CEREDIGION COUNTY
Hywel Dda University Health Board Draft 3 Year Integrated Medium Term Plan 2015/16 – 2017/18
DRAFT Operational Delivery Plan 2015-16 Date: 31st March 2015
HDUHB Operational Delivery Plan 2015-16 - Ceredigion Page 1 Draft and Confidential
CONTENTS:
Chapter Title Page Executive Summary 3
1 Ceredigion Perspective 4
2 Vision 6 Primary Community Acute
3 Demand and Capacity 11
4 Ceredigion Community and 11 Primary Care Operational Delivery Plan 2015-16
5 Shared Challenges across the 16 Three Counties of Hywel Dda
6 Savings Plans 26
HDUHB Operational Delivery Plan 2015-16 - Ceredigion Page 2 Draft and Confidential Executive Summary There is evidence that supports the impact of community services on admission to General Hospitals and provides confidence in the ability of the service to maintain individuals in the community. Recent developments in South Ceredigion have included the commissioning of interim beds for short periods of care providing admission avoidance, together with additions in community and palliative care provision. It is proposed a similar service in North Ceredigion will impact similarly on admissions to Bronglais Hospital.
Critical to patient flow into Bronglais General Hospital is the activity associated with patient flow from Gwynedd and Powys. There is a requirement for further scoping and introduction of initiatives to further impact on improving patient flow.
Transformation will require a clearly articulated vision, shared with partners and stakeholders. Without service transformation there is limited ability to release cash savings / cost avoidance as a part of a wholesale strategic realignment of service priorities. Care Closer to Home will mean some services moving from hospital to community where it is safe to do so, delivering care in this way will support our most vulnerable, frail and elderly and those with chronic or long term debilitating conditions to remain in the community in their own homes. This approach will allow our hospital services to concentrate on delivering planned and emergency care with adequate resources and capacity to do this well. Our services will be better able to achieve and deliver tier 1 targets and ensure that our complex health care systems can work effectively.
Capital developments in Cardigan, Tregaron (Cylch Caron) and Aberaeron are identified which will support the introduction of increased services in local communities and allow additional clinics, diagnostics and treatments to take place supported by Acute Clinicians.
Primary care will become central to the development of multidisciplinary teams providing increased support to patients in the community therefore preventing admissions wherever possible. Local Authority services will become integrated within these Community Resource Teams.
HDUHB Operational Delivery Plan 2015-16 - Ceredigion Page 3 Draft and Confidential
1. Ceredigion Perspective
The Ceredigion Operational Delivery Plan builds on the core values and strategic direction contained within the Integrated Medium Term Plan (IMTP), the Foundations for Change (F4C) Programme and the Single Integrated Plan for Ceredigion co-produced with our partners will inform the strategic and Public Health priorities.
To address health inequalities and life expectancy the following priority areas have been identified through the Foundations for Change Programme (F4C):
Alcohol – Reduce alcohol related health and social issues Appropriate Place of Care – Enabling patients to receive appropriate and safe care close to home Dying in place of choice – To increase the number of patients who have considered where they want to die Immunisations and Vaccinations – To achieve all the immunisation and vaccination targets: 50-75% uptake rates for season flu vaccine varying between different at risk groups and staff as detailed annually in the CMO guidance Health Inequalities – The differences in health outcomes between a higher rate of disease incidence in the more deprived areas compared to other areas. Concentrate on differences that are avoidable (inequities) Life expectancy (Healthy Life Expectancy) The number of years that a person can expect to live (a healthy life), on average, in a given population Stroke – Improve the outcomes for patients following a stroke.
Ceredigion is one of the largest counties in Wales geographically, covering nearly 1,800sq kilometres. The 76,000 population is concentrated along the cost, with Aberystwyth accommodating around 18- 20,000 people. The County is sparsely populated and is defined as a rural area and it has an ageing population. The six main towns (Aberaeron, Aberystwyth, Cardigan, Lampeter, Llandysul and Tregaron) all offer secondary education, employment, housing and retail opportunities.
Across the county there are 14 GP Practices and core GP services operate 8am to 6.30pm between Monday and Friday, with Out of Hours services operating at all other times. The Community Nursing service operates 7 days per week from 8am to 6pm. The Acute Response community nursing service operates 7 days per week, 24 hours cover.
There are 23 Community Pharmacy outlets and their core hours are from 0900-1800, with services available in the evenings and at weekends in some locations.
Clinical Nurse Specialists / Advanced Nurse and Advanced Therapy Practitioners are employed in numerous roles, supporting chronic condition management across the pathway of care.
Joint initiatives are in operation across each of the localities providing, long term care, palliative care, continuing health care, joint Service Level Agreements (SLAs).
HDUHB Operational Delivery Plan 2015-16 - Ceredigion Page 4 Draft and Confidential Therapists provide assessment, advice and interventions within all community environments and work across the interface of hospital and home.
