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Community Partnership Agreement Caerphilly

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Community Partnership Agreement Caerphilly COMMUNITY PARTNERSHIP AGREEMENT CAERPHILLY COUNTY BOROUGH COMMUNITY PARTNERSHIP AGREEMENT CAERPHILLY COUNTY BOROUGH CONTENTS 1. Purpose of the Document 2. Scope of the Document 3. Aims and Objectives of the Agreement 4. Caerphilly County Borough Strategic Context 5. Caerphilly County Borough Demographic Context 6. Modernising Community Services 4.1 Achievements to date (Phase 1) 4.2 Aspirations for maturity (Phase 2) 4.3 Achieving a balanced system (Phase 3) 7. Transitional Projects 2008 8. Transitional Projects 2009 9. Transitional Projects 2010 10. Transitional Projects 2011 11. Ensuring Optimum Use of Resources 11.1 Resource mapping 11.2 Opportunities for re-engineering 11.3 Use of flexibilities mechanisms current and planned 12. Measuring Effectiveness of the Agreement APPENDICES Appendix 1 – Task and Finish Group Terms of Reference Appendix 2 – Flexibilities Mechanism Schemes Appendix 3 – Partner Signatures to the Agreement 1. Purpose of the Document This Community Partnership Agreement has been developed by partners within Caerphilly County Borough in response to the requirements of WHC (2007) 023 NHS Commissioning Guidance. The primary purpose of the Community Partnership Agreement is to identify how the NHS, in the context of the advantages offered by co-terminosity, will work with Local Government, the voluntary and independent sectors to deliver improvements in Primary, Community, Intermediate and Social Care. The Agreement seeks to ensure: • Better planning and delivery of services. • Enhanced pooling of funds and sovereignty. • That the principles of the Beecham Review are evident at the local level. The Agreement aims to provide the framework through which health will be improved and community based services will be more effectively integrated, enabling people to access services as close to their home as is appropriate. The Agreement has been developed through a Partners Task and Finish Group, the terms of reference for which are attached as Appendix 1. 2. Scope of the Document Community services are services available in the community that enable people to live healthy, fulfilled and independent lives. This includes services such as: • Primary healthcare services including the General Practitioner, Dental, Pharmacy and Optometry services. • Generic community services such as the district nurse, health visitor, community midwife, community paediatric nurse, school nurse and community therapy services. • Specialist clinical or outreach services e.g. child and adolescent mental health services. • Local Authority social services, services provided by the Voluntary and Independent Sector such as Day Centre Services, Respite Care, Home Support, Residential and Nursing Home services. The term ‘community services’ may also refer to services that are less well known or less developed but can support health, independence and well being such as Telecare. The Agreement does not seek to replicate the Caerphilly Health Social Care and Well Being Strategy, rather to enhance that document through the formulation of a clear framework for community services development and investment. Key developments reflected through this work are: Creating independence through Avoiding admission self care and core services • Housing and health • Development of admission • Primary Care developments avoidance team • District Nursing Review • Continued investment in • Health Visiting review Wanless schemes • Development of Resource • Transitional plan for centre in North of County community based services Borough • Telecare and alarm schemes • Health Challenge Caerphilly • Change management model • Expert Patient programme Facilitating early discharge Maintaining independence • Development of joint hospital • Re-ablement and respite discharge teams model • Nearby Care Project • Graduated housing options • Concept of community care • Healthy Living Centres teams • Change management model – CCM/LTC Supporting vulnerable groups Redesign • Review of Mental health • Resources services • Workforce • Review of Learning Disability • Demand and capacity services • Referral management • Supporting people processes • Children’s services 3. Aims and Objectives of the Community Partnership Agreement WHC (2007) 023 NHS Commissioning Guidance makes clear that the aims of the Community Partnership Agreement are to: • Improve health. • Better more integrated community services. • The development of effective services for hard to reach or vulnerable citizens such as the homeless and substance users. • Close alignment of the NHS and wider public sector. LHBs with their partners will be expected to review current commissioning and management arrangements for community services including primary and intermediate care and chronic conditions management. Through the Agreement, partners aim to: • Commit to further integration of health and social care teams. • Commit to enabling the necessary shift of staff and financial resource from Secondary Care to Primary Care and Community based services. • Commit to testing new ways of working. • Commit to rebalancing the system of care to ensure that residents of Caerphilly County Borough receive the right care, in the right place at the right time. Of particular note, partners commit to the use of Flexibilities mechanisms for the following schemes: • Mental health services • Integrated equipment services • Development of an Integrated Health and Social Care Resource Centre in the North of the Borough • Services for children with a disability • Speech and language services for children • Hospital discharge team 4. Caerphilly County Borough Strategic Context The strategic direction for the development of community services emerges from National drivers, regional developments and identified local need. • National Context At the national level, the context is set through the Welsh Assembly Governments vision for public sector organisations, ‘Making the Connections’ (2006); the vision for the National Health Service in Wales ‘Designed for Life’ (May 2005); and Fulfilled lives, Supported Communities (February 2007) the Welsh Assembly Governments vision for Social Care. These documents set out the following and provide the framework for developing community services at the local level: Designed for Life (May 2005) Fulfilled Lives, supported communities (February 2007) • promoting health and well-being • simpler access and assessment, by addressing the determinants of and more developed self referral ill health and dealing with and self assessment; inequality; • appropriate access out of normal • adopting a citizen-centered model hours; for the provision of public services • services that give people real say across all sectors in Wales; about when and how they are delivered including offering • delivering cost-effective care citizens’ greater financial control; safely, sustainably, and as locally as possible in accordance with • person-centered care services published quality standards with dignity and respect for the throughout Wales; individual and no tolerance of abuse; • where possible, providing care in the home, or the community, • better information to service users rather than in hospital; and carers; • reconfiguring services so that they • more effective joint working with provide an optimal balance of all partners and a action to networked local hospital care and address the barriers to better centres of excellence linked by collaboration; technology; and • stronger joint commissioning with • achieving a balance across health and other services; services through a combination of investment, standard setting, • action to influence and develop public and professional services that deliver improved t ition and food security for engagement, ensuring value of nutrition and food security for money and improved outcomes users and their carers; • clearer outcome-based approaches to care planning; • more informed and shared decisions about managing risks; clear, simple systems of complaint and redress. • Regional Context At a regional level, the South East Wales Regional Plan sets the context for a major programme of redesign across the three Trusts from which Caerphilly Teaching Local Health Board commissions services: Gwent Healthcare NHS Trust, North Glamorgan NHS Trust (to become Cwm Taf NHS Trust on merging with Pontypridd and Rhondda NHS Trust on 1st April 2008) and Cardiff and Vale NHS Trust. The following factors are demonstrated through the South East Wales Regional Plan and will impact on the way in which care will be delivered in the future: • Less care delivered in main hospitals and more care delivered closer to people’s homes - More people with minor illnesses and injuries (such as minor cuts or sprains) or long-term conditions (such as diabetes, coronary heart disease or asthma) want to be looked after in or near their own homes. This will mean a wider range of services provided in the locality. • Advances in medical technology - Many people who used to need to stay in hospital for several days for a surgical procedure can now be treated as a day case. Diagnostic equipment can often be provided cheaply and effectively in local settings, rather than in the past when it was only possible to have it at major acute hospitals. This impacts on after care in the community. • The need for individual patient-focused care - Services must be focused on the needs of the individual, not on what is convenient for the service provider. For example, individuals should, where possible have access to ‘one-stop’ services, where they
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