Agenda Document Pack - Midlothian Integration Joint Board - Audit and Risk Committee - 06/06/2024
Midlothian Council · 6 June 2024
Back to Midlothian Integration Joint Board - Audit and Risk Committee — 6 June 2024 and its agenda
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Notice of Meeting and Agenda Midlothian Integration Joint Board - Audit and Risk Committee Venue: Virtual Meeting, Date: Thursday, 06 June 2024 Time: 14:00 Morag Barrow Chief Officer Contact: Clerk Name: Democratic Services Clerk Telephone: Clerk Email: democratic.services@midlothian.gov.uk Further Information: This is a meeting which is open to members of the public. Page 1 of 180
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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 Minute of the MIJB Audit and Risk Committee of 7 March 2024 5 - 10 5 Public Reports 5.1 Scottish Audit report on Mental Health – Head of Adult Services and Social Care 11 - 70 5.2 Appointment of an Independent Member to the A&R Committee - Chief Financial Officer (Interim) 71 - 74 5.3 Review of Risk Management Policy - Chief Financial Officer (Interim) 75 - 92 5.4 Risk Register – Chief Financial Officer (Interim) 93 - 98 5.5 Best Value Framework – Chief Financial Officer (Interim) 99 - 132 5.6 Revision of Terms of Reference – A&R and SPG – Chief Financial Officer (Interim) 133 - 144 5.7 Review of the Annual Governance Statement - Chief Internal Auditor 145 - 152 5.8 MIJB Internal Audit Annual Assurance Report – Chief Internal Auditor 153 - 166 5.9 MIJB Internal Audit Report: Publication Scheme – Chief Internal Auditor 167 - 180 6 Private Reports No items for discussion Page 2 of 180
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7 Date of Next Meeting The next meeting will be held on Thursday, 5 September 2024 at 2pm Page 3 of 180
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Midlothian Integration Joint Board Meeting Date Time Venue MIJB - Audit and Risk Committee Thursday 7 March 2024 2.00pm Virtual Meeting held using MS Teams Present (voting members): Val de Souza (Chair) Councillor McManus Councillor Parry Nadin Atka Present (non-voting members): Morag Barrow (Chief Officer) David King (Chief Finance Officer (Interim)) Duncan Stainbank (Chief Internal Auditor) Patricia Fraser (External Auditor) Claire Gardiner (External Auditor) Gill Main (Integration Manager) In attendance: Roxanne King Gary Leadbetter (Democratic Services Officer) Hannah Forbes (Assistant Democratic Services Officer) Apologies: MIJB – Audit and Risk Committee Thursday, 6 June 2024 Item No 4.1 Page 5 of 180
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2 MIJB - Audit and Risk Committee Thursday 7 March 2024 1. Welcome and Introductions The Chair welcomed everyone to the meeting of the Midlothian Integration Joint Board (MIJB) – Audit and Risk Committee. 2. Order of Business The Order of Business was as detailed in the agenda. 3. Declarations of interest No declarations of interest were received. 4. Minutes of Meeting 4.1 The Minute of Meeting of the Audit and Risk Committee held on 7 December 2023 was submitted. The Minute was approved as a correct record. 5. Public Reports 5.1 External Annual Audit Plan 2023/24, report by Audit Scotland The External Auditor presented the report, which summarises the work plan for the 2023/24 audit, and provided a summary of the main elements. The Chair thanked the External Auditor for the report and opened it up for questions. The Chief Officer queried the 6% increase in fees. The External Auditor stated that they understood the challenges around this, although noted that the fees are set centrally, and that Audit Scotland is facing financial pressures and are working hard to create efficiencies to Page 6 of 180
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3 MIJB - Audit and Risk Committee Thursday 7 March 2024 mitigate the impact of the increase. Some discussion took place on the financial pressures and challenges faced, noting that this was not something experienced by Midlothian IJB in isolation. 5.2 Local Government in Scotland: Financial Bulletin 2022/23, report by Audit Scotland The External Auditor presented the report and noted that it is for information. Discussion took place on the report, including the perceptions and complexities of funding, spend and reserves in relation to Councils and the pressures faced and the culture around this. 5.3 Q4 2023/24 Risk Register, report by Chief Finance Officer (Interim) The Chief Finance Officer (Interim) presented the report. The report presents the IJB’s Risk Register for Q4 2023/24. The risk register has been reviewed and amendments made, these are detailed below. At its meeting on 7th December 2024 the committee agreed to move its risk register onto the Datix system which is managed by NHS Lothian. The extract attached to this paper is from Datix along with appendices laying out Datix Impact and Consequences and the Datix Risk Matrix, the latter two being for the committee’s information. Three risks are now categorised as ‘very high’ all being a function of the severe financial challenges that the IJB and its partners are facing in 2024/25. The MIJB Audit and Risk Committee are asked to: 1. Note the Q4 Risk Register. 2. Consider if any further additions or changes should be made to the Risk Register. The Chair thanked the Chief Finance Officer (Interim) for the report and opened it up for questions. The Chair noted the offer in the report of a briefing on the use and workings of Datix for Members and welcomed this and asked that this is picked up and arranged. The Chief Officer noted that the layout of appendices in the report were being looked at in order to improve their presentation. The Chief Officer further explained that they were concerned around the potential decisions that partners will make for the next financial year and the unintended consequences that this may have for the MIJB. The Chair agreed that it would be helpful for this to be raised and noted that it may be helpful to have a section in the finance report that looks at the whole system and the impact on the MIJB. The Chief Internal Auditor explained that this will be covered slightly, noting that it is the broad thrust of the second audit on the audit plan which looks at capturing the impacts of transformational changes and that which happens at a system level. Page 7 of 180
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4 MIJB - Audit and Risk Committee Thursday 7 March 2024 Action – discuss and arrange a briefing on the use and working of Datix for Members – Val De Souza / Councillor McManus / Morag Barrow / Gill Main 5.4 Proposal for a Development Session for the Committee, report by Chief Internal Auditor The Chief Internal Auditor presented the report. The purpose of this report is to gain approval to the proposal to complete a self-analysis of the MIJB Audit & Risk Committee against the CIPFA Position Statement: Audit Committees in Local Authorities and Police 2022. Following this review that topics for Development sessions are identified and Development sessions scheduled for Audit & Risk Committee members following each Audit & Risk Committee meeting. The MIJB Audit and Risk Committee are asked to: 1. Approve the proposal for the Audit & Risk Committee self-assessment participation to be completed by June 2024. 2. Approve that development sessions will be held following each Audit & Risk Committee meeting throughout the year, based on the analysis of the self-assessment. The Chair thanked the Chief Internal Auditor for the report and opened it up for questions. The Chief Officer asked if the themes from the learning from East Lothian could be shared. The Chief Internal Auditor explained that there were four key areas being looked at which were government statements, fraud, risk and best value. The Chief Officer noted that they expected that there would be similar themes for the MIJB and asked if there was any opportunity for shared learning. The Chief Internal Auditor stated that they would look at this. Recommendations approved. 5.5 Internal Audit Report by Chief Internal Auditor The Chief Internal Auditor presented the report. The purpose of the Report is to present the proposed Internal Audit Annual Plan 2024/25 for the Midlothian Health and Social Care Integration Joint Board for discussion and approval by the MIJB Audit and Risk Committee. The MIJB Audit & Risk Committee are asked to approve the Internal Audit Annual Plan 2024/25 for the Midlothian Health and Social Care Integration Joint Board. The Chair thanked the Chief Internal Auditor for the report and opened it up for questions. Page 8 of 180
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5 MIJB - Audit and Risk Committee Thursday 7 March 2024 The Integration Manager noted some outstanding policies that are outdated and need to be picked up and agreed that they would discuss these with the Chief Internal Auditor. The Chief Officer questioned the use of the word “transformation” and suggested that this be revisited and perhaps rephrased to “grip and control.” Recommendation approved. 6. Private Reports No private business to be discussed at this meeting. 7. Date of next meeting The next meeting will be held on Thursday 6 June 2024 at 2.00pm. (Action: All Members to Note) The meeting terminated at 15:24. Page 9 of 180
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Midlothian Integration Joint Board Audit and Risk Committee Audit Scotland – Access to Adult Mental Health Services Thursday, 6 June 2024 Item number: 5.1 Executive summary Audit Scotland published an audit report in September 2023 on the access to adult mental health services in Scotland. This report noted that • Funding for adult mental health services in Scotland has increased significantly since 2017; however, the impact remains unclear due to a lack of data. • Access to these services remains challenging • The mental health workforce faces high vacancy rates, and progress in expanding primary care mental health support is delayed. • Disparities persist, particularly affecting ethnic minorities, rural residents, and those in poverty. • The government lacks sufficient oversight and focuses primarily on waiting times for psychological therapies. • The Scottish Government's progress on mental health commitments is mixed, with further goals not on track for achievement. Committee Members are asked to • Note this report Page 11 of 180
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Midlothian Integration Joint Board – Audit and Risk Committee Page 2 Report 1. Purpose 1.1 To present to the committee the finding from the Audit Scotland report on Adult Mental Health published in September 2023. 2. Recommendations 2.1 Committee members are asked to note the content of the Audit Scotland Report 3. Background and main report 3.1 Funding for adult mental health services has increased significantly since 2017. But a lack of data makes it hard to see what impact this increased spending has had. Accessing services remains slow and complicated for many people. The Covid-19 pandemic made this situation worse, particularly limiting access to face-to-face support. NHS boards are still not all routinely offering face-to-face appointments as a choice. The mental health workforce is under pressure, with high vacancy rates and turnover. And progress towards increasing the mental health support available from primary care, which is essential to improving access and relieving pressure on specialist services, has been delayed. 3.2 Accessing mental healthcare is more difficult for some people, for instance people from ethnic minorities, people living in rural areas and people living in poverty. People living in the most deprived areas are also three times more likely to end up in hospital for mental health issues than those in the least deprived areas. This is a long-standing problem and progress in tackling it has been slow. Mental health services cannot address this alone, and they are not yet working closely enough with other sectors, such as housing, welfare, and employability support services, to address and prevent some of the causes of poor mental health. 3.3 The Scottish Government does not have sufficient oversight of most adult mental health services because of a lack of information. It does not measure the quality of care or the outcomes for people receiving it. The Scottish Government focuses on only waiting times for psychological therapies to assess how adult mental health and wellbeing services are performing. Performance against this measure has improved, but NHS boards are still struggling to meet waiting times standards. The system is fragmented, and accountability is complex, with Page 12 of 180
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Midlothian Integration Joint Board – Audit and Risk Committee Page 3 multiple bodies involved in funding and providing mental health services. This causes complications and delays in developing services that focus on individuals’ needs. 3.4 The Scottish Government’s progress against commitments in its Mental Health Strategy 2017–2027 is mixed. It has since made further financial, operational and workforce commitments, but it is not currently on track to achieve them. These include increasing mental health funding by 25%, ensuring that ten per cent of front-line health spending is on mental health, and giving all GP practices access to primary care mental health and wellbeing services. 3.5 The table below summarises the recommendations of the report Audit Scotland Recommendations Stakeholder Responsible Situation Summary Scottish Government The Scottish Government should: 1. Implement DBI program recommendations by March 2024 Scottish Government Implement recommendations from the independent evaluation of the Distress Brief Intervention (DBI) program as part of Scotland-wide rollout by March 2024. 2. Publish guidance on measuring and evaluating outcomes Scottish Government Publish guidance on measuring and evaluating outcomes from mental health and wellbeing services in primary care before the end of 2023 (originally expected in April 2022). 3. Publish a costed delivery plan for primary care services Scottish Government Publish a costed delivery plan as soon as possible detailing the funding and workforce requirements to establish and accommodate primary care mental health and wellbeing services across Scotland by 2026. This plan should also outline how these services will collaborate with other sectors for holistic, person-centred support. 4. Start routinely publishing psychological therapies data Scottish Government, Public Health Scotland Collaborate with Public Health Scotland to start routinely publishing data on the effectiveness of the government's psychological therapies specification and quality standards for secondary mental health services, improving transparency and accountability for patients' experiences and outcomes over the next 12 months. 5. Improve transparency at Health and Social Care Partnership Scottish Government, Public Health Scotland Collaborate with Public Health Scotland to start routinely publishing psychological therapies performance data at HSCP level, in addition to NHS board level, within the next 12 months to enhance transparency and accountability for psychological therapies services. Page 13 of 180
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Midlothian Integration Joint Board – Audit and Risk Committee Page 4 Scottish Government and IJBs The Scottish Government and IJBs should: 6. Improve data quality for service planning and monitoring Scottish Government, IJBs Urgently work on enhancing the availability, quality, and utilisation of financial, operational, and workforce data. This will enable more accurate service and workforce planning, facilitate information sharing between health and social care partners, and allow for routine measurement, monitoring, and reporting on the quality of mental health services, patient outcomes, and the impact of investments. IJBs, HSCPs, and NHS Boards IJBs, HSCPs, and NHS boards should: 7. Offer choice between remote and face-to- face services IJBs, HSCPs, NHS boards Provide individuals with the option to choose between accessing mental health services remotely or face-to-face, aligning with the Digital Health and Care Strategy commitment. IJBs and Councils IJBs and councils should: 8. Enhance collaboration between various support services IJBs, councils Urgently improve the integration of mental health, primary care, housing, employability, and welfare support services. This should involve developing shared goals and targets, sharing data, and jointly funding services to address and prevent the underlying causes of poor mental health. (Finding and recommendation text verbatim from Audit Scotland, 2023) 4. Policy Implications 4.1 There are no further policy implications arising from this report. 5. Equalities Implications 1.2 There are no equalities implications arising from this report 6. Resource Implications 1.3 There are no resource implications arising from this report. Page 14 of 180
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Midlothian Integration Joint Board – Audit and Risk Committee Page 5 7. Risks 7.1 The IJB maintains a risk register, this paper does not identify any further risk. 8. Involving People 8.1 There are no direct implications for involving people as a result of this report. 9. Background Papers 9.2 None AUTHOR’S NAME DESIGNATION CONTACT INFO DATE Appendix – Audit Scotland report on Mental Health Page 15 of 180
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Adult mental health Prepared by Audit Scotland September 2023 Page 17 of 180
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2 Contents Key facts 3 Key messages 4 Recommendations 6 Introduction 8 1. Access to mental health support and services 10 2. Progress towards improving mental health services 27 3. How well resources for adult mental health are managed 38 4. Plans and strategic direction 46 Endnotes 49 Appendix 1 52 Appendix 2 53 Audit team The core audit team consisted of: Leigh Johnston, Eva Thomas-Tudo, Claire Tennyson and Jason Carter, with support from other colleagues and under the direction of Mark MacPherson. Accessibility You can find out more and read this report using assistive technology on our website. For information on our accessibility principles, please visit: www.audit-scotland.gov.uk/accessibility. Page 18 of 180
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3Key facts Key facts About one in four people experience mental health problems in any given year. People with lifelong mental illnesses are more likely to die 15-20 years prematurely because of physical health problems. 80.8 per cent of people started psychological therapies within 18 weeks of being referred for treatment in 2022/23. 2,742 people waited more than a year to start psychological therapies in 2022/23. £8.8 billion was the reported cost of poor mental health to the Scottish economy in 2019. NHS boards spent £1.2 billion on adult mental health in 2021/22. Councils spent £224.7 million on adult mental health in 2021/22. The Scottish Government’s Mental Health Directorate budget is £290.2 million in 2023/24. Page 19 of 180
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4Key messages Key messages 1 Funding for adult mental health services has increased significantly since 2017. But a lack of data makes it hard to see what impact this increased spending has had. Accessing services remains slow and complicated for many people. The Covid-19 pandemic made this situation worse, particularly limiting access to face-to-face support. NHS boards are still not all routinely offering face-to-face appointments as a choice. The mental health workforce is under pressure, with high vacancy rates and turnover. And progress towards increasing the mental health support available from primary care, which is essential to improving access and relieving pressure on specialist services, has been delayed. 2 Accessing mental healthcare is more difficult for some people, for instance people from ethnic minorities, people living in rural areas and people living in poverty. People living in the most deprived areas are also three times more likely to end up in hospital for mental health issues than those in the least deprived areas. This is a long-standing problem and progress in tackling it has been slow. Mental health services cannot address this alone, and they are not yet working closely enough with other sectors, such as housing, welfare, and employability support services, to address and prevent some of the causes of poor mental health. 3 The Scottish Government does not have sufficient oversight of most adult mental health services because of a lack of information. It does not measure the quality of care or the outcomes for people receiving it. The Scottish Government focuses on only waiting times for psychological therapies to Page 20 of 180
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Key messages 5 assess how adult mental health and wellbeing services are performing. Performance against this measure has improved, but NHS boards are still struggling to meet waiting times standards. The system is fragmented, and accountability is complex, with multiple bodies involved in funding and providing mental health services. This causes complications and delays in developing services that focus on individuals’ needs. 4 The Scottish Government’s progress against commitments in its Mental Health Strategy 2017–2027 is mixed. It has since made further financial, operational and workforce commitments, but it is not currently on track to achieve them. These include increasing mental health funding by 25 per cent, ensuring that ten per cent of front-line health spending is on mental health, and giving all GP practices access to primary care mental health and wellbeing services. Page 21 of 180
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6Recommendations Recommendations The Scottish Government should: • implement the recommendations of the independent evaluation of the Distress Brief Intervention (DBI) programme as part of rolling out the DBI programme across Scotland by March 2024 (Case study 1, page 21) • before the end of 2023, publish its guidance on measuring and evaluating outcomes from mental health and wellbeing services in primary care, which was expected to be published in April 2022 (paragraph 30) • publish a costed delivery plan, as soon as possible, setting out the funding and workforce needed to establish and accommodate primary care mental health and wellbeing services across Scotland by 2026, including how these services will work with other sectors to provide holistic, person-centred support (paragraphs 31 , 32 and 43) • in the next 12 months, work with Public Health Scotland to start routinely publishing, at least quarterly, how the Scottish Government’s psychological therapies specification and quality standards for secondary mental health services are improving the experiences and outcomes for people who use these services (paragraph 52) • in the next 12 months, work with Public Health Scotland to start routinely publishing psychological therapies performance at Health and Social Care Partnership (HSCP) level as well as NHS board level to improve transparency and accountability for psychological therapies services (paragraph 55). Page 22 of 180
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7Recommendations The Scottish Government and Integration Joint Boards (IJBs) should: • urgently progress work to improve the availability, quality, and use of financial, operational and workforce data so that: – service and workforce planning, particularly in primary, community, and social care, is based on accurate measures of existing provision and demand (paragraphs 14 , 90 and 97) – information can be shared between health and social care partners more easily (paragraphs 56–58) – they can routinely measure, monitor and report on the quality of mental health services and patient outcomes; the difference that investment is making to patients’ outcomes; and how much is being invested in preventative programmes of work and their impact (paragraphs 97–99). IJBs, HSCPs and NHS boards should: • provide people with a choice about whether they access mental health services remotely or face-to-face, in line with the commitment in the Digital Health and Care Strategy (paragraphs 25 and 26). IJBs and councils should: • urgently improve how mental health, primary care, housing, employability, and welfare support services work together to address and prevent the causes of poor mental health, by developing shared goals and targets, sharing data and jointly funding services (paragraphs 42 and 43). Page 23 of 180
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8Introduction Introduction Background 1. Supporting and improving mental health and wellbeing is a significant public health challenge that requires a coordinated response from a wide range of organisations. There is a need to focus on prevention and early intervention while maintaining access to specialist services for those with severe mental health issues. This is a difficult balance to achieve. 2. Mental health problems are very common. About one in four people experience mental health problems in any given year.1 The Covid-19 pandemic brought additional pressures on the population’s mental health (paragraph 15). National lockdowns meant that people were more isolated from family and friends, and access to support and services was impacted. 3. The Scottish Government and the Convention of Scottish Local Authorities (COSLA) identified mental wellbeing as one of six public health priorities for Scotland in 2018.2 The Scottish Government aimed to give equal priority to physical health and mental health in its Mental Health Strategy 2017–2027.3 It reported that people with lifelong mental illnesses are more likely to die 15-20 years prematurely. 4. The Mental Health Foundation reported that poor mental health cost the Scottish economy £8.8 billion in 2019.4 Most of these costs were not incurred by the healthcare sector. For example, 72 per cent can be accounted for by the lost productivity of people living with mental health conditions and costs incurred by unpaid informal carers. £8.8 billion is also likely to be a significant underestimate because of a lack of data. For instance, the figure does not include costs associated with the impact of poor mental health on areas including the criminal justice system, housing, and addictions services. About this report 5. This report has been prepared on behalf of the Auditor General for Scotland and the Accounts Commission. In 2018, we reported on children and young people’s mental health and made a commitment to further audit work on mental health-related issues. This performance audit focuses on mental health services for adults in Scotland. 6. The overall aim of the audit is to answer the question: How effectively are adult mental health services across Scotland being delivered? We have focused on the progress made since 2017, when the Scottish Government published its Mental Health Strategy 2017–2027. This report is in four parts: Page 24 of 180
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Introduction 9 • Part 1. Access to mental health support and services • Part 2. Progress towards improving mental health services • Part 3. How well resources for adult mental health are managed • Part 4. Plans and strategic direction. 7. Our findings and recommendations are based on evidence gathered through document review, data analysis, interviews and focus groups. We also carried out more in-depth fieldwork in three geographical areas to better understand local pressures and challenges, and to highlight areas of good practice. These areas were: Grampian – Aberdeen City, Aberdeenshire and Moray; Lanarkshire – North Lanarkshire and South Lanarkshire; and the Scottish Borders. Appendix 1 sets out more detail on our audit methodology. 8. We carried out three focus groups with people with lived experience of mental health problems. We have included quotes from these focus groups throughout the report to help illustrate our audit findings. We would like to thank the participants of these focus groups, and Vox Scotland and the Health and Social Care Alliance Scotland for facilitating the focus groups. 9. The audit focused on mental health support and services for adults in Scotland. The audit was not able to look in detail at specific mental health conditions, or significant topics that require distinct, specific types of support, such as: • transitions between services for children and young people to adult mental health services • dementia care • mental healthcare for prisoners. 10. The independent review of mental health law in Scotland published its final report in September 2022.5 The Scottish Government published its response to the recommendations in June 2023.6 This may lead to changes in mental health law, but in this audit we have examined mental health services as they currently stand. Page 25 of 180
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101. Access to mental health support and services 1. Access to mental health support and services The support that people need for their mental health varies considerably 11. Mental health problems are very common and have a considerable impact on people’s lives. These problems can vary from poor mental wellbeing and periods of emotional distress to severe and persistent, diagnosable mental illness. Many factors affect people’s mental health including genetics, life experiences, upbringing and environment. For instance, experiencing poverty, homelessness, and living in poor-quality housing all increase the risk of having mental health problems (paragraph 37). 12. The support that people need can also vary considerably, and not all mental health problems require a medical response. Adults access mental health support and services in a variety of settings. Exhibit 1 (page 11) outlines some of the main types of mental health support available in Scotland, although the services available vary throughout the country. 13. The system is complex (paragraphs 56–57). Services are provided by HSCPs, NHS boards, councils and the charity and voluntary sectors. Integration Joint Boards (IJBs) are responsible for planning, commissioning, and monitoring adult mental health services provided in the community and in hospitals. Some IJBs are also responsible for secure mental health services, with NHS boards having that responsibility in other areas. Page 26 of 180
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1. Access to mental health support and services 11 Exhibit 1. Examples of mental health support in Scotland Support for mental health problems varies from self-help to support mental wellbeing, through to highly specialised treatment for severe and enduring mental illnesses. Patient journey Prevention and mental wellbeing – Self-help Support for the population’s mental wellbeing. Types include: • Promotion of mental wellbeing • Websites such as NHS inform and Clear Your Head • Helplines such as Samaritans and Breathing Space • Community-based activities and peer support groups • Wider support such as employability and homelessness services. Primary care – Mostly self-referral Usually the first points of access for people seeking help for their mental health. Types include: • Appointments with GPS and other primary care staff • NHS 24 Mental Health Hub • Some psychological therapies • Distress Brief Interventions Case study 1. Secondary care – Requires a referral from primary care Treatment for people with longer-term or complex mental health conditions that cannot be managed by their GP or other primary care services. Types include: • Psychiatry services • Psychology services • Inpatient mental healthcare • Community mental health services • Crisis resolution services. Tertiary care – Highly specialised treatment Highly specialised treatment for people with complex mental illnesses that cannot be managed by primary or secondary services. Types include: • Forensic psychiatry – for people who have been, or are at risk of being, violent • Specialist perinatal mental health services • Specialist clinics for specific disorders such as eating disorders, mood disorders and personality disorders. Source: Audit Scotland Page 27 of 180
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1. Access to mental health support and services 12 The Scottish Government, IJBs and others have insufficient data to fully understand demand for mental healthcare 14. Comprehensive, good-quality data is essential for assessing demand and planning services. Information about demand for mental healthcare in Scotland only covers people already accessing, or trying to access, some mental health services. The Scottish Government estimated that only one in three people who would benefit from treatment for a mental illness was receiving it.7 This means there is potentially much higher demand for mental health support and services than the available data shows. For instance: • Data is not available to determine how many people have severe and enduring mental health conditions in Scotland.8 • Information is not available to accurately assess demand for mental health support in primary care in Scotland, but it is likely that demand is high. In 2018, a survey of more than 1,000 GPs across England and Wales estimated that 41 per cent of appointments relate to mental health.9 • Community mental health teams (CMHTs) provide specialist mental health services, but information on demand, such as referrals and caseloads, is not routinely collected. • No information is available that shows demand for psychiatric services. The number of appointments taking place is published, but no information is available on the number of referrals, the number of people on waiting lists, how long people are waiting for treatment or the length of treatment. • The quality, completeness and consistency of NHS boards’ submissions to the psychological therapies data set vary significantly, affecting the robustness of information that is available. There are indications that demand for mental healthcare has increased 15. The Covid-19 pandemic had a detrimental impact on the population’s mental health. Results from the Scottish Health Survey showed that mental wellbeing among adults was lower in 2021 than in 2019, and that 22 per cent of adults may have a psychiatric disorder, an increase from 17 per cent in 2019.10 16. Referrals to psychological therapies and admissions to inpatient mental healthcare have remained broadly stable since 2017/18. But other measures show that demand for mental healthcare has increased: • The number of people detained using the Mental Health Act because of an urgent need for treatment for a mental health Page 28 of 180
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1. Access to mental health support and services 13 disorder increased from 104 to 120 per 100,000 people between 2017/18 and 2021/22. It peaked in 2020/21 during the pandemic.11 • The number of police incidents relating to mental health increased by 62 per cent between 2018 and 2022, from 14,394 incidents to 23,259.12 13 • The Scottish Association for Mental Health (SAMH) reported a 50 per cent increase in demand for its information service during the pandemic.14 • The number of calls to NHS 24’s 111 Mental Health Hub increased by 436 per cent between 2019/20 and 2022/23, from an average of 2,136 calls per month, to an average of 11,457 calls per month. The increase can partly be explained by its expansion from operating eight hours per day to 24 hours per day from July 2020.15 17. Referrals for psychological therapies decreased temporarily at the start of the pandemic, but this could have been caused by a reduction in the availability of services during this time and fewer people contacting their GPs. ‘Waiting lists even pre-Covid were really ridiculous and at the moment waiting lists are horrendous... a lot of services have been withdrawn or shut down, it’s leaving a lot of really vulnerable people with no help and support.’ Focus group participant Accessing mental health services is slow and complicated for many people 18. Many people find accessing mental health and wellbeing services to be a slow and complicated process. SAMH surveys found that six out of ten people who had tried to access mental health support from their GP or specialist services since March 2021 reported facing challenges.16 19. People typically access mental health support in Scotland by visiting GPs for support and onward referral to specialist services. This can be slow, and many people who need mental health support do not meet the thresholds for specialist services. Moreover, the availability and awareness of other support, such as primary care mental health services (paragraphs 27–33), third sector services and peer support, varies across Scotland. Page 29 of 180
