialist staff in the East Lothian and Midlothian Public Protection Office (EMPPO) provide leadership, training, quality assurance and advice across the spectrum of public protection responsibilities. Public Protection Action Group sets and oversees the strategic direction of public protection services across NHS Lothian and provides an annual assurance report to the Healthcare Governance Committee around Public Protection. 3.2.13 Work to reduce the harm associated with substance use is a national priority, and multiagency working across East and Midlothian is the approach for the delivery of the Drug and Alcohol Partnership (MELDAP). Recent funding allocated from the Scottish Government has allowed the Partnership to invest further in services with the aim of improving the reach and effectiveness of our substance use service offer. Page 245 of 302
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6 A range of services are in place in Midlothian to assist people who face issues related to their own or others substance use. The MELDAP Strategic Group has multiagency representation and meets 6-weekly to deliver oversight of the performance and quality of a range of services. Midlothian HSCP delivers statutory Substance Use services, including the delivery of Medication Assisted Treatment (MAT), and adherence to MAT standards is subject to the scrutiny of a specialist oversight group. 3.2.14 Plans to Improve Oversight of Quality Midlothian HSCP has the ambition to deliver better care and support for people which delivers best value from the resources invested in health and social care. The HSCP Executive Management Team has committed to implement a Quality Management System (QMS) which will strengthen the links between the clinical and care governance workstreams and the management of performance and resources. The system covers the four domains of Quality Management: Quality Planning, Quality Control, Quality Assurance and Quality Improvement. Implementation of the QMS will require services to produce a service specification, and a service plan which identifies scope of service, resources available, Key Performance Indicators, quality measures and improvement activities which deliver targeted outcomes. Midlothian HSCP is working with the Scottish Government to create service specifications that are aligned to the Framework for Community Health and Social Care Integrated Services. This is an evidence-based framework that determines the foundations for best practice integrated care. This will support the mapping of current delivery, recognise existing good practice, and support self-evaluation to identify service gaps. This will support the implementation of the QMS and inform recommendations to the Board in relation to IJB Directions for 2023/24. An integrated approach will be introduced to provide governance assurance on the four governance domains of Safe, Effective, Person-Centred and Regulation. Governance Assurance will be clearly articulated by those responsible for services and action taken with and by the most appropriate people to address any outstanding issues. This framework will play a clear role in the system of Quality Management in providing Quality Assurance alongside, Quality Planning, Quality Control and Quality Improvement (Figure 1.). Page 246 of 302
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7 3.2.15 Governance and Assurance Framework The implementation of the QMS supports the provision of assurance around the quality of both delegated and hosted services. Development and testing of the Governance and Assurance Framework (GAF) for Allied Health Professionals (AHPs) working in Acute Serv differing operational management lines, reporting arrangements and escalation mechanisms across AHP services. The GAF has been designed to deliver a consistent approach to professional governance and aiming to prevent and reduce the need to duplicate processes and enhance and support use of existing mechanisms. A trial of the system is underway involving AHPs in HSCPs, including Midlothian, and a selection of single system AHP services including the Dietetics service which is hosted in Midlothian. Midlothian HSCP intends to implement the GAF across all hosted and delegated services over the next year. This will be completed electronically and visible on a dashboard accessed by operational and professional leads. 3.2.16 Performance Management The Partnership has recognised that approaches to performance management have not kept pace with the rapid redesign of many services during the pandemic. The Midlothian Performance Assurance and Governance Group (PAGG) has been convened to provide additional capacity outwith the IJB Board meeting to support further scrutiny of performance and support assurance reporting to the IJB. Membership includes Midlothian Local Intelligence Support Team and Midlothian Integration Joint Board (MIJB) members, to ensure representation of Midlothian Council, NHS Lothian and the third sector. Work is underway to design and implement a Performance Measurement Framework based on the 6 dimensions of quality that will provide the PAGG with the right information, in the right format, at the right time, and which will enable informed decision-making at operational and strategic levels. This comprehensive and ambitious programme of work which includes investment in additional performance management capacity will build quality improvement leadership skills and capacity across Partnership services and creates the potential to work with partners in Lothian and further afield to innovate and improve. The work underway to build skills and confidence to analyse a broader range of activity, process and outcome data will provide insights that inform better decision-making across the organisation, and which will ultimately provide enhanced oversight of the quality of care delivered across Midlothian HSCP. Page 247 of 302
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8 3.2.17 Systems and Processes to Identify Concerns about the Quality of Care The Executive Management Team holds brief informal meetings (huddles) three times weekly, and this forum provides an opportunity for any emerging concerns about quality of care to be raised. Activities that feed into this include the oversight of complaints and adverse events by managers and MSEAG, safety huddles, inspection activity, and the use of data around specific harms, including falls, medication errors, and healthcare associated infection. Safe staffing is the component in delivering safe, effective and person- centred care. Compliance with the Safecare staffing tool is monitored and is noted be good. The tool is used as the basis for understanding the staffing position in Midlothian Community Hospital. No other service areas within the Partnership have a real time staffing tool available, but the experience of managing workload and staffing pressures during the Covid-19 pandemic has enhanced local practices in collating and reporting staffing information. These continue to be in use at Service level and can be escalated to deliver assurance as required in the event of resilience or other concerns. The Partnership has developed effective working relationships with the Care Inspectorate, ensuring early action to address emerging concerns in registered services within the Midlothian area. The Midlothian Care Home Support Team has a specific role in supporting the quality of care for residents in the 10 Midlothian care homes. The team has supported recognition of concerns about the quality of care through their own direct work in care homes and their liaison with other professionals. place three times per week and provides senior oversight of emerging issues and improvement work and the opportunity to discuss any concerns raised by care home managers and/ or identified by the Care Home Support Team. This provides a route to discussion and escalation of concerns as required. Where concerns are raised, the relevant senior manager will bring to the EMT at the earliest opportunity, ensuring early senior decision making and a measured and proportionate response. Examples include the establishment of a weekly oversight group to monitor action plans around staffing and capacity in home care services, the service level response to administration errors in a vaccination centre and the enactment of processes to establish multiagency and large-scale enquiry processes around care concerns in care homes. Following recognition of concerns around staffing and service delivery and common themes emerging from complaints regarding the community dementia team, plans were developed and implemented to provide immediate support to the team. The Executive Team subsequently approved the proposal to establish a team, including external specialists, to undertake a review of the service and present proposals to the Senior leadership team within the next 3 months. The approaches described above ensure a clear escalation process through senior managers concerning quality of care issues. In the event that a member of staff felt unable to raise concerns around the quality of care, concerns can be raised through Page 248 of 302
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9 Partnership representatives, direct contact with the Chief Nurse, Chief AHP or Chief Social Worker, or alternatively through NHS Lothian speak up advocates . If all other routes are exhausted, the formal whistleblowing procedures of NHS Lothian or Midlothian Council provide a confidential route for concerns to be raised. The Governance and Assurance framework and the developing performance management framework described in this paper will build on existing systems and processes to provide improved oversight of the quality of care across all services and increased sensitivity to indicators that may identify concerns around the quality of care. 3.3 Monitoring Service Quality Outcomes 3.3.1 Services in MHSCP report service quality outcomes internally through Quality Improvement Teams to the Care and Clinical Governance Group. Opportunities to reduce variation in the approach to the reporting of quality outcomes and performance to deliver targets and standards has been recognised, and work to deliver a more consistent approach is underway. 3.3.2 The implementation of the Governance and Assurance and Performance Management frameworks described in this paper will take forward work that will ultimately support all MHSCP services to report an evidenced level of impact and assurance that relates to a service specification and objective targets and standards. 3.3.3 A quality planning approach has been adopted to five spotlight areas of work in year one of the (draft) MIJB Strategic Plan 2022-2025 and a system for planning, monitoring and reporting has been established. The first year of the plan are: Frailty Midlothian Community Hospital Primary Care Mental Health and Learning Disabilities, and Workforce Staff working in these five focus areas are already involved in work to test ideas and improve and share lessons to evidence the delivery of high-quality care. Integrated Project Management support has been invested in to accelerate the progress of existing service workplans, workforce development plans, individual appraisals and PDPs. To avoid additional layers of scrutiny and make best use of existing mechanisms, oversight of this work is located within existing Planning, Performance and Programme functions, providing structured opportunities to share learning across all five areas with monthly reporting to SMT and SPG (bi-monthly to IJB). Each spotlight group will ensure that cross cutting enablers and Digital, are embedded in the planning process. The approach has been designed to create opportunities for teams to develop and test new ways of working, aligned with other programmes (e.g. LACAS). 3.3.4 The Partnership is continuing work with its third-party partner, Matter of Focus, on outcome mapping using the OutNav approach. Work to develop quality management and performance measurement approaches and to relate these to IJB Directions, sits Page 249 of 302
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10 alongside work on OutNav to capture and link a wide range of evidence for evaluating progress in delivering outcomes. 3.3.5 MHSCP services are subject to external inspections from statutory bodies. This includes Healthcare Improvement Scotland, the Mental Welfare Commission and the Care Inspectorate. These reports are noted at the SMT and reported through the QITs and CCGG. Immediate action is taken where internal concerns or external inspections identify improvements are required to address standards of care. Operational and professional leads have shared oversight of action plans. Implementation is led by Service Managers and progress monitored and supported through operational and care and clinical governance routes, ensuring the implementation of actions which deliver sustainable improvement. 3.3.6 The development of primary care service re-design in the context of delivery of the new GMS contract 2018 is being planned with the seven key principles of Quality in mind. This change has already started with the move away from clinical assurance provided by the previous Quality and Outcomes Framework (QOF) introduced in the 2004 GMS contract. The new approach was introduced by the GMS Statement of Financial Entitlements for 2016-17 and sees all 12 of our local GP practices working together in a single Quality Cluster with the HSCP and NHS Lothian to identify local priorities to improve the quality of services and outcomes for people. 3.4 Impact on People Experiencing Care 3.4.1 Gathering and Responding to Feedback Services across Midlothian HSCP are utilising a range of approaches to gather and respond to feedback from people who use our services, their families and carers. These are reported by services through their QITs to the CCGG. Some examples include: Care Opinion is promoted for those who use Midlothian Community Hospital and the Hospital at Home service. Feedback is relayed to relevant staff who utilise learning to drive change and improvement. Work is ongoing to explore the potential for Care Opinion to be used more widely across Partnership services. Earlier this year, the team at Midlothian Community Hospital undertook a survey of stakeholders asking, What matters to you about Midlothian Community Hospital? e team received predominantly positive feedback, with the main request being that the Community Hospital be resourced to provide a wider range of services for local people. The survey identified that stakeholders find the hospital takes a person-centred approach, staff are kind and care is provided in an environment that is clean and welcoming. A creative approach to the feedback was taken and word clouds, wardles, were developed and framed to provide ward staff with a daily reminder of the positive difference they have made to patients and their families. A project to develop an understanding of the experience of people whose family Page 250 of 302
