Agenda Document Pack - Midlothian Integration Joint Board - 20/06/2024
Midlothian Council · 20 June 2024
Back to Midlothian Integration Joint Board — 20 June 2024 and its agenda
Text extracted from the council's PDF. Layout and reading order may differ from the original.
Page 1
Notice of Meeting and Agenda Midlothian Integration Joint Board Venue: Council Chambers/Hybrid, Midlothian House, Dalkeith, EH22 1DN Date: Thursday, 20 June 2024 Time: 14:00 Morag Barrow Chief Officer Contact: Clerk Name: Democratic Services Clerk Telephone: 0131 271 3160 Clerk Email: democratic.services@midlothian.gov.uk Further Information: This is a meeting which is open to members of the public. Page 1 of 380
Page 2
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 Minute of Midlothian Integration Joint Board Meeting of 18 April 2024 - submitted for approval 5 - 20 4.2 Minute of MIJB - Strategic Planning Group Meeting of 25 January 2024 - submitted for noting 21 - 28 4.3 Minute of MIJB - Audit and Risk Committee Meeting of 7 March 2024 - submitted for noting 29 - 34 5 Public Reports 5.1 Chair's Update - Councillor McManus, Chair 5.2 Chief Officer's Report – Morag Barrow, Chief Officer 35 - 46 For Decision 5.3 Annual Accounts 2023/24 - David King, Interim Chief Financial Officer (to follow) 5.4 MIJB Directions 2024/25 - Gill Main, Integration Manager and Elouise Johnstone, Performance Manager 47 - 88 5.5 Proposed Programme of Statutory Public Consultation on the Strategic Commissioning Plan 2025-40 - Gill Main, Integration Manager 89 - 102 5.6 Primary Care: General Practice Sustainability - Dr Rebecca Green, Clinical Director 103 - 112 5.7 Planning, Performance and Programme Recovery Action - Gill Main, Integration Manager 113 - 132 For Discussion 5.8 MIJB Finance Update - David King, Interim Chief Financial Officer 133 - 138 Page 2 of 380
Page 3
5.9 IJB Performance Report - Elouise Johnstone, Performance Manager 139 - 152 5.10a Public Health Prevention Update: A Strengthened Approach to Prevention across the Lothian Health and Care System - Jim Sherval, Public Health Consultant and Ashley Goodfellow, Deputy Director of Public Health and Health Policy 153 - 192 5.10b Director of Public Health Annual Report 2023 - Jim Sherval, Public Health Consultant and Ashley Goodfellow, Deputy Director of Public Health and Health Policy 193 - 228 For Noting 5.11 Multi-Agency Public Protection Arrangements (MAPPA) Report for Edinburgh, the Lothians, and the Scottish Borders - Fiona Kennedy, Group Service Manager 229 - 280 5.12 IJB Financial Recovery Actions: Commissioning - Nick Clater, Head of Adult Services 281 - 286 5.13 IJB Financial Recover Actions Equality Impact Assessments - Nick Clater, Head of Adult Services 287 - 370 5.14 Midlothian & East Lothian Drugs & Alcohol Partnership (MELDAP) Budget - Nick Clater, Head of Adult Services 371 - 380 6 Private Reports 7 Date of Next Meeting The next meeting will be held on Thursday, 22 August 2024 at 2pm. Page 3 of 380
Page 4
Page 4 of 380
Page 5
Midlothian Integration Joint Board Meeting Date Time Venue Midlothian Integration Joint Board Thursday, 18 April 2024 2.00pm Virtual Meeting held using Microsoft Teams. Present (voting members): Connor McManus (Chair) Val de Souza (Vice Chair NHS) Councillor Winchester Councillor Milligan Andrew Fleming (NHS Lothian) Angus McCann (NHS Lothian) Nadin Atka (NHS Lothian) (virtually) Councillor Parry (virtually) Present (non-voting members): Morag Barrow (Chief Officer) David King (Interim Chief Finance Officer) Joan Tranent (Chief Social Work Officer) Fiona Stratton (Chief Nurse) (attended virtually) Rebecca Green (Clinical Director) (attended virtually) Jordan Miller (Partnership Representative NHS) (attended virtually) Wanda Fairgrieve (Partnership Representative NHS) (attended virtually) Marlene Gill (User Representative) Keith Chapman (User Representative) Magda Clark (Third Sector Representative) (attended virtually) Claire Ross (Chief AHP) Grace Chalmers (Partnership Representative (MLC)) In attendance: Councillor McKenzie (attended virtually) Councillor McEwan Grace Cowan (Head of Primary Care and Older Peoples Services) Nick Clater (Head of Adult Services & Social Care) Gill Main (Integration Manager) Jenny Long (Director of Primary Care) Elouise Johnstone (Performance Manager) (attended virtually) Fiona Kennedy (Group Service Manager) Roxanne Watson (Executive Business Manager) Ruth Flynn (Public Health Practitioner) Rachael Mcgruer (Deputy Director of Adult Social Care Local Improvement & Gary Leadbetter (Democratic Services Officer) Midlothian Integration Joint Board Thursday, 20 June 2024 Item No 4.1 Page 5 of 380
Page 6
2 Midlothian Integration Joint Board Thursday 18 April 2024 1. Welcome and Introductions The Chair welcomed everyone to this Meeting of the Midlothian Integration Joint Board (MIJB). 2. Order of Business The order of business was confirmed as outlined in the agenda that had been previously circulated. 3. Declarations of Interest No declarations of interest were received. 4. Minute of Previous Meetings 4.1 The Minute of the Meeting of the MIJB held on 8 February 2024 was submitted for approval and agreed as a correct record. 4.2 The Minute of the Special Meeting of the MIJB held on 21 March 2024 was submitted for approval. Angus McCann stated that they had submitted their apologies for this meeting but that they were not noted. It was agreed that after this amendment was made then the Minute would be a correct record. 4.3 The Minute of the MIJB Audit and Risk Committee Meeting held on 7 December 2023 was submitted for noting. 5. Public Reports Transformation Division, Scot Gov) (attended virtually) Hannah Forbes (Assistant Democratic Services Officer) Apologies: Page 6 of 380
Page 7
3 Midlothian Integration Joint Board Thursday 18 April 2024 Report Title/Summary Decision Action Owner Date to be Completed/ Comments 5.1 Chair’s Update - Presented by Councillor McManus The Chair stated that they had sent letters to NHS, the Scottish Government and the Planning Board. They noted that they will share the replies once received. The Chair reminded the Members that a Chair was still being sought for the Strategic Planning Group. 5.2 Chief Officer’s Report – Presented by Morag Barrow, Chief Officer Morag Barrow, Chief Officer, presented their report which set out the key strategic updates for the MIJB Board meeting in April 2024. Members were asked to note the content of the report. The Chair thanked Morag Barrow for the report and opened it up for questions. Councillor Parry noted that some of the extra allocation MIJB received from Midlothian Council was to support people transitioning from young people services to adult services. Councillor Parry queried whether there had been any initial work across directorates around this. Morag Barrow explained that there are continual conversations, through the GIRFEC Board, around the challenges. Nick Clater, Head of Adult Services and Social Care, explained that a cross- departmental working group was being set up which will link in with various services. This will look at how young people will be transitioned more generally. Nick Clater talked about setting up a transition service which is ageless and works across a range of different departments. Joan Tranent, Chief Social Work Officer, explained that the CAMHS waiting list is doing fairly well and explained how it is split into two different waiting lists. Joan Tranent recognised that there are still challenges that exist in relation to the waiting lists. Councillor Milligan raised concerns around risks to GP practices and sustainability in respect of the areas where planning consent has been granted for a significant number of houses. Page 7 of 380
Page 8
4 Midlothian Integration Joint Board Thursday 18 April 2024 Report Title/Summary Decision Action Owner Date to be Completed/ Comments Morag Barrow stated that they shared the anxiety around this and outlined some of the actions that had been taken and are being taken. Val de Souza, Vice Chair, asked that in relation to community orders and the next time this information is supplied whether the percentage of self-referrals could be supplied. Val de Souza raised a query around the closing time of the MARS project and also questioned how things were going with the MHO workforce. Morag Barrow, in relation to the MARS project, stated that there were financial restrictions around the timings. Nick Clater explained that they were looking at piloting extending the service to 65 y/o’s for a period of time. Nick Clater also advised that the closing time is also around capacity, although this is being reviewed. In terms of the MHO workforce, Nick Clater stated that this is an aging workforce. They noted that there is success in getting 2 people through the course each year and than 2 is the maximum number that can be afforded. Angus McCann queried whether, in relation to frailty, this is an ongoing continuous improvement or something more substantial. Morag Barrow explained that the answer was probably yes to both. It was noted that tests are broadly still running and there needs to be a decision around whether these are scaled up or not. It was noted that this links into larger pieces of work that are ongoing. Keith Chapman noted that there was a lot of publicity around hospices struggling and queried whether there was any impacts locally. Fiona Kennedy, Group Service Manager, explained that Edinburgh HSCP hosts contracted work within two hospices in Edinburgh and there are ongoing discussions around the model of care. It was noted that there is increasing interest in moving to at home care. Fiona Kennedy explained that there is collective working to make sure people get the best possible care when they need it. Page 8 of 380
Page 9
5 Midlothian Integration Joint Board Thursday 18 April 2024 Report Title/Summary Decision Action Owner Date to be Completed/ Comments 5.3 MIJB Dates for December 24 – December 25 – Presented by Democratic Services The Chair presented the report. The purpose of the report was to set the dates for the meetings, committees, groups and development sessions on the MIJB for 2025. Members were asked to: • Approve the meeting schedule and development session dates for 2025. • Note the scheduling of service visits for the Members of the MIJB. Councillor Winchester moved the report and was seconded by Keith Chapman. Meeting schedule for 2025 dates approved. 5.4 MIJB Improvement Plan Financial Recovery Actions: Planning, Performance and Programme – Presented by Gill Main, Integration Manager Gill Main, Integration Manager, presented the report. The report presented three options to either reduce expenditure or rescind investment support to the Planning, Performance and Programme service as one of five Financial Recovery Action Plan to achieve the required financial recovery position. Members are asked to: • Consider the benefits and risks associated with the presented options. • Determine and agree a position in relation to 2024/25 funding for the service. The Chair thanked Gill Main for the report and opened it up for questions. Discussion took place around the paper and the difficulties of making a decision at this moment in time, particularly considering the following paper. The importance of this team was noted, but the financial pressures the HSCP are facing was also highlighted. Following further Options 1 and 2 to be worked out in more detail and brought back to MIJB. Page 9 of 380
Page 10
6 Midlothian Integration Joint Board Thursday 18 April 2024 Report Title/Summary Decision Action Owner Date to be Completed/ Comments discussion on the options it was agreed that options 1 and 2 seemed the most desirable and that these should be taken away and worked out in more detail, including fleshing out some of the risks and challenges, to then be brought back to the MIJB in June. 5.5 Midlothian Health and Social Care Partnership System Transformation Planning – Presented by Gill Main, Integration Manager Gill Main, Integration Manager, presented the report. The purpose of the paper was to note the planned Financial Recovery Actions within the context of transformation opportunities within Midlothian Health and Social Care strategic commissioning, planning and operational delivery. Members are asked to: • Consider the strategic whole-system transformation proposals and recommendations described in the report. • Determine which of these recommendations the Board would like to be considered as priority areas for investigation and development within the Strategic Commissioning Plan 2025/40. • Commission the Strategic Planning Group to take forward and identify strategic development. The Chair thanked Gill Main for the report and opened it up for questions. Morag Barrow noted that following the budget allocation a transformation board is about to be set up in the HSCP that will pick up all the key elements of transformation, including the transactional elements of year 1. Angus McCann queried whether the figures are in line with national figures or whether they are driven by Covid. Gill Main explained that that these are high-level, early indication data. David The Integration Manager Page 10 of 380
Page 11
7 Midlothian Integration Joint Board Thursday 18 April 2024 Report Title/Summary Decision Action Owner Date to be Completed/ Comments king explained that a lot of these things are still being delivered due to Covid as practices had to change and noted that this is one of the funding pressures. It was noted that this does need more work. It was agreed that the report be move forward with the recommendations outlined. 5.6 National Care Service Discussion – Presented by Rachael McGruer, Deputy Director of Adult Social Care Local Improvement & Transformation Division, Scottish Government Rachael McGruer, Deputy Director of Adult Social Care Local Improvement Local Improvement & Transformation Division, Scottish Government, shared and spoke to a presentation. The Chair thanked Rachael McGruer for the presentation and opened it up for questions. Councillor Milligan queried what benefit the National Care Service (NCS) would have for end users. Rachael McGruer explained that the NCS is a big step forward as there is currently no national oversight of the care service, so this would allow the development of national standards. Angus McCann requested additional details in relation to firming up governance structures and simplifying them and raised a query in relation to integrated digital records. Rachael McGruer stated that in terms of voting membership nothing had been firmed up, although advised that the Minister had stated that each integrated authority will have equal voting rights. Rachael McGruer noted that the NCS will be co-designed with delivery partners and service users. They further stated that there was no particular update on an integrated digital record but advised that the government is still committed to this. Page 11 of 380
Page 12
8 Midlothian Integration Joint Board Thursday 18 April 2024 Report Title/Summary Decision Action Owner Date to be Completed/ Comments Andrew Fleming queried when detail will be shared so that it could be better understood what the NCS will mean on the ground. Andrew Fleming also queried how the NCS will help with some of the difficult challenges being face, such as a lack of resources to deliver. Andrew Fleming further questioned who sits on the expert legislative advisory group, what the process around the advice provided is and how co-production with IJBs would work. Rachael McGruer, in relation to the first question, stated that they have written back to the Committee and intend to share the detail of changes to the Bill by June, including an outline of what will is likely to covered in the Stage 2 amendments. In terms of co-design, Rachael McGruer explained that the advisory group is focusing on primary legislation at the moment, noting that it is a framework bill. Rachael McGruer advised that the government is keen to work with partners on secondary legislation and guidance. In terms of working with Local Authorities, Rachael McGruer stated that they will work through HSCP and are keen to have discussions about how best to engage with IJBs. In terms of the membership of the advisory group, Rachael McGruer advised that there was a large membership composed of a range of different parties, such as representatives of providers, users, planners and deliverers of health and social care. Andrew Fleming queried if there was a published membership list of the advisory group and further questioned how the Bill will help IJBs deliver sustainable and social care services. Rachael McGruer advised that they would check the membership list and share this. They further advised that one of the key hopes for the NCS was a greater national oversight to better inform national planning and planning ahead and that the government is keen to make sure principles such as spare work are embedded within the service. Joan Tranent, Chief Social Work Officer, queried what the timescales are in relation to children’s services and justice. Rachael McGruer advised that there was not a specific timeframe in terms of when a decision will be made, but noted that Ministers are keen to ensure NCS has oversight of children’s services in some way and that the options are being worked through. It was further noted that there would be national standards which would be outcome Page 12 of 380
Page 13
9 Midlothian Integration Joint Board Thursday 18 April 2024 Report Title/Summary Decision Action Owner Date to be Completed/ Comments focused and that it would be at the discretion of Local Authorities in terms of how these services are delivered locally. The Chair, noting overspend, raised a concern around delivery of services as they are and queried how funding will work in the long term. Rachael McGruer advised that the NCS is about looking at how the services are delivered differently, and this would allow things such as sharing best practice. Rachael McGruer stated that they don’t think the funding situation is something the NCS is looking to address. In relation to the following questions raised by Val de Souza, Rachael McGruer provided the corresponding answers: • Noting that it was stated that the NCS goes significantly beyond the Feeley Review, more information around this was requested. • How the NCS is going to be better and how things would be done differently. Rachael McGruer, in relation to the above two questions, explained that the scope of the services has went beyond the review. Rachael McGruer also explained that strict stipulations would not be set out in terms of how localities might operate in areas. Rachael McGruer also advised that the government is keen to work with Local Authorities on how to better embed the principles which drive good locality management and enable good communities’ engagement. • Whether finances would still go through Local Authorities and health boards. Rachael McGruer explained that the majority of funding to IJBs from government would continue to go to Local Authorities and NHS, although Ministers are minded to place a power in the Bill which allows them to fund IJBs for specific circumstances, which is not currently possible. Page 13 of 380
Page 14
10 Midlothian Integration Joint Board Thursday 18 April 2024 Report Title/Summary Decision Action Owner Date to be Completed/ Comments • Keith Chapman noted that the problem with lived experience is that there are some groups which are better organised and have louder voices and so are often heard by politicians, compared to where more voices might be needed, noting that an example of an underrepresented group is often the socially economically deprived. Rachael McGruer agreed that these are important points and that the government is keen to tackle this, with it being one of the priority areas. Rachael McGruer explained that the government is carrying out work to engage with and capture the voices of those who are not traditionally listened to when co- design work is being undertaken. Rachael McGruer mentioned citizens panels and explained that this is an area the government is very much committed to addressing. Angus McCaan queried the legislative schedule in terms of completion and the expected timeframe in terms of implementation. Rachael McGruer explained that the legislative timetable is a matter for Parliament and so this is unknown, further nothing that the government is committed to launching the NCS in this Parliament which would be by spring 2026. The Chair stated that it would be useful to have Rachael McGruer back in the future. Rachael McGruer stated that they would be happy for their email address to be shared with members if there were further questions. 5.7 MIJB Finance Update – Presented by David King, Interim Chief Finance Officer David King, Interim Chief Finance Officer presented the report. This paper presents a further iteration of the IJB’s five-year financial plan (2024/25 to 2028/29), the previous version having been presented to the IJB at its December 2023 meeting. The five-year plan presented to the IJB in December 2023 projected a total financial gap from 2024/25 to 2028/29 of £99.5m. Having revised and reviewed the forecast and having incorporated the actions identified as part of the 2024/25 IJB budget setting the total projected gap is now £39m. Further work and proposals are now required to move towards a balanced position for 2025/26 and the years Page 14 of 380
Page 15
11 Midlothian Integration Joint Board Thursday 18 April 2024 Report Title/Summary Decision Action Owner Date to be Completed/ Comments thereafter. The IJB Strategic Plan is currently under review and work will continue to ensure that the financial plan is clearly mapped onto and driven by the Strategic Plan. Members are asked to: • Note the five-year plan update. • Note the ambition to take a transitional approach in 2024/25 to realign the strategic, financial and workforce planning with the new Strategic Commissioning Plan 2025/40 scheduled for publication in April 2025. • Support the work to ensure that the financial plan aligns with the IJB’s Strategic Plan. • Support the work to deliver a balanced five-year financial plan. The Chair thanked David King for the report and opened it up for questions, of which there were none. 5.8 MIJB Performance Report – Presented by Elouise Johnstone, Performance Manager Elouise Johnstone, Performance Manager, presented the report. The purpose of the report was to update the IJB on progress towards the IJB performance goals set for the financial year 2023/24. Due to the processes required to validate the data, the full reporting year is almost complete for all indicators. Members are asked to: • Note the performance against the IJB Improvement Goals for 2023/24. • Note the proposed new dates for Performance Assurance and Governance Group Meetings for 2024. The Chair thanked Elouise Johnstone for the report and opened it up for questions. Page 15 of 380
Page 16
12 Midlothian Integration Joint Board Thursday 18 April 2024 Report Title/Summary Decision Action Owner Date to be Completed/ Comments Val de Souza noted that the staff must be running very quickly with the work. Grace Cowan, Head of Primary Care and Older People’s Services, explained that a lot of work had been undertaken, noting that Midlothian had taken a different approach in that it has looked at a proactive in-reach model, explaining the work around this. Andrew Fleming stated that a couple of the measures seemed quite close and queried whether there was any indication of when the measures are close to understand the sensitivity of the figures. Elouise Johnstone explained that some of the challenge with the published data is that there is such a lag on it being available which means that some of the data is outdated. Elouise Johnstone advised that whilst the management data is more timely, it is not necessarily an actual reflection of how it will look in months to come when it is fully validated, noting that some of this activity is continuous live activity within the system. As such, it was noted that it is difficult to predict from one month to the next in terms of whether it will improve or not. 5.9 Public Health Prevention Update – Presented by Public Health Practitioner and Group Service Manager Ruth Flynn, Public Health Practitioner and Fiona Kennedy, Group Service Manager, shared and spoke to a presentation. The Chair thanked Ruth Flynn and Fiona Kennedy for the report and opened it up for questions. Angus McCann raised a query in relation to current prescribing. Ruth Flynn explained that at the moment GPs would pass cases on to wellbeing officers within the GP services and they would have the conversation and work out what would be the best approach. Ruth Flynn explained that the numbers around this are being collected, but noted the difficulties around this. Ruth Flynn further explained that the numbers of providers and their activities are also Page 16 of 380
Page 17
13 Midlothian Integration Joint Board Thursday 18 April 2024 Report Title/Summary Decision Action Owner Date to be Completed/ Comments being looked at, noting that part of the evaluation is looking at what is currently happening, but noted that it is not a blanket approach across the whole of the area. Andrew Fleming noted that one of the benefits is that it reduces the prescribing costs and queried if there was any way this impact could be assessed. Andrew Fleming also queried the equality dimension around this work, asking if different groups of individuals could be reached. Ruth Flynn advised that the economics aspect had not been looked at, noting that this was something that they tried to capture through evaluation and following the busy periods they would look at this further. In terms of equalities, Ruth Flynn advised that the activities generally happen in more deprived areas, so there is a feeling that they benefit the most from this. Ruth Flynn advised that an equalities impact assessment is also being looked at. 5.10 Integration Assurance Report – Fiona Stratton, Chief Nurse Fiona Stratton, Chief Nurse, presented the report. The report is the Integrated Governance report for MIJB. Members were asked to discuss and approve the content of the report. Keith Chapman queried whether there was good input from secondary care in relation to the clinical directory. Fiona Stratton stated that the need for secondary care involvement is low in terms of the instances where significant adverse events are looked at, but noted that it would be unusual for there not to be input and cooperation for services that have had hands on in a situation that had had a significant adverse event. 5.11 Annual Performance Report: Content and Proposed Timeline – Presented by Integration Manager Gill Main, Integration Manager, presented the report. The Midlothian Annual Performance Report provides information on the health and wellbeing of people and communities in Midlothian and an assessment of progress in relation to the nine National Health and Wellbeing Page 17 of 380
Page 18
14 Midlothian Integration Joint Board Thursday 18 April 2024 6. Private Reports No items for discussion. 7. Any Other Business No items for discussion. 8. Date of Next Meeting The next meetings of the Midlothian Integration Joint Board will be: • MIJB Development Session on Thursday, 16 May 2024 at 2pm. • MIJB held on Thursday, 20 June 2024 at 2pm. Report Title/Summary Decision Action Owner Date to be Completed/ Comments Outcomes. It also describes financial performance, and the quality of health and care services delivered during 2023-24. Members were asked to: • Note that as 2023/24 is a reporting year for the Health and Care Experienced survey, all indicators will be updated. • Note the timeline for data publication, governance meetings, and scheduled activities. The Chair thanked Gill Main for the report and opened it up for questions, of which there were none. Page 18 of 380
Page 19
15 Midlothian Integration Joint Board Thursday 18 April 2024 (Action: All Members to Note) The meeting terminated at 16:07pm. Page 19 of 380
Page 20
Page 20 of 380
Page 21
Midlothian Integration Joint Board Meeting Date Time Venue Strategic Planning Group Thursday 25 January 2024 14:00 – 16:00 Virtual Meeting held using MS Teams. Chair: Gill Main (Integration Manager) Vice Chair: Vacant Present (MIJB members): Keith Chapman (Lived Experience Member) Pauline Winchester (Midlothian Councillor) Angus McCann David King (Chief Finance Officer) Morag Barrow (Director, Midlothian HSCP) Grace Cowan (Head of Primary Care and Older People, Midlothian HSCP) Present (SPG Members): Nick Clater (Head of Adult Services, Midlothian HSCP) Fiona Kennedy (Service Manager, Midlothian HSCP) Roxanne Watson (Executive Business Manager, Midlothian HSCP) In attendance: Elouise Johnstone (Programme Manager, Midlothian HSCP) Irene Beautyman, (Place and Wellbeing Partnership Lead) Jim Sherval (Public Health Consultant) Jake Murray (Project team Manager, Midlothian HSCP) Kate Thornback (Equality and Human Rights Lead, Midlothian HSCP Emma-Jane Gunda (Assistant Strategic Programme Manager, Midlothian HSCP) Midlothian Integration Joint Board Thursday, 20 June 2024 Item No 4.2 Page 21 of 380
Page 22
2 Strategic Planning Group Thursday 25 January 2024 Susan Rintoul, (Shaping Places for Wellbeing Project Lead) Rebecca Hilton (Population Health Manager) Apologies: Johanne Simpson Saty Kaur Fiona Stratton Chris King James Hill Annette Lang Rebecca Miller Sarah Archibald Rachael Honeyman Rebecca Green 1. Welcome and introductions GM welcomed everyone to the meeting. 2. Order of Business The order of business was as set out in the agenda. 3. Minutes of Meeting and Action Log The Minutes of Meeting of the Strategic Planning Group held on 30 November 2023 were reviewed and approved. EG shared the action log, reviewed, and updated the actions to date. Page 22 of 380
Page 23
3 Strategic Planning Group Thursday 25 January 2024 4. Public Reports Report Title/Summary Decision Action Owner Date to be Completed/Comments 4.1 Chairs Update GM welcomed everyone to the meeting and asked if for anyone who would like to join the special meeting of the SPG at Midlothian Community Hospital on 5 March 2024. This is the Place Assessment for the Strategic Commissioning Plan, if anyone is interested in joining this session, GM asked them to contact Emma-Jane Gunda or Jac Kinnaird. 4.2 Finance Update – David King DK advised that the Quarter 3 position has not been published yet however a £2.6m overspend is predicted in health. DK confirmed the pressure in the system is underpinned by money sitting in reserves, and the Lothian position is likely to get worse with a £7.7m overspend in social care. DK confirmed there will be a IJB Financial Recovery session held on 29 February. MB commented that there is lots of operational work going on and the position has deteriorated due to the Scottish Government allocation. MB advised that the Council position will remain unknown until after the meeting in February. In the meantime, teams are working on plans with grip and control, ensuring services are working as efficiently as possible, then we may need to look at things we need to stop to make further savings. MB confirmed the third financial workshop for managers will be held on 7 February and after this we will be in a position to look at the gap. A bed-based review is also underway. MB is hoping to be able to present a draft plan to the IJB on 29 February. Page 23 of 380
Page 24
4 Strategic Planning Group Thursday 25 January 2024 Report Title/Summary Decision Action Owner Date to be Completed/Comments DK advised slides were previously circulated to the group after the last meeting by Jac Kinnaird and if anyone has not received these to indicate to the clerk. PW asked if the HSCP have any control over what can go on prescription. MB confirmed that Lothian are the best in Scotland and Midlothian are the best in Lothian however we have now been given any assurance nationally from prescribing. Teams have discussed prescribing waste and are looking at models to make changes locally. MB stated this is a significant pressure for Midlothian. 4.3 PAGG update – Elouise Johnstone EJ confirmed that the meeting of the Performance Assurance and Governance Group had been scheduled to meet in December, however due to a number of factors the meeting did not go ahead. The regular meetings will be restarted for 2024 and we will continue to ensure the membership reflects representation from IJB, HSCP officers and data specialists (both internal and from our partner organisations). 4.4. Workforce Governance Planning update – Gill Main GM confirmed that the Workforce Planning Lead has now left, and we are moving forward with project support focusing on supporting services with workforce plans and delivery finance, health and social care staffing legislation and baseline information. 4.5 Workforce Governance Staff engagement update – Fiona Kennedy FK advised that the group have recently met and discussed wellbeing, core and mandatory training, supervision registration workstreams and the emphasis on local employability strategy. FK confirmed a lot of work is going on with the delivery plan due to be revised and actions being taken forward to the current year. Page 24 of 380
Page 25
5 Strategic Planning Group Thursday 25 January 2024 Report Title/Summary Decision Action Owner Date to be Completed/Comments 5. Reports 5.1 Topic in Focus Strategic Commissioning Plan Update (Including Intro to Place Assessment) Paper presented by Jake Murray, Project Team Manager JM advised he has been working with the Lothian Health Board on the Shaping Places for Wellbeing programme which covers the impact our work has on our health and wellbeing. JM provided a short introduction to the Place Assessment topic, ahead of the planned Special SPG session in March. The briefing paper was shared with SPG papers for the group’s information on the workshop which outlines use of the 5 Place and Wellbeing Outcomes, Dalkeith inequalities data, and the report which will follow for consideration in the IJB Strategic Commissioning Plan. KC asked how the assessments are related. IB advised that data profiles are pulled together using ISMD. EJ commented that a number of houses are being built and there is an ISMD profile of our data zones given the rapid house development. IB confirmed that profiles for Dalkeith for immediate zones will only involve new housing in that area. IB added that there are others which have not been mapped out. GM asked the group to indicate if they would like to join the Place Session being held on 5 March 2024. JM provided an update on the progress of the Strategic Commissioning Plan 2025- 40. JM noted progress made to date highlighting the initial consultation with HSCP services and the public. JM commented there were clear themes within the feedback received, with community uncertainty around finance and concern about friction between strategy and operational spaces. JM asked the group to recognise and review the work to date and continue to support the development of the SCP through the next key phases, and highlight any areas for potential improvement. Page 25 of 380
Page 26
6 Strategic Planning Group Thursday 25 January 2024 Report Title/Summary Decision Action Owner Date to be Completed/Comments PW asked if this could go to public consultation to involve Community Councils and get others involved as we may get more engagement. GM advised that there is a statutory requirement to carry out a public consultation and Community Council will be contacted as part of that process. MB confirmed the last 18 months to 2 years has been spent linking operational plans with strategic objectives. 5.2 Items for Decision Community Engagement Self-Evaluation Update Paper presented by Kate Thornback, Equality and Human Rights Lead KT provided an update on the Healthcare Improvement Scotland Quality Framework for Community Engagement Self-Evaluation. KT advised that the 5-step process is underway, and a senior staff survey will be issued around community engagement. KT asked the group to complete the survey version most appropriate to them and consider the offer from Healthcare Improvement Scotland of additional workshops on topic for understanding and log any issues that could hinder proposed development timeline highlighted in appendix. KT advised that Healthcare Improvement Scotland have been notified of this activity and confirmed there will be no scrutiny of our process but are keen to see it for comparison with other organisations. Healthcare Improvement Scotland expressed interest in involvement with discussions to offer any necessary support. KT confirmed the next steps will be holding consensus and improvement sessions on where our priorities, strengths and weaknesses are. A core group have received an invitation to this face-to-face session being held at Midlothian Community Hospital, but KT is happy to open the meeting up if anyone else would like to attend on 21 February. SPG Members to indicate their interest to KT in attending sessions All 21/02/2024 Page 26 of 380
Page 27
7 Strategic Planning Group Thursday 25 January 2024 Report Title/Summary Decision Action Owner Date to be Completed/Comments KT advised that we will be moving to the planning stages in the next two weeks with completion due in June. GM advised that this is a statutory requirement. MB commented that given some financial challenges and a lot of consultation around Covid that this has not been a focus. MB thanked the team for their work around this. 5.3 Items for Discussion MIJB Commission: Scoping Exercise in relation to Local Employability and other Fair Work for Pay Options Update presented by Jim Sherval, Public Health Consultant, and Rebecca Hilton, Population Health Manager JS provided an update on supporting people in employment and advised that himself and RH have been working with other organisations to scope potential. RH confirmed that the project plan has been drafted and she plans to take this to the Workforce staff engagement group on 13 February and will return to the group with an update on the scoping exercise once it is underway. RH advised that the funding ends in April. GM confirmed that the Board are keen to understand how they can support this and requested an update on the scoping exercise in June. This would require an update to come back to SPG at the April or May meeting via the Staff Engagement Workforce group. NC asked where this fits into staff engagement as Fiona Kennedy chairs this group. GM confirmed the Staff Engagement Group Terms of Reference did include activity of this nature. MB reminded the group that we have no funding and asked them to be mindful of what is a realistic set of recommendations might look like. A set of proposals for SPGs consideration will be reviewed at the May SPG JS 23/05/2024 Page 27 of 380
Page 28
8 Strategic Planning Group Thursday 25 January 2024 Report Title/Summary Decision Action Owner Date to be Completed/Comments 5.4 Items for Discussion Directions Introduction presented by Gill Main, Integration Manager GM highlighted to the group that with the current and ongoing financial work the discussion on IJB Directions development would be deferred to a later meeting. Await final financial position GM April 2024 6. Any other business Report Title/Summary Decision Action Owner Date to be Completed/Comments Due to the requirement to hold an additional finance workshop for Board Members, the next meeting of the SPG on 29 February has been shortened to 30 minutes for essential governance business only. 7. Date of next meeting The next meeting of the Strategic Planning Group will be held on 29 February 2024 at 2.00pm. Please note this meeting is currently planned to be a virtual meeting using MS Teams. Actions: All Members please note and progress the actions detailed in this document Page 28 of 380
Page 29
Midlothian Integration Joint Board Meeting Date Time Venue MIJB - Audit and Risk Committee Thursday 7 March 2024 2.00pm Virtual Meeting held using MS Teams Present (voting members): Val de Souza (Chair) Councillor McManus Councillor Parry Nadin Atka Present (non-voting members): Morag Barrow (Chief Officer) David King (Chief Finance Officer (Interim)) Duncan Stainbank (Chief Internal Auditor) Patricia Fraser (External Auditor) Claire Gardiner (External Auditor) Gill Main (Integration Manager) In attendance: Roxanne King Gary Leadbetter (Democratic Services Officer) Hannah Forbes (Assistant Democratic Services Officer) Apologies: Midlothian Integration Joint Board Thursday, 20 June 2024 Item No 4.3 Page 29 of 380
Page 30
2 MIJB - Audit and Risk Committee Thursday 7 March 2024 1. Welcome and Introductions The Chair welcomed everyone to the meeting of the Midlothian Integration Joint Board (MIJB) – Audit and Risk Committee. 2. Order of Business The Order of Business was as detailed in the agenda. 3. Declarations of interest No declarations of interest were received. 4. Minutes of Meeting 4.1 The Minute of Meeting of the Audit and Risk Committee held on 7 December 2023 was submitted. The Minute was approved as a correct record. 5. Public Reports 5.1 External Annual Audit Plan 2023/24, report by Audit Scotland The External Auditor presented the report, which summarises the work plan for the 2023/24 audit, and provided a summary of the main elements. The Chair thanked the External Auditor for the report and opened it up for questions. The Chief Officer queried the 6% increase in fees. The External Auditor stated that they understood the challenges around this, although noted that the fees are set centrally, and that Audit Scotland is facing financial pressures and are working hard to create efficiencies to Page 30 of 380
Page 31
3 MIJB - Audit and Risk Committee Thursday 7 March 2024 mitigate the impact of the increase. Some discussion took place on the financial pressures and challenges faced, noting that this was not something experienced by Midlothian IJB in isolation. 5.2 Local Government in Scotland: Financial Bulletin 2022/23, report by Audit Scotland The External Auditor presented the report and noted that it is for information. Discussion took place on the report, including the perceptions and complexities of funding, spend and reserves in relation to Councils and the pressures faced and the culture around this. 5.3 Q4 2023/24 Risk Register, report by Chief Finance Officer (Interim) The Chief Finance Officer (Interim) presented the report. The report presents the IJB’s Risk Register for Q4 2023/24. The risk register has been reviewed and amendments made, these are detailed below. At its meeting on 7th December 2024 the committee agreed to move its risk register onto the Datix system which is managed by NHS Lothian. The extract attached to this paper is from Datix along with appendices laying out Datix Impact and Consequences and the Datix Risk Matrix, the latter two being for the committee’s information. Three risks are now categorised as ‘very high’ all being a function of the severe financial challenges that the IJB and its partners are facing in 2024/25. The MIJB Audit and Risk Committee are asked to: 1. Note the Q4 Risk Register. 2. Consider if any further additions or changes should be made to the Risk Register. The Chair thanked the Chief Finance Officer (Interim) for the report and opened it up for questions. The Chair noted the offer in the report of a briefing on the use and workings of Datix for Members and welcomed this and asked that this is picked up and arranged. The Chief Officer noted that the layout of appendices in the report were being looked at in order to improve their presentation. The Chief Officer further explained that they were concerned around the potential decisions that partners will make for the next financial year and the unintended consequences that this may have for the MIJB. The Chair agreed that it would be helpful for this to be raised and noted that it may be helpful to have a section in the finance report that looks at the whole system and the impact on the MIJB. The Chief Internal Auditor explained that this will be covered slightly, noting that it is the broad thrust of the second audit on the audit plan which looks at capturing the impacts of transformational changes and that which happens at a system level. Page 31 of 380
Page 32
4 MIJB - Audit and Risk Committee Thursday 7 March 2024 Action – discuss and arrange a briefing on the use and working of Datix for Members – Val De Souza / Councillor McManus / Morag Barrow / Gill Main 5.4 Proposal for a Development Session for the Committee, report by Chief Internal Auditor The Chief Internal Auditor presented the report. The purpose of this report is to gain approval to the proposal to complete a self-analysis of the MIJB Audit & Risk Committee against the CIPFA Position Statement: Audit Committees in Local Authorities and Police 2022. Following this review that topics for Development sessions are identified and Development sessions scheduled for Audit & Risk Committee members following each Audit & Risk Committee meeting. The MIJB Audit and Risk Committee are asked to: 1. Approve the proposal for the Audit & Risk Committee self-assessment participation to be completed by June 2024. 2. Approve that development sessions will be held following each Audit & Risk Committee meeting throughout the year, based on the analysis of the self-assessment. The Chair thanked the Chief Internal Auditor for the report and opened it up for questions. The Chief Officer asked if the themes from the learning from East Lothian could be shared. The Chief Internal Auditor explained that there were four key areas being looked at which were government statements, fraud, risk and best value. The Chief Officer noted that they expected that there would be similar themes for the MIJB and asked if there was any opportunity for shared learning. The Chief Internal Auditor stated that they would look at this. Recommendations approved. 5.5 Internal Audit Report by Chief Internal Auditor The Chief Internal Auditor presented the report. The purpose of the Report is to present the proposed Internal Audit Annual Plan 2024/25 for the Midlothian Health and Social Care Integration Joint Board for discussion and approval by the MIJB Audit and Risk Committee. The MIJB Audit & Risk Committee are asked to approve the Internal Audit Annual Plan 2024/25 for the Midlothian Health and Social Care Integration Joint Board. The Chair thanked the Chief Internal Auditor for the report and opened it up for questions. Page 32 of 380
Page 33
5 MIJB - Audit and Risk Committee Thursday 7 March 2024 The Integration Manager noted some outstanding policies that are outdated and need to be picked up and agreed that they would discuss these with the Chief Internal Auditor. The Chief Officer questioned the use of the word “transformation” and suggested that this be revisited and perhaps rephrased to “grip and control.” Recommendation approved. 6. Private Reports No private business to be discussed at this meeting. 7. Date of next meeting The next meeting will be held on Thursday 6 June 2024 at 2.00pm. (Action: All Members to Note) The meeting terminated at 15:24. Page 33 of 380
Page 34
Page 34 of 380
Page 35
Midlothian Integration Joint Board Thursday 20th June 2024, 14:00-16:00 Chief Officer’s Report Executive summary This paper sets out the key strategic updates for Midlothian Integration Joint Board (IJB) meeting June 2024. Board members are asked to: • Note the content of the report. # Item number: 5.2 Page 35 of 380
Page 36
Midlothian Integration Joint Board Midlothian Integration Joint Board Chief Officer’s Report 1 Purpose 1.1 The paper sets out the key strategic updates for Midlothian IJB Board meeting June 2024. 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 Head of Adult Services Mental Welfare Commission reports Midlothian Health and Social Care Partnership (HSCP) received 7 Mental Welfare Commission (MWC) Reports in 2023 and 2024. Within each report there are key finding areas in which Midlothian Mental Health services need to benchmark against and implement recommendations and findings. The following reports have been reviewed and work progressed to meet the recommendations: 1. MWC case of MR D 2. MWC case of Mr E 3. MWC case of GH 4. MWC Community Care and Treatment Orders 5. MWC AWI Act 6. MWC report Substance Use and Mental Health 7. MWC quality assurance visit to CMHT Midlothian HSCP continues to benchmark positively against the reports received by the MWC and any gaps in areas identified are highlighted and improvement work progressed to meet the recommendations. Midlothian HSCP can provide assurance on the delivery of all recommendations from the MWC. Substance Use Services Midlothian Substance Use services continue to make ongoing improvements to continue the delivery of the 90% target for National A 11 (A11 all individuals accessing services will be seen within 21 days from point of referral) Q2 and Q3, seen the services working towards improvement of 90%, where in Q4 Midlothian’s performance has been maintained at 100%. The services continue to provide direct Page 36 of 380
Page 37
Midlothian Integration Joint Board access to timely and appropriate treatment that best meets an individual’s needs, psycho-social support and peer led support for those affected by their or other drugs and/or alcohol use. Over 23/24 Midlothian Substance use Services continue to implement the 10 Medication Assisted treatment (MAT) standards, Midlothian was required to meet the standard of green 1-5 and 6-10 Amber, Midlothian has been successful assessed at Green 1-5 and provisionally Green 6—10, this is in recognition of all the work that the Substances Use services have achieved along with those who access our services, supporting our high risk individuals within their community. Learning Disability Investment in the housing, specialist support and training aspects of the support for people with complex needs related to learning disability and autism continues to pay dividends. Midlothian remains the area with the fewest inappropriate placements of the 32 partnerships and the lowest rate of people in urgent categories on Dynamic Support Register as detailed in the latest PHS publication ‘Insights into Learning Disabilities and Complex Needs: Statistics for Scotland’. Several of the housing elements of the Strategic Redesign of Learning Disability Services in Midlothian have moved on significantly. These developments are designed to support people, regardless of the level, range and complexity of need, to live independently with the same choice, control, and protection as any other citizen, in an environment that enables them to stay safe and empower them to participate in their local community. Building and care tenders are well underway for four people with a Profound and Multiple Learning Disability to move into Primrose Lodge in Loanhead in Autumn 2024. The main part of the building will be occupied by four tenants as their permanent home and the there are two further bedrooms that will be used for respite and short breaks for people with similar needs. St Cuthbert’s, a newly built development of eight single tenancies in the centre of Bonnyrigg, will be ready for occupation mid-June. The tenants will be a diverse group of young neurodiverse people and their support will be highly individualised and tailored to their particular needs, strengths and interests. Many will be young people in their first tenancy and there will be a strong focus on enhancing and transforming the health and wellbeing of tenants using innovative digital technologies. Making Choices Keeping Safe Midlothian is designed to support young people who to expose themselves to risk whilst navigating the complex world of relationships and social media. It is a series of themed workshops developed and designed around the lived experience of six young people with the aim of supporting them to stay safe whilst promoting their right to healthy relationships and a full life. The project demonstrates the value of partnership working and early intervention by bringing together the different perspectives of the young people themselves, their families and carers, the Social Work Learning Disability Team, Police Scotland, The Enable Local Area Coordination Service, The Community Learning Disability Team and third sector providers to understand the issues and develop a response that was uniquely designed to meet the needs of the young adults. Initial evaluation, as well as sustained attendance by the participants, has evidenced that the workshops are both popular and effective. The next course for a group of young men is currently underway. Page 37 of 380
Page 38
Midlothian Integration Joint Board The Pavilion Project is an imaginative developmental day opportunities programme for neurodiverse young adults with complex needs for whom group day services aren’t suitable. A close collaboration between the Learning Disability Social Work and Community Health Teams, Midlothian Leisure, Midlothian Day Services, and a number of third sector providers has created a programme of highly individualised, developmental opportunities for young neurodiverse adults which builds upon their skills and discovers new interests. To date the partnership has delivered 260 regular sessions of developmental community activity for 12 young people with complex needs. Time to reflect on the impacts of the work and contribute to setting subsequent aims as the activity develops and grows is central to the long-term success of this work and tailoring the right support for people with the most complex needs who are making the transition to adult life. The Transition Development Worker has now been in post for six months. A transition working group with cross sector participation has now been convened to oversee the development and delivery of a range of work streams and actions aimed at improving the process for young people transitioning from Children’s Services to Adult Services. This group is supported by a young person’s group and a parent carer group which are now both established. Justice The Justice Secretary, Angela Constance, delivered a statement to Parliament on 16th May 2024. The focus of the statement was in relation to the increase in the prison population which had risen sharply in the last 2 months from 7,948 on 18 March to 8,348. It was noted that significant work is underway nationally to address this including the following actions: Optimise the use of Home Detention Curfew: which is informed by risk assessment with individuals released subject to licence conditions. Across Scotland there are currently 97 people on HDC, an increase from around 50-60 previously. Section 11 of the Bail and Release from Custody (Scotland) Act 2023, which enables Scottish Ministers to release certain groups of prisoners in an emergency situation, is due to come into force on 26 May. It was announced this afternoon that should the legal test be met at that point – as is expected to be the case – the Scottish Government’s intention is to bring forward a proposal for the emergency release of prisoners as soon as possible after this provision comes into force. This is not a decision which has been taken lightly. However, the Scottish Government considers that this is a step that must be taken in order to ensure the security and good order of prisons as well as the health and safety of those living and working in our prisons. The safeguards built into the 2023 Act will apply. These include limiting release to those within 180 days of their scheduled release date, certain statutory exclusions - including in relation to those serving sentences for sexual offences or domestic abuse and a Governor veto. As of 31/1/2024 there were 79 individuals in SPS custody who reside in Midlothian. Approx 63% (N=50) of these individuals will be subject to statutory supervision managed by the Justice Service and 24% will be excluded due to the nature of the conviction. The Number 11 Allocations meeting ensures that information provided to us from SPS regarding all those received into custody, including estimated date of liberation, provides us with a framework to ensure that we are able to meet the needs of those coming out of custody and prepare for their Page 38 of 380
Page 39
Midlothian Integration Joint Board release. This includes support with accommodation, substance use, benefits and consideration for links to employability service where appropriate. The Number 11 Allocations meeting is a multi-agency approach to plan for the release of prisoners and is attended by representatives from both statutory and 3rd sector services including: Social Work, Health, Housing, Health in Mind and Change Grow Live. The Community Justice Partnership are also working collaboratively to ensure that all services are able to respond to changes that may result from this legislation. The Community Justice Coordinator has been keeping partners updated and it is the focus of the agenda for the next Community Justice Working Group. Community Justice is a multi-agency response to the prevention of crime and supporting people to stop committing crime. Stakeholders (including council, police, health service and voluntary sector) working together with communities to support victims of crime, families, people who have committed crime and who want to make positive changes to reduce the risk of reoffending. The Midlothian Justice Service provides both Structured Deferred Sentences and Supervised Bail to Courts which can be used as early intervention and robust alternatives to the use of remand. In light of the above, Midlothian is well placed to support the intended actions to reduce the pressure on the prison population and to meet the needs of those being released from custody or those who are managed in the community prior to sentence. Nick Clater, Head of Adult Services - nick.clater@midlothian.gov.uk 3.2 Head of Primary Care & Older People Midlothian Community Hospital wards continue to experience pressure in relation to flow through the system. Using the principals of Discharge Without Delay, teams are working hard to ensure work is progressed timeously to minimise delays in the discharge pathway. The graph below shows the downwards trajectory of the Total Occupied Beds Days for MCH, demonstrating the progress made in achieving the Scottish Governments aim of 85% bed occupancy. Page 39 of 380
Page 40
Midlothian Integration Joint Board Midlothian Community Hospital recently participated in the Day of Care Audit. This work involved staff from the Home First teams and their colleagues from across the hospital undertaking this important, informative work, and provided an opportunity to collaborate and scrutinise our current in-patient profile. The mental health wards also completed the Mental Health Bed Census 2024. Learning from the audit outcomes is reviewed with teams to ensure our systems and processes continue to focus on facilitation of discharge without delay. Midlothian HSCP launched a new Digital Flow App in October 2023 as a means of enhancing the screening and tracking of Midlothian residents to support admission prevention and discharge facilitation workstreams. Previous systems were labour intensive, person dependent and clunky, therefore the Flow App is more time efficient, streamlined and offers a means of improved communication to enable flow to be optimised throughout our system. It strengthens our commitment to a "single version of the truth" throughout our communication. The Flow App gives live sight of every Midlothian resident who is currently in an inpatient facility, and additionally gives live sight of every Midlothian resident who is in Emergency Department (ED) c. It lists key information to enable the Midlothian HSCP teams to inreach and facilitate an earlier appropriate discharge at any stage in the patient's journey, whether that be from ED, Acute Medical Unit (AMU) or one of the wards. It also enables the team to communicate actions and owners across the team, ensuring continuity of discharge planning. Since its launch, the team have found the Flow App to be invaluable in facilitating the work they do on a day-to-day basis. Midlothian HSCP vaccination service is currently operational across 3 sites (the main base being Midlothian Community Hospital) since the start of this year. The team moved back to Midlothian Community Hospital following the Scottish Governments request to step-down private venues as part of the transition to a business-as-usual model. Following the announced decommissioning of the Lothian vaccination enquiries line, each partnership will assume responsibility for a local enquiries line model with the go live date of 1st July 2024. Locally, plans are progressing to support this from existing staffing establishment as there is no additional funding to provide this locally. The addition to vaccination service provision in the form of a new Respiratory syncytial virus programme, (RSV) requires us to again reconfigure our delivery model to ensure we can provide the continued COVID programme alongside our other vaccination responsibilities. Letters and patient enquiries for RSV are expected to start soon. NHS Lothian are aiming to deliver RSV over 5 weeks (for Midlothian this is an eligible population of circa 5,500). The short timeframe for delivery is to provide contingency in case there is potential to start Autumn/Winter COVID programme earlier. The Autumn/Winter campaign will follow on immediately after the RSV campaign with circa 42,000 eligible for vaccine. We will be supporting student vaccination campaign this summer, to improve the uptake of crucial vaccinations in this group. We continue to support with MMR capacity (including supporting Occupational Health with staff MMR vaccines). Grace Cowan, Head of Primary Care & Older People - grace.cowan@nhs.scot Page 40 of 380
Page 41
Midlothian Integration Joint Board 3.3 Integration Manager Midlothian Integration Joint Board Strategic Commissioning Plan Work continues to support the next IJBs Strategic Commissioning Plan. The board met on 16th May for a development session to start refining the first working draft before the first full draft is presented to the Board in August 2024. A second-round programme of consultation will take place from September. Public Health Scotland SOURCE Return The Performance team recently met with Public Health Scotland to support improved understanding of local data and challenges in relation to the annual SOURCE report to the observed national variation noted by the performance team in data submissions. Midlothian IJB Annual Performance Report The Planning, Performance and Programme Team continue to develop the quality of reporting in the Annual Performance Report. Validated indicators will only be published in July. To allow time to analyse and report on local data meaningfully and complete internal governance will result in an October publication date. Audit Scotland Audit Scotland have approached Officers of the HSPC in relation to our work on IJB Performance Reporting using the OutNav Framework. The Audit Scotland team hope to include this work as a best practice case study in their upcoming IJB Finance and Performance report. Gill Main, Integration Manager – gill.main3@nhs.scot 3.4 Clinical Director General Practice All 11 practices currently still have open lists for registration and patient access to core general medical services. However, 3 practices have at least one GP vacancy, partly due to ongoing financial uncertainty related to NHS Lothian’s review of service level agreement and significant uplifts in charges for Facilities Management. Medical Staff At the end of June Dr Neelom Sharma, Consultant in General Adult Psychiatry, will be leaving Midlothian and moving on to take up a new post elsewhere. The Consultant post for Substance Use also remains vacant after another recent round of unsuccessful recruitment. Appropriate mitigations remain in place to ensure safe service provision during this time. Pharmacy Page 41 of 380
Page 42