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1. Access to mental health support and services 14 ‘People seem to go for appointments and be put onto a pathway. That pathway either comes abruptly to an end, through no fault of anyone’s – perhaps funding runs out, or one pathway leads to another pathway, but nothing seems to lead anywhere.’ ‘I was on the waiting list for two years to see a psychologist. I wasn’t aware if there were any other people within the NHS I could see or if there was any other help, I was just told about the psychologist.‘ ‘I do really like working with my clinical psychologist but in terms of getting the support in the first place and the waiting times, I found that very, very difficult and it was not a good experience for me.‘ Focus group participants 20. People can get information about mental health services through websites such as NHS Inform – Scotland’s national health information service – or through third sector organisations such as Samaritans or SAMH. But people can find accessing this information difficult, particularly when they are experiencing poor mental health. Results from a SAMH survey estimated that 800,000 adults in Scotland do not know where to go to get help for their mental health.17 ‘I’ve asked and asked and I’m getting no help anywhere whatsoever.’ ‘I think I know more about what’s out there than my GP does, even though she’s sympathetic and she does her best to help. I just don’t know what’s out there or what can best help me.’ ‘I got referred to a community psychiatric nurse but got a letter a couple of weeks later to say that it had been rejected so I was left in the middle of the pandemic looking at all these services online just totally overwhelmed.’ Focus group participant Page 30 of 180
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1. Access to mental health support and services 15 The Covid-19 pandemic led to a reduction in access to services, particularly face-to-face support 21. Access to mental health services decreased during the Covid-19 pandemic. The number of appointments across a range of mental health services dropped significantly during the first few months of the pandemic (Exhibit 2, page 16). For most services, this has since recovered to at least pre-pandemic levels. For general psychiatry however, the number of appointments has decreased again since mid- 2021, after an increase between July 2020 and June 2021. Data is not available to explain this decrease (paragraph 14), for example, whether it is caused by decreasing demand or capacity. The Royal College of Psychiatrists told us that demand for psychiatry services is high. 22. During the pandemic, face-to-face support was offered only where clinically necessary. SAMH published two reports covering the experiences of people trying to access mental health support during the pandemic. The first one found that there was widespread loss of face-to-face support during the pandemic.18 The second report, based on surveys carried out in late 2021 and early 2022, found that most mental health support was still being provided remotely.19 In 2022, most psychological therapies appointments took place digitally or by telephone (Exhibit 3, page 17). 23. Views about receiving mental health care and treatment remotely are mixed. SAMH reported that more than three-quarters of people felt that face-to-face support was far better than remote options, both telephone and video consulting.20 We found that remote options worked well for some people in our focus groups, but not for others. ‘You’ve got vulnerable people who are desperate to access treatment, but they don’t want to access treatment because it’s being done online when they don’t want to do it online. You have to give people the choice.’ ‘I did find it good because with my disability it’s really hard to leave the house. So in some ways it was actually really good to have it and still physically see them and talk to them. But it’s also difficult because of connection issues.’ ‘Being online can be good because it does allow you a bit more flexibility.’ Focus group participants Page 31 of 180
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1. Access to mental health support and services 16 Exhibit 2. Mental health services activity Activity across a range of mental health services decreased during the first few months of the Covid-19 pandemic but most have since returned to at least pre-pandemic levels. October to December 2017 March to June 2020 October to December 2022 Percentage change General psychiatry 52,794 52,276 -1% Psychiatry of old age 15,574 11000 14000 17000 16,512 6% Forensic psychiatry 627600 850 1100 1,000 59.5% April to June 2017 March to June 2020 January to March 2023 Psychological therapies 12,02812000 16000 20000 19,177 59.4% 2016/17 2019/20 2021/22 Inpatient mental healthcare 44,310 49,180 11% Note: Psychological therapies only includes new appointments; psychiatry specialties include new and return appointments. Source: Audit Scotland and Public Health Scotland Page 32 of 180
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1. Access to mental health support and services 17 Exhibit 3. Psychological therapies appointment types in 2022 The known proportion of appointments taking place remotely varies widely across NHS boards. Scotland NHS Ayrshire and Arran NHS Borders NHS Dumfries and Galloway NHS Fife NHS Forth Valley NHS Grampian NHS Greater Glasgow and Clyde NHS Highland NHS Lanarkshire NHS Lothian NHS Orkney NHS Shetland NHS Tayside NHS Western Isles Face-to-face Telephone or Video 86% 16% 29% 36% 52% 49% 41% 42% 32% 31% 6% 9% 40% 64% 59% 14% 84% 71% 48% 51% 56% 58% 68% 21% 94% 36% 41% 74% 55% 56% Note: NHS Ayrshire and Arran includes data from July to September 2022. Some appointment types are unknown, and so totals may not add up to 100 per cent. NHS Lothian has a particularly high rate of unknown appointment types because of limitations with how their systems recorded this information. The full list of data quality issues can be found in Public Health Scotland’s Psychological Therapies Waiting Times data quality publication (March 2023). Source: Audit Scotland and Public Health Scotland Page 33 of 180
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1. Access to mental health support and services 18 Remote options have increased access but not all NHS boards routinely offer face-to-face appointments as a choice 24. The Scottish Government has committed to expanding digital mental health services and self-help resources and increasing access to evidence-based psychological therapies and other support.21 There are also examples of new services being set up that will be provided entirely remotely, such as the Renew service in the Scottish Borders. Renew is a remote primary care service that offers assessment and treatment for patients experiencing mild to moderate anxiety and depression. 25. The Scottish Government and COSLA’s Digital Health and Care Strategy (2021) states that people will not be forced to use a digital service if it is not right for them. However, NHS boards reported a range of factors that affected the type of appointment that was offered, including the availability of clinical space, clinical need, and whether people are affected by digital exclusion.22 26. Increasing access to mental health support and services is necessary and welcome. But the Scottish Government, NHS boards and others who provide services must ensure that people are routinely given a choice about whether they access services remotely or face-to-face. Increasing the availability of mental health and wellbeing services in primary care is essential for improving access 27. GPs and wider teams based in primary care play a key role in providing mental healthcare. An estimated 41 per cent of GP appointments involve a mental health issue (paragraph 14). Increasing the availability of mental health and wellbeing services in primary care could help to prioritise prevention and early intervention and decrease pressure on specialist services. ‘My GP has done more for me than most psychiatrists have, and she’s not a trained psychiatrist. That tells me it’s not necessarily to do with the training and the qualifications that these people have.’ Focus group participant 28. The Royal College of General Practitioners told us that GPs need more support to address the mental health needs of patients. At March 2022, only 45 per cent of GP practices across Scotland reported having full access to mental health workers, and 66 per cent reported having full access to community link workers.23 This information was not available in the 2023 publication – GP practices were only asked whether they had any access to these workers, this could vary from minimal access to Community link workers work with GP practices to help patients access non- medical support for personal, social, emotional and financial issues. Page 34 of 180
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1. Access to mental health support and services 19 full access. At March 2023, 17 per cent of GP practices across Scotland reported having no access to mental health workers, and 20 per cent reported having no access to community link workers (down from 22 per cent and 24 per cent respectively in March 2022).24 ‘My GP surgery does have a counsellor who works alongside the GP practice but it’s mainly working with people who have addiction issues, rather than people with other emotional or psychological issues. More multi-disciplinary team support like that in GP practices would help free up NHS hospital services for people who are more seriously ill.’ Focus group participant 29. The Scottish Government has committed to ensuring that every GP practice has access to a mental health and wellbeing service by 2026.25 In January 2022, the Scottish Government issued planning guidance to IJBs on developing mental health and wellbeing in primary care services (MHWPCS).26 30. The planning guidance outlined that MHWPCS should offer assessment, advice, support, and treatment, provided by a multidisciplinary team. A key part of this guidance that would set out how to measure and evaluate outcomes from MHWPCS was expected to be published in April 2022, but it has still not been published. The Scottish Government should publish this as soon as possible. This is important, as it will allow data to be collected on how these services are improving people’s mental health and whether they are supporting the aims of the General Medical Services contract to refocus GPs’ roles as expert medical generalists.27 31. The planning guidance states that funding for MHWPCS is intended mainly for employing new staff and not for providing additional space to accommodate teams. Two of our in-depth fieldwork sites, North Lanarkshire and Moray, have expressed concerns about a lack of accommodation for their mental health primary care teams. This makes it difficult for staff to complete routine tasks, such as seeing clients and managing caseloads. 32. The Scottish Government’s Emergency Budget Review (EBR) delayed progress towards increasing the number of mental health workers and link workers in primary care. It cut funding for improving primary care services by £65 million and mental health funding by £38 million in 2022/23.28 The Scottish Government should publish a costed delivery plan that sets out the funding and workforce that will be needed to achieve its aim of establishing sustainable and effective MHWPCS across Scotland by 2026. Page 35 of 180
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1. Access to mental health support and services 20 33. Initiatives across Scotland have successfully increased both in-person and remote access to mental health support in primary care. Examples include the Distress Brief Intervention (DBI) programme (Case study 1, page 21) and the NHS 24 111 Mental Health Hub. The hub was established in 2019 but expanded considerably during the Covid- 19 pandemic. Accessing mental healthcare is disproportionately more difficult for some people 34. Some people, such as people with complex care needs and people with severe and enduring mental health problems, experience inequality in accessing mental healthcare. For example: • The Mental Welfare Commission reported that some GPs found that referrals to psychiatry services were rejected in the case of patients with substance misuse problems. GPs were advised to refer these patients to addictions services, even when the patient’s main problem is their mental illness.29 • The Scottish Mental Illness Stigma Study found that people with severe and enduring mental health problems experienced stigma and discrimination when trying to access mental healthcare. For instance, 71 per cent of respondents felt that they had been unfairly denied help for their mental illness because of stigma.30 35. Some groups also face practical barriers to accessing mental health and wellbeing services. For instance, access to specialist services in sign language, for people with hearing problems, is limited.31 Mental health services are less accessible for minority ethnic groups because of language and cultural barriers to communication.32 Long journeys and limited internet connectivity can make access for rural communities difficult. ‘If you live in a rural community or outside of a catchment area you have no services available. You try to access the services where they are available but you’re up against a brick wall.’ ‘Mental health services should be available to everybody when they need it. I wouldn’t go around with a broken leg for 20 years, it just wouldn’t happen, but you can have mental ill- health for that amount of time. It shouldn’t be any different. Mental health should be treated the same as any other part of your body, which just now it isn’t.’ Focus group participants Page 36 of 180
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1. Access to mental health support and services 21 Case study 1. The Distress Brief Intervention (DBI) programme The DBI programme is effective at supporting people experiencing distress. The Scottish Government developed the DBI programme as it recognised that there was a lack of support available for people experiencing distress, who did not require an emergency medical response. The Scottish Government tested the DBI programme between November 2016 and March 2021 across four sites: Aberdeen, Inverness, Lanarkshire, and the Scottish Borders. The DBI programme takes a two-level approach. Level 1 interventions are provided by trained front-line staff from primary care, Police Scotland, the Scottish Ambulance Service (SAS), Accident and Emergency departments (A&E) and NHS 24. Level 1 interventions aim to help people to cope with their immediate distress and offers the opportunity to be referred within 24 hours to a Level 2 intervention. Level 2 interventions are provided by trained third sector staff who work with individuals, for up to 14 days, to provide support and a personalised action plan for distress management. During the intervention, staff can help people access other services for follow-up support. An independent evaluation of the DBI programme pilot reported that DBIs work well for most people. Distress decreased during the DBI for 90 per cent of people. A key strength of the DBI programme was its ability to be tailored to individuals’ needs, and the Scottish Government’s DBI central team was essential to the programme’s success. This team coordinated services and communication, and enabled problem-solving. The evaluation also identified some challenges, including that some existing operational systems could not include DBI referrals. Some staff of existing services doubted the added value of the DBI programme and saw it as a replacement for more specialist services that they considered of greater value. Convincing existing services of the value of the DBI programme is likely to be an ongoing challenge during wider rollout, and effective engagement with them will be important for success. The DBI programme is now being rolled out nationally. The Scottish Government expects NHS boards to have embedded the DBI programme by March 2024. However, the Scottish Government will no longer provide local areas with dedicated funding for the programme, so partners will be expected to fund this using existing budgets. This creates the risk that the quality and availability of the DBI service could vary across the country, as partners manage increasingly tight budgets. The Scottish Government and partners involved in providing DBIs should implement the recommendations of the independent evaluation as part of the programme’s roll-out across Scotland. Source: Audit Scotland and Scottish Government Page 37 of 180
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1. Access to mental health support and services 22 36. People with mental health problems also experience inequality in accessing physical healthcare. People with lifelong mental illness have a 15–20-year-shorter life expectancy because of physical health problems.33 The Royal Pharmaceutical Society reported that reasons for this include poorer access to, or uptake of, physical healthcare.34 Mental health inequality is a long-standing problem and progress addressing this has been slow 37. Many inequalities in mental health arise because of inequalities in society. For instance, the Mental Health Foundation reported that experiencing poverty, homelessness, living in poor-quality housing and having limited access to green space all increase the chances of having a mental health problem.35 Experiencing prejudice, discrimination, bullying and social exclusion also increases the risk. 38. Mental health inequalities are a long-standing problem and have been made worse by the Covid-19 pandemic and cost-of-living crisis.36 The Mental Health Foundation reported that the cost-of-living crisis could have a negative effect on mental health on a similar scale to the Covid-19 pandemic. Our Local government in Scotland overview 2023 highlighted that persistently high levels of poverty and financial hardship is increasing pressure on local services, at a time when councils’ finances are under severe strain. Some people have a much greater risk of experiencing poor mental health. Exhibit 4 (page 23) provides some examples of this. Page 38 of 180
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1. Access to mental health support and services 23 Exhibit 4. Examples of mental health inequalities Some people are at greater risk of experiencing poor mental health. Deprivation People living in the most deprived areas are three times more likely to receive inpatient mental healthcare than people living in the least deprived areas. Deprivation 39% of emergency detentions using the Mental Health Act happened to people from the 20% most deprived areas of Scotland Long-term illness Mental wellbeing is lower among people with a long-term illness that limits their activities than for people with no long- term illness. Young people Younger people are more likely to experience anxiety – 22% of people aged 25-34 years reported experiencing at least two symptoms of anxiety, compared with 6% of people aged 65-74 years. LGBT+ 54% of LGBT+ people have a self- reported mental health problem. Learning disabilities Mental ill health is significantly more prevalent in adults with learning/ intellectual disabilities than in the general population. Note: In the Scottish Health Survey 2021, long-term conditions are defined as a physical or mental health condition or illness lasting, or expected to last, 12 months or more. Source: Audit Scotland, Mental Health Foundation, See Me, Mental Welfare Commission, Scottish Government, NHS Greater Glasgow and Clyde, NHS Lothian and Public Health Scotland, Scottish Learning Disabilities Observatory Page 39 of 180
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1. Access to mental health support and services 24 39. The Scottish Government recognises the importance of addressing inequalities in mental health, but the impact of its commitments is not always clear: • Its Mental Health Strategy 2017–2027 highlights the importance of taking a human rights-based approach (HRBA) to the actions set out in the strategy and improving access to mental health services for people most in need. But the Scottish Government is not clear about how it will adopt a HRBA in practice. For example, there is limited reference to incorporating the voices of lived experience throughout the commitments in the strategy. • Its Mental Health Transition and Recovery Plan (MHTRP), published in October 2020, aims to tackle inequalities through actions targeting employment, socio-economic inequalities and women and girls’ mental health.37 However, the plan did not outline timescales for all the actions and the Scottish Government has not carried out a review of progress towards meeting the plan’s objectives. 40. In 2021/22 the Scottish Government allocated £21 million, through the Communities Mental Health and Wellbeing Fund (CMHWF), to support some of the aims of the MHTRP. Third Sector Interfaces were responsible for distributing this funding. One of the key aims of the CMHWF is to prioritise ‘at risk’ groups, such as women, adults with a long-term health condition or disability and people facing socio-economic disadvantage. The Scottish Government allocated a further £15 million for 2022/23 and £15 million for 2023/24. 41. The Scottish Government has made good progress in considering mental health equalities and human rights in policy and practice: • It established a Mental Health Equalities Forum in February 2021, which aimed to ensure that equality and human rights are a central part of mental health policy and provision of services. The forum has contributed to key pieces of work, such as the CMHWF. • It also developed internal equality champions in its Mental Health Directorate to raise awareness of mental health inequalities. It has not yet, however, shown that mental health inequalities are being considered enough outside of the Mental Health Directorate. The social factors that lead to poor mental health must be addressed to decrease mental health inequalities 42. Mental health services cannot address mental health inequalities alone. They need to work more closely with other sectors, such as housing, employment, and welfare support, to address and prevent the causes of poor mental health. To do this effectively, these sectors need to develop shared goals and targets, share data and information, and The Scottish Government’s Mental Health Directorate leads on mental health policy and on delivering the Scottish Government’s commitments relating to mental health. Page 40 of 180
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1. Access to mental health support and services 25 jointly fund services. This work should be informed by people with lived experience of mental health issues and the third sector. ‘People develop addictions or mental health issues because of unemployment or poverty or other social issues. It’s important to recognise the more holistic influences on our mental, emotional, and physical health and wellbeing and start to address them properly.’ Focus group participant 43. Primary care services have an important role to play. It is vital that work to increase MHWPCS (paragraphs 27–33) involves considering how these services will work jointly with other sectors to provide holistic, person-centred support. Scotland could also learn from good practice around the world, such as the person-centred model used in Trieste, Italy (Case study 2, page 26). 44. The Scottish Government and COSLA recognise the need for a more collaborative approach. In June 2023, they signed up to a new agreement that aims to support better joint working.38 It sets out how the Scottish Government and councils will work together, including by focusing on achieving better outcomes, collaborating as early as possible on relevant policy areas and increasing the flexibility of how funding can be spent on local priorities. This agreement has the potential to enable a more joined-up approach in areas such as mental health, but it is too soon to see how well this will work in practice. Page 41 of 180
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1. Access to mental health support and services 26 Case study 2. Trieste model of mental healthcare The Trieste model provides timely, person-centred and holistic mental healthcare. The public, community-based mental healthcare system in Trieste, Italy, takes a person-centred, human rights-based approach to care. It has been recognised by the World Health Organization as an example of best practice.39 40 The main point of entry into mental health services in Trieste is through a network of community mental health centres (CMHCs). They operate 24 hours a day and provide holistic, comprehensive mental health support for anyone who asks for it. There are no waiting lists and no referral criteria – anyone can access this support. CMHCs provide services including walk-in clinics, home treatment, day care, psychological and social support, medication, overnight crisis care, rehabilitation services and residential services including supported housing. Use of inpatient care is very low, people are supported in their own homes and neighbourhoods as much as possible. The Trieste model recognises the value of including people in daily activities in their communities and of interpersonal relationships. CMHCs have links with other services, community organisations and peer and social networks, and connect people with education and employment opportunities and recreational activities. Each person using a CMHC is assigned a small multidisciplinary group of staff responsible for their care and support. Services are provided by a range of professionals, including psychiatrists, psychologists, social workers and nurses, and involve family members, friends, volunteers, and local organisations. People are actively involved in their own care. They help to develop personalised care plans, which consider a wide range of needs, not only clinical needs, including housing support, personal hygiene, finances and work. The model has improved user satisfaction and health outcomes for people with mental health conditions. Suicide rates and involuntary admissions have fallen, and stigma about mental health has decreased. The CMHC network is also significantly cheaper than the service provided before, costing just 37 per cent of the cost of the asylum it replaced. Source: Audit Scotland and the World Health Organization Page 42 of 180
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2. Progress towards improving mental health services 27 2. Progress towards improving mental health services Waiting times for psychological therapies have improved but NHS boards are still struggling to meet waiting times standards 45. Scotland’s performance against the national waiting times standard for patients referred to psychological therapies being seen within 18 weeks has improved from 76.5 per cent to 80.8 per cent between 2017/18 and 2022/23 (Exhibit 5, page 28). But it remains below the standard of 90 per cent. Despite an overall improvement in performance, the number of people who waited over a year to start treatment more than doubled from 1,171 people in 2017/18 to 2,742 in 2022/23. Numbers steadily increased from 2017/18, peaking in 2020/21, during the pandemic, at 3,837 people. 46. The proportion of people who waited over a year to start psychological therapies varies considerably between NHS boards. In 2022/23, 17.6 per cent of patients waited over a year in NHS Forth Valley, compared with zero per cent in NHS Lanarkshire and NHS Orkney. ‘It’s almost like you have to predict when you’re going to be ill. If you go to your GP and ask to be referred for something like talking therapies, you need help at that point not two years later.’ Focus group participant 47. The Scottish Government has been providing support to NHS boards to help them meet the psychological therapies waiting times standards, particularly to help them address long waits. It identified four NHS boards in spring 2022 in need of tailored support: NHS Forth Valley, NHS Grampian, NHS Highland and NHS Lothian. The Scottish Government told us that the tailored support for the identified boards had started but work in Grampian was delayed because of a vacant position of director of psychology (Case study 3, page 30). Page 43 of 180
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2. Progress towards improving mental health services 28 Exhibit 5. Psychological therapies waiting times performance: percentage of patients seen within 18 weeks 2017/18–2022/23 Most NHS boards have improved their waiting times performance since 2017/18 but are still struggling to reach the 90 per cent standard. Percentage point change 2017/18 2022/23 2017/18 to 2022/23 2021/22 to 2022/23 Scotland 76.5% 80.8% 4.2 -3.7 NHS Ayrshire and Arran 81.2% 87.6% 6.3 -2.3 NHS Borders 62.3% 84.3% 22.1 -1.3 NHS Dumfries and Galloway 72.7% 69.1% -3.6 -10.1 NHS Fife 70.2% 74.6% 4.4 -7.5 NHS Forth Valley 56.1% 67.7% 11.6 3.0 NHS Grampian 65.6% 68.8% 3.2 -15.1 NHS Greater Glasgow and Clyde 93.3% 86.8% -6.5 -5.4 Cont. Page 44 of 180
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2. Progress towards improving mental health services 29 Percentage point change 2017/18 2022/23 2017/18 to 2022/23 2021/22 to 2022/23 NHS Highland 85.3% 87.4% 2.1 -1.2 NHS Lanarkshire 81.6% 84.9% 3.2 0.8 NHS Lothian 69.5% 78.7% 9.2 0.2 NHS Orkney 60.2% 93.9% 33.6 19.1 NHS Shetland 56.3% 62.4% 6.1 13.0 NHS Tayside 59.6% 82.1% 22.5 -6.1 NHS Western Isles 89.6% 83.3% -6.3 -6.4 Note: From April 2019 NHS Ayrshire and Arran has been reporting on only psychological therapies as defined by Public Health Scotland, with wider services included before April 2019. NHS Greater Glasgow and Clyde, NHS Orkney and NHS Tayside did not submit all data for every month in 2017. The full list of data quality issues can be found in Public Health Scotland’s Psychological Therapies Waiting Times data quality publication (June 2023). Source: Audit Scotland and Public Health Scotland Page 45 of 180
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2. Progress towards improving mental health services 30 Case study 3. Grampian’s psychological therapies performance A review of psychological services across Grampian was delayed, but improvement work is now under way. Grampian’s performance against the psychological therapies waiting times standard has improved slightly, from 65.6 per cent of people being seen within 18 weeks in 2017/18 to 68.8 per cent in 2022/23. This is still lower than the Scottish average. Like in many other board areas, the number of people experiencing long waits in NHS Grampian increased between 2017/18 and 2022/23. In 2017/18, 25 people waited more than a year to be seen, increasing to 181 in 2022/23. Grampian has since made good progress with reducing long waits throughout 2023. A review of psychological services was delayed because the director of psychology position was vacant for two years, but this work has now started. The position has now been filled on an interim and part-time basis. The director of psychology from NHS Lothian is supporting the NHS Grampian interim director. NHS Grampian established a Psychological Therapies Improvement Board in September 2022 to monitor progress with Grampian’s psychological therapies improvement plan. The plan identified actions that needed to be taken to meet the national waiting times standard for psychological therapies, with a particular focus on addressing long waits. The plan highlighted several risks to achieving the waiting times standard, including demand pressures and recruitment and retention challenges, particularly for clinical psychologist posts. NHS Grampian also faced issues with the quality of its psychological therapies data. For instance, some areas were not entering details of psychological therapies appointments into the waiting times data set. NHS Grampian has been working to improve the quality of the data. For instance, it is rolling out a new system for recording and reporting activity data. It expects to complete this rollout by 2024. This will improve the reliability of the data and make it possible to monitor other things, such as length of treatment. Source: Audit Scotland, Public Health Scotland and NHS Grampian Page 46 of 180
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2. Progress towards improving mental health services 31 The Scottish Government does not measure the quality of mental healthcare or the outcomes for people receiving it 48. The Scottish Government does not measure the quality of services or outcomes for people receiving mental healthcare. For instance, it does not track whether services or interventions improve people’s mental health and wellbeing. There are some examples of local services measuring mental health outcomes, but this is not happening routinely across Scotland: • Aberdeenshire’s Mental Health Improvement and Wellbeing service uses a tool to assess progress in outcome measures including patients’ lifestyle, family and friends and feeling positive, following targeted work with a community link worker. • Lanarkshire’s Assessment Plus service uses clinical outcome measures, such as level of psychological distress, before and after the patient receives support from an assistant psychologist for up to four sessions. An internal evaluation found that it was effective in improving patients’ symptoms. 49. Scotland can learn from performance measures used elsewhere. For instance, NHS England uses a ‘recovery rate’ to assess a person’s experience of anxiety or depression after a talking therapy service, with the target that a minimum of 50 per cent of people who complete a course of treatment should recover.41 The Scottish Government lacks sufficient oversight of most adult mental health services 50. The Scottish Government does not have sufficient oversight of most adult mental health services because of a lack of information. The only national performance measure of adult mental health services is waiting times for psychological therapies. This means that insufficient focus is given to the wide range of mental health support and services that people with mental health problems rely on. 51. The Scottish Government recognises that psychological therapies waiting times do not provide sufficient information to assess how well adult mental health services are performing. It has been working to improve the way performance is measured and to improve the experiences of and outcomes for people accessing psychological therapies and secondary mental health services. To do this, it is developing the following: • National specification for psychological therapies and interventions (psychological therapies specification) – this aims to ensure that people who use these services receive the right information, care and support, at the right time, with the Page 47 of 180
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2. Progress towards improving mental health services 32 individual being involved in decisions. Measuring the quality of services is a key aim of the specification. • Quality standards for adult secondary mental health services – these aim to ensure that secondary mental health services meet the needs of everyone. The standards are focused on key themes including access to services; assessment, care planning, treatment, and support; moving between and out of services; workforce; and governance and accountability, that is, the way services are managed and who is accountable for this. 52. The psychological therapies specification and the quality standards are expected to be published in autumn 2023. The Scottish Government must work with NHS boards and HSCPs to embed these and start routinely publishing data on their impact on patients’ outcomes. 53. These pieces of work have the potential to improve transparency about how psychological therapies and secondary mental health services are performing. The Scottish Government must also improve its oversight of mental health support provided in primary care (paragraph 30) and by the third sector. Limited information about the performance of mental health services affects the extent to which IJBs are held accountable 54. The Scottish Government’s lack of oversight of most adult mental health services means that there is limited transparency and accountability nationally for how they are performing. Even for psychological therapies services, where more performance information is available than for most adult mental health services, the Scottish Government does not attribute accountability to the appropriate bodies. The Scottish Government holds NHS boards accountable, even though IJBs are responsible for planning, funding and overseeing the provision of these services, and operationally they are managed by HSCPs. For instance: • Public Health Scotland publishes psychological therapies data by NHS board area, meaning IJBs are not held publicly accountable for psychological therapies waiting times performance • the Scottish Government identified NHS board areas for tailored support, rather than IJB areas, that were struggling to meet waiting times standards • the Scottish Government provided funding so that all NHS boards could have a director of psychology who is professionally responsible for psychological therapies services. 55. The Scottish Government should work with NHS boards and IJBs to improve accountability arrangements, by scrutinising services Page 48 of 180