Dental, optometry, podiatry and the joint equipment store are available to support the needs of service users in the community.
Telehealth and Telecare developments continue to provide an infrastructure supporting care in the community, together with self-care management and ‘Expert’ service user programmes.
Joint Care Beds are jointly commissioned with the Local Authority and are available across Ceredigion in Local Authority residential homes.
Workforce
Within Ceredigion there are integrated Locality Managers with joint responsibility for Health and Social care supporting the Community Resource Teams.
Future workforce plans are based on the following assumptions:
Core service growth of 10% in clinical staff has been factored in to take account of future demographic projections; Details are included for the staffing implications of proposed service developments; Further detailed information around service change is contained in the Ceredigion Workforce Plan and supporting PIDs.
Estates
There is one District General Hospital in Ceredigion, Bronglais General Hospital, community hospitals/resource centres in Tregaron, Aberaeron and Cardigan and in addition there is a range of beds in the community across Ceredigion providing care closer to home. Flow from South Ceredigion for acute inpatient care is delivered in Glangwili and Withybush General Hospitals. In addition Ceredigion also works in partnership with the four Local Authorities of Pembrokeshire, Carmarthenshire, Powys and Gwynedd. Community services are provided from a range of GP Surgeries, Health Centres and Clinics. A previous business case was developed for the replacement of Aberaeron Hospital. This has not progressed to the capital programme. The current condition of Aberaeron Hospital is such that alternative provision will be necessary in the near future. An SBAR outlining potential alternatives has been developed for the delivery of services for Aberaeron. It is anticipated that services will continue to be provided locally.
IM&T
The sharing of information within health and across health and social care is paramount. A number of initiatives are in progress nationally including the development of a community information system to promote mobile working and information sharing for the Community Resource Teams. The introduction of an integrated assessment in April 2015 will assist in information sharing and governance.
HDUHB Operational Delivery Plan 2015-16 - Ceredigion Page 5 Draft and Confidential 2. VISION FOR PRIMARY, COMMUNITY AND ACUTE CARE
2.1 What do we mean by Care Closer to Home? We are clear about the need for change in how we deliver services, particularly the need for increased integration in health and social care, placing the individual at the centre with care services becoming increasingly accessible in local areas. To this end, our core aims are:
To ensure patients and their families receive community services that are safe and of the highest quality and provide the best experience and outcomes as cost effectively and as locally as possible. As part of prudent healthcare, we want to develop community services which encourage a culture of self management whilst helping and supporting people to optimise and maintain their own health, well-being and independence. To work with our population, our partners and our staff to deliver care that is responsive to local needs and addresses inequalities. The overall strategy within the acute setting is to ensure patients’ needs are met in the most efficient and effective way through clinical pathway redesign spanning from Primary Care through the Acute Setting and effective timely discharge.
Our intention is to achieve a plan for service transformation which results in a significant shift in the way services are provided across hospitals and the community, with some provision moving from hospitals to the community where safe and effective to do so. Delivering care in this way will support Care Closer to Home for our frail and elderly population, whilst allowing our hospitals to concentrate on what they do best – providing both planned and emergency care when it is needed.
2.2 Primary Care and Community Services In planning to deliver Care Closer to Home, the County will need to better manage the significant pressure on healthcare provision due to the increased prevalence of chronic conditions and level of frailty. Care Closer to Home will place Primary Care Teams at the centre of the care provider network. The delivery of community services are increasingly focused through enhanced CRTs and these provide a multidisciplinary approach to the management of patients in the community. CRTs objectives are to prevent unnecessary attendance at hospital through recognition and early identification of acute illness which can be managed in the community avoiding the consequent potential for admission to hospital. Complementary to the CRTs will be the development of enhanced facilitated discharge services, which will similarly provide a team approach to discharge facilitation. The CRT and discharge liaison will improve patient flow through the health and social care system.
The Health Board emphasis on providing Care Closer to Home can only be achieved through ensuring that we have robust sustainable community services which include Primary Care Services. Care Closer to Home will be based on the following operational principles:
Each Locality will include a partnership of health, local authority, third sector, independent sector and local mainstream services that deliver an individual service to care and meet the needs of people who are likely to benefit from an integrated approach. These are based around:
Prevention Anticipatory care Enhanced preparation for scheduled care Rapid community response to provide unscheduled care; Rehabilitation & enablement including supporting early discharge; Long term conditions management;
HDUHB Operational Delivery Plan 2015-16 - Ceredigion Page 6 Draft and Confidential Palliative and end of life care; and Long term care (including continuing healthcare).
To build on our existing seven localities to ensure each has a strong and sustainable workforce which is actively enabled to develop holistic and specialist skills to deliver care focused on the local priorities and needs.
Within the context of the CRTs, GPs will undertake a co-ordination and care planning role for people who are at greatest risk of deteriorating and losing independence. GPs will be supported by the Community Resource Team which includes a range of professions by working collectively to deliver integrated care. This will include effective transfer of care for those admitted to hospital and/or residential care and facilitating return to their own home wherever possible.