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11 member received end of life care in Midlothian Community Hospital or from the Midlothian District Nursing Service is nearing completion. The project, funded by the Scottish Government, has taken an experience-based co-design approach, and the final report is in preparation. Staff involved in the project have found the positive feedback on the end of life care they provided encouraging at a time where demand and capacity present daily challenges and where staff may question the impact they have. A huge amount of data has been gathered and the potential to use this to further understand and improve the delivery of end-of- life care is being explored. Learning from these projects, and those undertaken in other services, will continue to be shared with the aim of promoting ongoing work to gain meaningful feedback which can be sued to shape and improve our services. 3.4.2 Managing and Learning from Complaints All Midlothian HSCP services, including Primary Care, have a formal complaints procedure which is advertised and made available to patients on their request, and a standardised process is followed to deliver a response to the complainant within set time scale. Midlothian HSCP receives a small number of complaints and the systems for oversight and scrutiny aim to improve our performance to deliver responses to S targets. Chart 1 show 74 complaints received about NHS services within the partnership over the 3-year period August 2019 July 2022, with a stable median of 1 complaint received per month (Chart 2) It should be noted that independent contractor GP practices handle their own complaints separately, and complaints made about MHSCP services via Midlothian Council are not included in this data. Plans are in development to develop integrated oversight of complaints across all MHSCP services. Page 251 of 302
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12 The fortnightly SMT has oversight of response times for complaints, ensuring real time actions are agreed to respond to the concerns people raise about the care provided. A Lothian wide short life working group is underway to address improvement in complaints handling and it is expected this will be rolled out in Midlothian within the next 6 months. The development of MSEAG provides an opportunity to consider the alignment of NHS and MLC complaints handling processes, and how learning from complaints and feedback has greater priority and visibility in relation to the work to improvement the quality of experience and outcome for Midlothian residents. 3.5 Impact on Staff 3.5.1 Midlothian HSCP recognises our workforce as our greatest asset but in line with the national picture, recruiting and retaining the workforce we need to deliver our ambitions represents our biggest challenge. The Senior Management Team is prioritising workforce engagement, continued investment in our Wellbeing Lead post and the development of our HSCP workforce plan. 3.5.2 A range of mechanisms are in place to hear staff experience including team meetings, leadership walk rounds, iMatter and exit questionnaires and the Trickle app reported last year. NHS Lothian Partnership and Midlothian Council Staff Side representatives attend fortnightly Senior Management Team meetings and provide valuable input into discussions and decisions. A regular Partnership meeting, chaired by the lead Partnership representative, ensures a particular focus on staff experience and views. 3.5.3 Awareness has developed of issues that are important to our staff group and of work needed to support improved staff engagement. Our teams continue to face the challenges associated with the COVID-19 pandemic, workforce pressures and increasing demand and complexity in the context of concerns around the cost of living, climate change and geo-political instability. A Senior Manager is taking forward work on a Communication and Engagement Strategy and a Communication Plan which will deliver a more cohesive approach, offering staff across the partnership opportunities to identify how they would like to give and receive information. While Executi provide focused time for front line practitioners to meet and discuss their experience of delivering care to people in Midlothian with Senior Managers. 3.6 Delivery of Safe Care 3.6.1 Learning from Adverse Events Organisation and system-wide learning from adverse events and complaints is a critical component of improving the quality of care. The Midlothian Safety and Experience Action Group (MSEAG) has driven work to improve performance in relation to the completion of Significant Adverse Event (SAE) reviews to meet . This has reduced the time taken to identify and address factors that contributed to the adverse event to prevent similar harm occurring in future. Page 252 of 302
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13 SMT receives fortnightly updates on performance for all adverse events. While SAE review performance against timescales is much improved, work is continuing to maintain performance and assure the quality of the reviews. A programme of training will be delivered in September and October for all managers involved in the review of adverse events with the aim of improving the quality of investigation, action planning for improvement and shared learning. Chart 3 illustrates the reporting of all adverse events in Midlothian HSCP with the increased median noted last year remaining stable. Chart 4 illustrates that the adverse events resulting in major and moderate harm are maintained at a stable median. Chart 5 illustrates the breakdown of adverse events with serious harm by category. The Lothian Accreditation and Care Assurance Framework (LACAS) is now fully implemented in Midlothian Community Hospital, and supports the monitoring of the most common harms. LACAS improvement work and a Falls Improvement Working Group support ongoing work to address underlying causes of harm. Working Groups chaired by Service Managers bring a range of perspectives to the investigations into Page 253 of 302
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14 the occurrence of pressure ulcers and falls with serious harm. These groups are tasked to ensure learning is shared within and beyond the relevant service area. 3.6.2 Drug-related Deaths in Midlothian In 2021, 23 drug-related deaths were recorded in Midlothian, of those, 16 were men and 7 women. This represents an increase of 2 from 2020. eflect national data which shows that there was reduction in male deaths but an increase in female deaths. Data has identified that 14 (61%) of the people whose deaths were identified as drug related were not involved in services. The development of the assertive outreach model and work to increase the numbers of people who use substances to engage with services is critical and is being taken forward within Midlothian HSCP, with additional investment as described earlier in this report. Midlothian teams work with local partners delivering a range of initiatives to support people and reduce the harmful impact of long-term drug use. A holistic approach which addresses housing needs, family support and providing person-centred treatment is adopted alongside education, training and employment opportunities. Work is underway to create a more robust performance culture, improved use of measurement and further work to implement evidence-based approaches which have been shown to reduce drug related deaths. 3.7 Equitable care 3.7.1 An imperative for Health and Social Care Partnerships is their work at a population, community, and individual level to address inequality. Midlothian HSCP has developed effective integrated working and strong relationships with colleagues in Page 254 of 302
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15 Health Directorate to progress this objective. This enables cross cutting, integrated work across our services as evidenced in our Strategic Plan. The Partnership and the Integration Joint Board are conscious that the COVID 19 pandemic has magnified health inequalities, and work continues to address the impact of this at strategic and operational levels. 3.7.2 The Joint Strategic Needs Assessment provides equality data to aid understanding of current and emerging needs and support planning and action to address inequalities. Integrated Impact Assessment (IIAs) are a requirement for new policies and proposed service changes. With the implementation of the new Strategic Plan and the programme of recovery from the impacts of the pandemic, we anticipate an increase in the number of IIAs required. Training on IIAs is delivered by Midlothian Council available to Midlothian HSCP staff and volunteers. 3.7.3 The Partnership recognises the importance of building expertise to embed equality and rights in service design, delivery and review. Training is available to colleagues across the HSCP to improve their understanding, knowledge and skills around equality and diversity as well as an understanding of the public sector equality duty and its relevance to their roles. Our approach to the recommissioning of the care at home service included training for staff from the British Institute of Human Rights and build on this experience for future commissioning by the HSCP. 3.7.4 Membership of The Midlothian Council Equalities Forum will be extended to Midlothian HSCP employees. This Forum is made up of employees representing all nine protected characteristics, and others who support the aims of the forum. The forum will be supported by the Equalities Engagement Officer and Corporate Equality, Diversity & Human Rights Officer. It works to embed equality and fairness of opportunity across the council and HSCP, and to contribute to employee and community equality initiatives. Where required equality and diversity training will be provided to Forum members. 3.7.5 The Health and Social Care Partnership Website continues to be developed to ensure a wide range of information on the services provided is accessible to those with digital access. This includes Reachdeck which aims to help improve the accessibility, readability and reach of online content. 3.7.6 A small study undertaken in in 2021 evidenced the need to address digital exclusion in Midlothian. In response, digital is progressing to support people who want to, to access health and social care digitally. Training was developed and offered to HSCP and third sector staff working locally. Digital inclusion now forms part of the Midlothian HSCP Digital Implementation and Delivery Plan 2022-25. Collaborative work is progressing with the Community Planning Partnership to increase opportunities for people to have access to a device, connectivity, the means to pay for it, and basic digital skills. 3.7.7 The Partnership continues to invest in the provision of the Health Inclusion Team, providing 1:1 and group support from specialist Nurse Practitioners to support: people in homeless accommodation, people in receipt of justice services, carers, Page 255 of 302
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16 people in receipt of drug and alcohol services, Gypsy Travellers people <55yrs who have had more than 3 attendances at emergency departments in the Lothians within the last year. 3.7.8 The Mental Health, Substance Use, Public Health Practitioners, Health Visiting and Vaccination teams are examples of services who have actively developed approaches to address the access and uptake of services by groups in our communities who are less likely to access services and experience poorer outcomes as a result. 3.8 Workforce Management and Support 3.8.1 Workforce capacity is the key risk in the delivery of safe, effective and person-centred care. Extensive work has been undertaken to develop Midlothian HSCP Draft Workforce Strategy which was submitted to the Scottish Government at the end of July 2022. Work will continue in the autumn to finalise and implement this once feedback is received. 3.8.2 The development of the Strategy has prompted a review of our staff governance infrastructure and identified the work needed to address gaps in the data available to us. The lack of comparable data across all occupational groups limits our ability to critically examine the current workforce position in totality, thereby supporting integrated planning for future workforce requirements. Nursing and AHP workforce planning is at a more advanced stage than for other occupational groups, with work progressing to ensure compliance with Safe Staffing legislation, and to develop creative approaches to service needs including Advanced practice and Non- registered roles. 3.8.3 Detailed plans have been developed at a partnership level for services to support the Primary care Improvement Plan, in particular the development of pharmacotherapy, Musculo-skeletal and Community Treatment and Care (CTAC) services. Additional information about this is provided in section 5.2. The Executive Management Team has committed to implement a refreshed workforce planning and governance infrastructure supported by investment in capacity to deliver on our workforce planning needs. 3.8.4 Training and development plans are developed at a service level, commissioning and providing a range of education and training opportunities for staff. The Governance and Assurance Framework and Quality management approach will bring a more cohesive approach to understanding and providing assurance in relation 3.8.5 Midlothian HSCP has invested in the establishment of a Clinical Educator post in Midlothian Community Hospital as an approach to supporting staff in the workplace. This role increases the support staff have to maximise skills and learning in practice and carries a remit for non-registered and registered staff and students. Evaluation of the role will address some of our assumptions on recruitment, retention and the support available for staff to provide quality care. Although the post has only been in place for 2 months, the early evidence of impact on induction processes, practice Page 256 of 302
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17 learning for students, data availability on staff training and observed care and documentation is encouraging. With workforce challenges driving the need for innovative approaches to attract, train and nurture our teams, the evaluation of this post will support the Partnership in delivering its ambitions to ensure staff are skilled and supported to provide high quality care as close to home as possible. 3.8.6 Wellbeing Delivery Plan Wellbeing Lead post continues with the A Staff Wellbeing Delivery Plan has been implemented over the last year covering the domains of engagement, communication, access to support, leadership, mental wellbeing and environment. Initiatives include work to improve access to essential facilities for all community- based staff, a range of health awareness and health promoting activities, work to develop the availability of peer support and to improve awareness and uptake of mental health and wellbeing services. 3.9 Quality Improvement-based Leadership 3.9.1 Midlothian HSCP has made progress in developing a more cohesive and consistent approach to Quality Improvement based leadership. The implementation of the Quality Management System and the work on our Spotlight Programme and Performance Framework will enable us to address this is a methodical and consistent manner. This report has already described examples where staff are developing the knowledge and skills to enable them to test ideas and improve and share lessons to deliver high quality care, and some examples are provided below. This will be more widespread as services develop annual improvement plans. 3.9.2 A key enabler of Quality Improvement based leadership in Midlothian is our digital transformation programme, and is evidenced by the recent appointment of a Digital Programme Manager. In Midlothian, Digital is framed as a way of doing things which enhances our ability to deliver person centred services by creating the conditions to respond to the challenges we face in a consistent, high quality, and progressive way. Digital is cross cutting through all our work, with the expectation that service design and development is enabled by technology, creating value in new ways. Digital will support: The creation of new models of care Designing and deliver the best possible user experience with increased access and choices Developing technology-enhanced business processes and planning Supporting our staff, partners, and citizens to use and develop the confidence, knowledge, and skills to be involved. The Midlothian HSCP Digital Programme and Oversight Board is established to co- ordinate, direct, and oversee all digital activities and the structure includes a Senior Responsible Officer, The Chief Allied Health Professional (AHP)who provides a direct link to the Senior Management Team (SMT). Page 257 of 302