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2. Progress towards improving mental health services 33 performance at the appropriate level, and publishing performance data of mental health services, including psychological therapies waiting times, at HSCP level as well as NHS board level. This would: • allow people to see how mental health services in their local area are performing, making it easier to hold IJBs to account • make it easier to identify where additional support and resources are needed the most, for example if one HSCP area has consistently higher waiting times than others. Adult mental health services are fragmented, making it more difficult to develop person-centred services 56. Multiple organisations are involved in planning, funding and providing adult mental health services, including IJBs, HSCPs, NHS boards, councils and third sector organisations. Challenges that arise from this fragmented structure, including issues with information sharing and complicated governance and approval processes, make it more difficult to develop and provide person-centred services. 57. The arrangements for managing and providing adult mental health services in our in-depth fieldwork sites vary, but we identified some common challenges. Some of these challenges are not specific to mental health services. For example, representatives across our in-depth fieldwork sites told us the following: • The roles and responsibilities of health and social care partners are not always clearly distinct. This means that there is a lot of duplicate reporting through different governance and approval routes, which is inefficient, delays improvement projects, and delays patients’ access to appropriate support. • Sharing data and information between health and social care partners is a barrier and can cause significant delays to improvement projects in some areas. Problems arise when health and social care partners use different IT systems that are incompatible with each other. This makes truly integrated working more difficult. 58. Sharing data is a long-standing problem. In our 2018 report, Health and social care integration: Update on progress, we recommended that the Scottish Government address problems with data and information sharing, recognising that national solutions are needed. The Scottish Government has planned improvements as part of the development of the National Care Service, but these improvements will take several years to implement. 59. Case study 4 (page 34) summarises the progress made in Tayside since an independent inquiry into mental health services identified issues across a range of themes, including complex and unclear governance arrangements and challenging relationships between partners. Page 49 of 180
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2. Progress towards improving mental health services 34 Case study 4. Independent inquiry into mental health services at NHS Tayside Complex governance arrangements and challenging relationships between partners were identified in the independent inquiry of NHS Tayside’s mental health services. In September 2018, NHS Tayside commissioned an independent inquiry into mental health services, following widespread concerns raised in the Scottish Parliament in May 2018 regarding the accessibility, safety and standard of Tayside’s mental health services. In February 2020, the independent inquiry published its final report, which made 51 recommendations across five themes: • Strategic service design – services had focused on inpatient services and short-term issues, to the detriment of wider community services, and less priority had been given to early intervention and prevention. • Clarity of governance and leadership responsibility – governance arrangements for the planning and provision of services were complex and unclear. • Engaging with people – staff, including in the third sector, and patients and carers felt that they were not listened to or respected. • Learning culture – there was a culture of blaming and attributing fault rather than fostering a supportive environment for staff. • Communication – trust between partners, staff, patients, families, carers and communities had broken down. In October 2021, the Scottish Government appointed an independent oversight and assurance group to assess the progress towards addressing the issues that were identified. The group’s final report, published in January 2023, found that good progress had been made in some areas. It noted significant changes to the leadership of mental health services, with a new integrated leadership group that is working well. In addition, it found that reviewing and revising the three integration schemes across Tayside improved the clarity of health and social care partners’ roles and responsibilities for mental health services. The planning and commissioning for inpatient mental health services is delegated to the three IJBs, and one IJB has taken a leading role in coordinating this across Tayside. The report also outlined areas where little progress had been made, including an urgent need to improve governance and public performance reporting, and to develop greater trust with communities. Source: Audit Scotland, The Independent Inquiry into Mental Health Services in Tayside and the Independent Oversight and Assurance Group on Tayside’s Mental Health Services Page 50 of 180
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2. Progress towards improving mental health services 35 The Scottish Government’s progress towards implementing its Mental Health Strategy 2017–2027 is mixed 60. The Scottish Government’s Mental Health Strategy 2017–2027, published in March 2017, aims to ‘prevent and treat mental health problems with the same commitment, passion and drive as we do with physical health problems’. Of the 40 actions in the strategy, 25 relate to adult mental health. 61. The strategy has a clear ambition but the intended outcomes of most of the strategy’s actions are not clear. For instance, actions that commit funding or support do not make it clear what impact this funding or support is intended to have. Many actions do not include planned completion dates, which makes it difficult to assess whether the Scottish Government is on track to achieve them. 62. The Scottish Government has published three progress reports, the second of which was published in November 2019, just before the start of the Covid-19 pandemic. At this time, the Scottish Government reported that nine of the 25 actions relating to adult mental health had been completed. The Scottish Government is not clear in these progress reports about the impact of completing many of these actions or how they have contributed to achieving the overarching aim of the strategy. For instance: • Action 15: Increase the workforce to give access to dedicated mental health professionals to all A&Es, all GP practices, every police station custody suite, and to prisons. Over the next five years increasing additional investment to £35 million for 800 additional mental health workers in those key settings. By April 2022, 958.9 whole time equivalent (WTE) staff were recruited using Action 15 funding, exceeding its target. The Scottish Government is not, however, able to demonstrate that this has achieved the ambition of giving all A&Es, every police custody suite, and prisons, access to dedicated mental health staff. It did not achieve the aim in relation to all GP practices. In March 2022, 22 per cent of GP practices in Scotland had no access to mental health workers.42 • Action 29: Work with partners who provide smoking cessation programmes to target those programmes towards people with mental health problems. Guidance, developed by Action on Smoking and Health (Scotland), was issued to all NHS boards, and training was being provided for staff. Progress reports do not make clear what difference this has made to the number of people with mental health problems who smoke. Page 51 of 180
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2. Progress towards improving mental health services 36 • Action 38: Develop a quality indicator profile in mental health which will include measures across six quality dimensions – person-centred, safe, effective, efficient, equitable and timely. The quality indicator profile was launched in 2018. The second progress report committed to regularly report on all 30 quality indicators by January 2021. In the latest release in April 2023 however, just 19 indicators were published, and just 12 of those included updated data. The publication is marked as experimental and there are several data quality problems. It is not clear when these indicators will be sufficiently robust and regularly reported. 63. In some cases, the Scottish Government has gone further than its commitments in the 2017–2027 strategy. For instance, the Scottish Government has made a lot of progress in improving perinatal mental health services across Scotland (Case study 5, page 37). 64. The Covid-19 pandemic affected the progress and priorities of the strategy. The Scottish Government published its MHTRP in October 2020. This included more than 100 actions, including updated outstanding actions from the 2017–2027 strategy. It is not clear what progress has been made towards the commitments in the MHTRP (paragraph 39). In its third progress report, published in March 2021, the Scottish Government outlined five actions from the 2017–2027 strategy that it continued to prioritise during the pandemic. Three of these relate to adult mental health. Page 52 of 180
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2. Progress towards improving mental health services 37 Case study 5. Perinatal and infant mental health Access to perinatal and infant mental health support has improved since 2019. Perinatal mental health problems are very common and include a wide range of conditions, from postnatal depression to postnatal psychosis. They are estimated to affect up to one in five mothers, and one in ten fathers. Ten to 22 per cent of babies and young children are also estimated to experience mental health problems. In March 2019, the Scottish Government committed £50 million, across four years, to improve perinatal and infant mental health services in Scotland. The Perinatal and Infant Mental Health Programme Board was established to oversee and manage this investment until 2023. By December 2022, over £18 million had been allocated to fund 23 new perinatal and infant mental health services and expand four existing services. A further 11 services were in development. The Scottish Government has not published information on the remaining £32 million. From 2023, NHS boards will receive £8 million in recurring funding for these services. In October 2020, the Scottish Government launched the Perinatal and Infant Mental Health (PIMH) fund. This fund provided 34 charities with a total of £2.5 million to provide one-to-one and group-based support to parents, carers, and new babies between October 2020 and March 2023. An additional £1 million has been committed for 2023/24. Feedback from Inspiring Scotland from early 2022 showed that the PIMH fund is helping charities make a difference in people’s lives: • 5,444 people have been supported • 86 per cent of people said that they were less isolated • 77 per cent of people felt better able to meet the needs of their infants and children • 80 per cent of parents and carers received information or training about building a warm relationship with their infants. Although the availability of perinatal and infant mental healthcare has improved across Scotland, a 2023 report from the Maternal Mental Health Alliance found that only two out of 14 boards currently meet UK-wide quality standards for specialist perinatal mental healthcare. Since the Programme Board formally ended in March 2023, it is unclear how future service improvements will be monitored. Source: Audit Scotland, Scottish Government, Inspiring Scotland, and the Maternal Mental Health Alliance Page 53 of 180
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3. How well resources for adult mental health are managed 38 3. How well resources for adult mental health are managed Adult mental health spending has increased since 2017/18 65. In 2021/22, NHS boards reported that they spent £1.2 billion on adult mental health services, a 16 per cent increase in real terms since 2017/18 Exhibit 6.43 In 2021/22, councils reported that they spent £224.7 million on adult mental health services, a 14 per cent increase in real terms since 2017/18. 66. These figures do not include spending by NHS 24 and SAS. NHS 24 recorded that it spent £10.8 million in 2022/23, a 472 per cent increase since 2017/18 in real terms.44 SAS recorded that it spent £570,877 in 2021/22, a 253 per cent increase since 2019/20 in real terms.45 NHS 24 and SAS spending on mental health has increased significantly in recent years because they have expanded the mental health services that they provide. The estimated cost to policing of incidents relating to mental health in Scotland is £14.6 million per year.46 Exhibit 6. NHS boards spending on adult mental health services 2017/18–2021/22 Spending on adult mental health services has increased in real terms. 2017/18 2018/19 2019/20 2020/21 2021/22 0 200 400 600 800 1000 1200 £1.04bn £1.08bn £1.11bn £1.19bn £1.2bn £ million Note: A small proportion of the totals presented include spending on children and young people’s mental health; information is not available to split this spending between child and adult services. Spending data for clinical psychology is not available for 2020/21 and 2021/22, so is not included in totals for those years. This accounted for five per cent of total spending in 2019/20. Source: Audit Scotland and Public Health Scotland Page 54 of 180
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3. How well resources for adult mental health are managed 39 67. The Scottish Government has set the target that, by 2026, ten per cent of front-line health spending by NHS boards should be on mental health services (paragraph 92). In their 2023/24 Annual Delivery Plans, NHS boards were required to include their current percentage of frontline spending on mental health, and their planned trajectory towards the ten per cent target. However, NHS boards highlighted challenges in completing this work. For instance, the Scottish Government did not define front-line spending and mental health spending in guidance to NHS boards, so boards were not clear about what spending should be included. Further work is therefore taking place to collect and collate the information from NHS boards. Limited data and inconsistency in how spending is categorised make it difficult to track spending on adult mental health 68. Long-standing issues with the availability, consistency and quality of data make it difficult to track spending on adult mental health. For instance, there is variation in the way that mental health spending is reported, and detailed spending data has not been available since 2019/20 because of pressures caused by the Covid-19 pandemic. These issues need to be addressed. More detail about these issues can be found in Appendix 2. 69. Public Health Scotland should include spending by all services that provide adult mental healthcare in its reporting of NHS spending on adult mental health. This should include spending on clinical psychology and spending by NHS 24 and SAS. This will enable the Scottish Government to report more accurately on progress towards meeting its commitment to increase spending on mental health. ‘There’s all this information about X amount of money has been allocated to whatever service it is, and it sounds like an astronomical figure and yet you wonder how that money is spent and where that money goes, and what accountability there is for those spending decisions.’ Focus group participant The Scottish Government has significantly increased funding for mental health and wellbeing 70. Between 2017/18 and 2023/24, the Scottish Government’s Mental Health Directorate budget increased significantly, from £63.6 million to £290.2 million, a 356 per cent increase in real terms (Exhibit 7, page 40). This budget is used to fund national programmes and commitments, such as the Scottish Mental Health Law Review and the Mental Health Recovery and Renewal Fund. Page 55 of 180
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3. How well resources for adult mental health are managed 40 Exhibit 7. The Scottish Government’s Mental Health Directorate budget 2017/18–2023/24 in real terms The Scottish Government’s Mental Health Directorate budget has increased substantially. 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 2023/24 0 50 100 150 200 250 300 Real terms funding Funding reduction from Emergency Budget Review £63.6 £82.5 £97.9 £130.4 £296.8 £258.6 £290.2 £ million Note: Mental health funding reduced by £39 million in real terms in 2022/23 (£38 million in cash terms) as part of the emergency budget review. Source: Audit Scotland and Scottish Government 71. The Scottish Government allocated £120 million Recovery and Renewal funding in 2021/22 to support the commitments in the MHTRP. Examples of this include: • £21 million for supporting community mental health and wellbeing through the CMHWF (paragraph 40) • £9 million for psychological therapies • £4.5 million for emergency Covid funding for eating disorders • £1.5 million for mental health and wellbeing services in primary care. 72. Initially, this funding was provided on a one-off basis. This made it difficult to fill vacancies as many positions were available only on a fixed-term basis, which can be less desirable to applicants. The funding has now been incorporated into the recurring mental health budget and represents a significant increase in overall funding for mental health. 73. In November 2022, the Scottish Government announced a £38 million reduction in its Mental Health Directorate’s budget for 2022/23 as part of the EBR (paragraph 32). This means that the budget was 13 per cent lower, in real terms, than in 2021/22. The Scottish Government is considering the implications of these funding cuts on work to achieve waiting times standards, and on progressing the commitments within the new mental health strategy. Page 56 of 180
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3. How well resources for adult mental health are managed 41 Spending on medicines used for mental health has decreased over the last five years 74. NHS boards report on five types of medicines that are used to treat mental health problems. These are hypnotics and anxiolytics; drugs used in psychosis and related disorders; anti-depressant drugs; drugs for attention deficit hyperactivity disorder; and drugs for dementia.47 Spending on mental health prescribing should be interpreted with caution, as medicines used for mental health problems can also be used to treat other conditions. 75. Spending on mental health medicines within the community fell in real terms from £117.7 million in 2017/18 to £90.4 million in 2021/22.48 49 More items were dispensed in 2021/22, meaning that the fall in spending was caused by a decrease in the cost of these medicines. For instance, the cost per item for antipsychotics and related drugs was significantly higher in 2017/18 because of shortages of these medicines. Anti-depressants account for 43 per cent of total spending on mental health prescribing, a total of £38.8 million in 2021/22. Recruitment difficulties and high vacancy and turnover rates are putting pressure on the mental health workforce 76. Between 2017 and 2023, the WTE workforce increased for mental health nursing and psychological services roles, but the number of WTE general psychiatrists decreased (Exhibit 8, page 42). In addition, the estimated shortfall in WTE mental health officers (MHO) doubled between 2017 and 2021.50 77. Pressure on staff is increasing because of high vacancy and turnover rates and difficulties in filling vacancies Exhibit 8. Recent decreases in vacancies are only partly explained by increases in the number of WTE employed. NHS boards are having to compete with one another to recruit people for these roles. For example, there is a national shortage of psychologists and vacancies for general psychiatry consultants are the highest of all medical and dental consultant roles in Scotland. The Royal College of Psychiatrists also raised concerns that most NHS boards rely on locums who are not consultants to fill vacant consultant psychiatry posts. 78. Vacancies for mental health nurses have more than doubled between March 2017 and March 2023, and the turnover rate has reached a record high. The Scottish Government told us that not enough students are coming into mental health nursing despite an increase in funded places. The third sector also plays an important role in providing mental health services, but short-term funding and contracts affects their ability to recruit and retain staff.51 Page 57 of 180
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3. How well resources for adult mental health are managed 42 Exhibit 8. The mental health workforce: March 2017 – March 2023 The mental health nursing and psychological services workforce has grown since March 2017, but so have the number of vacancies. Mental Health Nursing Staff (WTE) March 2017 9,466 March 2023 9,923 Vacancy Rate8% Turnover Rate12% Vacancies (WTE) March 2017 381 March 2023 868 Psychological Services Staff (WTE) March 2017 1,097 March 2023 1,538 Vacancy Rate9% Turnover Rate10% Vacancies (WTE) March 2017 82 March 2023 157 General Psychiatrists (WTE) March 2017 330 Vacancy Rate9.5% Turnover Rate9% Vacancies (WTE) March 2017 36 March 2023 33 Note: Data collection of nursing and midwifery and consultant vacancies was disrupted during the Covid-19 pandemic. Some data providers were not able to supply this data, therefore figures for mental health nursing and general psychiatrists will be under-reported. Source: Audit Scotland and NHS Education for Scotland (NES) 1100 1350 1600 March 2023 316 Page 58 of 180
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3. How well resources for adult mental health are managed 43 79. The workforce plans of our in-depth fieldwork sites reflect these pressures. Borders is having difficulty recruiting to psychiatry posts and is relying on locums to fill gaps.52 Grampian is relying on locums to provide inpatient mental health services, and its spending on agency mental health nurses has increased.53 Lanarkshire has concerns about its ability to recruit to psychiatry, psychology and mental health nursing posts.54 It has also struggled to recruit nursing and dietetics staff to offer specialist treatment for adults with eating disorders. 80. The Scottish Government has not made progress with its commitment to help councils to address the shortfall in MHO capacity.55 From 2019 to 2022, the Scottish Government provided £1.89 million in funding to councils to train an additional 47 WTE MHOs. In 2021/22, a further £2.78 million was allocated to increase available MHO capacity by 53 WTE. Despite additional funding, the estimated shortfall grew. The Scottish Government has allocated a further £3.71 million in 2022/23 to address the shortfall. Some progress has been made with investing in innovative workforce roles 81. Since 2017, the Scottish Government has made progress towards reforming mental health services by investing in new mental health workforce roles. These new roles include: • enhanced psychological practitioners, who are trained on a six-month graduate-level course to provide psychological interventions for mild to moderate mental health difficulties • trained DBI staff from the third sector, who provide timely and efficient help for people experiencing distress (Case study 1, page 21) • psychological wellbeing practitioners, who provide telephone-based support at the NHS 24 111 Mental Health Hub • community link workers, who help patients to access a range of local, non-clinical services in the community to get support for issues that affect their mental health or wellbeing (for example financial or housing issues). 82. Our in-depth fieldwork sites are also introducing innovative workforce roles that could improve the way services are provided. Borders is introducing advanced nurse mental health practitioners and has already introduced peer support workers with lived experience of mental health problems. Aberdeen City has introduced a wellbeing practitioner as part of its GP practice-based mental health and wellbeing service and wants to expand this role further. Lanarkshire is planning to develop a remote psychological therapies team to help address difficulties with recruitment. It is too soon to be able to assess what impact these roles are having. Page 59 of 180
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3. How well resources for adult mental health are managed 44 Gaps in mental health workforce data limit the ability to effectively plan future workforce needs 83. Data on the mental health workforce in Scotland is fragmented and limited to only some roles providing mental healthcare. For instance, data on the mental health workforce in primary care, community mental health teams and the third sector is not routinely collected. 84. The Scottish Government commissioned the NHS Benchmarking Network to establish a baseline position on the composition of Scotland’s adult mental health workforce. This one-off piece of work found that, in March 2021, 12,351 WTE mental health staff were working across Scotland’s 14 regional NHS boards. This includes staff in adult mental health inpatient services, adult community mental health services and psychological services. It does not include staff working in primary care and Child and Adolescent Mental Health Services.56 85. The Scottish Government has asked NHS Education for Scotland (NES) to develop a dedicated NHS mental health workforce statistical publication. This would cover all staff involved in providing mental healthcare across the NHS, including primary care staff. NES would then look into ways of collecting and publishing data on mental health staff in social care and the third sector. 86. This work would significantly improve the information available on, and understanding of, the mental health workforce in Scotland, enabling more effective planning and monitoring. The NHS statistical publication was originally expected to be completed in 2023 but has been delayed. The Scottish Government has not provided NES with funding for this work because of reductions in funding following the EBR. NES told us that this work, once under way, will take about two years to complete. Workforce planning for mental health roles remains inadequate 87. Workforce planning for mental health roles has not improved since the publication of the Mental Health Strategy in 2017. The Scottish Government and COSLA’s Integrated Workforce Plan for Health and Social Care (2019) only includes modelling for how demand for MHOs and clinical psychologists is likely to grow.57 But this modelling is flawed: • It does not consider the difference between the time available for MHO work by exclusive MHOs, who work on only MHO duties, and by non-exclusive MHOs, who have other social work duties. This means that the number of WTE MHOs needed to meet shortfalls is likely to be significantly greater than predicted in the plan. Page 60 of 180
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3. How well resources for adult mental health are managed 45 • For clinical psychologists, it assumes an unrealistically low rate of annual growth in demand for psychological therapies, of 2.5 per cent, despite the historical trend of demand growing by an average of four per cent each year since 2013. 88. The workforce plans of our in-depth fieldwork sites do not provide clear or detailed projections of the size or composition of the mental health workforce that will be needed in the future. 89. The Scottish Government plans to publish a mental health workforce action plan setting out immediate, medium- and longer-term actions for the mental health workforce, and timeframes for achieving outcomes. Its approach to workforce planning will be based on the National Workforce Strategy for Health and Social Care in Scotland – to plan, attract, train, employ and nurture.58 90. The Scottish Government’s mental health workforce action plan should be informed by modelling of the numbers and roles of mental health workers that will be needed across primary and secondary care and the third sector. This modelling should include estimated numbers of staff for newly created roles, such as community link workers. Page 61 of 180
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4. Plans and strategic direction 46 4. Plans and strategic direction The Scottish Government has made ambitious commitments, but it is not on track to achieve them 91. The Scottish Government has made ambitious commitments relating to adult mental health services. For example, it has committed to significantly increasing funding for mental health, and to ensuring that all GP practices have access to primary care mental health and wellbeing services by 2026 (paragraphs 27–33). 92. The Scottish Government has committed to increasing the Mental Health Directorate budget by 25 per cent and ensuring that ten per cent of the front-line NHS budget is spent on mental health by the end of the current parliament, in 2026.59 60 The Scottish Government is facing considerable financial constraints (paragraph 96), and it is not currently on track to meet these commitments: • Before accounting for inflation, the Scottish Government’s Mental Health Directorate budget would need to reach £342 million by 2026/27. But the 2022/23 and 2023/24 budgets are lower than it projected would be needed to meet this target. • The Scottish Government’s own projections showed that mental health spending would decrease as a proportion of front-line NHS spending by 2026, from 9.8 per cent in 2021/22 to nine per cent in 2026/27. 93. The Scottish Government and COSLA published a new, joint, mental health and wellbeing strategy in late June 2023. The strategy outlines its vision ‘of a Scotland, free from stigma and inequality, where everyone fulfils their right to achieve the best mental health and wellbeing possible’.61 The strategy being published jointly is a positive and promising development. It recognises the importance of a whole- system approach to supporting mental health and wellbeing and provides a foundation for better joint working. 94. The strategy sets out high-level outcomes and priorities to support the delivery of its vision. But there is no detail in the strategy about how and when the priorities will be achieved. The Scottish Government plans to publish a delivery plan and mental health workforce plan to set out this detail. These documents are not expected to be published until autumn 2023. Page 62 of 180
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4. Plans and strategic direction 47 95. In these documents, the Scottish Government needs to be transparent and realistic about what it can achieve, particularly given that the Scottish Government, IJBs, NHS boards and councils are facing increasingly tight budgets. The messages in our NHS in Scotland 2022 report and Local government in Scotland overview 2023 were similar, and our Integration Joint Boards financial analysis 2021/22 report also outlined the financial challenges that IJBs are facing. 96. Our briefing paper, Scotland’s public finances: challenges and risks, reported that the Scottish Government will face difficult choices setting the 2023/24 budget. It highlights that a balance must be struck between short-term necessities and longer-term priorities. It also states that the Scottish Government will need to revisit its priorities if the economic and fiscal conditions worsen. The lack of comprehensive, good-quality financial, workforce and operational data makes it difficult for the Scottish Government and others to make informed decisions about priorities 97. In this report, we have highlighted the impact of limited or poor-quality financial, workforce and operational data. The Scottish Government should work with health and social care partners and the third sector to address this, to enable it to make informed decisions about priorities. This will allow the Scottish Government to effectively monitor its progress against the commitments in its new strategy. Improvement work should focus on demonstrating how it is measuring and monitoring: • the quality of mental health services and patient outcomes • what difference investment is making to patient outcomes • how much is being invested in preventative programmes of work and the impact of this on demand for mental health and wellbeing support. 98. The Scottish Government and health and social care partners should learn from NHS England, which publishes more detailed information on mental health services regularly. Although data quality and completeness are still problems that NHS England needs to address, information is now routinely published on service activity and performance, spending and inequalities.62 For example, NHS England publishes a mental health dashboard that covers: • access to, and associated spending on, a range of mental health services, including talking therapies, perinatal mental health services, crisis and acute care, and uptake of physical health checks • a recovery rate for patients accessing talking therapies (paragraph 49) which demonstrates the proportion of people accessing this service who recover following treatment Page 63 of 180
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4. Plans and strategic direction 48 • progress towards its commitment to increase the share of mental health spending, indicated by local spending on mental health and the proportion of areas that are meeting the commitment. 99. The Scottish Government and health and social care partners should consider how they can incorporate similar measures as part of regular reporting of activity, performance and spending on mental health services. Page 64 of 180
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49 1. Chapter title Endnotes E es 1 Scottish Health Survey 2021 edition, Scottish Government, November 2022. 2 Public health priorities for Scotland, Scottish Government and Convention of Scottish Local Authorities, June 2018. 3 Mental Health Strategy: 2017–2027, Scottish Government, March 2017. 4 The economic case for investing in the prevention of mental health conditions in the UK, Mental Health Foundation and London School of Economics and Political Science, February 2022. 5 Final report, Scottish mental health law review, September 2022. 6 Scottish mental health law review: our response, Scottish Government, June 2023. 7 Mental Health Strategy: 2017–2027, Scottish Government, March 2017. 8 The Scottish Mental Illness Stigma Study, Mental Health Foundation and See Me, September 2022. 9 GP mental health training survey summary, Mind, 2018. 10 Scottish Health Survey 2021 edition, Scottish Government, November 2022. 11 Mental Health Act monitoring report 2021-22, Mental Welfare Commission, November 2022. 12 Freedom of Information response, Police Scotland, February 2023. 13 The number of incidents relating to mental health in 2018 may be slightly higher than the number recorded because one police division only started using the reporting system from February 2018. 14 We won’t wait – strategy 2021-24, Scottish Association for Mental Health, October 2021. 15 Annual report and accounts for the year ended 31 March 2022, NHS 24, June 2022. 16 Still forgotten? Mental health care and treatment during the coronavirus pandemic, Scottish Association for Mental Health, October 2022. 17 Know where to go – A SAMH survey of general practitioners in Scotland, Scottish Association for Mental Health, March 2014. 18 Forgotten? Mental health care and treatment during the coronavirus pandemic, Scottish Association for Mental Health, March 2021. 19 Still Forgotten? Mental health care and treatment during the coronavirus pandemic, Scottish Association for Mental Health, October 2022. 20 Ibid. 21 Care in the digital age: delivery plan 2022 to 2023, Scottish Government, November 2022. 22 Psychological services waiting times in Scotland: data quality, Public Health Scotland, March 2023. 23 Primary Care Improvement Plans – Summary of Implementation Progress at March 2022, Scottish Government, June 2022. Page 65 of 180
