Agenda Document Pack - Midlothian Integration Joint Board - 13/10/2022
Midlothian Council · 13 October 2022
Back to Midlothian Integration Joint Board — 13 October 2022 and its agenda
Text extracted from the council's PDF. Layout and reading order may differ from the original.
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Notice of Meeting and Agenda Midlothian Integration Joint Board Venue: Virtual Meeting, Date: Thursday, 13 October 2022 Time: 14:00 Morag Barrow Chief Officer Contact: Clerk Name: Mike Broadway Clerk Telephone: 0131 271 3160 Clerk Email: mike.broadway@midlothian.gov.uk Further Information: This is a meeting which is open to members of the public. Page 1 of 276
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1 Welcome, Introductions and Apologies 2 Order of Business Including notice of new business submitted as urgent for consideration at the end of the meeting. 3 Declaration of Interest Members should declare any financial and non-financial interests they have in the items of business for consideration, identifying the relevant agenda item and the nature of their interest. 4 Minute of Previous Meeting 4.1 Minutes of the MIJB held of 25th August 2022 - for Approval 5 - 14 4.2 Minutes of the Special MIJB of 15th September 2022 - for Approval 15 - 20 4.3 Minutes of Audit and Risk Committee of 29th June 2022 - for Noting 21 - 26 4.4 Minutes of the Strategic Planning Group of 3rd August 2022 - for Noting 27 - 32 5 Public Reports 5.1 Chair’s Update – Val de Souza, Chair (14.10 -14.20) 5.2 Chief Officer Report - Morag Barrow, Chief Officer (14.20 -14.35) 33 - 38 5.3 Appointment of Audit and Risk Committee Member - Morag Barrow, Chief Officer 39 - 42 For Decision 5.4 Annual Performance Report 2021-22 - Gill Main, Integration Manager (14.35 - 14.40) 43 - 110 For Discussion 5.5 IJB Board Meeting Options - Roxanne Watson, Executive Business Manager (14.40 - 14.55) 111 - 116 5.6 IJB Draft Performance Framework (Phase 1) - Elouise Johnstone, Programme Manager for Performance (14.55 -15.05) 117 - 192 5.7 The CRT Dashboard: informing Practice and Improving Outcomes Presentation (Verbal Update) from Claire Yerramasu, Page 2 of 276
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Advance Practice Physiotherapist and Team Lead Physiotherapist (15.05 -15.25) 5.8 IJB Improvement Goals - Elouise Johnstone, Programme Manager for Performance (15.25 - 15.35) 193 - 212 For Noting 5.9 Integrated Care Assurance Report - Fiona Stratton, Chief Nurse (15.35 - 15.50) 213 - 242 5.10 Implementation of Medication Assisted Treatment Standards in Midlothian - Nick Clater, Head of Adult Services (15:50 - 15:55) 243 - 270 5.11 Finance Update – end of August 2022 - Claire Flannagan, Chief Finance Officer (15.55 - 16.00) 271 - 276 ( ) indicative timings. 6 Private Reports No items for discussion. 7 Date of Next Meeting The next meeting will be held on: • 17th November 2022 at 14.00 - Development Workshop (Public Protection) for Board Members only • 15th December 2022 at 14.00 - Midlothian Integration Joint Board Page 3 of 276
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Midlothian Integration Joint Board Meeting Date Time Venue Midlothian Integration Joint Board Thursday 25 August 2022 2.00pm Virtual Meeting held using Microsoft Teams. Present (voting members): Carolyn Hirst (Chair) Val de Souza Jock Encombe Angus McCann Cllr Derek Milligan Cllr Dianne Alexander (substitute for Cllr Colin Cassidy Cllr Connor McManus (substitute for Cllr Kelly Parry) Present (non-voting members): Nick Clater (Head of Adult & Social Care) Claire Flanagan (Chief Finance Officer) Fiona Stratton (Chief Nurse) Johanne Simpson (Medical Practitioner) Rebecca Green (Clinical Director) Grace Chalmers (Staff side representative) Wanda Fairgrieve (Staff side representative) Hannah Cairns (Allied Health Professional) Keith Chapman (User/Carer) Miriam Leighton (Third Sector) In attendance: Cllr Willie McEwan Nadin Akita Sandy Watson (Lead Pharmacist) Grace Cowan (Head of Primary Care and Older Peoples Services) Gill Main (Integration Manager) Elouise Johnstone (Programme Manager for Performance) Roxanne King (Executive Business Manager) Fiona Cadogan (Assistant Strategic Manager) Mike Broadway (Clerk) Apologies: Cllr Colin Cassidy (Vice Chair) Cllr Kelly Parry Cllr Pauline Winchester Cllr Stuart McKenzie (Proxy Member) Morag Barrow (Chief Officer) Joan Tranent (Chief Social Work Officer) Midlothian Integration Joint Board Thursday 13 October 2022 Item No 4.1 Page 5 of 276
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2 Midlothian Integration Joint Board Thursday 25 August 2022 1. Welcome and Introductions The Chair, Carolyn Hirst, in welcoming everyone to this virtual Meeting of the Midlothian Integration Joint Board, expressed her thanks for all the support given to her during her time as Chair, this being her final meeting before she retired as an NHS Lothian Non-Executive Board Member. She also extended a warm welcome on behalf of the Board to Rebecca Green (Clinical Director) and Johanne Simpson (Medical Practitioner). 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 Minutes of Meeting of the Midlothian Integration Joint Board held on 16 June 2022 were submitted and approved as a correct record. 4.2 The Minutes of Meeting of the MIJB Audit and Risk Committee held on 3 March 2022 were submitted and noted. 4.3 The Minutes of Meeting of the MIJB Strategic Planning Group held on 22 May 2022 were submitted and noted. 5. Public Reports Report Title/Summary Decision Action Owner Date to be Completed/Comments 5.1 Chief Officers Report This report provided a summary of the key service pressures and service developments which had occurred during the previous months across health and social care as well as looking ahead at future developments. Noted the issues and updates arising from the Chief Officers Report. Page 6 of 276
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3 Midlothian Integration Joint Board Thursday 25 August 2022 Report Title/Summary Decision Action Owner Date to be Completed/Comments Having heard from Nick Clater (Head of Adult & Social Care) on behalf of the Chief Officer in amplification of the report, the Board discussed the winter flu and covid-19 booster vaccination roll out, drug-related death figures for Midlothian, which it was noted would be the subject of the September IJB Development Session, and demand for aids and adaptation. 5.2 Chair’s Update - Presented by Carolyn Hirst Carolyn Hirst thanked all those involved in the recent Induction Sessions and hoped that Board Members had found them helpful. With regards the governance documentation circulated by the Standards Officer in advance of the sessions, she encouraged Members to complete and return the necessary information as quickly as possible if they had not already done so, and if anyone was having any difficulties completing any of it to just ask as help was available. Carolyn conclude by reminding everyone about the upcoming Development Workshop session on 15th September on the subject of substance use. Noted the Chairs update All To Note 5.3 Membership of Integration Joint Board - Report by Mike Broadway, Clerk to the Board and presented by Carolyn Hirst, Chair The purpose of this report was to seek the Board’s endorsement of nominations for NHS Lothian’s non- voting members on the Midlothian Integration Joint Board. (a) Agreed to endorse the NHS Lothian Board’s nominations for non-voting members of the Midlothian Integration Joint Board; and (b) Welcomed existing and new colleagues to the Midlothian IJB. Page 7 of 276
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4 Midlothian Integration Joint Board Thursday 25 August 2022 Report Title/Summary Decision Action Owner Date to be Completed/Comments The report explained that at the NHS Lothian Board meeting on 3 August 2022 it was agreed that:- • Dr Johanne Simpson who currently sits on the Midlothian IJB as a non-voting member and as the Board’s nominated “…registered medical practitioner employed by the health board and not providing primary medical services” - be re- appointed for a second three-year term, from 2 October 2022 to 1 October 2025; and • Dr Rebecca Green who took up post as the new Clinical Director of the Midlothian HSCP from 18 July 2022 be appointed as a new non-voting member of the Midlothian IJB and specifically as the “…registered medical practitioner whose name is on the list of primary medical services performers…”, to apply retrospectively from her date of appointment for a period of 3 years (18 July 2022 to 17 July 2025). 5.4 Records Management Plan Update - Paper presented by Roxanne Watson, Executive Business Manager. With reference to paragraph 5.4 of the Minutes of 11 October 2018, there was submitted a report the purpose of which was to update Members on the required updates and recommendations for the IJB Record Management Plan. Following the completion of proposed amendments, the IJB Records Management Plan would be submitted to the Record Keeper for review and feedback. This would form part (a) Approved the recommended updates as detailed in the report; (b) Noted the actions and agreed to review the completed Records Management Plan at a later meeting to allow the re-issue to the Records Keeper; (c) Agreed to receive quarterly updates on progress against the finalised action plan; and Page 8 of 276
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5 Midlothian Integration Joint Board Thursday 25 August 2022 Report Title/Summary Decision Action Owner Date to be Completed/Comments of the action plan, progress against which would be communicated to the IJB. The report explained that the Public Records (Scotland) Act 2011 required IJBs to develop a Records Management Plan (RMP). The IJBs current RMP was submitted to the Records Keeper in 2018. Recommendations were received from the Records Keeper in 2019, but due to pressures relating to the Covid-19 pandemic, work in this area was put on hold. The Board, having heard from Executive Business Manager, Roxanne Watson who having taken Members through the recommended changes and actions, responded to Members’ question and comments, acknowledged the importance of having an up-to-date Records Management Plan and proposed that rather than set up a separate local RMP planning group to provide further assurance on the governance of Records Management, the Strategic Planning Group be tasked with this role. (d) Agreed that the Strategic Planning Group be tasked with providing further assurance to the governance of Records Management. 5.5 Draft Annual Performance Report 2021-22 - Paper presented by Gill Main, Integration Manager. The purpose of this report was to update Members on the preparation, and proposed contents, of the draft Midlothian Annual Performance Report 2021/22, which would be presented to the October Board meeting for approval. (a) Noted the proposed content of the Annual Performance Report; (b) Noted that work on how IJBs took assurance on Hosted and Set Aside Services was currently ongoing; and (c) Noted an invitation to the Strategic Planning Group to discuss a full draft on 14th September 2022. Page 9 of 276
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6 Midlothian Integration Joint Board Thursday 25 August 2022 Report Title/Summary Decision Action Owner Date to be Completed/Comments The report advised that the Annual Performance Report provided information on the health and wellbeing of the people of Midlothian and an assessment of performance towards achieving the 9 National Health and Wellbeing Outcomes. It also described the financial performance of the IJB, and the quality of health and care services delivered during 2021-22. Integration Manager, Gill Main in speaking to the report provided the Board with a broad overview of the progress which had been made and thereafter responded to Members’ questions and comments. The Board, in considering the draft Annual Performance Report, discussed the issue of Hosted and Set Aside Services and how assurance was taken so that they could be included within the Annual Performance Report (APR), it being noted that work was in progress to include content in relation to the services hosted within Midlothian. Pan-Lothian discussion to enable hosted services to consistently report disaggregated performance data for each HSCP area is underway, but currently not available. In relation to Set Aside Services, it was also noted that steps to establish regular, targeted reporting is underway, but it would not be possible to retrospectively report for the 2021-22 Annual Report. The draft 2021-22 APR would be reviewed in more detail at the September Strategic Planning Group meeting to which all Board Member would be invited. Page 10 of 276
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7 Midlothian Integration Joint Board Thursday 25 August 2022 Report Title/Summary Decision Action Owner Date to be Completed/Comments 5.5 Learning Disability Service Update - Paper presented by Nick Clater, Head of Adult Services. With reference to paragraph 5.6 of the Minutes of 9 December 2021, there was submitted a report the purpose of which was to provide an update on Learning Disability services within Midlothian Health and Social Care Partnership (MHSCP). The report summarised the key points arising out of the analysis of the Learning Disability (LD) social care expenditure for MHSCP and the financial governance in place around LD expenditure. Identified some of the complexities around managing the cumulative expenditure where the scope for changing individual care packages can be limited. It also explored possible options to mitigate financial pressures and their potential impacts concluding the need for a review of Learning Disability services, involving a review of the full model of care, including transport costs; commissioned services’ funding and day service provision. The Board, having heard from Head of Adult & Social Care, Nick Clater, who provided an overview of the report and current position, before responding to Members’ question and comments, discussed the potential possible options detailed in the report, expressing support for the proposed review, but suggesting a 9 month timescale rather than the suggested 6 months. (a) Noted the contents of the report (b) Agreed that a review of Learning Disability services be progressed and concluded within a 9 months. Page 11 of 276
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8 Midlothian Integration Joint Board Thursday 25 August 2022 Report Title/Summary Decision Action Owner Date to be Completed/Comments 5.7 Clinical and Care Governance Group - Report by Fiona Stratton, Chief Nurse The purpose of this report was to provide assurance to the Board regarding the Care and Clinical Governance arrangements within Midlothian Health and Social Care Partnership and to provide an update on the work of the Clinical and Care Governance Group. Chief Nurse, Fiona Stratton was heard in amplification of the report, highlighted in particular the planned phased implementation of a Governance Assurance Framework across all operational teams and professional groups. This refreshed approach would in turn provide an opportunity for consideration to be given to how the HSCP reports assurance to the IJB, which was welcomed by Members. (a) Noted and approved the contents of the report. (b) Noted that an integrated assurance report will in future be provided that delivers assurance on clinical, care and business governance, and that this would hopefully commence from October 2022 5.8 Update to IJB Improvement Goals - Paper presented by Elouise Johnstone, Programme Manager for Performance. The purpose of this report was to update the Board on progress towards achieving the current IJB performance goals for the financial year 2022/23 and to provide an update on progress within the Spotlight programme. Programme Manager for Performance, Elouise Johnstone was heard in amplification of the report and thereafter responded to Members questions and (a) Noted the performance against the IJB Improvement Goals for 2022/23; and (b) Noted the update in relation to the Spotlight Programme. Page 12 of 276
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9 Midlothian Integration Joint Board Thursday 25 August 2022 Report Title/Summary Decision Action Owner Date to be Completed/Comments comments, following which there was a general discussion regarding the progress being made. 5.9 National Care Service (Scotland) Bill - Paper presented by Nick Clater, Head of Adult Services. The purpose of this report was to provide the Board with a summary of the key components of the National Care Service (Scotland) Bill which had been introduced to the Scottish Parliament on Monday 20 June and published on 21 June. The Bill set out a framework for community health, social care and social work, with the legal powers being enacted from 2026 onwards. Services would continue to be designed and delivered locally in response to need. Whilst the full implications of the Bill were still unclear at this point in time, the IJB would be kept up to date with developments as the Bill progresses The Board, having heard from Nick Clater, Head of Adult Services who thereafter responded to Members’ questions and comments, discussed some of the implications that might arise from the Bill. Noted the update relating to National Care Service (NCS) development. 5.10 Midlothian Community Pharmacy (Independent Contractors) Update Paper presented by Sandy Watson, Lead Pharmacist. The purpose of this report was to provide the Board with an update on the current service within community pharmacy in Midlothian with respect to (a) Noted the contents of the report. (b) Noted that a further report would be brought to the Board. Integration Manager Page 13 of 276
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10 Midlothian Integration Joint Board Thursday 25 August 2022 Report Title/Summary Decision Action Owner Date to be Completed/Comments demand and activity within core and enhanced services, as defined within the NHS Lothian Board Pharmaceutical Care Services Plan; and to advise of actions being taken by independent contractors to address current workforce challenges and associated short term, unplanned closures of community pharmacies. The Board, having heard from Lead Pharmacist Sandy Watson, who thereafter responded to Members questions and comments, considered the report and discussed the current Community Pharmacy provision. 6. Private Reports No private business to be discussed at this meeting. 7. Any other business Board Members joined Val de Souza in expressing their thanks to Carolyn Hirst for all her hard work as both a Member and latterly as the Chair of the Midlothian Board. Carolyn thanked everyone for their kind words and wished the Board every future success. 8. Date of next meeting The next meetings of the Midlothian Integration Joint Board would be held on: • Thursday 15 September 2022 2.00pm Special Midlothian Integration Joint Board/Development Workshop. • Thursday 13 October 2022 2.00pm Midlothian Integration Joint Board (Action: All Members to Note) The meeting terminated at 16:10. Page 14 of 276
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Midlothian Integration Joint Board Meeting Date Time Venue Special Midlothian Integration Joint Board Thursday 15 September 2022 2.00pm Virtual Meeting held using Microsoft Teams. Present (voting members): Val de Souza (Chair) Cllr Colin Cassidy (Vice Chair) Nadin Akta Jock Encombe Angus McCann Cllr Derek Milligan Cllr Kelly Parry Cllr Pauline Winchester Present (non-voting members): Morag Barrow (Chief Officer) Hannah Cairns (Allied Health Professional) Grace Chalmers (Staff side representative) Claire Flanagan (Chief Finance Officer) Rebecca Green (Clinical Director) Fiona Stratton (Chief Nurse) In attendance: Nick Clater (Head of Adult Services) Grace Cowan (Head of Primary Care and Older Peoples Services) Karen Darroch (Services Manager, Mental Health & Substance Misuse) Elouise Johnstone (Programme Manager) Gill Main (Integration Manager) Cllr Willie McEwan Cllr Stuart McKenzie Jim Sherval (Public Health Practitioner) Roxanne Watson (Executive Business Manager) Andrew Henderson (Clerk) Apologies: Joan Tranent (Chief Officer Children’s Services, Partnerships and Communities) Midlothian Integration Joint Board Thursday 13 October 2022 Item No: 4.2 Page 15 of 276
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2 Special Midlothian Integration Joint Board Thursday 15 September 2022 1. Welcome and Introductions The Chair of the Midlothian Integration Joint Board, Val de Souza, expressed the board’s heartfelt condolences to the Royal Family following the death of Queen Elizabeth II. Val de Souza then took the opportunity to welcome new and returning members to the Special Meeting of the Midlothian Integration Joint Board. 2. Order of Business The order of business was confirmed as outlined in the agenda that had been previously circulated. 3. Declarations of interest None 4. Public Reports Report Title/Summary Decision Action Owner Date to be Completed/Comments 4.1 Chair's Update By way of a chairs update, Val de Souza thanked the former Chair of the MIJB, Carolyn Hirst, for her work on the board and outlined her intention to meet with all of the board members individually over the coming months. Val de Souza highlighted that a development session would be arranged in future on the topics of Public Protection and Clinical Care and Governance. Val de Souza then made reference to the National enquiry into the handling of the pandemic and requested that documents that led to decisions being made be retained. Noted the Chairs update All to note. Page 16 of 276
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3 Special Midlothian Integration Joint Board Thursday 15 September 2022 Report Title/Summary Decision Action Owner Date to be Completed/Comments 4.2 2021/22 Audited Annual Accounts - Paper presented by Claire Flanagan, Chief Finance Officer. Claire Flanagan provided an overview of the of the audited annual accounts for 2021/22 highlighting that the accounts had been approved by the MIJB Audit and Risk committee in September acknowledging elements contained in appendix D that required following up. Claire Flanagan further highlighted a duplication in table 5 that would be removed prior to the final sign off. Reference was made to the year end position, underspends carried forward as earmarked reserves and the final reserve position. Claire Flanagan then responded to points of clarity. In relation to the change in budget monitoring throughout the year, Claire Flanagan acknowledged that EY had raised concerns with regard to the completeness of reporting over the previous year in relation to the Chief Finance Officer’s temporary cover and confirmed that following conversations with internal and external auditors since returning from leave that she would be reverting to the previous style of budget reporting used prior to 21/22. With regard to EY’s comments on shared services in relation to the Chief Finance Officer, Morag Barrow highlighted that she would discuss this with Val de Souza going forward. Reference was made to risks and mitigation and it was highlighted that with regard to workforce a) Board members noted the report of the independent auditor and; b) Approved the IJB’s annual accounts for 2021/22 All to note Chief Finance Officer Page 17 of 276
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4 Special Midlothian Integration Joint Board Thursday 15 September 2022 Report Title/Summary Decision Action Owner Date to be Completed/Comments pressures specific recognition should be given to social care and the risks caused as a result notional funding. Claire Flanagan clarified that as this was the final document, narrative changes could not be made but agreed to make specific reference in the risk section of the financial plan document. 4.3 Finance Update: Quarter 1 2022/23 - Paper presented by Claire Flanagan, Chief Finance Officer. Claire Flanagan provided an overview Finance Update: Quarter 1 2022/23 report highlighting £900,000 in projected overspends and that further reports would be brought in the future. Claire Flanagan further outlined services that would continue to be supported with COVID-19 funding that would be reported to the Scottish Government as ongoing COVID-19 expenditure. Claire Flanagan confirmed that a letter has been received from the Scottish Government regarding the reclaiming of MIJB unrequired COVID funds that had been allocated by Scottish Government, to cover wider national pressures. Claire Flanagan has discussed this with directors and confirmed a Q2 return will be produced, and that concerns regarding system pressures had been fed back. Claire Flanagan then agreed to circulate the letter from the Scottish Government amongst Board members. A discussion ensued in relation to overspend. Claire Flanagan highlighted that, given the national financial challenges at present, the MIJB continues to work with a) Noted the quarter one financial review undertaken by partners. b) Noted the COVID exit planning. c) Letter from Scottish Government regarding return of unspent COVID 19 funds to be circulated amongst board members. All to note All to note Chief Finance Officer Page 18 of 276
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5 Special Midlothian Integration Joint Board Thursday 15 September 2022 Report Title/Summary Decision Action Owner Date to be Completed/Comments NHS Lothian and Midlothian Council to ensure spending was appropriately directed and that a general reserve was in place and that the MIJB would need to continue to work with its partner organisations to ensure a continued break-even position going forward. Morag Barrow took the opportunity to highlight that overspends generally hailed from pharmaceutical costs and agency staff costs, relating to the national staff shortages. In response to comments regarding the Out Patient services provided at Midlothian Community Hospital, it was highlighted that several additional services had been secured including Audiology, Parkinson’s and Bladder and Bowel clinics. 4.4 2022/23 IJB Directions – Part Year Update - Paper presented by Gill Main, Integration Manager and Elouise Johnstone, Programme Manager for Performance. Gill Main provided a brief overview of the IJB Directions – Part Year Update – Paper, highlighting that this was a high level report due to the number of Directions, and to advise the Board on the RAG status. Gill Main then took the opportunity to respond to points of clarity. Gill Main clarified that in relation to the RAG status, red signified a delay, amber signified underway and green was on target for the end of the year. a) Members reviewed the part year performance updates for the 2022-23 Directions reviewed in detail by the Strategic Planning Group on the 14th of September 2022; b) Noted an invitation to Board members to join the executive HSCP team in a short series of workshops in late 2022 to develop strategic Directions for 2023-24; All to note All to note Page 19 of 276
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6 Special Midlothian Integration Joint Board Thursday 15 September 2022 5. Private Reports No private reports were submitted for consideration. 8. Date of next meeting The next meetings of the Midlothian Integration Joint Board would be held on: • Thursday 13 October 2022 • Thursday 10 November 2022 2.00pm 2.00pm MIJB Board Development Session (Action: All Members to Note) The meeting terminated at 15:10 Report Title/Summary Decision Action Owner Date to be Completed/Comments c) Considered recommendations to close, amend or replace Directions that have been identified for immediate review; d) And noted the intention to bring a final position on the 2022-23 Directions in February 2023 for the review and modification of proposed 2023-24 Directions ahead of approval in March 2023 and publication on 1st April 2023. Integration manager All to note Page 20 of 276
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Midlothian Integration Joint Board Meeting Date Time Venue Audit and Risk Committee Thursday 29 June 2022 9.00am Virtual Meeting held using MS Teams. Present (voting members): Cllr Colin Cassidy (Chair) Carolyn Hirst Councillor Kelly Parry Jock Encombe Pam Russell (Independent Member) Present (non-voting members): Morag Barrow (Chief Officer) Claire Flanagan (Chief Finance Officer) Jill Stacey (Chief Internal Auditor) In attendance: Grace Scanlin (EY, External Auditor) Roxanne Watson (Executive Business Manager) Mike Broadway (Clerk) Apologies: Stephen Reid (EY, External Auditor) Midlothian Integration Joint Board Thursday 13 October 2022 Item 4.3 Page 21 of 276
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2 Audit and Risk Committee Thursday 29 June 2022 1. Welcome and introductions The Chair, Councillor Colin Cassidy, welcomed everyone to this virtual meeting of the Audit and Risk Committee, following which there was a round of introductions. 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 at this stage of the proceedings. 4. Minutes of Meeting 4.1 The Minutes of Meeting of the Audit and Risk Committee held on 3 March 2022 was submitted and approved as a correct record. 5. Public Reports Report Title/Summary Decision Action Owner Date to be Completed/Comments 5.1 Midlothian IJB Internal Audit Annual Assurance Report 2021/22 – Report by Chief Internal Auditor. The purpose of this report was to present the Internal Audit Annual Assurance Report 2021/22 for the Midlothian Integration Joint Board (MIJB) which included the Chief Internal Auditor’s independent assurance opinion on the adequacy of the MIJB's overall control environment for the year ended 31 March 2022. (a) Noted the assurances contained within the Report and that a further report on the recently adopted CIPFA Code would be brought to the September meeting; (b) Agreed that the issue of the flow of information required by MIJB for assurance purposed be taken up with the Partners; and (c) Approve the Midlothian Integration Joint Board Internal Audit Annual Assurance Report 2021/22. Chief Finance Officer Chief Officer/ Chief Internal Auditor Chief Internal Auditor September 2022 Page 22 of 276
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3 Audit and Risk Committee Thursday 29 June 2022 Report Title/Summary Decision Action Owner Date to be Completed/Comments The report explained that the Public Sector Internal Audit Standards (PSIAS) required the MIJB’s Chief Internal Auditor to prepare an annual report that incorporated the annual opinion on the adequacy and effectiveness of MIJB’s framework of governance, risk management and control, a summary of the work that supports the opinion, and a statement on conformance with the PSIAS. Chief Internal Auditor, Jill Stacey, in presenting the report confirmed that based on their reviews, risk assessments and knowledge, the MIJB’s governance arrangements, risk management and systems of internal control were operating satisfactorily, and that the work and opinion of Internal Audit had been used to inform the Chief Officer’s Annual Governance Statement 2021/22. The Committee, in considering the Report, discussed the need for clarity regarding the flow of information from Partners to the MIJB on issues such as value for money/following the public pound, governance, risk, performance and internal control matters where they were the responsibilities of one of Partners but relevant to the MIJB for assurance purposes. Consideration was also given to the relevance and application of the recently adopted CIPFA Financial Management Code, 2021/22 in so far as it pertained to the operations of the MIJB. Page 23 of 276
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4 Audit and Risk Committee Thursday 29 June 2022 Report Title/Summary Decision Action Owner Date to be Completed/Comments 5.2 Midlothian IJB Annual Governance Statement 2021/22 – Report by Chief Internal Auditor. The purpose of this report was to present the draft Annual Governance Statement 2021/22 of the Midlothian Integration Joint Board by the Chief Officer that would be published as part of the Annual Report and Accounts 2021/22. The report explained that the CIPFA/SOLACE Framework ‘Delivering Good Governance in Local Government’ (2016) urged authorities to review the effectiveness of their existing governance arrangements against their Local Code, and prepare an annual governance statement and compliance report. The MIJB had approved a revised Local Code of Corporate Governance, on recommendation from the Audit and Risk Committee, in April 2021. In terms of overall corporate governance it was the Chief Officer’s opinion that, although there are a few areas of work to be completed for full compliance with the Local Code, the overall governance arrangements of the MIJB were operating satisfactorily. Having heard from both the Chief Internal Auditor, Jill Stacey, and Chief Officer, Morag Barrow, who responded to Members’ questions and comments, the Committee discussed the Annual Governance Statement 2021/22. (a) Agreed that the Annual Governance Statement 2021/22 reflected the risk environment and governance in place to achieve objectives, and acknowledged the actions identified by Management to improve internal controls and governance arrangements; and (b) Agreed that it be published as part of the Annual Report and Accounts 2021/22 of the Midlothian Integration Joint Board. Chief Finance Officer 30 June 2022 Page 24 of 276
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5 Audit and Risk Committee Thursday 29 June 2022 Report Title/Summary Decision Action Owner Date to be Completed/Comments 5.3 MIJB Draft Unaudited Annual Accounts 2021/22 – Report by Chief Finance Officer. The purpose of the report was to present the draft (unaudited) Annual Accounts of the MIJB for the year ending 31 March 2022 for consideration and approval. The report explained that MIJB was required to prepare a set of annual accounts for the financial year 2021/22. A draft of these accounts must be agreed by the MIJB before 30 June whereupon the draft must be published on the MIJB’s website and presented to the MIJB’s auditors for review. Having heard from Chief Finance Officer, Claire Flanagan, who responded to Members’ questions and comments, the Committee discussed the unaudited Annual Accounts. It was felt that the position relating to committed reserves was well explained and that it would be beneficial in assisting understanding of the position regarding these and other related matters. Agreed to approve the unaudited draft Annual Accounts 2020/21 for publication and submission to the external auditors for audit purposes. Chief Finance Officer 30 June 2022 6. Private Reports No private business to be discussed at this meeting. Page 25 of 276
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6 Audit and Risk Committee Thursday 29 June 2022 7. Any other business Report Title/Summary Decision Action Owner Date to be Completed/Comments 7.1 Membership The Committee, having noted that this was Jill Stacey’s final meeting as Chief Internal Auditor joined the Chair in thanking Jill and in wishing her all the best for the future. (a) Recorded an expression of thanks to Jill Stacey for her contributions as Chief Internal Auditor; and (b) Noted that the necessary steps were being taken to secure a suitable replacement. 8. Date of next meeting The next meeting of the Midlothian Integration Joint Board Audit and Risk Committee would be held on Thursday 1 September 2022 at 2 pm. (Action: All Members to Note) The meeting terminated at 9.54 am. Page 26 of 276
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Midlothian Integration Joint Board Meeting Date Time Venue Strategic Planning Group Wednesday 3 August 2022 14.00 Virtual Meeting held using MS Teams. Present (MIJB members): Carolyn Hirst (Chair) Val de Souza Councillor Colin Cassidy Present (HSCP): Gill Main (Integration Manager) Hannah Cairns (Chief AHP) Grace Cowan (Head of Primary Care & Older People) Nick Clater (Head of Adult Services) Lynn Freeman (Occupational Therapy Team Lead) Karen Darroch (Interim Service Manager, Mental Health & Substance Misuse Services) Matthew Curl (Digital Programme Lead) Elouise Johnstone (Programme Manager) In attendance: Jim Sherval (Consultant, Public Health) Rebecca Miller (Strategic Programme Manager) Rebecca Hilton (Strategic Programme Manager, Public Health) Gillian McCusker (Manager, Housing Services) Lesley Kelly (Interim Third Sector Rep) Christine Spurk (Learning & Development) Midlothian Integration Joint Board Thursday 13 October 2022 Item 4.4 Page 27 of 276
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2 Strategic Planning Group Wednesday 3 August 2022 Apologies: Morag Barrow (Chief Officer) Roxanne Watson (Executive Business Manager) Chris King (Finance) Debbie Crerar (Service Manager) Joan Tranent (Head of Social Work) Laura Hill (VOCAL) Lynne Douglas Heather Henderson Sandy Watson (Head of Pharmacy) Claire Dorrell Claire Flanagan (Finance) Wanda Fairgrieve (Partnership Rep) 1. Welcome and introductions Carolyn Hirst welcomed everyone to the meeting and introduced Val de Souza as the new Chair of the IJB as she will be stepping down from the end of August. Val de Souza provided a brief overview of her experience across Lanarkshire and the Lothians and was welcomed by the group membership. 2. Order of Business The order of business was as set out in the Agenda. 3. Minutes of Meeting The Minutes of Meeting of the Strategic Planning Group held on 25 May 2022 were reviewed for accuracy. Nick Clater noted an inaccuracy for change on page 2 by correcting Primrose Hill to Primrose Lodge. Nick Clater provided an update on the decant of Primrose Lodge and confirmed this is now delayed until September due to an outbreak of Legionella. Page 28 of 276
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3 Strategic Planning Group Wednesday 3 August 2022 4. Public Reports Report Title/Summary Decision Action Owner Date to be Completed/Comments 4.1 Chairs Update Chair discussed the meeting of the Strategic Planning Group and suggested future review to consider the group becoming a formal Committee rather than a discussion and exchange group. For incoming Chair to consider Chair 4.2 SoapBox Trauma Informed PDW – Christine Spurk Christine Spurk (CS) provided an overview of the Midlothian Trauma Training pilot and confirmed £40k of funding was received for this. CS discussed feedback received from staff who felt there was a gap in trauma training and wanted to be better informed. CS confirmed there are now 3 levels of staff training with 359 staff trained at level 1, 107 at level 2 and 12 members of staff within the Learning and Development team who have received intense trauma training at level 3. Nick Clater (NC) added the plan is to create and develop a Trauma post which is currently with recruitment. Val de Souza (VdS) commented this work must be integrated and trauma training should be a core for all training programmes. UK Prosperity Fund – Lesley Kelly Page 29 of 276
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4 Strategic Planning Group Wednesday 3 August 2022 Report Title/Summary Decision Action Owner Date to be Completed/Comments Lesley Kelly (LK) provided an overview of the paper. Lesley confirmed Scottish Government priorities and £3m of funding over 3 years, with £300k for this year, £700k for 2023 and £1.8m for 2024. Details of who can apply for this are still be published and the group will be updated in due course. An information event is planned for 30 August 2022 where third sector organisations can find out more about the proposed grants programme. Please contact Lesley directly to book. LK to share the summary for circulation to the group. Homelessness and Prevention – Rebecca Hilton Rebecca Hilton (RH) discussed the Scottish Government proposal to place a legal duty for services to ask and take action to prevent homelessness. RH is keen to investigate the responsibilities of the Health and Social Care Partnership and lead an oversight group. Gillian McCusker (GMcC) confirmed she is waiting on feedback from Scottish Government and will circulate the housing report to Jac Kinnaird to circulate with the minutes. LK/JK GMc/JK 07/07/2022 07/07/2022 4.3 Framework Draft of Annual Performance Report 2021-2022 – Gill Main & Elouise Johnstone Gill Main (GM) provided an overview of the draft Annual Performance Report 2021-22. This is the main IJB and HSCP performance report and both a mechanism of The Group requested additions to include • closer links between the vision of the Strategic Commissioning Plan 2019/22 (right care, right place, right time) and the performance data • greater use of lived experience to articulate the difference our service GM 14/08/2022 Page 30 of 276
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5 Strategic Planning Group Wednesday 3 August 2022 Report Title/Summary Decision Action Owner Date to be Completed/Comments accountability to Scottish Government and the people and communities of Midlothian. GM discussed the data is provisional as the PHS September data release must be used for reports published after July 2022. Chair invited comment from the group regarding areas for inclusion or other areas of developments. offers and supports have made in the lives of people and communities • to include a focus on the performance of our hosted service is e.g., dietetics IJB Board members will be invited to the 14th September SPG meeting to provide an opportunity to review and scrutinise the first full draft of the APR prior to the IJB meeting on 15th September JC/MB 4.4 Directions Update – Gill Main GM confirmed that on 30th June, following the June IJB Meeting, 2022-23 Directions were sent to the Chief Executives. No official response has been received. GM reviewed the work to date to bring Directions in line with new statutory guidance and into an auditable format. GM reviewed the process during this transitionary year to eliminate duplication and create a more streamlined set of strategic Directions for 2023-24. GM also advised of work to link Directions to the IJB Performance Framework (in development). Gill confirmed meetings are in place throughout August with the HSCP Sponsor of each Direction to ensure performance measures are in place and establish the part year position in terms of progress. Page 31 of 276
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6 Strategic Planning Group Wednesday 3 August 2022 Report Title/Summary Decision Action Owner Date to be Completed/Comments 4.5 Spotlight Programme Performance Data – Elouise Johnstone Elouise Johnstone discussed each Spotlight Programme and how they need to be aligned with the Directions and the strategic aims. A full update at the November meeting was requested. Exec Sponsors of each area should bring updates and be accompanied by Services Leads and the new Assistant Strategic Programme Managers (ASPMs) who will be in post. GC, NC 24/11/2022 6. Any other business Report Title/Summary Decision Action Owner Date to be Completed/Comments None. 7. Date of next meeting The next meeting of the Strategic Planning Group will be held on 24 November 2022 at 2.00pm. Actions: All Members please note and progress the actions detailed in this document The meeting terminated at 4.00pm Page 32 of 276
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Midlothian Integration Joint Board Thursday 13th October 2022, 14.00-16.00 Chief Officer Report Executive summary The paper sets out the key strategic updates for Midlothian IJB Board meeting October 2022. Board members are asked to: • Note the content of the report # Item number: 5.2 Page 33 of 276
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Midlothian Integration Joint Board Report Chief Officer Report 1 Purpose 1.1 The paper sets out the key strategic updates for Midlothian IJB Board meeting October 2022. 2 Recommendations 2.1 As a result of this report Members are asked to: • Note the content of the report 3 Background and main report 3.1 Chief Officer System Pressure System pressure remains across all services. The HSCP continue to work with NHS Lothian to support patient flow and support local care options where appropriate. Access to care home beds remains a local challenge, as well as rehearsed challenges to recruit carers, in line with national workforce challenges. The HSCP care at home service continue to deliver a year-on-year increase in provision of packages of care. There is significant concern nationally moving into winter this year, which traditionally presents additional demand relating to winter ailments/accidents. The HSCP have developed a full Winter plan, in line with Scottish Government guidance, and will monitor progress though a performance infrastructure across the next 6 months. A fuller brief will be provided in the IJB Assurance paper later on the agenda, with any additional suggestions/feedback from IJB members relating to the winter plan being well received. IJB Chief Internal Auditor post Members will be aware that the IJB received support from Midlothian Council for Chief Internal Auditor capacity. This is in line with the current Integration Scheme. This service provision was through a shared service with Scottish Borders Council. Failing to recruit to this post has led to the progression of a similar shared service model with East Lothian Council. Planning is underway for this to be in place once appropriate governance agreement is in place across both Councils, but it is anticipated to be around December 2022, upon which a specific paper will be presented to the IJB by Midlothian Council. Morag Barrow, Chief Officer - morag.barrow@nhslothian.scot.nhs.uk Page 34 of 276
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Midlothian Integration Joint Board 3.2 Head of Adult Services HSCP Mental Health and Resilience Service Midlothian Health and Social Care Partnership launched an innovative new compassionate Mental Health and Resilience Service (MHARS) on 1st August 2022. The purpose of this service is to improve access to care and support for residents of Midlothian who are experiencing crisis and/or distress with their mental health and/or mental wellbeing. The service is a collaborative approach between Midlothian HSCP and Penumbra, open to everyone aged 18 to 65 across Midlothian. MHARS offers same day direct access to Mental Health and Wellbeing support through a free confidential telephone number. The service is open seven days a week from 8am to 10pm and can be accessed without a referral from a doctor or other health professional. MHARS has been designed to offer support around an individual’s specific needs, and tailor support around what matters most to them. Since the launch, MHARS has received 126 contacts in total. The outcome of these contacts has enabled 57 individuals to receive further specific intervention in the form of ‘Distress Brief Intervention'. One individual required brief crisis follow-up from HSCP clinical support staff, and seven individuals required further mental health assessment from the Midlothian HSCP Intensive Home Treatment Team. Nine individuals have been referred to alternative services, such as Health In Mind/MELD and/or Substance Use Services, with 49 individuals requiring initial support and signposting to the various local community services within Midlothian. In addition, the service continues to build links and provide advice and support to other statutory and non-statutory services for residents in Midlothian. Working collaboratively with GP practices in Midlothian, a care navigation pathway has been developed to ensure that GP practices are appropriately signposting patients to MHARS. Early user feedback on MHARS has been positive. HSCP Learning and Development A new Trauma Development worker post is being progressed. This post will develop partnership working across Midlothian, with the vision for Midlothian to become a Trauma informed community. It will focus on public facing services and buildings to ensure people are treated with dignity and respect with a Trauma informed approach. A programme of training will be put in place and focus on priority groups in the first 6 months. Nick Clater, Head of Adult Services - Nick.clater@midlothian.gov.uk 3.3 HSCP Performance The HSCP have continued working on Outcome Mapping with Matter of Focus and refined the process with a more streamlined approach over the last 6 months. This redesign aims to meet the needs of services to record, analyse and articulate personal outcomes at a service or team level, and link directly to our 6 strategic aims. With this new approach, the HSCP will be able to aggregate collective progress towards the 6 strategic aims at an organisation level for the first time. The map is being tested across three new service areas and, if successful, would plan to roll out to all areas. The first of three tests of change took place on 23rd September with the Musculoskeletal physiotherapy team and was highly successful. Page 35 of 276
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Midlothian Integration Joint Board Future ambitions are to triangulate the aggregated organisational contribution to improving outcomes for people and progress towards the strategic aims with organisational activity data, and changes in population data. Gill Main, Integration Manager - gill.main3@nhslothian.scot.nhs.uk 3.4 AHP Governance and Assurance Framework Midlothian HSCP has been an early adopter in the testing phase of the Lothian-wide AHP Governance and Assurance Framework which has been developed and led by the Chief AHP in Midlothian. It is the only HSCP to have fully engaged in the initial testing period for Quarter 1 (Q1) which is now complete with evaluation concluded and benefits realised. Midlothian HSCP Senior AHP’s and Service Managers have been actively involved in the Q1 testing phase and have an Improvement Plan in place to develop the areas identified alongside Dietetics as a single system service hosted by Midlothian. The output and learning from the Q1 testing were presented to the Lothian AHP Strategic Leads Group and Midlothian HSCP Senior Management Team with a variety of benefits acknowledged including, provision of a toolkit to effectively manage services and provide consistent reporting of assurance, as well as being supportive of a culture of collaboration, shared responsibility, and ownership. Given the success of the initial phase of testing, a further phase is planned for Q2 before a full roll out of all AHP services across Lothian and the associated HSCP’s. It is anticipated that this will be from Q3 (January 2023) onwards. Midlothian HSCP will initially focus on the development of new performance indicators/frameworks for all services and professional groups, as well as Service Specifications and Service Plans. These areas will be addressed as a component of the HSCP Quality Management System, and an adapted Governance and Assurance Framework is currently being developed for use across all integrated services within the HSCP. Midlothian HSCP Neurological Conditions Project Midlothian HSCP received funding from the Scottish Government Framework for Neurological Care 2020-2025 for a system-wide Neurological project that has been underway since November 2021. The project aim was to execute a whole-system approach to improve outcomes for people living with a neurological condition who live in Midlothian, and their families. The initial scoping phase of the project has now concluded and, included local data analysis and gathering of evidence from engagement with stakeholders from Midlothian HSCP, NHS Lothian and community organisations. Evidence has also been gathered from engagement with a wide range of local people living with a neurological condition led by Artlink as our commissioned third-sector engagement partner. A self-evaluation analysis has been completed with range of stakeholders across the HSCP validated by NHS Lothian Neuro- Rehabilitation Group. In addition, a partnership project with Cerebral Palsy Scotland has been agreed and is underway to improve outcomes for this targeted group. This will support both respective organisations to achieve their project outcomes. Within a wider Project Group an initial test of change was agreed, and the project team are currently initiating this next stage in partnership with Thistle Wellbeing Service. It is anticipated that this test of change will be initiated from the end of October 2022 for 12 months. Further details will follow as the project progresses. Transforming Local Systems Technology Enabled Care (TEC) Pathfinder project In April 2019, Midlothian HSCP became one of four Pathfinder sites within the Scottish Government Transforming Local Systems (TLS) programme. Midlothian has been engaged in transforming the frailty system of care working with partners including the Digital Health Page 36 of 276
