Agenda Item Number 11c

MEETING Health Board DATE 1 December 2010 LEAD DIRECTOR Director of Primary Care, Community & Mental Health / Director of Strategic & Operational Planning SERVICE, WORKFORCE & Patient Safety, Governance & FINANCIAL FRAMEWORK - THEME Learning

TITLE OF REPORT

Stakeholder Engagement

SITUATION / PURPOSE OF REPORT

The purpose of this report is to provide the Board with an update on the current position in respect of a number of key areas of work related to stakeholder engagement across Cwm Taf.

BACKGROUND / INTRODUCTION

The Board aims to understand and satisfy the requirements of all its stakeholders by ensuring effective engagement takes place at all levels. This report sets out the current position in respect of a number of key areas of work that are progressing stakeholder engagement across Cwm Taf.

ASSESSMENT / GOVERNANCE AND RISK ISSUES

Localities Vision Paper

The Welsh Assembly Government published Setting the Direction: Primary & Community Services Strategic Framework in February 2010. It provides at a National level the strategic direction for the NHS in and, equally significant, the requirement for greater integration of Social Care and Health Services in the community.

The Localities Vision Paper (attached as Appendix 1) provides Board Members with advice on the outcome of discussions held between Cwm Taf LHB, County Borough Council and Cynon Taf County Borough Council regarding the model for developing integrated Health and Social Care Services in response to Setting the Direction.

1 Agenda Item Number 11c The Localities Vision Paper describes the challenges facing existing services and seeks approval in principle for the proposed new arrangements.

Draft Children and Young People's Plans 2011-14 for Rhondda Cynon Taff and Merthyr Tydfil

The Children and Young Peoples Partnerships in Rhondda Cynon Taff and Merthyr Tydfil are currently developing the next Children and Young People's Plan for 2011-14. The interim planning guidance restates that the children and young people’s plan is the defining statement of strategic planning intent and priorities for all children and young people’s services within each local authority area.

The Welsh Assembly Government expects Local Authorities, Local Health Boards and their partners to focus on outcomes for children and young people and to ensure that all their partnership working is effective and efficient. Partners are accountable to one another for the delivery of all services for children and young people in their area, and are expected to hold each other to account collectively as a partnership as well as individually as organisations.

The draft plans are due for publication on 1st April 2011 and consultation on the draft plan for Rhondda Cynon Taff has commenced and will run until 21st January 2011, with Merthyr Tydfil’s Plan due to commence consultation in December 2010 for 12 weeks. These our second Children & Young People’s Plans tell the story of what we have collectively achieved in the last three years, and building on that experience, set out our aims and objectives for the next three years.

Both Rhondda Cynon Taff and Merthyr Tydfil Children and Young Peoples Partnerships would be grateful to receive your views and feedback as required.

Cymorth Revenue Grant Arrangements for 2011-12 and Families First Pioneer Areas

The First Minister wrote to the Welsh Local Government Association in April 2010 setting out the intention to bring together a number of existing grant funding streams including Cymorth and the Child and Family Organisation Grant to support an innovative, national programme of activity designed to give effect to the Wales draft Child Poverty Strategy.

In July 2010, The Deputy Minister for Children, Huw Lewis, announced Wales’ first "Families First Pioneer Consortia areas": One in North Wales led by Wrexham working with Flintshire and Denbighshire, and another in led by working with Merthyr Tydfil and Blaenau . These pioneer areas will look at ways in which support for families, particularly those living in poverty can be developed and

2 Agenda Item Number 11c enhanced, in line with the principles set out in the child poverty strategy so that services are more family focused, bespoke, integrated, pro-active, intensive and reflective of local need.

The aim of Families First and the emergence of the a new Families First grant to replace Cymorth is to lead the way in improving the delivery of services to families across Wales, especially those living in poverty, as set out in the Welsh Assembly Government’s draft Child Poverty Strategy. It is a part of a wider programme of reform targeted at families most in need within Wales, including the Integrated Family Support Team and the Innovation and Efficiency Board Complex Families Review.

