Edinburgh Integration Joint Board Equality Outcomes and Mainstreaming Progress Report 2019 – 2023


In December 2019, the Edinburgh Integration Joint Board (EIJB) published its second Mainstreaming Equality and Outcomes Report. This stated how the EIJB proposed to mainstream equality into its day to day working and set out its Equality Outcomes. The EIJB agreed that updates should be provided annually.  This report sets out the progress made in achieving the agreed equality outcomes between 2019 -2023, and the ongoing work to mainstream equality.  The previous progress reports can be found here.

The Equality Act 2010, Public Sector Equality Duty (PSED) requires that the EIJB pays due regard to the need to:

  • eliminate discrimination, harassment, victimisation and any other conduct that is prohibited by the Equality Act
  • advance equality of opportunity between people who share a protected characteristic and those who do not
  • foster good relations between different people who share a protected characteristic and people who do not.

The protected characteristics are given in Appendix 1.

In Scotland, the PSED is underpinned by specific duties which require the EIJB to:

  • publish equality outcomes every four years
  • report progress on the outcomes and mainstreaming every two years.

Mainstreaming equality simply means integrating equality into the day-to-day working of the Edinburgh Health and Social Care Partnership to help ensure a fair and more equal society for the people of Edinburgh. The ways which the Partnership does this are outlined below.

Board Structure

The Edinburgh Integration Joint Board (EIJB) is responsible for the planning and oversight of the health and social care services which it has been delegated. (See Appendix 2). Membership of the EIJB includes residents with experience of using adult health and care services and/or have unpaid carer experience, alongside local councillors, NHS Board members, staff from the Health and Social Care Partnership and a representative from the voluntary sector.

The current membership of the board consists of 10 voting members (6 male and 4 female) and 13 non-voting members (4 male and 9 female).   Four non-voting members are residents who have had experience of using adult health and social care services and/or have unpaid carer experience. These members help ensure that the perspective of people who use adult health and social care services and that of the unpaid carer is heard in the deliberations of the Integration Joint Board. The current Board membership is set out in Appendix 3.

The Board meets every eight weeks and meetings are open to the public. To provide improved access for all, meetings are held in central Edinburgh with the option to dial in and attend virtually if more convenient.


The EIJB only employs 2 members of staff – the Chief Officer and the Chief Finance Officer.  All other staff are employed by either City of Edinburgh Council or NHS Lothian as part of the Edinburgh Health and Social Care Partnership (EHSCP). The EIJB continues to work alongside its partners to ensure a diverse workforce which reflects the residents of Edinburgh and promotes fairness. As the EIJB employs only 2 staff, it is not required to produce or publish staff equality information.

The EIJB published its Workforce Strategy “Working Together” in July 2022 and includes an accessible read version.  The strategy will deliver against an overarching vision and aspirations, as well as the 4 workforce priorities:  health and wellbeing; culture and identity; workforce capacity and transformation; and leadership and development.  The Strategy includes 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.

Strategic Plan

The Board has a legal duty to produce a Strategic Plan which sets out its plans, vision and long-term outcomes and is required to review its Plan at least every three years.  The current Strategic Plan was produced in August 2019 and can be found here.   Continuing review and refinement of the new plan is underway and is yet to be concluded.   The Chief Officer post has recently been taken up (November 2023) and the Service Director – Strategic Planning (EHSCP) post remains vacant. Through agreement with the Strategic Planning Group and following a pause in development, work has now restarted and the opportunity is being taken to re-evaluate the draft plan alongside recent key developments including the development of the Medium-Term Financial Strategy, delivery of the improvement plan and a refocusing on priority areas including the mental health and older people’s pathways and associated commissioning.

An updated strategic plan will be presented to the Strategic Planning Group in March 2024 for its consideration. An updated timeline, detailing plans for further engagement activity and confirmation of the governance arrangements which will be followed, will also be presented at this time.

The current Strategic Plan ensures that equality and rights considerations are embedded and has the wellbeing of people living in Edinburgh are at the heart of what it does.  The EIJB continues to be inclusive, transparent and compassionate, and places an emphasis is on:

  • quality
  • dignity and respect
  • putting people first through empowerment
  • honesty and transparency
  • working together.