Midlothian Integration Joint Board The Midlothian Primary Care Pharmacy Team have been shortlisted the Best Example of Quality, Innovation and Productivity award category in NHS Lothian’s 2024 Celebrating Success Awards in September. The team have also had two posters selected for the 2024 NHS Scotland Show on the 10th June in Glasgow. These posters describe and celebrate the successful implementation of the local Medicines Reconciliation Hub to improve the safety and efficiency of prescribing and medication transfer back to General Practice after hospital admissions, and a collaborative project with GP practices to move prescribing across to safer and more efficient repeat prescriptions saving at least 100 hours of combined GP/admin per month. Rebecca Green, Clinical Director – rebecca.green@nhs.scot 3.5 Chief Allied Health Professional Digital Digital Champions Network across Midlothian Council is reaching across HSCP; supporting teams from the ground up make best use of the technology we already have. One of the areas of focus is to enable teams across Council and Health have collaborative workspaces. This involves both IT departments and staff and is being supported by our Midlothian HSCP Digital Programme and Oversight Board (which reports back to SMT) This aligns to the wider national work (led by Digital Office and NSS) around Teams Federation. DPIA is progressing to support a new dashboard for Midcare. This developmental build has oversight of our TEC teams performance on Analogue to Digital including risk indexes (how we prioritise clients), how many clients have switched over, where reviews are required, stock management including equipment reclaim. We are currently augmenting this with Highlight reports (from April, monthly docked at SMT, attached for info). Flow hub are the single point of access for patients, enabling the flow of patients and their information safely across our HSCP. Recent example is the falls review work in Highbank. Identified the acute/MCH falls risk assessment was a gap in discharge handover which has now been added to reduce duplication and support local management of falls risks. A redefined project brief has been approved in principle by Scottish Government to enable the third phase of work known as Tech Pathfinder. This work will seek to target carers predominantly (e.g., Adult Carer Support Plan with 3rd sector partners), About Me which is a step closer to client held information as it’s a single version format. Falls As part of the NHS Lothian Falls programme, the falls education group has refreshed the content and appearance of both the falls public webpage and the staff intranet pages. The public webpages enable residents to navigate based on their local HSCP, providing prevention advice and signposting to a range of resources includes links to immediate support, a video on how to get up after a fall and includes Page 42 of 380
Page 43
Midlothian Integration Joint Board information for people in different settings across Lothian. The refreshed webpage can be accessed here. A new Falls dashboard is in testing. Demonstrates falls activity trends, diagnosis categories, diagnosis trends and heat maps within the dashboard which highlight across the Lothians where the falls prevalence’s and hot spots are. Modifications being made to ensure that falls can be presented by rate by 1000. A new Falls Strategy is expected early Summer. Based on 5 strategic pillars. Prevention, Collaboration, person centred, education and knowledge and data informed it defines commitments, what it means for staff and population. Implementation Plans will follow the formal launch including the Falls Community group, co-chaired by Midlothian HSCP Chief Allied Health Professional. Governance and Assurance Framework Q4 reporting across the HSCP was significantly improved in terms engagement with the digital app and level of governance and assurance reported compared to Quarter 3. A collaborative piece of work with all service managers was undertaken to explore and identify opportunities for process improvement. A number of adjustments were made which resulted in an overall position for Quarter 4 that is more reflective of the assurance levels across Midlothian HSCP services. Work continues to improve the useability and functionality of this tool alongside the NHS Lothian digital innovation team, ensuring that the reported areas are reflective of the services we provide. Weight Management - Tier 3 Recovery NHS Lothian Dietetics Service is hosted by Midlothian HSCP and has a range of pathways across our system including the Weight Management Service. Comprising of three tiers, the service most significantly impacted by the pandemic was the Tier 3 service. This service targets the more complex presentations; typically, patients with a BMI>35 and one or more associated obesity related conditions e.g., type 2 diabetes/sleep apnoea. This project seeks to support the Tier 3 waiting list recovery of the Dietetics Weight Management Service. This programme of work has included analysis of the current model of care considering population health challenges, resultant increasing demand and acuity alongside those who have experienced extensive waits due to service prioritisation as part of the covid-19 response. Tier 3 in particular is unprecedented and whilst not unique to Lothian, our demand per 1000 population is above the median at 6 and one of the highest in Scotland. Waiting list validation, job planning, and trajectory modelling are the current areas of focus. Claire Ross, Chief Allied Health Professional – claire.ross4@nhs.scot 3.6 Chief Nurse Three of our Midlothian HSCP nursing teams (Midlothian Community Hospital, under 5 immunisations and Number 11) were able to attend and present their work at the Page 43 of 380
Page 44
Midlothian Integration Joint Board 1-year anniversary of the NHS Lothian Nursing and Midwifery Strategic Plan. Launched in May 2023, this 5-year plan highlights the critical role of nurses in delivering quality care and our belief the Lothian is a Great Place to Work. It describes what nurses can expect from NHS Lothian, including career development, support for wellbeing and a commitment to enable the delivery of person-centered care. The event was attended by around 140 delegates from all over Lothian and celebrated the diversity of roles, backgrounds and experiences of our professional community and over 30 presentations were delivered to spotlight work being undertaken to deliver the 5 ambitions of the Strategic Plan - depicted in the graphic below. A poster will be presented at the NHS Scotland event taking place in Glasgow on Monday 10th June showcasing the findings of the Midlothian Palliative Care Feedback Project. This provides a great opportunity to share our learning which has influenced some changes to local processes, and which was published in a national journal in the latter part of 2023. Page 44 of 380
Page 45
Midlothian Integration Joint Board Mental Health, Substance Use and Learning Disability Nurses from Midlothian recently took part in a Lothian stakeholder event held as part of the National Mental Health Nursing Conversation that will inform the review of Mental Health Nursing in Scotland. The last review - Rights, Relationships and Recovery - was published in 2006. There have been significant developments to both the type of mental health services and the way in which they are delivered since the last review. There have also been many changes in mental health nursing roles, in areas such as specialist and advanced practice. Nurses unable to attend the event in person have been invited to respond online and further engagement is planned. Fiona Stratton, Chief Nurse – fiona.stratton@nhs.scot 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. 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 2024 // Page 45 of 380
Page 46
Page 46 of 380
Page 47
Midlothian Integration Joint Board Thursday 20th June 2024, 14:00 – 16:00 Midlothian IJB Directions 2023/24 Progress, and Proposed Directions for 2024/25 Executive summary This report sets out the performance of Midlothian Integration Joint Board on Directions for 2023/24 and presents the proposed Directions 2024/25. Integration Authorities, Health Boards and Local Authorities have a legal obligation to both issue and monitor the effectiveness of Directions as described in the Public Bodies (Joint Working) (Scotland) Act 2014. Midlothian IJB Directions are issued to the Chief Executives of Midlothian Council and NHS Lothian. The Midlothian Heath and Social Care performance on Directions 2023/24 is set out in appendix 1. Many of the 2023/24 Directions have not progressed as quickly as anticipated. Continuing to embed integrated practice and collaborative working would support positive change and improve outcomes. In light of the significant change in financial outlook experienced across health and social care in 2023/24, it is recommended not to significantly change Directions for 2024/25. This approach additionally allows partners the time to understand the full impact of funding changes and then work alongside Midlothian IJB to commission services in new and increasingly innovative ways. Reaching a balanced financial position and understanding the whole system impact is necessary to make the right decisions and prioritise the right actions. A set of proposed Directions for 2024/25 that are structed within the framework of the 9 National Health and Wellbeing Outcomes are presented for approval (appendix 2). These proposed Directions instruct partners to continue to embed the integrated practice and collaborative working described in the 2023/24 Directions to see positive change as quickly as possible and improve outcomes for people and communities. Board members are asked to: • Consider and approve the presented Directions for 2024/25 • Give delegated authority to the Chief Officer to issue these Directions to the Chief Executives of NHS Lothian and Midlothian Council by the end of June 2024. Item number: 5.4 Page 47 of 380
Page 48
Midlothian Integration Joint Board Midlothian Integration Joint Board Midlothian IJB Directions 2023/24 Progress, and Proposed Directions for 2024/25 1 Purpose 1.1 This report sets out the performance of Midlothian Integration Joint Board on Directions for 2023/24 and presents the proposed Directions 2024/25. 2 Recommendations 2.1 As a result of this report what are Members being asked to:- • Consider and approve the presented Directions for 2024/25 • Give delegated authority to the Chief Officer to issue these Directions to the Chief Executives of NHS Lothian and Midlothian Council by the end of June 2024. 3 Background and main report 3.1 Integration Authorities, Health Boards and Local Authorities have a legal obligation to both issue and monitor the effectiveness of Directions as described in the Public Bodies (Joint Working) (Scotland) Act 2014. Midlothian IJB Directions are issued to the Chief Executives of Midlothian Council and NHS Lothian. 3.2 Directions are how Midlothian IJB action their strategic plan. Directions are also an important part of governance and accountability between the IJB, the Health Board and the Local Authority. They are the legal basis on which the Health Board and the Local Authority deliver services that are under the control of the IJB. They are also a legal record of the Health Board and the Local Authority responsibility in relation to audit, finance, and decision-making. 3.3 The Midlothian Heath and Social Care performance on Directions 2023/24 is set out in appendix 1. Progress against individual Directions has been populated using the same template as at the half-year reporting point. Key limitations to progress against Directions have included the urgent requirement to develop and agree Financial Recovery Plans, and the loss of key specialist system supporting roles (i.e., Workforce Lead, and Digital Programme Manager), and the limited capacity of our partner organisations to prioritise whole-system activities. 3.4 Many of the 2023/24 Directions have not progressed as quickly as anticipated. Continuing to embed integrated practice within these Directions and continue to develop collaborative working would support positive change and improve outcomes. Page 48 of 380
Page 49
Midlothian Integration Joint Board 3.5 In light of the significant change in financial outlook experienced across health and social care in 2023/24, it is recommended not to significantly change Directions for 2024/25. This approach additionally allows partners the time to understand the full impact of funding changes and then work alongside Midlothian IJB to commission services in new and increasingly innovative ways. Reaching a balanced financial position and understanding the whole system impact is necessary to make the right decisions and prioritise the right actions. 3.6 A set of proposed Directions for 2024/25 that are structed within the framework of the 9 National Health and Wellbeing Outcomes are presented for approval (appendix 2). These proposed Directions instruct partners to continue to embed the integrated practice and collaborative working described in the 2023/24 Directions to see positive change as quickly as possible and improve outcomes for people and communities. 3.7 Of note are the proposed Directions under Health and Wellbeing Outcome Number 9: Use of Resources, as follows. • An addition to the existing Direction 9.1 asking NHS Lothian to provide quarterly progress information following the 2023/24 review of set aside funding. • A new set of Directions under 9.2 stating the 5 recovery actions of the IJB. • Direction 9.3 describing a programme of operational transformation over 5 years and a more immediate change programme in 2024/25. • A new Direction 9.4 requesting a collegiate approach to discussion between all partners where decisions about non delegated functions are likely to impact on the IJBs delegated functions. 4 Policy Implications 4.1 This paper supports the strategic Direction of the IJB and relates to the • Public Bodies (Joint Working) (Scotland) Act 2014. (section 26 and 26) and the requirement for Directions from Integration Authorities to Health Boards and Local Authorities. • Statutory Guidance (2020) on Directions from Integration Authorities to health boards and local authorities on how to improve practice in the issuing and implementation of Directions issued under the Public Bodies (Joint Working) (Scotland) Act 2014. 5 Directions 5.1 This report proposes the Midlothian IJB Directions for 2024/25. 6 Equalities Implications 6.1 There are no specific equalities implications from this report. All Directions are designed to progress the ambitions of the 6 strategic aims of the Midlothian Integration Joint Board Strategic Commissioning Plan 2022-25. An IIA has been published in relation to this plan. Page 49 of 380
Page 50
Midlothian Integration Joint Board 6.2 Health and Social Care Partnership service strategy, policy, plans, provisions, practices, and activities that relate to these Directions and the Strategic Plan are subject to a screening process to determine if an Integrated Impact Assessment (IIA) is required. 7 Resource Implications 7.1 Directions should include the financial resources available for carrying out the delegated functions, including the allocated budget and how that budget is to be used, whether this is a payment, or a sum set aside and made available. Funding by delegated functions can be found in appendix 2. 8 Risk 8.1 IJBs, Health Boards and Local Authorities have a legal obligation to issue and monitor the effectiveness of Directions as described in the Public Bodies (Joint Working) (Scotland) Act 2014. Not complying will pose legislative risks and it will be more difficult for the IJB to undertake its duties related to accountability and good governance. 9 Involving people 9.1 Community, staff and stakeholder engagement on the planning and review of services related to Directions will continue. 9.2 The Strategic Planning Group will review the progress towards these Directions and continually monitor the requirement to make recommendation to the Board in regards and necessary revision or addition to the IJBs Directions. 10 Background Papers AUTHOR’S NAME & DESIGNATION Gill Main, Integration Manager Elouise Johnstone, Strategic Performance Manager for Performance CONTACT INFO gill.main3@nhs.scot Elouise.johnstone@nhs.scot DATE 03/06/2024 Appendices: Appendix 1: Midlothian Integration Joint Board Directions Progress 2023/24 Appendix 2: Midlothian Integration Joint Board Directions 2024/25 Page 50 of 380
Page 51
Midlothian Integration Joint Board Directions 2023/24 Year End Report Page 51 of 380
Page 52
2 1 Health & Wellbeing People are able to look after and improve their health and wellbeing and live in good health for longer. No Direction Performance Measures Measure Update Source 1.1 All services delegated to Midlothian IJB must demonstrate through service planning and reporting how they have increased collaborative and integrated working that improves population health and wellbeing, by January 2024. By July 2023, Midlothian HSCP will provide assurance that the content of 100% of Service Plans supports collaborative and integrated working to improve population health. By January 2024, Midlothian HSCP will provide assurance that the content of 100% Service Reports includes evidence of collaborative and integrated working to improve population health. 92% complete The Health Inclusion Team continue to provide outreach and have carried out a health assessment with 171 people since April 2023. Most assessments were in the person’s home, the top intervention was healthcare and lifestyle, followed by advocacy/liaise/referral to partner agencies. Whole Systems Approach to Type II diabetes: increased strategic partners work locally and regionally to ensure work fits within NHS Lothian’s public health HSCP Service Plans HSCP Service Reports NHS Lothian / Midlothian Council Performance Reports Midlothian IJB Directions 2023-24 Page 52 of 380
Page 53
3 priorities and the partnership’s objectives. Working with partners around evaluation of the funded projects to help the people of Mayfield and Easthouses to have more access to healthy food options, keep physically active and have more money in their pockets. Midlothian HSCP continues to contribute to working groups to promote a public health agenda and increase strategic partners. Members of various groups including trauma training steering group, Mid & East Lothian Drug and Alcohol Partnership Group, Midlothian Suicide Prevention Group, Equally Safe Strategy Leadership Group, Midlothian will be Healthier Thematic Group, Lothian Green Health Network and the Third Sector Summit. Health Visiting have contributed to 105 GIRFEC meetings in 2023. The Pharmacy Service established Medicine Reconciliations support to all Midlothian GP practices to ensure safe, effective and timely access to medicines. The locally designed hub model has Page 53 of 380
Page 54
4 increased Immediate Discharge Letter (IDL) output from the Pharmacy team by 323% from 2021/22. 100% of IDLs are now completed by pharmacy, with 97% completed within the 48-hour target turnaround time. 1.2 To support proactive population approaches to health, wellbeing and wellness, services should ensure service planning demonstrates reduced medicalisation of non- medical issues, by January 2024. By January 2024, Midlothian HSCP will provide assurance that the content of 100% of Service Plans supports reduced medicalisation of non-medical issues. Green health prescribing has integrated working with key strategic partners through expanding the working group, linking with researchers to expand our knowledge, and sharing practice with colleagues. HSCP Service Plans HSCP Service Plans HSCP Service Reports NHS Lothian / Midlothian Council Performance Reports Page 54 of 380
Page 55
5 2 Living in the Community People are able to live, as much as possible, independently and at home or in a homely setting in their community. No Direction Performance Measures Measure Update Source 2.1 All services delegated to Midlothian IJB must evidence the connection with communities, partners, and use of technology to improve self- management and self-monitoring, by January 2024. By January 2024, Midlothian HSCP will provide assurance that the content of 100% Service Reports includes evidence of connection with communities, partners, and use of technology to improve self- management and self-monitoring. Mental Health services for adults aged 18+ have 33 digital on-line self-help platforms used across the service. There has been a 33% increase in access of Midspace, the self-help Mental Health digital platform Within the Community Respiratory Team, the LENUS digital self-monitoring project (for people living with Chronic Obstructive Pulmonary Disease) had to be stopped due to withdrawal of funding. HSCP Service Plans HSCP Service Reports NHS Lothian / Midlothian Council Performance Reports 2.2 All services delegated to Midlothian IJB must ensure service planning describes a clear process to ensure fair access, by January 2024. By January 2024, Midlothian HSCP will provide assurance of progress towards actions as detailed in the Midlothian IJB Mainstreaming Equalities Report & Action Plan 2023-25. The full report is available here: Midlothian_Integratio n_Joint_Board_2021_23 Page 55 of 380
Page 56
6 3 Positive Experiences & Dignity People who use health & social care services have positive experiences of those services, and have their dignity respected No Direction Performance Measures Measure Update Source 3.1 All services delegated to Midlothian IJB will contribute to the IJBs ability to describe activity, experience and outcomes. Services use and develop outcome mapping, by January 2024. By July 2023, Midlothian HSCP will provide assurance that the content of 100% of Service Plans supports the measurement of activity, experience and outcome. By January 2024, Midlothian HSCP will provide assurance that the content of 100% Service Reports includes evidence of the development and use of outcome mapping. 92% complete This work continues and has made important steps forward in 2023/24. More services are onboarded to OutNav, and a number of areas are using this information to better inform service redesign that it person led. However, it has not been possible to progress as anticipated due to a combination of service pressures and the significant focus in Q3 and Q4 on financial ‘Grip and Control’ exercises and Recovery Action Planning. Additionally, this work has been interrupted by personnel changes and some reconfiguration of service structures and oversight. HSCP Service Plans HSCP Service Reports NHS Lothian / Midlothian Council Performance Reports Page 56 of 380
Page 57
7 Good progress had been made in relation to our ability to use outcome mapping to support hosted service reporting within the dietetics service. Additionally, the IJB has developed its own strategic commissioning outcome map and continues to develop its ability to view in real time the aggregated progress of delegated functions towards its strategic aims. 3.2 All relevant services delegated to Midlothian IJB must develop and demonstrate an increase in the effective and proactive outreach to people living with frailty, by January 2024. By July 2023, Midlothian HSCP will provide assurance that the content of 100% of relevant Service Plans supports support proactive outreach to people living with frailty. By January 2024, Midlothian HSCP will provide assurance that the content of 100% of relevant Service Reports includes evidence of evidence of proactive outreach to people living with frailty. 69% complete An initial organisation-wide Frailty Event has taken place with representation and engagement from all relevant service stakeholders, including Head of Primary Care & Older People, Clinical Director, Chief Nurse and Chief AHP. The Dietetic service has representation on the NHS Lothian Strategic Falls Group, and HSCP Service Plans HSCP Service Reports NHS Lothian / Midlothian Council Performance Reports Page 57 of 380
Page 58
8 the local Midlothian Community Hospital Falls Group. 3.3 All services delegated to Midlothian IJB should review practices and further develop person-centred approaches to support recovery including The Midway and Good Conversations Approach, by January 2024. By January 2024, Midlothian HSCP will provide assurance that the content of 100% of Service Reports includes evidence of review of practices and further developments in person-centred approaches to support recovery including The Midway and Good Conversations Approach. Midway training was temporarily paused to allow for a full review of the training provision. The relaunch of the revised programme is provisionally scheduled for Autumn 2024. Examples of areas requiring more specialist training are Community Justice and Adult Support & Protection (ASP). 100% of staff working in Community Justice are trained to Level 2 Trauma (National Education for Scotland), and 100 % of ASP and Duty staff have completed Level 1 Trauma training. HSCP Service Plans HSCP Service Reports NHS Lothian / Midlothian Council Performance Reports Page 58 of 380
Page 59
9 4 Quality of Life Health & social care services help to maintain or improve the quality of life of people who use those. No Direction Performance Measures Measure and metric Update Source 4.1 NHS Lothian and Midlothian Council must ensure accessible feedback mechanisms for all people and communities by January 2024 in order to develop innovative, integrated service offers and supports. By January 2024, all NHS Lothian feedback mechanisms meet accessibility legislative requirements. By January 2024, all Midlothian Council feedback mechanisms meet accessibility legislative requirements The wards within Midlothian Community Hospital have developed short, user friendly feedback forms for patients and their relatives enabling them to share their thoughts and views of their experience of care within the hospital. There is also a QR code enabling people to leave the same type of feedback using their phones. The AHP team have also developed a specific feedback questionnaire around the therapies they deliver, and this is being used without patients on rehabilitation wards. A local feedback questionnaire is in place for Highbank respite users. The Care Opinion independent feedback website will be promoted for people using and/or affected by the Highbank respite service. HSCP Service Plans HSCP Service Reports NHS Lothian / Midlothian Council Performance Reports Page 59 of 380
Page 60
10 Occupational Therapy and Physical Disabilities service has introduced a paper and electronic feedback form for people to undertake when their involvement with the Service is complete. Through the use of OutNav, responses from service users through the feedback form and collation of emails from people that have been supported by the service, more information can be gathered to evidence that people engaging with the Service feel listened to and are treated with dignity and respect. People are letting the service know that when we are able to work together, that even a small piece of equipment or change to their home environment can make a huge difference to the quality of their life. MELDAP carried out a consultation process during the summer with people with livened and living experience, carers/families, members of the public, services and partners. This included noting their priorities in relation to prevention/children/families services, treatment service and recovery orientated provision. MELDAP is using the product from the latest service Page 60 of 380
Page 61
11 user/carer/public/service consultation to inform its priorities for the development of its next 3 year delivery plan. All Mental Health services gather patient feedback via various routes. In 2022-23 we established a lived experienced panel for mental health in collaboration with CAPS Advocacy. A session for mental health and substance use services (SUS) has been held with VOCAL. A Carer group for older adults has been established and is up and running. SUS has embedded lived experience, carers and staff experience in relation to all Medication Assisted Treatment standards, and over the last month completed trauma focused lived and staff experience for standards 6 and 10. Duty Social Work Team introduced a paper and electronic feedback form initially sent out to those identified as Unpaid Carers. This commenced in September 2023. The feedback survey is now offered to all service users the Duty team are in contact with. Page 61 of 380
Page 62
12 Justice Service users subject to community based sentences are asked for feedback at regular points in their orders or licences and they also complete an entry and exit questionnaire to measure changes in areas identified as impacting on risk of re- offending. Women who are supported as part of the Caledonian system are asked to complete a feedback/experiential feedback form at the end of engagement. We seek feedback from beneficiaries of unpaid work projects this includes individuals and organisations. The Spring Service use a variety of methods to seek feedback from the women involved in this service as not all are directly involved in the Justice Service. As part of community justice service user groups seek feedback and public consultation events. The InReach team continue to explore ways of strengthening their methods for capturing experience information. Informal mechanisms for capturing client feedback continue. Complaints are monitored, and actioned appropriately. The Care at Home team seek feedback on their services from clients at each review Page 62 of 380
Page 63
13 asking what the client feels about the service in terms of reliability, caring approach, needs met outlined in the care and support plan. For the 0-5 Immunisations Service, 292 feedback messages were received from the winter Flu campaign. These were overwhelmingly positive response, with some areas for improvement highlighted. Health Visiting feedback gathered about the service is overwhelmingly positive, with an audit process in place. The Dietetics hosted service is developing a tool to capture carer feedback for patients newly discharged on home enteral feeding. This will encompass discharge planning, confidence on discharge and dietetic support provided post discharge. MSK Physio and GP APP Service use Patient Reported Experience Measures, with options of a QR code, URL link by text message, via e-consult email or paper copy. Page 63 of 380
Page 64
14 4.2 In order to maximise opportunities to improve personal outcomes, all services delegated to Midlothian IJB should ensure that the principles of self-management are embedded in service delivery design, by January 2024. By July 2023, Midlothian HSCP will provide assurance that the content of 100% of Service Plans supports the principles of self- management being embedded in service delivery design. By January 2024, Midlothian HSCP will provide assurance that the content of 100% of Service Reports includes evidence of the principles of self-management being embedded in service delivery design. 62% complete The GP APP Service can demonstrate that 60% of consultations end in Self- management in 2023/24, which is an increase from the baseline of 45%. HSCP Service Plans HSCP Service Reports NHS Lothian / Midlothian Council Performance Reports 4.3 All relevant services delegated to Midlothian IJB should evidence how they are sharing information about Self Directed Support (SDS) options, and recording changes in uptake, by January 2024. By July 2023, Midlothian HSCP will provide assurance that the content of 100% of relevant Service Plans support sharing information about Self Directed Support (SDS) options. By January 2024, Midlothian HSCP will provide assurance that the content of 100% of relevant Service Reports include evidence of sharing information about Self Directed Support (SDS) options. By January 2024, Midlothian HSCP will provide assurance that the content of 100% of relevant Service Reports include evidence of changes in uptake of Self Directed Support (SDS) options. 75% complete Issues have been identified in relation to the complexity of SDS recording and reporting, and with the consistency of disaggregation across service areas. The annual SOURCE return of SDS data to Public Health Scotland will be reviewed to highlight any changes in uptake (following full validation). HSCP Service Plans HSCP Service Reports NHS Lothian / Midlothian Council Performance Reports Page 64 of 380
Page 65
15 5 Health Inequalities Health & social care services contribute to reducing health inequalities. No Direction Performance Measures Measure Update Source 5.1 NHS Lothian and Midlothian Council must ensure that data can be disaggregated by HSCP area in order to support the equitable provision of service offers and support across our communities, minimise disadvantage where possible, meet different needs, and encourage participation. This should include ensuring • systems and data have the capabilities to collect and filter data appropriately by HSCP area and by protected characteristics • health and social care workforce are suitably trained and skilled to gather and input this data, and • data quality assurance, by January 2025. By January 2025, HSCPs have timely, credible, disaggregated data to support the equitable provision of service offers and support across our communities, minimise disadvantage where possible, meet different needs, and encourage participation. By January 2025, Midlothian HSCP will provide assurance that 100% of the appropriate health and social care workforce Following Midlothian’s lead role in the pan- Lothian efforts to improve data visualisation, improved mechanisms are now in place that allow increased disaggregation of NHS data. The data quality remains a challenge that will require a whole-system effort across primary, secondary, community and social care. Data Loch now has 105 of the 120 Lothian GP practices signed-up to data sharing for research purposes. They have SIMD deprivation indices that they can map to patient post codes. Direction timeline: January 2025 HSCP Service Plans HSCP Service Reports NHS Lothian / Midlothian Council Performance Reports Page 65 of 380
Page 66
16 are suitably trained and skilled to gather and input this data. By January 2025, Midlothian HSCP will provide assurance that 100% of services have data quality assurance processes and structures in place. Direction timeline: January 2025 5.2 NHS Lothian and Midlothian Council must explore opportunities for integrated system- wide digital solutions and create an action plan of jointly agreed priorities by January 2024. By January 2024, a Joint Plan will be in place that describes the priority actions agreed between NHS Lothian and Midlothian Council. This should include, but not be limited to: Timeline, Allocation of tasks, Integrated Impact Assessment, Stakeholder Engagement, Governance structures (HSCP, NHS Lothian eHealth, Midlothian Digital Services). Progress towards this Direction continues to be significantly restricted by the vacant post of Digital Programme Lead. HSCP Service Plans HSCP Service Reports NHS Lothian / Midlothian Council Performance Reports Page 66 of 380
Page 67
17 6 Support for Carers People who provide unpaid care are supported to look after their health and wellbeing. No Direction Performance Measures Measure Update Source 6.1 All services delegated to Midlothian IJB that aim to move care from hospital to home should ensure service planning considers the impact of this on unpaid carers, and evidence appropriate supportive actions, by January 2024. By July 2023, Midlothian HSCP will provide assurance that the content of 100% of relevant Service Plans support consideration of the impact on unpaid carers of the movement of care from hospital to home. By January 2024, Midlothian HSCP will provide assurance that the content of 100% of relevant Service Plans includes evidence of planned appropriate supportive actions. 89% complete A new model of respite at Highbank Intermediate Care Facility that meets changing needs of people who require support, and their unpaid carers, has been reintroduced, with a positive response: 13 referrals resulting in 16 respite bookings. (2 further enquiries have been made about this service.) The Duty team continue to work with colleagues and Vocal to identify and support unpaid carers. Within this quarter there were a total of 64 referrals received with the reason for making contact noted as ‘Carer Stress’ and the Duty Team dealt with 6% of HSCP Service Plans HSCP Service Reports NHS Lothian / Midlothian Council Performance Reports Page 67 of 380
Page 68
18 these due to the nature of the concern and impact. The Duty supported 5% of the 41 adults who were supported with an Adult Carer Support Plan. An initial meeting was held between HSCP Carer and Home First Service Leads to connect relevant HSCP, Health and Voluntary Sector partners to take forward mapping/planning, establishing stakeholders, services, processes and timescales involved in the discharge process. This work aims to re-establish referral pathways and connections. Worker has recently started in post and is making connections with HSCP staff. 6.2 Explore and define the demand for and the benefit of a Midlothian Care and Support Co-operative in order to provide a platform that facilitates brokerage of personalised support for carers, identifies local assets, and enhances local economic value by January 2024. By January 2024, a Midlothian Care and Support Co-operative will be established. Work has started to scope the feasibility of a cooperative to support carers in Midlothian. Key stakeholders have met to understand and establish priority focus areas as part of this scoping exercise and to agree a timeline. The delay to this scoping exercise being initiated has impacted on the ability to make progress towards this Direction. Community Planning Partnership – Single Midlothian Plan H2 report 2023/24 Page 68 of 380
Page 69
19 7 Safe from Harm People using health & social care services are safe from harm. No Direction Performance Measures Measure Update Source 7.1 All relevant services delegated to Midlothian IJB must explore and evaluate the benefits and risks of adopting a ‘request for assistance’ approach as an alternative to a traditional referral pathways, by January 2024. By July 2023, Midlothian HSCP will provide assurance that the content of 100% of relevant Service Plans support exploration and evaluation of the benefits and risks of adopting a ‘request for assistance’ approach as an alternative to a traditional referral pathways. 62% complete HSCP Service Plans HSCP Service Reports 7.2 Where there is a statutory responsibility to manage harmful behaviours, all services must communicate the impact of action taken to maximise people's safety in our communities, by January 2024. By January 2024, Midlothian HSCP will provide assurance that the content of 100% of relevant Service Reports include evidence of the impact of action taken to maximise people's safety in our communities. The Adult Support and Protection Team (ASP Team) undertake a range of duties to identify, minimise and manage risk and ensure that all suspicions, disclosures or actual harm are acted upon. Measures to protect adults need to be considered in the context of wider range of support services and an ASP investigation may highlight gaps in support. In these instances, an assessment of need should be undertaken to identify and develop an outcomes focused care plan. During Q4 there were 232 referrals submitted under ASP, and 57% of these referrals were allocated HSCP Service Plans HSCP Service Reports NHS Lothian / Midlothian Council Performance Reports Page 69 of 380
Page 70
20 to a Council Officer for an inquiry to be completed to determine if the individual was an adult at risk of harm as defined by the Adult Support and Protection (Scotland) Act 2007, and appropriate action taken to reduce and/or mitigate the risk. Health Visiting engage in appropriate activity to ensure the safety of mothers of children under 5 yrs who are at risk of harm. This includes ensuring the Equally Safe Strategy, and the NSPCC HSB Framework and Action Plan, are all in place. 7.3 Services should improve the people who use substances’ understanding of their rights and responsibilities in relation to supported self-assessment and risk management, by January 2024. Services should evaluate the relationship between this work and any reduction in harm or improvements in personal outcomes. By July 2023, Midlothian HSCP will provide assurance that the content of 100% of relevant Service Plans support improvements in the people who use substances’ understanding of their rights and responsibilities in relation to supported self assessment and risk management. By January 2024, Midlothian HSCP will provide assurance that the content of 100% of relevant Service Reports include evidence improvements to the people who use substances’ understanding of their rights and 100% complete The focus of developments so far has been to address opioid dependence; however the standards aim to support system improvements for all drug related problems. HSCP Service Plans HSCP Service Reports NHS Lothian / Midlothian Council Performance Reports Page 70 of 380
Page 71
21 responsibilities in relation to supported self- assessment and risk management. Achievements to date for Medication Assisted Treatment standards 1-5: 1] Improved waiting times performance. 2] Same day start for people seeking OST [Opiate Substitute Therapies]. 3] Increased choice of medication with service delivering Buvidal as well as other opiate substitute therapies. 4] Assertive outreach to people who have experienced Near Fatal Overdose with range of interventions including support into treatment offered. 5] Improved range of harm reduction interventions delivered at same location. 6] Ongoing support including links to third sector partners and recovery community to help people remain in treatment for as long as possible. Page 71 of 380
Page 72
22 By July 2023, Midlothian HSCP will provide assurance that the content of 100% of relevant Service Plans support evaluation of the relationship between this work and any reduction in harm or improvements in personal outcomes. By January 2024, Midlothian HSCP will provide assurance that the content of 100% of relevant Service Reports include evidence of the evaluation of the relationship between this work and any reduction in harm or improvements in personal outcomes. 100% complete Within Substance Use services, the percentage of people commencing treatment within 21 days of referral reached 100% at Q4 2023/24. Page 72 of 380
Page 73
23 8 Workforce Staff are engaged with their work and are supported to continuously improve the information, support, care and treatment they provide. No Direction Performance Measures Measure Update Source 8.1 NHS Lothian and Midlothian Council should work in collaboration with Midlothian HSCP to support the delivery of the integrated Midlothian HSCP Staff Engagement Plan 2023-24. By January 2024, Midlothian HSCP will provide assurance that the HSCP Staff report increased levels of engagement with their work. By January 2024, Midlothian HSCP will provide assurance that the HSCP Staff report increased confidence in their abilities to continuously improve the information, support, care and treatment they provide. iMatter is the survey tool used to capture and measure HSCP staff engagement levels. The survey is run on an annual basis, in July. Midlothian HSCP has increased iMatter Employee Engagement Scores over the last three years as shown by the increasing Employee Engagement Index Scores. Year Response rates Employee Engageme nt Index Action Plans Agreed 2023 55% 80 69% 2022 48% 78 35% 2021 50% 77 2% Response rates for 2023 are higher than during the previous two years, and work will continue in 2023/24 to achieve the response rate target of 60%. NHS Lothian / Midlothian Council Performance Reports Page 73 of 380
Page 74
24 A better understanding is required relating to variation in completion rate, action planning and updating. This will inform targeted promotion to achieve increased organisational response, in order to have greater confidence in Midlothian HSCP performance. Examination across all domains described in the 2023 Midlothian HSCP Directorate report has helped identify opportunities for targeted action to improve staff engagement and wellbeing. Future reporting on this measure will be adjusted to account for NHS Lothian’s timeline for publishing the annual results. All wards in MCH (with the exception of Pennylane) have seen a significant reduction in their vacancy rate from the start of the year which demonstrates a positive picture in terms of recruitment and being recognised as the employer of choice. We have competed a full review of the functionality, effectiveness and uptake of Health and Social Care specific LearnPro modules. Page 74 of 380
Page 75
25 The ‘Haven’ staff wellbeing space opened on site. The Soup Stop continues to be a key feature of staff wellbeing, with in excess of 200 staff benefitting from this initiative. 8.2 NHS Lothian and Midlothian Council should work in collaboration with Midlothian HSCP to support the delivery of the Midlothian HSCP Integrated Workforce Plan 2022-25. Midlothian HSCP will provide assurance on the progress towards the objectives of the Midlothian HSCP Integrated Workforce Plan 2022-25 actions delivered. Between April and September 2023, a consultative and collaborative process was undertaken to establish the governance structure of the Midlothian Integrated Workforce Governance Board which commissions and oversees the work of two Subgroups: Workforce Planning (Access and Demand). and Staff Engagement (Staff Governance & Development). The Midlothian Integrated Workforce Governance Board oversees the work required to deliver the HSCP Integrated Workforce Plan 2022-25. This strategic workforce plan forms a key part of the work to align strategic, financial, and operational plans in order to ultimately support the delivery of right staff, in the right place, at the right time, within budget. Progress towards this Direction continues to be significantly restricted by the vacant post of Workforce Lead. NHS Lothian / Midlothian Council Performance Reports Page 75 of 380
Page 76
26 9 Use of Resources Resources are used effectively and efficiently. No Direction Performance Measures Measure Update Source 9.1 Maximise opportunities to work collaboratively across Lothian to design an approach and methodology to better understand and evidence the use of the set aside budget and associated services by HSCP area. This should include mechanism to better understand the impact of community prevention and early intervention activity across the whole system. HSCPs are provided with consistent, clear information relating to the use of the set aside budget and associated services. HSCPs can provide consistent, clear information to demonstrate the impact of community prevention and early intervention activity across the whole system. The Tableau Dashboard that provides management data relating to emergency / unscheduled care can now be fully interrogated at HSCP level (including SIMD filters). Pan-Lothian work continues to improve quality of protected characteristic cohort data. There are good examples of evidence in some service areas (e.g. Vaccination Programme, Community Respiratory Team, Newbyres Care Village, Community Justice). There is still work required to achieve consistent reporting across all service areas. The 0-5 Immunisations Midlothian data shows an uptake rate of 61.5% for seasonal flu, compared to a 54.2% pan-Lothian update (Midlothian has the highest uptake across the HSCPs). Audit of meeting documentation, including but not limited to: Minutes Papers Action Plans Action Trackers HSCP Service Plans HSCP Service Reports NHS Lothian / Midlothian Council Performance Reports Page 76 of 380
Page 77
27 The Health Visiting service is liaising on an ongoing basis with data analysts to try to link assessments over time and therefore demonstrate effective early intervention (rather than snapshot data). Despite challenges in Registered Nursing recruitment, over the past 12 months there has only been on vacant shift (day). This was covered by the patient’s family, so mitigated the need to arrange an Intensive Care Unit admission. 9.2 All services delegated to Midlothian IJB must be able to demonstrate Best Value with evidence based data and meet cost efficiency targets in 2023-24, 2024-25, and 2025-26. By January 2024, Midlothian HSCP will provide assurance that the content of 100% of relevant Service Reports include evidence of Best Value. By year-end 2023-24, 2024-25, and 2025-26, Midlothian HSCP will provide assurance that the content of 100% of relevant Service Reports include evidence of meeting annual cost efficiency targets. All services attended a series of three Financial Recovery Workshops hosted by Midlothian Health and Social Care Partnership with support from NHS Lothian’s Sustainability & Value Team. All services were required to submit Financial Recovery Templates, which were initially examined and monitored by Midlothian HSCP’s Finance and Performance Group. Ongoing work to connect the strategic and financial ambitions of the IJB, to operational strategic and financial planning, continue and will be addressed through Midlothian HSCP’s Operational Transformation Group, HSCP Service Plans HSCP Service Reports NHS Lothian / Midlothian Council Performance Reports Page 77 of 380
Page 78
28 alongside Midlothian HSCP’s Finance and Performance Group. Examples of work already underway include the Midlothian Bed-Based Care Review, redesign of Home First and a review of the strategy and vision for Newbyres Care Village. In addition, Midlothian HSCP is mindful of increasing demands on adult services as young people transition across the system with an estimated financial pressure of £2.5m within Learning Disability services for the period 2023-24 to 2025-26. A Transition Development Worker is now in post to support the development of a Transitions Framework. Page 78 of 380
Page 79
Midlothian Integration Joint Board Directions 2024-25 Page 79 of 380
Page 80
MIJB_Directions2023-24_v1 Introduction Midlothian Integration Joint Board (IJB) is a planning and decision-making body created by Midlothian Council and NHS Lothian in 2015. The IJB plans and directs health and social care services for the people of Midlothian using the integrated budget received from Midlothian Council and NHS Lothian. The Midlothian IJB Strategic Commissioning Plan 2022-25 focuses on prevention, early intervention, recovery, and self-management. The Strategic aims for 2022-25 are ambitions 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. Directions are the mechanism by which Integration Authorities communicate their priority actions to both Midlothian Council and NHS Lothian. Midlothian IJB Directions for 2024-25 require services to continue embedding the integrated practice and collaborative working to see positive change as quickly as possible and improve outcomes for people and communities. In light of the significant change in financial outlook experienced across health and social care, Midlothian IJB has decided not to significantly change Directions for 2024/25 to allow partners the time to understand the full impact of funding changes. Midlothian IJB must evolve and commission services in new and increasingly innovative ways while continuing to provide safe, high-quality care and support. However, Midlothian IJB is also mindful that reaching a balanced financial position and understanding the whole system impact is necessary to make the right decisions and prioritise the right actions. The Board will continue to consider when new Directions are indicated and issue to partners across 2024/25. The financial values (‘budgets’) attached to these Directions are based on a) Midlothian Council’s budget proposition of £63.534m was accepted by Midlothian IJB at the Board meeting on 21st March 2024. b) NHS Lothian indicative budget proposal of £94.906m was accepted by the IJB at the Board meeting on 21st March 2024. NHS Lothian continue to update the IJB’s health budget as additional allocations are received in year from the Scottish Government. The current opening budget is £94.923m Funding allocations can be found in Appendix 1 1 4 3 2 5 6 Page 80 of 380
Page 81
1.1 All functions delegated to Midlothian IJB must demonstrate through service planning and reporting how they have increased collaborative and integrated working that improves population health and wellbeing, by January 2025. 1.2 To support proactive population approaches to health, wellbeing and wellness, all delegated functions should ensure service planning demonstrates reduced medicalisation of non-medical issues, by January 2025. 2.1 All functions delegated to Midlothian IJB must evidence the connection with communities, partners, and use of technology to improve self-management and self-monitoring, by January 2025. 2.2 All functions delegated to Midlothian IJB must ensure service planning describes a clear process to ensure fair access, by January 2025. 3.1 All functions delegated to Midlothian IJB will contribute to the IJBs ability to describe activity, experience, and outcomes. This includes developing outcome mapping, by January 2025. 3.2 All relevant functions delegated to Midlothian IJB must develop and demonstrate an increase in the effective and proactive outreach to people living with frailty, by January 2025. 3.3 All functions delegated to Midlothian IJB should review practices and further develop person- centred approaches to support recovery including The Midway and Good Conversations approach, by January 2025. 1 Health & Wellbeing People are able to look after and improve their health and wellbeing and live in good health for longer. 2 Living in the Community People are able to live, as much as possible, independently and at home or in a homely setting in their community. 3 Positive Experiences & Dignity People who use health & social care services have positive experiences of those services, and have their dignity respected Page 81 of 380
Page 82
4.1 NHS Lothian and Midlothian Council must ensure accessible feedback mechanisms for all people and communities by January 2025 in order to develop innovative, integrated service offers and supports. 4.2 In order to maximise opportunities to improve personal outcomes, all functions delegated to Midlothian IJB should ensure that the principles of self-management are embedded in service delivery design, by January 2025. 4.3 All relevant functions delegated to Midlothian IJB should evidence how they are sharing information about Self Directed Support (SDS) options, and recording changes in uptake, by January 2025. 5.1 NHS Lothian and Midlothian Council must ensure that data can be disaggregated by HSCP area in order to support the equitable provision of service offers and support across our communities, minimise disadvantage where possible, meet different needs, and encourage participation. This should include ensuring • systems and data have the capabilities to collect and filter data appropriately by HSCP area and by protected characteristics • health and social care workforce are suitably trained and skilled to gather and input this data, and • data quality assurance, by January 2025. 5.2 NHS Lothian and Midlothian Council must explore opportunities for integrated system-wide digital solutions and create an action plan of jointly agreed priorities by January 2025. 6.1 All functions delegated to Midlothian IJB that aim to move care from hospital to home should ensure service planning considers the impact of this on unpaid carers, and evidence appropriate supportive actions, by January 2025. 6.2 Explore and define the demand for and the benefit of a Midlothian Care and Support Co-operative in order to provide a platform that facilitates brokerage of personalised support for carers, identifies local assets, and enhances local economic value by January 2025. 4 Quality of Life Health & social care services help to maintain or improve the quality of life of people who use those. 5 Health Inequalities Health & social care services contribute to reducing health inequalities 6 Support for Carers People who provide unpaid care are supported to look after their health and wellbeing. Page 82 of 380
Page 83
7.1 All relevant functions delegated to Midlothian IJB must explore and evaluate the benefits and risks of adopting a ‘request for assistance’ approach as an alternative to traditional referral pathways, by January 2025. 7.2 Where there is a statutory responsibility to manage harmful behaviours, all functions must communicate the impact of action taken to maximise people's safety in our communities, by January 2025. 7.3 All relevant functions should improve the people who use substances’ understanding of their rights and responsibilities in relation to supported self-assessment and risk management, by January 2025. Services should evaluate the relationship between this work and any reduction in harm or improvements in personal outcomes. 8.1 NHS Lothian and Midlothian Council should work in collaboration with Midlothian HSCP to support the delivery of the integrated Midlothian HSCP Staff Engagement Plan 2023-24. 8.2 NHS Lothian and Midlothian Council should work in collaboration with Midlothian HSCP to support the delivery of the Midlothian HSCP Integrated Workforce Plan 2022-25. 7 Safe from Harm People using health & social care services are safe from harm. 8 Workforce Staff are engaged with their work and are supported to continuously improve the information, support, care, and treatment they provide Page 83 of 380
Page 84
9.1 NHS Lothian should maximise opportunities to work collaboratively across Lothian to design an approach and methodology to better understand and evidence the use of the set aside budget and associated services by HSPC area. This should include mechanism to better understand the impact of community prevention and early intervention activity across the whole system. 9.1.1 Following the 2023/24 review of the set aside budget, NHS Lothian should report to Midlothian IJB on a quarterly basis with performance and financial progress information. 9.2 All functions delegated to Midlothian IJB must be able to demonstrate Best Value with evidence- based data based on the operational ‘grip and control’ schemes developed for 2024/25. Midlothian IJB has agreed a series of recovery actions as part of its 2024/25 budget setting and expects these to be actioned. These are specifically 9.2.1 care at home provision should be realigned to a 20/80 split (internal 20%, external 80%) by October 2024. 9.2.2 A 3% reduction in overall costs of commissioned arrangements should be achieved through a programme of transformational change in partnership with Midlothian Council and NHS Lothian by January 2025. 9.2.3 Newbyres Care Village must reduce agency usage and sustain operation within an established financial footprint October 2024. 9.2.4 Transport for service users must reduce in spend by £240,000 by October 2024. 9.2.5 Recurring staff-pay costs will reduce by £448K in Planning, Performance, and Programme service. 9.3 All delegated functions will participate in review of service provision driven by a 5-year operational transformation programme to consider long term reform. This includes a change programme for 2024/25 to support achieving a balanced financial position. 9.4 NHS Lothian and Midlothian Council should report to Midlothian IJB on a quarterly basis on their decisions in relation to non-delegated functions that will impact on delegated functions. 9 Use of Resources Resources are used effectively and efficiently. Page 84 of 380
Page 85
This Direction describes the action required in relation to the other core and hosted functions delegated to Midlothian IJB. A number of these Directions 1 to 9 will require service redesign and transformation. Functions delegated to Midlothian IJB are detailed in the Midlothian Integration Scheme. All functions, including hosted functions, should be provided in accordance with legislation, policies, and procedures. Unless specified in the accompanying Directions, services should continue to be provided to high standards within the available budgets. All services should provide information on both activity and outcomes for service offers and supports delivered to improve the health, wellbeing and wellness of the people and communities of Midlothian. Functions delegated to the IJB from NHS Lothian within the Integration Scheme are detailed below Provision for people over the age of 18 1. Accident and Emergency services provided in a hospital. 2. Inpatient hospital services relating to the following branches of medicine a. general medicine b. geriatric medicine c. rehabilitation medicine d. respiratory medicine; and e. Psychiatry of learning disability 3. Palliative care services provided in a hospital 4. Inpatient hospital services provided by General Medical Practitioners. 5. Services provided in a hospital in relation to an addiction or dependence on any substance. 6. Mental health services provided in a hospital, except secure forensic mental health services. 7. District nursing services 8. Services provided out with a hospital in relation to an addiction or dependence on any substance. 9. Services provided by allied health professionals in an outpatient department, clinic, or out with a hospital. 10. The public dental service. 11. Primary medical services provided under a general medical services contract, and arrangements for the provision of services made under section 17C of the National Health Service (Scotland) Act 1978, or an arrangement made in pursuance of section 2C(2) of the National Health Service (Scotland) Act 1978 12. General dental services provided under arrangements made in pursuance of section 25 of the National Health (Scotland) Act 1978(27). 13. Ophthalmic services provided under arrangements made in pursuance of section 17AA or section 26 of the National Health Service (Scotland) Act 1978(28). 10 Delegated Functions Core and hosted services within the NHSL Lothian and Midlothian Council Integration Scheme are detailed below Page 85 of 380
Page 86
14. Pharmaceutical services and additional pharmaceutical services provided under arrangements made in pursuance of sections 27 and 27A of the National Health Service (Scotland) Act 1978 15. Services providing primary medical services to patients during the out-of-hours period. 16. Services provided outwith a hospital in relation to geriatric medicine. 17. Palliative care services provided outwith a hospital. 18. Community learning disability services. 19. Mental health services provided outwith a hospital. 20. Continence services provided outwith a hospital. 21. Kidney dialysis services provided outwith a hospital. 22. Services provided by health professionals that aim to promote public health Provision for people under the age of 18 1. Primary medical services and general medical services (including generally practitioner pharmaceutical services) 2. General dental services, public dental services, and the services provided by the Edinburgh Dental Institute 3. General ophthalmic services 4. General pharmaceutical services 5. Out of hours primary medical services 6. Learning disabilities 7. Health visiting 8. School nursing Functions delegated to the IJB from Midlothian Council within the Integration Scheme are detailed below 1. Social work services for adults and older people 2. Services and support for adults with physical disabilities and learning disabilities 3. Mental health services 4. Drug and alcohol services 5. Adult protection and domestic abuse 6. Carers support services 7. Community care assessment teams 8. Support services 9. Care home services 10. Adult placement services 11. Health improvement services 12. Aspects of housing support, including aids and adaptations 13. Day services 14. Local area co-ordination 15. Respite provision 16. Occupational therapy services 17. Reablement services, equipment, and telecare 18. Justice social work services Page 86 of 380
Page 87
MIJB_Directions2023-24_v1 Appendix 1: Midlothian IJB Indicative Budgets for 2024/25 for Directions Health Service ML IJB 24/25 Budget £000’s Core Community Equipment 607 Community Hospitals 6,344 Community Nursing 1,745 Diabetes & Endocrinology 21 District Nursing 2,448 Geriatric Medicine 734 GMS 15,635 Health Visiting 2,432 Learning Disabilities 369 Mental Health 2,393 ML Partnership Management 414 PC Management 7,225 PC Services 466 Pharmacy 137 Prescribing 18,875 Reserves 100 Resource Transfer 6,973 Substance Misuse 197 Therapy Services 1,758 Core Total 68,873 Hosted Complex Care 174 Diabetes & Endocrinology 4 GMS (1,886) Hospices & Palliative Care 480 Learning Disabilities 1,225 LUCS 1,237 Mental Health 2,389 Oral Health Services 509 PC Services 652 Prescribing 73 Psychology Services 766 Public Health 168 Rehabilitation Medicine 1,014 Sexual Health 785 Substance Misuse 306 Therapy Services 1,353 UNPAC 657 Hosted Total 9,905 78,778 Acute (Set Aside) Acute Management 545 Cardiology 12 Children Therapies 20 Page 87 of 380
Page 88