Each pioneer area has been tasked with ensuring that efficient and effective service models to support families out of poverty are in place, in a way which is consistent with the three strategic objectives of the draft Child Poverty Strategy:

• To reduce the number of families living in workless households • To improve the skill level of parents and young people in low income families so that they can secure well paid employment • To reduce the inequalities in the health, education and economic outcomes for children living in poverty, by improving the outcomes of the poorest

A grant of £1.5 million is available in 2010/11 to support the work of the pioneer areas. The Welsh Assembly Government have been very clear that this is to help us deliver the Child Poverty Strategy, and have been specific around the funding use this year aiming to support the transformation of services and not service delivery, so to support the way we work together better in the future supporting development of infrastructure and tools to support our work.

A local draft plan has been developed which identifies the immediate work required to drive forward the most important priorities of our pioneer area and describes what we want to do to improve efficiency and effectiveness of services provided as part of the project.

Feedback from the Public Fora

The latest in the series of public fora were held in each of the four localities in the Cwm Taf Local Health Board (LHB) area during October/November 2010. The meetings provided members of the public and representatives of local organisations with information on the following matters:

• Developing Primary and Community Care Services (Merthyr Tydfil, Rhondda and Taff Ely); • An update on the Merthyr Tydfil Health and Social Care Health Park and developments at Prince Charles Hospital (Merthyr Tydfil);

3 Agenda Item Number 11c • The Individual Health Record (Merthyr Tydfil, Rhondda and Taff Ely); • An update on the Service Workforce and Financial Framework (Taff Ely); • An update of Primary Care and Hospital Estate in the Cynon Valley (Cynon Valley); • An update on local Mental Health Services (Cynon Valley) • Public Infection Protection (all)

More detailed information relating to the topics discussed at these meetings is provided in Appendix 2. The views of the attendees were captured and will be fed back into the LHB’s planning processes. Members also agreed that public fora meetings were a valuable engagement tool which local attendees wished to see continue.

Attendees reiterated the importance of on-going engagement during the development of health care services across the Cwm Taf LHB area. A number of very positive comments were received on feedback forms that indicated that the programme of topics chosen was well received.

The next series of public fora meetings are scheduled for the dates below: • Rhondda Valleys - 6th January 2011 • Cynon Valley – 13th January 2011 • Merthyr Tydfil – 25th January 2011 • Taff Ely Forum – 31st January 2011

The venues, times and agendas for the above events will be circulated when they have been finalised.

Stakeholder Reference Group Newsletter

The draft minutes from the last meeting of the ‘Shadow’ Stakeholder Reference Group held on 29th September were reported to the LHB Board at its meeting in November. That meeting focused specifically on the development of new Health, Social Care & Well-being Strategies and Children & Young People’s Plans for Merthyr Tydfil and Rhondda Cynon Taff, as well as providing an update on the development of the LHB’s Citizens Engagement Strategy. Attached as Appendix 3 for reference is the newsletter which was developed following that meeting. The purpose of the newsletter is to ensure that key messages from the Group can be cascaded more widely to stakeholder organisations and community groups, and to provide them with an opportunity to engage in future debates via their representatives on the Group.

The first full meeting of the Stakeholder Reference Group, chaired by Cllr. Gareth Jones was held on 25th November and focused on the development of mental health services for adults of working age (18-65 years). The draft minutes from that meeting will be presented to the LHB Board at its next meeting in February 2011.

4 Agenda Item Number 11c COMPACTS

A Compact is a partnership agreement between the third sector and the public sector. It provides a framework within which the development of shared aims, objectives, mutual respect and understanding will assist the ability of public and third sector partners to improve the quality of life for the people living within a particular County Borough.

Merthyr Tydfil, under the leadership of Voluntary Action Merthyr Tydfil (VAMT) developed a COMPACT which was developed in 2008 and signed up to by the Third Sector, Local Authority, LHB Communities First and Police in Merthyr Tydfil. Chairmanship of the Compact Project Board rotates annually between the partners and is currently held by Mrs Jenny Ludlow on behalf of the LHB.

The Merthyr Tydfil COMPACT has achieved much in its first two years, including the development of the Third Sector Commissioning Code of Practice and Codes of Practice for Volunteering, Partnership Working and Conflict Resolution and Disputes Mediation which were approved by the LHB Board at its last meeting.

Within Rhondda Cynon Taff a COMPACT was developed and agreed by local partners, including the former Local Health Group, in 2001. Whilst this document is no longer live, the legacy of the COMPACT still stands. Discussions have been held with Interlink to explore whether the COMPACT should be revisited, however the RCT view for the time being is that the principles of the COMPACT continue to be held by the partners through their mutual respect for each other and ways of working.

