At the Edinburgh Integration Board’s Your health. Your care. Your future events last month, we made a commitment to share answers for the Q&A questions not answered during the event.

You can read the responses below.

How does the Edinburgh Health and Social Care Partnership work with agencies to deliver care, home care and care at home?

The Edinburgh Health and Social Care Partnership works with many different organisations to deliver home based support services to Edinburgh citizens.

Some services are delivered by our in-house homecare and reablement teams, but the majority of services are delivered by a mixture of third sector and independent sector organisations on our behalf. We also work closely with EVOC, our third sector interface, and we employ an Independent Sector Lead through Scottish Care to help ensure good communication and partnership working across all our commissioned services.

As these are regulated services, they are monitored routinely by the Care Inspectorate who assess the quality of care being delivered to ensure it meets high standards. If any improvement is identified as being needed, they support services to make positive changes. We work closely with the Care Inspectorate and other agencies, meeting bi-monthly at our Multi Agency Quality Assurance group to review and monitor any concerns that have been raised about home-based support services.

We work very closely with our commissioned partner organisations to ensure that services grow sustainably and that the staff they employ are supported to maintain the highest standards. We host weekly meetings at locality level to match any unmet need and address any local issues, and we’re also currently undertaking a large co-production exercise to redesign our home based support services so that they are fit for the future.


What support does the EHSCP have in place to support its staff, mentally and physically?

The Partnership view the physical and mental health and wellbeing of our staff as a priority.  Our staff are employed by two organisations – NHS Lothian and the City of Edinburgh Council.  Both organisations provide a wide range of staff support ranging from Occupational Health and Staff Listening Services to online learning and self-help resources. These are detailed on the respective organisation’s websites.

In addition, the Partnership has recently created a Colleague Hub for all staff on its website. Since April the Partnership have been producing and distributing weekly “Wellbeing Wednesday” briefings for all staff which contain useful advice tips and links for support.  Managers are encouraged to have conversations with their teams and ensure those working remotely have regular check in time in addition to formal meetings.  We also produce regular “Thrive Edinburgh” newsletters on mental health and wellbeing highlighting initiatives, services and support across the city (23 issues since April 2020). There’s also a new national digital wellbeing service that has a range of self‑care and wellbeing resources.

 The Partnership is developing a new Workforce Strategy which will also focus on staff wellbeing.  Our Staff Wellbeing Champion will be working with a range of staff across the Partnership to further develop and ensure we can continue to be responsive to the health needs of staff working through the pandemic facing the additional  pressure and means that entails.


How does the EHSCP support unpaid carers?

We recognise the crucial role unpaid carers play in communities across Edinburgh.  We see carers as equal partners in the care of their loved ones. And we acknowledge the need to support carers to look after their own health and wellbeing, so they can continue to care for their loved ones.  The EHSCP commissions a number of third sector carer support organisations through grants and contracts to provide:

  • Information and advice on a range of subjects, including welfare benefits advice
  • Health and wellbeing support such as support groups, learning opportunities and counselling
  • Short breaks from caring for carers on their own or with the person they care for
  • Support for employers and for carers to be able to maintain their employment
  • Support for young adult carers aged 16-25 to have a life beyond caring
  • MECOPP – BME Carer  support service for Black and Minority Ethnic carers (primarily South Asian and Chinese) to include casework support, telephone based multi-lingual advice and information and carer training. Training on ‘achieving cultural competency’ will also be provided to health and social care staff.

From January 2021, the EHSCP is investing £17 million in carer supports across the city.

We also have a carer support team who can help carers to complete an Adult Carer Support Plan, which identifies what is important to the carer and what they need to continue in their own caring role and maintain their own health and wellbeing.

The Edinburgh Health and Social Care Partnership delivers over 110,000 hours a week of home-based support to Edinburgh citizens. We recognise the vital role that paid carers play in enabling Edinburgh citizens to live independently at home or in a homely setting.

We are currently in the process of redesigning our home-based support contract according to eight key themes identified by our own staff and those of our partner providers. Workforce is one of these eight key themes. Our new contract will support fair work and conditions, the sustainable recruitment and retention of staff by investing in their development and training and empower staff and ensure that they have access to digital tools and technology that help them to do their job.


