Edinburgh Integration
Joint Board

We do not all absorb information in the same way. One size does not fit all.

Not everyone has access to on-line engagement and communications and it should not be relied on.

We should be able to access groups and advocacy to help us find out information.

Consider ensuring that all digital information (i.e. on-line) is accessible to all.

Ethnic minority services are very difficult to source. We don’t have specific ethnic services anymore. Huge area of un-met need.

Self-directed support can work well however it is complex and difficult to navigate. More accessible information should be available about how the system works.

Why can’t you keep it simple, we do not want to keep filling in lots of forms.

The communications and engagement team have focused on ensuring that the website and all future communications, are accessible.

A new comms and engagement strategy is currently being developed for consideration in February 2024.

The Partnership also supports a number of knowledge information systems, including;

–        The EVOC Red Book – Directory of third sector organisations and their services

–       iThrive, an online space for mental health and wellbeing information in Edinburgh.  This has recently been expanded to include a staff (statutory and 3^rd sector partners) space to improve referral pathways.  This includes the Recite tool for full accessibility.

As part of Thrive Procurement, service user research to explore barriers to support has been commissioned. Particular research is focused around ethnic minority background, LGBTQI+, and young parents.

We continue to monitor and evaluate our Thrive Collective using quarterly monitoring and evaluation including qualitative data.  The Partnerships within the Collectives are agile and respond to need.

We work closely with EVOC in delivering the needs identified in the Integrated Impact Assessment for Thrive Welcome and through our recent inclusion of the Alcohol and Drug Partnership and homelessness within the Thrive Team.

Thrive Edinburgh are currently working in Partnership with Media Education to develop a narrative change framework.  2024 will see further development of our Elipses Programme, a narrative change Framework which will be delivered through a variety of mediums such as stories and film (service improvement).

The Edinburgh Wellbeing Pact is framed around the principles of mutuality and reciprocity, and these remain central to all the enactment activities which have been initiated to date. As part of our Community Mobilisation project, we are developing new ways to engage and fund the third sector, with emphasis on community and ethical commissioning process, community collaboration and assets.

The Edinburgh Pact webpage is now live and shares information in a variety of different media for example the site hosts audio podcasts and Picturing Health – a photography exhibition which reflects what health and social care means to individuals.

In April 2022 a full progress report was presented to the IJB with 7 further recommendations which were supported.

(This has been reframed as community mobilisation reflecting the themes identified by the Edinburgh Wellbeing Pact dialogue.)

–        what wellbeing means to you

–        how are you connected in your community (or not) and

–        what kind of things are important in your communities.

Community Mobilisation Developments include:

·        The Edinburgh Community Resilience Programme with Cyrenians and Queen Margaret University supports the health and wellbeing of Edinburgh’s older people. The programme builds on previous expertise and research which considers community navigation, social prescribing approaches and the Making it Clear resilience framework.

·        Op Ready with Edinburgh Leisure focuses on those whose current health status is affecting their receiving knee or hip surgical procedures.

·        The Community Taskforce Volunteer Programme led by Volunteer Edinburgh received recurring funding to enable the trained task force of over 400 people to continue to help Edinburgh residents with practical tasks such as dog walking, shopping collection and support after a hospital discharge.

·        The Fit and Active programme for People with Learning Disabilities with Edinburgh Leisure has created opportunities for people with learning disabilities to be physically active and socially connected.

A key component of community mobilisation has been the Learning by Doing Community Commissioning process for the allocation of the Scottish Government’s Community Mental Health and Wellbeing Fund. This approach has been used for the second year of allocation of the Scottish Government’s Mental Health and Wellbeing fund.

Consideration is now being given to the development of a partnership digital strategy including knowledge and information management of services and self-management resources.

iThrive is the online space for mental health and wellbeing in Edinburgh. Designed in collaboration with staff, lived experience, and carers it is fully maintained and kept up to date with ongoing input and developments.  Not only does it provide information about support, services, and activities across the city but provides resources for people to help self-manage. It also provides information for communities such as students.

Within the IIA process, consideration is given to how the changes will be communicated to those affected by the proposals, particularly those affected by sensory loss, speech impairment, low level literacy or numeracy, learning difficulties or English as a second language.