The EIJB has a wide range of Strategies and Plans in place which outline the ways in which we work and deliver services, illustrated un the diagram below, all of which take a human-rights, person-centred approach.  Being person-centred is a way of working that puts the person at the heart of every decision about their own health, social care and support, focusing on the needs of the person rather than the needs of the service and working with people to develop appropriate solutions instead of making decisions for them.

Key to this is working with the wider population to provide information and opportunities for healthy living, prevention of illness, appropriate interventions by the right people at the right time and planning for the future. Alongside this, encouraging the approach of considering people using health and social care services, as equal partners in planning, developing and monitoring support and care to make sure it meets individual needs, to achieve positive outcomes, have more good days and reduce inequality.

Edinburgh Health and Social care Partnership participate in a number of national developments to influence national strategy and plans, including developing local improvement approaches informing national policy design, testing & implementation for Getting It Right For Everyone, (GIRFE), the developing national framework for multi-agency working across adult health and social care support and services.

Relevant Strategies and Plans (Human Rights, Person-Centred Approach)

Staff training, awareness and understanding.

The EIJB continues to work with its partners to raise awareness of all aspects of equality and diversity.   Equality and Diversity Training is essential training for all staff in both the CEC and NHS Lothian and provides an understanding of the Equality Act and an awareness of the physical and cultural barriers which many people face.  In addition to the essential training, both CEC and NHS Lothian have over 100 online training courses and e-learnings relating to equality which all staff are encouraged to peruse and complete as appropriate.

A number of well-established NHS and Council colleague networks provide opportunities for peer support, act as a voice for members, share information and help build productive working relationships.  Networks include Women’s Network; Lesbian, Gay, Bisexual and Transgender + (LGBT+) network; Black and Minority Ethnic (BME) Networks – one of which is specifically for Health & Social Care colleagues; Carer’s Network; disability and long-term health conditions network and Forces Family Colleague Network.

Integrated Impact Assessments

Integrated Impact Assessments (IIAs) continue to be carried out as new policies and proposals develop.  These help ensure that any impacts which a policy or proposal may have on equality, human rights, environment and sustainability are considered and that appropriate actions are taken to mitigate any negative impacts and opportunities for improvements are considered.  The findings of the IIAs are included in EIJB’s committee reports to ensure that committee members consider any impacts which the proposal may have on equalities, human rights and sustainability in the decisions which they take.   IIIAs are published on the Partnership’s website.


Procurement is undertaken on behalf of the EIJB by either the City of Edinburgh Council or NHS Lothian. Both NHS Lothian and CEC have Equality & Diversity Procurement policies.  Fair Work practices and well embedded Community Benefits in procurement policy provide guidance for procurement officers when letting contracts to ensure that any supplier of goods or services meet the same values held by NHS Lothian and CEC.  The definition of Fair Work First used in the procurement process has been expanded to include the requirement to encourage the offer of flexible and family friendly practices for all workers and oppose the use of fire and rehire practices.  The national Public Sector Procurement tools, support and guidance sets this out.

Communications and Engagement Strategy

The current EHSCP Communications and Engagement Strategy (C&E Strategy) was developed and approved in June 2021.  This Strategy has been developed in response to the EIJB and the Edinburgh Health and Social Care Partnership’s (EHSCP) ambition to engage and communicate with the widest range of audiences to increase visibility and awareness.

The C&E Strategy includes communications and engagement objectives, approaches and an action plan for both the EIJB and the EHSCP.  The Communication and Engagement team will adhere to a principle of clear and accessible information whereby:

  • information and publications will be made widely accessible to audiences (where appropriate).
  • language and images used will reflect diversity and differing levels of engagement.
  • staff will be open and honest.

A revised Communication and Engagement Strategy is currently being developed and will be considered by the EIJB in February 2024.

The EIJB Equality Outcomes and Mainstreaming Report 2019- 23 identified 5 Equality Outcomes:

Equality Outcome 1: People know what support and services are available and know how to access them.

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

Equality Outcome 3: People are supported to lead an independent life.

Equality Outcome 4: Services are available fairly across the city.

Equality Outcome 5: Health Inequalities are reduced.

The table below provides an update on progress in implementing the actions identified in the Mainstreaming Equality and Outcomes Report.  The Equality Outcomes and associated actions were developed alongside the development of the EIJB’s Strategic Plan 2019-2022 which involved extensive public engagement over a significant period of time.  An early draft of the Plan was developed through work with reference groups made up of board members, officers, carers, service users and service providers.   A 3-month consultation on the early draft then took place which included an extensive series of engagement events (27 events) and surveys.

