A meeting of the Clackmannanshire and Stirling Integration Joint Board will be held on Wednesday 27 April 2016 at 2.00 - 4.00pm, in Kildean Suite, Forth Valley College, Stirling Campus
Please notify apologies for absence to [email protected]
AGENDA
1. NOTIFICATION OF APOLOGIES For Noting
2. NOTIFICATION OF SUBSTITUTES For Noting
3. DECLARATION(S) OF INTEREST For Noting
4. URGENT BUSINESS BROUGHT FORWARD BY CHAIRPERSON
5. MINUTE OF THE CLACKMANNANSHIRE & STIRLING INTEGRATION JOINT BOARD MEETING HELD ON 22 MARCH 2016 For Approval
6. MINUTE OF THE CLACKMANNANSHIRE & STIRLING SPECIAL INTEGRATION JOINT BOARD MEETING HELD ON 30 MARCH 2016 For Approval
7. MATTERS ARISING
8. DELAYED DISCHARGE PROGRESS REPORT For Noting (Paper presented by Kathy O’Neill and Val de Souza)
9. PARTNERSHIP FUNDING For Noting and Approval (Paper presented by Ewan Murray)
10. PROGRAMME WORKSTREAMS UPDATE For Noting (Paper presented by Lesley Fulford)
11. EQUALITIES MAINSTREAMING & OUTCOMES REPORT For Approval (Paper presented by Lesley Fulford)
12. GOVERNANCE
12.1 CHIEF INTERNAL AUDITOR For Approval (Paper presented by Kevin O’Kane)
12.2 AUDIT SCOTLAND REPORT For Noting (Paper presented by Kevin O’Kane)
13. PUBLIC HEALTH REPORT For Noting (Paper presented by Graham Foster)
14. COMMUNICATIONS PROTOCOL & FRAMEWORK For Noting and Approval (Paper presented by Elsbeth Campbell)
15. CARERS (SCOTLAND) ACT 2016 For Noting (Paper presented by Chris Sutton)
16. STRATHENDRICK For Approval (Paper presented by Chris Sutton)
17. NATIONAL CARE STANDARDS CONSULTATION For Noting (Paper presented by Lesley Fulford)
18. STIRLING CARE VILAGE For Noting and Approval (Paper presented by Kathy O’Neill)
19. ANY OTHER COMPETENT BUSINESS
20. DATE OF NEXT MEETING
Wednesday 22 June 2016, 2.00-4.00, Boardroom, Forth Valley College, Alloa Campus
Clackmannanshire & Stirling Integration Joint Board
27 April 2016
This report relates to Item 5 on the agenda
Minute of Clackmannanshire & Stirling Integration Joint Board meeting held on 22 March 2016
For Approval
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Minute of the Clackmannanshire & Stirling Integration Joint Board meeting held on Tuesday 22 March 2016, at 2.00pm, in Boardroom, Forth Valley College, Alloa Campus.
Present: Alex Linkston, Chairman (Chair) Councillor Les Sharp, Council Leader (Vice Chair) Joanne Chisholm, Non-Executive Board Member Rita Ciccu Moore (Substitute for Angela Wallace) Val de Souza, Chief Social Work Officer Councillor Scott Farmer John Ford, Non-Executive Board Member Graham Foster, Executive Board Member Jane Grant, Chief Executive Shubhanna Hussain-Ahmed, Unpaid Carers Representative for Stirling Councillor Kathleen Martin Morag Mason, Service User Representative for Stirling Natalie Masterson, Third Sector Representative for Stirling Teresa McNally, Service User Representative for Clackmannanshire Ewan Murray, Chief Finance Officer Elizabeth Ramsay, Unpaid Carers Representative for Clackmannanshire Abigail Robertson, Chair, Joint Trade Union Pamela Robertson, Chair, Forth Valley Joint Trade Union Forum Wendy Sharp, Third Sector Representative for Stirling Councillor Christine Simpson Shiona Strachan, Chief Officer
In Attendance: Hugh Coyle, Corporate Risk Coordinator Lesley Fulford, Programme Manager Allison Gallacher, Solicitor Stephanie McNairney, Project Administrator (Minute) Kathy O’Neill, General Manager, CHP’s
Elaine Vanhegan, Head of Performance Management, NHS Forth Valley Susan White, Housing Development and Regeneration Team Leader
1. APOLOGIES FOR ABSENCE
Apologies for absence were intimated on behalf of:
Councillor Donald Balsillie Councillor Johanna Boyd, Council Leader Stewart Carruth, Chief Executive, Stirling Council Fiona Gavine, Non-Executive Board Member Dr Tracey Gillies, Medical Director Tom Hart, Employee Director Elaine McPherson, Chief Executive Prof Angela Wallace, Nurse Director Dr Scott Williams, Primary Care
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2. NOTIFICATION OF SUBSTITUTES
• Rita Ciccu Moore substituted for Prof Angela Wallace • Julia Swan Substituted for Fiona Gavine
3. DECLARATION(S) OF INTEREST
There were no declarations of interest.
4. URGENT BUSINESS BROUGHT FORWARD BY CHAIRPERSON
There was no urgent business brought forward.
5. MINUTE OF MEETING HELD ON 24 FEBRUARY 2016
The minute of the meeting held on 24 February 2016 was approved as an accurate record, subject to the following clarifications:
• Correction of the date in the header of Item 5. This should read 2016 • Correction to Item 18. This should read Tuesday rather than Wednesday • Addition of Angela Leask Sharp in the list of those present
6. MATTERS ARISING
All matters were covered within substantive agenda items.
7. CHAIR & VICE CHAIR AND STANDING ORDERS
Shiona Strachan provided an overview of the amendments to the Charing arrangements and Standing Orders following discussion at the previous meeting.
Clackmannanshire Council and Stirling Council would share the 2 year appointing period, and meetings would move to bimonthly from April 2016.
The Integration Joint Board:
• Agreed that the local authorities should be able to ‘share’ each local authority appointing period for both the Chairperson and Vice-Chairperson and endorsed amendment to the Integration Joint Board’s Standing Orders to enable them to do so • Approved the amendments to the Standing Orders as set out in the paper to reflect this agreement • Noted initial discussion with Scottish Government is as detailed in section 5.8 • Delegated to Chief Officer to continue discussion in respect of the Integration Scheme and to advise the Integration Joint Board of the outcome in due course
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8. DELAYED DISCHARGE PROGRESS REPORT
Val de Souza provided an update on the status of Delayed Discharges.
A summary of people delayed at the census point in February 2016 was provided as well as an overview of the management actions being taken.
The Integration Joint Board noted performance and acknowledged the management actions undertaken.
9. STRATEGIC PLAN
Shiona Strachan provided an overview of the amendments and additions since the Strategic Plan was last presented to the Integration Joint Board, and noted that there were no material changes.
The Integration Joint Board:
• Approved the final draft Strategic Plan • Approved the final draft easy read Strategic Plan • Approved the equality and impact assessment
10. HOUSING CONTRIBUTION STATEMENTS
Susan White updated the Integration Joint Board on the latest versions of the Housing Contribution Statements, following a period of consultation and subsequent minor amendments made.
The Integration Joint Board approved the finalised Housing Contribution Statements as set out in Appendix 1 and 2
11. GOVERNANCE
11.1 CLINICAL AND CARE GOVERNANCE FRAMEWORK
Val de Souza presented a draft framework and provided an overview. It was noted that Clinical and Care Governance would link closely with the Performance Framework, and that regular performance updates would be brought to the Integration Joint Board.
The Integration Joint Board:
• Noted and acknowledged the work carried out by the work stream to develop the Clinical and Care Governance Framework • Agreed the Clinical and Care Governance Framework, including the establishment of a Clinical and Care Governance Oversight Group
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• Delegated authority to Dr Tracey Gillies and Val de Souza to establish the Clinical and Care Governance Oversight Group and further develop the terms of reference for the Clinical and Care Governance Oversight Group
11.2 INFORMATION GOVERNANCE
Alison Gallacher provided an update on Information Governance, which included information around the responsibilities of partner organisations: Data Protection Act; Freedom of Information Requests and Subject Access Requests.
The Integration Joint Board:
• Noted the responsibilities of the Integration Joint Board in terms of The Data Protection Act 1998, The Freedom of Information (Scotland) Act 2002, the Environmental Information (Scotland) Regulations 2004 and the Public Records (Scotland) Act 2011 • Approved o NHS Forth Valley responding to Subject Access Requests on behalf of the Integration Joint Board for an initial period of nine months and adopt the proposed Subject Access Request Procedure Flowchart o The Information Security Incident Reporting Policy o NHS Forth Valley responding to Freedom of Information Requests, review request and appeals on behalf of the Integration Joint Board for an initial period of nine months and adopt the proposed Freedom of Information Procedure Flowchart o The Model Publication Scheme • Delegated authority to the Chief Officer to: o Register the Integration Joint Board as a Data Controller with the Information Commissioner’s Office o Adopt Scottish Accord for the Sharing of Personal Information by signing the Declaration of Acceptance o Enter into any Information Sharing Protocols under Scottish Accord for the Sharing of Personal Information required to facilitate information sharing arrangements o Act as Senior Information Risk Owner
11.3 COMPLAINTS PROCESS
Elaine Vanhegan provided an overview of the Complaints Protocol developed by the workstream. The paper covered matters which could and could not be addressed via the framework.
There was some discussion around the importance of complaints and other types of feedback, and some differences in the processes by constituent parties.
The Integration Joint Board noted and acknowledged the work carried out to develop the Complaints Protocol and approved the Complaints Protocol acknowledging the forthcoming changes nationally in terms of complaints handling.
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11.4 EQUALITY
Lesley Fulford advised that the Scottish Government had added Integration Joint Boards to Schedule 19 of the Equality Act 2010 and to The Equality Act 2010 (Specific Duties) (Scotland) Regulations. This means that all Integration Joint Boards are subject to the legislation and Specific Duties.
The Integration Joint Board agreed:
• That the proposed model for equality impact assessments is used where an equality impact assessment is required; and • That the Chief Officer will prepare and publish the information required to fulfil the Board’s specific duties in relation to mainstreaming and outcomes
12. RISK STRATEGY
Hugh Coyle provided an overview of the proposed strategy developed by the Risk Workstream, in line with existing policies. Further clarity was required to align the strategy with Clinical & Care Governance, and the Performance Framework.
The Integration Joint Board:
• Considered and approved the Risk Management Strategy • Noted that the Strategic Risk Management Reporting should be developed alongside relevant (sub) Committee structures and governance arrangements • Noted that a Strategic Risk Register is being developed by the risk work- stream in relation to Clackmannanshire and Stirling • Noted that the Forth Valley Risk Workstream members will continue to support the Integration Joint Board
13. SCOTTISH LAW COMMISSION REPORT ON ADULTS WITH INCAPACITY
Val de Souza provided a brief overview of the initial response in respect to the Consultation Paper on the Scottish Law Commission Report on the Adults with Incapacity and specific issues associated with 'deprivation of liberty', and the potential implications.
The Integration Joint Board noted the initial response
14. SUPPORT SERVICES
Shiona Strachan provided an update of the work to establish the ongoing support requirements.
The Integration Joint Board:
• Noted the commitment within the local Integration Scheme • Agreed that proposals for consideration and approval will be brought forward by the Chief Officer at the June 2016 meeting
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15. LOCAL DELIVERY PLAN
Dr Graham Foster informed the Integration Joint Board of work undertaken to date around the development of the draft Local Delivery Plan. A final Local Delivery Plan was to be submitted to the Scottish Government by the end of May 2016.
The Integration Joint Board considered and noted the Draft Local Delivery Plan 2016/17
16. ANY OTHER COMPETENT BUSINESS
There was no further business to be discussed.
17. DATE OF NEXT MEETING
Wednesday 27 April 2016, 2.00-4.00, Kildean Suite. Forth Valley College, Stirling Campus.
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Clackmannanshire & Stirling Integration Joint Board
27 April 2016
This report relates to Item 6 on the agenda
Minute of Clackmannanshire & Stirling Integration Joint Board special meeting held on 30 March 2016
For Approval
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Minute of the Clackmannanshire & Stirling Integration Joint Board meeting held on Wednesday 30 March 2016, at 2.00pm, in the Kildean Suite, Forth Valley College, Stirling Campus.
Present: Alex Linkston, Chairman (Chair) Councillor Les Sharp, Council Leader (Vice Chair) Councillor Donald Balsillie Councillor Johanna Boyd, Council Leader Jim Boyle, Chief Finance Officer, Stirling Council Stewart Carruth, Chief Executive, Stirling Council Councillor Scott Farmer John Ford, Non-Executive Board Member Fiona Gavine, Non-Executive Board Member Ms Tracey Gillies, Medical Director Jane Grant, Chief Executive Tom Hart, Employee Director Shubhanna Hussain-Ahmed, Unpaid Carers Representative for Stirling Angela Leask Sharp, Third Sector Representative Councillor Kathleen Martin Morag Mason, Service User Representative for Stirling Natalie Masterson, Third Sector Representative for Stirling Teresa McNally, Service User Representative for Clackmannanshire Elaine McPherson, Chief Executive Ewan Murray, Chief Finance Officer Elizabeth Ramsay, Unpaid Carers Representative for Clackmannanshire Pamela Robertson, Chair, Forth Valley Joint Trade Union Forum Gareth Ruddock, Third Sector Representative for Clackmannanshire Wendy Sharp, Third Sector Representative Councillor Christine Simpson Shiona Strachan, Chief Officer Julia Swan, Non-Executive Board Member Lorraine Thomson, Substitute for Abigail Robertson Prof Angela Wallace, Nurse Director Dr Scott Williams, Primary Care Lead
In Attendance: Lesley Fulford, Programme Manager Carol Johnston, Performance & Quality Assurance Manager Ruth McColgan, Solicitor Stephanie McNairney, Project Administrator (Minute) Fiona Ramsay, Director of Finance Elaine Vanhegan, Head of Performance Management, NHS Forth Valley
1. APOLOGIES FOR ABSENCE
Apologies for absence were intimated on behalf of:
Joanne Chisholm, Non-Executive Board Member Val de Souza, Chief Social Work Officer Dr Graham Foster Kathy O’Neill, General Manager, CHP’s Abigail Robertson, Chair, Joint Staff Forum Page 2 of 6
2. NOTIFICATION OF SUBSTITUTES
• Phillip Gillespie substituted for Val de Souza • Ms Tracey Gillies substituted Dr Graham Foster • Julia Swan substituted for Joanne Chisholm
3. DECLARATION(S) OF INTEREST
There were no declarations of interest.
4. MATTERS ARISING
All matters were covered within substantive agenda items.
5. FINANCE
5.1 FINANCIAL REGULATIONS
Ewan Murray set out the proposed financial regulations which would support operations. These set out the responsibilities of the Integration Joint Board, the Chief Officer and the Chief Finance Officer, and would be subject to annual review.
The Integration Joint Board discussed various sections of the financial regulations and clarity was provided where required.
Section 4.5 around virement was to be reworded for clarity
The Integration Joint Board:
• Approved the Financial Regulations • Noted the responsibilities of the Board, Chief Officer and Chief Finance Officer • Agreed to the regular review of the financial regulations as the Board develops and task the Chief Finance Officer to undertake such review as and when required
5.2 PARTNERSHIP BUDGETS AND FINANCIAL ASSURANCE
Ewan Murray provided a presentation to supplement the content of the report which summarised:
• Due diligence • Financial assurance • Parity • First year budget • Significant risks
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Assurance was given that constituent partners would enter into further full and open discussion around parity to agree a mutually acceptable way forward, and noted an increasingly challenging financial environment.
It was suggested that members of the Integration Joint Board may benefit from support or training, to equip them to understand and scrutinise financial information which may be complex at times.
The Integration Joint Board:
• Noted the due diligence process that has taken place, in line with national guidance, to ensure that the basis of budgets delegated to the Integration Joint Board are reasonable and proportionate and that significant risks are highlighted • Approved the proposed resource transfers as the first year budget for the Integration Joint Board and for it to form the basis of the financial statement within the Strategic Plan • Noted the significant areas of financial risk • Noted the proposed utilisation of the Integration Funds including the due diligence process required of the Integration Joint Board Chief Finance Officer • Approved the establishment of a Leadership Group to provide oversight of financial performance including any financial recovery plans as required in line with the Integration Scheme • Noted the development of financial management and reporting arrangements
6. GOVERNANCE
6.1 PERFORMANCE FRAMEWORK
Elaine Vanhegan presented the proposed Performance Management Framework developed by the workstream to fulfil legislative requirements.
A full performance report would be provided annually, and some elements of performance would be reported to the Integration Joint Board more regularly.
The Integration Joint Board:
• Approved the Performance Management Framework, acknowledging that further development will be required over time as IJB processes become established • Noted that final lists of the Integration Functions Performance Targets and the Non-Integration Functions Performance Targets will be brought back to the IJB further to final decisions regarding the operational delivery arrangements • Noted the work to date in the development of sample Balanced Scorecards per partnership against the National Outcomes and Core Indicators and local measures • Acknowledged that further work is required to develop measures against the Strategic Plan focussing on core priorities
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• Noted the further development of the Covalent Performance Management System to support the overall process • Delegated authority to the Chief Officer to oversee the implementation of the overall Framework and specifically ensure processes are in place to fulfil the legislative requirements in the production of an Annual Report
6.2 DIRECTION FROM INTEGRATION JOINT BOARD
Ruth McColgan explained that Directions are the legally binding instrument through which the Integration Joint Board will ‘commission’ the constituent authorities to carry out statutory functions and implement its approved Strategic Plan.
Directions can be amended or revoked by the Integration Joint Board, but there would be no change to service delivery at this stage. Any proposed changes to service would be progressed through the usual process of business case development, consultation, and governance approvals prior to the issue of any Direction.
The Integration Joint Board:
• Approved the issuing of Directions to each of the constituent authorities prior to 31 March 2016 • Delegated authority to the Chief Officer to refine the draft Directions prior to issuing to the constituent authorities as appropriate
6.3 DELEGATION OF AUTHORITY
Ruth McColgan provided an overview of delegated authorities to be granted by the Integration Joint Board to enable to Chief Officer and Chief Finance Officer to act on its behalf. All key decisions would continue to be taken by the Integration Joint Board.
The Integration Joint Board approved the delegation of authorities to the Chief Officer and the Chief Financial Officer subject to the conditions set out within appendix 1 of the report.
7. ANY OTHER COMPETENT BUSINESS
Alex Linkston advised that Stephanie McNairney had been successfully appointed to a new post within NHS Forth Valley and that this would be her last attendance at the Board. He thanked Stephanie for her support to the Integration Joint Board.
Alex Linkston would step down as Chair of the Integration Joint Board on 31 March, and Councillor Les Sharp would take up the Chairmanship from 1 April. Councillor Sharp and Integration Joint Board thanked Alex Linkston for his input to the Board.
8. DATE OF NEXT MEETING
Wednesday 27 April 2016, 2.00-4.00, Kildean Suite. Forth Valley College, Stirling Campus.
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Clackmannanshire & Stirling Integration Joint Board
27 April 2016
This report relates to Item 8 on the agenda
DELAYED DISCHARGE PROGRESS REPORT
(Paper presented by Val de Souza / Kathy O’Neill)
For Noting
Approved for Submission by Shiona Strachan, Chief Officer Author Carol Johnson, Social Services Date: 27 April 2016 List of Background Papers:
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Title/Subject: Delayed Discharge Progress Report Meeting: Clackmannanshire & Stirling Integration Joint Board Date: 27 April 2016 Submitted By: Carol Johnson, Social Services Action: For Noting
1. Introduction
1.1 The purpose of this paper is to update the Integration Joint Board on the performance of the Clackmannanshire and Stirling Partnership in relation to the national delayed discharge target of 2 weeks. The longer term trend information relating to delayed discharge performance is set out in appendices 1, 2 and 3 of this report.
2. Recommendation
2.1 The Integration Joint Board (IJB) is asked to; • note the performance of the partnership based on the March 2016 census and provide appropriate challenge;
3. Background
3.1 As at March census date, there was 1 patient delayed awaiting discharge from hospital for Clackmannanshire, who was delayed less than 2 weeks. In Stirling, there was a total of 3 patients delayed awaiting discharge from hospital, of which 1 patient was delayed for more than 2 weeks.
3.2 Table 1 - Clackmannanshire Council
Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar 15 15 15 15 15 15 15 15 15 16 16 16 Total delays at census point (As 0 2 5 6 3 2 3 8 2 4 4 1 of 15th of each month) Total numbers of delays 0 1 0 4 1 2 1 1 0 1 1 0 over 2 weeks
Table 2 - Stirling Council Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar 15 15 15 15 15 15 15 15 15 16 16 16 Total delays at census point (As 1 15 11 11 7 9 10 17 5 8 7 3 of 15th of each month) Total numbers of delays 0 3 3 6 3 4 10 6 1 1 4 1 over 2 weeks
3.3 In addition to standard delays, there are patients whose discharge is complex (code 9) and whose discharge is part of a longer discharge planning process (code 100). The latter tend to be patients who are in long stay learning disability or mental health inpatient services. Code 100 relates to those patients who have been assessed for transfer to a specialist resource where no such resource is available or exists yet. Examples of this include patients awaiting transfer to a community setting as part of a commissioning or resettlement programme. As of 15 March 2016, there were 2 patients in Clackmannanshire and 1 patient in Stirling with a Code 100 applied.
3.4 Code 9 was introduced for very limited circumstances where NHS Chief Executives and local authority Directors of Social Work (or their nominated representatives) could explain why the discharge of patients was out with their control. These include patients delayed due to awaiting place availability in a high level needs’ specialist facility where no facilities exist and where an interim option is not appropriate, patients for whom an interim move is deemed unreasonable or where an adult may lack capacity. As of 15 March 2016 there were 5 patients in Clackmannanshire and 6 patients in Stirling in the Guardianship process. There was also 2 patients from Clackmannanshire who were awaiting specialist arrangements for discharge.
Table 3 - shows the total number of delays in Clackmannanshire expressed as bed days lost.
Table 3 - Clackmannanshire Council Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar 15 15 15 15 15 15 15 15 15 16 16 16 Total Bed Days lost 0 26 23 122 33 43 49 87 14 32 49 4 Standard Delays Total Bed Days Occupied 0 N/A N/A 120 17 43 29 27 0 25 28 0 over 2 weeks
Table 4 shows the total number of standard delays in Stirling expressed as bed days lost
Table 4 - Stirling Council Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar 15 15 15 15 15 15 15 15 15 16 16 16 Total Bed Days lost 60 106 140 248 95 109 316 233 33 68 110 64 standard Delays Total Bed Days Occupied N/A N/A N/A 178 64 85 301 172 18 25 92 55 over 2 weeks
4. Analysis of reasons for delay
4.1 The principal reasons for delay during the reporting period in Stirling was the result of the primary choice of care home being unavailable and patients awaiting the conclusion of a legal process/Guardianship. At the March census 6 patients were delayed awaiting the conclusion of a legal process in Stirling and 5 patients delayed in Clackmannanshire. The primary reason for Guardianship delays during this reporting period was a delay in acquiring legal aid for private Guardianship applications.
4.2 In Stirling there were a total 22 discharges from hospital of which 9 patients were discharged home with a care package 10 patients were discharged to a care home and 2 patients to intermediate care. In total 17 patients from Stirling were added to Edison the electronic recording system during the reporting period.
In Clackmannanshire 5 patients were discharged form hospital with 3 patients admitted to a care home and 2 patients admitted to intermediate care. In total 4 patients from Clackmannanshire were added to Edison the electronic recording system during the reporting period.
5. Conclusions
5.1 The report sets out the performance of the Clackmannanshire and Stirling Partnership based on the census data of 15 March 2016. The report advises the Integration Joint Board on the principal reasons for delay and the actions being taken forward by the Partnership to mitigate the delays.
6. Resource Implications
6.1 N/A
7. Impact on IJB Outcomes, Priorities and Outcomes
7.1 The actions outlined in this report contribute to the delivery of the National and local outcomes set out in the Strategic Plan.
8. Legal & Risk Implications
8.1 Risk as above.
9. Consultation
9.1 The Head of Social Services, the General Manager for Forth Valley Community Health Partnership's and the Chief Officer for Clackmannanshire & Stirling Health and Social Care Partnership have been consulted in the compiling of this report.
10. Equalities Assessment
10.1 N/A
11. Exempt reports
11.1 No
Appendix 1
Delayed Discharges Over 2 Weeks by Month and Local Authority Excludes Codes 9 and 100
Appendix 2
Delayed Discharges OBDs Over 2 Weeks by Month and Local Authority Excludes Codes 9 and 100
Appendix 3
Clackmannanshire & Stirling Integration Joint Board
27 April 2016
This report relates to Item 9 on the agenda
Partnership Funding
(Paper presented by Ewan C. Murray)
For Noting and Approval
Approved for Submission by Shiona Strachan, Chief Officer Author Ewan C. Murray, Chief Finance Officer Date: 27 April 2016 List of Background Papers: 28 August 2015 – 7. Delayed Discharge 13 May 2015 – 8. Integrated Care Programme 11 December 2015 – 8.1 Partnership Allocations Update 24 February 2016 – Partnership Funding 30 March 2016 – Due Diligence, Financial Assurance and First Year Budget
Title/Subject: Partnership Funding Meeting: Clackmannanshire & Stirling Integrated Joint Board Date: 27 April 2016 Submitted By: Ewan C. Murray, Chief Finance Officer Action: For Noting and Approval
1. Introduction
1.1 The purpose of this report is to update the Integration Joint Board on
• Progress on the review and evaluation of projects supported through Partnership Funding Streams including Integrated Care Fund, Delayed Discharges Funding and Partnership Bridging Resources. • An update on reported expenditure, subject to audit, to 31 March 2016 against these funding streams • Further detail on use of the partnerships share of £250m Integration Fund
1.2 The term Partnership Bridging Resources relates to residual funding from prior year Partnership Allocations (the Reshaping Care for Older People's Change Fund) which are currently being deployed to support service models on a transitional basis.
2. Executive Summary
2.1 The Transitional Board approved the Integrated Care Programme at its meeting on 13 May 2015 and the use of resources allocated to address Delayed Discharges at its meeting on 28 August 2015.
2.2 Update reports were provided at the 11 December 2015 and 24 February 2016 meetings of the Integration Joint Board.
2.3 Further guidance on the use of Integrated Care Funding and reporting requirements to Scottish Government were received on 24 March 2016 and a copy is attached as Appendix I to this report.
2.4 Expenditure plans for the partnerships share of the £250m Integration Fund were included, at a high level, within the first year budget setting paper approved by the Integration Joint Board at its meeting on 30 March 2016. This report includes further detail on the deployment of these resources.
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3. Recommendations
The Integration Joint Board is asked to:
3.1 Note the updated summary of partnership funding and projected expenditure.
3.2 Note the process of evaluation and review of projects funded through the Integrated Care Programme, Delayed Discharges Funding and Partnership Bridging Resources and agree to receive a full report for consideration and approval at the June 2016 Board meeting.
3.3 Note the further guidance on Integrated Care Fund received from Scottish Government. This requires partnerships to submit a report for Year 1 of the fund by end of May 2016. The Board is asked to note that the Chief Officer will submit a draft report within this timescale subject to the Integration Joint Board approving the report at its June 2016 meeting.
4. Background
4.1. The Transitional Board approved the Integrated Care Programme at its meeting on 13 May 2015 and the use of resources allocated to address Delayed Discharges at its meeting on 28 August 2015. The Integration Joint Board received a further update including details of projected expenditure levels at its meeting of 11 December 2015.
4.2. Partnership Funding which will be available to the partnership in 2016/17 and 2017/18 and referred to within this report are: • Integrated Care Fund • Delayed Discharge Funding • Partnership Bridging Resources
4.3. This report also provides further detail on the use of the partnership share of the Integration Fund further to agreement of the Partnership’s First Year Budget.
5. Integrated Care Fund, Delayed Discharge Funding and Partnership Bridging Resources
5.1. The following table details reported expenditure, subject to audit, against Partnership Funding in 2015/16.
Table 1: 2015/16 Expenditure
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This position is £0.272m less than the £3.217m previously reported forecast. This is mainly due to less than anticipated expenditure occurring relating to:
• Closer to Home • Anticipatory Care Team • Top up costs for Allan Lodge Beds • Enabling Funds • Rapid Access Frailty Clinic and Discharge Hub
The above position results in £1.098m of partnership funding being carried forward into 2016/17 proposed use of which will be factored into the report to be presented at the June 2016 meeting.
The partnership also reported expenditure of £0.109m against the Transitional Funding provided by Scottish Government to support the planning, preparation and development work for Health and Social Care Partnerships.
5.2. Partnership Funding Allocations for 2016/17 are detailed in table 2 below. These are subject to formal confirmation by Scottish Government.
Table 2: Partnership Funding 2016/17
5.3. A short life working group has been established as a sub-group of the Reshaping Care Strategy Group to complete an evaluation and review of projects funded through partnership funding streams in 2015/16. This will include alignment of investments to the priorities of the Strategic Plan. The work of the group is progressing well and progress was discussed with the Chief Officer and Chief Finance Officer on 7 April 2016.
To allow the working group adequate time to complete this work it was agreed at the February 2016 meeting that current projects would have funding extended by up to 6 months from April 2016. A list of projects with where funding is being extended is attached at Appendix II.
As previously agreed a full report and proposed spending plan will be submitted to the June 2016 Integration Joint Board meeting for approval. This will present the recommendations from the review and evaluation process and identify how the previously identified risk of shortfall on a recurrent basis is proposed to be addressed.
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6. Integration Fund
6.1. The 2016/17 Scottish Budget included a £250m integration fund which will flow via NHS Boards to be used to support social care spend across 2 traunches of £125m. The first traunche is to be utilised to support additional spend on expanding social care including growth in demand for services as a consequence of demographic growth and the second traunche to help meet a range of existing cost faced by Local Authorities including delivery of the Living Wage for social care workers from 1 October 2016.
6.2. Clackmannanshire and Stirling Councils proposed use of this funding within their revenue budget setting for 2016/17 in line with the terms of the Local Government Finance settlement set out by the Deputy First Minister. These proposals reflected best estimates of costs at that point in time.
6.3. A separate report is being presented to the Board on the issues and costs associated with the Carers Bill.
6.4. Further detail on the use of these resources is provided at Appendix III.
6.5. As previously report to the Board a sum of £0.457m has been uncommitted from these resources reflecting that some of the use of resources associated with the Integrated Care Programme is supporting a level of expenditure in social care services which would fit the criteria for the use of the Integration Fund. The proposed use of this sum will brought forward for approval within the detail spending plan to be presented at the June 2016 meeting.
6.6. The risk around the full year effect of the implementation of the Living Wage was highlighted with the budget paper approved by the Integration Joint Board at its meeting on 30 March 2016.
7. Impact on Integration Joint Board Outcomes and Priorities
7.1. The funding streams detailed in this report represent the a significant element of the resources available to the partnership to meet the priorities identified in the Strategic Plan therefore require to be invested in an optimal manner to address those priorities.
8. Legal & Risk Implications
8.1. There are no legal implications anticipated.
9. Consultation
9.1. The Joint Management Team and Reshaping Care Strategy Group have been consulted on the proposals attached.
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10. Equalities Assessment
10.1. An equalities assessment is not required for this exercise.
11. Exempt reports
11.1. Not exempt.
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Health and Social Care Integration Directorate Geoff Huggins, Director
T: 0131-244 3210 F: 0131-244-2042 E: [email protected]
Chief Officers – Integration Joint Boards Local Authority Chief Executives NHS Chief Executives
___ Our ref: ICF2016-18 24 March 2016
Dear Colleague
INTEGRATED CARE FUND – 2016-2018
As you are aware, we are coming to the end of the first year of the Integrated Care Fund (ICF) which was provided by the Scottish Government in 2015/16 to help Health and Social Care Partnerships to support investment in integrated services.
In March 2015, the Cabinet Secretary for Health, Wellbeing and Sport announced that an additional £100 million would be made available to Health and Social Care Partnerships through the ICF in each of the financial years 2016/17 and 2017/18. This additional support has given the Cabinet Secretary the opportunity to review the operation of the ICF and I am writing to outline how the fund should be distributed, used and monitored by partnerships going forward.
The same methodology will be used to allocate ICF resources to partnerships over the next two years and the allocations are set out in detail in Annex A. However, we consider that the use of the ICF can be more directly aligned to the delegated services in each partnership area. So, where partnerships have been delegated functions beyond the minimum required by the legislation, ICF resources may now be used to support those activities, based on your local needs.
You will also be aware, that as part of our 2016/17 budget we have allocated a further £250 million transfer from the NHS to Health and Social Care Partnerships to protect and grow social care services and to deliver our shared priorities. This is additional to the Integrated Care Fund and to the recurring £30m provided in 2015/16 to help tackle delayed discharges..
Of this £250 million, £125 million is to provide additional spend on social care to support the objectives of integration, including through making progress on social care charging thresholds for all non-residential services to address poverty. This additional money also reflects the need to expand capacity to accommodate growth in demand for services as a consequence of demographic change.
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With this in mind, I would remind you that the key purpose of the ICF is to act as a catalyst for service change and to support local ideas and thinking that contribute to that service change and move towards new models of care. As we move into year two, and given that partnerships are now established and strategic plans prepared and published, we would ask you to review locally your ICF activity and ensure that:
The key purpose of the ICF is maintained and it is used to support innovative new ideas and service change, designed to shift the balance of care, rather than to maintain historic arrangements; These should continue to be based around the 6 principles outlined in the ICF guidance for 2015/16 - these are attached at Annex B for reference; That activity supported through the ICF is clearly aligned with your published strategic plans.
Monitoring and Reporting on the ICF
We aim to keep the reporting and monitoring requirements proportionate for partnerships, whilst ensuring proper governance and oversight of the fund. ICF reporting should be complementary to the wider annual performance reporting cycle. This will allow Health and Social Care Partnerships to report the impact of their ICF investment more broadly as part of their overall strategic planning activity.
The monitoring and reporting for years two and three will therefore be as follows:
Partnerships will be asked to submit a detailed plan of their ICF activity at the start of each financial year. This should include the following details as a minimum: o the type of activity being supported and its purpose; o the expenditure associated with the activity as well as the sector it is supporting; o The outcomes it is seeking to achieve and the local indicators being used to monitor it, and: o Information about how the overall ICF activity links to the partnership’s wider strategic planning priorities.
Partnerships will no longer be required to submit 6 monthly monitoring reports. Partnerships should however ensure that robust local monitoring arrangements are in place which will allow them to report upon ICF activity. This should form part of the wider Health and Social Care Integration Partnership Performance Reports which should be published and sent to the Scottish Government..
We will produce revised guidance that will follow the key points set out in this letter and lay out the timescale for producing ICF plans and reports. In the meantime I would be grateful if your partnership prepares and submits its year 1 ICF report to the Scottish Government by the end of May 2016.
Third Sector
We are keen to support partnerships as they develop and this will include offering support in your engagement with the third sector. The third sector are valued contributors to integration and locally, should be engaged at every level. The sector incorporates a breadth of experience and knowledge that can be accessed via TSIs and also directly through experienced third sector organisations who are facilitators or who provide services directly to
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individuals. Partnership with the third sector is integral to a shift in the way that services are planned and delivered. Guidance on the role of the Third Sector Interface organisations in relation to integration activities is published on the Scottish Government website and can be accessed here - http://www.gov.scot/Resource/0047/00475591.pdf.
Four partnership areas are currently benefitting from support through the “threading the needle” project. Other small projects are under way or under consideration and we are supporting work through the ALLIANCE around integration. With all pieces of work, we will consider how to share the learning.
It would be helpful to have your views around engagement with the third sector in your local area and we would be happy to have discussions about the challenges and about any gaps you perceive around the existing support.
You will also wish to be aware that there are resources available online from “A Stitch in Time”. A wide range of materials has been produced to support third sector organisations and commissioners in understanding and evidencing the third sector’s contribution to achieving outcomes which matter to local people. The publications explain and show: What the third sector does and the difference they make;
Appropriate evaluation methods developed and used to collect evidence;
A range of relevant evidence. The resources can be found at the following link: http://www.evaluationsupportscotland.org.uk/how-can-we-help/shared-learning- programmes/stitch-time/
If you have any questions regarding the content above or wish to share your views about interaction with the third sector, please feel free to contact Brian Nisbet on 0131 244 3588 or Jacqueline Campbell, national policy lead for health & social care, on 0131 244 2270.
Yours sincerely
Geoff Huggins Director for Health and Social Care Integration
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ANNEX A NHS Board Partnership £m Ayrshire & Arran East Ayrshire 2.47 North Ayrshire 2.89 South Ayrshire 2.34 7.70 Borders Scottish Borders 2.13 Dumfries & Galloway Dumfries & Galloway 3.04 Fife Fife 6.73 Forth Valley Clackmannanshire 0.96 Falkirk 2.88 Stirling 1.52 5.36 Grampian Aberdeen City 3.75 Aberdeenshire 3.78 Moray 1.59 9.12 Greater Glasgow & Clyde West Dunbartonshire 1.99 East Dunbartonshire 1.70 East Renfrewshire 1.43 Glasgow City 13.29 Inverclyde 1.76 Renfrewshire 3.49 23.66 Highland Argyll & Bute 1.84 Highland 4.31 6.15 Lanarkshire North Lanarkshire 6.51 South Lanarkshire 6.04 12.55 Lothian East Lothian 1.76 Edinburgh, City of 8.19 Midlothian 1.44 West Lothian 2.85 14.24 Orkney Orkney Islands 0.41 Shetland Shetland Islands 0.41 Tayside Angus 2.13 Dundee City 3.10 Perth & Kinross 2.63 7.86 Western Isles Eilean Siar 0.64 Scotland 100.00 * Allocations to Health and Social Care Partnerships are based upon a composite of the NHS National Resource Allocation Committee (NRAC) and Local Government Grant Aided Expenditure (GAE) on a 1:1 ratio.]
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ANNEX B Principles
1. The Ministerial Strategic Group for Health and Community Care, the Scottish Government, COSLA, NHS Scotland and third and independent sector partners have agreed that six principles should underpin the use of the Integrated Care Fund:
Co-production – the use of the Fund must be developed in partnership, primarily between health, social care, housing, third sector, independent sector, people who use support and services and unpaid carers. It should take an inclusive and collaborative local approach that seeks out and fully supports the participation of the full range of stakeholders, particularly the third sector, in the assessment of priorities and delivery of innovative ways to deliver better outcomes
Sustainability – the Fund needs to lead to change that can be evidenced as making a difference that is sustainable and can be embedded through mainstream integrated funding sources in the future.
Locality – the locality aspects must include input from professionals, staff, users and carers and the public. Partnerships should develop plans with the people who best know the needs and wishes of the local population. Such a bottom-up approach should maximise the contribution of local assets including the third sector, volunteers and existing community networks. Partners will be expected to weight the use of their funding to areas of greatest need.
Leverage – the funding represents around 1% of the total spend on adult health and social care so must be able to support, unlock and improve the use of the total resource envelope. Our approach to strategic commissioning will be key to this so it is important that plans for the use of this resource are embedded in the strategic commissioning process.
Involvement – Partnerships should take a co-production, co-operative, participatory approach, ensuring the rights of people who use support and services and unpaid carers are central to the design and delivery of new ways of working – delivering support and services based on an equal and reciprocal person centred relationship between providers, users, families and communities. These relationships should be evidenced within each partnership’s plans.
Outcomes – partnerships will be expected to link the use of the funds to the delivery of integrated health and wellbeing outcomes for adult health and social care which will be the responsibility of the new Integration Joint Boards or lead agencies following enactment of the legislation for integration.