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Midlothian Integration Joint Board and Care Innovation Centre (DHI), VOCAL, and the British Red Cross. The DHI has brought service design expertise and technical build capabilities which have been fundamental to the Service Design approach required. Pathfinders were required to adopt the Scottish Approach to Service Design characterised by the Double Diamond which creates two spaces covering four phases: • Setting up the problem - Discover and Define - the challenge of our system putting the citizen at the centre of siloed, dis-integrated services rather than enabling them, by design, in a partnership of all the talents. • Generating a solution - Develop and Deliver – development of a prototype solution which focuses on changing ownership of data in our system with the citizen acting as the integration point. The TLS programme formally closed in September, pending impact evaluation due at the start of the next financial year. However, Midlothian HSCP Pathfinder work will continue until March 2023, due to the challenges resulting from Covid, and capacity in the core team. This will allow the team to complete functional prototype development alongside other output materials, including the learning that can be applied more widely in the Digital Programme. Hannah Cairns, Chief AHP - hannah.cairns@nhslothian.scot.nhs.uk 3.5 Primary Care in Midlothian All 12 GP practices remain open, providing full General Medical Services. However, in line with national trends, all practices are currently reporting increased patient demand for appointments. The HSCP will continue to support local practices to review local data and consider models of care that may support resilience moving forward. Winter plans have been requested as part of routine HSCP winter planning. Community Treatment & Assessment Centre (CTAC) services are provided in all 12 practices, with Phlebotomy appointment capacity recently being increased. Expansion of the Pharmacotherapy team continues, as well successful efficiency remodelling such as the Medicines Reconciliation Hub, and improvement work on high-risk medicines, acute prescribing and serial CMS prescriptions, which will all improve medication safety and access for patients. Dental, Optometry & Audiology Progress against Midlothian IJB Directions to date has been reviewed, and initial collaborative conversations have taken place in support of moving actions forward. Local New Audiology clinics for Midlothian residents at Midlothian Community Hospital will begin from October 2022. Older peoples’ care in Midlothian The two new Care of the Elderly Consultants who were appointed earlier this year have successfully supported the expansion and increased capacity in Midlothian’s Hospital at Home service, working closely with the service’s two Speciality Doctors. A further Consultant post is being recruited to, which will provide additional medical support for in-patients in Midlothian Community Hospital (MCH). New local Parkinson’s out-patient clinics have now been established at MCH, and planning has started to increase other available options for out-patient medical assessment & review. Rebecca Green, Clinical Director – rebecca.green@nhslothian.scot.nhs.uk Page 37 of 276
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Midlothian Integration Joint Board 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 October 2022 // Page 38 of 276
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Midlothian Integration Joint Board Midlothian Integration Joint Board Thursday 13th October 2022, 14.00-16.00 Appointment of Audit and Risk Committee Member Executive summary The purpose of this report is to seek approval for the appointment of a voting NHSL Member to fill a vacant position on the MIJB Audit and Risk Committee. Board Members are asked to approve the appointment of Nadin Akita as a member of the MIJB Audit and Risk Committee. # Item number: 5.3 Page 39 of 276
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Midlothian Integration Joint Board Report Appointment of Audit and Risk Committee Member 1 Purpose 1.1 The purpose of this report is to seek approval for the appointment of a voting NHSL Member to fill a vacant position on the MIJB Audit and Risk Committee. 2 Recommendations 2.1 Board Members are asked to approve the appointment of Nadin Akita as a member of the MIJB Audit and Risk Committee. 3 Background and main report Midlothian Integration Joint Board-Voting Member 3.1 Following recent changes in the NHS Lothian Board voting Members on the Midlothian IJB following the departure of Carolyn Hirst and Tricia Donald, a vacancy has arisen on the MIJB Audit and Risk Committee for a voting NHSL Member. This position having previously been held by Carolyn. Audit and Risk Committee 3.2 Under Standing Order 14, the Integration Joint Board shall appoint such committees, and working groups as it thinks fit and shall appoint committee members to fill any vacancy in the membership as and when required. 3.4 The Board is therefore invited to confirm the appointment of the undernoted voting Board Member to the vacant position on the Audit and Risk Committee – Nadin Akita. 4 Policy Implications 4.1 The Midlothian Integration Joint Board (MIJB), was established as a separate legal entity as required by The Public Bodies (Joint Working) (Scotland) Act 2014. It has responsible for the strategic planning and commissioning of a wide range of integrated health and social care services across the Midlothian partnership area, based on resources which have been delegated to it by the partners, Midlothian Council and NHS Lothian. Page 40 of 276
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Midlothian Integration Joint Board 4.2 The MIJB is therefore expected to operate under public sector good practice governance arrangements which are proportionate to its transactions and responsibilities to ensure the achievement of the objectives of Integration. 4.3 The establishment of robust internal controls, governance, and risk management arrangements is one of the key components of good governance, as is the oversight and scrutiny of their effectiveness. Good governance will enable the MIJB to pursue its vision effectively as well as underpinning that vision with mechanisms for control and management of risk. 4.4 The Audit and Risk Committee of the Midlothian Integration Joint Board is responsible for the promotion of best practice in the areas of risk management, financial procedures, internal controls, development of continuous improvement and review of External Audit and Internal Audit issues. 4.5 It is important that the MIJB’s Audit and Risk Committee fully complies with best practice guidance on Audit Committees to ensure it can demonstrate its effectiveness as a scrutiny body as a foundation for sound corporate governance for the Midlothian Integration Joint Board. 5 Equalities Implications 5.1 There are no specific equalities or diversities matters that require to be taken into account although it is worth noting that the Midlothian IJB has as one of its primary objectives, responsibility for addressing health inequalities. 6 Resource Implications 6.1 Resources are in place to support the MIJB and its Audit and Risk Committee to fulfil their remits. 7 Risk 7.1 It is essential that there is a clear and robust process for appointing voting and non- voting members to the IJB otherwise there is a risk that the arrangements will not be compliant with regulations. 7.2 There is a risk that if the MIJB Audit and Risk Committee does not fully comply with best practice guidance it limits its effectiveness as a scrutiny body and foundation for sound corporate governance. The appointment of a full membership compliment to the MIJB Audit and Risk Committee by the MIJB will assist in mitigating this risk. 8 Involving people 8.1 There are no specific implications for involving people as a result of this report. Page 41 of 276
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Midlothian Integration Joint Board 9 Background Papers 9.1 Nomination and Appointment of Members to the Midlothian Integration Joint Board – April 2022. AUTHOR’S NAME Mike Broadway DESIGNATION Clerk CONTACT INFO 0131 271 3160 mike.broadway@midlothian.gov.uk DATE 14 August 2020 Page 42 of 276
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Midlothian Integration Joint Board Thursday 13th October 2022, 14.00-16.00 Annual Performance Report 2021-22 Executive summary The IJB is required by Scottish Government and the 2014 Joint Working Act to publish an Annual Performance Report (APR). The Midlothian APR provides information on the health and wellbeing of the people of Midlothian and assesses performance towards meeting the 9 National Health and Wellbeing Outcomes. It also describes the financial performance of the Partnership and the quality of health and care services delivered during 2021-22. The first framework draft of the APR was discussed at the Strategic Planning Group (SPG) meeting held on the 3rd August, 2022. Scrutiny of the draft full report at SPG on 14th September, and the IJB on 15th September 2022 resulted in recommendations relating to structure and content. During the governance process relating to data included in the APR, an anomaly was noted in the Ministerial Steering Group (MSG) target for Delayed Discharge, Occupied Bed Days. The target set for 2021/22 was to reduce occupied bed days by 40%, however this had continued to be monitored against the 20% reduction set in 2020/2021. As the IJB have recently agreed a 20% reduction as the target for 2022/23, it is recommended that no further retrospective analysis is required. Board Members are asked to: • Grant delegated authority for Morag Barrow, Chief Officer, to publish the Annual Performance Report by 31st October 2022 • Note an anomaly in the 2021/2 performance target data for the MSG target for Delayed Discharge, Occupied Bed Days Item number: 5.4 Page 43 of 276
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Midlothian Integration Joint Board Report Annual Performance Report 2021-22 1 Purpose 1.1 The Midlothian Annual Performance Report provides information on the health and wellbeing of the people of Midlothian and an assessment of our performance towards achieving the 9 National Health and Wellbeing Outcomes. It also describes the financial performance of the IJB, and the quality of health and care services delivered during 2021-22. 2 Recommendations 2.1 As a result of this report what are Members are asked to: • Grant delegated authority for Morag Barrow, Chief Officer, to publish the Annual Performance Report by 31st October 2022 • Note an anomaly in the 2021/2 performance target data for the MSG target for Delayed Discharge, Occupied Bed Days 3 Background and main report 3.1 The IJB are required by Scottish Government and the 2014 Joint Working Act to publish an annual report detailing key achievements of the previous financial year and an assessment of performance against the national core suite of integration indicators and in meeting the 9 National Health and Wellbeing Outcomes. 3.2 The purpose of the Annual Performance Report is to provide an overview of performance of the IJB in planning and carrying out integrated functions and is produced for the benefit of the IJB, Partnerships and their communities. It must be made publicly available, written using plain English, and make good use of graphics and case studies to bring performance data to life. All published reports must also meet legal accessibility standards. 3.3 In recognition of the impact of Covid-19 on the planning and delivery of Health and Social Care, Scottish Government extended the date of publication of Annual Performance Reports through the Coronavirus Scotland Act (2020) Schedule 6, Part 3. 3.4 During the governance process relating to data included in the APR, an anomaly was noted in the Ministerial Steering Group (MSG) target for Delayed Discharge, Occupied Bed Days. The target set for 2021/22 was to reduce occupied bed days by 40%, however this had continued to be monitored against the 20% reduction set in 2020/2021. As the IJB have recently agreed a 20% reduction as the target for 2022/23, it is recommended that no further retrospective analysis is required. Page 44 of 276
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Midlothian Integration Joint Board 3.5 The first framework draft of the Annual Performance Report was discussed at the Strategic Planning Group (SPG) meeting held on the 3rd August, 2022. Scrutiny of the draft full report at SPG on 14th September, and the IJB on 15th September 2022 resulted in recommendations relating to structure and content. These have been addressed as follows • Ensured closer links between the vision of the Strategic Commissioning Plan 2019/22 (right care, right place, right time) and the performance data throughout • Added a paragraph in ‘Challenges’ highlighting the changes in demand and impact of delays to scheduled care and supporting more people with more complex needs within the community • Ensured a clear explanation is nearer the top of the report regarding the methodology used for the HACE survey, numbers of people selected for participation and responses received. • Made greater use of lived experience to articulate the difference our service offers and supports have made in the lives of people and communities • Noted specifically our hosted service is e.g., dietetics and ACENS • Revised the wording through the body of the text to ensure a balanced view of performance, particularly when we had not made progress • Added additional information regarding the detail of the HACE survey regarding GP practices in ‘Positive Experiences and Dignity’ • Added a short statement in ‘Use of Resources about the increased spend within the community and growth in community work • Added a consistent 4 statement approach to describe the data in the data appendix to support readers review the data. Each of the national indicators are described in the context of Midlothian performance compared to the previous year, the performance across Scotland, Midlothian’s performance in relation to Scotland’s performance, and a position for future work in Midlothian in relation to Scotland’s performance. 3.6 This report presents the final draft of the APR. It is therefore requested that Midlothian IJB agree delegated authority for Morag Barrow, Chief Officer, to publish the Annual Report by 31 October 2022, in line with the reporting timeframes set by Scottish Government. 4 Policy Implications 4.1 IJBs have a legal obligation to produce an annual performance report in line with The Public Bodies (Joint Working) (Content of Performance Reports) (Scotland) Regulations 2014 and the Scottish Government Guidance: Health and Social Care Integration Partnerships: reporting guidance. 4.2 This includes reporting on the national Core Suite of Integration Indicators provided by Public Health Scotland, using these to support reporting on how well we are progressing the 9 National Health and Wellbeing Outcomes which apply to integrated health and social care. 4.2 This Midlothian Annual Performance Report complies with all the requirements with the exception of a breakdown of spend per locality. Systems to facilitate a robust report on this are not yet in place. Page 45 of 276
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Midlothian Integration Joint Board 5 Directions 5.1 This report does not relate to any specific directions. 6 Equalities Implications 6.1 There are no equalities implications arising directly from this report. However, the report itself has been written with accessibility in mind. This includes being structured and written in a way that is easily followed and understood by those in our communities who may wish to read the report. This report meets the legal requirements for accessibility standards. 7 Resource Implications 7.1 There are no resource implications arising from this report. 8 Risk 8.1 IJBs, have a legal obligation to produce an annual performance report which meets the requirements set by Scottish Government. 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 The report highlights the involvement of users of people and communities in the development and recommissioning of services 10 Background Papers n/a AUTHOR’S NAME Gill Main DESIGNATION Integration Manager CONTACT INFO Via email or MS Teams DATE 02/10/2022 Appendices: Appendix 1: Annual Performance Report Page 46 of 276
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Midlothian Integration Joint Board Annual Performance Report 2021/22 Page 47 of 276
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Contents Executive Summary ................................................................................................. 3 Foreword ................................................................................................................. 6 Introduction ............................................................................................................ 7 Who we are .......................................................................................................... 7 What we are trying to achieve .............................................................................. 8 How do we know if we are achieving this? ......................................................... 10 The main challenges of 2021-22 .......................................................................... 11 How did we do? ..................................................................................................... 13 How we are reporting this data .......................................................................... 13 The National Indicators ....................................................................................... 14 Working with our Communities ............................................................................. 42 Delivering local services ...................................................................................... 42 Looking forward .................................................................................................... 44 Inspections ............................................................................................................ 46 IJB Business ........................................................................................................... 49 Communication and Engagement ....................................................................... 49 Integration Functions and Governance Decisions ................................................ 50 Data Appendix ....................................................................................................... 53 Ministerial Steering Group Targets ..................................................................... 63 Page 48 of 276
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Executive Summary The Midlothian Integration Joint Board (IJB) plan and direct health and social care services for the people of Midlothian. We are a planning and decision-making body responsible for the integrated budget from Midlothian Council and NHS Lothian. We are responsible for monitoring progress towards the National Health and Wellbeing Outcomes and the objectives in our Strategic Commissioning Plan 2019 to 2022. During this time we worked to ensure people had the right advice, care and support in the right place, at the right time to be able to lead long and healthy lives. We focused on prevention, recovery, independence, choice and control, equalities, supporting the person not just their condition, and high quality and coordinated care that is evidence based and provided locally. The pandemic did not stop us planning and delivering services but it reduced our capacity for implementing some planned redesigns of services. In many respects it accelerated change by creating opportunities to work together in new ways and strengthen our community connections. Considering the impact of all our services and supports is a complex exercise and involves a wide range of data. The Scottish Government measure our performance towards nine Health and Wellbeing Outcomes using data collected from Scottish Health and Care Experience (HACE) Survey and Scottish Government’s Ministerial Strategic Group (MSG) targets for hospital admissions. The challenges we faced We continued to face a number of challenges in 2021/22 including an ageing population, inequalities in health, a national workforce shortage, increasing reliance on unpaid carers and growing pressures on acute hospitals. There was an increase in demand for community services as the way people accessed planned and unscheduled care changed and we were supporting people when they had to wait longer for planned services with increasingly complex needs. More people are living in Midlothian than ever before, and this has meant changes to the average age of our population and typical household size. This may explain why some services are more in demand despite the gains we are making in quality and improvements. Our progress towards the National Outcomes In 2021/22, our priority continued to be the health and wellbeing of our communities and our workforce. Supporting people effectively and safely was more important than ever and services responded to evolving circumstances. Services provided face-to-face support where this kept people safe and well. However, in line with national guidance and restrictions, the way people accessed many of our services changed. During this time, most people surveyed continued to feel safe; felt enabled to look after their own health and wellbeing, and felt they had a say in how their services and support were provided. In 2021/22 the number of people under 75 who died prematurely in Midlothian reduced. Cardiovascular disease and cancer are strongly linked to deprivation and addressing the impact of poverty remained central to our work. We increased opportunities and access to employment Page 49 of 276
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alongside work to address drug and alcohol problems, and links to violence. By ensuring good mental wellbeing support, increasing educational attainment, and promoting healthier physical and social environments we anticipate that premature mortality will continue to reduce. We have improved our services to help people live as independently as possible at home or in a homely setting within their community. This includes reducing the number of days people have to stay in hospital when they are ready to return home and increasing the number of adults who have intensive care needs that are supported to live within their community. It is important that people see the right professional from the very first conversation and so we expanded the teams that work in our GP practices and in the community. There are now more specialist services including Physiotherapists, Primary Care Mental Health Nurses and Wellbeing Practitioners, Pharmacists, Advanced Nurse Practitioners for minor illness, Phlebotomists and Community Treatment & Assessment Clinic (CTAC) located in practices than ever before. People could usually access the care that they need directly from these professionals without needing to see a GP first. Respect and dignity are central to our values, and we made progress embedding a Human Rights approach across our services. Despite the ongoing challenges facing health and social care, the support delivered by Midlothian Health and Social Care Partnership helped improve the quality of life for 81% of the people who responded to the HACE survey, an increase of 13% from the previous year. Understanding the different types of support people need to achieve what matters to them continues to be an important part of our self-management approach. Health inequalities result in poorer outcomes for some people and communities. 1 in 4 children live in poverty in Midlothian. We continued to commit to having Good Conversations and using this approach to help addresses the impact of inequality. Good Conversations is an approach to change our culture and working with people’s life circumstances, supporting self-management, choice, and control. People say this approach is meaningful and makes a difference in their lives. The HACE survey highlighted that we must improve how we support unpaid carers. The work of our local voluntary organisations continues to be invaluable and the feedback they receive is generally more positive. However, we know that there are many carers who are ’hidden’, may not recognise themselves as carers, and do not access any support. We must continue to reach out to them. We must also recognise that the pressures on our ‘care at home’ services over the past year have contributed to an even greater reliance on families, neighbours, and friends. There are no quick solutions but improving support to unpaid carers will be a key task for the Partnership over the coming year. Our services and supports aim to keep people safe from harm and prevent avoidable risks. In 2021/22, we received 674 Adult Protection referrals. This was an increase of 49% than the previous year. In the past year 64% of people referred for Adult Support and Protection were over 65yrs old, 53% were females and the main reason for referral was neglect. Where it was feasible to reduce face-to-face contact, teams changed how services were delivered in line with national guidance and continued to see people face-to-face where this kept them safe and well. Voluntary organisations also worked hard to find safe ways of supporting vulnerable people. Page 50 of 276
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We still have work to do to improve. This includes better workforce planning to ensure our workforce has the knowledge and skills to meet the needs of people and communities. Feedback told us that accessing the right care at the right time was difficult for some people who needed support. The national indicators were implemented by the Scottish Government Ministerial Steering Group. We met 4 out of the 8 local targets we set against these national key indicators. Based on these targets, while the numbers of patients delayed in hospital remained high, the length of these delays were reduced by half as measured by delayed discharge bed days. This is, at least in part, due to our Home First philosophy and improving flow through the work of a range of services including the local Flow Hub and the Discharge to Assess Team. The quality of the services people received was rated as high by 78.6% of those surveyed and demonstrated a considerable increase in quality from the previous year. This was also reflected in the grades awarded to several social care services by the Care Inspectorate. Our budget and spending. Ensuring we make best use of our resources is a complex task. We had a total budget of £178m and ended the financial year with a small underspend of £10.5m. This underspend is made up of an underspend on the IJBs operations of £1.1m and earmarked funding, predominantly for COVID not spent in year of £9.7m. In 2021/22 there was an increase in the IJB spend within the community services. This is in line with our ambitions to develop health and social care services locally and away from hospital and highlights our ongoing commitment to transformation health and social care. However, the pressure on acute hospital remains very high. We continued to support people to improve their own health and all our services promote preventative action and early intervention. Future plans. Looking forward, we expect to face a number of opportunities, risks and uncertainties in the coming years. We recognise the scale of these, but also that services need a period of stability to recover and address the areas where waiting times have increased over the past 2 years. Our future direction and ambitions are set out in our 3-year Strategic Commissioning Plan. Over the last year many services have revaluated how best to meet the needs of people and their communities and are at the start of a new and exciting transformational change programme. We have set a balanced budget and will invest in key areas of prevention as well as make recommendation for how to use our reserves to support innovative practice and accelerate priority areas of transformation. The funding gap in future years and the potential for additional savings requirements creates significant uncertainty in relation to our ambitions. Evaluating how what we do changes outcomes for people and communities depends on many factors. We will develop our use of Outcome Mapping to help us record, analyse, and understand our performance towards our strategic aims of supporting people and communities look after and improve their health and wellbeing for longer. Page 51 of 276
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Foreword Welcome to our 7th Annual Performance Report which reflects on our progress and performance from 1st April 2021 to 31st March 2022. In introducing this report, it is important to acknowledge how the pandemic has continued to dominate our work over the past 12 months. Covid-19 continues to impact everyone and will have a long-term impact on our services and communities. New and evolving challenges have increased demand and sustained pressure across the whole system. Supporting people with Covid- 19, delivering vaccinations, keeping people safe and helping people manage their health and wellbeing have been our priorities. We have adapted our services to meet the needs of individuals, working together where this has required a different type of support. This Annual Report explains our performance; how well we have provided the right care, at the right time. Giving priority to responding to the pandemic has limited our capacity to deliver some core services. Our staff remain our greatest asset and I would like to thank all staff for their commitment and professionalism to keep people safe. Supporting staff remains a high priority and our new Wellbeing Lead has supported staff to remain safe and well. We will continue in our efforts to retain our staff and provide support and advice on health and wellbeing. As our recovery programme continues, we must reshape health and social care with a stronger emphasis on prevention and early intervention. We will listen to people and involve communities in how we design and deliver services. A community powered approach will ask ‘what makes us healthy?’ rather than ‘what makes us ill?’ and see communities, health and social care, housing, sport and leisure, welfare rights, employment services and the voluntary sector all playing a role in maintaining good health. We will strengthen our support for carers as we recognise their essential and valued role. Throughout the pandemic their contribution has been, and remains, critical. As Chief Officer, I am proud to lead health and social care, alongside our independent and third sector partners, to provide high quality care with professionalism and dedication, even in the most of challenging times. I look ahead with an increasing sense of optimism as we take forward our Strategic Commissioning Plan and redesign services based on views of our staff, people who have experienced our services, and our communities. Together we will improve our service and supports that help people live the lives they choose. Morag Barrow Chief Officer, Midlothian IJB Page 52 of 276
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Introduction This report gives an overview of our performance in planning and carrying out integrated functions. It looks at the progress we made over 2021/22 to deliver the key priorities of our 2019/22 Strategic Commissioning Plan. Who we are The Midlothian Integration Joint Board (IJB) plan and direct health and social care services for the people of Midlothian. We are a planning and decision-making body created by Midlothian Council and NHS Lothian. We are responsible for the integrated budget (received from Midlothian Council and NHS Lothian) and allocate this in line with our objectives in the Strategic Commissioning Plan. Our responsibilities and legal duties are outlined in the Public Bodies (Joint Working) (Scotland) Act (2014). The IJB meets regularly and includes members from NHS Lothian and Midlothian Council, the Third Sector, staff and people who represent the interests of people and communities, patients, service users and carers. Page 53 of 276
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What we are trying to achieve The Scottish Government measure our performance based on Health and Wellbeing Outcomes. National Health & Wellbeing Outcome 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 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. 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. 9 Use of Resources Resources are used effectively and efficiently. Page 54 of 276
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Our Strategic Commissioning Plan 2019 - 2022 Our vision in the Strategic Commissioning Plan was for everyone in Midlothian to have the right advice, care and support in the right place, at the right time to be able to lead long and healthy lives. We focused on prevention, recovery, independence, choice and control, equalities, supporting the person, not just their condition and high quality and coordinated care that is evidence based and provided locally. This report shows our progress and performance in the final year of this plan. While the pandemic did not stop us planning and delivering services, it reduced the capacity for implementing some planned redesigns of services. In many respects the crisis accelerated change and created opportunities to work together in new ways and strengthen our community connections. Integration, Quality, Best Value – ways to improve We think about how we can improve what we do in three ways; integration, quality, and Best Value. In this report we have detailed what we have done and how this has improved outcomes for people and communities. We have used the icons below to show good examples of integration, quality, or Best Value. Integration is about how we work with all our partners to ensure everyone gets the right care, at the right time, and in the right setting. Quality is about 6 key areas of services – are they safe, effective, efficient, timely, person centred, equitable. Best Value is about ensuring resources are well managed improving services that deliver the best possible outcomes for people and communities. Page 55 of 276
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How do we know if we are achieving this? You can see the details of our performance in the Data Appendix at the end of this report. We used a range of feedback to see how well we are doing. This included: • Feedback from people- who use our services, their families and carers We used a range of methods to gather feedback including surveys, compliments and complaints systems like Care Opinion, group events like the Older People’s Assemblies, and representation at planning groups. We also take into account information from Third Sector services such as VOCAL Carer’s survey. • Scottish Government Data - The National Performance Indicators These indicators include information gathered by the Scottish Health and Care Experience (HACE) Survey posted to a sample group of people in Scotland at the end of 2021. It asks about their experiences of health and social care services over the previous 12 months. 1,772 people responded from Midlothian. This is less than 2% of Midlothian’s population. The National Records of Scotland recorded Midlothian’s population was 93,150 on 30th June 2020. • Scottish Government’s Ministerial Strategic Group (MSG) targets These targets are for hospital admissions. Updated targets for 2021/22 were developed by Midlothian Health and Social Care Partnership, agreed by the IJB and submitted to Scottish Government in June 2021. Our targets are measured against a baseline from 2017/18. Understanding how we contribute to people’s outcomes The services we plan and direct must, by law, aim to improve outcomes for people who use our service, their carers and families. It is hard to evaluate how what we do changes outcomes as this depends on many factors. To try and better understand this, we have developed our use of Outcome Mapping to help us record, analyse and understand our impact on people and communities. Developing our performance framework We began to develop a Performance Management Framework to improve how we assess our performance. We reviewed our data sources, measures and metrics, checked the quality of our data and identified gaps. We are improving how we collect and present our data to show how we are meeting our aims and making best use of our resource. This will improve our ability to report on our performance for legislative and statutory requirements, local and national policy, best practice, professional guidance and evidencing the impact of integration. We have worked with other Health & Social Care Partnerships, Integration Joint Boards and external partners and explored opportunities to innovate using digital tools. Page 56 of 276
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The main challenges of 2021-22 The IJB was set up in 2015 to develop local solutions to improve health and care services. We still face some of the same issues such as an ageing population, inequalities in health, a national workforce shortage, increasing reliance on unpaid carers and growing pressures on acute hospitals. This year there have been a number of additional challenges including: • Covid-19 and the impact on the workforce Covid-19 increased the pressure on our already stretched workforce. Illness and absence reduced the number of available qualified staff, many of whom had increased demands through additional services such as mass vaccination programmes. • Increasing Demand The demand for community services increased due to changes in the how people accessed planned and unscheduled care. Continuing to support people when they had to wait longer for planned services further increased this pressure. In addition, higher numbers of people with increasingly complex needs who receive the support they needed in the community increased the pressure on many of our local services. This impacted on both our delegated service and the two Pan Lothian services hosted by Midlothian HSCP; the Adults with Complex and Exceptional Needs Service and Dietetics. • Wider Changes to Health and Social Care Planning The 2021 Feeley Independent Review of Adult Social Care brought uncertainty about how the Scottish Government might review the provision of care services. • Population Changes There have been changes to the overall size of our population, the number of older people living in Midlothian, and the number of single person households Population size Midlothian is one of the fastest growing areas in Scotland. By 2028 Midlothian’s population is projected to have grown by faster than anywhere else in Scotland. Population age The number of people over 75 is increasing. By 2028 the number of people over 75 is projected to increase by 41%. Household size More people are living alone with a third of all households having just 1 person. Older people are now more likely to live alone or in smaller households and older women are most likely to live alone. The Health Foundation found out that, when compared with people who live with others, people aged over 65 who live alone are more likely to have three or more long term conditions, go to their GP and A&E more and are at higher risk of being admitted to hospital. This helps to explain why some services are more in demand despite the gains we are making in quality and improvements. Page 57 of 276
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• Health Inequalities Covid-19 and the rising cost of living impacted people in unequal ways and the health gap between the richest and the poorest widened. During the year we had to focus on our crisis response to Covid-19 which meant some preventative programmes did not take place. • Unpaid Carers During the pandemic many people became carers for the first time. Covid-19 affected the way service offers and support could be delivered. Not all services and supports were able to work at full capacity due to restrictions and people had to take on tasks which the Care at Home services were unable to provide. Additionally, more people recognised they carried out a caring role and the demand for support for unpaid carers increased. Page 58 of 276
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How did we do? How we are reporting this data The information we use to measure our progress comes from several sources and is displayed in a way that makes it clear where we have done well and where we still have room to improve. The answers provided by Midlothian respondents to the HACE Survey are organised under the National Performance Indicators. In 2020 the Scottish Government made changes to the survey for National Performance Indicators 1-9. Some questions were added, some were amended, and some were removed (the full list of these changes is in the Scottish Government Technical Report). These changes mean it is difficult to compare our performance with previous years and, in some cases, means we only have data from 2020. We have provided the following data: • For Indicators 1-9 the data for 2021/22 is compared with 2019/20 only. • For Indicators 11-20 the data for 2021/22 in compared with the previous 4 years. 1,772 people responded from Midlothian. This is less than 2% of Midlothian’s population and the response rate increased with age and was highest in the 65+ age group (44%). This is compared to a response rate of 10% for those aged 17-34. In the Data Appendix we have provided more information about our progress over time and our position in comparison to the rest of Scotland. For some National Indicators the number of responses from each locality were too small to be published. We have designed the report to look at each of the Health and Wellbeing Outcomes alongside the National Performance Indicators used to measure each one. All National Performance Indicator data for Midlothian against the national average is in the Data Appendix Page 59 of 276
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The National Indicators - Our performance has improved compared to last year. - There hasn’t been a significant change in performance compared to last year. - Our performance has worsened compared to last year. National Indicator Our result Our Progress Adults are able to look after their health very well or quite well. 92% Adults supported at home agreed that they are supported to live as independently as possible. 73% Adults supported at home agreed they had a say in how their help, care or support was provided. 70% Adults supported at home agreed that their health and social care services seemed to be well coordinated. 64% Adults receiving care or support rated it as excellent or good. 79% Adults had a positive experience of the care provided by their GP practice. 62% Adults supported at home agreed services and support had an impact on improving or maintaining their quality of life. 81% Carers feel supported to continue in their caring role. 27% Adults supported at home agreed they felt safe. 79% Page 60 of 276
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. National Indicator Our result Our Progress Premature Mortality Rate (People under 75) 407 per 100,000 Emergency Admission Rate 11,568 per 100,000 Emergency Bed Day Rate 106,360 per 100,000 Readmission to hospital within 28 days. 105 per 1,000 Proportion of the last 6 months of life spent at home or a community setting. 88% Falls Rate (People over 65) 25% Care services graded Good or better in Care Inspectorate Inspections. 78% Adults with intensive care needs are receiving care at home. 64% The number of days people aged over 75 spend in hospital when they are ready to be discharged. 520 per 1,000 Health and Care resource spent on hospital stays where the person was admitted as an emergency. 23% Page 61 of 276
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National Indicators used to measure this outcome. Right care, right place, right time Our services aim to support people to look after their own health and wellbeing. We see ourselves as ‘facilitators’ and not ‘fixers’ and promote self-management through services and supports including welfare advice, and advice and support for people who are managing difficult circumstances. One example of this is the Community Respiratory Team who help people manage lung conditions like Chronic Obstructive Pulmonary Disease (COPD). They encourage self-management through promoting physical activity and signposting people to community services for health and wellbeing. They supported people in their own homes which often meant people didn’t need to go to hospital. Over the past year the team have helped prevent over 80 admissions to hospital and supported over 100 people leave hospital sooner to help them recover in their own home. National Indicator Our result Our Progress Adults are able to look after their health very well or quite well. 92% Premature Mortality Rate (People under 75) 407 per 100,000 Emergency Admission Rate 11,568 per 100,000 1 Health & Wellbeing People are able to look after and improve their health and wellbeing and live in good health for longer. Improving mental health support in the community. Over 90% of people requesting support from the Community Mental Health Team received support within 18 weeks. The Team worked with the Intensive Home Treatment Team to support people at risk of being admitted to hospital to receive care at home instead of on an acute mental health ward. They also worked with Psychological Therapy Services and Adult Services to redesign how people with Autism Spectrum Conditions were assessed and diagnosed. This reduced the waiting list time from 56 weeks to under 18 weeks. Page 62 of 276
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To improve the health and wellbeing of the population we needed to focus on the underlying causes of poor health and inequalities. Poor health can be the result of several factors, including diet, smoking, cultural factors and the sense of control people feel they have in their lives. Scotland has the highest rates of premature mortality in the UK. More than 20,000 people aged under 75 die each year, with a disproportionate number of these in the most deprived areas. In 2021/22 the number of people under 75 who died prematurely in Midlothian increased. Midlothian has a higher number of people with respiratory illness than the Scottish average. We suspect that there may be a connection between the number of people who prematurely died in 2021/22, the impact of COVID-19, and this vulnerable group. Cardiovascular disease and cancer are strongly linked to deprivation. Addressing the impact of poverty and increasing opportunities and access to employment is vital alongside work to address drug and alcohol problems, and links to violence. By ensuring good mental wellbeing support, increasing educational attainment, and promoting healthier physical and social environments we anticipate that premature mortality will reduce. Prevention and early intervention for type 2 diabetes The dietetics service supported people with, or at risk of developing, type 2 diabetes. People shared experiences and gained confidence to look after their own condition. • Over 250 people accessed support from weight management programmes • 125 people were referred for Physical Activity support • 90 people completed face to face group weight management programmes • 65 people were referred to the ‘Let’s Prevent Diabetes’ programme in McSence and Newbattle, with additional virtual support Activities were available for anyone living in Lothian giving choice about where and when people wanted to take part. Page 63 of 276
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National Indicators used to measure this outcome. National Indicator Our result Our Progress Adults supported at home agreed that they are supported to live as independently as possible. 73% Adults supported at home agreed they had a say in how their help, care or support was provided. 70% Emergency Admission Rate 11,568 per 100,000 Emergency Bed Day Rate 106,360 per 100,000 Readmission to hospital within 28 days 105 per 1,000 Proportion of the last 6 months of life spent at home or a community setting. 88% Falls Rate (People over 65) 25% Adults with intensive care needs are receiving care at home. 64% The number of days people aged over 75 spend in hospital when they are ready to be discharged. 520 per 1,000 Health and Care resource spent on hospital stays where the person was admitted as an emergency. 23% 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. Page 64 of 276
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Right care, right place, right time The indicators used in this section relate to the experience of people when they receive care in hospital. In 2021/22 there are good examples where we have improved our services including reducing the number of days people have to stay in hospital when they are ready to return home and increasing the number of adults who have intensive care needs that are supported to live within their community. Learning Disability Services worked with our partners to improve how people with complex care needs were supported to live well in their local community. People want to live independently in their own homes for as long as possible. Living well in good quality housing that meets people’s support needs is the foundation of good health. In 2021 we arranged 174 adaptations to people’s homes, providing 2,092 telecare packages, and increased the number of care at home hours by 7.8% to 17,000 hours per week. Weight management support was delivered to people in their own homes using the online platform “Near Me”. Over 80% of people who received support in this way reported that they would choose to continue with this as they liked being in their own home and not having to travel. Supporting people to lives good lives We know that people with learning disabilities often spend far longer in hospital than those without a learning disability. One local resident had spent nearly 17 years in hospital because appropriate housing and support had not been available locally to meet their needs. However, with local supported living facilities and integrated working across health, social care, social work, housing and the Richmond Fellowship Scotland, they are now living as independently as possible in their own community. They recently reported ‘The world is now my oyster!’ Ensuring people who are housebound received vaccinations The Housebound programme supported over 1,000 people whose health records indicated they were housebound and immunosuppressed. Telephone calls and Good Conversations to discuss people’s needs identified around 200 people who said they were able and willing to come into a clinic to be vaccinated. The remaining 800 patients were vaccinated at home. Page 65 of 276
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During the pandemic we worked with independent and Third Sector partners to support people stay safe and well at home during periods of lockdown, shielding, or self-isolation and expanded our support to help people get back home from hospital promptly and receive the right care at home. Preventing admissions to hospital for Chronic Heart Failure Pathhead Medical Practice worked with consultants at the Royal Infirmary to identify a small group of people with chronic heart failure who met the criteria for ‘medication optimisation’. This ensured they were offered the most effective medication to reduce their risk of needing to go to hospital. Digital skills for older people Volunteer Midlothian ran ‘Connect on Line’ classes for older people to develop skills and confidence to book appointments and tests, get vaccine certificates, complete the census, order online shopping, and use websites for price comparisons. Over 20 volunteers supported 51 older people to attend group sessions to learn new skills, 23 people received home visits, and many more were signposted to online safety, security, and energy workshops. The service purchased tablets, upgraded laptops, and gave out devices through their lending library. iPads and mobile Wi-Fi were obtained through the Scottish Government ‘Connecting Scotland’ scheme. Connect on Line also successfully applied to the National Databank scheme and received 30 phone sim cards for people experiencing data poverty. . ‘ ’ scheme. Page 66 of 276