The Equality Outcomes were developed from what people said was important to them ad what would help deliver against the outcomes, with the approach of “you said, we did” developed. While this is not an exhaustive list of actions which the EHSCP has taken to reduce inequality, it highlights progress across a diverse range of activities.

Where there is an indication of slippage or inability to take the action forward, the rationale has been indicated in the progress section.  The progress table below indicates whether EIJB/EHSCP is the lead in the action, or a partner with CEC and/or NHS Lothian responsible for taking the lead.

  Actions in category
1 Action is up and running and ongoing 23
2 Action is on target 15
3 Timescale for action has slipped 14
4 Action not yet started, for future consideration  1
  TOTAL 53
Equality Outcome 1:  People know what support and services are available and know how to access them.
Duty:  Advance equality of opportunity among those who share a protected characteristic and those who do not
What You Said What we will do Progress to Date RAG Date Due for Completion Lead or partner
Plain English should be used and not “Council speak” which is often not easy to understand.

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.

1.1 The annual EIJB communications and engagement action plan will use a wide range of channels to reach multiple audiences. The Consultation and Engagement Strategy outlines the various communications channels used to engage internally and externally.  EHSCP Communications and Engagement Strategy.

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.

3 The Communications and Engagement Strategy to be drafted by February 2024. Lead
1.2 We will work with our partners in the community to make people with protected characteristics more aware of what is available to them locally and how to access services. The Connect Here Initiative has been developed to help make community resources visible and accessible and outlines self-management resources for citizens.  The current,10th edition of Connect Here Directory reflects the changes in service delivery of Edinburgh’s community resources following the pandemic.

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 3rd 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).

1 Complete.  Directory will be regularly updated. Lead
1.3 Inclusive communication will be used throughout the development of the Edinburgh Offer. (now known as the Edinburgh Pact) Materials will be tailored to engage with specific audiences including those with specific communication needs. A range of different approaches were used to find out what health and care means to the people of Edinburgh and our partners in order to develop the Edinburgh Pact.  This included interviews, focus groups, public survey, group sessions with community of interest groups and participation in voluntary sector forums.

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.

1 Complete and ongoing Lead
1.4 The Community Investment strategy will recognise the need for additional ethnic minority services, in particular translation services.

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

To help inform Community Mobilisation, a series of Edinburgh Wellbeing Pact Summer Season conversations took place in 2022 across a range of communities (geographical, intertest and identity) including engagement and activities with ethnic minority groups.  The conversations with local communities asked:

–        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.

1 Complete and ongoing Lead
1.5 The new directory/self-help site will be developed with individuals to make any technology as accessible as possible for citizens. The Connect Here Initiative, led by HSCP, outlines a range of self-management resources for citizens.  For ease of use, the main directory of community resources is supported by a series of smaller thematic Connect Here small guides covering topics within the main directory. There are now 27 small guides for services available in Edinburgh including crisis guides, counselling services, physical and creative activities. Guides can be printed out as A5 double sided booklets and are regularly printed and shared by practitioners and made freely available.

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.

1 Complete and ongoing Lead
1.6 When new policies or service changes are introduced, care will be taken to ensure that changes are communicated to those that may be affected, in a manner which they can understand. Any potential equality impacts are considered when developing new policies or service changes and the Integrated Impact Assessment (IIA) process is used to facilitate this.

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.

1 Complete and ongoing Lead
1.7 Implementation of the health and social care, mental health and wellbeing actions of the British Sign Language Plan will continue A range of actions from the British Sign Language (BSL) Authority Plan has been carried out, including:

–       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.

2 BSL Plan runs to 2024 Partner of plan and lead for H&SC actions
1.8 People will have access to good quality independent advocacy, if they feel it is required. A Commissioning & Procurement process was undertaken following a period of co-production with Independent Advocacy providers, health and social care staff and wider stakeholder groups to establish the provision of quality Independent Advocacy services in the city. This resulted in 4 Independent Advocacy contracts being awarded across 3 Providers with all services commencing provision in July 23.

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.

1 Spring 2024 Lead
1.9 We will build the capacity for more peer led self-help groups. The value of peer support groups in helping to improve individual’s well-being is well recognised.  Capacity to deliver peer led self-help groups continues to develop across a range of programmes, services and contracts including Thrive, the Rehabilitation and Support Services and through the Health Inequalities and Prevention Grant Programme.  Some examples are provided below:

–      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.