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Clackmannanshire & Stirling Integration Joint Board
27 April 2016
This report relates to Item 10 on the agenda
Health and Social Care Integration Programme Plan Update
(Paper presented by Lesley Fulford)
For Noting
Approved for Submission by Shiona Strachan, Chief Officer Author Lesley Fulford, Programme Manager Date: 27 April 2016 List of Background Papers: 2015.09.17 Clackmannanshire & Stirling TB - Programme Work Streams Progress Report 2015.12.11 - Clackmannanshire & Stirling IJB - Work Stream Progress Report 2016.02.24 Clackmannanshire & Stirling IJB - Work Stream Progress Report
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Title/Subject: Health and Social Care Integration Programme Plan Update
Meeting: Clackmannanshire & Stirling Integration Joint Board Date: 27 April 2016 Submitted By: Lesley Fulford, Programme Manager Action: For Noting
1. Introduction
1.1 The purpose of the report is to provide an update to the Integration Joint Board on the programme of work to implement health and social care integration.
2. Executive Summary
2.1. The Public Bodies (Joint Working) (Scotland) Act 2014 sets out a number of statutory requirements for Health and Social Care Partnerships to meet in order to implement health and social care integration.
2.2. The Integration Joint Board has received regular reports noting the programme of work to ensure the Board is satisfying itself that all relevant matters are being progressed in a timely manner.
2.3. The key achievements since the report in February 2016 and future actions for these work stream groups are attached in Appendix 1.
2.4. In the April meeting of the Programme Board, members reviewed the work completed to date and are considering the work now required to be taken forward and how this will be structured.
3. Recommendations
The Integration Joint Board is asked to:
3.1. Note the content of the report and progress to date.
4. Background
4.1. The Public Bodies (Joint Working) (Scotland) Act 2014 sets out a number of statutory requirements for Health and Social Care Partnerships to meet in order to implement health and social care integration.
Page 2 of 10 5. Integration Programme Plan
5.1. The Integration Programme Plan and associated work streams have ensured the delivery and implementation of a range of tasks that are required to support new integration arrangements and to ensure the Partnership met their statutory obligations prior to 1 April 2016.
5.2. The work stream groups established to support integration arrangements are as follows:
. Strategic Planning group . Strategic Plan Working Group . FV wide Governance group . FV wide Finance group, with two supporting sub groups . FV wide HR workforce group . FV wide Performance and Measurement group . FV wide Data Sharing Partnership group . FV wide Clinical and Care Governance group . FV wide Risk Management group . Clackmannanshire & Stirling Partnership OD and Workforce Development group.
5.3. The key achievements updates since the report in February 2016 and future actions for these work stream groups are attached in Appendix 1.
6. Conclusions
6.1. Work has progressed within challenging deadlines, which has required strong commitment from all partners to ensure the Partnership met its statutory obligations under the Public Bodies (Joint Working) (Scotland) Act 2014 by 1 April 2016.
6.2. A number of the work streams have significant areas of work and will continue beyond March 2016 as part of the longer terms change programme. This programme of further work will be established through a review conducted by the Programme Board.
7. Resource Implications
7.1. The Integration Joint Board should note that the respective partners are contributing significant resources to support integration as reflected in the membership and areas of work being taken forward in the respective work streams. It should be noted that this is, at this point in time, considerable commitment for all parties.
Page 3 of 10 8. Impact on Integration Joint Board Outcomes, Priorities and Outcomes
8.1. By completing the work associated with the work streams the Partnership has met its statutory obligations under the Public Bodies (Joint Working) (Scotland) Act 2014 by 1 April 2016. The primary focus for the work streams was on meeting the core legal requirements and those provisions within the Integration Scheme by this deadline.
8.2. Further work is now required to ensure the Partnership embeds these activities.
9. Legal & Risk Implications
9.1. None to note.
10. Consultation
10.1. Work stream outputs, where required, will be subject to consultation.
11. Equality and Human Rights Impact Assessment
11.1. Equalities and Human Rights Impact Assessments will be carried out as required for each work stream. The recommendations in this report do not require an Equalities and Human Rights Assessment.
12. Exempt reports
12.1. No
Page 4 of 10 13. Appendix 1 – Programme Work Stream Update Work Stream Chair Key Milestones to Date Key Priorities / Actions OutlineTimescales Strategic Robert • Published the approved final version of • Develop Locality Needs May 2016 Planning Stevenson the Strategic Plan and Easy Read Assessments Working / Chris version • Develop Locality Plans 2016 / 2017 Group Sutton • Develop Market Facilitation December 2016 Statement Governance Patricia • IJB Complaints policy and • Publish Equalities Outcomes 30 April 2016 Cassidy procedures in place and Mainstreaming Report 2016 • FOI policy and procedures and November 2016 Publications Scheme in line with • IJB to put in place its own FOISA in place code – Ethical Standards in Public Life etc (Scotland) Act • IJB approved EQIA template to be 2000 31 March 2018 used • Creation of Records Management Policy, retention schedules and when invited submission to the Keeper of the Plan in line with PRSA
Finance Fiona • Completion of the initial budget • Refining the budget details Review- June 2016 Ramsay setting • Develop and agree the • Completion of the financial financial reporting regulations arrangements • Completion of internal and external • Preparation of the 15/16 Audit recommendations accounts
Page 5 of 10 Work Stream Chair Key Milestones to Date Key Priorities / Actions OutlineTimescales HR Workforce Helen • Strategic Workforce plan approved • Further Analysis of the June 2016 Kelly • Initial analysis of workforce data workforce data complete • Joint Staff Forum meetings arranged bi • Operational Plan to be drafted April - May 2016 monthly until March 2017. to support the workforce plan.
Performance Elaine • Performance Management Framework • Further development required & Vanhegan developed and approved by IJBs in as IJB becomes established. Measurement March – move to implementation. • Work stream will continue to meet. Focus will be: • To refine sample scorecards • Finalise relevant and priority indicators in line with strategic plan for Year 1 based on national outcomes priorities. and needs of Strategic Plan. • Create a project plan for May 2016 implementation of the • Preparation of Integration function Performance Framework • Performance target list and Non and covalent use moving May 2016 integration functions performance forward using shared target list. Finalise on agreement on dashboard portal operational functions. • Review reporting requirements - ongoing • Review the Integration • Close liaison with other work streams functions performance target May 2016 to prevent duplication i.e. data sharing list & Non integration IM&T continues functions performance target list. June 2016
Page 6 of 10 Work Stream Chair Key Milestones to Date Key Priorities / Actions OutlineTimescales
Data Sharing Jonathan • Information Sharing Board (ISB) bid • Portal Proof of Concept IJB Project Board - Partnership Procter for funding received in December, Options Paper being April Agreement to carry forward funding prepared for IJB PB Paul to next year to support wider review Woolman of DSP options End February (Interim) • Delayed discharges requirements analysis progressed and fed into new data collection exercise for partners. Completed
• Data Sharing Specifications for 3 March 2016 workstrands being pulled together. • Girfec Information April / May 2016 Requirements : - First draft received by DSP • Review by DSP at next April 16 meeting
• Older People’s services requirements analysis progressing Awaiting council • Technical workstrands and initial • Data Sharing Requirements SW information IJB requirements being scoped and to be identified expected in next developed. quarter
• Outline requirements for IT network access being requested from managers in various departments May 2016
Page 7 of 10 Work Stream Chair Key Milestones to Date Key Priorities / Actions OutlineTimescales • IT infrastructure SC Plan expected end June • Site Connectivity Tests to be completed • CIsco Ice authentication April 2016 plans being drawn up by Stirling and Clacks To be progressed over next 6 months Identify by JMTs – March16 • Initial ICT issues and Tech requirements scoped out and work-plan being drawn together Clinical & Tracey • Framework agreed by IJB (March • Terms of Reference to be June 2016 Care Gillies/Val 2016) agreed for the Clinical and Governance de Souza Care Governance Oversight Group and group to be established Risk Hugh • Risk Management Strategy agreed • Risk Reporting Framework June 2016 Coyle by IJB (March 2016) • (Appendix to Strategy) to be completed, once IJB agree governance structures.
• Risk Register drafted, following • Risk Register to be June 2016 Workshop with members of JMT in completed by June 2016, in Dec 2015. tandem with e.g. Strategic Plan actions. A paper outlining progress and next
Page 8 of 10 Work Stream Chair Key Milestones to Date Key Priorities / Actions OutlineTimescales steps will be submitted to JMT / Programme Board in April 2016. As required. • Risk Training for e.g. IJB members. Participation & Chris • Strategy was approved at February • Action plan for September 2016 Engagement Sutton IJB implementation will now be developed.
Organisational Morag Clackmannanshire & Stirling Clackmannanshire & Stirling Development McLaren • IJB development outputs and • Phase 2 of staff engagement & Workforce proposals for future development sessions in Summer 2016 Development agreed • Delivery of proposals signed off • Joint Workforce Development and for IJB development Training Framework agreed by JMT • Continued support for SPG • Development session with Strategic development Planning Group (SPG) delivered in • Initial scoping work to identify Feb. ’16. Initial high-level outputs joint priorities for Workforce agreed and used to shape future SPG Development and Training meetings • Deliver Partnership ‘Playing to • Outputs from Phase 1 of staff Your Strengths’ Leadership engagement noted and signed off by Development Programme. IJB; published on website and noted in Staff Brief Both Partnerships • OD support in planning/facilitating • Provide support to the strategic service development workshops (e.g. planning process, to enable the development of resulting
Page 9 of 10 Work Stream Chair Key Milestones to Date Key Priorities / Actions OutlineTimescales Community Nursing, Single Point of implementation plans as well- Access, Community GP Fellows) informed and fit for purpose. • Initial proposals for Joint Leadership • Provide support to locality and Management Development development process approved by JMT and IJB. • Continued OD support in • Initial Short Intervention Leadership planning/facilitating service Programme ‘Playing to Your Strengths’ development workshops (e.g. developed. Enhanced Community Team) • Induction Programme for Non-Voting • Support Chief Officer & Senior IJB members undertaken (Dec. ’15). Leaders to identify Leadership development needs and Both Partnerships priorities for 2016. • Integrated Workforce Plan developed • Support the Chief Officer and and approved, including priorities in Senior Leaders to review and relation to Workforce Engagement & develop Joint Management & Governance Structures to meet Support, Training and Development, the needs of the new Leadership and Management Partnership. Development and Organisational • Development of medium – long Design and Processes term OD & Workforce • OD support provided to GP Whole Development Plans for next 3-5 Systems Working meetings. years (in line with the Integrated • Sharing of lessons learned from Workforce Plan). national groups which members of the • Identify Joint Training & OD / WD group attend. Development priorities based on the Framework, to make best use of resources available
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Clackmannanshire & Stirling Integration Joint Board
27 April 2016
This report relates to Item 11 on the agenda
Equality Mainstreaming & Outcomes Report
(Paper presented by Lesley Fulford)
For Approval
Approved for Submission by Shiona Strachan, Chief Officer Author Lesley Fulford, Programme Manager Date: 27 April 2016 List of Background Papers: 2016.03.22 - Clackmannanshire & Stirling IJB - Equality Equality Act 2010 The Equality Act 2010 (Specific Duties) (Scotland) Regulations
Title/Subject: Equality Mainstreaming & Outcomes Report Meeting: Clackmannanshire & Stirling Integration Joint Board Date: 27 April 2016 Submitted By: Lesley Fulford, Programme Manager Action: For Approval
1. Introduction
1.1 This report presents a draft Equalities and Mainstreaming and Outcomes Report.
2. Executive Summary
2.1. The Scottish Government added Integration Joint Board’s (IJB) to Schedule 19 of the Equality Act 2010 and to The Equality Act 2010 (Specific Duties) (Scotland) Regulations. This means that all Integration Joint Boards are subject to the equality legislation and Specific Duties.
2.2. The Equality Act 2010 provides a legal framework to protect the rights of individuals and advance equality of opportunity for all. The Act restated and simplified 116 separate pieces of earlier equality legislation into one Act, the majority of which came into force in October 2010.
3. Recommendations
It is recommended that the Integration Joint Board:
3.1. Note the work undertaken to draft the attached draft report (appendix 1)
3.2. Approve the draft report (appendix 1) for publication by 30 April 2016.
4. Equality Legislation
4.1. The Equality Act 2010 provides the legislative framework for preventing discrimination and advancing equality of treatment. All organisations are bound by its provisions but public organisations have additional duties.
4.2. The Integration Joint Board is a public organisation subject to these duties. Significant obligations arise firstly from the public sector equality duty and, secondly, from the specific duties arising from regulations made by the Scottish Ministers.
4.3. The public sector equality duty set out in s149 of the Equality Act 2010 places an obligation on public authorities, in the exercise of their functions, to have due regard to the need to:
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• eliminate unlawful discrimination, harassment and victimisation; • advance equality of opportunity between different groups; and • foster good relations between different groups.
4.4. The broad purpose of the equality duty is to integrate consideration of equality and good relations into the day-to-day business of public authorities. The duty requires organisations to consider how they could positively contribute to the advancement of equality and good relations. It requires equality considerations to be reflected into the design of policies, the delivery of services and is a crucial consideration when changes which may impact on groups who share protected characteristics are made to services.
4.5. In the main this duty has been met by public authorities developing means to assess the impact of proposals in relation to the public sector equality duty and then having regard to the outcome of that assessment in its decision making. At the 22 March 2016 meeting of the IJB, members approved the use of a proposed equality impact assessment tool; this is available on the Integration Web Pages here.
4.6. The Equality Act 2010 (Specific Duties) (Scotland) Regulations 2012 place specific equality duties on public authorities, including the Board. The specific duties which are relevant to note in this report are: • reporting on the mainstreaming of the equality duty; • agreeing and publishing equality outcomes.
5. Equality Mainstreaming and Equality Outcomes
5.1. Mainstreaming means that equality is built into the way the Partnership will work; the way decisions are made; the way people who work for and on behalf of the Board behave; our performance and how we can improve. In other words, equality should be a component of everything the Integration Joint Board does. Mainstreaming the equality duty has a number of benefits including:
. equality becomes part of the structures, behaviours and culture of an authority . an authority knows and can demonstrate how, in carrying out its functions, it is promoting equality . mainstreaming equality contributes to continuous improvement and better performance.
5.2. The duty imposed on the Board is to publish a report on the progress is has made to make the equality duty integral to the exercise of its functions no later than 30 April 2016. There is a challenge in reporting at this stage as the Integration Joint Board has been in existence for a very short period of time and the integration functions will be delegated only a month before the date on which the report requires to be published. The report is not be lengthy and focusses on the processes put in place for mainstreaming equality in the future and importantly on the consideration of equality in the development of the Strategic Plan.
5.3. Equality Outcomes are distinct to each organisation and need to reflect its functions, responsibilities, priorities and methods of working. At its meeting on 22 Page 3 of 6
March the Board approved the adoption of outcomes based on the local outcomes already identified in the preparation of the Integration Scheme and the Strategic Plan. These are:
• Self Management - Individuals, their carers and families are enabled to manage their own health, care and wellbeing; • Community Focused Supports – Supports are in place, accessible and enable people, where possible, to live well for longer at home or in homely settings within their community; • Safety - Health and social care support systems help to keep people safe and live well for longer; • Decision Making - Individuals, their carers and families are involved in and are supported to manage decisions about their care and wellbeing; • Experience – Individuals will have a fair and positive experience of health and social care
5.4. Over the coming year, the development of the locality profiles and plans will provide an opportunity to review the Equality Outcomes for the Partnership. It is suggested that any Equality Outcomes established at this stage are reviewed with a view to more focussed outcomes informed by the first year of operation being adopted in April 2017. This would align with the review of Equalities Outcomes by NHS Forth Valley, Clackmannanshire Council and Stirling Council.
6. Integration Joint Board Responsibilities
6.1. The Integration Joint Board must publish a report on the progress it has made in integrating the general equality duty by 30 April 2016. This must include:
. annual breakdown of the information it has gathered under its duty to gather and use employee information . report on mainstreaming the equality duty with details of the progress that it has made in gathering and using that information to enable it to better perform the general equality duty . A set of equality outcomes.
The Integration Joint Board is also required to assess the impact on equality of their policies and practices, including the Strategic Plan. This assessment was approved by the Integration Joint Board on 22 March and is available online here.
7. Conclusions
7.1. It is proposed the Integration Joint Board approve the recommendations contained in this paper.
8. Resource Implications
8.1. The work required going forward will require support from equality leads in each of the partner organisations.
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9. Impact on Integration Joint Board Outcomes, Priorities and Outcomes
9.1. These actions will ensure the Integration Joint Board meets its obligations under Equality Act 2010 and to The Equality Act 2010 (Specific Duties) (Scotland) Regulations.
10. Legal & Risk Implications
10.1. These actions will ensure the Integration Joint Board meets its obligations under Equality Act 2010 and to The Equality Act 2010 (Specific Duties) (Scotland) Regulations
11. Consultation
11.1. Equality and governance leads in all partner organisations have been consulted in the drafting of this paper.
12. Equality and Human Rights Impact Assessment
12.1. Not required for this paper, these will be conducted as and when required.
13. Exempt reports
13.1. No
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Clackmannanshire & Stirling
Integration Joint Board
Equality Mainstreaming & Outcomes Report
April 2016
Date of First Issue: Not yet issued Approved by : On: Current Issue Date: 6 April 2016 Review Date: March 2017
Draft 6 April 2016 Page 1 of 16
Contents Page
1.0 Introduction ...... 3 1.1 Purpose of the Equality Report ...... 3 1.2 Legislative Context ...... 3 1.3 Health and Social Care Integration Context ...... 4 2.0 Benefits of Mainstreaming Equality and Diversity ...... 4 3.0 Clackmannanshire & Stirling Integration Joint Board ...... 4 4.0 Strategic Vision ...... 4 5.0 Profile of Clackmannanshire & Stirling ...... 6 6.0 Mainstreaming ...... 6 6.1 Board Membership ...... 6 6.2 Board Papers ...... 6 6.3 Partnership Working ...... 7 6.4 Monitoring and recording ...... 7 6.4.1 Monitoring within community involvement exercises ...... 7 6.4.2 Service delivery ...... 8 6.4.3 Existing equality data collection within Clackmannanshire & Stirling Partnership ...... 8 6.4.4 Participation and Engagement ...... 8 6.5 Mainstreaming Duty and Employment ...... 9 6.6 Procurement ...... 9 7.0 Equality Impact Assessments...... 9 7.1 What do we have in place? ...... 9 8.0 Identifying Equality Outcomes ...... 10 Table 1 – Agreed Equality Outcomes ...... 11 9.0 Outcomes Monitoring and Evaluation ...... 12 9.0 Year One (2016 / 2017) ...... 12 9.2 Year 2 (2017 / 2018) ...... 12 10.0 Appendices ...... 13 10.1 – Appendix 1 – Equality Impact Assessment Tool ...... 13
Draft 6 April 2016 Page 2 of 16
1.0 Introduction
1.1 Purpose of the Equality Report
The report sets out the progress Clackmannanshire & Stirling Integration Joint Board has made to meet the needs of the General Equality Duty by integrating the equality Duty into Board functions.
The Mainstreaming Report is designed to ensure:
• our organisation has an understanding of the issues in relation to diversity, including, but not limited to: o Equality, equity, and fairness o Prejudice & discrimination o Direct and indirect discrimination, victimisation, harassment, and reasonable adjustments o Positive action o Cultural competence in relation to the issues affecting people belonging to one or more of the protected groups o We promote “best practice‟ in relation to diversity within Clackmannanshire & Stirling Integration Joint Board, with our partners, service users and unpaid carers o We promote and foster good relations and understanding between different groups. • we do not discriminate as a service provider or in our exercising of public functions. • Equality and Diversity considerations are taken into account in all decision making;
1.2 Legislative Context
The public sector equality duty set out in s149 of the Equality Act 2010 places an obligation on public authorities, in the exercise of their functions, to have due regard to the need to:
• eliminate unlawful discrimination, harassment and victimisation; • advance equality of opportunity between different groups; and • foster good relations between different groups.
The Scottish Government added Integration Joint Board’s (IJB) to Schedule 19 of the Equality Act 2010 and to The Equality Act 2010 (Specific Duties) (Scotland) Regulations. This means that all Integration Joint Boards are subject to the equality legislation and Specific Duties.
The Equality Act 2010 (Specific Duties) (Scotland) Regulations 2012 place specific equality duties on public authorities, including the Integration Joint Board. Not all of the duties are relevant as the Integration Joint Board is not an employer. The specific duties which are relevant to note include: • reporting on the mainstreaming of the equality duty;
Draft 6 April 2016 Page 3 of 16
• agreeing and publishing equality outcomes; and • assessing and review policies and practices
1.3 Health and Social Care Integration Context
The Public Bodies (Joint Working)(Scotland) Act 2014 places a duty on Councils and Health Boards to delegate functions to an Integration Joint Board where that partnership has agreed to utilise a body corporate model.
Clackmannanshire Council, Stirling Council and NHS Forth Valley have formed the Clackmannanshire & Stirling Health and Social Care Partnership, the only multi authority partnership in Scotland.
2.0 Benefits of Mainstreaming Equality and Diversity
The Equality and Human Rights Mainstreaming Guidance identifies that mainstreaming the equality duty has a number of benefits including:
• Equality becomes part of everything we do, within our structures, behaviours and culture • We are more transparent and can demonstrate how, in carrying out our functions, we are promoting and embedding equality • Mainstreaming equality contributes to continuous improvement and better performance
3.0 Clackmannanshire & Stirling Integration Joint Board
There is already a foundation of existing good practice relating to equalities established by our partners. We will build upon and strengthen these foundations, embedding them further within our existing priorities.
Given this, it makes sense to ensure that our equality mainstreaming agenda is aligned with existing Council, Health Board, Scottish Government policy priorities, Local Delivery Plans and Single Outcome Agreements and integrates within current performance management systems where relevant.
As an Integration Joint Board we have a role to work in partnership with service users, unpaid carers, the public, staff, third and independent sector. This will provide a coherent approach to implementation, minimise duplication and support the ongoing mainstreaming of equality into policy and practice.
4.0 Strategic Vision
The Clackmannanshire & Stirling Integration Joint Boards Strategic Plan 2016 – 2019 sets out the vision and objectives for the period 2016 - 2019. The strategic
Draft 6 April 2016 Page 4 of 16
vision is in line with the Scottish Government’s 20:20 vision and the objectives and values are as follows:
Vision: enable people in the Clackmannanshire and Stirling Health & Social Care Partnership area to live full and positive lives within supportive communities.
Local Outcomes:
• Self Management - Individuals, their carers and families are enabled to manage their own health, care and well being; • Community Focused Supports – Supports are in place, accessible and enable people, where possible, to live well for longer at home or in homely settings within their community; • Safety - Health and social care support systems help to keep people safe and live well for longer; • Decision Making - Individuals, their carers and families are involved in and are supported to manage decisions about their care and wellbeing; • Experience – Individuals will have a fair and positive experience of health and social care
Objectives: • Placing communities and individuals at the centre of planning and delivery of services • Putting individuals, their carers and families at the centre of their own care pathway by prioritising the most appropriate care • Working with voluntary and community organisations (e.g. Third Sector, Independent Sector) • Provide joined up services to improve quality of lives • Building on the strengths of our communities • Recognising the importance of encouraging independence by focusing on re- ablement, rehabilitation and recovery; • All communication is clear, accessible and understandable and ensures a two way conversation • Encouraging continuous improvement by supporting and developing our workforce. • Reducing avoidable admissions to hospital • Information will be shared appropriately to ensure a safe transition between all services • Providing timely access to services, based on assessed need and best use of available resources • Identify and address inequalities
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5.0 Profile of Clackmannanshire & Stirling
Clackmannanshire & Stirling Integration Joint Board is made up of 35 members and these are listed on the Integration web pages. The Integration Joint Board controls an annual budget of £165.265million, and is responsible for providing health and social services for the population of Clackmannanshire & Stirling.
The Integration Joint Board does not employ any staff.
Clackmannanshire & Stirling has a population of approximately 142,770 and covers a large rural area in Stirling.
The Integration Joint Boards Strategic Plan and Strategic Needs Assessment provide further information on the profile of population and evidence used.
The consultation and engagement report and staff engagement report provides evidence of the range of work carried out over 2014, 2015 and early 2016 to engage with stakeholders to build the Strategic Plan then consult with interested parties.
6.0 Mainstreaming
Mainstreaming is a specific requirement for public bodies in relation to implementing the Equality Duty 2010. It requires the integration of equality into day-to-day working, taking equality into account in the way we exercise our functions.
The following sections confirm how the IJB has mainstreamed equalities into its activities to date.
6.1 Board Membership
Professional Board members were approached to join by virtue of the position of the office they hold such as Chief Social Work Officer, Chief Officer, Elected Member, Health Board non executive director. Other members were elected to the Board through a nomination and voting process designed in partnership with organisations such as: Stirling Carers Centre, Falkirk and Clackmannanshire Carers Centre, Public Partnership Forum, Clackmannanshire Third Sector Interface and Stirling Voluntary Enterprise.
6.2 Board Papers
The Clackmannanshire & Stirling Integration Joint Board has been meeting regularly and further information is available online.
To ensure that the needs of the general equality duty are considered in exercising our business functions and processes, including budget setting and project planning we have set as mandatory within the papers submitted to the Integration Joint Board an “Equality and Human Rights Impact Assessment‟ section which identifies if the
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papers have been assessed for equality and diversity and what the outcome has been.
Equality Impact Assessments will be published online and will be available here.
6.3 Partnership Working
We have a commitment to working in partnership with: other agencies and organisations from the public, third and independent sector as well as with our staff and service users, to plan and deliver services.
Our aim is to ensure that our services meet the needs of the whole community in the most effective way.
Through our partnership work we have been able to look at creative ways of involving communities in consultation and dialogue, as well as allowing us to actively promote the 3 principles of the General Duty.
The consultation and engagement report along with the staff engagement report highlights some of the work completed and how it represents the principles of the General Duty.
Extract from the consultation and engagement report:
The reports demonstrates broad engagement with a wide variety of stakeholders: approximately 700 people attended over 30 face to face sessions, whilst 56 individuals provided comment on the draft Strategic Plan and 27 sessions provided written group feedback.
6.4 Monitoring and recording
6.4.1 Monitoring within community involvement exercises
Processes are available within partner bodies which enables monitoring and recording of the profile of people attending general involvement exercises.
Equalities monitoring data has been collected at all engagement events held by the Partnership. The consultation and engagement report provides more detail. These engagement events have been supported by Public Partnership Forum, Scottish Health Council and others.
To maintain and develop our understanding of the local population we utilised an equalities monitoring form at all engagement events and we will continue to use this for engagement work.
The table below summarises the equalities data collected on individuals we engaged with through the consultation and engagement work, in total there were 36 completed forms.
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Equality Dimension Area 26 Respondents lived in Clackmannanshire, 9 in Stirling and 1 in Falkirk. Individual / Group 30 were responding as individuals, 3 as a group, 1 as an individual and group and 2 were left blank Stakeholder Group The majority of respondents were users of services as well as providers of unpaid care Gender 27 Respondents were female, 6 male and 3 declined to answer. Ethnic Group Scottish 17 Polish 14 English 2 British 1 Scottish & English 1 Religion Church of Scotland 10 Roman Catholic 8 Budhist 1 Church of England 1 Episcoopalean 1 Other Christian 3 None 5 Sexual Orientation Heterosexual / straight 30 Prefer not to answer / blank 6 Age The average age of respondents who completed the equalities information was 49, with the oldest being 76 and youngest 19.
This was not always completed by people attending engagement events therefore; we recognise additional work is required to inform the people as to the reasons why we are asking these questions and the benefits that can occur with the results identified from it.
6.4.2 Service delivery
Understanding how different people use our services is an important step in mainstreaming the equality duty in our service delivery functions. We are aware that gathering and using evidence is crucial to gaining this understanding. This information is currently collated by partner bodies and will continue to be so.
6.4.3 Existing equality data collection within Clackmannanshire & Stirling Partnership
The Strategic Needs Assessment and Locality Profiles (when developed) provide information on the Partnerships population and the protected characteristics.
6.4.4 Participation and Engagement
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The Partnership has developed and approved a Participation and Engagement Strategy which sets out the principles to be followed when any participate and engagement work is being taken forward.
The strategy was developed by a wide range of stakeholders and the action plan to implement the strategy will be developed over 2016.
6.5 Mainstreaming Duty and Employment
The Integration Joint Board is not an employing body and therefore is not subject to this duty.
6.6 Procurement
Procurement will be undertaken by each of the three partner bodies in line with their procurement strategy / policy. More information can be found on the partners web sites. www.nhsforthvalley.com www.clacksweb.org.uk/ www.stirling.gov.uk/home
7.0 Equality Impact Assessments
As a public body we are required to assess the effectiveness of our policies, strategies, services, functions and business plans that could impact on those with protected characteristics.
The equality impact assessment process is a way of examining new and existing policies, strategies, and changes or developments in service provision and functions to assess what impact, if any, they are likely to have.
Our legal requirement to do this covers only those individual characteristics identified in the Equality Act.
In Clackmannanshire & Stirling, we recognise that these categories are only one element of the inter-related determinants of health, social care and life experience. We have reflected this in our impact assessment process by including categories to reflect the cross cutting issues which may effect people including poverty, homelessness, carers etc.
The aim of the Equality Impact Assessment process is to anticipate whether the proposed policy, strategy, service or function has the potential to affect groups differently and to identify any likely positive or negative impact(s) that may be experienced. By following this process, we can ensure that we are better able to take advantage of every opportunity to promote equality and can embed plans to avoid disadvantage and discrimination.
7.1 What do we have in place?
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The Partnership utilises an agreed equality impact assessment tool (appendix 1) covering all protected characteristics and other factors in relation to inequalities.
Support can be provided on a needs led basis.
The impact assessment tool and previous assessments completed are available on the Equality & Diversity section of the integration web pages.
8.0 Identifying Equality Outcomes
Equality Outcomes are distinct to each organisation and need to reflect its functions, responsibilities, priorities and methods of working. The Integration Joint Board has adopted outcomes based on the local outcomes already identified in the preparation of the Integration Scheme and the Strategic Plan.
These are:
• Self Management - Individuals, their carers and families are enabled to manage their own health, care and well being; • Community Focused Supports – Supports are in place, accessible and enable people, where possible, to live well for longer at home or in homely settings within their community; • Safety - Health and social care support systems help to keep people safe and live well for longer; • Decision Making - Individuals, their carers and families are involved in and are supported to manage decisions about their care and wellbeing; • Experience – Individuals will have a fair and positive experience of health and social care
These outcomes were developed in consultation with a broad range of stakeholders in 2014/15.
Table 1 sets out how these outcomes align with the National Health and Wellbeing Outcomes, which part of the Duty and which protected characteristic they address.
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Table 1 – Agreed Equality Outcomes National Health & Wellbeing Partnership Component Duty “Protected Sources of evidence Outcomes Specific Outcomes OR Characteristic” justifying identification Potential Action Area as a priority People are able to look after Self Management - Advance equality of All (Age, Disability , Gender and improve their own health Individuals, their carers and opportunity Reassignment, Pregnancy & Evidence / data may also and wellbeing and live in families are enabled to Maternity, Race, Religion & assist in identifying delivery good health for longer. manage their own health, belief) Sex , Sexual targets and performance care and wellbeing; Orientation), particularly measurement elderly and disabled - Age and Disability People, including those with Community Focused Advance equality of All - as above, particularly disabilities, long term Supports – Supports are in opportunity elderly and disabled - Age conditions, or who are frail, place, accessible and enable and Disability. are able to live, as far as people, where possible, to Foster good relations reasonably practicable, live well for longer at home or independently and at home or in homely settings within their in a homely setting in their community; community. People who use health and Experience – Individuals will Advance equality of All - as above, particularly User satisfaction survey social care services have have a fair and positive opportunity elderly, disabled and LGBTI – results. positive experiences of those experience of health and Age , Disability, Gender Complaints services, and have their social care Eliminate discrimination , Reassignment and Sexual dignity respected. harassment and victimisation Orientation. Health and social care Decision Making Advance equality of All – as above, particularly services are centred on Individuals, their carers and opportunity elderly, disabled and carers - helping to maintain or families are involved in and Age and Disability improve the quality of life of are supported to manage Eliminate discrimination , service users decisions about their care harassment and victimisation and wellbeing; Health and social care Safety Advance equality of All – as above , particularly services contribute to Health and social care opportunity vulnerable elderly and reducing health inequalities support systems help to keep disabled - Age and Disability people safe and live well for longer
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Over the coming year, the development of the Locality Profiles and Plans will provide an opportunity to review the Equality Outcomes for the Partnership. The IJB have agreed to review these outcomes in April 2017 with a view to more focussed outcomes informed by the first year of operation. This provides the opportunity to align with the review of Equalities Outcomes by NHS Forth Valley, Clackmannanshire Council and Stirling Council.
9.0 Outcomes Monitoring and Evaluation
9.0 Year One (2016 / 2017)
The focus in year one will be on developing Locality Plans and refining the outcomes to align with partner review cycles.
9.2 Year 2 (2017 / 2018)
The focus in year two will be on further mainstreaming equality outcomes.
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10.0 Appendices 10.1 – Appendix 1 – Equality Impact Assessment Tool
Standard Impact Assessment Document (SIA) Please complete electronically and answer all questions unless instructed otherwise.
Section A Q1: Name of EQIA being completed i.e. name of policy, function etc.
Q1 a; Function Guidance Policy Project Protocol Service Other, please detail Q2: What is the scope of this SIA Service Specific Discipline Specific Other (Please Detail)
Q3: Is this a new development? (see Q1) Yes No Q4: If no to Q3 what is it replacing?
Q5: Team responsible for carrying out the Standard Impact Assessment? (please list)
Q6: Main person completing EQIA’s contact details Name: Telephone Number: Department: Email:
Q7: Describe the main aims, objective and intended outcomes
Q8: (i) Who is intended to benefit from the function/service development/other (Q1) – is it staff, service users or both? Staff Service Users Other Please identify ___Providers, third sector, independent sector (ii) Have they been involved in the development of the function/service development/other? Yes No (iii) If yes, who was involved and how were they involved? If no, is there a reason for this action?
(iv) Please include any evidence or relevant information that has influenced the decisions contained in this SIA; (this could include demographic profiles; audits; research; published evidence; health needs assessment; work based on national guidance or legislative requirements etc) Comments:
Q9: When looking at the impact on the equality groups, you must consider the following points in accordance with General Duty of the Equality Act 2010 see below: In summary, those subject to the Equality Duty must have due regard to the need to: • eliminate unlawful discrimination, harassment and victimisation; • advance equality of opportunity between different groups; and
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• foster good relations between different groups Has your assessment been able to demonstrate the following: Positive Impact, Negative / Adverse Impact or Neutral Impact? What impact has your review Comments had on the following Provide any evidence that supports ‘protected characteristics’: Adverse/ your conclusion/answer for Positive Neutral Negative evaluating the impact as being positive, negative or neutral (do not leave this area blank) Age Disability (incl. physical/ sensory problems, learning difficulties, communication needs; cognitive impairment) Gender Reassignment Marriage and Civil partnership Pregnancy and Maternity Race/Ethnicity Religion/Faith Sex/Gender Sexual orientation Staff (This could include details of staff training completed or required in relation to service delivery)
Cross cutting issues: Included are some areas for consideration. Please delete or add fields as appropriate. Further areas to consider in Appendix B Unpaid Carers Homeless Language/ Social Origins Literacy Low income/poverty Mental Health Problems Rural Areas Armed Services Veterans, Reservists and former Members of the Reserve Forces Third Sector Independent Sector Q10: If actions are required to address changes, please attach your action plan to this document. Action plan attached? Yes No
Q11: Is a detailed EQIA required? Yes No Please state your reason for choices made in Question 11.
The Strategic Needs Assessment at a Local Authority level will help inform the more detailed iteration of plans which will set out more detail of how we will achieve the vision and ambitious outcomes for the partnership. N.B. If the screening process has shown potential for a high negative impact you will be required to complete a detailed impact assessment.
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Date EQIA Completed DD / MM / YYYY Date of next EQIA DD / MM / YYYY Review Signature Print Name Department or Service
Please keep a completed copy of this template for your own records and attach to any appropriate tools as a record of SIA or EQIA completed. Send copy to [email protected]
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B: Standard/Detailed Impact Assessment Action Plan Name of document being EQIA’d:
Date Issue Action Required Lead (Name, title, Timescale Resource Implications Comments and contact details) 12/01/2016 Locality Plans Locality plans will March 2017 be developed over 2016.
Further Notes:
Signed: Date:
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Clackmannanshire & Stirling Integration Joint Board
27 April 2016
This report relates to Item 12.1 on the agenda
Appointment of Chief Internal Auditor
(Paper presented by Shiona Strachan, Chief Officer)
For Approval
Approved for Submission by Author Shiona Strachan, Chief Officer Date 27 April 2016 List of Background Papers Integration Joint Board 24 February 2016 – Provision of Internal Audit Scottish Government, Integration Financial Assurance (June 2015) Scottish Government Integrated Resources Advisory Group, Finance Guidance (June 2015)
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Title/Subject: Appointment of Chief Internal Auditor Meeting: Clackmannanshire & Stirling Integration Joint Board Date: 27 April 2016 Submitted By: Shiona Strachan, Chief Officer Action: For Approval
1. Introduction
1.1 This report confirms the nomination of Stirling Council’s Audit Manager (Kevin O’Kane) as Chief Internal Auditor to the Integration Joint Board, and seeks formal ratification of this appointment, which is for the period covering financial years up to 31 March 2019.
2. Executive Summary
2.1 The Integration Joint Board agreed, on 24 February 2016, that responsibility for Integration Joint Board Chief Internal Auditor duties will be undertaken by the Chief Internal Auditor of one of the constituent authorities, rotating between them on a three year basis. They have agreed that Stirling Council’s Audit Manager should be nominated as Chief Internal Auditor for the initial three year period, covering the financial years up to 31 March 2019.
2.3 Once appointed, the Chief Internal Auditor will bring forward a draft Internal Audit Plan for 2016/17, for approval by the Integration Joint Board or an appropriate sub-committee.
2.4 During 2015/16, each partner’s Internal Audit team has addressed requirements of the Scottish Government guidance on Integration Financial Assurance. The three teams have liaised on the approach to this work in order to achieve consistency and cohesion within the joint report, which will be brought forward once all of the underlying reports have been finalised.
3. Recommendations
The Integration Joint Board is asked to:
3.1. Approve the appointment of Stirling Council’s Audit Manager (Kevin O’Kane) as Chief Internal Auditor to the Integration Joint Board for the period covering financial years up to 31 March 2019;
3.2. Note that the Chief Internal Auditor will present a draft Internal Audit Plan for 2016/17 to the meeting of the Integration Joint Board on 22 June 2016, or to an audit committee (or equivalent) if established before that date; and,
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3.3. Note that the Chief Internal Auditor will provide a joint report on Integration Financial Assurance, on behalf of the chief audit executives of the three constituent authorities, to the meeting at which the draft Internal Audit Plan 2016/17 is presented.
4. Background
4.1. The Scottish Government established the Integrated Resources Advisory Group (IRAG) to consider the financial implications of integrating health and social care, and to help develop professional guidance. IRAG Finance Guidance outlines that the Integration Joint Board is responsible for establishing adequate and proportionate internal audit arrangements for review of the adequacy of the arrangements for risk management, governance and control of the delegated resources. This includes determining who will provide the internal audit service and nominating a Chief Internal Auditor.