Clinical intelligence held by GPs in relation to the local population will be used to assist risk stratification for a locality in order to target community resource appropriately, which will be undertaken by effective commissioning at a local level.
Each Community Pharmacy will offer a range of over the counter and consultation based advice to support self care for the community as well as lifestyle and chronic disease monitoring advice. Pharmacies will be part of a broader network accessing additional integrated community team support when they identify the early signs of patient deterioration.
Local community facilities will provide a base from which integrated services will operate and provide information and access to services supporting self management, health promotion and increasing community resilience. It is envisaged that community facilities will also work as a network across the Health Board to provide an increasing number of specialist services.
There will be access to beds within a range of community settings for people who need 24 /7 care but not requiring the level of care provided within an acute hospital setting, or those not able to be safely managed within their own home. These will either be directly provided or commissioned with a range of partners including the independents or third sectors. These services will provide: Rehabilitation during a period of intermediate care between acute hospital and home e.g. post operative trauma or rehabilitation after acute medical episode (usually < 30 days); Clinical care and observation supported by specific diagnostic services and social care during short period of illness or acute functional decline (usually <72hrs); Convalescence where care is required and active rehabilitation is limited by condition; Palliative care where appropriate and according to individual choice and circumstances; Respite care to support the carer and the patient; Assessment beds to determine the future care needs of the patient.
Specialist care will increasingly be available within the CRT model and include access to a range of specialist services including specialist rehabilitation, specialist nurses/therapists, low vision, community mental health, specialist palliative care, drug and alcohol services, and learning disability services. This will enable the model to work effectively by delivering care closer to people’s homes.
Primary and Community services will support our acute hospital services by providing as much care locally as is appropriate and safe to do so. Services will: Reflect the needs of the local population; Support local communities, linking closely with community teams and providing as a hub for wider community based activity;
HDUHB Operational Delivery Plan 2015-16 - Ceredigion Page 7 Draft and Confidential Work together as a network of facilities with provision of specialist community services across our population Support effective and timely transfer from acute hospitals. The CRTs will provide home based rehabilitation, or supportive care to enable a return to optimal independence, with reductions in inpatient length of stay avoiding delayed transfer of care; Deliver integrated ‘twilight’ services providing responsive transport home from hospital and commissioned support services to assist discharge; Provide a range of services from the Third Sector that will enable individuals to maintain their independence and improve their quality of life; Utilise Care and Repair services to speed up minor adaptations and provide practical support services to maintain people in their homes; Extend Telecare support – Hywel Dda has been engaged for a number of years in piloting the use of new technologies, such as Telehealth and telemedicine initiatives. This will support care within rural areas recognising particular areas of interest and taking into account the demography, geography, and health needs of our older population; Increase equipment provision to support people in their homes, to assist manual handling and care needs including bariatric and other specialist equipment.
In addition, by strengthening our frailty models, multi-disciplinary teams (MDT) including partner organisations, will provide local, comprehensive assessment and diagnostics services for frail and elderly patients. These include: Services for elderly patients requiring stabilisation or treatment including access to medical and surgical day units; Packages of planned inpatient rehabilitation care, supporting vulnerable adults in effective recovery and reablement, including improving therapy input; A greater range of outpatient services, with supporting diagnostic services to help clinicians make quicker diagnoses; Improving psychological care for patients with chronic conditions; Appropriate and timely access to Mental Health and Learning Disability services; Palliative and End of Life Care services.
2.3 Acute Services
The acute services in the Health Board working with the County Commissioners are working through a plan to deliver care as close to home as possible.
HDUHB Operational Delivery Plan 2015-16 - Ceredigion Page 8 Draft and Confidential The overall strategy within the Acute setting is to ensure patients’ needs are met in the most efficient and effective way.
Efficiencies will be gained in this approach however it is extremely important to remember that alongside the monetary savings there are numerous gains on quality and prevention of hospital acquired disease.
