Health, Social Care & Well-Being Strategy for Caerphilly County Borough 2011-2014
Better Better Health, Social Care Better Response Access and Well-being Better Choices
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This logo must appear in black and PT 286 only. Do not change colour. Acknowledgements Contents
The Health Social Care and Well-being Partnership would like to thank all those who gave their time Foreword 2 and shared their knowledge and expertise throughout the development of this strategy. Executive Summary 4 Chapter 1 About the Partnership 12 Who we are 12 What we do 13 Our Achievements 13 Chapter 2 Where we are now 17 National Drivers 17 Local Drivers 21 Caerphilly County Borough Needs Assessment 2010 27 Consulting 34 Chapter 3 Where we want to be 36 Our Vision 36 Outcomes & Priorities for work 36 Chapter 4 How as partners we will deliver 43 Working in Partnership 43 Resources 52 Action Planning 55 Chapter 5 How we will know we’re achieving 56 Progress Reporting 56 Outcome Indicators 56 Chapter 6 Conclusion 61 Points of contact 61
Acknowledgements
1 Foreword
Improving the Health and Well-being of a Reflecting on past strategies provides us with 5. To develop and strengthen preventative ●●The health and social care systems are population is not, and cannot be, the sole an important opportunity to see the journey work and service provision for vulnerable rebalanced to ensure more people are responsibility of one or two organisations, we have been on since 2005, and will continue children and adults to prevent crisis. supported at home or in the community and therefore the development of this to take over the next three years: ●●The second 2008-2011 strategy built on they live. Health, Social Care & Well-being Strategy ●●The first Health, Social Care & Well- these strategic objectives and proposed ●●Innovative models of health and social care reflects a multi-agency approach to further being Strategy 2005 – 2008, saw the further action to ensure the most effective are developed which makes accessibility improving the health and well-being of the development of the strategic vision for the outcomes for the population were secured. to services easier, and makes service population of Caerphilly county borough. county borough, the development of firm The 2011-2014 Strategy will not only reflect integration, integrated management and The Strategy is being developed at a time partnership relationships and started the the significant agenda of change within the seamless delivery possible. when there are significant challenges facing programme of systematic investment into locality, but also emerges at the mid-point in ●●Developments that have been underway for us all, and never has it been more important joint priorities. It was an important period its transformation. The Strategy will therefore many years are completed, for example the to find suitable, affordable and sustainable in determining the roadmap for the journey retain the strategic objectives previously set; new General hospital Ysbyty Ystrad Fawr. solutions to meet the needs of the population we continue to pursue today. seek to strengthen the strategic direction that ●●Commissioned services are reviewed in line of our county borough. The strategic objectives set at this time has been pursued over the past years, and with local priorities. Partners in Caerphilly county borough are were: endeavour to accelerate the pace of change to In order for this Strategy to make the pleased to present their third Health, Social ensure that: 1. To improve public health by promoting generational changes that we need, and Care & Well-being Strategy which will cover the factors which contribute to healthy ●●The aspirations set out in ‘Our Healthy for it to make any sustainable difference, its period from 1st April 2011 to 31st March 2014. lifestyles and well-being Future’ are realised. implementation needs to stimulate, encourage The Strategy has been prepared in order to 2. To reduce health inequalities by tackling ●●We make best possible use of the public and support every individual within Caerphilly ensure that the Local Authority and the Local the effects of deprivation and the wider resources available to us within a period of county borough to take more control and Health Board meet their statutory duty under determinants of health financial challenge. responsibility for their own, their families and Section 40 of the National Health Service ●● Strong relationships between providers and their communities health and well-being. We 3. To expand and develop community based (Wales) Act 2006. recipients of services in relation to health cannot do this alone – YOUR actions will make health and social care services to enable and social well-being are built. the difference that we all need. The Strategy comes at an exciting time for people to live safe, fulfilled lives that are as the locality and endeavours to build upon the active as possible. successes of the previous two strategies, to ensure health, social care and well-being issues 4. To enable independent living for families and carers by empowering them to Albert Heaney Sian Martin are planned, delivered and resourced in a co- Caerphilly County Borough Council Corporate Director Social Services Aneurin Bevan Health Board Locality Director (Caerphilly Locality) ordinated way, and expertise integrated across make informed choices, and offering Joint Chair of Health, Social Care & Well-being Partnership Joint Chair of Health, Social Care & Well-being Partnership public sector boundaries. opportunities for them to become involved in developing local services
Foreword
2 3 Executive Summary What we want to achieve These outcomes are: Theme 4: To enable independent living In addition, the Welsh Assembly Government has for families and carers by empowering them stated that they wish to see Health, Social Care This will be the third Health, Social Care & Theme 1: To improve public health by to make informed choices and offering and Well-being Strategies focus more on: Well-being Strategy. Our Vision for what we promoting factors which contribute to healthy opportunities for them to get involved in ultimately want to achieve for the county lifestyles and well-being. ●●Improving health and well-being and developing local services. reducing inequities, that is inequalities in borough has not changed from that set in Outcome 1: ‘People recognise and take health that are unfair and avoidable 2005. This Vision is that: responsibility for their own health and well- Outcome 6: ‘Individuals, families and being, and make use of the opportunities carers feel engaged, empowered and able to ●●Improving the provision, quality, integration, “Caerphilly county borough and support available to them.’ make informed choices about their own lives and sustainability of ‘overlapping services’, and lifestyles.’ that is services provided by the NHS, local Theme 2: To reduce health inequities by is a place where people live government and their partners to certain tackling the effects of deprivation and the Theme 5: To develop and strengthen specified groups. longer and healthier lives.” wider determinants of health. preventative work and service provision for vulnerable children and adults to prevent crisis. Specific achievements we hope to see The Strategy covers all ages within the Outcome 2: ‘The health and well-being Outcome 7: ‘Vulnerable Children, Adults materialise during the lifespan of this strategy are: population and will focus on services provided of individuals experiencing disadvantage and Families will be supported to prevent ●● by: will improve to the levels found among the Integrated teams providing services in advantaged.’ and reduce the negative impacts of crisis.’ the community, and based around the ●● The Local Authority individual (e.g. frailty model, integrated Theme 3: To expand and develop Using the findings contained within the ●●Aneurin Bevan Health Board mental health provision); community based health and social care 2010 Caerphilly Needs assessment and from ●●The Voluntary Sector and Community services to enable people to live safe, fulfilled consultation with the public and partners the ●●Delivery of modern health and social care organisations lives that are as active as possible. following areas have been identified as requiring environments (e.g. Ysbyty Ystrad Fawr, more focused joint action: Integrated Health and Social Care Resource ●●The Independent Sector, such as domiciliary Outcome 3: ‘People will have easier ●● Centre in the North); care, nursing and residential care homes, access to services and holistic care, Promoting Healthy Lifestyles looked after children and support services experienced in a seamless way irrespective of ●●Improving Mental Health and Well-being ●●Alignment of available resources to deliver for children and families. the joint priorities of the strategy; the organisation providing the service.’ ●●Tackling Deprivation In order to realise our Vision, the Health, Outcome 4: ‘All treatment and support ●●Decommissioning of environments of care Social Care & Well-being Partnership has set will be provided within acceptable timescales that are no longer suitable; and 7 long-term outcomes. These outcomes based on need.’ ●●A growing relationship with communities are ‘conditions of well-being’ that we want Outcome 5: ‘Wherever possible, services and a shared responsibility residents of Caerphilly county borough to are provided locally in community and towards securing health and experience. neighbourhood care settings by the most social well-being benefits. appropriate organisation.’
Executive Summary
4 5 How we’ll know that we’ve made a difference Theme 3: To expand and develop Theme 4: To enable independent living community based health and social care for families and carers by empowering them Key to us knowing that the actions we are taking Theme 2: To reduce health inequities by services to enable people to live safe, fulfilled to make informed choices and offering are the right ones, and ultimately achieving the tackling the effects of deprivation and the lives that are as active as possible. opportunities for them to get involved in outcomes that we want, we have identified some wider determinants of health. People will have easier access developing local services. incremental changes that we want residents of Outcome 3: Outcome 2: The health and well-being to services and holistic care, experienced in a Individuals, families and the county borough to begin to ‘see’ and ‘feel’. Outcome 6: of individuals experiencing disadvantage seamless way irrespective of the organisation carers feel engaged, empowered and able to These incremental changes will tell us that we’re will improve to the levels found among the providing the service. make informed choices about their own lives heading in the right direction. advantaged. All treatment and support will and lifestyles. The key changes we will look for and monitor Outcome 4: ●●People will be lifted out of poverty be provided within acceptable timescales ●●People have easy access to a range over the lifespan of this Strategy are: ●●Where appropriate, people will have access based on need. of appropriate information on service availability and community resources to Theme 1: To improve public health by to local health and well-being services to Outcome 5: Wherever possible, services promoting factors which contribute to healthy keep them healthy and living independently are provided locally in community and help make informed choices and lead fulfilled independent lives lifestyles and well-being. ●●People will have more opportunities to neighbourhood care settings by the most Outcome 1: People recognise and take engage in education, paid employment and appropriate organisation. ●●People feel that they are no longer ‘passive responsibility for their own health and well- volunteering ●●Where appropriate, people will have access recipients of services’ and understand they being, and make use of the opportunities are ‘active consumers’ with choices available ●●People live in a home that meets the Welsh to local health and well-being services to and support available to them. to them Housing Quality Standard (WHQS) keep them healthy and living independently ●●People will be more physically active ●●People know how to get involved and ●●People have access to the right benefits at ●●Service users/patients have increased levels become active participants in the design ●●People will make better use of the green the right time of customer satisfaction and planning of new services and service spaces around the county borough ●●People live in neighbourhoods that are ●●People are supported to manage their improvement ●●People will feel healthier both physically and clean, well managed and the environmental health and well-being conditions better ●●People feel supported along the journey mentally health of urban areas are of a high standard ●●There are no ‘gaps’ in service provision for back to independence ●●People will have workplaces that are safe ●●People have access to good transport links service users/patients ●●People will have improved knowledge on and healthy ●●People have shorter stays in hospital the appropriate use of services ●●People are positive role models for children ●●People have less reliance on residential and ●●People are not dependent on drugs and/or nursing care homes alcohol ●●People have equitable access to services ●●People are smoke free and support throughout the county borough ●●People choose to eat healthily ●●Service Providers work more closely together to respond to communities needs ●●Delayed transfers of care are reduced Executive Summary