IIA training sessions are held every 2 months and are open to all colleagues.  In the last 3 years, 595 colleagues across Lothian (176 EHSCP) have attended training.  Feedback on the training sessions has been extremely positive and results show confidence levels in undertaking IIAs rose from 1.9 before the training session to 3.6 out of 5 after training.

As part of Thrive Change of Conversation, Change the Culture they hold regular Thrive on Thursdays. These are opportunities to invite people to present on new items of work that may impact across stakeholders such as policies, or opportunities for consultations. Recent topics include strategy update for mental health and suicide prevention and the new human rights bill. It attracts stakeholders from across sectors and often leads to new connections and actions.

–       We’re currently reviewing and updating accessible film clips (BSL, subtitles and voiceovers) on the Edinburgh Health and Social Care Partnership (EHSCP) and the City of Edinburgh Council (CEC) websites and working in collaboration with the Communications Team.

–       We will be promoting our funded eight (8) mini See Hear projects funding, as part of the Scottish Government See Hear Strategy

–       We will review our See Hear Strategy work with the BSL Plan to join up some actions for ease and avoid duplication or overlap with other work.

–     Continue promoting NHS Inform / NHS 24 accessible film clips (BSL, subtitles and voiceovers) for individuals with sensory loss.

–               We have supported and funded CEC Edinburgh Museums and Galleries by developing accessible film clips (BSL, subtitles and voiceovers) for viewers to watch and learn from home or on the premises.

Further actions are to be carried out as per the plan, which runs to 2024.

The specification included several outcome areas to ensure more equal access to independent advocacy;

–       The recommissioning process further separated out provision for some people who have substance misuse issues to improve access to advocacy.

–       Additional funding has been allocated to Carers service which will allow a better targeted approach to unpaid carers who are women.

–       The needs for people in specific groups, including people from LGBT plus, have been highlighted in the new specification.

–       Feedback from user led advocacy feedback groups has been incorporated into the specification to improve access for people with disabilities and carers of people with physical disability.

–        A detailed service provision report analysing scope/volume and evidencing improved access to Advocacy will be due for submission from service providers in December 23 and initial indications are demonstrating quicker and easier access for people with substance misuse issues and carers.

–      Edinburgh Community Rehabilitation and Support Services (ECRSS)

–      facilitate a Peer Support group for people returning to work following Stroke, MS, Parkinson’s or any physical disabilities.  The Group was created because people highlighted that there was a gap in the service offered in terms of returning to work support.

–      In September 2023, ECRSS launched a weekly drop in ‘Heads-up Hub and Café’ where people with neurological conditions and their loved ones can come together to connect, learn, and support each other. This is targeted towards people living with MS, Stroke, Brain Injury, Parkinson’s Disease, MND and Huntington’s Disease. We can help if people have questions about Money, Technology, Work, Transport, Hobbies and Interests, Community Groups, Help for carers, Health and Wellbeing.

–      Bi-Polar Scotland are supported to host frequent groups for both young people and adults and provide them not only with a space to connect but also bring in people who can help or share things that might help.

–      Hosted by The Ripple Project and supported by EHSCP’s Long Term Conditions Programme, the North East Edinburgh Catch Your Breath Support Group has been established for people who have a lung condition and anybody affected by living with someone with a lung condition.  The group aims to provide a holistic response to the emotional, practical and physical issues people can face on a day-to-day basis. By bringing people together with similar conditions and experiences, the group facilitates peer support, provides opportunities to become more physically active, support healthy living and provide advice on condition management.  The group has been meeting monthly since October 2021, for groups of 10-20 people.

–      Since November 2020, as part of the Thrive procurement, we have been commissioning Health in Mind and CAPS Advocacy to host the peer community of practice. The community meet frequently to discuss opportunities such as training and development, sharing practice, generate new practice ideas with an overall aim of building capacity for peer support across Edinburgh. For further info visit: iThrive | Peer Community (ithriveedinburgh.org.uk)  In October a Peer event was held which invited peer workers from across the community to develop a joined approach to peer work, to support one another and to determine where else peer work would be of benefit.

This web-based tool Carer Support Finder was developed to enable carers to find the right support and services throughout each stage of the carer journey. The tool is widely promoted through events, partner videos and promotion on Lothian Buses which is proving to be extremely effective.