RECOMMENDATION

The Board is asked to note the content of this report.

5 Agenda Item Number 11c APPENDIX 1 Setting the Direction: Primary & Community Services Strategic Delivery Programme

Localities Vision Paper for Merthyr Tydfil and Rhondda Cynon Taf

INTRODUCTION & BACKGROUND

Earlier this year the Minister for Health and Social Care published Setting the Direction: Primary & Community Services Strategic Framework, which had been developed for her by Dr C D V Jones (GP and Chair of Cwm Taf Health Board). The premise for Setting the Direction is to move away from the traditional silos of care towards an integrated model built around the needs of our citizens.

The purpose of this paper is to set out the vision for the development of integrated health and social care ‘Localities’ across Merthyr Tydfil and Rhondda Cynon Taf. A new vision is needed to reflect our response to the emerging national and local drivers, including:

• The drive towards a personalised, citizen-focused service design and delivery. • The need to improve the impact of prevention and early intervention in reducing demand for high cost services. • The changing expectations that the public and service users have of health and social care and of other related services. • The economic climate, and in particular the impact of the comprehensive Spending Review.

It is clear that this period presents both considerable challenges and an opportunity to take a fresh look at the management and organisation of health and social care across children’s and adult services, and to explore new ways in which it can be both more efficient and effective.

“Whatever their difficulty or impairment, people should be supported to have control over the life they wish to live. People have a right to expect services, which help them to make full use of their potential, protect them from harm and offer a choice about how they are supported.”

The fundamental purpose is to design, develop and implement a new approach to managing the delivery of health and social care service responses across the communities of Merthyr Tydfil and Rhondda Cynon Taf and involves the following:

• scoping of the vision and the nature of changes required. • developing an integrated operating model to inform the detailed design of future service responses. • implementing changes and managing the transition.

This paper addresses the first of these points as the initial step forward.

Change is required but not only because of the financial climate but also because changing customer expectations demand it. We require a delivery plan that will be transparent clear and inclusive – owned by those that will deliver it. A plan that is

6 Agenda Item Number 11c clear about how we will ensure we deliver critical priorities such as safeguarding whilst also maintaining a focus on preventing escalation.

Our approach will be tested against the following success criteria: • Outcome focused: Better outcomes for families, individuals and communities in a proactive, proportionate and affordable way that will: • Clarify the role and focus services and explore the nature of generic and specialist roles. • Use up-to-date (and regularly updated) information which is shared with service users and between agencies and enable services to be targeted effectively. • Listen to the wishes of our service users . • Reduce unnecessary bureaucracy - this will challenge the bureaucratic assessment processes which delay access to support and tie up the expertise of staff in gate-keeping activities rather than the delivery of support. (Enabling efficiency savings to be made in the context of a cohesive and credible vision for future services). • A commissioning approach based on best value and efficiency and the principles of sustainability and partnerships. • Consider collaborative options and partnership solutions as the norm not the exception. • Understanding and managing risk throughout implementation.

This paper is the outcome of discussions held between Officers of Cwm Taf LHB, Merthyr Tydfil County Borough Council and Rhondda Cynon Taf County Borough Council as our response to that challenge.

The report provides an agreed understanding of the way forward for the 3 Authorities in working together to deliver an integrated health & social care service across the Cwm Taf area.

The strategic direction from the Welsh Assembly Government is clear: Services must be joined up, non-institutionalised and locality based. Services must focus on the citizen, promoting independence and preventing escalation and dependency.

WHAT IS IT THAT WE WANT TO DO?

Our primary goal is to ensure the right services are provided at the right time and in the right place. This will mean a rebalancing of services more towards locally-based services and services that promote good health and independence. In time it will be the norm that health and social care staff work more closely together in teams for each locality, as has been the model in mental health services for many years.

We want to do as much as we can to make sure people remain healthy and independent enjoying as many ‘well years’ as possible, we want to make the very best use of the skills and knowledge of our staff and we want to make sure that citizens get the best quality and range of care within the community across all age ranges. This will also involve ensuring individuals possess the skills to self-manage their health and well-being.