6 7 Theme 5: To develop and strengthen during the consultation events carried out in ●●Improve mental well-being ●●Address the Health and Social care needs preventative work and service provision for connection with the 2010 Health, Social Care ●●Improve health at work of those experiencing homelessness or vulnerable children and adults to prevent crisis. and Well-being Needs assessment and from the rooflessness. formal 12 week Strategy consultation process ●●Increase vaccination and immunisation rates Outcome 7: Vulnerable Children, Adults Theme 3: To expand and develop carried out from 18th October 2010 to 10th to target levels and Families will be supported to prevent community based health and social care January 2011. and reduce the negative impacts of crisis. Theme 2: To reduce health inequities by services to enable people to live safe, fulfilled The priority areas for work that will help to deliver tackling the effects of deprivation and the lives, that are as active as possible. ●●People have the right services provided at each outcome are as follows: wider determinants of health. the right time Outcome 3: People will have easier access Theme 1: To improve public health by Outcome 2: The health and well-being to services and holistic care, experienced ●●People recover from episodes of crisis in promoting factors which contribute to healthy of individuals experiencing disadvantage in a seamless way irrespective of the their lives quicker lifestyles and well-being. will improve to the levels found among the organisation providing the service. ●●People feel able to better cope with advantaged. Outcome 1: ‘People recognise and take All treatment and support episodes of crisis Outcome 4: responsibility for their own health and well- Priority areas for work: will be provided within acceptable timescales ●● People are empowered to seek support being, and make use of the opportunities ●●Ensure equitable access to health and well- based on need. when they need it and support available to them. being services across the county borough Outcome 5: Wherever possible, services ●● People do not use alcohol and drugs as a Priority areas for work: ●●Align partnership and organisational plans are provided locally in community and coping mechanism ●●Reduce the prevalence of smoking across to secure the health and well-being benefits neighbourhood care settings by the most ●●People are able to manage long-term the county borough that can be gained from: appropriate organisation. chronic conditions more effectively ●●Increase the participation rates in physical ●● being economically active Priority areas for work: ●● People have less long-term reliance on activity. This will include the development ●● a vibrant natural environment ●●Establish three neighbourhood care services and support of a ‘Creating an Active Caerphilly Strategy’ networks to: ●● living in a safe community These changes will not happen overnight; we are ●●Reduce the levels of unhealthy eating. This ●● Bring together primary care practitioners ●● a skilled and educated population dealing with long-term generational change. The will include addressing the identified needs and other community service providers steps we will take toward realising these changes around children and young people’s oral ●●Embed the use of Health Impact to plan and deliver services on a sub- will require a concerted and joined up effort health. Assessments across all policy areas locality basis from all organisations and from members of the ●●Reduce the harm caused from alcohol and ●●Address the health inequities that result ●● Agree priority areas for locality public. drugs from income, participation, service and development and work towards a environmental poverty. This will include What we’re going to do ●●Reduce teenage pregnancy rates delegated budget for the management supporting the development of a ‘Caerphilly of community services In order to achieve the changes we hope to ●●Reduce accident and injury rates among the County Borough Child Poverty Strategy’. see, a number of priority areas for work have very young and very old been identified. These priorities were generated
Executive Summary
8 9 ●●Redesign existing care pathways into Theme 4: To enable independent living Priority areas for work: Strategy Overview integrated community based provision, for families and carers by empowering them ●●Develop a multi-agency agency approach The Strategy comprises of six chapters, and wherever possible, to ensure more people to make informed choices and offering that meets the needs of those who are whilst reference is made to associated and are supported at home or in the community opportunities for them to get involved in vulnerable and/or socially excluded. complementary strategies throughout, it is they live. developing local services. ●●Particular attention will be given to: not the purpose of this Strategy to duplicate ●●Particular areas of activity will be on: Outcome 6: Individuals, families and others. Readers will be signposted towards these ●● Older Frail People supporting strategies for further details where ●● Implementation of the Frailty model carers feel engaged, empowered and able to make informed choices about their own lives ●● People with long-term conditions appropriate. ●● Integrated Mental Health services and lifestyles. ●● Victims of domestic abuse Chapter 1: provides the reader with an ●● Integrated Learning Disabilities services Priority areas for work: introduction to the Health, Social Care & Well- ●● Carers ●● Enhanced Substance Misuse services ●●Improve health knowledge and skills (health being Partnership – who we are, what we do and ●● People with: lists some of the key achievements that have ●●Enhanced access to services through the: literacy) to increase people’s capacity to manage their own health and better access ●● A mental health problem been made over the past 6 years. ●● Completion of the Ysbyty Ystrad Fawr health services. ●● Chapter 2: sets the scene of where we are now Hospital A learning disability in terms of the national and local drivers and ●●Develop and implement a consistent ●● ●● Completion of an Integrated Health & A physical disability and/or sensory approach to service user/patient presents a number of key challenges for the Social Care Resource Centre in the North impairment engagement county borough taken from the 2010 Caerphilly ●● ●● Development of innovative models of A substance misuse problem Needs Assessment. ●●Embed the provision of advocacy services health and social care ●● Vulnerable Families into all service design. Chapter 3: sets the scene for where we want ●●Ensure a range of fit for purpose ●● People who are homeless/roofless to be and the priority areas for work that will be ●●Implement the Communication and Public accommodation options are available that delivered over the next 3 years. relation plans developed to support the As mentioned in the Foreword of this Strategy meets the needs of those using them, details how we will work together major strategic changes in the county we are not starting from a blank sheet, and there Chapter 4: decommissioning public buildings for in partnerships to deliver the Strategy. Chapter borough. are work plans already in place that will help to which the NHS/Social Care partners have no 4 highlights the interface between the Health, drive the delivery of this Strategy. further appropriate use. Theme 5: To develop and strengthen Social Care & Well-being Partnership and the preventative work and service provision for Consolidating the full range of activity taking ●●Ensure effective transition planning systems other partnerships that sit within the community vulnerable children and adults to prevent crisis. place across the health, social care and are in place that meet the needs of the planning framework, and the contribution well-being spectrum into one action plan is individual. Outcome 7: Vulnerable Children, Adults that they will make towards the delivery of this and Families will be supported to prevent challenging, however an action plan will be Strategy. ●●Explore new roles enabling an innovative created that will unite new and existing activity. and reduce the negative impacts of crisis. details the monitoring and reporting approach to workforce redesign and This will be produced by the end of July 2011. Chapter 5: development. arrangements that will be established and the outcome indicators that will be used to evidence the impact the Strategy has had on the population of Caerphilly county borough. Chapter 6: offers a concise conclusion and Executive points of contact for further information. Summary
10 11 Chapter 1 What we do Health, Social Care and Well-being is multi- The Strategy has been prepared in order to About the Partnership faceted. It is about improving the health and ensure that the Local Authority and the Local social well-being of local people; ensuring Health Board meet their statutory duty under treatment and help is available when needed; Section 40 of the National Health Service Wales Who we are Delivery of the Health, Social Care & Well- having the skills to make changes in our own Act (2006). This also requires local authorities lives to prevent ill health; improving access to and key partners to cooperate across the range The Health, Social Care and Well-being being agenda cannot be done in isolation existing services and developing new models of functions to improve well-being. Partnership provides the overarching strategic and therefore the Partnership has established of service delivery that offer better outcomes leadership, direction and management for the strong links with the Children & Young for all. development of the health, social care and People’s Partnership, The Living Environment Our Achievements well-being agenda within Caerphilly county Partnership, Regeneration Partnership, Delivering the improvements needed within The previous two Health, Social Care & Well- borough. Community Safety Partnership, Caerphilly these areas demands strong partnership being Strategies have endeavoured to make Safeguarding Children Board and 50+ Positive working which shares our expertise and a difference to the lives of local people in The Health, Social Care and Well Being Action Partnership. The Education for Life resources, both financially and through a highly terms of their Health, Social Care & Well-being. Partnership is made up of senior operates as a theme rather than a group skilled and motivated workforce. This section shows some key achievements representatives from, Aneurin Bevan Health and links are maintained via the Education that have been delivered by the 2008-2011 Board, Caerphilly County Borough Council and The Partnership works together to ensure that Directorate and Children and Young People’s Strategy: Gwent Association of Voluntary Organisations. Partnership. These links will continue to be Caerphilly county borough residents enjoy good physical and emotional health, no matter Theme 1: To improve public health by Health, Social Care and Well-being is one of the strengthened over the lifespan of this strategy. where they live in the county borough. The promoting factors which contribute to healthy four key themes within the Caerphilly County The contribution that each partnership will Health, Social Care & Well-being Partnership lifestyles and well-being. Borough Community Strategy, as shown make towards the delivery of the priority areas pays particular attention to emerging needs, below: for work is shown on page 46. ●●Health Challenge Caerphilly county develops solutions to address difficult borough was launched in July 2008. problems within the Health and Social Care Community Strategy systems and maintains the links across the variety of Partnerships helping to deliver the Health, Social Care & Well-being Strategy.
Education Health, Social Living Regeneration for Life Care & Well-being Environment Partnership Theme Partnership Partnership
About the Partnership
12 13 Since then a number of high profile ●●An annual ‘Health Works Award’ is now part ●●The Health Board has continued to progress Social Care Resource centre in the North campaigns and interventions have been of the Caerphilly Business Forum awards its agenda of primary care development, of the county borough. Many changes to developed, supported and implemented. which recognises best practice health moving practices to independent service have already taken place in readiness ●●An exemplar ‘Schools Food and Fitness initiatives within the workplace. management in this period and merging a for this development, which is planned to Strategy and Action Plan’ was launched by ●●There is a downward trend in conception number of practices in line with the need open during 2012. the Healthy Schools Team in April 2008. rates in under 18 year olds showing the for multiple partnership arrangements. ●●The Diabetes Project team provides 100% of schools within the county borough lowest rate in 10 years in 2007. ●●An Accommodation Strategy for Older structured diabetes education for patients are now engaged with the Healthy Schools ●●An Alcohol Toolkit has been developed People has been developed. (X-PERT Patient) at a variety of locations scheme. to support workplaces in promoting staff ●●An All Wales Care Pathway for the Dying within the county borough. This helps ●●A Healthy Early Years and Healthy Colleges health. in Care homes is being implemented in patients to self-manage their diabetes. scheme have been piloted in the county Nursing Homes in the county borough. ●●The number of childcare places in registered Theme 2: To reduce health inequities by borough. The Healthy College scheme is childcare settings has increased close to the tackling the effects of deprivation and the ●●There are 29 GP practices in the county the first of its kind in Wales. Wales average. wider determinants of health. borough providing a range of enhanced ●●Opportunities to participate in sport and services, which include: Enhanced Diabetes, ●●Three extra care schemes in Crosskeys, ●●A supported housing, advice, family physical activity has been significantly Extended Opening Hours; Care Homes; Blackwood and Caerphilly have opened. mediation, empowerment (SAFE) project increased, this includes, community sport Homelessness; Learning Disabilities; Mental for 16-17 year olds in Risca has been ●●Of the 5825 social care clients aged 65+, coaches to deliver high quality physical Illness; H1N1 (flu); Human Papillomavirus; commissioned. Caerphilly helped 89% to continue to live activity opportunities and the ‘Coaches of and Extended Minor Surgery. All of these independently at home. This is higher than the Future’ scheme to develop opportunities ●●A new supported housing scheme for ensure the population have wider access to other comparable authorities. for young people to gain leadership people who have a substance misuse more services in a locality setting. problem opened in early 2010 with a young qualifications. ●●The Domiciliary Care Strategy has been fully Theme 4: To enable independent living mothers project planned to open in the ●●The rate of adult smokers has decreased implemented and a ‘Reablement’ service is for families and carers by empowering them Autumn 2010. since 2005. In Caerphilly county borough now operational. to make informed choices and offering ●●The number of supported living bed spaces opportunities for them to get involved in in 2008-09, 106 smokers who had been ●●A Joint Hospital Discharge team is fully have increased from 97 in 2003 to 181 in developing local services. treated by Stop Smoking Wales were still established and comprises nurse case 2009. ●●Information has been distributed across not smoking at 52 weeks. The rates (45%) managers and social workers. who remained a non-smoker for a year was all partners in relation to Falls Prevention. Theme 3: To expand and develop ●● higher than the average for Wales (37%). The new hospital ‘Ysbyty Ystrad Fawr’ is Posters have been displayed and community based health and social care scheduled to open in September 2011. presentations given. A Falls Register is ●●A programme of ‘Mental Health First Aid’ services to enable people to live safe, fulfilled A programme of decommissioning has currently being developed. training courses are being delivered to front lives, that are as active as possible commenced in readiness for the opening line staff in all partner agencies. ●●An Intermediate Care Directory has been ●●A locality approach to the implementation of the new hospital. A more comprehensive established for the county borough. of the National Strategy for primary and range of services will be available which community services ‘Setting the Direction’ means that less people will have to travel ●●The promoting independence project, has been established including the outside of the county borough. which focuses on the transition to adulthood and independence of young implementation of community resource ●●Plans are currently in place for the people with severe and complex needs teams, and neighbourhood care networks development of an Integrated Health and About the including a learning disability, has been Partnership expanded considerably.