Since November 2020, as part of Thrive Procurement process, wide stakeholder engagement has been taking place with carers who care for people experiencing poorer mental health wellbeing. This is being delivered through VOCAL. VOCAL worked with carers to hear their views about how mental health services engage with them and find ways of engaging them to improve their own caring situation and to improve mental health services more generally. Further info can be found at: Mental-Health-Carers-Consultation-Full-Report.pdf (vocal.org.uk)

The findings from this report are now being actioned.

Equality Outcome 2:  People are treated with respect and provided with the best advice and support.

Eliminate unlawful discrimination, harassment and victimisation and other conduct that is prohibited by the Equality Act 2010.

Foster good relations between people who share a relevant protected characteristic and those who do not.

A firmer focus on people with multiple intersecting characteristics is needed.

Providers of older people’s services need to make specific efforts to ensure that LGBTQI characteristics are recognised and taken into consideration.

I feel pressure is placed on patients in hospital and their representatives to make choices about their long-term future within unacceptable timescales.

It is important to make sure that we are safe in the community and that if we come out of hospital, we will not face discrimination.

We should educate people to raise awareness and acceptance.

Improved training in equality issues to raise cultural awareness and sensitivity should be compulsory for front line staff.

It is important that all people are treated with respect and given the same opportunities as everyone else.

Everyone is different and this needs to take into account people’s individual need when setting up their support.

Recognition of LGBTQI older adults is needed.

In addition to the mandatory training more focussed training is held regularly.  For example, training sessions were held for HSCP staff in 2022 which explored what it means to be anti-racist in the workplace environment.  135 HSCP staff attended the training and feedback was positive and showed that the majority of the staff who attended would strongly recommend the training to colleagues.

As at September 2023, there are now 25 innovation sites using this approach in a variety of teams and professions. It should be noted that the embedding of Three Conversations is a cultural change approach which will continue to require support for a number of years.

The One Assessment project commenced June 2023. This aims to provide staff with the relevant guidance and tools needed to deliver consistent, good quality and robust assessments through the implementation of a single assessment template (3Cs) across all assessment and care management teams, as well as support for embedding the approach into daily practice.

A Transformation-wide Training Pack is being considered for development with Learning and Development colleagues as part of the roll-out of Three Conversations and essential learning for new staff following roll out.

EHSCP one of 8 Getting it right for everyone (GIRFE) partnership pathfinders working with Scottish Govement Social Care and National Care Service Development Directorate.

GIRFE is a multi-agency approach to health and social care support and services from young adulthood to end of life care.

It will form the future practice model of all health and social care professionals and shape the design and delivery of services, ensuring that people’s needs are met.

GIRFE is about providing a more personalised way to access help and support when it is needed. It will place the person at the centre of all the decision making that affects them, with a joined-up consistent approach regardless of the support needed at any stage of life.

The national aim is to implement GIRFE across Scotland in Summer 2025.

–      A roll out of a new human rights awareness education programme, Mind Our Rights, to staff using people with lived experience as facilitators is progressing.

–      The Mental Welfare Commission’s booklet – “Rights in Mind Pathway” and communications continue to be shared with key staff offices and service users. Information cards with QR code and link to booklet are also being distributed widely.

–      A literature review of human rights-based approaches and supported decision making has been completed and shared.

–      More peer training, focussed on human rights, has been developed by Edinburgh’s Patient Council in collaboration with people with lived experience of mental health issues and has been well received by voluntary and statutory staff and hopes to expand in 20024.

–      Development and delivery of More-P by the patient’s council. Looking to expanding role out across other professional sectors. In addition, it should be delivered to college and university students.

Online MS Teams training entitled “Working with people with sight loss in your locality” was delivered to EHSCP staff in January and March 2021.

Twenty face to face workers within EHSCP were offered a place on the only Scottish pilot of RNIB’s “Vision Friends” training course.

Public Health Scotland’s BSL e-learning module and NHS Education for Scotland’s 3 sensory e-learning modules are mandated as essential pre-course learning for all EHSCP sensory training, and now form part of “Essential Learning for Care” staff training.

We will plan and deliver various online and in-person training to a wide variety of staff.

The Team will review and update Edinburgh Health and Social Care Partnership (EHSCP) and the City of Edinburgh Council (CEC) online training and learning development resources to ensure everything is up to date and appropriately defined – ORB and myLearning Hub.

Ongoing plans to deliver Deafness and Dementia awareness training in collaboration with the British Deaf Association Scotland (BDA Scotland).