Whilst the above strategy will deliver the direction of travel for acute services the elements making up the journey are those of efficiency and service improvement
Acute Services Reform Programme
Acute Services Reform Programme
CURRENT STATE OPPORTUNITIES FUTURE STATE Underpinned by patients, staff, commissioners & other stakeholders
Sustainability
Outpatients Emergency Inpatients Discharge Planning • Consultant led assessment process • Outpatients efficiency •Designed Patient pathways Consultant job planning •Speciality wards •Internal discharge workstreams • Improved booking •Consultant On call rotas •Weekend discharge project •Prescribing •Emergency Clinics •Inter agency workshops •Outreach services •Daily Board rounds •Ward coordinators •New to FU ratios Key Performance Indicators •Weekend plans(every patient) •TIA Direct access •Discharge lounge usage?? •Palpitation pathway • LOS •nursing documentation?? •MSK pathway •Nos in Emergency clinics •24hr discharge summary to GP •Long term condition pathways • Ward transfers •TTOs •Advice and Guidance •Increased patient/carers awareness l Elective Inpatients •EDD usage embedded and shared •Improved theatre utilisation •Improved therapies input •Clinical Pathways Key Performance Indicators Key Performance Indicators •Improved Pre op Assessment • Bed Capacity management • LOS Key Performance Indicators •RTT weeks •Reduced discharge time/ward •Clinic utilisation • Theatre utilisation •Increased weekend discharge •DNA rate •Audit pathway adherence •Audit of weekend plans •New to FU ratio • LOS •Nos through discharge lounge •ROTT Rate • Bed numbers •Reduced number of delays Stabilize-Optimize-Transform-Sustain
Unscheduled Care
In order to have a sustainable improvement to the Tier 1 targets relating to the Emergency and Urgent Care departments work needs to be focussed on timely discharges and also admission prevention. This will facilitate the patient flow teams and ensure that we have the ‘Right Patients in the Right Bed at the Right Time’.
There are several workstreams that need to be undertaken in parallel to ensure that the work list of patients currently remaining in an acute bed whilst the next step is facilitated and will be managed more effectively and the number of patients on each of the 4 work lists is reduced. Improving the patient flow will then ensure that the 4 hour performance target achieves 95% on every day of the week and that ambulance off load delays over 60 minutes and 12 hour breaches are a thing of the past except for exceptional circumstances.
HDUHB Operational Delivery Plan 2015-16 - Ceredigion Page 9 Draft and Confidential
The work will be focussed in the following areas:
Patient Flow / Discharge Support 12 hour discharge lounge with bed spaces on all 4 sites Monday to Friday – currently the discharge lounge provision varies markedly on each site, dedicated space will need to be identified on some sites and investments in band 5 and band 2 staffing. This will facilitate discharges before 10am and facilitate quicker turnaround of acute beds being made available to patients requiring admission Daily multidisciplinary board rounds of all patients on all acute inpatient areas – to ensure that all patients have a care and discharge plan agreed by the multidisciplinary team involved in providing care which is reviewed daily by the team to ensure and drive progress towards achieving the agreed goal and outcome Dedicated therapies support for each ward on all 4 sites – this forms a key step in the discharge process in terms of providing Occupational Therapy and Physiotherapy continuous contribution to discharge planning as well as functional improvement immediately following admission Transfer / Deep Cleaning Teams – teams to be attached to each discharge lounge, managed by the bed management teams to facilitate pulling of patients to the discharge lounges, transfer of patients from the Emergency Departments towards or diagnostic departments, undertaking deep clean of ward beds to ensure timely admissions. This would need investment of band 2 staff Centralised flow control room – provide a centralised control room to oversee Myrddin waits, identify potential blockages within the flow system, potential ambulance of load delays, management diverts between the 4 sites. This would be an early warning system to avoid breaches and delays. This would need investment in equipment and infrastructure and also band 4 staff to run the control room 24/7 Dedicated Complex Discharge Area – providing a dedicated area run on reduced staffing levels and with input from community, therapy and social care teams to provide a step down area from the acute hospital beds, ideally if this could be co-located with the dedicated discharge this would enable timely and efficient discharges of patients who currently remain in acute inpatient beds across all the wards on the 4 sites Roll out of Community Support Teams on all 4 sites – following a successful introduction of the Community Support Team model in Prince Philip Hospital investment will be needed to rollout the model on a 7 day basis across all 4 sites Reconfiguration of Beds – in line with the agreed nursing staffing levels of the Health Board, the beds need to be reviewed and reconfigured to ensure that the inpatient beds are aligned in the most efficient manner to the demand and the staffing levels for each ward area. This will not provide additional bed numbers but would assure that the type of bed is correct ensuring that the patient can be placed in the right bed initially, thus reducing bed movements.
Admission Prevention Senior Consultant presence at the front door – work to be undertaken to look at a revised model for front door assessment to avoid inappropriate admissions Front Door Frailty Assessment – to provide an efficient and consistent frailty assessment that can be utilised across both Health & Social Care, this would be available on attendance to Emergency Departments to enable any change in circumstances to be quickly identified and enable the patient to be referred on in a timely manner if necessary
HDUHB Operational Delivery Plan 2015-16 - Ceredigion Page 10 Draft and Confidential 7 Day Diagnostics and Therapy Input – to ensure consistent delivery of CT, Ultrasound, general X-Ray, Therapy and Pharmacy across all days and avoid inappropriate weekend admissions due to lack of diagnostic or therapies input The acute service must ensure that patient needs are met in the most efficient and effective way possible and intends to achieve this through a comprehensive change and service improvement programme to ensure delivery of the Tier 1 targets. The priorities are: Full bed stock review and reconfiguration Confirmation of nursing establishment numbers Robust mechanisms to facilitate patient flow pathways Maximum theatre productivity and efficiencies Development of competent and cohesive clinical teams Comprehensive understanding implementation of evidence based clinical pathways
Tier 1 Targets The costs of the initiatives in acute and community services are associated with the achievement of the Tier 1 targets and Acute PID. The achievement of key Tier 1 targets are profiled in the main body of the IMTP report.