Diabetes & Endocrinology 422 ED & Minor Injuries 2,739 General Medicine 6,055 Geriatric Medicine 2,922 Outpatients 126 Rehabilitation Medicine 343 Respiratory Medicine 1,198 Therapy Services 1,764 Acute Total 16,145 16,145 Total Health 94,923 Social Care Service ML IJB 24/25 Budget £000’s Core Addictions 35 Assessment and Care Management 3,984 Criminal Justice 36 Learning Disability Services 19,611 Management and Administration 115 MELDAP/Recovery Hub 248 Mental Health Services 1,175 Non-Specific Groups 1,124 Older People 31,113 People with AIDS/HIV (33) Performance and Planning 683 Physical Disability Services 3,940 Public Protection 795 Service Management 499 Strategic Commissioning 209 Total Social Care 63,524 Total IJB 155,177 Page 88 of 380
Page 89
Midlothian Integration Joint Board Thursday 20th June 2024, 14:00 – 16:00 Statutory Public Consultation: Proposed Programme of Activity Executive summary This report sets out the proposed programme of activities as part of the statutory public consultation on the Midlothian Integration Joint Board (IJB) Strategic Commissioning Plan (SCP) 2025 -2040. The Public Bodies (Joint Working) (Scotland) Act 2014 requires that IJBs involve a range of service providers, service users and their carers, representative bodies, and professionals in the strategic commissioning process. The Statutory Guidance for states that Integration Authorities should make best efforts to allow groups of people with an interest to participate in a consultation process to express their opinions on the draft plan. The proposed programme of public consultation events (appendix 1) has been designed to reach as many people in our communities as possible and in a variety of ways to ensure a broad range of opinions and feedback are considered. This includes written information, public meetings, focus groups, questionnaires and online and interactive discussion forums. A synopsis of events held, the feedback received, and the action taken to incorporate the view of people and communities into the Strategic Commissioning Plan 2025-40 will be detailed in Midlothian IJB Engagement Statement that must be published alongside the Plan. The Strategic Planning Group reviewed this plan on 23rd May 2024 and, with one amendment to ensure the IJB engaged with HSCP staff as part of this process, has recommended this plan to the Board for approval. Members are asked to: • review the proposed programme of activity for the statutory public consultation on the Midlothian IJB Strategic Commissioning Plan 2025-40 • approve this plan subject to any feedback, edits, and amendments required Item number: 5.5 Page 89 of 380
Page 90
Midlothian Integration Joint Board Midlothian Integration Joint Board Statutory Public Consultation: Proposed Programme of Activity 1 Purpose 1.1 This report sets out the proposed programme of activities as part of the statutory public consultation on the Midlothian Integration Joint Board (IJB) Strategic Commissioning Plan (SCP) 2025 -2040. 2 Recommendations 2.1 As a result of this report, Members are asked to: • review the proposed programme of activity for the statutory public consultation on the Midlothian IJB Strategic Commissioning Plan 2025-40 • approve this plan subject to any feedback, edits, and amendments required 3 Background and main report 3.1 The Public Bodies (Joint Working) (Scotland) Act 2014 requires that IJBs involve a range of service providers, service users and their carers, representative bodies, and professionals in the strategic commissioning process. The Statutory Guidance for states that Integration Authorities should make best efforts to allow groups of people with an interest to participate in a consultation process to express their opinions on the draft plan. 3.2 The proposed programme of public consultation events (appendix 1) has been designed to reach as many people in our communities as possible and to take place in a variety of ways to ensure a broad range of opinions and feedback are taken into account. This includes written information, public meetings, focus groups, questionnaires and online and interactive discussion forums. 3.3 The Strategic Planning Group reviewed this plan on 23rd May 2024 and, with one amendment to ensure the IJB engaged with HSCP staff as part of this process, has recommended this plan to the Board for approval. 3.4 A synopsis of events held, the feedback received, and the action taken to incorporate the view of people and communities into the Strategic Commissioning Plan 2025-40 will be detailed in Midlothian IJB Engagement Statement that must be published alongside the Strategic Commissioning Plan. Page 90 of 380
Page 91
Midlothian Integration Joint Board 4 Policy Implications 4.1 This plan is in accordance with the Scottish Government and COSLAs Planning with People refreshed guidance and in line with the Strategic Plans: Statutory Guidance. 5 Directions 5.1 This report does not: • directly impact upon service ability to deliver an existing Direction, • raise the need to bring suggested revisions or discuss operational implications for an existing Direction, or • highlight the potential requirement for a new Direction that should be brought to IJB. 6 Equalities Implications 6.1 This report does not have any direct implication for groups of people with protected characteristics. 6.2 The proposed programme of public consultation activities is designed to reach a wide and diverse range of people across Midlothian. 7 Resource Implications 7.1 The majority of activities in the proposed programme of public engagement events do not require additional resource beyond the time of IJB members and officers of the HSCP. 7.2 A small resource is ringfenced for public engagement activity and will be utilised where required. 8 Risk 8.1 There is a risk that a lack of workforce resource and capacity will reduce the scope of the any planned programme public engagement. 8.2 There is a risk that we cannot reach a diverse mix of people and communities that are underrepresented. 8.3 This may result in a limited range of views being heard and action taken to make this a plan a meaningful reality for people in Midlothian. Page 91 of 380
Page 92
Midlothian Integration Joint Board 9 Involving people 9.1 Integration Authorities have a duty to consult on Strategic Commissioning Plans. Statutory guidance requires Integration Authorities to prepare proposals about matters the strategic plan should contain, seek the views of the Strategic Planning Group on the proposals in order to prepare a first draft of the strategic plan, and consider the views of the group expressed during the consultation. 9.2 The Integration Authority must then seek the views of the Strategic Planning Group on the draft. Taking into consideration the views in response to the consultation on the first draft, the Integration Authority is required to prepare a second draft of the strategic plan and send a copy of it for comment to the Local Authority and the Health Board. 9.3 Under the Community Empowerment Act (Scotland) 2015, Integration Authorities also have responsibilities to work with local communities to plan and deliver better services which make a real difference to people’s lives. Statutory guidance requires Integration Authorities to develop an agreed communication and engagement plan at an early stage that makes best efforts to allow groups of people with an interest to participate and express opinions on the draft strategic plan. This must include plans to engage underrepresented groups. 10 Background Papers 10.1 None AUTHOR’S NAME Gill Main DESIGNATION Integration Manager CONTACT INFO Gill.main@nhslothian.scot.nhs.uk DATE 04/06/2024 Appendices: Appendix 1: Proposed Programme of Public Consultation Activities 2024 Page 92 of 380
Page 93
Appendix 1: Midlothian Integration Joint Board Proposed Programme of Public Consultation Activities 2024 Strategic Commissioning Plan (SCP) Public Consultation Activity Timeline Week Commencing Duration Consultation Activity Audience Promotion Distribution Resources 26th August 26th Aug – 30th April 2025 SCP page on Midlothian HSCP website Population Weekly social media posts – MHSCP, MLC Targeted promotion with all staff and a range of partners N/A Planning, Performance and Programme, MLC Workforce 26th August 26th August (Half Day) Distribution of paper-based surveys, fliers, and posters Population N/A Community Development Trusts Midlothian HSCP locations – Leisure Centres, Libraries, MCH, Daycentres Midlothian GP Surgeries Team resource: c3.75 hours for distribution of printed materials to various partners Page 93 of 380
Page 94
26th August 26th August – 31st October Online Survey Population Weekly social media posts – MHSCP, MLC Targeted location- based promotion Promotion of consultation via Community Councils Promotion of consultation via partners of underrepresented groups, including Carers, and people with disabilities Available online via SCP page on HSCP website Community Groups / Partner sites i.e. via Community Councils Social media post, digital posters Printed posters, fliers Printing, time for travel and distribution 26th August 26th August – 31st October Paper Based Survey Population Weekly social media posts – MHSCP, MLC Targeted location- based promotion Various (see item 2) Design of Social Media posts Printing, time for travel and distribution 26th August Date TBC Half Day Midlothian Youth Platform Hackathon Young people 12- 21 N/A N/A Team resources: 7.5 hours Page 94 of 380
Page 95
16th Sep Date TBC 90 mins Virtual Town Hall Population Weekly social media posts – MHSCP, MLC SCP page on HSCP website Eventbrite – accessed via the SCP page on HSCP website Members of the IJB and officers of the HSCP (ELT) Social media post, digital posters Team Resource for planning & facilitation: c15 hours 23rd September Date TBC 90 mins Virtual Town Hall HSCP Workforce Weekly social media posts – MHSCP, MLC SCP page on HSCP website Eventbrite – accessed via the SCP page on HSCP website Members of the IJB and officers of the HSCP (ELT) Social media post, digital posters Team Resource for planning & facilitation: c15 hours 30th September 30th September – 4th October Collation, thematic analysis, and review of Town Hall Feedback N/A N/A N/A Team resource for collation analysis and review: c15hours Page 95 of 380
Page 96
October - date TBC Half day Midlothian Disabled People’s Assembly People living with a disability / families / carers Social Media (HSCP & Forward Mid) MHSCP Engagement Landing Page In-Person Events (Midlothian Disabled People’s Assembly) Social media post, digital posters. Stand with information and fliers Team Resource for planning, engagement & attendance at session: c15 hours Monday 4th November November 4th (Half Day) Collection of completed paper- based surveys N/A N/A Team resource: c3.75 hours for collection of printed surveys Monday 4th November Monday 4th (1 day) Online survey Data Collation Paper based survey responses digitised Team resource for collation of digital data c3.75 Hours Digitisation of paper-based surveys c7.5 – 15 hours Monday 4th November Tuesday 5th – 8th November Data analysis N/A N/A Team resource for analysis c15 hours Page 96 of 380
Page 97
Stakeholders Organisation Demographic Action Group People with learning disabilities Ageing Well People aged 45-59 Alzheimer Scotland People living with Alzheimer’s ARKHA (ARK Housing Association) People experiencing Socioeconomic Disadvantage Art Link People with Physical Disabilities Autism ideas in Midlothian People with Autism BIELD Assisted living & Housing Bonnyrigg and Sherwood Community Development Trust General Public Bonnyrigg Trust General Public Broomhill Day Centre People with Physical Disabilities C&C Healthcare Café Connect (MVA) People with Physical Disabilities Carr Gomm People experiencing Socioeconomic disadvantage Castlerock Edinvar Housing Support Changeworks Environmental Charity Page 97 of 380
Page 98
Connect Scotland Family Education Engagement Cyrenians Homelessness Dalkeith Cab (Dalkeith & District Citizens Advice Bureau) People experiencing socioeconomic disadvantage Dalkeith Cab (Dalkeith & District Citizens Advice Bureau) People experiencing socioeconomic disadvantage Dalkeith & District Community Council General Population Deaf Action Deaf / Hard of Hearing Dementia Team People living with Dementia Disabled Sport People living with Physical Disability ELCAP People living with Learning Disabilities Enable Carers Erskine Veterans Eskbank and Newbattle Community Council General Population Gorebridge Community Council General Population Gorebridge Community Development Trust General Population Gorebridge Community Development Trust General Population Grassy Riggs People aged 60 -74 years Health in Mind Mental Health Page 98 of 380
Page 99
Howgate Community Council General Population Into Work People living with Learning Disabilities LCiL – inclusive living People living with Physical Disabilities Loanhead & District Community Council General Population Libraries General Population MAEDT (Mayfield & East Houses Development Trust) General Population Mayfield and Easthouses Development Trust (MAEDT) General Population McSense Care, property and training services MELD (Mid & East Lothian Drugs) Substance misuse MELDAP (Midlothian & East Lothian Drugs & Alcohol Partnership) Substance misuse Midlothian Voices (CAPS Advocacy) Veterans Midlothian Youth Platform People aged 16-21 MIDPA (Midlothian Disabled People's assembly) People living with Physical Disability Midspace Mental health MODA (Midlothian Older People's assembly) People aged 60-74 years MPEG Midlothian People's Equality Group LGBTQ+ Community MS group People living with Multiple Sclerosis Page 99 of 380
Page 100
MVACS - Midlothian Voluntary Action (MVA) Volunteers Neighbourhood Networks Adults with learning disabilities Newtongrange Development Trust General Population One Dalkeith General Population Park Cottage (Penumbra) Mental health Partners in Advocacy People Experiencing Socioeconomic Disadvantage PASDA People living with Learning Disabilities Penicuik Community Development Trust General Population Penicuik YMCA People aged 30-44 years Peniculk Citizens Advice Bureau People Experiencing Socioeconomic Disadvantage People First Scotland People Living with Physical Disabilities Places for People Mental health Redcross - British Red Cross Society People Experiencing Socioeconomic Disadvantage Redwoods People living with Learning Disabilities RNIB People who are Blind or partially sighted Rosehill - Rosehill (Society for the Sacred Heart) Care home Page 100 of 380
Page 101
Rosewell Development Trust General Population Rosewell Development Trust General Population SCRT Homecare Care home St. David’s Brandbury Day Centre People aged 75 years and older The Richmond Fellowship Scotland Mental health THERA People living with Learning Disabilities Thistle People living with Long Term Conditions Trustha Housing UNISON Legal/carer/financial advice VOCAL Carers Volunteer Midlothian People experiencing socioeconomic disadvantage Wee Breaks directory Carers With You People ages 75 years and older Women’s Aid (Women's Aid East & Midlothian Ltd) Women experiencing domestic abuse (*All stakeholders listed in this table were contacted during the first public consultation phase. If a response was received, their status was changed from ‘Inactive’ to ‘Active’) Page 101 of 380
Page 102
Page 102 of 380
Page 103
Midlothian Integration Joint Board Thursday 20th June 2024, 14:00-16:00 Primary Care: General Practice Sustainability Executive summary Over 60% of all healthcare activity takes place in primary care. General Practitioners (GPs) provide General Medical Services to all people and are very often the first point of access for a range of health and social care issues. 11 independent contractor GP practices across Midlothian currently deliver about 600k direct clinical encounters with patients each year but the sustainability of this level of provision is significantly threatened by rising demand, population growth, and premises and workforce availability, with the impending risk of further practice closures. Midlothian Health and Social Care Partnership (HSCP) recognises the significant financial and management burden that this would create, as well as the impact on the demand on access for wider healthcare and long-term population health. A 5-year operational delivery plan, based on national policy and local strategic intentions, has therefore been developed which sets out a range of options to mitigate against this risk and maintain the viability and resilience of our local GP practices to be able to continue to provide safe, effective, and person-centred care to the people of Midlothian. Members are asked to: • Note the key risks to delivery of the IJB’s obligations in regard to the delegated functions and progress towards its strategic plan and the 9 National Health & Wellbeing Outcomes • Consider commissioning the Strategic Planning Group (SPG) to work up a new Direction to identify opportunities to strategically reallocate resource in ways that will support shifting the balance of care to the community, including the delivery of healthcare by General Practice. Item number: 5.6 Page 103 of 380
Page 104
2 Midlothian Integration Joint Board Primary Care: General Practice Sustainability 1 Purpose 1.1 This report sets out the challenges, risks, and opportunities to maintain the sustainability of the delivery of core health care by General Practice in Midlothian over the next 5 years. 2 Recommendations 2.1 As a result of this report, Members are asked to: • Review the summary of the background challenges to the sustainability of independent General Practice in Midlothian and the proposed 5-year HSCP operational delivery plan to support GP practices to remain viable, open to new patient registration, and providing access to General Medical Services. • Note that GP Practices provide and coordinate the majority of health (and to an extent social care) services in Midlothian and that the impact of the challenges described is significant for the HSCP. • Note the key risks to delivery of the IJB’s obligations in regard to the delegated functions and progress towards its strategic plan and the 9 National Health & Wellbeing Outcomes. • Consider commissioning the Strategic Planning Group (SPG) to work up a new Direction for the Board’s deliberation to identify opportunities to strategically reallocate resource in ways that will support shifting the balance of care from hospitals to the community, including the delivery of healthcare by General Practice. 3 Background and main report 3.1 There are currently 11 GP practices in Midlothian all providing General Medical Services (including unscheduled care provision) and Enhanced Medical Services as Independent Contractors under a ‘17J’ contract to NHS Lothian. All currently have an open list to new patient registration. 3.2 596,428 direct clinical encounters (appointments) took place across Midlothian during 2023; an average of 5.7 clinical encounters per Midlothian resident. 3.3 Practice data submitted every week to the Lothian Medical Committee GP subcommittee over the last 18 months shows that GPs in Midlothian have had consistently more contact with people than in other areas and also consistently report signs of increased pressure which is likely to be unsustainable. Page 104 of 380
Page 105
3 3.4 In addition to the current pressures, the population of Midlothian is projected to be the fastest growing in Scotland, at a rate significantly higher than the national average. Population head count is expected to have increased by at least total of 13.8% in the ten years up to 2028, with a predicted extra 30,000 residents (calculation based on average size of a household in Midlothian, which is currently 2 adults and 0.3 children). 3.5 The impact of planned housing developments and the associated increase in the population of Midlothian will be most keenly felt in currently under-served areas (e.g., Roslin, Mayfield & Rosewell) and areas with the most significant increase in the population (e.g., Danderhall and Shawfair). 3.6 Capacity for GP practices to safely and sustainably absorb and deal with increasing demand and population growth is limited by both premises / available accommodation and workforce availability, which were detailed in an IJB development session on 21st March 2024. 3.18 A local GP practice sustainability risk matrix (which gives a weighted score to each practice based on list growth, as well as the percentage of older people, levels of economic deprivation, and premises pressure including the recent uplift in facilities maintenance costs) has been developed to help identify which practices are likely to be at the greatest risk of list closure or return of their contract, and therefore gives an early opportunity to help plan appropriate support and mitigations. 3.7 Taking the recommendations of the Scottish Government General Practice Task Group recommendations into account, the Lothian Strategic Development Framework priorities for Primary Care, and Midlothian IJB’s objectives for Primary Care in its strategic commissioning plan, the HSCP has developed a 5-year HSCP operational delivery plan to maintain the viability and resilience of our local GP practices. This lays out a step-by-step approach to: 3.7.1 Develop the Primary Care Improvement Plan multidisciplinary team, ensuring best value for money in terms of maximising the opportunities to relinquish workload from GPs, as well as improved management oversight and opportunities for further investment. 3.7.2 Plan and support the optimal use of premises and accommodation until Scottish Government capital funding is restarted and the development of a new practice at Shawfair can be recommenced. 3.7.3 Consider investment in additional digital infrastructure to increase access options for patients and increase productivity. 3.7.4 Continue communication campaigns with the general public to promote the use of the right service in the right place at the right time. 3.7.5 Monitor and support general practice staff wellbeing and resilience. 3.7.6 Incentivise specific clinical and prescribing projects which promote prevention and early intervention, deliver key strategic priorities, and deliver increased effectiveness and efficiencies. 3.7.7 Continue allocation of GMS-LEGUP funding to support practices with the highest list growth (including the option for the HSCP to fund additional LEGUPs if it will prevent practice list closure). Page 105 of 380
Page 106
4 3.7.8 Implementing standardised practice business continuity plans and a 2C- contingency plan to ensure that escalation and action is rehearsed and risks mitigated in the event of a practice closure. 3.7.9 Use data sources to monitor performance and mitigate for increasing patient demand and emerging risks contemporaneously. 3.7.10 Consider a public consultation of General Practice if experience of Access has declined again in the 2024 Health Care and Experience Survey (HACE). 3.7.11 Consider additional or recycled investment in other HSCP, integrated, or Third Sector services or organisations which would directly support general practice but absorbing patient demand and workload. 3.8 Progress against delivery plans, performance and assurance measures, and mitigation of risks will be subject to oversight of the HSCP Clinical Care and Governance Group (CCGG) and Service Management Team (SMT). Any identified risks of failure to progress delivery which puts the IJB strategic commissioning plan at risk will be escalated to the Strategic Planning Group (SPG) for further discussion. 4 Policy Implications 4.1 The Scottish General Medical Services (GMS) Contract (2018) set out a new direction for general practice in Scotland which aims to: • improve access for patients, address health inequalities and improve population health including mental health • provide financial stability for GPs, and reduce GP workload through the expansion of the primary care multidisciplinary team • redefines the role of the GP as an expert medical generalist focusing on complex care, reduce the risks associated with becoming a GP partner and encourage new entrants to the profession as well as help retain existing GPs. 4.2 The memorandum of understanding between the Scottish Government, the British Medical Association, Integration Authorities and NHS Board for the new GMS contract sets out the principles by which primary care redesign will be delivered. Crucial to this agreement is that services will only be transferred where it is sustainable for the local healthcare system and, most importantly, where it is safe, appropriate, and improves patient care. 4.3 As a result of the new Contract, all Integration Authorities now have locally-agreed Primary Care Improvement Plans which must include local multidisciplinary workforce planning to improve the primary care people receive in their communities. 4.4 The Scottish Government General Practice Task Group was established in May 2023 to develop a shared view on next steps for primary care transformation (specifically General Practice and the provision of primary medical services), in the wider context of NHS Recovery, Resilience and Transformation. Their report summarises key messages, agreed statements and proposed programmes of work intended to influence future direction, input and actions of key stakeholders. Page 106 of 380
Page 107
5 4.3 Many General Practices across Scotland already provide a high quality of care and access. However, this is not every person’s experience of accessing care, and the stress, worry and anxiety that this can cause to people, families and carers can be considerable. The Scottish Government General Practice Access Short Life Working Group have therefore published Access Principles which will improve access to care for people if they are applied by General Practices and Health Boards. However, General Practice will not be monitored or measured against the Access Principles as they are not quality standards. 5 Directions 5.1 This report does not directly impact upon the ability to deliver an existing Direction. However, Midlothian IJB relies on General Practice, as the first point of access and treatment for the majority of people, to indirectly deliver many Directions, in particular those relating to Health & Wellbeing, Positive Experiences & Dignity, Health Inequalities, and Safe from Harm (see Section 8, Risk). 5.2 Midlothian IJB may therefore wish to consider commissioning the Strategic Planning Group (SPG) to work up a new Direction for the Board’s deliberation to identify opportunities to strategically reallocate resource in ways that will support shifting the balance of care from hospitals to the community, including the delivery of healthcare by General Practice. 6 Equalities Implications 6.1 Currently all 11 practices in Midlothian have an open list for patient registration, meaning that all people, regardless of protected characteristics, have an equal opportunity to register with a GP practice of their choice, as long as their permanent address is within that practice’s specified boundary. 6.2 All practices are encouraged to take appropriate steps to ensure that medical services are provided in different ways to meet the different needs of people. 6.3 GPs have a key role – as part of integrated multidisciplinary primary care teams – in reducing or mitigating health inequalities, particularly in relation to socio- economic deprivation. We know that the Inverse Care Law, which was first defined by the GP Julian Tudor Hart in 1971 to describe how people who most need health care are least likely to receive it, manifesting in general practice in relation to the distribution of resources (fewer GPs and less funding) and within consultations (higher GP stress, lower patient enablement and worse outcomes). 6.4 Any change to the operation delivery model of General Practice in Midlothian as a result of practice closures will require careful planning to ensure that provision of and access to general medical services is equitable to all patient groups. Page 107 of 380
Page 108
6 7 Resource Implications 7.1 Over 60% of all healthcare activity takes place in primary care. General Practice provides General Medical Services to all people and is a key first point of access for a range of health and social care issues, with relatively low cost of healthcare per capita, a system of universal registration and lifelong record which creates the foundation for population-based care, generalist expertise, and the agility and responsiveness of practices to temporary challenges (e.g. Covid pandemic). Levels of trust in GPs remain generally high due to their anchor role in communities, and the fact that people turn to GP practices when other services are at capacity. 7.2 A GP consultation costs around £39 which compares to the average cost of £77 for someone who attends an urgent care centre and receives the lowest level of investigation and treatment or at least £359 for an individual at a major A&E department who receives more complex investigation and treatment. Primary care assessment and treatment is therefore real value for money and allows patients to be treated closer to home. 7.3 If a GP practice can no longer cope, with demand far exceeding capacity, they have the option to close their patient list to new registrations, but this usually creates a domino effect of instability and stress on surrounding practices. When a practice becomes unviable to financial instability or inability to recruit GP partners then it can choose to resign and hand back its ‘17J’ independent contractor status (as per Danderhall 2023). If no other local practice are willing or able to take on the contract and amalgamate their practices then the responsibility for delivering general medical services and patient access is transferred to the HSCP under ‘2C’ provision. It is well known that HSCP-managed ‘2C’ practices cost approximately 50% more to run, quickly outstripping central funding sources. 7.4 Most of General Practice’s funding currently comes directly from the Scottish Government for contractual General Medical Services, Enhanced Services (with a top-up by NHS Lothian), and for the Primary Care Improvement Plan multidisciplinary team workforce. 7.5 Only 32% of the Jim Crombie Primary Care funding (£500k pa) goes directly to General Practice, with the rest being invested in other HSCP services which may not directly support or mitigate for core medical services provision in the same way. 8 Risk 8.1 There is risk that the IJB fails to meet its obligations to deliver delegated functions under the Scheme of Integration, including provision of a high standard of equitable access to general medical services for all people in Midlothian, under Section 17C (personal medical or dental services) and Section 17J (general medical services). 8.2 In doing so there is also a risk that the IJB will fail to deliver sufficient progress towards its strategic plan and the 9 National Health & Wellbeing Outcomes, particularly in relation to: 8.2.1 Frailty – reduced capacity of local General Practice to identify people who are living with Frailty, develop person-centred anticipatory care plans to avoid Page 108 of 380
Page 109
7 unscheduled hospital admission, and coordinate access to relevant support services. 8.2.2 Long-term conditions – reduced capacity of local General Practice to provide lifestyle advice and appropriate interventions to prevent and reduce risk from long-term conditions, screen for and diagnose conditions earlier, and monitor and manage long-term disease to reduce risk of complications and mortality. 8.2.3 Under 18s – reduced capacity of local General Practice to work alongside HSCP Health Visiting services to prevent avoidable illness and unnecessary hospital admissions and monitor, improve and provide early interventions for children and young people’s physical and mental health. 8.2.4 Mental Health – reduced capacity of local General Practice to improve the physical health of people with mental illness and provide early access and interventions for people with mental distress and illness to avoid crisis, unscheduled hospital attendance, suicide. 8.2.5 Substance Use – reduced capacity of local General Practice to prevent future harm caused but the misuse of alcohol and/or drugs, recognise and protect vulnerable individuals, and promote recovery via the delivery of Medication Assisted Treatment (MAT) standard 7. 8.2.6 Primary Care - reduced capacity of local General Practice to respond to local population growth and sustain access to general medical services, providing care close to home. 8.2.7 Acute Services - reduced capacity of local General Practice to provide adequate unscheduled access to same-day medical assessment/treatment and avoid unnecessary hospital attendances or admission. 8.3 There is also a risk of financial overspend to the delegated budget relating to either: 8.3.1 the enforced management of HSCP-managed ‘2C’ medical practices if/when further local independent ‘17J’ GP practices collapse and hand back their contract, or 8.3.2 over-investment in other HSCP patient services which offer less value for money than general practice. 9 Involving people 9.1 This report has been written in collaboration with the Head of Service for Primary Care, the Primary Care Service Manager, and the GP and Practice Manager colleagues in the HSCP Primary Care Management team. 9.2 The IJB may wish to consider working collegiately with General Practice to undertake a public consultation should the Health and Care Experience (HACE) 2024 survey show a continued decline in the experience of and access to General Practice because of current and emerging pressures. 9.3 GPs themselves will be the most important stakeholders in any proposed changes to local general practice service model, delivery, or support, either positive or negative, and should therefore have the Tripartite involvement of the GP sub- committee of the Lothian Medical Committee. Page 109 of 380
Page 110
8 10 Background Papers 10.1 IJB report on Primary Care GP activity 9th February 2023 10.2 Scottish Government General Practice Task Group Roundtables report January 2024 AUTHOR’S NAME Dr Rebecca Green DESIGNATION Clinical Director / Clinical Lead for General Practice CONTACT INFO rebecca.green@nhs.scot DATE 31st May 2024 Page 110 of 380
Page 111
Page 111 of 380
Page 112
Page 112 of 380
Page 113
Midlothian Integration Joint Board Thursday 20th June 2024, 14:00-16:00 Midlothian Integration Joint Board Financial Recovery Action: Planning, Performance, and Programme Service Executive summary Following the Midlothian IJB on 21st March 2024, Midlothian IJB requested Midlothian HSCP review the posts within the Planning, Performance and Programme service as part of financial recovery. The total investment in this team is currently £448k annually. The Integration Manager presented an options paper to the Board on 18th April 2024 which set out the benefits and risks associated with three options and asked the Board to agree a funding position for 2024/25. The Board did not make a decision at this time. Instead, the Chief Finance Officer was asked to review the final out-turn position for 2023/24 and work with the Integration Manager to return with a proposal for a reduced level of funding in line with a natural attrition model. On 3rd May 2024, the Chief Finance Officer and the Chief Officer were made aware of a worsened financial position across the HSCP, and that the financial gap had increased. This deteriorating position reinforced that no reserves are available to continue funding for the Planning, Performance, and Programme Service and the Chief Finance Officer and the Chief Officer requested the Integration Manager consider the impact of a nil funding option. As a result of this report, Members are asked to: • consider the benefits and risks associated with this position. • note this is not a strategic or planned disinvestment, is a response to financial pressures in the wider system and therefore a high-risk strategy. . Item number: 5.7 Page 113 of 380
Page 114
Midlothian Integration Joint Board Midlothian Integration Joint Board Midlothian Integration Joint Board Financial Recovery Action: Planning, Performance, and Programme Service 1 Purpose 1.1 This report presents three options to reduce the financial investment from the Midlothian IJB reserves to support to the Planning, Performance and Programme service. This is one of five Financial Recovery Action Plans to achieve the required financial recovery position for 2024/25. 2 Recommendations 2.1 As a result of this report, Members are asked to: • consider the benefits and risks associated with this position. • note this is not a strategic or planned disinvestment, is a response to financial pressures in the wider system and therefore a high-risk strategy. 3 Background and main report 3.1 Following the Midlothian IJB on 21st March 2024, Midlothian IJB requested Midlothian HSCP review the posts within the Planning, Performance and Programme service as part of financial recovery. The total investment in this team is currently £448k annually. 3.2 The Integration Manager presented an options paper to the Board on 18th April 2024 which set out the benefits and risks associated with three options and asked the Board to agree a funding position for 2024/25. 3.3 The Board did not make a decision at this time. Instead, the Chief Finance Officer was asked to review the final out-turn position for 2023/24 and work with the Integration Manager to return with a proposal for a reduced level of funding in line with a natural attrition model. 3.4 On 3rd May 2024, the Chief Finance Officer and the Chief Officer were made aware of a worsened financial position across the HSCP, and that the financial gap had increased. This deteriorating position reinforced that no reserves are available to continue funding for the Planning, Performance, and Programme Service and the Chief Finance Officer and the Chief Officer requested the Integration Manager consider the impact of a nil funding option. Page 114 of 380
Page 115
Midlothian Integration Joint Board 3.5 The risks of a nil funding option are now presented to the Board to set out the reality and the scale of risk. To support Midlothian IJBs understanding of staffing costs and the scale of Organisational Change required, both the NHS and Local Government Workers Payrates 2023-24 can be found in appendix 1. 3.6 Risk 1: Coordination and oversight of statutory information management reporting The loss in capacity from natural attrition is already impacting on the ability to provide oversight and a coordinating role of statutory information management reporting. The HSPC is managing this internally to ensure statutory reporting can continue to be delivered. 3.7 Risk 2: Workforce The loss in capacity from natural attrition is already impacting on the ability to support a range of workforce related initiatives and the development of workforce planning. The Integration Manager has reprioritised workload to respond to only the statutory elements of this portfolio. This has had an impact on the ability to progress other key elements of the portfolio in a timely way. 3.8 Risk 3: Equality There is a risk that further loss in capacity will impact on the ability to provide equality Impact assessment support, reporting on Equality Impact Assessments, liaison with Equality and Human Rights Commission (EHRC), develop of the statutory IJB Equality Outcomes and update the Mainstreaming Equality Report / Action Plan. Midlothian IJB statutory requirements will be prioritised. Midlothian IJB should consider a formal request to NHS Lothian and Midlothian Council partners for the provision of specialist support and oversight. 3.9 Risk 4: IJB Statutory Duty to Consult There is a risk that further loss in capacity will impact on the ability to take forward a statutory public consultation on the IJB Strategic Commissioning Plan. Midlothian IJB should consider the elements of the proposed public consultation that can be stepped down and anticipate a limited analysis, examination, and deliberation of public feedback will be provided. 3.10 Risk 5: Community / Public Engagement There is a risk that further loss in capacity will impact on the ability to continue the IJB self-assessment using the Healthcare Improvement Scotland Quality Framework for Community Engagement and developing the associated action plan. 3.11 Risk 6: Third Sector Engagement There is a risk that further loss in capacity would result in an inability to plan and coordinate the Third Sector Summit. 3.12 Risk 7: IJB Meeting Support There is a risk that further loss in capacity will impact on quality and timeliness of business support to the Board. The Integration Manager will continue to provide member support and agenda planning alongside regular liaison with Chair, Vice Chair, and Chief Officer. All other meeting support activities would be stood down. Page 115 of 380
Page 116
Midlothian Integration Joint Board 3.13 Risk 8: Reduced ability to contribute to whole system transformation There is a risk that further loss in capacity will result in a significant reduction in resilience and system knowledge and impact on the extent to which the planning and performance team can contribute to the ambitions for data driven transformation and redesign outlined in the draft Strategic Commissioning Plan 2025-40. Midlothian IJB will have a limited ability to progress developmental work and may be required to negotiate additional support from partners. 3.14 Risk 9: Planning and Performance commissioned activity There is a risk that further loss in capacity will impact on the ability to support commissioned activity and reports to provide service insight or develop data visualisation tools. A limited and carefully prioritised amount of support will be available where it can be aligned to the Planning and Performance work approved by the Board to investigate and develop the system intelligence. 3.15 Risk 10: Risk to reporting functions There is a risk that further loss in capacity will result in a significant reduction in analytic capacity and a reduced ability to provide all the current reporting functions provided to IJB and HSCP services beyond and/or including statutory reporting. This is due to the loss in resource and capacity, as well as specialist skills in the use of Pentana, and MOSAIC. Midlothian IJB may be required to negotiate additional support from partners. 3.16 Risk 11: Loss of Planning and Performance developmental activity There is a risk that further loss in capacity will result in a significant reduction in resilience and system knowledge and limited or no ability to provide developmental work (dashboards and other data visualisation and impact narrative) to support the IJB and/or HSCP services interpret their activity and performance data to inform meaningful planning. Midlothian IJB may be required to negotiate additional support from partners. 3.17 Risk 12: The service is no longer viable and an organisational risk in itself There is a risk that the extent to which this service will experience a loss of capacity, resilience, and system knowledge will result in the service no longer being safe or viable and presenting as a significant risk to the organisation. Midlothian IJB must consider the possibility of being unable to meet a minimum standard of service, and the associated risks. 4 Policy Implications 4.1 This report has implications for a range of statutory duties currently undertaken by the Planning, Performance, and Programme service including • IJB Strategic Commissioning Plan • Consultation Statement (published alongside the Strategic Plan) • Housing Statement (published alongside the Strategic Plan) • IJB Joint Strategic Needs Assessment (JSNA) • IJB Directions and Annual Reporting • IJB Annual Performance Report • IJB Equality Outcomes and Mainstreaming Equality Report • IJB Market Facilitation Plan Page 116 of 380
Page 117
Midlothian Integration Joint Board • IJB Community Engagement Plan • IJB and HSCP Equality Impact Assessments • IJB Scheme of Publication and Information Guide (including all IJB and HSPC published material under the Scheme of Publication, paper and digital, including the website) • IJB and HSCP Public Engagement Statement • IJB and HSPC Integrated Workforce Plan • IJB connection with the Third Sector (Third Sector Summit) • Progressing the ambitions of the Strategic Commissioning Plan through project-based activity i.e., the upcoming Newbyres Report • IJB and HSCP Freedom of Information (FOI) requests • IJB and HSPC Subject Access Requests (SARs) • HSCP Service Planning and Reporting Support 5 Directions 5.1 A nil funding position for the Planning, Performance, and Programme service will directly impact in a proportionate way the contribution of the service to the following Directions, and ultimately Midlothian IJBs performance. • Direction 2.1 All services delegated to Midlothian IJB must evidence the connection with communities, partners, and use of technology to improve self-management and self-monitoring, by January 2024 • Direction 3.1 All services delegated to Midlothian IJB will contribute to the IJBs ability to describe activity, experience, and outcomes. Services must use and develop outcome mapping, by January 2024 • Direction 5.1 NHS Lothian and Midlothian Council must ensure that data can be disaggregated by HSCP area in order to support the equitable provision of service offers and support across our communities, minimise disadvantage where possible, meet different needs, and encourage participation. This should include ensuring - systems and data have the capabilities to collect and filter data appropriately by HSCP area and by protected characteristics - health and social care workforce are suitably trained and skilled to gather and input this data, and - data quality assurance, by January 2025 • Direction 5.2 NHS Lothian and Midlothian Council must explore opportunities for integrated system-wide digital solutions and create an action plan of jointly agreed priorities by January 2024 • Direction 8.2 NHS Lothian and Midlothian Council should work in collaboration with Midlothian HSCP to support the delivery of the Midlothian HSCP Integrated Workforce Plan 2022-25. Page 117 of 380
Page 118
Midlothian Integration Joint Board • Direction 9.1 9.1 Maximise opportunities to work collaboratively across Lothian to design an approach and methodology to better understand and evidence the use of the set aside budget and associated services by HSPC area. This should include mechanism to better understand the impact of community prevention and early intervention activity across the whole system. 6 Equalities Implications 6.1 This report does not directly impact on groups of people with protected characteristics. 6.2 However, when strategy plans, information, and services are not designed to be accessible, people get left behind without alternatives. Midlothian IJB will need to consider how it continues to meet statutory requirements without the planned contribution, specialist knowledge and project support capacity of the Planning, Performance and Programme service, and act lawfully in relation to: • Public Sector Equality Duties • Equality Act, 2010 6.3 In this regard, Midlothian IJB must consider its ability to meet statutory duties relating to major service change • Legal If an Integrated Authority cannot adequately show how the voices and needs of the most impacted, vulnerable, or legally protected people in communities have been sought and considered, particularly at the planning phase of the decision, it risks both penalty and legal challenge. Equality and Children Rights Impact Assessments (ECRIAs) must demonstrate a thorough exploration of potential impacts on communities and use this information to inform decision making. An example of when inadequate consideration to equality resulted in legal challenge being raised is the Scottish Borders Council in relation to the closure of Teviot Day Service, Hawick. • Moral/Ethical All major changes to policy, provision, or planning must involve a thorough exploration of the potential impacts of its proposed action through an Equality Impact Assessment (EIA), Failing to recognise, understand, identify and mitigate any barriers to equality that result from major service change may be considered unlawful discrimination, particularly in relation to people that have a Protected Characteristic or are vulnerable. If the voices of the people and communities are missing from the relevant stages in the process, Midlothian IJB could be considered to be exacerbating disadvantage and reinforcing systemic discrimination that has a negative impact on health inequalities and outcomes. Page 118 of 380
Page 119
Midlothian Integration Joint Board 6.4 The Planning, Performance and Programme service is currently supporting a number of pieces of work involved in Meeting the Accessible Information Standard to ensure the information provide about services is straightforward and easy to access. Meeting the Accessible Information Standards is seen as best practice to help implement the duties in the Equality Act including the duty to ensure that people with disabilities are not unfairly discriminated against. This work includes leading actions to implement improvement recommendations in the recent Care Inspectorate Joint Inspection of Adult Services. 6.5 Failure to make a reasonable adjustment is classed as discrimination and Midlothian IJB must identify, remove, reduce, or prevent barriers for people with disabilities where it is reasonable to do so. Providing information in an accessible format will always be deemed reasonable if not doing so would put someone at a substantial disadvantage. (NHS Lothian Impact Assessment Guidance). • Implementation of the Scheme of Publication Internal Audit have recently completed a review of the Midlothian IJB Scheme of Publication and will shortly be making their report and recommendations available. Provisional feedback indicates this will include a request to ensure the development of a ‘style guide’ for all information publicly available from Midlothian IJB and HPSC. This is to ensure format, content, and style of information is written in a way that can be accessed by everyone. • Improvement actions from the Care inspectorate in relation to the provision of service information Recommended actions require the specialist skills of the Planning, Performance, and Programme service to deliver the necessary improvements. • A planned review of the website The Web Content Accessibility Guidelines (WCAG) are being updated in October 2024 and will be the new minimum accessibility standard for all UK public sector websites and mobile apps. From October 2024, services will be monitored for WCAG 2.2 AA compliance. 6.6 Following a decision on funding from Midlothian IJB, work will commence to progress the Organisational Change required to reduce staff costs accordingly. An Equality and Children Rights Impact Assessment (ECRIA) will be undertaken as part of this process and made available to the Board for review and consideration. 7 Resource Implications 7.1 No recurring allocation resulting in a recurring saving of £448k and representing an approximate loss in 67% of the current team WTE. 7.2 The Board is asked to consider the following; • a continued recurring allocation of £144.5k will represent an approximate loss in 48% of the current team WTE, allow some resilience, partially mitigate these risks, and result in a recurring saving of £303.5k. • a continued recurring allocation of £83.5k will represent an approximate loss in 57% of the current team WTE, allow some resilience, and result in a recurring saving of £364.5k. Page 119 of 380
Page 120
Midlothian Integration Joint Board 8 Risk 8.1 The operational risks related to these financial options are details in 3.6 – 3.17. 8.2 This recovery action is not a strategic or planned disinvestment, but a response to financial pressures in the wider system. This is therefore a high-risk strategy. the WTE of the Planning, Performance and Programme service will reduce to less than the WTE in 2021, when the Board increased capacity in this area to improve performance and performance reporting. 8.3 Additionally, the financial savings detailed in this paper cannot be realised immediately. The process to realise the financial savings will require Organisational Change. Although this is a meaningful process that realises effective change, it is not a quick process and can take several months to conclude. Staff would continue to be protected under their employers’ terms and conditions and there is a risk that staff could remain in redeployment for up to 3 years before the saving is realised. 8.4 Reducing the support available to the IJB provided by the Planning, Performance, and Programme service may result in Midlothian IJB being unable to meet all of its legislative duties in relation to the delivery of statutory planning and reporting. Non- compliance with some statutory planning and reporting activity could risk an improvement notice, litigation, or penalty e.g., from the Equality and Human Rights Commission (EHRC), or the Information Commissioner’s Office (ICO). 9 Involving people 9.1 This report has been written in collaboration with the Chief Officer, Chief Finance Officer, the Integration Manager, and Finance partners. 10 Background Papers 10.1 2024 04 18 MIJB_Midlothian IJB Financial Recovery Action Planning, Performance & Programme AUTHOR’S NAME Gill Main DESIGNATION Integration Manager CONTACT INFO Via email or MS Teams DATE 03/06/2024 Appendices: Appendix 1: NHS and Local Government Workers Payrates 2023-24 Appendix 2: 2024 04 18 MIJB Midlothian IJB Financial Recovery Action Planning, Performance & Programme_Report Page 120 of 380
Page 121
Appendix 1: NHS and Local Government Workers Payrates 2023-24 NHS Gross Annual Salary (inclusive of employer's cost) Point Band 1 Band 2 Band 3 Band 4 Band 5 Band 6 Band 7 Band 8A Band 8B Band 8C Band 8D Band 9 00 30165 30330 33177 36057 39614 49892 61266 75797 89714 106182 126299 149621 01 30330 33177 36057 39614 49892 61266 75797 89714 106182 126299 149621 02 33042 35905 36057 42414 52145 63654 75797 89714 106182 126299 149621 03 33042 35905 39330 42414 52145 63654 75797 89714 106182 126299 149621 04 33042 35905 39330 49666 52145 63654 75797 89714 106182 126299 149621 05 33042 35905 39330 49666 61071 71467 81922 96058 113909 131759 156155 06 35905 39330 49666 61071 71467 07 49666 61071 71467 08 61071 71467 Page 121 of 380
Page 122
Midlothian Integration Joint Board Page 122 of 380
Page 123
Midlothian Integration Joint Board Thursday 18th April 2024, 14:00-16:00 Midlothian Integration Joint Board Financial Recovery Action: Planning, Performance, and Programme Service Executive summary On 21st March 2024 Midlothian IJB requested Midlothian HSCP review the posts within the Planning, Performance and Programme service previously agreed to be funded by Midlothian IJB. The total investment in this team was £448k annually, and this report presents the three options to either reduce expenditure or rescind investment support. This is one of five Financial Recovery Action Plans to achieve the required financial recovery position. In light of the budget position for 2024/25, the Chief Financial Officer and the Chief Officer met with the Integration Manager on 31st January 2024 to review this position and begin considering a set of recovery options. Work was undertaken to review core funding and establish what recurring resource can be utilised to support this position. Three options are now presented to Midlothian IJB ranging from continued investment at current staffing levels, to the removal of Midlothian IJB investment in this support service. Midlothian IJB currently funds 6.6WTE which is 60% of the service. As part of the 2023/24 HSCP financial recovery planning, the Planning, Performance and Programme service has already offered significant savings comparative to the size of the service. In 2023/24, the Planning, Performance and Programme service has • completed a review of contracts and Service Level Agreements (SLAs), that has resulted in an annual cost avoidance of £70k. • returned £114k in-year to the IJB reserves through a review of previously drawn down reserves for integrated transformation opportunities. • participated in the HSCP financial grip and control review and returned in-year non-recurring savings of £105k, approximately 14.5% of the total annual budget. • reviewed processes and activities to identify and eliminate inefficiencies i.e., process mapping and job planning. Members are asked to: • Consider the benefits and risks associated with the presented options • Determine and agree a position in relation to 2024/25 funding for this service Item number: 5.4 Page 123 of 380
Page 124
Midlothian Integration Joint Board Midlothian Integration Joint Board Midlothian Integration Joint Board Financial Recovery Action: Planning, Performance, and Programme Service 1 Purpose 1.1 This report presents three options to either reduce expenditure or rescind investment support to the Planning, Performance and Programme service as one of five Financial Recovery Action Plans to achieve the required financial recovery position. 2 Recommendations 2.1 As a result of this report, Members are asked to: • consider the benefits and risks associated with the presented options • determine and agree a position in relation to 2024/25 funding for this service 3 Background and main report 3.1 Following the Midlothian IJB on 21st March 2024, Midlothian IJB requested Midlothian HSCP review the posts within the Planning, Performance and Programme service as part of financial recovery. The total investment in this team is currently £448k annually. 3.2 The Planning Performance, and Programme service was established in November 2022. This repatriated a number of posts under one support service to ensure the most effective and efficient delivery of Midlothian IJB statutory duties, strategic planning, and reporting while also supporting a range of planning, performance, and project activity within Midlothian HSCP. 3.3 The Integration Manager leads this service, supports a number of leadership functions within Midlothian HSCP executive team, and has oversight of the strategic planning and associated governance functions of the IJB and HSCP. This is achieved through a networked model of delivery that relies on collaborative cross- system working and input from the performance and programme teams. 3.4 This work includes ensuring the statutory duties of Midlothian IJB as a Public Body are met, providing support to Midlothian IJB members, the coordination and planning of Midlothian IJB business, the coordination of statutory governance alongside the Chief Finance Officer and Standards Officer, managing Midlothian IJB publications, leading and coordinating statutory and locally mandated Page 124 of 380
Page 125
Midlothian Integration Joint Board Midlothian IJB and HSCP planning and reporting, and delivering project-based improvement activity to support Midlothian HSCP service delivery. 3.5 It is not possible to complete this full range of activity without project support and input from specialist posts. Midlothian IJB recognised this in 2021 when it agreed to fund 1.0 WTE of additional analyst support, in 2022 when it agreed to fund 3.0 WTE to advance and develop the ambitions of the Strategic Commissioning Plan, and again in 2023 when it agreed to fund a 0.6 WTE Equalities and Human Rights Lead post. 3.6 On 24th August 2023, Midlothian IJB agreed to fund in total 6.6 WTE within the Planning Performance, and Programme service over 5 years by moving this funding from Midlothian IJBs general reserve to the earmarked reserve. 3.7 The Planning, Performance, and Programme service has already undertaken the following ‘Grip and Control’ actions as part of the 2023/24 HSCP financial recovery planning • reviewed relevant contracts and Service Level Agreements (SLAs), that resulted in an annual cost avoidance of £70k. • returned £114k in-year to the IJB through a review of integrated transformation opportunities. • participated in the HSCP service-wide grip and control review and returned in-year non-recurring savings of £105k, approximately 14.5% of the total annual budget. • reviewed processes and activities to identify and eliminate inefficiencies i.e., process mapping and job planning. 3.8 In light of the budget position for 2024/25, the Chief Financial Officer and the Chief Officer met with the Integration Manager on 31st January 2024 to begin exploring the impact of reduced or rescinded financial support from Midlothian IJB. 3.9 The posts currently funded by Midlothian IJB are detailed in table 1. Table 1: Midlothian IJB financial commitment to Planning, Performance, and Programme Role Band WTE Annual Cost (£k) Cost 5 Years (£k) Programme Manager: Frailty 1 x B8a 1.00 76 379 Programme Manager: Workforce 1x B8a 1.00 76 379 Principal Analyst 1x B7 1.00 71 357 Equality and Human Rights Lead 1x B7 0.60 43 214 Project Team Manager 1x B7 1.00 71 357 Project Manager 1x B6 1.00 61 305 Project Support Manager 1x B5 1.00 50 248 Totals 7 6.60 448 2,241 3.10 Three options are now presented to Midlothian IJB ranging from continued investment at current staffing levels to the removal of Midlothian IJB investment in this support service. Page 125 of 380
Page 126
Midlothian Integration Joint Board 3.11 The four options available to the Midlothian IJB are • Option 1: Reduce expenditure based on natural attrition • Option 2: Reduce funding to Planning, Performance, and Programme • Option 3: Rescind funding to Planning, Performance, and Programme • Option 4: Continue to fund Planning, Performance, and Programme 3.12 Option 1: Reduce expenditure based on natural attrition There are currently 3 vacancies within the Planning, Performance and Programme service detailed in table 2. Recruitment to these vacant posts has been intentionally paused to maximise in-year savings and minimise the impact of future funding decisions. Table 2: currently vacant posts within the Planning, Performance, and Programme service Role Band WTE Annual Cost (£k) Cost 5 Years (£k) Programme Manager: Frailty (secondment until August 2024) 1 x B8a 1.00 76 379 Programme Manager: Workforce 1x B8a 1.00 76 379 Principal Analyst 1x B7 1.00 71 357 Totals 3 3 223 1,115 However, there is a financial risk associated with this option as the postholder for the Programme Manager: Frailty is on secondment and currently due to return to post in August 2025. Additionally, the impact of sustaining reduced capacity by not recruiting to these three posts has significantly increased the workload of the service and, in particular, the workload of the remaining service leadership. This position is not sustainable and, should option 1 be the Boards preferred choice, the HSPC will be required to agree to the reallocation of work which does not require the unique skills of the Planning, Performance and Programme service to other areas within the HSPC. 3.13 Option 2: Reduce funding to Planning, Performance, and Programme This option will require Midlothian IJB to determine if it can continue to provide a reduced amount of funding to this service. It is important to note that this option does not prevent the need for Organisational Change as strategic workforce planning is required to ensure the best mix of skills and competencies will be required alongside more significant reallocation of tasks across the system. In additional to the areas described in option 1, further mitigations would include • considering the ongoing use of funding for other currently vacant posts within the core funding of the service (e.g., the Programme Manager: Digital), • the initiation of Organisational Change to determine the most effective model of support service delivery across all teams within the Planning, Performance, and Programme portfolio. • negotiation with NHS Lothian and Midlothian Council regarding mutual aid for areas of statutory work that are identified as a risk • the cessation of all non-statutory work identified as outwith service capacity Page 126 of 380
Page 127