4.2. The Integration Joint Board is also required to comply with Article 7 of The Local Authority Accounts (Scotland) Regulations 2014, which states:
“7(1) A local authority must operate a professional and objective internal auditing service in accordance with recognised standards and practices in relation to internal auditing”.
5. Chief Internal Auditor
5.1. The Integration Joint Board agreed, on 24 February 2016, that:
• Internal Audit services will be provided by the partners’ Internal Audit Teams; and,
• responsibility for Integration Joint Board Chief Internal Auditor duties will be undertaken by the Chief Internal Auditor of one of the constituent authorities, rotating between them on a three year basis.
5.2. The role of Chief Internal Auditor (‘chief audit executive’ in terms of the Public Sector Internal Audit Standards) within the partners is filled by the Audit Manager within Stirling Council, the Internal Audit & Fraud Team Leader within Clackmannanshire Council, and the Chief Internal Auditor at NHS Forth Valley. They have agreed that Stirling Council’s Audit Manager should be nominated as Chief Internal Auditor for the initial three year period, covering the financial years up to 31 March 2019.
5.3. It is anticipated that, all things remaining equal, Chief Internal Auditor appointments under the approved arrangement will be as follows:
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Financial Years (1 April-31 March) Chief Internal Auditor provision
Up to and including 2018/19 Stirling Council
2019/20 to 2021/22 NHS Forth Valley
2021/22 to 2023/24 Clackmannanshire Council
2024/25 to 2026/27 NHS Forth Valley
6. Internal Audit work in 2015/16 and 2016/17
6.1. During 2015/16, each partner’s Internal Audit team has addressed requirements of the Scottish Government guidance on Integration Financial Assurance, in particular section 3.2.1, which states that:
“It is recommended that the initial sums should be determined on the basis of existing Health Board and Local Authority budgets, actual spend and financial plans for the delegated services. It is important that the plans are tested against recent actual expenditure and that the assumptions used in developing the plans and the associated risks are fully transparent.”
6.2. Specifically, the Internal Audit teams have reviewed the preparation of the initial budget allocations, with a view to reporting this both to their own audit committees and, in line with the guidance, jointly to the Integration Joint Board. The three teams have liaised on the approach to this work in order to achieve consistency and cohesion within the joint report, which will be brought forward once all of the underlying reports have been finalised.
6.3. Internal Audit plans for 2016/17 and subsequent years will require input from the Integration Joint Board Chief Officer, Chief Financial Officer, and External Auditor, as well as the Clackmannanshire Council and NHS Forth Valley Chief Internal Auditors. Preparatory work is required, including an audit risk assessment process that will involve consultation with relevant parties.
6.4. Currently, the scope of the risk assessment process is limited by the assumption that the internal audit of operational delivery of services will remain with the partners’ own internal audit teams, as set out in the IRAG guidance and consistent with section 4 of the Integration Scheme. This may be subject to change as and when the role of the Integration Joint Board evolves.
6.5. Indicative areas that will be included for consideration in the plan include:
• Strategic plan • Financial planning and control • Performance management • Governance • Annual report • Risk Management
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7. Conclusions
7.1. The Integration Joint Board has previously approved the provision of an Internal Audit service from within the partners’ existing Internal Audit teams, including the appointment of one of the chief audit executives as Chief Internal Auditor to the Integration Joint Board on a three-year rotational basis. The chief audit executives have agreed that Stirling Council’s Audit Manager should be nominated for appointment, and this is now put to the Integration Joint Board for formal ratification.
7.2. The Chief Internal Auditor will bring forward a draft Internal Audit Plan for 2016/17 to the Integration Joint Board meeting on 22 June 2016, or to the meeting of an audit committee if one has been established before then. It is expected that, at the same time, a joint report on Integration Financial Assurance will also be brought forward.
8. Resource Implications
8.1. There are no anticipated additional financial costs associated with the appointment of a Chief Internal Auditor from within the partners’ Internal Audit teams. It is expected that each of those teams will make resources available to support the achievement of the annual Internal Audit Plan, in line with the wider support services approach. The resource requirement will be established through the development of the Plan.
9. Impact on Integration Joint Board Priorities and Outcomes
9.1. The appointment of a Chief Internal Auditor is one of the key components of good corporate governance.
10. Legal & Risk Implications
10.1. Approval of the appointment of the Chief Internal Auditor will ensure that the Integration Joint Board complies with The Local Authority Accounts (Scotland) Regulations 2014 and professional guidance issued by the Integrated Resources Advisory Group (IRAG) in compliance with The Public Bodies (Joint Working) (Scotland) Act 2014.
11. Consultation
11.1. This report has been prepared by Stirling Council’s Audit Manager, as the nominated Chief Internal Auditor, in consultation with the Chief Internal Auditor for NHS Forth Valley and the Internal Audit & Fraud Team Leader for Clackmannanshire Council.
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12. Equality and Human Rights Impact Assessment
12.1. N/A
13. Exempt reports
13.1. Not exempt.
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Clackmannanshire & Stirling Integration Joint Board
27 April 2016
This report relates to Item 12.2 on the agenda
Audit Scotland report: ‘Changing Models of Health & Social Care’
(Paper presented by Shiona Strachan, Chief Office)
For Noting
Approved for Submission by Author Shiona Strachan, Chief Officer Date: 27 April 2016 List of Background Papers: Audit Scotland, Changing Models of Heath & Social Care (March 2016) Audit Scotland, Health and Social Care Integration (December 2015) Audit Scotland, Annual Report on NHS in Scotland 2013/14 (October 2014) Integration Joint Board 26th January 2016 - Audit Scotland National Report on Health and Social Care Integration Appendices: Appendix 1 - Audit Scotland, Changing Models of Heath & Social Care (March 2016) Appendix 2 – Audit Scotland, Supplementary document to Appendix 1
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Title/Subject: Audit Scotland report: ‘Changing Models of Health and Social Care’ (March 2016)
Meeting: Clackmannanshire & Stirling Integration Joint Board Date: 27 April 2016 Submitted By: Kevin O’Kane, Chief Internal Auditor Action: For Discussion
1. Introduction
1.1 This report draws attention to Audit Scotland’s report on Changing Models of Health and Social Care, published on 10 March 2016. It also highlights relevant recommendations contained in that report.
2. Executive Summary
2.1. The report on Changing Models of Health and Social Care is intended to build upon Audit Scotland’s previous work on health and social care, to identify new local models of care and to help increase the pace of change. It aims to support new integrated authorities to implement new ways of working and address the challenges facing health and social care services.
2.2. The report sets out a number of key messages, in addition to generic recommendations for action by NHS boards and councils working with integration authorities. It also makes recommendations for action by the Scottish Government and the Information Services Division of NHS National Services Scotland.
3. Recommendations
The Integration Joint Board is asked to:
3.1. Note the contents of Audit Scotland’s national report on Changing Models of Health and Social Care, as attached at Appendix 1, and the key messages and recommendations set-out at pages 5 to 7 therein.
4. Background
4.1. Audit Scotland prepares reports on behalf of both the Accounts Commission and the Auditor General for Scotland in terms of their roles as public spending watchdogs for local government and NHS bodies (among others), respectively.
4.2. Audit Scotland has reported previously that NHS boards and councils are finding it increasingly difficult to cope with pressures facing health and care services. The recent progress report on health and social care integration
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(Health and Social Care Integration (December 2015)) found that significant risks need to be addressed if integration is to fundamentally change the way services are delivered. Evidence suggested that integration authorities would not be in a position to make a major impact during 2016/17, with many still to set out clear targets and timescales showing how they will make a difference to people who use health and social care services. The December 2015 report was the first in a series of three planned progress reports, to be followed by:
• a report on integration authorities’ progress after their first year of being established; and, • a report on integration authorities’ longer-term impact in shifting resources to preventative services and community-based care and in improving outcomes for the people who use these services.
5. Audit Scotland report: ‘Changing Models of Health and Social Care’
5.1. This further report, titled Changing Models of Health and Social Care, is intended to build on key pressures identified in the demand and capacity work undertaken as part of the NHS in Scotland 2013/14 audit. It assesses how NHS boards, councils and partnerships might deliver services differently in the future to meet the needs of the population. It also highlights examples of new approaches to providing health and social care aimed at shifting the balance of care from hospitals to more homely and community-based settings, and considers some of the main challenges to delivering the transformational change needed to deliver the Scottish Government’s 2020 Vision for health and social care and actions required to address those.
5.2. The report includes two supplements:
• a handbook for local areas, including case studies, a system diagram of types of new care models being introduced in Scotland, and links to useful documents and checklists; and, • a model of East Lothian’s ‘whole system’ approach to introducing new ways of working and the data analysis and intelligence that new partners are using to inform their work.
5.3. The key messages contained in the report are that:
• transformational change is not happening fast enough to deliver the Scottish Government’s ambitious vision for health and social care of enabling everyone to live longer, healthier lives at home or in a homely setting, by 2020; • new approaches to health and social care are emerging in some parts of Scotland, demonstrating more innovative practice. However, new models are generally small-scale. The types of new models include community preventative approaches, better access to primary care and routine hospital treatments, enhanced community care models, intermediate care models and initiatives designed to reduce delayed discharges;
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• a lack of national leadership and clear planning is preventing the wider change urgently needed if Scotland’s health and social care services are to adapt to increasing pressures; • an increasing number of frail, older people with complex health needs is among the challenges facing services, with the number of people aged 85 and over in Scotland expected to double by 2034; and, • the new integration authorities have a pivotal role in transforming how services are delivered. The Auditor General and Accounts Commission have previously recommended that integration authorities should be clear about how they will use resources to integrate services and improve outcomes.
5.4. The report recommends that NHS boards and councils should work with integration authorities during their first year of integration to:
• carry out a shared analysis of local needs, and use this as a basis to inform plans to redesign local services, drawing on learning from established good practice; • ensure new ways of working, based on good practice from elsewhere, are implemented in their own areas to overcome some of the barriers to introducing new care models. It is worth noting that the Advice Line for You [ALFY] is cited as case study 5 ; • move away from short-term, small-scale approaches towards a longer- term approach to implementing new care models. They should do this by making the necessary changes to funding and the workforce, making best use of local data and intelligence, and ensuring that they properly implement and evaluate the new models; • ensure, when they are implementing new models of care, that they identify appropriate performance measures from the outset and track costs, savings and outcomes; and, • ensure clear principles are followed for implementing new care models.
6. Conclusion(s)
6.1. The report by Audit Scotland identifies a range of issues which require to be addressed to ensure the success of the transformation programme.
7. Resource Implications
7.1. There are no resource implications directly associated with drawing attention to Audit Scotland’s report. However, there may be costs associated with decisions on how to address the recommendations contained therein.
8. Impact on Integration Joint Board Outcomes and Priorities
8.1. The generic recommendations contained in the report have potential impact on the activities to be undertaken in order to successfully achieve the
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partnership’s priorities and outcomes. 9. Legal & Risk Implications
9.1. There are no legal implications arising directly from this report, which is providing information on a national audit. The integration authority and the partner bodies should be aware that there are reputational and audit risks of failure to adequately address the recommendations of Audit Scotland’s report. Implementation of the recommendations themselves may help address performance and financial risks.
10. Consultation
10.1. The heads of Internal Audit for Clackmannanshire Council and NHS Forth Valley have been consulted in preparing this report. The author is also the Audit Manager for Stirling Council. The report has also been shared with partners’ governance leads.
11. Equality and Human Rights Impact Assessment
11.1. N/A
12. Exempt reports
12.1. Not exempt.
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Health and social care series Changing models of health and social care
Prepared by Audit Scotland March 2016 The Accounts Commission The Accounts Commission is the public spending watchdog for local government. We hold councils in Scotland to account and help them improve. We operate impartially and independently of councils and of the Scottish Government, and we meet and report in public.
We expect councils to achieve the highest standards of governance and financial stewardship, and value for money in how they use their resources and provide their services.
Our work includes: • securing and acting upon the external audit of Scotland’s councils and various joint boards and committees • assessing the performance of councils in relation to Best Value and community planning • carrying out national performance audits to help councils improve their services • requiring councils to publish information to help the public assess their performance.
You can find out more about the work of the Accounts Commission on our website: www.audit-scotland.gov.uk/about/ac
Auditor General for Scotland The Auditor General’s role is to: • appoint auditors to Scotland’s central government and NHS bodies • examine how public bodies spend public money • help them to manage their finances to the highest standards • check whether they achieve value for money.
The Auditor General is independent and reports to the Scottish Parliament on the performance of: • directorates of the Scottish Government • government agencies, eg the Scottish Prison Service, Historic Scotland • NHS bodies • further education colleges • Scottish Water • NDPBs and others, eg Scottish Police Authority, Scottish Fire and Rescue Service.
You can find out more about the work of the Auditor General on our website: www.audit-scotland.gov.uk/about/ags
Audit Scotland is a statutory body set up in April 2000 under the Public Finance and Accountability (Scotland) Act 2000. We help the Auditor General for Scotland and the Accounts Commission check that organisations spending public money use it properly, efficiently and effectively. Changing models of health and social care | 3
Contents
Key facts 4
Summary 5
Part 1. Health and social care in Scotland 9
Part 2. New ways of providing health and social care 18
Part 3. Making it happen 26
Endnotes 40
Exhibit data When viewing this report online, you can access background data by clicking on the graph icon. The data file will open in a new window. 4 |
Key facts
Health budget in 2014/15
£11.86 billion Number of Scottish Government people receiving funding for councils £10.8 in 2014/15 ten or more hours 21,700 of homecare per billion week in 2014
Number of emergency Number of admissions 553,000 3.91 hospital bed days in 2013/14 million from emergency admissions
Proportion of GPs aged Increase in population aged 85 50 and over in 2015 34% 64% and over between 2014 and 2030 Summary | 5
Summary
Key messages 1 The growing number of people with complex health and social care needs, particularly frail older people, together with continuing tight finances, means that current models of care are unsustainable. New models of care are needed. With the right services many people could avoid unnecessary admissions to hospital, or be discharged more quickly when admission is needed. This would improve the quality of care and make better use of the resources available. 2 The Scottish Government has set out an ambitious vision for health and social care to respond to these challenges. There is widespread support for the 2020 Vision, which aims to enable everyone to live longer, healthier lives at home or in a homely setting. There is evidence that new approaches to health and care are being developed in parts of Scotland. the shift to 3 The shift to new models of care is not happening fast enough to meet the growing need, and the new models of care that are in new models place are generally small-scale and are not widespread. The Scottish of care is not Government needs to provide stronger leadership by developing a clear framework to guide local development and consolidating happening evidence of what works. It needs to set measures of success by fast enough which progress can be monitored. It also needs to model how much investment is needed in new services and new ways of working, and to meet the whether this can be achieved within existing and planned resources. growing 4 NHS boards and councils, working with integration authorities, can need do more to facilitate change. This includes focusing funding on community-based models and workforce planning to support new models. They also need to have a better understanding of the needs of their local populations, and evaluate new models and share learning.
Recommendations
The Scottish Government should:
• provide a clear framework by the end of 2016 of how it expects NHS boards, councils and integration authorities to achieve the 2020 Vision, outlining priorities and plans to reach its longer-term strategy up to 2030. This should include the longer-term changes required to skills, job roles and responsibilities within the health and social care 6 |
workforce. It also needs to align predictions of demand and supply with recruitment and training plans
• estimate the investment required to implement the 2020 Vision and the National Clinical Strategy
• ensure that long-term planning identifies and addresses the risks to implementing the 2020 Vision and the National Clinical Strategy, including:
–– barriers to shifting resources into the community, particularly in light of reducing health and social care budgets and the difficulties councils and NHS boards are experiencing in agreeing integrated budgets –– new integration authorities making the transition from focusing on structures and governance to what needs to be done on the ground to make the necessary changes to services –– building pressures in general practice, including problems with recruiting and retaining appropriate numbers of GPs. The role of GPs in moving towards the 2020 Vision should be a major focus of discussions with the profession as the new GP contract terms are developed for 2017
• ensure that learning from new care models across Scotland, and from other countries, is shared effectively with local bodies, to help increase the pace of change. This should include:
–– timescales, costs and resources required to implement new models, including staff training and development –– evaluation of the impact and outcomes –– how funding was secured –– key success factors, including how models have been scaled up and made sustainable
• work to reduce the barriers that prevent local bodies from implementing longer-term plans, including:
–– identifying longer-term funding to allow local bodies to develop new care models they can sustain in the future –– identifying a mechanism for shifting resources, including money and staff, from hospital to community settings –– being clearer about the appropriate balance of care between acute and community-based care and what this will look like in practice to support local areas to implement the 2020 Vision –– taking a lead on increasing public awareness about why services need to change –– addressing the gap in robust cost information and evidence of impact for new models. Summary | 7
NHS boards and councils should work with integration authorities during their first year of integration to:
• carry out a shared analysis of local needs, and use this as a basis to inform their plans to redesign local services, drawing on learning from established good practice
• ensure new ways of working, based on good practice from elsewhere, are implemented in their own areas to overcome some of the barriers to introducing new care models
• move away from short-term, small-scale approaches towards a longer-term approach to implementing new care models. They should do this by making the necessary changes to funding and the workforce, making best use of local data and intelligence, and ensuring that they properly implement and evaluate the new models
• ensure, when they are implementing new models of care, that they identify appropriate performance measures from the outset and track costs, savings and outcomes
• ensure clear principles are followed for implementing new care models, as set out in Exhibit 9 (page 30).
Information Services Division (ISD) should:
• ensure it shares and facilitates learning across Scotland about approaches to analysing data and intelligence, such as using data to better understand the needs of local populations.
Background
1. We have reported previously that NHS boards and councils are finding it increasingly difficult to cope with pressures facing health and care services. Our recent progress report on health and social care integration found that significant risks need to be addressed if integration is to fundamentally change the way health and care services are delivered. Evidence suggests that the new partnerships with statutory responsibilities to coordinate integrated health and social care services, integration authorities, will not be in a position to make a major impact during 2016/17. Many integration authorities have still to set out clear targets and timescales showing how they will make a difference to people who use health and social care services.
2. We have produced this report, building on our previous work on health and social care, to identify new local models of care and to help increase the pace of change. It aims to support new integrated authorities to implement new ways of working and address the challenges facing health and social care services. 8 |
3. We have produced two supplements to accompany this report:
• Supplement 1 [PDF] is a handbook for local areas and includes:
–– case studies referenced throughout the report –– a system diagram of the types of new care models being introduced across Scotland –– links to useful documents and checklists.
• Supplement 2 is a model of East Lothian’s whole-system approach to introducing new ways of working and the data analysis and intelligence that local partners are using to inform their work.
About the audit
4. This audit builds on key pressures identified in the demand and capacity work undertaken as part of the NHS in Scotland 2013/14 audit. It assesses how NHS boards, councils and partnerships might deliver services differently in the future to meet the needs of the population. Our report highlights examples of some of the new approaches to providing health and social care aimed at shifting the balance of care from hospitals to more homely and community-based settings. It also considers some of the main challenges to delivering the transformational change needed to deliver the Scottish Government’s 2020 Vision for health and social care and actions required to address them.
5. We gathered evidence for the audit by:
• analysing national and local information, for hospitals, councils and community-based services to identify pressures in the system, including performance, activity and financial data
• carrying out projection analysis to estimate the potential effect of increasing pressures in health and social care
• conducting desk-based research to identify examples of new care models outside Scotland
• working closely with one partnership area to illustrate the types of changes required and how this affects different parts of the health and social care system
• interviewing staff from NHS boards, councils, the Convention of Scottish Local Authorities (COSLA), the Scottish Government and other relevant organisations, such as professional and scrutiny bodies. Part 1. Health and social care in Scotland | 9
Part 1 Health and social care in Scotland
Health and social care services are facing increasing pressures
6. In recent years, demands on health and social care services have been increasing because of demographic changes. People are living longer with multiple long-term conditions and increasingly complex needs. At the same time, health and NHS boards and councils are facing increasingly difficult financial challenges. social care There is general recognition that changes are needed and that NHS boards and councils need to support more people in the community. services need to adapt The proportion of older, frail people is increasing 7. The proportion of older people is growing more rapidly than the rest of the to cope with population; this is a major factor contributing to the pressures on health and the effects of care services. The biggest changes are predicted in the 75 and over population (Exhibit 1). From 2002 to 2020, data shows an increase of around 6,600 people the changing aged 75 and over each year. From 2021 up to 2039, it is estimated there will population be around 16,000 more people aged 75 and over each year.1 The 85 and over population is estimated to double by 2034.
Exhibit 1 The projected population of older people in Scotland, 2014-30 The percentage of the population aged 75 and over is set to increase considerably over the next 15 years.
48% 64%
75 2014 2030 85 2014 2030 Population Population
433,235 640,129 114,375 187,219
Source: Projected population of Scotland (2014-based), National Records of Scotland, 2015
8. Although the population is ageing, overall healthy life expectancy (the number of years people might live in good health) has improved. Over time, this may help to reduce some of the pressure on health and social care services. Average healthy life expectancy increased between 2002 and 2008. It has remained at around the same level between 2009 and 2014. In 2014, average life expectancy for men was around 77 years and healthy life expectancy 60 years, and for women it was around 81 and 10 |
63 years.2, 3 However, healthy life expectancy for men in the most deprived areas in Scotland still remains 18 years lower than those in the least deprived areas. GPs working in deprived areas face significant challenges in tackling health inequalities. GPs working in practices serving the 100 most deprived areas in Scotland (Deep End project) reported the following:
• They treat more patients with multiple health problems than GPs working in less deprived areas.4
• They are constrained by a shortage of consultation time with patients that limits the opportunity to provide appropriate treatment, advice and referral to suitable services.5
9. As people age they are more likely to have multiple conditions and become frail. Frailty is a decreased ability to withstand illness or stress without loss of function. For frail people, a minor injury or illness can result in a significant loss of function. Common conditions, such as dementia, also contribute to frailty.6 In Scotland, an estimated ten per cent of people aged over 65 are frail and a further 42 per cent are at risk of becoming frail.7
10. Not all older people need support from health and care services, but for those that do, it is important that these services are well coordinated. They should focus on preventing ill health and where possible reduce the need for hospital- based care. Older people make more use of hospital services than the rest of the population, particularly unplanned care such as A&E services and emergency admission to hospital. Older patients are more likely to remain in hospital for longer. The majority of people who are nursed at home, and get help with daily living activities such as washing, dressing and eating, are aged 75 or older.8
The number of emergency admissions to hospital is increasing 11. The number of people admitted to hospital in an emergency is an important measure that can indicate problems in other parts of the health and care system, such as a lack of social care support in the local area. Of all admissions to acute hospitals, around 85 per cent are emergency admissions. Around 30 per cent of emergency admissions relate to surgical specialties, such as orthopaedic surgery or urology. The majority of these admissions are not preventable and these patients require hospital treatment. However, there is scope to reduce emergency admissions by providing more preventative and community-based services. This includes emergency admissions in medical specialties such as general medicine, geriatric medicine, psychiatry of old age, rehabilitation medicine, and GP beds. The number of people admitted to hospital in an emergency between 2005/06 and 2013/14 increased by almost 80,000 (17 per cent), to 553,000. The number of emergency admissions increased by 17 per cent for people aged 65-74, by 19 per cent for people aged 75-84 and by 39 per cent for people who were aged 85 and older (Exhibit 2, page 11). Older people are more likely to be admitted to hospital in an emergency than people aged under 65. In 2013/14, 71 per cent of emergency bed days were occupied by people aged 65 and over. Of these:
• 18 per cent were occupied by people aged 65-74
• 29 per cent were occupied by people aged 75-84
• 23 per cent were occupied by people aged 85 and older. Part 1. Health and social care in Scotland | 11
12. The number of emergency bed days for older people admitted to hospital three or more times in a year is increasing. Between 2005/06 and 2013/14, the number of bed days occupied by people aged 65 and over from multiple emergency admissions increased by 38 per cent to over 685,000 bed days. For people aged 65-74, the number of bed days increased by 18 per cent, for people aged 75-84 by 35 per cent, and for people aged 85 and older by 76 per cent (Exhibit 2). 9
13. Although the overall number of emergency bed days has been reducing, the number of emergency admissions has been increasing along with the associated costs. Patients admitted to hospital in an emergency have a shorter length of stay, but most costs are incurred in the first few days when tests,
Exhibit 2 Increase in emergency admissions and multiple emergency admission bed days, by age group, 2005/06 to 2013/14 The number of older patients admitted to hospital in an emergency and the number of bed days for multiple emergency admissions (three or more admissions in one year) have increased considerably.
80 76% 70 60 50 39% 40 35% 30 Percentage 17% 17% 18% 19% 20 13% 10 0 Under 65 65-74 75-84 85+
Emergency admissions Emergency bed days from multiple admissions
Source: SMR01 activity analysis provided to Audit Scotland by ISD, November 2015
investigations or treatments are carried out. An emergency admission to hospital is more expensive than a planned admission. This means that although the percentage increases in the number of all admissions to hospital and in the number of emergency admissions are similar, the percentage increase in costs for emergency admission is higher (Exhibit 3, page 12).
14. There is more to be done to ensure that people are receiving the best care and treatment, rather than being admitted to hospital as an emergency, and to reduce hospital costs to allow more effective use of resources. An example is putting in place models of care to support older people in the community and prevent admission to hospital where possible. We highlight examples of this happening in some areas later in the report. To address the current challenges in relation to emergency admissions, a number of partners across the health and care system need to work well together. This includes GPs, community nurses and social care staff. 12 |
Exhibit 3 Changes in admissions to hospital and associated costs and bed days, 2010/11 to 2013/14 The total number of emergency bed days has been decreasing, but the number of emergency admissions has been increasing along with the associated costs.
Admissions to hospital Hospital bed days
Number £ Costs Number All admissions Emergency All admissions Emergency All admissions Emergency admissions admissions admissions
752,000 553,000 £3.35 billion £2.57 billion 4.61 million 3.91 million 5% 6% 1% 5% 4% 3%
Source: IRF – NHS Scotland and Local Authority Social Care Expenditure – Financial Years 2010/11–2013/14, ISD Scotland, March 2015; SMR01 activity analysis provided to Audit Scotland by ISD, November 2015
Health and social care services need to adapt to cope with the effects of the changing population 15. Pressures on health and social care services are likely to continue to increase over the next 15 years. It is difficult to know the extent of this growth but NHS boards and councils are finding it challenging to cope with the present demand for health and social care services. These increasing pressures have significant implications for the cost of providing health and social care services and challenges in ensuring that people receive the right care, at the right time and in the right setting. To address this, local partnerships need to redesign services to avoid unnecessary admissions to hospital. Where hospital admissions cannot be avoided, support needs to be put in place to get people home as quickly and as safely as possible. Local areas are developing approaches involving targeting both small numbers of individuals who use high levels of resources and prevention in the broader population.
16. To help to explain the complexity of the health and social care system, and the potential impact changing demographics will have on services over the next 15 years, we have prepared Exhibit 4 (page 13). It shows projected rises in activity arising from a growing, ageing population. These are based on applying projected increases in the population to key measures that can indicate how well the system is working. The health and social care system is inter-related. If anything goes wrong in one part of the system, it can affect other parts of the system. The growing population will affect all parts of the health and social care system. If the population increases as predicted, and services continue to be delivered in the same way, the impact across the system is significant and highlights the need for change. Based on our projection analysis, in 2030, compared to 2013, there could be an additional:
• 1.9 million GP appointments and 1.5 million practice nurse appointments Part 1. Health and social care in Scotland | 13
Exhibit 4 Pressures on health and social care services, 2013-30 If current rates of activity continue, it is unlikely that health and social care services will be able to cope with the effects of the changing population unless they make major changes to the way they deliver services.
12% 33% 31% 2013 2030 2013 2030 2013 2030 16,301,615 18,200,000 61,060 81,000 20,529 26,800
GP consultations Homecare clients Homecare clients receiving 10+ hours of care per week 18% 35% 2013 2030 2013 2030 8,049,120 9,500,000 34,933 47,000 Projected change in the age structure of Scotland's Long-stay care Practice nurse population (2013-30). consultations home residents
68% 70 All ages 60 50 5% 44% 40 32% 30 20 10 2% -3% 0
0-15 16-64 65-74 75-84 85+ Age groups 26% 14% 2013 2030 2013 2030 1,017,925 1,280,000 452,359 514,000
Acute emergency bed days Acute day cases from patients with 3+ admissions 28% 16% 9% 2013 2030 2013 2030 2013 2030 3,910,221 5,000,000 553,211 640,000 1,645,914 1,800,000
Emergency bed days Acute emergency admissions New outpatient appointments Note: Each indicator (eg, number of emergency admissions) is calculated as a rate of the population by using National Records of Scotland mid-year population estimates. The rate in 2013/14 is assumed to continue over the projection years. Over each of the projected years, the estimated rate is multiplied by the estimated projected population to find the number for that indicator. Source: Audit Scotland analysis, 2016 14 |
• 20,000 homecare clients and 12,000 long-stay care home residents
• 87,000 emergency admissions to hospital and 1.1 million associated hospital bed days
• 62,000 hospital day cases and 154,000 outpatient appointments.
17. A number of factors will affect how much these pressures continue to increase, including: the ageing population; levels of deprivation and health inequalities; changes in healthy life expectancy; and the extent to which new ways of providing services are adopted, particularly preventative and community- based services. However, it is clear that health and social care services will need to be delivered differently to cope with the increasing pressures associated with the growing population.
NHS boards and councils are facing increasing financial pressures 18. The Scottish Government has estimated it would need an annual increase in investment of between £422 million and £625 million in health and social care services to keep pace with demand.10 Its assumption is based on current service models remaining the same and demand increasing in line with the growth in the older population and changes in healthy life expectancy. This level of investment is not sustainable in the current financial climate. Budgets for health and social care services are reducing. Over the period 2010/11 to 2014/15:
• The health budget decreased by 0.6 per cent in real terms, that is allowing for inflation, to £11.86 billion.11 The draft health budget is set to increase by 3.6 per cent in real terms in 2016/17. It includes £250 million of funding in NHS boards’ budgets for integration authorities aimed at improving outcomes in social care.12
• Scottish Government overall funding for councils decreased by 5.9 per cent in real terms to £10.8 billion. Between 2010/11 and 2013/14, spending on social care services increased slightly by two per cent to around £3 billion.13, 14 In 2016/17, Scottish Government funding for local government is set to decrease by 7.2 per cent.
GPs are central to developing new types of care, but pressures are building in general practice 19. GPs have a key role to play in coordinating care for patients, involving other professionals such as nurses, occupational therapists, physiotherapists and social workers as required. Owing to increasing pressures on GPs’ time, new models of care will need to ensure patients are referred to the most appropriate professional based on needs, allowing GPs to focus on patients with complex needs.
20. There is currently a major gap in information about demand and activity for most community health services, including general practice services. Until 2012/13, the Information Services Division (ISD) of National Services Scotland collated practice team information (PTI). This will be replaced by a new system, Scottish Primary Care Information Resource (SPIRE). A phased roll out of SPIRE is due to start in March 2016 and complete by January 2017. It is essential to have good information on the patterns of use of general practice and demand for services to be able to design new models of care. Part 1. Health and social care in Scotland | 15
21. In the absence of published demand and activity data, a number of other indicators point to pressures building in general practice. These include patients’ declining satisfaction with access to general practice, increasing patient visits to general practice, recruitment and retention issues, and dissatisfaction among GPs (Exhibit 5, page 16). These all have implications for the quality of care patients receive and their health outcomes. The National Audit Office has found that similar issues also exist in England.15 The Scottish Government is in the process of negotiating a new contract for 2017 with GPs, partly to address some of these concerns.
The Scottish Government has set out an ambitious vision for health and social care 22. In September 2011, in recognition of the challenges facing health and social care, the Scottish Government set out an ambitious vision to enable everyone to live longer, healthier lives at home or in a homely setting by 2020.16 This vision aims to help shape the future of healthcare in Scotland in the face of changing demographics and increasing demand for health services. Central to the vision is a healthcare system with integrated health and social care, and a focus on prevention, anticipation and supported self-management. Some of the main principles of the policy, particularly in relation to shifting more care and support into the community, are:
• focusing on prevention, anticipation, supported self-management and person-centred care
• expanding primary care, particularly general practice
• providing day case treatment as the norm when hospital treatment is required and cannot be provided in a community setting
• ensuring that people get back into their home or community environment as soon as appropriate, with minimal risk of re-admission
• improving the flow of patients through hospital, reducing the number of people attending A&E, and improving services at weekends and out-of-hours
• improving care for people with multiple and chronic conditions
• reducing health inequalities by targeting resources in the most deprived areas
• planning the workforce to ensure the right people, in the right numbers in the right jobs
• integrating adult health and social care.
Integration of health and social care is integral to delivering the 2020 Vision 23. Health and social care services in Scotland are currently undergoing reform. Under these arrangements NHS boards and councils are required, as a minimum, to combine their budgets for adult social care, adult primary healthcare and aspects of adult secondary healthcare. This accounts for more than £8 billion of funding that NHS boards and councils previously managed separately. The new integration authorities are expected to coordinate health and care services and commission NHS boards and councils to deliver services in line with a local strategic plan. Over time, the intention is that this will lead to a change in how services are provided, with a greater emphasis on preventative services and 16 |
Exhibit 5 Indicators of building pressure in general practice There is a lack of data on general practice activity and demand for services. But available indicators show pressures on general practice continuing to build.
General practice activity Patient experience 2013/14
1 in 6 patients found it difficult to increase in patient contacts between get through to their GP practice 11% 2003/04 and 2012/13 to 24.2 million on the telephone 94.5% 92.6% 92.4% 67% of contacts were with GPs in 2012/13 The percentage of people able to see or speak to a This increase is primarily driven by doctor or nurse within a rise in practice nurse contacts of 31% 48 hours has decreased 2009/10 2011/12 2013/14
2003/04 2012/13 of patients said they were able to book 6.0866.1 7.9678.0 78% appointments 3 or more days in advance million million
2015 BMA survey of 1,800 GPs in 8% Scotland 1-4 Change in patients 5 times Once times contacting their or more GP practice -2% 25% of GPs described their 2011/12 to 2013/14 workload as unmanagable
-15%
felt workload had a negative impact on 69% their personal commitment to their career 24.2 1.6 0.9 million million million 17% of practices had GP contacts A&E and Minor Out-of-hours contacts at least one vacancy PANTONE 262 (2012/13) Injury Unit attendances (2014/15) a third would like (2012/13) to retire by 2020 PANTONE 315 PANTONE 347 PANTONE 124 Workforce Percentage of PANTONE 319 37% GPs working 74% female GPs AS purple 2 part-time in 2013 AS teal 2 0 AS green 2 Around 1 in 2 community nurses 23% increase in female GPs male GPs AS yellow 2 were aged 50 and over, compared over the ten-year period with 1 in 3 hospital nurses in 2015 to 2015 AS blue 2 GP partners aged 50 and over 33% vs 34% of all GPs were aged 15% 0 0 50 and over in 2015, 0 decrease in male GPs compared with 29% in 2005 over the ten-year period PANTONE 262 42% to 2015 2005 2015 PANTONE 315 PANTONE 347 Source: Health and Care Experience Survey 2013/14, Scottish Government, May 2015; Practice Team Information (PTI), ISD Scotland, October 2013; GP Out of Hours Services in Scotland, 2014/15, ISD, August 2015; A&E and minor incidents unit (MIU)PANTONE activity 124 data provided to Audit Scotland by ISD, January 2014; Primary Care Workforce Survey 2013, ISD Scotland, September 2013; ThePANTONE UK nursing 319 labour market review 2013, Royal College of Nursing, September 2013; The future of general practice - survey results, British Medical Association (BMA), February 2015; Community nursing staff in post and vacancies, ISD Scotland, June 2015; Nursing and midwifery ASstaff purple in post 2, ISD Scotland, September 2015; BMA press release, 13 March 2015; Number of GPs in Scotland by age, designation and gender, ISDAS Scotland,teal 2 December 2015. AS green 2 AS yellow 2 AS blue 2
17% of practices had a third would like at least one vacancy to retire by 2020 PANTONE 262 PANTONE 315 increase of female GPs 35% over the 10 year period PANTONE 347 to 2013/14 PANTONE 124 PANTONE 319 AS purple 2 decrease of male GPs over the 10 year period AS teal 2 11% to 2013/14 AS green 2 AS yellow 2 AS blue 2 Part 1. Health and social care in Scotland | 17
allowing people to receive care and support in their home or local community, rather than being admitted to hospital. The integration authorities will be responsible for delivering new National Health and Wellbeing Outcomes.17 These focus on the experiences and quality of services for people using those services, carers and their families. Examples of the outcome indicators include the percentage of adults able to look after their health very well or quite well, and the percentage of people with a positive experience of the care provided by their GP practice.18
24. Our recent report on progress towards integration of health and social care services confirms that the new integration authorities are expected to be operational by the statutory deadline of 1 April 2016. However, there are a number of issues that the integration authorities need to address if they are to take a lead on improving local services. These include agreeing budgets, and setting out comprehensive strategic plans, clear targets and timescales to show how they will make a difference to people who use health and social care services. They will also need to deal with significant long-term workforce issues and ensure that complex governance arrangements, including the structures and processes for decision-making and accountability, work in practice.19 18 |
Part 2 New ways of providing health and social care
New approaches to delivering health and social care are emerging
25. We have identified a number of new models across Scotland that are designed to deliver more care to people in community settings in line with the 2020 Vision. We have identified different types of care models in local areas, including:
• community preventative approaches
• better access to primary care and routine hospital treatments
• enhanced community care models
• intermediate care models
• initiatives designed to reduce delayed discharges. new care 26. We have not reviewed all new models in all areas of Scotland. We have selected a number of examples in some areas of Scotland to illustrate the models are different types of models that exist and to highlight particular aspects of good emerging but practice (Exhibit 6, pages 20-21). These include ten primary and community care ‘test sites’ referenced in the Scottish Government’s Programme for there is a lack Government, published in September 2015.20, 21 Some of these are at an early of evidence stage of development and others are more established. They include: about what • local GP surgeries working together for faster appointments works
• GPs and health professionals, such as nurses, physiotherapists and pharmacists, working together in multidisciplinary teams
• providing treatment that patients currently have to travel to hospital to receive.
27. The Scottish Government intends to work closely with the ten test sites over the next two years to offer support and guidance and share learning.
28. We have produced a supplement to the report containing case studies (Supplement 1 [PDF] ). There are hyperlinks throughout the report to the relevant case studies.
29. Most new care models are designed to relieve pressures on the acute sector but have an impact on different parts of the health and social care system. A high-level system diagram showing where the new models of care described in Exhibit 6 sit within the overall health and social care system is set out in Supplement 1 [PDF] . Part 2. New ways of providing health and social care | 19
New models need to be implemented and evaluated properly 30. A common issue with many of the new care models being introduced across Scotland is a lack of evidence about the impact, implementation costs, efficiency gains or cash savings, and outcomes for service users. Some new ways of working are based on similar models from elsewhere, either another part of Scotland or other countries. But it is still important to monitor any new models to assess the impact on local systems and assess the costs, savings, outcomes and sustainability. This will help to assess the value for money of new models, whether the benefits justify the costs and if they should be rolled out more widely. For many of the new models that have been introduced in Scotland, it is too early to assess their impact. We were not able to carry out a cost benefit analysis for the care models described in Exhibit 6 owing to a lack of local cost information.