3. DEMAND AND CAPACITY
The acute services in Bronglais General Hospital will manage its elective and emergency demand through the following 12 month plan. From April until November 2015 the RTT will be delivered through the use of their Surgical Beds with a complete cessation of the outlier medical patients in surgical beds. Therefore the medical services will contain its demand within its designated beds through the opportunities created through the county PIDs and improved efficiencies in Patient Flow. From December until March 2015, elective activity will be reduced to urgent, cancer and daycase activity only. The beds released as a result of this will be made available for emergency activity.
4. CEREDIGION COMMUNITY AND PRIMARY CARE OPERATIONAL DELIVERY PLAN (2015/16) This section identifies the issues that will directly affect service delivery within Ceredigion in the first year of implementation of the IMTP. The north and south Localities of Ceredigion are aligned to the north and south GP Clusters. Monthly meetings are held within each Cluster to discuss the development of healthcare services within Ceredigion. Each Cluster has developed the following specific priorities within their Practice population:
North Ceredigion Cluster Priorities Heart Failure Diabetes Influenza Vaccinations Cancer End of Life MSK Rheumatology Leg Ulcers Sustainability
HDUHB Operational Delivery Plan 2015-16 - Ceredigion Page 11 Draft and Confidential South Ceredigion Cluster Priorities Increase in uptake of flu immunisation Improve Access – managing demand Recruitment marketing campaign to attract GPs to the area Strengthen the role and the use of the Welsh language in primary care as recommended by Welsh Government. Complex Care in the Community Psychological interventions OOH and improvement of hand over of care Urgent suspected cancer referrals feedback from secondary care National Priority Reviews – Polypharmacy; End of Life Care Retrospective Review; Early Diagnosis of Cancer.
The Cluster populations are as follows: North Locality South Locality Borth Surgery Ashleigh Surgery Llanilar Surgery Cardigan Health Centre Padarn Surgery Brynmeddyg Surgery Tregaron Surgery New Quay Surgery Church Surgery Meddygfa Emlyn Tanyfron Surgery Lampeter Surgery Ystwyth Surgery Llynyfran Surgery Meddyfa Teifi Total: 48,044 Total: 48,246
The sustainability of GP Practices is an area of concern nationally and is reflected within the local context, which is compounded by the rural nature of the county. Integrated primary care and community health and social care services support acute hospital services by providing as much care locally, preventing unnecessary admission and facilitating early, safe discharge.
Integrated Working Model
Single Point of Access (Underpinned with management, governance and process
GP Group A GP Group B GP Group C GP Group D
Within each cluster area there will be: • Rota for visits – efficiency; • Multidisciplinary working with teams • Shared job descriptions for generic support emphasising on: workers; • Discharge from emergency beds; • Night cover; • Short term interventions; • Commissioning, examples include: • Short term complex patients; • Marie Curie; • Longer term care planning; • Befriending; • Care co-ordination; • Self management support.
HDUHB Operational Delivery Plan 2015-16 - Ceredigion Page 12 Draft and Confidential
Vision – Community There are two localities North and South of the County which are coterminous with Local Authority boundaries. The Community Resource Team service model provides support to a collection of GP Practices in discrete ‘Neighbourhoods’ within each Cluster. This will enable the allocation of an integrated workforce responsive to clinical demand and providing a single point of access to the multi disciplinary team.
Following the restructuring of Social Care Community Services using the Intermediate Care Fund, the short term team has become operational since October 2014. Activity attached. This will allow for the integration of Health and Social Care teams to develop the Community Resource Teams in the North and South Ceredigion Localities.
A working Group has been established across health and social care to provide the operational detail to implement the Community Resource Teams. This Group will provide specific detail relating to the process of implementation, including the following:
Referral Single point of access Allocation Care coordination Multi-disciplinary Team Meetings Assessment process Documentation Care Plans Key performance indicators
The Welsh Government document supporting the introduction of care management and care planning will be implemented: ‘Framework for agreeing care with individuals who have long term conditions’.
Existing community teams across all sectors will work together in order to form the Community Resource Team (CRT). The CRT will provide a method of organising services within Ceredigion aligned to the clusters, North and South. The services will be provided and coordinated across organisations and commissioned when required, allowing the specific needs of the individual to be met.
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Our capital developments include the development of Integrated Resource Centres in Cardigan and Tregaron. Both projects are awaiting Outline Business Case approval. These schemes demonstrate integrated planning in partnerships between Ceredigion County Council, Primary Care, the Health Board and Housing Associations.
Patient Flow Investment in community services in Ceredigion will demonstrate a shift of health care from hospitals to settings closer to home and from reactive care to prevention and proactive models based on early intervention.