Midlothian Integration Joint Board The size of any reduction in funding would therefore determine the scope and remit of Organisational Change and influence the future choice of model to best utilise available resource. This option would also require Midlothian HSCP to consider other areas from which to achieve the remaining financial recovery value. 3.14 Option 3: Rescind funding to Planning, Performance, and Programme Should Midlothian IJB consider the preferred option, the cost avoidance over 5 years will be approximately £2.241m. However, this represents the loss of 6.6WTE in capacity which is a 60% loss across the team. As such, this option would require Organisational Change with a wide scope and remit across the HSCP in order to most equitably, effectively, and sustainably achieve the financial recovery value. This would necessitate the inclusion of all support services including Business functions, Admin, and the Service Planning Officers. 3.15 Option 4: Continue to fund Planning, Performance, and Programme Midlothian IJB could chose to continue to fund the Planning, Performance, and Programme service at the current level. This would require Midlothian HSCP to consider other areas from which to achieve the financial recovery value. In this scenario, the service would continue to review skill mix and allocation of workload as part of ongoing strategic workforce planning to ensure the ongoing Best Value from available resource. 3.16 Recommended Option The recommendation is to proceed with Option 2 as the preferred option and for Midlothian IJB to agree an ongoing commitment to the Planning, Performance, and Programme service. 4 Policy Implications 4.1 This report has implications for a range of statutory duties currently undertaken by the Planning, Performance, and Programme service including • IJB Strategic Commissioning Plan • Consultation Statement (published alongside the Strategic Plan) • Housing Statement (published alongside the Strategic Plan) • IJB Joint Strategic Needs Assessment (JSNA) • IJB Directions and Annual Reporting • IJB Annual Performance Report • IJB Equality Outcomes and Mainstreaming Equality Report • IJB Community Engagement Plan • IJB Market Facilitation Plan and the requirement for an associated HSPC Commissioning Strategy • IJB and HSCP Equality Impact Assessments • IJB Scheme of Publication and Information Guide (including all IJB and HSPC published material under the Scheme of Publication, paper and digital, including the website) • IJB and HSCP Public Engagement Statement Page 127 of 380
Page 128
Midlothian Integration Joint Board • IJB and HSPC Integrated Workforce Plan • IJB and HSCP contribution to the Midlothian Community Planning Partnership • IJB connection with the Third Sector (Third Sector Summit) • Progressing the ambitions of the Strategic Commissioning Plan through project-based activity i.e., the upcoming Newbyres Report • IJB and HSCP Freedom of Information (FOI) requests • IJB and HSPC Subject Access Requests (SARs) • HSCP Service Planning Support • HSCP Service Reporting Support 5 Directions 5.1 All three funding options relating to the Planning, Performance, and Programme service will directly impact upon the ability to deliver the following Directions in a way that is proportionate to the funding decision; • Direction 2.1 All services delegated to Midlothian IJB must evidence the connection with communities, partners, and use of technology to improve self-management and self-monitoring, by January 2024 • Direction 3.1 All services delegated to Midlothian IJB will contribute to the IJBs ability to describe activity, experience, and outcomes. Services must use and develop outcome mapping, by January 2024 • Direction 5.1 NHS Lothian and Midlothian Council must ensure that data can be disaggregated by HSCP area in order to support the equitable provision of service offers and support across our communities, minimise disadvantage where possible, meet different needs, and encourage participation. This should include ensuring - systems and data have the capabilities to collect and filter data appropriately by HSCP area and by protected characteristics - health and social care workforce are suitably trained and skilled to gather and input this data, and - data quality assurance, by January 2025 • Direction 5.2 NHS Lothian and Midlothian Council must explore opportunities for integrated system-wide digital solutions and create an action plan of jointly agreed priorities by January 2024 • Direction 8.2 NHS Lothian and Midlothian Council should work in collaboration with Midlothian HSCP to support the delivery of the Midlothian HSCP Integrated Workforce Plan 2022-25. • Direction 9.1 9.1 Maximise opportunities to work collaboratively across Lothian to design an approach and methodology to better understand and evidence the use of the set aside budget and associated services by HSPC area. This should Page 128 of 380
Page 129
Midlothian Integration Joint Board include mechanism to better understand the impact of community prevention and early intervention activity across the whole system. 6 Equalities Implications 6.1 This report does not directly impact on groups of people with protected characteristics. 6.2 However, when strategy plans, information, and services are not designed to be accessible, people get left behind without alternatives. Midlothian IJB will need to consider how it continues to meet statutory requirements without the planned contribution, specialist knowledge and project support capacity of the Planning, Performance and Programme service, and act lawfully in relation to: • Public Sector Equality Duties • Equality Act, 2010 6.3 In this regard, Midlothian IJB must consider its ability to meet statutory duties relating to major service change • Legally If an Integrated Authority cannot adequately show how the voices and needs of the most impacted, vulnerable, or legally protected people in communities have been sought and considered, particularly at the planning phase of the decision, it risks both penalty and legal challenge. Equality Impact Assessments (EIAs) must demonstrate a thorough exploration of potential impacts on communities and use this information to inform decision making. An example of when inadequate consideration to equality resulted in legal challenge being raised is the Scottish Borders Council in relation to the closure of Teviot Day Service, Hawick. • Moral/Ethical All major changes to policy, provision, or planning must involve a thorough exploration of the potential impacts of its proposed action through an Equality Impact Assessment (EIA), Failing to recognise, understand, identify and mitigate any barriers to equality that result from major service change may be considered unlawful discrimination, particularly in relation to people that have a Protected Characteristic or are vulnerable. If the voices of the people and communities are missing from the relevant stages in the process, Midlothian IJB could be considered to be exacerbating disadvantage and reinforcing systemic discrimination that has a negative impact on health inequalities and outcomes. 6.4 The Planning, Performance and Programme service is currently supporting a number of pieces of work involved in Meeting the Accessible Information Standard to ensure the information provide about services is straightforward and easy to access. Meeting the Accessible Information Standards is seen as best practice to help implement the duties in the Equality Act including the duty to ensure that people with disabilities are not unfairly discriminated against. This work includes Page 129 of 380
Page 130
Midlothian Integration Joint Board leading actions to implement improvement recommendations in the recent Care Inspectorate Joint Inspection of Adult Services. 6.5 Failure to make a reasonable adjustment is classed as discrimination and Midlothian IJB must identify, remove, reduce, or prevent barriers for people with disabilities where it is reasonable to do so. Providing information in an accessible format will always be deemed reasonable if not doing so would put someone at a substantial disadvantage. (NHS Lothian Impact Assessment Guidance). • Implementation of the Scheme of Publication Internal Audit have recently completed a review of the Midlothian IJB Scheme of Publication and will shortly be making their report and recommendations available. Provisional feedback indicates this will include a request to ensure the development of a ‘style guide’ for all information publicly available from Midlothian IJB and HPSC. This is to ensure format, content, and style of information is written in a way that can be accessed by everyone. • Improvement actions from the Care inspectorate in relation to the provision of service information Recommended actions require the specialist skills and project capacity of the Planning, Performance, and Programme service to deliver the necessary improvements. • A planned review of the website The Web Content Accessibility Guidelines (WCAG) are being updated in October 2024 and will be the new minimum accessibility standard for all UK public sector websites and mobile apps. From October 2024, services will be monitored for WCAG 2.2 AA compliance. 7 Resource Implications 7.1 This report presents a number of options that seek to achieve Best Value in the context of the financial position for 2024/25. 8 Risk 8.1 Should the Board choose to either reduce or rescind funding to this service, the financial saving cannot be realised immediately. The process to realise the financial savings will require Organisational Change and could involve a range of teams that provide support services. Although Organisational Change is a meaningful process that realises effective change, it is not a quick process and can take several months to conclude. 8.2 Reducing the support available to the IJB provided by the Planning, Performance, and Programme service will result in a risk that the IJB will not meet all of its legislative duties in relation to the delivery of statutory planning and reporting. Non- compliance with some statutory planning and reporting activity would risk an improvement notice, litigation, or penalty e.g., from the Equality and Human Rights Commission (EHRC), or the Information Commissioner’s Office (ICO). Page 130 of 380
Page 131
Midlothian Integration Joint Board 8.3 Any reduction in capacity within the Planning, Performance and Programme service will result in • agreeing the prioritisation of all work that is not a statutory requirement • requesting partner organisations support any key gaps in specialist input as required. 9 Involving people 9.1 This report has been written in collaboration with the Chief Officer, Chief Finance Officer, the Integration Manager, and Finance partners. 10 Background Papers 10.1 None AUTHOR’S NAME Gill Main DESIGNATION Integration Manager CONTACT INFO Via email or MS Teams DATE 07/04/2024 Appendices: None Page 131 of 380
Page 132
Page 132 of 380
Page 133
Midlothian Integration Joint Board Thursday, 20th June 2024 14:00-16:00 Financial Out-turn 2023/24, initial indication of 2024/25 position and financial planning for 2024/25. Executive summary This paper lays out the Midlothian Integration Joint Board’s (IJB) final financial out-turn for 2023/24. In summary the IJB broke even however in order to achieve this position it was obliged to use all of its available reserves. At the IJB’s March 2024 meeting the requirement to use the IJB’s available reserves to break-even in 2023/24 was noted. That said, the underlying out-turn for 2023/24 (before the use of unplanned reserves) was a significant overspend of £6.2m split between £1.8m in the IJB’s health budgets, £0.4m being the costs of the IJB’s strategic planning support (which was agreed to be funded through the reserve) and £4.0m within the social care budgets. It should be noted, however, that the social care position is net of the allocation of further earmarked reserves that were not built into the March 2024 forecast. This paper also considers the early indications of IJB’s financial position in 2024/25 and lays out the plans for further financial reporting in 2024/25 Members are asked to: • Note the final out-turn position including the use of the IJB reserves to achieve break-even. • Note the indicative financial position for month 1 in 2024/25. • Note the plans for further financial reporting for 2024/25 # Item number: 5.8 Page 133 of 380
Page 134
Midlothian Integration Joint Board Midlothian Integration Joint Board Financial Out-turn 2023/24, initial indication of 2024/25 position and financial planning for 2024/25 1 Purpose 1.1 This report sets out the final financial out-turn for the IJB for the financial year 2023/24. The report also provides an initial indication of the month one (April) 2024/25 position and lays out the financial reporting plans for the IJB for 2024/25. 2 Recommendations 2.1 As a result of this report, Members are asked to: • Note the final out-turn position including the use of the IJB reserves to achieve break-even. • Note the indicative financial position for month 1 in 2024/25. • Note the plans for further financial reporting for 2024/25 3 Background and main report Financial Out-turn 2023/24 3.1 At its March 2024 meeting the IJB was presented with a projected financial out-turn for 2023/24. This showed a projected out-turn of c. £6.6m of an overspend with c. £4.0 in the social care budgets and £2.6m within the health budgets. The report noted that the IJB would have to use its available reserves to break-even in 2023/24. 3.2 The IJB’s partners have now made the final 2023/24 position available. This shows an overspend of £6.2m. 3.3 The table below steps through the elements of the position, and lays out that actions that allow the IJB to have a break-even position for 2023/24. Values are (overspends)/Underspends Table 1 - IJB Out-turn 2023/24 £000's Notes Health Services (1,828) 1 Page 134 of 380
Page 135
Midlothian Integration Joint Board IJB Planning Support (413) 2 Social Care Services (3,941) 3 Total Overspend (6,182) Notes: 1. This is the overspend in the IJB’s Health Budgets for 2023/24. It should be noted that this position includes £1.7m of earmarked reserves. Earmarked reserves being funds that the IJB has carried from one financial year to the next to support a range of projects. For the purposes of presentation, earmarked reserves used in year are shown as part of the IJB’s budget. 2. The IJB agreed to provide additional support to its planning and performance team. This was to be funded in year from the general reserve. 3. This is the overspend in the IJB’s social care budgets. This position includes £4.4m of earmarked reserves. As part of the 2024/25 financial plan the use of a significant element of earmarked reserves as non-recurrent support was identified. The underlying social care position has worsened in the final month of the financial year and further earmarked reserves have had to be utilised in order to bring the overspend down to this value. These social care earmarked reserves from Scottish Government investments made at the start of 2022/23 to support social care services. 3.4 The IJB had a general reserve of c. £6.2m, this has now been utilised in its entirety to allow the IJB to break-even in 2023/24. 3.5 A further review of the impact of the 23/24 out-turn on the 2024/25 financial position along with a revised five-year financial plan will be presented to the IJB at its August 2024 meeting. Initial Indication of the 2024/25 financial position. 3.6 Although the IJB’s partners have not, as yet formally reported a month 1 position for 2024/25, indicative management information is available which shows that the IJB is overspent. Revision to the IJB’s Financial Reporting, forecasting and planning. 3.7 In the past the IJB has used the partners’ quarterly reviews to provide a projected financial out-turn position for the current year. Given that these reviews are not available to the IJB until after they have been through the partners own governance then the first quarter’s financial position and out-turn forecast is not reported to the IJB until September. The IJB uses this information and the partners own projected five-year financial plans to produce its own financial plan in December, which is then reviewed over the next quarter and becomes the basis of the IJB’s budget setting in March. 3.8 This worked well as long as the in-year financial position hovered around break- even and at least some additional investments were available for the next financial Page 135 of 380
Page 136
Midlothian Integration Joint Board year. This allowed the IJB to concentrate on its role as a strategic planning body and, in any event, the IJB has no direct governance over the partners operational teams who are delivering the IJB’s services. 3.9 However, in 2024/25 (and thereafter) the IJB’s financial challenges and risk have increased significantly. There is an underlying overspend within the IJB’s budget, most significantly within the social care budgets, and the first element of the 2024/25 financial plan was to deliver a recovery plan to bring these operational budgets back to a break-even position. There have also been a range of additional financial challenges identified in 2024/25 and notwithstanding the additional resources made available by Midlothian Council in their 2024/25 budget offer, the IJB still had to deliver c. £10.1m of recovery actions as part of its 2024/25 budget setting. 3.10 The use of virtually all the IJB reserves (both earmarked and general) to break- even in 2023/24 increased the financial risk for 2024/25. 3.11 Its therefore proposed that a revised financial monitoring and financial planning process be put in place. o At every IJB an indicative in year financial indication will be made available. This will be based on the information available from partners but, given that the financial position will not have been reported to the partners own boards of governance, this will simply be an indication of underspend/overspend. o If the above requires further recovery actions and proposals are available, then these will be presented to the IJB. o The IJB will be presented at its August and September meetings with a revised five-year plan. This will include any further revisions made to their plans by the partners and will include any further financial challenges that are known by the IJB. o A ‘final’ five-year plan will be presented to the IJB at its December meeting along with proposals to manage any future forecast financial pressures. 3.12 The work to ensure that the financial plan maps onto the delivery of the Strategic Plan will be built into the approach above. 4 Policy Implications 4.1 There are no new policy implication in the above paper. 5 Directions 5.1 There are no new directions required by this paper nor revised to those directions already made. 6 Equalities Implications Page 136 of 380
Page 137
Midlothian Integration Joint Board 6.1 There are no equalities implication arising from this paper. 7 Resource Implications 7.1 The resources implications are discussed above. 8 Risk 8.1 The risk of inadequate financial resources being available to the IJB is included in the IJB’s risk register. 9 Involving people 9.1 The IJB holds its meetings in public and makes its papers publicly available. 10 Background Papers 10.1 None AUTHOR’S NAME David King DESIGNATION Interim Chief Finance Officer CONTACT INFO David.king4@nhslothian.scot.nhs.uk DATE June 2024 Appendices: None Page 137 of 380
Page 138
Page 138 of 380
Page 139
Midlothian Integration Joint Board Thursday 20th June 2024, 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 2023/24. Due to the processes required to validate these data, the full reporting year is almost complete for all indicators. 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. It was agreed at the December 2023 Board meeting that the non-validated management data are examined in detail by the Performance Assurance and Governance Group each month. The Performance Assurance and Governance Group met on Thursday 30th May 2024. A review of Performance Assurance and Governance Group (PAGG) meeting dates was completed and revised dates were confirmed, to ensure better alignment with MIJB paper submission dates. Members are asked to: • Note the performance against the IJB Improvement Goals for 2023/24 (Appendix 1). • Note the confirmed new dates for Performance Assurance and Governance Group Meetings for 2024. Item number: 5.9 Page 139 of 380
Page 140
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 2023/24. Due to the processes required to validate these data, the full reporting year is almost complete for all indicators. 2 Recommendations 2.1 As a result of this report, Members are asked to: • Note the performance against the IJB Improvement Goals for 2023/24 (Appendix 1). • Note the confirmed new dates for Performance Assurance and Governance Group Meetings for 2024. 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. 3.5 Members are asked to note that there was an additional delay to the PHS update this quarter. This is due to some Health Boards having been unable to submit the required data to enable the production of the Scottish Morbidity Record. 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 140 of 380
Page 141
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 2023/24 Running Average 2,687 / month The validated data are available up to December 2023. Based on this information, the target is not currently being met. The most recent non-validated management information data indicate an improved position, currently meeting the target. 3.8 Emergency Admissions 2022/23 Target Rate per 100,000 767 / month 2023/24 Running Average 808 / month The validated data are only available up to September 2023. Based on this information, the target is not currently being met. The most recent non-validated management information data indicate that the target is not being met. 3.9 Unplanned Bed Days (Acute) 2022/23 Target Rate per 100,000 5,074 / month 2022/23 Rate 5,174 / month The validated data are only available up to March 2023. Based on this information, the target is not currently being met. The most recent non-validated management information data indicate a further improvement, currently meeting the target. 3.10 Delayed Discharge Occupied Bed Days 2022/23 Target Rate per 100,000 820 / month 2023/24 Running Average 750 / month The validated data are only available up to December 2023. Based on this information, the target is currently being met. The most recent non-validated management information data indicate that the target is not being met. 3.11 End of Life – Percentage of Last Six Months Spent in Large Hospitals 2022/23 Target Rate <8.7% 2021/22 Rate 8% The validated data are only available on a provisional basis for 2022/23. 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% 2021/22 Rate 96.9% The validated data are only available on a provisional basis for 2022/23. 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. Page 141 of 380
Page 142
Midlothian Integration Joint Board 3.13 It was agreed at the December 2023 Board meeting that the non-validated management data are examined in detail by the Performance Assurance and Governance Group each month. 3.14 Members are asked to note the confirmed meeting dates for the Performance Assurance and Governance Group (PAGG) for 2024. This is to ensure improved alignment with IJB paper submission dates. PAGG papers circulated PAGG Meeting IJB papers submission IJB meeting 23 May 30 May 3 June 20 June 26 Jul 8 Aug 5 Aug 22 Aug 5 Sep 12 Sep 30 Sep 17 Oct 14 Nov 21 Nov 2 Dec 19 Dec 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. 6.2 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. 7 Resource Implications 7.1 There will be resource implications resulting from further action to achieve these improvement goals. 8 Risk 8.1 The risk of not finding solutions to address complex performance measurement challenges is that we are underinformed in relation to increases in complexity, acuity and the resulting additional pressures these create for our workforce; and what this may mean for wellbeing, retention and recruitment. Page 142 of 380
Page 143
Midlothian Integration Joint Board 9 Involving people 9.1 The Performance Assurance & Governance Group (PAGG) meet monthly to review and discuss these and other measures as part of wider data assurance. 9.2 Membership of the group will be expanded to ensure increased representation of elected officials, the third sector and public health. 10 Background Papers 10.1 No background papers. AUTHOR’S NAME Elouise Johnstone DESIGNATION Strategic Programme Manager for Performance CONTACT INFO elouise.johnstone@nhslothian.scot.nhs.uk DATE 31st May 2024 Appendices: Appendix 1: Local Intelligence Support Team (LIST) Report describing progress against the IJB improvement goals. Page 143 of 380
Page 144
Page 144 of 380
Page 145
Midlothian HSCP MSG Indicators Performance from April 2019 to December 2023, with 2020/21 MSG targets and trends Local Intelligence Support Team (LIST), May 2024 Page 145 of 380
Page 146
Data Sources 2020/21 MSG Targets • Source: MSG data release v1.66, Apr-24; 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: June 2024 2Page 146 of 380
Page 147
A&E Attendances Source: MSG data release Apr-24; data published up to Dec-23 3 Year Annual Monthly 2020/21 Target Rate (per 100,000) 32,614 2,718 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) 33,147 2,762 2022/23 Rate (per 100,000) 32,462 2,705 2023/24 Running Average (Dec) 2,687 Page 147 of 380
Page 148
Emergency Admissions Source: MSG data release Apr-24; data published up to Sep-23 4 Year Annual Monthly 2020/21 Target Rate (per 100,000) 9,520 793 2019/20 Rate (per 100,000) 10,973 914 2020/21 Rate (per 100,000) 9,221 768 2021/22 Rate (per 100,000) 9,624 802 2022/23 Rate (per 100,000) 8,252 688 2023/24 Running Average (Sep) 808 Page 148 of 380
Page 149
Unplanned Bed Days - Acute Source: MSG data release Apr-24; data published up to Mar-23 5 Year Annual Monthly 2020/21 Target Rate (per 100,000) 62,963 5,247 2019/20 Rate (per 100,000) 64,742 5,395 2020/21 Rate (per 100,000) 57,506 4,792 2021/22 Rate (per 100,000) 57,897 4,825 2022/23 Rate (per 100,000) 62,084 5,174 Page 149 of 380
Page 150
Delayed Discharges Occupied Bed Days (18+) Source: MSG data release Apr-24; data published up to Dec-23 6 Year Annual Monthly 2020/21 Target Rate (per 100,000 18+) 13,886 1,157 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 Rate (per 100,000) 12,227 1,019 2023/24 Running Average (Dec) 765 Page 150 of 380
Page 151
End of Life - Percentage of Last Six Months Spent in Large Hospitals Source: MSG data release Apr-24; data published up to 2021/22 7 Year Annual 2020/21 Target <8.7 2019/2020 9.1 2020/2021 7.5 2021/2022 8 Page 151 of 380
Page 152
Page 152 of 380
Page 153
Midlothian Integration Joint Board Thursday, 20th June 2024, 14:00-16:00 A strengthened approach to prevention across the Lothian health and care system Executive summary The purpose of this report is to set out a strengthened approach to prevention across the Lothian health and care system and recommend that the Midlothian Integration Joint Board supports the recommendations set out in section 7 of the accompanying paper. Prevention is one of the most cost-effective interventions the NHS and wider health and care system can make in relation to improving population health and reducing inequalities. Maintaining a focus on primary, secondary and tertiary prevention is critical in delivering. long-term sustainability and reducing the future burden on the health and care system. The report recommends prioritising actions that improve the conditions in which people work, live and grow, delivered at both a whole population level and targeted at groups at highest risk. To embed prevention, the report prioritises prevention activity in three main areas: • Social determinants of health. • Maternal, children and young people’s health. • Tackling modifiable risk factors and the future burden of disease. Members are asked to: • Note the content of the report. • Endorse the recommendations set out in section 7 of Appendix 1. • Note the actions underway in Midlothian detailed in Appendix 2. Item number: 5.10 Page 153 of 380
Page 154
Midlothian Integration Joint Board Midlothian Integration Joint Board A strengthened approach to prevention across the Lothian health and care system 1 Purpose 1.1 The purpose of this report is to set out a strengthened approach to prevention across the Lothian health and care system and recommend that the Midlothian Integration Joint Board supports the recommendations set out in section 7 of the accompanying paper. 2 Recommendations 2.1 As a result of this report, Members are asked to: • Note the content of the report. • Endorse the recommendations set out in section 7 of Appendix 1. • Note the actions underway in Midlothian detailed in Appendix 2. 3 Background and main report 3.1 Prevention is one of the most cost-effective interventions the NHS and wider health and care system can make in relation to improving population health and reducing inequalities. Maintaining a focus on primary, secondary and tertiary prevention is critical in delivering long-term sustainability and reducing the future burden on the health and care system. 3.2 Delivering against our ambitions to improve population health and narrow inequalities in the current financial environment is challenging. However, it will be important to protect investment in prevention (where there is a demonstrable impact and return on investment in relation to population health outcomes) to minimise the risks associated with short-term financial decisions in terms of population health and inequalities. When making decisions on cost savings, it will be important to consider potential savings in the context of services and treatment that reduce the overall disease burden and look at the long-term gains that could be achieved by protecting investment in prevention activity. 3.3 Cardiovascular diseases, type-2 diabetes, cancers, neurological conditions, falls injuries, common infectious disease and chronic respiratory conditions are likely to Page 154 of 380
Page 155
Midlothian Integration Joint Board contribute the most significant burden on population health. Data also show a high burden from mental health in the working age population. Drug use disorders are a leading cause of ill health in younger cohorts (15-44 years). The data presented in the accompanying paper can be used to prioritise prevention activity for the health and care system, in a bid to reduce the future burden on population health and healthcare services. 3.4 If health outcomes are to improve in Lothian, there needs to be a strong focus on and investment in primary prevention; actions that improve the conditions in which people work, live and grow, delivered at both a whole population level and targeted at groups at highest risk. To embed prevention, the report prioritises prevention activity in three main areas: • Social determinants of health • Maternal, children and young people’s health • Tackling modifiable risk factors and the future burden of disease 3.5 It will be important for the Lothian health and care system to deliver prevention activity that shows impact in the short to medium term, whilst continuing to deliver prevention activity which will require a longer-term commitment. An implementation plan and measurement framework to assess the impact of prevention activity will be required. 4 Policy Implications 4.1 The data and evidence contained in this report can be used to inform and shape the development of local policy and future strategic planning and development. 5 Directions 5.1 This report does not impact on current directions. 6 Equalities Implications 6.1 Data and evidence (including that on health inequalities) were used to inform the approach and recommendations in the report. A full impact assessment will be carried out to inform the development of this work and a high-level prevention action plan. 6.2 Prevention activity which addresses the social determinants of health (including tackling poverty) has been identified as a key priority within the report. 7 Resource Implications Page 155 of 380
Page 156
Midlothian Integration Joint Board 7.1 There are no financial implications which result specifically from this report; however, report recommendations may have implications for future allocation and investment of resources. 8 Risk 8.1 There is a risk that prevention activity is deprioritised in the current financial climate, resulting in a decline in population health outcomes and further increases in health inequalities. 8.2 There is a risk that lack of a consistent approach to prevention activity across the health and care system results in limited improvement to population health outcomes and return on investment. 9 Involving people 9.1 Senior management teams across the health and care system have been, and continue to be, consulted on the strategic approach to prevention. 9.2 This report does not propose specific changes to health and care services and therefore no public consultation was required in its preparation. Any future service changes, made because of recommendations within this report, will be required to adhere to the duty to encourage public involvement. 10 Background Papers 10.1 None. AUTHOR’S NAME Ashley Goodfellow/Jim Sherval DESIGNATION Deputy Director of Public Health/Consultant in Public Health CONTACT INFO Ashley.Goodfellow2@nhs.scot / Jim.Sherval@nhs.scot DATE 20 May 2024 Appendices: Appendix 1: A Strengthened Approach to Prevention across the Lothian health and care system Appendix 2: Local prevention Actions Page 156 of 380
Page 157
1 Appendix 1 A strengthened approach to prevention across the Lothian health and care system 1. Introduction The purpose of this paper is to set out a strengthened approach to prevention across the Lothian health and care system. Prevention is one of the most cost-effective interventions the NHS and wider health and care system can make in relation to improving population health and reducing inequalities. Maintaining a focus on primary, secondary and tertiary prevention is critical in delivering long-term sustainability and reducing the future burden on the health and care system. Delivering against our ambitions to improve population health and narrow inequalities in the current financial environment is challenging. However, it will be important to protect investment in prevention (where there is a demonstrable impact and return on investment in relation to population health outcomes) to minimise the risks associated with short-term financial decisions in terms of population health and inequalities. This paper aims to: • Describe the burden of disease on population outcomes and healthcare services. • Describe why and how the Lothian health and care system should continue to prioritise primary prevention and its wider role in addressing inequalities as an Anchor Institution and community planning partner. • Identify an indicative set of interventions that we should continue to prioritise during this period of financial constraint. 2. Background Life expectancy is falling, with a growing difference in life expectancy between the most and least deprived groups. Additionally, people are spending more of their life in ill health. Population projections estimate that the population served by NHS Lothian will grow by 10.2% between 2018 and 2033 from 898,000 to 989,285 residentsi. Combined with an ageing populationii, multimorbidityiii, unmet healthcare needs exacerbated by COVID-19iv, and staffing pressuresv, there is concern that demand on health and social care services will continue to rise and become increasingly unsustainable. Our health is determined by a complex combination of social and economic factors. Where we live, our work conditions, our housing and education are fundamental building blocks in influencing our health and wellbeing. As Figure 1 below illustrates, healthcare is important, but other factors have a significant impact on health. This means we need to take action as the health and care system to support improvement in wellbeing across the building blocks of health and not focus on healthcare in isolation. Page 157 of 380
Page 158
2 Figure 1. Relative contribution to health from modifiable factors When making decisions on cost savings, it will be important to consider potential savings in the context of services and treatment that reduce the overall disease burden and look at the long-term gains that could be achieved by protecting investment in prevention activity. There are different types of prevention. • Primary prevention stops the problem occurring in the first place and is cost effective, with a median return on investment (ROI) of more than 14:1. It can be 3-4 times more cost-effective than investing in treatment. • Secondary prevention is intervening early, when the problem starts to emerge, to resolve it. • Tertiary prevention is making sure an ongoing problem is well managed to avoid crises and reduce its harmful consequences. There is a growing body of economic evidence that supports the case for investing in public health interventions and prevention. For every £1 invested in secondary and tertiary prevention, the median ROI was £5. For primary prevention interventions the ROI for every £1 invested was £34 for health protection (for example vaccines and immunisation) and £46 for legislative interventions (for example the ban on smoking in public places).vi Audit Scotland highlighted the importance of investing in measures that address the causes of ill-health to reduce long-term demand on the NHS. Investment in primary prevention was identified as giving the best opportunity to make the biggest difference to population health and future demand for services.vii A recent statement from the Royal College of Physicians reported that more than half of UK doctors had seen more patients with ill health over the last three months due to social and economic factors – living in mouldy damp homes, employment, lack of access to healthy food, poor air quality. These factors are significantly contributing to the workload of physicians.viii Page 158 of 380
Page 159
3 3. Burden of disease More than a quarter of all deaths in Scotland are avoidable (i.e., preventable or treatable). As a whole, Scotland’s population is expected to fall by 2043, but the burden of disease is expected to increase by 21% (note, the population of Lothian is not expected to reduce as per national predictions due to net migration). The Scottish Burden of Disease Study forecasts the overall burden to be largest for cardiovascular diseases, cancers, and neurological diseases, accounting for 68% of the total increase in forecasted disease burden. These estimates only account for projected demographic changes and do not factor in changes in disease prevalence and mortality that could occur due to changing risk factor profiles, reduced access to services, or advances in prevention and treatment. Maintaining and sustaining interventions and efforts to mitigate and prevent the underlying causes of these diseases is required to reduce forecasted disease burdens, and their impact on the long-term sustainability of the health and social care system. This section provides an overview of the types of disease that have the greatest impact on population health in Lothian, using data from the Scottish Burden of Disease Study and service data across primary and community services, outpatients, emergency department attendance and hospital inpatient activity. It can be used to assist discussions relating to health service prioritisation. Further data tables and charts can be found in Appendix 2. Years of life lost to disability (YLDs) were selected for the analyses presented here as a proxy for burden on the health system, rather than the social, emotional and economic burden of mortality. YLDs do not incorporate loss of healthy years of life due to death (as is the case for Disability Adjusted Life Years – DALYs). Figure 2 presents the absolute number of years of healthy life lost for the top 5 causes by age group, reflecting the likely activity burden of disease on services. It also highlights that the health service burden is likely to be greatest amongst those currently aged 25-44, which is likely to carry forward as this cohort ages. Page 159 of 380
Page 160
4 Figure 2. Number of years of healthy life lost, top 5 causes by age (both sexes, Lothian, 2019) Source: Scottish Burden of Disease Study Table 1 shows the incidence of the top 25 long-term conditions presenting at general practices in Lothian (based on a sample of 102 practices). Data show the weekly direct contact rate per 1,000 registered patients for the whole general practice team (all clinical staff excluding administrative staff). Direct encounters involve direct contact between clinical staff and a patient, including face-to-face surgery consultations, home visits, telephone consultations, video consultations, clinics and eConsultations that have been recorded on Vision/EMIS. These data highlight clear opportunities for preventative action, not least the range of health conditions affected by modifiable risk factors such as poor diet, low levels of physical activity, smoking, and substance use. Page 160 of 380
Page 161
5 Table 1. Incidence of top 25 long-term conditions presenting at general practices (based on a sample of 102 practices across Lothian) Long-term condition group Lothian Incidence per 100K (2022) Hypertension 714.1 Arthritis/Arthropathy 591.7 Active Cancer 421.2 Diabetes 403.7 Alcohol and substance misuse 348.2 Depression and related disorders 331.5 Asthma 293.0 Ischaemic Heart Disease 283.1 Chronic psychiatric disorders 272.8 Atrial Fibrillation 270.5 Obesity 235.8 Stroke 232.2 Progressive neurological disease 212.5 Chronic Obstructive Pulmonary Disease 211.5 Heart Failure 166.3 Osteoporosis 164.3 Hip fracture 118.5 Peripheral Vascular Disease 73.9 Liver disease 66.6 Bronchiectasis 44.9 Epilepsy 43.8 Inflammatory Bowel Disease 36.3 Pulmonary fibrosis 35.1 Renal disease 26.2 Abdominal Aortic Aneurysm 21.8 Source: LAS Primary Care Multimorbidity Tableau dashboard Figure 3 presents the number of individuals on the Tier 3 dietetics waiting list, by age and SIMD quintile. As this figure presents the absolute number of people waiting, and not percentage, it reflects the underlying demographic distribution of Lothian. However, despite Lothian having disproportionately fewer individuals living in Scotland’s most deprived areas, the absolute number of people waiting in the most deprived 40% (SIMD quintiles 1 and 2) remains where the largest burden on Tier 3 dietetics services is observed. Page 161 of 380
Page 162
6 Figure 3. Number of Lothian population on Tier 3 Dietetics Waiting list (by age and SIMD quintile) Figure 4 provides trends 2018-2023 in the number of NHS Lothian outpatient appointments by speciality (top 5 specialities as of Q2 2023). Figure 4. NHS Lothian trends 2018-2023 in number of outpatient appointments by specialty (top 5 specialties as of Q2 2023) Source: Scottish Health and Social Care Open Data The estimated cost of activity in the outpatient setting by specialty shows the overall highest cost burden is associated with gastroenterology (£24m), clinical radiology (£21m) and ophthalmology (£20m). Highest average cost per activity was in medical oncology (£805). The greatest levels of activity were in clinical radiology (303,479), general psychiatry (245,483) and physiotherapy (199,814). The data includes those who did not attend. Page 162 of 380
Page 163
7 Figure 5 demonstrates the proportion of emergency attendances that were diagnosed with a potentially preventable condition. The number, and proportion, of attendances due to preventable conditions has been increasing since 2019/20 and contributed to 8.3% of all attendances in 2022/23; almost returning to pre-pandemic levels (9.2% in 2018/19). Figure 5. Figure 6 shows the number of admissions with stays over 3 days for potentially preventable conditions, in the last 5 years. The conditions are broadly similar over the last five years and the effect of the pandemic can be seen in reducing longer admissions. However, the number of longer stays due to influenza and pneumonia have increased from pre-pandemic levels. Figure 6. Page 163 of 380
Page 164
8 Figure 7 shows the mean length of stay for conditions with the highest number of potentially preventable admissions. The length of stay is increasing for all displayed conditions after the pandemic, particularly for convulsions and epilepsy. The mean length of stay is highest for congestive heart failure and cellulitis. Figure 7. Note: outliers (length of stay greater than 8.5 days) are removed from this figure Finance estimate costs at individual patient level factoring in staff costs, length of stay and non-pay costs such as medication, food, and building costs. Data is based on primary diagnosis therefore long-term conditions (which may be a focus for prevention activity) are likely to be understated as they tend to be further down the coding line and coding is often incomplete. In 2022/23, diagnoses with the highest total costs included schizophrenia (£26.3m), falls (£24.7m), postpartum haemorrhage (£15m) and atherosclerotic heart disease (£10.4m). Average cost per activity is highest for mental health related conditions such as schizophrenia, dementia and eating disorders. The health needs of patients admitted to hospitals are also becoming more complex. In Scotland, a nationally representative study of almost 1.8 million people derived from electronic primary care records found a multimorbidity prevalence of 24%, with most people over the age of 65 years having multimorbidity.ix This study also found inequalities in multimorbidity across Scotland, with people living in the most deprived areas having higher rates of multimorbidity, with onset 10-15 years earlier, than those living in the least deprived areas. Page 164 of 380
Page 165
9 3.1 Data summary Cardiovascular diseases, type-2 diabetes, cancers, neurological conditions, falls injuries, common infectious disease and chronic respiratory conditions are likely to contribute the most significant burden on population health, and healthcare services. The data presented above can be used to prioritise prevention activity for the health and care system, in a bid to reduce the future burden on population health and healthcare services. Data also show a high burden from mental health and somatic symptoms in the working age population. Drug use disorders are a leading cause of ill health in younger cohorts (15-44 years). There are common disease risk factors associated with many of these conditions – poor diet, inactivity, smoking and alcohol use. There are opportunities to step-up structural interventions that address the availability and accessibility of alcohol and tobacco, the food environment, and the social factors that influence mental ill health. Immunisation programmes remain key to disease prevention, including those which result in prolonged hospital stays. Waiting list data (presented here for tier 3 weight management support) provides a stark illustration of the reason we need to invest more in prevention. The average wait time for tier 3 weight management services in Lothian is >250 days. The data demonstrates inequalities in health and service burden, with disproportionate waits for those in the 40% most deprived communities of Lothian. The data also highlight the challenge of increasing complexity and multimorbidity on services with increasing length of stay for potentially preventable conditions. It is important to understand the underlying reasons for increasing length of stay and this may provide a focus for targeted discharge planning to optimise flow through the acute healthcare system. If health outcomes are to improve in Lothian, there needs to be a strong focus on and investment in primary prevention; actions that improve the conditions in which people work, live and grow, delivered at both a whole population level and targeted at groups at highest risk.x 4. Feedback from Senior Leadership Teams Following presentation of a discussion paper on prevention at the Corporate Management Team, discussion has taken place with the Primary Care Joint Management Group, Acute Senior Management Team, and four HSCP Senior Management Teams (further meetings are planned with the Women’s and Children’s Corporate Management Teams and REAS Senior Management Team). Stakeholders were invited to share thoughts on the proposed approach to strengthening prevention across the Lothian health and care system, as well as identify priority areas for action. A summary of points raised is set out below. • Recognition of the importance of maintaining a focus on prevention, but an acknowledgement that this is challenging in the current financial climate. Page 165 of 380
Page 166
10 • Ensuring alignment with other prevention and early intervention strategies and plans to allow for a co-ordinated system-wide effort. • The need for future projections on population demographics and the burden of disease, to support service planning and to future-proof provision. • A focus on both access to and effectiveness of services, and how we ensure services are aligned to need (proportionate universalism). • Exploring the available evidence of effectiveness in terms of reducing (inappropriate) hospital attendance. Frequent attenders to the emergency department were also cited as an existing pressure on services. • Identifying opportunities for earlier intervention in disease pathways e.g., where is the greatest burden on outpatient services and are there opportunities to intervene earlier? • Ensuring work to tackle overconsumption of alcohol is explicit in prevention plans given the increasing detrimental impact on population health and healthcare services. • Premature frailty and support for healthy ageing. • Obesity and Type-2 diabetes creating pressure on services, and the need to disrupt the increasing trajectory given increasing cost of treatment. • Musculoskeletal conditions and the role of Allied Health Professionals. • Strategic approach to falls prevention. • Future management of long-term conditions e.g., Long-Covid and COPD. • Digital prevention opportunities and support for self-management. • Identifying the barriers to take-up of existing prevention programmes and enabling frontline teams to support patients to access the help available, for example, smoking cessation services. • The importance of healthy places and connected communities in improving population health and reducing health inequalities, including strengthening the role of the third sector in supporting people to take up opportunities to participate in their local community. Page 166 of 380
Page 167
11 5. Embedding prevention 5.1 Social determinants of health NHS Lothian and the four Health and Social Care Partnerships, as public health leaders, should prioritise work on addressing the social determinants of health alongside the direct delivery of healthcare. This includes continuing to deliver and develop work on their role as an Anchor Institution, tackling child poverty, income maximisation and support for the NHS workforce in the current financial climate. People’s health, and inequalities in health between different population groups, are significantly shaped by their access to money and resources, work, housing, transport, the quality of their neighbourhood and surroundings, as well as family, friends and community.xi Without these building blocks, it is harder for our population to live healthy lives. Although these determinants of health are largely shaped outside the Lothian health and care system, there are important roles for public health and strategic planning teams to engage with public, private and community and voluntary sector partners, in a place-based way, to ensure health is considered in wider policy making. NHS Lothian, as an anchor institution, is well placed to positively influence the social, economic and environmental conditions in local communities, thereby impacting on the wider determinants that influence health and wellbeing and ultimately preventing and reducing future ill health. There are also roles that all services can play in ensuring that the social determinants of health are considered as part of both service design, and the ways in which service users are supported to manage their health and wellbeing. Action should be prioritised in the following areas: • Access to money and resources – there is a strong relationship between money, income and wealth, and health outcomes. Taking action to reduce poverty and maximise incomes reduces financial stress and provides people with a standard of living that protects and promotes their health. • Access to and maintenance of employment – employment can have a significant influence on health and wellbeing. In addition to providing sufficient income and social connections, work quality and job security are also important factors which influence health and wellbeing. • Housing – secure, quality and affordable housing is a vital building block for physical and mental health and wellbeing. Spending a high proportion of household income on housing leaves less for other essentials such as food and energy costs. Action on improving housing stability and security, and preventing homelessness, can have a significant positive impact on people’s lives. • Transport – transport provides opportunities for active travel which has a direct positive impact on health. It can also be associated with negative effects such as air pollution. Transport supports other building blocks of health, by providing access to public services and employment. • Neighbourhood and surroundings – the environment in which people live can have a significant impact on health and health inequalities. Acting on, and increasing community resilience to, climate change can protect people from the effects of severe weather, infectious disease and other health impacts of climate changes. Working to address the Page 167 of 380
Page 168
12 commercial determinants of health can reduce the availability, accessibility and affordability of health-harming products such as alcohol, tobacco and food and drinks high in fat, sugar and salt. Local planning policy, and considering use of land and assets, can provide opportunities to improve population health, for example by increasing access to greenspace. • Family, friends and community – social relationships are important for health and wellbeing, and can reduce loneliness, reduce stress responses and influence healthy behaviours. Connecting with people in local communities and feeling safe can also influence health. Appendix 3 highlights detailed actions that can be taken within the Lothian health and care system on the social determinants of health, as well as other work that needs to be undertaken in partnership with wider stakeholders. 5.2 Maternal, children and young people’s health As the chances of lifelong health, wellbeing, illness and disease begin to accumulate even before conception, primary prevention that supports women pre-conception and children in their early years can lay the best foundation for future healthxii. The early years is the period of life when interventions to disrupt inequalities are most effective. Interventions in the early years have been shown to be cost-effective and yield significant return on investment. Research shows that high-quality birth-to-five programmes for disadvantaged children can deliver a 13% annual return on investment.xiii Therefore, it is important that protecting maternal and children’s services is a priority focus of future decision making. This should include working collaboratively with community planning partners to maintain a system wide focus on early years and children. Protecting investment in early years services will deliver better outcomes in education, health, social behaviours, and employment in the long term. It is essential for maximising future population health. Action should be prioritised in the following areas: • Child poverty – prevention of child poverty will improve the health of children and families and reduce health inequalities. • Access to long-acting reversible contraception (LARC) – ensuring accessibility of effective contraception (such as LARC) is proportionate to need, will contribute to reduced inequalities in unintended pregnancy and the associated personal and economic costs. • Smoking in pregnancy - reducing smoking prevalence among pregnant women has the potential for significant population health benefit, by reducing risk of still-birth, premature birth, low birthweight and other negative maternal and child health outcomes. • Perinatal, infant, children and young people’s mental health and wellbeing - good mental health support at an early age can protect and promote future mental wellbeing and resilience. Providing services that identify and treat perinatal mental health problems early and effectively leads to considerably better outcomes for women, babies, and families, and makes economic sense. • Infant feeding – breastfeeding protects both maternal and infant health from a range of diseases and infections and supports the mother-baby relationship and mental health Page 168 of 380
Page 169
13 and wellbeing. Breastfeeding results in fewer hospital admissions and GP consultations, contributing savings to the NHS. • Child development - problems with early child development are important as they are strongly associated with long-term health, educational, and wider social difficulties. Detecting developmental problems early provides the best opportunity to support children and families to improve outcomes, and ensure children are ready to learn. Appendix 3 highlights detailed actions that can be taken by the Lothian health and care system to protect and improve maternal, children and young people’s health. 5.3 Tackling modifiable risk factors and the future burden of disease For healthcare settings there is evidence to continue supporting interventions that tackle modifiable risk factors including smoking, alcohol and obesity and a continued focus on services that tackle respiratory, diabetes and cardiovascular conditions. These should be delivered alongside screening and immunisation programmes as part of an effective prevention plan. A range of public health programmes are already offered on a universal or targeted basis across Lothian. There is an opportunity to further explore how these offers are better linked to the scheduled or unscheduled care touch points that people already have with our services. This can be particularly important for certain population groups, including groups sometimes referred to as 'inclusion health groups', who may be more likely to present in an unscheduled way, as well as those who are supported by specialist services. Action should be prioritised in the following areas: • Hospital-based income maximisation services – patients’ income problems can impact the health and care system by resulting in delayed discharges, inappropriate use of clinical staff time, and increased recovery period and risk of readmission. Provision of hospital-based income maximisation services results in increased financial gain for patients. • Smoking cessation – smoking causes significant harm to individuals, families, the NHS and the economy. Smoking prevalence is significantly patterned by socioeconomic position. Referrals by health professionals of people who actively want to stop smoking have high chances of a successful quit, so ensuring pathways to smoking cessation are clear and effective is essential. • Cardiovascular disease - cardiovascular disease caused the greatest burden of disease in NHS Lothian and across Scotland in the Scottish Burden of Disease study, 2019.xiv Prevention has a key role in tackling the health burden from cardiovascular disease and opportunities to strengthen preventative action across cardiovascular pathways should be explored. • Type 2 diabetes – type 2 diabetes is affecting an increasing number of individuals, families and communities because of increasing levels of obesity and an ageing population. It is a condition that, for many people, could be prevented, or diagnosis delayed. Obesity, the main modifiable risk factor for type 2 diabetes, is a complex issue and is rooted in inequalities. Population-level approaches are required to disrupt the current upward trajectory for type 2 diabetes. Page 169 of 380
Page 170
14 • Immunisation - immunisation is the most cost-effective intervention for saving lives and improving the health of the population. Immunisations help protect the population against serious vaccine preventable illness. Concerted effort is required to improve, and reduce inequalities in, uptake of vaccinations. • Screening - national screening programmes are evidence based and can identify individuals who may be at future risk of a particular medical condition or disease or detect early indications of disease or conditions with the aim of intervening to reduce their risk. Screening uptake needs to be maximised to ensure programmes are effective and efficient, and to maximise population health gain. • Falls prevention - falls are estimated to cost the NHS more than £2.3bn per year. Morbidity from hip fracture contributes to the demand on health and social care services. Given the ageing population, this burden is likely to increase further over the coming years. Implementation of evidence-based interventions can be effective in preventing and reducing future risk of falls. Appendix 3 highlights detailed actions that can be taken within the Lothian health and care system to tackle the future burden of disease. 6. Implementation Consideration is required on how best to implement a more strategic approach to prevention activity, and how this is monitored and evaluated. ‘Implementation gaps’ in prevention activity often exist because uptake of existing programmes is too low, capacity to deliver stated ambitions is insufficient, prevention activity is underfunded, and investment is focused on short-term goals.xv It is important that implementation considers the above, and that prevention activity is integrated with the Lothian health and care system strategy (Lothian Strategic Development Framework) and the work of the established Programme Boards. A national population health strategy is under development and due to be published in Autumn 2024. It is important that Lothian’s approach to prevention is responsive to this national plan. An Integrated Impact Assessment is required on Lothian’s prevention plan to ensure it delivers for everyone who needs support, tackles health inequalities and promotes and furthers children’s rights. This will allow prevention activity to be targeted, where appropriate, to improve outcomes within available resources, as has been the case with recent decisions about prioritisation of insulin pump therapy for those with type 1 diabetes. It will be important for the Lothian health and care system to deliver prevention activity that shows impact in the short to medium term, whilst continuing to deliver prevention activity which will require a longer term commitment. A measurement framework to assess impact of prevention activity will be developed. Page 170 of 380
Page 171
15 7. Recommendations for the health and care system 1. NHS Lothian should use the data and evidence in this paper (and in Appendix 2) to inform forthcoming Integrated Impact Assessments that are being undertaken where reductions in healthcare are being considered, to ensure that those areas which would have the greatest impact on future population health outcomes are prioritised over other areas, acknowledging that reductions in healthcare provision do not have equal impact across the population. 2. NHS Lothian should continue its commitment to becoming an Anchor Institution with population health at the heart of the Lothian Strategic Development Framework. 3. Public health in Lothian should increase the pace of its activity with Community Planning Partnerships to take forward the interventions identified to address the social determinants of health as outlined in Appendix 3. 4. The four Integrated Joint Boards in Lothian should ensure that the evidence and data contained in this paper are incorporated into their current strategic plans and inform future planning and development. 5. Public health should work collaboratively with Acute and primary care services to ensure clinical staff can easily refer those who need non-clinical support to the appropriate service, thereby maximising use of existing prevention programmes such as income maximisation, smoking cessation, immunisation and screening. 6. NHS Lothian and the four health and social care partnerships should, where possible, protect and increase efforts to improve maternal, children and young people’s health, as the best investment to maximise future population health. 7. The Realistic Medicine Board and Public Health should consider how it can strengthen prevention across cardiovascular disease pathways, including type 2 diabetes. 8. The health and care system should consider and agree how it continues to integrate prevention activity within the Lothian health and care system strategy and set out how it will measure impact of prevention activity over the short, medium and longer term. Ashley Goodfellow Deputy Director of Public Health 11 April 2024 Acknowledgements With thanks to public health colleagues who helped draft this report and colleagues in Public Health Scotland for reference papers on Prevention and Prioritisation, and long-acting reversible contraception use in Scotland. Page 171 of 380