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Endnotes 50 24 Primary Care Improvement Plans – Summary of Implementation Progress at March 2023, Scottish Government, June 2023. 25 A Fairer, Greener Scotland: Programme for Government 2021-22, Scottish Government, September 2021. 26 Planning guidance for mental health and wellbeing in primary care services, Scottish Government, January 2022. 27 The 2018 general medical services contract in Scotland, Scottish Government, November 2017. 28 Emergency Budget Review: 2022 to 2023, Scottish Government, November 2022. 29 Ending the exclusion: care, treatment, and support for people with mental ill health and problem substance use in Scotland, Mental Welfare Commission, September 2022. 30 The Scottish Mental Illness Stigma Study, Mental Health Foundation and See Me, September 2022. 31 Priorities for access to treatment and joined up accessible services in Scotland, Scottish Parliament Cross Party Group on Mental Health, Scottish Association for Mental Health, November 2020. 32 Racial inequality and mental health in Scotland, Mental Welfare Commission, September 2021. 33 Management of physical health conditions in adults with severe mental disorders, WHO Guidelines, World Health Organization, November 2018. 34 Improving care of people with mental health conditions: how pharmacists can help, Royal Pharmaceutical Society, October 2020. 35 Tackling social inequalities to reduce mental health problems, Mental Health Foundation, April 2022. 36 Mental health and the cost-of-living crisis: another pandemic in the making? Mental Health Foundation, January 2023. 37 Mental health – Scotland’s transition and recovery, Scottish Government, October 2020. 38 New deal with local government – Verity House Agreement, Scottish Government, June 2023. 39 Guidance on community mental health services: promoting person-centred and rights-based approaches, World Health Organization, June 2021. 40 World mental health report: Transforming mental health for all, World Health Organization, June 2022. 41 A guide to IAPT data and publications, version 2.1 guidance document, NHS Digital, 2021. 42 Primary Care Improvement Plans – Summary of Implementation Progress at March 2022, Scottish Government, June 2022. 43 We refer to ‘real terms’ changes in this report. This means that we are showing financial information from past and future years at prices for the most recent year of data being presented (2021/22 and 2022/23), adjusted for inflation so that they are comparable. Real terms spending has been calculated using average gross domestic product deflators for 2020/21 and 2021/22. 44 A small proportion of NHS 24 spending on mental health contains spending on children and young people. 45 SAS spending on mental health includes some spending on child and adolescent mental health. 46 Criminal Justice Committee, 16th Meeting 2022 (Session 6), Policing and mental health, May 2022. 47 Medicines used in mental health – years between 2010 to 2011 and 2019 to 2020, Public Health Scotland, February 2021. 48 Ibid. Page 66 of 180
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Endnotes 51 49 Dispenser payments and prescription cost analysis – financial year 2021 to 2022, Public Health Scotland, September 2022. 50 Mental Health Officers (Scotland) Report 2021, Scottish Social Services Council, August 2022. 51 Looking ahead to the Scottish Government’s draft budget 2020-21: valuing the third sector, Equalities and Human Rights Committee, Scottish Parliament, November 2019. 52 Integrated Workforce Plan 2022–2025, Scottish Borders Health and Social Care Partnership, October 2022. 53 Workforce Plan 2022–2025, NHS Grampian, October 2022. 54 Lanarkshire health and social care integrated workforce plan 2022–2025, NHS Lanarkshire, Health and Social Care North Lanarkshire and South Lanarkshire Health and Social Care Partnership, November 2022. 55 An integrated health and social care workforce plan for Scotland, Scottish Government and COSLA, December 2019. 56 Scotland mental health workforce analytics: national census results, Scottish Government, August 2021. 57 An integrated health and social care workforce plan for Scotland, Scottish Government and COSLA, December 2019. 58 Health and social care: national workforce strategy, Scottish Government, March 2022. 59 A Fairer, Greener Scotland: Programme for Government 2021-22, Scottish Government, September 2021. 60 NHS Recovery Plan 2021–2026, Scottish Government, August 2021. 61 Mental Health and Wellbeing Strategy, Scottish Government and COSLA, June 2023. 62 Progress in improving mental health services in England, National Audit Office, December 2022. Page 67 of 180
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52Appendix 1 Appendix 1 Audit methodology This performance audit covers the whole system of adult mental health and wellbeing services in Scotland, including the services provided by NHS boards, HSCPs, councils and their partners. It covers: • access to mental health and wellbeing support • progress towards improving mental health and wellbeing services • how well resources for mental health services are managed • plans and strategic direction for mental health and wellbeing services. Our findings are based on evidence from sources that include: • the Scottish Government’s Mental Health Strategy 2017–2027 and associated documents • other relevant Scottish Government strategies, plans and internal documents • activity and performance data published by Public Health Scotland • workforce data published by NHS Education for Scotland • publicly available information, including Mental Welfare Commission reports, third sector organisation reports and survey results • interviews with stakeholders from organisations including the Scottish Government, Public Health Scotland, the Mental Welfare Commission, Royal College of General Practitioners, Royal College of Psychiatrists, NHS boards, HSCPs, the third sector and councils • Three focus groups with people with lived experience of mental health problems, and two focus groups with community link workers. We also carried out more in-depth fieldwork in three areas to gain a better understanding of local pressures and challenges, and to identify areas of good practice. We covered mental health and wellbeing services provided by the NHS boards, HSCPs and councils across these areas. We interviewed staff and reviewed local documentation and data. The in-depth fieldwork sites were: • Grampian: Aberdeen City, Aberdeenshire and Moray • Lanarkshire: North Lanarkshire and South Lanarkshire • Scottish Borders. Page 68 of 180
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53Appendix 2 Appendix 2 Problems with the quality of data reporting on mental health spending NHS spending data NHS spending is reported annually by Public Health Scotland, using submissions from NHS boards. The information submitted by boards and how this spending is categorised vary. Many of the categories have not been updated for many years, so no longer reflect the way that services are being provided. Submissions were much less detailed than usual in 2020/21 and 2021/22 because of pressures caused by the Covid-19 pandemic. For instance, data on spending on clinical psychology is not available for these years, which means that reported spending on adult mental health is not comparable with previous years. Councils’ spending data The Local Financial Return (LFR) data set on social work includes spending on mental healthcare for adults aged 18-65. The Scottish Government and councils have identified problems with the quality of this data. There are no criteria for what should be included under adult mental health and councils’ submissions are based on best estimates. There is possible duplication between data recorded on adult mental health and other categories, such as adults with learning disabilities. Information is also not available on how much is spent on mental healthcare for adults aged over 65 years. In 2021/22, information on specific services within the adult social care data set, including spending on adults with mental health needs, was published separately because of data quality concerns. It was recognised as less robust than the rest of the LFR. IJB spending data The level and detail of data on spending on adult mental health and wellbeing services in IJBs annual accounts vary across Scotland. Some IJBs record mental health within the same category as spending on other services, such as large hospital services, and addictions services. This means it is not possible to use IJB accounts information for reporting spending on adult mental health and wellbeing across Scotland. Page 69 of 180
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Adult mental health Audit Scotland, 4th Floor, 102 West Port, Edinburgh EH3 9DN Phone: 0131 625 1500 Email: info@audit-scotland.gov.uk www.audit-scotland.gov.uk ISBN 978 1 915839 21 3 AGS/2023/7 Page 70 of 180
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Midlothian Integration Joint Board Audit and Risk Committee Membership of Audit and Risk Committee– Independent Member Thursday, 6 June 2024 Item number: 5.2 Executive summary The IJB Audit and Risk committee’s terms of reference lay out the membership of the committee. That is four members from the voting members of the IJB (two from NHSiL and two from Midlothian Council) and an independent member. The latter being an individual who is not a member of the IJB (nor a member of the NHS Lothian Board nor a Midlothian Councillor) and is therefore literally independent from the IJB and its partners. Such an individual will bring their previous experience to the committee, provide an additional input into the work of the committee and support the committee’s role in assuring proper governance. This role is considered best practice in the development of an audit committee and such a member has sat on the IJB’s audit and Risk committee in previous years although currently this role is vacant. Committee members are asked to: • Support the appointment of an Independent Member for the committee. Page 71 of 180
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Midlothian Integration Joint Board – Audit and Risk Committee Page 2 Report 1. Purpose 1.1 This paper considers the appointment of an independent member to the IJB’s Audit and Risk committee which is covered by the Term’s of Reference of the committee. 2. Recommendations 2.1 Committee members are asked to • Support the appointment of an independent member to the committee. 3. Background and main report 3.1 The current Terms of Reference for the IJB’s Audit and risk committee lay out the membership of the committee. That is four voting members of the IJB along with an independent member who is not a member of the IJB nor a Midlothian Councillor nor a member of NHS Lothian Board. 3.2 Currently this particular role is vacant. 3.3 The quorum for the committee is three members including the independent member. 3.4 Best practice and guidance in the membership and governance of audit committees requires that an independent member is appointed. 3.5 It is important that the IJB and its committees operate as transparently as possible and that the opportunity to apply for this role is made widely available. Therefore it is proposed that the role is advertised on the IJB’s website. 3.6 That said, the previous independent members have been individuals known to the IJB Chief Officer or the chair who have been approached directly. Thus if no applications are forthcoming from the advertisement then the Committee should ask the Chief Officer to identify any individual who may be willing to serve. 3.7 Any candidates will then meet with the Committee chair who can then make an appropriate recommendation to the committee. 3.8 This role will not be remunerated. Page 72 of 180
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Midlothian Integration Joint Board – Audit and Risk Committee Page 3 4. Policy Implications 4.1 There are no further policy implications arising from this report. 5. Equalities Implications 5.1 There are no equalities implications arising from this report 6. Resource Implications 6.1 There are no resource implications arising from this report. 7 Risks 7.1 The are no further risks arising from this report. 8 Involving People 8.1 There are no direct implications for involving people as a result of this report. 9 Background Papers 9.2 None AUTHOR’S NAME David King DESIGNATION Interim Chief Finance Officer CONTACT INFO david.king4@nhslothian.scot.nhs.uk DATE May 2024 Page 73 of 180
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Midlothian Integration Joint Board Audit and Risk Committee Review of Risk Management Policy Thursday, 6 June 2024 Item number: 5.3 Executive summary The IJB approved its risk management policy at its meeting in February 2016. At its meeting in December 2017, the IJB’s Audit and Risk Committee recognised that ‘the IJB’s risk register (and risk management process) recognises the risk to the IJB’s own business – that is the preparation and delivery of the Strategic Plan. The IJB’s does not consider ‘operational’ risks, being the risks managed by the partners unless these risks are so significant that they would impact on the IJB’s Strategic plan. That said, it should be remembered that IJB is not in a position to manage such operational risks and would, in any event, depend on the management actions of the partners.’ Best practice would require that the IJB now reviews its Risk Management Policy and this paper lays out that review. Committee members are asked to: • Consider the revision and amendments to the current policy • Recommend these amendments to the IJB • Recommend that the IJB adopts this revised Risk Management Policy Page 75 of 180
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Midlothian Integration Joint Board – Audit and Risk Committee Page 2 Report 1. Purpose 1.1 This paper lays out a review of the IJB’s Risk Management Policy 2. Recommendations 2.1 Committee members are asked to • Consider the revision and amendments to the current policy • Recommend these amendments to the IJB • Recommend that the IJB adopts this revised Risk Management Policy 3. Background and main report 3.1 The IJB agreed and adopted its Risk Management Policy at its February 2016 meeting. 3.2 At its December 2017 meeting the IJB’s Audit and Risk committee reflected on the policy and noted that ‘the IJB’s risk register (and risk management process) recognises the risk to the IJB’s own business – that is the preparation and delivery of the Strategic Plan. The IJB’s does not consider ‘operational’ risks, being the risks managed by the partners unless these risks are so significant that they would impact on the IJB’s Strategic plan. That said, it should be remembered that IJB is not in a position to manage such operational risks and would, in any event, depend on the management actions of the partners’ 3.3 The Risk Management Policy now requires to be revised, reflecting the experience of the IJB over the past eight years. 3.4 The 2016 Risk Management Policy has been reviewed taking into account - • The Audit and Risk Committee’s reflection on what risks should be captured in the register, that is risks to the production and delivery of the Strategic Plan and the operational risks that will impact on the delivery of the Strategic Plan • That the policy should reflect more correctly the current arrangement for the management of the IJB and the support from the IJB partners. Page 76 of 180
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Midlothian Integration Joint Board – Audit and Risk Committee Page 3 3.5 Attached is a copy of the 2016 Risk Management Policy with the changes clearly tracked and notes made as appropriate. Committee members are asked to review this schedule. 3.6 The changes are not material but reflect that the IJB does not directly employ staff, deliver services directly nor have its own senior management team. 4. Policy Implications 4.1 There are no further policy implications arising from this report. 5. Equalities Implications 5.1 There are no equalities implications arising from this report 6. Resource Implications 6.1 There are no resource implications arising from this report. 7 Risks 7.1 The risks are described in the risk register which is attached 8 Involving People 8.1 There are no direct implications for involving people as a result of this report. 9 Background Papers 9.2 None AUTHOR’S NAME David King DESIGNATION Interim Chief Finance Officer CONTACT INFO david.king4@nhslothian.scot.nhs.uk DATE May 2024 Appendix 1 – Revised and annotated Risk Management Ploicy Page 77 of 180
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Midlothian Integration Joint Board Risk Management Policy Version No. 1.1 Date Effective: 00/00/0000 Review Date: 27/05/24 Page 79 of 180
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P a g e | 1 CONTENTS Policy – the risk management approach ................................................................................................ 2 Implementing the policy ...........................................................................................................................4 1. Introduction ........................................................................................................................................ 4 2. Risk management process ................................................................................................................. 4 3. Application of good risk management across the IJB activities ........................................................... 5 Realising the risk management vision ................................................................................................... 6 4. Risk management vision and measures of success ........................................................................... 6 Risk leadership and accountability ........................................................................................................ 6 5. Governance, roles and responsibilities ............................................................................................... 6 Resourcing risk management ................................................................................................................. 7 6. Resourcing the risk management framework ..................................................................................... 7 7. Resourcing those responsible for managing specific risks .................................................................. 7 Training, learning and development ...................................................................................................... 8 8. Risk management training and development opportunities ................................................................ 8 Monitoring activity and performance ......................................................................................................8 9. Monitoring risk management activity .................................................................................................. 8 10. Monitoring risk management performance ..........................................................................................8 Communicating risk management ......................................................................................................... 9 11. Communicating, consulting on and reviewing the risk management framework .................................. 9 Appendix 1 Risk Matrix ..........................................................................................................................10 Document Title: Risk Management Policy and Strategy Owner: Chief Officer Version No. v. 1.1 Superseded Version: V 1.0 Date Effective: 00/00/0000 Review Date: 27/05/2024 Page 80 of 180
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P a g e | 2 Policy – the risk management approach 1.1 The Midlothian Integration Joint Board (the Board)is committed to a culture where its those involved in planning and delivering the IJB’s strategy are encouraged to develop new initiatives, improve performance and achieve goals safely, effectively and efficiently by appropriate application of good risk management practice. 1.2 In doing so the Board aims to provide safe and effective care and treatment for patients and clients, and a safe environment for everyone working within the Joint Board and others who interact with the services delivered under the direction of the Joint Board. 1.3 The Board believes that appropriate application of good risk management will prevent or mitigate the effects of loss or harm and will increase success in the delivery of better clinical and financial outcomes, objectives, achievement of targets and fewer unexpected problems. 1.4 The Board purposefully seeks to promote an environment that is risk ‘aware’ and strives to place risk management information at the heart of key decisions. This means that the Board can take an effective approach to managing risk in a way that both address significant challenges and enable positive outcomes. 1.5 In normal circumstances: • Any very low or low risk is acceptable without further action to prevent or mitigate risk, • Any medium risk is tolerable – control measures implemented or introduced must be cost effective, • Any high risk may be tolerable – providing the Board is assured regarding the adequacy and effectiveness of the control measures in place. Any further control measures implemented or introduced must be cost effective in relation to the risk. • Any critical risks is considered unacceptable and measures must be taken to terminate, transfer or treat these risks to a tolerable position. 1.6 This can be seen clearly in the following matrix: Document Title: Risk Management Policy and Strategy Owner: Chief Officer Version No. V1.1 Superseded Version: V 1.0 Page 81 of 180
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P a g e | 3 1.7 The Board promotes the pursuit of opportunities that will benefit the delivery of the Strategic Plan. Opportunity-related risk must be carefully evaluated in the context of the anticipated benefits for patients, clients and the Board. 1.8 The Board will receive assurance reports (internal and external) not only on the adequacy but also the effectiveness of its risk management arrangements and will consequently value the contribution that risk management makes to the wider governance arrangements of the Board. 1.9 The Board, through the following risk management strategy, has established a Risk Management Framework, (which covers risk policy, procedure, process, systems, risk management roles and responsibilities). Document Title: Risk Management Policy and Strategy Owner: Chief Officer Version No. V 1.1 Superseded Version: V 1.0 Date Effective: 00/00/0000 Review Date: 27/05/24 Page 83 of 180
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P a g e | 4 Implementing the policy 1.1 The primary objectives of the policy will be to: ◼ promote awareness of risk and define responsibility for managing risk within the Integration Joint Board; ◼ establish communication and sharing of risk information through all areas of the Integration Joint Board; ◼ initiate measures to reduce the Integration Joint Board’s exposure to risk and potential loss; and, ◼ establish standards and principles for the efficient management of risk, including regular monitoring, reporting and review. 1.2 This policy takes a positive and holistic approach to risk management. The scope applies to all risks, whether relating to the clinical and care environment, employee safety and wellbeing, business risk, opportunities or threats. 1.3 Strategic risks represent the potential for the Integration Joint Board (IJB) to achieve (opportunity) or fail to meet (threat) its desired outcomes and objectives as set out within the Strategic Plan, and typically these risks require strategic leadership in the development of activities and application of controls to manage the risk. 1.4 Operational risks represent the potential for impact (opportunity or threat) within or arising from the activites of an individual service area or team operating within the scope of the Joint Board’s directions. Parent bodies will retain responsibility for managing operational risks as operational risks will be more ‘front-line’ in nature and the development of activities and controls to respond to these risks can be led by local managers and team leaders. Where a number of operational risks impact across multiple service areas or, because of interdependencies, require more strategic leadership, then these can be proposed for escalation to ‘strategic risk’ status for the IJB. 1.5 All risks will be analysed consistently with an evaluation of risk using the risk matrix shown in Appendix 1. 1.6 This document represents the risk management framework to be implemented across the Joint Board and will contribute to the Joint Board’s wider governance arrangements. 2. Risk management process 2.1 Risk Management is about the culture, processes and structures that are directed towards realising potential opportunities whilst managing adverse effects1. It is pro- active in understanding risk and uncertainty, it learns and builds upon existing good practice and is a continually evolving process that has an important role in ensuring that defensible and beneficial decisions are made. 2.2 The IJB will embed risk management practice by consistent application of the risk management process shown in the diagram on the right, in the planning of all all areas of service delivery and its own business activities. 1 Australia/ New Zealand Risk Management Standard, AS/NZS 4360: 2004 Document Title: Risk Management Policy and Strategy Owner: Chief Officer Version No. V 1.1 Superseded Version: V 1.0 Date Effective: 00/00/0000 Review Date: 27/05/2024 1. Introduction Page 84 of 180
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P a g e | 5 3. Application of good risk management across the IJB activities 3.1 Standard procedures (3.1.1 – 3.1.10) will be implemented across all areas of activity that are under the direction of the IJB in order to achieve consistent and effective implementation of good risk management. 3.1.1 Full implementation of the risk management process. This means that risk management information should (wherever possible) be used to guide major decisions in the same way that cost and benefit analysis is used. 3.1.2 Identification of risk using standard methodologies, and involving subject experts who have knowledge and experience of the activity or process under consideration. 3.1.3 Categorisation of risk under the headings below: ◼ Strategic Risks: such as risks that may arise from Political, Economical, Social, Technological, Legislative and Environmental factors that impact on the delivery of the Strategic Plan outcomes. ◼ Operational Risks: such as risks that may arise from or impact on Clinical Care and Treatment, Social Care and Treatment, Customer Service, Employee Health, Safety & Well-being, Business Continuity/ Supply Chain, Information Security and Asset Management. 3.1.4 Appropriate ownership of risk. Specific risks will be owned by/ assigned to whoever is best placed to manage the risk and oversee the development of any new risk controls required. 3.1.5 Consistent application of the agreed risk matrix to analyse risk in terms of likelihood of occurrence and potential impact, taking into account the effectiveness of risk control measures in place. The risk matrix to be used is attached in Appendix 1. 3.1.6 Consistent response to risk that is proportionate to the level of risk. This means that risk may be terminated; transferred elsewhere (ie to another partner or third party); tolerated as it is; or, treated with cost effective measures to bring it to a level where it is acceptable or tolerable for the Joint Board in keeping with its appetite/ tolerance for risk. In the case of opportunities, the Joint Board may ‘take’ an informed risk in terms of tolerating it if the opportunity is judged to be worthwhile pursuing and the Joint Board is confident in its ability to achieve the benefits and manage/ contain the associated risk. 3.1.7 Implementation and maintenance of a risk register as a means of collating risk information in a consistent format allowing comparison of risk evaluations, informed decision-making in relation to prioritising resources and ease of access to information for risk reporting. 3.1.8 Reporting of strategic risks and key operational risks to the Audit & Risk Committee on a quarterly basis and to the IJB on an annual basis, unless the quarterly reporting to the Audit & Risk Committee identifies a risk the IJB needs to be made aware of immediately. 3.1.9 Operation of a procedure for movement of risks between strategic and operational risk registers will be facilitated by the Chief Officer . 3.1.10 Routine reporting of risk information within and across teams and a commitment to a ‘lessons learned’ culture that seeks to learn from both good and poor experience in order to replicate good practice and reduce adverse events and associated complaints and claims. Document Title: Risk Management Policy and Strategy Owner: Chief Officer Version No. V 1.1 Superseded Version: V 1.0 Date Effective: 00/00/0000 Review Date: 27/05/2024 Page 85 of 180
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Realising the risk management vision P a g e | 6 4. Risk management vision and measures of success 4.1 In working towards this risk management vision the Joint Board aims to demonstrate a level of maturity where risk management is embedded and integrated in the decision making and operations of the IJB. 4.2 The measures of success for this vision will be: ◼ good financial outcomes for the Joint Board ◼ successful delivery of the strategic plan, ◼ successful outcomes from external scrutiny ◼ fewer unexpected/ unanticipated problems in the delivery of the Board’s directions ◼ fewer incidents/ accidents/ complaints ◼ fewer claims/ less litigation Risk leadership and accountability 5. Governance, roles and responsibilities 5.1 Integration Joint board Members of the Integration Joint Board are responsible for: ◼ oversight of the IJB’s risk management arrangements; ◼ receipt and review of reports on strategic risks and any key operational risks that require to be brought to the IJB’s attention; and, ◼ ensuring they are aware of any risks linked to recommendations from the Chief Officer concerning new priorities/ policies. 5.2 Chief Officer The Chief Officer has overall accountability for the IJB’s risk management policy, ensuring that suitable and effective arrangements are in place to manage the risks relating to the functions within the scope of the IJB. The Chief Officer will keep the Chief Executives of the IJB’s partner bodies informed of any significant existing or emerging risks that could seriously impact the IJB’s ability to deliver the outcomes of the Strategic Plan or the reputation of the IJB. 5.3 Chief Financial Officer The Chief Financial Officer will be responsible for promoting arrangements to identify and manage key business/financial risks and risk mitigation. Support from the IJB’s Partners for the IJB’s Partners are responsible for: ◼ supporting the Chief Officer and Chief Financial Officer in fulfilling their risk management responsibilities; ◼ arranging professional risk management support, guidance and training from partner bodies; Document Title: Risk Management Policy and Strategy Owner: Chief Officer Version No. V1.1 Superseded Version: V 1.0 Appropriate and effective risk management practice will be embraced throughout the Integration Joint Board as an enabler of success, whether delivering better outcomes for the people of Midlothian, protecting the health, safety and well-being of everyone who engages with the IJB or for maximising opportunity, delivering innovation and best value, and increasing performance. Page 86 of 180
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P a g e | 7 ◼ receipt and review of regular risk reports on strategic, shared and key operational risks and escalating any matters of concern to the IJB; and, ◼ ensuring that the standard procedures set out in section three of this strategy are actively promoted across their teams and within their areas of responsibility. 5.4 Individual Risk Owners It is the responsibility of each risk owner to ensure that: ◼ risks assigned to them are analysed in keeping with the agreed risk matrix; ◼ data on which risk evaluations are based are robust and reliable so far as possible; ◼ risks are defined clearly to make explicit the scope of the challenge, opportunity or hazard and the consequences that may arise; ◼ risk is reviewed not only in terms of likelihood and impact of occurrence, but takes account of any changes in context that may affect the risk; ◼ controls that are in place to manage the risk are proportionate to the context and level of risk. 5.5 Partner Bodies It is the responsibility of relevant specialists from the partner bodies, (such as internal audit, external audit, clinical and non clinical risk managers and health and safety advisers) to attend meetings as necessary to consider the implications of risks and provide relevant advice. It is the responsibility of the partner bodies to ensure they routinely seek to identify any residual risks and liabilities they retain in relation to the activities under the direction of the IJB. 5.6 Senior Information Risk Owner Responsibility for this specific role will remain with the individual partner bodies. Resourcing risk management 6. Resourcing the risk management Policy 6.1 Much of the work on developing and leading the ongoing implementation of the risk management Policy for the Joint Board will be resourced through the partners support to the IJB arrangements (referred to in 5.4). 6.2 Wherever possible the IJB will ensure that any related risk management training and education costs will be kept to a minimum, with the majority of risk-related courses/ training being delivered through resources already available to the IJB (the partner body risk managers/ risk management specialists). 7. Resourcing those responsible for managing specific risks 7.1 Where risks impact on a specific partner body and new risk control measures require to be developed and funded, it is expected that the costs will be borne by that partner organisation. 7.2 Financial decisions in respect of the IJB’s risk management arrangements will rest with the Chief Financial Officer. Document Title: Risk Management Policy and Strategy Owner: Chief Officer Version No. V 1.1 Superseded Version: V 1.0 Date Effective: 00/00/0000 Review Date: 27/05/2024 Page 88 of 180
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P a g e | 8 Training, learning and development 8.1 To implement effectively this policy, it is essential for people to have the competence and capacity for managing risk and handling risk judgements with confidence, to focus on learning from events and past experience in relation to what has worked well or could have been managed better, and to focus on identifying malfunctioning ‘systems’ rather than people. 8.2 Training is important and is essential in embedding a positive risk management culture across all activities under the direction of the IJB and in developing risk management maturity. The Chief Officer will regularly review risk management training and development needs and source the relevant training and development opportunities required (referred to in 5.4). Monitoring activity and performance 9. Monitoring risk management activity 9.1 The Joint Board operates in a dynamic and challenging environment. A suitable system is required to ensure risks are monitored for change in context and scoring so that appropriate response is made. 9.2 Monitoring will include review of the IJB’s risk profile at the Chief Officer’s level on a quarterly basis. 9.3 The risk register will be reviewed quarterly and presented to the IJB’s Ausit and Risk committee for consideration and comment 9.4 It is expected that partner bodies will use IJB risk reports to keep their own organisations updated on the management of the risks, highlighting any IJB risks that might impact on the partner organisation. 10. Monitoring risk management performance 10.1 Measuring, managing and monitoring risk management performance is key to the effective delivery of key objectives. 10.2 Key risk indicators (KRIs) will be linked where appropriate to specific risks to provide assurance on the performance of certain control measures. For example, specific clinical incident data can provide assurance that risks associated with the delivery of clinical care are controlled, or, budget monitoring PIs (Performance Indicators) can provide assurance that key financial risks are under control. 10.3 The performance data linked to the Strategic Plan will also inform the identification of new risks or highlight where existing risks require more attention. 10.4 Reviewing the Joint Board’s risk management arrangements on a regular basis will also constitute a ‘Plan/ Do/ Study/ Act review cycle that will shape future risk management priorities and activities of the Joint Board, inform subsequent revisions of this policy and drive continuous improvement in risk management across the Joint Board. Document Title: Risk Management Policy and Strategy Owner: Chief Officer 8. Risk management training and development opportunities Page 89 of 180
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P a g e | 9 10.5 10.5 Communicating risk management 11.1 Effective communication of risk management information across the Joint Board is essential to developing a consistent and effective approach to risk management. 11.2 Copies of this policy will be widely circulated via the the Chief Officer and will form the basis of any risk management training arranged by the IJB. 11.3 This policy and strategy will be reviewed regularly to ensure that it reflects current standards and best practice in risk management and fully reflects the Integration Joint Board’s business environment. Document Title: Risk Management Policy and Strategy Owner: Chief Officer Version No. Final DraftV 1.1 Superseded Version: V 1.0 Date Effective: 00/00/0000 Review Date: 27/05/2024 11. Communicating, consulting on and reviewing the risk management policy Page 91 of 180