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18 3.9.3 A multidisciplinary group involving clinical staff and managers from a range of services meets quarterly to have oversight of palliative and end of life care services. This is supported by links to the Lothian Palliative Care Managed Clinical Network. The group provides an opportunity to consider available data, identify gaps, share good practice, promote education and awareness and support quality improvement. Examples include: the implementation of a new pain assessment tool within Midlothian Community Hospital which has some potential for use in care home settings. Community Respiratory Team participation in a multidisciplinary meeting with hospice and community clinicians which aims to improve pathways for patients with severe Chronic Obstructive Pulmonary Disease (COPD) with the aim of delivering the most appropriate and holistic support in appropriate settings. a project to improve the quality and quantity of Anticipatory Care Plans in care home settings A Scottish Government funded evaluation and co-design approach to capturing feedback from families whose relative received end of life care from the Midlothian District nursing Service or in Midlothian Community Hospital which is nearing completion. 3.9.4 Midlothian has been exploring work to improve access, experience and outcomes for A programme of data driven improvement work has been progressed by a multidisciplinary group of clinicians and managers. The 'top 5' admission reasons for bed days for unplanned admissions were identified, and improvement cycles to progress understanding and drive change in pathways for the management of heart failure, COPD, cellulitis, pneumonia / flu and diabetic complications have made tangible differences to pathways, patient experience and bed utilisation. 4.0 Key Risks 4.1 The Midlothian HSCP Strategic Risk Register identifies a number of risks and the key risks are identified as: Capacity of to meet increased demand due to increasing population, age, and frailty addressed in the Primary Care Improvement Plan and on the NHS Lothian Corporate Risk register, see also section 5. Lack of availability of workforce with appropriate qualifications or skills, including General Practitioners, Staff Nurses, Advanced Nurse Practitioners, Advanced Physiotherapy Practitioners, District Nurses, and Social Care Workers - addressed in the HSCP Workforce Strategy. While concerns exist across all groups and reflects the National picture, District Nursing and Social care workers are a significant current concern. Emergency admissions and Delayed Discharges, particularly in relation to care at home capacity addressed through Care at Home recommissioning, Delayed Discharge plans and Acute Services Planning and Strategic Plans. Despite growth in care at home capacity, demand continues to outstrip the rate of workforce supply. Page 258 of 302
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19 4.2 Oversight of Risk Management As a division of NHS Lothian, Midlothian HSCP is compliant with the NHS Lothian Risk Management Policy. The Risk Management process within Midlothian was audited in 2021 and the finalised report confirmed that the Risk Management processes within Midlothian provided high assurance and demonstrated best practice in several areas: Midlothian HSCP Senior Management Team meet every 2 weeks and risk is a standing agenda item. The Senior Management Team is supported by 4 committees (Business Management Governance, Finance and Performance, Staff Governance and Clinical Care Governance) each of which have risk as a standing agenda item. Service level risks registers are locally managed and brought to Business Management Governance for oversight and escalation review. Risks are routinely monitored through these escalating levels with additional risk reviewed held with Midlothian Council and Midlothian IJB both strategically and operationally. Each risk recorded either operationally or strategically have actions associated to mitigate the risk, these are routinely monitored through the appropriate level of monitoring as mentioned above. Impacts of actions are monitored by the outcome, where improvement is not measurable, additional actions will be assigned to further mitigate the risk. Each risk has a risk owner identified who is the accountable person for managing the related actions and providing routine updates on the status of the risk. 4.3 Resilience and Major Incident Planning Midlothian Health and Social Care Partnership supports its partner organisations, NHS Lothian and Midlothian Council, to deliver their obligations as Category 1 responders. The Partnership provides Midlothian IJB with any relevant assurance in relation to incident management and response which supports its roles as a Category 1 responder. Midlothian Health and Social Care Partnership maintains major incident plans in line reporting cycle on resilience, major incident planning and business continuity. A virtual control room is in place for incident management. Service Managers are required to review and update their service-specific resilience and business continuity plans which feed into the overarching Midlothian Resilience Plan. 5.0 Risk Register 5.1 There are no new risks for the NHS Lothian Risk Register. Operational risks are captured in the Partnership Risk Register, which is updated and reviewed regularly, and when required escalated to the NHS Lothian Corporate Risk Register. Page 259 of 302
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20 5.2 HSCP mitigation plans contribute to the following risks on the NHS Lothian Corporate Risk Register: 5186 4 Hours Emergency Access Target 5187 Hospital Bed Occupancy (Previously Timely Discharge of Inpatients) 3829 Sustainability of Model of General Practice 5.3 4 Hours Emergency Access Target Midlothian HSCP has put in place strategic and operational mechanisms to mitigate risks associated with the 4-hour access target. A data driven approach identifying the most common presentations has been adopted to target effort where it will have most effect. The has developed to track admissions, including the development of a single point of access. This supports our Discharge to Assess team to patients from the Emergency Department as well as from the inpatient setting. Work described earlier in this paper around Preventable has been progressed to develop and promote alternatives to Emergency Department attendance, and a range of service responses have been put in place. 5.4 Hospital Bed Occupancy (Previously Timely Discharge of Inpatients) Midlothian has invested in substantial infrastructure to support clinically effective pathways which provide care as close to home as possible and thereby mitigate risks associated with hospital bed occupancy. This work is being further developed through our engagement with the programme of work on Discharge without Delay and is delivered through integrated, multiagency approaches which link with third sector capacity and carer support. In-patient admissions to acute services are tracked by our This supports identification of patients who can receive their treatment at home under the care of the Discharge to Assess or Hospital at Home teams, or who can receive their care in Midlothian Community Hospital where the Partnership has maintained the 20 additional beds in Glenlee ward. Capacity in both Hospital at Home and Discharge to Assess has been developed to support flow by providing alternatives to hospital-based care for Midlothian residents, which includes acute care at home, rehabilitation to support early discharge and bridging care at home packages. The In-reach social work team supports early discharge planning for patients who have complex and longer-term care needs. 5.5 A comprehensive analysis of the progress and risks associated with sustainability of the model of General Practice in Midlothian has been undertaken by the newly appointed Clinical Director. The Primary Care Improvement Plan has the oversight of the Midlothian Primary Care Planning group, The Director of Primary Care and the LMC. 5.5.1 Progressing well The latest revision of the Midlothian Primary Care Improvement Plan was reviewed and approved by the Lothian GP sub-committee earlier this year. Page 260 of 302
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21 There are currently no closed practice lists in Midlothian (although some remain partially restricted) and no directly managed section 2C practices. A full premises review has been undertaken. Financial assistance has been given several practices to assist with premise alterations to accommodate new PCIP staff. Plans are in progress for the HSCP to employ 2 full-time salaried GPs to support practices identified as facing the most significant risk to the GMS contract All 12 practices have Musculo-Skeletal Advanced Physiotherapy Practitioner services in place. Full Community Treatment and Care (CTAC) access is in place and partial access to phlebotomy and chronic disease monitoring data collection is in place across all 12 practices. All vaccines have been transferred from all 12 practices and all have partial access to Primary Care Mental Health Nurses. Partial level 1 Pharmacotherapy services including Medicines Reconciliation in place across all 12 practices. eart failure, and local frailty initiatives and improvement work in anticipatory care planning and identifying patients who should be on the palliative care register are examples of work that is progressing well to address our growing and ageing population. 5.5.2 Particular challenges The rapid growth and projected age profile of the Midlothian population is more marked than the Scottish average and creates considerable challenges around the mismatch between demand and capacity in Primary Care. The 2022/23 funding allocation is not enough for full delivery of Memorandum of Understanding (MOU2) ambitions, in particular full delivery of pharmacotherapy services. There is risk that funding may be lost (or shifted laterally away from frontline primary care) if there is ongoing recruitment failure due to national workforce shortages. A workforce survey was undertaken earlier this year which enabled the collation of a detailed overview of the Primary Care workforce challenges faced in in Midlothian. Vacancies across General Practitioner and Practice Nurse roles are well understood and these reflect the national picture and feed into recruitment and workforce development activity. Work is underway to deliver workforce wellbeing initiatives for all staff groups. Options to develop multidisciplinary skill mix, including the potential of engaging paramedics for cross-locality home visits, and Advanced Nurse Practitioners (ANP) for urgent care are under consideration although ambitions are set in the context of understanding the national picture of workforce availability. 6.0 Impact on Inequality, Including Health Inequalities There are no new actions arising from this report which would require the completion of an impact assessment. 7.0 Duty to Inform, Engage and Consult People who use our Services Page 261 of 302
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22 There are no specific changes proposed within this paper which would have an impact upon service users, however the committee should take assurance that the Service continues to maintain an active dialogue with all key stakeholders and consults widely on all service changes as required. 8.0 Resource Implications There are no resource implications arising from the contents of this paper. Fiona Stratton Chief Nurse, Midlothian HSCP 14th September 2022 fiona.stratton@nhslothian.scot.nhs.uk Page 262 of 302
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Midlothian Integration Joint Board Thursday, 22nd June 2023, 14:00-16:00. Director of Public Health Annual Report and Planned Midlothian Response Executive summary A presentation will be delivered by Jim Sherval, Consultant in Public Health, on the recent NHS Lothian Director of Public Health Annual Report 2022. The report is detailed in Appendix 1 and is intended to inform the Board so that discussions as to the potential Midlothian response can be explored at the meeting. Members are asked to: • Review and note the findings in the NHS Lothian Director of Public Health Annual Report; and • Consider the implications for Midlothian. # Appendices: Appendix 1: NHS Lothian Director of Public Health Annual Report 2022. Item number: 5.9 Page 263 of 302
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NHS Lothian Director of Public Health Annual Report 2022 PB 1 NHS Lothian Director of Public Health Annual Report 2022 Page 265 of 302
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NHS Lothian Director of Public Health Annual Report 2022 1 Contents Introduction ...............................................................................................................................1 Health and social inequalities in Lothian: understanding the needs of our population ............................................................................4 The role of public health partnerships in improving population health and reducing inequalities ..........................................................................17 Cost of living crisis: a partnership response ..........................................................................18 Child poverty and early years .................................................................................................21 Conclusion ..............................................................................................................................24 Improving and protecting the health of the people of Lothian ....................................................................................................................25 References ...............................................................................................................................26 Authors: Philip Conaglen Katie Dee Martin Higgins Dona Milne Ross Whitehead Page 266 of 302