Page 172
16 References i Population Projections for Scottish Areas (2018-based) | National Records of Scotland (nrscotland.gov.uk) ii Scotland's Census 2022 - Rounded population estimates | Scotland's Census (scotlandscensus.gov.uk) iii Scotland’s Health and Demographic Profile (www.gov.scot) iv Chapter 3: Health inequalities: Turning the Tide - Realistic Medicine - Doing the right thing: Chief Medical Officer annual report 2022 to 2023 - gov.scot (www.gov.scot) v NHS in Scotland 2022 (audit-scotland.gov.uk) vi Public health approach to prevention and the role of NHSScotland (publichealthscotland.scot) vii Audit Scotland. NHS in Scotland 2023. NHS in Scotland 2023 | Audit Scotland (audit- scotland.gov.uk) viii More than half of UK doctors seeing more patients with illness due to avoidable social harms | Royal College of Physicians of Edinburgh (rcpe.ac.uk) ix Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. (2012). Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross- sectional study. Lancet; 380(9836): 37-43. x public-health-approach-to-prevention-and-the-role-of-nhsscotland.pdf xi Evidence hub: What drives health inequalities? - The Health Foundation xii rcpch_prevention_vision_for_child_health_-_june_2019.pdf xiii FAQ for The Lifecycle Benefits of an Influential Early Childhood Program - The Heckman Equation xiv Scottish Burden of Disease study. Public Health Scotland. Available at: www.scotpho.org.uk/comparative-health/burden-of-disease/overview xv Office for Health Economics. Reimagining Prevention for a Healthier, More Prosperous Society. Reimagining-Prevention-Whitepaper-OHE.pdf Page 172 of 380
Page 173
1 Appendix 2 Embedding Prevention: Recommended actions for the health and care system – response to indicative actions Date: May 2024 This appendix sets out an initial response from a Midlothian perspective to the challenges set out in the paper to NHS Lothian Board meeting 24th April 2024 on strengthening our approach to prevention. Below are the recommended actions from the NHS Board paper and an initial response outlining action being taken or planned currently in Midlothian by the HSCP public health practitioners, the Public Health Directorate Partnership and Place team as well as other colleagues in the Health and Social Care Partnership and beyond. Social Determinants of health Access to money and resources - There is a strong relationship between money, income and wealth, and health outcomes. Taking action to reduce poverty and maximise incomes reduces financial stress and provides people with a standard of living that protects and promotes their health. Reduce stigma surrounding issues of financial wellbeing, to ensure that all frontline staff feel comfortable asking service users about financial wellbeing and knowledgeable to signpost or refer to relevant sources of support. HSCP Welfare Rights Team Provision of advice at Midlothian Community Hospital. Income Max/ Welfare advice review completed May 24 looking at equitable access to support across the life-course. Next step involves implementation plan which includes staff training and trauma informed delivery (Strategic Poverty Group). Invest to ensure there is good access to specialist welfare and debt advice across Lothian, including in locations that are easily accessible to those with high levels of need, such as schools, community venues, and primary care practices as well as acute health settings. Income Max/ Welfare advice review (as above) Ensure that where crisis support is offered (including support with access to emergency food) this is linked to longer term support to reduce the chance of that individual or family remaining in or returning to crisis. Income Max/ Welfare advice review (as above) Whole Systems Approach to Type II Diabetes in Mayfield and Easthouses is piloting a way to increase pantry membership through food bank referrals. Jac Kirkland and Amie Willson leading. Page 173 of 380
Page 174
2 Develop and embed referral pathways so that those in greatest need of support can be linked to it, rather than expecting them to navigate a complex system to access available resources. Income Max/ Welfare advice review (as above) Health Inclusion Team (known as the HIT team) within Midlothian HSCP is managed by public health practitioner and works in an outreach capacity with vulnerable communities to help navigate the health and care system. Access to and maintenance of employment - Employment can have a significant influence on health and wellbeing. In addition to providing sufficient income and social connections, work quality and job security are also important factors which influence health and wellbeing. Support local people from diverse backgrounds to access careers in health and social care, including through specific volunteering and training opportunities and employability programmes. HSCP Employability scoping completed and recommendations going to SPG May 2024. Fiona Kennedy & Becky Hilton leading. Support changes to our recruitment system to attract and support applicants from a wider range of backgrounds. HSCP Employability scoping completed and recommendations to SPG May 2024. Fiona Kennedy & Becky Hilton leading. Linked to work in the Learning and Development team co-ordinated by Anthea Fraser. Support people from a range of backgrounds and a range of needs including disability and caring responsibilities to remain in employment through the use of reasonable adjustments. Ensure that our local commissioning contributes to community benefits, including increased local employment. Recognise the importance of childcare, housing and other factors as a determinant of people’s ability to access and remain in employment, consider actions to improve this, including potential availability of land and assets for housing and childcare provision as well as potential joint recruitment to roles such as childcare and construction that are needed to enable more local people to work in health and social care. Actions contained in the Child Poverty Plan re reducing the cost of childcare actions in the Strategic Poverty Plan (Single Midlothian Plan) relating to these. We are currently not directly involved. Housing - Secure, quality and affordable housing is a vital building block for physical and mental health and wellbeing. Spending a high proportion of household income on housing leaves less for other essentials such as food and energy costs. Action on improving housing stability and security, and preventing homelessness, can have a significant positive impact on people’s lives. Page 174 of 380
Page 175
3 Recognise the importance of affordable, quality and stable home environments, work with community planning partners to • advocate for an increase in the proportion of housing available for social rent • identify partnership opportunities where NHS land and assets might contribute to provision of quality, affordable home building programmes, where disposal of land can both support housing and achieve income for NHS Lothian Housing as a determinant of health raised through public health involvement in the Local Development Plan – Evidence Report will be submitted to Scottish Govt in July. Ensure that frontline staff feel comfortable and knowledgeable to ‘ask and act’ in line with the forthcoming homelessness prevention duty, to identify and refer for support service users at potential risk of homelessness ML HSCP Public Health Practitioner in early stages of building a prevention group around reducing the risk of homelessness and the proposed Housing Bill in the Scottish Parliament. Improve preventative discharge planning to reduce the number of people who spend longer in hospital than required because of a lack of timely availability of suitable (including adapted) housing University of Edinburgh Public Health Masters student dissertation to help the HSCP look at the implications of the proposed duty to ask and act to prevent homelessness. This includes potential duties relating to hospital discharge where someone is at risk of homelessness. Work with the health and homelessness steering group (Ruth Flynn and Becky Hilton) Use population and disease projections to influence the design and development of future housing supply that will meet the needs of an aging population to enable them to live independently for longer. Partnership and Place Team and HSCP Planning and Performance Team contributed to the evidence gathering stage for Midlothian LPD2 – Evidence Report will be submitted to Scottish Govt in July Transport - Transport provides opportunities for active travel which has a direct positive impact on health. It can also be associated with negative effects such as air pollution. Transport supports other building blocks of health, by providing access to public services and employment Recognise the impact that affordable, healthy transport has on individuals’ ability to stay healthy and access a range of local services (including health services) and ensuring that we design services to be located close to where people live, or be digitally inclusive, to reduce the need for people to travel, as well as working with local authority colleagues to ensure sustainable transport options are provided and promoted in relation to access to our service. Supported the evidence gathering stage of Midlothian LPD2 – Evidence Report will be submitted to Scottish Govt in July (Becky Hilton & Jim Sherval). Page 175 of 380
Page 176
4 Recognise the impact that unsustainable travel behaviours can have on others’ health, including through air and noise pollution and road danger (which can therefore decrease participation in active travel) as well as wider impacts on greenhouse gas emissions and climate change and commit to reduce the proportion of staff who travel by unsustainable means. Consider the transport impact of the goods and services we procure. Neighbourhood and surroundings - The environment in which people live can have a significant impact on health and health inequalities. Acting on, and increasing community resilience to, climate change can protect people from the effects of severe weather, infectious disease and other health impacts of climate changes. Working to address the commercial determinants of health can reduce the availability, accessibility and affordability of health-harming products such as alcohol, tobacco and food and drinks high in fat, sugar and salt. Local planning policy, and considering use of land and assets, can provide opportunities to improve population health, for example by increasing access to greenspace. Recognise that the environments in which we live have a significant impact on our health and that the greatest emerging threat to heath and health inequalities is climate change and taking action, in line with the NHS Scotland Climate Emergency and Sustainability Strategy, to o reduce the greenhouse gas emissions associated with the provision of and access to health and care services, and o support the resilience of our communities, services and estate against extreme weather, infectious disease and other health impacts of climate change. Green health prescribing in Midlothian is well established and is currently linking to our CPP Greener group. Supported by Public Health Practitioner Supported the evidence gathering stage of Midlothian LPD2– Evidence Report will be submitted to Scottish Govt in July. Recognise the commercial determinants of health and take action to influence national policy in relation to alcohol, tobacco, gambling and food high in sugar salt and fat, as well as reducing local exposure to harmful commodities by influencing licensing, advertising, and implementing other policies such as Smoke Free Places and Good Food Nation. Scrutiny of alcohol licensing applications by Partnership and Place Team Whole Systems Approach to type II diabetes – Using the 7 levers reports as a tool to influence Community Planning Partnership around actions on obesity. Co-led by ML Public Health Practitioners and Partnership and Place Team. Page 176 of 380
Page 177
5 Taking local action to influence the built environment, including by influencing Local Development Plans and considering the way we use our own land and assets to support people to live healthy lives. Supported the evidence gathering stage of Midlothian LPD2. Evidence Report will be submitted to Scottish Govt in July. Family, Friends and Community - Social relationships are important for health and wellbeing, and can reduce loneliness, reduce stress responses and influence healthy behaviours. Connecting with people in local communities and feeling safe can also influence health. Ensure that through Community Planning Partnership work we invest in the development of resilient communities, both place-based and communities of interest, including ensuring that physical and digital spaces and other community resources are available to support residents to interact, support each other and live well, and that staff promote the use of these resources as part of people’s care Integrated working with each CPP theme to ensure a Public Health lens Ensure that as part of Realistic Medicine, individuals who use health and care services are, where appropriate, invited and supported to include their friends, family and communities in developing a personalised approach to living well and having their health and care needs met HIT team using ‘what matters to you’ principles to ensure person centred care and ensures feedback and views of lived experience shape the service. Lived experience is crucial to HSCP services and public health practitioners advocate for this in groups such as Community Justice, suicide prevention and MELDAP. Ensure that, in line with Scotland’s commitment to trauma informed practice, we develop and deliver services in a way that supports our service users and staff to have good conversations and safe relationships, as a key part of patient centred care. PHPs contribute to trauma informed group and help develop actions. Maternal, children and young people’s health - Prevention of child poverty will improve the health of children and families and reduce health inequalities. In implementing the Anchor Institution approach particular focus should be on ensuring that reducing child poverty and action on priority families (those most at risk of poverty) continues to be a priority for the Lothian health and care system. This should be part of an ongoing commitment to support Local Child Poverty Action Reports. Prioritise child poverty at senior level and include explicitly in strategic plans. Public Health sit on the Strategic Poverty CPP group and Cost of Living Taskforce and Child Poverty Working Group. Partnership & Place team have a lead child poverty role in partnership with a lead from Midlothian Page 177 of 380
Page 178
6 Council. Partnership & Place team support the implementation of the child poverty plan, some actions are in partnership with HSCP e.g. review of income max. Ensure reducing child poverty across priority groups is a priority outcome in anchor institution activity Employability Scoping Exercise and Income Max/ Welfare advice review (see above) Embed financial wellbeing pathways for pregnant women and families with children. Partnership & Place lead child poverty actions to improve the referral pathway between maternity/early years services and income max/welfare rights – working with Rachel Marples Increase awareness and understanding across frontline health and social care staff, including how to act on child poverty in their roles Partnership & Place lead child poverty actions to increase awareness and confidence among health and social care staff to identify poverty and refer for income max/welfare rights support (Amie Willson leading) Continuing to influence in the partnership space to ensure prevention of poverty is a priority across community planning activity Public health sit on the Strategic Poverty CPP group and Cost of Living Taskforce and Child Poverty Working Group. Partnership & Place team have a lead child poverty role in partnership with a lead from Midlothian Council. Long-acting reversible contraception - Optimising access to contraception services is an important action that health boards can take to support the prevention of unintended pregnancy and reduce the associated personal and economic costs. LARC is the most effective form of contraception. There was almost a five-fold increase in abortion rates in Scotland between 2021 and 2022. Long-acting reversible contraception (LARC) prescription rates fell by more than 40% in 2020 and have not yet fully recovered. Rates of abortion rose in most age groups and all SIMD quintiles, although they are highest in the most deprived areas. Ensuring accessibility of LARC services are proportionate to need will contribute to reduced inequalities in unintended pregnancy rates. The cost of early medical abortion at home and early surgical abortion is 2.5 and 4 times as much, respectively, as LARC.1 Health board areas with higher uptakes of LARC generally have lower abortion rates. Increased provision of LARC would be expected to lead to savings in the provision of abortion services. A UK economic analysis showed that for a population of 1000 women, initiation of LARC (even if not continued for five years) prevents on average an additional 47 unintended pregnancies per year at an annual net cost saving of over £51,000 compared with use of the combined oral contraceptive pill.2 1 https://www.bpas.org/abortion-care/considering-abortion/prices/ 2 Mavranezouli I, Wilkinson C. Long-acting reversible contraceptives: not only effective, but also a cost-effective option for the NHS. JFPRHC 2006;32 (1): 3-5. Page 178 of 380
Page 179
7 In Lothian, LARC is largely delivered in primary care, where a significant number of General Practitioners and Nurse Practitioners have been trained to fit LARC, and a Local Enhanced Service (LES) is in place. There are challenges with the current LES arrangements including increasing demand, a reduction in the number of trained practitioners who can fit LARC and accessing training. The challenges in primary care have a knock-on impact on Lothian Sexual Health Services, whereby increasing capacity to provide LARC could impact other services or reduce capacity to provide training to other practitioners. LARC uptake is determined by both patient preference and accessibility. NHS Lothian should take action to improve and ensure equity of access to LARC to optimise the prevention of unintended pregnancy. HIT Nurse runs sexual health clinic from No11 and can support conversation about LARC however cannot provide. HIT nurses in general do provide contraception advice and guidance. Partnership & Place team have worked across primary care, youth work, Healthy Respect and Education to create better connections and to address a number the findings of last year’s public health Master student on improving access to sexual health support and advice for young people. Smoking in Pregnancy - Smoking is a major risk factor for still-births, premature births, low birthweight and other negative maternal and child health outcomes. Reducing smoking prevalence among pregnant women has the potential for significant population health benefit. In Lothian, however, the number of pregnant women trying to quit is lower than the average for Scotland and successful quit rates are the lowest in Scotland.3 It is essential that staff working in antenatal and postnatal settings are aware of the specialist support available to help pregnant women (and other members of their household) stop smoking. During 2024-25, enhanced maternity smoking cessation support will be available for patients via all community midwifery teams in Lothian. Quit Your Way staff in Lothian have undertaken specialist training and all referrals from maternity services will be prioritised for support by practitioners. Midwifery teams need to be supported to: • Complete the short training module developed to support referral to Quit Your Way. • Record CO monitoring results during the antenatal booking appointment so that there is an accurate record of smoking status. Midlothian is the demonstrator site for this work. We have a dedicated advisor in Quit Your Way for women who smoke during pregnancy and the learning will be rolled out across Lothian (Amie Willson PH connection). 3 Public Health Scotland, NHS Stop Smoking Services, Scotland 2022/23. 2024, Public Health Scotland: Edinburgh. Page 179 of 380
Page 180
8 Make referrals to smoking cessation support for women who express a desire to quit. Perinatal, infant, children and young people’s mental health and wellbeing - Perinatal mental health problems affect at least 1 in 5 women. One in 20 will experience severe or complex issues requiring specialist care. Undetected and untreated, perinatal mental health problems can have a devastating effect on women, their babies, and the wider family network. Rates of maternal suicide are high, and it remains a leading cause of death during the perinatal period. The financial cost is significant; in 2014, untreated perinatal mental health problems were calculated to cost the UK up to £8.1 billion for each yearly group of births. Identifying and treating perinatal mental health problems early and effectively leads to considerably better outcomes for women, babies, and families and makes economic sense.4 Mothers with certain circumstances and characteristics are known to be at a higher risk of suffering mental illness during the perinatal period, including mothers from black and minority ethnic communities, young mothers, single mothers, and those experiencing domestic abuse, poverty and addiction. Improving the mental health and wellbeing of children and young people should be seen within the context of wider social inequalities and the families and communities in which children live. Good mental health support at an early age can protect and promote future mental wellbeing and resilience. Half of adult mental health problems start before the age of 14 and 75% start before the age of 24.5 The Lothian health and care system should continue to invest in and support delivery of high-quality, population-based specialist mental health services, and the continued roll out of a Lothian-wide specialist infant mental health service, currently being piloted in two geographical areas (South Edinburgh and Midlothian). Partnership & Place team sit on the Children and Young People Mental Health CPP Group to provide a public health lens The perinatal and infant mental health training programme should be embedded in agreed staff and service training plans. This includes a sustainable Solihull Approach, with a viable trainer cohort, rolling training programme and an embedded approach to use. 4 https://maternalmentalhealthalliance.org/media/filer_public/fc/07/fc07914b-45f1-449f-8daa-6325d746bec8/mmha-pimhs-briefing-perinatal-mental-health-scotland-feb24.pdf 5 Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005; 62(6):593-602. Page 180 of 380
Page 181
9 Establish Single Points of Access in each of the four partnership areas to ensure children and young people have timely access to appropriate emotional, mental health, and wellbeing support. Partnership & Place team sit on the Children and Young People Mental Health CPP Group to provide a PH lens. Project manager to start next month to bring momentum to developing a single point of access. Ensure professionals are appropriately trained and equipped to deliver services in a trauma-informed way Trauma informed training coordinator Continue to focus on prevention activity through Children’s Services Partnership structures, including work to address child poverty. Partnership & Place team sit on most CPP GIRFEC Groups to provide a public health perspective and are actively involved in several workstreams including a lead role in tackling child poverty. Infant Feeding - Increasing breastfeeding duration supports both the family and the NHS. Research has shown, if 45% of babies were exclusively breastfed for 4 months and 75% of neonatal babies were breastfed on discharge, then GP consultations and hospital admissions could be reduced, as follows: • Gastroenteritis - 10,000 fewer GP consultations and 3000 hospital admissions saving £3.6 million. • Respiratory - 22,000 fewer GP consultations and 6000 hospital admission saving £6.7million. • Ear infections - 21,000 fewer GP consultations saving £750,000. • NEC - 361 fewer cases, saving £6million. • Increasing breastfeeding supports could reduce childhood obesity by 5% saving £1.6million. Increasing breastfeeding rates also supports mothers. If half the mothers who currently aren't breastfeeding were supported to do so, breast cancer rates would be reduced saving £21 million.6 The Lothian health and care system should continue to work towards UNICEF Baby Friendly Initiative Sustainability by working with Baby Friendly Guardians Public Health should sustain and explore how it can expand the Delivering Early Breastfeeding Support project in other areas where breastfeeding drop off rates are higher Whole Systems Approach to Type II diabetes in Mayfield and Easthouses includes work to reduce drop off rates led by Amie Wilson in Partnership and Place Team Public Health should support the continued expansion of the HENRY (Health, Exercise and Nutrition for the Really Young) programme in conjunction with NES Whole Systems Approach to Type II diabetes in Mayfield and Easthouses - increasing HENRY Practitioners is an action and the WSA project has provided some funding for training for this. 6 Renfrew, M. J., Pokhrel, S., Quigley, M., McCormick, F., Fox-Rushby, J., Dodds, R., Duffy, S., Trueman, P., & Williams, A. (2012). Preventing disease and saving resources: the potential contribution of increasing breastfeeding rates in the UK. UNICEF UK. http://www.unicef.org.uk/Documents/Baby_Friendly/Research/Preventing_disease_saving_resources.pdf?epslanguage=en Page 181 of 380
Page 182
10 The health and care system should ensure all of its premises are Breastfeeding Friendly Partnership & Place team have been joint working with Maternal and Infant Nutrition Team (MIN) and community partners to ensure this (Amie Willson) Child Development - Early child development is influenced by both biological and environmental factors. Problems with early child development are important as they are strongly associated with long-term health, educational, and wider social difficulties. Detecting developmental problems early provides the best opportunity to support children and families to improve outcomes. There is good evidence that parenting support and enriched early learning opportunities can improve outcomes for children with, or at risk of, developmental delay. Child health, development and wellbeing is supported from pre-birth to pre-school through GIRFEC principles and strengths-based approaches, the Universal Health Visiting Pathway, Family Nurse Partnership, early learning and childcare, and multiagency family support services. Early identification of developmental concerns (such as speech, language and communication skills or emotional and behavioural development) allows practitioners to target interventions and support transitions to early learning and school in those who need it most, to reduce inequalities in early years development and future educational outcomes. Covid-19 containment measures have widened inequalities in early years development and educational attainment. Prior to 2019/20, positive progress had been observed across Lothian with reductions in the proportion of 27–30-month reviews identifying developmental concerns (from 18% of reviews in Lothian in 2013/14 down to 11% in 2018/19). From 2019/20 onwards, however, this progress stalled with slight increases across Lothian in the proportion of reviews identifying developmental concerns to over 13% in 2021/22. For each local authority area, developmental concerns pertaining to speech and language are most frequently identified, with the highest rate in West Lothian at 14%. There is a steep socioeconomic gradient in developmental concerns, particularly for speech and language development, with 16% of those living in the most deprived areas (SIMD 1) having a speech and language concern raised, compared to 5% in the least deprived areas (SIMD 10). Continue work to maximise coverage of the Universal Health Visiting Pathway, ensuring anticipatory care is delivered based on need using developmental concerns aggregated data, resulting in improved outcomes for the most deprived families Midlothian and Lothian lead the way for pathway delivery in Scotland. Data enables a focused approach to local concerns. QI initiatives improve data recording and reporting. Midlothian HSCP is delivering on the 12 priorities from the Integrated Children's Services Plan which includes improving both the Local Authority's ability to plan appropriately, and the experiences for children and young people at all transition points, particularly for children with additional support needs. This is particularly pertinent for Midlothian which is experiencing an unprecedented number of New to Area families, Page 182 of 380
Page 183
11 who until the point of arrival are unknown to local health and educational providers. Consider what further action is required to embed a whole system approach to speech, language and communication development, to ensure children’s early language development can be supported and improved Partnership working is underway to ensure local initiatives are in place to address the increase in developmental concerns particularly around speech and language maximising family's ability to access support at an early stage. (this is through the provision of informal 'Toddle In' sessions at the Health Centres, families are referred by the HV to a group run by the HV, Nursery Nurses with a Speech and Language therapist present, the group is set up with toys and books with a focus on play so the S< can observe the children at an early stage, covering a multitude of developmental and behavioural aspects including interaction advice) . The CIRCLE collaboration of Early Years Up Up and Away'! resources are now embedded across all Early Learning providers, providing a focus on children who may be at risk for poor achievement in language, literacy and learning. The SureStart and SW led family learning centres provide a strong family support model, including from 0 - 2. Funded providers and the local Authority are building established relationships with the local authority, professional learning and training packages are shared, ensuring a consistent and united approach. The Regional Early Speech and Language lead for SE Scotland has established links with local teams, focusing on early intervention, identifying the most effective ways to build the confidence and capability in the early years workforce to deliver ‘up stream’ support, as well as supporting the development of a national strategy. This work is capitalising on the existing commitment of staff working in the early years in Midlothian and strengthening existing relationships. Page 183 of 380
Page 184
12 Tackling modifiable risk factors and the future burden of disease Hospital-based income maximisation services - The effectiveness of providing welfare rights advice in NHS settings is well documented.7 Patients’ income problems can have significant impacts on the health and care system in the following ways: • Delayed discharges relating to welfare issues may continue to block beds unnecessarily. • Clinical staff time may be spent trying to address welfare issues with patients. • The stress of these practical issues may increase recovery time or be the root cause of readmission to hospital. • Staff mental health and absence levels may increase as a result of debt issues or benefit worries, both for themselves or having to support patients whilst also completing their clinical work. As part of the NHS Lothian Anchor Institution commitment, the NHS Lothian Charity has committed to five years funding for income maximisation services based at six Lothian hospitals (Royal Infirmary of Edinburgh, Royal Hospital for Children and Young People, Western General Hospital, St John’s Hospital, East Lothian Community Hospital, Midlothian Community Hospital). A new service model has been developed which means these hospitals have an on-site service which patients, their families, and NHS staff can access for support and advice on a range of topics including benefit claims, personal finances, housing, council tax, immigration, employment and debt. To ensure consistency and high-quality services, the organisations which provide the service are welfare advice specialists and all of them are required to meet the national standards for advice providers. All NHS staff should be aware of the option to refer patients to income maximisation services. The staff team can meet with clinical teams to discuss how the service can be used Partnership & Place team oversee the income max service based at MCH (also serves Highbank). Partnership & Place lead child poverty actions to increase awareness and confidence among Midlothian based health and social care staff to identify poverty and refer for income max/welfare rights support (Amie Willson leading). Investigate how the service might be extended to support other priority patient groups, most notably patients in mental health settings and community paediatric services. 7 Consilium Consultancy, et al., The Role of Advice Services in Health Outcomes: Evidence Review and Mapping Study. 2015, Advice Services Alliance and The Low Commission. Page 184 of 380
Page 185
13 Smoking Cessation - Smoking increases the risks of cancers, heart disease, respiratory diseases, strokes and diabetes. Second hand smoke is also a health risk particularly for pregnant women and young children. In 2021, smoking accounted for an estimated 8,260 deaths (250 deaths per 100,000 population) in those aged 35 and over in Scotland.8 Over 100,000 people were admitted to Scottish hospitals with smoking recorded as a primary or secondary cause of admission. Many smoking related illnesses, including Chronic Obstructive Pulmonary Disease (COPD), have long latency so that the impact of smoking is not apparent for decades. Smoking prevalence is significantly higher among adults than children and notably patterned by socioeconomic position. Tobacco consumption is an ongoing health inequality challenge as 24% of people living in the most deprived areas smoke compared with 5% in the less deprived areas.9 At the current rate, it is forecast that smoking prevalence rates in the most deprived section of society will be more than double the national target for a Tobacco Free Generation by 203410 which is why Quit Your Way (smoking cessation) services will continue to target our resources and staff expertise at smokers who live in our most deprived communities. Referrals by health professionals of people who actively want to stop smoking have high chances of a successful quit, so ensuring pathways to smoking cessation are clear is key. The Lothian smoking cessation service provides access to specialist support for patients referred from primary care and acute settings. In recognition of the harm to babies from smoking, there is also a specialist cessation support for pregnant women. Denormalising smoking across the Lothian health and care estate is something that needs to happen. Ensuring staff are aware of and adhere to the smoke free policy is the basis for this approach. If our staff smoke in healthcare settings, then we cannot expect patients, visitors and contractors not to smoke. Staff across Lothian should be encouraged to attend the 15-minute information sessions about the smoke free policy that the Tobacco Control team within public health can deliver Corporate Management Team should continue to support action on the Smoke Free Policy which is co-ordinated by the Smoke Free Monitoring Group Ensuring that all staff are clear how to refer patients to smoking cessation support is imperative. There is a very brief training available from the Quit Your Way team to help all staff to understand how to make a referral Partnership & Place team facilitate the Smoking in pregnancy demonstrator steering group which involves ensuring perinatal professionals and third sector partners know how to refer for support. 8 Scottish Public Health Observatory. Tobacco use: key points 2023 [cited 2024 20 February]; Available from: https://www.scotpho.org.uk/risk-factors/tobacco-use/key-points/. 9 Scotland, P.H.I.f., Tobacco use: adult smoking in Scotland. 10 Public Health Scotland, Review of Creating a tobacco-free generation: A Tobacco Control Strategy for Scotland 2023, Public Health Scotland: Edinburgh. Page 185 of 380
Page 186
14 Evidence also shows that smoking delays recovery from surgery. There is a further opportunity to enhance support for smoking cessation before people are admitted for planned surgery or healthcare procedures. This type of prevention work could be done in conjunction with developing work on prehabilitation Cardiovascular disease - Cardiovascular disease caused the greatest burden of disease in NHS Lothian and across Scotland in the Scottish Burden of Disease study, 2019.11 Ischaemic heart disease, which can lead to a heart attack, was responsible for 11.3% of all deaths in 2019, making it the disease with the biggest impact on mortality.12 Prevention has a key role in tackling the health burden from cardiovascular disease. Risk factors for cardiovascular disease, including heart disease and stroke, include high blood pressure, atrial fibrillation, obesity, smoking, alcohol consumption and lack of physical activity. Diabetes is also a key risk factor for heart disease. An estimated 610,000 adults in Scotland don’t know that they have high blood pressure. It is estimated that only 27% of adults with high blood pressure in Scotland have their blood pressure treated and controlled in line with the SIGN recommended level of 140/90mmHg.13 High impact interventions for cardiovascular disease, identified by NHS England, include community-based case finding for hypertension, high cholesterol and atrial fibrillation, as well as optimising treatment for these conditions. The Realistic Medicine Board and Public Health should continue to explore opportunities to strengthen preventative action across cardiovascular pathways, linking with colleagues in primary and secondary care to embed referral pathways for support to address risk factors, as well as considering health literacy and adherence to medication to optimise treatment of hypertension. 11 Scottish Burden of Disease study. Public Health Scotland. Available at: www.scotpho.org.uk/comparative-health/burden-of-disease/overview 12 Scotland’s Population: The Registrar General’s Annual Review of Demographic Trends, National Records of Scotland, 2018 13 Scottish Government, (2018) The Scottish Health Survey, 2017 edition: Volume 1: main report, A National Statistics Publication for Scotland, 2018, available at https://w ww2.gov.scot/Resource/0054/00540654.pdf, , accessed 21st October 2020 Page 186 of 380
Page 187
15 Type-2 diabetes - Type 2 diabetes is affecting an increasing number of individuals, families and communities because of increasing levels of obesity and an ageing population. It also has an important impact on health and other services. Between 10 and 12% of NHS budgets is spent on diabetes14. This equates to around £240million of NHS Lothian’s annual budget. However, type 2 diabetes is a condition that, for many people, could be prevented, or diagnosis delayed. Type 2 diabetes does not affect communities equally – it is more common in older people, men, lower socio-economic groups15 and in certain ethnic groups. Obesity, the main modifiable risk factor for type 2 diabetes, is a complex issue and is rooted in inequalities. It is important to strike the right balance between individual and population approaches when planning actions to disrupt the current upward trajectory for type 2 diabetes. Historically, public health actions, such as those to tackle obesity, have focused on individual-level changes to diet and physical activity, rather than the upstream actions required to alter structural and environmental determinants of health. To focus purely on individual behaviour can widen inequalities and increase obesity-related stigma. Individual approaches should be seen as just one component of a whole system response that includes upstream initiatives to tackle ‘obesogenic’ environments. 16 Public Health will continue to provide leadership on tackling the obesogenic environment and supporting the delivery of a Whole System Approach (WSA) to type-2 diabetes, working with stakeholders from across the community planning partnership, to help to tackle the root causes of overweight and obesity17. WSA pilot underway in Midlothian coming up to 6month evaluation point. We plan to use as a springboard to drive further work around obesity forward. The Maternal and Infant Nutrition service should continue to support breastfeeding initiation and continuation, and deliver and expand the HENRY programme, designed to increase staff knowledge, confidence and skills on health, exercise and family nutrition when working with families with young children in the most deprived areas. Partnership work between Partnership & Place and MIN to drive this forward locally. Both HENRY & reducing the breastfeeding drop off rate are part of the Whole Systems Approach to Type II Diabetes. 14 Inpatient costs for people with type 1 and type 2 diabetes in Scotland: a study from the Scottish Diabetes Research Network Epidemiology Group - PubMed (nih.gov) and Epidemiology Group - PubMed (nih.gov) and 2 Public health need and practice | Type 2 diabetes prevention: population and community-level interventions | Guidance | NICE 15 Marked and widening socioeconomic inequalities in type 2 diabetes prevalence in Scotland | Journal of Epidemiology & Community Health (bmj.com) 16 Balancing Upstream and Downstream Measures to Tackle the Obesity Epidemic: A Position Statement from the European Association for the Study of Obesity - PubMed (nih.gov) 17 Whole systems approaches to obesity and other complex public health challenges: a systematic review | BMC Public Health | Full Text (biomedcentral.com) Page 187 of 380
Page 188
16 Obesity is impacted by weight stigma. Public Health will facilitate the development of a programme on how to have positive conversations with families about weight and to avoid weight bias Proposal developed and funding being sourced to recruit a post to tackle weight stigma and bias in Midlothian (Jaqueline Kirkland) Midlothian HSCP should improve the effectiveness and efficiency of child and adult weight management programmes across the obesity pathway, which are accessible to local populations and robustly evaluated. Review of weight management services underway by Midlothian HSCP, in conjunction with Public Health. Discussions about work to analyse DNA data are planned. Community Planning Partnerships should continue to take a whole system approach to active travel, physical activity and use of green space Integrated working with each CPP theme to ensure a public health perspective. Plus, involvement in specific whole system projects involving CPP partners e.g. Mayfield and Easthouses and Dalkeith and Woodburn Women who experience gestational diabetes, and the services supporting them, should work together to improve outcomes for women and their families. Diabetes, maternity, health visiting, weight management, E-health, income maximisation and other services can contribute to an improved pathway. Immunisation Immunisation is the most cost-effective intervention for saving lives and improving the health of the population. Immunisations help protect the population against serious vaccine preventable illness, such as influenza, COVID-19, measles and pneumonia. Vaccination studies demonstrate effectiveness in reducing development of cervical cancer, GP consultations for influenza-like illness, swab positivity in primary care, laboratory confirmed hospitalisations and respiratory emergency department attendances. Work to improve local uptake rates across all vaccination programmes is an important preventative action. There has been a general decline in uptake of childhood vaccinations across all health boards in Scotland. In Lothian, at 5 years of age, uptake of the 4-in-1 booster vaccine (diphtheria, tetanus, whooping cough, polio) is 91.1% and the uptake for second dose of measles, mumps and rubella is 90.2%. Both have decreased from the previous year (92.4% and 91.9% respectively). Children from more deprived areas are less likely to be vaccinated than children in less deprived areas and this difference by deprivation has widened in 2023-24. In Winter 2023, Lothian’s seasonal flu/COVID-19 vaccination campaign kicked off its third year of delivery to help protect people who are eligible for one or both vaccines. Whilst Lothian exceeded the national COVID-19 uptake comparator for most cohorts, uptake for the winter flu 2023 campaign was below pre-pandemic uptake levels. Page 188 of 380
Page 189
17 Public Health should: • Continue to provide leadership and governance to the immunisation programme. • Support strategic discussions to explore the development of a flexible skilled workforce, able to deliver immunisations across the lifespan. • Engage with Public Health Scotland and other key stakeholders to influence national developments including data and digital (e- consent for parents and carers to streamline vaccine delivery in schools). • Understand public perceptions and identify the barriers to vaccination among parents and carers in relation to childhood vaccinations. • Continue concerted efforts to improve uptake and reduce inequalities working with our partners serving communities of faith, religion, ethnic minorities, for whom uptake is lower. • Support strengthened communications about the importance of vaccination, raising awareness with audiences including pregnant women and families with young children. HIT team did provide COVID and Flu immunisations to all the temporary accommodations within Midlothian (Jacqueline Kirkland) The wider health and social care system should: • Explore a more joined-up prevention and vaccination offer, offering multiple vaccinations to the whole family where eligible e.g., opportunistic MMR and HPV catch up. Teams could offer wider health inputs and interventions including type-2 diabetes prevention, oral health, or mental health and wellbeing advice. • Make the best use of a wide range of health professionals able to administer vaccinations and make vaccination promotion the business of everyone working in health settings. Exploration of non-traditional workforce, possibly medical and nursing students, recently retired, sexual health or drug and alcohol service teams could have a greater role in immunisation delivery. Strategic approach to education (Midlothian) group supported links for a public health joined up approach to health messaging. Some key areas being looked at are vaping, immunisations, screening, sexual health and drugs (Becky Hilton & Ruth Flynn). Page 189 of 380
Page 190
18 Screening National screening programmes are evidence based. Screening programmes involve the systematic offer of testing for populations or groups of apparently healthy people to identify individuals who may be at future risk of a particular medical condition or disease, or detect early indications of disease or conditions with the aim of offering intervention to reduce their risk.18 There are six National Screening Programmes in the UK, each of which are planned, delivered and governed through an agreed set of UK wide standards – Abdominal Aortic Aneurysm, Bowel, Breast, Cervical, Pregnancy and Newborn, and Diabetic Eye Screening. Screening uptake needs to be maximised to ensure the programmes are effective and efficient, and to maximise population health gain. Each programme is required to meet the national standards. Performance thresholds have been established for all National Screening Programmes that cover each part of the screening pathway from invitation through to screening test performance and on to time to diagnostic assessment. The achievable threshold represents the level at which the screening service is likely to be running optimally. All screening services should aspire to attain and maintain performance at or above this level. Each National Screening Programme also has an agreed set of Key Performance Indicators though which it is monitored. All parts of the system in Lothian with responsibility for delivery of screening programmes should continue to engage actively with local governance groups. Public Health will continue to oversee the governance of screening programmes and monitor the quality of each part of the pathway. Public Health have a key role in raising awareness about screening and addressing issues relating to uptake to maximise the opportunity for screening programme effectiveness, particularly in underserved groups. Strategic approach to education (Midlothian) group supported for a joined up approach to health messaging. Some key areas being looked at are vaping, immunisations, screening, sexual health and drugs. Public Health will continue to work with partners to ensure the pathway is working efficiently to ensure those who require further investigation have access to timeous investigation and treatment. Falls prevention Falls are estimated to cost the NHS more than £2.3bn per year. Morbidity from hip fracture contributes to the demand on health and social care services. Given the ageing population, this burden is likely to increase further over the coming years. 18 Screening. Evidence and Practice. Second Edition. Angela E. Raffle, Anne Mackie, and J. A. Muir Gr Page 190 of 380
Page 191
19 Evidence shows that effective interventions for falls prevention include: multifactorial risk assessment and timely and evidence-based tailored interventions for those at high risk of falls; evidence based strength and balance programmes and opportunities for those at low to moderate risk of falls; and home hazard assessment and improvement programmes. The health and care system should develop a consistent strategic approach to falls prevention in Lothian. The strategy should make high level recommendations for implementation across the four HSCPs and other key stakeholders. The NHS Lothian Falls Strategy is expected to be launched early Summer 2024. It will centre around 5 pillars, Prevention, Collaboration, Person- Centred, Education and Knowledge and Data Informed. These pillars frame what this strategy means for both staff and our communities. Supported by an infrastructure including an NHS Lothian wide Strategic Group and the Community Falls Group (co-chaired by Midlothian Chief AHP), work is already underway to enable improvements to communications including revised webpages. Going live on 30/5/24, these are HSCP specific and prevention focused, helping communities understand and navigate the available resources from Midlothian Active Choices to Midcare and beyond. Page 191 of 380
Page 192
Page 192 of 380
Page 193
Midlothian Integration Joint Board Thursday, 20th June 2024, 14:00-16:00 Director of Public Health Annual Report 2023 Executive summary 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. This year the focus is on maternal and child health, an area that we know has significant evidence of effectiveness in improving future health outcomes. This report provides data, evidence and examples of work underway to improve outcomes for children and young people. NHS Lothian and Midlothian Council have a statutory role to produce annual child poverty reports. This work continues to be a significant focus for public health teams alongside a wider programme, involving many parts of the health and care system, of activity that supports the most disadvantaged children and young people in the area. Members are asked to: • Note that the evidence relating to improving health outcomes is clear that a focus on the early years and children and young people’s wellbeing will have the greatest impact on future outcomes. This report provides a focus on those areas to inform future priorities across the health and care system and with other local partners. # Item number: 5.10 Page 193 of 380
Page 194
Midlothian Integration Joint Board Midlothian Integration Joint Board Director of Public Health Annual Report 2023 1 Purpose 1.1 The purpose of this report is to recommend that the Board takes note of the Director of Public Health’s Annual Report 2023. 2 Recommendations 2.1 As a result of this report, Members are asked to: • Note that the evidence relating to improving health outcomes is clear that a focus on the early years and children and young people’s wellbeing will have the greatest impact on future outcomes. This report provides a focus on those areas to inform future priorities across the health and care system and with other local partners. 3 Background and main report 3.1 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. The annual report informs this work by describing who our population are, what affects their health and what the evidence tells us that we should do to improve health outcomes. 3.2 The DPH report last year provided a general population health update and a focus on the work underway to address the cost-of-living crisis. This year we focus on maternal and child health, an area that we know has significant evidence of effectiveness in improving future health outcomes. 3.3 Delivering improvements in maternal, child and adolescent health outcomes means working with our public and voluntary and community sector partners across Lothian. Although financial shortfalls and demand across the public sector are huge challenges, an emphasis on prevention and long-term change remains important to improve health outcomes. 3.4 The report provides data, evidence, and examples of work underway to improve outcomes for children and young people. Our focus on child poverty which was highlighted in the report last year remains a priority for us and our partners. 4 Policy Implications 4.1 NHS Lothian and Midlothian Council have a statutory role to produce annual child poverty reports. This work continues to be a significant focus for public health Page 194 of 380
Page 195
Midlothian Integration Joint Board teams alongside a wider programme, involving many parts of the health and care system, of activity that supports the most disadvantaged children and young people in the area. 5 Directions 5.1 This report does not: • directly impact upon service ability to deliver an existing Direction, • raise the need to bring suggested revisions or discuss operational implications for an existing Direction, nor • highlight the requirement for a new Direction for Board consideration. 6 Equalities Implications 6.1 This report identifies areas of work that will improve outcomes for children and young people, reduce health inequalities, and ensure that we meet their rights under the United Nations Convention on the Rights of the Child. 7 Resource Implications 7.1 This report does not identify specific resource implications. However, resources are required to ensure that this work continues to be delivered. We do recognise that this will be a considerable challenge during a period of reduction in funding to public, community and voluntary sector services. 8 Risk 8.1 There are no corporate risks related to this report. 9 Involving people 9.1 This report does not relate to service changes and therefore has not been subject to local engagement. 10 Background Papers 10.1 None. AUTHOR’S NAME Dona Milne DESIGNATION Director of Public Health CONTACT INFO dona.milne@nhs.scot DATE 31/05/2024 Appendices: Appendix 1: NHS Lothian Director of Public Health Annual Report 2023 Page 195 of 380
Page 196
Page 196 of 380
Page 197
NHS Lothian Director of Public Health Annual Report 2023 1 NHS Lothian Director of Public Health Annual Report 2023 Page 197 of 380
Page 198
Contents Introduction ........................................................................................................................................2 Getting it Right for children and young people - a children’s rights approach ..........................4 Improving maternal health and tackling poverty Child and Family Poverty ..................................................................................................................6 Healthy Weight in Pregnancy ...........................................................................................................8 Smoking in Pregnancy........................................................................................................................9 Infant and child health and wellbeing Maternal and Infant Nutrition ........................................................................................................ 13 Immunisation .................................................................................................................................... 15 Early child development.................................................................................................................. 17 Adolescent Health and Wellbeing Healthy learning and development ............................................................................................... 20 Relationships, sexual health and parenthood .............................................................................. 23 Mental Health and Wellbeing ........................................................................................................ 25 Conclusion ........................................................................................................................................ 27 Improving and protecting the health of the people of Lothian.................................................. 28 Bibliography ..................................................................................................................................... 29 If you need a copy of this report in an alternative format or language please call 0131 242 1000 or email loth.equalityandhumanrights@nhs.scot Contributors : Gillian Amos Steff Kaye Kristen Bowles Yvonne Kerr Laura Cairns Tracy McGillivray Ashley Goodfellow Dona Milne Jim Sherval Sarah Tait Ross Whitehead Jamie Zike Martin Higgins Pamela Murray Page 198 of 380
Page 199
NHS Lothian Director of Public Health Annual Report 2023 1 Photo courtesy of Wester Hailes Youth Agency Page 199 of 380
Page 200
NHS Lothian Director of Public Health Annual Report 2023 Introduction The Public Health team in Lothian is committed to creating a society where everybody can thrive and everybody has the right building blocks for a healthy life – a stable job, good pay, quality housing and good education. In Lothian there are huge differences in life expectancy and other health outcomes that can be seen from very early in babies’ lives. All children and young people should be able to grow up in healthy and safe environments. The early years of a child’s life lay the foundations for their physical, social, intellectual, and emotional development. Policies focusing on children and young people’s health and wellbeing are based on prevention, early identification of need and early intervention with extra support for people identified as having the greatest need. Children and young people need environments where they are protected from harms such as air pollution, traffic danger, the impacts of poor-quality housing, as well as environments that allow them to realise their right to play, learn and be physically active including the opportunity to connect with nature. The Lothian Strategic Development Framework sets out a five-year strategy for the Lothian Health and Care system working alongside local partners. Improving maternal, children and young people’s health and wellbeing is a key part of the framework, with four priority areas: • Improving maternal health and tackling poverty • Infant and child health and wellbeing • Adolescent health and wellbeing • Supporting care experienced children, young people and families through delivery of The Promise. There is a statutory duty for health boards and local authorities to produce Children’s Services Plans every three years and to report progress on these annually. Children’s Services Partnership Groups are established in each of the four Lothian local authority areas and involve a range of community planning partners working collaboratively to develop strategic plans and deliver on identified priorities which aim to improve children and young people’s health and wellbeing. Each partnership plan reflects different priorities and needs; however, all four local partnership area plans are underpinned by commitments to tackling poverty and inequality, Children’s Rights, Getting it Right for Every Child (GIRFEC), and implementing The Promise. Our work to improve children and young people’s health and wellbeing is informed by data and evidence, a key part of which is listening to the voices of children and young people themselves. The national School Health and Wellbeing Survey is one way to find out more about the health and wellbeing of children and young people, to allow local partnerships to plan and act effectively to improve health outcomes for our population. The Public Health team has prioritised work on children and young people as the evidence tells us that if we want to make a difference to long term health outcomes, we need to build on work from the early years. The purpose of this report is to increase understanding amongst public and community and voluntary sector partners about where our efforts should go to ensure this work is embedded in all that we do. The report provides examples of activity to improve the health and development of pregnant women, children and young people, including protection from harms such as smoking, obesity, and infectious diseases. 2 Page 200 of 380
Page 201
NHS Lothian Director of Public Health Annual Report 2023 This years annual report deliberately focuses on the work we need to do to improve outcomes for children and young people - we know this is where the greatest gains in health improvement can be made. 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. Dona Milne, Director of Public Health and Health Policy NHS Lothian. 3 Page 201 of 380
Page 202
NHS Lothian Director of Public Health Annual Report 2023 Getting it Right for children and young people - a children’s rights approach To make Scotland the best place in the world to grow up, everyone supporting children and young people must develop and maintain positive relationships so that children feel loved, safe and respected. Support should be child-centred, empowering for families, and rooted in trusting relationships. It should be strengths based and proportionate to need. The United Nations Convention on the Rights of the Child (UNCRC) (Incorporation) (Scotland) Act was passed by the Scottish Parliament in December 2023 and received Royal Assent in January 2024. This establishes children’s rights in legislation. It recognises that childhood is special, that each child is an individual and must be allowed to grow, learn, play, develop and flourish with dignity. Public bodies must take steps to respect, protect, and fulfil children’s rights and ensure children and young people are involved and listened to in relation to decisions that affect them and their communities. The NHS Lothian Equality and Human Rights Strategy 2023-2028 is the mechanism through which we do this. The principles of GIRFEC are founded on the UNCRC and underpinned by a common definition of wellbeing; that children are: safe, healthy, achieving, nurtured, active, respected, responsible, and included. The principles of GIRFEC are well established in NHS Lothian providing a consistent framework and shared language to work with partners to support cultural norms that put the interests of children at the heart of what we do. NHS Lothian is committed to fulfilling The Promise which sets out a vision for what the future of care for Scotland’s children and young people could be. It advocates for more intensive, preventative support provided to families in order to keep them together where safe to do so and where this is not possible, the alternative should provide them with a loving home with positive and lasting relationships and support to thrive. NHS Lothian is working with partner organisations to implement the UNCRC, GIRFEC and The Promise and will share learning and build on what is going well. It is essential to listen to children and young people and ensure their voice is heard and at the forefront of decision making. Priorities for action • We will develop a UNCRC Incorporation implementation plan. • We will support services to understand the implications of UNCRC incorporation. • We will involve children in policy making and decisions about care and treatment. • We will monitor and evaluate the impact of policies and practices on children’s rights and wellbeing. 4 Page 202 of 380