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P a g e | 10 Appendix 1 Risk Matrix Risk Impact Risk should be analysed consistently across the IJB in terms of the significance of its impact and the likelihood of occurrence. The Risk Matrix is therefore the tool that is to be used for this purpose. Impact When considering the consequences of a potential risk, all scenarios must be considered. It may even be appropriate to consider the worst case scenario, however, those undertaking the risk analysis must be able to provide a robust rationale and have evidence to support their selection. For example, if ‘death’ could be the ultimate potential impact in relation to a specific problem, the risk assessors must have knowledge that this outcome has occurred in the past either internal or external to the IJB area of control; Likelihood Similarly when considering the likelihood of occurrence, the risk assessor’s judgement must be based on the prevalence of the event/ circumstance and outcome, backed up by experience and data such as relevant incidents/ events. Evaluation As shown in the matrix below, Impact x Likelihood produces an evaluation of the significance of risk, described as ‘Low’, ‘Moderate’, ‘High’ or ‘Very High’. How a risk is evaluated will determine how the risk is then treated: Very Low (1-3), Low (4-8), Medium (9-15), High (16-20), Critical (25) Page 92 of 180
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Midlothian Integration Joint Board Audit and Risk Committee Midlothian IJB Risk Register – Q1 2024/25 Thursday, 6 June 2024 Item number: 5.4 Executive summary This report presents the IJB’s Risk Register for Q1 2024/25. At the committee’s meeting in March 2024, a revised register was presented to the committee and the committee agreed that a briefing on the use of Datix would be helpful. Given that the membership of the committee is currently being reviewed this has been postponed. The risk register is reviewed on a quarterly basis and there have been no changes to the 2023/24 Q4 register with the exception of noting that the IJB has since set a balanced financial plan for 2024/25 Committee members are asked to: 1. Note the Q1 Risk Register. 2. Consider if any further additions or changes should be made to the risk register. 3. Agree to the proposal that, at a future meeting, a presentation on the use of Datix is provided to the committee along with a further more detailed consideration of the risk register Page 93 of 180
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Midlothian Integration Joint Board – Audit and Risk Committee Page 2 Report 1. Purpose 1.1 This report presents the IJB’s Q4 risk register for discussion by the committee. 2. Recommendations 2.1 Committee members are asked to • Note the Q1 risk register. • Consider if any further additions or changes should be made to the risk register. • Agree to the proposal that, at a future meeting, a presentation on the use of Datix is provided to the committee along with a further more detailed consideration of the risk register. 3. Background and main report 3.1 The IJB maintains a risk register in line with best practice. This register lays out the risks to the operation of the IJB – that is risks to the development of the Strategic Plan and the delivery of that plan though directions to its partners. 3.2 The register was last presented to the committee at its March 2024 meeting and has now been reviewed and updated to reflect the current position. 3.3 The updated risk register is attached as appendix 1. It should be noted that this is an extract from Datix and that there is a range of further information embedded in the Datix system which does not form part of this extract. 3.4 Risks 5771 ‘Strategic Commissioning Plan’, 5772 ‘Issuing of Directions’ and 5774 ‘Financial Sustainability’ are noted as ‘very high. This risk level is driven by the current financial settlements that the IJB’s funding partners are experiencing and the concomitant impact on both the partner’s delivery of the IJB’s Strategic Plan and financial challenges to the goals of the Strategic Plan arising for financial challenges within the IJB’s own budget. 3.5 It is proposed that a presentation is made at a future meeting to the committee regarding datix and how that system is used to manage risk and that a further more detailed discussion and consideration of the register is made then. 4. Policy Implications 4.1 There are no further policy implications arising from this report. Page 94 of 180
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Midlothian Integration Joint Board – Audit and Risk Committee Page 3 5. Equalities Implications 5.1 There are no equalities implications arising from this report 6. Resource Implications 6.1 There are no resource implications arising from this report. 7 Risks 7.1 The risks are described in the risk register which is attached 8 Involving People 8.1 There are no direct implications for involving people as a result of this report. 9 Background Papers 9.2 None AUTHOR’S NAME David King DESIGNATION Interim Chief Finance Officer CONTACT INFO david.king4@nhslothian.scot.nhs.uk DATE May 2024 Appendix 1 – Risk Register Extract– Q1 2024/25. Page 95 of 180
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ID Consequence (Current) Likelihood (Current) Rating (Current) Risk Level (Current) Consequenc e (Target) Likelihood (Target) Rating (Target) Risk Level (Target) Date opened Date Risk reviewed 5771 Chief Officer Integration Manager Strategic Commissioning Plan Risk Effect: Partners operational services may experience disruption to service delivery. Risk Consequence: The IJB may not see sufficient or adequate progress towards its 6 strategic aims and delivering its strategic plan. Reassurance is required from partners regarding the following 1. Resilience planning and Business continuity 2. Contract monitoring 3. Governance and Assurance 4. Outcomes for people and communities Major Almost Certain 20 Very High Minor Possible 6 Medium 26/02/2024 27/05/2024 5772 Chief Officer Integration Manager Issuing of Directions Risk Effect: There is a risk that the IJBs partners have insufficient workforce or other resources to execute the requirements and ambitions of the IJB Directions Risk Consequence: The IJB cannot deliver on its strategic plan or financial plan. Directions are monitored and reported on twice a year for performance updates. financial allocations are included within directions on an annual basis after IJB budgets have been set The Planning, Performance and Programme team continue to support with additional capacity to redesign and transform key areas of service delivery A project management approach continues to support key areas aiming to accelerate progress in the delivery of the MIJB Directions. Extreme Almost Certain 25 Very High Moderate Possible 9 Medium 26/02/2024 27/05/2024 5773 Chief Officer Executive Business Manager Category 1 Responder Status Risk Effect: IJBs role as Category 1 responders under the Civil Contingencies Act requires that our partners NHS Lothian and Midlothian Council maintain effective business continuity and resilience plans to ensure an appropriate response in times of emergency. There is a risk that our partners may not be able to provide these assurances. Risk Consequence: Failure to maintain up to date and effective resilience plans could result in services unable to maintain essential service delivery Assurance reporting to IJB routinely by Chief Nurse, Chief Social Worker and Resilience. Annual category 1 assurance report submitted to IJB via A&R comittee Robust operational process within Midlothian Health and Social Care to meet requirements Lessons learnt from COVID pandemic have been incorporated within standard service delivery, ongoing work to develop a quality management approach will provide additional partnership wide assurances to IJB. Moderate Unlikely 6 Medium Minor Unlikely 4 Medium 26/02/2024 27/05/2024 5774 Chief Officer Chief Finance Officer Financial Sustainability Risk Effect: The IJBs partners may not be able to allocate sufficient resource to deliver its Financial Plan and Strategic Plan. Risk Consequence: The IJB may not be able to deliver the Strategic Plan in order to function within the available resources. The IJB may have to amend the ambitions of Strategic in such a way that the progress towards the 6 strategic aim of the Strategic Plan and 9 National Health and Wellbeing Outcomes is compromised. Chief Finance Officer responsible for the governance, appropriate management of finance and financial administration of the IJB. Strong budgetary control systems in place within NHS Lothian and Midlothian Council. IJB Medium term financial plan developed annually. Working in partnership in the financial environment with Midlothian Council and NHS Lothian. IJB Set a balanced budget at its March 2024 meeting Extreme Almost Certain 25 Very High Moderate Possible 9 Medium 26/02/2024 27/05/2024 5775 Chief Officer Chief Finance Officer Impacts of New Legislation Risk Effect: There is a risk of further legislation, policy, or national improvement drivers which impact on the IJBs ability to deliver on the Strategic Plan, examples include the legislation relating to a National Care Service and the Health and Care (Staffing) (Scotland) Act 2019. Risk Consequence: The IJB and it partners may be distracted from the business of delivering the Strategic Plan. Legislation, policy, and national improvement drivers without fiscal supports will result in additional pressure on the IJB. Respond to Scottish Government information requests on impact of future legislation, policies, and national improvement drivers Horizon scanning for policy developments through partners and SMT network groups Close working relations with Scottish Government through Chief Finance Officer, Chief Officer and COSLA. Major Possible 12 High Moderate Possible 9 Medium 26/02/2024 27/05/2024 Q1 2024/25 Risk Register Extract Risk Owner Risk Handler Title Description Controls in place Residual Risk Target Risk Page 97 of 180
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Midlothian Integration Joint Board Audit and Risk Committee Best Value Framework Thursday, 6 June 2024 Item number: 5.5 Executive summary The IJB is governed by the same regulations that govern Local Authorities. Under these regulations the IJB has a statutory duty to deliver best value. The most recent revised statutory guidance on Best Value is attached to this report – this lays out what best value means and how local authorities can ensure that it is properly delivered. Fundamentally, best value means that the body (in this case the IJB) has proper arrangements to secure continuous improvements in how it delivers its functions. Elements of the guidance does not apply directly to the IJB – it is a strategic planning body and does not directly deliver any health or social care services but the broad principles do apply. Audit Scotland prepared best value questionnaire for IJBs to allow the IJB to clearly understand how the IJB could deliver its best value duty. A paper was presented to this committee at its March 2022 meeting working through this questionnaire and that the IJB prepare a best value framework. The IJB show now prepare a best value framework which they can the use on an annual basis to ensure that their duty of best value has been achieved. Committee members are asked to: • Request that the IJB develop a best value framework which can then used to assess the delivery of best value. Page 99 of 180
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Midlothian Integration Joint Board – Audit and Risk Committee Page 2 Report 1. Purpose This paper updates the committee on the duty of Best Value, on how that applies to the IJB and how the IJB can ensure that this duty is delivered. 2. Recommendations 2.1 Committee members are asked to • Request that the IJB develop a best value framework which can then used to assess the delivery of best value. 3. Background and main report 3.1 The IJB is constituted under s106 of the Local Government Scotland Act 2003. As such, along with all such bodies covered by this act, it has a statutory duty to secure best value. 3.2 These duties are – • The duty of Best Value, being to make arrangements to secure continuous improvement in performance (while maintaining an appropriate balance between quality and cost); and in making those arrangements and securing the balance, to have regard to economy, efficiency, effectiveness, the equal opportunities requirements and to contribute to the achievement of sustainable development. • The duty to achieve break-even in trading accounts subject to mandatory disclosure. • The duty to observe proper accounting practices. • The duty to make arrangements for the reporting to the public of the outcome of the performance of functions. The IJB has no trading accounts and this duty is not required. 3.3 The revised best value guidance (2020) is attached to this report for information. 3.4 There are seven broad themes against which the IJB can assess its compliance against its duty of best value. These are – 1 – Vision and Leadership 2 – Governance and Accountability 3 – Effective Use of Resources 4 – Partnerships and Collaborative Working 5 – Working with Communities 6 – Sustainable Development Page 100 of 180
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Midlothian Integration Joint Board – Audit and Risk Committee Page 3 7 – Fairness and Equality 3.5 Each of these themes is discussed further in the guidance which lays out, in considerable detail, both the importance of these themes and offers thoughts on how they can be delivered. 3.6 As is mentioned above the IJB, although covered by this duty, is a strategic planning body and does not deliver operational services in the way that Councils do. In order to clarify how IJB could ensure that they were addressing their duty of best value, Audit Scotland prepared a questionnaire. At its meeting in March 2022, the Audit and Risk committee the committee having requested that draft responses to the questionnaire be completed. This document is attached for information (appendix 2) 3.7 The committee agreed to recommend to the IJB that an appropriate Best Value framework is drawn up. This will mean that having agreed such a framework, hen on an annual basis the achievement of best value will be considered by looking at the work and actions of the IJB to deliver against the seven themes laid out above. 3.8 The IJB partners have slightly different approaches to Best Value. Midlothian Council is, of course covered, by the 2003 Act and the guidance as attached but NHS Lothian has a slightly different model. Health Boards have a statutory duty under the Public Finance and Accountability (Scotland) Act 2000) to use their resources ‘economically, efficiently and effectively’. This is, to all intents and purposes, the same as the duty of best value. 3.9 The IJB, when issuing directions to its partners, should also include a specific requirement for the partners to deliver the services recognising their duty of best value. 4. Policy Implications 4.1 There are no further policy implications arising from this report. 5. Equalities Implications 5.1 There are no equalities implications arising from this report. 6. Resource Implications 6.1 There are no resource implications arising from this report. 7 Risks 7.1 The are no further risks arising from this report. 8 Involving People Page 101 of 180
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Midlothian Integration Joint Board – Audit and Risk Committee Page 4 8.1 There are no direct implications for involving people as a result of this report. 9 Background Papers 9.2 None AUTHOR’S NAME David King DESIGNATION Interim Chief Finance Officer CONTACT INFO david.king4@nhslothian.scot.nhs.uk DATE May 2024 Appendix 1 – Best Value – Revised statutory guidance 2020. Appendix 2 – IJB Audit and Risk Paper – Best Value, consideration of the Audit Scotland Questionaire. Presented to the committee at its March 2022 meeting. Page 102 of 180
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Local Government in Scotland Act 2003 Best Value: Revised Statutory Guidance 2020 March 2020 Page 103 of 180
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LOCAL GOVERNMENT IN SCOTLAND ACT 2003 BEST VALUE: REVISED STATUTORY GUIDANCE 2020 CONTENTS Page SECTION 1 – OVERVIEW • The Duty of Best Value 2 • Purpose of the Guidance 2 • Best Value Themes 3 • Scope of the Guidance 3 • Working with Partners 4 • Role of the Accounts Commission 4 SECTION 2 – BEST VALUE THEMES Overview 5 Theme 1 – Vision and Leadership 5 Theme 2 – Governance and Accountability 7 Theme 3 – Effective Use of Resources 9 Theme 4 – Partnerships and Collaborative Working 13 Theme 5 – Working with Communities 15 Theme 6 – Sustainable Development 16 Theme 7 – Fairness and Equality 18 ANNEXES Steering Group Membership 20 Useful Resources 21 Page 104 of 180
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2 SECTION 1 – OVERVIEW The Duty of Best Value The Local Government in Scotland Act 2003 introduced a statutory framework for Best Value for local authorities. The Best Value duties set out in the Act are: • to make arrangements to secure continuous improvement in performance (while maintaining an appropriate balance between quality and cost); and, in making those arrangements and securing that balance, to have regard to economy, efficiency, effectiveness, the equal opportunities requirement and to contribute to the achievement of sustainable development • to achieve break-even trading accounts, subject to mandatory disclosure • to observe proper accounting practices • to make arrangements for the reporting to the public of the outcome of the performance of functions. Purpose of the Guidance Best Value guidance has been in place since 2004, identifying the characteristics of Best Value to help local authorities develop arrangements to demonstrate continuous improvement in their performance. In recognition of the changes since 2004 to the environment in which local authorities deliver services, a multi-agency steering group was tasked with reviewing and refreshing the guidance. The steering group endorsed the continuing relevance of the substance of the original guidance, but felt that it should be revised to reflect the current public service landscape in Scotland, with an increasing emphasis on citizens and personalised services, a focus on outcomes, and the need for innovation in designing public services for the future. The steering group also identified the need for synergy and alignment, so far as possible and appropriate, between the statutory guidance and the guidance on Best Value in public services, which applies to public bodies that are accountable to the Scottish ministers. This revised guidance has been produced by the steering group and reflects the priorities that it identified. It replaces the previous guidance that was published in 2004, which comprised both the statutory guidance by Scottish ministers and supporting guidance by the then Best Value Task Force, so that all the relevant guidance is now contained in this single document. Page 105 of 180
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3 Best Value Themes This revised guidance is framed around the following Best Value themes: 1. Vision and leadership 2. Governance and accountability 3. Effective use of resources 4. Partnerships and collaborative working 5. Working with communities 6. Sustainability 7. Fairness and equality As in the previous guidance, sustainability and fairness and equality continue to be cross-cutting themes that should be integral to all of the functions and activities carried out by a local authority to deliver good outcomes and achieve Best Value. Section 2 of this guidance explains these themes and how a local authority can demonstrate that it is delivering Best Value in respect of each theme. Scope of the Guidance This guidance applies to other bodies as required by Section 106 of the Local Government (Scotland) Act 1973, notably health and social care integration joint boards and other joint committees or boards, that are subject to the same statutory Best Value duties as local authorities and it should be interpreted and applied accordingly. Section 14 of the 2003 Act applies the Best Value duty to these other bodies and thus references throughout the guidance to ‘local authorities’ cover all such bodies. Other devolved public bodies, such as the NHS, are not directly covered by the 2003 Act. They are, however, under a similar Best Value duty, which is set out in the Scottish Public Finance Manual, and a statutory duty under the Public Finance and Accountability (Scotland) Act 2000) to use their resources ‘economically, efficiently and effectively’. Since 2003, the enactment of other key legislation has had a significant impact across Scotland, extending the requirements of Best Value beyond local authorities. The Public Bodies (Joint Working) (Scotland) Act 2014 has resulted in the integration of health and social care, while the Community Empowerment (Scotland) Act 2015 has strengthened the statutory base for community planning, and for involving and engaging communities in planning and decision-making about things that matter to them. Page 106 of 180
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4 Working with Partners Achieving Best Value is increasingly dependent on the effectiveness of partnerships and collaborative working arrangements with a range of stakeholders, in addition to how well a local authority manages its own activities. Since the original version of this guidance was published in 2004, there has been an increased focus on partnership and collaborative working across the public sector, with much more alignment of key plans and strategies among partners, and joint working to deliver shared outcomes. Alignment of key plans and strategies with its partners, an understanding of place, a commitment to reducing inequalities, empowering communities to affect change, and being able to demonstrate improved outcomes for people who use services are now key requirements in the achievement of Best Value. Although local authorities are not responsible for the performance of all partners in their areas, they are crucial in influencing many local services through their relationships with others. Local authorities achieving Best Value will be able to demonstrate a vision and direction of travel shared with key stakeholders in order to achieve key outcomes for local people. There are a number of areas where Best Value can be demonstrated only by working in strong partnership arrangements with bodies not covered by the statutory Best Value duties in the 2003 Act, and this is reflected in the guidance. This guidance should be read in conjunction with the statutory guidance on community planning, which describes how local authorities and other public sector bodies should work together in the context of community planning. Role of the Accounts Commission The Accounts Commission for Scotland is responsible for reporting on the performance by local authorities (and those other bodies covered by section 14 of the 2003 Act as discussed above, such as integration joint boards) of their Best Value and community planning duties. The Commission considers, in public, statutory reports from the Controller of Audit on Best Value, based upon the annual audit work by appointed external auditors in individual councils. Having considered such a report, the Commission has a range of powers that it can use, as set out in the Local Government (Scotland) Act 1973. They also make use as appropriate of the work of other local government scrutiny and inspection bodies. Page 107 of 180
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5 SECTION 2 – BEST VALUE THEMES Overview The 2004 Best Value guidance was structured around ten Best Value characteristics. This refreshed guidance reconfigures these characteristics into seven themes that better reflect the significantly changed policy and public service delivery landscape within which local authorities now operate. Local authorities must be able to demonstrate a focus on continuous improvement in performance around each of these themes. Theme 1 – Vision and Leadership Effective political and managerial leadership is central to delivering Best Value, through setting clear priorities and working effectively in partnership to achieve improved outcomes. Leaders should demonstrate behaviours and working relationships that foster a culture of cooperation, and a commitment to continuous improvement and innovation. In achieving Best Value, a local authority will be able to demonstrate the following: • Members and senior managers have a clear vision for their area that is shared with citizens, key partners and other stakeholders. • Members set strategic priorities that reflect the needs of communities and individual citizens, and that are aligned with the priorities of partners. • Effective leadership drives continuous improvement and supports the achievement of strategic objectives. This means that: 1. The local authority’s vision for its area is developed in partnership with its citizens, employees, key partners and other stakeholders. 2. Members set strategic priorities that contribute to achieving the local authority’s vision, reflect the needs of communities and individual citizens, and are aligned with the priorities of partners. They take decisions that contribute to the achievement of those priorities, in particular when allocating resources and in setting and monitoring performance targets. 3. The local authority’s vision and strategic priorities are clearly communicated to its citizens, staff and other partners. Page 108 of 180
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6 4. Strategic plans reflect a pace and depth of improvement that will lead to the realisation of the local authority’s priorities and the long-term sustainability of services. 5. Service plans are clearly linked to the local authority’s priorities and strategic plans. They reflect the priorities identified through community planning, and show how the local authority is working with partners to provide services that meet community needs. 6. Priority outcomes are clearly defined, and performance targets are set that drive continuous improvement in achieving those outcomes. 7. There are clear and effective mechanisms for scrutinising performance that enable the taking of informed decisions and the measuring of impacts and service outcomes. 8. There is a corporate approach to continuous improvement, with regular updating and monitoring of improvement plans. 9. The local authority and its partners agree on how the key elements of Best Value will contribute to achieving the commonly agreed local priorities and outcomes. These key elements include the need to: • secure continuous improvement, in particular for those services aligned to the local authority’s priorities • provide customer- and citizen-focused public services, which meet the needs of diverse communities • achieve the best balance of cost and quality in delivering services (having regard to economy, efficiency, effectiveness and equalities) • contribute to sustainable development • encourage and support innovation and creativity. 10. Members and senior managers communicate the approach to Best Value methodically throughout the local authority in terms that are relevant to its staff and set out clear expectations of them. The local authority has a positive culture in which its people understand its vision and objectives and how their efforts contribute to their achievement, and they are engaged with and committed to improvement. 11. Members and senior managers are self-aware. They commit to training and personal development to update and enhance their knowledge, skills, capacity and capabilities to deliver Best Value and perform their leadership roles, and they receive sufficient support to do so. 12. Leadership is effective and there is good collaborative working. Members and senior managers have a culture of cooperation and working constructively in partnership, informed by a clear understanding of their respective roles and responsibilities and characterised by mutual respect, trust, honesty and openness and by appropriate behaviours. Page 109 of 180
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7 Theme 2 – Governance and Accountability Effective governance and accountability arrangements, with openness and transparency in decision-making, schemes of delegation and effective reporting of performance, are essential for taking informed decisions, effective scrutiny of performance and stewardship of resources. In achieving Best Value, a local authority will be able to demonstrate the following: • A clear understanding and the application of the principles of good governance and transparency of decision-making at strategic, partnership and operational levels. • The existence of robust arrangements for scrutiny and performance reporting. • The existence of strategic service delivery and financial plans that align the allocation of resources with desired outcomes for the short, medium and long terms. This means that: 1. Members and senior managers ensure accountability and transparency through effective internal and external performance reporting, using robust data to demonstrate continuous improvement in the local authority’s priority outcome measures. 2. Management information and indicators that allow performance to be assessed are widely and consistently used by the local authority. Senior management regularly receives information that is used to inform members about performance. 3. Performance is reported to the public, to ensure that citizens are well informed about the quality of services being delivered and what they can expect in future. 4. Learning from previous performance, and from the performance of other local authorities, informs the review and development of strategies and plans to address areas of underperformance. 5. Key organisational processes are linked to, or integrated with, the planning cycle; these include strategic analyses, stakeholder consultations, fundamental reviews, performance management, staff appraisal and development schemes, and public performance reporting. 6. The local authority has a responsible attitude to managing risk, and business continuity plans (including civil contingencies and emergency plans) are in place to allow an effective and appropriate response to planned and unplanned events and circumstances. Page 110 of 180
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8 7. Key discussions and decision-making take place in public meetings, and reasonable measures are taken to make meeting agendas, reports and minutes accessible to the public, except when there are clear reasons why this would be inappropriate. 8. The local authority’s political structures support members in making informed decisions. 9. The scrutiny structures in the local authority support members in reviewing and challenging its performance. 10. Members and senior managers promote the highest standards of integrity and responsibility, establishing shared values, mutual trust and sound ethics across all activities. Effective procedures are in place to ensure that members and staff comply with relevant codes of conduct and policies. This includes ensuring that appropriate policies on fraud prevention, investigation and whistleblowing are established and implemented. 11. Members and senior managers understand and effectively communicate their respective and collective roles and responsibilities to members and staff. They understand that effective delegation enables and supports the local authority’s ability to achieve Best Value. 12. An information governance framework is in place that ensures proper recording of information, appropriate access to that information including by the public, and legislative compliance. 13. Technological innovation and digital transformation are promoted and used to ensure accessibility of performance information and public accountability. 14. Members and employees across the local authority understand and implement their responsibilities in relation to its Standing Orders and Financial Regulations. 15. There are clear governance and lines of accountability when delivering services via a third party, and there is evidence of the application of the principles within the ‘Following the Public Pound’ guidance when funding is provided to external bodies. Page 111 of 180
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9 Theme 3 – Effective Use of Resources Making the best use of public resources is at the heart of delivering Best Value. With clear plans and strategies in place, and with sound governance and strong leadership, a local authority will be well placed to ensure that all of its resources are deployed to achieve its strategic priorities, meet the needs of its communities and deliver continuous improvement. In achieving Best Value, a local authority will be able to demonstrate the following: • It makes best use of its financial and other resources in all of its activities. • Decisions on allocating resources are based on an integrated and strategic approach, are risk-aware and evidence-based, and contribute to the achievement of its strategic priorities. • It has robust procedures and controls in place to ensure that resources are used appropriately and effectively, and are not misused. • It works with its partners to maximise the use of their respective resources to achieve shared priorities and outcomes. This means that: Staff 1. A workforce strategy is in place that sets out expectations on how the local authority’s staff will deliver its vision, priorities and values. 2. The strategy is translated into workforce plans, covering employee numbers, skills, knowledge, competencies and organisational structures, that demonstrate how staff will be deployed to deliver the services planned for the future. Plans are regularly reviewed at appropriate intervals according to a clear review cycle. 3. All employees are managed effectively and efficiently, and know what is expected of them. Employee performance is regularly assessed through performance appraisal, with individuals and teams being supported to improve, where appropriate. 4. Members and senior managers understand and demonstrate that effective delegation is an important contribution to the local authority’s ability to achieve Best Value. 5. The contribution of staff to ensuring continuous improvement is supported, managed, reviewed and acknowledged. Page 112 of 180
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10 6. The local authority demonstrates a commitment to fairness, equity and safety in the workplace; it adopts relevant statutory guidance through progressive workplace policies and a commitment to best practice in workplace relationships. 7. Leaders ensure that there is the organisational capacity to deliver services through effective use of all employees and other resources. They communicate well with all staff and stakeholders, and ensure that the organisation promotes a citizen- and improvement-focused culture that delivers meaningful actions and outcomes. Asset management 1. There is a corporate approach to asset management that is reflected in asset management strategies and plans, which are subject to regular review. 2. There is a systematic and evidence-based approach to identifying and managing risks in relation to land, buildings, plant, equipment, vehicles, materials and digital infrastructure. 3. The local authority actively manages its asset base to contribute to its objectives and priorities. 4. Fixed assets are managed efficiently and effectively, taking account of availability, accessibility, safety, utilisation, cost, condition and depreciation. Information 1. Information is regarded as a strategic resource and is managed accordingly. 2. There is a clear digital strategy in place, which includes resilience plans for information systems. 3. Information is shared appropriately, and the local authority seeks to develop data compatibility with its partners. Financial management and planning 1. There is clear alignment between the local authority’s budgets and its strategic priorities. 2. Regular monitoring and reporting of financial outturns compared with budgets is carried out, and corrective action taken where necessary to ensure the alignment of budgets and outturns. 3. Financial plans show how the local authority will fund its services in the future. Long-term financial plans that include scenario planning for a range of funding levels are prepared and linked to strategic priorities. 4. An appropriate range of options is considered when taking decisions, and robust processes of option appraisal and self-assessment are applied. Page 113 of 180