We will launch our Care Homes Sensory Screening and Support project for individuals with sensory loss. We are working in collaboration with NHS Lothian, other Lothian Local Authorities, Sight Scotland, Visibility Scotland, etc. Training will be included for health care and care home staff.

Continue supporting and promoting Public Health Scotland’s (PHS) BSL e-learning module and NHS Education for Scotland’s (NHS NES) three (3) Sensory Loss e-learning modules for all EHSCP and CEC staff internally.

The new Progressive Stroke Pathway includes a new set of clinical priorities with greater emphasis on person-centred approaches throughout the pathway and more specific rehabilitation interventions. We have developed a strategy for the delivery of the necessary skills-based training which includes three aspects: 1) training delivery, 2) in-house follow-up sessions and mentoring to support application of training in practice, and 3) annual programmes of training delivery to ensure that new staff have the opportunity to acquire the required skills and knowledge.

Current training:

Stroke awareness course – aimed at social care staff – entry level knowledge.

Current care in stroke part one – core competency level full day course – aimed at staff new to stoke or those where stroke is not their main condition.

Current care in stroke part 2 – advancing level – full day course – aimed at experienced staff and those working directly with stroke patients.

Stroke topics – fortnightly webinars delivered over MS TEAMS (recorded able and available to watch for all staff)

In addition:

CHSS Online Stars modules – Core competency modules (which is a core requirement that all staff working in stroke should complete) and advancing levels modules – again online and staff groups encouraged to complete relevant modules.

The focus moving forward is to deliver additional training to all staff and ensure that all staff, whether new or experienced have the skills and knowledge required to provide the best possible care and evidenced based care for stroke patients in Lothian. Additional training is currently being developed for 2024 for all staff groups in line with the training identified by the recent progressive stroke pathway document and will be delivered on an annual basis or as needs require.

Training has continued to a variety of groups and partners on suicide prevention, both online and face to face. We continue to run awareness stalls in various public locations.  We have liaised with Welfare Rights colleagues given the current problems in society and we have included information on financial support.

Suicide awareness advice along with general public protection advice has also been delivered to a number of staff supporting Ukrainian refugees in Edinburgh by the Public Protection Officers.

This may be considered as part of future pathway reviews.

As part of the Culture & Identity priority, reference is made to a number of commitments regarding parity and equity; addressing inequalities; developing a fair and equal working culture and championing equality and fairness at the heart of everything we do. A Workforce Steering Group comprising senior executives and lead Trade Union and Partnership representatives was formed to begin leading on the implementation of the strategy.  Progress has been challenging due to a number of factors including winter and system pressures, and ongoing resource and capacity issues. As a result, the structural and governance arrangements are being reviewed as part of a reset for this important and necessary work. We are also working on an update to our workforce plan which is due for submission to the Scottish Government in October 2023.

Three Conversations is based on the principle that we should focus on what matters to people, working collaboratively with them as the experts in their own lives. It recognises the power of connecting people to the strengths and assets of community networks, and the necessity to work dynamically with people in crisis. Staff are encouraged to think creatively about how to support people to deliver improved outcomes.

Our Three Conversation approach remains a key strategic priority for the EIJB Work is underway to permanently embed the Three conversation approach into the way we do business. Approximately 70% of our assessment and care management staff now work in a Three Conversations way and implementation plans are in place to roll out the approach to 100% of this staff group, whilst also embedding it into a range of other teams where value can be added.

This ongoing roll-out will include developing a training pack through engagement with our learning and development colleagues.

·       to support people with dementia in their local communities and communities of interest, and

·       that their voices as Edinburgh citizens pro-actively contributes to developments across a range of areas.

As part of the EHSCP Community Mobilisation work Capacity to Collaborate workstream held a multi-agency event on 7 September 2022 with report on event available. There is opportunity for this to be included in the EHSCP Prevention and Early Intervention Strategy currently in development.

The vision – by 2024 the Herbert Protocol (form providing detailed information for people with dementia at risk of going missing) widely known as a support tool for people living with dementia and at risk of going missing.

EHSCP have lead role through multi-agency approach, and partnership working with Police Scotland, Scottish Care, Alzheimer Scotland and MILAN to embed into business as usual in Edinburgh.