14 15 ●●Provision of Independent Domestic Violence ●●Multi-agency education and awareness Advocate services has increased the use of raising sessions in relation to the Protection Chapter 2 civil law options to increase the safety of of Vulnerable Adults (POVA) have been victims’ of domestic abuse, and their ability rolled out across the county borough and Where we are now to remain in their own homes. information made available, in both hard copy format and via the inter/intranet. THEME 5: To develop and strengthen The development of this strategy takes More recently the Welsh Assembly Robust POVA processes have been put preventative work and service provision for place at a time when there are many Government have published ‘Setting the in place and the POVA team recently vulnerable children and adults to prevent crisis. changes taking place, both at a national Direction: A strategic framework for primary received a positive Care and Social Services and local level. A short synopsis is offered and community services’ which offers a useful ●●Provision of emergency safe housing for Inspectorate for Wales (CSSIW) inspection in here and shown diagrammatically on page framework against which existing primary women and children fleeing domestic Sept 2009. 19 in Figure B. These National and Local and community services, including social care abuse has been maintained by Women’s ●●Accommodation options for young people drivers have been considered alongside the services can be aligned to develop a system of Aid through Supporting People funding, leaving care have improved largely through evidence we have on local need, which is co-ordinated care at a sub locality level. offering support for up to 16 women the work of the Corporate Parenting Group. also presented within this chapter. and 64 children in Caerphilly at any one Specifically for primary and community time. A 4th Women’s Aid refuge has been ●●An increase in foster carers has allowed National Drivers services, ‘Setting the Direction’ provides a clear more children to remain living close to their strategy for the organisation of services: commissioned. At a National level, the Welsh Assembly parents and extended families which has ●●A Women’s Aid Homeless Prevention Government has set the direction of travel “Setting the Direction” is the key driver for improved placement stability. Children can Outreach worker has been funded to for improved Health and Social care. Their the development of locality and community also attend their usual school which has improve victims’ access to tenancy support vision has been reflected through a number based services and creating a “pull system” to also improved the attainment levels of care and explore alternative solutions to avoid of key documents that provide the agenda for change from reactive crisis management to a leavers. homelessness. change. These are: proactive, co-ordinated and preventative, with The Health, Social Care & Well-being a particular focus on high risk patient groups ●●The ‘Sanctuary Project’ has been key to ●●Making the Connections: Delivering Better Partnership are proud of the achievements and those with increasing frailty. ensuring victims of domestic abuse feel Services in Wales (2004) that have been made over the past 6 years and safe in their home. This project is funded As the model depicts (Figure A), ‘Setting the will continue to build upon the successes of ●●Designed for Life: Creating a world class by the Safer Caerphilly Community Safety Direction’ incorporates a number of service the previous two strategies, to ensure health, Health & Social Care for Wales for Wales in Partnership. The scheme provides improved components, these are: social care and well-being issues are planned, the 21st century (2005) home security to enable victims to remain ●●Locality Networks delivered and resourced in a co-ordinated way, ●●Fulfilled Lives, Supportive Communities: A in their own homes. integrating resources and expertise across the Strategy for Social Services in Wales over the ●●Communications Hubs public sector. next decade (2007) ●●Community Resource teams
About the Partnership
16 17 Figure A Future System of Care “Seamless Pull System” with Integrated Access to Information Figure B
National Drivers Local Drivers Pull Pull Caerphilly Annual Advocacy Carers Wales One Wales Community Social Services Strategy Strategy Organised System of Integrated Community Services Spatial Plan Strategy Directors Report Holistic provision is supported by: Primary Care L N Care which Assess Communications Hub is managed O E Fullfilled Lives, Aneurin Bevan Local Local Public Local Designed Records which C T Supportive Health Board Development Health Stategic Housing to add value are integrated Hospital A W Cmmunities Five Year Plan Plan Framework Strategy and accessible Based Care Shared Information based on GP Record L O Governance I R which is uni ed Voluntary Children T K Caerphilly Physical Capacity which Community OOH Our Healthy Rural Health Sector and Young is managed Discharge Resource Team Y S Food & Fitness Activity Future Plan Compact People’s Plan Expertise which Strategy LAPA is speci ed and deminishing Pull Pull Heads of Obesity Regeneration Commissioning Older People Caerphilly the Valley Pathway Strategy - Strategy for Accommodation Substance Strategy 2020 People, Mental Health Strategy Misuse Patient Journey Business, Places Strategy
Carers Child Poverty Measure Measure Safer Caerphilly Living Gwent Frailty Caerphilly Community Environment Programme Supporting Safety Strategy Partnership - Happily People Strategy Independent Operational Plan ●●GPs in Accident & Emergency Health, Social Care & Well-being Strategies that National Designed NSF Adult they wish to see Health, Social Care and Well- to Improve ●●GPs in Community Hospitals Homelessness Mental Health being Strategies focus more on: Strategy health & the Caerphilly Caerphilly Caerphilly Ysbyty ●●Planned NHS Continued Health Care management County Borough County Borough County Borough Ystrad Fawr ●●Improving health and well-being and provision of chronic NSF Children, Sexual Health Council Council WAG Community reducing inequities, that is inequalities in NSF older conditions in Young People Strategy Improvement Outcome Services ●●Chronic Condition management health that are unfair and avoidable people Wales & Maternity Plan Agreement Programme Services The Welsh Assembly Government have also ●●Improving the provision, quality, integration, stipulated within their guidance document and sustainability of ‘overlapping services’, Stroke Risk Fuel issued in connection with the development of that is services provided by the NHS, local Reduction Poverty The Right Action Plan government and their partners to certain Strategy to be Safe specified groups. The National and Local Policy framework is Where we outlined in Figure B. are now
18 19 ‘Our Healthy Future’ is the Public Health ●●Healthy sustainable communities ‘Our Healthy Future’ has significant implications social care services, the alignment of teams Strategic Framework for Wales and sets out ●●Prevention and early intervention for how all public and third sector services across geographical boundaries and for the the vision for the population of Wales to and the public, view health and health development of additional capacity within a experience improved quality and length of life, ●●Health as a shared goal improvement – is specifies that health primary and community setting. and fairer health outcomes for all. ●●Strengthening the evidence and monitoring improvement is everybody’s business. In order to meet the challenges facing the NHS The Strategy focuses on six key themes: progress Implementation of ‘Our Healthy Future’ will in Wales, the Welsh Assembly Government has ●●Health through the life course This is illustrated in Figure C below. require integrating prevention and health developed a Five Year Strategic Framework. This improvement into planning systems in order to framework measures Health outcomes, System ●●Reducing inequities in health rebalance the current system from treatment performance and Financial sustainability. In to prevention. response to this, Aneurin Bevan Health Board The new duties contained within the ‘Children has developed its own five year plan. Figure C Health & wellbeing & Families (Wales) Measure 2010’ places a ‘Aneurin Bevan Health Board’s Five Year through the life course requirement on each local authority and Welsh Plan’ aims to improve health, raise system and Healthy sustainable public body to develop a strategy to tackle service performance and quality, and transform child poverty that will complement the Welsh health services to create a health system that is communities Improved quality Assembly Government’s commitment to the fit for purpose. eradication of child poverty by 2020. The & length of life.. The five year plan focuses on five priority areas, Health, Social Care & Well-being Strategy 2011- these are: in health 2014 aims to give a clear account of what the Health, Social Care & Well-being Partnership 1. Delivering patient centred services; Reduced inequities within Caerphilly can do to help reduce 2. Focusing on safety excellence and quality poverty, particularly in the area of improving to ensure patients receive the best quality, Prevention & early health. evidence based care;
inter 3. Empowering staff; Local Drivers ..and fairer 4. Achieving better use of resources; and vention The local landscape is as equally dynamic as outcomes for all the national one. The recent development of 5. Improving public health. Health as a Aneurin Bevan Health Board, and its continued shared goal Central to this new Health, Social Care commitment to locality structures, and the and Well-being Strategy, the Health Board Strengthening strengthening role of the Local Service Board recognises that only a radical programme of evidence & monitoring provide an excellent platform for sustained service transformation will enable it to deliver progress partnership working. its ambitions and have made a “commitment to Through the implementation of previous make a difference” by: Health, Social Care & Well-Being Strategies, the ●●Capturing every opportunity to integrate Wanless Local Action Plan and the Integrated and rebalance care across the healthcare Primary Care Estates Strategy, partners within and social care systems Caerphilly county borough have already set the Where we ●●Trying to prevent as well as treat ill health are now agenda for the modernisation of health and
20 21 ●●Putting quality at the heart of everything ●●health promotion The concentric rings represent the various based services, the development of local they do ●●disease prevention levels or settings for care within the local health general hospitals in each of the 5 Local Health ●● community. The arrows represent the patient Board (LHB) areas, supported by a critical care Improving the quality of services and ●●safer communities minimise errors pathways, commencing at home or alternative centre in a central location. ●●meeting the needs of older people in their community setting, reaching inward through ●●Supporting, valuing and empowering staff At a local level, the Caerphilly Locality Division communities local hospital care to specialist care as required. to lead service improvement and rewarding has established its own ‘Service, Financial and At each stage the model aims to maximise excellence The ‘Gwent Clinical Futures Strategy’ remains Workforce’ plans for the forthcoming 5 years. It the service strategy for the area. This is a whole the services and care available locally that can sits within the Aneurin Bevan Health Board 5 ●● Making community services attractive system vision that takes into account primary, prevent the patient moving further down the year framework, and responds to the Clinical ●●Making health and healthcare a shared community, intermediate and secondary care. pathway. The Clinical Futures programme, sees Futures Redesign Strategy. It reflects the responsibility of the individual The approach is illustrated in Figure D: the strengthening of primary and community journey of rebalance as follows: ●● Working in partnership to shape the care Figure D system around the needs of patients. 2009 Closure of Oakdale Hospital (August 2009) Gwent Clinical Futures Pathways The Health, Social Care and Well-being Re-directed phlebotomy activity (October 2010) Strategy, incorporating the Aneurin Bevan Health Board five year plan, commits partners Closure of Aberbargoed Hospital (November 2010) to develop more efficient, integrated and Transitionally moved toward extending frailty beds (November 2010) modern services and recognises the need to Changed model in Redwood (January 2010) change the way services are delivered to reflect 2010
Older people, chronic changes in demography, particularly with Elective conditions etc Reduced Minor Injuries Activity (Autumn 2010) Mental Health the increase of older people, and those with Special & Implementation of Neighbourhood Care Networks (NCNs) (December 2010) chronic conditions who require services closer critical care services Confirmed Care of the Elderly, Palliative care, Chronic Conditions Management and to home and greater integration of care. Women & Children Local hospital stroke models (2010/11) services S It recognises that the critical areas we will have erv ty Emergency ices in communi S n to tackle together are: Community Resource Teams established (April 2011) elf ntio 2011 care, reve S promo n and p ●●integrating mental health services across ervices at home Opening of Ysbyty Ystrad Fawr (YYF) (December 2011) tio Se on health and social care lf ca venti re, promotion and pre Closure of Ystrad Mynach Hospital Closure of Caerphilly District Miners Hospital (CDMH) 2012 Closure of Ty Sirhowy North Resource Centre completed and open (Autumn 2012)