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National Indicators used to measure this outcome. Right care, right place, right time GP are independent contractors, and we continue to work closely together. The HACE survey covers elements of services that are delivered by GP independent contractors, and elements that are delivered by the HSCP. National Indicator Our result Our Progress Adults supported at home agreed they had a say in how their help, care or support was provided. 70% Adults supported at home agreed that their health and social care services seemed to be well coordinated. 64% Adults receiving care or support rated it as excellent or good. 79% Adults had a positive experience of the care provided by their GP practice. 62% Readmission to hospital within 28 days. 105 per 1,000 Proportion of the last 6 months of life spent at home or a community setting. 88% The number of days people aged over 75 spend in hospital when they are ready to be discharged. 520 per 1,000 3 Positive Experiences & Dignity People who use health & social care services have positive experiences of those services, and have their dignity respected Page 67 of 276
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Over a third of patients were concerned about the arrangements for accessing advice and support from local health centres but four of the 12 local practices rated consistently higher than the Scottish averages. 62% of people said they had a positive experience of the care provided by their GP practice. This is lower than in 2020/21 (67%) and is lower than the average in Scotland (67%, reduced from 79% in 2020/21). However, 88% of people said they had a positive experience when needing to see a GP urgently. This is a small increase from 2020/21 and is higher than the average for Scotland (85%). At least in part, we think more positive results are due to our Good Conversations approach and changes that increased opportunities to quickly assess urgent problems. Initial Primary Care medical assessment is now available by telephone, video, and email in some practices. Demand for GP appointments continued to increase with up to an estimated 10,000 patient contacts with a member of the primary care team in Midlothian each week. It is important to see the right professional from the very first conversation. To try and get this right more often all reception teams were trained in ‘Care Navigation’ conversations to make sure people are directed to the most appropriate community professional or service. We also expanded the teams that work in our GP practices and in the community. There are now more specialist services located in practices than ever before. People can usually access the care they need from Physiotherapists, Primary Care Mental Health Nurses, and Wellbeing Practitioners directly from these professionals without needing to see a GP first. Pharmacists, Advanced Nurse Practitioners for minor illness, Phlebotomists and Community Treatment & Assessment Clinic (CTAC) are also available at GP practices. Each GP practice in Midlothian has a tailored model of delivery to meet the needs of its own population. As a result, there is flexibility in the range and number of professionals available at each practice and how people contact the practice team. Future work includes addressing variation in the digital support available and improving access to consultations using online systems. Being seen quickly by the most appropriate professional leads to better outcomes and experiences. For example, or latest data shows that the MSK-APP service across all practices in Midlothian has freed up 2307 hours (61 days) of GP time since it started in 2019. This has resulted in 93% of people not requiring further GP input for their musculoskeletal issue after seeing a physiotherapist. Our own services work closely with hosted services in other areas of Lothian, for example, the Speech and Language Therapy Home First Team. They helped people with communication or swallowing difficulties and provided targeted support in people’s homes to avoid them having to stay in hospital or to help them get home from hospital more quickly. Page 68 of 276
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The Midlothian Community Treatment and Care (CTAC) Service worked alongside specialist teams, to improve outcomes for people with chronic long-term wounds. People said this improved their mood, motivation, and participation in activities previously limited by the challenges of long-term wound care including getting out and about locally, meeting friends and planning family visits. The CTAC team provided individualised care and supported over 20 people who now no longer need to visit health centres and GP practices for long-term wound management. Continuity matters and that an appointment with a GP adds best value to care where there is a need to investigate persistent or progressive symptoms of concern, or manage complex chronic illness, frailty, or palliative care. We saw this in 2021/22 where potentially preventable admissions for people with heart failure were reduced by 50% and avoided an unnecessary hospital stay. Helping people stay at home The Day Hospital were concerned about man attending the service who had experienced swallowing difficulties and significant weight loss. A number of professionals were considering admitting him to hospital. The Day Hospital suggested that the Home First Speech and Language Therapist (SLT) could help. The SLT reviewed how the man was swallowing and provided advice and strategies to help then followed up with a home visit. “The advice for my swallowing really helped. I am drinking more and not coughing nearly so much. It was so helpful for you to come to the house as getting out is difficult. You are a real brick, thank you!” Improving care at the end of life The Midlothian District Nursing service supported people with life limiting illnesses live at home at the end of their life. Staff teams tried to stay consistent to build relationships and provide emotional support. Our palliative care feedback project told us that families valued staff continuity and that those relationships helped them cope in difficult times. Over the past 2 years, the service increased the number of visits by 62% and increased the average time for each visit. Visits for symptom management were recognised as vital to ensure people were supported well at home and these visits increased by 142%. The Community Respiratory team supported people at the end of their COPD journey by focusing on shared decision making, individual choice, anticipatory care planning and quality end of life care as close to home as possible. Page 69 of 276
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National Indicators used to measure this outcome. Right care, right place, right time The support delivered by Midlothian Health and Social Care Partnership helped improve the quality of life for 81% of the people who responded to the HACE survey, an increase of 13% on the previous year. Cherry Road Day Centre used collaborative models of community support for people with complex care needs. Over 60 people with learning disabilities took part in creative workshops, educational activities and vocational opportunities. These reflected individuals’ interests and helped develop a better understanding of what matters to each person and what a good life means to them. People National Indicator Our result Our Progress Adults receiving care or support rated it as excellent or good. 79% Adults supported at home agreed services and support had an impact on improving or maintaining their quality of life. 81% Emergency Bed Day Rate 106,360 per 100,000 Readmission to hospital within 28 days 105 per 1,000 Falls Rate (People over 65) 25% The number of days people aged over 75 spend in hospital when they are ready to be discharged. 520 per 1,000 Health and Care resource spent on hospital stays where the person was admitted as an emergency. 23% 4 Quality of Life Health & social care services help to maintain or improve the quality of life of people who use those. Page 70 of 276
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designed their own environments and daily activities. Everyone’s contribution was valued equally and added to our understanding of different ways of seeing and experiencing the world. Weekly workshops supported meaningful activities in local community spaces included sensory sound sessions, product design, live music, and textiles. Understanding the different types of support people need to achieve what matters to them continues to be an important part of our self-management approach. Our services for older people adapted to people’s needs and offered support in new ways. Our Intermediate Care Community Teams partnered with the Red Cross to help people come home from hospital earlier and stay at home for longer. In the first 6 months, 95 people were supported to return home and live independently through advice with welfare benefits, assessments of the home and referrals for adaptations and equipment, referrals for social activities, and help with Power of Attorney applications. Physical activity plays a key role in both our physical and mental wellbeing and maintaining an active lifestyle is even more important as we get older. By helping people to remain active the risk of falls that result in a trip to hospital can be reduced. Our work to improve access to sport and leisure supported older people and those living with long term conditions. Supported Self-Management The Thistle Foundation provided supported self-management and carer support for people with long-term health conditions or facing challenging life situations. 1,400 people were referred for one to one support and group courses. 75 people attended online Lifestyle Management and Mindfulness courses to support them to feel more able to return to the activities that matter in their lives. One participant said, “In the first lockdown I couldn’t get out the door, I’d be crying, shaking and panicking. … I’m meeting friends again, and even going on the bus. One of the other ladies in the group and I support each other by video calling and saying ‘you go to your front door, and I’ll go to mine...’ I used to have high blood pressure stressing about going out. Because my blood pressure is coming down it makes my doctor happy – which makes me happy!” Improving access to Sport & Leisure Sport & Leisure provided support and opportunities for physical activity for people at risk from poor health outcomes related to inactivity across the pandemic. • 18,394 people aged over 50 took part in Ageing Well activities • 3,966 people with long-term conditions were supported by Midlothian Active Choices Page 71 of 276
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Respect and dignity are central to our values, and we made progress embedding a Human Rights approach across our services. Our new contracts with care at home providers specify how the service should promote human rights. We secured funding to deliver training to staff to support them to embed a human rights-based approach within our care homes. For people with learning disabilities a Human Rights Panel was established, led by ‘People First Midlothian’, and held human rights sessions focussing on supported decision-making. Training and further education The Midlothian Unpaid Work team develop and promote training pathways, further education and employment opportunities to support people with a previous pattern of offending. Workplace Health and Safety training was incorporated into inductions providing the opportunity to gain this SQA recognised qualification. First Aid at Work and Emergency First Aid courses are also regularly delivered by the team. In partnership with Midlothian’s Communities, Lifelong Learning and Employability team and local Higher Education providers, 83 courses have been completed with 55 individuals gaining qualifications in courses including the Construction Skills Certificate Scheme (CSCS) card, Rural Skills Course, and Adult Achievement Awards. Page 72 of 276
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National Indicators used to measure this outcome. Right care, right place, right time Health inequalities result in poorer outcomes for some people and communities. 1 in 4 children live in poverty in Midlothian. Adults living in areas of deprivation are more likely to be prescribed medication for anxiety or depression or go to hospital for a preventable reason than people living in affluent areas. People in areas of deprivation are more likely to die, on average, 9 years earlier than people living in more affluent areas. We have an obligation under the Equality Act 2010 to positively promote equality. We must advance equal opportunities and foster good relations between different people when carrying out our activities. As part of our responsibilities to consider how our services and supports might affect different groups in different ways and avoid unintended consequences, we completed 8 Integrated Impact Assessments to inform our planning and ensure our services and supports met the diverse needs of our communities. National Indicator Our result Our Progress Premature Mortality Rate (People under 75) 407 per 100,000 Emergency Admission Rate 11,568 per 100,000 5 Health Inequalities Health & social care services contribute to reducing health inequalities Vaccinations in the right place to reduce inequalities Pop-up vaccination clinics in Newbattle, Penicuik & Dalkeith vaccinated over 800 people in areas where we knew the number of people with vaccinations was low. The No.11 Service in Dalkeith supported the vaccination team to reach people known to be at risk of health inequalities within the Criminal Justice System and people recovering from substance use. Our Health Inclusion nurse vaccinated nearly 50 people living in hostels. Page 73 of 276
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‘Good Conversations’ is an approach to changing our culture, seeing ourselves as ‘facilitators’, ‘not ‘fixers’, understanding and working with people’s life circumstances, and supporting self- management, choice, and control. Good Conversations addresses the impact of inequality. 19 services redesigned how they welcome people and treating people as experts in their own lives. People said this approach was meaningful and made a difference in their lives. We work with people as equal partners and focus on what matters to them with a ‘whole person’ approach. “My appointments with people with a long-term condition have got shorter. I asked a person with chronic pain to talk about the day she coped and what she did and encouraged her to do more of the same.” General Practitioner “I felt really listened to. It was nice to take my time about things” Reducing A&E attendance The Health Inclusion Team supported 11 people under the age of 55 who had attended Accident and Emergency more than 3 times in a year. They supported people using ‘Good Conversations’ there was a 64% reduction in visits by the group. “I used to spend most of the appointment with a patient who has diabetes talking about their diet. On this occasion I asked what mattered and she said she was scared. This meant we discussed this and helped her to understand what would help her manage her condition.” Practice Nurse Page 74 of 276
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National Indicators used to measure this outcome. Right care, right place, right time In 2021/22 many people became carers for the first time or may have found their caring role significantly changed. Covid-19 affected the way services and support could be delivered, and people’s care needs changed. Not all services and supports were able to work at full capacity due to restrictions and people had to take on tasks which the Care at Home services were unable to provide. Restrictions in the availability of some support services accessed by carers, e.g., residential respite for older people, led to alternative solutions being piloted. Additionally, more people recognised they carried out a caring role and the demand for support, information and advice for unpaid carers increased. The last census told us that over 2,000 people in Midlothian provide substantial care of more than 50 hours per week. We continue to try and reach everyone who provides a caring role. We know that many unpaid carers are not actively known to our services. Perhaps the most concerning aspect of the HACE survey feedback is how poorly our unpaid carers feel supported. 19% of respondents (336 people) described themselves as having carer responsibilities. Although 60% of people who responded felt they had a good balance between caring and other things in their life, the Midlothian VOCAL carers survey found this to be much lower at 28%. This is particularly relevant as carers who are in contact with VOCAL are seeking support, information, and advice with their caring role, perhaps including how to manage their caring and health & wellbeing. Midlothian achieved slightly higher (40%) than the national average (39%) in the HACE survey when asking carers if they felt they had a say in the services provided for the person they care for. This was significantly higher (54%) in the VOCAL survey and likely due to the work of VOCAL to provide support and promote self-advocacy with carers. National Indicator Our result Our Progress Carers feel supported to continue in their caring role. 27% 6 Support for Carers People who provide unpaid care are supported to look after their health and wellbeing. Page 75 of 276
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We developed our Carers Strategy alongside a review of carers support and services. It aims to improve both the experience for carers and how caring is viewed and valued within our services and communities. Priority aims included: • Carer identification and Carer involvement • Access to Support, Information and Advice • Health & wellbeing (including breaks from caring) • Planning ahead and financial support We undertook a self-evaluation to help us understand how we can be more successful supporting unpaid carers in ways that are meaningful to them. We know that carer support is about the whole system working better together and have become more aware of the impact that capacity pressure on care at home, respite, and day services has on carers. We will continue to take a whole system approach to improve the support available and experience of unpaid carers. Increased carer support We awarded new and increased contracts to local organisations to support carers. The British Red Cross, Dalkeith Citizens Advice Bureau, and VOCAL increased capacity to support carers with financial advice and grants as well as improving earlier identification of those in a caring role. More carers were supported by VOCAL in 2021/22 with 1,130 people completing Adult Carer Support Plans, 198 people accessing a Wee Breaks grant, and 500 people going on a day-attraction break. “Getting the desired information/service quickly from one main contact point has reduced stress and uncertainties of finding and getting appropriate support” “I feel I am not alone. I know that in my day to day caring and when big decisions have to be made, I can access support” “The support from Wee Breaks was invaluable to us and kept us going” “I was torn to bits by it all and VOCAL gave me a steadying hand when I most needed it” Page 76 of 276
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National Indicators used to measure this outcome. Right care, right place, right time We received 674 Adult Protection referrals. This was an increase of 49 %, with 221 more than the previous year. In the past year 64% of people referred for Adult Support and Protection were over 65yrs old, 53% were females and the main reason for referral was neglect. National Indicator Our result Our Progress Adults supported at home agreed they felt safe. 79% Emergency Admission Rate 11,568 per 100,000 Emergency Bed Day Rate 106,360 per 100,000 Readmission to hospital within 28 days. 105 per 1,000 Falls Rate (People over 65) 25% Care services graded Good or better in Care Inspectorate Inspections. 78% Health and Care resource spent on hospital stays where the person was admitted as an emergency. 23% 7 Safe from Harm People using health & social care services are safe from harm. Page 77 of 276
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We supported people at risk of abuse from close family members. We worked with families to search for solutions or, in rare cases used legal proceedings to protect people. In 2021/22, two people were assessed as being at risk of harm from people close to them. The safest solution in both these cases was to seek a Banning Order through the courts. We worked with the police in reducing violence against women and girls. ‘Women’s Aid East and Midlothian’ provided support and refuge accommodation to women, children and young people who experienced domestic abuse. They remained fully operational and provided support to 306 women and 208 children and young people including refuge accommodation for 29 families. Our services and supports aim to keep people safe from harm and prevent avoidable risks. In 2021/22, where it was feasible to reduce face-to-face contact, teams made a number of changes to how services were delivered in line with national guidance. However, teams continued to see people face-to-face where this kept them safe and well. Third sector organisations also worked hard to find safe ways of supporting vulnerable people. Training staff on Adult Protection Adult Protection services delivered Adult Protection Council Officer training to social workers who carry out specific duties under Adult Protection legislation to protect vulnerable adults. 86 multi-agency staff in Midlothian and East Lothian attended a course on protecting adults at risk of financial harm. Supporting women affected by complex trauma The Spring service supported women affected by histories of complex trauma and substance use, mental health and/or offending behaviour to access support for all of their needs under one roof. The Spring service worked collaboratively with Women’s Aid East and Midlothian, Access to Industry, Health in Mind, Occupational Therapy, the Health Inclusion Team, and Justice Social Work. The ‘Stepping Stones’ programme was redesigned to integrate emotional regulation and distress management in all sessions, and renamed ‘Stepping Forward’. Women who have experienced trauma frequently report low self-esteem and low feelings of trust and hope. 83% of women who accessed the Spring service reported improvements in ‘identity and self-esteem’ and ‘trust and ‘hope’. Page 78 of 276
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We worked to ensure people could access information and know where to turn to for help. The ‘Older People’s Newsletter’ was printed and delivered to people who may have found it hard to find the information online. Digital poverty and variation in digital access became even more important to address in 2021/22 as we increased our use of technology to support people in the community. Working with The Connecting Scotland scheme and our Third Sector colleagues, we jointly distributed 116 iPads and digital devices to people. Our work to keep people safe and well at home also includes the use of telehealth equipment. During 2021/22 there were 25,175 responses to alarms within the home for Midlothian Residents. The majority of alarms were responded to by health and social care staff (65%) with family members providing support where appropriate (35%). Keeping people safe in their own homes Our community alarm systems help keep people safe and well in their own homes. We provided a range of sensors including community alarms, smoke and CO2 detectors, a bed sensor, a door sensor and a falls detector. These are linked to a call centre who can respond if someone doesn’t respond to the alarm. This helps people feel able to remain in her own home and feel safe. We provided support for people leaving hospital such as falls alarms to ensure help was at hand quickly when needed. Page 79 of 276
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National Indicators used to measure this outcome. These are no National Indicators to measure our progress towards this outcome and we use staff surveys to evaluate our performance. Right care, right place, right time iMatter staff survey Over half of the workforce (700 staff) responded to our annual survey. Despite the pandemic resulting in some of the most challenging times in our working lives, staff rated the level of support from the HSCP in relation to their health and wellbeing as constant with previous years. More flexible and home working, staff vaccinations and personal protection equipment helped staff feel safe and valued but 27% of staff told us there was room for improvement. We recognised the importance of easy access to support and appointed a Wellbeing Lead to listen to staff, provide the right resources, and offer access to coaching. Health and wellbeing Our staff and partners in every sector showed an enormous commitment to supporting people and communities in 2021/22 as we continued to feel the impact of the pandemic. Supporting our staff to perform well, feel safe, and properly valued so they can continue to deliver high quality services was identified as one of our five top priorities and a ‘Spotlight’ area in 21/22. 8 Workforce Staff are engaged with their work and are supported to continuously improve the information, support, care and treatment they provide Supporting our staff to rest, refuel and recover Reduced access or closure of local premises meant it was often difficult for staff to find somewhere to eat or drink, rest, or use a toilet while working in the local community. We identified 21 Midlothian Council and NHS Lothian buildings with suitable areas to rest, refresh, and refuel. Our staff co-created a logo, promotional materials and a map. Page 80 of 276
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National recruitment crisis Scotland saw a significant drop in workforce over the past two years and much of this was due to the impact of COVID-19. Chronic illness, long covid, increasing difficulties with mental health and well-being, people taking on a new caring role or choosing early retirement, adjusting working patterns and reducing working hours to manage new commitments all impacted on the choices people have made in relation to their working lives. Finding recruitment solutions We want Midlothian to be a place where people chose to work and be part of health and social care within their community. In 2021/22 the NHS and the Council workforce in Midlothian grew by 11% to 1,090 whole-time equivalent staff. This figure is more than double when we also consider our independent and third sector partners. Despite this, the impact of the pandemic continued to be felt across services nationally, and pressure on existing staff was amplified by recruitment difficulties. Care at home services and care homes experienced significant recruitment challenges and this impacted on the number of staff who completed SVQ training. Where staff were historically supported to gain SVQ qualifications while working, having more new staff in the workforce than usual meant the proportion of staff who had completed all the relevant SVQ qualifications dropped from 85% to 60%. A new Clinical Educator post was created at Midlothian Community Hospital to address recruitment challenges by supporting staff to develop into new roles. This helped to develop and assess competences, consolidate new skills, and provide support for learning and improvement. Initiatives to address staff shortages were put in place including career pathways for nursing posts; foundation courses and modern apprenticeships in the community hospital; increased capacity for SVQ programmes; and increased capacity to train social work students. Training staff In 2021/22 we secured premises to provide local training and wellbeing support, with plans to open our training suite in Hardengreen in 2022/23. Training and staff development opportunities were available to all staff although this was constrained by the capacity of services to release staff. The Midway approach offered all staff training in areas such as trauma and health literacy, 287 participants went on Bitesize training and 91 staff have been trained on improving their skills in Good Conversations to support self-management. Page 81 of 276
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Training and staff development opportunities are readily available to all staff both online and face to face. Ongoing training is important to keep staff safe and maintain registration and we continued to support the capacity of services to release staff wherever possible. Quality Improvement Team Staff benefited from opportunities for reflection and learning together to continuously improve the information, support, care, and treatment they provide. Quality Improvement Teams were one way we support our staff to engage in continuous improvement of experiences and outcomes of care. These teams used data to identify and prioritise areas where we could improve, try new ideas, and share learning. Quality improvement to improve outcomes The Intensive Home Treatment Team identified that a brief crisis intervention would reduce the risk of admission to hospital for some people experiencing mental health difficulties. The team found that by creating the ‘Crisis Intervention and Monitoring Pathway, people in crisis but without a known diagnosis could see significant change with only require a short period of intervention and benefit from recommended supports. This will be piloted within the Mental Health and Resilience Service and outcomes reviewed in 2022/23. Page 82 of 276
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National Indicators used to measure this outcome. Right care, right place, right time Ensuring we make best use of our resources is a complex task. We continued to prioritise our work on prevention, early identification, and early intervention. In 2021/22, we continued to invest in our work in the community so more people were treated at home and avoid a hospital admission. For example, the Discharge to Assess Team recruited 36 health care assistants to enable people to return home as soon as they were fit to do so. Our continued investment in Home First services and the implementation of the Primary Care Improvement Plan are examples of increased investment in community services and our commitment to reduce our reliance upon hospitals. National Indicator Our result Our Progress Adults supported at home agreed that their health and social care services seemed to be well coordinated. 64% Emergency Admission Rate 11,568 per 100,000 Proportion of the last 6 months of life spent at home or a community setting. 88% Falls Rate (People over 65) 25% The number of days people aged over 75 spend in hospital when they are ready to be discharged. 520 per 1,000 Health and Care resource spent on hospital stays where the person was admitted as an emergency. 23% 9 Use of Resources Resources are used effectively and efficiently. Page 83 of 276
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However, the pressure on acute hospital remained very high. We continued to support people to improve their own health and all our services promote preventative action and early intervention. Our work on reducing the incidence of diabetes as a partner in the South East Scotland Diabetes Strategy is an example of this. We must also help people stay as well as possible when they have long term conditions and the Improving Cancer Journey programme in collaboration with Macmillan is an example of this. The emphasis given nationally and locally to vaccinating against COVID reflects the importance of prevention wherever possible. We performed better than the Scottish average for all 3 doses with 100% of people having their first dose. Our overall performance on vaccination rates compares well to elsewhere in Scotland demonstrating our resilience and ability to adapt and deliver service in new and innovative ways. Successful vaccination programme As part of one of the most effective vaccination programmes in Scotland, Gorebridge Leisure Centre was transformed into a local and accessible vaccination centre. As a result, vaccination uptake significantly improved in 2021-22 The Flu vaccination team designed clinics in response to views about the convenience of location and times. The pre-school vaccination team opened a telephone helpline for queries, created more flexible clinic times at a variety of accessible locations, and offered drop-ins rather than set appointments. The team increased capacity at every clinic by improving the process and reducing appointment times from 20 minutes to 15 minutes. Weekend and Friday afternoon clinics proved to be very popular. Sport and Leisure staff provided support including helping people maintain social distancing whilst queuing and answering questions for people attending. Positive and effective working between NHS Lothian, Sport and Leisure staff, St Johns Ambulance and volunteers ensured around 9000 vaccinations a week were safely delivered. Page 84 of 276
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How We Spent Our Money (2021/22 subject to audit) The IJB had a total budget of £178m and ended the financial year with a small underspend of £10.5m. This underspend is made up of an underspend on the IJBs operations of £1.1m and earmarked funding, predominantly for COVID not spent in year of £9.7m. For more information see our Annual Accounts. Direct Midlothian Services Budget Spend Variance Community AHPS £2,707,000 £2,788,000 -£81,000 Community Hospitals £5,715,000 £5,891,000 -£176,000 District Nursing £5,923,000 £5,875,000 £48,000 General Medical Services £33,882,000 £33,859,000 £23,000 Health Visiting £2,233,000 £2,221,000 £12,000 Mental Health £2,950,000 £2,825,000 £125,000 Other £1,275,000 -£4,875,000 £6,150,000 Prescribing £19,101,000 £19,253,000 -£152,000 Resource Transfer £7,172,000 £7,172,000 £0 Older People £22,842,000 £19,001,000 £3,841,000 Learning Disabilities £16,548,000 £16,528,000 £20,000 Mental Health £1,177,000 £1,387,000 -£210,000 Physical Disabilities £3,537,000 £4,086,000 -£549,000 Assessment and Care Management £3,378,000 £2,987,000 £391,000 Other £3,113,000 £2,361,000 £752,000 Midlothian Share of pan-Lothian Set Aside £20,548,000 £20,698,000 -£150,000 Mental Health £2,662,000 £2,715,000 -£53,000 Learning Disabilities £1,415,000 £1,427,000 -£12,000 GP Out of Hours £3,144,000 £3,102,000 £42,000 Rehabilitation £879,000 £791,000 £88,000 Sexual Health £696,000 £676,000 £20,000 Psychology £846,000 £855,000 -£9,000 Substance Misuse £375,000 £363,000 £12,000 Allied Health Professions £1,622,000 £1,494,000 £128,000 Oral Health £1,853,000 £1,822,000 £31,000 Other £1,438,000 £1,210,000 £228,000 Dental £5,855,000 £5,855,000 £0 Ophthalmology £1,742,000 £1,742,000 £0 Pharmacy £3,795,000 £3,795,000 £0 £178,423,000 £167,904,000 £10,519,000 Page 85 of 276
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Financial Challenges During 2021/22 COVID-19 Financial Impact COVID-19 disrupted patient journeys and service delivery and delayed access to secondary care treatment which might otherwise reduce care requirements for individuals. We remain committed to supporting our partners (Midlothian Council and NHS Lothian) during this very difficult time but we anticipate that, as the impacts of the pandemic become more manageable, we will be able to return to a more ‘business as usual’ position. During the financial year, we spent around £5,488,000 to support the additional costs of health and social care generated by the COVID-19 pandemic. This was funded through our COVID-19 reserve along with additional funding from the Scottish Government. In addition, we continued to support NHS Lothian with its remobilisation plan as part of the overall recovery of services from the pandemic. Social Care There was an overspend within adult services, specifically for clients with physical disabilities. This was offset by a significant underspend in services for older people. Health Although there were operational overspends within Community Hospitals, as a result in the changing environment and nature of patients these were offset by vacancies across the system and slippage of programmes. For our Hosted and Set Aside services the areas with continued pressures being experienced Mental Health Inpatient services with additional capacity being required in year to cope with high demand and the increased demand on the community equipment store. The main pressure for Set Aside services in this financial year lies within Gastroenterology Services and the ongoing pressure with drug costs for the treatment of long-term gastroenterology conditions. Junior Medical pay pressure also continued during this year, where additional staffing was required to fill gaps in rotas and where there were service pressures. The Junior Medical position has improved significantly from previous years but still remains a pressure. The Scottish Government released funding to cover the impact of COVID costs on NHS Lothian’s position and that funding has been allocated to delegated and set aside services to offset additional expenditure incurred. With COVID funding being allocated across the IJBs set aside specialities to cover additional costs incurred around extra staffing to cope with COVID-19, the overall position on set aside is much improved compared to previous years. We have a duty under the Local Government Act 2003 to make arrangements to secure Best Value. Best Value includes aspects of economy, efficiency, effectiveness, equal opportunity requirements, and sustainable development. In 2021/22 there was an increase in the IJB spend within the community services. This is in line with our ambitions to develop health and social care services locally. Examples of this are our home first model, the development of intermediate care services locally, including discharge to assess and hospital to home. Page 86 of 276
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Main Areas of Spend (2017/18-2021/22) The graph below compares our spend trends for the past 5 years. We are unable to report on spend by locality as we do not hold data in this form. 0 10000 20000 30000 40000 50000 60000 70000 80000 90000 100000 Community Hospital Prescribing GMS Other £ 000's 2017/18 2018/19 2019/20 2020/21 2021/22 Page 87 of 276
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Working with our Communities The Public Bodies Act requires that each Integration Authority area is split into at least two localities. The data from the HACE Survey is included in an appendix to this report. However, the number are often too small to be reported. There is no natural split into two or more areas nor is the population large enough to make a locality approach viable for commissioning services. As the smallest mainland authority in Scotland, we do not consider this is a meaningful approach. Instead, we work with the local Community Planning Partnership and Neighbourhood plans to work with 16 natural communities to identify what is working well and plan areas for development. The voluntary sector has strong roots in local areas and supports a system wide understanding of community intelligence that is invaluable. Our ongoing partnership with the third sector is at the core of our work in communities. This approach has been particularly effective during civil emergencies such as extreme weather conditions and, more recently, the pandemic. Delivering local services • Local Care & Treatment Centres Three Care and Treatment Centres were established in 2020/21 and they continued to support people this year. We also expanded local multidisciplinary primary care teams to provide local access to services such as physiotherapy, pharmacy and wellbeing. • Cash in your Pocket Through targeted leafleting and the provision of local advice, Cash in Your Pocket was a multi-agency approach to increasing uptake of benefits entitlement for older people involving the Citizens advice Bureau (CAB), Housing Associations, Voluntary Organisations, and the HSCP. Over a three-month period, these agencies supported people to access an additional £531,645 in their pockets. This coordinated campaign saw an increase of approximately 25% on the same period in the previous year. • Local support for local need In partnership with Midlothian Voluntary Action, the Mental Health Foundation distributed £297,000 of new investment to address isolation, recovery from Covid-19 and support suicide prevention. There were 27 successful applications based in local communities including a men’s club in Pathhead and activities for older people in Cousland. • Easily Accessible services New initiatives provided local services – for example to increase the uptake of benefits and prevent diabetes through weight management and physical activity groups. Page 88 of 276
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• Vaccinations The vaccination programme was delivered in localities to ensure easy access and reduce the need to use public transport. This included working with popular local commercial partners like IKEA to reach as many people as possible. • Planning for the future Plans have been developed to address the growing needs for local health centres in areas such as Shawfair, and developments have progressed well to establish extra-care housing in Dalkeith, Gorebridge and Bonnyrigg. • Supporting vulnerable people through the lockdowns Statutory services worked alongside community councils and volunteers to support vulnerable people with food, shopping, prescription and isolation. Voluntary organisations such as Red Cross, Thistle Foundation and Grassy Riggs supported vulnerable people in areas of deprivation including Mayfield, Dalkeith and Gorebridge. The approach to more proactive work in areas of deprivation will be revisited as part of the broader ‘area targeting’ activities led by the Community Planning Partnership in 22-23. Despite the continued pressures of the pandemic the commitment to maintain and strengthen work with the Third sector was evident through the programme of Third Sector Summits that continued online to ensure that staff across sectors were equipped to recognise and address the impact of health inequalities. Supporting local communities During periods of national restriction, the Grassy Riggs drop-in café closed but the staff continued to support the local community in a variety of ways. Staff and volunteers carried out regular welfare phone calls and delivered steak pies and soup every week to 21 local people who were vulnerable or unable to leave the house. By keeping in touch with people, staff and volunteers were able to provide support and direct people to other services. Common issues were support for carers, wellbeing and wellness, and bereavement. The Grassy Riggs staff supported older people who were anxious and worried about their health and more vulnerable to Covid-19. A small number of people who have not felt confident to return since the Café reopening in May 2021 continue to benefit from telephone support Page 89 of 276
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Looking forward We expect to face a number of opportunities, risks and uncertainties in the coming years. We recognise the scale of these, but also that services need a period of stability to recover and address the areas where waiting times have increased over the past 2 years. Our future direction and ambitions are set out in our 3-year Strategic Commissioning Plan. This recognises our ability to progress transformational change was severely restricted by the impact of the pandemic as well as what can realistically be achieved within a one or two-year timeframe. Over the last year many services have revaluated how best to meet the needs of people and communities and are at the start of a new and exciting transformational change programme. We set a balanced budget and will invest in key areas of prevention as well as make recommendations for how to use our reserves to support innovative practice and accelerate priority areas of transformation. The funding gap in future years and the potential for additional savings requirements creates significant uncertainty in relation to our ambitions. Finance In March 2022 we undertook part of the annual financial assurance process to review the budget offer for 2022/23 from Midlothian Council and NHS Lothian. This identified financial challenges, but we accepted the budget as it passed the two tests of ‘fair’ and ‘adequacy’. It should be noted that this was a challenging settlement for the IJB, and any further reduction will undoubtably impact on service delivery. We must ensure Best Value by continuing the transformation of health and social care to deliver are safe, effective, efficient, person-centred, timely and equitable services. Covid-19 The coronavirus pandemic remains a significant challenge with uncertainty around further waves and outbreaks. This will remain at the forefront of our planning. Community Growth More than 12,000 new houses will be built in the next 3 years. This will pose challenges for our services and change the face of some local communities. As people live for longer many more people will be living at home with frailty and/or dementia and/or multiple health conditions. An increasing number of people live on their own, and for some this will bring a risk of isolation. Primary Care and Community Services Recruitment and retention is a growing problem in health and social care. There is a shortage of GPs; a significant proportion of District Nurses are nearing retirement; while care at home providers find it difficult to attract and keep care at home workers despite measures such as the living wage and guaranteed hours. The aging population means these pressures will almost certainly increase. The Acute hospitals that support the population of Midlothian (The Royal Infirmary of Edinburgh and the Western General Hospital) remain under significant pressure and exist, as do other social Page 90 of 276
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care and health services, in a financially challenging environment. We will continue to invest and develop community-based alternatives that will minimise avoidable and inappropriate admissions. Introduction of a National Care Service Bill The National Care Service (Scotland) Bill was introduced to Parliament on 20 June 2022 and Scottish Government have committed to establishing a functioning National Care Service by 2026. This will mean changes to governance and delivery of health and social care. We will work in close collaboration with Scottish Government to try and ensure that gains in integrated working and more closely integrated services continues to progress. Improving Quality of Services and Outcomes for People We need to continue to develop our ability to deliver high quality services through a quality programme. Alongside this we need to develop ways of understanding the impact these services have on people’s own personal goals in relation to their health and wellbeing. We have committed to an ambitious programme of self-evaluation, quality management and outcome mapping to become a more responsive and effective provider of health and social care services. In addition, the capacity to provide local training and wellbeing support across the partnership will be enhanced during 22/23 with the acquisition of a training suite in Hardengreen. Improving Reporting of Hosted Services As we develop our own performance measures, we have become even more aware of how important it is to be able to report well to other areas of the system that depend on our data and receive quality data in return. An example of this is the services that are delivered on a pan Lothian basis but hosted within one of the four HSCP across Lothian. All four HSCPs are working together to ensure that these hosted services can provide accurate and meaningful local performance data for each HSCP area in the future. Page 91 of 276
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Inspections The Care Inspectorate inspect care homes and care at home services to check the quality of care. The majority of care homes in Midlothian are not managed by the HSCP. Read the full reports at the Care Inspectorate website Care at Home Services Name Date People's wellbeing Leadership Staff team Setting Care & support planning Care & support during COVID Call In Homecare 01/12/2021 4 Good 5 Very Good - - - 4 Good Cera Midlothian 01/06/2021 4 Good - - - - Midlothian Council Various 4 Good 4 Good - - - 4 Good Recommendations and Areas for Improvement (if any) Name Recommended Improvement Call in Homecare People should be reassured that their care and support plans contain the most current and up to date information. Cera Care Midlothian Ensure improvement in the oversight, recording and reporting systems to ensure these comply with legal responsibility. The management team should review client care plans on a regular basis 6 Excellent 5 Very Good 4 Good 3 Adequate 2 Weak 1 Poor Page 92 of 276
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Care Homes for Older People Name Date People's wellbeing Leadership Staff team Setting Care & support planning Care & support during COVID Nazareth House Various 2 Weak 2 Weak 2 Weak 3 Adequate - 3 Adequate Pitendriech 22/11/2021 4 Good - - - - 3 Adequate Guthrie House 28/02/2022 4 Good - - - - 4 Good Springfield Bank Various 3-Adequate 3-Adequate - - - 3 Adequate Drummond Grange 18/06/2021 4-Good - - - - 3 Adequate Archview Lodge 01/06/2021 4 Good - - - 4-Good 4-Good Recommendations and Areas for Improvement (if any) Name Recommended Improvement Nazareth House Care records reflect care given. People should have confidence that their needs and wishes are met. Staff must appropriately support service users who are experiencing stress and distress. Service users experience a service which is well led and managed, which results in better outcomes for service users. Staff are able to support service users to receive care that meets their health, safety and wellbeing needs and enables them to experience respectful, personalised and compassionate care. Springfield Bank People should be respected and treated with dignity. People should have confidence that their needs and wishes are met. People should experience care and support that is right for them. People should be able to eat and drink well. Drummond Grange People should experience a clean environment that reduces the risk of any cross infection. People should feel they are kept as safe as possible from the risks of cross infection. Archview Lodge Personal plans record all risk, health, welfare and safety needs, in a coherent manner, which identifies how service user needs are to be met. Page 93 of 276
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Intermediate Care Homes Name Date People's wellbeing Leadership Staff team Setting Care & support planning Care & support during COVID Highbank 05/07/2021 4 Good - - - - 4 Good Recommendations and Areas for Improvement (if any) Name Recommended Improvement Highbank People should feel confident they will receive the care and support they need. Staff should follow the 'Open with Care' guidance on visiting. Staff should be aware of the legal framework that supports adults with incapacity to ensure their rights are met. People experiencing care who are at risk of falling should be cared for in ways that promote their safety and independence. Page 94 of 276
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IJB Business Communication and Engagement We undertook a large-scale consultation as we were developing our 3-year Strategic Commissioning Plan. We consulted people who use our services, staff and members of the public on services they use and their views on how we plan our services as a whole. This process took many months, and we did it in several stages. You can read a full report on our website. Developing our vision, values, and strategic aims Our vision and values were discussed with senior staff and 6 strategic aims were developed with staff, planning leads, planning groups and community partners. Developing our 3-year plan Our plan is divided into different areas of work, each led by a planning lead. Each planning lead was asked to work with partners and front-line staff to gather the views of people who use their services. They did this though surveys, focus groups, interviews and Question and Answer sessions. They also used consultation findings such as the Citizen’s Panel and recommissioning information. Over 3,000 people’s views were included and helped shape draft plans for each area. Consulting on our draft ideas Once we had our draft plan, we asked people if they thought it was an equitable and effective use of resources. We put a copy of it in every library and online, posted it on social media and sent a postcard to every household in Midlothian to let people know about it. Key stakeholders including neighbouring IJBs, NHS Directors, the Integration Joint Board, the public and third sector organisations all commented on it. The Midlothian Learning Disability Planning Group was supported by ‘Expert Panels’ to draw together experts, including people with lived experience, to develop solutions in partnership for the areas of our Strategic Plan that affect people with a learning disability, their families, and carers. We consulted with members of staff and third sector organisations using an ‘integrated impact assessment’. This helped us avoid negative impacts on different groups of people including those with protected characteristics, and on human rights, sustainability, and the environment. What we found out – people value services centred around the person. There were a few common themes throughout the consultation including: • Flexible support. People spoke of how services could be improved to offer more flexible and joined up support. • Feeling heard and valued. People spoke of the need to feel safe, welcome, and heard. This included not having to repeat your story, and not feeling processed, judged, or rushed. • Supported Self-Management. People told us we need to support the fabric that keeps them well through better information on what is available and being able to access services directly. Page 95 of 276