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11 5. The local authority has clear plans for how it will change services and realise efficiencies to close future budget gaps. 6. Members and senior managers have a clear understanding of likely future pressures on services and of how investment in preventative approaches can help alleviate those pressures, and they use that understanding to inform decisions. 7. Financial performance is systematically measured across all areas of activity, and regularly scrutinised by managers and members. 8. There is a robust system of financial controls in place that provides clear accountability, stakeholder assurance, and compliance with statutory requirements and recognised accounting standards. 9. The local authority complies with legal and best practice requirements in the procurement and strategic commissioning of goods, services and works, including the Scottish Model of Procurement. There is clear accountability within procurement and commissioning arrangements. 10. There are clear and effective governance and accountability arrangements in place covering partnerships between the local authority and its arm’s-length external organisations (ALEOs), including for performance monitoring and the early identification of any significant financial and service risks; there is evidence of the application of the principles of ‘Following the Public Pound.’ 11. The local authority has a reserves policy that supports its future financial sustainability, and its reserves are held in accordance with that policy. Performance management 1. Effective performance management arrangements are in place to promote the effective use of the local authority’s resources. Performance is systematically measured across all areas of activity, and performance reports are regularly scrutinised by managers and elected members. The performance management system is effective in addressing areas of underperformance, identifying the scope for improvement and agreeing remedial action. 2. There is a corporate approach to identifying, monitoring and reporting on improvement actions that will lead to continuous improvement in priority areas. Improvement actions are clearly articulated and include identifying responsible officers and target timelines. 3. The local authority uses self-evaluation to identify areas for improvement. This includes the use of comparative analyses to benchmark, monitor and improve performance. Page 114 of 180
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12 4. The local authority takes an innovative approach when considering how services will be delivered in the future. It looks at the activities of other organisations, beyond its area, to consider new ways of doing things. A full range of options is considered, and self-assessment activity and options appraisal can be demonstrated to be rigorous and transparent. 5. Evaluation tools are in place to link inputs, activities and outputs to the outcomes that they are designed to achieve. There is evidence to demonstrate that improvement actions lead to continuous improvement and better outcomes in priority service areas. 6. The local authority seeks and takes account of feedback from citizens and service users on performance when developing improvement plans. 7. Improvement plans reflect a pace and depth of improvement that will lead to the realisation of the local authority’s priorities and the long-term sustainability of services. 8. Performance information reporting to stakeholders is regular and gives a balanced view of the local authority’s performance, linked to its priority service areas. The information provided is relevant to its audience, and clearly demonstrates whether or not strategic and operational objectives and targets are being met. 9. The local authority demonstrates a trend of improvement over time in delivering its strategic priorities. Page 115 of 180
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13 Theme 4 – Partnerships and Collaborative Working The public service landscape in Scotland requires local authorities to work in partnership with a wide range of national, regional and local agencies and interests across the public, third and private sectors. A local authority should be able to demonstrate how it, in partnership with all relevant stakeholders, provides effective leadership to meet local needs and deliver desired outcomes. It should demonstrate commitment to and understanding of the benefits gained by effective collaborative working and how this facilitates the achievement of strategic objectives. Within joint working arrangements, Best Value cannot be measured solely on the performance of a single organisation in isolation from its partners. A local authority will be able to demonstrate how its partnership arrangements lead to the achievement of Best Value. In achieving Best Value, a local authority will be able to demonstrate the following: • Members and senior managers have established and developed a culture that encourages collaborative working and service provision that will contribute to better and customer-focused outcomes. • Effective governance arrangements for Community Planning Partnerships and other partnerships and collaborative arrangements are in place, including structures with clear lines of responsibility and accountability, clear roles and responsibilities, and agreement around targets and milestones. This means that: 1. Members and senior managers actively encourage opportunities for formal and informal joint/integrated working, joint use of resources and joint funding arrangements, where these will offer scope for service improvement and better outcomes. 2. The local authority is committed to working with partner organisations to ensure a coordinated approach to meeting the needs of its stakeholders and communities. This includes: • scenario planning with partners to identify opportunities to achieve Best Value • collaborative leadership to identify Best Value partnership solutions to achieve better outcomes for local people • proactively identifying opportunities to invest in and commit to shared services • integrated management of resources where appropriate • effective monitoring of collective performance, including self-assessment and reviews of the partnership strategy, to ensure the achievement of objectives Page 116 of 180
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14 • developing a joint understanding of all place-based capital and revenue expenditure. 3. Members and senior managers identify and address any impediments that inhibit collaborative working. The local authority and its partners develop a shared approach to evaluating the effectiveness of collaborative and integrated working. 4. In undertaking its community planning duties the local authority works constructively with partners to agree a joint vision for the Community Planning Partnership and integrates shared priorities and objectives into its planning, performance management and public reporting mechanisms. Service plans clearly reflect the priorities identified through community planning, and show how the local authority is working with partners to provide services that meet stakeholder and community needs. Page 117 of 180
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15 Theme 5 – Working with Communities Local authorities, both individually and with their community planning partners, have a responsibility to ensure that people and communities are able to be fully involved in the decisions that affect their everyday lives. Community bodies – as defined in the Community Empowerment Act 2015 (section 4(9)) – must be at the heart of decision- making processes that agree strategic priorities and direction. In achieving Best Value, a local authority will be able to demonstrate the following: • Early and meaningful engagement and effective collaboration with communities to identify and understand local needs, and in decisions that affect the planning and delivery of services. • A commitment to reducing inequalities and empowering communities to effect change and deliver better local outcomes. • That engagement with communities has influenced strategic planning processes, the setting of priorities and the development of locality plans. This means that: 1. Members and senior managers ensure that meaningful consultation and engagement in relation to strategic planning take place at an early stage and that the process of consultation and engagement is open, fair and inclusive. 2. Members and senior managers are proactive in identifying the needs of communities, citizens, customers, staff and other stakeholders; plans, priorities and actions are demonstrably informed by an understanding of those needs. 3. Communities are involved in making decisions about local services, and are empowered to identify and help deliver the services that they need. Suitable techniques are in place to gather the views of citizens, and to assess and measure change in communities as a result of service interventions. 4. Active steps are taken to encourage the participation of hard-to-reach communities. 5. The local authority and its Community Planning Partnership work effectively with communities to improve outcomes and address inequalities. 6. A locality-based approach to community planning has a positive impact on service delivery within communities, and demonstrates the capacity for change and for reducing inequality in local communities by focusing on early intervention and prevention. Page 118 of 180
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16 7. Members and senior managers work effectively with partners and stakeholders to identify a clear set of priorities that respond to the needs of communities in both the short and the longer term. The local authority and its partners are organised to deliver on those priorities, and clearly demonstrate that their approach ensures that the needs of their communities are being met. 8. The local authority engages effectively with customers and communities by offering a range of communication channels, including innovative digital solutions and social media. 9. The local authority plays an active role in civic life and supports community leadership. The two cross-cutting themes that a Best Value local authority should fully embrace across all of its activities are Theme 6, sustainable development, and Theme 7, fairness and equality. Theme 6 – Sustainable Development Sustainable development is commonly defined as securing a balance of social, economic and environmental wellbeing in the impact of activities and decisions, and seeking to meet the needs of the present without compromising the ability of future generations to meet their own needs. The United Nations Sustainable Development Goals provide a fuller definition and set out an internationally agreed performance framework for their achievement. Sustainable development is a fundamental part of Best Value. It should be reflected in a local authority’s vision and strategic priorities, highlighted in all plans at corporate and service level, and a guiding principle for all of its activities. Every aspect of activity in a local authority, from planning to delivery and review, should contribute to achieving sustainable development. In achieving Best Value, a local authority will be able to demonstrate the following: • Sustainable development is reflected in its vision and strategic priorities. • Sustainable development considerations are embedded in its governance arrangements. • Resources are planned and used in a way that contributes to sustainable development. • Sustainable development is effectively promoted through partnership working. Page 119 of 180
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17 This means that: 1. Leaders create a culture throughout the local authority that focuses on sustainable development, with clear accountability for its delivery across the leadership and management team. 2. There is a clear framework in place that facilitates the integration of sustainable development into all of the local authority’s policies, financial plans, decision- making, services and activities through strategic-, corporate- and service-level action. In doing so, the local authority will be able to demonstrate that it is making a strategic and operational contribution to sustainable development. 3. The local authority has set out clear guiding principles that demonstrate its, and its partners’, commitment to sustainable development. 4. There is a broad range of qualitative and quantitative measures and indicators in place to demonstrate the impact of sustainable development in relation to key economic, social and environmental issues. 5. Performance in relation to sustainable development is evaluated, publicly reported and scrutinised. Page 120 of 180
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18 Theme 7 – Fairness and Equality Tackling poverty, reducing inequality and promoting fairness, respect and dignity for all citizens should be key priorities for local authorities and all of their partners, including local communities. In achieving Best Value, a local authority will be able to demonstrate the following: • That equality and equity considerations lie at the heart of strategic planning and service delivery. • A commitment to tackling discrimination, advancing equality of opportunity and promoting good relations both within its own organisation and the wider community. • That equality, diversity and human rights are embedded in its vision and strategic direction and throughout all of its work, including its collaborative and integrated community planning and other partnership arrangements. • A culture that encourages equal opportunities and is working towards the elimination of discrimination. This means that: 1. The local authority demonstrates compliance with all statutory duties in relation to equalities and human rights. 2. The local authority is taking active steps to tackle inequalities and promote fairness across the organisation and its wider partnerships, including work and living conditions, education and community participation. 3. The local authority and its partners have an agreed action plan aimed at tackling inequality, poverty and addressing fairness issues identified in local communities. 4. The local authority engages in open, fair and inclusive dialogue to ensure that information on services and performance is accessible to all, and that every effort has been made to reach hard-to-reach groups and individuals. 5. The local authority ensures that all employees are engaged in its commitment to equality and fairness outcomes, and that its contribution to the achievement of equality outcomes is reflected throughout its corporate processes. 6. The local authority engages with and involves equality groups to improve and inform the development of relevant policies and practices, and takes account of socio-economic disadvantage when making strategic decisions. Page 121 of 180
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19 7. The equality impact of policies and practices delivered through partnerships is always considered. Equality impact information and data is analysed when planning the delivery of services, and measuring performance. 8. The local authority’s approach to securing continuous improvement in delivering on fairness and equality priorities and actions is regularly scrutinised and well evidenced. Page 122 of 180
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20 Best Value Guidance Refresh – National Steering Group The steering group comprised officials from the Scottish Government, the Convention of Scottish Local Authorities (COSLA), the Society of Local Authority Chief Executives (SOLACE), the Scottish Trades Union Congress (STUC) and the Scottish Public Services Ombudsman (SPSO). Officials from Audit Scotland also attended meetings in an observational capacity: David Martin, SOLACE and Chief Executive of Dundee City Local Authority (Chair) Fiona Mitchell-Knight, Audit Scotland (observer) Fraser McKinlay, Audit Scotland (observer) Garrick Smyth, COSLA James Fowlie, COSLA Sandra Lorimer, Dundee City Local Authority Brian Peddie, Scottish Government John Stevenson, SPSO Mike Kirby (Unison), STUC Contributors: Anne Margaret Black, East Ayrshire Integration Joint Board Lorraine Gillies, Audit Scotland Page 123 of 180
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21 Useful Resources Audit Scotland Further information on the audit of Best Value can be found on the Audit Scotland website Audit Scotland issued on behalf of the Strategic Scrutiny Group Principles for community empowerment which aims to raise awareness of community empowerment and promote a shared understanding across scrutiny bodies to support high-quality scrutiny of community empowerment. Accounts Commission The “How Councils Work” series of reports produced by the Accounts Commission provides useful information and practical advice on a range of issues that are relevant to Best Value. ‘Following the Public Pound’ guidance is intended to ensure proper accountability for funds or other resources that are transferred by councils to arm’s-length bodies, such as companies, trusts and voluntary bodies funds, and to ensure that the principles of regularity and probity are not circumvented. It has the support of the Convention of Scottish Local Authorities. Scottish Government Best Value in Public Services: Guidance for Accountable Officers Community empowerment: information can be found on the Scottish Government website. Other resources The European Foundation for Quality Management (EFQM) Excellence Model was developed by the EFQM. It is widely used as a framework for continuous improvement activity by private, public and voluntary sector organisations. More information can be found on the Quality Scotland web site. The National Standards for Community Engagement are good-practice principles designed to improve and guide the process of community engagement. The Place Standard tool provides a simple framework to structure conversations about place taking into account both the physical elements of a place and its social aspects. The Public Service Improvement Framework (PSIF), produced by the Improvement Service, is a self-assessment framework that enables organisations to conduct a comprehensive review of their own activities and results. The Sustainable Development Network provides information and advice on sustainable development in the public sector in Scotland. Page 124 of 180
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© Crown copyright 2020 This publication is licensed under the terms of the Open Government Licence v3.0 except where otherwise stated. To view this licence, visit nationalarchives.gov.uk/doc/open- government-licence/version/3 or write to the Information Policy Team, The National Archives, Kew, London TW9 4DU, or email: psi@nationalarchives.gsi.gov.uk. Where we have identified any third party copyright information you will need to obtain permission from the copyright holders concerned. This publication is available at www.gov.scot Any enquiries regarding this publication should be sent to us at The Scottish Government St Andrew’s House Edinburgh EH1 3DG ISBN: 978-1-83960-602-1 (web only) Published by The Scottish Government, March 2020 Produced for The Scottish Government by APS Group Scotland, 21 Tennant Street, Edinburgh EH6 5NA PPDAS704906 (03/20) w w w . g o v . s c o tPage 125 of 180
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Audit Scotland Questionaries – IJB Best Value – suggested responses Midlothian Integration Joint Board Audit and Risk Committee 3rd March 2022 Best Value – Consideration of the Audit Scotland Questionnaire Executive summary At its December 2021 meeting the committee received a paper on the Audit Scotland best Value questionnaire for IJBs. The committee decided that it should consider a further paper that would lay out suggested responses to the best value questionnaire and allow the committee some further time to consider these responses and how the committee can assure itself that the principles of best value are being applied to the work of the IJB, that is the development and delivery of the IJB’s Strategic Plan. The committee is asked to :- 1. Consider this report, suggesting revisions/additions as required. 2. Request the preparation of an appropriate best value framework for adoption by the IJB. # Item number: 5.6 Page 127 of 180
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Midlothian Integration Joint Board Report Best Value – Consideration of the Audit Scotland Questionnaire 1 Purpose 1.1 At its meeting in December the IJB received a paper of the Audit Scotland best value questionnaire for IJBs. It agreed to consider this in an extended committee meeting and that this consideration should be supported by a draft set of responses to the questionnaire. 2 Recommendations 2.1 As a result of this report Members are being asked to:- • Consider this report, suggesting revisions/additions as required. • Request the preparation of an appropriate best value framework for adoption by the IJB. 3 Background and main report 3.1 The Audit Scotland guidance note on best value was published in March 2018. Although this note was to support auditors in their assessment of the delivery of best value it also contains a useful questionnaire to assess the achievement of best value in IJBs. 3.2 Appendix A lays out the 10 questions and provides a suggested response to each of the questions along with a consideration of assurance that might be provided to support the responses 3.3 Whist the responses are draft and for discussion, having agreed the response to the questionnaire the IJB can proceed to agree a Best Value framework. This has been done successfully by a number of other public bodies. 3.4 The revised best value guidance (2020) is also attached as Appendix B. 4 Policy Implications 4.1 There are no policy implications from this report. 5 Directions 5.1 There are no implications on directions from this report. Page 128 of 180
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Midlothian Integration Joint Board 6 Equalities Implications 6.1 There are no equalities implications from this report 7 Resource Implications 7.1 There are no resource implications from this report. 8 Risk 8.1 The risks raised by this report are already included within the IJB risk register. 9 Involving people 9.1 The IJB’s annual accounts will be published on the IJB website. 10 Background Papers 10.1 None. AUTHOR’S NAME David King DESIGNATION Interim Chief Finance Officer CONTACT INFO David.King4@nhslothian.scot.nhs.uk DATE February 2022 Appendices: A - Audit Scotland Best Value questionnaire for IJBs – draft responses. B – Best Value – revised statutory guidance 2020. Page 129 of 180
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Audit Scotland Questionaries – IJB Best Value – suggested responses Question IJB Response Assurance 1. Who do you consider to be accountable for securing Best Value in the IJB? In principle the voting members, the Chief Officer and the S95 Officer. In practice the Chief Officer and the CFO as S95 Officer. The work of the groups that support the IJB – the SPG, the Planning & Transformation group and proposed performance group 2. How do you receive assurance that the services supporting the delivery of the strategic plan are securing Best Value? In terms of operational delivery of the functions, the partners (Midlothian Council and NHS Lothian) must provide assurance to the IJB. That assurance is provided by the governance arrangements of the partners, the appropriate elements of which are reported to the IJB Update on the delivery of the Directions reported to the IJB and the work of the proposed performance group 3. Do you consider there to be sufficient buy-in to the IJB’s longer term vision from partner officers and members? Yes. Both partners have a very good record of having supported the Board since its inception with voting members regularly attending board meetings and workshops. For example the leader of Midlothian Council has always been a member of the IJB. Minutes of the IJB - shows attendance. 4. How is value for money demonstrated in the decisions made by the IJB? Through the Strategic plan and the directions and the work of the groups that support the IJB – the SPG, the Planning & Transformation group and proposed performance group The proposed performance group will consider the delivery of the directions. 5. Do you consider there to be a culture of continuous improvement Yes, this is part of the IJB’s ethos and is laid out in both the Integration Scheme and the Strategic Plan. There is a significant commitment to building capacity for Minutes of the SPG and the Transformation and Planning Group. Minutes of Integrated Planning Groups. Page 130 of 180
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Midlothian Integration Joint Board continuous improvement and ongoing work to align methodologies and practices across integrated services 6. Have there been any service reviews undertaken since establishment – have improvements been identified? Is there any evidence of improvements in services and/or reductions in pressures as a result of joint working? Yes – the creation of an integrated management team. The development of integrated operational teams and close working with the local GP practices. Further examples include – Home first team - improvements in patient flow and achievement of the MSG performance targets Extra care housing (Cowan court staffing model) Highbank Intermediate care model Primary care Improvement Plan Mental health model – minimal use of REH acute/rehab beds/MH delays Whole system Diabetes work LD model – able to support in local model so less use of acute REAS beds ‘No 11’ service – co-located teams (SMS, Justice, Mental health) 7. Have identified improvement actions been prioritised in terms of those likely to have the greatest impact? Yes, recent strategic planning and performance recruitment provides the opportunity to further develop the ability for performance to strategically inform quality planning and strategic modelling. Directions comprise of 5 service level impact priorities in each area 8. What steps are taken to ensure that quality of care and service provided is not compromised as a result of costs saving measures? The IJB’s financial strategy commits it to living within the totality of its resources and this will be delivered through service transformation and not cost saving measures. Investment in the performance team who will develop a Assurance through scrutiny at the proposed performance group, the Planning and Page 131 of 180
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Midlothian Integration Joint Board performance framework for the IJB. Future work will seek to develop and embed a broad Performance Framework for the Partnership. This will aim to use a range of measures and metrics that evidence quality, inform planning and develop plans to deliver sustainable and high-quality care. Transformation group and SPG 9. Is performance information reported to the board of sufficient detail to enable value for money to be assessed? Yes. This is being further development by the appointment of a performance manager and a supporting performance team Performance reports to IJB. Appointment of a Performance Team 10. How does the IJB ensure that management of resources (finances, workforce etc.) is effective and sustainable? Through the development of the IJB’s multi-year, balanced financial plan which will articulate how the Strategic Plan is delivered in financial terms. The HSCP has produced an updated workforce plan that is cognisant of the challenges and opportunities presented by a range of dynamic influences across workforce recruitment and retention, wellbeing and wellness. IJB Finance Strategy, IJB Workforce Strategy. Page 132 of 180
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Midlothian Integration Joint Board Audit and Risk Committee Revisions of Terms of Reference for the Audit and Risk Committee and the Strategic Planning Group Thursday, 6 June 2024 Item number: 5.6 Executive summary The IJB has two committees. These are – • The Strategic Planning Group – this is a statutory requirement under the Public Bodies (Joint Working) Act 2014. • An Audit and Risk Committee – this is the IJB’s committee of governance. The Terms of Reference (ToR) for both these committees now required to be reviewed given that the current documents are several years old. The Audit and Risk committee cannot agree these ToR’s, that is a matter for the IJB itself however it will be very helpful if the committee can consider these revised and reviewed ToRs and, when these ToRs are presented to the IJB, reflect its opinions at that time. Committee members are asked to: • Consider these revised ToRs and reflect on any suggested amendments. Page 133 of 180
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Midlothian Integration Joint Board – Audit and Risk Committee Page 2 Report 1. Purpose 1.1 This report presents, for comment only, revised Terms of reference for the IJB’s Audit and Risk Committee and the IJB’s Strategic Planning Group. 2. Recommendations 2.1 Committee members are asked to • Consider these revised Terms of Reference and reflect on any suggested amendments 3. Background and main report 3.1 The IJB has two committees – The Strategic Planning Group (SPG) – this is a statutory committee required by the Public Bodies (joint Working) Act 2014 that set up Integration Authorities. Midlothian Integration Joint Board is the Integration Authority for Midlothian. An Audit and Risk Committee (A&R) – this is the IJB’s committee of governance and is set up in terms of best practice in the governance of public bodies. 3.2 Although there is a range of statutory guidance in the membership, management and role of the SPG, the specific terms of reference for Midlothian IJB are agreed by the IJB. As the experience of the IJB matures its important to review how the SPG functions and, in any even, best practice suggests that the ToR of any committee be reviewed and revised every few years. 3.3 Similarly there is a range of guidance from various bodies regarding the constitution and role of Audit and Risk committees but again the IJB would wish to reflect on this and the ToR of that committee also requires to be revised. 3.4 It is not the role of the Audit and Risk committee to review and agree its own ToR nor indeed that of the SPG. However, the Audit and Risk committee has a clear role in the governance of the IJB and the IJB would wish to be advised of the committee’s reflection on these two revised Term’s Of Reference. 3.5 It should be noted that both ToRs have been reduced in length and simplified hopefully allowing a more clear understanding of the role and purpose of both committees. It should also be noted that the membership of the SPG in terms of voting members of the IJB has been more clearly laid out. Page 134 of 180
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Midlothian Integration Joint Board – Audit and Risk Committee Page 3 3.6 When these revised ToR’s are presented to the IJB for agreement, any comments made by the committee will be included in the covering papers. . 4. Policy Implications 4.1 There are no further policy implications arising from this report. 5. Equalities Implications 5.1 There are no equalities implications arising from this report 6. Resource Implications 6.1 There are no resource implications arising from this report. 7 Risks 7.1 The risks are described in the risk register which is attached 8 Involving People 8.1 There are no direct implications for involving people as a result of this report. 9 Background Papers 9.2 None AUTHOR’S NAME David King DESIGNATION Interim Chief Finance Officer CONTACT INFO david.king4@nhslothian.scot.nhs.uk DATE May 2024 Appendix 1 – Draft revised Terms of Reference of the Midlothian IJB Audit and Risk Committee Appendix 2 – Draft revised Terms of Reference of the Midlothian IJB Strategic Planning Group Page 135 of 180
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1 Midlothian Integration Joint Board Audit and Risk Committee ToR Midlothian Integration Joint Board Audit and Risk Committee Terms of Reference 1. PURPOSE 1.1 The Midlothian Integration Joint Board (IJB) Audit and Risk Committee will hold overarching responsibility to review and provide assurance on the IJB’s corporate governance arrangements. The Committee will report any concerns regarding the corporate governance arrangements to the IJB. 1.2 The Audit and Risk Committee shall formally report to Midlothian Integration Joint Board. The diagram above illustrates the relationship between the Audit and Risk Committee the Integration Joint Board, and other relevant bodies. This committee will be a standing committee of the IJB. Section 3.11 of the financial regulations of the IJB (approved by the IJB on 29th October 2015) state that the IJB will have an audit and risk committee. The members of the committee will be appointed by the IJB. 2. REMIT 2.1 The remit of the Audit and Risk Committee is to • review the IJB’s corporate governance arrangements against the good governance framework and consider annual governance reports and assurances. • review the Annual Governance Statement prior to approval and consider whether it properly reflects the risk environment and supporting assurances. • monitor the effective development and operation of risk management in the IJB. • consider reports on the effectiveness of internal controls and monitor the implementation of agreed actions. Page 137 of 180
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2 Midlothian Integration Joint Board Audit and Risk Committee ToR • approve the risk-based internal audit plan, including internal audit’s resources requirements, the approach to using other sources of assurance and any work required to place reliance upon those other sources. • consider reports from the Chief Internal Auditor on internal audit’s performance during the year, including the performance of external providers of internal audit services. • Review the delivery of best value by the IJB. • consider the external auditor’s annual letter, relevant reports, and the report to those charged with governance. • consider specific reports as agreed with the external auditor. • comment on the scope and depth of external audit work and to ensure it gives value for money. • commission work from internal and external audit. • review the annual statement of accounts. • consider the external auditor’s report to those charged with governance on issues arising from the audit of the accounts. 3. MEMBERSHIP 3.1 The role of Chair will be held by a voting member of the IJB noting that the Chair of the IJB cannot also be the Chair of the Audit and Risk Committee. 3.2 The role of Vice Chair will be held by one of the voting members of the IJB who is also a member of the Audit and Risk Committee. 3.3 The Audit and Risk Committee shall comprise of: • Four Voting Members of the IJB (inclusive of the Chair), two from Midlothian Council and two from NHS Lothian. • An Independent Member. The following Officers will be in attendance • The IJB’s Chief Officer • The IJB’s Chief Finance Officer • The IJBs Chief Internal Auditor. • The IJB’s Appointed Auditor (external auditor) • The HSCP’s Integration Manager 3.4 Each member should have a nominated deputy who will attend meetings in their absence. 3.5 The committee may ask any other members of the IJB or any officers from either partner to join the committee’s meetings as required. 4. QUORUM 4.1 The quorum will be three members out of the five members detailed in 3.3 (that is including the independent member if one is appointed). Page 138 of 180
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3 Midlothian Integration Joint Board Audit and Risk Committee ToR 5. ROLE OF THE MEMBERSHIP 5.1 Members will be expected to review and comment on papers and reports presented to the committee. 5.2 Members may require, through the Chair, further information to be provided on any matter they consider not to have been fully explored. 5.3 The Chair and members will provide a report to the IJB annually reflecting on the work of the committee. 5.4 The Chair and the members having reviewed the IJB’s risk register will present that annually to the IJB 6. FREQUENCY OF MEETINGS 6.1 The Audit and Risk Committee will be scheduled to meet every quarter. 6.2 The Chair may, at any time, convene additional meetings. 7. SUPPORT AND MINUTES 7.1 Administrative support will be provided by the Midlothian Council’s Democratic Services. 8. CONDUCT OF BUSINESS 8.1 Meetings will be called by the Chair. 8.2 A calendar of meetings for each year shall be agreed by members of the IJB and distributed. 8.3 The body of the agenda will consist of • Minutes of the previous meeting • Review of the Risk Register • Reports from Internal/External Auditors • Any further reports as agreed. 8.4 The Chair will review all submissions for suggested agenda items and circulate an agenda at least five working days before the date of the meeting. 9. REPORTING ARRANGEMENTS 9.1 A record of the agenda and action notes will be maintained. 9.2 Actions generated during the meeting will also be captured using an Action Log. Page 139 of 180