2013 Closure of Redwood Hospital
2014 Outstanding Service Pathway changes Where we are now
22 23 The Annual Quality Framework (AQF) 2011 improvement against all the health specialty 3. Develop a 3 year Social Care Engagement These are: /12 is part of the planning framework for the indicators defined for clinical service areas in Strategy to further improve how the ●●Babies are born healthy NHS linked to the Five Year Strategy. The AQF Wales. Directorate engages with residents of ●● sets out a number of key action areas that the Caerphilly in planning and evaluating Pre-school aged children are healthy, safe Each NHS Organisation (Local Health Boards, and develop to their potential NHS needs to address for 2011 /12. Public Health Wales, Velindre and Welsh services. ●● The AQF has moved away from the use of Ambulance Services NHS Trust) will be required 4. Work with Partner agencies to improve School aged children and young people are process targets, to setting clinical and patient to develop an updated five year plan, together and strengthen transition arrangement safe, healthy and equipped for adulthood outcome measures. It recognises that this is the with an annual plan which addresses the key for young people moving from Children’s ●●Working age adults live healthier lives for start of a new way of working, and more work actions in the 2011 /12 AQF. Services into Adult Services longer is required to develop this work in the future. The Annual Director’s Report is a requirement 5. Continue to implement the Medium Term ●●Older people age well in to their retirement It builds on three key areas from the five year placed on the Corporate Director Social Financial Plan to maintain the provision of ●●Frail people are happily independent vision: Services. By September each year the Director quality services through robust financial The Public Health Team have identified ●●do more to protect and improve health is required to publish a report outlining planning and commissioning arrangements. the main determinants of these outcomes, for all: within 5 years, there must be a the effectiveness of how Caerphilly County 6. To work with partner agencies to explore established through a review of research significant, measurable improvement in Borough Council delivers Social Services to its further opportunities for developing jointly literature and explored using ‘driver diagrams’ reducing health problems in all the priority citizens. The Annual Director’s Report provides provided, integrated or shared services. (Figure E). Low birthweight, for example, is areas in Our Healthy Future (OHF), and details on areas in which the Directorate does 7. To complete a 3 year Workforce a good indicator to tell us whether babies concentrating efforts on the specific key well, issues for further development and the Development Plan to support the are being born healthy; a driver diagram outcomes identified from the Prevention key priorities for the Directorate of Social continued development of a skilled and illustrating the causes and effective actions and Promotion National Programme; Services’ continued improvement into the future. motivated staff group that provides high to tackle low birthweight is shown below. ●●create integrated services: there must be quality social care services. The Public Health Team have developed a In September 2010, the Director published a significant, measurable improvement in list of priority actions that organisations and his first Annual Report, in which he identified The Director will publish the second Annual joint working in primary, community care partnerships should take forward to make an seven key priorities for the Directorate of Social Report on the Effectiveness of Social Services in and social care services, evidenced in the impact on the identified outcomes. To ensure Services. These are: September 2011. annual primary care reports, and delivery delivery of this Strategy, we will utilise this against the priorities identified within 1. Building on the improvements made in In order to implement ‘Our Healthy Future’, the evidence to ensure that services are effective in Setting the Direction; relation to assessment of need, to ensure Gwent Public Health Team - in consultation meeting what we want to achieve. with local partners - have developed a set ●●modernise what the NHS does so that that assessments are timely and of a consistent quality. of ‘Local Public Health Outcomes’. These it has systems that deliver and sustain outcomes cover each of the life stages. excellent services to meet the needs of 2. Maintain sound practices in relation to patients and maximise clinical outcomes: the protection of vulnerable children and there will be a significant, measurable adults, and build upon current partnership arrangements.
Where we are now
24 25 Primary Secondary Effective Action Figure E Driver (Interventions/ Together these individual organisational Geography and Population Driver Services/Programmes/ (Outcome (Causes/ agendas reflect a significant programme of In terms of the geography and population of Determinants) Policy) Indicator) redesign and integration for the next 3 years the county borough, the needs assessment and beyond. highlights a particular challenge in connection Babies are born with projected demographic changes. The Low birth weight Smoking/Exposure to • Intervention/Services/Programme: healthy Caerphilly County Borough statistics show that the 75-84 age group is tobacco smoke • Specialist smoking cessation service Needs Assessment 2010 projected to increase fairly steadily up to 2028. Pre-school children Age at conception • Quality & access of midwifery Before developing any Strategy it is important The number of people in this age group is are safe, healthy Development to have a clear understanding of the issues that projected to increase by 65% between 2008 Ante-natal care • Enhanced antenatal support (eg. and develop their milestones we face – we need to understand a problem and 2033. In addition, the 85+ age group is Maternal parentcraft) potential before we think about a solution. This is a projected to increase steadily until the end of hypertension • Flying Start (eg. lifestyle, debt, simple equation that we all use in everyday life. the projection period in 2033. The number Children & Young Substance misuse social support) of people in this age group is projected to people are safe, The Needs Assessment 2010 was developed (drugs and alcohol) • Sexual Health outreach (eg. condom increase by 162.5% between 2008 and 2033. Shared healthy and Mental Well-being using and epidemiological approach. An Maternal nutrition distribution) Services will need to be planned effectively Health equipped for epidemiological approach involves gathering to address the projected increase in the Outcomes adulthood Chronic maternal • Healthy Start (eg. vitamins for statistical data which profiles the health and well-being of the population and then population of the county borough, particularly Across the illness pregnant women) supplementing the information with the views the ageing population. Life Course Working age Infection • Family Planning (eg. emergency adults live healthy Morbidity expressed by professionals and members of Domestic violence contraception) Public Health lives for longer the public. • Drug and alcohol services (eg. Many factors influence people’s health Stress and anxiety The full 2010 Needs Assessment can be needle exchange) and well-being. Apart from individual Older people age during pregnancy made available on request or by accessing medical factors, these include how much well into their Premature mortality • Healthy Schools (eg. sex education) the Caerphilly County Borough Community Low income income people have, the quality of the retirement Planning Website at www.caerphilly.gov. Wider determinants: accommodation they live in and whether they Low education level uk/communityplanning on the Health, feel safe in their community. The environment, Frail people • Social and cultural norms Social Care & Well-being page; or via www. locally and globally, has a big impact on health are happily Hospital admissions • Education aneurinbevanhb.wales.nhs.uk and well-being. These factors are known as independent • Financial inclusion • Economic development The Needs assessment highlighted a number the determinants of health shown in Figure of key challenges. The information given F. Public health seeks to influence these below is only an extract. Should you wish determinants to bring about better Health Inequities more detailed information, this can be (Secial populations) health and well-being in the accessed via the websites mentioned above. county borough. • Families in deprived or rural areas • Low income families • Minority ethnic communities • Teenage pregnancies Where we • Pregnant women with chronic are now disease/disability
26 27 Figure F ●●Two-thirds of the adult population do not ethnic groups, age groups. It is also suggested eat the recommended ‘5 a day’ of fruit and that people suffering from mental health LOBAL ECOSYS G TEM vegetables. problems or learning disabilities have worse
AL ENVIRON UR ME ●● health than the rest of the population. The AT N Most people are not active enough. In N ENVIRON T ILT M causes of health inequities are multifaceted, U EN 2007-08, only 28% of adults in Caerphilly B T ACTIVITI and include numerous lifestyle factors for g ES in county borough were meeting physical v Li e s o ECO v A ts M AL NO in S example, smoking, alcohol intake, nutrition g e C M i activity guidelines. a c , O g t r n t g L Y , r , B i la MU P e W a in OM NI i and exercise. Wider determinants such as b P C T la e o h a p n Y t a , o l EST y d ●●26% of adults in Caerphilly county borough c s p i a LIF YL s t h t y E N M i e poverty, housing and education also play an t i it W n , i l g o iv v e a p t o e a R r c r g , t a n h k t e smoke. The Wales average is (24%). e a i a r o r r l / w , L a S L k r integral part along with access to appropriate c a u d c i a s u , c f o e L l l i e t PEOPLE t s i e n i m g t a r t h y b e i a i s a ●● d healthcare. u k l t h a y In the Welsh Health Survey for 2008, 45% n s l c i P l
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W factors reported drinking more than the daily are also crucial as inequities can be often Other Neighbourhoods recommended amount of alcohol on at passed down from one generation to the next. least one day in the past week. other Regions This is not only to do with genetic factors, ●●28% of adults were categorised as binge but behaviours during pregnancy, and health drinking (drinking more than twice the daily behaviours learnt by children from their Macro-economy, Politics Culture, Global forces recommended amount) on any one day in parents. The determinants of health and well-being the previous week. The Needs assessment highlighted a number in our neighbourhoods ●●We are failing to meet some key Welsh of key challenges in relation to Health Assembly Government Targets in respect of inequities: immunisations. ●●For the Health domain of the Welsh Index ●●The average 5 year old in the county of Multiple Deprivation 2008 14 of the How people live their lives also affects their ●●Premature (under 75 years of age) death borough has 2.4 teeth decayed, filled or 110 Lower Super Output Areas within the health and well-being. People who don’t rates remain significantly higher than the extracted due to caries, compared with county borough (12.7%) fell within the 10% smoke, who don’t drink alcohol above the Wales average. just under 2 teeth in Wales as a whole. most deprived category across Wales. Caerphilly county brough ranks fourth recommended amount, who eat a balanced ●●Conception rates in under 18 year olds in ●●The percentage of the population aged 16 highest local authority in Wales. diet and are physically active will, potentially, Caerphilly county borough are higher than to retirement who are economically active live longer and healthier lives. i.e. people who are either in employment, the average for Wales. Health Inequities self employed or are registered The Needs assessment highlighted a number ●●Based on self-reported data, 62% of the Health inequities can be found in many aspects unemployed, within the county borough is of key challenges in relation to Public Health: adult population in the county borough can of health; for example, more affluent people lower than the average for Wales. be categorised as overweight or obese. live longer than less affluent people, and generally have more years of better health. ●●Caerphilly county borough has higher levels of people claiming Incapacity Benefit or Health inequities are not only apparent Severe Disablement Allowance (benefits between people of different socio-economic received when an individual cannot work groups but exist between different genders, Where we due to ill health or disability) than in Wales are now or England & Wales as a whole.