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NHS Lothian Director of Public Health Annual Report 2022 1 Introduction Austerity, a pandemic and a cost of living crisis The Director of Public Health has a responsibility to ensure that the needs of the population are considered regularly as part of local and national policy developments. One of the ways in which this is done is through the production of an annual report that explains who our population are, what affects their health and what the evidence tells us that we should do to improve health outcomes. It is important that all of us working to improve health understand the issues facing our local population. We want our public health teams locally, and the public and voluntary and community sector partners that we work with, to share our understanding of population health needs and for us all to work together to prevent future ill health and reduce inequalities. Shared understanding of need and what can make a difference is the first step in focusing our efforts on actions that will achieve real change and a positive impact. As a Public Health department, our responsibility is to improve and protect the health of everyone living in Lothian. Some people live long, largely healthy lives. But a significant number of people live more difficult lives, have poor health and die younger than they should. We know the things that people need to be healthy: a nurturing, safe, secure childhood, enough money, a decent home, a decent job, a good education and a sense of control and belonging. It is public health specialists’ role to recognise what everyone needs for good health and to identify what needs to happen to make a difference for the people whose health is poor. Unfortunately, the last decade has seen disruption to the lives of people within the UK: the negative impacts of austerity, EU Exit, a pandemic and a cost of living crisis have led to a period of instability and uncertainty for us all. These social and economic trends were evident even before the onset of the COVID-19 pandemic and the associated health impacts have been exacerbated since. These have had a significant impact on people’s physical and mental health and these impacts are likely to be seen for some time. There has been a disproportionate impact on those who are socioeconomically disadvantaged and who subsequently bear a higher burden of ill health. Average life expectancy in Scotland has stalled since 2013,[17] a phenomenon driven mostly by declining life expectancy among the most deprived communities in the country.[21, 22] In Lothian, the trends are broadly similar to what has been happening across Scotland as Figure 1 shows. Although life expectancy in Lothian is typically slightly above the Scottish average, aggregate figures mask wide inequalities in life expectancy (see Figures 11-14), particularly for males. For instance, in the City of Edinburgh, males living in the most deprived areas live an average of 12 fewer years than those living in the least deprived areas (2016-2020 averages of 71.3 vs 83.1 years respectively). These outcomes are the result of ‘systematic, unfair differences in the health of the population that occur across social classes or population groups’. People from lower socio-economic positions, ethnic minority populations, people living with disabilities, care-experienced people Page 267 of 302
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NHS Lothian Director of Public Health Annual Report 2022 2 and other vulnerable populations more commonly experience poor health.[23] The causes of stalling life expectancy have been associated with a number of explanations including a cohort effect relating to drug related deaths, high winter mortality[24] and most compellingly, the impacts of the UK government’s austerity programme.[25, 26] Research highlights that social circumstances rather than behavioural choices are the most influential determinants of health inequalities and are therefore the most promising levers for change. An accumulation of positive and negative effects on health and wellbeing contribute to widening inequalities across the life course.[27] In particular, early years are crucial to health later in life and it is now apparent that adverse childhood experience manifests as multiple negative adult health impacts.[28, 29] The impacts of chronic stress, precipitated by poor quality employment or poverty for example, create many physical and mental health problems. Being homeless also increases the risk of poorer health; during 2021/22, more than 4,200 people in Lothian were assessed as homeless or at risk of homelessness.[30-33] The intersection of different experiences and life circumstances drives inequality and poverty at an individual and population level. This results in differences in individual experiences of, for example, discrimination, prejudice, stigma, low income, and opportunities. We need to move away from perceptions that these circumstances are based on lifestyle choices: they are not and the people most affected have the least control over these circumstances. !" !# !$ !% !& &" &# &$ '((# '(($ '((% '((& #""" #""# #""$ #""% #""& #"'" #"'# #"'$ #"'% #"'& #"#" !"#$%$&'$()*+(,%*)%-".)/%0,$*.12 3$*. !"#$%&'()'*"+&'&,-&./01.2'0/'3"%/4'5(66787979:' !"#$%"&'()*+,-$. !"#$%"&'(/0*+%$.1 2$%"&'()*+,-$. 2$%"&'(/0*+%$.1 Page 268 of 302
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NHS Lothian Director of Public Health Annual Report 2022 2 3 This report provides a summary of key demographics of the Lothian population, some key health outcomes and their social determinants. We intend this report to be a useful source of demographic information for public, voluntary and community sector partners in Lothian to shape local policy and service discussions. We have deliberately chosen to focus on inequalities and deprivation at this time as they are the biggest influences on population health. This annual report also has a particular focus on what we can do to reduce inequalities through our immediate response with our partners, to the cost of living crisis and our longer term efforts to improve children’s early years and to reduce child poverty as examples of work underway in Lothian to address inequalities and improve population health. Of course, the work of public health in Lothian spans many more areas of work than we have featured here. We have responsibility for the oversight of significant population health initiatives such as all immunisation programmes, pharmaceutical and dental public health, national screening programmes, delivery of an effective health protection function alongside services such as Healthy Respect, Maternal and Infant Nutrition and Quit Your Way, our smoking cessation service. There are reports for all of these services available separately. Those of you that are interested in finding out more about the work of the Public Health Department in Lothian, should visit our webpages at https://weare.nhslothian. scot/publichealth. Dona Milne Director of Public Health and Health Policy, NHS Lothian COVID-19 pandemic impacts COVID-19 exacerbated existing health and social inequalities in Lothian and Scotland.[1-4] Those in insecure employment, unable to work from home, experiencing digital exclusion, lacking financial and other resources such as their own transport, were worst equipped to follow isolation and distancing guidelines. In turn this meant they were more exposed to and more susceptible to the negative social and health impacts associated with COVID-19. [5-7] Males, people aged 70 years and older, people working in lower paid jobs [8] and people from some ethnic minority groups are more likely to die from COVID-19 than other population groups. [9-14] The impacts of institutional racism – poorer housing conditions, lower paid jobs, more unemployment – manifest themselves in terms of greater risk from COVID infection and a harder financial and social impact associated with loss of income and unemployment. Crucially, the higher mortality risk for people from ethnic minority groups is not explained by biological differences but social determinants.[2, 9, 10, 15, 16] National Records of Scotland data indicate that people from the most deprived communities are 2.4 times more likely than the least deprived to die from COVID-19; the size of this gap widened from 2.1 to 2.4 as the pandemic progressed.[18] There is also evidence of longer-term health complications from Long COVID.[19, 20] Page 269 of 302
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NHS Lothian Director of Public Health Annual Report 2022
4
Health and social inequalities in Lothian:
understanding the needs of our population
Demography
As of mid-2021, Lothian has a total population of 916,310, representing an increase of around
17.6% since mid-2001.[34] Figure 2 presents a breakdown of Lothian’s population by age and
local authority.
Lothian has a similar proportion of under 16-year-olds as the rest of Scotland (16.6%), but the
population aged 16-64 is slightly larger than seen in Scotland, largely due to the working-age
population in and around Edinburgh. The proportion of the population over 64 years old is
slightly smaller than seen nationally.
National Records of Scotland (NRS) projects that by 2033, the population of Lothian will
have risen to 989,285, a rise of 8% compared to 2021.[35] 80% of the population increase in
Scotland as a whole between 2021 and 2033 is projected to happen in Lothian. Across Lothian,
a small reduction in the under 16 population is projected (-2.8% between 2018 and 2033), with
increases in the working age1 and pensionable age groups of 11.0% and 20.4%, respectively.
Figure 3 presents a breakdown of these projected population changes between 2018 and
2023 by age group and local authority.
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NHS Lothian Director of Public Health Annual Report 2022 5 These projections highlight potential reductions in the under 16 population (owing to reductions in birth rate) for most of Lothian’s local authority areas except Midlothian, where the proportion of this age group is expected to rise by 13%. The proportion of the population that is working-age is not expected to rise considerably across Scotland; however, the size of this age group is projected to rise by 11% across Lothian. This reflects migration to the region for study and work, particularly from overseas (NRS projects net migration of 57,379 into Lothian between 2018 and 2028, of which 45,523 are expected from overseas). Across Lothian’s local authority areas, increases of at least 17% are projected in the proportion of the population aged 65 and over. These projections highlight ongoing change in the demographic profile of Lothian, and a shift in the ratio of economically active to economically inactive individuals. This will necessitate adaptation of health and social care services and increased focus on the prevention and management of long-term illnesses. People experiencing deprivation in Lothian In comparison with the rest of Scotland, Lothian has proportionately fewer areas classified among the most deprived in the country. Around 11% of Lothian’s population, just over 100,000 people, live in areas categorised as among the 20% most deprived in Scotland. The greatest number of these areas are located within Edinburgh (approximately 62,000 individuals) but proportionately West Lothian has the highest share of its population (26,500) living in the most deprived communities (14.3%). ,'" ,+ " + '" '+ #" #+ K66%*E$1 L/"67.$+ 0*E$7%?%)5%@:2 G5.M"+E%*E$ J$+1"5+*-6$%*E$ *+7%5N$. J.5O$()$7%'5'D6*)"5+%(/*+E$%0P2 !"#$%&'@)';%<A&./&>'-<-$=0/"<1'.401#&B'32'0#& 579(C879@@: /0*+%$.1 K1-.<:46, 3"&+()*+,-$. 2-1%*+,-$. K$&+()*+,-$. Page 271 of 302
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NHS Lothian Director of Public Health Annual Report 2022 6 7 Table 1. SIMD 2020 datazones by population share in Lothian (2021)[36] SIMD 1 (Most Deprived 20% data zones) SIMD 2 SIMD 3 SIMD 4 SIMD 5 (Least Deprived 20% data zones) Edinburgh 11.8 14.3 14.3 17.5 42.0 East Lothian 4.8 28.1 22.3 25.5 19.3 Midlothian 7.5 32.8 23.9 21.4 14.4 West Lothian 14.3 27.8 18.9 20.6 18.4 Lothian 11.0 20.6 17.2 19.5 31.7 Although area-level deprivation is helpful for understanding how concentrations of disadvantage or need can occur, it is important to note that many people experiencing socio economic disadvantage in Lothian live outside areas categorised as the most deprived communities, which are shaded dark red in Figure 4, which maps Scottish Index of Multiple Deprivation (SIMD)2 in the region.[37] 2. The Scottish Index of Multiple Deprivation is a relative measure of deprivation across 6,976 small areas (called data zones). If an area is identified as ‘deprived’, this can relate to people having a low income but it can also mean fewer resources or opportunities. SIMD looks at the extent to which an area is deprived across seven domains: income, employment, education, health, access to services, crime and housing. SIMD is an area-based measure of relative deprivation: not every person in a highly deprived area will themselves be experiencing high levels of deprivation. SIMD ranks data zones from most deprived (ranked 1) to least deprived (ranked 6,976). People using SIMD will often focus on the data zones below a certain rank, for example, the 5%, 10%, 15% or 20% most deprived data zones in Scotland. Deciles (10%) and quintiles (20%) are common units of analysis. (Scottish Index of Multiple Deprivation 2020 - gov.scot (www.gov.scot)) Page 272 of 302
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NHS Lothian Director of Public Health Annual Report 2022 7 Figure 4: Scottish Index of Multiple Deprivation 2020 quintiles for Lothian Mortality In 2021, 8,595 people died in Lothian[38] (there were 8,426 births).[39] Figure 5 shows the age standardised mortality rate for Lothian and its constituent local authority areas between 2006 and 2021. Lothian’s all-cause mortality rates are typically around 5-10% lower than national rates. In 2021, Scotland’s rate was 1,200 deaths per 100,000, whereas Lothian’s was 1,105 deaths per 100,000. Mirroring the national picture, the all-cause mortality rate in Lothian had seen reductions in the 13 years after 2006. This downward trend was interrupted by a spike in mortality in 2020 across Lothian’s constituent areas. This reflects the direct and indirect impacts of the COVID-19 pandemic, and was particularly the case in West Lothian which saw its all-cause mortality rate increase by nearly 20% between 2019 and 2020, potentially reflecting a larger proportion of socioeconomic deprivation in this local authority area. In 2021, the leading causes of death in Scotland were ischaemic heart disease, dementia, COVID-19, lung cancers and cerebrovascular disease (stroke), together accounting for around 40% of all deaths nationally. In Lothian, instances of these common causes of death are approximately equivalent to national rates, or slightly lower, likely reflecting that Lothian’s population as a whole is less deprived than the national average. Page 273 of 302
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NHS Lothian Director of Public Health Annual Report 2022 8 Premature All-Cause Mortality Over a third (38%) of the deaths in Lothian in 2021 occurred among those aged under 75 years.[38] Each of the 3,213 deaths in Lothian occurring before the age of 75 constitute early mortalities, reflecting unfulfilled life expectancy. A substantial proportion of these premature mortalities are due to what some authors call ‘deaths of despair’ (suicide, alcohol- and drug- related mortality) which are heavily patterned by age, sex and socioeconomic status (see below for examples of health outcomes by the Scottish Index of Multiple Deprivation).[24, 40] Males aged 35-54 are, for instance, particularly likely to experience a drug-related death, with 44% of all deaths involving drugs occurring among this group. The number of deaths from such causes has increased sharply in recent years with a 98% increase in drug-related deaths in Lothian since 2014. Lothian recorded 197 drug-related deaths in 2021, its highest ever total. Figure 6 shows, similarly to overall mortality, that premature mortality rates in Lothian are around 5-10% lower than those observed nationally most likely due to the higher proportion of people in Lothian living in less deprived communities. Also mirroring overall mortality, the early mortality rate reduced in the decade after 2006, but this trend reversed following the onset of the COVID-19 pandemic. In 2020 and 2021 there were a total of 1,565 deaths from COVID-19 in Lothian, of which 24% (381) were amongst those aged under 75. '""" '"+" ''"" ''+" '#"" '#+" '*"" '*+" #""% #""! #""& #""( #"'" #"'' #"'# #"'* #"'$ #"'+ #"'% #"'! #"'& #"'( #"#" #"#' CD.5'$*+%*E$Q1)*+7*.7"1$7% R5.)*6"),%.*)$ 0'$.%@??;???%'5'D6*)"5+2 3$*. !"#$%&'D)'E==8.0$?&'F<%/0="/2B'0=='0#&?' 5799G8797(: /0*+%$.1 )*+,-$. Page 274 of 302
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NHS Lothian Director of Public Health Annual Report 2022
9
Morbidity
While mortality data represent a useful objective barometer of population health, the role of
public health professionals is to improve and protect the health of Lothian’s population in its
broadest sense. We want people not just to live longer, but to live longer, healthier lives. Fuller
definitions of health go beyond the ultimate endpoint of death and encompass individual’s
subjective experience, mental health and wellbeing.