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Integration Functions and Governance Decisions Scheme of Integration The Integration Scheme is the document which outlines the establishment, governance, scope, and operation of the Midlothian Integration Joint Board. Legislation requires the Health Board and the Council to jointly agree the scheme and then carry out a review within five years of Scottish Government approval. The Midlothian Integration Joint Board was established on 27 June 2015. A review of the Integration Scheme should have been completed in 2020 but was delayed until 2021 due to the challenges brought by the pandemic. In light of the continuing pressures on health and care and the proposed establishment of a National Care Service, the review focused on agreeing a consistent approach to be taken in all four Lothian Integration Schemes and rather than a full review of delegated services. The proposed revised Scheme of Integration was approved by Midlothian Council and by NHS Lothian Board in June 2022 before submission to Scottish Government for consideration and final approval. Strategic Commissioning Plan Following a substantial programme of consultation and the updating of the Joint Needs Assessment, the Strategic Commissioning Plan for 2022-25 was developed and approved by the IJB. Directions A revised approach to managing progress was agreed on 17th June 2021 and a six-monthly review of progress was considered by the IJB on 9th December 2021. New Directions were included within the Action Plans supporting the new Strategy. IJB Voting Members Carolyn Hirst and Patricia Donald, both NHS Board members, were reappointed to the IJB Key Decisions Taken by the Integration Joint Board in 2021/22 • Finance NHS Lothian Budget Offer 2021/22 Accepted 8th April 2021 Audited Annual Accounts Approved 9th September 2021 IJB Outline Budget 2022/23 Agreed 17th March 2022 • Strategic Planning Strategic Plan 2022-25 Approved in principle 17th March 2022 Directions Performance Management Agreed 17th June 2021 Directions Progress Report Noted 9th December 2021 • Governance Local Code of Corporate Governance Approved 8th April 2021 Audit and Risk Annual Report 2020/21 Approved 26th August 2021 • Performance Amended Improvement Goals Approved 8th April 2021 Performance Management Structure and Additional Resources Approved 26th August 2021 Page 96 of 276
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Improvement Goals and an Outcome-based Approach Progress noted 26th August 2021 Annual Performance Report Contents Approved 14th October 2021 • General Public Engagement Strategic Statement Approved in Principle 8th April 2021 Equality Outcomes 2021-25 and Mainstreaming Report Approved 8th April 2021 Draft IJB Complaints Handling Procedure Approved 8th April 2021 Workforce Development Plan Approved for Implementation 17th June 2021 Copies of the relevant reports can be found in the committee reports on the Midlothian Integration Joint Board pages of the Midlothian Council website Page 97 of 276
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Data Appendix In 2021-22, Midlothian’s performance was the same compared to 2020-2021. Overall performance across Scotland got worse by 2 percentage points. Midlothian’s performance was better than across Scotland. We are doing well in relation to national performance. In 2021-22, Midlothian’s performance worsened compared to 2020-2021 by 7 percentage points. Overall performance across Scotland got worse by 3 percentage points. Midlothian’s performance was worse than across Scotland. We have more work to do in relation to national performance. 93% 93% 92% 91% 0% 20% 40% 60% 80% 100% 80% 81% 73% 79% 0% 20% 40% 60% 80% 100% National Indicator Our result Our Progress Adults are able to look after their health very well or quite well. 92% National Indicator Our result Our Progress Adults supported at home agreed that they are supported to live as independently as possible. 73% Page 99 of 276
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In 2021-22, Midlothian’s performance improved compared to 2020-2021 by 4 percentage points. Overall performance across Scotland got worse by 4 percentage points. Midlothian’s performance was the same as across Scotland. We are doing well in relation to national performance. In 2021-22, Midlothian’s performance stayed the same compared to 2020-2021 Overall performance across Scotland got worse by 8 percentage points. Midlothian’s performance was worse than across Scotland. We have more work to do in relation to national performance. 67%75% 71%71% 0% 20% 40% 60% 80% 100% 65% 74% 65% 66% 0% 20% 40% 60% 80% 100% National Indicator Our result Our Progress Adults supported at home agreed they had a say in how their help, care or support was provided. 70% National Indicator Our result Our Progress Adults supported at home agreed that their health and social care services seemed to be well coordinated. 64% Page 100 of 276
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In 2021-22, Midlothian’s performance improved compared to 2020-2021 by 16 percentage points. Overall performance across Scotland got worse by 5 percentage points. Midlothian’s performance was better than across Scotland. We are doing well in relation to national performance. In 2021-22, Midlothian’s performance worsened compared to 2020-2021 by 7 percentage points. Overall performance across Scotland got worse by 12 percentage points. Midlothian’s performance was worse than across Scotland. There is more work to do in relation to national performance. 63% 80% 79% 75% 0% 20% 40% 60% 80% 100% 69% 79% 62% 67% 0% 20% 40% 60% 80% 100% National Indicator Our result Our Progress Adults receiving care or support rated it as excellent or good. 79% National Indicator Our result Our Progress Adults had a positive experience of the care provided by their GP practice. 62% Page 101 of 276
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In 2021-22, Midlothian’s performance improved compared to 2020-2021 by 13 percentage points. Overall performance across Scotland got worse by 2 percentage points. Midlothian’s performance was better than across Scotland. We are doing well in relation to national performance. In 2021-22, Midlothian’s performance worsened compared to 2020-2021 5 percentage points. Overall performance across Scotland got worse by 4 percentage points. Midlothian’s performance was worse than across Scotland. We have more work to do in relation to national performance. 68% 80% 81% 78% 0% 20% 40% 60% 80% 100% 32% 34% 27% 30% 0% 20% 40% 60% 80% 100% National Indicator Our result Our Progress Adults supported at home agreed services and support had an impact on improving or maintaining their quality of life. 81% National Indicator Our result Our Progress Carers feel supported to continue in their caring role. 27% Page 102 of 276
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In 2021-22, Midlothian’s performance improved compared to 2020-2021 by 12 percentage points. Overall performance across Scotland got worse by 3 percentage points. Midlothian’s performance was the same as across Scotland. We are doing well in relation to national performance. In 2021-22, Midlothian’s performance worsened compared to 2020-2021 by 3%. Overall performance across Scotland got worse by 3%. Midlothian’s performance was better than across Scotland. We have more work to do in relation to national performance. 67% 83% 79% 80% 0% 20% 40% 60% 80% 100% National Indicator Our result Our Progress Adults supported at home agreed they felt safe. 79% National Indicator Our result Our Progress Premature Mortality Rate (People under 75) 407 per 100,000 Page 103 of 276
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In 2021-22, Midlothian’s performance worsened compared to 2020-2021 by 3% i.e., the number of people who needed to be urgently admitted to hospital increased. Overall performance across Scotland got worse by 6%. Midlothian’s performance was worse than across Scotland. We have more work to do in relation to national performance. In 2021-22, Midlothian’s performance worsened compared to 2020-2021 by 4% i.e., people spent more days in hospital as part of an emergency admission. Overall performance across Scotland got worse by 8%. Midlothian’s performance was better than across Scotland. We have more work to do in relation to national performance. National Indicator Our result Our Progress Emergency Admission Rate 11,568 per 100,000 National Indicator Our result Our Progress Emergency Bed Day Rate 106,360 per 100,000 Page 104 of 276
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In 2021-22, Midlothian’s performance improved compared to 2020-2021 by 17%. Overall performance across Scotland got better by 8%. Midlothian’s performance was better than across Scotland. We are doing well in relation to national performance. In 2021-22, Midlothian’s performance stayed the same compared to 2020-2021. Overall performance across Scotland stayed the same. Midlothian’s performance was worse than across Scotland. We have more work to do in relation to national performance. National Indicator Our result Our Progress Readmission to hospital within 28 days. 105 per 1,000 National Indicator Our result Our Progress Proportion of the last 6 months of life spent at home or a community setting. 88% Page 105 of 276
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In 2021-22, Midlothian’s performance improved compared to 2020-2021 by 4%. Overall performance across Scotland got worse by 5%. Midlothian’s performance was worse than across Scotland. We have more work to do in relation to national performance. In 2021-22, Midlothian’s performance worsened compared to 2020-2021 by 4 percentage points. Overall performance across Scotland got worse by 6 percentage points. Midlothian’s performance was better than across Scotland. We have more work to do alongside national performance. National Indicator Our result Our Progress Falls Rate (People over 65) 25% National Indicator Our result Our Progress Care services graded Good or better in Care Inspectorate Inspections. 78% Page 106 of 276
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In 2021-22, Midlothian’s performance improved compared to 2020-2021 by 7 percentage points. Overall performance across Scotland got better by 2 percentage points. Midlothian’s performance was worse than across Scotland. We have more work to do to match national performance. In 2021-22, Midlothian’s performance improved compared to 2020-2021 by 22%. Overall performance across Scotland got worse by 57%. Midlothian’s performance was better than across Scotland. We are doing well in relation to national performance. National Indicator Our result Our Progress Adults with intensive care needs are receiving care at home. 64% National Indicator Our result Our Progress The number of days people aged over 75 spend in hospital when they are ready to be discharged. 520 per 1,000 Page 107 of 276
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This data is no longer collated and not current. NHS Boards were not able to provide detailed cost information for 2020/21 due to changes in service delivery during the pandemic. As a result, PHS have not provided information for indicator 20 beyond 2019/20. PHS previously published information to calendar year 2020 using costs from 2019/20 as a proxy but, given the impact of the COVID-19 pandemic on activity and expenditure, PHS no longer consider this appropriate National Indicator Our result Our Progress Health and Care resource spent on hospital stays where the person was admitted as an emergency. 23% Page 108 of 276
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Ministerial Steering Group Targets Updated targets for 2021/22 were developed by the HSCP, agreed by the IJB and submitted to Scottish Government in April 2021. Our targets are measured against a baseline from 2017/18. MEASURE 2017- 18 2018- 19 2019- 20 2020- 21 2021- 22 STATUS Reduce emergency admissions into hospital from Midlothian by 5% (all ages) 9,028 8,841 10,966 9,207 9,287* Not achieved Reduce number of unscheduled hospital bed days: acute specialties by 10% (all ages) 63,019 62,372 59,798 57,459 55,275* Achieved Decrease in the use of unscheduled geriatric long-stay beds (all ages) 12,734 13,551 12,806 12,802 14,367** Not achieved Decrease in the use of unscheduled mental health beds (all ages) 14,843 15,162 13,708 12,511 10,624 Achieved Maintain Emergency Department Attendance at baseline level (all ages) 29,382 29,688 33,319 26,390 31,295 Not achieved Maintain Delayed Discharge Occupied Bed Days below 40% of the 2017/18 activity 12,295 12,934 10,412 7,150 6,135 Not achieved Reduce the percentage of time people spend in a large hospital in their last six months of life 8.7% 9.8% 9.1% 7.4% 7.9% Achieved Maintain the proportion of people over the age of 65 who are living in the community at 97% or higher 96.4% 96.5% 96.7% 97% No data Achieved SOURCE: Public Health Scotland Integration Performance Indicators Sep 2022 Notes *Where noted the calendar year 2021 is used as a proxy for 2021/22 due to the national data for 2020/21 being incomplete. We have done this following guidance from Public Health Scotland. **Where noted the data is provisional. Figures presented will not take into account the full impact of the precautionary measures that were in still place due to COVID-19 during early 2021. Page 109 of 276
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Midlothian Integration Joint Board Thursday 13th October 2022, 14.00-16.00 IJB Board Meeting Options Executive summary This report provides the Midlothian Integration Joint Board with an update the current options available for hosting the Board meetings going forward. Board members are asked to: • Agree to the recommendation of continuing to host the IJB Board Meeting virtually throughout winter. • Review the options available for hosting the IJB Board meetings ongoing and agree which option would be most suitable for the Board. • Agree to the associated costs # Item number: 5.5 Page 111 of 276
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Midlothian Integration Joint Board Report IJB Board Meeting Options 1 Purpose 1.1 The purpose of this report is to update the Midlothian IJB with available options for hosting the IJB Board meeting ongoing. There are 3 options being proposed in this report: 1. Continue with virtual 2. Develop a hybrid model to allow for both face to face and remote attenders 3. Face to face only The details for each option are included within this report (3.2). Midlothian IJB is asked to review and agree on a preferred option. It is recommended that this change takes place from April 2023 to allow Midlothian HSCP to focus on delivery of the Winter Plan throughout the period of November 22 – March 23. It is expected that this winter will be increasingly challenging with significant pressures already being felt across the system. 2 Recommendations 2.1 As a result of this report Board Members are asked to: • Agree to the recommendation of continuing to host the IJB Board Meeting virtually until April 2023. • Review the options available for hosting the IJB Board meetings ongoing and agree which option would be most suitable for the Board. • Agree to the associated costs 3 Background and main report 3.1 Background In response to the COVID-19 Pandemic and to ensure the safety of staff and Board members, Midlothian IJB Board meetings were moved to virtual from early 2020 to present. The way we work now has changed with remote working policies in place with both our partner agencies and the vast majority of all corporate meetings being held virtually. This report is to review how we host our IJB Board meetings and provide the board with an update on the available alternatives for their consideration. Page 112 of 276
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3.2 Options for consideration Model Details Required Specifications Positive Outcomes Risks Associated Costs Virtual The IJB Board meeting continues to be held virtually on Microsoft Teams. Ensuring each board member has IT equipment to allow for remote attendance at the meeting. Administration of the Board meeting will continue as it Is currently managed ensuring that links to attend are made available to Board members, staff and public. Offers flexibility for members. Reduces travel time and costs. Effective use of time. Reduces risks of Flu/Cold/Covid-19 transmission. No costs associated with hosting the meeting. In line with partners remote working policies. Virtual meetings can be difficult for some attenders to navigate. Technical IT issues can cause delays or even cancellation of essential meetings. Team building/developing effective relationships can be more challenging in a virtual environment. £0 – board members are already provided with IT equipment. Page 113 of 276
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Midlothian Integration Joint Board Hybrid The IJB Board meeting is held in a venue – Newbattle Community Campus, where members can either attend in person or attend remotely. Newbattle Community Campus has a board room with capacity to seat 30. Catering is available on site for refreshments. Suitable IT equipment on site able to run a Midlothian Council connection for Teams to allow for remote attendance. Brings a flexible model to bring both face to face and remote attenders together. Is inclusive to both face to face and remote attenders. In line with partners remote working policies. Additional costs to members/pubic attenders for travel. Additional time required to allow for travel. Careful management needed of the meeting to ensure that remote attenders feel included and able to contribute. Increased risk of Cold, Flu, Covid-19 transmission. £81 per Board meeting (based on 3 hr meeting at £27 per hour) Additional costs for refreshments. Additional costs for staff travel. Face to Face only The IJB Board meeting is held in a venue – Newbattle Community Campus. Newbattle Community Campus has a board room with capacity to seat 30. Catering is available on site for refreshments. Removes dependency on IT and risk of IT failure. Exclusive to those who prefer remote working. Additional travel costs. £81 per Board meeting (based on 3 hr meeting at £27 per hour) Additional costs for refreshments. Page 114 of 276
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Midlothian Integration Joint Board Additional time required to allow for travel. Increased risk of Cold, Flu, Covid-19 transmission. Additional costs for staff travel. 3.2 Board members are asked to review the above options and agree which is the preferred option to be taken forward. Associated costs, risks and positive outcomes have been included alongside each option. 3.3 As previously detailed, it is recommended that any change to the model commences from April 2023 to allow capacity and flexibility to implement our Winter Plan and focus on supporting staff and services through the winter period of November 2022 – March 2023. 3.5 The venue detailed in this report - Newbattle Community Campus is accessible within Midlothian with free car parking, the meeting room is suitable for up to 30 attendees and offers a fully compatible IT service to support Midlothian Council connection. There is a smart board with HDMI cabling which supports Microsoft Teams with suitable audio and camera facilities. The cost per hour is best value compared to other conference venues within Lothian offering the same level of IT facilities. Page 115 of 276
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3.4 Policy Implications None 3.5 Directions The contents of this report does not impact any directions. 3.6 Equalities Implications To ensure equality to all members, the hybrid model offers flexibility to those who work remotely and to those who are comfortable returning face to face. This option would be our recommendation to the Board. 3.7 Resource Implications There are no resource implications arising from this paper 4 Risk All risks associated with the related options have been detailed in section 3.2 above. 5 Involving people N/A 6 Background Papers AUTHOR’S NAME Roxanne Watson DESIGNATION Executive Business Manager CONTACT INFO Roxanne.King@nhslothian.scot.nhs.uk DATE 30-09-22 Page 116 of 276
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Midlothian Integration Joint Board Thursday 13th October 2022, 14.00-16.00 IJB Draft Performance Framework (Phase 1) Executive summary The purpose of this paper is to inform review and discussion of the first draft of the IJB Performance Framework (Phase 1). Board members are asked to: • Note the Performance Framework; • Provide feedback regarding the purpose, content, and accessibility of the Performance Framework; • Highlight any points for clarification; and • Identify any areas for improvement. # Item number: 5.6 Page 117 of 276
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Midlothian Integration Joint Board Report IJB Draft Performance Framework (Phase 1) 1 Purpose The purpose of this paper is to inform review and discussion of the first draft of the IJB Performance Framework (Phase 1). 2 Recommendations As a result of this paper Members are asked to: 2.1 Note the Performance Framework; 2.2 Provide feedback regarding the purpose, content, and accessibility of the Performance Framework; 2.3 Highlight any points for clarification; and 2.4 Identify any areas for improvement. 3 Background and main report 3.1 The core objectives of a Performance Management System are: • For performance evaluation; • To improve work and performance; and • For staff development and continuous learning. 3.2 For a Performance Management System to succeed, it needs to be built upon a solid foundation of measurement – to understand, to improve, and to provide evidence. A Performance Framework is a structured tool to support these activities in a consistent manner across a complex system. 3.3 The IJB has previously set out the ambition to develop a Performance Framework, and is currently subject to an open audit action: “Performance measures in the MIJB’s Performance Management Framework should be more appropriately aligned to key priorities and outcomes of its Strategic Plan”. 3.4 Phase 1 will cover the Directions in their current form, and therefore will be revised accordingly when Directions are updated. The aim is that the next phase will Page 118 of 276
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Midlothian Integration Joint Board provide a more streamlined document, that acknowledges and aligns with a number of key pieces of work that are in development. 3.5 The frequency timescales indicated in the Performance Framework are when the external data are made available to the HSCP for review and wider sharing / reporting. 3.6 This IJB Performance Framework will be complemented by a separate Performance Framework for the HSCP which will be available in early 2023, focussing on operational (rather than strategic) data. 3.7 We will include a formal report of progress towards the aim of creating Performance Frameworks, that sit within a Performance Management System, within the Annual Performance Report for 2022/23. This will reference the ambition we described in the Annual Performance Report for 2021/22. 4 Policy Implications The Performance Framework has been designed to support several activities, including the following statutory reporting requirements: 4.1 IJBs have a legal obligation to produce an annual performance report in line with The Public Bodies (Joint Working) (Content of Performance Reports) (Scotland) Regulations 2014 and the Scottish Government Guidance: Health and Social Care Integration Partnerships: reporting guidance. 4.2 This includes reporting on the national Core Suite of Integration Indicators provided by Public Health Scotland, using these to support reporting on how well we are progressing the 9 National Health and Wellbeing Outcomes which apply to integrated health and social care. 5 Directions Implications 5.1 There are no implications on the Directions. The Performance Framework is a resource to support the Directions and will be subject to regular review as indicated by the Integration Manager and / or the Performance Manager. 6 Equalities Implications 6.1 There are no equality implications from this Performance Framework itself but there may be implications in the actions that result from work to achieve the aims described therein. 7 Resource Implications Page 119 of 276
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Midlothian Integration Joint Board 7.1 There may be resource implications resulting from further actions to achieve the ambitions of the Performance Framework in respect of the workforce required to undertake data analysis and presentation. 8 Risk 8.1 The primary risk is that the IJB fails to monitor relevant performance measures in a way that articulates outcomes as well as outputs. Traditional attribution-based analysis approaches will not provide the strategic-level data required to demonstrate evidence of progress towards IJB Aims, Directions and National Health and Wellbeing Outcomes. 8.2 The secondary risk is that the HSCP fails to retain / recruit the appropriately qualified workforce within the Performance Team during this period of continued instability across health and care systems. There is a growing recognition of the organisational value of this expertise, and as a result the employment market is becoming increasingly competitive and volatile. 9 Involving people 9.1 The Performance Assurance & Governance Group (PAGG) meet monthly to review and discuss these measures as part of wider data assurance. Membership of the group will be expanded to ensure increased representation of elected officials, the third sector and public health. 10 Background Papers AUTHOR’S NAME Elouise Johnstone DESIGNATION Performance Manager CONTACT INFO elouise.johnstone@nhslothian.scot.nhs.uk DATE 03/10/2022 Appendix 1: Draft IJB Performance Framework (Phase 1) Page 120 of 276
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Midlothian Integration Joint Board Performance Framework Phase 1: 2022/23 Page 121 of 276
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Contents Introduction to Performance Management 3 What is a Performance Framework 5 Why do we need a Performance Framework 7 What does the Performance Framework include 9 Measures 10 IJB Strategic Aims IJB Improvement Goals (MSG) National Health and Wellbeing Outcomes IJB Directions Page 122 of 276
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Introduction to Performance Management Performance management has been described simply as “the organisation of work to achieve the best possible results”.1 It is an approach that needs to recognise the context and culture of an organisation, and can vary from organisation to organisation, depending on that context. It seeks to concentrate on ‘individual’ performance (at person, team, and service levels) to achieve organisational objectives and strategic ambitions. It functions as the system by which those high-level ambitions are translated into operational actions and results. As a concept performance management is not new and has been used as an industry term since the 1970s. However, it is only much more recently that it has been embraced in the public sector, and in health and care in particular. Done well, it is a way of working that improves quality, reduces cost and develops staff capabilities. A performance management system provides a formal structure for the following activities: Adapted from Armstrong and Baron (1998) It also requires a structure that includes roles within management to assure the activities above, so that individual staff and managers are assigned specific responsibilities within the performance management system. 1 Fowler, 1990 Communicate a vision of objectives to staff Set service, team, and individual performance targets that are related to wider objectives Conduct a formal review of progress towards these targets Use the review process to identify training and development needs Evaluates the whole process to improve all six dimensions of Quality Page 123 of 276
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Health and care is a complex, adaptive system which can make performance management and measurement a difficult task. Not everything we do lends itself to traditional approaches to measurement, so we need to bring in other sources of information and design ways to analyse them in a way that supports our understanding. This will include both qualitative and quantitative data, drawn from formal and informal sources, gathered in a structured and systematic way. Analysis must be consistent across all parts of the system, with clear communication of messages around activity, experience and outcome. Traditional approaches that focus solely on outputs carry an inherent risk that we miss the opportunity to evidence the impact of our actions. This risk can be mitigated by taking a contribution-based approach to measurement and evaluation. A performance management framework will make it possible to set out: Aims and outcomes; Models of care; Performance measures; Targets (where required); Performance monitoring and evaluation; Statutory performance reporting requirements; and Performance improvement. Page 124 of 276
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What is a Performance Framework A performance framework is a summary of all the measures used to determine how well an organisation is meeting its aims. There are five key steps set out below: 1. Agree measures A performance framework needs to contain clearly defined measures and data sources. They should link as closely as possible to the aim, whilst taking a pragmatic approach to the use of proxy measures. The measures must be monitored regularly and consistently, with the insights being shared with team, service and organisational leads, along with Board members where appropriate. The measures should be designed in a way that supports their use for other functions, for example audits and reports to partners, people and communities. Clarity of definitions is critical to the success of measurement and may take several iterations to achieve. 2. Collect data Once the measures have been agreed, then the data to evidence them can be collected. This is likely to involve accessing data from multiple systems, including operational, financial and HR, as well as feedback surveys (e.g. Care Opinion, Health and Care Experience Survey) or external benchmarking data (e.g. Core Suite of Integration Indicators). Under current data sharing arrangements, one of the most significant challenges faced by Midlothian Health and Social Care Partnership is the lack of access to a safe, structured data warehouse. Collecting and connecting this data is a complex set of tasks and whilst many tools exist (e.g. Tableau, PowerBI), they are not yet used consistently across our partner organisations. 3. Analyse information When the data has been collected, it must be carefully analysed to ensure that no details have been overlooked. The time it takes to thoroughly interrogate data is often underestimated. Working with teams to understand their data needs provides an opportunity to ask useful questions: What do others need to know about our performance? How do we know what good looks like? Page 125 of 276
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How do we know if our performance is meeting any required standards? If our performance is good, could it be even better? How are we doing in relation to similar teams / services / organisations? Is there variation in our data and do we understand it? Are there any significant shifts / trends? What is the impact of any changes in performance? 4. Present Results Data presentation, done well, looks simple. It is a complex task requiring a combination of skills: analysis, design and communication. Successful presentation of data requires: · Understand the audience, to provide the data they need, in a format they can understand, acknowledging the variation in requirements of detail and granularity; · Simplify the message to reduce confusion and distraction, by designing simple, clear and accurate visuals. Additional information may be required to provide wider context for the data – this should be kept to the minimum; · Communicate the message using the visual that is most effective: this will often be graphs and tables. Simplify these as far as is possible. 5. Make decisions The presentation of performance data needs to be accessible to the relevant audience and provide the information they need to make good decisions. This could include Red/Amber/Green status, measured over time to understand any trends, with additional information to provide wider context (e.g. how are other parts of the system performing). The context should inform, and therefore support, better decision-making regarding prioritisation, service delivery and design, allocation of resurces and the ongoing measurement required to monitor progress / impact of any change. The measures within the Performance Framework should be reviewed regularly to ensure they continue to meet requirements across the whole system. Page 126 of 276
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Why do we need a Performance Framework At its most fundamental level, a Performance Framework should support the following activities: • measure • monitor • inform / report • decide. We measure our performance to see what is working well, what can be improved and how well we are meeting the key aims of integration, our strategic aims and progressing our strategic plan. We plan and direct health and social care services and manage the allocation of the budget. We aim to: • Improve the quality of health and social care services and achieve the 9 national health and wellbeing outcomes; • Change how health and social care is delivered to better understand and meet the needs of the increasing number of people with long term health conditions, with complex needs and those who need support, working with people as partners in their health and social care. • Provide more support, treatment, and care for people in their homes, communities, or a homely setting rather than in hospitals. IJB Requirements A Performance Framework can also play a role in assurance and governance around sources and use of data for reporting on outputs and outcomes. The Integration Joint Board is the governing body for what is commonly referred to as the Midlothian Health & Social Care Partnership. These Standing Orders are made under the Public Bodies (Joint Working) (Scotland) Act 2014 and the Public Bodies (Joint Working) (Integration Joint Boards) (Scotland) Order 2014 (No 285) (“the Order”). Matters Reserved for the Integration Joint Board: Strategic Planning 12.5 The Integration Joint Board shall establish a Strategic Planning Group (Section 32 of Public Bodies (Joint Working) Scotland Act 2014), and appoint its membership (except for the members nominated by each constituent party). Page 127 of 276
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12.6 The Integration Joint Board shall approve its Strategic Plan (Section 33) and any other strategies that it may need to develop for all the functions which have been delegated to it. The Integration Joint Board will also review the effectiveness of its Strategic Plan (Section 37). 12.7 The Integration Joint Board shall review and approve its contribution to the Community Planning Partnership for the local authority area. The Integration Joint Board shall also appoint its representative(s) at Community Planning Partnership meetings. Performance Management 12.15 The Integration Joint Board shall approve the content, format, and frequency of performance reporting. 12.16 The Integration Joint Board shall approve its performance report for the reporting year. IJB Reporting Integration authority: performance report (1)Each integration authority must prepare a performance report for the reporting year. (2)A performance report is a report setting out an assessment of performance during the reporting year to which it relates in planning and carrying out the integration functions for the area of the local authority. (3)The Scottish Ministers may by regulations prescribe the form and content of performance reports. (4)An integration authority must— (a)publish each performance report before the expiry of the period of 4 months beginning with the end of the reporting year, and (b)provide a copy of it to the persons mentioned in subsection (5). (5)Those persons are— (a)where the integration authority is an integration joint board, each constituent authority, (b)where the integration authority is a local authority and a Health Board acting jointly, the integration joint monitoring committee, (c)where the integration authority is a Health Board or a local authority— (i)the integration joint monitoring committee, and Page 128 of 276
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(ii)the other authority. (6)A constituent authority must provide an integration authority which is an integration joint board with such information as the authority may reasonably require for the purpose of preparing a performance report. (7)The other authority must provide an integration authority which is a Health Board or a local authority with such information as the integration authority may reasonably require for the purpose of preparing a performance report. (8)In this section— • “other authority” means the local authority or the Health Board with which the integration authority prepared the integration scheme in pursuance of which the integration authority acquired its delegated functions, • “reporting year”, in relation to an integration authority, means— (a) the period beginning with the date prescribed under section 9(3) or, as the case may be, 15(2) and ending on the first anniversary of that date, and (b) each subsequent period of a year. What does the Performance Framework include The following pages describe the measures, data sources and frequency for: • IJB Strategic Aims • IJB Improvement Goals (MSG) • National Health and Wellbeing Outcomes • IJB Directions Page 129 of 276
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Measures Phase 1: 2022/23 Page 130 of 276
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Midlothian IJB Strategic Aims (Year 1: 2022-23) Aim Data Source Frequency 1 Increase people’s support and opportunities to stay well, prevent ill or worsening health, and plan ahead. OutNav* Service outcome data Annually & end of Strategic Plan period 2 Enable more people to get support, treatment and care in community and home-based settings. OutNav* Service outcome data Annually & end of Strategic Plan period 3 Increase people’s choice and control over their support and services. OutNav* Service outcome data Annually & end of Strategic Plan period 4 Support more people with rehabilitation and recovery OutNav* Service outcome data Annually & end of Strategic Plan period 5 Improve our ability to promote and protect people's human rights, including social and economic rights and meet our duties under human rights law through our services and support. OutNav* Service outcome data Annually & end of Strategic Plan period 6 Expand our joint working, integration of services, and partnership work with primary care, third sector organisations, providers, unpaid carers, and communities to better meet people’s needs. OutNav* Service outcome data Annually & end of Strategic Plan period * Not all services are currently using OutNav so local service outcome data will be used Page 131 of 276
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Midlothian IJB Local Improvement Goals 2022-23 Ministerial Steering Group Indicator 2022/23 Target Rate per 100,000 Data Source Frequency A&E Attendances 2,629 / month LIST Report (PHS) Monthly Emergency Admissions 767 / month LIST Report (PHS) Monthly Unplanned Bed Days 5,074 / month LIST Report (PHS) Monthly Delayed Discharge Occupied Bed Days 820 / month LIST Report (PHS) Monthly End of Life - Percentage of Last Six Months Spent in Large Hospitals <8.7% LIST Report (PHS) Monthly Balance of Care >96.4% LIST Report (PHS) Monthly Page 132 of 276
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National Health and Wellbeing Outcomes 2022-23 Outcome Data Source Frequency Health & Wellbeing: People are able to look after and improve their health and wellbeing and live in good health for longer Health and Care Experience Survey Core Suite of Integration Indicators Bi-Annual Annual 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 Health and Care Experience Survey Core Suite of Integration Indicators Bi-Annual Annual Positive Experiences & Dignity: People who use health & social care services have positive experiences of those services, and have their dignity respected Health and Care Experience Survey Core Suite of Integration Indicators Bi-Annual Annual Quality of Life: Health & social care services help to maintain or improve the quality of life of people who use those. Health and Care Experience Survey Core Suite of Integration Indicators Bi-Annual Annual Health Inequalities: Health & social care services contribute to reducing health inequalities. Health and Care Experience Survey Core Suite of Integration Indicators Bi-Annual Annual Support for Carers: People who provide unpaid care are supported to look after their health and wellbeing. Health and Care Experience Survey Core Suite of Integration Indicators Bi-Annual Annual Safe from Harm: People using health & social care services are safe from harm. Health and Care Experience Survey Core Suite of Integration Indicators Bi-Annual Annual Workforce: Staff are engaged with their work and are supported to continuously improve the information, support, care and treatment they provide. Health and Care Experience Survey Core Suite of Integration Indicators Bi-Annual Annual Use of Resources: Resources are used effectively and efficiently Health and Care Experience Survey Core Suite of Integration Indicators Bi-Annual Annual Page 133 of 276
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14 Direction No 1 No Area Direction Performance Measures What is the measure you are using to demonstrate progress? How will you know that a change is an improvement? What is the data/information source being used? MIJB- 1.1 Unscheduled Care - Acute Hospitals Continue with a programme to review potentially preventable admissions including a specific focus on frailty, falls, COPD, and the vaccination programme Number of admissions coded (from TRAK discharge coding) Reduction in admissions that are coded for conditions within scope of PPA working group TRAK MIJB- 1.6 Unscheduled Care - Acute Hospitals Evaluate the impact of the enhanced ‘Discharge to Assess’ Service to determine the case for continued investment by 30th September 2022 Number of care packages bridged Length of bridging package Number of facilitated non delayed discharges per week Number of bed days saved Average Barthel scores are higher on discharge from D2A than on admission to D2A Please list MIJB- 1.3 Unscheduled Care - Acute Hospitals Evaluate the impact of new approaches to In Reach (including identifying patients suitable for Reablement in Medicine of the Elderly wards) by 30th September 2022 % of Midlothian patients discharged without delay Number of standard delays Number of complex delays Number of care packages bridged by Discharge 2 Assess DWD of 99% = flow/ capacity/ demand in alignment Daily planning call to track all Midlothian residents: - attending ED being admitted to AMU being admitted to a ward Midlothian IJB Directions 2022-23 Page 134 of 276
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15 No Area Direction Performance Measures What is the measure you are using to demonstrate progress? How will you know that a change is an improvement? What is the data/information source being used? MIJB- 1.13 Unscheduled Care - Acute Hospitals Reduce unscheduled respiratory admissions by expanding the CRT to 6 days pw; improving pathways to the team; and promoting self-management Number of unscheduled respiratory admissions Reduction in number of unscheduled respiratory admissions CRT dashboard (Tableau / TRAK) MIJB- 1.14 Unscheduled Care - Acute Hospitals Ensure the MIJB remains sighted on action and progress in relation to those aspects of the Unscheduled Care Board workstreams relevant to Midlothian as well as locally determined work such as Midlothian Community Hospital, Home First Services, Primary Care and Potentially Preventable Admissions (PPAs). A quarterly report should be provided by the Head of Primary Care and Older People’s Services Just the measure please, no narrative Outcome, process and / or balancing How does it look different and how do you know it is ‘better’ Please list MIJB- 1.15 Unscheduled Care - Acute Hospitals NHS Lothian should continue to provide monthly financial reporting of the set aside areas. Additionally, Acute Services should provide quarterly financial information on the set-aside budget that should now also include intelligence and narrative to detail the nature of financial variance and support the IJBs understanding of areas of mutual concern Just the measure please, no narrative Outcome, process and / or balancing How does it look different and how do you know it is ‘better’ Please list Page 135 of 276
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16 No Area Direction Performance Measures What is the measure you are using to demonstrate progress? How will you know that a change is an improvement? What is the data/information source being used? MIJB- 1.16 Unscheduled Care - Acute Hospitals Develop and evaluate pro-active in-reach into hospital when someone with frailty is admitted by December 2022 Please see narrative MIJB- 1.17 Unscheduled Care - Acute Hospitals Develop virtual medical teams involving frailty GPs and key hospital consultants by December 2022** Just the measure please, no narrative Outcome, process and / or balancing How does it look different and how do you know it is ‘better’ Please list MIJB- 1.18 Unscheduled Care - Acute Hospitals Implement a "Planned Date of Discharge" approach to reduce delayed discharge bed days. PDD implementation in MCH and Highbank PDD implemented in MCH and Highbank TRAK Highbank local data MIJB- 1.19 Unscheduled Care - Acute Hospitals Complete an evaluation of the delivery of the 7 principles of the Lothian Home First approach in order to understand current performance and opportunities for improvement In conjunction with NHS Lothian and the other HSCPs, a whole system evaluation was undertaken to understand current performance and opportunities for improvement in relation to delayed discharge. Please see the narrative below. This evaluation was based on Home First principles and focused on the pathways in and out of our main hospitals. A Midlothian Action Plan was developed as an outcome of this work. The areas of focus for Midlothian were to ensure – • all parties were working to a PDD and discharges were planned and executed across 7 days. • A Home First approach was embedded within all our teams, with home being the default position for all people leaving hospital. • Robust data was being used to measure performance, drive improvement and identify concerns. • Assessments for long term needs were not being made when a person was in acute crisis. As a result a number of workstreams were established, the progress of this is documented in Directions MIJB-1.3, MIJB-1.6, MIJB-1.13, MIJB-1.18. Page 136 of 276
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17 Direction No 2 No Area Direction Performance Measures What is the measure you are using to demonstrate progress? How will you know that a change is an improvement? What is the data/information source being used? MIJB- 2.3 Accident and Emergency (A&E) Agree Midlothian response to national redesign of urgent care programme to improve access to urgent care pathways so people receive the right care, in the right place, at the right time by 30th September 2022 Just the measure please, no narrative Outcome, process and /or balancing What does it look different and how do you know it is better Please list MIJB- 2.6 Accident and Emergency (A&E) Continue to reshape pathways to ensure people access community-based services wherever viable. This Direction is captured in MJB-1.6 and MIJB-1.13. It is recommended that the Board consider closing this Direction MIJB- 2.8 Accident and Emergency (A&E) Implement a tableau dashboard to support managers in accessing performance data to determine the impact of community services in reducing A&E attendances and unscheduled admissions by 30th September 2022 CRT Dashboard is up and running Improved access to robust data Tableau MIJB- 2.11 Accident and Emergency (A&E) Take an active role in pan-Lothian decisions around A&E front-door redesign (Midlothian IJB set-aside budget) and ensure engagement of acute services staff in Midlothian Acute Page 137 of 276
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18 Services Planning Groups No Area Direction Performance Measures What is the measure you are using to demonstrate progress? How will you know that a change is an improvement? What is the data/information source being used? MIJB- 2.12 Accident and Emergency (A&E) Review musculoskeletal pathways to increase the use of the MSK service as an alternative to A&E attendance No of redirects from Lothian unscheduled care in to the GP APP service An increase in referral numbers – patients redirected via 111 to a more appropriate route for the right care at the right time with the right person Service level data collected and stored on excel spread sheet in GP APP service It is recommended that the Board consider this Direction being either closed as the MSK and GP APP services will only redirect a very small amount of traffic from A&E (in reality MIU) or relocated and revised as a redirect from GP services rather than A&E. This would be well evidenced MIJB- 2.13 Accident and Emergency (A&E) Evaluate and continue to monitor the impact of the Single Point of Access on ensuring people access community-based services and reducing demand on A and E and unscheduled admissions. A formal evaluation of the SPOA has been delayed due to service pressures A formal evaluation of the SPOA has been delayed due to service pressures Page 138 of 276
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19 Direction No 3 No Area Direction Performance Measures What is the measure you are using to demonstrate progress? How will you know that a change is an improvement? What is the data/information source being used? MIJB- 3.4 MCH Review progress in the development of Glenlee Ward at Midlothian Community Hospital as a step-up from community and day treatment facility by 30 September 2022 Ward activity data e.g. number of admissions / discharges, no. of admissions to RIE Patient experience, improved patient pathway, reduction in ED attendance/admission Tableau, Trak, Patient Stories, Care Opinion It is recommended that to change the ward identified in this Direction due to ward configuration changes “Review progress in the development of Loanesk Ward at Midlothian Community Hospital as a step-up from community and day treatment facility by 30 September 2022” Progress has been limited by the challenges introduced by covid. The team are now looking at models across the country to establish a sustainable model for the future. Step up is currently offered on a case-by-case basis in discussion with clinical and medical teams are required. MIJB- 3.5 MCH Improve patient flow by reviewing and strengthening assessment and rehabilitation processes by January 2023 7-point improvement plan TRAK The AHP team have broadened their area of cover to include the continued rehabilitation of patients who are transferred from MCH to High bank Intermediate Care facility. They also provide therapy to residents who may develop the need for intervention to support their independence. A seven-point improvement plan has been completed that resulted in 1. The same prioritisation tools are used across both sites. 2. AHP participation in the daily Rapid Rundown MCH 3. Aligned assessment tools with the community intermediate care team 4. adopted a ‘named therapist’ approach to support continuity and stability during therapy delivery 5. Weekly caseload review to establish and action shared goals and aims across the professional groups 6. Established AHP leadership 7. Increased PT capacity (WTE) Along with the reduction in Covid-19 restrictions, this has re-established the opportunity for a creative approach to therapy Page 139 of 276