Page 203
NHS Lothian Director of Public Health Annual Report 2023 5 Improving maternal health and tackling poverty Page 203 of 380
Page 204
NHS Lothian Director of Public Health Annual Report 2023 Child and Family Poverty Child poverty has a harmful impact on the health and wellbeing, education, and life chances of children, young people, and their families. Some families are at higher than average risk of poverty and require targeted support. The NHS is tackling child poverty, in particular by maximising patient income, but also by increasing opportunities for local employment of those most affected by poverty. The Child Poverty (Scotland) Act 2017 places a duty on local authorities and health boards to jointly prepare an annual report on the activity they have taken, and will take, to reduce child poverty in their local area through action on the three main drivers of poverty: income from employment, income from social security benefits and reducing the cost of living. Child Poverty has increased in Scotland over the last few years due to many factors including the rise in the cost of living. Figure 1: End Child Poverty statistics 2021/22 6 Page 204 of 380
Page 205
NHS Lothian Director of Public Health Annual Report 2023 In order to reduce child poverty we need to focus initially on increasing the amount of money that people have to live on. One of the ways that we can do that is through increased access to welfare rights, income maximisation and debt advice. We have these services in each local authority area and we are working with partners to review these services and to ensure equitable access to these services for everyone that needs them. Financial wellbeing referral pathways are being established in midwifery, health visiting and family nurse partnership services to ensure people worried about money are identified and supported to access help. Welfare advice services in Lothian hospitals which, since October 2022, have supported 1,350 clients with financial gain totalling over £1.1 million, are being increased. Staff across the Lothian health and care system will be trained to support increased take-up of benefits and how to refer to local money advice services. NHS Lothian will explore the feasibility of automating referrals to financial advice. A national Infant Food Insecurity Toolkit was launched in February 2024. In addition, a cash- first pathway for crisis infant food insecurity support will be developed in Lothian. Priorities for action • We will continue to work with partners to produce Local Child Poverty Action Plans and Reports to address the main drivers of poverty and support those most at risk of poverty. • We will work with partners to develop a child poverty dataset to enable us to prioritise action where it is needed most and to monitor the progress of these actions to ensure they are making a difference. • We will continue to increase the work of NHS Lothian to tackle child poverty through our employability and recruitment processes. 7 Page 205 of 380
Page 206
NHS Lothian Director of Public Health Annual Report 2023 Healthy Weight in Pregnancy There is a strong relationship between a mother’s weight (her Body Mass Index or BMI) and where she lives. Overweight and obesity can affect fertility and is associated with increased risks for mothers and babies. This includes conditions like gestational diabetes, high blood pressure and increased risk of miscarriage and stillbirth. Maternal obesity is associated with obesity in children. In the least deprived areas of Lothian (SIMD 5) only 15% of mothers are overweight or obese and over half (53%) are a healthy weight. In comparison a higher percentage of mothers in the most deprived areas of Lothian (SIMD 1) are overweight or obese (31%) and a smaller percentage (36%) are a healthy weight. Figure 2: Percent of pregnant women who are of a healthy weight for financial year 2022/23 In Lothian, pregnant women with obesity are offered specialist support during pregnancy to enable them to achieve a successful outcome for mum and baby. Pregnant women with gestational diabetes receive help in the community to maintain glycaemic control and are offered support postnatally to prevent or delay the onset of type-2 diabetes in the future. Priorities for action • We will continue to work with a range of partners to improve food and physical activity environments to support people to achieve a healthy weight. • We will work with weight management services to improve the support available for pregnant and postnatal women. • We will explore what more we can do to support women to achieve a healthy weight before pregnancy. 8 Page 206 of 380
Page 207
NHS Lothian Director of Public Health Annual Report 2023 Smoking in Pregnancy Smoking is a major risk factor for still-births, premature births, low birthweight and other negative maternal and child health outcomes. NHS Lothian is committed to a system response to support pregnant women to stop smoking. Support to stop smoking is offered by teams in every NHS Board across Scotland through a service called ‘Quit Your Way’. Smoking in pregnancy by deprivation There is a relationship between smoking in pregnancy and age and deprivation. Across all deprivation levels, more than 30% of babies born to mothers under 20 are exposed to tobacco in the womb. The percentage of mothers who smoke generally decreases with age and when deprivation decreases. Figure 3 9 Page 207 of 380
Page 208
NHS Lothian Director of Public Health Annual Report 2023 Support to stop smoking Across Scotland, over the last ten years, fewer pregnant women have been recorded as trying to quit smoking. Those who do try to quit however are now more likely to be successful. (NHS Stop Smoking Services, Scotland 2022/23. Public Health Scotland) In Lothian, the numbers trying to quit are lower than the scottish average and success rates are the lowest in Scotland. To improve this, a whole system maternity project has started in Midlothian. This aims to support 30% of women identified as smoking at booking appointment to try to quit smoking through: • Training maternity staff to support conversations about smoking at booking visits • Distributing carbon monoxide monitors to the midwifery team and training staff on how to use them • Automating referrals to the smoking cessation team • Training each of the Quit Your Way teams in Lothian to provide specialist support for pregnant women. Engagement is the initial, but essential, starting point for a successful smoking quit. Our data show that the enhanced service model in Midlothian has delivered higher engagement rates than in other areas of the service when the support has been in place. 10 Page 208 of 380
Page 209
NHS Lothian Director of Public Health Annual Report 2023 Figure 4: Percentage of women across Lothian who made a quit attempt (Women were identified as smoking at booking appointment and supported by NHS Lothian Quit Your Way Services) 2018-2023 Priorities for action • We will support women to stop smoking by delivering a whole system response where maternity services staff and smoking cessation specialists are working together to support women. • We will monitor our performance and continuously strive to make improvements to increase access and to support women to stop smoking. • We will roll out the enhanced maternity smoking cessation approach across community midwifery teams in Lothian and all referrals from maternity services will be prioritised for support by these practitioners. 11 Page 209 of 380
Page 210
NHS Lothian Director of Public Health Annual Report 2023 12 Infant and child health and wellbeing Page 210 of 380
Page 211
NHS Lothian Director of Public Health Annual Report 2023 Maternal and Infant Nutrition Preconception, pregnancy and early childhood are crucial periods in establishing good nutrition and developing healthy eating habits which continue throughout life. The Maternal and Infant Nutrition (MIN) service within Public Health supports families with infant feeding during the first year of life. The MIN service provides support to reduce breastfeeding drop off at 6-8 weeks and supports staff to have increased knowledge and confidence around nutrition. NHS Lothian breastfeeding rates at 6-8 weeks are better than the Scottish average. There has been an improvement over time in Lothian’s breastfeeding drop-off rate compared to the target values established by the national aim to reduce drop-off by 10% between 2019 and 2025. In 2017/18, Lothian’s rate of breastfeeding drop off at 6-8 weeks was over 28% whereas it was under 23% in 2021/22, which is a move in the right direction, with more women breastfeeding for longer. Figure 5: Breastfeeding drop off rate The proportion of women breastfeeding in Lothian was 59% compared to 45% in Scotland. Rates vary across the four local authority areas in Lothian, from 70% in Edinburgh City to 42% in West Lothian. A dedicated project to reduce breastfeeding drop off rates in West Lothian has been established - Delivering Early Breastfeeding Support (DEBS). DEBS provides proactive 13 Page 211 of 380
Page 212
NHS Lothian Director of Public Health Annual Report 2023 breastfeeding support in addition to universal maternity care. Outcomes show the project has reduced the drop off in breastfeeding at 6-8 weeks across all areas (regardless of level of deprivation) and contributed to the improving breastfeeding rates in West Lothian. During 2023, the MIN service led accreditation for the UNICEF UK Baby Friendly Initiative in Neonatal services and reaccreditation in Maternity services in Lothian. This is the first time that maternity, neonatal and community services in Lothian have been accredited. The Royal Hospital for Children and Young People has been selected as the only site in Scotland to pilot UNICEF accreditation within a children’s hospital. Moving on from milk feeding is another important milestone in a child’s life. The MIN service supports this by working with the Dietetics service to deliver training on weaning for health visiting staff. Our HENRY (Health, Exercise and Nutrition for the Really Young) programme has been increasing community-based family support workers’ knowledge, confidence and skills about family food and nutrition. This project has linked with our whole system approach to support an increase in child healthy weight and a reduction in the onset of obesity and type-2 diabetes. Priorities for action • We will continue to work towards UNICEF baby friendly initiative sustainability by working with our Baby Friendly Guardians. • We will explore the feasibility of expanding the DEBS project to other areas where breastfeeding drop off is higher. • We will support the expansion of HENRY across Scotland alongside NHS Education for Scotland. 14 Page 212 of 380
Page 213
NHS Lothian Director of Public Health Annual Report 2023 Immunisation Immunisation programmes save lives and are an important part of prevention in public health. The Immunisation team work with Health and Social Care Partnerships, local authorities and community and voluntary sector partners to protect the people of Lothian against vaccine preventable diseases. NHS Lothian routine childhood immunisation uptake remains high but has been declining over the last few years. Childhood immunisation statistics show that uptake of measles, mumps, and rubella (MMR) vaccine in 2022 was 90% for two doses at 5 years of age, a reduction of 1.5% from 2021 and below the World Health Organisation 95% target. Reasons for the decline include new arrivals to Lothian, vaccine hesitancy and barriers to accessing services, such as the cost of travel for appointments. Figure 6: Uptake rates of measles, mumps and rubella (MMR2) in NHS Lothian and Scotland Vaccine-preventable diseases in our children have not disappeared. We are seeing the threat from measles, which can spread very easily among those who are unvaccinated, as the number of cases in England and Europe has increased. NHS Lothian and Health and Social Care Partnership vaccination teams have started a catch-up campaign for children and young people with missed MMR vaccines in order to protect them from this increased threat. The Immunisation team continues to focus on supporting childhood immunisations by ensuring coverage is high overall with additional efforts to engage families living in areas of higher deprivation or families from ethnic minority backgrounds where vaccination uptake is lower. Our routine immunisation surveillance data is used to help the team work together with a range of organisations to inform and deliver targeted interventions. 15 Page 213 of 380
Page 214
NHS Lothian Director of Public Health Annual Report 2023 Understanding Lothian population attitudes to vaccination is key and in 2024/25 we will complete research with parents and carers to help us understand barriers and enablers to childhood immunisations. Immunisation services must continue to be safely delivered, reflecting our local population needs. Priorities for action • We will develop our understanding of public perceptions and views to provide good information about immunisation. • We will continue to improve uptake of immunisation and reduce inequalities in those who are vaccinated. • We will develop an integrated and flexible vaccination workforce to deliver an effective and efficient service. 16 Page 214 of 380
Page 215
NHS Lothian Director of Public Health Annual Report 2023 Early child development Early child development is important as it is strongly associated with long-term health, education and wider social outcomes. Detecting developmental problems early provides the best opportunity to support children and families to improve outcomes. There is good evidence that parenting support and early learning opportunities can improve outcomes for children with, or at risk of, developmental delay. There is a steep socioeconomic gradient in developmental concerns, particularly for speech and language development, with 16% of those living in the most deprived areas (SIMD 1) having a speech and language concern identified, compared to 5% in the least deprived areas (SIMD 10). Positive progress had been observed across Lothian with reductions in the proportion of reviews identifying children with a developmental concern, from 18% in 2013/14 to 11% in 2018/19. From 2019/20 onwards, this progress stalled, with a small increase in concerns about child developmental being identified in Lothian, to 13% of reviews in 2021/22. Figure 7: Developmental concerns at the 27–30-month review 17 Page 215 of 380
Page 216
NHS Lothian Director of Public Health Annual Report 2023 Figure 8: Top 3 concerns raised at the 27-30-month review At 27-30 months of age, speech and language is the concern most commonly identified in children. These concerns are most common in West Lothian where 14% of reviews identified a speech and language problem. Child development is supported through GIRFEC principles and strengths-based approaches, the Universal Health Visiting Pathway, Family Nurse Partnership, early learning and childcare, and multiagency family support services. Early identification of developmental concerns, such as speech and language, allows practitioners to provide interventions to those who need it most, to reduce inequalities in early years development and future educational outcomes. Priorities for action • We will work together with partners to ensure concerns about child development are identified early and interventions are in place to support children and families to meet expected development outcomes. • We will consider what further action is needed to ensure children’s early language development is supported and improved. 18 Page 216 of 380
Page 217
NHS Lothian Director of Public Health Annual Report 2023 19 Adolescent Health and Wellbeing Page 217 of 380
Page 218
NHS Lothian Director of Public Health Annual Report 2023 Healthy learning and development One of the building blocks of health is education. We know that addressing educational attainment and children and young people’s attendance at school can increase their future life chances and reduce inequalities longer term. There are significant differences in educational outcomes between those living in the most deprived (SIMD 1) and least deprived (SIMD 5) areas. Along with our data on early child development, it illustrates the need to focus our attention on increasing attendance at school by those children living in deprived circumstances and to provide whole family support to ensure continuing engagement in education to prevent and reduce future inequalities. Early level attainment (literacy) Figure 9: Percentage of P1 pupils achieving expected literacy levels Local authority areas in Lothian each show a steep socioeconomic gradient in primary 1 literacy levels. For example, in East Lothian, 52% of primary 1 pupils living in the most deprived areas (SIMD 1) achieved expected reading levels compared to 81% of those in the least deprived areas (SIMD 5). A similar pattern is observed for numeracy. 20 Page 218 of 380
Page 219
NHS Lothian Director of Public Health Annual Report 2023 School attendance Figure 10: Primary school attendance Local authority areas in Lothian each show a socioeconomic gradient in school attendance. In the city of Edinburgh in 2020/21, school attendance was 90.5% for those living in the most deprived areas (SIMD1) compared to 96.2% in the least deprived areas (SIMD 5). Improving this situation continues to be a priority for education departments, schools and their local partners who are supporting children and families. 21 Page 219 of 380
Page 220
NHS Lothian Director of Public Health Annual Report 2023 Positive destinations Figure 11: Percentage of school leavers in positive destinations The chart above shows trends over time in the percentage of school leavers in positive destinations (including higher and further education, employment, training and voluntary work), by care experience. The figure highlights a wide, but narrowing, gap with care experienced young people being far less likely to leave school for a positive destination than the total school-leaver population. As of 2017, 94.7% of the total school-leaver population were in a positive destination compared to 72.4% of care experienced young people. A range of activity is being delivered through Children’s Services Partnerships to support children’s development, readiness to learn, and attainment. This includes whole family support, early education and childcare, and youth work approaches. Priorities for action • We will continue to work with our partners to identify need and ensure children, young people and families have access to the support they need to thrive. • We will continue to build on the work of NHS Lothian as an Anchor Institution to support young people through training and employment opportunities. 22 Page 220 of 380
Page 221
NHS Lothian Director of Public Health Annual Report 2023 Relationships, sexual health and parenthood Among the under 25 population, knowledge, behaviours and outcomes in sexual health and conception have changed in recent years. Due to disruption to school attendance during the Covid-19 pandemic, children and young people missed out on key areas of education including relationships, sexual health and parenthood (RSHP) education. Practitioners in sexual health services report gaps in young people’s knowledge and an increasing impact of misinformation from social media. The 2022 Health Behaviours in School-aged Children Scotland survey reported a continued decline in sexual activity among under 16s. Of the 15-year-olds who had had sex, 34% did not use a condom or birth control during their last intercourse. Although teenage pregnancy rates in Scotland continue to decline, those living in the most deprived areas had teenage pregnancy rates more than four times higher than those living in the least deprived areas (44.3 compared to 9.9 per 1,000 women). Despite the reported decline in rates of sexual activity in young people under 16 years, sexually transmitted infections (STIs) and harmful sexual behaviours are at the highest for over a decade. Since 2019, gonorrhoea infections among sexually active people aged under 25 years have doubled. Some groups of children and young people are particularly vulnerable to poor sexual health and wellbeing. These are LGBT+ young people, those with care experience, and young people with a learning disability. LGBT+ young people are more likely to engage in sexual intercourse and more likely to say they were not ready for their first sexual experience. Evidence supports a strong link between age at first anal intercourse and infection with HIV/STIs, which means efforts to delay first sexual activity could be protective. Care experienced children and young people have less access to consistent sources of sex and relationships education. Interrupted or low school attendance and placements with different carers can mean learning is through older relatives, self-research, or through experience. Young people with learning disabilities are more likely to miss out on protective factors such as RSHP and more likely to be victims of sexual abuse. Evidence suggests the rates of sexual activity among 19 and 20-year-olds with a learning disability are not significantly different to those without a learning disability, but pregnancy rates are double. Young people’s sexual health needs can be supported, and inequalities addressed, through evidence based RSHP provision delivered by trained, competent teachers and staff, alongside providing young people friendly, inclusive and accessible sexual health services. 23 Page 221 of 380
Page 222
NHS Lothian Director of Public Health Annual Report 2023 Priorities for action • We will continue to deliver multiagency workforce development opportunities across Lothian. • We will deliver a partnership project to develop a resource for LGBT+ Inclusion in youth and children’s education and services. • We will develop flexible models for school and community-based early intervention sexual health services. • We will develop accessible information on sex and relationships, including Easy-Read information. 24 Page 222 of 380
Page 223
NHS Lothian Director of Public Health Annual Report 2023 Mental Health and Wellbeing When children and young people do not receive timely support for their mental health needs, this can lead to spikes of demand for more specialist support, such as that provided by Child and Adolescent Mental Health Services. Intervening early to support mental wellbeing helps children and young people develop the skills they need to live healthy and happy lives. Data from the Health Behaviour in School-aged Children Study highlight continued deterioration of young people’s mental health and wellbeing. These downward trends for 11–15-year-olds have been evident since around 2010, and as of 2022, the levels of self- reported confidence and happiness (for girls) are the lowest observed in nearly 30 years. Figure 12: Often or always feel confident The cost of living crisis has worsened the impact of the pandemic on children and families with around one fifth of children in Lothian now living in families affected by poverty. There is a strong relationship between poverty and mental health and wellbeing. Supporting prevention and early intervention and timely access to support is key to reducing waiting lists and improving outcomes for children and young people. Partnership working across public and third sectors is crucial to meet the changing needs of children and families. In Lothian, partners are working to develop Single Points of Access to mental health and wellbeing support for children, young people and families. This enables faster and easier access to low, moderate and specialist levels of support, depending on need. It is vital that services are delivered in a trauma-informed way by suitably trained staff. Work to develop Single Points of Access has included consultation with young people, mapping of existing services, and development of user-friendly referral processes. 25 Page 223 of 380
Page 224
NHS Lothian Director of Public Health Annual Report 2023 Priorities for action • Continue to develop Single Points of Access to ensure children and young people have timely access to appropriate emotional, mental health, and wellbeing support. • Ensure professionals are appropriately trained and equipped to deliver services in a trauma-informed way. • Continue to focus on prevention activity through Children’s Services Partnership structures, including work to address child poverty. 26 Page 224 of 380
Page 225
NHS Lothian Director of Public Health Annual Report 2023 Conclusion This report has deliberately focused on the health and wellbeing of our children and young people in Lothian as the greatest opportunity for influencing change to improve long term outcomes. The data tells us that we continue to see significant inequalities throughout these life stages. We have worked with partners within the health and care system and the wider community planning partnerships, who have a responsibility to produce plans to improve outcomes for children and young people, to ensure that this data and evidence informs the actions we will take locally. Our goal is to continue to bring attention to the needs of our children and young people and their families to inform our work in this area. During a period of significant reductions in public sector resources there is a danger that we will see reductions in services for children, young people and families. The evidence is overwhelming that continued investment in the lives of our children and young people will reduce future inequalities, improve future health outcomes and reduce future demand on the health and care system. This report calls on all public, community and voluntary sector organisations to consider the data presented and how it can shape their work. It seeks a commitment from partners to work together on the actions in the report that we feel will make the biggest difference (based upon the evidence we have) to the lives of children and young people. We look forward to our continued work with partners to see these improvements being achieved. 27 Page 225 of 380
Page 226
NHS Lothian Director of Public Health Annual Report 2023 Improving and protecting the health of the people of Lothian The Role of the Public Health Department in Lothian Approximately 175 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. > 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 four services that deliver Board-wide remits: (i) Resilience (ii) Equalities and Human Rights (iii) Safe Haven, and (iv) Child Health Commissioner 28 Page 226 of 380
Page 227
NHS Lothian Director of Public Health Annual Report 2023 Bibliography Getting it Right for children and young people – a children’s rights approach: The United Nations Convention on the Rights of the Child (UNCRC) (Incorporation) (Scotland) Act NHS Lothian Equality and Human Rights Strategy 2023-2028: Healthy and better lives for everyone Getting it right for every child (GIRFEC) The Promise: Independent Care Review Improving maternal health and tackling poverty: NHS Stop Smoking Services Scotland. Public Health Scotland. April 2022 to March 2023 Infant and Child Health and Wellbeing: UNICEF UK. The Baby Friendly Initiative Childhood immunisation statistics Scotland. Public Health Scotland. Quarter and year ending 31 December 2022 Adolescent Health and Wellbeing Health Behaviour in School-aged Children: WHO collaborative cross-national study (HBSC). Findings from the HBSC 2022 survey in Scotland. Executive Summary Teenage pregnancies: Year of conception, ending 31 December 2021. Public Health Scotland Gonorrhoea infection in Scotland 2013-2022 report. Public Health Scotland A Summary of Evidence for Relationships, Sexual Health and Parenthood (RSHP) Education in Schools Sexual Health & Healthy Relationships Resources Sexual Activity and Sexual Health among young adults with and without mild/moderate intellectual disability Health Behaviour in School-aged Children: WHO collaborative cross-national study (HBSC). Findings from the HBSC 2022 survey in Scotland. Executive Summary Conclusion Health Equity in England: The Marmot Review 10 Years On 29 Page 227 of 380
Page 228
NHS Lothian Director of Public Health Annual Report 2023 30 www.nhslothian.scot Page 228 of 380
Page 229
Midlothian Integration Joint Board Thursday 20th June 2024, 14:00-16:00 Multi-Agency Public Protection Arrangements (MAPPA) Annual Report for 2022/2023 Executive summary The Multi-Agency Public Protection Arrangements (MAPPA), are a set of statutory partnership working arrangements introduced in 2007 under Section 10 of the Management of Offenders etc. (Scotland) Act 2005 (the 2005 Act). The purpose of MAPPA is the protection of the public and the reduction of serious harm. In Scotland MAPPA brings together the Police, Scottish Prison Service (SPS), Health Boards and the Local Authorities in partnership as the Responsible Authorities, to assess and manage the risk posed by certain categories of offender: • Sex offenders who are subject to notification requirements under the Sexual Offences Act 2003; • Mentally disordered restricted patients; and • Other individuals who by reason of their conviction are assessed by the Responsible Authorities as posing a risk of serious harm to the public. A number of other agencies have a ‘Duty to Cooperate’ (DTC) with the Responsible Authorities, including housing providers, the voluntary sector, Social Security Scotland and the Children's Reporter. The operation of MAPPA in Scotland is supported by National Guidance 1 and procedures. There are ten MAPPA regions in Scotland and each region is overseen by a Strategic Oversight Group (SOG) consisting of senior representatives from each of the Responsible Authorities. In each MAPPA region the SOG meets regularly and monitors and reviews how the MAPPA arrangements are working. Item number: 5.11 Page 229 of 380
Page 230
Midlothian Integration Joint Board The MAPPA National Strategic Group is responsible for the strategic oversight and development of MAPPA. It is chaired by the Scottish Government and includes the 10 MAPPA SOG Chairs and representatives from the Responsible Authorities. Responsible Authorities fulfil their statutory duties in part by jointly preparing and publishing their own local MAPPA annual reports. This report covers the published Edinburgh, the Lothians and the Scottish Borders MAPPA Annual Report 2022-2023 (appendix 1) and acknowledges the MAPPA National Overview Report for Scotland (appendix 2), again from the period of 1 April 2022 to 31 March 2023. This is the sixteenth year of MAPPA in operation in Scotland and provides an overview of the main national developments as a result of work conducted by the Scottish Government and its partners. Members are asked to: • Note the contents of the report # Page 230 of 380
Page 231
Midlothian Integration Joint Board Midlothian Integration Joint Board Multi-Agency Public Protection Arrangements (MAPPA) Annual Report for 2022/2023 1 Purpose 1.1 This is a cover report for the Edinburgh, the Lothians, and Scottish Borders MAPPA Annual Report for 2022/2023 which was published on Friday 27th October 2023 (appendix 1). 2 Recommendations 2.1 As a result of this report, Members are asked to: • Note the contents of the report. 3 Background and main report 3.1 Multi-Agency Public Protection Arrangements, more commonly referred to as MAPPA, are a set of partnership working arrangements put in place for the fundamental purpose of public protection and managing the risk of serious harm. MAPPA is not a statutory body, but it is a statutory framework through which the Responsible Authorities discharge their responsibilities to protect the public in a co- ordinated manner. MAPPA was introduced in Scotland in 2007 by The Management of Offenders etc. (Scotland) Act 2005. This Act also outlines the responsibility of the Strategic Oversight Group (SOG) to provide local leadership across the MAPPA area, to be responsible for performance monitoring and quality assurance and for the submission of the Annual Report. In 2007 the following categories of individuals were subject to management under MAPPA: • Registered Sex Offenders (RSOs) – those individuals required to comply with the sex offender notification requirements (SONR) • Restricted Patients.- patients subject to a compulsion order with restriction order, a hospital direction or a transfer for treatment direction; that is patients who are subject to special restrictions under the Mental Health (Care and Treatment) (Scotland) Act 2003. In 2016 the Scottish Government updated the MAPPA Guidance to include a 3rd category: Page 231 of 380
Page 232
Midlothian Integration Joint Board • Other Risk of Serious Harm Individuals - these are individuals who are not required to comply with the SONR or who are not Restricted Patients; but who by reason of their conviction; are considered by the Responsible Authorities to be persons who may cause serious harm to the public at large. There are three MAPPA management levels to ensure that resources are focused where they are needed most to reduce the risk of harm. These are: Level 1 - routine risk management by the Responsible Authority Level 2 - Multi agency risk management Level 3 - Multi-agency Public Protection Panels. Partnership working is a key function within MAPPA and brings together representatives from the Responsible Authorities: Police Scotland, Social Work, Housing, Health and Scottish Prison Service to oversee the practical management of those who have committed a sexual offence, or who are assessed to pose a significant risk of harm to the public. 3.2 The 2022/23 report, includes a forward completed by Joan Tranent, Chair of the Edinburgh, Lothians and Scottish Borders Strategic Oversight Group which highlights the work undertaken by all agencies to manage individuals who present the highest risk of harm to our communities and the importance of the presence of stabilising factors such as accommodation, access to support networks and being integrated into local communities. The housing of individuals, who have committed sexual offences, is a matter on which some members of the public can have strong opinions. It is important that we work with our communities to raise understanding and awareness of public protection and that public protection is our highest priority. Number of Registered Sex Offenders managed between: 1st April 2022 and 31st March 2023 780 1st April 2021 and 31st March 2022 912 1st April 2020 and 31st March 2021 899 1st April 2019 and 31st March 2020 916 The majority of cases continue to be managed at Level 1: 767 (98%) with the remaining 13 individuals being managed at Level 2. There were no cases managed under Category 3 (Other Risk of Harm Offender) in the reporting year. 3.3 Across the Edinburgh, Lothians and Scottish Borders the reconviction rates for RSOs continues to remain relatively low. Iin the reporting year 25 individuals were convicted of a further Group 1 (non-sexual violent) crime or Group 2 (Sexual) crime in the reporting year (3%). Although not contained in the Annual Report I have provided the following figures for Midlothian to provide a local context for individuals managed under MAPPA. Page 232 of 380
Page 233
Midlothian Integration Joint Board Midlothian 2021 2022 2023 RSOs managed in the community on 31 March 52 55 54 RSO’s subject to statutory supervision 18 19 15 RSOs managed at Level 1 in the community on 31 March 51 53 51 RSOs managed at Level 2 in the community on 31 March 1 0 3 RSOs managed at Level 3 in the community on 31 March 0 1 0 RSOs reported for breaches of notification 1 0 1 RSOs convicted of a further group 1 or group 2 crime (1 relates to non-sexual crimes of violence and group 2 relates to sexual crimes.) 1(group 1) 1(group 2) 2 (Group 1) 1 (Group 1) 3.4 Impact on Performance and Outcomes: To ensure that the statutory duties of MAPPA are discharged effectively there are two Groups that provide oversight and governance across Edinburgh, the Lothians and Scottish Borders: Strategic Oversight Group and MAPPA Operational Group. Together they have oversight and co-ordination of MAPPA and have a responsibility to share learning, develop best practice and promote consistency. The East and Midlothian MAPPA Group (EMMG) is a local partnership approach to the management of high-risk offenders in East Lothian and Midlothian and provides strategic direction to local agencies. The EMMG reports to the Public Protection Committee and the Critical Services Oversight Group. While this is a challenging area of work there is no evidence of concerning practice or delivery of MAPPA in Midlothian. Justice Social Workers are highly skilled and trained in the use of accredited risk assessment tools. In collaboration with other agencies, they formulate risk and from this develop risk management plans to manage and supervise individuals convicted of sexual offences or who have caused significant harm to others. The Edinburgh, the Lothians and Scottish Borders Strategic Oversight Group has continued to support the development of practice and during this reporting year a number of on-line multi-agency training events were held. This included two events to provide staff with the key information of the learning from Significant Case Reviews, Initial Case Reviews and MAPPA case file audits. The events were Page 233 of 380
Page 234
Midlothian Integration Joint Board attended by staff and managers from all agencies engaged in the management of high-risk offenders. 4 Policy Implications 4.1 Adopting a Preventative Approach: The fundamental purpose of MAPPA is public protection. As one of the key partners the Justice Service focus on early prevention and intervention strategies to reduce the risk of offending behaviour and to ensure that Midlothian is safer. Within legislation there are a number of monitoring interventions and strategies which agencies can use as part of preventative measures. This includes the use of remote electronic monitoring equipment and Sexual Offences Prevention Orders. 5 Directions 5.1 Direction 1- Health and Wellbeing 5.2 Direction 5.1- Health Inequalities 5.3 Direction 7- Safe from Harm 6 Equalities Implications 6.1 Not Applicable. 7 Resource Implications 7.1 There are no resource implications associated with this report. Ring-fenced funding associated with Justice Service Delivery. 8 Risk 8.1 The MAPPA process makes a significant contribution to the management of risk and the protection of the public in Midlothian. 8.2 There are risks associated with the potential for negative media coverage of individuals managed under MAPPA within Midlothian. To mitigate against this there are robust communication and contingency plans out in place in advance of the release of any individual whose case may attract media attention. 9 Involving people 9.1 Involving Communities and Other Stakeholders: The MAPPA Annual Report is accessible to the public. The Scottish Government also publishes National Overview Report which is included as an appendix. As part of performance management collaborative feedback is sought from service users to ensure effective service provision and information provided is appropriate and Page 234 of 380
Page 235
Midlothian Integration Joint Board relevant. All service users subject to supervision, as part of a licence or order imposed by the Court, complete an entry and exit questionnaire to support service improvement. 10 Background Papers 10.1 None AUTHOR’S NAME Fiona Kennedy DESIGNATION Group Service Manager CONTACT INFO Fiona.kennedy2@Midlothian.gov.uk DATE 27/05/2024 Appendices: Appendix 1: Edinburgh, the Lothians, and Scottish Borders MAPPA Annual Report 2022/23 Appendix 2: MAPPA Scotland Annual Overview Report 2022/23 Page 235 of 380
Page 236
Page 236 of 380
Page 237
2022-2023 Edinburgh, the Lothians and Scottish Borders Multi-Agency Public Protection Arrangements Edinburgh, the Lothians and Scottish Borders Multi-Agency Public Protection Arrangements ANNUAL REPORT 2022-2023 Page 237 of 380
Page 238
2022-2023 Edinburgh, the Lothians and Scottish Borders Multi-Agency Public Protection Arrangements Edinburgh, the Lothians and Scottish Borders Multi-Agency Public Protection Arrangements Page 238 of 380
Page 239
2022-2023 Contents 1 Foreword 2 2 Multi-Agency Public Protection Arrangements in Edinburgh, the Lothians and Scottish Borders 4 3 Roles and Responsibilities 6 4 Achievements in Developing Practice 12 5 Strategic Overview Arrangements 15 6 Statistical Information 17 Page 239 of 380
Page 240
2022-2023 Edinburgh, the Lothians and Scottish Borders Multi-Agency Public Protection Arrangements \2 1 Foreword Page 240 of 380
Page 241
2022-2023 \3 Multi Agency Public Protection Arrangements (MAPPA) are a mechanism through which agencies can discharge their statutory responsibilities more effectively and protect the public in a co-ordinated way. The purpose of MAPPA is to help reduce the re-offending behaviour of sexual and violent offenders to protect the public from serious harm. Agencies across Edinburgh, the Lothians and Scottish Borders work in partnership to manage those individuals who present the highest risk of harm to our communities. The strength of the partnership between prison, police, health and local authority has continued to strengthen since the introduction of MAPPA. When a sex offender is released from prison subject of statutory supervision, or is subject of statutory supervision as part of a community order, they are required to be housed within their own council area. An offender cannot be placed in another council area without the consent and agreement of the receiving local authority area. Extensive research and reviews by experts have shown that the provision of stable housing, access to support networks and effective monitoring are key ways to minimise the risks posed by sex offenders. If we move sex offenders from neighbourhood to neighbourhood we may push them away from the very support that is promoting a positive change in their life, to be replaced by a vacuum that may lead to re-offending. We recognise and understand that members of the public may have strong feelings about the housing of sex offenders in their communities and our aim is to work with the community and to reassure people that public safety remains our highest priority. Re-offending by people managed under MAPPA remains low and this reflects the work we do together. Our utmost priority is to keep the public safe, particularly the most vulnerable members of our communities. Joan Tranent Chair Edinburgh, the Lothians and Scottish Borders Strategic Oversight Group Foreword Page 241 of 380
Page 242
2022-2023 Edinburgh, the Lothians and Scottish Borders Multi-Agency Public Protection Arrangements \4 2 What is MAPPA? Multi-Agency Public Protection Arrangements in Edinburgh, the Lothians and Scottish Borders Multi-Agency Public Protection Arrangements (MAPPA) provide a framework to manage the risk posed by registered sex offenders and restricted patients (mainly violent offenders, with a small number of sex offenders). On 31 March 2016, the Scottish Government published new MAPPA Guidance. This guidance reflects the new risk of serious harm category 3, for offenders who by reason of their conviction are subject to supervision in the community, and are assessed by the responsible authorities as posing a high or very high risk of serious harm to the public, which requires active multi-agency management at MAPPA Level 2 or 3. Page 242 of 380
Page 243
2022-2023 \5 On 31 March 2022, the Scottish Government published an updated version of the National MAPPA Guidance, which reflects an on-going programme of revision to take into account new legislation as well as changes in guidance, policy and effective practice. MAPPA brings together professionals from the police, social work, housing, health and the Scottish Prison Service in Edinburgh, the Lothians and Scottish Borders. These agencies are known as the ‘responsible authorities’. While the arrangements are co-ordinated by a central unit based in Edinburgh, the practical management of offenders remains the responsibility of these agencies at local level. The area covered by our arrangements incorporates the local authority areas of the City of Edinburgh, East Lothian, Midlothian, West Lothian and the Scottish Borders, representing a mixture of urban and rural areas. The responsible authorities represented are: » The City of Edinburgh Council » East Lothian Council » Midlothian Council » West Lothian Council » Scottish Borders Council » Police Scotland » Scottish Prison Service » NHS Lothian » NHS Borders There are three MAPPA management levels to ensure that resources are focused where they are needed most to reduce the risk of harm. Over the course of this annual reporting year, we managed 963 registered sex offenders under MAPPA; 93.25% (898) at Level 1; 6.65% (64) at Level 2; and 0.10% (1) at Level 3. Over the course of this annual reporting year we managed 10 CAT 3 Violent Offenders under MAPPA and all were managed at MAPPA Level 2. Over the past year, there have been 60 MAPPA Level 2 meetings across Edinburgh, the Lothians and Scottish Borders, which managed RSOs and serious risk of harm violent offenders. We have returned to face to face meetings but with the added advantage of attendees being able to join the meeting via MS Teams, where appropriate. Each Level 2 meeting will consider a number of offenders. A Level 3 meeting will only consider one offender and there were 6 Level 3 meetings convened during the reporting year, which all related to the an RSO. The 2022/23 MAPPA National Annual Report provides a picture of the main national developments in relation to MAPPA and can be viewed on the Scottish Government website under recent publications. Page 243 of 380
Page 244
2022-2023 Edinburgh, the Lothians and Scottish Borders Multi-Agency Public Protection Arrangements \6 3 Roles and Responsibilities Page 244 of 380
Page 245
2022-2023 \7 The responsible authorities for each area are required to involve other key agencies in the management of offenders. This is an important part of MAPPA, involving the exchange of information and drawing on the collective knowledge and expertise of numerous agencies. The roles and responsibilities in relation to MAPPA in our local area are outlined below. Police Scotland is responsible for the enforcement of the notification and compliance requirements of the Sexual Offences Act 2003 (sex offender registration), and for policing activities, including risk assessment, preventative/ monitoring strategies, as well as investigation and prosecution of any registered sex offender who re-offends. Responsibilities include: maintaining an accurate record of those offenders resident in each local authority area subject to the notification requirements; the creation of risk management plans to mitigate or reduce risk; making enquiries where such persons fail to comply with the requirements placed on them and managing sex offenders whose current behaviour is of concern. Police Scotland is the lead responsible authority for those community-based registered sex offenders who are not subject to any other form of statutory supervision. These duties are carried out in partnership with all responsible authorities and ‘duty to co- operate’ agencies. The local authority is the responsible authority for registered sex offenders who are subject to statutory supervision. The Council’s justice social work service is responsible for the supervision of such offenders but housing, adult social care and children and families services also play a key role in the management of sex offenders in the community. Justice social work makes a significant contribution to public protection by supervising and managing registered sex offenders in accordance with the requirements of MAPPA and other public protection-related legislation. Page 245 of 380
Page 246
2022-2023 \8 Social workers supervise offenders on community payback orders and prisoners who have been released subject to formal supervision. Social workers are required to use accredited risk assessment tools, and develop plans for the risk management and supervision of offenders in collaboration with other agencies. Social workers can request that additional requirements or conditions be placed on orders and licences by the courts and the Parole Board. These requirements and conditions can range from restrictions relating to accommodation and employment, to instructions to avoid certain locations or victims, or to attend counselling or treatment programmes. These requirements and conditions allow social workers to monitor and influence aspects of offender’s behaviour, as breaches of requirements or conditions can lead to the court or Parole Board returning the offender to custody. Each local authority in Edinburgh, the Lothians and Scottish Borders has a Sexual and Violent Offender Liaison Officer (SAVALO) or Lead Officer in the justice social work service who acts as a single point of contact for information relating to registered sex offenders and violent offenders managed under MAPPA. They are responsible for chairing risk management case conferences and liaising with other agencies as appropriate. Local authority housing SOLOs are responsible for offenders access to housing. This includes accessing temporary accommodation and identification of suitable permanent housing. Registered social landlords contribute to public protection. As a ‘duty to co-operate’ agencies, they work with the local authority housing SOLO to identify positive housing solutions. The role of the housing service is to contribute to the ‘responsible authorities’ management of risk through: » providing suitable accommodation » contributing to environmental risk assessments to ensure accommodation is appropriate » liaising with the responsible authorities regarding the ongoing management and monitoring of the risk of the offender as a tenant, including any tenancy moves or evictions » having regard to community safety and having in place contingency plans for when a property is no longer suitable and/or the offender’s safety is at risk. Page 246 of 380
Page 247
2022-2023 \9 The local authority is responsible for ensuring the development of a strategic response to the housing of sex offenders. However, in any local authority area there is likely to be a multiplicity of housing providers, and local authorities must involve and consult registered social landlords in their area when developing their strategic response. It is the responsibility of the local authority to provide an initial single point of contact for accommodation requests from other responsible authorities. This single point of contact is the housing SOLO, whose role involves: » identifying the most appropriate housing provider following risk assessment » ensuring that when an appropriate housing provider has been identified, they are included by the responsible authorities in liaison arrangements relevant to the identification of appropriate housing and the management of risk » liaising pro-actively with responsible authorities and housing providers regarding ongoing risk management and community safety issues. NHS Lothian continues to play an important role in MAPPA locally through being the responsible authority for mentally disordered restricted patients and in fulfilling its wider duty to co- operate in the management of violent offenders and registered sex offenders. NHS Lothian has a Public Protection structure (including child protection, adult protection and MAPPA) which is the responsibility of the Executive Nurse Director at Health Board level. There is a Director for Public Protection, a Clinical Nurse Manager, a MAPPA Health Liaison Officer, alongside Designated Consultants for MAPPA (who are consultant forensic mental health clinicians). The aim of the NHS Lothian structure and input is to provide governance for NHS Lothian’s contribution to Public Protection and to ensure that health issues (including mental health, physical health, staff and patient safety, information sharing) that arise in relation to MAPPA cases are dealt with appropriately. The Director of Public Protection attends all level 3 MAPPA meetings; The NHS Lothian Serious Offender Liaison Service (SOLS) representatives attend all level 2 and level 3 MAPPA meetings; and the Health Liaison Officer attends all level 2 and some level 3 MAPPA meetings. The NHS Lothian Serious Offender Liaison Service (SOLS) continues to provide specialist clinical consultation, training, assessment and clinical supervision to support the management of serious violent and sexual offenders being managed in the community. Page 247 of 380
Page 248
2022-2023 \10 During the reporting year SOLS completed 26 case discussions with frontline staff from social work and police responsible for the management of the individual concerned. There were 31 referrals to their service by social work and police, which led to 23 risk assessments being completed on those individuals deemed to present a serious risk of harm to the public. NHS Borders also makes an important contribution to MAPPA. NHS Borders continues to work collaboratively with MAPPA partners to ensure appropriate, relevant and proportionate responses to information sharing requests to support the management and assessment of risk. The Single Point of Contact (SPOC), with operational responsibility for dealing with MAPPA health information requests is the Nurse Consultant Public Protection or a member of the NHSB Public Protection Nursing Team. MAPPA level two meetings are attended by a representative from the NHSB Public Protection Nursing Team. There may also be representation provided from the Learning Disability Forensic Team and/or Mental Health Psychology services dependent on whether this is a concern relative to a learning disability, mental illness or addiction. MAPPA level three meetings will be attended by NHSB Strategic Lead and/or Nurse Consultant for Public Protection. NHSB Chief Executive and Nursing Director will be made aware of these meetings and will be asked to attend where appropriate. Community Intervention Services for Sex Offenders (CISSO) This service continues to support partner agencies in the risk management of people with sexual convictions through the delivery of community-based group treatment programmes and individual interventions, addressing the behaviour and attitudes associated with sexual offending. In addition, staff provide assessments and offer advice and consultation to criminal justice social workers in Edinburgh, the Lothians, and Scottish Borders. CISSO received 101-referrals in 2022/23, which resulted in 70-people receiving a service. We continue to see clients in West Lothian, one-day a fortnight and have reintroduced the “CISSO link person”, where a CISSO worker regularly bases themselves in a locality office, to see clients and speak to staff, in East Lothian, Scottish Borders and Midlothian. Group-based interventions are delivered from our Grindlay Street Court offices in Edinburgh. Pending the planned national roll-out of Moving Forwards 2 Change (MF2C) in 2024, CISSO has continued to deliver its forerunner, Moving Forwards Making Changes (MFMC), including an adapted MFMC group for men with enhanced learning needs. Page 248 of 380
Page 249
2022-2023 \11 Other group-based programmes delivered include lower-intensity interventions for men whose offending was technology mediated, as well as Survive and Thrive, for men with interpersonal trauma. This is a psychoeducational intervention, looking at increasing understanding of how past interpersonal trauma can impact on current functioning and practical strategies to help people to manage this impact more effectively. CISSO has also supported Edinburgh’s involvement in the pilot of a risk assessment framework for men who have been convicted of offences relating to Indecent Images of Children. Further information about this pilot is available on the Risk Management Authority website. Another development has been the training of CISSO staff in the Static-99R risk assessment tool, as part of a small Community Justice Scotland-led test for change in the event that there is a need to replace the Risk Matrix 2000. CISSO has also continued to support national training around working with people with sexual offending. This Community Justice Scotland coordinated training takes a tiered approach starting with the delivery of a 1-day introductory course (Introduction to Sexually Harmful Behaviour), which may be followed by training in specialist risk assessment tools (the Risk Matrix 2000 / Stable & Acute 2007) as well as MFMC case-manager / facilitator training. Training has used a blended model of online resource packs, virtual delivery and face-to-face. It is anticipated that this blended model of delivery will allow for more flexible training events in the future. Keeping Children Safe The Community Disclosure Scheme provides that parents, carers and guardians of children under 18 can ask for information about a named person who may have contact with their child if they are concerned that he or she might have convictions for sexual offences against children (e.g. if a parent wants to find out more about a new partner). Police officers discuss the concerns of the applicant in a face-to-face meeting and offer advice and support. In this reporting year, police in Edinburgh, the Lothians and Scottish Borders received 51 applications under this scheme. Further information can be found at: Sex Offender Community Disclosure Scheme Form | Police Scotland Page 249 of 380
Page 250
2022-2023 Edinburgh, the Lothians and Scottish Borders Multi-Agency Public Protection Arrangements \12 Achievements in Developing Practice 4 Page 250 of 380
Page 251
2022-2023 \13 Training and Promoting MAPPA During this reporting year, we have held a number of multi-agency training events. During the course of the reporting year, the MAPPA Co-ordinator facilitated a peer review process for all managers who chair Level 2 Meetings. This allowed each Level 2 Panel member to be reviewed by the MAPPA Co-ordinator and a fellow Level 2 chair from another area, but also involved them in reviewing a colleague, which allowed them to reflect not only on their own practice but also the benefit of having observed a colleague. In February and March 2023, the MAPPA Co-ordinator facilitated a series of workshops across our five local authority areas for Level 2/3 MAPPA Panel Members to discuss their role and responsibilities and to enhance their understanding of the Multi-Agency Public Protection Arrangements. In February 2023, Edinburgh, the Lothians and Scottish Borders Strategic Oversight Group commissioned the Keil Centre to present a training session, with a view to increase understanding on how we create a culture within our organisations that promotes/supports adherence and compliance to our processes and procedures. In March 2023, the Keil Centre presented a training session to SOG members which provided a positive learning experience. On 30 March 2023, Edinburgh, the Lothians and Scottish Borders Strategic Oversight Group commissioned the MAPPA Annual Conference. The event was attended by staff and managers from all agencies involved in the management of registered sex offenders. The morning session was delivered by Dr Katharine Russell, Consultant Clinical Psychologist, NHS Lothian and focused of risk assessment from analysis to communication. The afternoon session was delivered by Gillian Walker, Deputy Governor, HMP Edinburgh and focused on the role of the multidisciplinary Risk Management Team, the decision making body for agreeing progression to less secure conditions or community access. The final session was delivered by Dr Jamie Kirkland, Consultant Clinical Psychologist, NHS Lothian and focused on offenders with intellectual disabilities. This event was well attended and very positive feedback was received. Page 251 of 380
Page 252
2022-2023 \14 Developing the use of remote electronic monitoring equipment Due to advance in technology the internet can be accessed through a variety of devices. The monitoring of devices is the responsibility of the ‘responsible authority’. Where the Parole Board or Court have granted a condition or requirement to monitor an offender’s electronic devices for example within a Community Payback Order or a Sexual Offences Prevention Order, then remote electronic monitoring of their internet enable devices can be considered. eSafe is a managed monitoring service that tracks the individual’s use of their I.T. devices to detect signs of inappropriate and/or criminal behaviour. eSafe is only deployed in cases where it is an agreed strategy of the risk management plan. In all cases, installation and monitoring are undertaken with the knowledge of the offender. Where there is an initial detection of a potential offence or breach of the order then the lead agency will be informed. If there are concerns relative to imminent or ongoing contact offending or any concerns relative to a suicide risk or serious self-harm, eSafe will notify the police via the 999 system. Police Scotland and all five local authorities within the Edinburgh, the Lothians and Scottish Borders are developing their use of remote electronic monitoring software. Developing the use of Sexual Offences Prevention Orders (SOPO) The SOPO is an order granted by the Court. It places conditions on an offender’s behaviour, provides a power of arrest if breached and enhances the police role in managing such offenders. SOPOs could initially only contain prohibitive measures, however, a change in legislation in November 2011 allows for these orders to contain positive obligations as well as prohibitions. For some offenders, the existence of a SOPO is enough to provide structure to their daily life, through which they may avoid further offending. On 31 March 2023, there were 81 SOPOs in place in our area. Page 252 of 380
Page 253
2022-2023 Edinburgh, the Lothians and Scottish Borders Multi-Agency Public Protection Arrangements \15 5 Strategic Overview Arrangements Page 253 of 380
Page 254
2022-2023 \16 Edinburgh, the Lothians and Scottish Borders – Strategic Oversight Group This group is responsible for the overview and co-ordination of the Multi-Agency Public Protection Arrangements, ensuring the sharing of best practice and learning from significant case reviews. The group also provides a strategic lead for developing local multi-agency policy and strategy in relation to shared priorities regarding the management of offenders. Edinburgh, the Lothians and Scottish Borders – MAPPA Operational Group This multi-agency operational group supports the work of the Strategic Oversight Group. Its remit is to share learning, develop best practice and ensure consistency of practice. Local Offender Management/MAPPA Committees These local committees monitor the performance and quality of local service delivery; they provide strategic direction to local member agencies; and develop local policy and practice. These committees include representatives from all key agencies, a number of whom are also members of the local child and adult protection committees, ensuring effective communication across public protection. These local committees report to their respective Chief Officer Groups within their local authority area. NHS Lothian Public Protection Action Group (PPAG) The main aim of this group is to ensure NHS Lothian discharges its responsibilities for Public Protection including MAPPA, This group provides a general forum to discuss important practice issues, in addition to developing good practice in relation to the management of high-risk offenders in the health care setting. PPAG reports to the NHS Board through the Healthcare Governance Committee. Page 254 of 380
Page 255
2022-2023 Edinburgh, the Lothians and Scottish Borders Multi-Agency Public Protection Arrangements \17 6 Statistical Information Unless stated, the statistics recorded are for the reporting period 1 April 2022 to 31 March 2023 Page 255 of 380