7 Agenda Item Number 11c LOCALITY MODEL

It is proposed that we deliver co-ordinated health and social care services which are organised within 4 Localities - Merthyr Tydfil, Cynon, Rhondda and Taff Ely. These localities will be the core structural building block of community services. Having populations of circa 55-60,000 (which is considered to be critical mass for locality areas), the crucial concepts relating to localities are that: • their boundaries are agreed between health and social care, and be meaningful in terms of geography, natural communities and functions such as patient flows; • their focus is primarily on the citizen (and relevant agent/advocate) rather than on professionals and organisations; • they are of a population size which enables effective and efficient delivery of community services; • they are led by multi-sector locality leadership teams which will include clinical lead and social services members, who will drive locality service planning and be responsible for service delivery. • they are able to utilise the full community based resource, responding to local needs and, where appropriate, create truly integrated multi-professional teams across health and social care • they utilise joint leadership to lower the boundaries between and within organisations and professional groups; • they have clearly specified budgets and resource availability and move towards joint accountability for performance and resource utilisation; • they build up a network of health, social care and third sector services, driven by the needs of each locality area; • they actively strive towards developing improved communication mechanisms between organisations; • they engage with others (e.g. WAG) to establish an evidence-base for what works and what does not work in integrating health and social care and managing changes appropriately.

The statutory requirements for Health Social Care and Wellbeing (HSCWB) Strategies and Children & Young People’s Plans at Local Authority level will continue to be central to the service improvement agenda. The Locality model will enable the development of local HSCWB and Children & Young People’s Delivery Plans that better reflect the particular needs of individual communities that can be aggregated at Local Authority level and LHB level to inform the overall development and performance-management agenda.

LOCALITY SERVICES

Services will be brought together across health and social care in phases. The aim is to create integrated, citizen-focused teams of workers from adult social care and community-based health staff in the following client areas and in the following order:

• People with a physical disability or chronic condition (principally older people) • Mental Health Services (including older people’s mental health); and • Learning Disability Services

At this moment in time it is not intended to incorporate Local Authority Children’s services within the Locality model arrangements. The importance of close working 8 Agenda Item Number 11c relationships with other services like Education, Police and Housing etc will require more detailed consideration but we would anticipate in time that Local Authority Children’s services could be accommodated within this model. For operational purposes Cwm Taf LHB will be organising their Children’s services within the proposed Locality model

Assessment of need will be pivotal to ensuring individuals are sign-posted to the most appropriate services, which includes third sector provision and self-care programmes.

Good progress is already being made in health to pull services across from hospital bases into being locality based. For example, some surgical and ENT (ear, nose and throat) services are already being moved across into the community, as are Children’s Nurse Specialists and the Community Drug and Alcohol Team. Similarly, the two Councils have well-developed Reablement Teams which are demonstrating clear outcomes in enabling people to reach their full potential in terms of recovery, well-being and independence. This is having a significant positive impact on the demands for home care as well as facilitating timely discharge from hospitals.

Not all services will immediately be located within Locality Teams although the intention will be to locate as much of the Health & Social Care services as is possible in Locality Teams. Some services however, due mainly to economies of scale, lend themselves to be managed across localities or will require service changes before integration within Localities:-

• In Health such Community based services will be part of a Community Resource Team working across Cwm Taf • In Social Care these relate mainly to provider side services (e.g. Residential Homes, Day Centres etc), and these will initially remain within the Local Authority infrastructure. They will transfer into the integrated service by agreement.

The list below indicates the range of services that will be considered for inclusion either within or across Localities. Implementation will then take place on a phased basis: • Child & Adolescent Mental Health Services (CAMHS) • Cardiac Rehabilitation • Chronic Conditions Management Team (e.g. diabetes and respiratory) • Communications Hub (Directory of Services; Call handling (inc all health community services; and Care Co-ordination) • Community Drug & Alcohol Teams • Community Equipment (including telecare and telehealth) • Community Hospitals • Community Learning Disability Teams • Community Mental Health Teams • Community Paediatric Nursing Team • Community Paediatrics (medical) • Community Pain Team • Community Transport (include non emergency patient transport) • Continence Service • Continuing Health Care