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20 No Area Direction Performance Measures What is the measure you are using to demonstrate progress? How will you know that a change is an improvement? What is the data/information source being used? MIJB- 3.6 MCH The option appraisal regarding the most appropriate outpatient clinics and day treatment to be provided in Midlothian Community Hospital should be completed by 30 September 2022. This should include an examination of the viability of chemotherapy; and consideration of the potential role of remote technology in providing consultations with specialist medical and nursing staff A comprehensive review of clinic use is complete When we have relocated clinics that do not require to be based in a hospital setting review of MHSCP premises (currently underway) Progress has been limited by the challenges introduced by covid and further negotiation with acute colleagues to progress this Directions. Outpatient services has operated a centralised model to support the recovery agenda, and this has not yet included discussion to improve opportunities to provide the right care in the right place at the right time that includes MCH. MIJB- 3.7 MCH Improve accessible information about the services provided through MCH by September 2022 Information is available in a range of formats and meeting accessibility standards Awareness raising programme in place at local community facilities e.g., libraries, leisure centres etc Effective multi-media communications plan will be in place Progress against Communications Plan Better information provision across the partnership is an area for improvement and noted as an area of focus for 2023-24. This will be dependent on the identification of resource to support design, production, publications, web support and communications. Page 140 of 276
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21 No Area Direction What is the measure you are using to demonstrate progress? How will you know that a change is an improvement? What is the data/information source being used? MIJB- 3.8 MCH Develop a new model of care for older people with mental illness Safe Staffing Full staffing to support new model of care in place Reduced vacancy rate • Safe Staffing workforce tools • SSTS JobTrain It is recommended that to change the wording of the Direction to reflect more appropriate recovery-based language “Develop a new model of care for older people with mental health needs” Developments and changes to the configuration and use of wards at MCH has impacted on the ability to complete this direction. However, a significant amount of work has been undertaken to better understand the needs of people accessing these services and introduce the MCH elements of a whole system model • A new staffing model • Adopting a person-centred model form preadmission • A new environmental ward layout MIJB- 3.9 MCH Improve recruitment processes through stronger advertising, the provision of ongoing training and the development of increased specialist opportunities by January 2023 Vacancy rate Clinical Education Facilitator will be in post to increase retention and drive recruitment by supporting new staff in induction and orientation, education and training and staff development. SSTS JobTrain Safe Staffing Workforce Tool MIJB- 3.10 MCH Review the full service model at MCH including frailty step-up, step down Work is ongoing to define the MCH vision as a Centre of Excellence for Older People. A full proposal is under development. MCH Pathways group recommended with wide representation of clinicians and services. Action plan to be developed to support work of this group. Page 141 of 276
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22 Direction No 4 No Area Direction Performance Measures What is the measure you are using to demonstrate progress? How will you know that a change is an improvement? What is the data/information source being used? MIJB- 4.2 Palliative Care Undertake an audit of admissions to Acute Hospitals of patients in receipt of palliative care in order to ensure equitable provision and strengthen local services (care homes, district nursing, MCH and Hospital at Home) by 30th September 2022 No. admissions to RIE / WGH for palliative care / end-of-life care (LIST Team working to produce audit of admissions) Accurate coding of admissions TRAK LIST have begun work on coding. However, challenges around coding of admissions may make the production of reliable data difficult or even impossible. The ability to progress this is not within local control. MIJB- 4.4 Palliative Care Obtain family, carer and staff feedback on the quality of palliative and end of life care provided in Midlothian Community Hospital and the District Nursing service by 30th September 2022 The completion of the project The evaluation may provide data which will inform change to improve Qualitative evaluation of experience of family members using an experienced based co- design model carer and staff participation Funded by Scottish Government; final outputs expected October/ November 2022. Has been identified that there is potential for data to be used for secondary research due to quantity of data generated. Page 142 of 276
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23 No Area Direction Performance Measures What is the measure you are using to demonstrate progress? How will you know that a change is an improvement? What is the data/information source being used? MIJB- 4.5 Palliative Care Evaluate the impact of the Palliative Care Champion Network across Midlothian care homes by October 2022 Completed evaluation of the network The evaluation should identify the extent to which the network does or can support change and improvement Range of Quantitative and qualitative data from Midlothian care Homes and the care Home Support team This is an evaluation as the network is strengthened based on what we know works and can be improved. MIJB- 4.6 Palliative Care Ensure that services can access accurate data from the Palliative Care Registers in GP practices in order to design and delivery of service that best meet the needs of local people and communities % of patients registered on the Palliative care registers across the 12 Midlothian GP practices Consistent quality in the data across Midlothian Practices Comparison of numbers of people on palliative care registers in Midlothian with national average Palliative care registers in GP practices using Vision and EMIS data searches The GP Quality Cluster is actively taking this work forward MIJB- 4.7 Palliative Care Receive assurance from Edinburgh HSCP who host the Lothian Palliative Care Service on the review and development of the approach and quality of care provided by the contracted services (St Columba’s and Marie Curie) Assurance from Edinburgh HSCP on delivery of service to Midlothian residents Establishing regular updates In development Report provided to Edinburgh HSCP including inspection data and reports Page 143 of 276
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24 Direction No 5 No Area Direction Performance Measures What is the measure you are using to demonstrate progress? How will you know that a change is an improvement? What is the data/information source being used? MIJB- 5.3 Primary Medical Services Implementation of the Community Treatment and Care Centre model (CTAC) to effectively manage and support patients with long term/chronic conditions in the community (PCIP priority) by 31 July 2022 Number of CTAC appts per 1000 patients at each practice Appointments per practice, % filled and unfilled, Number of phlebotomy appts, Number of “good conversations” documented Increase in overall number of CTAC appts GP clinical system (Vision or EMIS) MIJB- 5.5 Primary Medical Services Continued implementation of the Prescribing Plan with 100% of Practices with Pharmacotherapy level 1 service in place by 30th September 2022 Percentage of practice coverage meeting the agreed level Vacancy rates Increase in % of practice coverage Reduced vacancy rate Reduced staff turnover Staff gaining additional skills / qualifications SSTS staffing list Practice coverage MIJB- 5.6 Primary Medical Services Funding above the 21/22 PCIF allocation secured to enable the Pharmacotherapy service to be scaled up to all practices Read code activity in practices indicating Pharmacy activity Percentage of Practice access to pharmacy team over 5-day week, via the central Hub model. Increase in Read codes indicating Pharmacy activity Increased access to 5-day week service Monthly read code capture from GP practice systems. Page 144 of 276
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25 No Area Direction Performance Measures What is the measure you are using to demonstrate progress? How will you know that a change is an improvement? What is the data/information source being used? MIJB- 5.7 Primary Medical Services Established Medicine Reconciliations service provided to all practices by 30th September 2022 Number of IDLs completed Monthly report showing percentage of Immediate Discharge Letter (IDL) Medicines Reconciliation processes completed within Scottish Patient Safety Programme guidance Increase in number of IDLs completed Monthly report showing increase in percentage of Immediate Discharge Letter (IDL) Medicines Reconciliation processes completed within Scottish Patient Safety Programme guidance Read code capture from GP practice systems Turnaround times determined from docman dashboard MIJB- 5.8 Primary Medical Services Progress Capital Development programme in Primary Care developing plans for new health centres in Shawfair and in South Bonnyrigg addressing the current demand on healthcare facilities and predicted population growth in both these areas. (PCIP priority) Shawfair proposal has been submitted to Scottish Government but was returned as over the stature of time (due to Covid delays). Request has been made to update the Impact Assessment and return for consideration. South Bonnyrigg will be submitted this year for NHS Lothian progression MIJB- 5.9 Primary Medical Services Review admissions to hospital from care homes at nights and weekends to identify opportunities for earlier intervention and care closer to home • Number of admissions outside of routine GP hours (8am – 6pm) to hospital • Proportion of admissions which may have been avoidable • Recurrent themes / factors in potentially avoidable admissions • Meaningful KIS / ACPs in place for those patients who were admitted • Reduction in number of hospital admissions which could have been managed in primary care • Improved patient experience of managing acute medical conditions • Improved care home staff experience of managing acute medical conditions • TRAK • Care Home log • Care home staff and patient interviews • Trak EPR • KIS / ACP reports held by care home It is recommended that the Board consider closing this Direction as this action sits within the operational work plan of the Potentially Preventable Admissions working group Page 145 of 276
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26 MIJB- 5.10 Primary Medical Services Increase collaboration for data sharing between GPs and the HSCP to improve health outcomes Number or % of GP practices participating in the GPAS alert system Notification of practice status will allow HSCP to respond with support where required and/or plan to mitigate risks GPAS alert system (reported weekly by Practice Managers to the Local Medical Committee who will share the data) MIJB- 5.11 Primary Medical Services Develop a joint digital plan for the optimisation of new technologies across primary care Number of patients who are referred and access digital self-management options for Long Covid symptoms Patients can access timely support for self- management Reduced health miles Reduced impact on GP, physio, OT, MH services Potential to be scaled up to other long-term conditions in future Feedback data from CHSS/Pogo platform MIJB- 5.12 Primary Medical Services Develop a communications plan about access to GPs and Community Services Number or % practices who have shared access comms with patients (any format) in last month More patients access right care from right professional at right time. Reduced demand on GP Increased pt. satisfaction Increased supported self- management GP Practice Websites; Facebook; Twitter; Local Newsletters Google Analytics to record page views, bounce rate etc. Practice specific training in care navigation for signposting to local resources. Page 146 of 276
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27 No Area Direction Performance Measures What is the measure you are using to demonstrate progress? How will you know that a change is an improvement? What is the data/information source being used? MIJB- 5.13 Primary Medical Services Primary Care services should consider and plan for the additional health and care services required in relation to additional housing developments to ensure that the special needs of the Midlothian population are being taken into account fully. It is recommended that this Direction is included in the work required to complete Direction 5.8 MIJB- 5.14 Primary Medical Services Improve primary care quality and options for older people Percentage of older people (>65y) who have had a frailty assessment, polypharmacy review, and / or Anticipatory Care Plan Person-centred care Appropriate proactive and realistic actions to reduce risk of falls & unscheduled admission GP systems / SPIRE IJB- 5.15 Primary Medical Services Improve quality and options for people with frailty in primary care by 30th September 2022 through proactive in-reach to Edinburgh Royal Infirmary when someone with frailty is admitted and virtual medical teams involving the frailty GPs and key hospital consultants OT / Red Cross project GP follow-up post ED attendance project. Number of Anticipatory Care Plan (ACP) / Key Information Summaries accessed at change points/deterioration ACP discussions embedded within current holistic assessment Reduced readmissions to RIE for people with frailty who have an ED attendance or admission < 48 hours. Improved functional outcomes. TRAK Mosaic Care opinion MIJB- 5.16 Primary Medical Services Evaluate the feasibility of improving continuity of care by General Practice and community services Usual Provider of Care Index (UPCI) Improved continuity in primary care reduces risk of unscheduled admission and death UPCI (extraction by NHS Lothian Primary Care Data Analyst) Page 147 of 276
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28 Direction No 6 No Area Direction Performance Measures What is the measure you are using to demonstrate progress? How will you know that a change is an improvement? What is the data/information source being used? MIJB- 6.4 Community Health Services Work to ensure our frailty services are accessible to people under 65 years by December 2021 There is currently no way to identify people under 65 using eFI. There is potential to use the Rockwood Frailty score although this is not currently embedded in practice It is recommended that the Board review this Direction along with others to consolidate and redefine all Directions relating to Frailty for 2023-24. Please also see MIJB-8.1 MIJB- 6.5 Community Health Services Work with other Lothian Health & Social Care Partnerships to implement appropriate model and financial plan for complex care by 30th September 2022 As coping and options appraisal will be completed We will be able to provide the right support to meet the increased demand Service level data from ACENS MIJB- 6.6 Community Health Services Secure clinical space to provide the vaccination programme for flu and COVID Venues Operating hours Appropriate clinical space at venues to provide equitable access Operating hours that provide equitable access HSCP operational reports MIJB- 6.7 Community Health Services Develop the Community Treatment and Care (CTAC) Service to be accessible from all GP Practices SEE ALSO 5.3 Full time staff will be in every GP Practice Increase in available appointment slots Vision with support from LIST Page 148 of 276
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29 No Area Direction Performance Measures What is the measure you are using to demonstrate progress? How will you know that a change is an improvement? What is the data/information source being used? MIJB- 6.8 Community Health Services Develop an integrated Falls Pathway across HSCP and Third Sector, including proactive identification of those who may be at risk The number of falls related A&E attendances A reduction in the number of falls related A&E attendances TRAK MIJB- 6.9 Community Health Services Implement a falls prevention programme with cross sector support that includes targeted training and increased options for physical activity This Directions is dependent on the success of MIJB-6.8 This Direction asks for a Falls Prevention Programme to be established. This work is currently progressing via a Falls Pathway. It is recommended to review this direction again the progress delivered by the falls pathway and consider whether the Direction requires review. This Directions is dependent on the success of MIJB-6.8 MIJB- 6.10 Community Health Services Identify, assess and support frail people, moderate or severe, subject to an ED admission of less than 24 hours OT / Red Cross project GP follow-up post ED attendance project. Reduced readmissions to RIE for people with frailty who have an ED attendance or admission < 48 hours. Improved functional outcomes. TRAK Mosaic Care opinion It is recommended that the Board review this Direction along with others to consolidate and redefine all Directions relating to Frailty for 2023-24 Please also see MIJB-5.15 MIJB- 6.11 Community Health Services Increase the number and improve the quality of anticipatory care plans for people living with frailty • The number and quality of Anticipatory Care Plan (ACP) / Key Information Summaries. • The number of Anticipatory Care Plan (ACP) / Key Information Summaries accessed at change points/deterioration An increase in the quality and quantity of Anticipatory Care Plan (ACP) / Key Information Summaries and discussions embedded within current holistic assessment GP Practice systems and TRAK Page 149 of 276
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30 No Area Direction Performance Measures What is the measure you are using to demonstrate progress? How will you know that a change is an improvement? What is the data/information source being used? MIJB- 6.12 Community Health Services Develop an improvement programme to identify people who are frail, provide holistic assessment and strengthen coordination of care It is recommended that the Board review this Direction along with others to consolidate and redefine all Directions relating to Frailty for 2023-24 It is recommended that the Board review this Direction along with others to consolidate and redefine all Directions relating to Frailty for 2023-24 MIJB- 6.13 Community Health Services Commit to strengthen community rehabilitations pathways by April 2023 across health and social care services in line with the Rehabilitation Framework and the Review of Adult Social Care Please see MIJB-9.6 MIJB- 6.14 Community Health Services Develop a dedicated system for data analysis / reporting of falls data to identify clear priorities and inform future direction of falls work by 30th September 2022 The creation of a functional dashboard that enables data from both NHS and LA A functional dashboard will be in place with robust data that provides insight to proactively identified people at risk IG is not in place to enable this work MIJB- 6.15 Community Health Services Work with Primary Care providers to develop a standard identification process, signposting / self-referral system for all patients at risk of falls linked into the integrated Falls Pathway by 30th September 2022 Please see MIJB-6.8 It is recommended that the Board review this Direction along with others to related to falls and consider this Direction closed due to duplication (see MIJB-6.8). primary care will be included in a system wide Falls Pathway. Page 150 of 276
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31 No Area Direction Performance Measures What is the measure you are using to demonstrate progress? How will you know that a change is an improvement? What is the data/information source being used? MIJB- 6.16 Community Health Services Continue review of AHP model of care to Highbank and MCH to create a flexible and responsive single workforce by December 2022. Prioritisation criteria Implementation of a prioritisation system to consistently identify the people at greatest risk/need Consistency of approach with equitable AHP access across MCH and Highbank TRAK MIJB- 6.17 Community Health Services Review podiatry provision in Midlothian, in particular for people with Type 2 Diabetes by January 2023 This Direction relates to a hosted service within West Lothian. Midlothian disaggregated data for hosted services is not currently reported. Work is ongoing within the CO group to establish effective and consistent reporting mechanisms for hosted services. MIJB- 6.18 Community Health Services Undertake a detailed review to establish the extent and nature of pressures on District Nursing and present proposals for transformation Resource and Safe staffing to deliver the service Appropriate Resource and Safe staffing is in place to deliver the service and meet demand TRAK Page 151 of 276
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32 Direction No 7 No Area Direction Performance Measures What is the measure you are using to demonstrate progress? How will you know that a change is an improvement? What is the data/information source being used? MIJB- 7.2 Dental, Ophthalmic & Audiology Use data from NHS Lothian Public Health to determine the impact of NHS general dental services on the oral and general health of Midlothian population and use this information to identify further actions if required by 30th September 2022 There are no public health data about the oral health of adults that could be used to inform this Direction. Such analysis would be complicated as people often have a GDP some distance from their home and many GDP work both within the NHS and privately MIJB- 7.4 Dental, Ophthalmic & Audiology Work with Director of Edinburgh Dental Institute to consider how best the Oral Health Improvement Plan recommendations on ‘Meeting the Needs of an Ageing Population’ can be jointly pursued by 30th September 2022 A suite of outcome measures for OHI is being developed by the Dental Public Health support for NHSL to be used uniformly across all HSCPs. When we achieve consistency in approach across all HSCP areas, using one data set for monitoring purposes MIJB- 7.5 Dental, Ophthalmic & Audiology The role of Optometry services in pathways of care for patients in a range of services such as general medical practice, ophthalmology, diabetes and A&E, providing both ongoing and urgent care for patients closer to home to be clarified by 30th September 2022 Reduction in referrals to Secondary Care Reduction in waiting times The “complex conditions scheme" is an intra-referral system where optometrists who find that a patient who has certain anterior eye conditions which would usually be referred to the Hospital Eye Service can instead refer these patients to an independent prescriber optometrist Intra-referral system Page 152 of 276
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33 No Area Direction Performance Measures What is the measure you are using to demonstrate progress? How will you know that a change is an improvement? What is the data/information source being used? MIJB- 7.6 Dental, Ophthalmic & Audiology Evaluate the impact of community glaucoma specialist optometrists by 30th September 2022 Number of patients being discharged from acute to community Pt satisfaction questionnaires % of patients re-referred to Ophthalmology Increased management of patients with low-risk disease being reviewed in the community, closer to home by advanced Optometrists. Anticipated that 25% of patients currently seen in hospital settings for review could be transferred to this community-based management pathway. TBC MIJB- 7.7 Dental, Ophthalmic & Audiology Quarterly meetings should be established between the Partnership and these three hosted services. They should agree local plans and monitor progress Number of, and attendance at, local independent contractor meetings Progress in implementing in Direction 7 Local MIJB- 7.8 Dental, Ophthalmic & Audiology Work with Audiology Services to determine the feasibility of establishing an audiology clinic(s) in Midlothian Percentage of Midlothian patients referred to Audiology who receive assessment or assistance near to home Number of patients able to self-refer to audiology services Reduced health miles Improved patient satisfaction Reduced GP workload Page 153 of 276
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34 Direction No 8 No Area Direction Performance Measures What is the measure you are using to demonstrate progress? How will you know that a change is an improvement? What is the data/information source being used? MIJB- 8.1 Older People The e-Frailty Programme should be progressed to improve coordination of care and to provide support at an earlier stage. This includes the use of learning from the e-frailty programme to develop a frailty informed workforce by 30th September 2022 (see also MIJB-5 Directions relating to Frailty) This Direction was written at a time when the ambition was to create a Frailty Programme. Due to the changes in service configuration since March 2020 this has not been progressed. As such, the recommendation is to review 1. The wording of this Direction to reflect the frailty pathway work underway Develop and evaluate an e-Frailty Pathway that proactively identifies people who may be at risk of poorer outcomes and effectively signpost to preventative service offers and supports 2. Review, consolidate and redefine all Directions relating to Frailty for 2023-24 MIJB- 8.3 Older People Undertake a review of day support, explore all options for people in Midlothian who are isolated, including alternatives to building based support by 30th September 2022 Completion of review It is recommended that Directions MIJB-8.3 is closed and a MIJB-8.11 is reworded to reflect ongoing ambitions and extended to January 2023 Suggested wording for MIJB-8.11 “Undertake a review of day support and design a new model of day service provision including alternatives to building based support by September 2023” Page 154 of 276
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35 No Area Direction Performance Measures What is the measure you are using to demonstrate progress? How will you know that a change is an improvement? What is the data/information source being used? MIJB- 8.4 Older People Implement a respite policy; undertake an option appraisal; and develop an action plan to strengthen the provision and accessibility of respite care Respite policy & plan in place Increase in availability & uptake of respite beds in Midlothian MOSAIC Cowan Court provide data directly MIJB- 8.11 Older People Review and design a new model of day service provision The recommendations for design of a new model of day service provision will be informed by the review under Direction 8.3. Directions MIJB-8.3 and MIJB-8.11 are similar. It is recommended that Directions MIJB-8.3 is closed and a MIJB-8.11 is reworded to reflect ongoing ambitions and extended to January 2023. Suggested wording for MIJB-8.11 “Undertake a review of day support and design a new model of day service provision including alternatives to building based support by September 2023” MIJB- 8.12 Older People Increase the availability of Intermediate Care available in Midlothian communities within Extra Care Housing new build facilities and from suitable existing housing stock. Number of Intermediate Care flats in ECH Increase in number Final project plan MIJB- 8.13 Older People Continue to evaluate impact of developments to Midlothian Intermediate Care Services. This would incorporate a detailed plan to design a reshaped model of care in preparation for the provision of new purpose-built accommodation in 2024 Building delays due to Covid & supply chain issues have had a consequential impact on work to inform the design of appropriate models of care Page 155 of 276
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36 No Area Direction Performance Measures What is the measure you are using to demonstrate progress? How will you know that a change is an improvement? What is the data/information source being used? MIJB- 8.14 Older People Co-locate and integrate intermediate care teams with the Home First Service All teams working from the same premises Collaborative working and timely information-sharing to inform holistic decision-making Facilities plans Qualitative examples of good practice leading to improved outcomes for people Page 156 of 276
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37 Direction No 9 No Area Direction Performance Measures What is the measure you are using to demonstrate progress? How will you know that a change is an improvement? What is the data/information source being used? MIJB- 9.1 Physical Disability, Sensory Impairment & Long-Term Conditions All service providers should adopt an approach which focuses on personal outcomes and encourages self-management and recovery by 30th September 2022 No data available MIJB- 9.2 Physical Disability, Sensory Impairment & Long-Term Conditions A full appraisal of the optimum balance of community based and hospital-based services should be carried out within the context of the re- provision of Astley Ainslie by 30th September 2022 Recommendation that Direction be removed as doesn’t reflect current service design / priorities MIJB- 9.3 Physical Disability, Sensory Impairment & Long-Term Conditions There should be collaboration, where feasible, with Housing Providers and national policy makers to press for change in policy around the inadequate availability of suitable housing in new housing developments. Number of wheelchair housing / Extra Care properties increased. Midlothian Council approval of recommended wheelchair housing targets of 20 per year for 2022 - 2027 Increased wheelchair housing /Extra Care Housing stock. Reduced wheelchair / ECH waiting lists MC Housing stock data for identified housing types ie wheelchair, ECH MIJB- 9.4 Physical Disability, Sensory Impairment & Long-Term Conditions Review role of Midlothian Community Physical Rehabilitation Team (MCPRT) in line with ongoing development of intermediate care to maximise impact on people with a long-term condition or who have experienced an acute event by 30th September 2022 Page 157 of 276
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38 No Area Direction Performance Measures & Update What is the measure you are using to demonstrate progress? How will you know that a change is an improvement? What is the data/information source being used? MIJB- 9.6 Physical Disability, Sensory Impairment & Long-Term Conditions Develop clear pathways and support for people affected by neurological conditions by 30th September 2022 Quarterly reports are submitted to the Scottish Government on progress in delivering the project aims in line with the Scottish Government Neurological Care and Support Framework. The Midlothian Neurological Project Plan is in place that sets out key milestones. Performance measures will be established as part of the project development in September to November 2022 to implement ‘tests of change’. As part of the ‘test of change’ we will evaluate the impact on people living with neurological conditions, and teams that support them. As part of a whole system evaluation we will consider balancing and process measures. Data will be gathered from multiple sources that will be established during the test of change. This will include data from the individuals that engage with the ‘test of change’ models and from the teams that support them. MIJB- 9.7 Physical Disability, Sensory Impairment & Long-Term Conditions Reduce waiting times in the Physical Disability Team Reduction in Physical Disability/LTC waiting list Reduction in waiting times – more timely access for those waiting MOSAIC MIJB- 9.8 Physical Disability, Sensory Impairment & Long-Term Conditions Develop the provision of Self- Directed Support in line with the new national standards No data available Page 158 of 276
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39 No Area Direction Performance Measures What is the measure you are using to demonstrate progress? How will you know that a change is an improvement? What is the data/information source being used? MIJB- 9.9 Physical Disability, Sensory Impairment & Long-Term Conditions Support people to stay active through increased access to rehabilitation and supported leisure activities No. of supported activity opportunities available per week Increased participation figures by total number of attendances due to increased capacity and availability. Legend – S&L Leisure Management System MIJB- 9.10 Physical Disability, Sensory Impairment & Long-Term Conditions Provide more localised services for people with a hearing impairment including audiology clinics, and hearing aid repairs and provision of batteries Amount of people using the weekly Hearing Aid Repair Clinic. Further measure would be an increase in people seen locally by audiology as well as increase in people seen hearing aid repair clinics A room in made available in MCH for face to face audiology clinics. This would mean that 6 people could be seen once a week at this clinic rather than having to travel out of area into Edinburgh. ‘Enable’ were providing coordination / collection of Hearing Aid repairs in local libraries / Townhalls. No statistical data can be provided but they report this was well used and people benefitted from social interaction / peer support Figures provided from Audiology re repair clinics Page 159 of 276
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40 No Area Direction Performance Measures What is the measure you are using to demonstrate progress? How will you know that a change is an improvement? What is the data/information source being used? MIJB- 9.11 Physical Disability, Sensory Impairment & Long-Term Conditions Develop more integrated and localised services for people with a visual impairment Information via Annual Report from Sight Scotland on the number of clients they have provided rehabilitation / mobility training to and number of clients they have supported in this period. Prior to 2021 there was no formal contract in place. There are now formal reporting structures with targets identified around the number of people to be supported by Sight Scotland. Targets also exist around waiting time and are being met. People are seen in their home environment as soon as possible after diagnosis. Data re referrals and contacts from Sight Scotland. Personal testimonies from clients who have used the Service MIJB- 9.12 Physical Disability, Sensory Impairment & Long-Term Conditions Increase access to health and wellbeing support for people at higher risk of health inequalities No data available Page 160 of 276
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41 No Area Direction Performance Measures What is the measure you are using to demonstrate progress? How will you know that a change is an improvement? What is the data/information source being used? MIJB- 9.13 Physical Disability, Sensory Impairment & Long-Term Conditions Develop clear pathways, improve screening and support provision of local treatment where possible for long term conditions such and cancer and type 2 diabetes) by March 2023 Reduction in HbA1c Referral Numbers Patient engagement numbers & completion of programmes Reduction in HbA1c will lead to a reduction in development in Type 2 DM and complications Increased referrals from or to other services Increased numbers of patients who opt in to programmes TRAK Sci Diabetes Referrals Develop clear pathways, improve screening and support provision of local treatment where possible for long term conditions such and cancer and type 2 diabetes) by March 2023 ICJ to reach 30% of people with a new cancer diagnosis, rising to 50% by final year of Macmillan funding Routine monitoring provides activity data in terms of the number of assessments (eHNA) completed, care plans produced and shared, referral routes into the service, onward referrals & service reach into SIMD 1 & 2 areas. Outcomes: impact on wellbeing: Income maximisation- e.g. Macmillan grant, monies written off , benefits secured Number of people who have maintained or been supported back into employment Housing- number adaptations, re-housing, rent arrears managed / avoided, tenancy Universal offer to everyone in Midlothian affected by cancer Pro-active reach out via PHS letter to all newly diagnosed people Focus on ‘what matters to the person’, early identification of non-medical concerns, support to access appropriate support options & to self-management Impact of mitigating against financial consequences Impact of supporting people to Quantitative information via Macmillan’s eHNA system Outcomes data from partners: Welfare Benefits, Housing, Midlothian Active Choices Qualitative data- case studies, service user & staff feedback Page 161 of 276
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42 maintained Case studies/ qualitative info of people’s journeys. Staff feedback Service user feedback be more active Access to services and support at an earlier point in time Page 162 of 276
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43 Direction No 10 No Area Direction Performance Measures & Update What is the measure you are using to demonstrate progress? How will you know that a change is an improvement? What is the data/information source being used? MIJB- 10.1 Learning Disability Review day care provision and associated costs including transport with recommendations for future action and transformation by February 2023 Project Plans Goals of project plan met Tracking project plan MIJB- 10.3 Learning Disability Complete retender of the taxi contract for existing taxi services Project Plans Goals of project plan met Tracking project plan MIJB- 10.3 Learning Disability Complete retender of the taxi contract for existing taxi services Project Plans Goals of project plan met Tracking project plan MIJB- 10.4 Learning Disability Strengthen joint working of Learning Disability Services and care providers to inform longer-term changes in how adult social care is planned and delivered Project Plans Goals of project plan met Completion Evaluation Report Tracking project plan MIJB- 10.6 Learning Disability Strengthen work with people with complex needs by improving staff skills in using positive behavioural support and through the application of a risk tool Project Plans Monitoring PBS Referrals Goals of project plan met Evidence of successful PBS intervention Tracking project plan Quarterly report of PBS referrals Page 163 of 276
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44 No Area Direction Performance Measures & Update What is the measure you are using to demonstrate progress? How will you know that a change is an improvement? What is the data/information source being used? MIJB- 10.7 Learning Disability Work with individual providers to pilot new community based and personalised models of day services by February 2023 Project Plans Goals of project plan met Completion Evaluation Report Tracking project plan MIJB- 10.8 Learning Disability Develop more Keep Safe spaces to reduce incidence and fear of abuse Project Plans Goals of project plan met Tracking project plan MIJB- 10.9 Learning Disability Implement a series of measures to promote human rights enabled by Expert Panels Project Plans Goals of project plan met Completion Evaluation Report Tracking project plan MIJB- 10.10 Learning Disability Implement a programme of work to improve the experience of transition to adulthood This will be progressed through the GIRFEC Board End of year evaluation report Governance structures around transitions being put in place MIJB- 10.11 Learning Disability Continue to monitor progress and commission care and support services in relation to the new housing model in Bonnyrigg (8 flats) by December 2023 Project Plans Project Plan Completed Tracking project plan MIJB- 10.12 Learning Disability Continue to support the long-term plan for Primrose Lodge including the contingency use of Teviot Court and associated works for people with profound and multiple learning difficulties Project Plans Project Plan Completed Tracking project plan Page 164 of 276
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45 Direction No 11 No Area Direction Performance Measures What is the measure you are using to demonstrate progress? How will you know that a change is an improvement? What is the data/information source being used? MIJB- 11.1 Mental Health Continue to explore options for recovery for people experiencing poor mental health through development of community-based housing with access to appropriate support Approval of application for Grade 5 and 4 accommodation – Full business case Development of potential cluster accommodation (Grade 3) Consideration of Specific home support services for mental health Meetings between Housing and Mental Health Endorsement and developments of varied housing options and home care supports specifically for mental health - Present to Capital Planning Board for consideration Individuals not to be placed inappropriately or remaining in hospital Full Business case document currently being drafted Individuals identified for specific housing and support needs MIJB- 11.2 Mental Health Continue with a review effectiveness of the multidisciplinary/multiagency approach to mental health, substance misuse and criminal justice now operational at Number 11 (multiagency hub) by September 2022 with a particular attention to tackling stigma and discrimination Development of bespoke action plans from outcome of staff and Service user survey Development of Collaborative working pathways No 11 allocation meeting Lead agency pathway Dual diagnosis pathway NFO Feedback and complaints specifically around stigma and discrimination Completion of action plans Staff survey and No 11 Service user survey Datix and Sophera No 11 Building meeting Page 165 of 276
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46 No Area Direction Performance Measures What is the measure you are using to demonstrate progress? How will you know that a change is an improvement? What is the data/information source being used? MIJB- 11.4 Mental Health A coherent approach to the delivery of services to support improved mental wellbeing should be developed and evaluated. This should include new services funded through Action 15 along with the Wellbeing and Access Point services. A key element of this work is to identify new approaches to addressing the continuing pressures on Psychological Therapies Primary Care mental Health Team- GP time saved SG outcome measures for 22/26 Mental health and well being monies GP time saved Improve access to primary care mental health from 17 and 9 month over life span (none dementia) PC Data set SG data set MIJB- 11.9 Mental Health Phase 2 - Royal Edinburgh Hospital - NHS Lothian to ensure better care for physical health needs of Midlothian in- patients at the Royal Edinburgh Hospital campus by proceeding with the development of the business case for Phase 2 and the planning and delivery of integrated rehabilitation services. NHS Lothian to ensure Midlothian HSCP is involved in development, decision- making and approval of the business case Midlothian have a seat on the core group business meeting for phase 2 Physical health: all patients receive a clerk in on admission All patients receive a clerk in on admission TRAK Page 166 of 276
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47 No Area Direction Performance Measures What is the measure you are using to demonstrate progress? How will you know that a change is an improvement? What is the data/information source being used? MIJB- 11.11 Mental Health Implement updated Suicide Prevention Action Plan including Scottish Government’s 4 new priorities by December 2022 Midlothian Every life Matters Meeting Action plan To be defined Action plan MIJB- 11.13 Mental Health Work with Psychological Therapies to increase the number of people commencing (general adult) treatment within 18 weeks to 90% by July 2022 A12 wait times measure Individuals being referred for psychological therapy are being seen within 18 weeks Management report Leads meeting MIJB- 11.14 Mental Health Work with other Lothian IJBs to agree plans for pan-Lothian and hosted mental health service provision 2022-25 by July 2022. This includes Royal Edinburgh Hospital services such as Forensic Psychiatry and Eating Disorders Services and the implementation of the Early Intervention in Psychosis Action Plan Forensic psychiatry- not able to report on Eating disorder - in progress core meeting Midlothian has a seat Early Intervention in Psychosis Action Plan – Not able to report on . Clear in reach pathways to LEADS, Carer, Peer and advocacy As part of the core croup local data from GPs obtained regarding referrals to dieticians shared with core group Page 167 of 276
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48 No Area Direction Performance Measures What is the measure you are using to demonstrate progress? How will you know that a change is an improvement? What is the data/information source being used? MIJB- 11.15 Mental Health Train all HSCP staff in ASIST and Safe Talk to help prevent suicide No of individuals trained across the HSCP Increase in no of individuals trained across the HSCP Training data through HIM MIJB- 11.16 Mental Health Develop use of group work, including peer support, for users and carers Remobilisation of group work across services Development of specific carers group – in conjunction with Vocal Health and mind report All groups re-established Staff team updates PTS action plan HIM – mental health support MIJB- 11.17 Mental Health Reduce waiting times for occupational therapy through triage, sign posting and pathway efficiency measures Reduction of waiting times to be reactive to MDT Implementation of Triage assessment clinics Recruitment SBAR to F&P to address workforce Reduction in wait times OT more integrated into MDT TRAK MIJB- 11.18 Mental Health Promote self-management through increased access to Midspace Access to Midspace Increased visibility, increase of individuals access HIM collate data on individuals access midspace Page 168 of 276
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49 No Area Direction Performance Measures What is the measure you are using to demonstrate progress? How will you know that a change is an improvement? What is the data/information source being used? MIJB- 11.19 Mental Health Increase recovery-focused support both on a one to one and group basis Recommendation to remove this direction as all mental health activity is recovery focused MIJB- 11.20 Mental Health Support the Rapid Rehousing Policy through the delivery of a Housing First approach, increasing support to people in temporary accommodation with Mental Health difficulties Acceptance to tenancy Referral routes and referrals Management transfers Sustained permanent housing and support for individuals who are experiencing homelessness with complex needs such as Substance use with or without mental health Housing development options team – Housing first MIJB- 11.21 Mental Health The Partnership should work with its Community Planning partners and with local communities to develop ways of reducing stigma throughout Midlothian Please see narrative below Page 169 of 276
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50 Direction No 12 No Area Direction Performance Measures What is the measure you are using to demonstrate progress? How will you know that a change is an improvement? What is the data/information source being used? MIJB- 12.1 Substance Use Ensure that people’s involvement in the planning, delivery and reviewing of their individual care is maximised. This relates to the eight National Quality principles Implementation of Electronic Audit- Person centred care plans MELD- Outcome star Clear evidence of Improved standard of person-centred care planning (positive return 60-80%) Personal outcome measure TRAK Outcome star online tool MIJB- 12.3 Substance Use People with lived experience to be members of the MELDAP Strategic Group This measure has been superseded by new requirements from Scottish Government MIJB- 12.2 Substance Use Evidence that people using MELDAP funded services contribute to ongoing development of the service. Services have in place systems to collect the views of people who use their service. Peer staff trained Embedded tools to receive individuals’ feedback across services. Implementation of feedback into service improvement LLE panels established Summary of experiential evidence, Development of service systems to collect the views of people who use it. Datix - SUS Yearly patient/carers feedback Patient experience team Page 170 of 276
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51 No Area Direction Performance Measures What is the measure you are using to demonstrate progress? How will you know that a change is an improvement? What is the data/information source being used? MIJB- 12.4 Substance Use MH&SCP/MELDAP will increase the numbers of paid and unpaid Peer Supporters in Midlothian by 30th September 2022 Number of Peer Workers in post. Number of peer training course offered. Number of peer volunteers. Increase in peer and volunteer workers numbers Data provided by Health in Mind MIJB- 12.5 Substance Use Employment opportunities for people in recovery should be increased by improving engagement in education, training and volunteering by 30th September 2022 Number of ‘students’ supported by the Recovery College. Outcomes of education provided: Qualifications Volunteering Employment Evidence of increased engagement, support and improved outcomes Commissioned service - Recovery College service data MIJB- 12.6 Substance Use MH&SCP/MELDAP and NHS Lothian should further develop working practices to ensure a seamless provision of services to those people using No11. Maximise the use of the building by recovery-oriented groups in the evenings and at the weekend Number of groups available Increased access to group provision No 11 Building services meeting Page 171 of 276
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52 No Area Direction Performance Measures What is the measure you are using to demonstrate progress? How will you know that a change is an improvement? What is the data/information source being used? MIJB- 12.7 Substance Use Maintain innovative practices using digital platforms introduced during the pandemic Number of: • basic phones • digital top ups and • tablets issued to most vulnerable individuals and families. Comments made by people receiving support MELD is the co-ordinating organisation and provided data on the number of basic phones, digital top ups and tablets issued. MIJB- 12.8 Substance Use Ensure the provision of Medication Assisted Treatment is safe, effective and of high quality 1-5 & 8 are green by Mar 2023 (% for criteria within each MAT standard) 1 % green 2 % green 3 % green 4 % green 5 % green Development and implementation of the performance and assurance report Rag rate all green by March 2023 Improvement to compliance with MAT Access standard 21 days referral to treatment 90% standard TRAK Daisy HSCP Performance and assurance report MIJB- 12.9 Substance Use Implement new access arrangements to improve waiting times for treatment Number of people using the Contact Service. Direct referrals to SUS through alternative routes People are provided with information they need about services and if appropriate how to access these services. Improved Waiting Times performance against the National Standard. MELD TRAK Page 172 of 276
