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 attend once for tests and diagnosis, rather than having to make several visits.
• A changing workforce - Making sure that we respond to the changing needs of our workforce by developing new roles and working differently to meet the needs of individuals and the staff that serve them.
• Value for money and affordability - Making sure that we use our available resources as effectively as possible. The Review of Health and Social Care in Wales was clear that we cannot continue to deliver health-care services in the way we do now. It highlighted the need to invest more effectively in primary and community-based services and to reorganise our hospital-based services to improve health and wellbeing within the available resources.
The following assumptions are made through the various redesign programmes:
Gwent Clinical Futures Programme - Proposes the development of 6 Local General Hospitals and a specialist Critical Care Centre to serve the population of Gwent. Ysbyty Ystrad Fawr Local General Hospital, which will serve the Caerphilly County Borough population, is at Final Business Case (FBC) stage (the FBC is due to be submitted to the Welsh Assembly Government in July 2008) with a building completion timescale of early 2011. The current timescale for completing the whole Clinical Futures building programme is 2015.
The performance assumptions which underpin the programme are:
• Elective Surgical Inpatients < 3 days LOS-> Day Cases
• Reduce Length of Stay (LOS) by 15%
• Avoid 50% of EMAs < 3 days LOS for all HRGs
• 90% Occupancy Elective & Emergency activity
• Improved Care Pathways
• 85% of >10 /14 days LOS transfer out of acute hospital setting
• 90% > 21/28 days LOS transfer out of Intermediate Care
Ysbyty Ystrad Fawr (Caerphilly Local General Hospital) – Caerphilly LGH is a key component of the Clinical Futures Programme, and proposes a hospital of approximately 270 beds with 24 / 7 Local Emergency Centre, surgical treatment, rehabilitation services, mental health services, midwifery lead services and out-patients services. The project is at the Full Business Case stage of the planning process with the building phase due for completion in early 2011.
North Glamorgan NHS Trust – There are a series of projects underway in North Glamorgan NHS Trust which contribute to the major redesign programme underway between RCT and Merthyr, some of which are outlined below:
Ward refurbishment programme – Currently at FBC stage with an implementation phase running between 2008 – 2011. There will be 12 x 24 bedded wards with 50% single room provision. The programme is complex with periods of time where a significant number of beds will be ‘out of the system’ whilst ward areas are being modified/upgraded. The tLHB is working with North Glamorgan NHS Trust to model in more detail the programme and bed profile over time in order to quantify the potential impact on patient service access issues.
Emergency Services Redesign – This scheme proposes a remodelled Emergency Department comprising co-located Accident and Emergency and CCU services alongside a Clinical Decisions Unit. This scheme is at OBC stage.
Health & Well-being Centre – This is planned for Merthyr Tydfil town centre, and will accommodate a similar range of services to the Resource Centre being planned for Rhymney – it will not however have beds. Timescales are yet to be determined.
An activity shift of approximately 1/3 of all emergency activity from PCH to the New LGH in Caerphilly is assumed within the OBC and FBC for the LGH development.
There are also assumptions made on the future number of beds required based on modelling work undertaken by Tribal Secta Management Consultants with North Glamorgan NHS Trust, with further work currently being undertaken by the Trust, and the 3 main Commissioners to assess the impact on the number of beds on a year by year basis.
Cardiff and the Vale of Glamorgan Programme for Health Service Improvement (PHSI)– The tLHB is a member of the Programme Board which has steered the development and submission of a Strategic Outline Programme (SOP) document to WAG in Autumn 2006. The SOP has been included in the all Wales Capital Programme by WAG and proposes service redesign of the patient pathway across a range of specialty based services. Work to date has enabled the development of high level clinical pathways which are now subject to detailed implementation work to inform the OBC. Public consultation on the (PHSI) proposals is planned for summer 2008.
The potential impact of all of the above assumptions and service redesign programmes, aligned with projected demographic changes over the next 5 years, present a challenging landscape for partners in Caerphilly County Borough.
• Local Context
Through the implementation of the Caerphilly Health Social Care and Well- Being Strategy; the Wanless Local Action Plan and the Integrated Primary Care Estates Strategy, Partners within Caerphilly County Borough, have already set the agenda for the modernisation of health and social care services, the alignment of teams across geographical boundaries and the development of additional capacity within a primary and community setting. The introduction of the Local Service Board in Caerphilly adds significant strength to the planning and modernising of services in line with the recommendations of the Beecham Review.
Key priorities for change at the local level are:
• Redesigning community services to optimise the resources available within all community based teams
• Redesigning secondary care in order to improve efficiency and transfer resources currently in hospital services into the community in order to manage the demand on acute services.
• Developing holistic approaches that remove organisational and professional boundaries when assessing need.
• Focusing on achieving better outcomes for patients, improving quality and getting more from shared resources.
• Developing integrated care where the key objectives are to shift the balance of care from institutional settings to supporting people in the community, and adding value to services resulting in people receiving the right care in the right place at the right time. • Improving the patient and carer experience.
• To work alongside the voluntary sector to develop a mixed economy of care.
• Tackling health and well being challenges in a changing population profile which means the need to plan for services to increasing
• Addressing the increased numbers of vulnerable adults and older people who will require more care and support.
• Improving the effectiveness of primary care referrals and managing demand.
• Reducing delayed transfers of care.
• Integrating patient care through service redesign and re-modelling.
• Re-engineering community resource to respond to shifting pressures.
• To seek to rebalance the inequalities in health agenda. 5. Caerphilly County Borough Demographic Context
The County Borough of Caerphilly was created in 1996 as part of the re- organisation of Local Government in Wales. It occupies 28,000 hectares of the South Wales valleys, stretching over 40km between the urban centres of Cardiff and Newport in the south and the Brecon Beacons to the North, taking in all parts of the valleys of the rivers Rhymney, Sirhowy and Ebbw. It comprises 33 wards, with approximately 50 distinct towns and villages, the largest being Caerphilly town itself with a population of 28,000, and other significant settlements including Bargoed, Blackwood, Newbridge, Risca and Ystrad Mynach as shown on the map overleaf.