31. Many organisations highlighted the lack of time, resource and skills as a barrier to carrying out major change and also to properly evaluating new models. Senior managers in local bodies need to recognise that a successful change programme requires strong leadership and experience in change management to take forward major changes to services. Also, sufficient resources need to be included in the business case for changes to be properly implemented and evaluated.
More can be learned from the innovation of others
32. Although not all the models and approaches listed in Exhibit 6 will be directly transferable in their entirety to other areas, they each include aspects of innovation and improvement which can help inform how services could develop in other areas. In the following paragraphs we explore particular aspects of some of the models in more detail to provide a flavour of the new approaches being taken in some local areas.
Using a model of care focusing on the whole population to achieve a sustainable service Population health models of care aim to improve the health of the entire population, rather than targeting specific age groups or certain conditions. Within this model the focus is on preventative measures and reducing inequalities. Case study 1 [PDF] provides details of a GP practice in Forfar developing a model of care focused on the whole population to improve access, health and wellbeing and to sustain services in the longer term in the light of the pressures we highlighted in Part 1.
33. The Nuka model of care from Alaska, also described in Case study 1 [PDF] , has influenced the model the Forfar GP practice is developing. Native Alaskans create, manage and own the whole healthcare system. Multidisciplinary teams provide integrated health and care services in primary care centres and the community. These are coordinated with a range of other services and combined with a broader approach to improving family and community wellbeing.
Multidisciplinary teams working together to keep people at home 34. Recent work by the King’s Fund suggests that collaboration through place- based systems of care offers NHS organisations the best opportunity for tackling the growing challenges facing them. This is where organisations work together to improve health and care for the local populations they serve.22 There are examples of place-based care in Scotland in Tayside (Case study 2 [PDF] ) and Glasgow (Case study 3 [PDF] ). 20 |
Exhibit 6 New models of health and social care in Scotland We have identified different types of new approaches to delivering health and social care in Scotland.
Community preventative approaches These help people to stay in the community, in particular people with multiple conditions and complex needs. These approaches aim to help people self-care and to reduce people’s demands for healthcare in the longer term. Examples of self-care include changing diet, taking more exercise or taking medicines at the right time. • Two GP practices in Forfar are planning to merge into one of the largest practices in Scotland. Patients will be allocated to one of five multidisciplinary teams within the practice, each delivering a patient-centred model of care. Each multidisciplinary team will include GPs, nurses, healthcare assistants, an administrator and a named community nurse. The patients are encouraged to manage their conditions and self-care (Case study 1 [PDF] ). • The House of Care model is being tested in Lothian, Tayside and Glasgow. This approach encourages people living with multiple, long-term conditions to self-manage their care through joint planning, goal-setting and action planning. • Patients with complex and/or multiple conditions from deprived areas in Glasgow may be eligible to be part of the CAREplus initiative. Inclusion allows patients longer consultations with a GP or nurse. This enables them to discuss their problems in more detail and make a list of priorities (Case study 3 [PDF] ). • The Links Worker Programme has placed community links practitioners in GP practices in deprived areas of Glasgow. They are not medically qualified, but link practices and patients with community-based services and resources such as lunch clubs and self-help groups based on individual patients' needs (Case study 3 [PDF] ).
Improved access to primary care and routine hospital treatments These approaches are designed to improve access to care for local people by health professionals working together, or in a different way. • New community health hubs in Fife and Forth Valley: Patients will be able to get access to a range of services that they would normally have had to travel to an acute hospital to receive. A new type of doctor will be part of the healthcare team. They will be qualified GPs with an extra year of training to give them the skills they need to work across primary and acute care. This training began in autumn 2015. • The new model of delivering healthcare for the Small Isles (Canna, Rum, Eigg, Muck and surrounding islands) is a combination of telehealth facilities and improving local skills to deal with healthcare needs. This is alongside a visiting service provided through NHS Highland’s new rural support team, initially led by two GPs based on Skye. The rural support team includes GPs, nurse practitioners and paramedics.
Enhanced community care This is a multidisciplinary team approach aimed at keeping people at home or in a homely setting, managing crisis situations and avoiding inappropriate admission to hospital. Some models also support quicker discharge from hospital. • The Tayside Enhanced Community Support Service enables GPs, with the support of a multidisciplinary team, to lead the assessment of older people with frailty and at risk of unplanned hospital admission, and to respond to any increased need for health and social care support (Case study 2 [PDF] ).
Cont. Part 2. New ways of providing health and social care | 21
Enhanced community care (continued) • East Lothian service for the integrated care of the elderly (ELSIE): This whole-system approach offers access to multidisciplinary and multiagency emergency care at home, or the place people call home, to older people. The service offers a single point of contact for both people who are at risk of being admitted to hospital, and to actively facilitate the discharge of people from hospital (Supplement 2 ). • Forth Valley’s Advice Line For You (ALFY) is a nurse-led telephone advice line to help older people remain well at home. Nursing advice is available 24 hours a day, seven days a week (Case study 5 [PDF] ). • The Govan SHIP project aims to reduce demand for acute and residential care and improve chronic disease management. Four GP practices in Govan Health Centre provide a multidisciplinary approach to patients of any age who are known to be vulnerable (Case study 3 [PDF] ). • Community-based dementia care: In Perth and Kinross, the closure of a number of community hospital dementia beds allowed increased investment in community mental health teams that are looking after more patients in their own homes (Case study 8 [PDF] ).
Intermediate care This involves time-limited interventions aimed at promoting faster recovery from illness and maintaining the independence of people who might otherwise face unnecessarily prolonged hospital stays or inappropriate admission to hospital or residential care. • The Glasgow Reablement Service provides tailored support to people in their own home for up to six weeks. It builds confidence by helping people regain their skills to do what they can and want to do for themselves at home (Case study 8 [PDF] ). • Bed-based intermediate care is provided across most health and social care partnerships. Step-up beds are for people admitted from home for assessment and rehabilitation as an alternative to acute hospital admission. Step-down beds are for people who are well enough to be discharged from acute hospital but need a further period of assessment and rehabilitation before they can return home.
Reducing delayed discharges These approaches aim to increase the understanding of the reasons for delays in patients being discharged from hospital, and find ways to reduce this. A number of models combine reducing delayed discharges with providing enhanced care in the community to prevent people being admitted to hospital in the first place. • Tayside Enhanced Community Support Service (as above) • East Lothian Service for the integrated care of the elderly (ELSIE) (as above) • The Glasgow 72-hour discharge model ensures patients who are considered fit for discharge from hospital are discharged within 72 hours. Their options for discharge are to go home, or home with support in place if needed. Another option is for people to go to a temporary care bed for a maximum of four weeks where they will be assessed and rehabilitated and a care plan will be developed and agreed for them. • The East Lothian ‘Discharge to Assess’ service is delivered by physiotherapists and occupational therapists who provide early supported discharge and assess patients at home, rather than in an acute setting. This includes arranging equipment, active rehabilitation and developing packages of care. The service is an integral part of ELSIE (as mentioned in the above section: 'Enhanced community care').
Source: Audit Scotland
35. A number of areas across Scotland have recently introduced an enhanced community support model. This tends to involve multidisciplinary teams delivering an enhanced level of care, working together to keep people at home or in a homely setting, managing crisis situations and avoiding inappropriate admission to hospital. Tayside has combined this model of care with a local area-based approach that aligns consultant geriatricians to GP practices (Case study 2 [PDF] ). 22 |
36. Most enhanced community support service models are targeted towards older people. However, in one area of Glasgow, three new linked approaches to delivering health and social care are facilitating an enhanced service for anyone in the local population who is judged to be vulnerable. This includes people with mental health problems or people who use services frequently and people with complex needs. Case study 3 [PDF] provides more detail of these three approaches and includes patient stories to illustrate the difference the new approaches have made to people using the service.
Nurse-led approaches that maximise the population’s resilience 37. The Buurtzorg model of care from the Netherlands is an example of an effective nurse-led approach to delivering health and social care that maximises people’s resilience (their ability to withstand stress and challenge) (Case study 4 [PDF] ). Health and social care organisations can help to build people’s resilience by: supporting them to look after themselves; providing preventative services that keep them well in the community; and by ensuring they know how to access help if things go wrong. Forth Valley has introduced some of the elements of this approach in its Advice Line For You (ALFY) model (Case study 5 [PDF] ).
38. The ALFY model’s Your Plan enables people to take responsibility for the challenges they face and to use their own skills and abilities, and friends, family and people who care for them, to develop resilience. This echoes the Buurtzorg service that promotes self-care, independence and the use of informal carers. The Buurtzorg model has improved the quality of patient care through round-the-clock access to a district nursing team by telephone or a home visit service. Results have shown:
• a correlated decrease in unplanned care and hospital admissions
• better patient satisfaction, when compared to other homecare providers in the Netherlands.23
Longer-term strategic approaches 39. We have found evidence of longer-term programmes supporting the 2020 Vision, where organisations have built on previous work, identified priority areas to focus on and are working on scaling up a number of models:
• The Scottish Ambulance Service’s strategic approach to patient care involves closer working with primary care teams to ensure patients are referred to the most appropriate service, and to avoid admission to hospital wherever possible (Case study 6 [PDF] ).
• The Scottish Centre for Telehealth and Telecare’s Technology Enabled Care Programme encourages more use of established technology to help improve health and wellbeing outcomes (Case study 7 [PDF] ).
Taking a whole-system approach 40. East Lothian partnership is taking a whole-system approach to understanding its local population and planning health and social care services and has the following long-term objectives:
• to increase the percentage of over 65s living at home • to increase the percentage of spending on community care compared with institutional care • to increase years of healthy life. Part 2. New ways of providing health and social care | 23
41. East Lothian recognises a number of challenges to providing health and social care services to its local population. East Lothian is developing intelligence about various parts of the health and social care system and using it to improve the way it delivers services. An analysis of East Lothian’s population and primary care data shows:
• an ageing population with increasing levels of frailty and complex health needs
• increasing hospital admissions in some local areas from younger people with increasing long-term conditions and ill-health
• the groups of people who use a disproportionately high level of health services are those who are nearing the end of their life, are in care homes or have mental health needs
• relatively low numbers of people being admitted to hospital in an emergency, but high rates of occupied bed days and delays in discharge from hospital
• variety in the quality of access to GPs in different practices across East Lothian
• a predicted shortage of GPs owing to an ageing workforce
• preliminary information on the demand levels on GPs, such as the percentage of the practice population presenting to the GP each week.
42. To meet its objectives, East Lothian is focusing on:
• understanding the pattern of service use by high resource users and working out ways of intervening earlier to improve the support people receive and reduce unnecessary demand for services
• expanding ELSIE for people who are at risk of admission to hospital or have just been discharged from hospital to 24 hours a day, seven days a week
• supporting primary care services to meet demand to improve access for patients and to promote early intervention and prevention
• conducting a comprehensive bed modelling exercise to address the problem of delayed discharges, bring patients from Edinburgh hospitals closer to home and ensure efficiency and effectiveness of services.
43. East Lothian is bringing together growing intelligence about its population, how people access services, and various strands of work which all aim to improve how it delivers services. This is allowing the partnership to build a comprehensive picture of the needs of its local population. It is also taking into account how changes to services affect different parts of the health and social care system and how these are linked. However, the partnership still has to fully evaluate the impact of new ways of working it has recently introduced. The different elements of East Lothian’s whole-system approach to health and social care are summarised in Exhibit 7 (pages 24-25). An interactive version of this exhibit is set out in Supplement 2 and provides more detail on the overall approach. 24 | Part 2. New ways of providing health and social care | 25
Exhibit 7 Exhibit 7 continued East Lothian's whole-system model In East Lothian intelligence on various parts of the health and social care system is being used to change the way that services are being delivered.
Sheltered Intermediate housing care step-up New Community Hospital Delayed discharge Engaging housing Bed modelling work beds (planned East Lothian Delayed prediction model departments for Roodlands discharge (planned) Very sheltered Hospital) housing Hospitals (within and Delayed discharge outside East mapping Lothian) Care home residents, High costs of Intermediate care step-down beds. analysis of pathways Care homes in Health and 20 step-down beds at Crookston and understanding East Lothian ELSIE model Social Care Day Centre hospital admissions Discharge Hospital Hospital to Assess TO home AT home Lack of home Limited Emergency care capacity care home Care home liaison team Social Work capacity Service
Stronger links between Ageing population and frailty Care at home ELSIE staff and Marie Curie hospice (eg secondments) People at end of life: End of life care (high number End of life care model analysis of patient pathways. of acute bed days in last six (planned) Understanding preventable months of life) hospital admissions NHS 24 De-centralising District Nursing team (planned) People with mental health needs: analysis of patient GP out-of-hours service pathways. Understanding Mental health conditions preventable hospital admissions Home Out-of-hours Other Community Health Service centre Services including pharmacy, occupational therapy, Understanding out-of- Third Sector physiotherapy hours admission patterns Volunteer services Community Capacity for older people Building Projects Planned review of GP practices out-of-hours team Older people's Community health requirements resource centre transport
Community Day centre Assessing link Understanding Practice risk Variation in Future capacity networks development Federation of GP practices between demand same day demand assessment tool access and issues in GP for same day demand. GP GP telephone and capacity and and complex care service across workforce practices joining together access pilot practice income demand East Lothian to improve same day access for their patients Primary care strategy High-level training for to develop a triage 14 Advanced Nurse system where patients Practitioners (eg, qualified are referred to the most for home visits) Core service Flow of people appropriate professional Influence of intelligence based on needs Local data/intelligence Intelligence icon or a new intervention Project/new intervention East Lothian Service for Integrated Source: Audit Scotland care of the Elderly (ELSIE) 26 |
Part 3 Making it happen
The transformational change required to deliver the 2020 Vision is not happening
44. Public sector bodies have continued to deliver health and social care services in an increasingly challenging environment. This includes tightening budgets, changing demographics, growing demand for services, increasing complexity of cases and rising expectations from people who use these services. Alongside these pressures, NHS boards and councils are implementing major service reform to integrate adult health and social care services. It is clear that services cannot continue in the same way within the current resources available.
45. Transformational change is required to meet the Scottish Government’s vision to shift the balance of care to more homely and community-based settings. the Scottish NHS boards and councils need to significantly change the way they provide services and how they work with the voluntary and private sectors. Traditionally Government there has been an emphasis on hospital and other institutional care rather than needs to the community-based and preventative approach outlined in the 2020 Vision. We have highlighted in previous reports that despite the Scottish Government’s provide considerable focus and resources aimed at shifting the balance of care over a stronger number of years, this has not changed to any great extent.24 We will monitor trends in the balance of care as part of our ongoing work on health and social leadership by care integration. developing
46. Over the four-year period from 2010/11 to 2013/14, the balance of expenditure a clear on institutional services, such as hospitals and care homes, and on care at framework home or in community settings, has remained static. The percentage of total expenditure on adult health and social care (around £11.7 billion) has remained to guide local at 56 per cent for institutional-based care and 44 per cent for community-based development care (Exhibit 8, page 27).
47. Our 2015 annual report on the NHS in Scotland highlighted that the Scottish Government has not made sufficient progress towards achieving its 2020 Vision of changing the balance of care to more homely and community-based settings.25 In this audit looking at changing models of care, we found that there are many small-scale models and pilots across Scotland delivering new approaches to health and social care. However, there is limited evidence of transformational change happening on the scale required to meet the objectives of the 2020 Vision. Most initiatives are at a relatively early stage and have yet to be fully evaluated. This means the potential outcomes for service users and impact on resources are still to be fully established. Currently clear plans are lacking at a national and local level about what is needed to sustain new models of care. Examples include the funding, workforce and long-term planning requirements that are needed to ensure successful pilots are continued and scaled up. Part 3. Making it happen | 27
Exhibit 8 Breakdown of adult health and social care expenditure, 2010/11 to 2013/14 The proportion of expenditure on institutional and community-based care has remained static.
56% 44%
2010/11
2011/12
2012/13
2013/14
0 20 40 60 80 100 Percentage
Institutional-based care Community-based care Local government Local government Care homes Home care Other accommodation-based social care Other community-based social care NHS NHS Non-elective inpatients Community-based NHS Elective inpatients GP prescribing Day case Other family health service excl. GP prescribing Other hospital
Note: Other accommodation-based social care includes sheltered housing, hostels and supported accommodation. Other community-based social care includes meals, community service, prison social work, youth crime and youth work services. Other hospital includes maternity inpatients, special care baby units, outpatients and day patients. Other family health service excl. GP prescribing is General Medical Services expenditure. Source: IRF–NHS Scotland and Local Authority Social Care Expenditure–Financial Years 2010/11–2013/14, ISD Scotland, March 2015
48. In June 2015, the Cabinet Secretary for Health, Wellbeing and Sport confirmed that the Scottish Government and NHS boards had not made sufficient progress towards delivering the 2020 Vision. At the same time, the Scottish Government announced plans to launch a new national conversation on the future of healthcare in Scotland. The Scottish Government decided to consider a longer-term plan, beyond 2020, to make more progress and increase the pace of implementing the vision and to expand the current focus of the vision.
49. The Scottish Government has engaged with staff, service users and other interested groups about improving the health of the population and its plans for health and social care services. It published a National Clinical Strategy in February 2016 setting out its plans for health and social care in Scotland over the next 10 to 15 years. The Scottish Government has published this strategy to help partners as they implement the 2020 Vision. The strategy also comments on the direction of travel beyond 2020. The new strategy describes a number of new proposals and changes to current services. GPs will focus on care that is more complex and the wider primary care team will develop extended skills and responsibilities. A new structure is proposed for a network of hospital services with more specialities planned and provided on a regional or national basis. There is also a strong focus on the need to reduce waste, harm and variation in treatment and making more use of technology to support and improve care. 28 |
The Scottish Government needs to provide stronger leadership and a clear plan for implementing the 2020 Vision
50. The Scottish Government’s overall aim of enabling everyone to live longer, healthier lives at home, or in a homely setting, by 2020 is widely accepted. In May 2013, the Scottish Government set out high-level priority areas for action during 2013/14.26 This lacked a clear framework of how it expects NHS boards and councils to achieve this in practice, and there are no clear measures of success, such as milestones and indicators to measure progress. The cost implications of implementing the 2020 Vision are unknown and there is a lack of detail about the main principles of the policy (paragraph 22). There is also slow progress in developing the workforce needed for new models of care and a lack of information about capital investment to support the 2020 Vision.27 The recently published National Clinical Strategy is intended to provide a clearer framework, but it does not detail how the high-level proposals will be implemented or contain any milestones or indicators or financial analysis.
51. The introduction of health and social care integration means there is now much more flexibility for partners to develop local solutions to local problems as they develop services and support systems to help people to live independently at home or in a homely setting. There is still an important role for Government to set the strategic direction and then to provide the support local partners need to ensure they are able to implement more effective models of care, if the pace of change is to increase.
52. In order for the 2020 Vision and the National Clinical Strategy to be realised, the Scottish Government needs to clarify:
• the immediate and longer-term priorities for local bodies to focus on
• a clear framework to guide local development of new care models, including the types of models to be tested, the resources required (such as funding and skills, job roles and responsibilities of the workforce), and how new models will be tested and rolled out in a coordinated way
• long-term funding plans to help implement the 2020 Vision and the National Clinical Strategy, to allow local bodies to plan and implement sustainable, large-scale changes to services
• how it will measure progress, for example by setting milestones and indicators.
The Scottish Government needs to identify priorities and risks 53. The Scottish Government needs to provide a clear plan now about what needs to be done to reach its longer-term strategy up to 2030. It should identify short, medium and long-term priorities for delivering its vision over the next 15 years. Examples include focusing on implementing high-impact changes to providing services in the short term, identifying the funding and other resources required for the medium term and achieving improved outcomes for the population in the long term. In its plans, the Scottish Government needs to identify and take into account specific risks to delivering its 2020 Vision and longer-term strategy. This should include the following: Part 3. Making it happen | 29
• The risks we have highlighted in our report on health and social care integration. Up to late 2015, the focus has been on getting the structures and governance in place for health and social care integration. The Scottish Government will need to ensure that the new partnerships make the transition to focusing on what needs to be done on the ground to make the necessary changes to services.
• Health and social care budgets. Real-terms reductions in NHS and council budgets will pose risks to implementing new models and shifting more care into community-based settings. Council budgets have seen significant cuts in recent years and although new integrated health and social care budgets should allow funding to flow from NHS to social care budgets, it is not yet certain this will happen in practice. Councils and NHS boards are finding it difficult to agree budgets for the new integration authorities.
• The building pressures in general practice, including problems with recruiting and retaining the workforce. The new GP contract that will come into effect in Scotland in 2017 will be crucial in managing the role of general practice in helping to implement the changes required to meet the 2020 Vision. The role of GPs in moving towards the 2020 Vision should be a major focus of the discussions between the Scottish Government and the profession as the new contract terms are developed.
The Scottish Government should outline clear principles for implementing new care models 54. Various principles should be followed for new care models to be implemented, tested, evaluated and rolled out successfully. If local bodies are to expand and roll out new models, they must have thorough information on the costs involved for planning and ensuring the models are sustainable. The Scottish Government has not provided an estimate of the investment needed to implement its 2020 Vision and longer-term strategy, and whether it can be achieved within existing resources. It needs to model how much investment is needed in new services and new ways of working and if it can be achieved within existing and planned resources.
55. Staff implementing new models should have a business plan that clearly details how they will implement, monitor and review them. Exhibit 9 (page 30) summarises principles for implementing new care models. It draws on the information collated from our fieldwork and the learning shared by local bodies and other organisations. Links to toolkits and reports that may be useful for NHS boards, councils and integration authorities for implementing new models of care are included in Supplement 1 [PDF] .
56. Few of the models outlined in Exhibit 6 have been fully costed or properly evaluated. In several cases, it is too early to assess the impact of new ways of working. However, sometimes this is due to the lack of good monitoring data or the lack of skills and resources to carry out an evaluation. Generally, there is a lack of evidence of community-based models having a major impact and clarity about what works. This is a common problem, not unique to Scotland, but a crucial one to address so that local areas can efficiently identify and implement the most effective models.28 30 |
Exhibit 9 Principles for planning, implementing, monitoring and reviewing new care models New care models should be properly planned, implemented, monitored and evaluated to ensure value for money and sustainability.
Develop a clear business plan detailing timescales, resources (such as equipment, staff and training), costs, estimated savings and efficiencies, sources of funding, a risk assessment, plans to pilot, scale up and make the approach sustainable, methods for evaluating and measuring impact, and options for shifting resources and building community capacity
Make good use of local data Share data and learning and intelligence to understand across professional groups the local population and inform and organisations service change
Consult with the general Focus on a small public and engage number of models in with service users to priority areas and do ensure an understanding these well, rather than and acceptance of trying to change too new models and why many things at once services need to change
Allow sufficient time to Ensure staff are well test new ways of working informed and on board and to gather evidence of with new ways of working what works
Consider basing models around small Identify how technology can be local areas or clusters with groups of used to support new models and staff who know the local population make them more efficient in light of and are best placed to identify those limitations of funding and workforce at risk and provide preventative measures or intensive support
Source: Audit Scotland
Mechanisms to support a significant shift in resources from acute to community settings are needed 57. Moving towards more community-based care is central to the 2020 Vision, but the balance of care is not shifting (Exhibit 8). To achieve the transformational change required to meet the 2020 Vision, the Scottish Government needs to Part 3. Making it happen | 31
identify mechanisms that will drive a significant shift of resources from acute to community settings. Some local partnerships have found innovative ways to overcome barriers to improvement, but more can be done to facilitate change locally. The Scottish Government has an important role to play in supporting local bodies make these changes.
58. There are tools that can facilitate the transfer of resources across a local system, demonstrated in the examples seen in Tayside, Glasgow and Highland (Case study 8 [PDF] and Case study 9 [PDF] ). Scotland could apply learning from other countries. For example, Canterbury, New Zealand, shifted the balance of care through strong leadership, a clear vision, and a collaborative and whole-system approach. An important factor was its focus on ‘one system, one budget’. It prioritised spending on those in greater need to reduce relying on residential care and to keep people in their own homes for longer. This had the effect of reducing demand and costs for hospital and other institutional care, and allowed for more investment in the community (Case study 10 [PDF] ).
59. The Scottish Government needs to identify what balance of care it wants to achieve, what this will look like in practice and the financial implications of achieving this. The Scottish Government should challenge local partnerships to be clear about their specific ambitions in relation to the balance of acute and community care in their local areas, with clear timescales and milestones for achieving it.
60. The continued focus on targets in the acute sector is counterproductive to moving more funding into the community. NHS boards are under significant pressure to meet challenging hospital waiting time targets. This means that the acute sector continues to absorb considerable resources to meet these targets. A focus on short-term funding and increasing use of the private sector to help meet targets does not demonstrate value for money. The focus on annual targets does not help to achieve the longer-term aims and objectives of the NHS. Integration authorities are required to deliver outcome measures. This recent development with a greater focus on improving people's experiences of health and social care services is more helpful than focusing on narrow performance targets.
61. The Scottish Government needs to identify adequate and timely longer-term funding to support transformational change. It has provided multiple short-term funds to help local bodies implement change, but these do not provide the level of funding or certainty to make large-scale sustainable changes.29 It has announced a £30 million transformational change fund to ‘support creativity and transformation’ in its draft budget for 2016-17.
62. In 2014, we reported on progress of the Scottish Government’s policy of reshaping care for older people.30 As part of this audit, we considered the impact of the £300 million Change Fund over four years, introduced by government in 2011/12 to support its policy. We found that the Change Fund had led to the development of a number of small-scale initiatives, but that they were not always evidence-based or monitored on an ongoing basis. It was unclear how successful projects would be sustained and expanded.31
63. Similar challenges in transforming services to have a greater focus on community-based care are also evident in England. There may be lessons to learn from the approach NHS England is taking to testing and rolling out new models of care, but it is too early to assess the effectiveness of its approach. 32 |
The Health Foundation and the King’s Fund have recommended that existing disparate strands of funding for transforming services in NHS England should be pooled into one transformation fund. They also recommend that a single body, with strong, expert leadership, oversees the investment for transformational change and that ongoing evaluation should be a core activity of the fund. They advise that the fund must be properly resourced to support investment in the four key areas that are essential for successful transformation: staff time, programme infrastructure, physical infrastructure and double-running costs.32
There is a lack of coordinated, clear and accessible learning 64. The current fragmented approach to implementing new ways of working means that the learning within individual organisations, and the work carried out by various national bodies, is not being consolidated. The Scottish Government needs to coordinate new ways of working and information at a national level to ensure a more efficient and effective approach. The Scottish Government should draw on successful improvement models it has implemented in other areas, such as its patient safety programme.
65. Support for service change and improvement has been available to local bodies from a number of national organisations, such as the Quality, Efficiency and Support Team (QuEST) within the Scottish Government, Healthcare Improvement Scotland (HIS), ISD, the Scottish Centre for Telehealth and Telecare, and the Joint Improvement Team (JIT). However, the activities of these various organisations are not well coordinated. They all have slightly different roles and the learning from the work they do with local bodies is not drawn together. A significant amount of information is available on the various organisations’ websites, but it is not always easy to navigate or identify the key information partners should use when they are considering implementing a new model of care. This information could be used to better effect to help increase the pace of change.
66. From April 2016, QuEST, HIS and JIT will combine into one integrated improvement resource. Its overall aim is to support and facilitate NHS boards, integration authorities and their partners to deliver care and support that will improve health and wellbeing outcomes for their populations.33 This new integrated improvement resource is a positive step and will facilitate a more coordinated national approach and will make better use of improvement resources available to support partnerships.
The public's perception of health and social care services needs to change 67. The Scottish Government first set out its vision for a different health and social care system in 2011, but the system remains largely the same, and the public has not seen major redesign of local services in many parts of Scotland. NHS boards, councils and integration authorities will need to adopt innovative models of care and ways of working that are quite different from traditional services to provide opportunities for better care. They will need to exercise much more flexibility in how they use resources, such as money; assets, including buildings and equipment; and their workforce. This involves making difficult decisions about changing, reducing or cutting some services. Services cannot continue as they are and a significant cultural shift in the behaviour of the public is required about how they access, use and receive services. The introduction of health and social care integration provides an opportunity to engage more directly with communities about services and the need for change. Part 3. Making it happen | 33
68. Local communities have strong ties to existing services which can make discussions about changes difficult, for example discussions about changing how hospital services are delivered. There are recent examples in NHS Tayside where the board consulted extensively with the public about closing community hospital beds. The board explained why it needed to close beds and the benefits of providing services differently. It also engaged with patients and their families about their needs and how they could best be met in the new care model in a more homely setting. By closing care of elderly and dementia beds in a number of community hospitals, NHS Tayside has been able to shift more resources into community teams. This has allowed many more patients to be supported in the community and they are now receiving care in their homes instead of being admitted to hospital (Case study 8 [PDF] ). It is important that NHS boards, councils and partnerships involve staff and local people as they develop new models of care. The Nuka model of care illustrates the benefits of staff and local people being closely involved in developing their local services (Case study 1 [PDF] ).
69. The Scottish Government cannot make the significant changes that are required on its own. Local bodies also need to work closely with staff to develop and implement new ways of working. Fifty-five per cent of staff in NHS Scotland responding to the 2015 national staff survey reported that they are kept well informed about what is happening in their NHS board. Only 28 per cent of staff reported that they are consulted about change at work.34 A focus on local populations within integration authorities will have an important role in reforming how to deliver services. This should bring together local GPs and other health and care professionals, along with service users, to help plan and decide how to make changes to local services.
NHS boards and councils can do more to address barriers and facilitate change
70. Staff within NHS boards and councils still face many barriers to making the level of changes required. We highlighted in Part 2 some examples of new care models being introduced across Scotland. Staff leading these often faced difficulties getting these in place or rolling them out. But new models have been successfully implemented where staff have taken a strategic approach with clear plans, aims and outcomes. Some of the main challenges to implementing new models include:
• overcoming structural and cultural barriers when bringing together staff from different parts of an organisation or from different organisations
• freeing up staff time to develop and implement new care models
• securing funding for new approaches owing to limited evidence of what works
• having resources for a long enough period to be able to fully test new models to demonstrate any benefits and outcomes for service users
• lack of robust evaluation of new models and being able to identify the attributable impact of a particular approach alongside other services and programmes
• temporary funding and staffing preventing the models continuing or expanding
• shifting resources from acute to community-based settings to allow new care models to develop significantly in line with national policy. 34 |
Funding needs to be focused on new community-based models 71. At the same time as dealing with increasing demand, NHS boards are facing a tightening financial position and councils are experiencing budget cuts (Part 1). The NHS is finding it difficult to release funding from the acute sector to increase investment in the community. Councils are finding it difficult to fund the level of social care services required to meet current demand, and the demands on health and social care services are likely to continue to increase. Barriers to releasing funding to invest in new care models include the following:
• Some NHS boards are overspending against their planned hospital budgets owing to pressures on hospital services. This makes it more challenging to release any funding to invest in community-based services. For example, NHS Highland has overspent on its budget for Raigmore hospital over the last five years (£9.6 million in 2013/14) and NHS Fife has overspent on its acute services division budget for the last two years (£10.6 million in 2014/15).35, 36 In August 2015, NHS Greater Glasgow and Clyde reported spending levels of £5.3 million over its projected acute services division budget. The board had aimed to be £1.7 million over of its budget at that point in the year to be able to achieve a breakeven position by the end of the financial year.37
• Investment in NHS community-based services has not increased at the same rate as investment in hospital-based services. Between 2010/11 and 2013/14, spending on community-based services increased by 4.9 per cent in cash terms, but reduced by 0.5 per cent in real terms. Spending on hospital-based services increased by 8.4 per cent in cash terms and by 2.8 per cent in real terms.38
• Making improvements in preventing hospital care can increase costs in the community. For example, new care models to prevent admission to hospital increase the costs in community-based health and social care services, such as additional homecare, but the savings in hospital care are often not realised or transferred.
• New community-based care models may place additional pressure on councils already struggling to cope with demand for social care services and are not sustainable without a shift in funding.
• Public and political resistance to closing local hospitals or wards makes it difficult to release significant amounts of funding to invest in radically changing the way services are delivered.
• Closing a small number of hospital beds, or one or two wards, releases limited cash as many of the overhead costs remain or are only slightly reduced. Examples of overhead costs include theatre costs, input from staff covering a number of wards or specialties, cleaning and porter costs, and heating and lighting costs.
72. We did find some examples of local areas overcoming these difficulties and finding innovative ways to direct more funding to community-based care models. In Tayside, closure of community hospital dementia beds has allowed increased investment in community-based teams that are looking after more patients in their own homes. In Glasgow, the reablement service is helping more people to live independently and freeing up more resources for homecare Part 3. Making it happen | 35
services (Case study 8 [PDF] ). In Perth and Kinross and Highland, local areas are using tools to manage scarce resources and competing demands (Case study 9 [PDF] ). There are also lessons from other countries. In Canterbury, New Zealand, a long-term transformational programme and integrated system has increased investment in community-based care and shifted the balance of care (Case study 10 [PDF] ). The introduction of health and social care integration brings opportunities for partners to overcome barriers to shifting resources to more community-based and preventative services.
Changing models of care have implications for the structure and skills of the workforce 73. NHS boards and councils face major challenges in ensuring that staff with the right skills are able to provide new community-based models of care to meet the needs of the population. Recruiting and retaining staff on permanent contracts remains a significant problem for the NHS and the social care sector. In the NHS, vacancy rates, staff turnover rates and sickness absence levels all increased during 2014/15. Our NHS in Scotland 2015 [PDF] report stated that a national coordinated approach is needed to help resolve current and future workforce issues. It highlighted that the approach should assess longer- term changes to skills, job roles and responsibilities within the sector as well as aligning predictions of demand and supply with recruitment and training plans. This is necessary to help ensure the NHS workforce adapts to changes in the population’s needs and how services are delivered in the future. We plan to carry out further work on the NHS workforce during 2016/17.
74. Over many years, councils have had difficulties recruiting and retaining care home and homecare staff. Organisations in areas such as Edinburgh and Aberdeen, with high living costs, have had particular difficulties. There is a need to develop a valued, stable, skilled and motivated workforce. We plan to publish a report on Social Work in Scotland in Summer 2016. This will examine issues with recruiting and retaining social work staff in more detail.
75. To shift to more community-based services and care in homely settings, the availability and development of community-based staff with the right skills is crucial. But the balance of community-based staff has not increased significantly in recent years. For example:
• Between 2009 and 2013, the estimated number of GPs in post in Scottish general practices increased by less than one per cent, from 3,700 WTE to 3,735 WTE. The Royal College of General Practitioners in Scotland has calculated that an additional 740 GPs are required in Scotland by 2020, based on predicted population growth.39
• Between 2009 and 2014, there have been some changes in the number of people in the social care workforce. Adult day care services staff decreased by nine per cent. The number of adult care home staff increased slightly (one per cent). Staff providing housing support and care at home services increased overall by four per cent, however decreased by three per cent between 2009 and 2013, and only increased again between 2013 and 2014 by six per cent.40 Between 2010 and 2014 the number of people receiving homecare fell by nearly seven per cent to 61,740, while the total number of homecare hours rose by over seven per cent to 678,900. The number of people receiving ten or more hours of homecare per week, those with more complex needs, increased by four per cent to 21,700.41 36 |
76. A number of other workforce issues were raised in our fieldwork, including the following:
• Limited capacity in general practice to cope with increasing demand.
• An increasing workload for GPs and the wider primary care team from monitoring patients on long-term medicines.
• GPs do not have protected time for service development, research and strategic meetings. This makes it difficult for GPs to get involved in developing new care models.
• Fewer junior doctors are choosing general practice as a profession.
• Problems recruiting nurses in specialty areas linked to caring for frail and elderly patients.
• A need to train more nurses who currently work in hospitals so they can work in the community.
77. Some local areas are finding solutions to the workforce issues we describe above. We found examples of different groups of staff getting involved in new community-based care models to reduce the pressure on limited GP capacity. Different professions are also working together in multidisciplinary teams to provide more efficient and better quality care, for example in Glasgow, Grampian and East Lothian (Case study 11 [PDF] ).
78. BMA Scotland has set out a new role for GPs. It has proposed that GPs should be the senior clinical decision-makers in the community, become more involved in making improvements across the system and focus on complex care in the community. This would mean GPs being less involved in more routine tasks and other health professionals in the wider community team taking on extended roles.42 This is a proposal in the new National Clinical Strategy. A review of primary care out-of-hours services also recognises the importance of a multidisciplinary team approach and the contribution of the wider team. It proposes a new model for patient access to out-of-hours care.43
79. In June 2015, the Scottish Government announced it was providing a primary care investment fund of £50 million over three years to help address workload and recruitment issues in primary care. It is a modest amount and represents around 3.5 per cent of the Scottish Government’s primary and community services budget.44 The Scottish Government anticipates that it will provide an initial impetus to encourage GPs to try new ways of working over the next three years. But it is not clear how its effectiveness will be monitored.
80. Key elements of the three-year fund include the following:
• Primary Care Transformation Fund allocating £20.5 million to GP practices to test new ways of working to address current demand. The Scottish Government is developing a framework for the fund and is inviting health boards and integration authorities to develop proposals to test new ways of working in primary care. Information on the application process and selection criteria was made publicly available in February 2016. Part 3. Making it happen | 37
• An investment of £16.2 million for Pharmacist Independent Prescribers to recruit up to 140 new pharmacists. The aim is that they will work with GP practices to help care for patients with long-term conditions and to free up GPs’ time so they can spend it with other patients.
• A GP Recruitment and Retention Programme of £2.5 million to explore the issues surrounding recruiting and retaining GPs. The programme will implement proposals to increase the number of medical students who choose to go into GP training and encourage GPs to work in rural and economically deprived areas.
• A £6 million Digital Services Development Fund to help GP practices put digital services in place more quickly. This includes developing online booking for appointments and implementing webGP, an electronic consultation and self-help web service hosted on a GP practice’s website.
• The balance of just under £5 million will be used to fund:
–– equipment to enable optometrists to screen people for glaucoma –– changes to front-line services so that Allied Health Professionals, such as physiotherapists, can better support active and independent living –– a leadership programme to equip GPs with the necessary skills to play a leading role in developing local integration work –– additional research and training through the Scottish School of Primary Care.45 81. In February 2016, the Scottish Government announced a further £27 million investment over the next five years to develop the NHS workforce. This includes £3 million to train 500 advanced nurse practitioners and over £23 million to increase the number of medical school places and widen access to medical schools. A new entry-level programme will be introduced to support and encourage more people from deprived backgrounds to study medicine.
82. Many general practices are struggling to recruit and retain staff. During 2015, NHS boards had to support nine practices that were not able to continue as successful businesses and provide the services required to their local population. This may become an increasing problem in light of the building pressures we have outlined throughout this report what impact it has on. Where NHS boards have had to step, it is not clear what impact this has had on the performance of practices and the services provided to patients. The Scottish Government should monitor these practices for any improvements or deterioration in the way services are provided, and share any learning.
A better understanding of the needs of local populations is required 83. NHS boards, councils and partnerships need to have a good understanding of their local population and how people use different services so they can provide services that effectively meet local needs. This understanding can help to identify where resources, including money and staff, are being directed and if they are using these resources in the best way. It can also help to identify changes required to the way services are delivered and how resources can be redirected to priority areas. 38 |
84. We found that NHS boards, councils and partnerships are at varying stages with this kind of analysis and taking different approaches to it. However, integration authorities will all have to carry out needs assessments of their local population, and this is an important step in improving local analysis. The organisations that are making good use of their local data are starting to think differently about how they can best deliver and redesign services. They are identifying a small number of priorities to focus on, which is much more manageable than trying to fix everything at once. It is also more effective than having too many small-scale projects that are difficult to manage and unlikely to demonstrate a significant impact.