1 Peer groups have been established and are up and running Lead for some, partner on others
1.10 We will prepare and make available, easily understood, good quality information and advice regarding Self Directed Support. An inspection report of adult social work and social care in Edinburgh was published in March 2023.  This made several key areas for improvement, one of which was around SDS and identified that self-directed support had not been implemented effectively.  Actions to rectify this from a key focus of the EIJB’s Improvement Plan and will be monitored through this. 3 2024 Lead
1.11 We will work to ensure unpaid carers are made aware of the support that is available through active promotion of the service. Following co-production, contracts were issued for carer support services starting in January 2021.  The contract was split into 8 lots with lot 1 having a focus on identifying carers and awareness.  The length of the contract is 5 years, with the option to extend for 3 years.  This is seen as a real positive, providing longer term sustainability, and a strong foundation for growth and development.  A range of actions are being undertaken as part of this work and include, for example, the VOCAL carer support finder which went live and assists carers to find information, advice and support across the city and complements face to face and telephone advice and support.

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.

2 Contract ends 2026 (with option up to 2029) Lead

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.


What You Said What we will do Progress to Date RAG Date Due for Completion Lead or partner
A workforce which reflects the diversity of the people it serves is likely to improve institutional awareness of barriers, lead to improvement in services for people with diverse characteristics and instil confidence in users with diverse characteristics.

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.

2.1 Staff training and awareness raising of all aspects of equality and rights including intersectionality, socio-economic, cultural and physical barriers will be further prioritised. Awareness raising of equality and diversity for staff continues through CEC and NHS Lothian.    Mandatory equality and diversity training is provided which gives an understanding of the Equality Act and an awareness of the physical and cultural barriers which many people with protected characteristics face.

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.

1 Ongoing Partner
We continue to roll out the Three Conversations model as a strategic and cultural framework to working with the people who approach us for support. Three Conversations takes a more personal approach and 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.  The approach has a clear focus on providing choice and control in how their support is provided.

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.

3 Ongoing Lead
To releive pressure on patients making choices about their long-term futures, the EHSCP Anticipatory Care Planning (ACP)/Future Care Planning programme takes a human-rights based approach and enables people and their carers to plan ahead and make informed choices about their care and treatment based on what matters most.  This approach helps ensure that individuals can control and actively participate in the decision making that affects their lives.  Self management also helps build skills, knowledge and confidence.

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.

As part of the Thrive – Rights in Mind priority, a stakeholder group has been established, the ‘Rights in Mind Partnership’ to progress a range of actions to help embed human rights in mental health service provision. Some of the key actions being progressed include the following:

–      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.

2.2 We will carry out staff training across the public, third and independent sectors aimed at equipping staff with the skills to work and communicate more effectively with people with sensory loss. The “Sensory Impairment Awareness and Skills” training programme commenced delivery in December 2019 and training covered working and communicating with people with acquired hearing loss, Deaf BSL users, and people with sight loss.

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.

2 BSL Plan runs to 2024 Lead
2.3 Specialist training will be encouraged, for example in Stroke Education. Stroke is the most common cause of severe physical disability amongst adults in Scotland, Training in Stroke Education is being delivered across the city to HSCP staff in partnership with NHS Lothian.

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.


2 Ongoing Partner (Lead is NHS and Scottish Government
2.4 An increased number of training courses and suicide prevention initiatives targeting specific high-risk groups, will be provided. Suicide Prevention work in Edinburgh continues, and now focuses on achieving a response to the Suicide Prevention Strategy, Action Plan and Outcomes Framework ‘Creating Hope Together’.  In Edinburgh we held an event in Springtime 2023 attended by around 100 delegates to determine what actions were required under the new Strategy Outcomes.  In response to this we have developed a delivery framework with 4 sub-groups:  Data and Insights, Space Time Compassion, Supporting Our Communities, Supporting People The sub groups feed into the overarching Creating Hope Together Steering Group.

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.

2 Ongoing Lead
2.5 Collaboration with University of Edinburgh to develop care home training and research centre of excellence. The collaborative work with the University of Edinburgh on the development of care home training and an Edinburgh Training Research Centre is currently paused.

This may be considered as part of future pathway reviews.