The County Borough is divided into three localities as follows:
• The North of the County Borough - extending from Rhymney in the North to Ystrad Mynach in the south. It includes other centres of population such as Bargoed, New Tredegar, Pengam, Gelligaer and Nelson as well as the Rhymney and Darran Valleys;
• The East of the county borough - extending from above Markham in the North to Risca in the south. It includes Pontllanfraith and Risca as its main centres of population as well as smaller centres such as Oakdale, Cefn Fforest and Newbridge;
• The South of the county borough - comprising the Caerphilly Basin and the Aber Valley with Caerphilly as its main centre of population.
Population
The 2005 mid year estimate of population states that the resident population of Caerphilly County Borough is approximately 170,000. This number has remained relatively stable for Caerphilly as a whole, however, numbers within the South have increased, whilst those in the North have decreased 49% of the population are male and 51% female, and the age composition is broadly in line with that of the rest of England and Wales. There is no major change in the overall population projected for 2011.
There is an age demographic change with increasing numbers of older people and decreasing numbers of young people. The number of people at retirement age and over are projected to increase by approximately 15% by 2011. This will have a significant impact on health and social care services within the Borough as this age group is a significant consumer of health and social care services.
The population of the County Borough is unevenly distributed with the areas at the northern extremes of the North and East localities having geographically large electoral divisions with fewer than 2750 people living in them. The centre of the Caerphilly basin is more heavily populated. Bedwas, Trethomas and Machen and Penryhoel have 13 per cent of the County Borough total population between them.
From an economic perspective, over the last 20 years there has been a dramatic decline in the traditional heavy industries of coal and steel, and the Borough now has the third lowest rates of economic activity in Wales, exacerbated by low levels of skills, educational achievement and lack of qualifications. Although unemployment has declined in recent years, its legacy of poverty and deprivation have clearly had an impact on the health of the population. There is well-documented evidence of a high correlation between socio economic deprivation and ill health. Some of the results of deprivation, such as low level of car ownership, make it difficult for people to access the services that they need.
The Caerphilly County Borough Health, Social Care and Well Being Needs Assessment 2007 illustrates the following:
• There is a high death rate from chronic obstructive pulmonary disease
• The rate of people admitted to hospital for Coronary Heart Disease (CHD) is significantly higher than the Welsh average, and premature deaths due to CHD are the worst in Wales
• Dental health for 5 year olds is poor and has deteriorated since the last needs assessment
• Self reported limiting long term illness, physical and mental health are amongst the worst in Wales
• Adult residents have one of the lowest consumption levels of fruit and vegetables in Wales
• Adult obesity levels are above average for Wales.
• Binge drinking levels in 16 and over year olds are above average for Wales.
• Smoking rates are above average for Wales.
• There are high levels of economic inactivity, also high levels claiming Incapacity Benefit, of which a third are due to mental health reasons.
• 11% of Caerphilly borough is in the “most deprived” category in Wales.
• Children entering the care system tend to be as a result of families under stress, children being abused or neglected, parents having problems coping with a child’s behaviour.
• The development of a multi-agency Strategy for children with disabilities to reduce carer stress and improve outcomes for children is a priority.
The complete Needs Assessment can be downloaded from Caerphilly County Borough Council www.caerphilly.gov.uk and Caerphilly teaching Local Health Board www.caerphillylhb.wales.nhs.uk
The Needs Assessment also identified the current service pressures experienced throughout the county borough:
• The demand for health and social care services continues to increase, particularly in terms of the population growth of older people who are disproportionately high users of health and social care services, as well people with long term conditions.
• The health, social care and well being sector has some areas where there is an ageing workforce and high levels of vacancies, making the recruitment and retention of qualified staff across many disciplines a challenge. Some services are provided in buildings that require upgrading to meet modern standards.
• Support to informal carers is essential to maintain people within their own communities. Identification, assessment and respite options are needed to enable unpaid carers to fulfil their chosen caring responsibilities
• There is a lack of availability of local placements for looked after children (children who are under the care of the local authority) There is a pressing need to increase availability of family support options to prevent children coming into the care system and provide cost effective, good quality facilities for children with complex needs within the county borough.
• Work opportunities and mainstream community facilities including leisure, culture, housing and personal development should be more open and accessible to people with long-term conditions, including those with learning disabilities, people with mental health problems and those with physical disabilities and sensory impairments.
• Services need to continue to work together to increase responsiveness to improve the service experience users.
• Pressures of NHS continuing health care and delayed transfers of care place added pressure on partnership working, and require joint solutions to give real benefit for local people
• People in crisis need earlier responses that prevent family breakdown, ill health and enable individuals to take more responsibility for their care and well being.
• There is poor access to affordable housing within the County Borough.
• There is a significant lack of single person housing, particularly for those under 25 years of age, which results in young single people being housed in hostels outside of the borough
• There is a need to grow capacity within residential and nursing homes, particularly for people who have dementia. A steady growth is also required within schemes that enable people to have their own front door and access personal care and support. However, whilst consideration needs to be given to issues within the nursing home and Independant Sector (in relation to services for older people with mental health problems) partners do not seek to employ old hospital estate which is no longer suitable for modern health or social care provisions.
It is recognised that the population will have varying levels of need, and therefore the following groups are identified
• people who are generally well and able to live fairly independent lives , though sometimes with the support of family and friends and low level of formal support
• people with more significant care needs, such as people living in the community who are frail or have a long standing disability, including people with a learning disability
• people who have chronic conditions , including mental health problems or other health problems such as arthritis, diabetes or respiratory disease
• people who need rapid access to health and social care, for anything from emergency dental treatment or meals on wheels to emergency cardiac surgery or Telecare support.