Health and social care data is improving 85. ISD is developing an extensive database of linked data on health and social care activity and costs and demographic information. It is making this information available to NHS boards, councils and partnerships to help them gain a better understanding of the needs of their local population, current patterns of care and how resources are being used. The Health and Social Care Data Integration and Intelligence Project (HSCDIIP), now known as Source, is a long-term project that aims to support integration authorities by improving data sharing across health and social care.46 From April 2015, the central team has begun sharing local data in the form of an interactive dashboard that contains easy-to-read information summaries. This has required local areas to sign an information governance agreement to enable NHS boards and councils to view each other’s data across a local population. Some partnership areas have taken some time to get these agreements in place and therefore gain access to the analysis. As at February 2016, five partnerships had finalised these agreements and undergone training for the software that will allow them to access and analyse the linked data for their local area (Angus, Borders, Dumfries and Galloway, East Renfrewshire, and Midlothian). This is the first time this linked data has been available and this is a valuable resource for partnerships.
86. ISD is also providing data and analytical support through a Local Intelligence Support Team (LIST) initiative. This allows partnerships to have an information specialist from ISD working with them in their local area. The central team can also provide additional support and tailored analysis. This includes forecasting costs, pathway analysis to show how individuals move from one service to another, and the resource associated with the use of different services at a local population level.
87. Some areas have made good use of the support provided by the Source team to better understand their population and also the data that has been made available to them. This includes Perth and Kinross, East Lothian, and West Dunbartonshire (Case study 12 [PDF] ).
88. These examples demonstrate how detailed analysis of local data at a local area and individual level is crucial in understanding the needs of a population, how people are currently using services and how costs are incurred. This then provides local areas with the information they need to identify how services can be provided differently and more efficiently to provide better outcomes for people and reduce costs. Using this information to identify the individuals at most risk of their health deteriorating allows preventative measures to be put in place or for care to be provided in a more effective and efficient way. This has the potential to free up resources across the whole system. If local areas do not have this level of information, they will not be able to properly plan or transform services in the future. Part 3. Making it happen | 39
89. ISD is in a good position, through the Source and LIST work, to share good practice about data analysis across all partnership areas. ISD held a conference in September 2015 to share early learning from across Scotland. ISD should continue to share good practice. This could include:
• hosting further national events
• publishing good practice examples on its website to illustrate how local areas are making good use of data
• developing toolkits to assist partnership areas to identify appropriate approaches to analysing and understanding local data. 40 |
Endnotes
1 Projected Population of Scotland (2014-based), National Records of Scotland, October 2015.
2 There is a discontinuity in healthy life expectancy (HLE) data owing to a change in methodology to align with the European Union. This results in estimates of HLE at birth from 2009 onwards being over eight years lower than in 2008 for each sex.
3 Healthy life expectancy: Scotland, Scottish Public Health Observatory, December 2015.
4 Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study, K Barnett, S Mercer, M Norbury, G Watt, S Wyke and B Guthrie, Lancet, May 2012.
5 Patient encounters in very deprived areas, G Watt, British Journal of General Practice, January 2011.
6 Frailty and the geriatrician, Age and Ageing, vol 33, no 5, pp 429–30, Rockwood K, Hubbard R, 2004.
7 Think Frailty: Improving the identification and management of frailty, Health Improvement Scotland, April 2014.
8 The care of frail older people with complex needs: time for a revolution, The King's Fund, March 2012.
9 SMR01 activity analysis provided to Audit Scotland by ISD, November 2015.
10 Scottish Government analysis of projected health and social care expenditure. Provided to Audit Scotland in February 2016.
11 NHS in Scotland 2015 [PDF] , Audit Scotland, October 2015.
12 Scotland’s Spending Plans and Draft Budget 2016-17, Scottish Government, December 2015.
13 An overview of local government in 2015 [PDF] , Audit Scotland, March 2015.
14 IRF-NHS Scotland and Local Authority Social Care Expenditure-Financial Years 2010/11-2013/14, ISD Scotland, March 2015.
15 Stocktake of access to general practice in England, National Audit Office, November 2015.
16 2020 Vision: Strategic Narrative, Scottish Government, September 2011.
17 http://www.gov.scot/Topics/Health/Policy/Adult-Health-SocialCare-Integration/Outcomes
18 Core Suite of Integration Indicators, Scottish Government, March 2015.
19 Health and social care integration: Progress update [PDF] , Audit Scotland, December 2015.
20 A Stronger Scotland: The Government's Programme for Scotland 2015-16, Scottish Government, September 2015.
21 The ten test sites are in Glasgow, Edinburgh, Fife, Tayside, Forth Valley, Campbeltown, West Lochaber, Islay, Mid-Argyll, and Clackmannanshire.
22 Place-based systems of care, The King's Fund, November 2015.
23 The Buurtzorg Nederland (homecare provider) model, Observations for the United Kingdom (UK), Royal College of Nursing, 2015.
24 NHS in Scotland 2013/14 [PDF] , Audit Scotland, October 2014; Reshaping care for older people [PDF] , Audit Scotland, February 2014; Review of Community Health Partnerships [PDF] , Audit Scotland, June 2011. Endnotes | 41
25 NHS in Scotland 2015 [PDF] , Audit Scotland, October 2015.
26 Route Map to the 2020 Vision for Health and Social Care, Scottish Government, May 2013.
27 NHS in Scotland 2015 [PDF] , Audit Scotland, October 2015.
28 Evaluating integrated and community-based care: How do we know what works?, Nuffield Trust, June 2013.
29 From 2015/16 to 2017/18, the Scottish Government is providing the following funding to local bodies to support improvements in health and social care: £300 million integrated care fund; £100 million to reduce delayed discharges; £30 million for telehealth; £60 million to support improvements in primary care; £51.5 million for a social care fund.
30 Reshaping Care for Older People: A Programme for Change 2011‑2021, Scottish Government, August 2012.
31 Reshaping Care for Older People [PDF] , Audit Scotland, February 2014.
32 Making change possible: A Transformation Fund for the NHS, The Health Foundation and the King's Fund, July 2015.
33 Laying the Foundations for an integrated improvement resource, Healthcare Improvement Scotland, Quality and Efficiency Support Team, Scottish Government and Joint Improvement Team, September 2015.
34 NHS Scotland Staff Survey: National Report, Scottish Government, November 2015.
35 The 2014/15 audit of NHS Highland: Update on 2013/14 financial management issues [PDF] , Audit Scotland, October 2015
36 NHS Fife 2014/15 annual audit report for the board of NHS Fife and the Auditor General for Scotland [PDF] , Audit Scotland, June 2015.
37 Financial Monitoring Report for the 5 month period to 31 August 2015, Board Papers, NHS Greater Glasgow and Clyde, October 2015.
38 IRF-NHS Scotland and Local Authority Social Care Expenditure-Financial Years 2010/11-2013/14, ISD Scotland, March 2015.
39 A Blueprint for Scottish General Practice, Royal College of General Practitioners Scotland, July 2015.
40 Scottish Social Service Sector: Report on 2014 Workforce Data, Scottish Social Services Council, August 2015.
41 Health and Social Care Datasets-Social Care Survey, Scottish Government, 2015.
42 Redesigning primary care for Scotland’s communities, BMA Scotland, December 2015.
43 Main Report of the National Review of Primary Care Out of Hours Services, Scottish Government, November 2015.
44 Scottish Budget: Draft Budget 2015-16, Scottish Government, October 2014.
45 Primary care investment news release, Scottish Government, June 2015.
46 http://www.isdscotland.org/Health-Topics/Health-and-Social-Community-Care/Health-and-Social-Care- Integration/docs/health-and-social-care-information-flyer-141211.pdf
Changing models of health and social care
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Health and social care series Changing models of health and social care Case studies and supplementary materials
Prepared by Audit Scotland March 2016 The Accounts Commission The Accounts Commission is the public spending watchdog for local government. We hold councils in Scotland to account and help them improve. We operate impartially and independently of councils and of the Scottish Government, and we meet and report in public.
We expect councils to achieve the highest standards of governance and financial stewardship, and value for money in how they use their resources and provide their services.
Our work includes: • securing and acting upon the external audit of Scotland’s councils and various joint boards and committees • assessing the performance of councils in relation to Best Value and community planning • carrying out national performance audits to help councils improve their services • requiring councils to publish information to help the public assess their performance.
You can find out more about the work of the Accounts Commission on our website: www.audit-scotland.gov.uk/about/ac
Auditor General for Scotland The Auditor General’s role is to: • appoint auditors to Scotland’s central government and NHS bodies • examine how public bodies spend public money • help them to manage their finances to the highest standards • check whether they achieve value for money.
The Auditor General is independent and reports to the Scottish Parliament on the performance of: • directorates of the Scottish Government • government agencies, eg the Scottish Prison Service, Historic Scotland • NHS bodies • further education colleges • Scottish Water • NDPBs and others, eg Scottish Police Authority, Scottish Fire and Rescue Service.
You can find out more about the work of the Auditor General on our website: www.audit-scotland.gov.uk/about/ags
Audit Scotland is a statutory body set up in April 2000 under the Public Finance and Accountability (Scotland) Act 2000. We help the Auditor General for Scotland and the Accounts Commission check that organisations spending public money use it properly, efficiently and effectively. Changing models of health and social care: Case studies and supplementary materials | 3
Contents
Introduction 4
System diagram of new care models 5
Case studies:
1. Population health models of care (Forfar and Nuka) 7
2. Tayside's enhanced community support service 9
3. New approaches to patient care in Govan 10
4. The Buurtzorg model of care 12
5. Forth Valley’s Advice Line For You (ALFY) 13
6. The Scottish Ambulance Service’s longer-term strategic approach 14
7. Scottish Centre for Telehealth and Telecare’s three-year programme 16
8. Overcoming barriers to directing funding to new care models 17
9. Redirecting resources to priority areas 18
10. Shifting resources to community-based settings; examples from other countries 20
11. Overcoming workforce challenges to providing new care models 21
12. Local areas making good use of data analysis 23
Links to useful information 24 4 |
Introduction
This supplement accompanies the main report Changing models of health and social care. We have identified a number of new care models introduced across Scotland that are designed to deliver more care to people in community settings in line with the 2020 Vision. At a local level, we have identified different types of care models, including:
• community preventative approaches
• better access to primary care and routine hospital treatments
• enhanced community care models
• intermediate care models
• initiatives designed to reduce delayed discharges.
We have not reviewed all new models in all areas of Scotland. We have selected a number of examples in some areas of Scotland to illustrate the different types of models that exist. We highlight particular aspects of good practice from these case studies in Part 3 of the main report and how these might help NHS boards, councils and integrated authorities overcome some of the barriers to introducing new ways of working.
Most initiatives are at a relatively early stage and have yet to be fully evaluated. This means the potential outcomes for service users and impact on resources are still to be fully established. We were not able to carry out a cost benefit analysis for the care models described in our report owing to a lack of local cost information.
Various principles should be followed for new care models to be implemented, tested, evaluated and rolled out successfully. If local bodies are to expand and roll out new models, they must have thorough information on the costs involved for planning and ensuring the models are sustainable. We summarise principles for implementing new care models in Exhibit 9 in the main report. System diagram of new care models | 5
System diagram of new care models
Most new care models are designed to relieve pressures on the acute sector but they can have an impact on different parts of the health and social care system. A high-level system diagram showing where the models of care (described in Exhibit 6 in the main report) sit within the overall health and social care system is set out on (page 6). Many of these care models are described in more detail in the following case studies.
This diagram shows the different types of models in the context of people's increasing health and social care needs and the complexity of care they require. The different types of models aim to provide the most appropriate care in the most appropriate setting, and wherever possible in the person's home or a homely setting in the community. Where hospital care is the most appropriate option, there are models that support quicker discharge of people, with ongoing care needs, back into the community. 6 |
System diagram of new care models
Increasing health and social care needs and complexity
Acute care/ hospital services
Enhanced Reducing delayed Improved access to Intermediate care – community discharges primary care and step up beds support Examples: Tayside routine hospital Enhanced community care Enhanced Community treatments Examples: Tayside Enhanced Support Service, East Examples: Community Support Service, Lothian’s Hospital to Home Community health East Lothian Service for and Discharge to Assess hubs in Forth Valley the Integrated care of the services, Glasgow 72- hour and Fife, new Elderly, Forth Valley’s Advice discharge model model of delivering Line For You, Govan SHIP healthcare for the Intermediate care – step down project, Community-based Small Isles beds and reablement Example: dementia care service in Glasgow Reablement Service Perth and Kinross Community- Emergency Other Care Care at GP based social work community homes home practices support service health services
GP out of hours NHS 24 service
Self-management/ Community preventative approaches prevention Examples: Living it up, House of Care, Forfar population health model of care, CAREplus initiative, Links Worker programme Case studies | 7
Case studies
Case study 1 Two GP surgeries in Forfar are joining together to deliver a population health model of care based on the Alaskan Nuka model of care A GP practice in Forfar is developing a new model of care to improve access, health and wellbeing and sustain services in the longer term.
Forfar model
Patients and staff in Forfar have been involved in designing a new model of primary care, due to be launched in 2016, that aims to ensure that:
• patients are seen in the right place at the right time by the right person
• patients are encouraged to take control of and manage, their own care with support from staff, and that patient experience and outcomes are positive
• staff are positive about making the model work, and their skills are used effectively, and that the practice is profitable and able to continue over the longer term.
The merged practice will split into small integrated teams each working from the same site. The teams will include GPs, nurses, healthcare assistants, administrative staff and community nurses, each looking after a population of around 2,820 patients. Each patient is looked after by a small team to enable continuous care by the same professionals and develop positive relationships. The team will aim to provide as much support as they can every time the patient needs to attend the practice to reduce the need for return visits. Patients will speak to a member of the team before they attend the practice to work out which members of staff they should see when they come in. The practice will carry out all tests and investigations at the same time if possible. There are plans for each team to also provide a psychology and a social prescribing service (linking people up to activities in the community they might benefit from). 8 |
Nuka model
The Nuka model of care from Alaska has influenced the model the Forfar population is developing. Multidisciplinary teams provide integrated health and care services in primary care centres and the community. These are coordinated with a range of other services and combined with a broader approach to improving family and community wellbeing. This includes education, training and engaging with the community across the population about issues such as abuse, neglect and domestic violence. All of Nuka’s services aim to build on the culture of the Alaska Native community.
Native Alaskans create, manage and own the whole healthcare system. They do this by:
• being actively involved in the management and governance structure
• participating in advisory groups in their local areas
• taking part in surveys, focus groups and telephone hotlines used by managers to ensure that people can give feedback that is acted on.
Since it was established, the Nuka model of care has significantly improved access to primary care services. Customer satisfaction has increased and there have been large reductions in emergency care and hospital admissions.
Source: Transforming Primary Care Service Delivery in Forfar, Creating a healthier Scotland website, 2015 ; Nuka system of care, Alaska, King's Fund, 2015 Case studies | 9
Case study 2 Tayside's older people locality model and enhanced community support service Tayside has combined its older people locality model that aligns consultant geriatricians to GP practices, with an enhanced community support service.
The Tayside approach aims to:
• prevent older people at risk of an unplanned hospital admission being admitted by identifying them and giving them an enhanced level of support at home before they reach crisis point
• facilitate patients' discharge from Ninewells (the acute hospital) to home or to a more homely setting, such as a community hospital.
The enhanced community support service is delivered by a multidisciplinary team (MDT) at GP practice level. The patient's assessment is led by the GP while the enhanced care package tends to be coordinated by either an advanced nurse practitioner specialising in medicine for the elderly or a senior district nurse with time protected for the assessment of frail people and care coordination. The MDT, which also involves nurses, community pharmacists, allied health professionals, community mental health staff and social workers, meet weekly to discuss patients currently receiving the enhanced service and to identify others who could benefit from the service. The teams also have links with the voluntary sector.
What makes this model different from others in Scotland is the integration of care between the primary and acute sectors in local areas through the alignment of consultant geriatricians with GP practices. As well as attending the weekly practice-based MDT meetings, the consultant geriatrician will be involved in the care of any patients from that practice admitted to hospital. They will be well placed to advise the MDT on what will be required to be in place for individual patients to be discharged from hospital, providing a continuity of care.
Three council areas within NHS Tayside, Dundee City, Angus, and Perth and Kinross, have developed this approach at different rates. As they have done this they have built on existing services and improvement work and responded to the specific needs of the area. Across Tayside, as at September 2015, the model covered 27 per cent of people aged over 75. The three areas within Tayside are continuing to roll out this approach.
Source: Audit Scotland 10 |
Case study 3 The impact on patients of new approaches to patient care in Govan Patient stories describe how the Govan SHIP (Social and Health Integrated Partnership) project made a difference to the number of attendances at A&E for one individual and how the care of an elderly person with dementia was improved.
Three new, linked approaches to delivering health and social care have recently been introduced in Govan, one of the most deprived areas in Scotland:
• The Govan SHIP project aims to reduce demand on acute and residential care and improve chronic disease management. Four GP practices in Govan Health Centre are involved in the project, which adopts a multidisciplinary approach. Each multidisciplinary team (MDT) is made up of professionals from across hospitals and the community, including social care, and manages patients in crisis. The patients selected for the project are children and adults who are known to be vulnerable, for example people with mental health problems and/or addiction issues, people who use services frequently and older people and adults with complex needs.
• Patients with complex and/or multiple conditions may be eligible to be part of the CAREplus initiative. Inclusion allows patients to be given longer consultations with a GP or nurse. This enables them to discuss their problems in more detail and make a list of priorities.
• The Scottish Government-funded Links Worker Programme has placed community links practitioners in two GP practices in Govan. They are not medically qualified, but link practices and patients with community-based services and resources such as lunch clubs and self-help groups based on individual patient's needs.
The Govan SHIP project has developed patient stories to illustrate the difference the new approaches in Govan have made since they were introduced in April 2015.
Patient story 1
This story concerns a 22-year-old with known personality disorder and anxiety illness. In seven years, this person had presented to A&E 590 times. Multiple agencies were involved in the person's care, including psychiatry, general practice, emergency care, third sector support agencies and a prison liaison officer.
By including this individual in the Govan SHIP project, the GP's time could be freed up by one of the two locum GPs funded through the project, to allow them to attend regular meetings about the care of the person. These were also attended by psychiatry, a prison officer, social work, A&E and GP out-of-hours colleagues. A plan for a regular, prolonged, 30-minute appointment with the GP was instigated with weekly follow-up by community psychiatric nursing and a clear plan for out of hours was written and documented. Case studies | 11
Prior to involvement in the project, the person had attended A&E 30 times between November 2014 and January 2015. Since the person began regularly attending GP appointments in January 2015, there have been only six presentations between May 2015 and July 2015.
Patient story 2
This story concerns a 66-year-old with dementia whose social circumstances are extremely poor. The person's carer is their daughter who has serious addiction issues. There were significant concerns for this person’s safety at home although they wished to remain there and had the capacity to make that decision.
Enrolling this patient in the Govan SHIP project allowed a round-table discussion with multiple agencies. This included joint visiting with social work and addiction teams who were involved with the carer and also by psychiatry. GP attendance at multidisciplinary meetings allowed for the sharing of additional information, which could then be passed on to the carer. This resulted in enhanced engagement with the carer, care staff and social work. A plan was set in place to allow Cordia (home care provider) to gain access for personal care and support and for Key Housing (housing association) to assist in improving the standard of cleanliness within the home.
Without involving this person in the project, the GP would not have been able to attend MDT meetings. Engagement with the carer and the multiple agencies involved in the person's care would also have been much more difficult.
Source: Audit Scotland; The Govan SHIP (Social and Health Integrated Partnership) Project, Creating a healthier Scotland website, 2015 12 |
Case study 4 The Buurtzorg model of care The Buurtzorg approach is an internationally renowned model of care from the Netherlands.
Founded in the Netherlands in 2006/07, Buurtzorg is a unique district nursing system which is internationally renowned for being entirely nurse-led and cost effective. Before Buurtzorg, home care services in the Netherlands were fragmented with patients being cared for by multiple practitioners and providers.
Ongoing financial pressures within the health sector led to home care providers cutting costs by employing a low-paid and poorly skilled workforce. They were unable to properly care for patients with complex needs and this led to a decline in patient health and satisfaction.
Buurtzorg’s answer to this problem was to give its district nurses far greater control over patient care. Nurses lead the assessment, planning and coordination of patient care. The model consists of small self- managing teams with a maximum of 12 professionals including nurses and allied health professionals such as occupational therapists. These teams coordinate care for a specific catchment area.
The Buurtzorg service:
• provides a holistic assessment of an individual's needs, including their medical, personal and social care needs, that feeds into a care plan
• identifies networks of informal care and assesses ways to involve these carers in the individual's treatment plan
• identifies any other formal carers and helps to coordinate care between providers
• delivers a range of care from basic nursing to palliative care
• supports clients in their home
• promotes self-care and independence.
Source: A new perspective on elder care in the Netherlands, The Journal (AARP International), 2011 Case studies | 13
Case study 5 Forth Valley's Advice Line For You (ALFY) Forth Valley has combined a nurse-led telephone advice service with a focus on self-management of care.
Forth Valley's ALFY model is a nurse-led telephone advice service designed to support older people to remain well at home. It is aimed at people aged 65 and over and their carers and is available 24 hours a day, seven days a week. The initiative was successfully piloted in Bo'ness and has recently been rolled out across Forth Valley.
Experienced nurses provide advice and support at points of uncertainty or crisis. Support ranges from:
• providing general health advice and reassurance
• arranging a nurse assessment and organising a home visit day or night
• organising for certain equipment to be provided to support people at home
• arranging an appointment to attend the Rapid Access Frailty Clinic at the acute hospital
• providing access to general or specialist medical advice or review as required
• arranging a referral to the community rehabilitation service
• prioritising access to social care services determined by need
• giving people information about local voluntary organisations.
As part of the initiative, older people are also encouraged to develop a personal care plan known as Your Plan and share this with their family, and those people closest to them, as well as health and care professionals. Your Plan allows people to document in one place all the important things that matter to them about their health and care needs. By sharing this information, everyone will know what to do if a problem arises and what support they could give to help people maintain a good life.
Source: Audit Scotland; http://nhsforthvalley.com/alfy 14 |
Case study 6 The Scottish Ambulance Service's longer-term strategic approach The SAS's strategy aims to treat more patients in the community.
The Scottish Ambulance Service's five-year strategy Towards 2020: Taking Care to the Patient aims to increase the proportion of patients treated at the scene. The service developed the strategy in consultation with stakeholders and the general public. It has been built around the levels of emergency categories and the top ten conditions of patients they treat. The different types of patients' conditions require quite different responses, for example around 40 per cent of patients require immediate emergency care that will require them to be treated in a hospital. Around 60 per cent have a minor ailment or an exacerbation of a long-term condition that could potentially be treated in the community or require more diagnostic assessment to ensure they get to the right place for treatment first time.
This approach requires closer working with primary care to ensure patients are referred to the most appropriate service. This ensures they are treated in the community, if appropriate, with adequate support. The SAS is also investing in:
• technology to improve diagnostics and treatment provided on the scene
• training and skills development of the workforce in treating common long-term conditions and more preventative approaches to keep patients at home or in a homely setting.
Examples of the approaches the SAS is implementing as part of their strategy include the following:
• In NHS Borders and Lothian, ambulance staff are developing extended skills to enable them to operate as practitioners to see, treat and discharge, or refer patients. This allows patients to remain at home or in the community.
• In Grangemouth, paramedics are working within general practice during normal hours from Mondays to Fridays.
• In NHS Lanarkshire, the SAS is helping to develop an Age Specific Service Emergency Team (ASSET) hospital at home service for frail and elderly patients who are over 75 in North Lanarkshire.
• A system for dealing with falls across all 32 partnership areas in Scotland. Evidence shows that in around 40-50 per cent of calls to the SAS, the person is uninjured. However, previously the SAS had little or no access to community services, as an alternative to taking the patient to hospital. More recently, the SAS has worked with partnerships to get rapid access to falls teams to reduce the number of people who are taken to hospital due to a fall. Case studies | 15
The strategy is backed up by a workforce development plan, a digital technology plan, and a financial plan. The first year of the plan has been funded by non-recurring funding. But the SAS will require extra funding each year to implement the subsequent four years of the plan up to 2020. The Scottish Government has approved the strategic and financial plans outlining an additional recurring investment of around £21.4 million over five years, with equal levels of additional expenditure required. In its draft budget for 2016-17, the Scottish Government plans to increase revenue funding to the SAS by 1.7 per cent and to allocate a recurring amount of £5 million to support the five-year strategy.
Source: Audit Scotland; Towards 2020: Taking Care to the Patient, Scottish Ambulance Service, 2015 16 |
Case study 7 Scottish Centre for Telehealth and Telecare (SCTT) Technology Enabled Care (TEC) Programme The TEC programme is encouraging more use of tried and tested technology to help improve health and wellbeing outcomes.
Telehealth and telecare aim to improve outcomes for individuals in their homes or in community settings by using technology as an integral part of their care and support. Examples of telehealth and telecare approaches include:
• door contact alarms for people with dementia
• using video-conferencing to diagnose patients in remote areas
• using home health monitoring devices, such as oxygen gauges, for patients suffering from lung disease
• making online information available so people with long-term conditions can take control of their own care.
These resources can help people maximise their independence and provide support to carers, as well as preventing them from being admitted to hospital and, if they are, making it easier for them to get an earlier discharge.
The SCTT Technology Enabled Care (TEC) Programme is a £30 million initiative to encourage more use of tried and tested technology to help improve health and wellbeing outcomes from 2015 to 2018. The programme was developed after evidence from the Joint Improvement Team's review of the Telehealth and Telecare Delivery Plan. It found that many small-scale projects in this area had no clear plans on how to make them available to more people.
The TEC Programme focuses on scaling up five key areas that have proven to work to make them sustainable in the longer term:
• home health monitoring
• NHS video-conferencing
• telecare packages
• online platforms that give people direct access to information, advice and assistance
• switching telecare from outdated, expensive, telephone-based technology to more efficient and integrated digital technology.
Source: Audit Scotland; Scottish Centre for Telehealth and Telecare; Joint Improvement Team Case studies | 17
Case study 8 Examples of overcoming barriers to directing funding to new care models Some local areas are finding ways to direct more funding to community-based care models.
Moving money away from institutional-based care
There are some examples of disinvestment in small community hospitals, rather than large acute hospitals, to increase investment in community-based care models. NHS Tayside has closed beds in a number of community hospitals to fund services in more homely settings. In Angus, the closure of a community hospital helped to fund the enhanced community support service (Case study 2). In Perth and Kinross, the closure of a number of community hospital dementia beds released resources to help develop community older people mental health teams. In the Strathmore area, the year before the hospital dementia unit closed, 40 patients were admitted for acute dementia assessment or intervention. The community-based team now provides care for over 800 people living with dementia in their homes. In Pitlochry, the dementia unit was closed. This allowed the board to transfer staff into the North West community-based mental health team. In the previous year, 19 patients were admitted into the hospital unit. The team is now visiting around 300 patients in their homes. These services were developed without any additional funding, apart from a small amount of money to support project management and training and development of staff in the Strathmore service.
Community interventions to release more funding
Glasgow City Council, in partnership with NHS Greater Glasgow and Clyde, has a reablement programme to support people to remain at home safely and independently for as long as possible. With increasing demand for home care services, it has freed up resources, including money and staff, to allow more home care services to be provided. People referred for home care are assessed to find out if they are suitable for the reablement programme. Over the last three years, on average around 40 per cent of people who have completed the programme required no further home care. For people who require ongoing support there has been around a 20 per cent reduction in home care packages. The reablement programme released cash savings in the home care budget of £2.75 million in 2013/14 and £1.75 million in 2014/15. For 2015/16, Social Work has set a target to make efficiency savings of ten per cent across all care at home services, including reablement, provided by external provider Cordia.
Source: Audit Scotland 18 |
Case study 9 Examples of redirecting resources to priority areas Some local areas are using tools to manage scarce resources and competing demands.
Some areas are adopting a programme budget and marginal analysis (PBMA) approach. This considers:
• how current available resources are used
• if more resources should be directed to certain services or groups of people
• where care could be provided more efficiently and more resources redirected to priority areas
• areas of care where fewer resources should be allocated as they could be used more effectively in priority areas.
Perth and Kinross Partnership
• Perth and Kinross Council and NHS Tayside have carried out extensive analysis to gain a better understanding of the population and how people are using local health and social care services. They have found that there is considerable variation across the whole partnership area and also within local areas.
• They are currently considering how they can use the PBMA approach to reduce the level of variation and better use their resources. They are currently developing 'fair local area consumption targets'. These are based on current consumption patterns and include an efficiency component to stretch and encourage better use of resources.
• Each local area would receive a notional budget based on a consumption rate, multiplied by the weighted population. They would be able to compare this against current consumption to identify the potential they can gain from improving services and how their population accesses them. They would also be able to benchmark against other areas.
• It is hoped that benchmarking and discussions across local areas will drive changes in clinical decisions and lead to less variation and consumption levels closer to the 'fair consumption target'.
• The benefits of this approach are not just expected to be monetary. The aim will be to encourage more integrated working, more engagement and understanding of the range of community resources and assets, and to achieve better outcomes for the local population.
• The PBMA programme aims to give an incentive and identify opportunities and priorities to shift the balance of care away from high-cost hospital and care homes towards more community- based services in local areas. Case studies | 19
South and Mid-Highland care at home services
• In Highland the PBMA approach was used to look at reform of care at home services in South and Mid Highland. This had previously been seen as too big an issue to tackle all at once. The care at home services provided by the council had received poor quality ratings and there were difficulties in recruiting staff. Along with some closures and suspension of admissions to care homes, based on quality issues, this was having a negative impact on delayed discharges from hospital owing to lack of care provision.
• A development group was set up to examine how care at home services could be expanded to meet increasing need, and the quality of care improved. The main aim was to provide more home care hours, more efficiently by recruiting and retaining good staff.
• At the time the new model was developed, NHS Highland was purchasing care at home services from the independent sector at £15.97 an hour, while the in-house service cost was about £29 an hour. The independent sector hours were also delivered at a higher quality grading and with greater flexibility.
• The approach the group took was to shift to more independent care at home services, suspend in-house recruitment of care at home staff, and to increase the hourly purchase rate by £0.75 to move closer towards a living wage. (The UK Home Care Association calculated the hourly rate councils should pay to providers in order to comply with the UK living wage was £18.59 – applicable at November 2014.)
• This resulted in a reduction of 12 whole-time equivalent in-house staff and £288,000 was reallocated from in-house services to the independent sector and self-directed support (around 4.5 per cent of the overall budget). There has been a decrease in the number of people delayed from discharge from hospital. It is less than the group predicted, but it may be too early to see the full impact of the change which was implemented in late 2014.
• The group decided to implement the full living wage for independent sector staff from May 2015, at an additional cost of £767,000. This is to be financed by an accelerated reduction in the in-house service and non-recurrent funding of £500,000 to fund the double-running costs in 2015/16.
Source: Developing priority setting processes in Health and Social Care Partnerships: learning from the pilot sites, Scottish Public Health Network, November 2015 20 |
Case study 10 Examples of shifting resources to community-based settings from other countries In Canterbury, New Zealand, a long-term transformational programme and integrated system has increased investment in community-based care and shifted the balance of care.
From 2007, the District Health Board for Canterbury has been working towards an integrated health and social care system. It was initiated by the chief executive at the time, who recognised that the current way of operating was unsustainable. There was increasing pressure on hospital beds, long waiting times for patients, inefficient use of resources and the board was running a deficit against its budget.
Staff were fully involved in developing a long-term vision for what the health and social care system should look like in 2020, and how it should be changed. They were given explicit permission by the chief executive to change the system. A set of strategic goals and principles were agreed about how the system should develop and what it should look like. These placed the patient very much at the centre.
A focus on transformational change across the whole system led to hospital clinicians and GPs working together to achieve the same vision: shifting much more care into the community and reducing inefficiencies in the system. Although the new community models required considerable additional investment, the Board also reviewed spending in a number of areas. It reduced spending in areas with low impact and prioritised spending to those in greater need to reduce the reliance on residential care and keep people in their own homes for longer. This had the effect of reduced demand and costs for hospital and other institutional care, allowing for more investment in the community.
Key success factors of the approach in Canterbury include:
• strong leadership
• agreeing a clear vision that staff are signed up to and know what they are working towards
• a collaborative and whole system approach – 'one system, one budget'
• investment in large-scale, transformational change
• sustained support and investment in providing staff with the skills needed to innovate
• making the system more efficient and making best use of the existing budget.
Source: The quest for integrated health and social care: A case study in Canterbury, New Zealand, The King's Fund, September 2013 Case studies | 21
Case study 11 Examples of overcoming workforce challenges to providing new care models Some areas are developing models with other professionals taking over part of the GP role or supplementing it.
Govan Social and Health Integrated Partnership (SHIP) project
The budget for the SHIP project (Case study 3) includes funding for two locum GPs. This provides protected time for GPs involved in the project. It also allows them to provide extended consultations to patients with complex needs and take part in other clinical and project development activities.
Community Links Practitioners, whom we refer to in Case study 3, also help to relieve pressure on general practice and the limited time GPs have to spend with patients. They are able to spend time with patients to understand the wider non-medical issues that may be affecting their health and help them get access to suitable resources within their community that can benefit their health. This might include social and lunch clubs, self-help groups, befriending organisations, and employment or voluntary-work agencies.
Increased use of advanced nurse practitioners in NHS Grampian's out-of- hours service
Advanced nurse practitioners (ANPs) are highly qualified nurses, who have the clinical expertise, knowledge and experience needed to work at an advanced level of nursing practice. They are able to act as a senior clinical decision-maker, with the authority and autonomy to make complex decisions about a patient’s care.
GMED is NHS Grampian's urgent medical service when GP practices are closed. The GMED team is made up of a range of health professionals and support staff including GPs, advanced nurse practitioners, drivers and call handlers. As fewer GPs choose to do out-of-hours shifts and with evidence that GMED ANPs can manage approximately 95 per cent of patients, GMED has employed an increasing number of ANPs.
The 2015 national review of primary care out-of-hours services recommended the introduction of a similar GP-led model delivered by a multidisciplinary team. The principle behind the model is that patients will be seen by the most appropriate professional to meet their individual needs. That might not be a GP but could be a nurse, or a physiotherapist or social worker. 22 |
East Lothian hospital at home and integrated care model
This model provides local GPs direct access to emergency care at home for their patients with a single point of contact for people who are at risk of admission to hospital. It also allows patients to be discharged earlier from hospital and supported at home. The system works by local GPs taking over responsibility for the local population’s health and social care needs, including triaging, treating and directly admitting patients to local hospitals if required. Advanced nurse practitioners are picking up some of the GPs’ role, including home visits and prescribing and a key improvement has been supporting and addressing significant GP workload in care homes. In addition to nurses, the extensive multidisciplinary team includes a consultant physician, physiotherapist, occupational therapist, pharmacist, community psychiatric nurse, carer link worker, and dedicated emergency care support and input by social work. The team has a ‘huddle’ (a short meeting) every day to discuss the care patients need and any follow-up required once patients have been discharged from the service. To do this, the team liaises closely with GPs and district nurses as well as acute hospitals. The service is soon to extend to a 24-hour, seven day service and is working with the local primary care out-of-hours service to develop referral routes.
Source: Audit Scotland; Nurse Innovators: Clinical Decision-making in Action, RCN Scotland, 2015; GMED Out of Hours Service Information for Patients, Carers, Public and Interested Parties, NHS Grampian, January 2011; Main Report of the National Review of Primary Care Out of Hours Services, Scottish Government, 2015 Case studies | 23
Case study 12 Examples of local areas making good use of data analysis Some areas are making good use of data analysis to understand their local population and redesign services.
High resource individuals (HRIs) Across Scotland a small number of people with complex needs use a large amount of the overall resources in the health and social care system. This analysis has revealed that costs for each person vary vastly. The data is available at an individual level which allows local areas to examine the use of services by HRIs and how costs are incurred.
For example in Perth and Kinross, analysis of one general practice population showed that five per cent of the population (fewer than 150 people) used 54 per cent of the resources (£3.8 million). This pattern of a small number of people (2-5 per cent of each partnership) consuming about 50 per cent of all expenditure is replicated across Scotland. Local analysis has shown that people in the least deprived areas and in urban areas are higher users of services than those in more deprived areas and in rural areas. It has also shown that people who are high users of NHS services tend to be low users of social care services and vice versa.
End of life care and costs This is linked to HRI analysis. In the last 6-12 months before death, people tend to use significantly more health and social care services, particularly acute hospital services, and this results in higher costs. ISD and some local areas have been analysing the pattern of care for individuals to understand what this looks like and if care can be provided differently.
For example, East Lothian has one of the highest end-of-life care costs in Scotland. It also has one of the highest rates of people dying in hospital. Care home costs are also a significant part of the costs. The partnership is examining local data to better understand this pattern and find out if people are being admitted to hospital from care homes, from care homes to hospitals, or both. It is trying to determine if there is more it can do to prevent admission to hospital by providing more care in care homes or if there are different ways to deliver care other than in a care home.
Understanding the local population and projected use of services NHS boards and councils need to have good intelligence on the profile of the local population to understand current and future needs, and to plan future services.
For example, West Dunbartonshire has carried out analysis of long-term conditions within the local population, including service use and the associated costs, along with projections of the population and future demand for services. It is using this information to inform its strategic planning. It is also using this local intelligence for anticipatory care planning and identifying older people at risk of admission to hospital. The information is available to the whole health and social care team and has allowed resources to be directed towards additional support and community-based alternatives to hospital care.
Source: Audit Scotland 24 |
Links to useful information
We have drawn together links to various reports, toolkits and websites that NHS boards, councils and partnerships may find useful when developing new models of care.
Link to report, toolkit or other Description of information summary information Information Services Division (ISD) This document provides guidance on data sources available to support a local population needs assessment. Population needs assessment for health and social care partnerships NHS Scotland Quality Improvement Hub This website describes seven stages of implementing improvements, with questions at each stage and links to tools. Improvement journey Scottish Ambulance Service (SAS)/ This document provides practical guidance and case studies to Joint Improvement Team (JIT) help health and social care professionals, planners and managers. Although aimed at falls prevention, it has a useful checklist at the Making the Right Call for a Fall end about how to make organisational change work and questions to consider for implementing service redesign. Scottish Government A framework developed to help achieve significant lasting improvement across public services. It is designed to prompt 3-step Improvement Framework for self-assessment and debate, and to encourage those working in Public Services public services to create the conditions for, and implement, the improvements that will make a difference. Scottish Public Health Network This report describes the use of Programme Budgeting and Marginal Analysis (PBMA), an analytical approach to assessing the Developing priority setting processes costs and benefits of alternative courses of action. It can enable in Health and Social Care Partnerships: health and social care partnerships to identify the potential effect learning from the pilot sites of shifting patterns of investment, and disinvestment, within and between programmes of activity – in terms of outcomes for patients and service users, and effective use of resources. NHS England These websites provide details of the new models of care being tested in NHS England and planning tools to support New care models 'Vanguard sites' commissioners.
Planning support tools . Cont Links to useful information | 25
Link to report, toolkit or other Description of information summary information Health Foundation This blog by the Health Foundation talks about how to replicate and spread good practice and includes links to a number of resources on Information on spreading its website for scaling up and rolling out new ways of working. improvement The King's Fund • The King's Fund is an independent charity working to improve health and care in England. It publishes a large number of reports Transforming our health care system: and briefing papers that are equally as relevant to health and Ten priorities for commissioners social care services in Scotland. We have highlighted a few reports with useful checklists or tools.