The main steps identified are to: Reduce the complexity of services Wrap services around Primary Care Establish multi disciplinary teams for those with complex needs including social care, mental health and other services. Support from specialist medical input including Consultant services. Create services that offer alternatives to hospital. Develop capability to engage and create sustainable communities. This approach requires locality based teams that are arranged around Primary Care and natural geographies, providing access to 24/7 services as standard, and complemented by flexible and responsive Health and Social Care.
Patient flow meetings have been established within Bronglais General Hospital including Health and Social Care staff and the Third Sector.
This process has identified some training issues within the hospital: Timeliness of Multi-Disciplinary Team meetings Timeliness of completing Decision Support Tools (DSTs) Understanding of community services and skills
HDUHB Operational Delivery Plan 2015-16 - Ceredigion Page 14 Draft and Confidential Access to therapies Identified Expected Date of Discharge Palliative care is predominantly being provided in the Community using a range of core and Commissioned services. There is a timely response to those in Hospital who wish to die at home A review of patients admitted through A&E has highlighted a range of issues, particularly the need for leadership, increased support within the community for those with chronic conditions, sometimes resulting in admission with sepsis, falls, dehydration etc. There is also a need for improved transport arrangements and seven day services to assist in arranging community services at weekends The leg clinic provides an opportunity for the safe and efficient treatment of leg ulcers etc. This has been piloted in Cardigan and is currently being evaluated. This arrangement has been extended across Ceredigion Training is underway for the succession planning of nurses to provide treatment within the Minor Injuries Unit in Cardigan. This is a nurse led service which we anticipate extending to 7 days It is anticipated that in preparation for the Cylch Caron development, staff from Tregaron hospital will undertake training in community service provision from March 2015. This will coincide with the phased reduction of beds within the hospital Seven day services are required to facilitate discharges and prevent unnecessary delays. The patient flow is particularly complicated by access from Powys and Gwynedd; this will be considered within the Mid Wales Study; and also in the south of the county, with patient flow to Glangwili and Withybush Hospitals.
There is a significant patient flow to Bronglais from Powys and Gwynedd and there is difficulty in discharging patients when medically fit. During the period October 2014 to January 2015 there were 132 bed days lost due to delays in discharging medically for patients back to Gwynedd, which equates to 1.13 beds; and 128 bed days lost for Powys patients, which equates to 1.09 bed days (2.22 beds in total). This is a risk to the delivery of services at Bronglais.
County Plans and Actions
The following developments are in progress to support the implementation of Community Resource Teams.
Community Services The Intermediate Care Fund (ICF) has provided an opportunity for social care to restructure domiciliary care providing a “short term care team” which will form the social care input within the CRT The closure of inpatient beds in Cardigan has led to the implementation of an enhanced community nursing service within the south locality. Evidence is available which identifies the activity associated with this team, including admission prevention, timely discharge, palliative care and support to district nursing activities Interim beds have been commissioned which provide access for six weeks for assessment, treatment, rehabilitation or palliative care. Evidence is available which identifies the activity associated with the use of Interim beds. The anticipated growth has been reflected within the plan. Alternative placements are also provided in Ceredigion Local Authority residential homes with the commissioning of 10 Joint Care beds which are supported by therapists and the Community Nursing teams
HDUHB Operational Delivery Plan 2015-16 - Ceredigion Page 15 Draft and Confidential Discussions with GP’s in cluster meetings have led to specific pilots for multi disciplinary team development, with Newcastle Emlyn practice commencing in April 2015. A detailed plan is established to take this forward A voluntary sector development to support patients on discharge from hospital will be introduced There is currently increased outpatient activity within the Community. It is anticipated with the development of the new resource centres additional activity and new clinics will be provided Resources have been reassigned to provide specialist nurse support within the CRT model These are identified as a cost pressure, requiring back fill for nurses within the core team Third Sector Brokers contribute to MDT meetings within the hospital and community, raising awareness of 3rd Sector Services instigating referrals, signposting to services, identifying gaps in provision and informing commissioning All Memorandums of Understanding and Service Level agreements are being reviewed. This includes the revenue associated with the reablement service. This will allow changes to the way therapy services will be delivered in the Community With the increase in community service delivery, including palliative care, equipment requirements have increased. The anticipated increase in equipment is identified within the plan.
5. SHARED CHALLENGES ACROSS THE THREE COUNTIES OF HYWEL DDA The key shared challenges across the three Counties in relation to the delivery of care are described in further detail below:
Primary Care Cluster Plans A key community development within the Health Board is the establishment of the of 7 GP clusters which are co-terminus with the 7 localities and provide a multidisciplinary forum for identifying the clinical priorities within each cluster.
The locality team will discuss future developments and plans within cluster meetings and respond to the specific challenges and issues identified by practices.
Multidisciplinary MDT arrangements will be developed within discreet collectives of practice populations, providing particular support in addressing the specific clinical priorities and implementing the model of care within that area.