What support does the EIJB and EHSCP provide to people receiving, or requiring, care at home?

Although there has been understandable attention on those awaiting discharge from hospital, given the risks to them and the strain on the whole system which results in an unnecessary delay in discharge, we continue to offer equal priority for those awaiting care within the community.

We are focused on providing the right assessment in the most appropriate setting, rather than a hard and fast rule over where an assessment is carried out. A medical assessment is most appropriate in a clinical setting, but GP’s can also do these within someone’s home. An acute setting may also not be the right place to be making an assessment of someone’s long term social care needs. They are rarely configured to be able to accurately make such assessments. However, medical and clinical input into what heath needs may have to be met within the community is an important facet of a good ‘rounded’ assessment.


How does the EHSCP and EIJB work with the BAME community?

The undertaking of Integrated Impact Assessments (IIA) is one of the main ways in which the EIJB seeks to ensure equality is mainstreamed across the organisation. The IIA process helps ensure that partners consider any impacts which a proposal may have on equality, human rights, sustainability and the environment. The IIA process is integral to the development of any new proposal. The process ensures that consideration is given to any potential impacts which a proposal may have on those with protected characteristics and those in poverty or at risk of falling into poverty. The assessment process helps identify actions which can be taken to mitigate any negative impacts and enhance any positive impacts.  Regular IIA training is held and is open to all staff.

The Black and Minority Ethnic Equality Workers Forum meet to discuss common issues that affect all minority ethnic employees and their communities. The Forum also works with managers to promote best practice in service delivery in relation to equality and diversity matters.

The Partnership commissions a range of specific programmes and initiatives across the city including:

Feniks: Counselling, “Reach Out, Help Within”

This project aims to tackle mental health inequalities and social isolation amongst Polish and Central Eastern European people in Edinburgh.

MECOPP – Jump Start

The project delivers a broad-based health literacy and health improvement service to Chinese people aged 40+ who are disadvantaged by age, disability or long-term health condition, economic or social circumstances. It provides health information sessions, educational workshops, physical activity programmes and support for civic engagement.

MECOPP BME Carer Support

This is a carer support service for Black and Minority Ethnic carers (primarily South Asian and Chinese) and includes casework support, telephone based multilingual advice and information and carer training. Training on ‘achieving cultural competency’ is also provided to health and social care staff.

Multi-Cultural Family Base – Syrian Men’s Mental Health Group

This group supports Syrian men newly arrived in Edinburgh under the United Nations Scheme for Vulnerable Persons Relocation.  The group supports men with issues including integration, employment and English language.

Sikh Sanjog

The Health and Wellbeing Group, partnering with health organisations, delivers a programme focussing on preventative measures by providing a safe space for ethnic minority women to access bespoke activities. It is designed to support their mental and physical health and wellbeing, reduce isolation and loneliness, increase confidence and develop interpersonal skills.

As part of our work to develop the Edinburgh Health and Social Care Pact, we have reached out to a large number of BAME and Faith groups across the city (72 in total) and are hoping to have some productive dialogues with community members and organisations early in the new year.


The EIJB mentioned the need to be more efficient with finances, to ensure the right care is delivered at the right time for the people of Edinburgh. Does this mean that there will be cuts or that certain sites might be sold off?

Like many other public sector organisations, the IJB faces sustained reductions in funding coupled with demand for health and social care services which is projected to increase significantly, and at a faster rate, than the wider economy.  In response to these twin drivers we must agree a balanced budget which in turn leads to a requirement for efficiencies. The IJB itself does not, itself, own any properties so any decision to sell sites sits with our partners in either NHS Lothian or the City of Edinburgh Council.


How are community services resourced?

The IJB uses its budget of around £700m to commission services for Edinburgh citizens.  Our strategic plan sets out our strategy over a 3-year period, including our priorities.


Is a future of Integrated Health & Social Care also going to take into account intertwined issues of substance misuse, crime, employment and domestic violence?

The Edinburgh Health and Social Care Partnership are represented on all public protection committees and these include; Offender Management, Child Protection, Adult Protection and Equally Safe (Domestic Abuse) and the Alcohol and Drug Partnership. These committees report to Edinburgh Chief Officers Group and the Chief Officer of EHSCP attends. The work of the committees and of the Chief Officers Group ensures that the strategy and impact in each area of people’s lives addresses what can be interrelated issues.