Health is defined by the World Health Organisation as “a state of
complete physical, mental and social well-being and not merely the
absence of disease and infirmity”.
Similarly to the observed stagnation in overall life expectancy, there is evidence that the
number of years we live in good health is not improving over time. Figures 7 and 8 below
present trends in Scotland’s and Lothian’s healthy life expectancy3, for females and males
respectively.
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3. Healthy life expectancy is estimated by combining objective mortality records with subjective assessments of individuals’ self-rated
health. Stagnation in healthy life expectancy therefore reflects a combination of stalling life expectancy and reductions in the number
of people self-assessing their health as “very good” or “good”.
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NHS Lothian Director of Public Health Annual Report 2022 11 Figure 9 shows the rate of healthy years of life lost to illness4 for the top 10 causes in Lothian in 2019, by sex.[41] While males typically have lower life expectancy and higher mortality rates, Figure 9 also demonstrates that females have a higher burden for many of the leading causes of ill health. This is particularly true for headache disorders and anxiety disorders, where females’ rate of years lost to ill health is over double that experienced by males. Males have a higher burden for relatively few of the top causes of ill-health, with the most notable exception being for diabetes where males’ rate of years lost to ill health is around 1.5 times that experienced by females. The total burden of illness increases with age, and the nature of ill health changes qualitatively throughout the life course. In Lothian in 2019, the estimated total amount of healthy years of life lost for those under 15 is a rate of 2,805 years per 100,000. This increases around ten times among those aged 85 and older (24,253 years of healthy life lost per 100,000). Figures 10a and 10b present data on healthy years of life lost, presenting the top five causes within each age and sex group for Lothian in 2019. The figures highlight a high and persistent burden of mental health disorders (depression, anxiety disorders) from a relatively early age in both males and females. Indeed, collectively, mental health disorders were estimated to be responsible for over 19,431 years of healthy life lost in Lothian in 2019, around 20% of the total burden of ill health. The figures also highlight a gendered burden of ill health due to drug use for males between the ages of 15-44, which is not captured fully within drug-related death statistics. " #"" $"" %"" &"" '""" '#"" '$"" '%"" !"#$%&'($&)*$)+'($,&-) .+,/+00-") 1+&*&'2+$*-0"/*+/0 3)4-+56$*-0"/*+/0 705+"&/52/-5-0 .-&%+5+0$8+99-5:0 752+/$8:0':9"0(+9+5&9$*-0"/*+/0 3;+</+9&5+*$&)*$"52+/$2+&/-);$9"00 =+/+%/">&0':9&/$*-0+&0+ ?(-)$&)*$0:%':5&)+":0$*-0+&0+0 3$*.1%5#%6"#$%651)%)5%"66%/$*6)/% 0.*)$%'$.%@??;???2 !"#$%&'6)'K&0%?'<+'4&0=/42'="+&'=<?/B'32'?&,' 5*</4"01B'79(6:' !"#$%" 2$%" 4. (YLDs: years lost to disability) Page 277 of 302
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NHS Lothian Director of Public Health Annual Report 2022 12 ? A?? 8??? 8A?? >??? >A?? H??? HA?? /5-.($.1(&:<0:+$."*:&(1-&"$&"& Y"$1$0,"(1-&*41"4& ^*.6".-+$%(<-4+,(1"7"0+& C&+,#$ _%-.1."&&($.1(J-&-*.(%*&& Y"$1$0,"(1-&*41"4& )*@(<$05($.1(."05(;$-. N";4"&&-*. C.E-"+B(1-&*41"4& /5-.($.1(&:<0:+$."*:&(1-&"$&"& Y"$1$0,"(1-&*41"4& )*@(<$05($.1(."05(;$-. N";4"&&-*. C.E-"+B(1-&*41"4& `B."0*%*6-0$%(1-&"$&"& )*@(<$05($.1(."05(;$-. Y"$1$0,"(1-&*41"4& N";4"&&-*. C.E-"+B(1-&*41"4& a&+"*$4+,4-+-& )*@(<$05($.1(."05(;$-. a&+"*$4+,4-+-& N";4"&&-*. C.E-"+B(1-&*41"4& C%Q,"-#"4b&(1-&"$&"($.1(*+,"4(1"#".+-$& C%Q,"-#"4b&(1-&"$&"($.1(*+,"4(1"#".+-$& ^"4"<4*J$&0:%$4(1-&"$&" )*@(<$05($.1(."05(;$-. C+4-$%(7-<4-%%$+-*.($.1(7%:++"4 a4$%(1-&*41"4& 3$*.1%5#%6"#$%651)%)5%"66%/$*6)/% 0.*)$%'$.%@??;???2 !"#$%&'(90)'K&0%?'<+'4&0=/42'="+&'=<?/B'/<-'.0$?&?'32'0#&' 5*</4"01'+&F0=&?B'79(6:' FQ%*)%PP BQ%*)%FP PQ%*)%MP MQ%*)%XP XQ%-6,%)+'& Y6,'&%BQ% Page 278 of 302
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NHS Lothian Director of Public Health Annual Report 2022 13 ? A?? 8??? 8A?? >??? >A?? H??? HA?? C&+,#$ /5-.($.1(&:<0:+$."*:&(1-&"$&"& ^*.6".-+$%(<-4+,(1"7"0+& Y"$1$0,"(1-&*41"4& a+,"4(#".+$%(,"$%+,(1-&*41"4& Y"$1$0,"(1-&*41"4& N4:6(:&"(1-&*41"4& N";4"&&-*. )*@(<$05($.1(."05(;$-. /5-.($.1(&:<0:+$."*:&(1-&"$&"& N";4"&&-*. )*@(<$05($.1(."05(;$-. N4:6(:&"(1-&*41"4& Y"$1$0,"(1-&*41"4& C.E-"+B(1-&*41"4& N";4"&&-*. )*@(<$05($.1(."05(;$-. C.E-"+B(1-&*41"4& Y"$1$0,"(1-&*41"4& C%0*,*%(:&"(1-&*41"4& )*@(<$05($.1(."05(;$-. ^"4"<4*J$&0:%$4(1-&"$&" N-$<"+"&(#"%%-+:& N";4"&&-*. M&0,$"#-0(,"$4+(1-&"$&" ^"4"<4*J$&0:%$4(1-&"$&" C%Q,"-#"4b&(1-&"$&"($.1(*+,"4(1"#".+-$& C+4-$%(7-<4-%%$+-*.($.1(7%:++"4 N";4"&&-*. M&0,$"#-0(,"$4+(1-&"$&" 3$*.1%5#%6"#$%651)%)5%"66%/$*6)/% 0.*)$%'$.%@??;???2 !"#$%&'(93)'K&0%?'<+'4&0=/42'="+&'=<?/B'/<-'.0$?&?'32'0#&' 5*</4"01'F0=&?B'79(6:' FQ%*)%PP BQ%*)%FP PQ%*)%MP MQ%*)%XP XQ%-6,%)+'& Y6,'&%BQ% Page 279 of 302
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NHS Lothian Director of Public Health Annual Report 2022 14 Inequalities in mortality and morbidity The above aggregate figures mask significant socioeconomic inequalities in mortality and morbidity. A wide range of health outcomes are patterned by socioeconomic status, with people living in more deprived communities consistently experiencing worse outcomes than those living in less deprived areas, for practically any conceivable health-related outcome. Figures 11-14 below present examples of these outcomes by deprivation quintile. Figures 12 and 13 highlight particularly steep inequalities in premature mortalities, with premature deaths in those aged 15-44 being 4.5 times more likely in the most deprived areas compared to the least deprived. Figure 14 highlights that steep inequalities in health-related outcomes are evident from as early as infants’ 27-30 month review. Concerns raised in the development of speech, language and communication skills reiterates that socioeconomic disadvantage can precipitate impairment in the skills that young people need to thrive socially, professionally, and academically, reinforcing cycles of deprivation. " #"" $"" %"" &"" '""" '#"" '$"" '%"" '&"" '-,-./01 23456732 # * $ +-,-83901 23456732 K66Q(*D1$%R5.)*"),%.*)$%0*E$Q1$&% 1)*+7*.7"1$7%.*)$%'$.%@??;???2 4TIU%VD"+)"6$ !"#$%&'(()'E==8.0$?&'F<%/0="/2'%0/&'32'LMJN'O$"1/"=&' 5*</4"01B'0=='0#&?B'79(6879: Page 280 of 302
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NHS Lothian Director of Public Health Annual Report 2022 15 " #" $" %" &" '"" '#" '$" '%" '&" #"" '-,-:/01 23456732 # * $ +-,-;3901 23456732 K66Q(*D1$%R 5.)*"),%.*)$%0*E$Q1$&% 1)*+7*.7"1$7%.*)$%'$.%@??;???2 4TIU%VD"+)"6$ !"#$%&'(7)'N&0/4?B'0#&>'(D8II'2&0%?B' 32'LMJN'O$"1/"=&'5*</4"01B'79(6879: " +" '"" '+" #"" #+" '-,-:/01 23456732 # * $ +-,-;3901 23456732 K66Q(*D1$%R 5.)*"),%.*)$%0*E$Q1$&% 1)*+7*.7"1$7%.*)$%'$.%@??;???2 4TIU%VD"+)"6$ !"#$%&'(@)'P0%=2'>&0/4?'+%<F'.01.&%'5$1>&%'HD' 2&0%?:B'32'LMJN'O$"1/"=&'5*</4"01B'79(C879: Page 281 of 302
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NHS Lothian Director of Public Health Annual Report 2022 16 " # $ % & '" '# '$ '% '-,-:/01 23456732 # * $ +-,-;3901 23456732 J$.($+)*E$%5#%.$N"$W1% "7$+)"#,"+E%*%1'$$(/;%6*+ED*E$% 5.%(5R D+"(*)"5+%(5+($.+%0P 2 4TIU%VD"+)"6$ !"#$%&'(I)'7H8@9'J<1/4'Q&R"&S)'L-&&.4B' =01#$0#&'01>'.<FF$1".0/"<1'.<1.&%1?B'32' LMJN'O$"1/"=&'5*</4"01B'797(: Page 282 of 302
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NHS Lothian Director of Public Health Annual Report 2022 16 17 The role of public health partnerships in improving population health and reducing inequalities The impacts of austerity, the COVID-19 pandemic and the cost of living crisis have made life even more difficult for many people and has reinforced the need to challenge existing inequalities. The pandemic highlighted the continued risks from infectious and communicable diseases. A strong, co-ordinated response to new or emerging diseases is essential. The design and delivery of health and care – and other public services – should reflect levels of need in populations and should be focused on improving the health of the most disadvantaged groups as well as reducing the entire social gradient of health outcomes across the population.[42] There is a large body of evidence that shows that allocation of resources is not always determined by population health need.[43, 44] But population health improvement and measures to reduce inequalities is a task extending beyond the public health department and the wider NHS – it requires coordination of effort across the public and voluntary and community sectors. The fundamental causes of health inequalities such as power and wealth affect the distribution of wider environmental influences such as the availability of jobs, good quality housing, education and learning opportunities, access to services and social status.[45] But it is necessary to tackle social causes of ill health such as low income, homelessness, poor housing, in-work poverty, unemployment, worklessness, and poor education to improve overall health and, especially, to tackle health inequalities. The old adage that prevention is better than cure still holds true. “ Why treat people and send them back to the conditions that made them sick?” Michael Marmot, The Health Gap (2015) Public, community and voluntary sector agencies must work closely with local communities to focus on these determinants to improve health. And during an ongoing period of social, economic and political change, there are some issues that present an urgent challenge. Work with our community planning partners must focus on short-term mitigation of the cost of living and child poverty crises while also focusing on preventative policy solutions that have greatest potential to change longer-term trends in health inequalities. The rest of this report focuses on actions that need to be taken by all of us to tackle the cost of living crisis and work we can do to support children and young people in Lothian facing some of the most severe challenges. Page 283 of 302