28 29 ●●In 2008, Caerphilly had the 10th highest rate ●●Caerphilly county borough ranked 5th worst Never has it been more important to ensure Pharmaceutical Services: of children living in workless households in Wales, with 11% of adults reporting being that services are planned effectively in order ●●Currently the majority of pharmacies are i.e. children who are living in working-age treated for a mental illness compared with to address the projected increase in the not providing a repeat dispensing service households with no one in employment, 9% for Wales as a whole. population of the county borough, particularly which is part of the Community Pharmacy amongst the 22 Welsh local authorities. the ageing population. Gaps in Service Provision Contract. ●●In 2009, the average gross weekly earnings The Needs assessment highlighted a number At a service level, residents in the county Primary Care: for full time workers in Caerphilly county of gaps in relation to Service provision. Some borough access their health and social care ●● borough was £412, compared with a Wales of these were: Increased training of primary care services from a variety of places that often average of £444.90. practitioners in respiratory diagnosis and extends outside of the Caerphilly county Public Health: care is needed. Currently, there is only an ●● The percentage of working age adults with borough area, especially for acute health care ●●The F3 project is funded by Big Lottery and outpatient clinic held one day a week for no qualifications has gradually fallen since services. the last programme will end in July 2011. respiratory patients at Caerphilly District 2001. However it remains 5 to 7 percentage Having access to the right services at the right After this date there will no longer be a Miners Hospital with no respiratory points above the Welsh average making it time is vital to maintaining good health, well- family focused intervention addressing the specialist input for patients. one of the highest ranking local authorities. being and independence, and also to ensure childhood obesity issue. ●●The full range of family planning is not ●● The poorest quality housing within the that where health inequities exist these are not ●●A referral pathway needs to be developed available at each GP practice although each Caerphilly county borough is located within exacerbated by poor access and availability. between maternity services and Stop ABHB Locality area has practices offering the the private rented sector. There are increasing examples of integrated Smoking Wales full range. ●● Access to services from one valley to planning and delivery, across traditional public Substance Misuse: ●●Areas of the county borough have problems another can be difficult, and communities sector and geographical boundaries. Some ●●There is a significant lack of appropriate with access to NHS dentistry. This tends to on higher ground can be even more examples of this are articulated through the mental health support services for be in areas with poor oral health amongst isolated. commissioning strategies that have been substance misusers. adults and children. ●● developed for client groups, such as those with Due to the nature of the built environment, ●●Not all optometry and other services are learning disabilities, mental health and physical ●●Primary Care / Shared Care – the air pollution is becoming an increasing accessible to the disabled. problem in some dense urban areas. disabilities and sensory impairments, and development of Shared Care throughout through new programmes of work such as the Caerphilly has proceeded at a slow pace. ●●There is little dedicated resource to support ●●In Caerphilly county borough, 26.3% have a Gwent wide Frailty programme. There is still a significant gap in provision. the clinical assessment of patients in a limiting long-term illness, the fifth highest ●● community setting in the county orough proportion in Wales. Within the county Caerphilly county borough has a very large Harm reduction is identified as an area ●● borough, the highest proportions are in the population coupled with some of the poorest requiring further development There is a need for an accelerated focus on north, and the lowest in the south. levels of health and social well-being in Wales, ●●There is a gap in provision around patients at risk of unnecessary admission, and very significant inequalities between and community detox services particularly in the Long Term Conditions within individual wards. In addition to this spectrum. ●●Residential rehabilitation and after care there is poor local access to services with the need to be developed and made more majority of residents having to travel outside readily available. the county borough for both outpatient and inpatient care. The opening of Ysbyty Ystrad Where we Fawr will help to resolve this problem. are now
30 31 Maternity Services: ●●Expansion of floating support for domestic ●●There is limited dedicated capacity for falls Domestic Abuse: ●●Inadequate provision of sonography abuse victims, homeless people, vulnerable services in the county borough ●●Provision of refuge accommodation for services. families, substance misusers, ex offenders, Advocacy: those with complex needs (substance people with learning disabilities and mental misuse, mental health issues). The current Sexual Health: health problems. ●●Currently no specific advocacy service for lesbian, gay and bisexual individuals. refuge provision is unable to accept victims ●●Expansion of C-Card Scheme above current ●●Introduce direct access bed spaces. with high levels of need. levels may not be possible due to current ●●Currently no specific advocacy service for ●● ●● financial restraints. Maintainance of current Develop more supported living for people adults about to be discharged from hospital. Provision for young men aged 16-18 years. with mental health problems. These young men are currently unable level of C-Card scheme provision may also Transport: come under threat due to current financial ●●Develop specialist anti social behaviour to be housed alongside mum in refuge ●● circumstances. services. Some rural areas remain isolated and accommodation geographically inaccessible with infrequent ●● There are limited Sexually Transmitted Falls and Falls Prevention: bus services, which can create difficulties Infection testing facilities within Aneurin ●●Gaps in service exist within the existing for some residents in accessing key services Bevan Health Board. falls service at Ystrad Mynach Hospital in and facilities. ●● There are no Genito Urinary Medicine (GUM) comparison to standards to meet evidence Social Care Older People: Clinic facilities within Caerphilly county based practice. ●●The current fabric in terms of council owned borough. ●● Lack of a Community response service residential and care homes is dated and Mental Health: results in fragmentation of the pathway and needs refurbishment or replacement. ●●The First Access Service needs to be inconsistency of service for service users/ carers. ●●The lack of beds for young people with extended to cover the whole of the county physical disabilities results in current ●● borough Following treatment for an injurious registered establishments applying for ●●The Assertive Outreach Team needs to be fall, older people should be offered a variations to allow them to accept such extended to provide a service to the whole multidisciplinary assessment to identify referrals. There is a need to grow capacity of the county borough and address future risk and individualized in this area and to provide suitably adapted intervention aimed at promoting ●●Additional work is needed to develop a premises for independent living for people independence and improving physical with physical disabilities. range of ‘move-on’ accommodation with and psychological function. Gaps exist in appropriate levels of support at both the the current care pathway to meet NICE low and medium level. Guidelines. Supporting People: ●●No specialised falls team. ●●Expand temporary and permanent ●●Lack of evidence based community step supported accommodation for single down services for those at risk of falling or at people. risk of further falls.
Where we are now
32 33 Consulting Accordingly, these have been adopted by the ●●Outcome 6: Individuals, families and carers be expected, have been shaped by personal feel engaged, empowered and able to make and professional opinions. The Partnership will As has been the case in past, core statistical Partnership as priority areas for work over the informed choices about their own lives and endeavour to ensure that action plans capture data to inform the Health, Social Care & Well- lifespan of this Strategy. lifestyles. not only the opinions expressed, but are being Strategy has been drawn from national The next stage of the Strategy development supported by a robust evidence base. and local databases. process involved a formal 12 week public Respondents also expressed an opinion that the priority areas of work should be: The process used to develop this Strategy An aim of this Strategy is to try to ensure that consultation. The Consultation period ran has been mindful of equality issues and a the supply of services is more compatible with from 18th October 2010 to 10th January 2011. ●●Drugs full equality impact assessment has been the needs and demands of our current and We received 79 completed questionnaires ●●Access to health and well-being services completed in order to ensure that no section future populations. In order to try to establish returned electronically via the Web and e-mail. ●● of the population has been disproportionately what these needs are, we sought the views of a Of those who returned the questionnaire, Mental health 30 were members of the public, 26 were affected. wide range of stakeholders. ●●Tackling poverty responding in a professional capacity and Should you wish to view the full reports Gathering the perception based data that we ●●Redesign of care pathways 18 were representing a range of groups or produced in connection with any of the needed for the 2010 Needs Assessment was organisations. 5 people did not complete ●●Older frail people Needs Assessment consultation events carried out during July 2010. This exercise this question. We also received a number of that took place, or the formal 12 week took the form of three events. This first was ●●Alignment of partnership and organisational general written responses. Consultation Findings Report, information is a Caerphilly Viewpoint Panel held on 12th plans The overall conclusion made by the Health, available online from www.caerphilly.gov.uk/ July 2010. The Viewpoint panel is made up ●●Improve health knowledge and skills (health Social Care & Well-being Partnership from the communityplanning or www.caerphillyasks. of residents across the county borough. The literacy) and ensuring health education is responses received was that the Outcomes, org.uk, or by contacting Lianne Dallimore, second involved the Community Partnership integral across all parts of the education Priority areas for work and the direction of the Health, Social Care & Well-being Partnership Area Steering Groups on 15th July 2010; and system Coordinator at: finally, the third a Multi-agency event attended 2011-2014 Health, Social Care & Well-being ●●Vulnerable families by a wide range of professional working Strategy is well supported. The responses Caerphilly County Borough Council, did not appear to suggest that any significant within and around the Health, Social Care & Respondents suggested that addressing the Ty Penallta, Tredomen Business Park, change to the Strategy was required. Well-being arena on 19th July 2010. All three health and well-being needs of those who Ystrad Mynach, Hengoed, CF83 7PG. events engaged a total of 127 people. From the responses received, delivery of the were homeless or roofless was missing from Phone: 01443 864679 Common emerging themes in all three events following outcomes were felt to be a priority: the Strategy. The Health, Social Care & Well- Email: [email protected] were: ●●Outcome 1: People recognise and take being Partnership supported this view. 1. Promote Healthy Lifestyles responsibility for their own health and well- Views expressed by participants throughout being and make use of the opportunities the development of the Needs assessment 2. Improve Mental Health and Well-being and support available to them. and formal consultation phase will, as would 3. Tackle Deprivation
Where we are now