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1 Midlothian Integration Joint Board Strategic Planning Group ToR Midlothian Integration Joint Board Strategic Planning Group Terms of Reference 1. PURPOSE 1.1 The Midlothian Integration Joint Board (IJB) Strategic Planning Group will hold overarching responsibility to develop and review the IJB Strategic Commissioning Plan, monitor the delivery of this plan, and evaluate progress towards its strategic aims. The Strategic Planning Group will report any concerns regarding the Strategic Commissioning Plan or the ability to make progress towards its strategic aims to the IJB. 1.2 The Public Bodies (Joint Working) (Scotland) Act 2014 (Section 32) places a duty on Integration Authorities to establish a Strategic Planning Group to support the development and review of a strategic commissioning plan. 1.3 The Strategic Planning Group shall formally report to Midlothian Integration Joint Board. The diagram above illustrates the relationship between the Strategic Planning Group the Integration Joint Board, and other relevant bodies. This committee will be a standing committee of the IJB. 2. REMIT 2.1 The remit of the Strategic Planning Group is to • Influence and shape the development of the Strategic Commissioning Plan • Update the Strategic Commissioning Plan every 3 years • Monitor and evaluate progress towards the strategic aims • Articulate and report on the IJB’s contribution and progress towards the 9 National Health and Wellbeing Outcomes in Midlothian Page 141 of 180
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2 Midlothian Integration Joint Board Strategic Planning Group ToR • Consider the required Directions from Midlothian IJB to Midlothian Council and/or NHS Lothian in order to deliver the Strategic Plan and recommend these Directions to the IJB for formal adoption. • Review the strategic planning process for the IJB. 3. MEMBERSHIP 3.1 The role of Chair will be held by a voting member of the IJB noting that the Chair of the IJB cannot also be the Chair of the Strategic Planning Group. 3.2 The role of Vice Chair will be held by a voting member of the IJB who is also a member of the Strategic Planning Group. 3.3 Where the Integration Authority is an Integration Joint Board, the Strategic Planning Group membership must include • at least one person nominated by the Health Board which is a constituent authority in relation to the Integration Joint Board (NHS Lothian) • where one local authority is a constituent authority in relation to the Integration Joint Board, at least one person nominated by the local authority (Midlothian Council) 3.4 Membership of the Strategic Planning Group must comprise of: • Four Voting Members of the IJB (inclusive of the Chair and Vice Chair), two from Midlothian Council and two from NHS Lothian • The IJB’s Chief Officer • The IJB’s Chief Finance Officer • The HSCP’s Integration Manager • The HSCP’s Strategic Programme Manager for Performance 3.5 Strategic Planning Group must also include representation from • Carers • Public Member • Lived Experience Member • NHS Lothian Partnership Representative • Midlothian Council Partnership Representative • Social Care Professionals • Health Professionals • Commercial Providers of Health and Social Care • Non-Commercial Providers of Health and Social Care • Non-Commercial Providers of Social Housing • Third Sector Bodies carrying out activities related to Health or Social Care 3.6 Each member should have a nominated deputy who will attend meetings in their absence. 3.7 The Chair may ask any other members of the IJB or any officers from either partner to join the Strategic Planning Group meetings as required. 4. QUORUM 4.1 The quorum will be six members out of the ten members detailed in 3.3 and 3.4 Page 142 of 180
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3 Midlothian Integration Joint Board Strategic Planning Group ToR 5. ROLE OF THE MEMBERSHIP 5.1 Members will be expected to review and comment on papers and reports presented to the committee. 5.2 Members may require, through the Chair, further information to be provided on any matter they consider not to have been fully explored. 5.3 The Chair and members will provide a report to the IJB annually reflecting on the work of the committee. 6. FREQUENCY OF MEETINGS 6.1 The Strategic Planning Group will be scheduled to meet 6 times per year, a meeting in the month before each Integration Joint Board meeting. 6.2 The Chair may, at any time, convene additional meetings. 7. SUPPORT AND MINUTES 7.1 Administrative support will be provided by the Midlothian Council’s Democratic Services. 8. CONDUCT OF BUSINESS 8.1 Meetings will be called by the Chair. 8.2 A calendar of meetings for each year shall be agreed by members of the IJB and distributed. 8.3 The body of the agenda will consist of • Minutes of the previous meeting • Review of the Action Log • Review of the Risk Register • Any further reports as agreed. 8.4 The Chair will review all submissions for suggested agenda items and circulate an agenda at least five working days before the date of the meeting. 9. REPORTING ARRANGEMENTS 9.1 A record of the agenda and action notes will be maintained. 9.2 Actions generated during the meeting will also be captured using an Action Log. Page 143 of 180
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Midlothian IJB Audit and Risk Committee Thursday, 6 June 2024 Midlothian Health and Social Care Integration Joint Board Annual Governance Statement 2023/24 Executive summary The purpose of this report is to present the draft Annual Governance Statement 2023/24 for the Midlothian Health and Social Care Integration Joint Board (MIJB) which explains the MIJB’s governance arrangements and system of internal control and reports on their effectiveness for the year ended 31 March 2024. The MIJB Audit and Risk Committee is therefore asked to: Consider the Midlothian Health and Social Care Integration Joint Board draft Annual Governance Statement 2023/24 (Appendix 1), which explains the MIJB’s governance arrangements and system of internal control and reports on their effectiveness for the year ended 31 March 2024, and provide any commentary thereon and approve for inclusion in the draft Annual Accounts 2023/24. # Item number: 5.7 Agenda number Page 145 of 180
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Midlothian Integration Joint Board Report Midlothian Health and Social Care Integration Joint Board Annual Governance Statement 2023/24 1 Purpose 1.1 The purpose of this report is to present the draft Annual Governance Statement 2023/24 for the Midlothian Health and Social Care Integration Joint Board (MIJB) which explains the MIJB’s governance arrangements and system of internal control and reports on their effectiveness for the year ended 31 March 2024. 2 Recommendations 2.1 Members of the MIJB Audit and Risk Committee are asked to: Consider the Midlothian Health and Social Care Integration Joint Board draft Annual Governance Statement 2023/24 (Appendix 1), which explains the MIJB’s governance arrangements and system of internal control and reports on their effectiveness for the year ended 31 March 2024, and provide any commentary thereon and approve for inclusion in the draft Annual Accounts 2023/24. 3 Background and main report 3.1 The Midlothian Integration Joint Board (MIJB), established as a separate legal entity as required by the Act, is 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. 3.2 Regulation 5(2) of the Local Authority Accounts (Scotland) Regulations 2014 requires an authority to conduct a review at least once in a year of the effectiveness of its system of internal control and include a statement reporting on the review with any published Statement of Accounts. Regulation 5(4) of the Local Authority Accounts (Scotland) Regulations 2014 require that for a local authority in Scotland the statement is an Annual Governance Statement. 3.3 The CIPFA Good Governance Framework states that Local authorities are required to prepare an annual governance statement in order to report publicly on the extent to which they comply with their own code of governance, which in turn is consistent with the good governance principles in this Framework. This includes how they have monitored and evaluated the effectiveness of their governance arrangements in the year, and on any planned changes in the coming period. Page 146 of 180
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Midlothian Integration Joint Board 3.4 The MIJB Audit & Risk Committee remit includes a review the IJB’s corporate governance arrangements against the good governance framework and consider annual governance reports and assurances. This paper and approval of the Annual Governance Statement fulfils this part of the remit. 4 Directions 4.1 There are no Directions implications arising from this report. 5 Equalities Implications 5.1 There are no direct equalities implications arising from this report. 6 Resource Implications 6.1 There are no direct resource implications as a result of this report. 7 Risk 7.1 There are no direct risk implications as a result of this report. 8 Involving people 8.1 The Audit & Risk Committee are being given initial review of the Annual Governance Statement which will be reviewed by the MIJB Chair, Chief Officer and Chief Finance Officer as part of the Annual Accounts process. Audit Scotland as the appointed External Auditors will also review the Annual Governance Statement as part of the Annual Accounts review. 9 Background Papers 9.1 Appendix 1 A AUTHOR’S NAME Duncan Stainbank DESIGNATION MIJB Chief Internal Auditor CONTACT INFO Duncan.Stainbank@midlothian.gov.uk DATE 30 May 2024 Page 147 of 180
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Appendix 1: MIJB Annual Governance Statement 2023/24 Introduction The Annual Governance Statement explains the MIJB’s governance arrangements and system of internal control and reports on their effectiveness. Scope of Responsibility The MIJB is responsible for ensuring that its business is conducted in accordance with the law and proper standards, and that public money is safeguarded and properly accounted for and used economically, efficiently and effectively. To meet this responsibility, the MIJB has established arrangements for governance which includes a system of internal control. The system is intended to manage risk to support the achievement of the MIJB’s policies, aims and objectives. Reliance is also placed on NHS Lothian and Midlothian Council’s (the partners) systems of internal control that support compliance with both organisations’ policies and promotes achievement of each organisation’s aims and objectives, as well as those of the MIJB. The system can only provide reasonable and not absolute assurance of effectiveness. The Governance Framework and Internal Control System The Board of the MIJB comprises voting members, nominated by either NHS Lothian or Midlothian Council, as well as non-voting members including a Chief Officer appointed by the Board. The current MIJB Local Code of Corporate Governance (MIJB Local Code), which was approved by the Board on 8 April 2021, sets out the framework and key principles, which require to be complied with, to demonstrate effective governance. The MIJB Local Code reflects the changing context of integration and is consistent with the principles and recommendations of the new CIPFA/SOLACE Framework ‘Delivering Good Governance in Local Government’ (2016) and the supporting guidance notes for Scottish authorities. The overall aim of the Framework is to ensure that: resources are directed in accordance with agreed policy and according to priorities; there is sound and inclusive decision making; and there is clear accountability for the use of those resources in order to achieve desired outcomes for service users and communities. The main features of the governance framework and internal control system associated with the seven core principles of good governance defined in the MIJB Local Code in existence during 2023/24 included: A. Behaving with integrity, demonstrating strong commitment to ethical values, and respecting rule of law The roles and responsibilities of Board members and statutory officers and the processes to govern the conduct of the Board’s business are defined in the Scheme of Integration which was approved by the Board and NHS Lothian in June 2022, which serves as the approved constitution, and Standing Orders, a revision of which was approved by the Board in February 2023, to make sure that public business is conducted with fairness and integrity. The Ethical Standards in Public Life (Scotland) Act 2000 provides for Codes of Conduct for local authority councillors and members of relevant public bodies. As a Public Body listed in schedule 3 of the Act, the MIJB is required to produce a Code of Conduct, which was approved by the Board in April 2022. The MIJB is dependent upon arrangements within the partner organisations for areas such as: • ensuring legal compliance in the operation of services; • handling complaints; • ethical awareness training and whistleblowing policies and procedures; • staff appointment and appraisal processes which take account of values and ethical behaviour; • identifying, mitigating and recording conflicts of interest, hospitality and gifts; and • procurement of goods and services which are sustainable, represent value of money and which reinforce ethical values. Other areas where the MIJB places significant reliance on arrangements in place within the partner organisations are set out in the remainder of the statement. Page 149 of 180
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The Chief Officer is responsible for ensuring that agreed procedures are followed and that all applicable statutes and regulations are complied with. Professional advice on the discharge of duties is provided to the Board by the MIJB Chief Officer supported by Chief Financial Officer, Chief Internal Auditor and Board Clerk as appropriate. B. Ensuring openness and comprehensive stakeholder engagement Board meetings are held in public unless there are good reasons for not doing so on the grounds of confidentiality. Unless confidential, decisions made by the Board are documented in the public domain. Community engagement was encouraged as part of the development of the Scheme of Integration and the Strategic Plans of the Health and Social Care Integration Joint Board were developed following consultations with interested parties including members of the public. C. Defining outcomes in terms of sustainable economic, social, and environmental benefits The vision, strategic objectives and outcomes are reflected in the Midlothian Health & Social Care Integration Joint Board third Strategic Plan 2022-25 was approved in April 2022 and has been updated to reflect on-going assessment of need and priorities following public consultation. Implementation is underpinned by the associated Directions, on which progress reports are presented to the Board. Implications are considered during the decision making process within the standard report template covering Policy, Equalities, Resources, Risk, and Involving People. D. Determining the interventions necessary to optimise the achievement of the intended outcomes In determining how services and other courses of action should be planned and delivered, the MIJB has a statutory responsibility to involve patients and members of the public. The MIJB Strategic Plan is based on consultation during its review and update. The MIJB has issued Directions to the partners for service delivery and for service redesign and recommissioning in line with the transformation programme. E. Developing the entity’s capacity, including the capability of its leadership and the individuals within it The MIJB Chief Officer is responsible and accountable to the Board for all aspects of management including promoting sound governance and providing quality information/support to inform decision-making and scrutiny. Regular meetings are held between the Chief Officer and the Chair and Vice Chair of the MIJB. The MIJB Chief Officer also meets regularly with representatives from the partner organisations. Members of the MIJB Board are provided with the opportunity to attend Development Sessions relevant to their role as part of their development programme. The MIJB has also undertaken a Self-Assessment Completed in August 2023 with an improvement plan being approved. A 3 year Workforce Plan 2022-25 has been created, approved and published to help ensure it has the right people, with the right skills, in the right place, at the right time to support the delivery of its strategic objectives and priorities. F. Managing risks & performance through robust internal control & strong public financial management The MIJB Chief Officer has overall responsibility for directing and controlling the partnership to deliver health and social care services. The MIJB Board is responsible for key decision-making. The MIJB has approved a Risk Management Strategy which includes: the reporting structure; types of risks to be reported; risk management framework and process; roles and responsibilities; and monitoring risk management activity and performance. This Strategy is being updated and approved in 2024. The MIJB Chief Financial Officer is responsible for the proper administration of all aspects of the MIJB’s financial affairs including ensuring advice is given to the Board on all financial matters. The MIJB’s system of internal financial control is dependent upon the framework of financial regulations, regular management information (including Revenue Budget Monitoring reports to the Board), administrative procedures (including segregation of duties), management supervision and systems of delegation and accountability within the partner organisations. Page 150 of 180
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The MIJB also relies upon the partners for: • Counter fraud and anti-corruption arrangements; and • Management of data in accordance with applicable legislation. G. Implementing good practices in transparency, reporting, and audit to deliver effective accountability The Shared Chief Internal Auditor of Midlothian Council is the MIJB’s Chief Internal Auditor whose role is to provide an independent and objective annual opinion on the effectiveness of the MIJB’s internal controls, risk management and governance. This is carried out in conformance with the Public Sector Internal Audit Standards. The MIJB responds to the findings and recommendations of Internal Audit, External Audit, Scrutiny and Inspection bodies. The MIJB Audit and Risk Committee is integral to overseeing assurance and monitoring improvements in internal controls, risk management and governance. Performance Reports were presented to the Board for monitoring and control of achievement of Local Improvement Goals. An Annual Performance Report for 2023/24 is being prepared to outline progress against strategic objectives over the year. The Annual Accounts and Report for 2023/24 will set out the financial position in accordance with relevant accounting regulations and is being prepared. Review of Adequacy and Effectiveness The MIJB is required to conduct an annual review of the effectiveness of its governance framework. The review was informed by: an annual self-assessment carried out by Internal Audit against the MIJB’s Local Code of Corporate Governance; Internal Audit reports for the MIJB; External Audit reports for the MIJB; relevant reports by other external scrutiny bodies and inspection agencies; and relevant partners’ (NHS Lothian and Midlothian Council) Internal Audit and External Audit reports. In respect of the three improvement areas of governance identified by the MIJB in 2020/21, there have been developments during the year in all three of these. Specifically, the risk register has been developed to include and additional risk specific to the Boards financial challenge, the IJB Strategic Plan and the medium term financial plan continue to be further developed to include a more explicit link, however this work remains ongoing, governance processes to manage the monitoring of financial recovery plans remain ongoing. Improvement Areas of Governance The review activity outlined above has identified the following areas where further improvement in governance arrangements can be made to enhance compliance with the Local Code: 1 The Medium term financial plan should be further developed to include a more explicit link to the Midlothian IJB Strategic Plan. 2 Given the significant challenges in developing financial recovery plans of approximately £10million for 2023/24 confirmation of the governance process of monitoring against the achievement of these recovery plans should continue to be developed. 3 Improvements to the Midlothian publication scheme are required in order to ensure that the Register of Interests for Board Members, the Public Engagement Statement and financial information is accessible through the Midlothian IJB Publication scheme. The implementation of these actions to enhance the governance arrangements in 2024/25 will be driven and monitored by the MIJB Chief Officer in order to inform the next annual review. Internal Audit work planned in 2024/25 is designed to test improvements and compliance in governance. Conclusion and Opinion on Assurance It is our opinion that reasonable assurance can be placed upon the adequacy and effectiveness of the MIJB’s governance arrangements and system of internal control, while recognising that further improvements are required to fully demonstrate compliance with the Local Code in order for the MIJB to fully meet its principal objectives. Systems are in place to regularly review and improve governance arrangements and the system of internal control. Page 151 of 180
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___________________ ______________________ Morag Barrow Connor McManus Chief Officer MIJB Chair of the MIJB Page 152 of 180
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Midlothian IJB Audit and Risk Committee Thursday, 6 June 2024 Midlothian Health and Social Care Integration Joint Board Internal Audit Annual Assurance Report 2023/24 Executive summary The purpose of this report is to present the Internal Audit Annual Assurance Report 2023/24 for the Midlothian Health and Social Care Integration Joint Board (MIJB) which includes the Chief Internal Auditor’s independent assurance opinion on the adequacy of MIJB's overall control environment for the year ended 31 March 2024. The MIJB Audit and Risk Committee is therefore asked to: Consider the Midlothian Health and Social Care Integration Joint Board Internal Audit Annual Assurance Report 2023/24 (Appendix 1), which sets out the findings and conclusions arising from all Internal Audit work for the year to 31 March 2024, consider the assurances contained therein, and provide any commentary thereon. # Item number: 5.8 Agenda number Page 153 of 180
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Midlothian Integration Joint Board Report Midlothian Health and Social Care Integration Joint Board Internal Audit Annual Assurance Report 2023/24 1 Purpose 1.1 The purpose of this report is to present the Internal Audit Annual Assurance Report 2023/24 for the Midlothian Health and Social Care Integration Joint Board (MIJB) which includes the Chief Internal Auditor’s independent assurance opinion on the adequacy of the arrangements for governance, risk management and internal control by the MIJB of the delegated resources. 2 Recommendations 2.1 Members of the MIJB Audit and Risk Committee are asked to: Consider the MIJB Internal Audit Annual Assurance Report 2023/24 (Appendix 1), which sets out the findings and conclusions arising from all Internal Audit work carried out for the year to 31 March 2024, consider the assurances contained therein, and provide any commentary thereon. 3 Background and main report 3.1 The Midlothian Integration Joint Board (MIJB), established as a separate legal entity as required by the Act, is 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. 3.2 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. The establishment of robust Risk Management and Audit arrangements is one of the key components of good governance and will be critical to the capacity of the MIJB to function effectively. 3.3 The Public Sector Internal Audit Standards (PSIAS) require the MIJB’s Chief Internal Auditor to prepare an annual report that incorporates the 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. 3.4 The MIJB Internal Audit Annual Assurance Report 2023/24 (Appendix 1) includes the MIJB Chief Internal Auditor’s independent and objective opinion regarding the adequacy and effectiveness of governance, risk management and internal control within the MIJB to fulfil the statutory role of Internal Audit. To ensure the annual Page 154 of 180
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Midlothian Integration Joint Board reporting requirements of the Public Sector Internal Audit Standards (PSIAS) are met, the Report also includes a summary of the Internal Audit activity during the year that supports the opinion, and summarises the outcome of the self- assessment of the Internal Audit service against the Public Sector Internal Audit Standards (PSIAS). 3.5 The Report provides assurances in relation to the MIJB’s corporate governance framework that is a key component in underpinning delivery of the MIJB’s strategic priorities and has been used to inform the Chief Officer’s Annual Governance Statement 2023/24. 3.6 In addition to its own governance arrangements, the MIJB places reliance on the governance arrangements adopted by NHS Lothian and Midlothian Council, the partners. Where appropriate, existing mechanisms embedded within both NHS Lothian and Midlothian Council have been used to provide assurance to the MIJB. When appropriate these reports are presented to the Audit & Governance Committee to aid the understanding of the governance arrangements in place in the partner organisations. 4 Directions 4.1 There are no Directions implications arising from this report. 5 Equalities Implications 5.1 There are no direct equalities implications arising from this report. 6 Resource Implications 6.1 There is a commitment to provide Internal Audit resource to the Midlothian Health and Social Care Integration Joint Board (MIJB) for review of the adequacy of the arrangements for risk management, governance and control by the MIJB of the delegated resources. 6.2 Internal Audit service is provided by Midlothian Council’s Internal Audit team, which has a shared service arrangement with East Lothian Council including the appointed Chief Internal Auditor (from January 2023). This is also supported by specific resource from the NHS Lothian Internal Audit team reporting to the Chief Internal Auditor. The staff who performed the MIJB Internal Audit work hold relevant professional qualifications and have the necessary experience, knowledge, skills and competencies (such as the Code of Ethics set out in the PSIAS). 6.3 The Midlothian Internal Audit Annual Plan 2023/24 approved by the MIJB Audit and Risk Committee on 2 March 2023 was based on the assumption that Midlothian Council’s Internal Audit function provides 40 days and NHS Lothian Internal Audit team provides 30 days to support the delivery of the Plan. A summary of the Internal Audit work that was undertaken during the year that supports the annual opinion is stated in Appendix 1. Page 155 of 180
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Midlothian Integration Joint Board 7 Risk 7.1 The PSIAS require Internal Audit to evaluate the effectiveness of the MIJB’s Risk Management arrangements and contribute to improvements in the process. Key components of the audit planning process include a clear understanding of the MIJB’s functions, associated risks, and potential range and breadth of audit areas for inclusion within the Plan to provide the audit opinion. Internal Audit work carried out has been risk-based and, where appropriate, has tested the management of risk by the MIJB of the delegated resources. 7.2 Internal Audit provides assurance to MIJB Management, Audit and Risk Committee and the Board on the adequacy and effectiveness of internal controls and governance within the MIJB, including risk management, and to highlight good practice and recommend improvements. 7.3 It is anticipated that improvements in the management and mitigation of risks will arise as a direct result of MIJB Management implementing the Internal Audit recommendations. 8 Involving people 8.1 The MIJB Chief Officer, Chief Finance Officer and Integration Manager have received the MIJB Internal Audit Annual Assurance Report 2023/24 that sets out the work of Internal Audit and independent opinion on the adequacy and effectiveness of the governance, risk management and internal controls to assist them in discharging their roles and responsibilities. The MIJB Chief Officer will consider the Internal Audit findings and conclusions detailed in the above Report when completing the MIJB’s Annual Governance Statement 2023/24. 9 Background Papers 9.1 Midlothian IJB Internal Audit Annual Plan 2023/24 (approved by the MIJB Audit and Risk Committee on 2 March 2023) AUTHOR’S NAME Duncan Stainbank DESIGNATION MIJB Chief Internal Auditor CONTACT INFO DATE 30 May 2024 Page 156 of 180
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Internal Audit Annual Assurance Report 2023/24 for Midlothian Health and Social Care Integration Joint Board 1 Introduction 1.1 The Public Sector Internal Audit Standards (PSIAS) (2017) requires that: “The chief audit executive [MIJB’s Chief Internal Auditor] must deliver an annual internal audit opinion and report that can be used by the organisation to inform its governance statement. The annual internal audit opinion must conclude on the overall adequacy and effectiveness of the organisation’s framework of governance, risk management and control. The annual report must incorporate: • the opinion; • a summary of the work that supports the opinion; and • a statement on conformance with the Public Sector Internal Audit Standards and the results of the quality assurance and improvement programme.” 2 Opinion on the Governance, Risk Management and Internal Control 2.1 My opinion is that the Midlothian Health and Social Care Integration Joint Board’s governance arrangements, risk management and systems of internal control are operating satisfactorily. There has been good progress made by Management during the year with the completion of recommendations. 2.2 The MIJB operates under good public sector practice governance arrangements through its Board and Committee meetings that support scrutiny and transparency of decisions made. There is good compliance by the MIJB of the requirements of the Public Bodies (Scotland) Act 2014 and the guidance through its Directions to Partners (NHS Lothian and Midlothian Council) for the delivery of the services. The vision, strategic objectives and outcomes going forward are reflected following extensive consultation in the Strategic Plan 2022-2025, approved by the Board in April 2022. The MIJB is making continued progress towards delivering integrated Health and Social Care services. 2.3 The current MIJB Local Code of Corporate Governance (Local Code), which was approved by the Board on 8 April 2021, sets out the framework and key principles, which require to be complied with, to demonstrate effective governance. The Local Code complies with the CIPFA/SOLACE ‘Delivering Good Governance in Local Government Framework’ (2016) in all significant aspects. It reflects the changing context of integration and the appropriate framework for effective governance of the MIJB’s business, including its role as the strategic commissioning body i.e. setting out when responsibility lies with the Board or where reliance is placed on the arrangements in place at its Partners. Governance arrangements in place are generally sound and are being further developed. The Internal Audit high level review and assessment of the Local Code has identified aspects of governance arrangements where some improvement is required. Page 157 of 180
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2.4 A Risk Management Policy, reporting regime and risk register highlighting the MIJB strategic risks, mitigating controls, residual risk and accompanying actions have been regularly reviewed, updated and reported during the year to the Audit and Risk Committee to fulfil its oversight role to monitor the IJB’s risk management arrangements. The MIJB Risk Management Policy is now in need of review which is currently being undertaken and a revised Risk Management Policy will be submitted to the Audit & Risk Committee for approval in 2024. 2.5 At the MIJB’s December meeting a paper laying out an initial financial plan for 2024/25 to 2028/29 was presented. For 2024/25 this projected an opening financial gap of c. £12.6m, split between £4.8m in health and £7.7m for social care. The MIJB Budget Setting 2024/25 paper approved at the MIJB March meeting that this position was prior to the Scottish Government’s own budget setting process, the impact of which was to increase the IJB’s gap to a forecast position of £14.3m. The forecasts were subsequently revised and additional funding was made available by Midlothian Council. However there remains a financial pressure for Midlothian IJB in 24/25 of c. £10.0m. A series of proposals have been brought forward by the operational management teams which allowed the IJB to set a balanced budget for 2024/25. 2.6 The MIJB Five Year Financial Plan 2024/25-2028/29 submitted to the MIJB meeting in April 2024 stated the following the five-year plan presented to the IJB in December 2023 projected a total financial gap from 2024/25 to 2028/29 of £99.5m. Having revised and reviewed the forecast and having incorporated the actions identified as part of the 2024/25 IJB budget setting the total projected gap is now £39m. Further work and proposals are now required to move towards a balanced position for 2025/26 and the years thereafter. The IJB Strategic Plan is currently under review and work will continue to ensure that the financial plan is clearly mapped onto and driven by the Strategic Plan. 2.7 Further improvements in governance, risk management and internal control will be made by Management through the full implementation of previous Internal Audit recommendations. Internal Audit will continue to follow-up on their implementation and present progress reports. 3 Scope of the Internal Audit Annual Plan 2023/24 3.1 We summarise below the work we have undertaken to obtain assurances over the arrangements in place for each area considered and our conclusions on the effectiveness and appropriateness of these arrangements are listed in section 4. Local Code of Corporate Governance 3.2 In considering the delivery of integrated services, we carried out a high level review of the Local Code of Corporate Governance to assess compliance with the requirements of the following seven core principles set out in the 2016 CIPFA/SOLACE Framework: • clarity of roles and responsibilities including arrangements for the operation of Standing Orders; • behaving with integrity, demonstrating strong commitment to ethical values, and respecting the rule of law; • ensuring openness and comprehensive stakeholder engagement; • defining outcomes in terms of sustainable economic, social, and environmental benefits; • determining the interventions necessary to optimise the achievement of the intended outcomes; • developing the entity’s capacity, including the capability of its leadership and the individuals within it; and • implementing good practices in transparency, reporting, and audit to deliver effective accountability. Page 158 of 180
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Strategic Planning 3.3 In considering the delivery of integrated services we attended the MIJB meetings to observe planning, approval, monitoring and review activity of the Midlothian Health and Social Care Integration Joint Board’s business and performance. Risk Management 3.4 We carried out a high level assessment of processes for managing and monitoring risks to determine the effectiveness of arrangements for managing uncertainty over the achievement of the strategic objectives of the MIJB. The Internal Audit review of medium term financial planning identified a recommendation for the IJB Risk Register to include a specific risk in relation to the Board’s financial challenges in the years ahead. Financial Management 3.5 A specific review of medium term financial planning was undertaken in 2022/23, this was completed in partnership with NHS Lothian internal audit team resource. We reviewed the effectiveness of processes associated with the financial planning of the resources delegated to the partnership and the monitoring and reporting of financial activities in a transparent manner in accordance with best accounting practice. Internal audit have one remaining recommendation for implementation from this review being the following: The Medium-term Financial Plan should be developed to include a more explicit link to the Midlothian IJB Strategic Plan and its priorities for the years ahead. This should also include the Board’s strategic priorities in a local and national context, alongside the financial risks associated with the plan’s assumptions. Internal Audit will continue to monitor the implementation of this recommendation going forward. 3.6 The recommendations from the one completed full review of the Publication Scheme are detailed in section 6.1 below. Annual Audit Work 3.7 Furthermore Midlothian Council’s Internal Audit resources were also deployed in undertaking the following annual audit work for the MIJB during the year: • Recommendations Follow-Up Review (Undertake two reviews. Refer to Section 5 below). • Administration of Audit Scotland Reports (Monitor publication of Audit Scotland reports and co-ordinate submission by Management of relevant Audit Scotland Reports to the MIJB Audit and Risk Committee / Board). • Audit Committee Self-Assessment (Development of templates that will assist the Chair in undertaking a self-assessment of the MIJB Audit and Risk Committee against the 2022 revised CIPFA best practice guidance and in implementing any areas of improvement in support of their development). • Attendance at Board / Committee meetings (Prepare for and attend MIJB Board / Audit and Risk Committee meetings and assisting in arranging the MIJB Board Self-evaluation). • Planning for 2024/25 (Update Audit Universe, develop and consult on coverage within the MIJB Internal Audit Annual Plan 2024/25). 3.8 For assurance purposes, the MIJB Audit and Risk Committee was made aware of reports by other bodies that relate to the business of the MIJB including those by the Partners’ Internal Auditors, Audit Scotland and other national scrutiny and audit bodies. Page 159 of 180