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NHS Lothian Director of Public Health Annual Report 2022 18 Cost of living crisis: a partnership response The last fifteen years have seen a series of economic shocks as well as a pandemic and now a cost of living crisis; each of these have caused stresses to the labour market and the housing market as well as individuals’ resilience. Cumulatively, the impacts on health have been devastating. As poverty levels in Scotland – and in Lothian – have increased in recent years so too health inequalities have increased. At least 13% of children in Lothian now live in relative poverty, rising to nearly one in five in West Lothian (Figure 15).5 The most disadvantaged people are those who have experienced the worst outcomes. Research into the causes of health inequalities highlights many contributory factors. But having enough money, good quality affordable housing and secure, fairly-paid jobs are the foundations of good health; without these, people’s ability to live a long and healthy life will continue to decline. Background Work by the Poverty Commissions in East Lothian and Edinburgh has highlighted the extent of poverty in each area. More recently, anti-poverty groups in each Community Planning Partnership have championed actions to counter the impacts of poverty. The pandemic and the cost of living crisis are notable for the greater proportion of the population affected by '" '' '# '* '$ '+ '% '! '& '( #" #"'+ #"'% #"'! #"'& #"'( #"#" J$.($+)*E$%5#%(/"67.$+%"+%65W% "+(5R$%#*R"6"$1%0P2 3$*. !"#$%&'(D)'T4"=>%&1'5$1>&%'(G:'="R"1#'"1'%&=0/"R&' -<R&%/2'579(D87979: 3"&+()*+,-$. 2-1%*+,-$. K$&+()*+,-$. ^-+B(*7(K1-.<:46, 5 Relative low income is defined as a family in low income Before Housing Costs (BHC) in the reference year. A family must have claimed Child Benefit and at least one other household benefit (Universal Credit, tax credits, or Housing Benefit) at any point in the year to be classed as low income in these statistics. NB Figure 15 omits provisional data from 2021. Given that housing costs are a substantial and growing contribution to household expenditure, it is important, where possible, to consider estimates of child poverty after housing costs. The University of Loughborough’s estimates of child poverty rates after housing costs in 2019/20 are around 10% higher than the equivalent estimates before housing costs (West Lothian: 25%, East Lothian: 25% , Midlothian: 24%, City of Edinburgh: 20%) - https://www.jrf.org.uk/data/child-poverty-rates-local-authority. Page 284 of 302
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NHS Lothian Director of Public Health Annual Report 2022 19 daily and weekly struggles to pay bills and provide food. Community resilience was tested throughout the pandemic and the cost of living crisis is another major threat to population health. The increase in emergency Scottish Welfare Fund payments and the ongoing demand for food banks were other manifestations of extreme poverty. The number of people experiencing in-work poverty has increased even since the height of the pandemic. By October 2022 the number of people in Lothian claiming Universal Credit while working has more than doubled since February 2020 from 11,320 to 26,462. This increase in claims has been happening at the same time as the unemployment rate has declined, inflation has been rising and job vacancies are high. Figure 16 shows that the number of working-age benefit claimants increased by at least 25% in each of Lothian’s council areas between February and May 2020. These increases reached as high as a 43% increase (in City of Edinburgh) relative to levels immediately prior to the pandemic and as of May 2022 had not returned to pre-pandemic levels (remaining at least 16% higher than levels in February 2020). What does a public health partnership response look like? There is consistent evidence that shows the relationship between lower income and poor health outcomes.[46] Although cash transfers do not address the range of economic factors that contribute to people’s levels of income inequality, immediate assistance is an effective way to help people in greatest need. This does not prevent long-term poverty but it mitigates against the worst outcomes. " "<# "<$ "<% "<& ' '<# '<$ " '" #" *" $" +" %" !" =3>,'* ?/7,'* @AB,'$ .9C,'+ =3>,'% ?/7,'% @AB,'! .9C,'& =3>,'( ?/7,'( @AB,#" .9C,#' =3>,## L6*"R*"+)%(5D+);%I"66"5+1%04(5)6*+72 L6*"R*"+)%(5D+);%8/5D1*+71 0!5)/"*+%65(*6%*D)/5.")"$12 5!&3'79(@8J02'7977: K1-.<:46, 3"&+()*+,-$. 2-1%*+,-$. K$&+()*+,-$. /0*+%$.1 Figure 16: Working age benefit claimants (Feb 2013-May 2022) Page 285 of 302
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NHS Lothian Director of Public Health Annual Report 2022 20 21 Most British anti-poverty groups are now supportive of direct payments and measures that increase the amount of money in people’s pockets rather than alternative ways of providing cash. In recent years, research has highlighted that conditional and unconditional cash transfers are effective ways of providing control and ownership for recipients of funds to determine their own essential spending.[47, 48] The moral economy of social security has in the past framed poor people as undeserving and careless with money resulting in high levels of stigma being experienced by those most in need. But there is minimal evidence that people choose to spend their money on luxuries instead of essentials and we should stop treating people in this way as it is discriminatory, unfair and unwarranted. In Scotland, existing systems such as The Scottish Welfare Fund or Child Poverty Payment have provided effective channels for getting money to people in greatest need during lockdown. Cash payments also avoid the stigma associated with other forms of welfare support. Welfare advice, debt advice, support for social security claims and income maximisation are all important forms of short-term support. The immediate purpose of these types of intervention is basic survival. More preventative work – budgeting, support around employment and education and so on - is important to help people once basic needs have been secured and must be part of our anti-poverty strategies. But meeting basic needs is now a priority during this cost of living crisis. So, we need to do both. The expertise around income maximisation exists in specialist teams based in local authorities, the Department of Work and Pensions, Social Security Scotland and the voluntary and community sectors6. These teams can provide full support for their clients and link them to other forms of support such as food banks or pantries and advice about housing, childcare and employment and training. Our Public Health Partnership and Place teams are supporting statutory and voluntary and community sector colleagues to deliver these services by providing some funding, supporting training programmes and contributing to wider anti-poverty work of which income maximisation is a core activity. NHS Lothian has also secured five years of funding from the NHS Lothian Charity for income maximisation services based in six hospitals across the region. Our services will operate at the Western General Hospital, Royal Infirmary of Edinburgh and Royal Hospital for Children and Young People, an expansion of the service at St John’s Hospital and new services at Midlothian Community Hospital and East Lothian Community Hospital. These services are delivered by voluntary and community sector partners due to the expertise they have to support our patients and their families and carers. Hospital Income Maximisation can also have benefits for patient care by releasing trained clinical staff to do vital patient care. There is evidence that welfare issues contribute to delayed discharges. For patients, financial stress may increase recovery time and may be the root cause of readmission to hospital. Hospital Income Maximisation services puts money in people’s pockets • At our adult hospitals in Edinburgh during 2020-21, each contact identified entitlement to an extra £1,800 per person • £1,600 per contact was achieved for people accessing the service at The Royal Hospital for Children and Young People. 6 For example, Citizens Advice Edinburgh, Citizens Advice West Lothian, Penicuik Citizens Advice, Musselburgh Citizens Advice, Haddington Citizens Advice, Granton Information Centre Page 286 of 302
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NHS Lothian Director of Public Health Annual Report 2022 20 21 Child poverty and early years Since the Fair Society Healthy Lives, Marmot Review in 2010, health inequalities research in the UK has consistently emphasised that cognitive, social and emotional development in the early years is a priority for public health. The reasons why are straightforward: “ Such is the strength of evidence linking experiences in the early years to later health outcomes that this was the priority area for the 2010 Marmot Review, for three main reasons. Firstly, inequalities in the early years have lifelong impacts, secondly, it is the period of life when interventions to disrupt inequalities are most effective, and thirdly and related to the first two points, interventions in the early years have been shown to be cost- effective and to yield significant returns on investment.” It has also become evident that adverse childhood experiences play a major constraining role in shaping adults’ abilities to cope with later life. Early life trauma is increasingly recognised as a factor in adverse outcomes in adulthood. Care experienced children in particular are among the most vulnerable of all our populations.[49] Getting childhood right means better lives for everyone. Background One of the more troubling trends of the early twenty first century has been data showing decline in indicators of health and growing health inequalities among children. Since 2000, we have seen • an increase in mental health concerns for children[50] • increasing inequalities in child overweight and obesity[51] • low child physical activity rates[52] • increasing mortality rates and still birth in the most deprived communities[53] • poor health outcomes for mothers and babies from ethnic minority communities;[54] and • evidence that social deprivation is affecting babies’ speech and language development systematically by 30 months (see Figure 14).[55] Although COVID-19 did not affect children directly to the extent of older population groups there is emerging evidence of longer-term impacts associated with lockdown and mitigation necessitated by the pandemic. Furthermore, austerity and the cost of living crisis mean that there have been increases in the number of households across Scotland and Lothian where children experience poverty (see Figure 15). Page 287 of 302
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NHS Lothian Director of Public Health Annual Report 2022 22 What does a public health partnership response look like? Public Health teams support work in Children’s Partnerships alongside NHS, local authority and Voluntary and community sector colleagues to ensure that children across Lothian are given the best start in life. In particular, teams work to support initiatives focusing on reducing child poverty, improving early years linguistic, cognitive, physical and emotional outcomes, building children’s confidence and wellbeing, investing in maternity services, early years education (including parenting) and delivering the commitment encapsulated by The Promise to all children who have experience with the care sector. Child poverty NHS Lothian’s child poverty work is part of a wider commitment to tackling inequalities and the effects of poverty with partners. The Child Poverty (Scotland) Act 2017 requires each local authority and NHS Board partnership in Scotland to produce annual Local Child Poverty Action Reports. The legislation includes targets for reducing child poverty. Work across Scotland should focus on three key drivers of poverty: income from employment, costs of living, and income from social security and benefits in kind as illustrated in the diagram below. Figure 17: Drivers of Child Poverty (The Scottish Government) Partners in Lothian have committed to a series of poverty focused measures to support families in the region. Public Health teams are working with the NHS and local partners to support a more consistent approach to delivery of these actions in each Lothian local authority area: • Strengthening financial wellbeing pathways across midwifery, health visiting and Family Nurse Partnership services to increase identification of, and support to, those most in need • Reviewing current provision of income maximisation services to inform future provision, strengthen communication to front-line staff and service users, and improve reach and impact of income maximisation service provision, including in community health settings Page 288 of 302