34 35 disease, helps people to live longer, and to live We have identified that we will know when Chapter 3 more healthily. Healthier lives can, of course, we’ve achieved this because: Where we want to be mean happier lives. ●●People will be more physically active Improvements in public health, through proper ●●People will make better use of the green sanitation, good hygiene and vaccination over spaces around the county borough Our Vision Theme 3. To expand and develop community- the years have led to the control and virtual ●●People will feel healthier both physically and This will be the third Health, Social Care & Well- based health and social care services elimination of diseases that once killed millions mentally being Strategy. The intention of this Strategy is to enable people to live safe, fulfilled of people worldwide, but we now face new to act as the Framework from which all other lives that are as active as possible. challenges. ●●People will have workplaces that are safe Health, Social Care & Well-being plans and Theme 4. To enable independent living for Lots of factors influence people’s health and and healthy policies will stem. families and carers by empowering well-being. Apart from individual medical ●●People are positive role models for children them to make informed choices, and factors, these include how much money As would be expected with any long term ●● People are not dependent on drugs and/or offering opportunities for them to people have (which can be influenced by how strategy, our vision remains unchanged to that alcohol set back in 2005. This Vision is that: become involved in developing local they got on in school or whether they have services. a job), what sort of housing they live in and ●● People are smoke free “Caerphilly county borough Theme 5. To develop and strengthen whether they feel safe in their community. ●● People choose to eat healthily is a place where people live preventative work and service These factors are known as the determinants of The priority areas for work that we want to provision for vulnerable children and longer and healthier lives.” health. Public health seeks to influence these pay particular attention to over the next 3 adults to prevent crisis. determinants in the direction of better health years that will play a key role in achieving the In order to achieve the vision set for Caerphilly Within each strategic theme we have set and well-being. outcome set are: county borough the following strategic themes a number of long-term outcomes. The How people live their lives also affects their Priority areas for work: have been carried forward from the previous outcomes we have set are challenging and health and well-being. People who don’t ●●Reduce the prevalence of smoking across strategy to offer a framework for action within may not be acieved fully by 2014, however smoke, drink alcohol in moderation, who eat a the county borough the county borough: this strategy will continue the journey that we balanced diet and are physically active will, in have been on since 2005 and will work towards ●●Increase the participation rates in physical Theme 1. To improve public health by general, live longer and healthier lives. ultimately achieving these outcomes. activity. This will include the development promoting factors which contribute With this in mind, we want Caerphilly county of a ‘Creating an Active Caerphilly’ Strategy to healthy lifestyles and well-being. borough to be a place where: Outcomes & Priorities for work Theme 2. To reduce health inequities by ‘People recognise and take responsibility tackling the effects of deprivation Theme 1: To improve public health by for their own health and well-being, and and the wider determinants of promoting factors which contribute to healthy make use of the opportunities and support health. lifestyles and well-being. available to them.’ Good public health protects people against
Where we want to be
36 37 ●●Reduce the levels of unhealthy eating. This We have identified that we will know when ●● living in a safe community ‘People will have easier access to services will include addressing the identified needs we’ve achieved this because: and holistic care, experienced in a seamless ●● having a skilled and educated population around children and young people’s oral ●●People will be lifted out of poverty way irrespective of the organisation health. ●●Embed the use of Health Impact providing the service.’ ●●Where appropriate, people will have access Assessments across all policy areas ●● Reduce the harm caused from alcohol and to local health and well-being services to ‘All treatment and support will be provided drugs ●●Address the health inequities that result within acceptable timescales based on keep them healthy and living independently from income, participation, service and ●● need.’ Reduce teenage pregnancy rates ●●People will have more opportunities to environmental poverty. This will include ●●Reduce accident and injury rates among the engage in education, paid employment and supporting the development of the ‘Wherever possible, services are provided very old and very young volunteering ‘Caerphilly County Borough Child Poverty locally in community and neighbourhood Strategy’. care settings by the most appropriate ●● Improve mental well-being ●●People live in a home that meets the Welsh organisation.’ Housing Quality Standard (WHQS) ●●Address the Health and Social care needs ●●Improve health at work We have identified that we will know when ●● of those experiencing homelessness or ●●Increase vaccination and immunisation rates People have access to the right benefits at we’ve achieved this because: the right time rooflessness. to target levels ●●Where appropriate, people will have access ●●People live in neighbourhoods that are Theme 2: To reduce health inequities by Theme 3: To expand and develop to local health and well-being services to tackling the effects of deprivation and the clean, well managed and the environmental community based health and social care keep them healthy and living independently health of urban areas are of a high standard services to enable people to live safe, fulfilled wider determinants of health. ●●Service users/patients have increased levels ●● lives that are as active as possible. The severity and duration of poverty has been People have access to good transport links of customer satisfaction This thematic area will look at how partners shown to have the greatest continuing impact The priority areas for work that we want to ●● will work together to improve the provision, People are supported to manage their on a person’s life and life chances. Tackling the pay particular attention to over the next 3 health and well-being conditions better effects that poverty and deprivation has on a years that will play a key role in achieving the quality, integration and sustainability of ●● person’s health will require a joint effort from outcome set are: overlapping services to ensure that people There are no ‘gaps’ in service provision for of all ages live independently for as long as service users/patients a wide range of organisations, and will require Priority areas for work: us to look at the social determinants of health, possible. The specific direction for Children ●●People have shorter stays in hospital ●●Ensure equitable access to health and well- and Young People services within Caerphilly healthy behaviours, health literacy, access ●●People have less reliance on residential and to health and social services, and evidence, being services across the county borough county borough will be detailed within the Children and Young People’s Plan. nursing care homes intelligence and monitoring. ●●Align partnership and organisational plans ●●People have equitable access to services With this in mind, we want Caerphilly county to secure the health and well-being benefits With this in mind, we want Caerphilly county that can be gained from: borough to be a place where: and support throughout the county borough to be a place where: borough ‘The health and well-being of individuals ●● being economically active experiencing disadvantage will improve to ●● a vibrant natural environment the levels found among the advantaged.’
Where we want to be
38 39 ●●Service Providers work more closely ●●Enhanced access to services through the: Theme 4: To enable independent living ●●People will know how to get involved and together to respond to communities needs become active participants in the design ●● Completion of the Ysbyty Ystrad Fawr for families and carers by empowering them ●●Delayed transfers of care are reduced Hospital to make informed choices and offering and planning of new services and service opportunities for them to get involved in improvement The priority areas for work that we want to ●● Completion of an Integrated Health & developing local services. ●● pay particular attention to over the next 3 Social Care Resource Centre in the North People will feel supported along the journey years that will play a key role in achieving the Listening to, and learning from people who use back to independence ●● Development of innovative models of health and social care services is key to creating ●● outcomes set are: health and social care People will have improved knowledge on successful customer focused services. This the appropriate use of services Priority areas for work: ●●Ensure a range of fit for purpose theme will focus on people having a greater ●● ●●Establish three neighbourhood care accommodation options are available that influence over how services are developed The priority areas for work that we want to networks to: meets the needs of those using them, and increasing peoples knowledge of the pay particular attention to over the next 3 decommissioning public buildings for services available. This will ensure services are years that will play a key role in achieving ●● Bring together primary care practitioners developed by the people who use them and the outcome set are: and other community service providers which the NHS/Social Care partners have no will help to improve public understanding of to plan and deliver services on a sub- further appropriate use Priority areas for work: what services do, and when they can be used. locality basis ●●Ensure effective transition planning systems ●●Improve health knowledge and skills (health are in place that meets the needs of the With this in mind, we want Caerphilly county literacy) to increase people’s capacity to ●● Agree priority areas for locality borough to be a place where: development and work towards a individual manage their own health and better access delegated budget for the management ●●Explore new roles enabling an innovative ‘Individuals, families and carers feel health services. of community services approach to workforce redesign and engaged, empowered and able to make ●●Develop and implement a consistent informed choices about their own lives and ●●Redesign existing care pathways into development approach to service user/patient lifestyles.’ integrated community based provision, Particular attention will be paid to services engagement wherever possible, to ensure more people which support: We have identified that we will know when ●●Embed the provision of Advocacy services are supported at home or in the community we’ve achieved this because: into all service design ●● Older frail people they live. ●●People will have easy access to a range ●●Implement the Communication and Public ●● People with Long-term conditions Particular areas of activity will be: of appropriate information on service relation plans developed to support the ●● People with Mental Health problems availability and community resources to major strategic changes in the county ●● Implementation of the Frailty model ●● People with Learning disabilities help make informed choices and lead borough. ●● Integrated Mental Health services fulfilled independent lives ●● People with Physical disability and ●● Integrated Learning Disabilities services Sensory Impairment ●●People feel that they are no longer ‘passive ●● Enhanced Substance Misuse services recipients of services’ and understand they ●● People with Substance misuse problems are ‘active consumers’ with choices available ●● Victims of Domestic Abuse to them ●● Enhanced provision in a primary care setting Where we want to be
40 41 Theme 5: To develop and strengthen ●●People do not use alcohol and drugs as a preventative work and service provision for coping mechanism Chapter 4 vulnerable children and adults to prevent crisis. ●● People are able to manage their long-term How as partners we will deliver Crisis can be defined several ways. It is a chronic conditions more effectively turning point in a person’s life, a stressful ●● People will have less long-term reliance on Improving the Health and Well-being of a ●●Simplicity life experience affecting the stability of an services and support individual so that their ability to cope or even population is not, and cannot be, the sole ●●Clarity of purpose and function function may be seriously compromised or The priorities for work and development over responsibility of one or two organisations ●● Accountability; and most importantly impaired. the next 3 years that will contribute towards alone – all statutory, voluntary, private the delivery of our outcome are: organisations and community partnerships ●●Deliverability Crises occur episodically during the normal Priority areas for work: will have an active role to play. How the lifespan for individuals, families, groups and Partnership will work with its partners will Working in Partnership communities. They have different levels ●●Develop a multi-agency approach that be key to the successful delivery of this The role that Aneurin Bevan Health Board, of impact. If a problem continues then a meets the needs of adults, children and Health, Social Care & Well-being Strategy, Caerphilly County Borough Council Social prolonged impact may take place. This is families who are vulnerable and/or socially and in future years. Services Directorate and Gwent Association when providing the right support, advice and excluded. of Voluntary Organisations will play will be services are critical. A new delivery framework for the Health, Particular attention will be given to: Social Care & Well-being Strategy 2011-2014 intrinsic within each priority area for work, With this in mind, we want Caerphilly county ●● Older Frail People is currently in development. The delivery but as mentioned previously, the role that borough to be a place where: framework will ensure that the priority other partners will play in the delivery of this ●● People with long-term conditions ‘Vulnerable Children, Adults and Families areas for work identified within the 2011- strategy will be equally vital to its success. will be supported to prevent and reduce the ●● Victims of domestic abuse 2014 Strategy are delivered in an efficient Given the cross cutting nature of Health and negative impacts of crisis.’ ●● Carers and effective manner, which supports and Social Well-being, a number of direct and encourages cross partnership working and indirect relationships have been formed across We have identified that we will know when ●● People with: the community planning framework. Direct we’ve achieved this because: creates a ‘joined-up’ approach to delivery. ●● A mental health problem Effective and coordinated strategic planning relationships have been identified with: ●●People will have the right services provided ●● A learning disability across departments and sectors will create at the right time opportunities for making better use of existing Health Challenge Caerphilly ●● A physical disability and/or sensory ●●People will recover from episodes of crisis in resources. County Borough impairment their lives quicker The Health, Social Care & Well-being People’s lives are influenced at a local level in ●● A substance misuse problem ●●People feel able to better cope with Partnership aims to ensure that the delivery their homes, their schools, their communities episodes of crisis ●●Vulnerable families framework implemented will be based on the principles of: ●● People are empowered to seek support ●●People who are homeless/roofless when they need it