The Edinburgh implementation has continued throughout 2023 through promotion and activity across communities, primary care, social services, third and independent sector services, hospitals, care homes, care at home, day services, students, minority ethnic groups, sensory impairment and other areas. Review of workstream planned early 2024.

EHSCP had health and social care lead role with national partners in successful Scotland wide launch September 2021, using learning from Edinburgh work to inform launch activity.

The Discharge without Delay (DwD) programme was implemented across Medicine of the Elderly wards (MoE) in the WGH and RIE in October 2022 with the aim to reduce the rate of bed occupancy by patients who have a delayed discharge from wards 101, 201, 202 and 203 at the Royal Infirmary of Edinburgh and wards 50 and 51 at the Western General Hospital by 50% by March 2023.

This involved roll out and implementation of Planned Date of Discharge (PDD) across sites to discharge plan, proactively and efficiently from the point of admission. This supports the Home First approach of ensuring that long term care decisions and assessments are undertaken in the most appropriate setting at the right time for the person and that a culture of discharge without delay becomes the norm.

Our recent evaluation of the DWD Phase 1 Programme has evidenced that despite not reaching our statement aim target, a 50% reduction in bed occupancy by patients in delay, it was evident in the WGH specifically, the average LOS has shortened by 9 days when comparing to previous years. Bed occupancy by patients in delay across both RIE and WGH sites has reduced by 16% during phase 1.

The DwD Programme evaluation of phase 1 has evidenced that although the statement aim target of a 50% reduction in bed occupancy by patients in delay was not fully achieved, a 50% reduction in bed occupancy by patients in delay was evident in the WGH site and the average LOS shortened by 9 days when comparing to previous years. Bed occupancy by patients in delay across both RIE and WGH sites reduced by 16% during phase 1.

DwD phase 2 is underway with proposed implementation of a whole system discharge planning approach focused on the 0-72hour presentation at RIE Acute hospital.  The focus will be to avoid unnecessary and avoidable admission ensuring alternative community pathways are identified at the earliest opportunity.

The EIJB approved its inaugural workforce strategy, Working Together, in early 2022 and one of the key areas of focus is learning and development. As part of a recent review of our governance models, a new Workforce Board has been established, providing leadership and oversight at the most senior levels for the development and implementation of our workforce strategy. Professional and clinical leadership has been strengthened with the recruitment of a chief AHP and Lead Social Worker for the EHSCP, and learning and development plans are in development for these professional groups.

Disabled people should be supported to be part of life in Edinburgh, not just disability things.

We would like equality of access to services via different channels to support those who can self-help and drive their own care and wellbeing either individually or by support from friends and family and third sector.

Changing Places toilets should become mainstream. The lack of accessible toilets with a hoist etc is limiting our access to the community.

We need more accessible, affordable houses for young disabled people.

The Council should fund job opportunities and support for people with learning disabilities to get jobs.

From February 2022 to April 2024, we are engaging with a wide range of stakeholder to develop and implement this menu of choices to ensure people who have a learning disability have equal opportunities to live life to its fullest potential. We have now completed a service user survey and carer survey in in April and September 2022 and will be using the feedback to hold a stakeholders’ event in October 2022 to discuss the emerging issues and begin to develop further options for adults who have learning disabilities. The process is on track to conclude in 2024.

As part of the integrated impact assessment for the Thrive Welcome Teams an action will be to look at and consider approaches on how to improve pathways for mental health and wellbeing support for people with learning disabilities.

From January 2023 to October 2023, we have carried out further engagement with adults who have a learning disability and carers/parents of young people in transition from children to adults services on New Models of Day Support. The focus has been on seeking views on the emerging change suggestions around day support and further feedback will shape the final phase of this project which is on track to conclude by April 2024.

The concepts of digital poverty and digital inequity are at the forefront of the service delivery and post-pandemic redesign and services are considering how they meet the needs of everyone including those who are unable or find it difficult to access technology and digital support.

A digital programme has been developed which reports into the new Change Board. Early scoping is underway to identify and define programmes of work including the future strategy for technology enabled care. As part of the work in response to the Care Inspectorate inspection of social work and social care services, a renewed focus has been placed in the potential offered by TEC solutions as part of wider support packages. A temporary review team is in place to address backlogs and is taking the opportunity to work with individuals and their families to explore the role that TEWC solutions can play.  Work is also progressing in partnership with the Scottish Government Digital Office in relation to the transition from analogue to digital and the implementation of a new digital alarm receiving centre (ARC) will provide the foundation for future TEC innovation.