Recognising that good housing is integral to good health and wellbeing what role does the IJB have, if any, in joint planning with housing, whether through local authorities or housing associations, to meet local needs?

The EIJB has good partnership working with all the key agencies involved in the provision of housing. Good outcomes have been achieved for people with disabilities through close planning with 21st Century homes, with commitment being made to make new build properties available to people with a disability. That partnership has been extended to plan for people with mental health and older people. There is also a forum for housing associations to be key partners in provision and planning for housing.


Can people with a learning disability voice their choice when seeking support?

People with a learning disability have the right to voice their choice when seeking support whether this be day or supported living. The organisations mentioned are chosen by people as their preferred choice. The Partnership’s role is to ensure that that provision has the required elements in place and fulfils the registration standards set by the Care Inspectorate.


How are mental health services preparing for increased demand due to COVID-19?

We have comprehensive plans in place across the city for our adult health and social care provision. We are actively reviewing these plans now, in light of the pandemic, as we may need to accelerate or reprioritise some of our programmes of work to reflect the emerging evidence on the impact of COVID-19 on people’s mental health and wellbeing.  We are also working with national partners through United Against Suicide, See Me and the national distress brief Interventions Programme ensuring that Edinburgh benefits as fully as possible from a range of national initiatives and programmes. In addition we are working with a wide range of city partners through the Thrive Edinburgh Assembly, to ensure that mental health and wellbeing is viewed as everyone’s responsibility across Edinburgh’s public, business , 3rd and academic sectors.


What are the current plans to improve the current mental health services in Edinburgh?

There is a comprehensive Thrive Edinburgh Adult Health and Social Care Commissioning Plan which sets out our priorities.  This is supported by an outcomes evaluation framework which reflects both person centred outcomes and system/financial outcomes. Within the Commissioning plan there are 35 change programmes – brief updates on active programmes are detailed below.

Building resilient communities and addressing inequalities

  • For Universities and Colleges and student and staff mental health wellbeing we are redesigning care pathway with mental health services and training staff to deliver interpersonal psychotherapy counselling
  • Every Life Matters is focusing on high risk groups including Polish men living in Edinburgh
  • We are developing social enterprise opportunities which will provide paid employment and volunteering opportunities for people with mental health problems

A Place to Live

  • We are developing a framework agreement for supported accommodation and support at home services which increases the ability for providers to respond flexibly to fluctuating levels of need
  • Technology enabled care has a major role to play, making maximum use of the opportunities afforded by Digital Health Scotland.
  • We are commissioning additional support and accommodation places increasing the number of places available

Get help when needed

  • We are increasing the workforce who can respond to distress in A & E departments, police custody and prison settings.
  • We have introduced Prospect Test of Concept in primary care settings which may have the potential to transform the primary care workforce.
  • We have introduced new Thrive Welcome Teams in each of the 4 localities who are prototyping the new delivery model. The new model sees an integrated statutory and third sector team working with people in distress and experiencing mental health problems to create a Thrive plan informed by good conversations. The conversations focus on what the person has identified is important to them and the team then help facilitate this. Data, including outcome measure, is being collated from all four teams.

Thrive “Get Help When Needed Collective

  • The recommendations from this commissioning programme were supported by the Sustainability and Policy Committee on 6 August.
  • A range of new 3rd sector services have formed the Thrive Collective which provide a wide range of emotional, psychosocial, psychological and practical support for people in a ranges of places and spaces across the city.
  • Contracts have been awarded for a five year period with an option to extend for a further three years. These awards will help contribute to building a sustainable 3rd sector across the city and the new services commenced on 1 December 2020.

Rights in Mind

  • Work is underway to review the legislative frameworks used to manage risk and promote empowerment and it will include a review of current mechanisms
  • A Rights In Minds online Conference was held on 8 October and a comprehensive work plan is being developed to take forward agreed actions.
  • A proposal for a user-led, collective advocacy project which will aim to promote rights-based care to train and raise awareness of rights-based care practice across professionals who work with people using mental health services in the City, is being developed.