Of equal importance to developing Health and Social Care services is the agenda of co-production of good health and wellbeing between service providers and service users. There is a major programme of work related to health promotion and self care within the County Borough, which includes:
• Increasing the amount of health promotion activity to assist individuals to live a healthy lifestyle and to maintain and improve health.
• To improve self care amongst those with chronic conditions.
• Increasing the number of patients learning to self manage their conditions through self management programmes.
• Improving patient involvement in consultations and decision making.
• Exploring the potential for health coaching / mentoring.
In order to simultaneously; respond to current and projected community based needs and systematically rebalance acute and community services, three phases of development have been identified.
6. Modernising Community Services
6.1 Achievements To Date (Phase 1)
Over recent years partners, in Caerphilly County Borough have worked together to develop enhanced primary, community and social care services, recognising these services as major components in a wider system of health and social care redesign.
Initial worked commenced during 2003 with the development of the Whole Systems Action and Implementation Plan, aimed at tackling delayed transfers of care. This work was formalised through the strategic development of the Health Social Care and Well Being Strategy 2005-2008 in Caerphilly County Borough, and operationalised through the development and implementation of the Wanless Local Action Plan. The Wanless Local Action Plan set out an ambitious programme of change for community services within Caerphilly County Borough. Therefore a significant and major programme of whole system health and social care redesign provides the context within which this Partnership Agreement has been developed.
This history of joint working and in establishing joint solutions to resolve common problems, places in Caerphilly County Borough in a good position to move community services investment into a matured system of integrated health and social care in order to fulfil the aspirations for level 1 services communicated through the Welsh Assembly Government Strategy for healthcare service redesign (Designed for Life) and to achieve the objectives set out in the Social Services Strategy Fulfilled Lives supported Communities.
The period between 2004 – 2007 has seen significant investment through Wanless funded projects aimed at:
• Reducing delayed transfers of care. • Managing demand in more appropriate parts of the system. • Rebalancing acute and community services.
6.2 Aspirations of Maturity (Phase 2) 2007-10
Partners in Caerphilly County Borough have developed a number of community based projects, which now need to be refocused as a system of care. During this second phase, the following key outcomes are planned:
In 2007 Caerphilly Teaching Local Health Board reviewed progress and considered plans for the system change. There was a full review of investment across community services (a review of investment via Wanless and the development of the Community Services Framework) and a variety of proposals from inside the individual organisations across the health and social care system in the County Borough which suggest an agenda of considerable change in the coming years. Of particular note will be the introduction of a variety of schemes related to active case management whether this be from within practices within the community to avoid admission or within the acute sector in terms of expediting discharge and ensuring most appropriate response.
There are also a variety of projects being undertaken which are aimed at building capacity in primary and community based services. These include the potential for earlier introduction of service model changes, the potential for phlebotomy services to be more appropriately provided in primary care and the potential of introducing demand management schemes within a primary care environment e.g. enhanced services for minor surgery.
During 2008 a number of initiatives commenced in 2007, will be fully implemented i.e. the new community nursing model. This year will also see the further implementation of reviews and recommendations which are due to report at the beginning of that year i.e. the mental health services review. 2008 also sees the beginning of repatriation of services for functional assessment for older adult mental health (from Newport to Ystrad Mynach) and the repatriation of support care from Abertillery to Ystrad Mynach. This will require an additional 21 beds to be provided by Gwent Healthcare NHS Trust within the borough however it is anticipated that capacity will have been released from the case management schemes to enable this to happen.
In the North of the Borough Cwm Taf NHS Trust is established and Prince Charles Hospital, commences phase 1 of the ward refurbishment programme when approximately 12 acute beds will be taken out of the trust bed compliment. Social care services also commence a programme of modernisation, and seek to realise full implementation of modernised day services, a growth in capacity in Borough and a reduction of out of area placements.
2009 presents particular challenges in the system of health and social care for Caerphilly County Borough. Through modernised acute services and a growth in community based services, this year has the potential to see a possible change in case mix of patients being managed in a community hospital setting in a shift towards a more proactive model of care and in pursuit of achieving future models of care in advance of major system change. Phases 2, 3 and 4 of the ward refurbishment programme at Prince Charles Hospital also take place during this year, this could signify a reduction in bed numbers which will require a growth of community services to accommodate the change.
Other important factors this year are the implementation of the European Working Time Directive and the unknown impact of this to date. The full impact of any demand management schemes that have been developed within primary care should also be realised this year.
6.3 Achieving a Balanced System (Phase 3: 2010-2013)
During 2010 phases 5 and 6 of the Prince Charles Hospital ward refurbishment programme are scheduled to be completed. Once again this could indicate a reduction of bed based activity, and the need to provide alternate models of care in a community based setting in line with the model of care changes already agreed through the Rhondda Cynon Taff and Merthyr Tydfil Redesign Programmes and Gwent Clinical Futures Programme.
During this year we will ensure that all long term care patients are being cared for in an appropriate setting in advance of Ysbyty Ystrad Fawr Local General Hospital opening and the closure of Caerphilly District Miners’ Hospital and Ystrad Mynach Hospital in the following 12 months.
Both Ysbyty Ystrad Fawr and the new Emergency Care Centre at Prince Charles Hospital are due to open during 2011. The ward refurbishment programme at Prince Charles Hospital will be fully implemented and the full impact of reduced beds will be seen. There is also during this year, an interim plan to be developed within the Royal Gwent Hospital to continue to provide critical care services in advance of the Specialist and Critical Care Centre opening.
There will be further repatriation of activity undertaken this year with approximately 10% of attendances from the Accident and Emergency department at Prince Charles Hospital needing to be repatriated back to the County Borough, 26 bed equivalents (22 medical and 4 surgical) to be transferred from Prince Charles Hospital to Ysbyty Ystrad Fawr and nearly 40% of general medicine and emergency medical admissions from Prince Charles Hospital to Ysbyty Ystrad Fawr. In addition to these service repatriations there is an assumption within the Merthyr Tydfil programme that 44 beds will be saved through the implementation of demand management schemes by LHBs this equates to approximately 10 beds for Caerphilly County Borough.