9 Agenda Item Number 11c • Day care services (health, social care & third sector) • Discharge Liaison • District Nursing • General Medical Services (GPs, Dentists, Community Optometrists, Community Pharmacists) • Health Therapy Services (Physiotherapy, Occupational Therapy, Podiatry, Speech & Language Therapy, Dietetics) • Health Visiting Service • Initial Response • Minor Injury Services • Nursing & Residential Homes • Older People & Physical Disability Care Management Teams • Older People’s Community Mental Health Teams • Paediatric Clinical Nurse Specialists • Palliative Care Service • Pulmonary Rehabilitation • Reablement • School Nursing • Sensory Impairment Services • Sexual health services • Smoking Cessation • Stroke rehabilitation services • Third Sector Services • Wound Care/Tissue Viability

MANAGEMENT ARRANGEMENTS

The localities will have a single line management model (which could be drawn from any one of the partner agencies or professions). Clinical and Professional Social Care leadership will be built into the structure and is an important aspect to ensuring the successful implementation of the Localities model.

CONCLUSION

In summary: • Services need to be intelligence led, making better use of what we know (e.g, people with chronic conditions or use of GP predictive tools); • Services should be about preventing escalation and promoting reablement or acute responses when necessary. • Services must have a citizen focus, allowing for a holistic model rather than the traditional medical model. • Services must be more responsive/able to deliver when people need support to avoid defaulting to hospitals/nursing and residential homes • Services need to avoid duplication of assessments/interventions by different agencies. Single point of access to services will provide opportunities to achieving this • Services need to be seamless • Management must be integrated and empowered to plan and deliver services and control resources • Services must be rooted in the community

10 Agenda Item Number 11c APPENDIX 2

FEEDBACK FROM THE PUBLIC FORA MEETINGS HELD IN OCTOBER/NOVEMBER 2010

The following report represents a summary of the issues discussed at the Merthyr Tydfil, Taff Ely and Cynon Valley Fora. Please note that feedback from the Rhondda Valleys Forum is not included as the meeting was held on 29th November. A verbal update from this meeting will be provided to the Board.

DEVELOPING PRIMARY AND COMMUNITY CARE SERVICES (Merthyr Tydfil and Taff Ely)

Mrs Allison Williams, Director of Primary, Community and Mental Health Services (Taff Ely) and Mr Craige Wilson, Assistant Director Primary Care and Localities (Merthyr Tydfil) provided information on progress made with regard to Primary and Community Services across the Cwm Taf area. It was indicated that the newly implemented Locality Matrix Model and the appointment of Locality Clinical Directors has led to the following achievements:

¾ Establishment of Locality and Community Resources Teams ¾ Transfer of some Community Hospital and District Nursing Services into localities ¾ Improved communication links between secondary and primary care ¾ Commencement of the transfer of services from secondary to primary care.

The improvement of communication links and the introduction of the communication hub were discussed. This was supplemented with information on the progress made in Orthopaedic/Minor Surgery Services, ENT, Optician Led Services and other medical services which included:

¾ Heart failure testing ¾ Community diabetes service (consultant led – commenced in two GP practices) ¾ Local warfarin (INR) service ¾ Community chronic pain service ¾ Community COPD service (commencing in Merthyr).

The presentation concluded by listing the Division’s future priorities which include:

¾ Improving care co-ordination ¾ Improving access to GP services (already five practices have extended their hours) ¾ GP support to Emergency Departments ¾ Consultant led intermediate care service

11 Agenda Item Number 11c ¾ Minor oral surgery – dental practices ¾ Intra Venous antibiotic service at home.

One of the concerns voiced at both fora was the fear that there would not be sufficient staff in the community and, if it required extra nurses etc, how would they be funded? It was indicated that there would be no extra funding and the present resources will have to be used differently. This means reviewing the whole range of service provision and our interface with partners, predominantly the Third Sector and Local Authorities.

AN UPDATE ON THE MERTHYR TYDFIL HEALTH AND SOCIAL CARE HEALTH PARK AND DEVELOPMENTS AT PRINCE CHARLES HOSPITAL (Merthyr Tydfil)

Mr Geoff Walsh, Head of Major Projects Cwm Taf LHB, provided the meeting with a comprehensive update on the progress being made on the Merthyr Tydfil Health Park. This included information and photographs on the present position, artist impressions of the new facility and also details on the community involvement in the project. Mr Walsh invited members of the fora to attend a site visit at the Georgetown Plateau site, arranged by the contractors.