An Edinburgh Self-Management Practitioner Toolkit has been developed, developing competencies in self-management practices and increasing capacity to deliver a human-rights based approach.  The Edinburgh Self-Management Network for Practitioners facilitates cross-sector peer support and raises awareness of models of practice/resources, shared on the Self-Management Community of Practice online Knowledge Hub.

EHSCP is working with Healthcare Improvement Scotland (HIS) to deliver a web and

mobile self-management and shared decisions practitioner toolkit hosted on the

Right Decision Service. In the initial phase of design and testing the self-management toolkit will be an Edinburgh cross-sector practitioner resource

A review of the current Dementia Post-diagnostic Support Service in Edinburgh has been completed. This included a targeted approach to seek the views from people with a dementia diagnosis and their carers.  The new model includes flexibility and access that is person-centred, will work with other services to promote healthier lifestyles, include referral for carers and help challenge stigma around dementia.

The new contract to provide this Post Diagnostic Support (PDS) is in the final stages of procurement and will start in April 2024.

PDS is also provided by community mental health staff.  PDS development continues to be taken forward through a range of activities in Edinburgh on a co-production partnership basis.

This continues to be significantly impacted by challenges trying to recruit additional staff due to a national shortage of psychiatrists of old age. A plan is currently in development to recruit and train Advanced Nurse Practitioners, and to work with other related clinical specialty areas, to look at opportunities to increase diagnostic capacity.

We have continued to work closely with partners in the Council’s housebuilding team to work on new housing developments across Edinburgh, this is delivering on our key strategy of 4,500 homes for people with additional support needs. However, increased costs and availability of funding for specialist needs and specifications remains a challenge.

New flats have now been built by CEC for people with a learning disability in North Sighthill, 6 flats will be available for people to have their own tenancy. Other developments continue to be planned across Edinburgh.

A further five wheelchair homes have been delivered this year and nine accessible ground floor flats. 46 new ground floor flats and 19 new wheelchair flats are due to be delivered this year.

A central government fund has been established to create more Changing Places toilets in existing buildings.

Why do some areas of Edinburgh have care package requirements met much quicker than others? Weeks compared to months.

There appears to be a discrepancy between budgets for support for different client groups.

There should be no post code lottery across the city.

The localities provide both a ‘front door’ access point to health and social care services, as well as the place from which longer-term support is organised.

An operational review of the Locality structure is ongoing.  In addition, better access to services has been identified as a focus of work within the Improvement Plan to ensure that people at risk of harm are identified, the right action is taken quickly and waiting times for those who need support is reduced.

Care at Home Contract

The EHSCP intent is to commission improved integrated support options for people living at home which are sustainable, well-coordinated, accessible and appropriate and that support improved outcomes for people.

Starting with care at home and then moving forward across all homebased support arrangements we intend to implement an approach that ensures equity of access, as well as the quality of support experienced, by people and their unpaid carers across the city.

Significant consultation has taken place with both internal and external homebased support organisations to understand the challenges experienced while delivering services in Edinburgh and inform the change required to deliver on a shared vision for the future.  We have also consulted with the individuals being supported and unpaid carers via a Homebased Care Consultation and Individual Impact Assessments.

Proposals for the size and function of our internal care at home services and commissioning of the external care at home were approved by EIJB on 21 September 2023, with approval given to proceed with commission of up to 50,000 hours of weekly care at home support in Edinburgh. Commissioning/procurement activity for the Care at Home Framework will now resume in October 2023, to identify providers who have met the Procurement Stage 1 minimum qualification criteria to move forward with the next stages of co-production and to eventual submission of tenders to be considered for contract awards. It is anticipated that the new framework will commence early in the second half of 2024.

Care at home continues to experience significant challenges both in terms of capacity to meet demand for these services as a result of COVID, Brexit, increased cost of living challenges both in terms of services and providers businesses, recruitment and retention of care workers, but also in the increased complexity of support that individuals require after 2 years of lock down or reduced access to other services and the hardship that we are seeing people who require support experiencing and the increasing concerns about at risk, frail and elderly individuals being able to meet their basic needs in terms of heating their homes and managing to meet their nutritional needs and the negative impact this may have on their health and wellbeing and level of support required from both care at home services and alternative support organisations.