During 2012. the key project which the tLHB is aware of at this moment is the movement of beds from the St Tydfil site on to the Prince Charles Hospital site.
The main body of this Agreement offers more detail on each of these schemes, and leads the reader through a timeline, and represents a critical path for change related to the rebalance of the health and social care system within Caerphilly County Borough.
The structure further aims to reflect for each year of the Agreement:
• Service developments / reinvestment
• Opportunity for shifts in where demand is managed
• De-commissioning opportunities
7. TRANSITIONAL PROJECTS 2008
Aligned with national direction, the major area of investment for partners in Caerphilly County Borough is a growth in primary and intermediate care services. The Primary Care Investment Plan, details specific growths in this element of the service, and therefore this Agreement focuses predominantly on intermediate care where significant interface between partners is essential.
Intermediate care services, need to be based on the needs of local populations, with service users having access to a variety of intermediate and community care services that, when provided to the right person at the right time, will promote and maintain the health and independence of that person. Partners in Caerphilly County Borough are working together to develop a whole system philosophy where admission to hospital is the last, not the first resort. The key message is that intermediate and community services need to be designed, reviewed and evaluated to ensure they support independence for the people who use them. The last few years has seen significant investment in community and intermediate care sectors in the Borough, with ‘Wanless’ investment heralding a period of growth and enabling the vision for community and intermediate care services to be realised. Work in the last two years has focussed on the development of new roles and community based schemes, including the review and modernisation of traditional service provision in the Borough e.g. District Nursing services and Home Care services, with emphasis placed on maximising the effectiveness of the patient’s journey through the hospital system by improving discharge processes and avoiding admission to hospital whenever possible. The ongoing development of community based support services and care-at-home schemes feature prominently in the planned service model outlined below:
The Vision for Intermediate and Community Care Services within Caerphilly County Borough
GP / Primary Healthcare Team
Consultant Community Physician (Intermediate Care) or Nurse Case Manager
Discharge Support
Joint Hospital Discharge Team Alternatives to Minor Aids Adaptations Admission to hospital at times Age Concern Discharge Scheme Hospital of crisis and exacerbation Nearby Care Model (CDMH) District Nursing (unscheduled North Resource services) Core community Centre Rapid Response support services Team Reablement Community Emergency Care District Nursing Rehabilitation at Home (scheduled services) Beds: patient Virtual Ward Voluntary Sector pathway LTC care manager
7.1 Service Developments
• Appointment of a Community Consultant
The appointment of a community consultant physician was first mooted in the Wanless Local Action Plan 2004, however due to various reasons, the post was not filled. The system of care locally requires clinical accountability at this level, and therefore funding for this post.
The post holder will be part of the Community Division of the Trust with close working relationships and clinical governance activities with the existing Consultant Geriatricians and Consultant Physicians. The Consultant will have admission rights to secondary care beds in the Community Hospitals and to the Local General Hospital where there will be twinning arrangements for clinical activity and continued professional development with a named Consultant Geriatrician.
Specifically the post will be responsible for the nearby care ward, which will consist of a 24 bedded unit in Caerphilly District Miners’ Hospital. This is a new initiative which is at the forefront of clinical redesign, with the focus being upon drawing patients through the care pathway to discharge home, supported by other intermediate care schemes. The job plan for this role supports the development of the nearby care model and hospital discharge team, supported by the advanced practitioners working in the community.
There is also opportunity to develop GP specialist interest roles in the North of the Borough, with a strong leadership link to this role
• Nearby Patient Care
Building on a Scandinavian approach, the Nearby Patient Care project enables a particular cohort of patients within Caerphilly District Miners Hospital to be fast tracked through the system, and an appropriate health and social care response to on-wardly support the individuals within the community on discharge. It is anticipated that in the first instance that this model will be tested in Caerphilly District Miners Hospital. The approach enables an approach to clinical care that minimises length of stay, and mobilises targeted interventions for ‘at risk’ cohort of patients within CDMH along with active case management from the point of admission
• Joint Hospital Discharge Team
In order to support the Nearby care project and accelerate timely discharge, an integrated discharge team is currently being developed, and will be fully realised through 2008. The approach will bring together the Nurse Case Managers, Occupational Therapy posts and social work investment into one management structure working to common objectives and performance targets. The development will enable the use of a section 33 agreement. Challenges to the project remain a lack of capacity within the independent sector (particularly nursing for old age psychiatry) and the alignment of the project with newly configured reablement and district nursing services.
• Implementation of New Model for Community Nursing
This project sees the implementation of recommendations arising from the review of community nursing undertaken during 2007. By early 2008 full implementation should have been realised with the new team structures being communicated and implemented between December 2007 and March 2008.
The Caerphilly County Borough District Nursing Service has been reconfigured to provide a wide range of generalist and specialist nursing services to meet the challenging and diverse needs of the population of Caerphilly County Borough. These services will be provided in conjunction and close liaison with multi-disciplinary teams across the primary, secondary, community and social care systems.
The Caerphilly District Nursing Service will be characterised by a model of care that is informed by needs led assessment and will be underpinned by strong practice partnerships between the designated link nurse and practice nurse. Development of the ‘virtual ward’ concept and the delivery of seamless care will be key features of the service.
During 2008, a competency assessment within the practice nursing service will also be undertaken.
• Integrated Health and Social Care Equipment Service
Partners in the Borough have committed to developing an integrated health and social care community equipment service, utilising the development of a section 33 agreement. This will enable a Gwent wide service to be developed under one management structure and utilising a pooled budget.
• Reshaping Domiciliary Care Services across Independent and Statutory Service Providers.