Care coordination and care planning will be introduced within MDT meetings, including the range of professions, disciplines and organisations which will contribute to the care of individuals with chronic conditions, vulnerable and complex presentations and those with mental illness including dementia.
Recruitment options and new ways of working will be considered in order to improve the sustainability of Primary Care services. The introduction of Advanced Practitioners, specialist Nurses ad multidisciplinary teams will support General Practitioners in delivering care closer to home.
Ideas developed within cluster arrangements to reduce admissions to hospital and assist the early discharge of patients will be implemented, supported by community staff.
HDUHB Operational Delivery Plan 2015-16 - Ceredigion Page 16 Draft and Confidential The implementation of standardised systems across Primary Care will assist in risk stratification and assist in the needs analysis within each practice, informing the community team in respect of caseload management.
Welsh Audit Office Review of District Nursing The Welsh Audit Office (WAO) review of District Nursing was conducted between March and August 2014 across the three counties of Hywel Dda University Health Board. Audit activities such as team surveys; individual workload diary reviews; review of referral process; caseload reviews and a Health Board Survey were included.
The Welsh Audit Office report was shared with the Health Board at varying team meetings following its collation and prior to the dissemination of the report. Health Board comments were invited and received by the Welsh Audit Office.
The final WAO report was received in December 2014. The report covers the three counties audit and highlights that several areas within District Nursing must be addressed. The Community and Primary Nurse Managers across the three counties are working together, to identify the required actions discussed within the report. This work will support the development of a clear District Nursing Specification and Policy; a review of the referral and caseload management issues; whilst ensuring that the District Nurse Team reflects the needs of the local communities. The continuous revision and updating of the education needs of our community staff is paramount to the development of community nursing, thus promoting performance and quality for the patients of Hywel Dda University Health Board.
The three County Directors and Commissioners are working together to ensure the full implementation of the recommendation of the audit report; this will be undertaken in year one.
Chronic Conditions To support the development of Care Closer to home and the multidisciplinary approach to the Community Resource Team, we need to develop layers of care for people with chronic/long term conditions enabling people to self manage their condition where ever possible and be supported through care closer to home when an exacerbation or crisis occurs preventing the need for a hospital admission. The specialist services will need to interface with people with chronic/ long term conditions the wider community including third sector as well as all primary, community and secondary resources, enabling the care pathway to become an end to end service. This includes services such as the ART team, palliative services, community nursing team, MAST and rapid response domiciliary care out of hours service, linking to secondary care when necessary. A more integrated approach will provide a comprehensive service.
The Health Board is focussing on a basket of eight chronic conditions: Alzheimer’s, Atrial fibrillation, Cardiovascular, CVA, Diabetes, Musculoskeletal, Neurological, Respiratory. We should be targeting at least 10% of our population that has a long term condition every year and providing them with a self management programme. If all people with a long term conditions had a self management programme on diagnosis this should delay the deterioration of the condition therefore reducing the need for health intervention
Four levels of care are identified to improve chronic conditions management and the areas we have the potential to make the improvements are:-
Level 2: Population management: ‘Practice based’ CCM Programme includes targeted information, monitoring and proactive management, referral to self management programmes and voluntary
HDUHB Operational Delivery Plan 2015-16 - Ceredigion Page 17 Draft and Confidential sector services, Secondary prevention to ensure complications are prevented, slow down deterioration and help avoid further chronic conditions arising; Level 3: High Risk Management: ‘Network based’ CCM services includes services provided at “network” level for patients at high risk, depending on locally developed plans may be provided in community-based facilities, hospitals, other health centres / clinics, or in individual GP practices on behalf of the network. Referral to specialist services to help manage their condition at home, patient held management plans and engagement and support of carers.
Life expectancy across the Health Board is increasing – with potential for these additional years of life to be spent in less favourable health or in prolonged periods of poor health and dependence. Increase in age related chronic conditions such as circulatory and respiratory diseases and cancers.
Population shift is prevalent with older people now making up a larger proportion of the population.
Through proactive management the ambition is to: Reduce the number of emergency hospital admissions for the basket of eight chronic condition. Reduce the number of emergency hospital re-admissions for the basket of eight chronic conditions. Improve quality of life outcomes. Improve access to self management programmes to ensure at least 10% of people with chronic conditions attend a programme annually.
Improving Access to Psychological Therapies Improved self management, change of health behaviour and treatment of psychological difficulties is necessary for sustainable health services. Increasing psychological skills in the existing workforce is necessary to improve psychological wellbeing in chronic conditions and enhanced self management.
The co- morbidities of psychological difficulties in chronic conditions leads to a 45% increase in healthcare costs. The increasing aging population, increase in the levels of obesity and chronic conditions will lead to a continued pressure on health services, increased hospital admissions and an exacerbation of physical and psychological symptoms. A third of adults report having at least one chronic condition. Two thirds of over 65 years of age report having one condition. A third of these have multiple chronic conditions
Reducing depression and anxiety within chronic conditions will produce efficiency savings whilst improving skills across the health service leading to an improved approach and culture within the organisation.