At this time we continue to work closely with care at home providers delivering support on behalf of EHSCP to optimise and maximise the use of their capacity across the city and to ensure that, where possible, we continue to work closely and in partnership with providers and them with each other to ensure stability of services as we enter what will again be a very challenging and pressurised period for both the Health and Social Care Sector in the coming winter months.

An interim Lead Commissioner has been appointed as indicated above to review a number of adult pathways across Edinburgh.  This programme of work will link up with work to re-provide Intermediate Care capacity and rebalance the hospital based complex clinical care function across Edinburgh, as well as interfacing with the Older People’s Mental Health programme and work being led by the Chief Nurse in relation to internal care home capacity.

Detail on performance against the Key Performance Indicators, associated with delivering the agreed six key priority areas of the Carers Strategy can be found in the Performance and Evaluation Year 2 Report

In addition, key work areas for the Carer Strategic Partnership Group going forward are aligned with the refreshed Carer Strategy 2023-26.

This also includes action to extend the Edinburgh  Short Break Services Statement 2019, which will continue to  provide information to carers and cared for people so that they:

·         Know they can have a break in a range of ways.

·         Are informed about short breaks that are available.

·         Have choice in the support they access and are able to optimise self-directed support options.

·         Can identify what a short break means for them, and how they can be supported to meet their needs and achieve their personal outcomes and more.

The Short Breaks Implementation plan will also be developed from 2024 onwards, which will incorporate the key aspects of the Supporting Adult Carers and Caring Relationships Policy, and national guidance to consider collaboration; promotion of variety; sustainable group options; optimisation of SDS options; explore short breaks brokerage model, to ensure a range of opportunities are available to meet a variety of complex needs.

Reduce inequalities of outcome caused by socio-economic disadvantage.

Need to appreciate social factors – poverty as a barrier to taking responsibility for own health. I think wealthier people with more resources are much more likely to be able to manage their own health.

How are you how going to influence housing/place and employability?

Target resources at communities and citizens who are already adversely impacted by inequality in their day to day lives; people in poverty, single parents, BMD communities, communities with high crime rates, levels of drugs and alcohol deaths etc.

The Edinburgh Community Rehabilitation & Support Service provides access to a multidisciplinary team to support rehabilitation and employment, based on individual needs, in the community following a Stroke or a Physical Disability. The team is trained in the ‘3 conversations’ and Good Conversations approaches, focussing on what’s important to service users, then looking creatively at the wider range of options before considering the next step. ECRSS offer a flexible, personalised service providing 1:1 input or group work – incorporating health promotion and self-management strategies.

The Smart Home at ECRSS is an inclusive living space created to showcase how everyday digital technologies have the potential to transform the day-to-day lives of people living with disabilities or health conditions and those who have a caring role. ECRSS offer appointments for technology demonstration, assessment, temporary loan, and support to procure technology for the workplace/education settings.

In addition to the above, ECRSS also run a Peer Support group who meet once a month in Longstone, the group is aimed at people who have physical disability or long-term health condition and are coping with work related issues. The group is also used to support new clients going through that transition back to work.

The Edinburgh Joint Carer Strategy has been refreshed and can be found here,  The refreshed strategy has a greater focus on Young Adult Carers throughout and a Key focus for development  is the Young adult carer action plan.

Edinburgh

–  Recruitment and training have been completed for 6 Volunteer Champions, working with ethnic minority groups to support awareness and access to screening and immunisations. 6 sessions have been held across 2022-23 with a particular focus on working with the Ukrainian refugee community.

–  Royal Edinburgh Hospital long term rehabilitation wards benefit from an onsite cervical screening clinic. This continues to support anyone who is due or overdue their cervical screening. To date 4 out of 12 eligible patients have had their cervical screening completed. Development and delivery of a screening pathway addressing capacity and consent and awareness training for staff on signs and symptoms continues to be rolled out.

·        Implementation of a pilot project offering onsite Sexual and Reproductive Health and cervical screening services to inpatient in acute adult wards has started. To date 45 patients attended with 6 completing overdue cervical screening.

Pan Lothian

–  Completion and launch of the Easy Read Health Screening website (Health Screening – NHS Lothian | Our Services).to support informed decision making when invited to screening. This has video/easy read text and social stories for each of the screening programmes alongside more detailed information and links for family, carers, and health professionals.