Domiciliary care (home care) can be described as being “ a variety of practical and personal tasks provided to vulnerable people in a community based setting as opposed to institutional care, to enable them to live as independently as possible at home” The need and demand for domiciliary care is growing alongside the increase in the population of older people and people with long term conditions. Domiciliary care, together with other support is set to grow. In order to support people at home, to avoid hospital admission and to facilitate rapid discharge from hospital, domiciliary care services will be delivered both alongside and, in an integrated way. Specifically redesign of the service will enable: • In-house service helping people with life limiting illness, those who have complex and multiple problems, those whose medical condition will deteriorate over time and those who require palliative care. • External providers to support those with less complex needs through commissioning arrangements through the independent sector.
• The over-riding approach to development will be one of reablement and of supporting people back to independence. The initial intervention will be up to a six week re-ablement package and only where there is continued evidence of need will longer term packages put in place.
• Modernisation of Day Care Services
Transforming day care is informed by the need to develop services that move away from traditional settings that were often seen as institutional, segregated, with a group focus - limiting personal expression, individual exploration of personal interests and development. Provision was often viewed as being primarily providing respite and limiting the contribution to social inclusion or developing independence.
Developing new services creates a variety of challenges namely the release of resources invested in buildings and staff, accelerating acceptance and delivery of mainstream and community services – leisure, employment services etc. as well as balancing the need for day respite and creating dynamic rehabiltative models of short term delivery that develop independent living skills.
• Building Capacity to Reduce Out of Borough Placements
Caerphilly County Borough, currently has a number of vulnerable people placed outside of the County Borough in order to have their care needs met. Placing vulnerable people out of borough adds additional barriers and complexity particularly in terms of monitoring and support and carers travelling etc. The ability to create an appropriate presence to ensure quality, fulfil the role of corporate parent for children and ensure service users complex needs are consistently met becomes more challenging. The ability to stimulate growth of provision will be paramount in ensuring improved user experience and satisfaction. It will also enable service to be more sensitive to the needs of users by enabling them to maintain their links with their local community and social networks. During 2008, a range of enhanced provision will be considered, the number of high cost out of borough placements will be reduced, and savings reinvested in local preventative services and action will be taken to enhance stability of Long Term Foster placements and increase the number of in house foster carers.
• Work with Partners to Improve Transition
Looked after children, children with disabilities, and other children require continued support into adulthood. There is a need for a coordinated approach, across child and adult services. This approach also needs to incorporate positive working relationships with other agencies to ensure continuity of planning and resources. Specifically during 2008, action will be taken to implement protocols with partners particularly education to support children with disabilities, Autistic Spectrum Disorders and learning disabilities; further develop transitional planning and reviews for vulnerable young people as they enter adulthood and embed Caerphilly County Borough’s Transitional Policy and Practice Guidance.
• Modernisation of Mental Health Services
This modernisation programme stems from the requirements of the revised Adult Mental Health NSF 'Raising the Standard' and the review of adult mental health services in Caerphilly County Borough undertaken by Research & Development in Mental Health (RDMH) in 2007.The service will become increasingly outcome focussed and supporting the 'recovery' model of care thorough the development of care pathways. There will be close collaboration with local, regional and national partners to ensure Caerphilly residents have access to a full range of generic and specialist mental health services and support. Work will continue to ensure full integration of health and social services to provide one seamless service.
Priority areas for improvement, amongst others, are:-
• Alignment of Level One components - a comprehensive re- engineering of access to support and treatment services through a community focussed stepped approach. Enabling people to access the right level of support at the right time to suit their individual needs. This will include gateway workers First Access/ASDIT primary care counselling and GP based services.
• The CMHTs will continue to be the cornerstone of the service through which services users and specialist team and services will deliver a collaborative structure programme of support. The CMHT will need to be enhanced to provide intensive home treatment and crisis support, together with further development of a Caerphilly wide assertive outreach team.
• Inpatient Services - With the development of the new local general hospital which will reprovide inpatient mental health services there is a opportunity to ensure we create the right therapeutic environment for mental health patients and staff, ensure maximum benefit for all stakeholders.
• The voluntary sector is currently underdeveloped in the Borough in relation to mental health support services. There is a wide range of skills and expertise with in the sector that will require more encouragement and support to achieve it's potential in delivering a comprehensive range of services to the Borough. The Voluntary Sector has to be a integral part of the service redesign and modernisation process.
• Service User Involvement There needs to be a comprehensive and fully resourced services user involvement programme in the Borough to ensure that services users and carers are able to make their much needed contribution to the areas of service redesign, recruitment of staff and service evaluation.
• A wider range of supported accommodation for mental health services users is needed in the Borough. This will need to be based around a range of accommodation that offers alternatives to hospital admission and a tiered level of accommodation to enable early discharge and ongoing rehabilitation services.
This mental health redesign programme offers the opportunity to develop an integrated team under one management structure and utilising a pooled budget, which will enable clear leadership and commissioning structures to be developed.
7.2 MANAGEMENT OF DEMAND
• Minor Illnesses to GPs from Accident and Emergency
There is an assumption that some activity being seen in Accident and Emergency departments in both Prince Charles Hospital and within Gwent Healthcare NHS Trust will in future, be cared for within the community. The Teaching Local Health Board commissions a range of minor surgery enhanced services from GPs in the area and this may in part be an appropriate response to some of that repatriation. It is suggested that work is done to map the enhanced services for minor operations across the borough and to consider the role of pharmacy in the management of minor illness. The tLHB is also working with local GP’s on the development and implementation of a minor injuries local enhanced service.
• GP Phlebotomy
There is a high amount of activity being seen within the phlebotomy service at Caerphilly District Miners Hospital which could more effectively be managed within primary care. It is understood that there may be many blocks which make the system work as it does currently and it has been agreed that activity in this area will seek to be reduced during 2008.