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NHS Lothian Director of Public Health Annual Report 2022 22 23 • Ensuring NHS/HSCP staff and services have the knowledge and skills to support increased take-up of both Social Security Scotland’s package of five family benefits and Early Learning and Childcare places for eligible two-year-olds. Early Years NHS Lothian’s Maternal and Infant Nutrition Service is based in Public Health. This allows our teams to link more effectively with midwives and health visitors to deliver the preventative approach that underpins the universal health visiting pathway. The team provides expert advice and support for preconception and early pregnancy health, breastfeeding (including support for UNICEF Baby Friendly accreditation) and infant nutrition. The HENRY (Health, Exercise, Nutrition for the Really Young) training programme to increase staff knowledge, confidence and skills has been shared with community learning and development, education, children and family centres, health visiting teams, and community-based food projects through 2021 and 2022 as an aid to support early intervention and prevention of childhood obesity. No Wrong Door Public Health teams are working with Children’s Partnerships to expand the No Wrong Door Approach. This approach is based on a single point of access which simplifies the referral process for support for children and young people with mental health and wellbeing related needs and ensures that they are being matched with the most appropriate service for them. The approach ensures that children and young people are able to access the right support, at the right time, and in the right place, be that through universal services such as school nursing or youth work, community health or voluntary and community sector services, or where more specialist input may be required. Page 289 of 302
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NHS Lothian Director of Public Health Annual Report 2022 24 25 Conclusion The importance of acting on common partnership goals The lives of Lothian’s population are being cut short, with some dying over a decade earlier than others, owing to the circumstances in which they live. We can, and must, create a society where everybody has an opportunity to thrive by making sure the necessary building blocks for health are in place. More than ever, it is important that people have jobs that are secure and rewarding, an affordable, comfortable home, a nurturing upbringing and a good education, as these elements set the foundation for good health outcomes. NHS Lothian is working closely with local communities and the voluntary and community sector to ensure that more people have these building blocks, and we are doing so with a focus on early years, child poverty and the cost of living. We are using our role as an Anchor organisation to reduce inequalities through ensuring all our contractors pay the living wage, that we provide local employment opportunities, that we procure local services and use our land and estates well for the common good. Local partnerships can address local population health needs through combining our efforts across the public and voluntary and community sectors and beyond to invest in local areas, but we also need Scottish and UK Governments to address the factors that are outwith our control. We need to see rates of benefits maintained to cope with increased inflation to protect and increase incomes for low income households. We would like to see the real living wage and the minimum wage uprated for those under the age of 22 to ensure that younger adults receive equal pay for equal work. And we would like to see wellbeing prioritised in national and local economic policies and strategies. Page 290 of 302
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NHS Lothian Director of Public Health Annual Report 2022 24 25 Improving and protecting the health of the people of Lothian The Role of the Public Health Department in Lothian Approximately 200 people are employed in the department. We operate four divisions as illustrated below. We provide specialist advice and leadership to NHS Lothian, the four Lothian local authorities and the voluntary and community sector to shape services and create healthy communities for everyone. • Health Care Public Health The Health Care Public Health team provide: > Leadership and oversight across the pathways of the six National Screening Programmes (breast cancer, bowel cancer, cervical cancer, diabetic eye screening, abdominal aortic aneurysm, pregnancy and new-born) > Dental Public Health expertise to assess and improve the oral health needs of the population > Strategic leadership and assurance for Immunisation Programmes > Professional expertise on pharmaceutical public health • Business and Administration The Business and Administration team provide flexible administrative and clerical support across the Department. They play a critical governance role ensuring that the Department has robust processes and business procedures to meet strategic and operational objectives and priorities. The team also monitor and track workforce performance. • Health Protection The Health Protection team work to protect the health of the local population from communicable and infectious diseases and environmental hazards. The team provides specialist public health advice, direction and operational support to NHS Lothian, local authorities and other agencies. • Population Health The Population Health division includes: > Partnership and Place teams for each of Lothian’s four local authority areas focusing on tackling inequalities and improving population health Other population health functions cover the whole of Lothian: > a Public Health Intelligence Team providing high-quality, rigorous evidence and data for public health strategy and policy > Maternal and Children’s Public Health, including the Maternal and Infant Nutrition team and Child Health Commissioner. > a Sexual Health Improvement team (Healthy Respect) and > a Tobacco Control team which includes NHS Lothian’s Quit Your Way smoking cessation service. • Board wide hosted programmes Public Health and Health Policy hosts three services that deliver Board-wide remits: (i) Resilience (ii) Equalities and Human Rights, and (iii) Safe Haven. Page 291 of 302
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NHS Lothian Director of Public Health Annual Report 2022 26 27 References 1. Marmot, M. and J. Allen, COVID-19: exposing and amplifying inequalities. Journal of Epidemiology and Community Health, 2020. 74(9): p. 681-682. 2. Marmot, M., et al., Build Back Fairer: The COVID-19 Marmot Review. The Pandemic, Socioeconomic and Health Inequalities in England. 2020, Institute of Health Equity: London. 3. Woodward, M., S.A.E. Peters, and K. Harris, Social deprivation as a risk factor for COVID-19 mortality among women and men in the UK Biobank: nature of risk and context suggests that social interventions are essential to mitigate the effects of future pandemics. Journal of Epidemiology and Community Health, 2021. 75(11): p. 1050-1055. 4. Wyper, G.M.A., et al., Inequalities in population health loss by multiple deprivation: COVID-19 and pre-pandemic all-cause disability-adjusted life years (DALYs) in Scotland. International Journal for Equity in Health, 2021. 20(1): p. 214. 5. Burström, B. and W. Tao, Social determinants of health and inequalities in COVID-19. European Journal of Public Health, 2020. 6. Mutambudzi, M., et al., Occupation and risk of severe COVID-19: prospective cohort study of 120 075 UK Biobank participants. Occupational and Environmental Medicine, 2021. 78(5): p. 307-314. 7. Rhodes, S., et al., Occupational differences in SARS-CoV-2 infection: analysis of the UK ONS COVID-19 infection survey. Journal of Epidemiology and Community Health, 2022. 76(10): p. 841-846. 8. Williamson, E.J., et al., Factors associated with COVID-19-related death using OpenSAFELY. Nature, 2020. 584(7821): p. 430-436. 9. Harrison, E., et al., Ethnicity and Outcomes from COVID-19: The ISARIC CCP-UK Prospective Observational Cohort Study of Hospitalised Patients. SSRN Electronic Journal, 2020. 10. Aldridge, R., et al., Black, Asian and Minority Ethnic groups in England are at increased risk of death from COVID-19: indirect standardisation of NHS mortality data Wellcome Open Research, 2020. 5(88). 11. Gruer, L.D., et al., Complex differences in infection rates between ethnic groups in Scotland: a retrospective, national census-linked cohort study of 1.65 million cases. Journal of Public Health, 2021. 12. Mathur, R., et al., Ethnic differences in SARS-CoV-2 infection and COVID-19-related hospitalisation, intensive care unit admission, and death in 17 million adults in England: an observational cohort study using the OpenSAFELY platform. The Lancet, 2021. 397(10286): p. 1711-1724. 13. Sze, S., et al., Ethnicity and clinical outcomes in COVID-19: A systematic review and meta- analysis. EClinicalMedicine, 2020. 29-30: p. 100630. 14. Nafilyan, V., et al., Ethnic differences in COVID-19 mortality during the first two waves of the Coronavirus Pandemic: a nationwide cohort study of 29 million adults in England. European Journal of Epidemiology, 2021. 36(6): p. 605-617. 15. Raisi-Estabragh, Z., et al., Greater risk of severe COVID-19 in Black, Asian and Minority Ethnic populations is not explained by cardiometabolic, socioeconomic or behavioural factors, or by 25(OH)-vitamin D status: study of 1326 cases from the UK Biobank. Journal of Public Health, 2020. Page 292 of 302