Where we want to be
42 43 and their workplaces. Health Challenge Health in the early years and adolescence These priorities are: The effects that substance abuse can have on Caerphilly county borough (HCCcb) is the local Good health in the early years and adolescence ●● Reduce anti-social behaviour and an individual and to the wider community can response to the national Health Challenge is a vital contribution to maintaining good improve the street scene be profound. There are complex issues that issued by the Welsh Assembly Government to can be linked to crime, poverty, homelessness, health through life. ●● Reduce the harm caused by alcohol achieve healthy lifestyles for individuals and the break up of families and even death. A ●● Broaden partnership delivery organsations in Wales. Family health and well-being Substance Misuse Action Team (SMAT) has Anti-social behaviour remains a major concern HCCcb is a partnership between Caerphilly The health and well-being of children is subsequently been set up to work to reduce for communities and has been identified County Borough Council, Aneurin Bevan intimately connected with that of their families. substance misuse throughout Caerphilly as a priority because it is the single highest Health Board, the local public health team county borough. Transition arrangements community issue raised. and a number of voluntary and private sector The Safer Caerphilly Community Safety Children will use other services besides those organisations. We work together to encourage, Reducing the harm caused by alcohol has Partnership is also committed to putting a stop specifically designed for them; and children will support and empower people to lead happy been identified as both a national and local to domestic abuse in the county borough, and go on to use services designed for adults, so and healthy lives, through the provision of priority because alcohol has been established provides victims of domestic abuse and their good transitional arrangements are vital. information about local activities and services as being the ‘major substance of misuse’ in the families with the appropriate help and advice and linking them with current advice on a Alignment between the Health, Social Care & Caerphilly county borough. There has also that they need. Well-being Strategy and the Children & Young been an increase in hospital admissions for range of health related issues. The Health, Social Care & Well-being People’s Plan will be crucial within these areas alcohol related conditions, emanating from HCCcb delivers on the key themes identified Partnership will work in partnership with the in order to ensure that the Health, Social Care within the local area. Strong ‘causal’ links can in Our Healthy Future, addressing smoking, Safer Caerphilly Community Safety Partnership & Well-being services that our children and also be made to other priorities such as violent alcohol, mental well-being, reducing health to specifically tackle issues connected with young people may require now, or in the crime and anti-social behaviour. inequities, physical activity, nutrition and sexual substance abuse and domestic violence. future, are delivered at the right time, by the health in particular. right person, in the right place. The Children & Figure G Young People’s Partnership delivery structure is Children and Young CYPP Co-ordinator Children and Young People’s Partnership People’s Partnership illustrated in Figure G. The Children & Young Peoples’ Partnership Safer Caerphilly Community CYPP Central has been identified by the Welsh Assembly Safety Partnership Support Team Government as the strategic lead for all The Safer Caerphilly Community Safety children and young people’s services. Partnership is a joint statutory partnership Core Core Core Core Core Core Co-ordinating Core However, the synergy that exists between both Aim 1 Aim 2 Aim 3 Aim 5 Aim 6 Aim 7 between Caerphilly County Borough Council, Group Aim 4 agendas cannot be overlooked. For example: Have a flying Have a Enjoy the best Are listened to, Have a safe Are not Gwent Police, Gwent Police Authority, Aneurin • Chair of each Core Aim Have access start in life comprehensive possible health treated with home and disadvantaged Group to play, sport, Bevan Local Health Board, South Wales Fire range of and freedom leisure and respect and community by poverty and Rescue Service and the Gwent Probation • Lead Person of each education from abuse, cultural have their race which supports cross-cutting theme * & learning victimisation activities and cultural physical and Service. opportunities and exploitation identity emotional recognised wellbeing The priorities for the Safer Caerphilly Community Safety Partnership are contained Youth Support within the Safer Caerphilly Community Safety *Cross-cutting Themes Services How as partners Partnership plan 2008-2011. Equalities Welsh Language Safeguarding Sustainability Participation Workforce Development Advocacy Steering Group we will deliver
44 45 Partnership Working Across the Community Planning Framework Priority areas for work Partners who can help us
The following delivery matrix has been Plan 2011-2014. This will be produced by the Reduce teenage pregnancy rates Children & Young Peoples Partnership constructed to identify some of the wider end of July 2011. CCBC Education & Leisure Directorate partners and partnerships that have a role to As mentioned previously, the role that Public Health Wales play in the delivery of the 2011-2014 Health, Aneurin Bevan Health Board, Caerphilly Social Care & Well-being Strategy. Reduce accident and injury rates among the Community Safety Partnership County Borough Council Social Services very old and very young It is not the intention of this list to be Directorate and Gwent Association of Voluntary Children & Young Peoples Partnership exhaustive, but to give a flavour of some of the Organisations will play will be central to Public Health Wales partners/partnerships that we will be engaging the delivery of each priority areas for work, 50+ Positive Action Partnership with. Specific partners will be detailed within and therefore these organisations are not our Health, Social Care & Well-being Action specifically named. Caerphilly Safeguarding Children Board Improve mental well-being Public Health Wales Priority areas for work Partners who can help us Health Challenge Caerphilly Reduce the prevalence of smoking across the Health Challenge Caerphilly Children & Young Peoples Partnership borough Children & Young Peoples Partnership 50+ Positive Action Partnership Public Health Wales Improve health at work Public Health Wales Increase the participation rates in physical CCBC Education & Leisure Directorate CCBC Corporate Health Improvement Group activity. This will include the development of a Living Environment Partnership Increase vaccination and immunisation rates to Public Health Wales ‘Creating an Active Caerphilly’ Strategy Health Challenge Caerphilly target levels Children & Young Peoples Partnership Public Health Wales 50+ Positive Action Partnership 50+ Positive Action Partnership Caerphilly Safeguarding Children Board Reduce the levels of unhealthy eating. This will Children & Young Peoples Partnership Ensure equitable access to health and well- Public Health Wales include addressing the identified needs around CCBC Education & Leisure Directorate being services across the borough Health Challenge Caerphilly children and young people’s oral health Public Health Wales Children & Young Peoples Partnership Stop the growth in harm from alcohol and Community Safety Partnership Community Safety Partnership drugs Children & Young Peoples Partnership Public Health Wales Caerphilly Safeguarding Children Board
How as partners we will deliver
46 47 Priority areas for work Partners who can help us Priority areas for work Partners who can help us Align partnership and organisational plans to Regeneration Partnership Establish three neighbourhood care networks Regeneration Partnership secure the health and well-being benefits that Living Environment Partnership to: Children & Young People’s Partnership can be gained from: ●● Community Safety Partnership Bring together primary care practitioners Public Health Wales being economically active and other community service providers to CCBC Education & Leisure Directorate Health Challenge Caerphilly a vibrant natural environment plan and deliver services on a sub-locality Children & Young People’s Partnership basis living in a safe community Caerphilly Safeguarding Children Board ●●Agree priority areas for locality having a skilled and educated population development and work towards a Embed the use of Health Impact Assessments CCBC Policy Unit delegated budget for the management of community services across all policy areas Regeneration Partnership Redesign existing care pathways into Community Safety Partnership Living Environment Partnership integrated community based provision, Children & Young People’s Partnership Community Safety Partnership wherever possible, to ensure more people are Children & Young People’s Partnership supported at home or in the community they live. 50+ Positive Action Partnership Particular areas of activity will be: CCBC Corporate Equalities Group ●●Implementation of the Frailty model Health Challenge Caerphilly ●●Integrated Mental Health services CCBC Corporate Health Improvement Group ●●Integrated Learning Disabilities services Caerphilly Safeguarding Children Board ●●Enhanced Substance Misuse services Address the health inequities that result Regeneration Partnership Enhanced access to services through the: Health Challenge Caerphilly from income, participation, service and Living Environment Partnership environmental poverty. This will include ●●Completion of the Ysbyty Ystrad Fawr Public Health Wales Community Safety Partnership supporting the development of the ‘Caerphilly Hospital County Borough Child Poverty Strategy’ Children & Young People’s Partnership ●●Completion of an Integrated Health & Social Public Health Wales Care Resource Centre in the North Health Challenge Caerphilly ●●Development of innovative models of Caerphilly Safeguarding Children Board health and social care
How as partners we will deliver
48 49 Priority areas for work Partners who can help us Priority areas for work Partners who can help us Ensure a range of fit for purpose Supporting People Develop a multi-agency agency approach that Community Safety Partnership accommodation options are available that 50+ Positive Action Partnership meets the needs of those who are vulnerable Children & Young Peoples Partnership meets the needs of those using them, and/or socially excluded. 50+ Positive Action Partnership decommissioning public buildings for which Particular attention will be given to: the NHS/Social Care partners have no further Supporting People appropriate use ●●Older Frail People Caerphilly Safeguarding Children Board ●●People with long-term conditions Ensure effective transition planning systems Children & Young Peoples Partnership are in place that meet the needs of the ●●Victims of domestic abuse individual ●●Carers Explore new roles enabling an innovative Public Health Wales ●●People with: approach to workforce redesign and Children & Young Peoples Partnership ●● A mental health problem development ●● A learning disability
Improve health knowledge and skills (health Public Health Wales ●● A physical disability and/or sensory literacy) to increase people’s capacity to Health Challenge Caerphilly impairment manage their own health and better access health services 50+ Positive Action Partnership ●● A substance misuse problem Children & Young Peoples Partnership ●●Vulnerable Families ●● Develop and implement a consistent Children & Young Peoples Partnership People who are homeless/roofless approach to service user/patient engagement 50+ Positive Action Partnership CCBC Communications Unit
Embed the provision of advocacy services into Children & Young Peoples Partnership all service design 50+ Positive Action Partnership
Implement the Communication and Public Regeneration Partnership relation plans developed to support the major Public Health Wales strategic changes in the borough Health Challenge Caerphilly
How as partners we will deliver