• Repatriation of Functional Assessment
As earlier noted, there are plans to transfer eight beds from Newport to Ystrad Mynach Hospital for this service provision. It is noted that staff form Newport and Abertillery who support these people currently will also be transferred into the Caerphilly County Borough to continue to support the transfer of patient care. • Development of Sub Acute Ward
This project will be complete by 2008 and as earlier noted will allow the repatriation of mental health activity back into the borough, following the repatriation of mental health activity back into the Borough following transfer of beds from ystrad Mynach to CDMH.
• Reconfiguration of Beds in CMDH (7 medical beds)
This scheme relates to the reconfiguration of beds within Caerphilly District Miners Hospital and the development of nearby care, along with other reconfiguration of acute medical and surgical beds.
It is anticipated that capacity will be released at Ystrad Mynach to allow Caerphilly borough residents who are currently in Newport awaiting functional assessment (8) and Cwmtillery Ward in Aberbeeg Hospital (11 patients) to be repatriated to Ystrad Mynach Hospital.
• Early Repatriation of Surgical Activity from Prince Charles Hospital to Caerphilly
It is anticipated that surgical activity could be repatriated in advance of the new hospital feasibility of this will be explored by both Trusts during 2008.
• Phase 1 of Ward Refurbishment Prince Charles Hospital
The ward refurbishment programme at Prince Charles Hospital is extensive and sees the majority of wards refurbished between the period of 2008 and 2012. During this period there will be a accumulative reduction of beds. The first phase is due to start in 2008 and is in the first instance likely to see the reduction of 12 medical beds. The impact of this change could be an increase in bed pressures and to this end could impact on emergency medical admissions and other provider Trusts in the area.
7.3 DE-COMMISSIONING
• Day Hospital
The day hospital will close in advance of the new Ysbyty Ystrad Fawr Local General Hospital opening. There are no plans for the re-provision of this service within that development. Patients currently attending the day hospital, will, following their hospital stay be transferred to the care of their GPs.
• Minor Injuries Unit at Aberbargoed Hospital
This scheme is related to the low activity levels within the minor injuries unit at Aberbargoed Hospital. It has been agreed with the Community Health Council that the minor injuries unit is closed with effect from 29th February 2008.
KEY IMPACT AREAS DURING THIS PHASE
Key impact and alignment areas to be discussed at inaugural modernisation group
8. TRANSITIONAL PROJECTS 2009
8.1 SERVICE DEVELOPMENTS
There are no specific service developments this year aside of the continuation of projects already commenced in 2007 and 2008, and preparation in readiness for service changes as outlined in subsequent years.
8.2 OPPORTUNITIES TO MANAGE DEMAND IN ALTERNATE PARTS OF THE SYSTEM
• Phases 2, 3 and 4 of PCH Ward Refurbishment
This project continues the programme of work commenced in 2008 and will see accumulative effect of beds being taken from the system to a maximum number of 60 with 2009. This is the critical flashpoint year where there are three phases of approximately 12 beds reduction in each phase. This work is critical to enable the Trust to meet its health and safety requirements.
• Impact of Demand Management Schemes in Primary Care
There are approximately 14 schemes within the Demand Management Plan of the Teaching Local Health Board and the impact of these should be fully realised by the end of 2009. This is subject to resources being available to fully implement the project.
8.3 OPPORTUNITIES FOR DE-COMMISSIONING
• Oakdale Hospital
The lease for Oakdale Hospital ceases during 2009. Gwent Healthcare NHS Trust would not seek to extend beyond this time frame in line with the time scales associated with the new Local General Hospital within Caerphilly County Borough. As a result the 16 beds currently at Oakdale would be decommissioned, and the palliative care beds would be recommissioned. This would see the closure of 16 beds, two of which are dedicated to palliative care provision. The major implications relating to this closure are an increase in demand for EMI services provision in alternative locations and an impact upon social care.
• Changing Model of Care at Redwood Memorial Hospital
Redwood Memorial Hospital is a community hospital which provides a range of outpatient based services and has 21 GP managed beds serving the population of the north of the borough. The opening of Ysbyty Ystrad Fawr Local General Hospital in 2011 will coincide with the closure of a number of hospitals in the borough, including Redwood Memorial Hospital. However, recognising the geographic isolation of the population served, the level of health and social care need as well as the range of GP provided services in this part of the borough, it has been agreed with the north of the borough community that a health and social care resource centre will be developed, based on identified need, prior to the closure of Redwood Memorial Hospital. The multiagency planning process has delivered a number of agreed service models for the resource centre and, working with the local GPs, it is proposed that the inpatient beds service model be implemented in advance of the opening of the resource centre enabling a planned reduction in the current number of beds from 21 to 12. The model of inpatient care anticipated for the resource centre would enable patients, with a long term condition predominately, to step up into the hospital beds for active management and return to their homes. This would see a shift in the model of care to one that discourages patients being stepped down into a community hospital bed but supported to return home instead.
KEY IMPACT AREAS DURING THIS PHASE
Key impact and alignment areas to be discussed at inaugural modernisation group
9. TRANSITIONAL PROJECTS 2010
9.1 SERVICE DEVELOPMENT
• Development of Integrated Resource Centre in North of Caerphilly County Borough
The integrated health and social care resource centre in the North of Caerphilly County Borough offers the opportunity for one management structure across a range of health and social care services for:
• Older peoples assessment and care management
• Children & Families services
• One stop shop for primary care (GP surgeries, enhanced services, dentist and optometrist)
• Community mental health services
• Community re-ablement and rehabilitation services
• Palliative care provision
The resource centre will be a hub in the system of health and social services for the North of the Borough enabling full integration, and seamless provision. Opportunities for section 33 agreement around this development need full consideration.
9.2 OPPORTUNITIES FOR DEMAND TO BE MANAGED IN ALTERATE PARTS OF SYSTEM
• Phases 5 and 6 of the Ward Refurbishment Programme at Prince Charles Hospital
The ward refurbishment programme continues at Prince Charles Hospital during this year where the 5th and 6th phase of the programme are due to take place. Set out once closures and note dependencies in relation to SCCC and Newport Local General Hospital.