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NHS Lothian Director of Public Health Annual Report 2022 26 27 16. Razai, M.S., et al., Mitigating ethnic disparities in covid-19 and beyond. BMJ, 2021. 372: p. m4921. 17. Ramsay, J., et al., How have changes in death by cause and age group contributed to the recent stalling of life expectancy gains in Scotland? Comparative decomposition analysis of mortality data, 2000–2002 to 2015–2017. BMJ Open, 2020. 10(10): p. e036529. 18. National Records of Scotland, Deaths involving coronavirus (COVID-19) in Scotland, Week 45 (25-31 October). 2022, NRS: Edinburgh 19. Ayoubkhani, D., et al., Post-covid syndrome in individuals admitted to hospital with covid-19: retrospective cohort study. BMJ, 2021. 372: p. n693. 20. Drake, T.M., et al., Characterisation of in-hospital complications associated with COVID-19 using the ISARIC WHO Clinical Characterisation Protocol UK: a prospective, multicentre cohort study. The Lancet, 2021. 398(10296): p. 223-237. 21. Fenton, L., et al., Socioeconomic inequality in recent adverse all-cause mortality trends in Scotland. Journal of Epidemiology and Community Health, 2019. 73(10): p. 971-974. 22. McCartney, G., et al., Resetting the course for population health: evidence and recommendations to address stalled mortality improvements in Scotland and the rest of the UK. 2022, Glasgow Centre for Population Health and University of Glasgow: Glasgow. 23. Braveman, P. and L. Gottlieb, The social determinants of health: it’s time to consider the causes of the causes. Public health reports (Washington, D.C. : 1974), 2014. 129 Suppl 2(Suppl 2): p. 19-31. 24. Allik, M., et al., Deaths of despair: cause-specific mortality and socioeconomic inequalities in cause-specific mortality among young men in Scotland. International Journal for Equity in Health, 2020. 19(1): p. 215. 25. Walsh, D., G.M.A. Wyper, and G. McCartney, Trends in healthy life expectancy in the age of austerity. Journal of Epidemiology and Community Health, 2022: p. jech-2022-219011. 26. McCartney, G., et al., Is austerity a cause of slower improvements in mortality in high- income countries? A panel analysis. Social Science & Medicine, 2022. 313: p. 115397. 27. Gondek, D., et al., Prevalence and early-life determinants of mid-life multimorbidity: evidence from the 1970 British birth cohort. BMC Public Health, 2021. 21(1): p. 1319. 28. Bellis, M.A., et al., Measuring mortality and the burden of adult disease associated with adverse childhood experiences in England: a national survey. Journal of Public Health, 2014. 29. Hughes, K., et al., The effect of multiple adverse childhood experiences on health: a systematic review and meta-analysis. The Lancet Public Health, 2017. 2(8): p. e356-e366. 30. Tweed, E.J., et al., Health of people experiencing co-occurring homelessness, imprisonment, substance use, sex work and/or severe mental illness in high-income countries: a systematic review and meta-analysis. Journal of Epidemiology and Community Health, 2021: p. jech-2020-215975. 31. Aldridge, R.W., et al., Morbidity and mortality in homeless individuals, prisoners, sex workers, and individuals with substance use disorders in high-income countries: a systematic review and meta-analysis. The Lancet, 2018. 391(10117 ): p. 241 - 250. 32. Scottish Government, Homelessness in Scotland: 2021/22, 2022, Scottish Government: Edinburgh. 33. Waugh, A., et al., Health and Homelessness in Scotland, 2018, Scottish Government: Edinburgh. Page 293 of 302
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NHS Lothian Director of Public Health Annual Report 2022 28 29 34. National Records of Scotland, Mid-2021 Population Estimates Scotland. 2022, NRS: Edinburgh 35. National Records of Scotland, Population Projections for Scottish Areas 2018-based. 2020, NRS: Edinburgh 36. National Records of Scotland. Population Estimates by Scottish Index of Multiple Deprivation (SIMD) (Table 3). 2022 [cited 2022 14 November]; Available from: https:// www.nrscotland.gov.uk/statistics-and-data/statistics/statistics-by-theme/population/ population-estimates/2011-based-special-area-population-estimates/population- estimates-by-simd-2016. 37. Robertson, L., Poverty in Edinburgh: The Key Issues. 2019, Edinburgh Poverty Commission: Edinburgh. 38. National Records of Scotland. Age-standardised Death Rates Calculated Using the European Standard Population. 2022 [cited 2022 14 November]; Available from: https:// www.nrscotland.gov.uk/statistics-and-data/statistics/statistics-by-theme/vital-events/ deaths/age-standardised-death-rates-calculated-using-the-esp. 39. National Records of Scotland. Births by sex, year and post-April 2014 NHS Board area, 1991 to 2021. Vital Events 2022 [cited 2022 14 November ]; Available from: https://www. nrscotland.gov.uk/statistics-and-data/statistics/statistics-by-theme/vital-events/births/ births-time-series-data. 40. Walsh, D., et al., Deaths from ‘diseases of despair’ in Britain: comparing suicide, alcohol- related and drug-related mortality for birth cohorts in Scotland, England and Wales, and selected cities. Journal of Epidemiology and Community Health, 2021: p. jech-2020- 216220. 41. Scottish Public Health Observatory. Scottish Burden of Disease Study 2016: local area burden of disease profiles for disease groups. [Spreadsheet] 2021 18 March 2021 [cited 2021 05 August]; An excel workbook detailing burden of disease estimates (DALYs, YLD, YLL and deaths) for 21 broad disease groupings, stratified by: Local authority, Gender, Age-group]. Available from: https://www.scotpho.org.uk/comparative-health/burden-of- disease/sbod-local-2016/. 42. NHS Health Scotland, Proportionate universalism and health inequalities, 2014, NHS Health Scotland: Edinburgh. 43. McLean, G., et al., General practice funding underpins the persistence of the inverse care law: cross-sectional study in Scotland. British Journal of General Practice, 2015. 65(641): p. e799-e805. 44. Tudor Hart, J., The Inverse Care Law. The Lancet, 1971. 297(7696): p. 405-412. 45. Macintyre, S., Inequalities in health in Scotland: what are they and what can we do about them?, in MRC Social and Public Health Sciences Unit Occasional Papers. 2007, MRC Social and Public Health Sciences Unit: Glasgow. 46. Pickett, K.E. and R.G. Wilkinson, Income inequality and health: A causal review. Social Science & Medicine, 2015. 128(0): p. 316–326. 47. Crossley, T.F. and F. Zilio, The health benefits of a targeted cash transfer: The UK Winter Fuel Payment. Health Economics, 2018. 27(9): p. 1354-1365. 48. Beatty, T.K.M., et al., Cash by any other name? Evidence on labeling from the UK Winter Fuel Payment. Journal of Public Economics, 2014. 118: p. 86-96. Page 294 of 302
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NHS Lothian Director of Public Health Annual Report 2022 28 29 49. Fleming, M., et al., Educational and health outcomes of schoolchildren in local authority care in Scotland: A retrospective record linkage study. PLOS Medicine, 2021. 18(11): p. e1003832. 50. Inchley, J., et al., Health Behaviour in School-Aged Children (HBSC). Growing up unequal: HBSC, 2016. 51. Stewart, R., et al., Trends in socioeconomic inequalities in underweight and obesity in 5-year-old children, 2011–2018: a population-based, repeated cross-sectional study. BMJ Open, 2021. 11(3): p. e042023. 52. Bardid, F., et al., Results from Scotland’s 2021 report card on physical activity and health for children and youth: Grades, secular trends, and socio-economic inequalities. Journal of Exercise Science & Fitness, 2022. 20(4): p. 317-322. 53. Harpur, A., et al., Trends in infant mortality and stillbirth rates in Scotland by socio- economic position, 2000–2018: a longitudinal ecological study. BMC Public Health, 2021. 21(1): p. 995. 54. Knight, M., et al., Saving Lives, Improving Mothers’ Care Core Report - Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2018-20. 2022, National Perinatal Epidemiology Unit, University of Oxford: Oxford. 55. Ene, D., et al., Associations of Socioeconomic Deprivation and Preterm Birth With Speech, Language, and Communication Concerns Among Children Aged 27 to 30 Months. JAMA Network Open, 2019. 2(9): p. e1911027-e1911027. Page 295 of 302
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Midlothian Integration Joint Board Thursday 22nd June 2023, 14:00 – 16:00 Learning Disability Service Review Executive summary This report provides Midlothian Integration Joint Board (MIJB) with an update on the review of Learning Disability Services which is currently in progress Board members are asked to: 1. Note contents of the interim report and, 2. Note the remit of the review and agree the timescale for reporting to the MIJB. # Item number: 5.10 Page 299 of 302
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Midlothian Integration Joint Board Midlothian Integration Joint Board Learning Disability Service Review 1 Purpose 1.1 The purpose of this paper is to provide an update on the review of Learning Disability Services within Midlothian. 2 Recommendations 2.1 As a result of this report what are Members being asked to: - • Note contents of the interim report, • Note the remit of the review and agree the timescale for reporting to the MIJB. 3 Background and main report 3.1 The MIJB received a report on Learning Disability Services in August 2022 and agreed that a review of Learning Disability Services should be progressed. 3.2 The Chief Officer commissioned an independent consultant to undertake this review in January 2023. 3.3 The contextual factors that shape the requirement for this review include: - • The increase in the number of people receiving Learning Disability Services and the increased complexity in their care needs which has led to increased expenditure and significant financial pressure; • There are approximately 400 adults with a learning disability who receive directly funded services from Midlothian Health and Social Care Partnership. • Analysis of financial pressures arising from young people with Learning Disabilities transitioning from Children’s to Adult Services has estimated there will be a further pressure of £1.9m over the next 3 financial years. 3.4 The scope of the review includes the governance, planning, resourcing, commissioning, and delivery aspects of all Learning Disability Service provision in Midlothian. This review will include consideration of:- • The commissioned and non-commissioned services within Midlothian; • Current resourcing, including any changes in the underlying cost of Learning Disability Services, the impact of recent and future transition cases and identification of gaps where additional resourcing including finance is required; • Sustainability of service provision and determine options for transformation of services taking account of the risks and cultural challenges to be managed; • Current best practice in Learning Disability Service provisions in accordance with the Keys to Life Implementation Framework, Learning/Intellectual Page 300 of 302
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Midlothian Integration Joint Board Disability and Autism: Transformation Plan and the Coming Home Implementation Plan; • Benchmark Learning Disability Service provision with other health and social care partnerships. 3.5 The report on findings from the review will be brought to the August 2023 IJB meeting for consideration. 4 Policy Implications 4.1 The aims and ethos of the Learning Disability services as articulated through the relevant strategic plans fit with the general policy direction of the Midlothian IJB, in providing more care closer to home and more care being community based. 5 Directions 5.1 Direction 10 (and the actions associated) on Learning Disability, specifically: “We are committed to empower people with learning disabilities and autism to recognise and realise their human rights and to participate in community life free from fear, harassment and abuse”. 6 Equalities Implications 6.1 The work undertaken by the Learning Disability services aim to significantly reduce inequalities for that client/patient group. 7 Resource Implications 7.1 It is noted that Learning Disability services are currently operating with an overspend and that the projected transition from child to adult services will add to the existing cost pressures. The review will seek to identify potential areas for transformation to support future sustainability. 8 Risk 8.1 The financial pressure within Learning Disability Services presents a risk to Midlothian IJB. 9 Involving people 9.1 Midlothian HSCP Learning Disability Service teams, commissioned services, and People First are being engaged in the review. 10 Background Papers None AUTHOR’S NAME Nick Clater DESIGNATION Head of Adult Services, Midlothian HSCP CONTACT INFO Nick.clater@Midlothian.gov.uk DATE 5 June 2023 Page 301 of 302
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Midlothian Integration Joint Board Appendices: None Page 302 of 302