4 Partner
2.6 The Workforce Strategy will consider how best it can achieve a workforce which reflects the diversity of the population of Edinburgh. Working Together is Edinburgh Partnership’s workforce strategy for a caring, healthier and safer Edinburgh and includes strong links to the issues of fairness and equality.  The strategy highlights 4 key broad priority areas of focus, these being: Health and Wellbeing; Culture & Identity; Capacity and Transformation; and Leadership & Development.

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.

1 Strategy complete, implementation is ongoing Lead
2.7 Develop and train staff in the Three Conversation approach which will focus on what matters to the individual. It recognises the value of a person-centred way of working and recognises that everyone is different and requires different types and levels of support. We continue to roll out the Three Conversations model as a strategic and cultural framework to working with the people who approach us for support. This approach aims to achieve improved outcomes for people and families, working in a more preventative and personal way.

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.


3 Ongoing Lead
2.8 Support further development of the Dementia Friendly Edinburgh programme. Dementia Friendly Edinburgh (DFE) activity continues to be led by a variety of multi-agency partners across the city, for example Dementia Friendly Pentlands and Dementia Friendly Capital Theatres, Dementia Meeting Centres. However, further resource is required to stimulate growth of more dementia friendly areas across Edinburgh

·       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.

 3 Ongoing Partner
2.8 Support further development of the Dementia Friendly Edinburgh programme. Implementation of the Herbert Protocol is a key activity as part of DFE workstream.

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.

2.9 Revise the Edinburgh Autism Plan. The Edinburgh Autism Strategy concluded in May 2021. The Scottish Government is now developing further plans and recommendations for neurodivergent people, including autistic adults and the EHSCP can consider the local impacts when the national plans are further developed. 1 Lead
2.10 We will develop and implement a model to ensure that people return “home first” from hospital, wherever possible, before decisions on longer term care and support are made. The Home First approach is well embedded within many areas across the Health & Social Care system in Edinburgh. Home First Edinburgh includes the development of services and pathways to better support people to remain at home or in a homely setting, preventing admission to hospital and providing alternatives to hospital where it is safe to do so. Home First key developments continue to expand and evolve, this includes Hospital at Home (HaH), the Community Respiratory Team (CRT), our Single Point of Access for urgent care within the Flow Navigation Centre, and Discharge to Assess (D2A).

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.

1 Lead
2.11 We will evaluate Good Conversation Training and take forward lessons learnt. The principles and ethos of the former Good Conversation training align with the Three Conversations approach which is being rolled out across a variety of teams within the Partnership. The new Change Board has recently renewed its commitment to accelerating the roll out of 3 Conversations to all assessment and care management teams, embedding consistent practice and quality conversations.

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.


3 Lead
Equality Outcome 3:  Individuals are supported to lead an independent life. *
Duty:  Advance equality of opportunity between those who share a relevant protected characteristic and those who do not
What You Said What we will do Progress to Date RAG Date Due for Completion Lead or partner
It should be easier to access Personal Assistants and supporters, who are essential to independence and quality of life, including support to communicate if required, while out and about

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.

3.1 We will roll out the plan for Self Directed Support including trialling and feedback mechanism. As noted above, an inspection report of adult social work and social care in Edinburgh was published in March 2023.  This made several key areas for improvement, one of which was around SDS and identified that self-directed support had not been implemented effectively.  Actions to rectify this from a key focus of the EIJB’s Improvement Plan and will be monitored through this. 3 Partner
3.2 We will redesign our approach to providing support for individuals with learning disabilities. This will include the redesign of policies, staffing models and support service models. We participated in Health Improvement Scotland’s New Models of Day Support Collaborative from October 2020 – March 2021. This process supported us to define and consider approaches to day support that best meets the needs of individuals who have a learning disability (LD) and their carers. We now want to further develop a menu of choices that reflect the vision of support for people with learning disabilities.

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.




April 2024 Lead
3.3 We will develop and roll out an overarching Technology Enable Care strategy and plan to maximise the benefits and usage of technology to support individuals and their families. There is recognition that all aspects of technology enabled care and digital innovation require to be at the forefront of service delivery for the EHSCP now and in the future.

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.