–  Our Quality Improvement projects continue and includes projects in both primary and secondary care. For example.

o   Head & Neck Cancer Intervention project looking at delivery of an early brief intervention working with NHS teams and voluntary sector organisations. To date, 10 organisations in Edinburgh have engaged, and will be delivering the brief intervention sessions in 2023/24. Dental students are due to start the project in 2023/2024

o   Embedding the management and delivery of Staff Cervical Screening Clinics within Women’s Services continues to offer improved access to cervical screening. Around 4-6 clinics/month are held across the main hospital sites with some evening clinics and is addressing the challenges of accessing primary care services for shift workers, and other staff groups.

o   Engagement work has been undertaken to understand the factors and barriers that can contribute to a poorer uptake of cervical screening in young women and anyone with a cervix (aged 25-29). Focusing on the areas of SIMD 1, 2 & 3 where data shows the poorest uptake.

Work is ongoing with stakeholders to understand the Did Not Attend (DNA) rate for Diabetic Eye Screening (DES) in Lothian and develop a plan to address the identified possible reasons for DNAs, with interventions tailored for the specific population groups being targeted

The CLWs offer a service which includes practice based, face to face appointments, telephone support and accompanied visits. There have been positive impacts for clients (age range is 16 and above), with significant improvements in health and wellbeing and increased numbers of patient engagements.  People experiencing mental health issues (47%) or social isolation/loneliness (27%) are the main reasons for referrals.  In total 6213 onward links were made to services, projects and activities across Edinburgh.

A pilot of the social prescribing platform, Elemental, has been implemented in 18 practices with attached CLWs. Evaluation of the effectiveness of the software will be carried out over the autumn of 2023.

A secondment opportunity to Scottish Government created a gap in the management structure which allowed us to develop and test Senior CLW roles – with great success to date.

Work with students from the various universities and colleges across the city continues to be well received.  As is the CLWs pioneering involvement in the first year medical students’ exploration of social prescribing.

The Network has established relationships with colleagues in housing and arts practitioners through meetings and small working groups to enhance partnership working.  Similar work with other demographics, e.g. older people, and employability services is planned for the coming months.

Networking meetings with colleagues working in localities have returned as face-to-face events.  These have evaluated well.

The CLWs and Edinburgh’s six ‘Improving the Cancer Journey’ Link Workers (Macmillan) have, and continue, to share training and development opportunities building understanding and good relationships.

The consortium delivering welfare rights and debt advice in Edinburgh consists of Citizens Advice Edinburgh, Community Help & Advice Initiative and Granton Information Centre and continues to deliver in GP practices and health centres, community mental health hubs and drug and addiction recovery hubs. The welfare rights and debt advisors work closely with the community link workers, primary care staff and the locality community mental health and addiction teams. From April 2022 to March 2023, the consortium supported 11,710 clients with an outcome of £7.6m financial gains for the Edinburgh citizen. These services continue to be strengthened by additional funding from Scottish Government through the Welfare Advice & Health Partnership and UK Shared Prosperity Funding

Edinburgh CLW Network was selected as a Scottish participant in a second stage comprehensive, UK wide research project looking at the efficacy of community link working.

Minority Ethnic Health Inclusion Service (MEHIS) continues to provide a multi-lingual link worker advocacy service and works with all minority Ethnic communities, refugees and asylum seekers.The three objectives of MEHIS are to:•       Provide a Multi-lingual Link worker /Advocacy service•       Reduce minority ethnic health inequalities•       Promote equality in Health care policy, planning and practice.

Housing First offers people experiencing homelessness with complex needs access to permanent secure housing (which they would previously have been bypassed for) with extensive wrap around support for as long as they need it.  Since August 2018, Edinburgh’s most vulnerable citizens have been offered Housing First.

The high tenancy sustainment rate achieved demonstrates that  when people have the foundation of a home and stability they are able  take advantage of support services which can help build a platform to pursue personal goals and improve quality of life  thus ending their homelessness.

The Asset Investment Steering group has also ceased at this time due to staffing challenges however, governance structures do exist to progress and approve capital investment requests.

The Partnership continues to work closely with colleagues in the City of Edinburgh Council to inform the Capital Investment plan to describe the H&SC requirements for future infrastructure developments”.