Page 256
2022-2023 \18 Table 1: General REGISTERED SEX OFFENDERS (RSO’s) No. a) Number of: I. at liberty and living in the area on 31 March 780 a) Number of: II. per 100,000 population on 31 March 76 b) The number having a notification requirement who were reported for breaches of the requirements to notify 36 Table 2: Civil Orders applied and granted in relation to registered sex offenders THE NUMBER OF No. a) Sexual Offences Prevention Orders (SOPOs) in force on 31 March 81 b) SOPO’S granted by courts between 1 April and 31 March 26 c) Risk of Sexual Harm Orders (RSHOs) in force on 31 March 1 d) Sexual Harm Prevention Orders (SHPOs) in force on 31 March 35 e) SHPOs granted by courts between 1 April and 31 March 8 f) Sexual Risk Orders (SROs) in force on 31 March 0 g) Foreign Travel Orders imposed by the courts between 1 April and 31 March 0 h) Notification Orders imposed by the courts between 1 April and 31 March 2 Table 3: Registered sex offenders by level, re-convictions and notifications REGISTERED SEX OFFENDERS (RSO’s) No. a) Number of RSOs managed by MAPPA level as at 31 March: 780 I. MAPPA Level 1 767 II. MAPPA Level 2 13 III. MAPPP Level 3 0 b) Number of Registered Sex Offenders convicted of a further group 1 or 2 crime between 1st April and 31st March: 25 c) Number of RSO’s returned to custody for a breach of statutory conditions between 1 April and 31 March (including those returned to custody because of a conviction for a group 1 or 2 crime): 19 d) Number of individuals subject to the SONR indefinite period review process (under the terms of the Sexual Offences Act 2003 (Remedial) (Scotland) Order 2011) between 1 April and 31 March: 34 e) Number of notification continuation orders issued for individuals subject to SONR for an indefinite period (under the terms of the Sexual Offences Act 2003 (Remedial) (Scotland) Order 2011) between 1 April and 31 March: 26 f) Number of RSO’s subject to formal disclosure: 12 Page 256 of 380
Page 257
2022-2023 \19 Table 4: Restricted Patients RESTRICTED PATIENTS (RP’s): No. 1) Number of RP’s a) The Health Board(s) in your MAPPA region had responsibility for on 31 March 2023 49 b) The Health Board(s) in your MAPPA region had responsibility for during the reporting year (1 April 2022 to 31 March 2023) 50 2) Number within hospital/ community as at 31 March: a) State Hospital 9 b) Other hospital in your area: 27 c) Community (conditional discharge) 13 3) Number managed by MAPPA Level as at 31 March 1) MAPPA Level 1 49 2) MAPPA Level 2 0 3) MAPPA Level 3 0 4) Number of RP’s recalled by Scottish Ministers during the reporting year 0 Table 5: Statistical Information – other serious risk of harm offenders SERIOUS RISK OF HARM OFFENDERS: No. a) Number of offenders managed by MAPPA level as at 31 March: 1) MAPPA Level 2: 2 2) MAPPA Level 3: 0 b) Number of offenders convicted of a further Group 1 or 2 crime: 1) MAPPA Level 2: 0 2) MAPPA Level 3: 0 c) Number of offenders returned to custody for a breach of statutory conditions (including those returned to custody because of a conviction of Group 1 or 2 crime) 6 d) Number of notifications made to DWP under the terms of the Management of Offenders etc. (Scotland) Act, 2005 (Disclosure of Information) Order 2010 between 1 April and 31 March 2 Table 6: Registered sex offenders managed in the community under statutory conditions and/or notification requirements on 31 March 2022 CONDITIONS NUMBER PERCENTAGE % On statutory supervision 250 32.05 Subject to notification requirements only 530 67.95 Page 257 of 380
Page 258
2022-2023 12524-23-AR Edinburgh, the Lothians and Scottish Borders Multi-Agency Public Protection Arrangements COUNCIL Partners: NHS Border NHS Lothian Scottish Prison Service Midlothain Council East Lothian Council West Lothian Council Edinburgh Council Scottish Borders Council Police Scotland Page 258 of 380
Page 259
Multi-Agency Public Protection Arrangements (MAPPA) in Scotland: National Overview Report 2022-2023 October 2023 Page 259 of 380
Page 260
2 Contents 1. Background .......................................................................................................... 3 2. Justice Policy Context .......................................................................................... 4 3. National MAPPA Developments ........................................................................... 4 4. Risk Management Authority ................................................................................. 7 5. The Scottish Prison Service (SPS) ....................................................................... 8 6. Health ................................................................................................................. 11 7. Police Scotland................................................................................................... 12 8. Sex Offender Community Disclosure Scheme (Keeping Children Safe) ............ 13 9. Social Work Scotland ......................................................................................... 13 10. Social Security Scotland ..................................................................................... 14 Appendix A: Geographical MAPPA Region Model for Scotland ............................... 16 Appendix B: MAPPA Website Addresses ................................................................. 17 Appendix C: MAPPA National Data.......................................................................... 19 Page 260 of 380
Page 261
3 Multi-Agency Public Protection Arrangements (MAPPA) in Scotland: National Overview Report 2022-2023 1. Background The Multi-Agency Public Protection Arrangements (MAPPA), are a set of statutory partnership working arrangements introduced in 2007 under Section 10 of the Management of Offenders etc. (Scotland) Act 2005 (the 2005 Act). The purpose of MAPPA is the protection of the public and the reduction of serious harm. In Scotland MAPPA brings together the Police, Scottish Prison Service (SPS), Health Boards and the Local Authorities in partnership as the Responsible Authorities, to assess and manage the risk posed by certain categories of offender: • Sex offenders who are subject to notification requirements under the Sexual Offences Act 2003; • Mentally disordered restricted patients; and • Other individuals who by reason of their conviction are assessed by the Responsible Authorities as posing a risk of serious harm to the public. A number of other agencies have a ‘Duty to Cooperate’ (DTC) with the Responsible Authorities, including housing providers, the voluntary sector, Social Security Scotland and the Children's Reporter. The operation of MAPPA in Scotland is supported by National Guidance1 and procedures. There are ten MAPPA regions in Scotland (Appendix A) and each region is overseen by a Strategic Oversight Group (SOG) consisting of senior representatives from each of the Responsible Authorities. In each MAPPA region the SOG meets regularly and monitors and reviews how the MAPPA arrangements are working. The MAPPA National Strategic Group is responsible for the strategic oversight and development of MAPPA. It is chaired by the Scottish Government and includes the 10 MAPPA SOG Chairs and representatives from the Responsible Authorities. Responsible Authorities fulfil their statutory duties in part by jointly preparing and publishing their own local MAPPA annual reports. Each of these can be viewed on Local Authority websites, links to which are included at Appendix B. This report covers the period from 1 April 2022 to 31 March 2023, the sixteenth year of MAPPA in operation in Scotland and provides an overview of the main national developments as a result of work conducted by the Scottish Government and its partners. The report comprises a range of contributions from each of the Responsible Authorities, which outlines the progress made in respect to MAPPA during the reporting period, and includes details of ongoing work and future plans. 1 Scottish Government Multi-Agency Public Protection Arrangements (MAPPA): National Guidance (www.gov.scot) Page 261 of 380
Page 262
4 There are a number of statistics on Registered Sex Offenders included in the report (Appendix C) which have been extracted from the ViSOR (Violent and Sex Offender Register) database. These figures provide a snapshot as at 31 March 2023. 2. Justice Policy Context The Scottish Government in its Programme for Government (2023 to 2024)2 sets out its three connected core missions which are: (i) Equality – tackling poverty and protecting people from harm; (ii) Opportunity – a fair, green and growing economy; and (iii) Communities – prioritising our public services. The ambition of protecting people from harm underscores the Government’s commitment to prioritising the safety and security of the people of Scotland. The Cabinet Secretary for Justice and Home Affairs emphasises that this is her clear priority and that genuine equality and opportunity are dependent on ensuring we live in a just, safe, and resilient Scotland where everyone can reach their potential and contribute fully to society. The Government’s vision for reforming the Justice system to ensure that victims and witnesses are treated compassionately and that a trauma informed approach is applied, is combined with its commitment to ensuring effective public protection approaches to managing those individuals who commit the most serious violent and sexual offences. Focusing on rehabilitation both in custody and in the community is the best way to reduce offending and make our communities safer. Delivery of the National Community Justice Strategy3 contributes to the achievement of those aims as does the continued application of Multi-Agency Public Protection Arrangements designed to assess, manage and minimise the potential risks posed by the most serious offenders through collaborative working. 3. National MAPPA Developments Nationally MAPPA has seen a number of developments in the past 12 months and work continues to deliver future improvements to the multi-agency working arrangements. A summary of the work over the reporting period includes: MAPPS Development As part of supporting joint working across the UK for the purposes of public protection, the Home Office is developing an enhanced system to replace the existing ViSOR system in conjunction with UK partners (including Scotland’s MAPPA Responsible Authorities). It will be called the Multi-Agency Public Protection System (MAPPS). Once introduced, MAPPS will enhance existing public protection partnerships as well as delivering wider public protection benefits and MAPPA benefits including accurate 2 Programme for Government 2023 to 2024 - gov.scot (www.gov.scot) 3 National Strategy for Community Justice - gov.scot (www.gov.scot) Page 262 of 380
Page 263
5 and timely sign-posting between all Responsible Authorities of those managed under MAPPA and greater facilitation of cross-border information sharing. For the period of this MAPPA annual overview report, the UK Government (UKG) MAPPS Programme led 10 multi-agency MAPPS specific groups/committees – listed below. Scottish MAPPA Responsible Authorities have contributed and supported the development of the process not least by their representation across all 10 Groups, listed below: • Executive Committee • Steering Committee • National Data Controllers Group • Executive Training Group • Innovation, Technology and Security Group • Operational Training Group (closed 9 March 2023 and replaced with 1-2-1 sessions) • Business Standards Group • Product Owners Working Group • Operational Users Group • Scottish Users Group In addition to this, a specific Scottish Government (SG) led Scottish MAPPS Group evolved from earlier discussions led by SG on multi-agency information sharing. This Group met initially in February 2023 with an original aim to provide a forum to discuss Scottish specific aspects of the UKG led MAPPS Groups. It also aimed to help collate and connect the work of the Groups for Scottish representatives to discuss and disseminate. In addition, and where necessary, the Group sought to agree a Scottish position on issues to be fed back into MAPPS governance (particularly to the Executive Committee which provides sign-off on MAPPS Programme key decisions). Scottish partners continue to work closely with UKG, and a further update will be provided in the next reporting period. MAPPA and Terrorism Individuals convicted of terrorism and terrorism-related offences can be managed under the MAPPA framework where they meet the relevant criteria relating to the level of risk of serious harm they present to the public. The Scottish Government chaired MAPPA Development Group continues to work with the Responsible Authorities in considering the existing and future role of MAPPA in the risk assessment and risk management arrangements for individuals convicted of terrorism and terrorism-related offences. For the period of this report, work has focussed on improving connections between terrorism policy and MAPPA, including considering case studies and exploring the need for updates to tools and/or guidance. Page 263 of 380
Page 264
6 The Scottish CONTEST Delivery Group, chaired by the Deputy Chief Constable, is responsible for oversight of the delivery of the CONTEST Strategy4 (the UK Government’s Counter-Terrorism Strategy) in Scotland. The MAPPA Development Group was tasked with exploring specific questions for the Scottish CONTEST Delivery Group in relation to links to MAPPA. An update was provided to the Scottish CONTEST Delivery Group in February. Work continues on the development of a bespoke chapter of the MAPPA National Guidance covering MAPPA and terrorism offending. Moving Forward 2 Change (MF2C) The Moving Forward: Making Changes (MF:MC) programme was designed jointly by the Scottish Prison Service and the Community Justice Division of the Scottish Government, with the aim of reducing the risk of sexual offending recidivism. National programmes are one of the suite of tools available as part of a rounded approach to protection interventions which align with the Scottish Government’s focus on reducing reoffending and rehabilitating offenders, while at the same time protecting the public. The programme was introduced in Scotland in 2014 following accreditation by the Scottish Advisory Panel on Offender Rehabilitation (SAPOR) and though accreditation has now lapsed there was agreement amongst partners that the programme should continue to be delivered to accredited standards. A National Advisory Board, set up in May 2019, unanimously concluded that a revision (not a replacement) of the programme was required. The re-designed programme, called Moving Forward 2 Change (MF2C), reflects a developing evidence base, advice from SAPOR, evaluation recommendations5, and stakeholder consultations. The pilot of MF2C launched on 1 July 2022 in two custodial sites – HMP Edinburgh, and HMP Barlinnie; and three community sites – East Renfrewshire, East Dunbartonshire and North Lanarkshire. There is a regular reporting requirement to the National Design Lead to ensure the safety of the staff and participants. Where feedback indicates any risk of harm to either a participant or staff member, the Steering Group will be convened and make a recommendation of how to manage that risk. Changes will be made as necessary (and with approval of the MF2C Steering Group) to ensure that the pilot participants receive an appropriate level of service and that the pilots inform the ongoing development of MF2C. The initial design phase of the project will be completed by the end of 2023 and it is hoped that the roll out and accreditation process will begin in 2024. MF2C interim training is being delivered (September – November 2023) so that pilot sites can continue to deliver MF2C. All MF:MC sites were offered critical needs training should they be unable to continue delivery until MF2C is rolled out. Critical need sites will also be included in the MF2C interim training. 4 CONTEST Strategy 2023 5 Moving Forward: Making Changes - An Evaluation of a Group-based Treatment Programme for Sex Offenders (www.gov.scot) Page 264 of 380
Page 265
7 New Behavioural Orders On the 31 March 2023 sections 10 to 40 of the Abusive Behaviour and Sexual Harm (Scotland) Act 2016 (“the 2016 Act”) came into force. These sections introduced two preventative orders which can be applied to relevant sex offenders and those who pose a risk of harm: Sexual Harm Prevention Orders (SHPOs), and Sexual Risk Orders (SROs) respectively. These new orders replaced Sexual Offences Prevention Orders (SOPOs), Foreign Travel Orders (FTOs) and Risk of Sexual Harm Orders (RSHOs). The new orders are designed to protect the public from sexual harm and contain a lower threshold than the previous orders. For instance, they can be used to manage risk to vulnerable adults, as well as children, protecting them from sexual harm outside of the UK. Also, their remit is wider, enabling, for example, foreign travel restrictions to be applied under either type of order. 4. Risk Management Authority The Risk Management Authority (RMA) continues to work to protect the public by reducing the risk of serious harm posed by violent and sexual offending. It does this through ensuring that effective, evidence-based risk assessment and risk management practices are in place in Scotland. Collaboration is essential to this work and in 2022-23 the RMA has maintained its close engagement with partner agencies to deliver and progress key business objectives. The RMA Business Plan for 2023-24 can be found here. Education and Training In 2022-23 the RMA worked with community partners to identify areas of training need to help improve understanding of the Order for Lifelong Restriction (OLR) sentence. Over the same period, the RMA delivered five risk practice courses to justice social workers and to 85 Police Scotland colleagues at a single large-scale event. The RMA also facilitated bespoke training and awareness sessions relating to risk assessment and risk management with Parole Board for Scotland Members and representatives from Parole Scotland. Level of Service/Case Management Inventory (LS/CMI) Review of Closed Cases LS/CMI is a comprehensive general offending assessment and case management planning method. It is used by all community and prison based justice social work services in Scotland to aid decisions on the level and focus of intervention with individuals (aged 16+) who have been involved in offending. In March 2022 the RMA were tasked to lead a review of closed6 LS/CMI cases affected by system errors within the supporting IT infrastructure. The purpose of this 6 Where a person no longer requires to be assessed or managed by the Justice Social Work service, the service closes the record (the case) within the LS/CMI system. Page 265 of 380
Page 266
8 review was to determine whether errors had any material impact on public safety or on any of the individuals who had been subject to those assessments. The multi- agency review considered 1032 cases and found no evidence that the inaccuracies led to any material impact. The report made 12 recommendations relating to Policy, Practice, Quality Assurance, Training, and the LS/CMI System. In 2022-23, the RMA will look to progress and to support others to progress those recommendations. In particular, a review of the implementation of the Framework for Risk Assessment, Management and Evaluation (FRAME) will commence this year. The Review report can be found here. Internet Offending Assessment Framework A two-year pilot of the framework for assessing recidivism risk in those convicted of possessing indecent images of children was commenced in June 2022 and this work is ongoing. The eight local authority pilot areas – South Ayrshire, Glasgow, South Lanarkshire, Edinburgh, East Lothian and the Tayside Partnership areas of Dundee, Angus, Perth and Kinross – have received training in the use of the C-PORT & CASIC assessment tool and have begun assessing individuals. First Grant of Temporary Release (FGTR) The RMA and the Scottish Prison Service have commenced a four-year pilot in which RMA staff evaluate risk assessments and risk management plans for certain life sentence prisoner FGTR applications. This external secondary assurance process applies only to complex cases and is intended to support the development of risk practice, to identify and build upon areas of good practice, and ensure FGTR decisions are based on high-quality information about risk. Counter-Terrorism Counter-terrorism remains an area of significant focus for the RMA. In 2022-23 the RMA formalised its working arrangements with the Counter-Terrorism Assessment Rehabilitation Centre (CT-ARC), and also welcomed the Australian Independent National Security Legislation Monitor (INSLM). Work with the Prisons Oversight Group and other justice partners to develop pathways for the assessment and management of this group of individuals also continues. 5. The Scottish Prison Service (SPS) The Scottish Prison Service (SPS) is an Executive Agency of the Scottish Government. The SPS’s principal objective is to contribute to making Scotland Safer and Stronger. It has a duty to protect the public from harm by keeping those who have been sentenced in safe and secure custody. Its commitment to public safety is delivered through constructive engagement with those in its care, focussing on recovery and reintegration. The risk assessment and management of individuals in custody who are subject to release on licence is carried out in partnership with Local Authority Justice Social Workers, through an enhanced version of the Integrated Case Management (ICM) Page 266 of 380
Page 267
9 process. A key objective of ICM is to ensure that - along with the Police and other community justice partners, such as Local Authority Social Work, Housing, and Children and Families Departments - SPS meets statutory requirements to establish joint arrangements for assessing and managing the risk posed by individuals subject to MAPPA, including the sharing of information with community partners. Such individuals are risk assessed, using a structured professional judgement approach informed by a variety of risk assessment tools to determine the management of the individual whilst in custody, and in preparation for pre-release planning and release. For certain individuals, a Psychological Risk Assessment may be carried out by SPS Forensic Psychologists and used to inform ICM case conferences and at key points in a person's time in custody, to share information and inform action plans. SPS establishments work in partnership with MAPPA Coordinators, prison and community-based Justice Social Work Teams and Police Scotland Offender Management Units. SPS is represented on the Scottish Government MAPPA National Strategic Group, MAPPA Development Group and other short-life working groups, established to progress the future delivery of MAPPA. Prison Governors also contribute to and attend local Strategic Oversight Groups. Programme Delivery Between April 2022 and March 2023, programme delivery achieved more stability following the COVID-19 pandemic and relaxation of covid-related practices. The following table provides an overview of programme targets and completions from this delivery period: Programme Target Risk Target Completions7 Number of Completions Moving Forward 2 Change (Pilot) Sexual Offending Pilot8 9 Self-Change Programme (SCP) High intensity Violence 36 31 Discovery Moderate Intensity Violence 56 36 Constructs Problem Solving and Consequential Thinking 56 56 Pathways Substance Use connected to offending behaviour 48 41 7 SPS set target completions at the beginning of each delivery year based on programmes waiting list priorities and resources across delivery sites. 8 As a Pilot Programme no targets were set. These can be determined following the pilot period and confirmation of approximate completion times per participant. Page 267 of 380
Page 268
10 Youth Justice Modular for young people in custody Requirement/ Needs-led 7 Ultimate Self Adult women in custody Requirement/ Needs-led 14 Short-term intervention Programme (STIP) Focus on desistence for men serving a short-term prison sentence Requirement/ Needs-led 430 Programme Developments/Design The 2022-23 delivery period also held some positive outcomes in terms of the MFMC re-design (MF2C). Pilot programmes are ongoing and evaluation of MF2C will take place in the lead up to the end of this delivery period. SPS will continue to deliver MF2C following the pilot period as the main moderate intensity intervention for those who have sexually offended. The Self-Change Programme (SCP) has also been piloted in HMP Glenochil and HMP Edinburgh with some re-design updates. SCP continues to be delivered in HMP Shotts and HMP Low Moss. In the April 2023-March 2024 delivery period, evaluations of both MF2C and SCP will be complete and subsequently the programme materials will be presented to SAPOR for accreditation. With the opening of HMP Stirling, a version of the Short Term Intervention Programme (STIP) has also been developed for female prisoners who have short- term sentences (F-STIP). Implementation of this is ongoing, with staff training being a requirement for this to progress. Resource and Delivery Focus Across some SPS sites there are at times requirements for Programmes Officers to be redeployed into other operational roles. This has some impact on the programme delivery, with each site managing this locally. In line with previous years, completions have also been impacted by staff turnover, which in turn has an impact on training requirements. This continues to be managed via the national training plan, Programme Manager meetings and centrally within HQ. The Psychology function is responsible for the Treatment Management of high intensity programmes as well as training delivery for programmes. Due to the difficulties in recruiting and retaining qualified psychologists, the training schedule has been reduced for critical requirements only. This has been planned in order to have minimal impact on national programme delivery plans. Future Focus SPS remains cognisant of the needs of the population of individuals who are awaiting offending behaviour programmes. Each year the National Waiting Lists are reviewed to inform delivery. As such, high intensity programmes will continue to be Page 268 of 380
Page 269
11 an area of focus. For the SCP, there is additional staff training planned to allow this programme to also be delivered in HMP Perth within the April 2023-March 2024 delivery period. SPS also offers a range of other opportunities and support to people in custody to help them build their strengths and address their needs in preparation for release. Such support is assessed on an individual basis and can include substance misuse treatment, assistance with mental health, vocational and academic education to increase job readiness, and support with family matters such as parenting and relationships. 6. Health The roles and responsibilities of the NHS within the MAPPA framework are set out in the Management of Offenders etc. (Scotland) Act 2005. On 31 March 2022 there were 304 restricted patients recorded on ViSOR as being managed under the MAPPA process in Scotland. Work began last year on the collation of restricted patients’ data nationally for annual reporting purposes with a view to ensuring that what is provided is meaningful and robust. The Scottish Government continues to provide funding to the Forensic Mental Health Services Managed Care Network (the Forensic Network) to support engagement by the NHS with MAPPA. The Forensic Network, through the Lead for Serious and Violent Offenders, supports the NHS MAPPA work in a number of ways. These include: attendance at National Strategic meetings on behalf of Health, for example, those related to MAPPS and information sharing processes; chairing regular meetings with MAPPA Health liaison colleagues to share good practice; and undertaking specific MAPPA related pieces of work. The Forensic Network also supports the MAPPA Clinical Forum, an annual practitioner forum which has the objectives of “Networking, Education, Operations and Policy”. The forum provides a vehicle for services to consider areas within MAPPA practice that might require guidance and a shared approach, as well as providing the opportunity to network and share good practice. Work is currently being undertaken to refresh the current picture of key MAPPA contacts within all Health Boards and strengthen health links across Boards. The Independent Review into the Delivery of Forensic Mental Health Services The Independent Review into the Delivery of Forensic Mental Health Services chaired by Derek Barron published its final report in February 2021. The Review made a number of recommendations, which, if taken forward will have implications for MAPPA partners. One MAPPA specific recommendation is for the Scottish Government to consider the development of a more consistent way of sharing forensic mental health expertise with MAPPA partners and other external individuals or organisations (including other NHS services) across the country, citing the NHS Lothian Serious Offender Liaison Services and NHS Greater Glasgow and Clyde Page 269 of 380
Page 270
12 STAR services as potential models for this. The Forensic Network, in conjunction with the Scottish Government, has commenced work on this. The proposed model of service, which aims to facilitate the provision of advice and support to MAPPA partners in a more consistent way across the country, is being taken forward by NHS Lothian with support provided by the Forensic Network. Scottish Government continues to progress a programme of work to deliver the commitments made in response to the Review, aligning with the finalisation of the Mental Health and Wellbeing Delivery Plan. Following this, consideration will be given to communicating the planned next steps for this work to key stakeholders. 7. Police Scotland Police Scotland works in partnership with other Responsible Authorities and DTC Agencies to provide effective and efficient policing of Registered Sex Offenders (RSOs) and Other Risk of Serious Harm individuals in pursuance of overall MAPPA management. This is achieved through consistent practice, enhancing and developing new and existing partnerships to manage the inherent risks and challenges posed by these individuals. Recognising the critical role of lawful, effective and efficient information sharing, Police Scotland has supported the Home Office and SG in the development of MAPPS, promoting its use in Scotland as the platform for the secure storage and sharing of information between MAPPA Responsible Authorities. Police Scotland has continued to engage with the SG and MAPPA partners seeking the development of a modern, fit for purpose, MAPPA communication strategy to build community confidence through promotion of the ongoing work of Responsible Authorities and DTC agencies. In pursuance of continual professional development, Police Scotland’s National Sex Offender Policing Unit has assessed recent Home Office commissioned academic research on offender profiles and behaviours in England and Wales, identifying changing demands and learning opportunities to develop ongoing Sex Offender Policing practices. Police Scotland remains engaged with SG to develop appropriate legislation to best serve MAPPA objectives and protect communities of Scotland from current and future risks. Page 270 of 380
Page 271
13 8. Sex Offender Community Disclosure Scheme (Keeping Children Safe) The Sex Offender Community Disclosure Scheme (Keeping Children Safe) was introduced across Scotland in 2011 and is managed by Police Scotland. The scheme enables parents, carers or guardians to make a formal request for information about a named person who may have contact with their child if they are concerned that the person may be a risk to their child's safety and wellbeing. For the year 2022-2023, Police Scotland received a total of 349 applications, an increase of 11 from the previous year. Online submission was the most common method of application with 330 received this way – an increase of 26 from the previous business year. Each application submitted is carefully reviewed and risk assessed by specialist officers, including consideration of whether there is material to disclose. These processes help ensure potentially direct or indirect risks towards children are identified quickly and progressed by Police Scotland. Of the 349 applications received, a total of 14 progressed for disclosure, 3 of which were in relation to concerns around an RSO. The scheme remains a proactive tool for protecting children, providing a clear access route for the public to raise potential child protection concerns and allowing parents/carers to take informed action to safeguard their children or indeed providing parents/carers with reassurance. 9. Social Work Scotland Social Work Scotland is the professional body for social work leaders, working closely with partners to shape policy and practice, and improve the quality and experience of social work services. The local authority is the Responsible Authority with primary responsibility for the management of individuals subject to statutory supervision in the community. This responsibility for the joint arrangements within a local authority lies primarily with the Chief Social Work Officer. However, other local authority services, such as housing, education and children and families, also have key duties in relation to this function. As a Responsible Authority, the local authority is a key member of MAPPA Strategic Oversight Groups and contributes to significant case reviews and the implementation of any related recommendations pertaining to practice or adherence to legislation and guidance. The local authority is also a key member of local Public Protection Chief Officer Groups, and Social Work Scotland is represented on the SG MAPPA National Strategic Group by the Chair of the Justice Standing Committee. The management of the vast majority of RSOs is Police led for the purposes of MAPPA, however justice social work supervises and manages significant numbers of RSOs managed at MAPPA risk Levels 1 and 2 who are subject to community payback orders and licences following release from prison. This requires having a capable, well-trained workforce in order to manage this range of individuals. Page 271 of 380
Page 272
14 Local authorities are also the lead Responsible Authority for MAPPA Category 3, Other Risk of Serious Harm Individuals. This includes people who are not required to comply with the Sex Offender Notification Requirements and who are assessed by the Responsible Authorities as posing a high or very high risk of serious harm to the public (for example, people convicted of serious violent and domestic abuse related offences). As with RSOs, the local authority is responsible for holding the community payback order or licence and for taking action to initiate breach proceedings with the court or the Parole Board where a person has breached their order or licence. This involves monitoring, management and targeted intervention to address offending and prevention of further offending. In certain cases, this will require recommending immediate recall to prison where there is an imminent risk of serious harm. During 2022-2023, Justice Social Work has continued to: • work in collaboration with other Responsible Authorities and DTC agencies to ensure the protection of the public; • provide criminal justice social work reports and risk assessments to inform the court sentencing process; • provide a throughcare service to prisoners released on statutory supervision including ongoing risk assessment, developing risk management plans, contributing to the Scottish Prison Service’s enhanced Integrated Case Management (ICM) process and providing reports to the Parole Board for Scotland; • deliver programmes to address sexual offending to individuals subject to community payback orders and licences in the community. Justice social work professionals are also involved in contributing to the design, testing and training of the new MF2C programme. There are three local authorities piloting the new programme. This includes developing the intervention on release for those who have offended sexually and are assessed as highest risk and have undertaken the self-change programme in custody. Social Work Scotland has been involved with local and UK partners in the development of the MAPPS programme. Ongoing work and further development will be required prior to the gradual implementation of the system, from October 2025. 10. Social Security Scotland On 8 January 2021, the Management of Offenders etc. (Scotland) Act 2005 (Specification of Persons) Amendment Order 2020 came into force. The 2020 Order amended the Management of Offenders etc. (Scotland) Act 2005 (Specification of Persons) Order 2007 to include Social Security Scotland as a DTC agency under the terms of the 2005 Act and this Order provides for the exchange of certain prescribed information for those individuals subject to MAPPA. Since becoming a DTC agency on 8 January 2021, Social Security Scotland has shared appropriate information to manage the risk posed by individuals subject to MAPPA for the protection of the public. Page 272 of 380
Page 273
15 Over the course of the last year, Social Security Scotland continued to develop relationships with the Responsible Authorities. They have informed the appropriate stakeholders of the new benefits they administer by corresponding directly with all Responsible Authorities via email and face to face sessions. This ensures they continue to receive notifications regarding individuals subject to MAPPA. They have continued to support the learning and development opportunities for the teams involved in MAPPA activity and updating guidance where appropriate. Over the next 12 months Social Security Scotland aims to develop further its relationships throughout the MAPPA network to continue meeting their DTC responsibilities. Page 273 of 380
Page 274
16 Appendix A: Geographical MAPPA Region Model for Scotland Page 274 of 380
Page 275
17 Appendix B: MAPPA Website Addresses Edinburgh, the Lothians and Scottish Borders www.edinburgh.gov.uk www.midlothian.gov.uk www.westlothian.gov.uk www.eastlothian.gov.uk/mappa www.scotborders.gov.uk/MAPPAreport Fife Homepage | Fife Council Forth Valley Home | Stirling Council www.clacks.gov.uk/community/ccjp/ www.falkirk.gov.uk/services/people-communities/community-justice.aspx Glasgow Homepage of Glasgow City Council - Glasgow City Council Grampian http://www.ouraberdeenshire.org.uk/our-priorities/aberdeenshire-community-justice- partnership/mappa/ www.aberdeencity.gov.uk Moray Council - Moray Council Highlands and Islands www.orkney.gov.uk/Service-Directory/S/criminal-justice-team.htm#MultiAgency Shetland Islands Council – Shetland Islands Council www.highland.gov.uk CnES Web (cne-siar.gov.uk) Lanarkshire www.northlanarkshire.gov.uk/ www.southlanarkshire.gov.uk/ North Strathclyde www.argyll-bute.gov.uk www.eastdunbarton.gov.uk www.eastrenfrewshire.gov.uk www.inverclyde.gov.uk www.renfrewshire.gov.uk www.west-dunbarton.gov.uk South West Scotland Multi Agency Public Protection Arrangements - Dumfries and Galloway Council (dumgal.gov.uk) www.south-ayrshire.gov.uk www.north-ayrshire.gov.uk www.east-ayrshire.gov.uk Page 275 of 380
Page 276
18 Tayside www.Angus.gov.uk www.PKC.gov.uk www.dundeecity.gov.uk Page 276 of 380
Page 277
19 Appendix C: MAPPA National Data This Appendix outlines patterns in information on Registered Sex Offenders (RSOs) extracted from the ViSOR database on 31 March of each year. This provides a snapshot at a point in time. Numbers of Registered Sex Offenders in Scotland, 2022 to 2023 Category 2022 2023 RSOs managed in custody and in the community on 31 March 6,038 6,420 RSOs managed in the community on 31 March 4,520 4,747 RSOs managed at Level 1 in the community on 31 March 4,407 4,584 RSOs managed at Level 2 in the community on 31 March 111 140 RSOs managed at Level 3 in the community on 31 March 2 1 RSOs reported for breaches of notification 374 465 RSOs convicted of a further group 1 or 2 crime9 114 139 RSOs wanted on 31 March 16 13 RSOs missing on 31 March 0 0 On 31 March 2023, there were 6,420 RSOs in Scotland who were managed in custody or in the community. The total number of RSOs has increased by 6% compared with 2022 when there were 6,038 recorded. On 31 March 2023, 74% of RSOs (4,747 RSOs) were being managed in the community, with the majority of these (4,584 RSOs) being managed at the lowest MAPPA management level, Level 1. The remaining RSOs (141) were being managed at level 2 or level 3. In 2022-2023, 93% of RSOs (5,970 RSOs) complied with their notification requirements under the Sexual Offences Act 2003, compared to 94% (5,664 RSOs) in 2021-22. The proportion of RSOs who failed to comply with their notification requirements has increased to 7%, having been consistently at around 5%-6% for the previous six years. Sex Offender Notification Requirements are robustly policed so that those who breach their terms are identified at the earliest opportunity. The RSO can receive a maximum penalty of 5 years' imprisonment for failing to comply with notification requirements. 9 Group 1 and 2 crimes - Group 1 relates to non-sexual crimes of violence and group 2 relates to sexual crimes. Page 277 of 380
Page 278
20 The National Statistics on Recorded Crime in Scotland 2022-23 published in June 2023, illustrated that sexual crimes accounted for 5% of all crimes recorded in Scotland in 2022-23, as was the case in 2021-22. The report stated that sexual crimes recorded by the police in Scotland decreased by 3% from 15,049 in 2021-22 to 14,602 in 2022-23. Despite this decrease sexual crimes have been on a long- term upward trend since 1974, with some fluctuations, with historical reporting of sexual crimes continuing to play a role in this. As detailed in the report, information from Police Scotland suggests that just over a fifth (21%) of sexual crimes in 2022- 23 were recorded at least one year after they occurred. The increase in sexual cyber-crimes has also had an impact on the trend of recorded sexual crimes over the past ten years. The number of RSOs who have been convicted of a further Group 1 or 2 crime has increased in the last year (139 in 2022-23 compared to 114 in 2021-22). These convictions include offences detected as a result of proactive management and effective policing by the partner agencies. When individuals managed under MAPPA commit further serious offences, the significant case review process examines the MAPPA policies and processes in place for the management of the individual. It identifies areas of learning and good practice and so contributes to continuous learning to improve future policy and practice. Wanted and Missing Registered Sex Offenders: A Missing person is defined as anyone whose whereabouts is unknown and: • where the circumstances are out of character; or • the context suggests the person may be subject to crime; or • the person is at risk of harm to themselves or another. Wanted Registered Sex Offenders are defined as those who are subject to the notification requirements of the Sexual Offences Act 2003 and who have a live warrant in force. On 31 March 2023, of the 13 wanted RSO’s, 11 were assessed as having left the United Kingdom with no indication that they have returned and 2 were believed to be within the United Kingdom. The latest update from Police Scotland provides that of the 2 RSO’s who were wanted and believed to be within the United Kingdom, one has since been apprehended and the other has now been assessed as having left the United Kingdom. Police Scotland treat all missing and wanted RSOs with the utmost seriousness and carry out thorough enquiries to trace their whereabouts and to re-establish the management required to protect the public. On all occasions a Senior Investigating Officer of a rank no less than Inspector will be appointed to lead these investigations. Up to date figures are available via the Police Scotland Website. Page 278 of 380
Page 279
© Crown copyright 2023 This publication is licensed under the terms of the Open Government Licence v3.0 except where otherwise stated. To view this licence, visit nationalarchives.gov.uk/doc/open- government-licence/version/3 or write to the Information Policy Team, The National Archives, Kew, London TW9 4DU, or email: psi@nationalarchives.gsi.gov.uk. Where we have identified any third party copyright information you will need to obtain permission from the copyright holders concerned. This publication is available at www.gov.scot Any enquiries regarding this publication should be sent to us at The Scottish Government St Andrew’s House Edinburgh EH1 3DG ISBN: 978-1-83521-536-4 (web only) Published by The Scottish Government, October 2023 Produced for The Scottish Government by APS Group Scotland, 21 Tennant Street, Edinburgh EH6 5NA PPDAS1359202 (10/23) w w w . g o v . s c o tPage 279 of 380
Page 280
Page 280 of 380
Page 281
Midlothian Integration Joint Board Thursday 20th June 2024, 14:00-16:00 Midlothian Integration Joint Board Financial Recovery Action: Commissioned Services Executive summary At the Special Integration Joint Board (IJB) held on 21st March 2024, the Interim Chief Finance Officer presented the IJB Budget Setting Report for 2024/25. One of the proposals put forward was a 3% reduction in overall costs of commissioned arrangements to be achieved through a programme of transformational change in partnership with Midlothian Council and NHS Lothian. This report provides a brief update of progress regarding this financial recovery action. Following the Special IJB meeting in March 2024, the Head of Adult Services and Service Manager (Adults) held 5 meetings in total with care and service providers of social care services within Midlothian. The meetings provided an overview of the IJB budget, the challenges therein and the proposals put forward. Moreover, there was an attempt to undertake early engagement and co-production with providers with a view to presenting a way forward to achieve the efficiency. As a result of this report, Members are asked to: • Note the progress made with providers. • Note that there are a range of transformational change suggestions made by providers and that these will be explored over the next 4 months. • Note the need to undertake this work alongside the additional work being undertaken to reduce resource panel spend in social care. • Note that 600 care packages are now being reviewed and that the conclusion of these at the end of September 2024 will provide further clarity on whether at that point a reduction in the number of commissioned hours will need to be applied to meet the financial recovery action for commissioning. • Note that whilst this work concludes, further three-month extensions will be given to relevant providers. Item number: 5.12 Page 281 of 380
Page 282
Midlothian Integration Joint Board Midlothian Integration Joint Board Midlothian Integration Joint Board Financial Recovery Action: Commissioned Services 1 Purpose 1.1 This report presents an update to Members regarding the scoping of the commissioning proposal agreed at the Special IJB in March 2024. This is one of five Financial Recovery Action Plans to achieve the required financial recovery position for 2024/25. The work regarding this needs to be viewed within the context of work being undertaken to review all care packages provided via the social care resource panel budgets. 2 Recommendations 2.1 As a result of this report, Members are asked to: • Note the progress made with providers. • Note that there are a range of transformational change suggestions made by providers and that these will be explored over the next 4 months. • Note the need to undertake this work alongside the additional work being undertaken to reduce resource panel spend in social care. • Note that 600 care packages are now being reviewed and that the conclusion of these at the end of September 2024 will provide further clarity on whether at that point a reduction in the number of commissioned hours will need to be applied to meet the financial recovery action for commissioning. • Note that whilst this work concludes, further three month extensions will be given to relevant providers. 3 Background and main report 3.1 Following the Special Midlothian IJB on 21st March 2024, Midlothian IJB requested that an update be brought to the June IJB offering clarity on timings regarding how to progress the savings proposal that 3% be reduced from the overall commissioning budget for the IJB for 2024/25. 3.2 This report summarises the consultation with care and service providers in relation to the proposal for a 3% reduction in overall costs of commissioned arrangements to be achieved through a programme of transformational change. 3.3 A series of meetings were held with care and service providers to highlight the financial challenges faced by Midlothian IJB and the proposal for a 3% reduction in overall costs of commissioned arrangements. It was noted that there would be follow up meetings at stages of the process. Current contracts were extended for a Page 282 of 380
Page 283
Midlothian Integration Joint Board further three months to enable this process to begin and for this report to be submitted to the June IJB. 3.4 In addition to collating feedback from these meetings, providers of commissioned services were asked to submit detailed information around the following areas: • Breakdown of Costs – Detailed breakdown of the cost-of-service provision to provide transparency and assurance related to commissioned costs. • Care Package Reviews – Services they are providing where there may be scope for reviewing a packaged of care. • Transformational Change – Suggestions for initiatives for transformational change that would help deliver efficiencies. • Risks and Issues – Any specific risks or issues they wanted to highlight to the HSCP. 3.5 Providers submitted a range of suggestions for transformational change. These will be scoped out over the next three months to ascertain what they can contribute to the recovery action: • Initiatives to reduce the cost of care provision. • Improved governance. • Managing provider overheads. • Utilising shared support. • Transport. • Self-travel. • Assistance with premises. • Transition to hourly rates. • Extension of support provision. • Reviewing overall service model. • Increased use of community-based services. 3.6 Scope for One-off Financial Saving A number of savings have been identified on a non-recurring through enhanced financial administrative management. 3.7 Reviews of Care Packages Midlothian HSCP will review approximately 600 care packages to ensure care provided meets person centred need. A process has been developed and centres around the creation of an HSCP Review Team with support from existing Practice Teams. It is anticipated that the bulk of the 600 reviews and reassessments will be completed by the end of September 2024. Social Workers and Occupational Therapists will work alongside service users, their carers and care providers and a letter for service users has been produced outlining the process. 3.8 To assist with this review process, and as part of safe and quality-based care provision, a sharpened Eligibility Criteria (retaining the “Substantial” and “Critical” criteria) and a new Resource Panel procedure have been developed to ensure consistency in application, and rolled out to staff along with briefing sessions. Page 283 of 380
Page 284
Midlothian Integration Joint Board 3.9 It is recommended that this piece of work be allowed to be completed before a final decision is made regarding a cut in hours or rates to providers. The aim is to complete this by September 2024. 3.10 A further piece of work is also required around demographics and increasing need in certain areas (e.g. transitions and older people). 3.11 Conclusion Progress with providers continues to be made and there remains a strong commitment to ensuring that they are included in the work to achieve this recovery action. 3.12 It is anticipated that the work being undertaken to review all care packages must result in the Resource Panels for social care operating within a more sustainable financial footprint, whilst retaining a safe and quality-based care provision, that is tailored to personal need, relating to the Eligibility Criteria. 4 Policy Implications 4.1 This report has implications for a range of statutory duties currently undertaken by the Health and Social Care Partnership. 5 Directions 5.1 Work to actualise this recovery action will directly impact upon the ability to deliver the following Directions: • Direction 2.1 • Direction 2.2 • Direction 4.2 • Direction 6.1 • Direction 9.2 6 Equalities Implications 6.1 This report has an impact on groups of people with protected characteristics. An Equality Impact Assessment (EIA) has been completed. 7 Resource Implications 7.1 There are resource implications for the IJB and its balanced budget for 2024/25 if the savings earmarked in the recovery action are not met. 8 Risk 8.1 It is acknowledged that, whilst the work continues with providers to identify savings, there is a risk of slippage in the timeframe. It is anticipated that an indicative figure of saving will be available by mid-July. 9 Involving people 9.1 This report has been written in collaboration with Finance partners. Page 284 of 380
Page 285
Midlothian Integration Joint Board 10 Background Papers 10.1 None. AUTHOR’S NAME Nick Clater DESIGNATION Head of Adult Services & Deputy Chief Social Work Officer CONTACT INFO nick.clater@midlothian.gov.uk DATE 05/06/2024 Appendices: None. Page 285 of 380
Page 286
Page 286 of 380
Page 287
Midlothian Integration Joint Board Thursday 20th June 2024, 14:00-16:00 Midlothian Integration Joint Board Financial Recovery Action: Equality Impact Assessments Executive summary At the Special Integration Joint Board (IJB) held on 21st March 2024, the Interim Chief Finance Officer presented the IJB Budget Setting Report for 2024/25. It was noted that there remained a financial pressure for Midlothian IJB in 2024/25 of c.£10m. It was further noted that the operational management teams had put forward a number of proposals which would, if agreed, allow the IJB to set a balanced budget for 2024/25. Members were asked to: 1. Note the development of the 2024/25 budget setting process. 2. Consider the proposals that support the development of a balanced budget for 2024/25. 3. Agree to set a balanced budget for 2024/25 on the presumption of the delivery of the savings programmes include working with the other IJBs and NHS Lothian to deliver a balanced position for the Set Aside budget. A number of proposals were put forward: • A shifting of the balance of care at home provision to 80 per cent external and 20 per cent internal provision. • An overall reduction in the commissioning spend of 3%. • A reduction in the overspend in Newbyers Care Village. • A reduction in transport spend in social care. This report notes that Equality Impact Assessments have been completed for these 4 financial recovery actions and are attached as appendices to this report. As a result of this report, Members are asked to: • Note that EIAs have been completed for these 4 financial recovery actions. Item number: 5.13 Page 287 of 380
Page 288
Midlothian Integration Joint Board Midlothian Integration Joint Board Midlothian Integration Joint Board Financial Recovery Action: Equality Impact Assessments 1 Purpose 1.1 This report presents an update to Members regarding the completion of Integrated Impact Assessments for the 4 relevant financial recovery actions. 2 Recommendations 2.1 As a result of this report, Members are asked to: • Note that EIAs have been completed for these 4 financial recovery actions. 3 Background and main report 3.1 Following the Special Midlothian IJB on 21st March 2024, where financial recovery actions were agreed, Equality Impact Assessments were required for the 4 recovery actions agreed. These are provided as appendices to this report. 4 Policy Implications 4.1 This report has implications for a range of statutory duties currently undertaken by the Health and Social Care Partnership: • The Social Work (Scotland) Act 1968. • Chronically Sick and Disabled Persons Act 1972. • Disabled Persons Act 1986. • Disabled Persons (Services, Consultation and Representatives) Act 1986. • The National Health Service and Community Care Act 1990. • Community Care Direct Payments Act 1996. • The Human Rights Act 1998. • The Adults with Incapacity (Scotland) Act 2000. • The Regulation of Care (Scotland) Act 2001. • The Community Care & Health (Scotland) Act 2002. • The Mental Health (Care and Treatment) (Scotland) Act 2003. • The Adult Support and Protection (Scotland) Act 2007. • The Welfare Reform Act 2009. • The Public Services Reform Act (Scotland) 2010. • The Equalities Act 2010. • Social Care (Self-directed Support) (Scotland) Act 2013. • The Mental Health (Care and Treatment) (Scotland) Act 2015. 5 Directions Page 288 of 380
Page 289
Midlothian Integration Joint Board 5.1 Work to actualise this recovery action will directly impact upon the ability to deliver the following Directions: • Direction 2.2 All services delegated to Midlothian IJB must ensure service planning describes a clear process to ensure fair access, by January 2024. • Direction 4.2 In order to maximise opportunities to improve personal outcomes, all services delegated to Midlothian IJB should ensure that the principles of self- management are embedded in service delivery design, by January 2024. • Direction 6.1 All services delegated to Midlothian IJB that aim to move care from hospital to home should ensure service planning considers the impact of this on unpaid carers, and evidence appropriate supportive actions, by January 2024. 6 Equalities Implications 6.1 This report has an impact on groups of people with protected characteristics. 6.2 Midlothian IJB must consider its ability to meet statutory duties • Legally If an Integrated Authority cannot adequately show how the voices and needs of the most impacted, vulnerable, or legally protected people in communities have been sought and considered, particularly at the planning phase of the decision, it risks both penalty and legal challenge. • Moral/Ethical All major changes to policy, provision, or planning must involve a thorough exploration of the potential impacts of its proposed action through an Equality Impact Assessment (EIA). Failing to recognise, understand, identify and mitigate any barriers to equality that result from major service change may be considered unlawful discrimination, particularly in relation to people that have a Protected Characteristic or are vulnerable. If the voices of the people and communities are missing from the relevant stages in the process, Midlothian IJB could be considered to be exacerbating disadvantage and reinforcing systemic discrimination that has a negative impact on health inequalities and outcomes. 7 Resource Implications 7.1 There are resource implications for the IJB and its balanced budget for 2024/25 if the savings earmarked in the recovery actions are not met. Page 289 of 380
Page 290
Midlothian Integration Joint Board 8 Risk 8.1 The financial recovery actions are a response to financial pressures in the system, particularly the social care system, and there are therefore risks attached to these. 9 Involving people 9.1 This report has been written in collaboration with Public Health Practitioners. 10 Background Papers 10.1 None. AUTHOR’S NAME Nick Clater DESIGNATION Head of Adult Services & Deputy Chief Social Work Officer CONTACT INFO nick.clater@midlothian.gov.uk DATE 05/06/2024 . Appendices: Appendix 1: Care at Home Integrated Impact Assessment Appendix 2: Commissioning Integrated Impact Assessment Appendix 3: Newbyres Integrated Impact Assessment Appendix 4: Transport Integrated Impact Assessment Page 290 of 380
Page 291
1 Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report Care at Home Page 291 of 380
Page 292
2 Contents Description 3 Evidence 3 Impact on equality & socio-economic disadvantage 5 Impact on UNCRC rights 12 Making a difference 19 Sharing with decision-makers 20 Monitoring the impact 20 Page 292 of 380
Page 293
3 Description Guidance pages 4-7 Title of proposed work Financial recovery actions: Care at home Purpose/objective of proposed work Realigning staff to 20/80 split (external) Who will be affected by this proposed work Service users of Care at Home and Care at Home staff. Report written by: Note – only need the job title: Public Health Practitioners Report authorised by: Note – only need the job title for person with responsibility for agreeing the final proposal: Head of Adult Services Date:16th May 2024 PLEASE NOTE Once your proposal has been agreed and signed off, send the completed Impact Assessment Report to impactassessments@nhslothian.scot.nhs.uk for publication on NHS Lothian website. You can use this email address to feed back on the impact assessment process. Evidence Guidance pages 9-15 Evidence used: List the evidence you used, including if you involved people with relevant protected characteristics and lived experience. Evidence was gathered from our Joint Strategic Needs Assessment, financial information and internal service data. Page 293 of 380
Page 294
4 Summary of findings: Include evidence about relevant population demographics, different health and/ or employment inequalities, people’s different needs and how to meet them, barriers and how to address them, inclusion/ participation in the service, diversity in employment and any complaints and feedback. Overall Midlothian’s population is increasing we are projected to have the 22nd highest population out of the 32 council areas in Scotland in 2028. The 75 years old and over age group is projected to see the largest percentage increase (+40.9%) by 2028 in Midlothian. The Midlothian population has been growing and the largest percentage increase is predicted to be in those aged 75 and over. In 2022, 19% of the population in Midlothian were aged 65 and over. As a result, it is likely that numbers of people with a diagnosis of dementia across Midlothian will increase noticeably. Dementia is slightly more common in women than in men which is to be expected with women living on average longer than men. Older people also make up a significant percentage of unpaid carers 36% and 57% of people who are cared for by an unpaid carer are older. Our current gap between life expectancy and healthy life expectancy has increased by 0.9 years for both men and woman since 2019 in Midlothian. Female and male life and healthy life expectancy is comparable to the Scottish average. 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%. There are some areas of Midlothian which are classified as areas of deprivation. The Scottish Index of Multiple Deprivation shows there are currently 10 data zones in Midlothian within the most deprived 20% data zones in Scotland. Two of these data zone is in the most deprived 5%, both in Dalkeith. Examples of the effect of these inequalities on health in Midlothian are early death due to coronary heart disease are 55% higher, hospital stay for a preventable reason is 38% more likely, the difference in Life expectancy is people live 9 years shorter, prescription for anxiety/ depression is 30% higher and there is 24% of children living in poverty. Midlothian HSCP faces various workforce challenges such as staffing a growing and ageing Population, a reduced availability of staff with appropriate qualifications or skills, the range of support available for unpaid carers, environmental considerations, financial and whole system pressures. Page 294 of 380
Page 295
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 5 Impact on equality & socio-economic disadvantage Guidance pages 16-22 Negative impacts Using the evidence you have collected, explain if your proposal could be discriminatory and/ or put a group of people sharing one of these characteristics at a disadvantage for a reason connected to that characteristic. Note – answer yes/ no and if yes provide brief reasons. Relevant group Could your work result in unlawful discrimination? Could your work put people at a disadvantage/ make their lives worse? People in different age groups No Yes, especially those in elderly population could have a longer waiting time for care in a setting not of their choosing, especially if recruitment isn’t fulfilled. The population increase within elderly is continuing to grow as will demand for this service. Disabled people No No specific impact for this characteristic however they may have more than one. Trans and non-binary people No No Page 295 of 380