3 Ongoing work Lead
3.4 We will develop ‘new types’ of befriending leading to provision of city-wide service to work with befriending organisations to co-ordinate activity in service delivery. Various third sector organisations are funded through grants or contracts to provide Befriending Services across the city. The current Health Inequalities Grant Programme has been extended to 31 March 2025.  An overview of the activities, which targeted disadvantaged communities and addressed factors such as community resilience and improved physical and mental health and wellbeing, including befriending services, can be found here. 1 March 2025 Lead
3.5 We will work with public and community services to use tools e.g. Lifecurve that identify those who would most benefit from a self-enablement approach. To enable health, social care and third sector practitioners to have a shared approach to supporting people with self-management, the EHSCP’s Long Term Condition Programme has formed the Edinburgh Management Network. Practitioners come together in a community of practice, facilitated through an online platform to connect with partners, share good practice, find out about services, activities and events, and innovate self-management approaches.

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

1 Lead
3.6 We will support developments for timely dementia diagnosis and quality post-diagnostic support for people who have a dementia diagnosis, and those who give support. Development work continues to manage the demand for assessment and diagnosis of dementia – see below 3.6.

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.

2 31 March 2024 Lead
3.6 We will support developments for timely dementia diagnosis and quality post-diagnostic support for people who have a dementia diagnosis, and those who give support. The Dementia Delivery Group (previously Dementia Transformation Group) is established to provide oversight and progress development on priority areas. Group meeting on 5 December 2023 to review current priorities and develop outline plan that will link to local and national drivers and priority areas. 2
3.6 We will support developments for timely dementia diagnosis and quality post-diagnostic support for people who have a dementia diagnosis, and those who give support. There have been impacts on delays to dementia diagnosis during COVID-19 pandemic, combined with increased demographic demand. Work has been underway from early 2022 to reduce diagnostic wait times, including longer-term diagnostic capability through development of Advanced Nurse Practitioner (ANP) role.

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.

3.7 We will continue to work with 21st Century homes to provide accessible properties that can meet people’s support needs and maximise the use of assistive technology to enhance people’s independence Workshops have taken place with the Council housebuilding team to seek views of multiple disciplines, both operationally and strategically, across the EHSCP about key elements to consider for accessibility and ensuring digital literacy/access to associated tools is a key priority.

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.

2 2024 Partner – CEC Lead
3.8 We will provide training and employment opportunities for young people who have disabilities through the Project SEARCH programme. The Project SEARCH programme provides employment and learning opportunities for young people with a disability and is managed through colleagues in City of Edinburgh Council in partnership with NHS, Edinburgh College and Into Work. 2 Ongoing work by CEC CEC
3.9 We will work with partners to make changing place toilets more available. The awareness of the need for Changing Places toilets continues to grow however the challenge continues to be with retrofitting older buildings.  Work with partners to identify potential suitable locations for changing place toilets is continuing.

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


3 Ongoing Partner
Equality Outcome 4: There is equity of services both geographically across the city and between client groups.
Duty Advance equality of opportunity between those who share a relevant protected characteristic and those who do not.
What You Said What we will do Progress to Date RAG Date Due for Completion Lead or partner
End of Life Care service needs to be available across the city.

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.

4.1 We will work with providers in Edinburgh to provide hospice care to those nearing the end of their lives and to provide community based palliative care support across the city. Specialist palliative care is provided by 2 hospices which support all areas of the city.   Work is being done to help ensure service delivery both within the hospice (in-patient) as well as across their community and outward facing teams.  Both hospices care for all patient groups (adults) with the exception of children. 2 Lead
4.2 We will develop the model of one hub across four localities with clear and consistent priorities. Community health and social care services in Edinburgh are organised around four localities: South East, South West, North East and North West. The management of most community health and social care services is carried out in these localities.   Each locality has a hub team that responds to new and urgent work and two cluster care management teams that arrange and review ongoing support. There is also a mental health and substance misuse team in each locality.

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.

3 No date for completion has been specified
4.3 Reviews will be carried out on various services which will include ensuring that services are delivered fairly across the city. Reviews include: capacity and function of internal care at home service; care at home contract; alternative delivery models and capacity review of local authority and private care homes. An interim Lead Commissioner has been appointed to review mental health, disabilities and older people’s pathways across Edinburgh and will develop associated commissioning plans.

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.

3 EIJB approval of Phase 1 of the Bed Base Strategy Lead
4.4 Map availability and pathways to community-based respite places and aim to simplify, improve and make more equitable. Short breaks and breaks from caring priorities are part of existing Carer Contract awards. All current contracts are on track.

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.