Place-based systems of care • Ten design principles to guide systems of care (page 12) • Emerging examples of place-based systems of care in the NHS (page 30) The quest for integrated health and • 'Pictogram' of the new health and social care system in social care: A case study in Canterbury, Canterbury (page 9) New Zealand Nuffield Trust The Nuffield Trust has undertaken evaluations of over 30 community-based interventions designed to reduce emergency Evaluating integrated and community- hospital admissions. This report presents the key learning from based care: How do we know what these studies. works? The Nuffield Trust is developing a page on its website that will Developing evaluation methods to help pull together developments from its research project to develop the NHS provide care more effectively evaluation methods further, including published papers and details of events. ALLIANCE Scotland The Year of Care Partnerships developed a collaborative care planning approach to support people with long-term conditions. It is Scotland's House of Care being tested in a number of areas in Scotland.
Year of Care House For the latest news, reports Audit Scotland, 4th Floor, 102 West Port, Edinburgh EH3 9DN and updates, follow us on: T: 0131 625 1500 E: [email protected] www.audit-scotland.gov.uk
Changing models of health and social care Case studies and supplementary materials
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ISBN 978 1 909705 84 5 AGS/2016/02
This publication is printed on 100% recycled, uncoated paper
Clackmannanshire & Stirling Integration Joint Board
27 April 2016
This report relates to Item 13 on the agenda
Report of the Director of Public Health
(Paper presented by Dr Graham Foster)
For Noting
Approved for Submission by Shiona Strachan, Chief Officer Author Dr Graham Foster, Director of Public Health Date: 27 April 2016 List of Background Papers: Report of the Director of Public Health 2013-15, www.nhsforthvalley.com
Page 1 of 4
Title/Subject: Report of the Director of Public Health Meeting: Clackmannanshire & Stirling Integration Joint Board Date: 27 April 2016 Submitted By: Dr Foster Action: For Noting
1. Introduction
1.1. The purpose of this paper is to ask members to note the publication of the Report of the Director of Public Health: The Health of the Population of Forth Valley 2013 - 2015.
2. Executive Summary
2.1. The Director of Public Health in each NHS Board area is entitled to produce reports on the public’s health. The report describes the demographics and background health of the local population and highlights a number of key areas of public health work ongoing in NHS Forth Valley.
3. Recommendations
3.1. The Integration Joint Board is asked to: Note the NHS Forth Valley Report of the Director of Public Health 2013-15, which was approved by Forth Valley NHS Board on 26 January 2016 and is published on the NHS Forth Valley website.
4. Background
4.1. This is the first Report of the Director of Public Health produced by Dr Foster and covers the period from October 2013.
5. Main Body Of The Report
5.1. The report describes the demographics and background health of the local population and highlights a number of key areas of public health work ongoing in NHS Forth Valley, described under three main themes;
• Service improvement and development – planning, delivering and evaluating the range of interventions provided by NHS Forth Valley and partners in order to better meet the needs of the population. • Health improvement – helping people to maximise their wellbeing by making healthy choices, and developing knowledge and skills. • Health protection – delivering interventions that reduce the risk of communicable disease and environmental hazards.
Page 2 of 4
The report does not attempt to provide comprehensive comment on all areas of work but each section selects a number of key elements from the above three themes and provides an overview of the range of work undertaken.
Since 2009 the report is no longer published as a printed report but instead is available via the NHS Forth Valley website. Previous annual reports included large volumes of data published annually but in response to new technologies this report provides only a local summary from the vast resources now readily available via the internet. Where possible the electronic version provides web links to relevant background data and other useful resources and web sites.
Dr Foster suggests a vision for Public Health in Forth Valley focused on three main areas;
• children and the early years • ‘worthwhile work’ • substance misuse
By concentrating efforts around these three pillars Dr Foster hopes to improve the health and wellbeing of our local population and break the vicious cycle of challenging circumstances in the early years leading to difficulties in securing employment and the potential for increasing substance misuse.
Work in collaboration with partners in these three areas will influence a much broader spectrum of health outcomes over and above those within each pillar.
Dr Foster explains that in keeping with the Scottish Government 2020 vision, NHS Forth Valley has been working, as part of our Clinical Services Review, to provide more efficient services that will help people to live longer healthier lives closer to home. This will be achieved through; integration of health and social care, a greater focus on prevention, anticipatory care plans and self management and a shift towards treatment in a community setting with day case treatment available when required. Care will be provided to the highest standard of quality whatever the setting. All decisions will be made with the person at the centre and the focus will be on ensuring that people are able to return to their home or community environment as soon as appropriate whilst minimising the risk of re-admission.
Addressing health inequalities underpins all public health work. Substantial areas of Forth Valley are deprived and have high levels of behaviours and diseases associated with deprivation, for example, substance use, obesity, heart disease and cancer. For those who live in less deprived areas, health challenges include a lack of physical activity, poor diet and the environmental impacts of our 21st century lifestyle.
Dr Foster advocates a local approach to public health work that will focus primarily on the ‘upstream’ underlying causes of inequalities in health.
Page 3 of 4
6. Conclusions
6.1. The Integration Joint Board is asked to note the content of the report and the proposed targeted approach using three pillars of public health action.
7. Resource Implications
7.1. There are no direct resource implications for the Integration Joint Board.
8. Impact on Integration Joint Board Outcomes, Priorities and Outcomes
8.1. The report supports IJB outcomes as set out in the Strategic Plan.
9. Legal & Risk Implications
9.1. None.
10. Consultation
10.1. None.
11. Equality and Human Rights Impact Assessment
11.1. The report describes inequalities in health and wellbeing.
12. Exempt reports
12.1. N/A
Page 4 of 4
Report of the Director of Public Health
The Health of the Population of Forth Valley 2013-2015
Table of Contents
Foreword...... 3 Facts and figures about the people living in Forth Valley ...... 6 NHS Forth Valley ...... 6 Population by age, Local Authority and gender ...... 7 Population projections ...... 8 Economic circumstances of Forth Valley people ...... 9 Trends in common diseases ...... 11 Heart Disease ...... 11 Stroke ...... 13 Cancer ...... 14 Diabetes ...... 15 Service Improvement and Development ...... 16 Health and Social Care Integration ...... 16 Clinical Services Review ...... 16 Health Improvement ...... 20 Early Years Collaborative ...... 20 Oral and Dental Health ...... 22 Substance Use ...... 23 Alcohol ...... 23 Alcohol-related deaths in Scotland ...... 23 Smoking ...... 26 Prison health ...... 27 The Value of Community ...... 29 Asset based approach ...... 29 Keep well ...... 30 Examples of health improvement work ...... 31 Healthy weight ...... 31 Health Protection ...... 33 Protecting the population from Tuberculosis ...... 33 Immunisations ...... 34 Childhood Immunisation Programme ...... 34 New Immunisation programmes ...... 35 Emergency Planning and Civil Contingencies ...... 36 Prevent Strategy ...... 36 Blood borne viruses (BBV) and Sexual Health ...... 37 Screening ...... 38 Adult screening- ...... 38 Pregnancy and Newborn screening ...... 38 Breast ...... 39 Cervical ...... 39 Bowel ...... 39 Summary...... 40
2
Foreword
As Director of Public Health and Strategic Planning, I am pleased to present this report on the health of the population of Forth Valley for the period October 2013 to September 2015.
This report describes the demographics and background health of our local population and highlights a number of key areas of work ongoing in NHS Forth Valley described under three main themes;
• Service improvement and development – planning, delivering and evaluating the range of interventions provided by NHS Forth Valley and partners in order to better meet the needs of the population. • Health improvement – helping people to maximise their wellbeing by making healthy choices, and developing knowledge and skills. • Health protection – delivering interventions that reduce the risk of communicable disease and environmental hazards.
Each section selects a number of key elements from the above three themes providing an overview of the range of work undertaken, however this report does not attempt to provide comprehensive comment on all areas of work. The report provides only a summary and overview of the vast scope of resources now readily available via the internet. Where possible the electronic version provides web-links to relevant and useful resources.
My vision for Public Health in Forth Valley focuses on the three main areas of;
• children and the early years • ‘worthwhile work’ • substance misuse
Concentrating on these three pillars will help to improve the health and wellbeing of our local population and break the vicious cycle of challenging circumstances in the early years leading to difficulties in securing employment and the potential for increasing substance misuse.
If we can effectively deliver on these three challenges we will do much to tackle the underlying cause of inequalities and ill health, promote wellbeing and positive health including mental health. Focusing on ‘worthwhile work’ will also deliver additional benefits such as reductions in offending and reoffending. Issues associated with these pillars can form the foundation of many of the problems we see in our society. Work in collaboration with partners in these three areas will influence a much broader spectrum of health outcomes over and above those within the immediate sphere of each pillar.
3
The health of the population in Forth Valley is continuing to improve. Our health successes include a continuing decrease in the death rate from heart disease, stroke and cancer. As we overcome many of the more “traditional” life threatening diseases such as heart attacks, our focus of healthcare is moving towards treating and supporting people living with long term conditions (LTC). We face significant challenges with changing demographics. Our local population of over 75 year olds, for example, is set to more than double by 2037. People are living longer and are increasingly likely to be living with more than one long term condition. These factors present a huge challenge to our NHS.
In keeping with the Scottish Government, 2011 strategy; 2020 vision1, NHS Forth Valley has been working, as part of our Clinical Services Review, to provide more efficient services that will help people to live longer healthier lives at home. This will be achieved through; integration of health and social care, a greater focus on prevention, anticipatory care plans and self management and a shift towards treatment in a community setting with day case treatment available when required. Care will be provided to the highest standard of quality whatever the setting. All decisions will be made with the person at the centre and the focus will be on ensuring that people are able to return to their home or community environment as soon as appropriate whilst minimising the risk of re- admission.
Following legislative change around health and social care integration2, new Health and Social Care Partnerships (HSCP), will be jointly run by Integration Joint Boards who will have delegated authority from the constituent parties and have the ability to direct the NHS and Local Authority through the Strategic Plan. These will be operational by April 2016. There will be two HSCPs in Forth Valley, one for Falkirk and one for Clackmannanshire and Stirling. Currently there are Transitional Boards preparing for implementation in 2016.
We look forward to the publication of the new NHS Forth Valley Health Strategy for the next five years which will be published early in 2016 and will bring together these various strands of activity.
The 2014 Scottish Independence referendum resulted in an overall vote to remain as part of the UK. This has resulted in new powers devolved to the Scottish Government, which have the potential to be used to improve health and reduce inequalities.
Economic austerity has resulted in changes to the benefit system through welfare reform, changes in patterns of employment and reduced funding for the public sector. These factors impact on people’s health, particularly those already experiencing health inequalities. The Poverty and Income Inequality in Scotland: 2013/143 report states that 14% of children in Scotland are living in relative poverty (before housing costs) or 22% if considered after housing costs. The report from the Scottish Parliament, Welfare Reform Committee; 1st Report, 2015 (Session4); The Cumulative Impact of Welfare Reform on Households in Scotland4, notes that once the welfare reforms are fully in place (around 2018) the cumulative effect is likely to see incomes reduced, on average by £440 a year, for
1 2020 Vision 2The Public Bodies (Joint Working) (Scotland) Act 3 Scottish Government: Poverty and Income Inequality in Scotland:2013/14 4 Scottish Parliament, Welfare Reform Committee; 1st Report, 2015 (Session4), The Cumulative Impact of Welfare Reform on Households in Scotland
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every adult of working age in Scotland. Families with dependent children, in particular lone parents and those with health problems or disabilities who claim benefits are expected to experience a marked impact. The average losses in Scotland have been mitigated following the decision to maintain Council Tax benefits and to offset the ‘Bedroom Tax’.
Addressing health inequalities underpins our work. Substantial areas of Forth Valley are deprived and have high levels of behaviours and diseases associated with deprivation, for example, substance use, obesity, heart disease and cancer. For those who live in less deprived areas, health challenges include a lack of physical activity, poor diet and the environmental impacts of our 21st century lifestyle.
Further progress to improve population health will depend on our ability to work with our partners on the ‘upstream’ issues which are the fundamental causes of inequalities in health.
Dr Graham Foster Director of Public Health and Strategic Planning, NHS Forth Valley
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Facts and figures about the people living in Forth Valley
NHS Forth Valley Around 300,000 people live in the NHS Forth Valley area. Forth Valley lies within Central Scotland and stretches from Killin and Tyndrum in the North to Strathblane and Bo’ness in the South, covering approximately 1,000 square miles (Figure 1).
The boundaries of NHS Forth Valley are co-terminus with the three Local Authorities; Clackmannanshire Stirling and Falkirk. NHS Forth Valley is a single integrated healthcare system comprising acute hospital services, and community based services which have been delivered through three Community Health Partnerships (CHPs). Retrospective data are reported under the three CHP areas.
Figure 1: Forth Valley geographic area
Source: The Scottish Government
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The Scottish Public Health Observatory (ScotPHO) health and wellbeing profiles provide detailed information at Local Authority level. It is important to remember that when looking at statistics for small populations the differences are not always statistically significant; therefore it is useful to remember that longer term trends can better demonstrate the true position.
As an example of the type of information available, the estimated smoking prevalence of around 1 in 4 (25.5%) for Clackmannanshire and 1 in 5 (19.9%) in Falkirk is not significantly different from the Scottish average of 23.0 %. In Stirling the smoking prevalence is less than 1 in 5 (18.5%) and is statistically significantly lower than the Scottish average. Given the importance of early years it is concerning for example that the percentage of mothers smoking during pregnancy is 25.3% for Clackmannanshire which is statistically significantly worse than the Scottish average of 20.0%.
Population by age, Local Authority and gender The Forth Valley mid-year estimates for 2014 (Figure 2) indicate greater numbers in age cohorts 45- 59 years and 30-44 years in all three Local Authority areas except Stirling where the 30-44 years age band is relatively smaller. This has implications for services such as sexual health and maternity.
Figure 2: Mid Year Population Estimate for Forth Valley by Local Authority; 2014
40000
35000
30000
25000
20000
Population 15000
10000
5000
0 0-14 15-29 30-44 45-59 60-74 75+ Age cohort Clackmannanshire Falkirk Stirling
Source: Data extracted from National Records of Scotland
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There are slightly more females than males in all three local authority areas within Forth Valley (Figure 3).
Figure 3: Mid Year Population Estimate; 2014 by gender and Local Authority
90000
80000
70000
60000
50000
40000
Population 30000
20000
10000
0 Clackmannashire Falkirk Stirling Local Authority
Males Females
Source: Data extracted from National Records of Scotland
Population projections Population projections indicate that the population of Forth Valley is rising faster than the Scottish average. The total population of Forth Valley is projected to increase by 10% between 2012 and 2037 compared to an increase of 8.9% in Scotland overall.
The most notable increase in population projections is within the 65 and over age cohorts where the population is expected to rise by 70.5% from 51,500 in 2012 to 87,700 in 2037, accounting for just over 1 in 4 of the population. The numbers of those aged 75 and over are projected to rise by 101.5% from 22,406 in 2012 to 45,153 in 2037 when this group will represent around 1 in 7 of the population. “The population of Forth Valley is projected to
increase by 10% between 2012 and 2037.”
Figure 4 demonstrates the projected change in the population age profile from 2015 to 2035 with the large group of those currently aged 45-55 years graduating to the 65-75 year age group in 2035, but without a corresponding increase in the younger age groups.
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Figure 4: 2012-based principal population projections by sex for Forth Valley over a twenty year period (2015-2035)
2015 2020 90+ 90+
80 to 84 years 80 to 84 years
70 to 74 years 70 to 74 years
60 to 64 years 60 to 64 years
50 to 54 years 50 to 54 years 40 to 44 years 40 to 44 years 30 to 34 years 30 to 34 years 20 to 24 years 20 to 24 years 10 to 14 years 10 to 14 years 0 to 4 years 0 to 4 years -15000 -5000 5000 15000 -15000 -5000 5000 15000 MALES FEMALES MALES FEMALES
2025 2035 90+ 90+ 80 to 84 years 80 to 84 years 70 to 74 years 70 to 74 years 60 to 64 years 60 to 64 years 50 to 54 years 50 to 54 years 40 to 44 years 40 to 44 years 30 to 34 years 30 to 34 years 20 to 24 years 20 to 24 years 10 to 14 years 10 to 14 years 0 to 4 years 0 to 4 years -15000 -5000 5000 15000 -15000 -5000 5000 15000 MALES FEMALES MALES FEMALES
Source: Data extracted from National Records of Scotland
Economic circumstances of Forth Valley people The percentage of working age adults claiming incapacity benefit, severe disability allowance (SDA) or employment support allowance (ESA), is greatest in Clackmannanshire at 5.7% compared to either Falkirk or Stirling. Similarly the rates of income deprivation are also higher in Clackmannanshire (Table 1) 5.
Within Scotland, Clackmannanshire has the highest percentage of 16-19 year olds not in employment, education or training.
These local data are consistent with Figure 5 which highlights the areas of deprivation within Forth Valley by Scottish Index of Multiple Deprivation (SIMD) deciles with the lighter areas representing the more deprived communities.
5 SCOTPHO Health and Wellbeing Profiles
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Table 1: Social care and economic data for Forth Valley by Local Authority (2013)
Clackmannan Falkirk Stirling Scotland shire % Working age adults claiming 5.7% 4.9% 4.0% 5% incapacity benefit, severe CI: 5.5-6.0 CI: 4.8-5.0 CI:4.1-3.9 disability allowance (SDA) or employment support allowance (ESA) Rate of income deprivation 15.4% 12.7% 9.9% 13.2% CI: 15.1-15.7 CI: 12.5-12.9 CI: 9.7-10.1
% 16-19 year olds not in 12.1% 8.6 % 5.6% 7.8%. employment, education or CI: 10.8-13.4 CI: 8.0-9.3 CI: 5.0-6.2 training (NEET)
Figure 5: Forth Valley Map detailing areas of deprivation by SIMD datazone
Sources: SIMD 2012, Scottish Government; Ordnance Survey data © Crown copyright and database right 2015;
“The numbers of people in the 65 and over age group is
expected to rise by 70.5% between 2012 and 2037.”
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Trends in common diseases
At UK level, cardiovascular disease (CVD), mainly coronary heart disease and stroke, remains a significant burden and a major cause of death. Of note, in 2012, for the first time, cancer narrowly took the lead as the foremost cause of death at 29% compared to cardiovascular deaths at 28% for both sexes together6. Spilt by gender, cancer is the most common cause of death for men (32%) while cardiovascular disease remains the leading cause of death for women (28%). CVD mortality rates are higher in Scotland and the North of England compared to the South of England. Improvements in survival mean that we now experience a higher prevalence of people living with CVD with subsequent increase in relevant prescriptions.
Heart Disease The number of premature deaths from heart disease in Forth Valley has continued to fall over the past decade. For under-75 year old males in Forth Valley, the mortality rate from ischaemic heart disease per 100,000 population has decreased substantially from 141.3 to 89.1, between 2004 and 2013. For females of the same age range, the rate per 100,000 population has decreased from 44.8 to 27.2. The combined rate per 100,000 population for both sexes has fallen from 93.1 to 58.1, during the same period (Figure 6).
The reduction in premature deaths from ischaemic heart disease reflects a position where more people are surviving and living with the disease. This has resulted in an increased need for treatment and healthcare as the population ages.
Figure 7 demonstrates the differences in mortality (deaths) from coronary heart disease (CHD) across the deprivation quintiles. There has been a reduction in mortality in all the deprivation quintiles over the decade 2004-2013 with a greater reduction observed in CHD mortality rate among the least deprived quintile (46.4%) compared to the most deprived quintile (40.7%). The absolute difference in mortality rate per 100,000 population, between the most and least deprived quintile has decreased from 152 to 102 over the last decade.
Although the situation is improving for all the population it is disappointing that the most deprived quintile are only now experiencing the level of mortality which the least deprived groups achieved 10 years ago.
6 Bhatnagar P, Wickramasinghe K, Williams J, Rayner M, Townsend N ,The epidemiology of cardiovascular disease in the UK 2014; Heart BMJ, June 2014, http://heart.bmj.com/content/early/2015/05/06/heartjnl-2015-307516.full?sid=b4e64c83- 6681-4b9b-a347-e48ee34776ee
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Figure 6: Age-sex standardised mortality rate per 100,000 population1 for coronary heart disease in under 75 year olds by year of death, Forth Valley residents; 2004-2013
180.0
160.0 140.0
120.0 100.0 80.0 60.0 Rate per 100,000 per Rate 40.0 20.0 Directly Standardised Mortality - 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 males females both sexes
Source: Data extracted from NHS National Services Scotland: Information Services Division
1. The European Standard Population (ESP), which was first used in 1976, was revised in 2013. Figures using ESP1976 and ESP2013 are not comparable
Figure 7: Coronary heart disease1 deaths by deprivation (SIMD) quintile2 2013 European age and sex standardised mortality rates per 100,000 population3
400
350
300
250
200
150 100,000 100
50
0
Directlystandardised mortalityrate per 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Most Deprived Quintile 1 Quintile 2 Quintile 3 Quintile 4 Least Deprived Quintile 5
Source: Data extracted from NHS National Services Scotland: Information Services Division
1. Analysis includes ICD-10 codes I20-I25 2. Uses 2012 version of SIMD 3. The European Standard Population (ESP), which was first used in 1976, was revised in 2013. Figures using ESP1976 and ESP2013 are not comparable.
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Stroke The number of deaths from stroke has fallen during the past decade. Deaths for 65-74 year olds in Forth Valley, from 2004 to 2013 are shown in Figure 8. This age cohort is a high risk group for stroke compared to younger age groups and demonstrates mortality rates reducing from 168.5 per 100,000 population in 2004 to 95.1 per 100,000 population in 20137.
Figure 8: Age-sex standardised mortality rate per 100,000 population1 for stroke in 64-75 year olds by year of death, Forth Valley residents; 2004-2013
180.0
160.0
140.0
120.0
100.0
80.0
60.0 100,000 population 100,000 40.0
20.0
Directlystandardised mortalityrate per - 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Males Females Both Sexes
Source: Data extracted from NHS National Services Scotland: Information Services Division
1. The European Standard Population (ESP), which was first used in 1976, was revised in 2013. Figures using ESP1976 and ESP2013 are not comparable
The Scottish Government’s 2009 action plan8 reiterated their earlier target to reduce premature mortality among all those under 75 years from stroke, by 50%. At Scottish level, between 1995 and 2010 there was a 59% reduction in the mortality rate for cerebrovascular disease, with a corresponding 56% reduction in Forth Valley.9
7ISD Scotland, Stroke, Topic areas, mortality 8 Scottish Government: Better Heart Disease and Stroke Care Action Plan (2009) 99 ISD Scotland, Stroke, Background and Policy
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Cancer Within Forth Valley, between 1995 and 2013, the number of deaths from all cancer types has shown a downward trend (Figure 9).
Figure 9: Trends in mortality from all cancer types including non-melanoma skin (ICD-10 C00-C97) Forth Valley; persons under 75, 1995-2013
300
250
1 200
150
100 100,000 population population 100,000
50
Directlystandardised mortalityrate per 0 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 Year of Death Registration Truncated EASR2 (using ESP20131) - Lower 95% CI - Upper 95% CI
Source: Data extracted from NHS National Services Scotland: Information Services Division; Cancer Statistics
1. The European Standard Population (ESP), which was first used in 1976, was revised in 2013. Figures using ESP1976 and ESP2013 are not comparable.
Although there has been a downward overall downward there continue to be marked differences in the rate of new cases of cancer and deaths from cancer between deprivation groups. In the most deprived areas, rates for all new cancers combined are almost a third higher than those seen in the least deprived areas. Mortality rates are over two-thirds higher in the most deprived areas compared with the least deprived areas.10 Figure 10 illustrates the correlation of new cancers and deaths from cancer across the deprivation groups.
Certain cancers are more strongly correlated with deprivation. Cancers associated with smoking have the highest incidence (new cases) and mortality rates in deprived areas. Cervical cancer reflects socio-economic differences in exposure to risk factors and lower attendance at cervical screening for women from more deprived areas. Other cancers such as breast cancer and malignant melanoma are associated with a higher incidence in the least deprived areas.
10 Information Services Division: Cancer Mortality in Scotland (2014)
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Figure 10: Cancer1 Incidence (2009-2013) and Mortality (2010-2014) by deprivation quintile2 in Scotland. Age-standardised rates3
Source: ISD, Cancer Mortality in Scotland (2014); Scottish Cancer Registry, ISD (registrations): National Records of Scotland (deaths) 1 All cancers excluding non-melanoma skin cancers (ICD-10 C00-C97 excl C44). 2 Deprivation quintile based on SIMD 2012. 3. The European Standard Population (ESP), which was first used in 1976, was revised in 2013. Figures using ESP1976 and ESP2013 are not comparable.
Diabetes The Scottish Diabetes Survey 2012 reported that the number of people with diabetes continues to increase by around 10,000 each year. This increase in new cases against a background of those continuing to live with diabetes presents greater organisational and resource pressures11.
The 2012 age adjusted prevalence of all types of diabetes across Scotland, using the Scottish population as the reference population structure, ranged from 4.14% to 5.46% with the prevalence in Forth Valley sitting at 5.05%. This represents 14,850 people. The prevalence of diabetes is particularly high among those aged 65 and over, with a crude prevalence in Forth Valley of 15.5%, (Scotland; 15%).
The majority of patients registered with diabetes in Forth Valley had type 2 diabetes (13,091 or 88.2%), a condition mostly affecting the older population. The number of patients with type 1 diabetes continues to rise each year reflecting the rising incidence of type 1 diabetes in children over the last 40 years.
Of those patients with type 1 diabetes and a recorded BMI, 38% were overweight (BMI 25-30kg/m2) while 25.5% were obese (BMI 30kg/m2 or above). Similarly for those with Type 2 diabetes and a registered BMI, 31.6% diabetes were overweight (BMI 25-30kg/m2) and 55.5% obese (BMI 30kg/m2 or above. Almost 1 in 5 people with diabetes were recorded as being a current smoker.
11 NHS Scotland, Scottish Diabetes Survey 2012;Scottish Diabetes Survey Monitoring Group
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Service Improvement and Development
Health and Social Care Integration The Public Bodies (Joint Working) (Scotland) Act12 was granted royal assent on 1st April 2014. This presents the framework for integrating health and social care in Scotland through; • integration of adult health and social care budgets • nationally agreed outcomes applying across health and social care for which NHS Boards and Local Authorities will be jointly accountable • a stronger role for clinicians and care professionals along with third and independent sectors in the planning and delivery of services
In Forth Valley work is underway to develop the local vision around local health and social care integration. The current vision13 is: to enable people to live full and positive lives within supportive communities.
Work will focus on measures to drive:
• Self Management - individuals, their carers and families are enabled to manage their own health, care and wellbeing • Community Focused Supports – supports are in place, accessible and enable people, where possible, to live well for longer at home or in homely settings within their community • Safety - health and social care support systems help to keep people safe and live well for longer • Autonomy and Decision Making - individuals, their carers and families are involved in and are supported to manage decisions about their care and wellbeing • Experience –individuals will have a fair and positive experience of health and social care
From April 2016, there will be an Integrated Joint Board (IJB) for each health and social care partnership within Forth Valley; one for Falkirk and one for Stirling and Clackmannanshire. These will oversee the planning, management and delivery of relevant health and social care services.
Clinical Services Review A Clinical Services Review for NHS Forth Valley has been underway since 2014, to inform the healthcare strategy (2016-2020) in setting out our plans and priorities. In 2011, the Christie Commission14 noted the need for a change in the design and delivery of public services to tackle the root causes of inequality and move away from the high levels of “failure demand”. This term
12 The Public Bodies (Joint Working) (Scotland) Act 13 NHS Forth Valley Health and Social Care Integration Scheme 14 Christie Commission
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describes the situation when a high proportion of public spending is spent on dealing with demand that could have been avoided by earlier preventative measures. This work needs to be done by empowering and working more closely with individuals and communities, harnessing their talents and assets, supporting self reliance and community resilience. The report further notes the need to integrate services, prioritise negative outcomes, reduce duplication and share services in order to improve efficiency.
The Clinical Services Review (CSR) aims to reshape services to meet the needs of a rapidly ageing population, manage increasing demand for health services particularly for people with longer term and complex needs and deliver more care at home or in local communities so patients can retain their independence, surrounded by family and friends.
As part of this, the Forth Valley Case for Change15 details the future trends in the size and age of our local population alongside social factors affecting health and wellbeing, estimating future service activity and forecasting future levels of several common diseases and long term conditions. Demand for healthcare services is exceeding supply in our current model and the analysis in the Case for Change helps inform planning and service delivery to meet future local healthcare needs, keep pace with demand and deliver a safe, effective, person-centred care, to promote population health improvement and to maintain financial balance as detailed in the NHS Scotland 2020 Vision16.
The CSR has eight workstreams, covering the majority of all clinical work, including planned and unscheduled care, topics such as cancer, long term conditions and end of life care, client groups such as women and children and frail older people and clinical support services and infrastructure. Each workstream has a clinical and managerial lead with planning support. There has also been considerable public and staff consultation resulting in over 500 individual public, patient and staff responses, more than 60 meetings with key patient groups, staff postcards and suggestion boxes , focus groups, four public open meetings, 50 work stream meetings and over 2000 specific items of feedback.
The key enablers from both the public and staff were remarkably similar as shown in Figure 11. Delivering a person centred approach and ensuring appropriate access were identified as the main issues. These were followed by the need for continuous, coordinated and integrated care, improved communication and attitude, and the need to address capacity issues.
15 Forth Valley; Case for Change 2014 16 Scottish Government: 2020 Vision
17
Figure 11: Key enablers identified following consultation (reproduced with permission from Forth Valley Planning team)
The main strategic themes emerging from this consultation focus on person centeredness and integration. Care should be provided in high quality settings as close to home as possible. Staff should be developed for more generic roles working in multidisciplinary community teams based within the locality and formally involving the third sector.
Multidisciplinary teams should facilitate self care and anticipatory care planning and patients will be discharged and assessed in their own surroundings, reducing delayed discharges and improving patient flow through the hospital. End of life care should focus on ensuring that patients end their
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days in the most appropriate setting. Services, approaches and workforce need to be more integrated, run across seven days and utilise more IT and technology solutions wherever suitable. Mental health services are important and will receive at least the same priority as those addressing physical health. Prevention needs to be delivered across a range of interventions from the basic aspects of the physical and social environment through to the most highly technical surgical and medical treatments.
A key priority is to ensure services are person centred. This means that individuals should be engaged – with their own health, services and society in general and enabled to help themselves, and make positive changes and improvement that will impact on health and wellbeing.
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Health Improvement
A wide range of initiatives are delivered under the heading of health improvement. Those targeting children and young people currently have our highest priority. Substance use, prison health and oral and dental health and working with communities are also key areas of local work.
Early Years Collaborative 17 The Early Years Collaborative (EYC) is an initiative launched by the Scottish Government in October 2012, with the ambition of ‘making Scotland the best place in the world to grow up for all babies, children, mothers, fathers and families’ (SG 2013). It is the world’s first multi-agency quality improvement programme, involving social services, health, education, police and third sector professionals in all 32 Community Planning Partnerships and a wide range of national partners. Its focus is on strengthening and building on services, using an improvement science methodology; - the PDSA cycle – Plan, Do, Study Act (Figure 12). This method enables local practitioners to test (through ‘tests of change’), measure, implement and scale up new ways of working to improve outcomes for children and families, across four workstreams.
Figure 12: PDSA cycle Each of the four workstreams has an aim relating to a particular age and stage in the early years. Numerous ‘tests of change’ have been carried out including; antenatal booking, healthy start vitamins, communications systems and attendance at 27-30 month reviews - resulting in many positive outcomes. Some examples are listed below. NHS Forth Valley is closely involved in the EYC and is currently expanding its tests of change.
Workstream 1: Conception to one year
The aim of this workstream is to ensure that from 2010 to 2015, women experience positive pregnancies, resulting in the birth of more healthy babies as evidenced by a reduction of 15% in the rates of stillbirths and infant mortality. Forth Valley’s maternity services set and achieved the aim of ensuring that, by October 2014, 80% of all newly pregnant mothers had registered with the service by the 10th week of pregnancy for ongoing support and care.
17 Image taken from http://www.earlyyearscollaborative.co.uk/about-the-collaborative
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Workstream 2: One year to 30 months
The aim of this workstream is to ensure that by the end of 2016, 85% of all children have reached the expected developmental milestones at the time of the child’s 27-30 month child health review.
Forth Valley’s Health Visitors are linking with Child Health to help reduce the number of incomplete review documents requiring follow up.
Workstream 3: 30 months to primary school
The aim of this workstream is to ensure that by end of 2017, 90% of all children have reached the expected developmental milestones at the time the child starts primary school.
Communication impairment is the most common developmental difficulty in early childhood. In Forth Valley, it was identified as the highest area of new concern, at over 10%, at the Health Visitor 27-30 month review. The actual figure
is likely to be higher than this as the data only include the families who attended.
In Stirling, LIFT is a universal, asset-based approach offering families living in disadvantaged areas the chance to acquire knowledge and skills to improve the quality of their everyday interactions with their child. This in turn will have positive effects on spoken language development and improved life outcomes.
The project has initially been piloted in year one in three nurseries in three
phases and will be extended to a further two nurseries in year two.
Workstream 4: Start of primary to the end of Primary 4
The aim of this workstream is to ensure that by the end of 2012, 90% of all children have reached the expected developmental milestones and learning outcomes by the end of Primary 4.
Forth Valley is supporting the roll-out of the of the ‘Daily Mile’, an exercise intervention from St Ninian’s Primary school to other schools in Forth Valley. “The Daily Mile can do more for the health of children than any other healthcare
system” (Maureen Bisognano, CEO, Institute for Healthcare Improvement)
Leadership
Supporting the four workstreams is a leadership strand that takes a strategic overview of all activity and provides direction. In Forth Valley there are two leadership groups, one covering Falkirk and the other covering both Clackmannanshire and Stirling.
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Oral and Dental Health
A key priority in recent years has been to improve the dental health of local children. Scotland has a poor history of dental ill health; childhood dental extractions have for many years been the most common reason for a child requiring a general anaesthetic.
Forth Valley continues to meet its annual target for the proportion of children in Primary 1 (P1) and Primary 7 (P7) with no apparent decay, with 66% of P1 and 67% of P7 free of obvious tooth decay (Figure 13). These improvements in oral health are closely associated with the development of the Childsmile programme (www.child-smile.org) which has been developing and evolving since 2006. The programme integrates four elements providing oral health packs to young children, toothbrushing programmes in all nursery establishments and targeted primary schools. This is supplemented by fluoride varnish applications in nurseries and primary schools in the more disadvantaged areas; currently 28% of nurseries and 25% of primary schools. The improvement in children’s dental health has seen falls in the number of fillings and extractions required with a substantial fall in the number of dental general anaesthetics being required from an
average of 50 per month in 2009 to 20 per month at the end of 2014.
Figure 13: The proportion of Primary 1 (P1) and Primary 7 (P7) children in Forth Valley free of obvious dental decay 1987-2014 80
70
60
50
40
Percentage Percentage 30
20
10
0 1987 1989 1992 1995 1997 2000 2004 2006 2008 2010 2012 2014
P1 P7 2010 Target
Source: Data from NHS Scotland National Dental Inspection Programme
2014 saw the publication of an updated SIGN guideline18 on dental interventions to prevent caries in children which was chaired by one of our Dental Public Health Consultants.
18 Dental Interventions to prevent caries in children: SIGN guideline
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In 2015 an Orthodontic Needs Assessment for Scotland19 was published. This group was chaired by one of our local consultants in Dental Public Health.
The Caring for Smiles20 programme for those in care homes was rolled out in Forth Valley in 2013 and has promoted additional activity in and around dental care provision within a residential care framework. Public dental service staff are supporting the training and delivery of individual oral care plans for all of Forth Valley care home residents. To date 1,149 carers have received specific training and 73 facilities have participated. Later this year a new SCQF (Scottish Credit & Qualifications Framework) rated qualification will be available and our staff are currently undergoing training to deliver this to care home staff.
In addition a wide range of oral health improvement programmes continue to run in schools, pharmacies, the workplace, in prisons and with other vulnerable groups.
Substance Use The Forth Valley Alcohol and Drug Partnership (ADP) is chaired by the Director of Public Health who is also the local champion for Recovery Orientated Systems of Care (ROSC).
The Forth Valley ADP commissioned Public Health to produce a Substance Use Healthcare Needs Assessment. This document details the health effects, and impact on healthcare services, of alcohol, drugs and tobacco use by the people of Forth Valley.
Alcohol
Drinking too much alcohol is harmful to health and is estimated to cause around 20 deaths per week in Scotland.21
Alcohol-related deaths in Scotland
• There were 1,100 alcohol-related deaths in 2013 (where alcohol was the underlying cause of death). • 741 of those deaths were men, 359 were women.
19 NHS Scotland, Scottish Dental; An orthodontic needs assessment report 20 NHS Health Scotland: Caring for smiles- A guide for carers 21 National Records for Scotland(NRS).
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• Over the years since 1979, there have been roughly twice as many male deaths as female deaths. • 472 deaths were people aged 45-59, 359 deaths in the 60-74 age group, 164 deaths in the 30-44 age group, and smaller numbers for other age groups. • The 45-59 age group has had the largest number of alcohol-related deaths in almost every year since 1979. • Although alcohol-related deaths have declined in recent years, rates remain higher than they were in the early 1980s and higher than those in England and Wales.22
The decline in alcohol related deaths during the past decade is evident for the whole of Scotland although for individual Boards it is less obvious due to small numbers and wide confidence intervals. See Figure 14.
Figure 14: Number of alcohol related deaths by year 1979-2013: Scotland vs Forth Valley
1800
1600 1400 1200 1000 800 600 400
Number of of Number alcohol deaths related 200 0
Year Scotland Forth Valley
Source: National Records for Scotland: Alcohol Related Deaths
Alcohol is classified by the International Agency for Research on Cancer (IARC) as a group 1 carcinogen, meaning it can cause cancer in humans. Tobacco and asbestos are other substances in this group. It is a recognised risk factor in a significant number of different cancers including: the breast, liver, bowel, mouth, throat, larynx (voice box) and oesophagus. It's estimated that alcohol is responsible for around 4% of cancers in the UK, about 12,800 cases a year.23
22 MESAS 4th Annual Report 23 Parkin, DM, Cancers attributable to consumption of alcohol in the UK in 2010: British Journal of Cancer (2011),195, S14- S18
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During pregnancy, current advice is that the safest approach is not to drink alcohol at all. Alcohol can affect the developing fetus with a wide range of differing impacts including lifelong conditions, known under the umbrella term of Fetal Alcohol Spectrum Disorders (FASD). The level and nature of the conditions under the term FASD relate to the amount drunk and the developmental stage of the fetus at the time. Heavy drinking can cause the baby to develop fetal alcohol syndrome (FAS). This is a serious condition where children have restricted growth, facial abnormalities and learning and behavioural disorders, which are long lasting and may be lifelong. Current advice is that the safest approach is not to drink alcohol at all during pregnancy.
During pregnancy;
No alcohol, no risk
A number of steps have been taken nationally to try and reduce the unacceptably high level of alcohol consumption in Scotland, thereby reducing the harm caused by alcohol. This is a complex challenge which requires public agencies to work jointly with the alcohol producers and retailers.