Page 296
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 6 Relevant group Could your work result in unlawful discrimination? Could your work put people at a disadvantage/ make their lives worse? People who are pregnant or on maternity leave No No. People from different ethnic backgrounds No No People with religious or protected beliefs No No Men and women [This may include carers, because many are women.] No Yes, may disproportionally effect women as they tend to work in care roles. People who are heterosexual, lesbian, gay or bisexual No No People who are married or in a civil partnership [only in employment situations] No No Page 296 of 380
Page 297
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 7 Relevant group Could your work result in unlawful discrimination? Could your work put people at a disadvantage/ make their lives worse? Care experienced people NOTE - there is no legal protection from discrimination on basis of care experience. No Yes, could have a longer waiting time for care in a setting not of their choosing, especially if recruitment isn’t fulfilled. People experiencing health inequalities caused by socio- economic disadvantage [This may include people living in different or difficult circumstances such as people experiencing homelessness, who are in prison or are ex-offenders, people with addictions and people involved with prostitution. Note – travel costs have a particular impact on people experiencing poverty.] NOTE - there is no legal protection from discrimination on basis of socio-economic disadvantage. No Yes, are potentially more vulnerable to co-morbidities and therefore in more need of the service and health inequalities could worsen if waiting times due to recruitment were longer. People experiencing employment inequalities caused by socio-economic disadvantage [This may include people living in different or difficult circumstances, such as people experiencing homelessness, who are in prison or NOTE - there is no legal protection from discrimination in employment on basis of socio-economic disadvantage. No Yes, are potentially more vulnerable to co-morbidities and therefore in more need of the service and health inequalities could worsen if waiting times due to recruitment were longer. Page 297 of 380
Page 298
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 8 Relevant group Could your work result in unlawful discrimination? Could your work put people at a disadvantage/ make their lives worse? ex-offenders, people with addictions, ex-service personnel/veterans and people involved with prostitution. Note – travel costs have a particular impact on people experiencing poverty.] Carers NOTE - there is no legal protection from discrimination on basis of caring responsibilities. Women continue to have the majority of caring responsibilities and can be put at a particular disadvantage in connection with this. This may be unlawful indirect sex discrimination. No Yes, the potential disruption due to recruitment might impact on their wellbeing. Page 298 of 380
Page 299
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 9 Positive impact Using the evidence you have collected, explain if and how your proposal could have a positive impact on reducing inequalities experienced by groups of people sharing these characteristics. Note – answer yes/ no and if yes provide brief reasons. Relevant group Can your work advance equality of opportunity? [reduce disadvantage, meet needs, increase participation] Can your work foster good relations? [reduce prejudice + increase tolerance] People in different age groups Yes, potentially bigger staff pool with external providers which can ease pressures in the system. No Disabled people Yes, potentially bigger staff pool with external providers which can ease pressures in the system. No Trans and non-binary people No No People who are pregnant or on maternity leave No No People from different ethnic backgrounds No No Page 299 of 380
Page 300
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 10 Relevant group Can your work advance equality of opportunity? [reduce disadvantage, meet needs, increase participation] Can your work foster good relations? [reduce prejudice + increase tolerance] People with religious or protected beliefs No No Men or women [This may include carers, because many are women] Yes, potentially more job opportunities in the community. No People who are heterosexual, lesbian, gay or bisexual No No Care experienced people Yes, potentially bigger staff pool with external providers which can ease pressures in the system. No People who experience health inequalities caused by socio-economic disadvantage [This may include people in different or difficult circumstances, such as people experiencing homelessness, who are in prison or ex-offenders, people with addictions and Yes, potentially bigger staff pool with external providers which can ease pressures in the system. No Page 300 of 380
Page 301
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 11 Relevant group Can your work advance equality of opportunity? [reduce disadvantage, meet needs, increase participation] Can your work foster good relations? [reduce prejudice + increase tolerance] people involved with prostitution. Note – travel costs have a particular impact on people experiencing poverty.] People who experience employment inequalities caused by socio-economic disadvantage. [This may include people in different or difficult circumstances, such as people experiencing homelessness, who are in prison or ex-offenders, people with addictions, ex- service personnel/veterans and people involved with prostitution. Note – travel costs have a particular impact on people experiencing poverty.] Yes, potentially bigger staff pool with external providers which can ease pressures in the system. No Carers Yes, potentially bigger staff pool with external providers which can ease pressures in the system. No Page 301 of 380
Page 302
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 12 Impact on UNCRC rights Guidance pages 23-25 If your proposal does not affect children and young people do not complete this section. If your proposal affects children and young people, use the evidence you have collected to explain how your proposal could impact Children’s Rights. Not all UNCRC rights may apply to your proposal. If this is the case, simply say ‘Not relevant’ or ‘no known relevance’. UNCRC right How will your work limit or restrict this right? How will your work progress this right? Are any groups of children particularly impacted 3 – best interests of the child 4. making rights real 5 – family guidance as children develop 6 – life, survival and development Page 302 of 380
Page 303
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 13 UNCRC right How will your work limit or restrict this right? How will your work progress this right? Are any groups of children particularly impacted 7 – name and nationality 8 – identity 9 – keeping families together 10 - contact with parents across countries 11 – protection from kidnapping 12 – respect for children’s views Page 303 of 380
Page 304
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 14 UNCRC right How will your work limit or restrict this right? How will your work progress this right? Are any groups of children particularly impacted 13 – sharing thoughts freely 14 – freedom of thought and religion 15 –freedom of association and peaceful assembly 16 – protection of privacy 17 – access to information 18 – responsibility of parents Page 304 of 380
Page 305
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 15 UNCRC right How will your work limit or restrict this right? How will your work progress this right? Are any groups of children particularly impacted 19 – protection from violence 20 – children without families 21 – children who are adopted 22 – refugee children 23 – disabled children 24 – enjoyment of the highest attainable standard of health Page 305 of 380
Page 306
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 16 UNCRC right How will your work limit or restrict this right? How will your work progress this right? Are any groups of children particularly impacted 25 – review of a child’s placement 26 – social and economic help 27 – food, clothing and safe home 28 – access to education 29 – aims of education 30 – minority culture, language and religion Page 306 of 380
Page 307
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 17 UNCRC right How will your work limit or restrict this right? How will your work progress this right? Are any groups of children particularly impacted 31 – rest, play, culture, arts 32 – protection from harmful work 33 – protection from harmful drugs 34 – protection from sexual abuse 35 – prevention of sale and trafficking 36 – protection from exploitation Page 307 of 380
Page 308
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 18 UNCRC right How will your work limit or restrict this right? How will your work progress this right? Are any groups of children particularly impacted 37 – children in detention 38 – protection in war 39 – recovery and reintegration Page 308 of 380
Page 309
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 19 Making a difference What changes will you make to your proposal based on the results of this impact assessment? Changes What difference this will make Page 309 of 380
Page 310
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 20 Sharing with decision-makers Guidance page 26 Explain how you will make sure the results of your impact assessment will be taken into account by decision-makers before a final decision is taken. Monitoring the impact Guidance page 27 How will you monitor the actual impact of this piece of work on equality, socio-economic disadvantage or children’s rights? Performance Indicator for equality, socio-economic disadvantage and children’s rights. What impact are you measuring Report quarterly on outnav indicators Population needs Finance Outcomes Page 310 of 380
Page 311
1 Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report Commissioning Page 311 of 380
Page 312
2 Contents Description 3 Evidence 3 Impact on equality & socio-economic disadvantage 5 Impact on UNCRC rights 12 Making a difference 19 Sharing with decision-makers 20 Monitoring the impact 20 Page 312 of 380
Page 313
3 Description Guidance pages 4-7 Title of proposed work Financial recovery actions: Commissioning of services Purpose/objective of proposed work A 3% reduction in overall costs of commissioned arrangements to be achieved through a programme of transformational change in partnership with Midlothian Council and NHS Lothian. Who will be affected by this proposed work The adult population of Midlothian, whom may use HSCP commissioned services. Report written by: Note – only need the job title: Public Health Practitioners Report authorised by: Note – only need the job title for person with responsibility for agreeing the final proposal: Head of Adult Services Date: 16th May 2024 PLEASE NOTE Once your proposal has been agreed and signed off, send the completed Impact Assessment Report to impactassessments@nhslothian.scot.nhs.uk for publication on NHS Lothian website. You can use this email address to feed back on the impact assessment process. Evidence Guidance pages 9-15 Evidence used: List the evidence you used, including if you involved people with relevant protected characteristics and lived experience. Evidence was gathered from our Joint Strategic Needs Assessment, financial information and internal service data. Page 313 of 380
Page 314
4 Summary of findings: Include evidence about relevant population demographics, different health and/ or employment inequalities, people’s different needs and how to meet them, barriers and how to address them, inclusion/ participation in the service, diversity in employment and any complaints and feedback. Overall Midlothian’s population is increasing we are projected to have the 22nd highest population out of the 32 council areas in Scotland in 2028. The 75 years old and over age group is projected to see the largest percentage increase (+40.9%) by 2028 in Midlothian. Our current gap between life expectancy and healthy life expectancy has increased by 0.9 years for both men and woman since 2019 in Midlothian. Female and male life and healthy life expectancy is comparable to the Scottish average. There are some areas of Midlothian which are classified as areas of deprivation. The Scottish Index of Multiple Deprivation shows there are currently 10 data zones in Midlothian within the most deprived 20% data zones in Scotland. Two of these data zone is in the most deprived 5%, both in Dalkeith. Examples of the effect of these inequalities on health in Midlothian are early death due to coronary heart disease are 55% higher, hospital stay for a preventable reason is 38% more likely, the difference in Life expectancy is people live 9 years shorter, prescription for anxiety/ depression is 30% higher and there is 24% of children living in poverty. This proposal will reduce the amount of commissioned service provision within Midlothian which will affect all populations of Midlothian, in particular those with most care needs. Page 314 of 380
Page 315
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 5 Impact on equality & socio-economic disadvantage Guidance pages 16-22 Negative impacts Using the evidence you have collected, explain if your proposal could be discriminatory and/ or put a group of people sharing one of these characteristics at a disadvantage for a reason connected to that characteristic. Note – answer yes/ no and if yes provide brief reasons. Relevant group Could your work result in unlawful discrimination? Could your work put people at a disadvantage/ make their lives worse? People in different age groups No Yes, the reduction in commissioning budget will have a significant impact on all our commissioned services provided to the community. Those most vulnerable to health inequalities could be the most affected. Our commissioned services span the adult life course therefore could impact all age groups. Disabled people No Yes, the reduction in commissioning budget will have a significant impact on all our commissioned services provided to the community. Most of our commissioned services work with those vulnerable communities including those living with a disability so these cuts do have the potential to impact on their current level of care. Trans and non-binary people No No – at present no specific service is commissioned by HSCP for this group, however if they fall into one of the other protected characteristics categories they could be impacted. Page 315 of 380
Page 316
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 6 Relevant group Could your work result in unlawful discrimination? Could your work put people at a disadvantage/ make their lives worse? People who are pregnant or on maternity leave No No direct effect. People from different ethnic backgrounds No No – at present no specific service is commissioned by HSCP for this group, however if they fall into one of the other protected characteristics categories they could be impacted. People with religious or protected beliefs No No Men and women [This may include carers, because many are women.] No Yes, the reduction in commissioning budget will have a significant impact on all our commissioned services provided to the community. Those most vulnerable to health inequalities could be the most affected. Our commissioned services span the adult life course therefore could impact all age groups. People who are heterosexual, lesbian, gay or bisexual No No – at present no specific service is commissioned by HSCP for this group, however if they fall into one of the other protected characteristics categories they could be impacted. Page 316 of 380
Page 317
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 7 Relevant group Could your work result in unlawful discrimination? Could your work put people at a disadvantage/ make their lives worse? People who are married or in a civil partnership [only in employment situations] No No Care experienced people NOTE - there is no legal protection from discrimination on basis of care experience. No Yes, the reduction in commissioning budget will have a significant impact on all our commissioned services provided to the community. Those most vulnerable to health inequalities could be the most affected. People experiencing health inequalities caused by socio- economic disadvantage [This may include people living in different or difficult circumstances such as people experiencing homelessness, who are in prison or are ex-offenders, people with addictions and people involved with prostitution. Note – travel costs have a particular impact on people experiencing poverty.] NOTE - there is no legal protection from discrimination on basis of socio-economic disadvantage. No Yes, the reduction in commissioning budget will have a significant impact on all our commissioned services provided to the community. Those most vulnerable to health inequalities could be the most affected. People experiencing employment inequalities caused by socio-economic disadvantage NOTE - there is no legal protection from discrimination in employment on basis of socio-economic disadvantage. Yes, the reduction in commissioning budget will have a significant impact on all our commissioned services provided to the community. Those most vulnerable to health inequalities could be the most affected. Page 317 of 380
Page 318
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 8 Relevant group Could your work result in unlawful discrimination? Could your work put people at a disadvantage/ make their lives worse? [This may include people living in different or difficult circumstances, such as people experiencing homelessness, who are in prison or ex-offenders, people with addictions, ex-service personnel/veterans and people involved with prostitution. Note – travel costs have a particular impact on people experiencing poverty.] No Carers NOTE - there is no legal protection from discrimination on basis of caring responsibilities. Women continue to have the majority of caring responsibilities and can be put at a particular disadvantage in connection with this. This may be unlawful indirect sex discrimination. No Yes, the reduction in commissioning budget will have a significant impact on all our commissioned services provided to the community. Those most vulnerable to health inequalities could be the most affected. The reduction in services could require more carers. Page 318 of 380
Page 319
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 9 Positive impact Using the evidence you have collected, explain if and how your proposal could have a positive impact on reducing inequalities experienced by groups of people sharing these characteristics. Note – answer yes/ no and if yes provide brief reasons. Relevant group Can your work advance equality of opportunity? [reduce disadvantage, meet needs, increase participation] Can your work foster good relations? [reduce prejudice + increase tolerance] People in different age groups No No Disabled people No No Trans and non-binary people No No People who are pregnant or on maternity leave No No People from different ethnic backgrounds No No Page 319 of 380
Page 320
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 10 Relevant group Can your work advance equality of opportunity? [reduce disadvantage, meet needs, increase participation] Can your work foster good relations? [reduce prejudice + increase tolerance] People with religious or protected beliefs No No Men or women [This may include carers, because many are women] No No People who are heterosexual, lesbian, gay or bisexual No No Care experienced people No No People who experience health inequalities caused by socio-economic disadvantage [This may include people in different or difficult circumstances, such as people experiencing homelessness, who are in prison or ex-offenders, people with addictions and No No Page 320 of 380
Page 321
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 11 Relevant group Can your work advance equality of opportunity? [reduce disadvantage, meet needs, increase participation] Can your work foster good relations? [reduce prejudice + increase tolerance] people involved with prostitution. Note – travel costs have a particular impact on people experiencing poverty.] People who experience employment inequalities caused by socio-economic disadvantage. [This may include people in different or difficult circumstances, such as people experiencing homelessness, who are in prison or ex-offenders, people with addictions, ex- service personnel/veterans and people involved with prostitution. Note – travel costs have a particular impact on people experiencing poverty.] No No Carers No No Page 321 of 380
Page 322
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 12 Impact on UNCRC rights Guidance pages 23-25 If your proposal does not affect children and young people do not complete this section. If your proposal affects children and young people, use the evidence you have collected to explain how your proposal could impact Children’s Rights. Not all UNCRC rights may apply to your proposal. If this is the case, simply say ‘Not relevant’ or ‘no known relevance’. UNCRC right How will your work limit or restrict this right? How will your work progress this right? Are any groups of children particularly impacted 3 – best interests of the child 4. making rights real 5 – family guidance as children develop 6 – life, survival and development Page 322 of 380
Page 323
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 13 UNCRC right How will your work limit or restrict this right? How will your work progress this right? Are any groups of children particularly impacted 7 – name and nationality 8 – identity 9 – keeping families together 10 - contact with parents across countries 11 – protection from kidnapping 12 – respect for children’s views Page 323 of 380
Page 324
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 14 UNCRC right How will your work limit or restrict this right? How will your work progress this right? Are any groups of children particularly impacted 13 – sharing thoughts freely 14 – freedom of thought and religion 15 –freedom of association and peaceful assembly 16 – protection of privacy 17 – access to information 18 – responsibility of parents Page 324 of 380
Page 325
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 15 UNCRC right How will your work limit or restrict this right? How will your work progress this right? Are any groups of children particularly impacted 19 – protection from violence 20 – children without families 21 – children who are adopted 22 – refugee children 23 – disabled children 24 – enjoyment of the highest attainable standard of health Page 325 of 380
Page 326
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 16 UNCRC right How will your work limit or restrict this right? How will your work progress this right? Are any groups of children particularly impacted 25 – review of a child’s placement 26 – social and economic help 27 – food, clothing and safe home 28 – access to education 29 – aims of education 30 – minority culture, language and religion Page 326 of 380
Page 327
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 17 UNCRC right How will your work limit or restrict this right? How will your work progress this right? Are any groups of children particularly impacted 31 – rest, play, culture, arts 32 – protection from harmful work 33 – protection from harmful drugs 34 – protection from sexual abuse 35 – prevention of sale and trafficking 36 – protection from exploitation Page 327 of 380
Page 328
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 18 UNCRC right How will your work limit or restrict this right? How will your work progress this right? Are any groups of children particularly impacted 37 – children in detention 38 – protection in war 39 – recovery and reintegration Page 328 of 380
Page 329
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 19 Making a difference What changes will you make to your proposal based on the results of this impact assessment? Changes What difference this will make Continue to work alongside the transformational blueprint work and try to mitigate risks and impacts where possible. Potentially limit the impacts of those most in need. Page 329 of 380
Page 330
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 20 Sharing with decision-makers Guidance page 26 Explain how you will make sure the results of your impact assessment will be taken into account by decision-makers before a final decision is taken. Monitoring the impact Guidance page 27 How will you monitor the actual impact of this piece of work on equality, socio-economic disadvantage or children’s rights? Performance Indicator for equality, socio-economic disadvantage and children’s rights. What impact are you measuring Report quarterly on outnav indicators Population needs Finance Outcomes Page 330 of 380
Page 331
1 Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report Newbyres Page 331 of 380
Page 332
2 Contents Description 3 Evidence 3 Impact on equality & socio-economic disadvantage 5 Impact on UNCRC rights 12 Making a difference 19 Sharing with decision-makers 20 Monitoring the impact 20 Page 332 of 380
Page 333
3 Description Guidance pages 4-7 Title of proposed work Financial recovery actions: Newbyres Purpose/objective of proposed work A reduction in agency usage in Newbyres Care Village and a sustained operation within an established financial footprint. Who will be affected by this proposed work Service users of Newbyres and their families and staff Report written by: Note – only need the job title: Public Health Practitioners Report authorised by: Note – only need the job title for person with responsibility for agreeing the final proposal: Head of Adult Service. Date: 16th May 2024 PLEASE NOTE Once your proposal has been agreed and signed off, send the completed Impact Assessment Report to impactassessments@nhslothian.scot.nhs.uk for publication on NHS Lothian website. You can use this email address to feed back on the impact assessment process. Evidence Guidance pages 9-15 Evidence used: List the evidence you used, including if you involved people with relevant protected characteristics and lived experience. Evidence was gathered from our Joint Strategic Needs Assessment, financial information and internal service data. Page 333 of 380
Page 334
4 Summary of findings: Include evidence about relevant population demographics, different health and/ or employment inequalities, people’s different needs and how to meet them, barriers and how to address them, inclusion/ participation in the service, diversity in employment and any complaints and feedback. Overall Midlothian’s population is increasing we are projected to have the 22nd highest population out of the 32 council areas in Scotland in 2028. The 75 years old and over age group is projected to see the largest percentage increase (+40.9%) by 2028 in Midlothian. The Midlothian population has been growing and the largest percentage increase is predicted to be in those aged 75 and over. In 2022, 19% of the population in Midlothian were aged 65 and over. As a result, it is likely that numbers of people with a diagnosis of dementia across Midlothian will increase noticeably. Dementia is slightly more common in women than in men which is to be expected with women living on average longer than men. Older people also make up a significant percentage of unpaid carers 36% and 57% of people who are cared for by an unpaid carer are older. Our current gap between life expectancy and healthy life expectancy has increased by 0.9 years for both men and woman since 2019 in Midlothian. Female and male life and healthy life expectancy is comparable to the Scottish average. 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%. There are some areas of Midlothian which are classified as areas of deprivation. The Scottish Index of Multiple Deprivation shows there are currently 10 data zones in Midlothian within the most deprived 20% data zones in Scotland. Two of these data zone is in the most deprived 5%, both in Dalkeith. Examples of the effect of these inequalities on health in Midlothian are early death due to coronary heart disease are 55% higher, hospital stay for a preventable reason is 38% more likely, the difference in Life expectancy is people live 9 years shorter, prescription for anxiety/ depression is 30% higher and there is 24% of children living in poverty. Midlothian HSCP faces various workforce challenges such as staffing a growing and ageing Population, a reduced availability of staff with appropriate qualifications or skills, the range of support available for unpaid carers, environmental considerations, financial and whole system pressures. Page 334 of 380
Page 335
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 5 Impact on equality & socio-economic disadvantage Guidance pages 16-22 Negative impacts Using the evidence you have collected, explain if your proposal could be discriminatory and/ or put a group of people sharing one of these characteristics at a disadvantage for a reason connected to that characteristic. Note – answer yes/ no and if yes provide brief reasons. Relevant group Could your work result in unlawful discrimination? Could your work put people at a disadvantage/ make their lives worse? People in different age groups No Yes, the population increase within elderly is continuing to grow as will demand for this service could expand. Disabled people No No Trans and non-binary people No No Page 335 of 380
Page 336
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 6 Relevant group Could your work result in unlawful discrimination? Could your work put people at a disadvantage/ make their lives worse? People who are pregnant or on maternity leave No No. People from different ethnic backgrounds No No People with religious or protected beliefs No No Men and women [This may include carers, because many are women.] No No People who are heterosexual, lesbian, gay or bisexual No No People who are married or in a civil partnership [only in employment situations] No No Page 336 of 380
Page 337
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 7 Relevant group Could your work result in unlawful discrimination? Could your work put people at a disadvantage/ make their lives worse? Care experienced people NOTE - there is no legal protection from discrimination on basis of care experience. No Yes, changes in staff could impact on care. People experiencing health inequalities caused by socio- economic disadvantage [This may include people living in different or difficult circumstances such as people experiencing homelessness, who are in prison or are ex-offenders, people with addictions and people involved with prostitution. Note – travel costs have a particular impact on people experiencing poverty.] NOTE - there is no legal protection from discrimination on basis of socio-economic disadvantage. No No People experiencing employment inequalities caused by socio-economic disadvantage [This may include people living in different or difficult circumstances, such as people experiencing homelessness, who are in prison or NOTE - there is no legal protection from discrimination in employment on basis of socio-economic disadvantage. No No Page 337 of 380
Page 338
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 8 Relevant group Could your work result in unlawful discrimination? Could your work put people at a disadvantage/ make their lives worse? ex-offenders, people with addictions, ex-service personnel/veterans and people involved with prostitution. Note – travel costs have a particular impact on people experiencing poverty.] Carers NOTE - there is no legal protection from discrimination on basis of caring responsibilities. Women continue to have the majority of caring responsibilities and can be put at a particular disadvantage in connection with this. This may be unlawful indirect sex discrimination. No Yes, changes in staff could impact on care. Page 338 of 380
Page 339
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 9 Positive impact Using the evidence you have collected, explain if and how your proposal could have a positive impact on reducing inequalities experienced by groups of people sharing these characteristics. Note – answer yes/ no and if yes provide brief reasons. Relevant group Can your work advance equality of opportunity? [reduce disadvantage, meet needs, increase participation] Can your work foster good relations? [reduce prejudice + increase tolerance] People in different age groups Yes, retention of staff could positively impact on care. Potential for more care home beds to be available. No Disabled people No No Trans and non-binary people No No People who are pregnant or on maternity leave No No People from different ethnic backgrounds No No Page 339 of 380
Page 340
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 10 Relevant group Can your work advance equality of opportunity? [reduce disadvantage, meet needs, increase participation] Can your work foster good relations? [reduce prejudice + increase tolerance] People with religious or protected beliefs No No Men or women [This may include carers, because many are women] No No People who are heterosexual, lesbian, gay or bisexual No No Care experienced people Yes, retention of staff could positively impact on care. Potential for more care home beds to be available. No People who experience health inequalities caused by socio-economic disadvantage [This may include people in different or difficult circumstances, such as people experiencing homelessness, who are in prison or ex-offenders, people with addictions and No No Page 340 of 380
Page 341
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 11 Relevant group Can your work advance equality of opportunity? [reduce disadvantage, meet needs, increase participation] Can your work foster good relations? [reduce prejudice + increase tolerance] people involved with prostitution. Note – travel costs have a particular impact on people experiencing poverty.] People who experience employment inequalities caused by socio-economic disadvantage. [This may include people in different or difficult circumstances, such as people experiencing homelessness, who are in prison or ex-offenders, people with addictions, ex- service personnel/veterans and people involved with prostitution. Note – travel costs have a particular impact on people experiencing poverty.] No No Carers Yes, retention of staff could positively impact on care. Potential for more care home beds to be available. No Page 341 of 380
Page 342
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 12 Impact on UNCRC rights Guidance pages 23-25 If your proposal does not affect children and young people do not complete this section. If your proposal affects children and young people, use the evidence you have collected to explain how your proposal could impact Children’s Rights. Not all UNCRC rights may apply to your proposal. If this is the case, simply say ‘Not relevant’ or ‘no known relevance’. UNCRC right How will your work limit or restrict this right? How will your work progress this right? Are any groups of children particularly impacted 3 – best interests of the child 4. making rights real 5 – family guidance as children develop 6 – life, survival and development Page 342 of 380
Page 343
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 13 UNCRC right How will your work limit or restrict this right? How will your work progress this right? Are any groups of children particularly impacted 7 – name and nationality 8 – identity 9 – keeping families together 10 - contact with parents across countries 11 – protection from kidnapping 12 – respect for children’s views Page 343 of 380
Page 344
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 14 UNCRC right How will your work limit or restrict this right? How will your work progress this right? Are any groups of children particularly impacted 13 – sharing thoughts freely 14 – freedom of thought and religion 15 –freedom of association and peaceful assembly 16 – protection of privacy 17 – access to information 18 – responsibility of parents Page 344 of 380
Page 345
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 15 UNCRC right How will your work limit or restrict this right? How will your work progress this right? Are any groups of children particularly impacted 19 – protection from violence 20 – children without families 21 – children who are adopted 22 – refugee children 23 – disabled children 24 – enjoyment of the highest attainable standard of health Page 345 of 380
Page 346
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 16 UNCRC right How will your work limit or restrict this right? How will your work progress this right? Are any groups of children particularly impacted 25 – review of a child’s placement 26 – social and economic help 27 – food, clothing and safe home 28 – access to education 29 – aims of education 30 – minority culture, language and religion Page 346 of 380
Page 347
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 17 UNCRC right How will your work limit or restrict this right? How will your work progress this right? Are any groups of children particularly impacted 31 – rest, play, culture, arts 32 – protection from harmful work 33 – protection from harmful drugs 34 – protection from sexual abuse 35 – prevention of sale and trafficking 36 – protection from exploitation Page 347 of 380
Page 348
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 18 UNCRC right How will your work limit or restrict this right? How will your work progress this right? Are any groups of children particularly impacted 37 – children in detention 38 – protection in war 39 – recovery and reintegration Page 348 of 380
Page 349
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 19 Making a difference What changes will you make to your proposal based on the results of this impact assessment? Changes What difference this will make Page 349 of 380
Page 350
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 20 Sharing with decision-makers Guidance page 26 Explain how you will make sure the results of your impact assessment will be taken into account by decision-makers before a final decision is taken. Monitoring the impact Guidance page 27 How will you monitor the actual impact of this piece of work on equality, socio-economic disadvantage or children’s rights? Performance Indicator for equality, socio-economic disadvantage and children’s rights. What impact are you measuring Report quarterly on outnav indicators Population needs Finance Outcomes Page 350 of 380
Page 351
1 Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report Transport Page 351 of 380
Page 352
2 Contents Description 3 Evidence 3 Impact on equality & socio-economic disadvantage 5 Impact on UNCRC rights 12 Making a difference 19 Sharing with decision-makers 20 Monitoring the impact 20 Page 352 of 380
Page 353
3 Description Guidance pages 4-7 Title of proposed work Financial recovery actions: Transport spend review Purpose/objective of proposed work Reduction of spend for service users being reviewed Who will be affected by this proposed work The adult population of Midlothian, whom may use HSCP transport services. Report written by: Note – only need the job title: Public Health Practitioners Report authorised by: Note – only need the job title for person with responsibility for agreeing the final proposal: Head of Adult Services Date: 16th May 2024 PLEASE NOTE Once your proposal has been agreed and signed off, send the completed Impact Assessment Report to impactassessments@nhslothian.scot.nhs.uk for publication on NHS Lothian website. You can use this email address to feed back on the impact assessment process. Evidence Guidance pages 9-15 Evidence used: List the evidence you used, including if you involved people with relevant protected characteristics and lived experience. Evidence was gathered from our Joint Strategic Needs Assessment, financial information and internal service data. Page 353 of 380
Page 354
4 Summary of findings: Include evidence about relevant population demographics, different health and/ or employment inequalities, people’s different needs and how to meet them, barriers and how to address them, inclusion/ participation in the service, diversity in employment and any complaints and feedback. Overall Midlothian’s population is increasing we are projected to have the 22nd highest population out of the 32 council areas in Scotland in 2028. The 75 years old and over age group is projected to see the largest percentage increase (+40.9%) by 2028 in Midlothian. The Midlothian population has been growing and the largest percentage increase is predicted to be in those aged 75 and over. In 2022, 19% of the population in Midlothian were aged 65 and over. As a result, it is likely that numbers of people with a diagnosis of dementia across Midlothian will increase noticeably. Dementia is slightly more common in women than in men which is to be expected with women living on average longer than men. Older people also make up a significant percentage of unpaid carers 36% and 57% of people who are cared for by an unpaid carer are older. Our current gap between life expectancy and healthy life expectancy has increased by 0.9 years for both men and woman since 2019 in Midlothian. Female and male life and healthy life expectancy is comparable to the Scottish average. 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%. There are some areas of Midlothian which are classified as areas of deprivation. The Scottish Index of Multiple Deprivation shows there are currently 10 data zones in Midlothian within the most deprived 20% data zones in Scotland. Two of these data zone is in the most deprived 5%, both in Dalkeith. Examples of the effect of these inequalities on health in Midlothian are early death due to coronary heart disease are 55% higher, hospital stay for a preventable reason is 38% more likely, the difference in Life expectancy is people live 9 years shorter, prescription for anxiety/ depression is 30% higher and there is 24% of children living in poverty. Midlothian is considered a semi-rural community and public transport can be limited within in the county. Page 354 of 380
Page 355
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 5 Impact on equality & socio-economic disadvantage Guidance pages 16-22 Negative impacts Using the evidence you have collected, explain if your proposal could be discriminatory and/ or put a group of people sharing one of these characteristics at a disadvantage for a reason connected to that characteristic. Note – answer yes/ no and if yes provide brief reasons. Relevant group Could your work result in unlawful discrimination? Could your work put people at a disadvantage/ make their lives worse? People in different age groups No Yes, the reduction in transport spending could have significant impact on all ages. Await review outcome to know specific impacts. Disabled people No Yes, the reduction in transport spending would significantly impact this group. Await review outcome to know specific impacts for this population. Trans and non-binary people No No Page 355 of 380
Page 356
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 6 Relevant group Could your work result in unlawful discrimination? Could your work put people at a disadvantage/ make their lives worse? People who are pregnant or on maternity leave No No. People from different ethnic backgrounds No No People with religious or protected beliefs No No Men and women [This may include carers, because many are women.] No No People who are heterosexual, lesbian, gay or bisexual No No People who are married or in a civil partnership [only in employment situations] No No Page 356 of 380
Page 357
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 7 Relevant group Could your work result in unlawful discrimination? Could your work put people at a disadvantage/ make their lives worse? Care experienced people NOTE - there is no legal protection from discrimination on basis of care experience. No Yes, the reduction in transport spending could have significant impact. Await review outcome to know specific impacts. People experiencing health inequalities caused by socio- economic disadvantage [This may include people living in different or difficult circumstances such as people experiencing homelessness, who are in prison or are ex-offenders, people with addictions and people involved with prostitution. Note – travel costs have a particular impact on people experiencing poverty.] NOTE - there is no legal protection from discrimination on basis of socio-economic disadvantage. No Yes, the reduction in transport spending could have significant impact. Await review outcome to know specific impacts. People experiencing employment inequalities caused by socio-economic disadvantage [This may include people living in different or difficult circumstances, such as people experiencing homelessness, who are in prison or NOTE - there is no legal protection from discrimination in employment on basis of socio-economic disadvantage. No Yes, the reduction in transport spending could have significant impact. Await review outcome to know specific impacts. Page 357 of 380
Page 358
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 8 Relevant group Could your work result in unlawful discrimination? Could your work put people at a disadvantage/ make their lives worse? ex-offenders, people with addictions, ex-service personnel/veterans and people involved with prostitution. Note – travel costs have a particular impact on people experiencing poverty.] Carers NOTE - there is no legal protection from discrimination on basis of caring responsibilities. Women continue to have the majority of caring responsibilities and can be put at a particular disadvantage in connection with this. This may be unlawful indirect sex discrimination. No Yes, the reduction in transport spending could have significant impact. Await review outcome to know specific impacts. The reduction in transport services could require more carers time. Page 358 of 380
Page 359
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 9 Positive impact Using the evidence you have collected, explain if and how your proposal could have a positive impact on reducing inequalities experienced by groups of people sharing these characteristics. Note – answer yes/ no and if yes provide brief reasons. Relevant group Can your work advance equality of opportunity? [reduce disadvantage, meet needs, increase participation] Can your work foster good relations? [reduce prejudice + increase tolerance] People in different age groups Yes, reviewing this spending means potentially ensuring those most in need are continuing to be provided for. No Disabled people Yes, reviewing this spending means potentially ensuring those most in need are continuing to be provided for. No Trans and non-binary people No No People who are pregnant or on maternity leave No No People from different ethnic backgrounds No No Page 359 of 380
Page 360
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 10 Relevant group Can your work advance equality of opportunity? [reduce disadvantage, meet needs, increase participation] Can your work foster good relations? [reduce prejudice + increase tolerance] People with religious or protected beliefs No No Men or women [This may include carers, because many are women] No No People who are heterosexual, lesbian, gay or bisexual No No Care experienced people Yes, reviewing this spending means potentially ensuring those most in need are continuing to be provided for. No People who experience health inequalities caused by socio-economic disadvantage [This may include people in different or difficult circumstances, such as people experiencing homelessness, who are in prison or ex-offenders, people with addictions and Yes, reviewing this spending means potentially ensuring those most in need are continuing to be provided for. No Page 360 of 380
Page 361
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 11 Relevant group Can your work advance equality of opportunity? [reduce disadvantage, meet needs, increase participation] Can your work foster good relations? [reduce prejudice + increase tolerance] people involved with prostitution. Note – travel costs have a particular impact on people experiencing poverty.] People who experience employment inequalities caused by socio-economic disadvantage. [This may include people in different or difficult circumstances, such as people experiencing homelessness, who are in prison or ex-offenders, people with addictions, ex- service personnel/veterans and people involved with prostitution. Note – travel costs have a particular impact on people experiencing poverty.] Yes, reviewing this spending means potentially ensuring those most in need are continuing to be provided for. No Carers Yes, reviewing this spending means potentially ensuring those most in need are continuing to be provided for. No Page 361 of 380
Page 362
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 12 Impact on UNCRC rights Guidance pages 23-25 If your proposal does not affect children and young people do not complete this section. If your proposal affects children and young people, use the evidence you have collected to explain how your proposal could impact Children’s Rights. Not all UNCRC rights may apply to your proposal. If this is the case, simply say ‘Not relevant’ or ‘no known relevance’. UNCRC right How will your work limit or restrict this right? How will your work progress this right? Are any groups of children particularly impacted 3 – best interests of the child 4. making rights real 5 – family guidance as children develop 6 – life, survival and development Page 362 of 380
Page 363
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 13 UNCRC right How will your work limit or restrict this right? How will your work progress this right? Are any groups of children particularly impacted 7 – name and nationality 8 – identity 9 – keeping families together 10 - contact with parents across countries 11 – protection from kidnapping 12 – respect for children’s views Page 363 of 380
Page 364
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 14 UNCRC right How will your work limit or restrict this right? How will your work progress this right? Are any groups of children particularly impacted 13 – sharing thoughts freely 14 – freedom of thought and religion 15 –freedom of association and peaceful assembly 16 – protection of privacy 17 – access to information 18 – responsibility of parents Page 364 of 380
Page 365
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 15 UNCRC right How will your work limit or restrict this right? How will your work progress this right? Are any groups of children particularly impacted 19 – protection from violence 20 – children without families 21 – children who are adopted 22 – refugee children 23 – disabled children 24 – enjoyment of the highest attainable standard of health Page 365 of 380
Page 366
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 16 UNCRC right How will your work limit or restrict this right? How will your work progress this right? Are any groups of children particularly impacted 25 – review of a child’s placement 26 – social and economic help 27 – food, clothing and safe home 28 – access to education 29 – aims of education 30 – minority culture, language and religion Page 366 of 380
Page 367
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 17 UNCRC right How will your work limit or restrict this right? How will your work progress this right? Are any groups of children particularly impacted 31 – rest, play, culture, arts 32 – protection from harmful work 33 – protection from harmful drugs 34 – protection from sexual abuse 35 – prevention of sale and trafficking 36 – protection from exploitation Page 367 of 380
Page 368
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 18 UNCRC right How will your work limit or restrict this right? How will your work progress this right? Are any groups of children particularly impacted 37 – children in detention 38 – protection in war 39 – recovery and reintegration Page 368 of 380
Page 369
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 19 Making a difference What changes will you make to your proposal based on the results of this impact assessment? Changes What difference this will make Continue to work alongside the transformational blueprint work and try to mitigate risks and impacts where possible. Potentially limit the impacts of those most in need. Page 369 of 380
Page 370
Equality. Fairer Scotland. Children’s Rights. Impact Assessment Report 20 Sharing with decision-makers Guidance page 26 Explain how you will make sure the results of your impact assessment will be taken into account by decision-makers before a final decision is taken. Monitoring the impact Guidance page 27 How will you monitor the actual impact of this piece of work on equality, socio-economic disadvantage or children’s rights? Performance Indicator for equality, socio-economic disadvantage and children’s rights. What impact are you measuring Report quarterly on outnav indicators Population needs Finance Outcomes Page 370 of 380
Page 371
Midlothian Integration Joint Board Thursday, 20th June 2024, 14:00-16:00 MELDAP Finance and Delivery Report Executive summary Midlothian and East Lothian Drugs and Alcohol Partnership (MELDAP) is the local Alcohol and Drugs Partnership (ADP). As such MELDAP is required to report on an annual basis on aspects of service delivery and ministerial priorities as directed by the Scottish Government. This report highlights MELDAP’s finance and performance in relation to the Scottish Government Access and Medication Assisted Treatment (MAT) Standards. Members are asked to: • to note the financial information in Section 3. • to recognise the performance of MELDAP and its services in meeting Scottish Government Access and Medication Assisted Treatment (MAT) Standards. # Item number: 5.14 Page 371 of 380
Page 372
Midlothian Integration Joint Board Midlothian Integration Joint Board MELDAP Finance and Delivery Report 1 Purpose 1.1 This report provides an overview of MELDAP, including a financial summary and performance against key Scottish Government priorities. 2 Recommendations 2.1 The Midlothian Integration Joint Board (IJB) is asked to note the financial information in Table 1. 2.2 The IJB is asked to recognise the performance of MELDAP and its services in meeting Scottish Government Access and Medication Assisted Treatment (MAT) Standards. 3 Background and main report 3.1 Aims & Objectives MELDAP’s primary aim is to co-ordinate the design, commissioning and delivery of alcohol and drug services across East Lothian and Midlothian, to ensure that these services are needs led, recovery focused, based on evidence of what makes a difference and are delivered in an effective, efficient way. A key component in the achievement of this aim will be that services are designed around the needs of people who use and need our services, and their families who play an integral part in their design and evaluation. 3.2 MELDAP also aims to: • Reduce the harm to individuals and promote recovery from substance use. • Protect children and young people from the effects of parental substance use. • Promote early intervention to prevent the harmful use of alcohol and drugs. • Develop high quality services responsive to the changing needs of people who use our services. • Challenge the stigma and discrimination people who use substances experience. Financial Overview 3.3 Funding for MELDAP is divided into two sections: core funding and additional investments for priority areas. Core funding consists of recurring allocations from the NHS, Midlothian Council, and the Scottish Government. Additional investments are fixed-term allocations from the Scottish Government aimed at addressing priority areas outlined in the National Drugs Mission. These priority areas include: Page 372 of 380
Page 373
Midlothian Integration Joint Board • Whole Family Approaches • Drugs Mission • Residential Care • Outreach and Near Fatal Overdose • MAT Implementation 3.4 The table below shows the detail for each of the allocations: Type Value (£k) Comments Core 1,600 Recurring Funding Whole Family Approach 65 Ends April 2026 Drugs Mission 91 Ends April 2026 Residential Care 92 Ends April 2026 Stabilisation 45 Ends April 2026 Lived & Living Experience 9 Ends April 2026 Outreach and Near Fatal Overdose 112 Ends April 2026 MAT Implementation 270 Ends April 2026 Total 2,284 3.5 MELDAP commissions services from a range of providers to ensure effective and quality care is provided. A high-level overview of the investment profiles is shown below: Organisation Value (£k) Share (%) NHS 1,281 56 Social Care 121 5 Third Sector 882 39 Total 2,284 100% 3.6 MELDAP produce a balanced plan each year and report spend through the overarching MELDAP Strategic Group and local financial governance groups. 3.7 As the MELDAP funding is earmarked it is not subject to the requirement to produce financial recovery plans, however given the current financial climate there is a further focus on reviewing all investments to ensure best value. 3.8 One of the biggest financial risks associated to drug treatment services is the rollout out of Buvidal. 3.9 In October 2021 the Scottish Government instructed that areas should support a switch from current opiate substitution therapy (OST) formulations to Buvidal. The costs of Buvidal are on average £2.2k per patient more expensive than oral Methadone/oral Buprenorphine. There has been no additional funding allocated to cover the rollout which has resulted in a financial pressure to NHS Lothian due to the uptake and cost of the medicine. Below shows the Buvidal spend increase year on year: Page 373 of 380
Page 374
Midlothian Integration Joint Board Delivery and Outcomes (Implementation of the National Medication Assisted Treatment (MAT) Standards and other work) 3.10 The 10 MAT standards were introduced in 2020 and structured around the principles of Access, Choice, and Support. A key aim of the standards is to place people at the centre of our services and the importance of treating individuals with dignity and respect, being non-judgemental in all our approaches. This approach reflects the human rights-based approach set out in Rights, Respect and Recovery: Alcohol and Drugs Treatment Strategy (2018), and is closely aligned to the recommendations in the final 2022 report by the Scottish Drugs Deaths Taskforce: Changing Lives. 3.11 In June 2023, following submission of process, numerical and experiential evidence to the MAT Implementation Support Team (MIST) from the Scottish Government, MELDAP and its services were awarded a RAG status of provisional Green for MAT standards 1 to 5. 3.12 MELDAP and its services submitted process, numerical and experiential evidence to MIST in mid-April 2024 in relation to the assessment of sustained performance of MAT standards 1 to 5 and initial implementation of MAT Standards 6-10, which are to be fully implemented by April 2025. 3.13 Whilst indications are that MELDAP and its services have met and exceeded Scottish Government expectations, we will be formally advised of final Red, Amber, Green (RAG) assessment in June 2024. 3.14 MELDAP services in Midlothian meet the Access Standard set by the Scottish Government. This requires that 90% of people are seen (referral to treatment) within 3 weeks and 100% within 5 weeks. Performance for Q4 of 2023/24 is 100% within 3 weeks. 3.15 National research indicates that being in service is a protective factor in relation to reducing the risk of near fatal/fatal overdose and alcohol specific illness and death. To this end, over the last few years MELDAP, has introduced a direct support Contact Service provided through a 3rd sector provider. This ensures that people can call and receive immediate advice, information and support into treatment, psycho-social assistance, recovery support and other service provision. Based on 20/21 21/22 22/23 23/24 Series1 41 45 88 128 0 20 40 60 80 100 120 140 Spend (£k) Page 374 of 380
Page 375
Midlothian Integration Joint Board comments from people and families we are also currently piloting an out of hours Contact service extension in both East Lothian and Midlothian. 3.16 MELDAP continues to support the Horizons Recovery Café in Dalkeith. 3.17 In 2023/24, MELDAP also assisted and funded the development of “Low Threshold” Café in Penicuik with the specific remit of assisting those who are not yet accessing treatment and support services to engage with this type of service provision. 4 Policy Implications 4.1 No Policy Implications are noted. 5 Directions 5.1 This report does not need a new direction and has no implications for current directions. 6 Equalities Implications 6.1 The subject of this report does not affect the wellbeing of the community or have a significant impact on equality, the environment or economy. 7 Resource Implications 7.1 Financial Information is noted in the table at Section 3. 8 Risk 8.1 No risks identified for 2024/25 9 Involving people 9.1 The MELDAP Strategic Group (which includes representatives from the HSCP, Police and 3rd Sector) has oversight and responsibility for the financial spend. MELDAP are currently working on potential measures to sustain a balanced budget for 2025/26. 9.2 A further paper is to be taken to the MELDAP Strategic Group setting out options and recommendations for action. If this is agreed by the Strategic Group, MELDAP will move forward with the work in full collaboration with partners. 10 Background Papers 10.1 No background papers. AUTHOR’S NAME Nick Clater DESIGNATION Head of Adult Services & Deputy Chief Social Work Officer CONTACT INFO nick.clater@midlothian.gov.uk DATE 20th June 2024 Page 375 of 380
Page 376
Midlothian Integration Joint Board Appendices: Appendix 1: The Medication Assisted Treatment Standards (MAT Standards) Page 376 of 380
Page 377
Appendix One: The Medication Assisted Treatment Standards (MAT Standards) MAT 1. All people accessing services have the option to start MAT from the same day of presentation. MAT 2. All people are supported to make an informed choice on what medication to use for MAT, and the appropriate dose. MAT 3. All people at high risk of drug-related harm are proactively identified and offered support to commence or continue MAT. MAT 4. All people are offered evidence-based harm reduction at the point of MAT delivery. MAT 5. All people will receive support to remain in treatment for as long as requested. MAT 6 . Psychological Support - The system that provides MAT is psychologically informed (tier 1); routinely delivers evidence-based low intensity psychosocial interventions (tier 2); and supports individuals to grow social networks. MAT 7. All people have the option of MAT shared with Primary Care. MAT 8. Independent Advocacy and Social Support - All people have access to independent advocacy and support for housing, welfare and income needs. MAT 9. Mental Health - All people with co-occurring drug use and mental health difficulties can receive mental health care at the point of MAT delivery. MAT 10. Trauma Informed Care - All people receive trauma informed care. Page 377 of 380
Page 378
Page 378 of 380
Page 379
Appendix One: The Medication Assisted Treatment Standards (MAT Standards) MAT 1. All people accessing services have the option to start MAT from the same day of presentation. MAT 2. All people are supported to make an informed choice on what medication to use for MAT, and the appropriate dose. MAT 3. All people at high risk of drug-related harm are proactively identified and offered support to commence or continue MAT. MAT 4. All people are offered evidence-based harm reduction at the point of MAT delivery. MAT 5. All people will receive support to remain in treatment for as long as requested. MAT 6 . Psychological Support - The system that provides MAT is psychologically informed (tier 1); routinely delivers evidence-based low intensity psychosocial interventions (tier 2); and supports individuals to grow social networks. MAT 7. All people have the option of MAT shared with Primary Care. MAT 8. Independent Advocacy and Social Support - All people have access to independent advocacy and support for housing, welfare and income needs. MAT 9. Mental Health - All people with co-occurring drug use and mental health difficulties can receive mental health care at the point of MAT delivery. MAT 10. Trauma Informed Care - All people receive trauma informed care. Page 379 of 380
Page 380
Page 380 of 380