2 Lead
Equality Outcome 5:  Health inequalities are reduced
Duty:  Advance equality of opportunity between people who share a relevant protective characteristic and those who do not.

Reduce inequalities of outcome caused by socio-economic disadvantage.

What you Said What will we do Progress RAG Date Due for Completion Lead or partner
How can we close/narrow the inequality gap?

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.

5.1 Increase opportunities for vulnerable people, of supporting, sustaining and achieving paid employment, volunteering and education. The contract with Volunteer Edinburgh continues to provide support to people with long term conditions, disabilities & other support needs to secure and sustain volunteering opportunities.  In addition to working with individuals, support and guidance is also given to volunteer involving organisations.

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.

1 Ongoing – contract until March 2024 with new contract beginning in April 2024 Lead
1 Ongoing Lead
5.2 Inclusive Edinburgh homeless service will provide an integrated response to homeless people with complex needs including a housing first option and open its new Centre in 2020. ‘The Access Place’ opened at the end of 2021 and offers homeless people with complex needs a one stop shop where they can access integrated primary care, housing and social work support. The facility is run by the Edinburgh Health and Social Care Partnership and allows homeless people who have complex needs to seek advice and support with medical, housing and social care issues.  People who use services have been involved in the redesign with the physical environment and social spaces within the building developed to create a psychological environment where those accessing care and support can feel safe.


1 Centre opened Nov 2021 Lead
5.3 Continue with and review independent advocacy support for mitigating against Universal Credit. A service level agreement is in place with Advocard to provide independent individual advocacy for any prisoners in HMP Edinburgh and individual and collective advocacy services for Edinburgh residents who use mental health services and are claiming benefits, including (but not limited to) Employment Support Allowance, Personal Independence Payment and Universal Credit 2 Ongoing Lead
5.4 Improve the pathway for students with caring responsibilities, across colleges and universities to access care and support statutory services. Following co-production, contracts were issued for carers support starting in January 2021.  The contract was split into 8 lots with lot 6 focussing on young adult carers (aged 16 to 25 and no longer at school). The services delivering on Lot 6 have made good progress.  The Widening Access programme for example, recognises that the cost-of-living crisis has impacted on young carers and young adult carers.  This programme of work with Further Education and Higher Education institutions aims to   help students who were looking for employment instead of continuing in FE/HE, remain in education.

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.

2 Work ongoing – contracts to 2026 with option to extend to 2029 Lead
5.5 Review health screening programmes that people have access to but are not engaging with. Over the last year cancer and non-cancer screening programmes have been working with screening services to help eliminate barriers which may prevent people from attending screening. For example:


–  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

1 Ongoing Support
5.6 The link worker network, which supports GPs in areas of economic deprivation, will be augmented with a strengthened welfare rights capacity through third sector partners. The Community Link Worker Network deploys 24 CLWs to 45 GP practices, employed by 10 Third Sector Organisations.

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.

1 Community Link Worker Network established and ongoing Lead
5.7 Edinburgh Access GP Practice will work with housing colleagues to support and promote the Housing First model. Since August 2018, Edinburgh has been one of 5 areas across Scotland who have worked alongside partner agencies to implement the Housing First Pathfinder Project.

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.

1 Project established and work is ongoing Partner
5.8 The Inclusion Health group will seek to improve care and support for the most vulnerable population groups in the city. Edinburgh Health and Social Care Partnership is a member of The Centre for Homelessness and Inclusion Health – a collaboration between the University of Edinburgh and local partners in Scotland to improve the health and wellbeing of people who experience homelessness.   It brings together people with lived experience of homelessness, those working in the NHS, third sector, policy, local government and academia to work together to develop learning, teaching and research to improve the health and wellbeing of people who experience the worst health outcomes in society. The Centre for Homelessness and Inclusion Health was established in 2017 and since then, have built up strong partnerships working across a range of different homelessness organisation in the city.  We have increased our understanding of different perspectives – including those of people with lived experience of homelessness – and developed a clear vision of how we can work together to make a difference. 1 Centre and partnership working established. Partner
5.9 Through the Future Focussed Infrastructure (FFI) Project, continue joint work to identify need for and ensure provision of affordable, warm, adaptable, accessible and connected homes to meet needs within the city (short, medium and long term). Investment in existing homes to improve health through improving housing quality. Implementation and mainstreaming of Housing First approach. The Future Focused Infrastructure project no longer exists as a stand alone project. There is an expectation that any project or service that has a capital investment requirement, develops a supporting business case accordingly.