One of the aims is to reduce the amount of alcohol being drunk through making alcohol more expensive. The Alcohol (Minimum Pricing) (Scotland) Act 201224 was passed on 24 May 2012. Its implementation has been delayed by the legal challenge led by the Scotch Whisky Association which opposes the Scottish Government's bid to charge a minimum price for alcohol of 50p a unit. This matter was referred to the European Court of Justice.
On December 5, 2014, the Road Traffic Act 1988 (Prescribed Limit) (Scotland) Regulations 201425 introduced lower limits for blood alcohol when driving, from 80mg to 50 mg in every 100 ml of blood, bringing Scotland into line with most other European countries. This is anticipated to reduce the number of fatalities and injuries sustained in traffic accidents.
At a local level a representative of the Health Board, usually Public Health is a statutory member of the local Licensing Forum which is run by Local Councils. We contribute to guidance produced by the forums as well as having the opportunity to object to individual license applications submitted to the local Licensing Boards. Despite the best of intentions it can be difficult to influence local licensing decisions due to commercial interests.
24 The Alcohol (Minimum Pricing) (Scotland) Act 2012 25 The Road Traffic Act 1988 (Prescribed Limit) (Scotland) Regulations 2014
25
Smoking Perhaps the most successful public health measure in recent times has been the adoption of legislation to ban smoking in public places which has seen a significant change in public attitudes and behaviours. Further legislation introduced in April 2013 is the Tobacco Display Regulations (Scotland)26, which requires large shops to cover up tobacco products (cigarettes, cigars and rolling tobacco) to reduce children and young people’s exposure to tobacco products; this was extended to include small shops from April 2015.
In line with the Scottish Government Strategy; hospital grounds are to be smoke-free from March 2015. This has proved difficult to implement and we await further legislation to make this enforceable.
The Scottish Government issued guidance to NHS Scotland and the Local Authorities in 2005 encouraging them to demonstrate leadership in implementing smoking policies and promoting smoke-free lifestyles. This was subsequently re-enforced in the Health Promoting Health Service HPHS, CEL (1) 2012.27
In 2013 the Scottish Government published a new tobacco strategy ‘Creating a tobacco-free generation: A tobacco control strategy for Scotland 2013’28, This sets out action requiring all NHS Boards to implement and enforce smoke-free hospital grounds by 31 March 2015. In response to this NHS Forth Valley appointed a Tobacco Control Officer to help reduce smoking at hospital entrances and grounds, by staff, patients and visitors. The post covers Forth Valley Royal Hospital, Clackmannanshire Community Healthcare Centre, Falkirk Community Hospital, and Stirling Community Hospital. Achieving smoke free NHS grounds has proved difficult to implement although we continue to ask the local smokers to respect our smoke-free policy we await further legislation to make this enforceable.
The mental health unit at FVRH is currently working towards the unit being smoke free within the same time frame in partnership with staff and patients.
A report on NHS smoking cessation service statistics contains data for the calendar year 2012. NHS Forth Valley continues to meet HEAT targets in terms of numbers of people stopping smoking within four weeks of setting a quit date with 61% of those quitting (self reported) coming from the 40% most deprived communities. 19% of pregnant smokers are attempting to quit using NHS cessation services. These figures support research which has found that smoking cessation services are effective in reaching deprived
communities.
26 Tobacco Display Regulations (Scotland) 2013 27 Health Promoting Health Service CEL(2012) 01 28 Creating a Tobacco-Free Generation, A Tobacco Control Strategy for Scotland
26
A new HEAT target was set for NHSScotland to deliver universal smoking cessation services to achieve at least 12,000 successful quits, at 12 weeks post quit, in the 40% most deprived within- board SIMD areas (60% for island health boards) over 1 year ending March 2015. For NHS Forth Valley this challenging target proved unachievable but local services are now on track to deliver the further revised 2015-16 target.
More information on HEAT targets can be found on the Scottish Government website.
Prison health The NHS has had responsibility for prison healthcare since 2011, requiring prisoners to have access to the same quality and range of healthcare services as members of the public. With three prisons, (HMP Cornton Vale, HMP Glenochil and HMYOI Polmont), within its geographical boundary, NHS Forth Valley has responsibility for the healthcare needs of 26% of the total Scottish prison population.
Independent Advocacy services are now available in all three prisons within NHS Forth Valley following a Public Health Review of the Need for Independent Advocacy within Forth Valley Prisons29 commissioned by the Forth Valley Prison Healthcare Liaison Group. The needs assessment highlighted the extent of mental health need and requirement for Independent Advocacy under the Mental Health (Care and Treatment) (Scotland) Act 200330. The National Prisoner Healthcare Network- Mental Health Report 31 further emphasised the importance of Independent Advocacy for those in and leaving prison. This is a joint responsibility between the local Health Board and Local Authority.
The Public Health Officer, in NHS Forth Valley, has worked with the Criminal Justice Authority at a national level on a scoping exercise covering all Independent Advocacy providers for all prisons in Scotland. This led to the development of a model of implementation for all NHS Boards who have prisons within their boundaries. The final report will be published in November 2015.
As part of an overall programme to reduce health inequalities and re- offending, NHS Forth Valley has been working in partnership with the Scottish Prison Service and the Community Justice Authorities in Forth Valley to improve offender health. In our three prisons this is being taken forward through the implementation of the Better Health Better Lives for Prisoners Health Improvement Framework. The work is being undertaken through a whole prison approach which advocates that when improving health and wellbeing in prison everyone has a role, not solely those with the responsibility for providing healthcare. It recognises that the risk factors for poor health are interrelated and best tackled
29 A Review of the Need for Independent Advocacy within Forth Valley Prisons 30 Mental Health (Care and Treatment) (Scotland) Act 2003, section 259 (4) 31 National Prisoner Healthcare Network- Mental Health Report
27
through comprehensive, integrated programmes in the context and places where people live their lives.
Offending and poor health and wellbeing are closely linked with social and economic problems. Poor oral health is more common in the most disadvantaged individuals, a greater proportion of who enter our criminal justice system. NHS Forth Valley has worked to improve oral health through measures such as increasing dental hygiene measures, encouraging dental registration on release and increasing access to fresh fruit and vegetables. Successful programmes have been established to provide offenders with the skills and knowledge to cook healthy nutritious meals and this is further supported in the community by Criminal Justice Social Work.
One of our Dental Public Health Consultants has published work on improving dental health in prisoners32.
For 2015-16 a local team has begun pioneering research to establish the prevalence of tuberculosis (TB) in the Scottish prison population. The local BBV and sexual health MCN (Managed Care Network) is working hard to identify and treat Hepatitis C in prisoners.
32 Scottish Oral Health Improvement Prison Programme (SOHIPP)
28
The Value of Community Working with communities through focussing on their existing strengths and capabilities, encouraging people to take control of their own health; and promoting self esteem and coping skills can help buffer and protect against life’s stresses and prevent ill health33.
Asset based approach A health ‘asset’ has been defined as “any factor or resource which enhances the ability of communities and populations to maintain and sustain health and wellbeing and to help reduce health inequalities”34 . This can include skills, knowledge and connections as well as the physical and economic resources of local places, businesses and organisations. In summary, an ‘asset based’ approach can be thought of as redressing the balance from needs towards strengths.
Within Forth Valley asset based community development first started in Hawkhill, Alloa. The success of this work has been presented at a national meeting to the Scottish Government and other Health Boards. Other asset based work is ongoing in several communities within Forth Valley.
Hawkhill Since the introduction of the asset based approach in Hawkhill, there have been many new initiatives including the; “Man Up “group set up by men in the area to support each other, a community garden, a school walking bus, homework clubs, fitness classes, groups for mothers and a ‘ nifty fifties’ club. Further benefits have been gained through work with other agencies, e.g. Job Centre Plus have provided laptops to the job club in response to demand. A local Christmas card initiative for older people provided an opportunity to include information from the Fire Service encouraging uptake of safety checks. As a consequence of the asset based work in Hawkhill Community Centre, participation has risen three to four fold.
Close working with local authority colleagues has resulted in significant housing improvements included replaced boilers/radiators, increased loft insulation and provision of cavity wall insulation.
Initially the local population have prioritised issues such as safety and fear of crime. Calls concerning anti-social behaviour to the police in the area appear to have dramatically reduced and local residents report feeling a considerable improvement in community spirit and reduced fear of crime. For example, there were six calls to police regarding anti-social behaviour in the first three months of 2013 compared to 46 calls in one month alone during the previous year.
Fallin A similar asset based community project is also underway in Fallin, a former mining village to the East of Stirling. Health improvement staff are working to engage with the local population and address health issues where possible.
33 Annual Report of the Chief Medical Officer 2009 34 Morgan A, Ziglio E. Revitalising the evidence base for public health: an assets model. Promotion and Education 2007;14:17.
29
Camelon ‘Our Place’ is a place-based initiative funded by the Big Lottery which currently has a five year project in Camelon. The project aims to empower local people and organisations to bring about a lasting positive difference to their neighbourhood using an asset-based community development approach.
Public health is working with health providers, other local agencies and the local community to support this project. The aim is to make a long-lasting difference to those with most need in order to try and reduce inequalities. An event was held for health and other agencies and members of the community to explore local strengths and weaknesses and develop ideas to take forward. Local people in Camelon and those working in the area are taking part in a community survey to determine their local priorities. Subsequent to this, local groups and organisations in Camelon have been able to apply for funding for projects that are in keeping with achieving the 'vision' developed from this community survey.
Keep well Keep well Forth Valley is a key part of the general health improvement/ health inequalities programme in Forth Valley and delivers NHS and partner agency aims on: reducing inequality (whether related to deprivation, gender, ethnicity or other,) implementing an assets-based approach, providing person-centred care, integrating health and social care and improving employability. The programme is focussed on a co-production approach through whole-person enablement and empowerment.
Keep well delivers more than 3,000 health assessments per year (equivalent to 2.3% of the local population aged 40-65), mainly to people living within areas of relative deprivation.
Individuals are invited to accept a health assessment with the experienced specialist team and subsequent consultations take a holistic, comprehensive and structured approach. These may identify a wide range of health and wellbeing associated issues with a focus on employability and men’s health, identifying opportunities for improvement.
Key themes continue to be - ethos and approach, complexity (recognising and accommodating it), empathy and compassion, innovation and application of a new, unique approach, the importance of giving time; and underpinning it all, an approach based on values and principles.
Outcome reviews are now a standard feature of the Keep well process. These reviews have shown that significant behaviour change can be achieved following the Keep well assessment.
30
Examples of health improvement work
Healthy weight As the population both and enjoys improved life circumstances, health challenges such as obesity are becoming increasingly prevalent. In some areas of Forth Valley more than half of adults are clinically overweight or obese. Although NHS Forth Valley does provide a range of clinical supports and interventions for obesity our main priority is to try and focus on the importance of prevention and lifestyle change to reduce obesity at a population level. Adults are encouraged to make use of established and proven weight loss programmes and techniques and supported by our healthy weight website: “Choose to Lose”
We support a wide range of measures to focus public attention on healthy eating and exercise.
In Forth Valley the Child Healthy Weight (HEAT 3) Target has been delivered primarily through the Max in the Middle and Max in the Class programmes designed by the INTERACT team, Health Promotion Services. This work complements ongoing work to support the Curriculum for Excellence Health and Wellbeing experiences and outcomes.
The Max programmes are innovative schools based child health interventions using interactive health promotion to deliver potentially lifelong health benefits to local children in Forth Valley. The programmes aim to empower and educate primary school children in relation to healthy eating, physical activity and life choice using a non- judgmental whole class approach which is memorable, exciting and non- stigmatising.
Between October 2013 and March 2015 the Max programmes were delivered to over 80 primary school classes (approx 2,000 young people) in the Forth Valley area with priority given to schools with a high proportion of free school meals.
The Max in the Middle intervention is a one week 'whole class' programme for primary 6 or 7 which delivers 18 hours of experiential learning on health and well being, promoting enthusiasm and parental engagement whilst limiting stigmatisation. Dance and drama specialists work in small teams with the class teacher.
31
Parents made the following comments after their children took part in the Max in the Middle Programme in November 2014 and are indicative of the ‘ripple effect’ from the classroom experience to the home.
“My daughter’s attitude and emotions were different, she appeared to be both inspired and
motivated by the programme.”
“Started having breakfast before
school.”
“Wanted to cook and make at home
what they had learnt on ‘Tasty
Tuesdays.”
“It was easier to get him to go
outside and play instead of constantly being in the house.”
The Max in the Class intervention is focused on staff development for primary 5 and 6 teachers who are then supported in delivering a six session intervention that is incorporated into the ongoing curriculum.
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Health Protection
The work of the Health Protection Team is an important function, providing a 24 hours a day, seven days a week service to protect the local population by ensuring the safety and quality of the general environment including food, water and air, preventing the transmission of communicable disease and managing outbreaks and other incidents which threaten public health.
Statistics and data on the detection and prevention of communicable diseases are available on the Health Protection Scotland website.
Protecting the population from Tuberculosis Amidst concern that tuberculosis (TB) is increasing and that the epidemiology of the disease has changed, the Scottish Government published the TB Action Plan for Scotland 2011 which made several recommendations to improve surveillance, diagnosis and prevention of the disease.
Since 2005 BCG Immunisation programme has been provided to people who are at risk of TB, living in Forth Valley. The key part is a neonatal programme aimed at protecting those children most at risk of exposure to TB. Although identification of these children can be challenging, all children at risk should be given a BCG and local processes are in place to assist with identifying them.
A Public Health led clinic was set up in April 2013 in Forth Valley Royal Hospital for administration of Mantoux testing and BCG and for assessing contacts of TB cases.
To assist with diagnosis of latent TB and screening of vulnerable groups, a new blood test, Interferon-Gamma Release Assay (IGRA), was introduced for relevant patient groups. This has the benefit of a single patient visit and faster results compared with skin testing.
In terms of diagnostic testing, use of liquid cultures of sputum began in Forth Valley in November 2013. This can reduce the delays in obtaining results and drug sensitivities from weeks to days.
The Health Protection (TB) Nurse and Respiratory (TB) Nurses provide the key worker roles for patients with TB, providing both support with diagnosis and assessment for the provision of the Directly Observed Treatment Service (DOTS). Direct observation of patients taking their prescribed medication in relation to TB ensures compliance to complete the full course of treatment. This helps to prevent the spread of the TB to others and decreases the chances of treatment failure or relapse.
A study is underway to investigate the prevalence of TB in Scottish Prisons. There has been an increase in TB in English prisons with associated policy to mitigate this. The current study will help inform Scottish Government policy for future action.
Screening of high risk ‘New Entrants’ to Forth Valley for TB is being developed.
33
Using a preventative approach, faster testing and improved compliance with treatment is likely to reduce the potential for spread within the community.
Immunisations
Childhood Immunisation Programme NHS Forth Valley meets and regularly exceeds the recommended target of 95% uptake for Primary Immunisations.
The following significant changes to the Scottish Immunisation programme have been successfully implemented since 2013:
• the introduction of Rotavirus into the childhood immunisation programme for infants aged two and three months • the removal of the second dose of Meningococcal C given at four months and the addition of a dose at the S3 booster appointment • the introduction of a shingles vaccine for people aged 70 years (routine cohort) with a phased catch up programme over a number of years to protect against herpes zoster • the phased introduction of an extension to the seasonal flu programme using the intranasal flu vaccine and targeting children from 2 years to primary school age. This programme may be extended to secondary school aged children in the coming years.
The extension of the seasonal flu programme for primary school aged children was initially introduced in a pilot programme (2013-14) and delivered by weekend flu sessions. This pilot focused on a limited number (25%) of Forth Valley primary school aged children, with good uptake of around 62%. Besides the direct benefit of protection afforded by the vaccine, the weekend approach also yielded indirect benefits which included wider engagement of the family and minimal disruption to the child’s education and the school nursing service. Unfortunately when rolled out to the full programme in 2014-15, this model of weekend delivery emphasised the dependence on parents to bring the child for vaccination and uptake remained static at around 63%.
Based on experience nationally, and the success of other Health Boards, NHS Forth Valley has adopted the weekday model of delivery for the 2015-16 programme. Furthermore the success of Immunisation Teams in delivering this programme in other Health Boards has also been recognised. A business case for an Immunisation Team was presented to the Health Board and support was given to establish an Immunisation Team within the Public Health directorate.
As well as delivering core immunisation programmes the team represents a significant enhancement to our ability to mobilise nursing resources to health protection incidents and challenges.
From 2015-16, the Immunisation team will deliver the seasonal flu programme in Primary Schools, and also provide support, resilience and flexibility to all current and developing vaccination programmes and the implementation of future national immunisation programmes.
34
Immunisation uptake statistics for all Boards and CHPs can be found on the ISD website35.
Seasonal Influenza Vaccination Programme (adult) NHS Forth Valley has had the highest uptake for the over 65 year olds for the last seven years, and is regularly in the top three Health Boards for the under 65 cohort groups. 2014-15 figures show:
• FV Current uptake >65yrs 79.2% (Scottish average 76.3%) • FV Current uptake <65yrs 56.5% (Scottish average 54%) • FV Staff uptake 39.6% (Scottish Average 34.7%)
Human Papilloma Virus Vaccine The Human Papilloma Virus (HPV) vaccination programme in Scotland started in 2008. The programme helps protect girls against cervical cancer later in life by routinely immunising them in early secondary school, at around 11-13 years of age through a school based vaccination programme. The vaccine protects against the two high risk HPV; types HPV-16 and HPV-18, known to cause over 70% of cases of cervical cancer. In 2014-15 over 94% of S2 girls in Forth Valley received the first dose of the HPV vaccine; this was the highest uptake amongst the Health Boards in Scotland, with the Scottish average at 91.4%. The HPV vaccine does not protect against all cervical cancers, so regular cervical screening is still important.
In September 2014, the schedule changed from three to two doses following revised guidance from the Joint Committee of Vaccination and Immunisation (JCVI).
New Immunisation programmes
Meningitis B Vaccine The immunisation programme against Meningitis B (Men B) was included as part of the routine childhood vaccination programme, from 1st September 2015, with an appropriate catch up programme for babies at the start of the implementation period. A total of three doses are given at two, four and 12 months of age.
Meningitis ACWY Vaccine In February 2015 the JCVI recommended the introduction of a meningococcal ACWY vaccination programme for young people to protect against Meningitis W (Men W), following an annual increase in cases since 2009. In Scotland there were 5 cases in 2014 compared to 6 cases in the first half of 2015 of which there was one death. The immunisation programme commenced in summer 2015. The programme had 2 components: • The Primary Care based S5 and S6 School leavers and Freshers’ Programme which commenced in August 2015 • The school based catch up programme for 14-18 year olds which began in December 2015
In addition, the Men ACWY vaccine will be added to the routine adolescent schools programme from spring 2016 as a direct replacement for the Men C vaccine.
35 ISD: Child Health Publication
35
Emergency Planning and Civil Contingencies Since the last annual report there have been structural changes impacting on national planning for emergencies.
The formation of a single national police service (Police Scotland) and a single Scottish Fire and Rescue Service provides an opportunity to consider the most effective multi-agency emergency planning and response coordination arrangements. The eight existing Strategic Coordination Groups (SCGs), based on the former policing areas structure moved to three Regional Resilience Partnerships (RRPs) in November 2013. At a strategic level, NHS Forth Valley became part of the East of Scotland Resilience Partnership incorporating the former Fife, Lothian & Borders and Central Scotland SCGs. The local working arrangements at tactical level are referred to as Local Resilience Partnerships (LRP) and include Central LRP, Fife LRP and Lothian & Borders LRP.
Emergency planning has been involved in a number of exercises with partner agencies, testing the NHS response to potential major incidents both internally and externally with partner organisations.
There has been considerable Public Health involvement in civil contingency planning. Partnership working is essential to safely deliver large public events, each of which results in a large influx of visitors and consequently a temporary increase in local population. Stirling hosted the 6th Annual Armed Forces Day National event and the Bannockburn 700 year anniversary on the same weekend in June 2014. Glasgow hosted the Commonwealth Games from 23 July to 3 August 2014 leaving a legacy which we hope will lead to improved lifestyles with a positive impact on health and wellbeing. Thereafter in September the Ryder Cup was held at nearby Gleneagles with transport links from Stirling.
Recent global concerns, relating to the increase in terrorist driven incidents has resulted in a UK Government response (Prevent) to encourage public sector staff to be aware of their role in the culture of vigilance around terrorism and in particular to prevent vulnerable individuals from radicalisation, especially on-line.
Prevent Strategy UK Government’s overarching counter terrorism strategy is CONTEST36, with Prevent being one of four underlying strands. Prevent aims to stop people becoming radicalised or supporting terrorism. The health service is a key partner and plays a significant role in the delivery of Prevent as healthcare staff can recognise and support individuals, both patients and staff, who may be vulnerable and susceptible to radicalisation by extremists or terrorists. The NHS Forth Valley Prevent Implementation Policy describes the escalation process for raising Prevent-related concerns and provides practical guidance, to help reduce the risk of an individual becoming drawn into terrorism. An awareness-raising programme will be put into place to promote the understanding of radicalisation issues, confidence in dealing with Prevent-related concerns, and a culture of vigilance. This programme was rolled out from autumn 2015.
36 Playing our Part- Prevent Guidance for Health Boards- Jan 2015
36
Blood borne viruses (BBV) and Sexual Health In 2011 the Scottish Government published The Sexual Health and BBV framework 2011-1537 setting out the Scottish Government's agenda in relation to sexual health, HIV, hepatitis C and hepatitis B. The existing structures have been combined into the Forth Valley Sexual Health and BBV Managed Care Network (MCN) which will deliver the main outcomes.
Forth Valley has experienced significant developments in recent years for sexual health services. The Forth Valley Sexual Health Action Plan describes recent changes, successes and improvements with BBV and sexual health teams working closely. This work benefits from being part of the West of Scotland Sexual Health Managed Clinical Network (MCN), established in 2010.
The Forth Valley Sexual Health Action Plan sets out to: • Improve the sexual health and well-being of Forth Valley population, ensuring that inequalities in sexual health are addressed
The Action Plan identified the following key areas for development over the period of 2011-2013 in Forth Valley: • men who have sex with men • unwanted pregnancies • condoms • HIV • increase knowledge of HIV and STIs amongst vulnerable populations • partnership working
The key areas for development have all been incorporated into the work programme.
Public Health has recently completed a Sexual Health and Blood Borne Virus (BBV) Needs Assessment38 which will help inform strategic planning, commissioning and development of high quality sexual health services within NHS Forth Valley.
37 The Sexual Health and BBV framework 2011-15 38 Forth Valley Sexual Health and Blood Borne Virus (BBV) Needs Assessment
37
Screening
Adult screening-
Cancer screening: see Table 2 Cervical screening NHS Forth Valley has developed a best practice guidance paper: “Optingout women from the Scottish Cervical Screening Programme” recognising the need for a consistent and transparent approach to women who opt out of the Scottish Cervical Programme to ensure women are fully informed and all those eligible are maintained on registers. This approach has been adopted by the National Cervical Screening Programme.
Abdominal Aortic Aneurysm screening The abdominal aortic aneurysm screening programme (AAA) was rolled out across Scotland, with implementation starting in Forth Valley in October 2013. This involves an ultrasound scan of the abdomen for all men when they reach the age of 65 years. NHS Forth Valley manages local scanning and management of results across three sites: FVRH, Stirling Community Hospital and Clackmannanshire Community Healthcare Centre. Uptake has been good – 87% (93% in least deprived quintile), with at least 1,500 scans anticipated per year. Across Scotland there have been fewer referrals requiring surgery than initially expected. The reasons for this are being explored at a national level.
Further information available at: NHS Inform; AAA screening
Diabetic Retinopathy screening The Scottish Diabetic Retinopathy Screening Collaborative delivers a targeted screening programme for diabetic retinopathy screening. Retinopathy is a condition that is particularly prevalent in people with diabetes and can cause serious damage to the eyes and may result in blindness. If detected early and treated appropriately, damage can be minimised. Screening is offered annually to all patients over 12 years who have diabetes.
Pregnancy and Newborn screening The public health service continues to support pregnancy and newborn screening programmes. Several different screening tests are undertaken throughout pregnancy and the newborn period. These include blood tests for a variety of inherited blood disorders and high risk infections such as Hepatitis B, ultrasound scans performed at different stages of pregnancy to screen for foetal anomalies, routine examination of the newborn, the newborn bloodspot test and newborn hearing screening.
38
Scottish Cancer Eligibility Test Uptake in Forth Programme Developments Impact Screening Valley % (Scottish Programmes uptake %) Breast Women Mammogram 2011-2014; Recent formal review of breast screening service to In 2013-14, over 1,450 cases of screen detected breast aged 50-70 approximately ensure it remained effective and sustainable cancer were diagnosed in women of all ages. 39 Women every 3 years 72.1 (72.9) For every 400 women screened regularly for 10 years, one over 70 Over 3 yr rolling period Ongoing transformation from analogue equipment less women will die from breast cancer. This means around can self to digital mammography 130 women are prevented from dying from breast cancer refer each year in Scotland. Breast screening is an area that has been recently considered by a group of experts and they estimate that for every 1 woman who has her life saved from breast cancer through breast screening, 3 women will be diagnosed with breast cancer that might never have become life threatening.40 Women Cervical smear 2013-2014 From April 2016: Around 5,000 lives saved in the UK every year 43 Cervical aged 20-60 every 3 years • age range will change to 25-64yrs 8 out of 10 cervical cancers prevented from developing. 72.7 (70.7) • frequency of cervical screening will continue to be Eligible group with every 3 years from age 25 to age 50, but will smear in previous 3.5 change to be every 5 years for women from age 50 41 years to 64 plus 364 days of age. • Women on non-routine screening (where screening results have shown changes that require further investigation/follow up) will be invited up to age 70 years plus 364 days of age (a change from current arrangements up to age 68). 42 Bowel All men Home testing 2014 Bowel scope screening being offered to some men Home testing prevents 150 deaths from bowel cancer every and kit for stool Males; 53.8(53.3) and women during pilot phase year.45 women every 2 years Females; 58.6(58.8) aged 50– Overall;56.3(56.1)44
74
Table 2: Adult Cancer Screening programmes
39 ISD Scotland, Scottish Breast Screening Programme 40 NHS Health Scotland: Breast Cancer, Helping you decide 41 ISD Scotland, Cervical screening 42 National Services Division, NSD Cervical Screening 43 NHS Health Scotland Cervical Screening Leaflet. Put it on your list 44 ISD, Scottish Bowel Screening Programme 45 NHS Health Scotland ;Bowel Screening; The bowel screening test, your questions answered. 39
Summary
This report provides access to useful information on the health and wellbeing of the local population in Forth Valley as well as presenting an overview of the work within Public Health. Our key priorities are supporting children in the early years, promoting access to ‘worthwhile work’ and delivering substance misuse services with a recovery orientated focus. We also acknowledge the need to ensure our services address the needs of an ageing population.
I hope that as well as providing a source of Forth Valley specific publications this report will be used as a gateway to Public Health issues and resources, particularly those found on-line.
40
Acknowledgments
The support and assistance of the following people and organisations are gratefully acknowledged:
Thanks to Dr Rosemary Millar and Dr Aileen Holliday for editing this report.
Those who contributed include: Dr Henry Prempeh, Dr Oliver Harding, Dr Jennifer Champion, Dr Sarah Couper, Mrs Hazel Meechan, Mr Tom Houston, Mrs Alison Morrison, Mr Colin Sumpter, Mr Derek Richards, Ms Jennifer Rodger, Ms Louise Hammell, Dr Jane Bray, Mrs Carol Crawford, Mrs Ann McGregor and Mrs Kirsten Pettigrew.
Thanks for helpful comments from our communications department, particularly Mrs Elspeth Campbell and Miss Lindsay Hathaway.
Any feedback and ideas for future reports will be appreciated:
Contact: Aileen Holliday Directorate of Public Health Forth Valley Health Board Carseview House Castle Business Park Stirling FK9 4SW Tel 01786 457251
Email: [email protected]
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42
Clackmannanshire & Stirling Integration Joint Board
27 April 2016
This report relates to Item 14 on the agenda
Communications Protocol and Framework
(Paper presented by Elsbeth Campbell, & Deborah Kilpatrick)
For Noting and Approval
Approved for Submission by Shiona Strachan, Chief Officer Author Elsbeth Campbell, Head of Communications, NHS Forth Valley, Deborah Kilpatrick, Senior Communications Advisor, Stirling Council and Karen Payton, Communications & Community Team Leader, Clackmannanshire Council Date: 27 April 2016 List of Background Papers: N/A
Page 1 of 4
Title/Subject: Communications Protocol & Framework Meeting: Clackmannanshire & Stirling Integration Joint Board Date: 27 April 2016 Submitted By: Elsbeth Campbell, Head of Communications (NHS Forth Valley), Deborah Kilpatrick, Senior Communications Advisor (Stirling Council), Karen Payton, Communications & Community Team Leader (Clackmannanshire Council).
Action: For Approval
1. Introduction
1.1 The purpose of this report is to set out a proposed framework and protocol for internal and external communication by the Integration Joint Board. Clear, consistent, timely and accessible communications for service users, carers, employees, communities and other stakeholders will increase understanding of what health and social care integration involves and what it means for individuals and their care.
2. Executive Summary
2.1. This framework has been developed jointly by NHS Forth Valley and Falkirk, Clackmannanshire and Stirling Councils. It draws on discussions with communications leads in other areas and the best practice presented at seminars organised by the Scottish Government.
3. Recommendations
The Integration Joint Board is asked to:
3.1. Approve the attached framework and protocol for internal and external communications
3.2. Note that a communications action plan will be brought forward to the June IJB meeting for approval.
4. Background
4.1 The framework aims to ensure that:
o Staff, third sector and independent service providers in both Partnerships have access to information about health and social care integration and are kept informed of relevant changes and developments which affect them and the services they provide in a consistent and co-ordinated way.
Page 2 of 4
o Service users, families, carers and the public are reassured that they will still have access to the health and social care services they require and are kept updated on relevant local developments, benefits and improvements.
4.2 In order to achieve this, it recommends that a joined-up approach to communications is adopted, drawing on well-established arrangements for collaborative working on communications. It also sets out some key actions that will underpin this approach.
4.3 These include ongoing development of: o Core key messages o A scheduled programme of communications activities linked to key developments and milestones o A focus on practical and tangible improvements, benefits and outcomes rather than structures, policies and legislation o A consistent visual identity for the Partnership which reflects its vision and values
4.4 It is recognised that while many of the issues will be similar for both Partnerships, there will be a need to develop distinctive communications for each Partnership to reflect differences in approaches, priority and timing.
4.5 An action plan is currently being developed which will outline key communications activities and opportunities for the next year. This will be presented to the IJB meeting in June 2016 for approval. Work will also be undertaken to explore options for a potential new visual identity for the Clackmannanshire and Stirling Health and Social Care Partnership.
5. Resource Implications
5.1 No additional communications resources have been identified to support the Health and Social Care Partnership, so action plans and activities will need to take account of the current available capacity across NHS Forth Valley and the two local authorities.
6. Impact on Integration Joint Board Outcomes, Priorities and Outcomes
6.1. The Communications Action Plan will ensure the delivery of key messages and communications activity to support the implementation of the Strategic Plan.
7. Legal & Risk Implications
7.1 There are no additional legal and risk implications associated with this report.
Page 3 of 4
8. Consultation
8.1 No additional consultation has been undertaken for the purpose of this report however the Framework takes account of best practice and learning from other Health and Social Care Partnerships across Scotland.
9. Equality and Human Rights Impact Assessment
9.1. It is recognised that there are equalities issues in relation to the provision of accessible communications and these will be taken into account.
Page 4 of 4
1
Contents
A Forth Valley Communications Framework Overview 3
Achieving a joined-up approach to communications 4
Key Outcomes 5
Key Stakeholders 5
Internal Communications 6
Media and External communications 6
Online communications – website and social media 8
Cross-organisation communications 9
The way forward 9
Appendix 1 – Interim Branding Guidelines 10
Appendix 2 – Key Aims and Messages 12
Appendix 3 - Notes to Editors 14
Appendix 4 Key Contacts & Communications Channels 15
2
A FORTH VALLEY COMMUNICATIONS FRAMEWORK - OVERVIEW
Legislation in the form of the Public Bodies (Joint working) (Scotland) Act 2014 came into force on 1 April 2014. The Act requires Health Boards and Local Authorities to integrate their health and social care services. This means that local teams across health and social care in Forth Valley will work together to deliver quality, sustainable care and services resulting in improved outcomes for the people and their families who use these services.
Integration Joint Boards will oversee work with staff in NHS Forth Valley, Falkirk Council, Clackmannanshire Council and Stirling Council to make the necessary plans and put in place the essential arrangements for the coordinated delivery of health and social care. This will ensure that those individuals with long-term conditions and disabilities, many of whom are older people, will get the joined-up and seamless support and care that they need to live safely and independently in their own homes for as long as possible.
Clear, consistent, timely, targeted and accessible communications for service users, carers, staff, communities and other stakeholders is vital to raise awareness and understanding of what health and social care integration is all about and what it means for individuals and their care.
Integration is not about starting again as health and social care organisations across Forth Valley already work closely together and there are a number of successful examples of joint working which can be developed going forward. There are also many good, on-going examples of joined-up communications between partner agencies and this protocol aims to enhance and build on these existing relationships and arrangements.
This communications framework aims to ensure:
• Staff, third sector and independent service providers in NHS Forth Valley and the three local authorities have access to information about health and social care integration and are kept informed of relevant changes and developments which affect them and the services they provide in a consistent and co- ordinated way
• Service users, families, carers and the public are reassured that they will still have access to the health and social care services they require and are kept updated on relevant local developments, benefits and improvements
It is widely accepted that all organisations involved in Health and Social Care Integration must involve, engage and communicate with their staff and stakeholders. There is a real risk of inconsistent and uncoordinated messaging being issued by partners due to having two Partnerships involved in taking forward integration across Forth Valley. A joined-up, consistent and co-ordinated approach to communications is therefore important to ensure staff, service users and other key stakeholders receive the same messages and information at the same time.
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ACHIEVING A JOINED UP APPROACH TO COMMUNICATIONS
Key Principles
It is important to remember that there are already many good, on-going examples of joined- up communications between partner organisations. All local authorities in Forth Valley and NHS Forth Valley, along with many of our third and independent sector partners, have established working relationships with effective arrangements in place for external and internal communications. All of the partner organisations also have access to a wide range of well-established and effective communication tools and channels which have been developed and improved over many years. It is therefore vital to make use of these existing tools and channels to communicate effectively with key stakeholders and avoid setting up separate stand-alone channels and resources specifically for the two new Health and Social Care Partnerships (HSCPs) which are not integrated with existing communication tools. This will ensure that the ongoing work to support the integration of services is not communicated in a silo separate from other core health and social care communications activity but instead becomes an integral and core part of existing communications within each of the partner agencies.
Much of the initial development of HSCPs focuses on the framework to support integration, including governance and legislative requirements. It is important, however, to remember that, while these are important and of interest to a number of staff directly involved in these areas, they are not likely to be of widespread interest to patients and the wider general public. It is therefore important to tailor information to the needs of individual audiences and ensure that it is relevant and provided in a way that is easy to understand. While internal communications are likely to remain an important focus during the first year of operation, there will also be opportunities to engage service users, unpaid carers, third and independent sectors and local communities developing local plans. As the HSCPs develop and evolve, there will be more opportunities to communicate relevant information to service users, the wider general public and local communities. These external communications should predominantly focus on tangible benefits, achievements and outcomes rather than structures, organisational and operational arrangements.
This will be achieved through the ongoing development of:
• Core key messages
• Core Frequently Asked Questions (FAQs) which can be built on to meet the needs of individual Partnerships as they develop
• A timeline for key communications and engagement milestones highlighted in an annual action plan
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• Joint approach to internal communications
• Joint approach to external communications and media enquiries
• A joined-up approach to online content on public-facing websites and social media communications
• A focus on practical and tangible improvements, benefits and outcomes rather than structures, policies and legislation
• The use of relevant local Partnership case studies of staff and patients/service users sharing their experiences of integration and involvement in integration planning
• Regular and ongoing dialogue between communications leads in each of the Partnership organisations to share experience and best-practice
• Practical and effective solutions to address cross-organisation communications needs and provide support in a joined up and equitable way
It is also recognised that, while many of the issues will be similar for both Partnerships, there will be a need to customise communications for each Partnership to reflect differences in approaches, priorities and timing. The possibility of developing branding for the new HSCPs has been raised and work is now underway to agree a process to identify potential options. In the meantime, existing partner logos should continue to be used for relevant publications and reports as outlined in Appendix 1.
KEY OUTCOMES
There are nine national outcomes and work has also been undertaken to identify a number of local priorities to meet the needs of communities across Forth Valley. These are set out in the Strategic Plans for each HSCP which will be implemented over a three year period.
KEY STAKEHOLDERS
As part of our working arrangements, it is important to identify and engage with both our internal and external stakeholders.
How we communicate with them is detailed elsewhere in this protocol however these have been identified as the main groups we will communicate with.
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Internal
Staff from the three local authorities; NHS Forth Valley staff; elected members; Board members; GPs and other independent health contractors such as dentists, pharmacists and opticians.
External
Service users; unpaid carers; community groups; the Third Sector; independent providers of health and social care services; MPs and MSPs; Scottish Government; relevant health and social care inspectorates; local media
JOINT INTERNAL COMMUNICATIONS PROTOCOL
Wherever possible, information about relevant changes, decisions and developments should be made available to staff in the three local authorities and NHS Forth Valley before it becomes public. Communications leads from each of the Partner organisations should therefore work together to develop, agree the content of internal communications and ensure these shared consistently with staff at the same time using existing, established internal communication channels such as staff intranets, emails and staff briefs. Managers and team leaders will be asked to ensure that the information is made available to staff without easy access to computers.
While some individuals will have a specific interest in governance arrangements, structures and legislation the vast majority of staff will be more interested in relevant service developments, announcements, plans and priorities which are likely to directly affect them or service users or patients they work with. Internal communications should therefore focus on the information which is likely to be of interest and relevant to local staff and ensure that information is provided in a format which is easy to understand and free from jargon.
JOINT MEDIA AND EXTERNAL COMMUNICATIONS PROTOCOL
Communication leads will work closely with Chief Officers and other relevant staff to make sure that all information shared with the public, the media and other stakeholders is accurate, consistent, clear and coordinated.
Partnership communication teams will work together to manage media enquiries and issue information to the media in a joined up and co-ordinated way, working with relevant local staff and service leads.
Partner organisations will work together to provide communications support to the HSCPs, including media management. This includes responding to any media enquiries relating to the activities, plans and performance of the HSCPs. Responses will be developed and approved by the most appropriate individual. In general, comments relating to the plans, policies and performance of the HSCP will be attributed to a spokesperson for the 6
Partnership. This will normally be the Chief Officer, Chair or relevant member of the Integration Joint Board. Enquiries regarding routine, day-to-day operational and service issues will continue to be dealt with by the relevant service, clinical or professional leads within each of the Partner organisations and communications staff will work together to ensure that relevant requests, enquiries and responses are shared with appropriate staff within each organisation.
Staff or Board members who are contacted directly by the media for comment on Partnership business or activities should contact a member of staff from either of the partner organisation’s communications teams immediately for advice, support and guidance.
Proactive Communications
Communications teams from the relevant local authorities and NHS Forth Valley will work together to proactively promote the work and services which the HSCP is responsible for. All proactive communications and comments relating to the work of either HSCP will be jointly developed and agreed in advance. Communications teams will also work together to identify and agree a joint approach to new or emerging issues.