9.3 OPPORTUNITIES FOR DE-COMMISSIONING & REINVESTMENT
KEY IMPACT AREAS DURING THIS PHASE
Key impact and alignment areas to be discussed at inaugural modernisation group
10. TRANSITIONAL PROJECTS 2011
10. 1 SERVICE DEVELOPMENTS
• Opening of Ysbyty Ystrad Fawr
The commissioning of the Ysbyty Ystrad Fawr Local General Hospital is scheduled to occur in the spring 2011. The Local General Hospital will enable the repatriation of in patient day case and out patient activity facilitating local access to majority of hospital provided services for borough residents.
• New Emergency Care Centre at Prince Charles Hospital
The Emergency Care Centre will provide accident and emergency services (including dedicated paediatric facilities) together with medical and surgical assessment in a clinical decisions unit. In addition the adjacent orthopaedic clinic will be refurbished and within this the GP out of hours services will be provided. The Centre is due to open early 2011.
• Integrated Health & Social Care Resource Centre in the North of the County Borough
This project commences its build and service transition scheme this year, further detail is outlined in 2010.
10.2 OPPORTUNITIES TO MANAGE DEMAND IN ALTERNATE PARTS OF THE SYSTEM
• Repatriation Assumptions
The assumptions related to attendance at Accident and Emergency activity being transferred to Ysbyty Ystrad Fawr from Prince Charles and model of care reduction will be realised during 2011/2012.
• Full Repatriation of Surgical Activity from Prince Charles Hospital
It was agreed within the assumptions of the business case related to the new hospital in Caerphilly that surgical activity at Prince Charles Hospital for Caerphilly borough residents will be repatriated during 2011 when the new hospital opens.
10.3 OPPORTUNITIES FOR DECOMMISSIONING & REINVESTMENT
• Completed Ward Refurbishment at Prince Charles Hospital
As of yet the impact of the full programme is unknown, however could be as many as 60 beds taken from the system.
KEY IMPACT AREAS DURING THIS PHASE
Key impact and alignment areas to be discussed at inaugural modernisation group
11. Ensuring Optimum Use of Resources
11.1 Resource Mapping
There are a variety of funding streams which currently support the delivery of community services:
Simplistically, these can be viewed as following: Core LA & LHB funds
Wanless Joint Allocation Working Special Grant
Budgets related to Enhanced Supporting primary care contracts Services People
All of these budgets are currently committed, and would require dis- investment, from other areas if they are to be utilised to respond to the aspirations within this agreement. The following illustrates the current split across priority areas:
Ot her Primary Care sup p o rt , 3 9 3 V o lunt ary sect o r, 759 .124 758 8 LA excluding Wanless ab o ve, Dent al, 78 71.53 78 1761.79 3 52 5 Pharmacist s & Prescribing , 4 2 553 .9 6
GMS, 23092.734
Wanless, 58 2 4 Clinics in GP Practices, 345 M ent al healt h not includ ed abo ve, 3 4 4 Ot her cost s, 3 357.70 5 Townsend schemes, 847.845 NHS Trust providers, 140535.8177 Co nt inuing Care & FNC, 54 8 1.22 8
NHS Trust providers Other costs Continuing Care & FNC Townsend schemes Mental health not included above Secondary Care Clinics undertaken in GP Practices Wanless GMS Pharmacists & Prescribing Dental Other Primary Care support Voluntary sector LA excluding Wanless above 11.2 Use of Flexibilities Mechanisms Current and Planned
Caerphilly County Borough currently has 8 different schemes funded by the joint working special grant, and using flexibility mechanisms. Detail on each of the schemes is attached in Appendix 2.
There are further plans to realise the benefits of the mechanisms through exploring the potential for pooled budgets, (through a section 33 agreement) for the following schemes:
• Mental health services
• Integrated equipment stores
• 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
Opportunities for Flexibility Mechanisms
Lead Integrated Pooled Budget Commissioning Provision Mental Health Joint commissioner First Access & Services would increase ASDIT commissioning Community capacity and create Mental Health a unified approach Teams across the piece Integrated day hospital with social services Day unit/Care
Community Lead Single manager Revenue Budget Equipment commissioning Joint Equipment Service arrangements Service
Resource Clinical lead/ Centres General Manager Joint Community Care Teams
Joint Hospital Joint Hospital Joint Hospital Discharge Discharge Team Discharge Team Scheme Children with Joint Multi-agency Disabilities Commissioner integrated service
Joint Health and Social Care Hospital Discharge Team
11.3 Workforce Redesign
In line with Designed for work, the Strategy developed to support Designed for Life, the following principles will be adhered to in implementing this Agreement.
The workforce will:
• Be designed around individuals, pathways and service needs • Work across traditional professional boundaries • Work across organisational boundaries • Work through managed networks to provide care • Reflect a shift from secondary to primary care provision • Evolve and develop in innovative ways as service needs change • Be developed with the full engagement of clinical and professional leaders • Be developed around workforce competencies, career pathways and the Knowledge & Skills Framework • Be regulated and accredited within new arrangements • Be involved directly in the development of roles
12 Measuring Effectiveness of the Agreement
A rebalance of community services is dependent upon the successful implementation of the schemes outlined within this Agreement. Accountability for delivery with partner organisations, thus maintaining the Agreement will occur through the Caerphilly Health Social Care & Well-Being Partnership and Local Service Board. APPENDIX 1
COMMUNITY PARTNERSHIP AGREEMENT
Task and Finish Group Terms of Reference
BACKGROUND
Making the Connections: Delivering Beyond Boundaries, Designed for Life, Beecham Review and Fulfilled Lives Supportive Communities all identify the need to strengthen and closely align commissioning arrangements across the sectors.