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”.

3 Delayed due to resource and capacity challenges Lead

*Independent living means all people having the same freedom, choice, dignity and control as other citizens at home, at work, and in the community. It does not mean living by yourself or fending for yourself. It means having rights to practical assistance and support to participate in society and live an ordinary life. This is the definition of independent living adopted in the strategic approach to independent living, by the Scottish Government, COSLA, the NHS and the Disabled People‘s Independent Living Movement. Without care and support and the opportunity to direct their support, many people would not be able to participate in society and live an ordinary life.

  • age
  • disability
  • gender reassignment
  • marriage and civil partnership
  • pregnancy and maternity
  • race
  • religion or belief
  • sex
  • sexual orientation.
  • Under the Fairer Scotland Act, inequalities of outcome caused by socio-economic disadvantage must be considered in strategic decisions.
  • The EIJB is responsible for planning the future direction of, and overseeing the operational delivery of, integrated health and social care services for the citizens of Edinburgh. These services are delegated to EIJB from our partners, the City of Edinburgh Council and NHS Lothian. They are largely delivered by the Edinburgh Health and Social Care Partnership (the Partnership), although some are managed by NHS Lothian on our behalf. These are referred to as “hosted” or “set aside” services. The full range of delegated services is set out in the table below:
    Adult social care Community Health Hospital-based Services
    Community health Hospital-based services

    • Assessment and care

    management including

    occupational therapy

    • Residential care

    • Extra-care housing and

    sheltered housing

    • Intermediate care

    • Supported housing – learning


    • Rehabilitation – mental health

    • Day services

    • Local area coordination

    • Care at home services

    • Reablement

    • Rapid response

    • Telecare

    • Respite services

    • Quality assurance and


    • Sensory loss services

    • Drugs and alcohol services

    • District nursing

    • Services relating to an


    • Services provided by allied

    health professionals (AHPs)

    • Community dental services

    • Primary medical services (GP)*

    • General dental services*

    • Ophthalmic services*

    • Pharmaceutical services*

    • Out-of-hours primary medical


    • Community geriatric medicine

    • Palliative care

    • Mental health services

    • Continence services

    • Kidney dialysis

    • Prison health care service

    • Public health services

    * includes responsibility for those aged under 18

    • A&E

    • General medicine

    • Geriatric medicine

    • Rehabilitation medicine

    • Respiratory medicine

    • Psychiatry of learning


    • Palliative care

    • Hospital services provided by


    • Mental health services

    provided in a hospital with

    exception of forensic mental

    health services

    • Services relating to an

    addiction or dependence on any substance

    The Public Bodies (Joint Working) (Scotland) Act 2014 sets the framework for integrating adult health and social care support. Further information regarding this can be found here.

Voting Members

Katharina Kasper (Chair)

Councillor Tim Pogson (Vice Chair) – Council Elected Member

Elizabeth Gordon – NHS Lothian non executive board member of the EIJB

George Gordon – NHS Lothian non executive board member of the EIJB

Peter Knight – NHS Lothian non executive board member of the EIJB

Peter Murray – NHS Lothian non executive board member of the EIJB (till December 2023)

Councillor Euan Davidson – Council Elected Member

Councillor Claire Miller – Council Elected Member

Councillor Max Mitchell – Council Elected Member

Councillor Vicky Nicolson – Council Elected Member

Non-Voting Members

Bridie Ashrowan – Third Sector Representative

Robin Balfour – Interim Clinical Director

Heather Cameron – Lead Allied Healthcare Professional

Christine Farquhar – Carer Representative (till December 2023)

Helen FitzGerald – NHS Lead Partnership/Staff Side Representative

Ruth Hendery – Carer Representative (till December 2023)

Kirsten Hey – CEC Staff Side Representative

Grant Macrae – Service User Representative (till December 2023)

Jacqui Macrae – Chief Nurse

Allister McKillop – Service User Rep

Eugene Mullan – Service User Representative (from December 2023)

Moira Pringle – Chief Finance Officer

Emma Reynish – Associate Medical Director, Medicine of the Elderly, Edinburgh Royal Infirmary, NHS Lothian

Pat Togher – Chief Officer

Rachel Gentleman (Secretary)

Matthew Brass (Secretary)