Depending on which services the communication relates to – i.e. local social care or local health care services – the communications staff from one of the partner organisations may agree to take the lead role in co-ordinating PR and publicity. This may include drafting and issuing media releases, arranging photo-calls and media briefings and developing articles for partner publications. Promotional material and information will be shared with relevant partners and promoted in a consistent and joined up way using existing communication tools within each of the Partner organisations such as websites, social media channels and publications. Initial web pages have been created to provide information and updates on health and social care integration in Forth Valley. These are hosted on the NHS Forth Valley website (www.nhsforthvalley.comand linked to from the three council websites to avoid duplication and provide consistent messages.
Corporate Communications
Each partner organisation has access to a number of well established and effective communication vehicles to raise awareness of their work amongst staff and the general public. Core publications include the Falkirk Council News (Falkirk Council’s public newspaper which is delivered to every home in the Falkirk Council area), Community Health News (NHS Forth Valley’s public magazine) and Staff News (NHS Forth Valley’s staff magazine), Grapevine (Clackmannanshire Council's staff magazine) and View (Clackmannanshire Council's public newspaper which is delivered to every home in the Clackmannanshire Council area). All partners also have websites, intranets, staff bulletins and a range of social media channels which can be used to provide local information and updates on health and social care integration.
Communications leads from each of the Partner organisations will continue to make use of these valuable corporate resources to provide relevant news, updates and information on integration and consider if any additional resources or tools are required in the future to meet the needs of the HSCPs.
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Monitoring and Review
This protocol will be reviewed and updated on a regular basis to take account of the development of the HSCPs and the new Integrated Joint Boards. Key communications priorities will be identified and agreed bi-annually and action plans will be developed for specific events or initiatives, as required.
ONLINE COMMUNICATIONS - WEBSITE AND SOCIAL MEDIA
Easy to access online information is very important to many service users. Many people with long-term conditions and disabilities view the internet and information-sharing websites as a lifeline to keep up-to-date with what services, care and support can be provided for their condition.
Of equal importance, employee engagement is key for reducing uncertainty at times of change and will help ensure employees are 'on board'. Intranets are a key communication tool for staff and can be used to provide regular progress messages, information and support in times of change and highlight the opportunities that change presents for staff.
To help ensure consistency and reduce duplication, particularly in the early stages it is recommended that:
• General information about Health and Social Care Integration in Forth Valley, with agreed local and Scottish Government key messages and information such as FAQs will be highlighted on a joint web section hosted on the NHS Forth Valley website (www.nhsforthvalley.com/hsci)
• Clackmannanshire, Falkirk and Stirling Council websites will link directly to this joint section to signpost the public to consistent information about Health and Social Care Integration in Forth Valley
• All Partners will work together to prepare appropriate case studies to help illustrate the benefits of integration and how it can work in practice
• Consistent staff messages and briefings will be developed and shared by Partner organisations to ensure local staff are kept updated on relevant information as work progress
• A pro-active approach will be taken to keep communities updated through social media on relevant local events and developments. Social media will also be used to encourage feedback on specific issues, plans and priorities
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CROSS-ORGANISATION COMMUNICATIONS
Each organisation has different ways and methods of communicating with staff and service users. Communication teams will work together to explore practical solutions and identify opportunities to ensure a joined up and co-ordinated approach across organisations, making best use of existing tools and resources.
Forward planning will also be key to ensure there is sufficient time for proper preparation, discussion and dialogue on key communication issues and priorities. There will also be opportunities to share experience on common themes and emerging issues as the new Partnerships and IJBs develop. This will help shape the communications protocol which will be reviewed and updated as plans progress.
THE WAY FORWARD
This Forth Valley wide Communications Framework and Protocol is a live document which will evolve as Health and Social Care Integration progresses across Forth Valley.
This document provides a practical framework and key principles for all partner organisations to use as guidance to ensure a joined up and consistent approach to communications from the outset.
Taking forward Health and Social Care Integration across four individual and complex organisations and two new Partnerships will provide both communication challenges and opportunities however these will be addressed by:
• Ongoing close working and regular meetings between the communication leads from each of the partner agencies to discuss opportunities, share learning, best practice and experience • Making best use of existing communication tools and channels • Working together to address communication issues and identify solutions • Thinking ahead to co-ordinate and plan effectively for future priorities • Focusing on outcomes, benefits and improvements rather than structures, policy and legislation
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Appendix 1 – Interim Branding guidelines
Branding • On internal bulletins to be circulated to staff, the main partner logos (NHS Forth Valley and Falkirk Council for the Falkirk Partnership; NHS Forth Valley, Clackmannanshire Council and Stirling Council for the Clackmannanshire & Stirling Partnership) will be displayed at equal size at the top of the bulletin. These guidelines also apply to job packs, recruitment adverts and other printed and online material. The logos need only to appear once. • For relevant Falkirk Partnership publications the Falkirk Council logo should be displayed at the top left hand side with the NHS Forth Valley logo displayed at the top right. • For relevant Clackmannanshire and Stirling Partnership publications the Clackmannanshire Council logo should be displayed at the top left hand side, Stirling Council logo in the centre and NHS Forth Valley logo displayed at the top right. Clackmannanshire's logo will be its 'partnership' version, without the web address. Stirling's logo will be its colour version; mono for mono print (as per example below) • For Forth Valley wide partnership publications the logos should be displayed in this order (left to right): Clackmannanshire Council, Stirling Council. Falkirk Council. NHS Forth Valley. • Media releases should clearly indicate in the content or notes for editors that they are being sent on behalf of all partners • Media releases should contain the core key messages in the notes for editors • Protocols will be agreed for introducing and describing the Board, Chief Officer, Chairman, Vice Chairman etc in communication materials in due course.
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Style
Text should be in Arial font, at least 11 point. Underlining and FULL CAPS are not recommended. Instead bold and italics can be used for highlighting and headings.
The overall approach should be to keep the look simple, clear and professional.
A selection of approved photographs of each of the partner council areas and NHS Forth Valley services are available and care should be taken to include photographs representing all partners, geographic locations and areas of work.
Partner web addresses, social media details and other relevant contact details should be provided on relevant publications, reports and documents.
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Appendix 2 - Key Aims and Messages
KEY AIMS
Health and Social Care Integration aims to:
• Make it easier and quicker to access services and support • Help people to stay fit and healthy so that they can live safely and independently in their own home for as long as possible • Provide care that is tailored to individual needs • Improve the quality and consistency of services for patients, service users, carers, families and communities • Make better and more effective use of the resources and skills available • Deliver services in a joined up way by bridging gaps and removing duplication • Make it easier for staff to share information, expertise and experience • Respond to the different health and social care needs of local communities
There are nine national outcomes and work has also been undertaken to identify a number of local priorities to meet the needs of communities across Forth Valley.
KEY MESSAGES
• Health and social care integration is about improving care and putting people first – services will be more focused on individuals and tailored to their individual needs.
• These new Partnerships will be responsible for ensuring that people with long-term conditions and disabilities, many of whom are older people, will get the joined-up and seamless support and care that they need to live safely and independently in their own homes for as long as possible.
• Integration is not about starting again as all health and social care organisations in Falkirk, Stirling and Clackmannanshire work well together and there are already many successful examples of joint working which can be built on.
• Working together will help us provide even better services for our communities and ensure local people receive high quality, well co-ordinated care as close to home as possible.
• Local people don’t need to do anything differently; services will be more joined-up behind the scenes and health and social care staff will be working side-by-side to support individuals and communities.
• There are no plans to transfer any NHS Forth Valley, Falkirk Council, Clackmannanshire Council and Stirling Council staff to other organisations as a result
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of integration. Staff will remain with their existing employer and retain their existing terms and conditions of service.
• Health and social care staff, the third and independent sectors, along with local communities, will play a key role in helping to shape and deliver the new ways of working together
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Appendix 3 - Notes to Editor
This agreed notes to editor should be used in any media releases issued on behalf of the Health and Social Care Partnerships in Forth Valley.
Falkirk Health and Social Care Partnership is a joint partnership between NHS Forth Valley and Falkirk Council. It oversees the planning and delivery of a wide range of local health and social services and ensures these are provided in a joined up way to make it easier and quicker for local people across Falkirk to access the services and support they require.
Clackmannanshire and Stirling Health and Social Care Partnership is a joint partnership between NHS Forth Valley, Clackmannanshire Council and Stirling Council. It oversees the planning and delivery of a wide range of local health and social services and ensures these are provided in a joined up way to make it easier and quicker for local people across Clackmannanshire and Stirling to access the services and support they require.
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Appendix 4 - Key Communications Contacts & Communication Channels
Organisation Name Designation Contact Available Channels NHS Forth Valley Elsbeth Head of 01786 457264 Web: nhsforthvalley.com Campbell Communications Twitter:@NHSForthValley 07500 108847 Facebook: facebook/nhsforthvalley [email protected] Staff Magazine: Staff News (Quarterly)
Public Magazine: Community Health News (Quarterly)
Intranet - StaffNet
NHS Forth Valley Kate Communications 01786 457236 Fawcett Manager [email protected]
Clackmannanshire Karen Communications 01259 452027 Web: clacksweb.org.uk Council Payton Team Leader [email protected] Twitter:@clackscouncil
Facebook: facebook\officialclackmannanshire council
Staff Magazine: Grapevine
Public Magazine: Clackmannanshire View (Quarterly)
Intranet: Connect
Clackmannanshire Carla Communications 01259 452023 Council MacFarlane Officer [email protected]
Stirling Council Kirsty Scott Manager 01786 233064 Web: www.stirling.gov.uk Twitter: @stirlingcouncil Communications, [email protected] Marketing and Facebook: Events facebook/stirlingcouncil
Intranet: The Source
Stirling Council Deborah Senior 01786 233 036 Kilpatrick Communications [email protected] Adviser
Falkirk Council Caroline Communications 01324 506051 Web: www.falkirk.gov.uk Binnie and Participation Twitter: @falkirkcouncil Manager 07803898007 [email protected] Intranet: Inside Falkirk
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Staff newsletter – Talking Shop
Newspaper – Falkirk Council News (three times a year)
Tenant magazine – Tenant Talk (twice a year)
Plasma screen in public buildings throughout the area
Falkirk Council Julie Press and Public 01324 506064 Paterson Relations Officer [email protected]
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Clackmannanshire & Stirling Integration Joint Board
27 April 2016
This report relates to Item 15 on the agenda
Carers (Scotland) Act 2016
For Approval
Approved for Submission by Shiona Strachan, Chief Officer Author Mairi Macdonald, Planning & Commissioning Officer Date: 27 April 2016 List of Background Papers: Carers (Scotland ) Act 2016
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Title/Subject: Carers (Scotland) Act 2016 Meeting: Clackmannanshire & Stirling Integration Joint Board Date: 27 April 2016 Submitted By: Mairi MacDonald, Planning and Commissioning Officer Action: For Information
1. EXECUTIVE SUMMARY
1.1 The purpose of this report is to update members on the main provisions of the Carers (Scotland) Act 2016.
2. RECOMMENDATION(S)
The Integration Joint Board is asked to: -
2.1 Note the passing of the Carers (Scotland) Act on 4 February 2016.
2.2 Note the main provisions and implications of the Carers (Scotland) Act 2016, in particular the potential cost pressures.
3. MAIN BODY OF REPORT
3.1 The Carers (Scotland) Bill has now completed its passage through Parliament with stage 3 concluding on 4 February 2016. It is anticipated that the Act will be implemented from April 2017.
3.2 The intention of the Act is to ensure that carers of any age are supported to continue with their caring role, should they wish to do so, and are able to have a life alongside their caring responsibilities. For young carers the intention is also to ensure that they have a childhood similar to their non-carer peers.
3.3 The legislation places a duty on local authorities to provide support to those carers who meet local eligibility criteria. Following on from the Carers (Waiving of Charges for Support) (Scotland) Regulations 2014, all support provided to carers must be free of charge. This includes both support provided directly to the carer, such as help with housework and replacement care provided to the cared-for while the carer is having a break from caring.
3.4 The Act introduces a universal entitlement to assessment for carers, regardless of the level or frequency of care they provide. It also includes detailed prescription around processes such as assessment, support planning and review. A breakdown of the main provisions of the legislation is attached as Appendix 1.
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3.5 The Act clarifies the position on which local authority is responsible for completing assessments where carers and the person cared for live in different local authority areas. For adult carers, it will be the local authority in which the person receiving care lives. For young carers the responsibility for preparing the statement will remain with the authority in which they live.
3.6 The legislation requires that carers are fully involved in this process and that local criteria and strategies are jointly authored by local authorities and NHS Boards and local carers’ groups, such as Central Carers’ Association to define the local response.
3.7 There is an assurance that the waiving of charges to carers will be funded from the point that the Carers (Scotland) Act comes in to force. Social Work Scotland Resources Committee and the Scottish Government Information Service Division have worked together to arrive at an estimate of the income councils will lose from charges. This work produced an estimate of £16 million.
3.8 In the meantime COSLA continues to pursue the matter of funding as their understanding is that no additional funding will be provided by the Scottish Government in 2016/17. Given the requirement to waive charges arises from the use of a power and not a duty, the government's policy position is that councils must find the funds from within existing resources, or choose not to use the power. COSLA is also pursuing an agreement with Scottish Government to re-open funding negotiations should demand exceed Government estimates.
3.9 Within this partnership services for adult carers is in scope of the Integration Joint Board. Young carers and their needs will be addressed through childrens services Joint work will be required to ensure an equitable response and to identify any resulting cost pressures.
3.10 The Integration Joint Board should be aware that certain aspects of the Act are expected to be prescribed statutory functions which 'must' be delegated by the constituent authorities to the IJB. As such, after they have been delegated, it would be for the IJB to issue Direction(s) specifying how those in- scope statutory functions are to be delivered by constituent authorities. The mechanism by which delegation of these functions to the IJB would occur, and clarification as to whether Integration Scheme amendment would be necessary to effect this, remains unclear and we await further guidance from the Scottish Government in advance of the enactment of the provisions of the Act
4. RESOURCE IMPLICATIONS
4.1 The Carers Act is likely to result in an increased demand for assessment and support services. From enactment of the Act in 2017/18, the Scottish Government expects the demand for assessments to increase slowly with the percentage of carers receiving an Adult Carer’s Support Plan rising to 16% by 2021/22.
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4.2 As outlined in the Strategic Plan and the Needs Assessment the 2011 Census records 8,265 carers across Stirling and 4693 carers across Clackmannanshire, a total of 12, 958.
4.3. Many people who fulfil a caring role do not identify themselves as carers and it is therefore likely that these figures underestimate the true extent of caring in the area. The Scottish Health Survey 2013/14 estimated that 17% of the adult population and 4% of people under the age of 16 provide unpaid care. If these figures are applied to Stirling and Clackmannanshire it would suggest the number of carers could be as high as 15,982 and 8,745 respectively.
4.4. Advice and information for carers in Stirling is provided by Stirling Carers’ Centre who receive £109,744 from Stirling Council to provide this service. During 2014/15 there were 2,453 adult carers and 256 young carers registered with Stirling Carers Centre. Advice and information for carers in Clackmannanshire is provided by Central Carers’ Association who receive funding of £58,188 from Clackmannanshire Council to provide this service. During 2014/15 there were 759 adult carers and 226 young carers registered with Central Carers who live in Clackmannanshire. NHS Forth Valley also provide funding to Carers organisations to support their work including the Carers Information Strategy. The level of financial support relating to the Clackmannanshire and Stirling partnership is currently £0.191m per annum.
4.6 The Scottish Government estimates that 60% of adult carers with an Adult Carer’s Support Plan and 69% of young carers with a Young Carers Statement will be eligible for additional care and support. Based on the figures for 2021/22 this would equate to the provision of care and support services to an additional 450 to 2,089 people across Stirling and Clackmannanshire.
4.5 The Carers Act has financial implications in terms of direct service delivery costs and indirect resourcing costs. It is estimated that waiving charges to carers will result in a loss of £300k [Stirling] and £180k [Clackmannanshire] per annum potential income through current charging policies.
4.6 The partnership will require to develop and review of local eligibility criteria, short break statements and carers’ strategies.
5. IMPACT ON IJB OUTCOMES AND PRIORITIES
5.1 The Carers (Scotland) Act 2016 is consistent with the vision and core priorities of the Integration Joint Board.
6. LEGAL AND RISK IMPLICATIONS
6.1 Not applicable for the purpose of this report.
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7. CONSULTATION
7.1 N/A
8. EQUALITIES ASSESSMENT
8.1 N/A
9. EXEMPT REPORTS
9.1 Not exempt.
10. APPENDICES Appendix 1 – Main Provisions of the Carers (Scotland) Act 2016
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Appendix 1 – Main Provisions of the Carers (Scotland) Act 2016
The Act introduces a range of new provisions to identify, assess and support carers. These include:
• A statutory duty to offer and prepare an Adult Carer Support Plan (ACSP) or Young Carers Statement (YCS) for anyone identified as a carer or for anyone who requests an assessment and appears to be a carer
• A duty to provide support to carers whose needs meet local eligibility criteria. Within this consideration must be given to whether support should include the provision of a short break
• A power to provide support and/or information and advice to carers whose needs do not meet eligibility criteria
• The waiving of all charges for support provided to carers
• A duty to establish and maintain, or where a service already exists, continue to provide an information and advice service for carers
• The joint creation of local carers' strategies by Local Authorities and Health Boards
• The publishing of a short breaks statement by Local Authorities
• Greater requirements to involve carers in service design and delivery including in the development of local eligibility criteria
• A duty to include carers in hospital discharge planning
In addition, the legislation widens the definition of a carer, removing the requirement for a person to be providing or intending to provide regular and substantial care to someone receiving community care services.
A suite of regulations and guidelines will accompany the legislation. Alongside these, Scottish Ministers will set timescales for the development of ACSP and YCS where the person cares for someone with a terminal illness, processes and timescales for reviewing strategies and local policies and the monitoring and evaluation of the legislation.
Scottish Ministers also retain a number of powers, including the power to set national eligibility criteria, should local criteria be deemed to be ineffective, and to make further regulations in relation to ACSP and YCS including what information they must contain and the frequency and procedure for reviews.
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Clackmannanshire & Stirling Integration Joint Board
27 April 2016
This report relates to Item 16 on the agenda
Strathendrick Care Home and Developing a Local Care Hub
(Paper presented by Val de Souza)
For Noting and Approval
Approved for Submission by Shiona Strachan, Chief Officer Authors Janice Young, Acting Service Manager David Niven, Programme Coordinator Date: 27 April 2016 List of Background Papers: None
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Title/Subject: Strathendrick Care Home and the Development of a Care Hub Meeting: Clackmannanshire & Stirling Integration Joint Board Date: 27 April 2016 Submitted By: Val de Souza Action: For Noting
1. Introduction
1.1 This paper provides the Integration Joint Board with information in relation to the work being carried out in South West Rural Stirling.
1.2 A series of meetings have been held with local people and representatives from South West Rural Stirling to explore the development of a community based care hub model that serves this area, supporting older people to live well closer to home.
1.3 Stirling Council requested at a Council meeting on 10 December 2015, that the Head of Service for social services report back to Council on 19 May 2016 with the findings of this community engagement exercise. It is proposed that the outcomes of this exercise continue to be developed with a view to developing a future proposal to the Integration Joint Board.
2. Executive Summary
2.1 Communities in South West Rural Stirling have expressed an interest in supporting the Health and Social Care partnership to develop a model of care using the Strathendrick Care Home facility as a base to provide in-reach and out-reach supports to older people to help avoid unnecessary admission to hospital and support timely discharge. This model of care would also support older people to live full and positive lives within supportive communities and to support carers in line with the Strategic Plan for the Health and Social Care Partnership.
3. Recommendations
The Integration Joint Board is asked to:
3.1 Note the engagement of the local community in discussion on the range and type of services which would meet the needs of the local population.
3.2 To note that a further update has been requested by Stirling Council on 19 May 2016, to advise them of the outcomes of local community engagement.
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3.3 To agree that a further update will be presented to the Integration Joint Board in October 2016, outlining potential service delivery options to meet the needs of the population of South West Rural Stirling.
4. Background
4.1 Strathendrick Care Home is a small 12 bedded unit in central Balfron and provides services to the South West rural area of Stirling including Strathblane, Killearn, Croftamie, Buchlyvie and Kippen. The service currently provides 4 long term places with an additional 2 respite beds and 6 beds providing short term assessment focused on supporting hospital discharge and prevention of admission.
4.2 A commitment was made by Stirling Council in December 2015, to carry out a community engagement exercise with local communities in the South West Rural Stirling area, with a focus on the possibility of developing a proposal for a local care hub based around the Strathendrick Care Home facility. This followed a decision by Stirling Council to support the submission of the Full Business Case for Stirling Care Village, but to consider alternatives to raising capital investment for this through the land receipts of all existing care homes owned by the Council. Specifically, a request was made to engage with local communities to establish views on future service delivery models.
4.3 Since December 2015, a series of meetings have been held to consider the development of a community hub model building on the work already in place in Callander, and basing any redesign on the strategic needs assessment and the Strategic Plan commitments. Any potential re design of services would need to be achieved from within existing resources, whilst exploring potential alternative and supplementary forms of support and funding. Some early stage discussions have also taken place with the local community on the role of the third sector and community volunteers. For example, suggestions for further development have included access to volunteer responder schemes and local telehealthcare champions, as well as using technology enabled care to support professional and social connections such as video conferencing.
5. Conclusions
5.1. In conclusion, positive steps have been taken in terms of engagement with the local communities of South West Rural Stirling, with a view to developing an outline re design proposal for future service delivery options which meet the strategic priority of reducing unplanned admissions to acute services, while supporting the overall vision that people live full and positive lives within supportive communities.
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6. Resource Implications
6.1. There are no immediate resource implications to this engagement work with communities of South West Rural Stirling.
7. Impact on Integration Joint Board Outcomes, Priorities and Outcomes
7.1. The outcomes in supporting South West Rural Stirling communities in their desire to develop services which meet their local needs, provides a positive impact upon Integration Joint Board outcomes and priorities as outlined in the Strategic Plan 2016-19.
8. Legal & Risk Implications
8.1. There are no legal implications.
9. Consultation
9.1. This paper provides an up-date on methods of engagement held through the establishment of a steering group consisting of community members, local authority, NHS Forth Valley and Third Sector members.
10. Equality and Human Rights Impact Assessment
10.1. N/A.
11. Exempt reports
11.1. Not Exempt.
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Clackmannanshire & Stirling Integration Joint Board
27 April 2016
This report relates to Item 17 on the agenda
National Care Standards
Paper presented by Lesley Fulford
For Noting
Approved for Submission by Shiona Strachan, Chief Officer Author Lesley Fulford, Programme Manager Date: 27 April 2016 List of Background Papers: The papers that may be referred to within the report or previous papers on the same or related subjects.
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Title/Subject: National Care Standards – Consultation Report Meeting: Clackmannanshire & Stirling Integration Joint Board Date: 27 April 2016 Submitted By: Lesley Fulford, Programme Manager Action: For Noting
1. Introduction
1.1 This report highlights the outcome of the first stage of consultation for the National Care Standards
2. Executive Summary
2.1. Last year the Scottish Government announced a review of the National Care Standards and undertook a public consultation to gather views of how best to do this.
2.2. Subsequently the Care Inspectorate and Healthcare Improvement Scotland were tasked to lead the development group that will co-produce these new standards working alongside people using services, providers and other agencies.
2.3. The first stage consultation has now concluded and the principles (appendix 1) and consultation report (appendix 2) are attached.
3. Recommendations
The Integration Joint Board is asked to:
3.1. Note the outcome of the first stage of consultation
4. National Care Standards
4.1. Last year the Scottish Government announced a review of the National Care Standards and undertook a public consultation to gather views of how best to do this.
4.2. Subsequently the Care Inspectorate and Healthcare Improvement Scotland were tasked to lead the development group that will co-produce these new standards working alongside people using services, providers and other agencies.
4.3. The first stage consultation has now concluded and the principles (appendix 1) and consultation report (appendix 2) are attached.
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4.4. At a recent Scotland Policy Conferences Keynote Seminar: Integrating health and social care in Scotland attended by the Chief Officer and Programme Manager on 2 March 2016, Karen Reid, Chief Executive, Care Inspectorate confirmed:
o Consultation took place over November 2015 o Scottish Minister has signed off principles o Next step is general and specific standards and these will be phased in from April 2017.
5. Conclusions
5.1. The Integration Joint Board is asked to note the outcome of the consultation.
6. Resource Implications
6.1. None to note at this stage.
7. Impact on Integration Joint Board Outcomes, Priorities and Outcomes
7.1. None to note at this stage.
8. Legal & Risk Implications
8.1. None to note at this stage.
9. Consultation
9.1. None required at this stage.
10. Equality and Human Rights Impact Assessment
10.1. Not required
11. Exempt reports
11.1. No
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NATIONAL CARE STANDARDS
REVIEW PRINCIPLES Dignity and respect • My human rights are respected and promoted. • I am respected and treated with dignity as an individual. • I am treated fairly and do not experience discrimination. • My privacy is respected.
Compassion • I experience warm, compassionate and nurturing care and support. • My care is provided by people who understand and are sensitive to my needs and my wishes.
Be included • I receive the right information, at the right time and in a way that I can understand. • I am supported to make informed choices, so that I can control my care and support. • I am included in wider decisions about the way the service is provided, and my suggestions, feedback and concerns are considered. • I am supported to participate fully and actively in my community.
Responsive care and support • My health and social care needs are assessed and reviewed to ensure I receive the right support and care at the right time. • My care and support adapts when my needs, choices and decisions change. • I experience consistency in who provides my care and support and in how it is provided. • If I make a complaint it is acted on.
Wellbeing • I am asked about my lifestyle preferences and aspirations, and I am supported to achieve these. • I am encouraged and helped to achieve my full potential. • I am supported to make informed choices, even if this means I might be taking personal risks. • I feel safe and I am protected from neglect, abuse, or avoidable harm. February 2016
National Care Standards Review Overarching Principles Consultation Report
February 2016
Background
The National Care Standards are a set of standards for care services in Scotland. They help everyone understand what they can expect when they access health and social care services. They also help services understand the quality and standards of care that they should provide.
The standards are one of the measures by which the Care Inspectorate and Healthcare Improvement Scotland assess the quality, safety and effectiveness of care.
Since their introduction in 2002, the National Care Standards have not been reviewed, and so, in line with current expectations of compassionate, high quality, safe and effective care, Scottish Ministers committed to a review of the standards.
A Project Board was established, to provide strategic direction to the review, with representatives drawn from organisations which support the delivery and improvement of health and care services in Scotland. The Project Board is the decision making body and is tasked with making recommendations to the Scottish Ministers regarding the new standards. A Development Group, co-chaired by the Care Inspectorate and Healthcare Improvement Scotland, was established with relevant key stakeholders to develop draft standards for the Project Board.
It was agreed that the standards would be developed across three levels:
Level one : overarching principles which underpin the new National Care Standards for care services in Scotland, which apply across all health and social care services, including hospitals, independent healthcare, NHS surgeries, social work provision, criminal justice, social care, early learning and childcare.
Level two: general standards which apply across a number of related services or in specific sectors
Level three: specific standards which apply to particular settings
This report provides information and analysis of the consultation on the overarching principles.
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Consultation on the overarching principles
A public consultation on the seven draft overarching principles ran from 26 October–10 December 2015. We sought to engage everyone with an interest and involvement in health or social care, whether personal or professional, to take part in the consultation to help the standards evolve to meet the needs, rights and choices of people across Scotland. We asked people to share their feedback using a number of mechanisms: attend consultation sessions, submit written responses and complete an online survey (SurveyMonkey®).
Analysis
Every comment was reviewed by the project team. All duplicate submissions were removed. Data was stored and analysed in accordance with all relevant data protection legislation.
Responses
We received 1737 responses. The responses were submitted by service users, family members and members of the public, as well as service user and provider groups and organisations (see Table 1). Submissions were received from across Scotland.
Table 1: Consultation respondents Respondent type % Number People involved in receiving care 33 688 A person who uses a service 11 222 Family member/carer 8 171 Member of public 6 123 Working for an organisation that represents people using services 6 132 On behalf of service user 2 40 People involved in delivering care 37 774 Working in health, care or support services 41 859 Volunteer 2 47 Other organisations 25 545 A provider and/or organisation representing providers 15 322 Representing a professional body 2 52 Working for a commissioning service 1 18 Working for a scrutiny/regulation body 1 21 Other 4 82 Total 99 2089* * respondents could select more than one option
We received comments from across health and social care settings including care homes for older people and other adults, care at home, housing support for other adults, early years, care homes for children and young people, school care accommodation, NHS boards, Allied Health Professionals, nurses and GPs.
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Support for principles
During the consultation we asked respondents to indicate their support for each principle. Over 96% of respondents agreed/strongly agreed with each individual principle, Table 2.
Table 2: support for individual principles Principle Strongly Agree Disagree Strongly Agree % % Disagree % % I am entitled to be respected 17 82 1 1 I am entitled to compassion 19 78 3 1 I am entitled to be included 22 74 3 1 I am entitled to be treated fairly 15 83 2 1 I am entitled to a responsive service 21 75 3 1 I am entitled to be safe 16 82 2 1 I am entitled to personal wellbeing 22 75 2 1
There were no trends found when we reviewed the disagreed/strongly disagreed principles by setting (such as health or social care), respondent type (eg service users or staff) or from submitting organisation.
Comments and suggestions
In addition to indicating their support for the principles, we also asked respondents to provide comments and suggestions on the wording, layout and scope of the principles. All the feedback was reviewed and themes were identified. The National Care Standards review team considered all themes, and presented these to the Development Group for discussion and agreement on changes to the draft principles.
The revised principles are presented, alongside the original principles, in Appendix 1.
Many of the changes that respondents suggested, for example, to clarify and simplify layout and text, have been made.
Summary of revisions
Changes to layout and structure: • Removal of duplication and crossover • Principles merged and streamlined • Removal of introductory phrase ‘I am entitled to...’
Changes to text • Language simplified, clarified and made more accessible • Inclusion of key words and themes from consultation, for example: - service users exercising choice rather than just expressing views - service users having privacy
- assessment and knowledge of needs
- greater service user involvement in decision making, more control
and more active citizenship - Lifestyle preferences and aspirations more personal and inclusive than goals - consistency of staff and limiting turnover integral to achieving quality - and encouraged
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Some of the suggested changes that respondents shared during the consultation were not included in the revised principles because the amendment was considered to be:
covered by the existing or revised text too setting specific not applicable to the overarching principles but relevant to general or specialist standards, or outwith the scope of the standards review
Examples of suggested changes that have not been included in the revised principles
Covered by existing or revised text, for example
advocacy was felt to be included by the new phrasing ‘I am supported to make informed choices, so that I can control my care and support’. continuity of care was considered to be covered by the new phrase ‘I experience consistency in who provides my care and support and how it is provided. citizenship was judged to be sufficiently covered by the new phrasing ‘I am supported to participate fully and actively in my community’.
Too setting specific, for example love and recovery were not considered applicable to all health and health and social care settings, but may be suitable for informing wording and decisions at other levels of the standards secure was felt not applicable to all services for example to advocacy and support services
Not applicable to principles but relevant to general or specialist standards A number of the suggested changes were felt to relate more to the development of general or specialist standards, for example, staffing, resources, the environment and end of life care and support.
Outwith scope of review A very limited number of the comments related to areas outwith the scope of the consultation, such as commentaries on how inspections were undertaken or related to a particular concern the individual had with a service. These will be considered in the appropriate way.
The revised principles have approved by the Cabinet Secretary (February 2016).
Next Steps From February 2016, we will work on developing the new national care standards based on the agreed principles. We will develop general standards, which are common to all services, and specialist standards for service users with specific needs.
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The general and specialist standards will be developed with users, carers, providers, staff and other stakeholders. There will be a public consultation in the autumn which will cover both the general and specialist standards. We will ensure that the standards are shared with all those that indicated, in the consultation on the overarching principle, their preference to be involved in our consultation on general and specialist standards. We will also engage with individuals and groups which were identified as under-represented in the overarching principle’s consultation, including those from remote and rural areas, settings such as housing and client groups including learning disabilities.
The new standards will be rolled out from April 2017 and, as inspection methodology develops, will be used for all inspections of registered services and other scrutiny activity. They will also help inform the joint strategic inspections of health and social care provision for children and adults.
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Appendix 1: Original and revised principles (approved by Cabinet Secretary February 2016)
Proposed draft principles Revised principles I am entitled to be respected Dignity and respect (respected and treated fairly merged) My opinions, privacy, beliefs, values and culture are respected. My human rights are respected and promoted. I am treated with dignity. I am respected and treated with dignity as I am entitled to be treated fairly an individual.
I am valued as an individual and I am I am treated fairly and do not experience treated fairly. discrimination.
My human rights are respected and My privacy is respected. promoted.
I do not experience discrimination.
I am entitled to compassion Compassion
I experience warm, compassionate and I experience warm, compassionate and nurturing care provided by people nurturing care and support. sensitive to my needs and wishes. My care is provided by who understand and are sensitive to my needs and my wishes.
I am entitled to be included Be included I receive the right information, at the right time and in a way that I can I receive the right information, at the right understand. time and in a way that I can understand.
I am supported in my right to make I am supported to make informed choices, informed choices and decisions about so that I can control my care and support. my care and support.
I am involved in wider decisions about I am included in wider decisions about the the way the service is provided. When I way the service is provided, and my make suggestions and voice concerns I suggestions, feedback and concerns are am listened to. considered. I can play a full role in the community around me. I am supported to participate fully and actively in my community.
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Proposed draft principles Revised principles I am entitled to a responsive service Responsive care and support
I receive the right care and support at My health and social care needs are the right time. assessed and reviewed to ensure I receive the right support and care at the right My care and support responds when my time. needs, views and decisions change. My care and support adapts when my I have personal goals, aspirations and the needs, choices and decisions change. support to achieve them. I experience consistency in who provides my care and support and in how it is provided.
If I make a complaint it is acted on.
I am entitled to be safe Wellbeing (safe and personal wellbeing merged) I am safe, free from harm and abuse. I am asked about my lifestyle preferences My care and support is provided in an and aspirations, and I am supported to environment in which I feel safe. achieve these.
I am supported and encouraged to I am encouraged and helped to achieve my achieve my aspirations and potential, full potential. even when this means I might be taking risks. I am supported to make informed choices, even if this means I might be taking personal risks. I am entitled to personal wellbeing I feel safe and I am protected from I have individual health and wellbeing neglect, abuse, or avoidable harm. preferences and outcomes.
I am supported to achieve these, and to realise my potential.
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Clackmannanshire & Stirling Integration Joint Board
27 April 2016
This report relates to Item 18 on the agenda
Stirling Care Village Update
(Paper presented by Kathy O’Neill, General Manager, Community Services Directorate, NHS Forth Valley)
For Noting
Approved for Submission by Shiona Strachan, Chief Officer Author Kathy O’Neill, General Manager, NHS FV Morag Farquhar, Project Director Ewan C. Murray, Chief Finance Officer (in capacity of project accountant for the development) Date 27 April 2016 List of Background Papers Stirling Care Village – Case for Change Element of Full Business Case, 11 December 2015
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Title/Subject: Stirling Care Village Update Meeting: Clackmannanshire & Stirling Integration Joint Board Date: 27 April 2016 Submitted By: Kathy O’Neill, General Manager Action: For Noting
1. Introduction
1.1 This report provides the Integration Joint Board with an update on progress to complete the Full Business Case for Stirling Care Village and progress to financial close to allow construction to commence following the required approvals.
2. Executive Summary
2.1 The case for change element of the Full Business Case was presented to the Integration Joint Board in December 2015 where the Board agreed the core principles detailed subject to the complete Business Case incorporating the full resources. The case for change was subsequently presented to the Capital Investment Group of Scottish Government in January 2016.
2.2 Feedback on the case for change element of the Full Business Case was received from Scottish Government on 4 April 2016. This detailed issues which required to be explained or addressed either before submission of the final Full Business Case to the Capital Investment Group or beforehand. None of the feedback or issues to be address would materially affect the Full Business Case or the project overall.
Subsequent to this feedback agreement was also reached with Scottish Government on how the value of the capital prepayment from Scottish Government agreed at Outline Business Case stage should be presented within the Final Full Business Case. Full clarity on this aspect will require to be reached prior to financial close.
2.3 There is now a need to progress with updating and finalising the Full Business Case including the Economic and Financial Appraisals as quickly as possible to bring the project to financial close and minimise risk of further increases in costs for the project.
2.4 A paper on the final Full Business Case will be presented for consideration at the June meeting of the Integration Joint Board.
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3. Recommendations
The Integration Joint Board is asked to:
3.1. Note the progress being made to finalise the Full Business Case and achieve Financial Close.
3.2. Note that a paper on the final Full Business Case including resource implications will be brought forward to the June meeting.
4. Considerations
4.1. The Scottish Government provided feedback on the case for change Element of the Full Business Case on 4 April 2016. The feedback highlighted some issues they would wish further expanded or clarified within the final Full Business Case document or answered in advance. None of the feedback is anticipated to materially affect the proposed physical structure or care model proposed in the business case.
4.2. The feedback from Scottish Government related to:
• Setting the business case in an updated strategic context taking into account establishment of Integration Joint Boards, the approval of the Strategic Plan and NHS Forth Valley’s current Local Delivery Plan. • Ensuring the anticipated benefits of the project are clearly articulated including further detail of the capacity planning for the Care Hub. • Technical and contractual issues.
4.3. The Scottish Government also agreed the assumptions to be used in the final Full Business Case to replace the planned capital prepayment assumed at Outline Business Case. It will now be assumed that the equivalent value will be met by Scottish Government in the form of revenue support over the life of the contract though Scottish Government will further consider options in relation to this. This is an outcome of the changes to European Accounting Regulations describing in the previous paper to the Integration Joint Board.
4.4. There is now an urgent need to progress with completion of the Final Full Business Case and submit this to the Capital Investment Group for approval to minimise the impact of increased costs through inflation on the capital and ongoing revenue costs on the project.
4.5. The Project Board are currently progressing with plan to achieve financial close as quickly as possible whilst ensuring appropriate management of the risks associated with the project and the necessary governance arrangements are met. Dialogue with Scottish Government around this is ongoing.
4.6. It is planned to submit the final Full Business Case to the June meeting of the Capital Investment Group for consideration and approval.
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4.7. To achieve this the final Full Business Case will require to be approved by NHS Forth Valley, the Scottish Ambulance Service and Stirling Council before the Capital Investment Group meeting and by the Integration Joint Board at its June meeting.
4.8. There will also require to be formal agreement reached with the GP Practices where services will transfer to the Primary Care centre element of the Care Village.
4.9. The Project Agreement for Stirling Care Village will be entered into by NHS Forth Valley on behalf of all the participants at financial close. This agreement requires to be underpinned by ‘back-to-back’ formal agreements with the other participants at financial close. The Project Agreement is the legal document which sets out contractual and financial responsibilities of the various parties over the life of the contract.
5. Resource Implications
5.1. The full resource implications including economic and financial appraisals will be documented within the final Full Business Case including significant revenue support from Scottish Government.
6. Impact on Integration Joint Board Priorities and Outcomes
6.1. Delivering the Stirling Care Village is one of the priorities detailed in the Integration Joint Boards Strategic Plan.
7. Legal & Risk Implications
7.1. The legal and risk implications will be documented within the full business case.
8. Consultation
8.1. The Chief Officer.
9. Equality and Human Rights Impact Assessment
9.1. N/A.
10. Exempt reports
10.1. Not exempt.
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