On 30th March 2007 the Welsh Assembly Government issued the Welsh Health Circular (2007) 023 – NHS Commissioning Guidance. The guidance notably sets out the need for local partners to capitalise on their co-terminosity to better plan and deliver services, achieve the potential gains from pooling funds and sovereignty.
PURPOSE OF THE TASK AND FINISH GROUP
The group will be time limited and take action to devise a local response in terms of the Community Partnership Agreement (CPA) for Caerphilly county borough by 31ST March 2008.
SCOPE
To work in collaboration to strengthen integrated working across primary, community, social care and local authority functions.
FUNCTIONS
To bring agencies together to combine their skills and knowledge to meet the growing complexity of health, social care and well being needs within the county borough in order to
• Improve health and well being • Explore integrated community services • Develop effective approaches that enable the reduction of health inequalities particularly for “seldom heard” or vulnerable citizens such as substance misusers and homeless • Ensure closer alignment across the public sector
The group will consolidate a programme of work that will form a solid platform so that substantial progress can be made from April 2008.
The group will take specific action to: Be informed by and make the appropriate links between coexisting strategies, guidance and policies by:
• Informing and be informed by the developments of the Health, Social Care & Well-being Strategy and Children and Young Peoples Single Plan.
• Be mindful of a variety of influences such as Clinical Futures service design programme and Level 1 progress to date and Community Services Framework. In addition National Service Frameworks and Designed to Improve Health and the Management of Chronic Conditions in Wales in order to meet published standards, so that the problems presented by chronic disease in the community can be anticipated and managed.
Review commissioning arrangements
Together partners will:
• Explore current commissioning and management arrangements.
• Identify areas where commissioning can be done in partnership
• Determine what needs to be done to enable future joint commissioning by defining the necessary steps needed, from April 2008, to make this happen.
Explore Flexibilities
Explore the local potential of ‘Flexibility’ mechanisms and Section 33 agreements by:
• Reviewing current Section 28 Partnership Agreements and Section 31 agreements with a view to identifying which will be appropriate to become Section 33 Agreements.
• Identify the structural changes needed to support the growth of Section 31 Agreements and development needs of organisations.
Community Partnership Agreement
Together the group will work together to:
• Develop the structure of the agreement • Identify appropriate content • Draft the agreement • Consult and engage widely within organisations • Ensure appropriate sign off and authorisation of the document FORM
The group aims to:
Work in partnership, engaging appropriate stakeholders from the voluntary sector, Gwent NHS Trust, CtLHB and CCBC.
Meet regularly, at least once a month. Tasks will be allocated and actions to take place between meetings.
A chair will be appointed at the first meeting. They will ensure:
• That a minute taker attends meetings and produces minutes that clearly highlight actions. These are to be circulated within one week of the meeting taking place and identifying the responsible person and the timescale for completion of the task.
• Consensus and general agreement on proposed actions.
• Inclusion of appropriate agencies and seek to promote active engagement in debate and development of the agreement.
MEMBERSHIP
Members will be:
CCBC Social Services -Assistant Director - Adult Supporting People Manager Housing - Chief housing officer Environment - Health Alliance Education representative Gwent Health Care Trust Locality Manager Local Public Health Team Head of Health Promotion LHB Director of Strategic Planning & Modernisation Head of Strategic Planning & Modernisation Nurse Director Consultant Nurse Community Child Health Voluntary Sector H&SC facilitator H&SC Voluntary sector rep Advisers Finance Partnerships Coordinator Children & Young People’s Framework ACCOUNTABILITY AND AUTHORISATION PROCESS
The task and finish group will act as a sub-group of the Adult Joint Strategic Planning Group (AJSPG). It will report progress to the AJSPG six weekly and provide notes of meetings for circulation.
Local Service Board
Health, Social, Care C & YP FRAMEWORK CMT, & Well Being Partnership Scrutiny, tLHB Board Cabinet
Social Services Adult Joint Strategic tLHB Management DMG Planning Group Team
CPA T&F Group Figure 1.
The Community Partnership Agreement will be authorised through the Partnership decision making process as illustrated in figure 1 above.
REF: / CPA/T of R Agreed 25 October 2007 APPENDIX 2
SCHEMES FUNDED THROUGH JOINT WORKING SPECIAL GRANT
Caerphilly County Borough currently have 8 different schemes funded through the Joint Working Special Grant, and utilising flexibility mechanisms, they are listed in the table below:
Scheme Description Costing Allocated to Scheme Reablement Team Facilitate timely discharge, reducing £110.176 delayed transfers of care from hospital, enabling rehabilitation on a continuum between health and social care, to avoid inappropriate hospital admission. Home Treatment Holistic care, treatment and support £99.016 Team – Mental Health service for older people with mental Older Adults health difficulties, within their own homes. Development of a therapeutic relationship with patient and or family/carers, ensuring continuity of care and the complex clinical presentation of some clients. Early Years Language Early years language and development £108.600 Support and support service within nursery setting to Development support pre-school children’s ability to manage their own behaviour, learn and communicate effectively through a programme of interventions National Children’s To provide a key worker to children, £70.604 Homes Key Working under the age of five, with complex Project disabilities and their families, acting as the point of contact and co-ordinating the services involved in the child’s care. Gwent Education Early and timely identification of speech, £33.028 Language Project language and communication difficulties in children and make recommendations for appropriate specialist intervention. Empowering teachers and parents to meet the needs of children with speech and language difficulties through delivering specialist training. Joint Occupational Integrated Occupational Therapy service £40.000 Therapy for patients with complex needs on discharge from hospital Integrated seamless OT service enabling six week support, post discharge to settle in the community Joint Planning – To enable the interface between £10.000 Standing Conference members of the Caerphilly Standing Co-ordinator (GAVO) Conference Executive, latterly LSB, including public, voluntary and community sector representatives. tLHB Support – To support the work of the HSCWB £166.663 Partnership Unit Partnership, development and implementation of the HSCWB Strategy. APPENDIX 3
PARTNER SIGNATURES TO THE AGREEMENT