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53 Direction No 13 No Area Direction Performance Measures What is the measure you are using to demonstrate progress? How will you know that a change is an improvement? What is the data/information source being used? MIJB- 13.4 Community Justice Continue to develop the SPRING service. Specifically develop ‘Stepping Stones’ and the ‘Next Steps’ phase of SPRING. The output measures are: 1. Increase the number of referrals to SPRING service for women by 5% 2. The number and percentage of women who attend Spring Service initial appointment who go on to engage with the service for at least three months (5%) 3. Number of women engaging with the Next Steps phase (increase number of women engaging with next steps). Data gathered from Outcome Star will ascertain if women are achieving their personal outcomes. Outcome Star (quantitative) Entry/Exit questionnaires (quantitative) Transformational evaluations (qualitative) Focus groups (qualitative) MIJB- 13.5 Community Justice Prevent the risk of further offending by improving interventions with people who are on/ have completed a Community Payback Order 1. Number of people successfully completing CPOs 2. Develop a trauma informed service for men on Community Payback Order supervision Successful completion of CPOs Reconvictions rates: The last set of available data is 2018/2019. LSCMI - National risk and needs assessment Exit/entry questionnaires Page 173 of 276
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54 No Area Direction Performance Measures What is the measure you are using to demonstrate progress? How will you know that a change is an improvement? What is the data/information source being used? MIJB- 13.6 Community Justice Improve understanding of Community Justice amongst staff, the public and local businesses 1. Ongoing engagement with local communities and business through social media - good news stories regarding CPOs and unpaid work beneficiaries 2. Publish a Community Justice E-learning toolkit for all Council staff 3. Redesign and develop measurable outcomes for beneficiaries of Unpaid Work Projects, and market online application form for unpaid work. Midlothian’s Community Justice Toolkit was developed for staff using Learnpro, a compulsory learning module for Midlothian Council Staff. The work of the Unpaid Work team has been highlighted on Social Media and increased opportunities to support and work alongside local communities. Evidence of improvement can be demonstrated by the increase in referrals to the Community Payback Team from other Health and Social Care services, Learnpro Citizens Panel Focus groups Referral and feedback from beneficiaries of unpaid work projects Mosaic Social Media Page 174 of 276
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55 Direction No 14 No Area Direction Performance Measures & Update What is the measure you are using to demonstrate progress? How will you know that a change is an improvement? What is the data/information source being used? MIJB- 14.3 Unpaid Carers Improve carer identification through connections to services, and through information to the public to support increased awareness of the carer role and self-identification by January 2023 Number of new carers identified (broken down by organisation / provider eg VOCAL) Increase in number of new carers identified Expansion in number of organisations referring HSCP Performance Improvement Team reporting of social care activity; VOCAL quarterly (quantitative) and 6- monthly (qualitative) reporting. When contracts begin, data will be gathered from the monitoring and evaluation frameworks for Alzheimer Scotland and Grassy Riggs MIJB- 14.5 Unpaid Carers Improve information on respite care including entitlement and availability Targets from Respite Action Plan: 1. Definition published and accessible - hard copy and digitally 2. Increased number of staff trained 3. Number of attendees at Annual Respite and Short Breaks Event 4. Respite discussion recorded in 100% Carer Support Plans 5. Number of information packs distributed Increased number of staff trained Number of attendees at Annual Respite and Short Breaks Event % of Carer Support Plans with Respite discussion recorded HSCP Performance Improvement Team reporting of social care activity; VOCAL quarterly (quantitative) and 6- monthly (qualitative) reporting. Page 175 of 276
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56 No Area Direction Performance Measures What is the measure you are using to demonstrate progress? How will you know that a change is an improvement? What is the data/information source being used? MIJB- 14.6 Unpaid Carers Improve quality of life of carers through increased access to support, counselling and respite. This should include increased awareness of respite and breaks from caring amongst HSCP staff 1. Income maximization target £400K – VOCAL 2. Carers reporting increased awareness and confidence after attending training 3. Target 125 – VOCAL (carer training re wellbeing and breaks from caring) 4. Target 150 – VOCAL (training relating to carer awareness, info and advice, carer rights). Meeting targets: • Income maximization £400K – VOCAL • Carers reporting increased awareness and confidence after attending training • 125 – VOCAL (carer training re wellbeing and breaks from caring) • 150 – VOCAL (training relating to carer awareness, info and advice, carer rights). HSCP Performance Improvement Team reporting of social care activity; VOCAL quarterly (quantitative) and 6- monthly (qualitative) reporting. MIJB- 14.7 Unpaid Carers Investigate opportunities to increase residential respite availability options Number of respite beds to support the cared- for person so the unpaid carer can take a break from caring Increase in number of respite beds Performance Improvement Team reporting MIJB- 14.8 Unpaid Carers Develop an improved understanding of current and future demand for the full range of respite opportunities available to adults in Midlothian Work with Performance and Improvement team to design and implement a system for data analysis / reporting of respite data that will improve: • monitoring of respite experience • reporting to respite providers • accuracy of systems for recording respite • monitoring of respite experience • improve reporting to respite providers We will have systems to identify current demand data and evaluation of existing provision, and future demand where we can use population-level data better predict need and inform planning. OutNav Page 176 of 276
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57 Direction No 15 No Area Direction Performance Measures What is the measure you are using to demonstrate progress? How will you know that a change is an improvement? What is the data/information source being used? MIJB- 15.2 Care at Home Implement a multifaceted workforce plan that includes council and external providers by 30th September 2022 This has been superseded by the Midlothian HSCP workforce plan which is in draft and awaiting approval from Scottish Government MIJB- 15.4 Care at Home Implement care at home services, in line with the vision statement and human rights-based approach. Establish robust monitoring systems to ensure block contracts are effectively implemented, and to demonstrate the impact of care at home on promoting human rights by 30th September 2022 MIJB- 15.5 Care at Home Complete a whole system service review of care at home to support transformation and meet increasing service demand Directions MIJB-15.5 and MIJB-15.7 are similar, and it is recommended that MIJB-15.5 is closed and a MIJB-15.7 is reworded and extended to September 2023 Complete a whole system service review of care at home to support transformation and develop a sustainable model of service delivery by Feb 2023 Page 177 of 276
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58 No Area Direction Performance Measures What is the measure you are using to demonstrate progress? How will you know that a change is an improvement? What is the data/information source being used? MIJB- 15.6 Care at Home Ensure service redesign includes the provision for appropriate care services to meet the demand in relation to new extra care housing It is recommended that this direction be reviewed to reflect more specifically the requirement to develop a sustainable staffing model Explore, develop and establishment a sustainable staffing model for Extra Care Housing sites by June 2023 MIJB- 15.7 Care at Home Review the Internal Home Care Service and develop a sustainable model of service delivery by December 2022 Directions MIJB-15.5 and MIJB-15.7 are similar. It is recommended that MIJB-15.5 is closed and a MIJB-15.7 is reworded and extended to February 2023 Complete a whole system service review of care at home to support transformation and develop a sustainable model of service delivery by September 2023 Page 178 of 276
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59 Direction No 18 No Area Direction Performance Measures What is the measure you are using to demonstrate progress? How will you know that a change is an improvement? What is the data/information source being used? MIJB- 18.1 Adult Protection & Domestic Abuse Review the effectiveness of the new combined Public Protection module, covering Child Protection, Violence Against Women and Girls and Adult Support and Protection by 30th September 2022 Review the needs assessment to review learning from this and extract measure/data This Direction has been complete and should be closed. There is a quarterly Public Protection half day training course that is offered to staff working in Midlothian HSCP. This is at ‘level one’ (awareness and response) and is open to staff who have not completed any PP training or are new in post, and who work across all services in East Lothian and Midlothian. The East Lothian and Midlothian Public Protection Committee Learning and Development Sub-group reviews the evaluation report of each training course. This course is consistently evaluated positively. Evaluation is not broken down by area or organisation. MIJB- 18.7 Adult Protection & Domestic Abuse Complete joint strategic needs assessment for Public Protection to identify gaps in services, including early and effective intervention services for children experiencing the impact of Domestic Abuse and adults experiencing Domestic Abuse by December 2022 The Joint Strategic Needs Assessment was completed in 2021 and presented to the Critical Services Oversight Group in September 2021. The JSNA is being progressed by CSOG with no resolution to the provision of services, the gaps and needs have been clearly outlined in the JSNA, The actions that can be influenced by the HSCP are complete and the IJB may wish to consider how to influence the progression of discussion with CSOG. Page 179 of 276
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60 No Area Direction Performance Measures What is the measure you are using to demonstrate progress? How will you know that a change is an improvement? What is the data/information source being used? MIJB- 18.4 Adult Protection & Domestic Abuse Support the embedding of Safe and Together (keeping the child Safe and Together with the non- offending parent) including training across social, health and care services No of staff completing training in the local authority area No of staff in process of undertaking the training Audit of case files will demonstrate impact of training on practice. Audit includes 17 questions with quantitative reporting, and qualitative analysis. Data is reported to Public Protection Office from staff completing training. Implementation group oversees data quality MIJB- 18.8 Adult Protection & Domestic Abuse Develop guidance to support the implementation of the East Lothian and Midlothian Position Statement on Commercial Sexual Exploitation and link work with the Midlothian equalities outcomes by 30th September 2022 Production of guidance The guidance is in draft form ongoing MIJB- 18.9 Adult Protection & Domestic Abuse Evaluate Midlothian Council Safe Leave Programme - for those employees who are experiencing gender-based violence and need additional time off work to deal with resulting matters by 30th September 2022 The evaluation has not been done and there are no plans to evaluate the Safe Leave at present. Page 180 of 276
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61 No Area Direction Performance Measures & Update What is the measure you are using to demonstrate progress? How will you know that a change is an improvement? What is the data/information source being used? MIJB- 18.10 Adult Protection & Domestic Abuse Review and streamline the Adult Support and Protection referrals process by December 2022 This Direction pre-dates 2020 and work is now required to understand the current situation to understand the most effective action to see change MIJB- 18.11 Adult Protection & Domestic Abuse Implement changes arising from the review of the ASP (Scotland) Act 2007 1. The production of ASP procedures 2. Council Officer training 3. Council Officer forum This Direction has been completed. Revision to training materials for ASP N/A (complete) MIJB- 18.12 Adult Protection & Domestic Abuse Embed the Equally Safe priorities to prevent/tackle violence women and girls Development of Equally Safe Strategy Equally Safe priorities are embedded in practice To be developed as part of strategy This requires an Equally Safe strategy for Midlothian, the development of which has been approved in principle. The timescale for commencing development of this is November 2022. MIJB- 18.13 Adult Protection & Domestic Abuse Increase knowledge of gender- based violence for all HSCP staff 1. Number of training courses delivered - VAWG - Domestic Abuse 2. Number of staff attending 3. Impact of training MIJB- 18.14 Adult Protection & Domestic Abuse Improve staff skills in managing cases which do not meet the ASP criteria Please see narrative below Page 181 of 276
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62 No Area Direction Performance Measures What is the measure you are using to demonstrate progress? How will you know that a change is an improvement? What is the data/information source being used? MIJB- 18.15 Adult Protection & Domestic Abuse Improve knowledge and skills of Council Officers in their work in ASP 1. No of Council Officers trained. 2. No of Council Officers forums delivered and no of attendees. Evidence of content covered. Agendas and note of meeting MIJB- 18.16 Adult Protection & Domestic Abuse Improve risk management in care homes in Adult Support and Protection practice Action plan to be developed Page 182 of 276
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63 Direction No 19 No Area Direction Performance Measures What is the measure you are using to demonstrate progress? How will you know that a change is an improvement? What is the data/information source being used? MIJB- 19.2 Public Health Continue a programme of work to enable people to stay well with a range of service offers and improve health and wellbeing support for people at higher risk of health inequalities. This should specifically include targets that aim to: Percentage of actions that are on target or completed to address money worries across all HSCP strategic action plans 80% on target or completed Bespoke local systems 38% of plans have actions to address money worries Analysis in progress increase the number of people who are supported to address money worries, reduce isolation** This is a historic Direction that creates a number of challenges in relation to delivery and measurability. It is recommended to review this Direction and to better reflect achievable deliverables in 2022/23 and review the strategic direction for 2023/24 Increase the number of women who quit smoking during pregnancy Once the service model is established work towards: 1. a monthly engagement (quit date set) rate of 30% 2. an annual 12 week quit rate of 35% of those who have set a quit date) Increase in successful outcomes re quitting (note that reporting under this measure is currently specific to pregnant women) National Smoking Cessation Database - NSCD increase the number of people who are physically active, Percentage of actions that are on target or completed to increase physical activity across all HSCP strategic action plans. (80% to be on target/completed) 80% to be on target/completed Bespoke local system Page 183 of 276
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64 increase green prescribing pilot stage: Achieve 4 GPs, Physiotherapists and Pharmacist’s to start prescribing 4 services to provide green health opportunities 4 GPs, Physiotherapists and Pharmacist’s will have started prescribing 4 services will be providing green health opportunities Bespoke local system identify areas of work to address poverty See first area above re measures and data addressing money worries section. MIJB- 19.6 Public Health Deliver an evaluation report detailing the impact of the HIT (Health Inequalities Team) including a recommendation for future investment by 30th September 2022 A report and recommendation Evaluation report will guide further improvement Evaluation data MIJB- 19.7 Public Health Initiate discussions with the 3 other Integrated Joint Boards about the potential disaggregation of Public Health funding including but not limited to Health Improvement Fund, Hep C and Blood Borne Virus by 30th September 2022. Discussion has taken place Very difficult to say Bespoke This is a historic Direction, it is requested that Board reconsider this Direction Page 184 of 276
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65 No Area Direction Performance Measures What is the measure you are using to demonstrate progress? How will you know that a change is an improvement? What is the data/information source being used? MIJB- 19.11 Public Health Embed the Midway working with planning groups, training staff and supporting service design Percentage of actions that are on target or completed to embed the Midway across all HSCP strategic action plans. (80% target) 80 staff from the HSPC, Council and Third Sector trained in Good Conversations by April 2023. 80% of participants completing Good Conversations evaluation stating they have the confidence, knowledge and skills to put what they have learnt into practice. Increase Good Conversations training capacity by 1 additional trainer 5 teams who incorporate preparing people into their design 80% of actions to be on target/completed 80 staff will be trained 80% of participants will state they have the confidence, knowledge and skills to put what they have learnt into practice. Increase in local training capacity by 1 trainer 5 teams will have incorporated preparing people into their design Bespoke local system Bespoke local system Bespoke local system Bespoke local system Bespoke local system Page 185 of 276
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66 No Area Direction Performance Measure What is the measure you are using to demonstrate progress? How will you know that a change is an improvement? What is the data/information source being used? MIJB-19.12 Public Health Increase trauma-informed practice across Health and Social Care and Community Planning Number of people trained Level 1 x 400 Level 2 x 110 by April 2023 Internal MIJB-19.13 Public Health Deliver an evaluation report detailing the impact of the Improving the Cancer Journey (ICJ) programme by 30th September 2022 Evaluation report Evaluation report will guide further improvement See narrative below for information sources MIJB- 19.153 Public Health Improve screening and early detection rates 10 training sessions/ workshops delivered by April 2023 50 people participated in phase 2 by April 2023 6 opportunities for joint working agreed and in progress by April 2023. Bespoke Page 186 of 276
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67 Direction No 20 No Area Direction Performance Measures What is the measure you are using to demonstrate progress? How will you know that a change is an improvement? What is the data/information source being used? MIJB- 20.3 Services to People under 18years (H/V) Review the management structure for all nursing in Midlothian including health visiting by 31st January 2023 Organisational structure May be difficult to demonstrate, but potential to utilise option appraisal and for evaluation to be undertaken to address this measure MHSCP organisational structure MIJB- 20.9 Services to People under 18years (0-5) Grow and develop the school nursing service to address the increasing need for services to support children and young people's mental health and wellbeing needs (in line with Scottish Government priorities) by January 2023 1. Scottish Government funding. 2. Increasing capacity and competency of the School Nursing workforce will reduce waiting times, prevent delay in treatment/care and facilitate early intervention. 3. NHS Lothian to receive 36.3 wte Specialist Community Public Health Nurses. Midlothian will receive NRAC share of 12% (4.3 wte) by January 2024. 1. Increased and upskilled workforce. 2. demonstrating progress implementing the School Nursing Pathway. 1. eESS and Tableau dashboard for workforce info 2. TRAK Page 187 of 276
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68 No Area Direction Performance Measures What is the measure you are using to demonstrate progress? How will you know that a change is an improvement? What is the data/information source being used? MIJB- 20.10 Services to People under 18years (0-5) Reduce inequality through the delivery of consistent health visiting interventions through the effective implementation of the Universal Health Visiting Pathway by 30th September 2022. This will include ensuring health visitors are trained to support parents and carers with the skills they need to meet the individual mental health and wellbeing needs of their children Universal Health Visiting Pathway Compliance with the pathway at each specific time point to an agreed percentage point Data pulled from the local Trak system and Public Health Scotland using data for each of the 12 specified contact points. MIJB- 20.11 Services to People under 18years (0-5) Implement the school nursing pathway in line with Scottish Government guidance School Nursing data set implementation plan. The implementation of the data set will enable the progress of pathway implementation to be monitored and reported to NHS Lothian Health Visiting and School Nursing Strategy Board and within relevant reporting and governance structures within MHSCP and to the IJB. Trak Page 188 of 276
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69 No Area Direction Performance Measures What is the measure you are using to demonstrate progress? How will you know that a change is an improvement? What is the data/information source being used? MIJB- 20.12 Services to People under 18years (0-5) Target health inequalities through early detection of concerns and increased uptake of vaccinations by delivering service offer and supports that are person-centred e.g., gypsy travellers and working with families who appear on the ‘failure to attend’ list by 30th September 2022 Vaccination numbers delivered in line with SG recommended uptake levels for antenatal women and children 0 – 6yrs. This is subject to National and Lothian wide scrutiny. The numbers of vaccinations will increase, particularly for those which the primary care givers are less likely to take their children for (national trends) The gypsy traveller site in Midlothian is currently closed with no occupants. There is liaison with Public Health who monitor this site Families scheduled for immunisations are targeted prior to their appointment when possible (staff dependant) which will maximise attendance and decrease overall failures to attend. Service design is adapted to enable families who find it more challenging to travel to appointments and/or to certain venues at certain times to attend for vaccination National data pulled from PHS using information gathered from the Child Health Surveillance Programme Local data pulled from Trak Page 189 of 276
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70 Direction No 25 No Area Direction Performance Measures What is the measure you are using to demonstrate progress? How will you know that a change is an improvement? What is the data/information source being used? MIJB- 25.1 Financial Support the recovery from the pandemic, partners may spend up to the balance of the covid earmarked reserves (£9,703,000) to address identified and continuing pressures in relation to the pandemic for delegated functions. This should be in line with the existing HSCP covid related planning in conjunction with NHS Lothian and Midlothian Council Scottish Government Covid-19 returns Appropriate draw down of the Covid-19 reserve Partners financial ledgers MIJB- 25.2 Financial Support the redesign of services covered by the funding streams within earmarked reserves for delegated functions including provision to support Unpaid Carers, Care at Home and MELDAP (£7,938,000) The local plans for the earmarked funding streams Appropriate draw down of the earmarked reserves Partners financial ledgers Page 190 of 276
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71 No Area Direction Performance Measures What is the measure you are using to demonstrate progress? How will you know that a change is an improvement? What is the data or information source being used? MIJB- 25.3 Financial Using only the monies in excess of the recommended reserve fund in line with the IJB Reserves Policy (£2,800,000), the general reserves should be used to support the delivery of the IJBs Strategic Commissioning Plan 2022-25. Allocation of funds should be following agreement from the IJB with the intention of accelerating the progress within delegated functions towards achieving the 6 aims of the Strategic Commissioning Plan. This should include capacity to progress key work in relation to an outcomes focused approach Number of proposals supported by the IJB Increase in the spent supported by the IJB Partners financial ledgers MIJB- 25.4 Financial Acute services should continue to provide quarterly financial information on the set- aside budget that outlines budget, expenditure and variance. This should now also include intelligence and narrative to detail the nature of financial variance and support the IJBs understanding of areas of mutual concern Quarterly Set-Aside reporting to SPG Appropriate output and action from the discussion at SPG NHS Lothian Acute financial ledger and mapping table Page 191 of 276
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Midlothian Integration Joint Board Thursday 13th October 2022, 14.00-16.00 IJB Improvement Goals Executive summary The purpose of this report is to update the IJB on progress towards achieving the current IJB performance goals for the financial year 2022/23. Board members are asked to: • Note the performance against the IJB Improvement Goals for 2022/23. # Item number: 5.8 Page 193 of 276
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Midlothian Integration Joint Board Report Update to the IJB Improvement Goals 1 Purpose The purpose of this report is to update the IJB on progress towards achieving the current IJB performance goals (2022/23). 2 Recommendations 2.1 As a result of this report Members are asked to:- • Note the performance against the IJB Improvement Goals for 2022/23 (Appendix 1); 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 (find out more here). 3.2 At the IJB meeting in June 2022 the Performance Assurance & Governance Group recommended that the improvement goals for 2022/23 were set in order to prioritise an increase in system stability, focussing on workforce recovery and wellbeing. 3.3 The Members approved the following goals, based on a continuation of the target rates set for 2021/22: MSG Indicator 2021/22 Target Rate per 100,000 2021/22 Running Average per 100,000 2022/23 Target Rate per 100,000 A&E Attendances 2,629 / month 2,789 (at Feb 2022) 2,629 / month Emergency Admissions 767 / month 820 (at Feb 2022) 767 / month Unplanned Bed Days 5,074 / month 4,714 (at Feb 2022) 5,074 / month Delayed Discharge 820 / month 680 (at Feb 2022) 820 / month Page 194 of 276
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Midlothian Integration Joint Board Occupied Bed Days End of Life - Percentage of Last Six Months Spent in Large Hospitals <8.7% 7.4% (provisional) <8.7% Balance of Care >96.4% 96.7% (provisional) >96.4% 3.4 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 with regard to data completeness (slide 4). Due to the processes required to validate these data, there is an inbuilt reporting delay and this information is not taken from a “live” system. This means that we are not yet in a position to calculate the full year average performance for 2021/22. 4 Directions 4.1 There are no implications on the Directions. 5 Equalities Implications 5.1 There are no equality implications from focussing on these goals but there may be implications in the actions that result from work to achieve them. The focus of most of the goals is on reducing hospital activity and hospitals are not used equally by the population. There are groups of people that make more use of hospitals than others – for example older people, people living in areas of deprivation or people who live alone. 6 Resource Implications 6.1 There will be resource implications resulting from further action to achieve these improvement goals. 7 Risk 7.1 The main risk is that the IJB fails to set improvement goals that take cognisance of the continued instability of health and care systems, and the ongoing challenges of supporting workforce wellbeing. 8 Involving people 8.1 The Performance Assurance & Governance Group (PAGG) meet monthly to review and discuss these measures as part of wider data assurance. Membership of the group will be expanded to ensure increased representation of elected officials, the third sector and public health. Page 195 of 276
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Midlothian Integration Joint Board 9 Background Papers AUTHOR’S NAME Elouise Johnstone DESIGNATION Performance Manager CONTACT INFO elouise.johnstone@nhslothian.scot.nhs.uk DATE 04/10/2022 Appendix 1: LIST Report describing progress against the IJB improvement goals 2022/23 Page 196 of 276
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Midlothian HSCP MSG Indicators Performance from April 2019 to June 2022, with 2020/21 MSG targets and trends Local Intelligence Support Team (LIST), September 2022 Management information – not for onward distribution Page 197 of 276
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Contents 1. Methodology 2. Data completeness 3. 2020/21 MSG targets and actuals 4. A&E attendances a) weekly figures by age group b) monthly proportions by age group c) 4 hour performance d) admission conversion rates 3. Emergency admissions 4. Unplanned bed days: a) Acute b) Geriatric Long Stay c) Mental Health 5. Delayed discharges occupied bed days 6. Balance of care 7. End of life 2Page 198 of 276
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2020/21 MSG Targets - Methodology • The MSG Objectives Performa was submitted in February 2020 which specified the 2020/21 targets and an action plan on how those targets were to be achieved • 2017/18 MSG data was used as the baseline to calculate the 2020/21 targets 3Page 199 of 276
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Data completeness Source: MSG data release Aug-22, PHS 4 Indicator Published until Provisional until Data completeness issues 1. A&E attendances Jun-22 n/a - 2. Emergency admissions Dec-21 Jun-22 (SMR01) Nov-20 = 93%, Nov-21 = 95% 3a. Unplanned bed days (acute) Dec-21 Jun-22 (SMR01) Nov-20 = 93%, Nov-21 = 95% 3b. Unplanned bed days (GLS) n/a Jun-22 (SMR01E) Quarters ending: Sep-21 = 95%; Dec-21 = 95%; Mar-22=92%; Jun-22 = 87% 3c. Unplanned bed days (MH) Mar-21 Jun-22 (SMR04) Quarters ending: Jun-22 = 90% 4. Delayed discharges occupied bed days Jun-22 n/a - 5. Last 6 months of life (% in community setting) 2020/21 2021/22 - 6. Balance of care (% at home) n/a 2020/21 - Page 200 of 276
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2020/21 targets and actuals Source: MSG objectives 2020-21 template - Midlothian IJB; MSG data release Aug-22, PHS • Indicators 3b and 6 are still provisional. 5 Indicator 2020/21 target Annual Monthly Annual Monthly 1. A&E attendances Maintain 31,543 2,629 26,390 2,199 ✓ 2. Emergency admissions 5% decrease 9,207 767 9,207 767 ✓ 3a. Unplanned bed days (acute) 10% decrease 60,888 5,074 57,459 4,788 ✓ 3b. Unplanned bed days (GLS) Decrease <13,733 <1,144 14,122 (p) 1,177 (p) X 3c. Unplanned bed days (MH) Decrease <15,910 <1,326 12,511 1,043 ✓ 4. Delayed discharges occupied bed days 20% decrease 9,836 820 9,779 815 ✓ 5. Last 6 months of life (% in large hospital) Decrease <8.7% - 7.8% - ✓ 6. Balance of care (% at home) Increase >96.4% - 97.% - ✓ 2020/21 target (rate per 100,000) 2020/21 (rate per 100,000) Target met (p) = provisional Page 201 of 276
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Data Sources 2020/21 MSG Targets • Source: MSG data release v1.57, Aug-22; 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: Sep-22 6Page 202 of 276
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A&E Attendances Source: MSG data release Aug-22; data published up to Jun-22 • The rate of attendances in 2020/21 was 21% lower than 2019/20, and 17% lower than the 2017/18 baseline year. Much of this may be due to covid-19. • The rate of attendances had increased back to typical levels by Aug-20, but steadily decreased again until Mar-21 when it started increasing. • From May-21 – Nov-21 it exceeded the 2020/21 target level. Between Dec- 21 and Feb-22 it dipped below the target again. • The 2020/21 target was met 7 Target = maintain Annual Monthly 2020/21 Target Rate (per 100,000) 31,543 2,629 2019/20 Rate (per 100,000) 33,319 2,777 2020/21 Rate (per 100,000) 26,390 2,199 2021/22 Rate (per 100,000) 33,053 2,754 2022/23 Running average (Jun) 2,868 Page 203 of 276
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A&E 4 hour performance Source: MSG data release Aug-22; data published up to Jun-22 • Four hour performance was steady through the winter of 2020-21 • Overall four-hour performance for 2020/21 was 79.9%, a slight decrease from the 2019/20 level (85.2%) • Performance through 2021/22 steadily declined, and has been around 62-65% since Feb-22 8Page 204 of 276
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Emergency Admissions Source: MSG data release Aug-22; data published up to Dec-21 • The rate of emergency admissions dropped in Apr- 20 due to Covid-19, but quickly returned to more typical levels – although remained lower than 2019/20 until March-21 • In the first quarter of 2021/22 the admissions rate increased above the 2020/21 target level and above 2020/21 levels; this discrepancy has reduced since • The 2020/21 target was met 9 Target = 5% decrease Annual Monthly 2020/21 Target Rate (per 100,000) 9,207 767 2019/20 Rate (per 100,000) 10,966 914 2020/21 Rate (per 100,000) 9,207 767 2021/22 Running average (Dec) 7,464 829 Page 205 of 276
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Unplanned Bed Days - Acute Source: MSG data release Aug-22; data published up to Dec-21 • The rate dropped drastically in Apr-20 due to Covid-19, but was back to a more typical level by Jul-20. • The rate has remained stable since then • The 2020/21 target was met 10 Target = 10% decrease Annual Monthly 2020/21 Target Rate (per 100,000) 60,888 5,074 2019/20 Rate (per 100,000) 64,683 5,390 2020/21 Rate (per 100,000) 57,459 4,788 2021/22 Running average (Dec) 43,153 4,795 Page 206 of 276
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Unplanned Bed Days – Mental Health Source: MSG data release Aug-22; data published up to Mar-21 • The rate of MH bed days has been lower than the target level since Jun-19 • The 2020/21 target was met 11 Target = decrease Annual Monthly 2020/21 Target Rate (per 100,000) 15,912 1,326 2019/20 Rate (per 100,000) 13,708 1,142 2020/21 Rate (per 100,000) 12,511 1,043 Page 207 of 276
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Delayed Discharges Occupied Bed Days Source: MSG data release Aug-22; data published up to Jun-22 • The rate of delayed discharge occupied bed days in Apr-20 was about 80% lower than the previous April’s rate due to Covid-19 • The rate has remained mostly lower than the previous year ever since; during much of 2021/22 it was lower than the 2020/21 target level, although it has now exceeded it since Feb- 22 and has risen substantially over the last two months • The 2020/21 target was met 12 Target = 20% decrease Annual Monthly 2020/21 Target Rate (per 100,000) 9,836 820 2019/20 Rate (per 100,000) 14,336 1,195 2020/21 Rate (per 100,000) 9,779 815 2021/22 Rate (per 100,000) 8,249 687 2022/23 Running average (Jun) 1,093 Page 208 of 276
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Delayed Discharges: Trends by Reason for Delay Data Source: Public Health Scotland Delayed Discharge Census September 2022 Publication 13 • These charts show the long term trend and the yearly average of the number of delays caused by: Assessments; Place Availability and Waiting on Care Arrangements. • Data has been taken from the monthly Census from Public Health Scotland. • Performance has been improving since before the pandemic, although the last few months have seen a substantial uptick in delays, particularly for Assessments.Page 209 of 276
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Delayed Discharges (all reasons): Midlothian Position Data Source: Public Health Scotland Delayed Discharges September 2022 Publication 14Page 210 of 276
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End of Life - Percentage of Last Six Months Spent in Large Hospitals Source: MSG data release Aug-22; data published up to 2020/21 15 • The 2020/21 target was met • The provisional percentage for 2021/22 is below the target and is higher than the 2020/21 level Target = decrease Annual 2020/21 Target <8.7% 2019/20 9.1% 2020/21 7.5% Page 211 of 276
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Midlothian Integration Joint Board Thursday 13th October 2022, 14.00-16.00 Integrated Care Assurance Report Executive summary This report provides the Midlothian Integration Joint Board with an update on assurance arrangement in the Midlothian Health and Social Care Partnership (MHSCP). It outlines the clinical and care governance arrangements in place to provide professional governance, and assurance regarding the safety, effectiveness, and person centredness of services, including hosted services. The report provides an update on the corporate business assurance arrangements including risk and resilience management, winter planning and the introduction of a Quality Management approach. Board members are asked to: • Note the assurance measures in place across MHSCP and take moderate assurance that the partnership has robust systems and processes in place to ensure the provision of safe, effective, and high-quality care across all professional groups and corporate business, for operational services which are delegated and hosted. • Note, and support planning in place for Winter 2022/23 # Item number: 5.9 Page 213 of 276
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Midlothian Integration Joint Board Report Integrated Assurance Report 1 Purpose 1.1 The purpose of this report is to recommend that the Midlothian Integration Joint Board takes moderate assurance that Midlothian Health and Social Care Partnership has appropriate systems and processes in place to ensure the provision of safe, effective, and high-quality care across the Partnership. 2 Recommendations 2.1 As a result of this report Board Members are asked to: • Take moderate assurance that the Midlothian Health and Social Care Partnership management team have comprehensive systems in place to deliver robust health, care, professional and business governance across the Partnership. • Note the ongoing work to deliver programmes of change and improvement across the Partnership and the governance processes in place to oversee this work. • Note, and support planning in place to cover Winter 2022/23 3 Background and main report 3.1 Current Governance and Assurance Processes The Midlothian HSCP Management Team is responsible for the management and oversight of a range of delegated health and social care services within Midlothian, and for two hosted Lothian services (Dietetics, and the Adults with Complex and Exceptional Needs Service) 3.2 Integrated Governance Structure and Processes The Midlothian HSCP management team have developed a governance structure to ensure that services are provided with management support and that oversight is in place for the management of clinical, care, professional leadership and business continuity, quality and governance. • Fortnightly Senior Management Team (SMT) meetings chaired by the Director of Health and Social Care provide ongoing formal oversight of Page 214 of 276
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Midlothian Integration Joint Board service developments, discussion of emerging issues, and verbal updates are received on adverse events, complaints and performance, risk and resilience issues. • The Midlothian Safety and Experience Action Group (MSEAG) chaired by the Chief Nurse and attended by the Clinical Director, Heads of Service and relevant Service Managers meets fortnightly to manage and have oversight of the review of significant adverse events within Midlothian HSCP. • Quality Improvement Teams (QITS) are organised at service level and are chaired by Service Managers. QITs are required to meet at least four times per year and are required to provide assurance around the safety, effectiveness, and person centredness of the services delivered. • The QITS report to the quarterly meeting of the Care and Clinical Governance Group (CCGG), submitting a standard template covering the dimensions of quality, improvement activity, inspection updates and identifying service level and escalated risks. • An annual report is provided to NHS Lothian Healthcare Governance Committee. This provides assurance that Midlothian Health and Social Care Partnership has comprehensive systems in place to deliver robust health and care governance across all services. The report, appended to this document also outlines the work undertaken to deliver programmes of change and improvement across the Partnership and the governance processes in place to oversee this work, including identification and mitigation of risks to patient safety • The NHS Lothian Accreditation and Care Assurance Standards (LACAS) provide a framework to give organisational and service user assurance that quality person-centred care is being delivered consistently across all NHS Lothian’s in-patient services. • The AHP Governance and Assurance Framework is currently under testing and provides a robust and consistent structure for all AHP services across NHS Lothian and the associated HSCP’s. Midlothian HSCP services with AHP’s in their integrated teams and the hosted Dietetics services report on a quarterly basis. Improvement action plans are in place and are overseen by the SMT on a quarterly basis. • Midlothian HSCP meets the requirements set out in the Civil Contingencies Act by completing annual assurance reports for both NHS Lothian and Midlothian Council on their compliance with their requirements as Category 1 Responders. • Additional governance is provided on compliance with responsibilities set out in Midlothian Council’s Financial Regulations and Directives for ensuring the security, custody, and control of all resources. • The NHS Lothian Annual Certificate of Assurance Governance Statement confirms that Midlothian HSCP has undertaken a review, evidenced by the completed Internal Control Checklist, of the internal control arrangements in place within the HSCP covering resilience, risk management, financial management and compliance with NHSL governance arrangements. • The Midlothian Performance Assurance and Governance Group (PAGG) has been convened to provide additional capacity out with the IJB Board Page 215 of 276
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Midlothian Integration Joint Board meeting to support further scrutiny of performance and support assurance reporting to the IJB. Membership includes Midlothian HSCP’s Executive Team, Performance Team, Local Intelligence Support Team and Midlothian Integration Joint Board (MIJB) members, to ensure representation of Midlothian Council, NHS Lothian and the third sector. • A quality planning approach has been adopted to five spotlight areas of work in year one of the MIJB Strategic Plan 2022-2025 and a system for planning, monitoring, and reporting has been established. The five areas of ‘Spotlight’ work for first year of the plan are: ▪ Frailty ▪ Midlothian Community Hospital ▪ Primary Care ▪ Mental Health and Learning Disabilities, and ▪ Workforce • MHSCP services are subject to external inspections from statutory bodies. This includes Healthcare Improvement Scotland, the Mental Welfare Commission and the Care Inspectorate. These reports are noted at the SMT and reported through the QITs and CCGG. 3.3 Professional Governance Assurance NHS Lothian and Midlothian Council are the bodies responsible for ensuring care, clinical, performance and business governance are in place. These bodies are subsequently responsible for providing the Midlothian Integration Joint Board, as the commissioning body, with assurance around the systems in place to deliver safe, effective and person-centred services. 3.3 Local Authority (Social Work) The requirement for every local authority to appoint a Chief Social Work Officer (CSWO) is set out in section 3 of the Social Work (Scotland) 1968 Act. The role provides a strategic and professional leadership role in the delivery of social work services. The role is also within integrated arrangements brought in through the Public Bodies (Joint Working) (Scotland) Act 2014. The CSWO’s responsibilities in relation to local authority social work functions continue to apply to functions which are being delivered by other bodies under integration arrangements. The CSWO should assist local authorities and their partners in understanding the complexities and cross-cutting nature of social work service delivery including particular issues such as corporate parenting, child protection, adult protection and the management of high-risk offenders. The CSWO also has a contribution to make in supporting overall performance improvement and management of corporate risk. Practically within Midlothian, the current Head of Adult Services, who is a qualified Social Worker, deputises for the CSWO when they are unavailable. There is a current piece of work to ensure that CSWO assurance requirements are included in the wider quality management framework and clinical and care governance Page 216 of 276
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Midlothian Integration Joint Board arrangements within the HSCP and IJB. It is an area of development, and it is acknowledged that greater assurance within social work services would be beneficial. 3.4 NHS Lothian (Nursing and Allied Health Professions) Clinical governance is provided through the systems and processes described in section 3.2. Professional governance and support is delivered by the Clinical Director, Chief Nurse and Chief AHP as professional leads. In addition, the AHP Governance and Assurance Framework is being implemented for the four domains of Governance: Safe, Effective, Person-Centred and Regulatory (see above). It is anticipated that this framework will be adapted to be used for all integrated services and professions in Midlothian HSCP to strengthen governance and assurance mechanisms as a component of a total system for Quality Management. 3.6 Hosted Services Historically, two pan Lothian services are hosted by Midlothian HSCP. These are the Adults with Complex and Exceptional Needs Service (ACENS) and Dietetics. Both hosted services have direct operational management from a member of the HSCP Senior Management team. • ACENS is under the direct line management of the Chief Nurse who leads on the scrutiny of activity and performance and provides line management and professional support to the Team manager. Finance and performance information is provided within the HSCP and over the last year, more regular reporting to the Lothian Chief Officers has been commenced. ACENS has a local QIT and provides assurance to NHS Lothian through the Midlothian Clinical and Care Governance Group. • Dietetics is a large service delivering across the 3 acute hospitals and 4 HSCPs. Under the new leadership team including the Head of Dietetics, and the Chief Allied Health Professional (AHP) in Midlothian HSCP, development is underway to ensure that all aspects of Dietetics Governance Assurance, Quality and Performance are robustly managed, reportable and improvement orientated. 3.7 Protecting People at Risk of Harm Systems and processes are in place deliver oversight and assurance around the work undertaken within Midlothian HSCP services to improve the safety of people at risk of harm. • Public Protection duties are delivered under the oversight of the East and Midlothian Public Protection Committee (EMPPC), and the NHS Lothian Public Protection Action Group (PPAG). • The EMPPC is a multi-agency statutory committee which addresses Adult Support and Protection, Child Protection, Violence against Women and Girls and the Multiagency Public Protection Arrangements (MAPPA) for service users in East Lothian and Midlothian. The committee has a wide range of multiagency senior representatives across services and key agencies and reports to the Critical Services Oversight Group (CSOG) where the Chief Officers of core partners provide strategic leadership, Page 217 of 276
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Midlothian Integration Joint Board scrutiny, governance and direction to the EMPPC. • NHS Lothian’s Public Protection Action Group sets and oversees the strategic direction of public protection services across NHS Lothian and provides an annual assurance report to the Healthcare Governance Committee around Public Protection. • Work to reduce the harm associated with substance use is a national priority, and multiagency working across East and Midlothian is the approach for the delivery of the Drug and Alcohol Partnership (MELDAP). Recent funding allocated from the Scottish Government has allowed the Partnership to invest further in services with the aim of improving the reach and effectiveness of our substance use service offer. 3.8 Future Planning 3.8.1 Winter Planning It is recognised that demand for services is likely to be at its highest level during the winter period. Winter planning is undertaken to ensure the continued delivery of quality care by the Partnership, over winter alongside ongoing pressures arising from COVID-19 with the background of pre-existing and continuing workforce challenges. This plan builds on lessons learned from Winter 2021/22 and uses the resilience principles adopted by the HSCP. Winter plans are required to ensure: • That comprehensive, joined-up plans internal and external to Midlothian Health and Social Care Partnership are in place, including robust monitoring and escalation processes. • high-quality service provision of is maintained through periods of increased pressure. • The impact of pressures on the levels of service, national targets and finance are effectively managed. • Interventions are put in place to mitigate the emergence of significant pressures on the system 3.8.2 Winter Plan Oversight Arrangements • Performance relating to the Winter Plan isa standing agenda item on the Senior Management Team (SMT) governance meeting. • A winter performance dashboard is being implemented and will be utilised to monitor the performance of key services throughout the winter period. This will be presented at both SMT, and the Winter Executive Management Team (EMT) for review. • A strategic EMT will be convened weekly to monitor performance and retain oversight of winter pressures and performance across the HSCP. • An operational Winter Oversight Group will be convened weekly to monitor service level impacts and mitigate any escalating issues. This group will act as the main dissemination point of information and to record progress made against specific winter interventions being put in place and to monitor staff absence levels. Page 218 of 276