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4 Summary Findings and Conclusions arising from Delivery of the Internal Audit Annual Plan 2023/24 4.1 Local Code of Corporate Governance 4.1.1 The Integration Joint Board is a legal entity in its own right and as a public body it should operate under public sector good practice governance arrangements which are proportionate to its transactions and responsibilities. 4.1.2 A Local Code of Corporate Governance and Standing Orders have been approved by the Board. These documents encapsulate the public sector good practice principles and by following them the Board demonstrates sound governance arrangements. 4.1.3 We conducted a high level review of the MIJB’s updated Local Code of Corporate Governance and consider that the Governance arrangements are generally sound, although there is scope for improvement in compliance with some parts of the CIPFA/SOLACE Framework as set out in section 5 below. 4.1.4 The Scottish Government approved the new Midlothian Scheme of Integration scheme in May 2023. 4.1.5 The IJB has taken steps to improve governance arrangements in a number of areas: • A Self-evaluation review of the IJB Board was completed in August 2023. • Scheme of Publication 4.1.6 We have made no recommendations in respect of the corporate governance arrangements of the Integration Joint Board in this report. Governance and transparency is concerned with the effectiveness of scrutiny and governance arrangements, leadership and decision making, and transparent reporting of financial and performance information. Conclusion: Governance arrangements in place are generally sound and are being further developed. The Internal Audit high level review of the Local Code of Corporate Governance has identified aspects of governance arrangements where some improvement is required, as set out in Internal Audit recommendations made in previous years or the current year. Page 160 of 180
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4.2 Internal Control and Governance – Strategic Planning 4.2.1 Our attendance at virtual Board meetings and review of the Minutes of meetings which we did not attend continues to indicate that strong strategic leadership is in place and that the Health and Social Care partners are working together in a constructive way. 4.2.2 A Strategic Plan 2022-2025 has been developed and approved by the IJB in April 2022, which sets out the vision and values for the IJB. Community engagement was at the heart of developing the new Strategic Plan in line with good practice. However, this Strategic Plan is currently being reviewed to allow it to be linked to the MIJB Five Year Financial Plan 2024/25-2028/29. 4.2.3 Legislation requires that the specification of what action the delivery partners are required to undertake are set out in formal instructions, referred to as Directions. MIJB Directions for 2023-24 were issues to the Chief Executives of Midlothian Council and NHS Lothian on the 31st March 2023. An IJB Directions Half Year Report was provided to MIJB in September 2023. 4.2.5 We have made no recommendations in respect of governance arrangements in this report. Action required by Management is clearly identified, understood and ongoing. Delivering integrated services which are effective and efficient requires an agreed formal statement of the MIJB’s vision and intended outcomes and plans as well as exercising strategic leadership to deliver those outcomes. Conclusion: The MIJB is demonstrating strategic leadership by developing and clearly communicating its purpose and vision and its intended outcomes for service users. The vision, strategic objectives and outcomes are reflected in the Strategic Plan 2022-2025, although this is being reviewed to ensure greater linkage with the MIJB Five Year Financial Plan. The MIJB is making continued progress towards delivering integrated Health and Social Care services. Page 161 of 180
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4.3 Risk Management 4.3.1 Risk management is an important and integral part of good governance and a system of internal controls. It is crucial that risks to the achievement of outcomes are identified and managed. 4.3.2 The MIJB has an approved Risk Management Policy in place which sets out the risk management framework and process, roles and responsibilities, as well as monitoring arrangements. This is now out of date and is being revised and will be approved by the MIJB Audit & Risk Committee in 2024. 4.3.3 Risk management is an integral part of all activities and must be considered in all aspects of decision making. The standard template for decision-making reports to the MIJB and its Committees includes a section on implications covering risk. When taking a longer-term view with regard to decision making, risks associated with the potential conflicts between the MIJB’s intended outcomes and short-term to medium term financial constraints are not particularly well expressed. 4.3.4 The MIJB needs to gain assurance on risks associated with delivering services through the partners. Midlothian has recognised that the risks facing the MIJB are those which relates to the MIJB’s own business. Operational risks facing the partners are the concern of the partners except and until a partner risk becomes so significant that it would impact upon the MIJB’s Strategic Plan. Implicitly this is recognised in the Risk Management Policy in that the partners should regularly bring the relevant risks to the attention of the MIJB. 4.3.5 The MIJB maintains a risk register which is reviewed regularly by the relevant risk owners, scrutinised by the MIJB Audit and Risk Committee at its quarterly meetings and reported every quarter to the Board to ensure that the MIJB is kept informed of its key risks and the actions undertaken to manage these risks. The risk register is comprehensive and responsibilities for managing individual risks are clearly allocated although the emerging risk in relation to the future financial challenges facing MIJB requires to be added to the risk register. 4.3.6 We have made no recommendations in respect of risk management arrangements in this report. Risk management is a process of identifying potential risks to the achievement of objectives in advance, analysing them and taking precautionary steps in order to mitigate those risks, thus managing the effect of uncertainty on objectives. Conclusion: Effective risk management processes are in place. There is an opportunity to assess the content of the MIJB Risk Register against the Strategic Plan 2022-2025 that has been developed and approved to ensure the MIJB Risk Register reflects the strategic risks facing the MIJB against the achievement of objectives and priorities set out in the Strategic Plan, improvements in reflecting the risk of potential future financial constraints have now been reflected in the risk register and is being monitored. Page 162 of 180
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4.4 Financial Management 4.4.1 At the MIJB’s December meeting a paper laying out an initial financial plan for 2024/25 to 2028/29 was presented. For 2024/25 this projected an opening financial gap of c. £12.6m, split between £4.8m in health and £7.7m for social care. The MIJB Budget Setting 2024/25 paper approved at the MIJB March meeting that This position was prior to the Scottish Government’s own budget setting process, the impact of which was to increase the IJB’s gap to a forecast position of £14.3m. The forecasts were subsequently revised and additional funding was made available by Midlothian Council. However there remains a financial pressure for Midlothian IJB in 24/25 of c. £10.0m. A series of proposals have been brought forward by the operational management teams which would allowed the IJB to set a balanced budget for 2024/25. 4.4.2 The IJB’s budget setting amounts to agreeing the budget offers from the Partners, then allocates the equivalent annual budget to the Partners. Partner budget offers for 2022/23 were agreed in March 2022. In March 2023, the IJB agreed the recommendation not to accept the IJB budget offer from Midlothian Council for 2023/24 as it was not in line with the parameters set by Scottish Government. Further ongoing work to develop a balanced budget has been undertaken and a financial recovery options report is being presented to the June 2023 IJB requesting agreement to which recovery actions should be progressed by officers to support the subsequent funding gap. 4.4.3 During the year, the Board has received financial updates on the expected outturn for the year on an appropriate format as identified above early warning of financial issues has been provided through this reporting. 4.4.4 At the December 2021 meeting, the Audit and Risk Committee agreed to recommend to the Board the adoption of the CIPFA Financial Management Code, in so far as it applies to the operation of the IJB subject to a further report regarding how the FM Code would apply to the IJB and how assurance would be sought on it. In March 2022, it received a report which concluded that “some standards do not apply to the IJB and, of the rest, the IJB is delivering against them. That said, this analysis highlights that the development of the multi-year, balanced, financial plan is critical.” 4.4.5 We reviewed the extent that the CIPFA Financial Management Code applies to the IJB, evidence suggests that the IJB fully complies with the code other than areas around demonstrating clarity on financial sustainability for the future and reliance on partners for value for money appraisals, which requires further ongoing work. The areas of the CIPFA FM code considered only partially compliant are: Part E: (The financial management style of the authority supports financial sustainability); Part F: (The authority has carried out a credible and transparent financial resilience assessment); Part G: (The authority understands its prospects for financial sustainability in the longer term and has reported this clearly to members); Part I: (The authority has a rolling multi-year medium-term financial plan consistent with sustainable service plans); A strong system of financial management is essential for the successful implementation of policies and the achievement of intended outcomes, as it will enforce financial discipline, strategic allocation of resources, efficient service delivery, and accountability. Page 163 of 180
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Part L: (The budget report includes a statement by the chief finance officer on the robustness of the estimates and a statement on the adequacy of the proposed financial reserves); Part M: (The authority uses an appropriate documented option appraisal methodology to demonstrate the value for money of its decisions); and Part N: (The leadership team takes action using reports enabling it to identify and correct emerging risks to its budget strategy and financial sustainability). 4.4.8 We have made no recommendations in respect of financial management arrangements in this report, although relevant recommendations were included in the Internal Audit Medium Term Financial Planning review. 5 Recommendations Follow-Up Reviews 5.1 The Internal Audit Follow-up of Recommendations Report was presented to the MIJB Audit and Risk Committee in December 2023. This showed good progress with the completion of 7 recommendations with evidence of improved internal controls and governance, and reduced risk - only 2 recommendations remained outstanding at this point. Conclusion: An appropriate and balanced medium term financial plan remains under development with regular reporting being provided on progress, however budget pressures and the requirement for recovery plans to be monitored result in further work being required to demonstrate financial sustainability moving forward. The budgetary monitoring process has been appropriate during the year providing the Board with sufficient information to allow for effective budget monitoring. Whilst the IJB does comply with the CIPFA Financial Management Code in most areas, there are a number of areas where full compliance will require further development of financially sustainable plans moving forward. Page 164 of 180
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6 Recommendations and actions arising from Internal Audit Annual Plan 2023/24 6.1 Recommendations in reports are suggested changes to existing procedures or processes. The rating of each recommendation reflects our risk assessment of non-implementation, being the product of the likelihood of the risk materialising and its impact. The ratings are: Ratings for Recommendations High – Recommendations relating to factors fundamental to the success of the control objectives of the system. The weaknesses may give rise to significant financial loss/misstatement or failure of business processes. Medium – Recommendations which will improve the efficiency and effectiveness of the existing controls. . Low – Recommendations concerning minor issues that are not critical, but which may prevent attainment of best practice and/or operational efficiency. Recommendation Rating Agreed Management actions Responsibility and timescale 1 The Register of Interests for Board members should be uploaded to the IJB website and linked through the documented MPS. Management should conclude the review of the Public Engagement Statement and make this available through the IJB website, linked also through the documented MPS Management should ensure that financial information is appropriate and accessible both online and through the documented MPS. Management should ensure that the information available online is linked to the relevant class within the documented MPS. Medium 1. Management will review the MPS and include additional links where they can be directly tracked to electronic documents, including the Register of Interests for Board members. 2. Management will also review the minimum service requirement for provision of information on the Midlothian Health and Social Care website, coordinate the provision of information and ensure this is uploaded. . 1. Integration Manager, Midlothian Health and Social Care Partnership – 31 May 2024 2. Integration Manager, Midlothian Health and Social Care Partnership – 30 December 2024 2 Management should ensure that there is information included within the documented MPS and online to advise members of the public on how to submit freedom of information requests. Low Management will ensure that the Midlothian Health and Social Care website clearly outlines how members of the public should submit Freedom of Information requests Integration Manager, Midlothian Health and Social Care Partnership – 31 May 2024 Page 165 of 180
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Recommendation Rating Agreed Management actions Responsibility and timescale 3 Management should consider the Scottish Information Commissioners self-assessment modules and determine the most appropriate to complete, thereafter a schedule for the completion should be agreed. Where necessary, an action plan should be developed to address any gaps identified by the assessment. Low Management will assess current publication activity and practice using the Scottish Information Commissioners self-assessment checklist. Thereafter, any improvement opportunities will be identified and a plan for their implementation agreed. Integration Manager, Midlothian Health and Social Care Partnership – 30 November 2024 7 Public Sector Internal Audit Standards (PSIAS) 7.1 The 2023-24 self-assessment of practices against the professional standards PSIAS (2017) has indicated that Midlothian Council’s Internal Audit function ‘Fully Conforms’ with the requirements within the 13 Assessment Areas of the Definition of Internal Auditing, the Code of Ethics, the Attribute Standards and the Performance Standards. Duncan Stainbank Bsc (Hons) CPFA MIJB Chief Internal Auditor 30 May 2024 Page 166 of 180
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Midlothian Integration Joint Board Audit and Risk Committee Thursday, 6 June 2024 Midlothian IJB Internal Audit Report: Publication Scheme Executive summary The purpose of this report is to present the findings and recommendations from the recently completed Internal Audit review of the Publication Scheme, completed in partnership between the Midlothian Council and NHS Lothian Internal Audit teams. The MIJB Audit and Risk Committee is therefore asked to consider the findings and recommendation from the final Internal Audit review of the Publication Scheme. Item number: 5.9 Page 167 of 180
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Midlothian Integration Joint Board Page 2 Report Midlothian Internal Audit Report: Medium Term Financial Planning 1. Purpose 1.1 The purpose of this report is to present the findings and recommendations from the recently completed Internal Audit review of the Publication Scheme, completed in partnership between the Midlothian Council and NHS Lothian Internal Audit teams 2. Recommendations 2.1 To consider the findings and recommendations from the recently completed Internal Audit review of the Publication Scheme. 3. Background and main report 3.1 As part of the Internal Audit Plan for 2023/24, approved by the audit and risk committee on 28 June 2023, an Internal Audit of the MIJB Publication Scheme. 3.2 The report presents the findings of the review with the internal audit work undertaken by the NHS Lothian Internal Audit team and managed through the Midlothian Council Internal Audit team. The report provides 1 medium and 2 low rated recommendations that have all been agreed by the Integration Manager, Midlothian Health & Social Care Partnership. 4. Directions 4.1 There are no Directions implications arising from this report. 5. Equalities Implications 5.1 There are no equalities implications. 6. Resource Implications 6.1 There are no resource implications. Page 168 of 180
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Midlothian Integration Joint Board Page 3 7. Risks 7.1 Key risks in relation to ensuring maintenance of an appropriate and adequate Publication Scheme within the IJB have been considered as part of the review. 8. Involving People 8.1 Consultation on this Internal Audit Report has been undertaken with the MIJB Chief Officer and Integration Manager, Midlothian Health & Social Care Partnership prior to submission to the MIJB Audit and Risk Committee. 9. Background Papers See Appendix 1. AUTHOR’S NAME Duncan Stainbank DESIGNATION MIJB Chief Internal Auditor CONTACT INFO Duncan.Stainbank@midlothian.gov.uk DATE 30/05/2024 Page 169 of 180
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Midlothian IJB Publication Scheme April 2024 Conclusion Reasonable Assurance Page 171 of 180
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Contents page Executive Summary 3 Headlines 4 Areas where expected controls are met/good practice 5 Detailed Recommendations 6 Appendices Appendix A – Recommendation Grading/Overall opinion 9 Appendix B – Resource, acknowledgements & distribution list 10 Page 172 of 180
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Conclusion: Reasonable Assurance The Midlothian IJB has formally adopted the Model Publication Scheme (MPS) without amendments and made a significant amount of information available to view online and through the MPS. Information has in the main been appropriately classified in the MPS and the associated Guide to Information also adheres to the six MPS Principles. Some improvement opportunities have been identified relating to accessibility of the information available, alongside a self-assessment exercise. 1 Executive Summary: Background In July 2015 Midlothian IJB (MIJB) took on duties in the Midlothian Council area for development of integrated planning and delivery of health and social The Freedom of Information (Scotland) Act 2002 (FOISA) places a duty on Scottish public authorities to publish information proactively. Authorities must have regard to the public interest in the information they hold and make information available so it can be accessed without having to make a request for it under section 1 of FOISA. The duty to publish is in addition to the obligation to respond to requests for information. In addition, the Environmental Information (Scotland) Regulations (2004) (the EIRs) require authorities to publish environmental information proactively, particularly information they hold in electronic formats. The Scottish Information Commissioner has developed a Model Publication Scheme (MPS) to support Scottish public authorities to meet their publication scheme duties under both FOISA and the EIRs. By adopting the MPS, authorities commit to publishing, as a minimum, specified types of information, through their own Guide to Information. Summary of findings & recommendations The following key findings and recommendations are highlighted, which have all been agreed by the Integration Manager, Midlothian Health and Social Care Partnership: • While the Board has made a significant amount of information available online, work is required to insert additional links in the documented MPS and upload information to the web pages. Management have agreed to review the MPS and include additional links where they can be directly tracked to electronic documents, alongside the review of the minimum service requirement for provision of information on the Midlothian Health and Social Care website by 31 May 2024 (MPS review) and 30 December 2024 (review of minimum service requirement). • There is no guidance or instruction include within the documented MPS or online advising the public on how to submit freedom of information requests. Management have agreed to ensure that the Midlothian Health and Social Care website clearly outlines how members of the public should submit Freedom of Information requests by 31 May 2024. • Current activity and practice has not been assessed using the Scottish Information Commissioners self-assessment checklist. Management have agreed to assess current publication activity and practice using the Scottish Information Commissioners self-assessment checklist by 30 November 2024. While the Integration Manager has been identified as the responsible officer in this report. Future accountability for the actions arising from the key findings and recommendations is dependent on a decision as to whether business support continues to sit with the Integration Manager. This portfolio is one that traditionally should sit with the Executive Business Manager however is temporarily being supported by the Integration Manager. Materiality There are no reported resource implications from the Model Publication Scheme, although it should be noted that uncertainty around the future management of the portfolio may impact on the IJB’s ability to progress the report recommendations. Recommendations Grade High Medium Low Total Current Report - 1 2 3 Prior report N/A N/A N/A N/A Page 173 of 180
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4 2 Headlines Objectives Conclusion Comment 1. The IJB has made a corporate decision to adopt the MPS without amendment, with the Scottish Information Commissioner notified of this Substantial Assurance At its meeting on 7 December 2023, the MIJB Audit and Risk Committee was presented with a reviewed and updated MIJB, which was accepted without amendment. Committee papers were shared with the Board on 21 December where it was agreed to formally adopt the MPS. Thereafter the Scottish Information Commissioner was notified. 2. The IJB has Identified its information that is covered by the MPS and any additional information in which there is a public interest in publication. Reasonable Assurance While the MPS has included, where necessary, the nine classes of information, further work is required to include additional links in the documented MPS and make available additional information under some classes. Such as the Register of Interests of the Board and Public Engagement Statement. 3. The IJB has produced and published a Guide to Information, ensuring that the arrangements for publication meet the six MPS Principles. Reasonable Assurance The MIJB’s Guide to Information has been incorporated into its MPS. While review of the MPS against the six Principals has noted that there is guidance to ensure that requests for information in alternative formats are managed, there is no inclusion of information relating specifically to Freedom of Information Requests. 5. The IJB has completed the Scottish Information Commissioners Self-assessment Toolkit to capture its publication activity and assess performance against publication standards. Reasonable Assurance No self-assessment exercise has been carried out. This has been assigned to the Midlothian HSCP Business Support Manager to undertake on behalf of Midlothian IJB. 6. Training is provided to relevant staff to ensure that the IJB publishes only information that is relevant and appropriate Reasonable Assurance Training requirements are in the process of being agreed between the Integration Manager, Chair, Vice Chair and Chief Officer. A ‘Writing for Publication Style Guide’ is being produced by the Planning, Performance and Programme service and this will form part of the induction and/or training for all relevant staff as required. Page 174 of 180
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5 3 Areas where expected controls are met/good practice. No. Areas of Positive Assurance 1. The Board has prepared and approved for publication the IJB’s Model Publication Scheme without amendment, with the Scottish Information Commissioner notified of this. The documented MPS has been made available to view on the IJB website. 2. The MPS has clearly stated the classes of information that is available to view, the Board has also through its MPS imposed the six principles which govern the way it makes its information available through the Guide to Information. 3. Routine review of the documented MPS and accompanying electronic information is in place and aligned with the completion of the Boards annual governance review. 4. The website for the IJB is straightforward to navigate and includes a number of documents relevant to the performance and operation of the HSCP. Page 175 of 180
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6 4 Detailed Recommendations Availability of Information Objective 2 The IJB has Identified its information that is covered by the MPS and any additional information in which there is a public interest in publication Grade Recommendation The MPS and Guide to Information is effectively an “index” of the information an organisations publish and a “how to” guide to access it. The IJB has identified within its documented MPS the classes of information that is to be held and made available for the public to view. Testing was carried out to review the MPS and compare this against the minimum advised by the Commissioner, alongside confirming that the information is readily available for the public to view. Some observations requiring attention are listed below: • While the Board members’ register of Interests has been reviewed by the IJB Standards Officer no prepared document has been uploaded to the IJB website. • The Public Engagement Statement available through the IJB website is dated from 2021 and requires updating. A review of the document is underway, scheduled to be completed by September 2024. • The documented MPS has included a link to the MIJB 2021/22 Annual Accounts. However, the more recent accounts for financial year 2022/23 are available through the What We Do link links on the IJB website. • The IJB’s Financial Plans are not available through its documented MPS or website. • While the Board has included under the What We Do tab on its website, the 2022/25 Workforce Plan and Records Management Plan, neither are accessible under class 5 of the documented MPS. • While the Board has included under the What We Do tab on its website, the Equalities Outcomes & Mainstreaming Report 2021-25 and the Equalities Outcomes & Mainstreaming Update & Future Plans 2023, neither are accessible under class 7 of the documented MPS. There is a risk that reduced accessibility to information will result in the IJB not making as much information available as possible, including access to specific advice and guidance. Medium 2.1 The Register of Interests for Board members should be uploaded to the IJB website and linked through the documented MPS. Management should conclude the review of the Public Engagement Statement and make this available through the IJB website, linked also through the documented MPS Management should ensure that financial information is appropriate and accessible both online and through the documented MPS. Management should ensure that the information available online is linked to the relevant class within the documented MPS. Management response Responsible officer & target date 1. Management will review the MPS and include additional links where they can be directly tracked to electronic documents, including the Register of Interests for Board members. 2. Management will also review the minimum service requirement for provision of information on the Midlothian Health and Social Care website, coordinate the provision of information and ensure this is uploaded. 1. Integration Manager, Midlothian Health and Social Care Partnership – 31 May 2024 2. Integration Manager, Midlothian Health and Social Care Partnership – 30 December 2024 Page 176 of 180
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7 4 Detailed Recommendations Accessibility and Contact Objective 3 The IJB has produced and published a Guide to Information, ensuring that the arrangements for publication meet the six MPS Principles Grade Recommendation Under Class 5 of the MPS (how an organisation manages its human, physical and information resources). The Scottish information Commissioner expects authorities to publish Freedom of information policies and procedures information. While the Notification Form previously submitted to the Commissioner records contact details of the individual responsible within the Board for Freedom of Information requests. There is no guidance or instruction include within the documented MPS or online advising the public on how to submit them There is a risk that members of the pubic may be unable to access certain information that is not readily available through the IJB website and Guide to Information. Low 3.3 Management should ensure that there is information included within the documented MPS and online to advise members of the public on how to submit freedom of information requests. Management response Responsible officer & target date Management will ensure that the Midlothian Health and Social Care website clearly outlines how members of the public should submit Freedom of Information requests Integration Manager, Midlothian Health and Social Care Partnership – 31 May 2024 Page 177 of 180
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8 4 Detailed Recommendations Self-assessment and Training Objective 5 The IJB has completed the Scottish Information Commissioners Self-Assessment Toolkit to capture its publication activity and assess performance against publication standards Grade Recommendation The Scottish Information Commissioners Self-Assessment Toolkit has been developed to help authorities to: • Capture current activity and practice. • Assess how well they are performing against a set of standards. • Improve their FOI practices, procedures and administrative arrangements. To date, no self-assessment exercise has been carried out. However, a piece of work has been assigned to the Midlothian HSCP Business Support Manager (with other staff to support as necessary) to consider modules 2, 4 and 6 of the self-assessment. Training requirements are in the process of being agreed between the Integration Manager, Chair, Vice Chair and Chief Officer. A ‘Writing for Publication Style Guide’ is being produced by the Planning, Performance and Programme service and this will form part of the induction and/or training for all relevant staff as required. There is a risk that without proper assessment of the Board’s publishing requirements and activities information is either not routinely available that should be, or that staff are unaware of their duties and responsibilities in publishing data. Low 5.1 Management should consider the Scottish Information Commissioners self-assessment modules and determine the most appropriate to complete, thereafter a schedule for the completion should be agreed. Where necessary, an action plan should be developed to address any gaps identified by the assessment. Management response Responsible officer & target date Management will assess current publication activity and practice using the Scottish Information Commissioners self-assessment checklist. Thereafter, any improvement opportunities will be identified and a plan for their implementation agreed. Integration Manager, Midlothian Health and Social Care Partnership – 30 November 2024 Page 178 of 180
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9 A Recommendation Grading/Overall opinion definitions Recommendation Definition High Recommendations relating to factors fundamental to the success of the control objectives of the system. The weaknesses may give rise to significant financial loss/misstatement or failure of business processes. Medium Recommendations which will improve the efficiency and effectiveness of the existing controls. Low Recommendations concerning minor issues that are not critical, but which may prevent attainment of best practice and/or operational efficiency. Levels of Assurance Definition Substantial Assurance A sound system of governance, risk management and control exists, with internal controls operating effectively and being consistently applied to support the achievement of objectives in the area audited. Reasonable Assurance There is a generally sound system of governance, risk management and control in place. Some issues, non- compliance or scope for improvement were identified which may put at risk the achievement of objectives in the area audited. Limited Assurance Significant gaps, weaknesses or non-compliance were identified. Improvement is required to the system of governance, risk management and control to effectively manage risks to the achievement of objectives in the area audited No Assurance Immediate action is required to address fundamental gaps, weaknesses or non-compliance identified. The system of governance, risk management and control is inadequate to effectively manage risks to the achievement of objectives in the area audited. Page 179 of 180
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10 B Resource, acknowledgements & distribution list Internal audit Service Manager, Internal Audit: Duncan Stainbank Principal Auditor: Russell Richmond-McIntosh Report distribution Audit & Risk Committee Integration Manager – Midlothian HSCP Chief Officer – Midlothian IJB Audit Scotland Review Dates Completed By /Date Internal Audit Draft Report Submission 23 February 2024 Management Review Completion 26 February 2024 Final Report Issue 25 April 2024 Acknowledgements. The weaknesses identified during the course of our audit have been brought to the attention of Management. The weaknesses outlined are those, which have come to our attention during the course of our normal audit work and are not necessarily all of the weaknesses, which may exist. Although we include a number of specific recommendations, it is the responsibility of Management to determine the extent of the internal control systems appropriate to the IJB Publication Scheme. The content of this report has been discussed with the Integration Manager - HSCP to confirm factual accuracy. The assistance and cooperation received during the course of our audit is gratefully acknowledged. Page 180 of 180