Details were also provided on the progress of developments at Prince Charles Hospital. The developments included the:

• ward refurbishment scheme; • Emergency Care Centre development; • PCH Day Surgery Unit; • Macmillan/Day Oncology Unit at PCH; • PCH Renal Dialysis Unit.

It was indicated that the recent amount of capital funding awarded to the Cwm Taf LHB (in excess of £180 million) has been unprecedented. Mr Walsh promised that the Major Projects Department would continue to update future fora on all aspects of the improvements.

A number of attendees expressed their gratitude for a very positive report on significant local developments.

THE INDIVIDUAL HEALTH RECORD (Merthyr Tydfil and Taff Ely)

Dr Nigel Waskett provided a short briefing on the significant progress that had been made on the development of the Individual Health Record (IHR) Scheme which the LHB is aiming to introduce to the majority of areas of and Cwm Taf by November/December 2010.

The presentation stimulated a number of questions concerning the security of the information held and the availability to view one’s IHR. Dr Waskett indicated that all information will be held on a secure server in

12 Agenda Item Number 11c Cardiff. Out-of-hours IHR information is transferred to the patient’s GP record and cannot be downloaded onto memory stick, DVD disc or laptops. Interest was expressed as to whether the IHR could be accessed if the patient was taken ill in other parts of the UK. It was noted that this was an all-Wales initiative at the moment and England had followed a different method which did not appear to be as successful.

STRATEGIC WORKFORCE AND FINANCIAL FRAMEWORK CWM TAF LHB FIVE YEAR PLAN (Taff Ely)

Ms Alison Lagier, Director of Strategic and Operational Planning, provided an overview on the progress of the proposed Strategic Workforce and Financial Framework (SWaFF) - Five Year Plan.

The presentation included details of Cwm Taf’s vision and the key drivers on which the framework is based. This led to the provision of information on the future of acute hospitals across the area. Indication was provided that the sustainability of acute services in Cwm Taf is dependent in part on changes in neighbouring Health Board areas. It was also noted that any change in services across Cwm Taf will impact on patient flow in neighbouring Health board areas and vice versa. It is therefore vital that there is partnership work with neighbouring Health Boards to ensure that plans align.

A commitment was made to provide regular updates on its progress at future meetings.

UPDATE ON MENTAL HEALTH SERVICES (Cynon Valley)

Dr Paul Davies, Primary, Community and Mental Health Services provided an insight into local mental health services. This included information on:

• The present position on Mental Health Services in Cwm Taf • Growth in Mental Health Services provision • Plans for future Mental Health Services across Wales • The introduction of Mental Health measures • Looking ahead to improved mental health in Cwm Taf.

AN UPDATE OF PRIMARY CARE AND HOSPITAL ESTATE IN THE CYNON VALLEY (Cynon Valley)

A request was made at the Cynon Valley Forum, held in July 2010, that further information is provided on major Primary Care estate issues within the Cynon Valley. Mr Craige Wilson, Assistant Director Primary Care and Localities, provided an update on the present position with regard to the and Mountain Ash Primary Care Centres and the Health Centre. This presentation generated questions centred on the manner in which the new facilities are to be funded. Mr Wilson explained that it is planned that the centres in Mountain Ash and Aberdare will be funded

13 Agenda Item Number 11c through third party developers whilst Hirwaun is smaller and the funding for this building has always been identified and secured.

Mrs Alison Lagier then provided information on the present situation with regard to the new Mountain Ash Hospital and the future of Aberdare and Mountain Ash Hospital sites. Concern was expressed as to how funding realised from the sale of the two hospitals would be used.

Ms Mererid Velios from Celfwaith, a company that has recently been awarded the contract to provide art for the new Mountain Ash Hospital, provided a presentation on the designs suggested for various areas of the building. It was noted that staff at the existing hospitals, local artists and school children will be contacted with a view to being involved in future plans.

PUBLIC INFECTION PROTECTION (Merthyr Tydfil, Taff Ely and Cynon Valley)

Mr Colin Pike, Lead Nurse in Infection Prevention and Control, addressed the fora meetings on the causes of Norovirus outbreaks in hospitals and institutions. He also discussed ways in which visitors can assist the Health Board in minimising the spread of these infections. In conclusion it was indicated that:

• The illness usually lasts twenty four to forty eight hours. • Relatives should not visit a hospital if they or their family have suffering from any of the suggested symptoms until they have been well for at least 48 hours

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