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Midlothian Integration Joint Board • Cross partner working between NHS Lothian, Midlothian Council and other Category 1 responders will be undertaken to monitor potential winter pressures e.g. severe weather, increased staff absences due to covid/flu, and other significant pressures within acute hospital and/or HSCP services. 3.8.3 Planned Improvement Activities Midlothian HSCP has the ambition to deliver better care and support for people which delivers best value from the resources invested in health and social care. The HSCP Executive Management Team has committed to implement a Quality Management System (QMS) which will strengthen the links between the clinical and care governance workstreams and the management of performance and resources. The QMS covers the four domains of Quality Management: Quality Planning, Quality Control, Quality Assurance and Quality Improvement (figure 1.). Implementation of the QMS will require service areas to produce a service specification, and individual service plans which identifies scope of service, resources available, Key Performance Indicators, quality measures and improvement activities which deliver targeted outcomes. In addition, the current QIT and CCGG will be remodelled and strengthened to create a more integrated approach inclusive of both health and social care. Midlothian HSCP is working with the Scottish Government to create service specifications that are aligned to the Framework for Community Health and Social Care Integrated Services. This is an evidence-based framework that determines the foundations for best practice integrated care. This will support the mapping of current delivery, recognise existing good practice, and support self- evaluation to identify service gaps. This will support the implementation of the QMS and inform recommendations to the Board in relation to IJB Directions for 2023/24. An integrated framework (currently being tested for the AHP’s) will be introduced to provide Governance and Assurance on the four governance domains of Safe, Effective, Person-Centred and Regulation. Governance Assurance will be clearly articulated by those responsible for services and action taken with and by the most appropriate people to address any outstanding issues. Page 219 of 276
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Midlothian Integration Joint Board 4. Policy Implications As described above. 5. Directions The contents of this report pertain to all the IJB Directions. 6. Equalities Implications The contents of this report pertain to all service providers and users across the partnership including those with protected characteristics. 7. Resource Implications There are no resource implications arising from this paper. 8. Risk The contents of this report pertain to all aspects of quality including the reduction of risks that relate to the safety of people, workforce, building and business continuity. 9. Involving people There are no specific changes proposed within this paper which would have an impact upon service users, however the committee should take assurance that the Service continues to maintain an active dialogue with all key stakeholders and consults widely on all service changes as required. 10. Background Papers AUTHOR’S NAME Hannah Cairns Chief AHP, Nick Clater Head of Adult Services, Fiona Stratton Chief Nurse, Joan Tranent Chief Social Work Officer & Roxanne Watson, Executive Business Manager DESIGNATION Professional and Business Leads, Midlothian HSCP CONTACT INFO MS Teams and Email Hannah.Cairns@nhslothian.scot.nhs.uk Fiona.Stratton@nhslothian.scot.nhs.uk Nick.Clater@midlothian.gov.uk Joan.Tranent@midlothian.gov.uk Roxanne.Watson@midlothian.gov.uk DATE 03-10-22 Appendix 1: Healthcare Governance Report September 2022 Page 220 of 276
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NHS LOTHIAN Healthcare Governance Committee 27 September 2022 Fiona Stratton, Chief Nurse, Midlothian HSCP MIDLOTHIAN HEALTH AND SOCIAL CARE PARTNERSHIP: ANNUAL REPORT 1 Purpose of the Report 1.1 The purpose of this report is to recommend that the Committee take moderate assurance that Midlothian Health and Social Care Partnership has robust systems and processes in place to ensure the provision of safe, effective and high-quality care across the Partnership. Any member wishing additional information should contact the Executive Lead in advance of the meeting. 2 Recommendations 2.1 The Committee is recommended to: ▪ Take moderate assurance that the Midlothian Health and Social Care Partnership management team have comprehensive systems in place to deliver robust health and care governance across all services. ▪ Note the ongoing work to deliver programmes of change and improvement across the Partnership and the governance processes in place to oversee this work, including identification and mitigation of risks to patient safety. 3 Discussion of Key Issues 3.1 Scope of Services 3.1.1 The Midlothian HSCP Core Management Team is responsible for the management and oversight of a range of delegated health and social care services within Midlothian and for two hosted pan Lothian services, Dietetics and the Adults with Complex and Exceptional Needs Service (ACENS). 3.1.2 Delegated services delivered by the HSCP include: • Adult Social Work • Care homes and Care Home Support • Community Adult Mental Health Older Peoples’ Mental Health & Dementia • Community Learning Disabilities • Community Treatment and Care Centres (CTACs) • District Nursing • Hospital at Home • Intermediate care: Home First and Discharge to Assess Page 221 of 276
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2 • Midlothian Community Hospital • Occupational Therapy • Physiotherapy • Primary Care (GP, community pharmacy, dentistry and optometry services) • Public Health and Health Improvement • Sport and leisure • Substance Use 3.2 Oversight of quality 3.2.1 The Midlothian HSCP management team have developed a governance structure to ensure that services are provided with management support and that oversight is in place for the management of clinical and care quality and governance. 3.2.2 Fortnightly Senior Management Team meetings chaired by the Joint Director provide ongoing formal oversight of service developments, discussion of emerging issues, and verbal updates are received on adverse events, complaints and performance, risk and resilience issues. 3.2.3 The Midlothian Safety and Experience Action Group (MSEAG) chaired by the Chief Nurse and attended by the Clinical Director, Heads of Service and relevant Service Managers meets fortnightly to manage and have oversight of the review of significant adverse events within Midlothian HSCP. This group undertakes initial consideration of Local Case Reviews into suicides and unexpected deaths of people engaged in mental health and substance use services and commissions external reviews in accordance with NHS Lothian’s Management of Adverse Events Procedure. The group has oversight of performance of the performance in relation to the completion of significant adverse events within timescales and considerable improvement has been made (Chart 1) Chart 1: Significant Adverse Event Reviews Midlothian November 2020- August 2022 Page 222 of 276
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3 Subgroups are established to progress, support and quality assure local reviews of inpatient falls and pressure ulcers. An action tracker is in place to ensure that learning from adverse events is translated into action to improve patient safety. Plans are in development to strengthen the oversight of adverse events and complaints by MSEAG. There is recognition of the need to improve oversight of complaints and adverse events within Midlothian Council services, and to have regular oversight at Partnership level around the reporting of common harms to support early identification of trends and to support improvement actions. 3.2.4 Quality Improvement Teams (QITS) are organised at service level and are chaired by Service Managers. This structure includes the Primary Care Cluster Quality Network of all 12 Midlothian GP practices, chaired by the Cluster Quality Lead and attended by the Clinical Director. QITs are required to meet at least four times per year and are required to provide assurance around the safety, effectiveness and person centredness of the services delivered. This includes oversight of the inspections undertaken by regulatory bodies, including the monitoring of action plans for improvements associated with Healthcare Improvement Scotland inspections and Care Inspectorate Inspections of internally provided regulated services 3.2.5 The QITS report to the quarterly meeting of the Care and Clinical Governance group (CCGG), submitting a standard template covering the dimensions of quality, improvement activity, inspection updates and identifying service level and escalated risks. The CCGG is attended by the Clinical Director, Chief AHP, Heads of Service, Service Mangers, key staff with Quality Improvement, Risk Management and Performance roles and is chaired by the Chief Nurse. 3.2.6 Working groups are established to drive improvement work within Midlothian Community Hospital including Medicines Management, Falls and Food, Fluid and Nutrition. Infection Control is a standing item on the monthly Senior Charge Nurse meeting chaired by the Service Manager and links are maintained between the MCH team and specialist Infection Prevention and Control Nurses. 3.2.7 The NHS Lothian Accreditation and Care Assurance Standards (LACAS) provide a framework to give organisational and service user assurance that quality person- centred care is being delivered consistently across all NHS Lothian’s services. The Framework has been developed to promote Quality Assurance activity which can be utilised to positively inform and drive improvement by engaging front line clinical staff in areas of focus. The 5 in-patient areas in Midlothian Community Hospital have implemented the Lothian Accreditation and Care Assurance Standards. Participation has been incremental with 2 areas having completed 3 cycles of assurance, 4 out of 5 participating in the 2nd cycle and all 5 areas completing the cycle in June 2022. The most recent LACAS review cycle identified clear themes, both in good practice and areas for improvement, which will inform quality improvement priorities at both ward and site level. A high standard of care was observed during the Ward Observations visits and a Gold Level of Assurance awarded to Seven Standards. Continuous improvement in standard attainment has been delivered across the 3 Page 223 of 276
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4 cycles, with staff reporting positive experience of involvement in the process and enthusiasm to evidence high standards of person centred and effective care. 3.2.8 Two Pan Lothian services are hosted by Midlothian HSCP, the Adults with Complex and Exceptional Needs Service (ACENS) and Dietetics. Both hosted services have direct operational management from a member of the Senior Management team. 3.2.9 ACENS is under the direct line management of the Chief Nurse who leads on the scrutiny of activity and performance and provides line management and professional support to the Team manager. Finance and performance information is provided within the HSCP and over the last year, more regular reporting to the Lothian Chief Officers has been commenced. ACENS has a local QIT and provides assurance to the Clinical and Care Governance group. ACENS has experienced a significant increase in demand over the last 18 months, and a waiting list has developed. Discussion of concerns around the growing gap between capacity and demand was undertaken with the Midlothian Joint Director/Chief Officer, the Director for Primary and Community Nursing, and the Finance Business partner. A paper was taken to the Lothian Chief Officers’ group outlining the complex challenges faced in growing the service to meet demand. The Chief Officers acknowledged the significant progress the service had made to meet demand and address service challenges over recent years. It was agreed that options needed to be developed around a service model and financial framework that would deliver an approach that would ensure safe and sustainable service delivery going forward. This work is being progressed with the expectation that an option paper will be take to the Chief Officers’ group in October 2022. 3.2.10 Dietetics is a large service delivering across the 3 acute hospitals and 4 HSCPs. Dieticians work as part of the multidisciplinary teams in a range of settings. Under the new leadership team including the Head of Dietetics, and the Chief Allied Health Professional (AHP) in Midlothian HSCP, development is underway to ensure that all aspects of Dietetics Governance Assurance, Quality and Performance are robustly managed, reportable and improvement orientated. One component of this has been involvement in the initial testing period of the NHS Lothian AHP Governance and Assurance Framework. Several areas of improvement have been identified and will be monitored on an ongoing basis via the monthly Dietetics Service Leads group and more formally on a quarterly basis via the AHP Governance and Assurance Framework submissions. This information will be routinely reported internally via the Midlothian HSCP Clinical and Care Governance Group, have oversight from AHP Director in NHSL and can be made available to other HSCP areas as is necessary and helpful to support oversight of the delivery of this hosted service within their integrated services. 3.2.11 Midlothian HSCP directly manages the Health Visiting Service and the delivery of Immunisations to Children under 5 years. Clinical Governance assurance is delivered through the QIT and the Clinical Care and Governance Group. Midlothian HSCP has invested in the leadership of the service and appointed a Clinical Nurse Manager in February 2022. Improved data quality and availability is driving understanding of the delivery of the Universal Health Visiting Pathway, providing the team with opportunities to benchmark, plan and deliver improvement and developing work to report on Page 224 of 276
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5 outcomes. Midlothian Health Visiting has benefitted from significant investment in Health Visitor training to secure a workforce that aligns to population need, but it is recognised that other partnerships in Lothian continue to experience shortfalls in staffing due to the age profile of their workforce and there is recognition of the imperative to work collaboratively to ensure the wellbeing of our youngest citizens. Pan Lothian work under the oversight and direction of the Children and Young People Health and Wellbeing Board ensures demographic and epidemiological trends inform shared decision making to support workforce and service planning. Health visiting also features in the remit of the Midlothian GIRFEC Board, with managers and clinicians working with multi agency colleagues to deliver the Integrated Children’s Services Plan. 3.2.12 Systems and processes are in place deliver oversight and assurance around the work undertaken within Midlothian HSCP services to improve the safety of people at risk of harm. Public Protection duties are delivered under the oversight of the East and Midlothian Public Protection Committee (EMPPC), and the NHS Lothian Public Protection Action Group (PPAG). The EMPPC is a multi-agency statutory committee which addresses Adult Support and Protection, Child Protection, Violence against Women and Girls and the Multiagency Public Protection Arrangements (MAPPA) for service users in East Lothian and Midlothian. The committee has a wide range of multiagency senior representatives across services and key agencies and reports to the Critical Services Oversight Group (CSOG) where the Chief Officers of core partners provide strategic leadership, scrutiny, governance and direction to the EMPPC. The Committee includes key senior officers from the statutory and third sectors who work in partnership to deliver leadership, expertise and support to scrutinise and improve public protection arrangements. Subgroups progress work around Performance and Quality improvement, Learning and Practice Development, Offender Management and Violence Against Women and Girls. The East Lothian and Midlothian Public Protection Committee and its sub-groups are supported by a team of specialist staff in the East Lothian and Midlothian Public Protection Office (EMPPO) and NHS Lothian’s Public Protection team who provide leadership, training, quality assurance and advice across the spectrum of public protection responsibilities. NHS Lothian’s Public Protection Action Group sets and oversees the strategic direction of public protection services across NHS Lothian and provides an annual assurance report to the Healthcare Governance Committee around Public Protection. 3.2.13 Work to reduce the harm associated with substance use is a national priority, and multiagency working across East and Midlothian is the approach for the delivery of the Drug and Alcohol Partnership (MELDAP). Recent funding allocated from the Scottish Government has allowed the Partnership to invest further in services with the aim of improving the reach and effectiveness of our substance use service offer. Page 225 of 276
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6 A range of services are in place in Midlothian to assist people who face issues related to their own or others substance use. The MELDAP Strategic Group has multiagency representation and meets 6-weekly to deliver oversight of the performance and quality of a range of services. Midlothian HSCP delivers statutory Substance Use services, including the delivery of Medication Assisted Treatment (MAT), and adherence to MAT standards is subject to the scrutiny of a specialist oversight group. 3.2.14 Plans to Improve Oversight of Quality Midlothian HSCP has the ambition to deliver better care and support for people which delivers best value from the resources invested in health and social care. The HSCP Executive Management Team has committed to implement a Quality Management System (QMS) which will strengthen the links between the clinical and care governance workstreams and the management of performance and resources. The system covers the four domains of Quality Management: Quality Planning, Quality Control, Quality Assurance and Quality Improvement. Implementation of the QMS will require services to produce a service specification, and a service plan which identifies scope of service, resources available, Key Performance Indicators, quality measures and improvement activities which deliver targeted outcomes. Midlothian HSCP is working with the Scottish Government to create service specifications that are aligned to the Framework for Community Health and Social Care Integrated Services. This is an evidence-based framework that determines the foundations for best practice integrated care. This will support the mapping of current delivery, recognise existing good practice, and support self-evaluation to identify service gaps. This will support the implementation of the QMS and inform recommendations to the Board in relation to IJB Directions for 2023/24. An integrated approach will be introduced to provide governance assurance on the four governance domains of Safe, Effective, Person-Centred and Regulation. Governance Assurance will be clearly articulated by those responsible for services and action taken with and by the most appropriate people to address any outstanding issues. This framework will play a clear role in the system of Quality Management in providing Quality Assurance alongside, Quality Planning, Quality Control and Quality Improvement (Figure 1.). Page 226 of 276
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7 3.2.15 Governance and Assurance Framework The implementation of the QMS supports the provision of assurance around the quality of both delegated and hosted services. Development and testing of the Governance and Assurance Framework (GAF) for Allied Health Professionals (AHPs) working in Acute Services and the four Lothian HSCP’s has been led by Midlothian HSCP’s Chief AHP. This framework has addressed the challenge of differing operational management lines, reporting arrangements and escalation mechanisms across AHP services. The GAF has been designed to deliver a consistent approach to professional governance and aiming to prevent and reduce the need to duplicate processes and enhance and support use of existing mechanisms. A trial of the system is underway involving AHPs in HSCPs, including Midlothian, and a selection of single system AHP services including the Dietetics service which is hosted in Midlothian. Midlothian HSCP intends to implement the GAF across all hosted and delegated services over the next year. This will be completed electronically and visible on a dashboard accessed by operational and professional leads. 3.2.16 Performance Management The Partnership has recognised that approaches to performance management have not kept pace with the rapid redesign of many services during the pandemic. The Midlothian Performance Assurance and Governance Group (PAGG) has been convened to provide additional capacity outwith the IJB Board meeting to support further scrutiny of performance and support assurance reporting to the IJB. Membership includes Midlothian HSCP’s Executive Team, Performance Team, Local Intelligence Support Team and Midlothian Integration Joint Board (MIJB) members, to ensure representation of Midlothian Council, NHS Lothian and the third sector. Work is underway to design and implement a Performance Measurement Framework based on the 6 dimensions of quality that will provide the PAGG with the right information, in the right format, at the right time, and which will enable informed decision-making at operational and strategic levels. This comprehensive and ambitious programme of work which includes investment in additional performance management capacity will build quality improvement leadership skills and capacity across Partnership services and creates the potential to work with partners in Lothian and further afield to innovate and improve. The work underway to build skills and confidence to analyse a broader range of activity, process and outcome data will provide insights that inform better decision-making across the organisation, and which will ultimately provide enhanced oversight of the quality of care delivered across Midlothian HSCP. Page 227 of 276
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8 3.2.17 Systems and Processes to Identify Concerns about the Quality of Care The Executive Management Team holds brief informal meetings (huddles) three times weekly, and this forum provides an opportunity for any emerging concerns about quality of care to be raised. Activities that feed into this include the oversight of complaints and adverse events by managers and MSEAG, safety huddles, inspection activity, and the use of data around specific harms, including falls, medication errors, and healthcare associated infection. Safe staffing is the component in delivering safe, effective and person- centred care. Compliance with the Safecare staffing tool is monitored and is noted be good. The tool is used as the basis for understanding the staffing position in Midlothian Community Hospital. No other service areas within the Partnership have a real time staffing tool available, but the experience of managing workload and staffing pressures during the Covid-19 pandemic has enhanced local practices in collating and reporting staffing information. These continue to be in use at Service level and can be escalated to deliver assurance as required in the event of resilience or other concerns. The Partnership has developed effective working relationships with the Care Inspectorate, ensuring early action to address emerging concerns in registered services within the Midlothian area. The Midlothian Care Home Support Team has a specific role in supporting the quality of care for residents in the 10 Midlothian care homes. The team has supported recognition of concerns about the quality of care through their own direct work in care homes and their liaison with other professionals. The Midlothian ‘rapid rundown’ takes place three times per week and provides senior oversight of emerging issues and improvement work and the opportunity to discuss any concerns raised by care home managers and/ or identified by the Care Home Support Team. This provides a route to discussion and escalation of concerns as required. Where concerns are raised, the relevant senior manager will bring to the EMT at the earliest opportunity, ensuring early senior decision making and a measured and proportionate response. Examples include the establishment of a weekly oversight group to monitor action plans around staffing and capacity in home care services, the service level response to administration errors in a vaccination centre and the enactment of processes to establish multiagency and large-scale enquiry processes around care concerns in care homes. Following recognition of concerns around staffing and service delivery and common themes emerging from complaints regarding the community dementia team, plans were developed and implemented to provide immediate support to the team. The Executive Team subsequently approved the proposal to establish a team, including external specialists, to undertake a review of the service and present proposals to the Senior leadership team within the next 3 months. The approaches described above ensure a clear escalation process through senior managers concerning quality of care issues. In the event that a member of staff felt unable to raise concerns around the quality of care, concerns can be raised through Page 228 of 276
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9 Partnership representatives, direct contact with the Chief Nurse, Chief AHP or Chief Social Worker, or alternatively through NHS Lothian ‘speak up advocates’. If all other routes are exhausted, the formal whistleblowing procedures of NHS Lothian or Midlothian Council provide a confidential route for concerns to be raised. The Governance and Assurance framework and the developing performance management framework described in this paper will build on existing systems and processes to provide improved oversight of the quality of care across all services and increased sensitivity to indicators that may identify concerns around the quality of care. 3.3 Monitoring Service Quality Outcomes 3.3.1 Services in MHSCP report service quality outcomes internally through Quality Improvement Teams to the Care and Clinical Governance Group. Opportunities to reduce variation in the approach to the reporting of quality outcomes and performance to deliver targets and standards has been recognised, and work to deliver a more consistent approach is underway. 3.3.2 The implementation of the Governance and Assurance and Performance Management frameworks described in this paper will take forward work that will ultimately support all MHSCP services to report an evidenced level of impact and assurance that relates to a service specification and objective targets and standards. 3.3.3 A quality planning approach has been adopted to five spotlight areas of work in year one of the (draft) MIJB Strategic Plan 2022-2025 and a system for planning, monitoring and reporting has been established. The five areas of ‘Spotlight’ work for first year of the plan are: ▪ Frailty ▪ Midlothian Community Hospital ▪ Primary Care ▪ Mental Health and Learning Disabilities, and ▪ Workforce Staff working in these five focus areas are already involved in work to test ideas and improve and share lessons to evidence the delivery of high-quality care. Integrated Project Management support has been invested in to accelerate the progress of existing service workplans, workforce development plans, individual appraisals and PDPs. To avoid additional layers of scrutiny and make best use of existing mechanisms, oversight of this work is located within existing Planning, Performance and Programme functions, providing structured opportunities to share learning across all five areas with monthly reporting to SMT and SPG (bi-monthly to IJB). Each spotlight group will ensure that cross cutting enablers and Digital, are embedded in the planning process. The approach has been designed to create opportunities for teams to develop and test new ways of working, aligned with other programmes (e.g. LACAS). 3.3.4 The Partnership is continuing work with its third-party partner, Matter of Focus, on outcome mapping using the OutNav approach. Work to develop quality management and performance measurement approaches and to relate these to IJB Directions, sits Page 229 of 276
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10 alongside work on OutNav to capture and link a wide range of evidence for evaluating progress in delivering outcomes. 3.3.5 MHSCP services are subject to external inspections from statutory bodies. This includes Healthcare Improvement Scotland, the Mental Welfare Commission and the Care Inspectorate. These reports are noted at the SMT and reported through the QITs and CCGG. Immediate action is taken where internal concerns or external inspections identify improvements are required to address standards of care. Operational and professional leads have shared oversight of action plans. Implementation is led by Service Managers and progress monitored and supported through operational and care and clinical governance routes, ensuring the implementation of actions which deliver sustainable improvement. 3.3.6 The development of primary care service re-design in the context of delivery of the new GMS contract 2018 is being planned with the seven key principles of Quality in mind. This change has already started with the move away from clinical assurance provided by the previous Quality and Outcomes Framework (QOF) introduced in the 2004 GMS contract. The new approach was introduced by the GMS Statement of Financial Entitlements for 2016-17 and sees all 12 of our local GP practices working together in a single Quality Cluster with the HSCP and NHS Lothian to identify local priorities to improve the quality of services and outcomes for people. 3.4 Impact on People Experiencing Care 3.4.1 Gathering and Responding to Feedback Services across Midlothian HSCP are utilising a range of approaches to gather and respond to feedback from people who use our services, their families and carers. These are reported by services through their QITs to the CCGG. Some examples include: ▪ Care Opinion is promoted for those who use Midlothian Community Hospital and the Hospital at Home service. Feedback is relayed to relevant staff who utilise learning to drive change and improvement. Work is ongoing to explore the potential for Care Opinion to be used more widely across Partnership services. ▪ Earlier this year, the team at Midlothian Community Hospital undertook a survey of stakeholders asking, ‘What matters to you about Midlothian Community Hospital?’. The team received predominantly positive feedback, with the main request being that the Community Hospital be resourced to provide a wider range of services for local people. The survey identified that stakeholders find the hospital takes a person-centred approach, staff are kind and care is provided in an environment that is clean and welcoming. A creative approach to the feedback was taken and word clouds, ‘wardles’, were developed and framed to provide ward staff with a daily reminder of the positive difference they have made to patients and their families. ▪ A project to develop an understanding of the experience of people whose family Page 230 of 276
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11 member received end of life care in Midlothian Community Hospital or from the Midlothian District Nursing Service is nearing completion. The project, funded by the Scottish Government, has taken an experience-based co-design approach, and the final report is in preparation. Staff involved in the project have found the positive feedback on the end of life care they provided encouraging at a time where demand and capacity present daily challenges and where staff may question the impact they have. A huge amount of data has been gathered and the potential to use this to further understand and improve the delivery of end-of- life care is being explored. Learning from these projects, and those undertaken in other services, will continue to be shared with the aim of promoting ongoing work to gain meaningful feedback which can be sued to shape and improve our services. 3.4.2 Managing and Learning from Complaints All Midlothian HSCP services, including Primary Care, have a formal complaints procedure which is advertised and made available to patients on their request, and a standardised process is followed to deliver a response to the complainant within set time scale. Midlothian HSCP receives a small number of complaints and the systems for oversight and scrutiny aim to improve our performance to deliver responses to Stage 1 and Stage 2 complaints within the Scottish Complaints Ombudsman’s targets. Chart 1 show 74 complaints received about NHS services within the partnership over the 3-year period August 2019 – July 2022, with a stable median of 1 complaint received per month (Chart 2) It should be noted that independent contractor GP practices handle their own complaints separately, and complaints made about MHSCP services via Midlothian Council are not included in this data. Plans are in development to develop integrated oversight of complaints across all MHSCP services. Page 231 of 276
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12 The fortnightly SMT has oversight of response times for complaints, ensuring real time actions are agreed to respond to the concerns people raise about the care provided. A Lothian wide short life working group is underway to address improvement in complaints handling and it is expected this will be rolled out in Midlothian within the next 6 months. The development of MSEAG provides an opportunity to consider the alignment of NHS and MLC complaints handling processes, and how learning from complaints and feedback has greater priority and visibility in relation to the work to improvement the quality of experience and outcome for Midlothian residents. 3.5 Impact on Staff 3.5.1 Midlothian HSCP recognises our workforce as our greatest asset but in line with the national picture, recruiting and retaining the workforce we need to deliver our ambitions represents our biggest challenge. The Senior Management Team is prioritising workforce engagement, continued investment in our Wellbeing Lead post and the development of our HSCP workforce plan. 3.5.2 A range of mechanisms are in place to hear staff experience including team meetings, leadership walk rounds, iMatter and exit questionnaires and the Trickle app reported last year. NHS Lothian Partnership and Midlothian Council Staff Side representatives attend fortnightly Senior Management Team meetings and provide valuable input into discussions and decisions. A regular Partnership meeting, chaired by the lead Partnership representative, ensures a particular focus on staff experience and views. 3.5.3 Awareness has developed of issues that are important to our staff group and of work needed to support improved staff engagement. Our teams continue to face the challenges associated with the COVID-19 pandemic, workforce pressures and increasing demand and complexity in the context of concerns around the cost of living, climate change and geo-political instability. A Senior Manager is taking forward work on a Communication and Engagement Strategy and a Communication Plan which will deliver a more cohesive approach, offering staff across the partnership opportunities to identify how they would like to give and receive information. While Executive Team members are regularly ‘out and about’, this refreshed approach will provide focused time for front line practitioners to meet and discuss their experience of delivering care to people in Midlothian with Senior Managers. 3.6 Delivery of Safe Care 3.6.1 Learning from Adverse Events Organisation and system-wide learning from adverse events and complaints is a critical component of improving the quality of care. The Midlothian Safety and Experience Action Group (MSEAG) has driven work to improve performance in relation to the completion of Significant Adverse Event (SAE) reviews to meet Healthcare Improvement Scotland key performance indicators (KPI’s). This has reduced the time taken to identify and address factors that contributed to the adverse event to prevent similar harm occurring in future. Page 232 of 276
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13 SMT receives fortnightly updates on performance for all adverse events. While SAE review performance against timescales is much improved, work is continuing to maintain performance and assure the quality of the reviews. A programme of training will be delivered in September and October for all managers involved in the review of adverse events with the aim of improving the quality of investigation, action planning for improvement and shared learning. Chart 3 illustrates the reporting of all adverse events in Midlothian HSCP with the increased median noted last year remaining stable. Chart 4 illustrates that the adverse events resulting in major and moderate harm are maintained at a stable median. Chart 5 illustrates the breakdown of adverse events with serious harm by category. The Lothian Accreditation and Care Assurance Framework (LACAS) is now fully implemented in Midlothian Community Hospital, and supports the monitoring of the most common harms. LACAS improvement work and a Falls Improvement Working Group support ongoing work to address underlying causes of harm. Working Groups chaired by Service Managers bring a range of perspectives to the investigations into Page 233 of 276
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14 the occurrence of pressure ulcers and falls with serious harm. These groups are tasked to ensure learning is shared within and beyond the relevant service area. 3.6.2 Drug-related Deaths in Midlothian In 2021, 23 drug-related deaths were recorded in Midlothian, of those, 16 were men and 7 women. This represents an increase of 2 from 2020. Midlothian’s trends reflect national data which shows that there was reduction in male deaths but an increase in female deaths. Data has identified that 14 (61%) of the people whose deaths were identified as drug related were not involved in services. The development of the assertive outreach model and work to increase the numbers of people who use substances to engage with services is critical and is being taken forward within Midlothian HSCP, with additional investment as described earlier in this report. Midlothian teams work with local partners delivering a range of initiatives to support people and reduce the harmful impact of long-term drug use. A holistic approach which addresses housing needs, family support and providing person-centred treatment is adopted alongside education, training and employment opportunities. Work is underway to create a more robust performance culture, improved use of measurement and further work to implement evidence-based approaches which have been shown to reduce drug related deaths. 3.7 Equitable care 3.7.1 An imperative for Health and Social Care Partnerships is their work at a population, community, and individual level to address inequality. Midlothian HSCP has developed effective integrated working and strong relationships with colleagues in Page 234 of 276
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15 NHS Lothian’s Public Health Directorate to progress this objective. This enables cross cutting, integrated work across our services as evidenced in our Strategic Plan. The Partnership and the Integration Joint Board are conscious that the COVID 19 pandemic has magnified health inequalities, and work continues to address the impact of this at strategic and operational levels. 3.7.2 The Joint Strategic Needs Assessment provides equality data to aid understanding of current and emerging needs and support planning and action to address inequalities. Integrated Impact Assessment (IIAs) are a requirement for new policies and proposed service changes. With the implementation of the new Strategic Plan and the programme of recovery from the impacts of the pandemic, we anticipate an increase in the number of IIAs required. Training on IIAs is delivered by Midlothian Council available to Midlothian HSCP staff and volunteers. 3.7.3 The Partnership recognises the importance of building expertise to embed equality and rights in service design, delivery and review. Training is available to colleagues across the HSCP to improve their understanding, knowledge and skills around equality and diversity as well as an understanding of the public sector equality duty and its relevance to their roles. Our approach to the recommissioning of the care at home service included training for staff from the British Institute of Human Rights and creating a monitoring and evaluation framework. It is the Partnership’s intention to build on this experience for future commissioning by the HSCP. 3.7.4 Membership of The Midlothian Council Equalities Forum will be extended to Midlothian HSCP employees. This Forum is made up of employees representing all nine protected characteristics, and others who support the aims of the forum. The forum will be supported by the Equalities Engagement Officer and Corporate Equality, Diversity & Human Rights Officer. It works to embed equality and fairness of opportunity across the council and HSCP, and to contribute to employee and community equality initiatives. Where required equality and diversity training will be provided to Forum members. 3.7.5 The Health and Social Care Partnership Website continues to be developed to ensure a wide range of information on the services provided is accessible to those with digital access. This includes Reachdeck which aims to help improve the accessibility, readability and reach of online content. 3.7.6 A small study undertaken in in 2021 evidenced the need to address digital exclusion in Midlothian. In response, digital skills development work is progressing to support people who want to, to access health and social care digitally. Training was developed and offered to HSCP and third sector staff working locally. Digital inclusion now forms part of the Midlothian HSCP Digital Implementation and Delivery Plan 2022-25. Collaborative work is progressing with the Community Planning Partnership to increase opportunities for people to have access to a device, connectivity, the means to pay for it, and basic digital skills. 3.7.7 The Partnership continues to invest in the provision of the Health Inclusion Team, providing 1:1 and group support from specialist Nurse Practitioners to support: • people in homeless accommodation, • people in receipt of justice services, • carers, Page 235 of 276
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16 • people in receipt of drug and alcohol services, • Gypsy Travellers • people <55yrs who have had more than 3 attendances at emergency departments in the Lothians within the last year. 3.7.8 The Mental Health, Substance Use, Public Health Practitioners, Health Visiting and Vaccination teams are examples of services who have actively developed approaches to address the access and uptake of services by groups in our communities who are less likely to access services and experience poorer outcomes as a result. 3.8 Workforce Management and Support 3.8.1 Workforce capacity is the key risk in the delivery of safe, effective and person-centred care. Extensive work has been undertaken to develop Midlothian HSCP’s Draft Workforce Strategy which was submitted to the Scottish Government at the end of July 2022. Work will continue in the autumn to finalise and implement this once feedback is received. 3.8.2 The development of the Strategy has prompted a review of our staff governance infrastructure and identified the work needed to address gaps in the data available to us. The lack of comparable data across all occupational groups limits our ability to critically examine the current workforce position in totality, thereby supporting integrated planning for future workforce requirements. Nursing and AHP workforce planning is at a more advanced stage than for other occupational groups, with work progressing to ensure compliance with Safe Staffing legislation, and to develop creative approaches to service needs including Advanced practice and Non- registered roles. 3.8.3 Detailed plans have been developed at a partnership level for services to support the Primary care Improvement Plan, in particular the development of pharmacotherapy, Musculo-skeletal and Community Treatment and Care (CTAC) services. Additional information about this is provided in section 5.2. The Executive Management Team has committed to implement a refreshed workforce planning and governance infrastructure supported by investment in capacity to deliver on our workforce planning needs. 3.8.4 Training and development plans are developed at a service level, with NHS Lothian’s Clinical Education Team and Midlothian HSCP’s Learning and Development Team commissioning and providing a range of education and training opportunities for staff. The Governance and Assurance Framework and Quality management approach will bring a more cohesive approach to understanding and providing assurance in relation to the Partnership’s workforce needs. 3.8.5 Midlothian HSCP has invested in the establishment of a Clinical Educator post in Midlothian Community Hospital as an approach to supporting staff in the workplace. This role increases the support staff have to maximise skills and learning in practice and carries a remit for non-registered and registered staff and students. Evaluation of the role will address some of our assumptions on recruitment, retention and the support available for staff to provide quality care. Although the post has only been in place for 2 months, the early evidence of impact on induction processes, practice Page 236 of 276
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17 learning for students, data availability on staff training and observed care and documentation is encouraging. With workforce challenges driving the need for innovative approaches to attract, train and nurture our teams, the evaluation of this post will support the Partnership in delivering its ambitions to ensure staff are skilled and supported to provide high quality care as close to home as possible. 3.8.6 Wellbeing Delivery Plan Underpinning the partnership’s commitment to staff support and engagement, investment in our Wellbeing Lead post continues with the aim of delivering innovative solutions which improve and support wellbeing across all the teams in Midlothian Health & Social Care Partnership. A Staff Wellbeing Delivery Plan has been implemented over the last year covering the domains of engagement, communication, access to support, leadership, mental wellbeing and environment. Initiatives include work to improve access to essential facilities for all community- based staff, a range of health awareness and health promoting activities, work to develop the availability of peer support and to improve awareness and uptake of mental health and wellbeing services. 3.9 Quality Improvement-based Leadership 3.9.1 Midlothian HSCP has made progress in developing a more cohesive and consistent approach to Quality Improvement based leadership. The implementation of the Quality Management System and the work on our Spotlight Programme and Performance Framework will enable us to address this is a methodical and consistent manner. This report has already described examples where staff are developing the knowledge and skills to enable them to test ideas and improve and share lessons to deliver high quality care, and some examples are provided below. This will be more widespread as services develop annual improvement plans. 3.9.2 A key enabler of Quality Improvement based leadership in Midlothian is our digital transformation programme, and the Partnership’s commitment to this is evidenced by the recent appointment of a Digital Programme Manager. In Midlothian, Digital is framed as a way of doing things which enhances our ability to deliver person centred services by creating the conditions to respond to the challenges we face in a consistent, high quality, and progressive way. Digital is cross cutting through all our work, with the expectation that service design and development is enabled by technology, creating value in new ways. Digital will support: • The creation of new models of care • Designing and deliver the best possible user experience with increased access and choices • Developing technology-enhanced business processes and planning • Supporting our staff, partners, and citizens to use and develop the confidence, knowledge, and skills to be involved. The Midlothian HSCP Digital Programme and Oversight Board is established to co- ordinate, direct, and oversee all digital activities and the structure includes a Senior Responsible Officer, The Chief Allied Health Professional (AHP)who provides a direct link to the Senior Management Team (SMT). Page 237 of 276
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18 3.9.3 A multidisciplinary group involving clinical staff and managers from a range of services meets quarterly to have oversight of palliative and end of life care services. This is supported by links to the Lothian Palliative Care Managed Clinical Network. The group provides an opportunity to consider available data, identify gaps, share good practice, promote education and awareness and support quality improvement. Examples include: • the implementation of a new pain assessment tool within Midlothian Community Hospital which has some potential for use in care home settings. • Community Respiratory Team participation in a multidisciplinary meeting with hospice and community clinicians which aims to improve pathways for patients with severe Chronic Obstructive Pulmonary Disease (COPD) with the aim of delivering the most appropriate and holistic support in appropriate settings. • a project to improve the quality and quantity of Anticipatory Care Plans in care home settings • A Scottish Government funded evaluation and co-design approach to capturing feedback from families whose relative received end of life care from the Midlothian District nursing Service or in Midlothian Community Hospital which is nearing completion. 3.9.4 Midlothian has been exploring work to improve access, experience and outcomes for patients under the heading of ‘Potentially Preventable Admissions’. A programme of data driven improvement work has been progressed by a multidisciplinary group of clinicians and managers. The 'top 5' admission reasons for bed days for unplanned admissions were identified, and improvement cycles to progress understanding and drive change in pathways for the management of heart failure, COPD, cellulitis, pneumonia / flu and diabetic complications have made tangible differences to pathways, patient experience and bed utilisation. 4.0 Key Risks 4.1 The Midlothian HSCP Strategic Risk Register identifies a number of risks and the key risks are identified as: • Capacity of to meet increased demand due to increasing population, age, and frailty –addressed in the Primary Care Improvement Plan and on the NHS Lothian Corporate Risk register, see also section 5. • Lack of availability of workforce with appropriate qualifications or skills, including General Practitioners, Staff Nurses, Advanced Nurse Practitioners, Advanced Physiotherapy Practitioners, District Nurses, and Social Care Workers - addressed in the HSCP Workforce Strategy. While concerns exist across all groups and reflects the National picture, District Nursing and Social care workers are a significant current concern. • Emergency admissions and Delayed Discharges, particularly in relation to care at home capacity –addressed through Care at Home recommissioning, Delayed Discharge plans and Acute Services Planning and Strategic Plans. Despite growth in care at home capacity, demand continues to outstrip the rate of workforce supply. Page 238 of 276