Meet the Treatment Gaps

  • Working with colleagues at the Royal hospital Edinburgh we will review the current pathways into the acute psychiatric ward at the Royal Edinburgh Hospital for people who are admitted for less than five days or remain in an acute ward for longer than 100 days. This “deep dive” will enable us to identify stages in the person’s journey where responses could have been different which may have avoided admission or shortened length of stay.
  • In January 2021, work will commence to review the integrated care pathways (Bipolar, Schizophrenia, Neuro-developmental disorders; Eating disorders, Personality Disorder, Perinatal Mental Health and Depression) to ensure that our services are rights based, provide evidenced based clinical treatment as defined by SIGN and NICE[1], and that there is a comprehensive focus on meaningful days and community connecting.
  • We are finalising plans for a matched care model for women with multiple and complex needs, increasing residential places, training, support and case management across community and inpatient settings.

Thrive Briefings

  • From 8 April 2020 the Thrive team have produced weekly briefings, moving to fortnightly briefings in August
  • The briefings have covered a wide range of topics and information to support people’s mental health and wellbeing
  • The briefings are circulated directly to circa 800 organisations and individuals across Edinburgh, posted on the Edinburgh Thrive website and the publication of each issue is tweeted. They are also included in the Health and Social Care Partnership’s colleague briefings.


How does the EHSCP use Link Workers to support people?

The Community Link Workers are embedded in 37 of Edinburgh’s 70 GP practice teams.  Where appropriate, patients are referred to link workers to assist with social issues (e.g. social isolation/loneliness) and supported to make links to community activities and relevant local services. The work is preventative and contributes to the Partnership’s objectives.

The posts are funded either as part of a national Scottish Government programme with a focus on health inequalities or as an element of the practice’s Primary Care Improvement Plan resource, with the practice able to identify the most appropriate patient cohort(s).

The Community Link Worker model promotes between 4 and 6 hour-long sessions with a link worker.  In the main, this is adequate to identify appropriate activities/services and make initial links.  However, Community Link Workers have found that this aspect of their work has changed during lockdown/COVID Tiers and as a result the CLW Network plans to review current caseloads and sessional arrangements.

In instances when the service required by the patient falls out with the scope of the Community Link Worker (e.g. benefits advice), the link worker has broad network of colleagues to whom they can refer the patient to.


There is a lot of emphasis on self-management of health conditions at present but what about those who are not able to self-manage?

The EHSCP aim to enable as many people as possible to maintain or improve their levels of independence and self-management. However, we recognise that for some people this may take time and they may always require support. We always work alongside the individual and ensure that the support offered is adequate and appropriate to meet their individual needs, acknowledging that they may change over time and that flexibility and responsiveness are key.


What is being done to ensure social care can proactively respond to what comes out of any of the “Three Conversations”?

Three Conversations (3Cs) is about working with people and their families to establish what matters to them and build a good life with stable, resilient and appropriate support. EHSCP have chosen to implement the 3Cs model because it underpins and supports our intent, strategic priorities, vision and values. We are working to embed this approach across all of our health and social care services, moving away from the idea that the task is to process and refer people and presume the need for formal services, and instead focus on getting to know people and their situations, helping them when they are in crisis, linking them to their local communities and helping them to build a good life with the right support at the right time.

The 3Cs model represents a culture shift in the way we work, and while there is still a long way to go before it will be rolled out across the whole Partnership, there is a lot of progress and pace is picking up. By working to embed and roll out the approach, we aim to build a culture that allows us to proactively respond to people’s needs and recognise the strengths of individuals, families, carers, and communities; building independence and self-reliance.

Staff report that the model has enabled them to respond more quickly and provide support that is needs-based rather than systems led. The approach has resulted in more meaningful work and improved job satisfaction. It also represents a culture shift where frontline teams have been given freedom to think creatively about potential support. The use of Direct Payments is being encouraged to allow more flexibility for people, and internal barriers and bureaucracy are being challenged. We continue to work closely with EVOC and other organisations to build on their knowledge of community resources and increase the range of options available to people so that we can respond to what citizens of Edinburgh need. We are also gathering evidence to inform our wider community mobilisation work, and gaps highlighted through the work of the innovation sites will feed into this project.