50 51 Resources future delivery of services is met. Key to this developing their skills and knowledge whilst Fawr Local General Hospital and the strategy is the active engagement of staff to delivering high quality services which are development of the North Resource Centre. Workforce Development and Redesign identify the skill sets to deliver the services. valued by the users. Engaging with staff in ●●Development of the Gwent Frailty The Health and Social care sector is one of the There are already programmes of redesign and changes to the services and ensuring time Programme. largest employers in the county borough. The development underway, that will be realised is allocated for their development should ●● effective delivery of high quality services is within this strategy period, specifically that from part of the retention strategy. There is a Looking at new and innovative ways to dependent upon having the right staff with the related to Ysbyty Ystrad Fawr and the Frailty commitment within this strategy, and within deliver services. right skills and experience at the right time. It programme. the programmes of redesign that has already ●●Volunteering as a means to develop is also important to have a workforce with the been alluded to, to ensure where opportunities confidence, basic skills and a gateway into flexibility to develop their skills to adapt to the Workforce redesign arise that consideration for cross-sector roles employment. changing environment in which they operate. In order for services to be more flexible to are considered. This Strategy seeks to balance the vision of The demands placed upon the services by support the needs of patients and clients, the enabling county borough residents to ‘live the residents of the borough will challenge Health Board and Local Authority will continue Finances longer and healthier lives’, and the use of how these services are delivered and new to explore opportunities to reduce duplication This Strategy works specifically to make resources and our longer-term responsibility. and innovative models will be developed to of work and make best use of the skills and improvements to increase life expectancy and respond to these demands. Workforce planning knowledge we have across the Health and improve health and well-being. The processes Whilst we need to improve the well-being will play a fundamental role in this process as it Social care workforce. This joint approach to to achieve this will be mindful of fulfilling not and quality of life, we must do it in a way that aligns the skills and competencies of the staff delivering services will harness the experience only our current responsibilities, but also our reduces the amount of resources used in doing required to meet these objectives. of both organisations. Staff can then develop responsibilities to the future and being careful this. This will reduce the demands that we put Specifically it is likely new staff roles will a mutual understanding of the needs of to ensure that options are sustainable. on the environment and natural resources. emerge, that will bridge the health and social residents and actively work together to ensure The recently published WAG paper “Sustainable Through effective partnership working, the care divide. Examples of this are the new their expectations are met. Social Services for Wales: A Framework for local authority, NHS, voluntary and business health and social care generic worker roles, sectors can achieve this by: Recruitment and Retention Action” reinforces the need for public sector and the integrated health and social care team organisations to work collaboratively with ●● The recruitment and retention of suitably Achieving value for money by eliminating manager roles. other partners and the independent sector to qualified staff must be a high priority. It unnecessary consumption, reducing waste ensure that person-centered fit-for-purpose Developing a skilled workforce is important that key posts are identified and duplication through more efficient and services are provided in our communities. The Health and Social Care workforce strategies and strategies are developed to ensure effective use of resources. Health, Social Care & Well-being Strategy aims must focus on developing our staff to meet the ongoing supply of staff to these posts. ●●Better use of the built environment by: to make these connections in a number of these challenges and ensure there are Many of these skills will be in short supply areas, including the following: ●● Bringing care closer to home, reducing programmes in place for them to acquire the and initiatives to improve the image of the the need to travel. skills required. These skills need to link closely sector within the borough will have to be ●●Maximising the impact of the health and with the operational requirements of the undertaken to attract the best applicants. social care sector as an economic force organisation to ensure both the current and Retention of staff can be achieved through through initiatives such as Ysbyty Ystrad
How as partners we will deliver
52 53 ●● Improving local access to services and the rollout of the Gwent Frailty Programme in Caerphilly Locality of Aneurin Bevan Health Action Planning Board, there are significant financial challenges increased use of renewable materials. April 2011. The Health Social Care and Well-being Strategy around remaining within budget as a result of ●●Reducing any negative impacts on the Partners have a variety of funding streams is not a fixed and final plan but a framework a number of cost pressures and in particular in natural environment by being more to support the delivery of the Strategy. The which sets out what will be taken forward over respect of Continuing Care and Prescribing. energy efficient, better location of services, majority of public funding is allocated to the the next three year period. Over the three years of the Strategy partners appropriate use of construction materials Local Authority and the Local Health Board As mentioned in the Foreword of this Strategy will work to create a shift of resources from that ensure that resources are used on an annual basis by the Welsh Assembly we are not starting from a blank sheet, and secondary care into community-based efficiently and that demands on energy, Government. This funding is provided to there are work plans already in place that will services in order to move care closer to home. water and transportation are minimised. deliver key services in health and social care help to drive the delivery of this Strategy. Partners have recognised that there are and in many cases targets are set to ensure that As resources are released for investment in there is a culture of continuous improvement primary care services there will be a reduced Consolidating the full range of activity taking a variety of opportunities for services to place across the health, social care and work closer together. The ability for partner in the delivery of services. demand for hospital care. To achieve this in a systematic way, across the whole system, well-being spectrum into one action plan is agencies to create a ‘One Service Approach’ The current economic climate has resulted challenging, however an action plan will be would greatly benefit the service experience in there being significant cuts in public the Partnership will work strategically using flexibility mechanisms to develop a more created that will unite new and existing activity. of people who use services, particularly expenditure funding. The 2010/11 budget This will be produced by the end of July 2011. people who have support from a variety of for Caerphilly County Borough Council’s integrated health and social care system. agencies. To achieve this partners will use Social Services Directorate is £70.98m. Whilst the opportunities found within Section 33 of the 2011/12 WAG financial settlement has the National Health Service (Wales) Act 2006. provided an element of protection against These provide an enabling framework so that the public sector cuts for Social Services, the money can be pooled between health bodies Directorate will need to manage significant and health-related Local Authority services, cost pressures as it progresses through the and resources and management structures next 3 years due to increases in demand can be integrated. Increased use of Section for services. An updated Medium-Term 33’s will allow joined-up commissioning Financial Plan is being developed alongside for existing as well as new services. These proposals for the reconfiguration of services arrangements will include lead commissioning, to deliver efficiencies whilst ensuring that the integrated provision and pooled budgets. A maintenance and improvement of service pooled budget arrangement is already in place standards are also at the core of the proposals. between the 5 Gwent Local Authorities and Opportunities for further collaboration will be the Aneurin Bevan Health Board for the Gwent- an essential element of this process. Wide Integrated Community Equipment The budget for Aneurin Bevan Health Board Services (GWICES) and the same organisations for 2010-11 is £997m. Specifically for the are finalising a pooled budget arrangement for
How as partners we will deliver
54 55 Chapter 5 The indicators/data sets we have chosen are: Theme 1: To improve public health by promoting factors which contribute to healthy lifestyles How we will know we’re achieving and well-being. ‘People recognise and take responsibility for their own health and well-being, and make use of the opportunities and support available to them.’ Progress Reporting It is very important that we can measure Quantity & Quality Indicators Impact Indicators clearly what progress is being made during the Participation rates in sports/clubs/ Usage of walking and cycle Survival rates of major lifespan of the Strategy and what difference it is organised events routes illnesses making. Visitor numbers to country parks Participation rates at walking Body Mass Index Rates Progress will be monitored quarterly by the groups 25+ and 30+ Health, Social Care & Well-being Partnership Number of employers / Referral to exercise rates Rates of mental illness and feedback will also be given regularly to a businesses achieving a corporate range of partnership groups and contributory health standard statutory organisations. Prescribing rates of anti- Number of people accessing Levels of dental decay An annual report will be produced which will depressants for depression and/or ‘get cooking classes’ i.e. dental caries enable the partnership to reflect on progress anxiety made and refocus activities if necessary, informing the development of action plans for ✓ of quantity, quality and impact indicators. the coming year. Uptake of screening opportunities Number of food outlets with Premature mortality When combined together they will paint a a healthy options scheme and morbidity rates We will use all lead organisation websites to picture of the progress we have made towards keep the public informed on our performance. achieving our vision of: Investment levels into health Levels of active travel Rates of Chronic illness Outcome Indicators promotion, early detection and “Caerphilly county borough is a place where The Health, Social Care & Well-being Strategy prevention. people live longer and healthier lives.” presents an opportunity for partners to Rates of Coronary Heart collectively agree a set of data that will The Health, Social Care & Well-being Disease evidence that we are achieving the outcomes Partnership will review these indicators Alcohol and drug rates set out in this plan. We have chosen a mixture annually. Infant mortality and morbidity rates Smoking rates (adult and children) Low birth rates Maternal smoking and How we will know alcohol rates we’re achieving Immunisation rates
56 57 Theme 2: To reduce health inequities by tackling the effects of deprivation and the wider Theme 3: To expand and develop community based health and social care services to enable determinants of health. people to live safe, fulfilled lives that are as active as possible. ‘The health and well-being of individuals experiencing disadvantage will improve to the levels ‘People will have easier access to services and holistic care, experienced in a seamless way found among the advantaged.’ irrespective of the organisation providing the service.’ ‘All treatment and support will be provided within acceptable timescales based on need.’ Quantity & Quality Indicators Impact Indicators ‘Wherever possible, services are provided locally in community and neighbourhood care Number of Primary Care Employment/ % of people classified as settings by the most appropriate organisation.’ facilities per planning area Unemployment levels economically activity
Crime and Fear of crime rates Self employment rates % of applications where Quantity & Quality Indicators Impact Indicators homelessness has been NHS timescale standards Number of complaints/ % of frail/vulnerable people prevented compliments supported to live in their own homes Average income levels Length of stay in hospital Hospital admissions and % of people accessing Debt levels readmission rates reablement who no longer % of properties meeting require a service upon exit the Welsh Housing Quality Standard Theme 4: To enable independent living for families and carers by empowering them to make informed choices and offering opportunities for them to get involved in developing local services. Levels of adult education ‘Individuals, families and carers feel engaged, empowered and able to make informed choices % of the county borough that about their own lives and lifestyles.’ meets Technical Advice Note 16 targets in terms of distance Quantity & Quality Indicators Impact Indicators and accessibility Number of people utilising Number of one-stop-shops % of people who feel able WAG Child Poverty indicators voluntary sector and advocacy and mobile units and supported to manage services their own health
Number of engagement tools/ Number of expert mechanisms being utilised i.e. patient programmes and web, text, facebook, twitter participation rates etc.
How we will know we’re achieving
58 59 Theme 5: To develop and strengthen preventative work and service provision for vulnerable children and adults to prevent crisis. Chapter 6 ‘Vulnerable Children, Adults and Families will be supported to prevent and reduce the Conclusion negative impacts of crisis.’
This strategy has set out an ambitious and Quantity & Quality Indicators Impact Indicators innovative vision for the improvement of Health, Number of preventative/crisis Number of people accessing % of care plans with Social Care and Well-being within Caerphilly intervention services preventative/crisis intervention achieved outcomes county borough. The priority areas for work and services action plan that will be implemented will help all partners in the area to realise their common Number of referrals and re- ●●Hospital admission and re- % rates of: vision, assist to strengthen partnership working referrals for: admission rates for: ●●Domestic Abuse within the county borough and ultimately ●● ●● secure improved outcomes for the population. Victims of Domestic Abuse Domestic Abuse ●●Substance misuse ●● ●● Substance misuse Substance misuse ●●Carers Assessment Points of Contact ●● ●● Carers Assessments POVA ●●POVA If you would like further information on the ●● ●● Health, Social Care & Well-being Strategy POVA Children Injury ●●Children in need 2011-2014 please contact Lianne Dallimore, ●●Children in need ●●Mental health incl. ●●Mental health Health, Social Care & Well-being Partnership Self harm ●●Mental health Coordinator at: ●●Falls Caerphilly County Borough Council, ●●Malnutrition Ty Penallta, Tredomen Business Park, ●●Chronic conditions Ystrad Mynach, Hengoed CF83 7PG. Telephone: 01443 864679 % of frail/vulnerable Email: [email protected] people supported to live in their own homes Or, please visit the following websites: www.caerphilly.gov.uk/communityplanning www.aneurinbevanhb.wales.nhs.uk
How we will know we’re achieving
60 61 This publication is available in Welsh, other languages or formats on request. Mae’r cyhoeddiad hwn ar gael yn Gymraeg ac mewn ieithoedd neu fformatau eraill ar gais.