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19 4.2 Oversight of Risk Management As a division of NHS Lothian, Midlothian HSCP is compliant with the NHS Lothian Risk Management Policy. The Risk Management process within Midlothian was audited in 2021 and the finalised report confirmed that the Risk Management processes within Midlothian provided high assurance and demonstrated best practice in several areas: • Midlothian HSCP Senior Management Team meet every 2 weeks and risk is a standing agenda item. • The Senior Management Team is supported by 4 committees (Business Management Governance, Finance and Performance, Staff Governance and Clinical Care Governance) each of which have risk as a standing agenda item. • Service level risks registers are locally managed and brought to Business Management Governance for oversight and escalation review. • Risks are routinely monitored through these escalating levels with additional risk reviewed held with Midlothian Council and Midlothian IJB both strategically and operationally. • Each risk recorded either operationally or strategically have actions associated to mitigate the risk, these are routinely monitored through the appropriate level of monitoring as mentioned above. Impacts of actions are monitored by the outcome, where improvement is not measurable, additional actions will be assigned to further mitigate the risk. • Each risk has a risk owner identified who is the accountable person for managing the related actions and providing routine updates on the status of the risk. 4.3 Resilience and Major Incident Planning Midlothian Health and Social Care Partnership supports its partner organisations, NHS Lothian and Midlothian Council, to deliver their obligations as Category 1 responders. The Partnership provides Midlothian IJB with any relevant assurance in relation to incident management and response which supports its roles as a Category 1 responder. Midlothian Health and Social Care Partnership maintains major incident plans in line with NHS Lothian’s Resilience Policy and provides assurance through NHS Lothian’s reporting cycle on resilience, major incident planning and business continuity. A virtual control room is in place for incident management. Service Managers are required to review and update their service-specific resilience and business continuity plans which feed into the overarching Midlothian Resilience Plan. 5.0 Risk Register 5.1 There are no new risks for the NHS Lothian Risk Register. Operational risks are captured in the Partnership Risk Register, which is updated and reviewed regularly, and when required escalated to the NHS Lothian Corporate Risk Register. Page 239 of 276
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20 5.2 HSCP mitigation plans contribute to the following risks on the NHS Lothian Corporate Risk Register: 5186 4 Hours Emergency Access Target 5187 Hospital Bed Occupancy (Previously Timely Discharge of Inpatients) 3829 Sustainability of Model of General Practice 5.3 4 Hours Emergency Access Target Midlothian HSCP has put in place strategic and operational mechanisms to mitigate risks associated with the 4-hour access target. A data driven approach identifying the most common presentations has been adopted to target effort where it will have most effect. The ‘Flow Team’ has developed to track admissions, including the development of a single point of access. This supports our Discharge to Assess team to ‘pull’ patients from the Emergency Department as well as from the inpatient setting. Work described earlier in this paper around ‘Potentially Preventable Admissions’ has been progressed to develop and promote alternatives to Emergency Department attendance, and a range of service responses have been put in place. 5.4 Hospital Bed Occupancy (Previously Timely Discharge of Inpatients) Midlothian has invested in substantial infrastructure to support clinically effective ‘Home First’ pathways which provide care as close to home as possible and thereby mitigate risks associated with hospital bed occupancy. This work is being further developed through our engagement with the programme of work on Discharge without Delay and is delivered through integrated, multiagency approaches which link with third sector capacity and carer support. In-patient admissions to acute services are tracked by our ‘Flow Team’. This supports identification of patients who can receive their treatment at home under the care of the Discharge to Assess or Hospital at Home teams, or who can receive their care in Midlothian Community Hospital where the Partnership has maintained the 20 additional beds in Glenlee ward. Capacity in both Hospital at Home and Discharge to Assess has been developed to support flow by providing alternatives to hospital-based care for Midlothian residents, which includes acute care at home, rehabilitation to support early discharge and bridging care at home packages. The In-reach social work team supports early discharge planning for patients who have complex and longer-term care needs. 5.5 A comprehensive analysis of the progress and risks associated with sustainability of the model of General Practice in Midlothian has been undertaken by the newly appointed Clinical Director. The Primary Care Improvement Plan has the oversight of the Midlothian Primary Care Planning group, The Director of Primary Care and the LMC. 5.5.1 Progressing well The latest revision of the Midlothian Primary Care Improvement Plan was reviewed and approved by the Lothian GP sub-committee earlier this year. Page 240 of 276
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21 There are currently no closed practice lists in Midlothian (although some remain partially restricted) and no directly managed section 2C practices. A full premises review has been undertaken. Financial assistance has been given several practices to assist with premise alterations to accommodate new PCIP staff. Plans are in progress for the HSCP to employ 2 full-time salaried GPs to support practices identified as facing the most significant risk to the GMS contract All 12 practices have Musculo-Skeletal Advanced Physiotherapy Practitioner services in place. Full Community Treatment and Care (CTAC) access is in place and partial access to phlebotomy and chronic disease monitoring data collection is in place across all 12 practices. All vaccines have been transferred from all 12 practices and all have partial access to Primary Care Mental Health Nurses. Partial level 1 Pharmacotherapy services including Medicines Reconciliation in place across all 12 practices. Successful ‘Preventing Potentially Avoidable Admissions’ work, e.g., heart failure, and local frailty initiatives and improvement work in anticipatory care planning and identifying patients who should be on the palliative care register are examples of work that is progressing well to address our growing and ageing population. 5.5.2 Particular challenges The rapid growth and projected age profile of the Midlothian population is more marked than the Scottish average and creates considerable challenges around the mismatch between demand and capacity in Primary Care. The 2022/23 funding allocation is not enough for full delivery of Memorandum of Understanding (MOU2) ambitions, in particular full delivery of pharmacotherapy services. There is risk that funding may be lost (or shifted laterally away from frontline primary care) if there is ongoing recruitment failure due to national workforce shortages. A workforce survey was undertaken earlier this year which enabled the collation of a detailed overview of the Primary Care workforce challenges faced in in Midlothian. Vacancies across General Practitioner and Practice Nurse roles are well understood and these reflect the national picture and feed into recruitment and workforce development activity. Work is underway to deliver workforce wellbeing initiatives for all staff groups. Options to develop multidisciplinary skill mix, including the potential of engaging paramedics for cross-locality home visits, and Advanced Nurse Practitioners (ANP) for urgent care are under consideration although ambitions are set in the context of understanding the national picture of workforce availability. 6.0 Impact on Inequality, Including Health Inequalities There are no new actions arising from this report which would require the completion of an impact assessment. 7.0 Duty to Inform, Engage and Consult People who use our Services Page 241 of 276
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22 There are no specific changes proposed within this paper which would have an impact upon service users, however the committee should take assurance that the Service continues to maintain an active dialogue with all key stakeholders and consults widely on all service changes as required. 8.0 Resource Implications There are no resource implications arising from the contents of this paper. Fiona Stratton Chief Nurse, Midlothian HSCP 14th September 2022 fiona.stratton@nhslothian.scot.nhs.uk Page 242 of 276
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Midlothian Integration Joint Board Thursday 13th October 2022, 14.00-16.00 Implementation of Medication Assisted Treatment Standards in Midlothian Executive summary Insert summary of purpose of report and report contents Board members are asked to: • Note this report on the implementation of Medication Assisted Treatment Standards in Midlothian in relation to appendix 1. # Item number: 5.10 Page 243 of 276
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Midlothian Integration Joint Board Report Implementation of Medication Assisted Treatment Standards in Midlothian 1 Purpose 1.1 This is an information report providing an update on the implementation of Medication Assisted Treatment Standards in Midlothian. 2 Recommendations 2.1 As a result of this report what are Members being asked to:- • Note the report • Take cognisance of the information, actions, timescales, risks and mitigations noted in appendix 1 3 Background and main report 3.1 In June 2021, the Medication Assisted Treatment (MAT) standards were published by the Scottish Government. 3.2 The standards provide a framework to ensure that the provision of MAT is safe, effective, acceptable, accessible and person-centred to enable people and their families to benefit from high-quality treatment and care including psychological and social support. 3.3 The Scottish Government have required local partners and services to focus on the delivery of MAT Standards 1 to 5. These are to be fully implemented by April 2023. These are: 1. All people accessing services have the option to start MAT from the same day of presentation. 2. All people are supported to make an informed choice on what medication to us for MAT, and the appropriate dose. 3. All people at high risk of drug-related harm are proactively identified and offered support to commence or continue MAT. 4. All people are offered evidence-based harm reduction at the point of MAT delivery. 5. All people will receive support to remain in treatment for as long as requested. 3.4 During 2022/23, work will also continue to embed Standard 7 [noted below] Standard 7 All people have the option of MAT shared with Primary Care. This will be a significant challenge for Midlothian because of the low numbers of practices Page 244 of 276
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Midlothian Integration Joint Board accepting people back from secondary care and the consistently large caseload at Number 11. 3.5 For the summary of all the standards and the detail about Standards 6, 8, 9 & 10, please click on the link below: www.gov.scot/publications/medication-assisted-treatment-mat-standards-scotland- access-choice-support/ 3.6 In order to support local areas to implement MAT Standards [initially 1-5 & 7], the Scottish Government has created a MAT Implementation Support Team (MIST) A Midlothian and East Lothian Drugs and Alcohol Partnership (MELDAP) funding proposal was submitted to MIST with the purpose to assist with the implementation of the MAT Standards. MELDAP received the funding and augmented the financial resource to allow recruitment of HSCP/3rd Sector staff that will focus on supporting people into treatment, increase the level of support and improve retention in services. These being key areas for intervention and prevention in relation to near fatal and fatal overdose. 3.7 As part of this work, Midlothian Health and Social Care Partnership/MELDAP are required to develop an implementation plan to deliver all 10 standards and submit this to the Scottish Government. The plan has been developed with a range of MELDAP partners (appendix 1). The plan is in line with Scottish Government requirements and Governance arrangements for local oversight of progress against this plan will be managed by the following: • Midlothian HSCP and MELDAP will co-ordinate monthly meetings of a new MAT Implementation Group, membership of which will include all partners with responsibility for delivery of actions. This group will review progress against the agreed actions and will ratify a quarterly report which will highlight risks to delivery. Operational strategic managers will report on the Implementation Plan to Head of Service and Chief Officer monthly. • This quarterly report will be presented to Midlothian HSCP Senior Management Team for comment and to address any risks to delivery. • The report will be passed to the two Chief Executives for agreement before being shared with the SG. 3.8 Timelines for each of the above will be established when the submission dates to the SG have been confirmed. 3.9 Ongoing experiential data gathering and widespread involvement of People with Lived and Living Experience in the delivery of treatment and support, which includes their involvement in underpinning needs assessment work. 4 Policy Implications 4.1 In June 2021, the Medication Assisted Treatment (MAT) standards were published by the Scottish Government. 4.2 A key aim of the standards is to place vulnerable people at the centre of our services and the importance of treating individuals with dignity and respect, being Page 245 of 276
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Midlothian Integration Joint Board non-judgemental in all of our approaches. This approach reflects the human rights based approach set out in Rights, respect and recovery: alcohol and drugs treatment strategy (2018). The principles of access, choice and support were also key to the successful implementation. 5 Directions 5.1 Does this report need a new direction or any implications for an existing one? 6 Equalities Implications 6.1 Not applicable. 7 Resource Implications 7.1 For the initial phase of delivery of these standards there are no resource implications in this report as funding is in place as noted in section 3 of this report. The funding of £303,000 [from MIST/MELDAP] is to be used for the following recruitment of new staff. (£000’s/ year) Clinical Nurse Lead X 2 £126,936 Recovery practitioners x 2 £80,000 Band 6 x 1.8 £96,940 8 Risk 8.1 Please note the risks and mitigations on page 18 of Appendix A 9 Involving people 9.1 The MAT Implementation Plan has been developed with a range of MELDAP partners from MLHSCP/3rd Sector. 10 Background Papers n/a Appendix 1: MAT Standards Implementation Plan MLHSCP AUTHOR’S NAME Nick Clater DESIGNATION Head of Adult Services CONTACT INFO nick.clater@midlothian.gov.uk DATE 03/10/2022 Page 246 of 276
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1 MAT STANDARDS IMPLEMENTATION PLAN This MAT Standards Implementation Plan has been produced to set out actions being taken in the Integration Authority area: Midlothian HSCP The lead officer/postholder nominated to ensure delivery of this Implementation Plan is: Name Position/Job Title Nick Clater Head of Adult Services, Midlothian HSCP This Plan is intended to ensure that services in the Integration Authority area are meeting the standards and the respective criteria for each standard as set out in the Drug Deaths Taskforce report: Medication Assisted Treatment standards: access, choice, support published in May 2021. This Plan has been developed by partners and has taken account of the voices of lived and living experience. The Governance arrangements for local oversight of progress against this Plan, including the role of lived and living experience in this is as follows: The plan has been developed with a range of ADP partners. The governance of the plan is in line with the Minister’s letter: • Midlothian HSCP and MELDAP will co-ordinate monthly meetings of a new MAT implementation Group, membership of which will include all partners with responsibility for delivery of actions. This group will review progress against the agreed actions and will ratify a quarterly report which will highlight risks to delivery. Operational strategic managers will report on the implementation plan to Head of Service and Chief Officer monthly. • This quarterly report will be presented to Midlothian HSCP Senior Management Team for comment and to address any risks to delivery. • The report will be passed to the two Chief Executives and Chair of the Midlothian Integrated Joint Board for agreement before being shared with the SG. Timelines for each of the above will be established when the submission dates to the SG have been confirmed. Page 247 of 276
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2 Ongoing experiential data gathering and widespread involvement of People with Lived Experience in the delivery of treatment and support, which includes their involvement in underpinning needs assessment work. NB: This Plan is being submitted prior to submission and approval by the NHS Lothian Board, Midlothian Council Cabinet and Midlothian Integrated Joint Board. Key Chief Officers are listed below. Name Position Delivery Partner Date signed Morag Barrow Joint Director of Midlothian HSCP Mid HSCP/MELDAP Midlothian IJB Meeting - 13/10/22 Callum Campbell Chief Executive NHS Lothian NHS Lothian NHS Lothian Board Meeting – 08/10/22 Dr Grace Vickers Chief Executive Midlothian Council Midlothian Council Midlothian Council Cabinet – 18/10/22 Val de Souza Chair Midlothian IJB Midlothian IJB Midlothian IJB Meeting – 13/10/22 Glossary of abbreviations: Abbreviation Description Mid SUS Midlothian Substance Use Service MELDAP Mid and East Lothian Alcohol and Drugs partnership MidH&SCP Midlothian Health and Social care Partnership MIST MAT standards Implementation Support Team (Public Health Scotland) ORT Opiate Replacement Therapy QI Quality Improvement RMN Registered Mental Health Nurse MELD Midlothian and East Lothian Drugs HIM Health In Mind Page 248 of 276
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3 Recovery Practitioners MELD recovery workers Peer Peer workers Appendices: • Appendix 1: Key Delivery risks • Appendix 2: Summary of recruitment plans: • Appendix 3: Summary of developmental/ QI projects: • Appendix 4: Lead Contacts of organisations involved in implementation Background reading: Evidence-based assessment of progress, MAT standards 1–5. April 2022, Edinburgh Supplementary information for the national benchmarking report on implementation of the Medication Assisted Treatment (MAT) standards. 2021/22 p357-375) Page 249 of 276
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4 MAT Standard 1 All people accessing services have the option to start MAT from the same day of presentation. April 2022 RAG status: Amber. Implement changes agreed with MIST teams Summary of current performance: Local guidance allows for same day start of MAT, but there are several routes into treatment (Contact Service, Harm reduction Team, GP direct referral, No 11 services). As part of the current review we were able to identify current challenges this indicated variable waits and same day initiation of prescribing. This was staffing dependant. Summary action plan: Development of specific daily clinic time to offer same day assessment and treatment start. This will offer assessment and initiation five days a week to people presenting themselves, being referred by other agencies or attending with the support of outreach teams. It will offer treatment in community settings where this is required. (£000’s/ year) Clinical Nurse Lead X 2 £127 Recovery practitioners x 2 £80 Band 6 x 1.8 £97 Actions/deliverables to implement standard 1 Lead Timescales to complete Implement clinic offering same day access, open 5 days a week, supported by outreach Recruitment of staff to MidLothian Substance Use Service (MidSUS) Funding confirmation MELDAP April 2022 First round of Advertisement MidSUS July 2022 Second round of advertisement MidSUS August 2022 Third round of advertisement Mid SUS September 2022 Fourth round (if required) Mid SUS October 2022 Expansion in voluntary sector partner’s (MELD) capacity 2 wte Page 250 of 276
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5 Funding confirmation/ contracts in place MELDAP July 2022 First round of Advertisement (awaiting HSCP) MELD September 2022 Second round of advertisement (if needed) MELD December 2022 Test of Change Improve efficiency of Contact service – Standard operating procedure for same day access MELD/MidSUS/HIM October 2022 Standard operating procedures, improved pathways, including outreach support for those people who can’t access MidSUS/MELD/HIM November 2022 Primary care in reach pathway, improve pathways to and from Primary care Mid SUS November 2022 QI charter agreed MELDAP/ MIDH&SCP/ MIST October 2022 Monitoring and oversight Monthly Meetings with Chief Officer and Head of Service MidH&SCPMELDAP October 2022 MAT 1 reporting submitted to SG/PHS Mid HSCP/MELDAP February 2023 Six month progress report MidH&SCP/ MELDAP June 2023 Justice Services Ensure that those identified in police custody or courts as needing treatment have access to assessment and treatment start in situ, a direct pathway for continuity of prescribing and outreach to support continued engagement MELDAP and various local partners alongside MIST April 2023 Ensure, treatment can be initiated in HMP Edinburgh and that all people returning to the Midlothian community from any prison have continuity of care, this is managed through our current No 11 Allocation meeting Mid SUS and Midlothian Justice Complete and On going Page 251 of 276
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6 MAT Standard 2 All people are supported to make an informed choice on what medication to use for MAT and the appropriate dose. April 2022. RAG status: Amber The key development in this area is to demonstrate and provide evidence of person centred informed medication choice. Establishment of Buvidal clinic. Summary of Current position/ planned actions Most components of this standard are already in place; there is no time limited care and there are choice in relation to dose and medications. The key development in this area is roll out of Buvidal (a novel, injected medication formulation with significant advantages). This is currently offered to a proportion of patients in secondary care, mostly people who have recently entered treatment. The standard requires it to be offered to all of those entering treatment but also conversion to it should be systematically offered to the existing patients. The NHS and MELDAP have developed an agreed pathway for people to start on/ convert to Buvidal. The key new things required to implement it are 1) capacity to dispense the drug in secondary care (nursing time) and 2) dispensing arrangements in community pharmacy (via a new contract) – this is currently being piloted in 3 pharmacies (Lead by REAS) As with MAT 1, the next milestone is the development of a clinic response, in this case requiring recruitment of two band 7 nurses, prescribing. We have been successful in recruitment of both posts .Other costs associated with the roll out of Buvidal (medication costs, pharmacy charges) are not part of the ADP financial plan. Page 252 of 276
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7 Actions/deliverables to implement standard 2 Lead Timescales to complete Improve access to Buvidal Recruitment to MidSUS team Funding confirmation MELDAP April 2022 First round of Advertisement MidHSCP August 2022 Second round of advertisement (if needed) MidHSCP September 2022 Clinic set up Development Service procedures, pathways MIdSUS November 2022 Clinic open and taking existing Buvidal patients MidSUS November 2022 Establish arrangements for community pharmacy Dispensing Pilot sites in place REAS August 2022 Evaluation of Pharmacy Buvidal dispensing REAS December 2022 Systematically offer choice to existing patients in secondary care Plan for offering conversion for secondary care patients Mid SUS December 2022 Monitoring and oversight eAnnual MAT 2 reporting submitted to SG/ PHS NHSL PH February 2023 Mid SUS Information Pack To develop medication information sheet to be included in the Mid SUS information pack providing details on medication options, enhancing person centred choice Mid SUS December 22 Justice Services Ensure that those identified in Police custody or courts as needing treatment or those on DTTO have access to the full range of medications MELDAP and various local partners alongside MIST April 2023 Ensure that treatment options in HMP Edinburgh include all medications MELDAP and various local partners alongside MIST April 2023 Page 253 of 276
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8 MAT Standard 3 All people at high risk of drug-related harm are proactively identified and offered support to commence or continue MAT. RAG status: Amber Midlothian SUS Team MELD and HIM have established an agreed approach involving outreach nurse and peer worker who will reach out to people who are identified as being in crisis and at high risk of drug related death and harms and those who have experienced NFO. Subject to the outcomes of the performance monitoring exercise, the current work plus planned actions (including additional investment) will deliver the standard before April 2023. Summary of present/ planned actions: Midlothian has an established network of teams who reach out to people who are identified as being in crisis and at high risk of drug related death. Subject to the outcomes of ongoing performance monitoring, it is anticipated that the current work plus planned actions (including additional investment) will deliver the standard before April 2023. Actions for this area focus on standardising practice, evidencing impact and stabilising and Maintaining funding. Summary action plan • Secure capacity for outreach to those in crisis • Ensure that Assertive outreach is linked to the arrangements for rapid access to treatment (MAT 1) • Systematise and standardise approaches to decision making, practice, risk management and reporting evidence Summary budget: Several of the key elements of the current provision have been developed using current and New ADP funding and it has been agreed to commit revenue to these. Current non-recurring investments (to be extended) £000’s pa Harm Reduction Team £3 A&E navigators £7 Drug liaison nursing contribution £3 Proposed new development: Additional outreach – out of hours provision £24 NFO peer support worker £25 Page 254 of 276
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9 • Diversify the skill mix of those doing outreach • Ensure integration with other systems (vulnerable adults, MH, Justice etc) and between elements of our own system Actions/deliverables to implement standard 3 Lead Timescales to complete Standardising practice and ensuring governance: Implementation of core group to agree Standardise and share operating procedures: assessment, risk assessment and decision- making paperwork for each of the teams. Mid SUS/MELD/HIM October 2022 Establish NFO working group to make recommendation on practice including development of related performance metrics MELDAP/ Mid SUS/MELD/HIM August - September 2022 Expanding capacity and securing funding Recruit nursing and third sector staff MidHSCP/MELD/HIM December 2022 Develop package of support including Naloxone, IEP, mobile phone (with key contact numbers) for people including those experiencing NFO who do not want to engage with treatment services –harm reduction MidSUS/MELD/HIM/MELDAP December 2022 Reaching high risk individuals in specific environments: Establish standard joint working and training offer with homeless and hostel teams to support MAT 3 delivery in these settings Mid SUS/MELD/HIM December 2022 Develop as TOC the use of Low Threshold Café’s in areas of high DRD/NFO to engage with people at high risk of harm MidSUS/MELD/HIM January 2023 Develop and implement clear joint protocols (rapid response) for disengagement MidSUS/MELD/HIM December 2022 Continue No 11 allocation meeting for Peoples Prison liberation MidSUS/Justice Complete and ongoing Page 255 of 276
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10 Continue Alcohol court as required (co-dependency) MidSUS/Justice Complete and ongoing MAT Standard 4 All people are offered evidence- based harm reduction at the point of MAT delivery. RAG status: Amber: most interventions are available in most settings and it is anticipated that the current work plus planned actions will deliver the standard before April 2023 Current and planned actions: This standard is partially implemented (amber) because it is not clear that the core interventions (naloxone, injection equipment, blood-borne virus testing) are consistently available at the same time as all MAT appointments. However, most interventions are available in the setting and it is anticipated that the current work plus planned actions will deliver the standard before April 2023. Note that the assessment of this standard does not include primary care settings. Actions/deliverables to implement standard 4 Lead Timescales to complete BBV testing Survey to identify the proportion of staff trained (nursing and voluntary sec) MidSUS/BBV Team January 2023 Action plan for to bring it towards 100% MidSUS/BBV Team January 2023 Audit of case notes MidSUS/BBV Team March 2023 Assessment of injecting risk Survey to identify the proportion of staff who have completed injecting training (nursing and vol sec) SDF/MidSUS January 2023 Action plan for each team to bring it towards 100% MidSUS/ SDF January 2023 Audit of case notes MidSUS March 2023 Injecting equipment provision Ensure that if possible that all rooms in which ORT is offered by specialist services have equipment in MidSUS February 2023 Page 256 of 276
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11 Naloxone and overdose awareness training Increase range of settings and groups provided with training MidSUS/MELD/HIM March 2023 Wound care training Survey to identify the proportion of staff who have completed injecting training (nursing and vol sec) MidSUS March 2023 Action plan for each team to bring it towards 100% MidSUS March 2023 Audit of case notes MidSUS March 2023 Justice Service Include DTTO in all MAT 4 developments alongside other community treatment services MELDAP/ CEC/ REAS March 2023 Ensure that the elements of MAT 4 that can be delivered in a prison environment are delivered in HMP Edinburgh MELDAP/ REAS March 2023 MAT Standard 5, & 7 and Treatment target: All people will receive support to remain in treatment for as long as requested and will have the option of MAT shared with Primary Care; increase by 9% the numbers on Opiate Replacement Treatment by April 2024 RAG status: Amber MidSUS caseloads are high, 370. The test of change in reach into GP practices will enhance and enable a continuum step model to allow a person to move up and down the continuum from Voluntary/peer support to secondary care this enabling a person to receive support by the right person at the right time and remain in treatment for as long as requested. Midlothian SUS/MELD/HIM will work to engage a 9% increase of individuals into treatment, average of additional 35 individuals in treatment by April 2024. Page 257 of 276
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12 Summary of present/ planned actions There are no limits on the time that people can remain in care but there is a finite capacity for treatment. The clinical and voluntary sector workforce in specialist services is smaller than required to deliver care to the current patient group. It is further depleted by recruitment challenges, staff absence and reliance on temporary posts. MAT 5 requires systems of care to “have pathways in place or models of support that are flexible and offer different care packages that [range from low [to high] intensity” and to ensure that people are able to move easily between these models of care according to need. It is not clear that the current system of care is able to achieve this. Within current resource constraints (funding, premises, available workforce) and models, meeting the existing pressures. In December 2021 the MELDAP made an application to MIST (the MAT standards Implementation Support Team) describing a plan with the following intended outcomes • Reducing practitioner caseloads • Developing Low intensity care in community settings - demonstrating models of high volume care/ increased safe, Page 258 of 276
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13 MAT compliant throughput from secondary care to increase the number of people who can be treated). • Maximising use of primary care The implementation plan for this work consists of • recruitment (summarised in appendix 1) and • Commitments to Quality Improvement projects (summarised in appendix 2. This plan has been agreed between • MELDAP • key delivery partners Midlothian HSCP, third sector (Meld) • The organisations who will support the change (NHSL Public Health, MIST, REAS PCFT). Actions/deliverables to implement standard 5, 7 and Treatment Target Lead Timescales to complete Expand and diversify workforce in locality teams Recruitment in MidSUS Funding confirmation MELDAP August 2022 First round of Advertisement Mid SUS August 2022 Second round of advertisement (if needed) Mid SUS September 2022 Expansion in voluntary sector partner’s (MELD) capacity Funding confirmation/ contracts in place MELDAP August 2022 First round of Advertisement MELD October 2022 Second round of advertisement (if needed) MELD December 2022 Develop new models of care through tests of change Page 259 of 276
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14 Alcohol Pathway improvement (to increase efficiency and patient experience co-dependency, releasing capacity) Mid SUS/MELD/HIM March 2023 QI charters/ baseline measures MidSUS, MELD and HIM with support from NHSL PH and MIST November 2022 MAT Standard 6 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. This standard focuses on the key role that positive relationships and social connection have to play in people's recovery. Services recognise that for many people, substances have been used as a way to cope with difficult emotions and issues from the past. Services will aim to support people to develop positive relationships and new ways of coping as these are just as important as having the right medication. Completed and planned actions are noted below Note that standards 6 - 10 were not formally evaluated in March 2022. However, planning and implementation for MAT 6 in the Lothian’s are understood to be well developed by national standards. Actions/deliverables to implement standard 6 Lead Timescales to complete Establish required MAT 6 strategic leadership/steering group with appropriate membership and function NHSL Clinical Psychology Complete Page 260 of 276
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15 Develop an overall MAT 6 delivery plan for Mid HSCP NHSL Clinical Psychology Complete Develop service specific delivery plans for all Mid HSCP services (including a framework for evidencing and reporting implementation progress) NHSL Clinical Psychology December 2022 To carry out a baseline audit of current service delivery in relation to the key elements of Mat 6. This includes: a) Staff survey b) Service user survey NHSL Clinical Psychology a) Compl ete b) Decem ber 2022 Initiate ongoing process of service development/ improvement to ensure the service culture and environment is psychologically-informed NHSL Clinical Psychology March 2023 Develop a workforce development plan clearly outlining MAT 6 training and supervision requirements and plans for delivery. NHSL Clinical Psychology Complete Make available training, coaching and supervision for staff in key evidence-based MAT 6 psychosocial interventions NHSL Clinical Psychology Complete Make available regular reflective practice space for staff working across all service areas NHSL Clinical Psychology December 2022 Ensure appropriate staff have psychosocial interventions delivery, with protected time to deliver (and attending coaching/supervision) NHSL Clinical Psychology December 2022 Page 261 of 276
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16 Develop resources (tools, manuals etc) to support staff to deliver MAT 6 psychosocial interventions NHSL Clinical Psychology December 2022 Establish a collaborative MAT 6 care planning process which has the service users’ views at the centre. NHSL Clinical Psychology December 2022 MAT Standard 7 All people have the option of MAT shared with Primary Care. RAG status: AMBER Please see above (MAT 5 plan): Improvement in ensuring the maximum appropriate use of primary care through • improving communication between primary care, secondary care, and non-stat addiction agencies. • improving primary care confidence in shared care treatment and/ or by supporting pathway changes which encourage smooth transfer of patient care to primary care and appropriate referral from primary to secondary care. Primary care: Maximising the appropriate pathways to and from primary care Lead Timescales to complete Recruitment of RMNs MidSUS March 2023 Develop and implement clear pathways and joint partnership working to enable a person to have the right support at the right time in the right place MidSUS, MELD HIM, Primary care and Mid HSCP March 2023 QI charters/ baseline measures MidSUS with support from Mist November 2022 Improved throughput, case management and role delineation QI charters/ baseline measures MidHSCP and MIST November 2022 Page 262 of 276
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17 MAT Standard 8 All people have access to independent advocacy and support for housing, welfare and income needs. RAG status: AMBER Actions/deliverables to implement standard 8 Lead Timescales to complete Continue provision of Independent Advocacy through CAPS MELDAP Complete Continue support from Welfare rights Mid HSCP Complete Continue Support from Shelter – Housing MidHSCP Complete Publish leaflet detailing MAT rights and the organisations who will advocate and support patients to receive them MELDAP February 2023 Undertake development with treatment teams to ensure that pathways to these services are understood by all frontline practitioners MELDAP March 2023 Continue provide support for families (through VOCAL) MELDAP Complete Justice Services Include DTTO in all MAT 8 developments alongside other community treatment services MELDAP/CEC/REAS March 2023 Ensure that the MAT 8 standards that can be delivered in a prison environment are delivered in HMP Edinburgh MELDAP/REAS March 2023 MAT Standard 9 All people with co-occurring drug use and mental health difficulties can receive mental health care at the point of MAT delivery. RAG status: GREEN People have the right to ask for support with mental health problems and to engage in mental health treatment while being supported as part of their drug treatment and care. No 11 integrated building where SUS and MH services are collocated and working partnership with shared care pathways and Lead agency protocol The local system of secondary care has strengths in this notably integration between the vol sec, social work and clinical teams; and shared locality management of MH and drug and alcohol teams. Complete - July 2022 Page 263 of 276
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18 MAT Standard 10: All people receive trauma informed care. Completed and planned actions are noted below Note that standards 6 - 10 were not formally evaluated in March 2022. However, planning and implementation for MAT 6 in the Lothians are understood to be well developed by national standards. Actions/deliverables to implement standard 10 Lead Timescales to complete Establish required MAT 6 strategic leadership/steering group with appropriate membership and function NHSL Clinical Psychology Complete Develop an overall MAT 10 delivery plan for MELDAP NHSL Clinical Psychology Complete To carry out a baseline audit of current service delivery in relation to the key elements of Mat 6 & 10. This includes: a) Staff survey b) Service user survey c) Trauma Walkthroughs (Of Note Midlothian was a pilot site for SG Trauma informed practice, No 11 is a specifically designed trauma informed building/workforce) NHSL Clinical Psychology a) Complete b) December 2022 c) March 2023 Initiate a process of continuous quality improvement underpinned by the principles of trauma informed care NHSL Clinical Psychology March 2023 Initiate a process where service users are continually asked for their views on service delivery and areas for improvement (in line with TIC) NHSL Clinical Psychology March 2023 Offer appropriate training supervision for all staff to work safely and effectively with trauma NHSL Clinical Psychology Complete Page 264 of 276
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19 Develop a wellbeing planning tool and activities (e.g. staff mindfulness groups) to support staff health and wellbeing NHSL Clinical Psychology March 2023 Appropriate screening tools to be identified for use routinely (as appropriate) so that trauma is recognised NHSL Clinical Psychology March 2023 Page 265 of 276
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20 Appendix 1: Key Delivery risks Implementation, Performance management and governance Implementing the plan requires rapid decision-making and sufficient management capacity to change services quickly. Mitigations for this risk will include strong management support and direct oversight by senior managers, incorporated into the monthly mangers meetings. Workforce expansion and development: The key professional groups needed to deliver the expansion plan are Mental Health Nurses, Prescribers (medical and non-medical) and recovery practitioners and Peer support workers and peer development peer workers. Mitigations for this risk might include engagement with wider workforce development processes within partner organisations, if recruitment poses challenges. Premises and facilities Challenges created by the current premises include: • Insufficient office space for expanding staff and insufficient delivery space for patient numbers – limited room capacity restricts how flexible services can be (essential for our patient group). Resources and capacity: Although the recently allocated £303k is a welcome expansion (and, as noted above, probably as large an increase in capacity as could be implemented immediately), it is not clear that this will be sufficient to relieve current pressures and meet increased expectations. Mitigation will require ongoing monitoring of progress and pressures. Reporting and data gathering: A system of quarterly reporting has been put in place. It requires evidence of continuous improvement toward MAT standards 1-5 and towards the target of increasing numbers of people in ORT. Mitigation would include investment in systems improvement and/ or admin attached to teams on a non-recurring basis. Potential addition of a data analyst within MELDAP to support Inaccurate predictions of demand: the plan represents a significant lowering of the threshold for entering treatment. This is exactly the intended effect and is very necessary. However, there is the risk that improving access will result in greater numbers coming forward than can be safely treated. Conversely, the additional capacity may not result in additional presentations (risking inefficient use of resources and less public health impact). These risks have been mitigated by planning and will be carefully monitored, with additional measures to engage patients if needed. Page 266 of 276
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21 Appendix 2: Summary of recruitment plans: Permanent additional recruitment: Professional group Number to be recruited MAT Standard Expanding capacity: B7 Clinical Nurse Leads NMP 2 1, 2 ,4 Including treatment target Band 6 RMN 1 1,4, ,7 Band 6 RMN 0.8 1 1, 3 , 4 Recover practitioners MELD 2 1,3, 4 All of the core posts are to be advertised through a single recruitment process (in each organisation) by october2022, re advertised as needed in December 2022. Additional non-recurring funding for staffing or other uses is available within the MELDAP budget. All partners, particularly Mid H&SCP are able to have requests for this funding considered where it would achieve MAT standards. Page 267 of 276
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22 Appendix 3: Summary of developmental/ QI projects: All of these are to be delivered alongside the expansion of staffing numbers Key developmental projects: Lead operational team(s) delivering Lead QI support Same day access Mid SUS MELD HIM MIST Primary care in reach Mid SUS Implementation of the Buvidal pathway Mid SUS MIST Increasing capacity • Improving links Primary care (resulting in greater use of available capacity) Mid SUS Mist • More effective alcohol pathway for co- dependency (leading to efficiencies, improved patient experience and higher throughput) Mid SUS MELD HIM MIST • Improved throughput, case management and role delineation Mid SUS MELD HIN MIST Improving access to physical healthcare for patients of people All Teams MIST Page 268 of 276
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23 Appendix 5: Lead Contacts of organisations involved in implementation: Organisation Contact MELDAP Martin Bonnar <Mbonnar@eastlothian.gov.uk Head Service Nick Clater <nick.clater@midlothian.gov.uk> Service manager Karen Darroch <karen.darroch@nhslothian.scot.nhs.uk> MIST Dave Taylor <david.taylor28@nhs.scot> NHSL PH James Shanley <James.Shanley@nhslothian.scot.nhs.uk>; REAS (HRT) Jim Sherval <Jim.Sherval@nhslothian.scot.nhs.uk>;; REAS (PCFT) Judith Craven <Judith.Craven@nhslothian.scot.nhs.uk>; David Ewart <David.Ewart@nhslothian.scot.nhs.uk> MELD "Dave Gasparini" <davegasparini@meld-drugs.org.uk> Clinical Psychology Peter Littlewood ,peter.littlewood@nhslothian.scot.nhs.uk> Page 269 of 276
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Midlothian Integration Joint Board Thursday 13th October 2022, 14.00-16.00 Finance Update – end of August 2022 Executive summary This report informs the Board on the IJB’s partners financial forecast for the financial year 2022/23 as at the end of August 2022. The report also updates the Board on the recent correspondence from Scottish Government regarding IJB COVID reserves. Board members are asked to: 1. Note the end of August 2022 financial forecast position for the IJB. 2. Note the COVID correspondence from Scottish Government. # Item number: 5.11 Page 271 of 276
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Midlothian Integration Joint Board Report Finance Update – end of August 2022 1 Purpose 1.1 This report lays out the most recent financial forecasts from Partners and the projected financial position of the IJB for 2022/23. Plus updates the Board on the recent correspondence from Scottish Government regarding IJB COVID reserves. 2 Recommendations 2.1 As a result of this report Members are being asked to:- • Note the end of August 2022 financial forecast position for the IJB. • Note the COVID correspondence from Scottish Government. 3 Background and main report 3.1 At the IJB meeting during September 2022, the IJB received the outputs from the Quarter 1 review exercise undertaken by its Partners Midlothian Council and NHS Lothian which projected the financial position for the IJB for the year 2022/23. 3.2 The output of the Quarter 1 review was a projected overspend of £902k. These financial forecast projections are now routinely monitored and updated as new information is made available. Both Partners have reviewed the forecasts during the end of August 2022 reporting cycle which has result in no change in the financial forecast of the IJB shown below Annual Budget as at end of August 2022 Forecast Expenditure August 2022 Forecast Under/(Over) Spend £k £k £k Core 65,775 65,648 127 Hosted 12,655 12,647 8 Set Aside 19,087 20,125 -1,038 Health 97,517 98,419 -902 Social Care 56,710 56,710 0 Total 154,227 155,129 -902 (Fig 1: IJB Financial Forecasts 2022/23) Page 272 of 276
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Midlothian Integration Joint Board 3.3 The end of August 2022 projections are still in line with the Quarter 1 review. A Quarter 2 review which is a fuller forecasting exercise will be undertaken after end of September 2022 financial positions are closed. This will take the first 6 months of financial information and make updated financial projections for 2022/23. 3.4 The Core services within Health although reporting a very small underspend do have some areas with financial challenges these are the Community Hospital and Health Visiting. 3.5 Within Set Aside services the forecast continues to highlight the financial pressures driven by staffing costs being higher due to the use of agency and locum staff to fill gaps and the increased cost within acute drugs driven by both increased demand and price. This area is the major overspend of the IJB and we are working with acute colleagues to determine if there are any recovery action to mitigate this pressure. 3.6 The Social Care overall forecast is break even, but it should be noted that there are underlying pressures that need to be addressed to ensure this position can be achieved. There are financial challenges within Newbyres Care Home where the high use of agency staff has increased expenditure significantly. This is a major financial pressure currently being offset by areas of projected underspend. The projection for Newbyres is circa £1.3m to £1.5m of a projected overspend against its delegated budget. A short term recovery plan for this financial year and longer term plan has been requested within the HSCP. 3.7 At the IJB in September 2022 the finance report also reported on the COVID exit work within the HSCP and the national shortfall in funding. The HSCP COVID costs for 2022/23 are now only • an additional ward within Midlothian Community Hospital, • additional costs in Primary Care (GMS and Prescribing), • costs relating to the ongoing sustainability payments to our external providers • and the loss of income from core services. 3.8 During September 2022 a letter from Scottish Government titled Update on COVID reserves was sent to HSCP Chief Officers, HSCP Chief Finance Officers, NHS Directors of Finance, LG Directors of Finance. This letter references the reclaiming of IJB COVID reserves “There have been a number of significant changes to Public Health policies in relation to Covid over the summer, resulting in the profile of Covid spend reducing significantly compared to when funding was provided to IJBs for Covid purposes. In response to this, the Scottish Government will reclaim surplus Covid reserves to be redistributed across the sector to meet current Covid priorities. The detail of this will follow at an IJB level and the process and timetable will follow through further communications.” 3.9 This letter has been shared with members and at this stage we await further correspondence on the detail of this. Page 273 of 276
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Midlothian Integration Joint Board 3.10 The outturn projections will continue to be refined throughout the year, and regular updates will be brought back to the IJB. The main outstanding risk not included in the above projections is the settlement of the pay awards. We await clarity to assess the impact of this with our Partners both in terms of cost projections and any additional funding. 4 Policy Implications 4.1 There are no policy implications from this report. 5 Directions 5.1 The utilising of our COVID funding is in line with our direction to Partners, Direction 25 Financial Instruction. 6 Equalities Implications 6.1 There are no equalities implications from this report. 7 Resource Implications 7.1 The resource implications are laid out above. 8 Risk 8.1 The risk of ongoing COVID related expenditure with no COVID funding from Government in future years is highlighted above. 8.2 The risk regarding the pay awards settlement is raised above in report 8.3 The “business as usual” risks raised by this report are already included within the IJB risk register. 9 Involving people 9.1 The IJB papers are publically available. 10 Background Papers 10.1 None Page 274 of 276
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Midlothian Integration Joint Board AUTHOR’S NAME Claire Flanagan DESIGNATION Chief Finance Officer CONTACT INFO claire.flanagan@nhslothian.scot.nhs.uk DATE October 2022 Page 275 of 276
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