Palliative Care Specialist Palliative Care is defined by being a Consultant Led service. Within the Health Board Welsh Government funding has facilitated a Consultant expansion programme and vacant posts are currently being advertised. The Specialist Service includes Macmillan Specialist Nurses, Physiotherapy, Occupational Therapy, Psychological Therapy and Bereavement Services. The wider Primary Care and Community Nursing Service provide the core service provision for Palliative Care and End of Life Care.
HDUHB Operational Delivery Plan 2015-16 - Ceredigion Page 18 Draft and Confidential Leg Clinics An estimated 0.1% of the British population suffers with debilitating chronic leg ulcers. The prevalence of leg ulceration increases with age and can be as many as 20 in every 5 people over the age of 80. The cost of leg ulceration is high, both financially and in terms of quality of life for the patient. The cost to the NHS estimated to be £300-£600 million per year. Research has shown that is possible to heal up to 83% of venous leg ulcers.
Currently across Hywel Dda there is evidence of mixed service of delivering care across the region to people with leg ulcers. A scoping exercise was undertaken in 2009 and 2012 to clarify who provided leg ulcer management for mobile patients across Hywel Dda Health Board. The report confirmed that there was evidence of mixed service delivery across the region, with the majority of Practice Nurses providing leg ulcer management, but that it was also delivered by District Nurses with some Practices providing a joint service.
The report highlighted issues such as responsibility for the patient, nursing skills and patent experience and outcomes. All need to be urgently addressed due to the recent withdrawal of some GP’s from providing the service.
Following the scoping exercise a Task and Finish Group was established to look at a way forward of delivering the service. The group comprised of representation from vascular, dermatology, nursing, medicines management services, the LMC and patient representation. Four options for delivering the service were reviewed – Status Quo; Local Enhanced Service; Lindsey Leg Club; Leg Ulcer Clinics.
The Task and Finish Group recommended the adoption of Leg Ulcer Clinics as the preferred service model. Pilots have been established in some areas across Hywel Dda; however, before full roll out the following factors need to be considered before the service is fully implemented: Number and location of clinics; Venue requirements; Staffing requirements – impact on Community Nursing Services; Scope of the clinic; Competencies including education and training; Evaluation methodology.
Phlebotomy Currently within Hywel Dda, the Phlebotomy service is delivered within a variety of settings including primary, secondary care premises and the patients’ homes. A recent scoping exercise carried out across the 55 GP Surgeries in Hywel Dda identified that the service is inconsistent and inequitable. Some patients are able to receive phlebotomy services within their own GP practices, nearer to their homes whilst some are directed to their local general hospital which could be some miles from where they live. The findings identified that currently there is a two tier system with significant variation in services to patients across the three Counties.
Within Primary Care there are significant differences in what Practices feel they are funded for within the global sum. This significant challenge is due mainly to historical payment streams which were then carried on into MPIG. The inequity has resulted in several GP Practices across Hywel Dda withdrawing from undertaking secondary care generated ‘bloods’. The LMC have acknowledged that the service provision of phlebotomy services is inconsistent and inequitable across the Health Board.
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A model of service delivery needs to be developed for phlebotomy services across Hywel Dda that will ensure consistency and equity of service provision.
Proposed service delivery options for discussion are as follows: 1. Do nothing and keep the inconsistencies; 2. Transfer the savings from secondary care vacancies into primary care to provide additional support; 3. Fund all GP Practices for taking on additional work from secondary care like OPD tests – which may reduce the staffing levels in secondary care further and release funding; 4. Whole-scale shift some phlebotomy services into primary care to deliver the secondary care elements; 5. Tender out to alternative providers like Community Pharmacies to provide phlebotomy services across the Health Board.
These options can be considered in isolation or as a mixed model.
Medicines Management The support and involvement of the medicines management team is essential when new services and new initiatives are being planned. This will involve the medicines management team across secondary and primary care.
Future initiatives will involve the development of a flexible workforce to meet the change in service provision and patients’ needs. This will include 7 day working.
Domiciliary Care Workers and Medicines Administration There is an issue across Wales (and the UK) in relation to medicines administration with the potential for different policies to be introduced across Hywel Dda.
There are a number of key risks and issues that require attention in order to ensure consistent approaches and competency in administration across domiciliary care workers from commissioned services.
A review of the governance in respect of medication administration is required and a training framework introduced across Hywel Dda.
It is suggested that medicines are supplied in original packs with the use of a medication administration record sheet (MAR) in line with current best practice.
This lack of consistent approach leaves both patients and domiciliary care workers exposed to potential risk of harm. It also raises concerns in the legal position of both health and social services in the event of a serious incident relating to medication administration. A well trained workforce of domiciliary care workers will reduce the need for District Nurses to administer medicine within the community, releasing them to undertake more complex/urgent interventions.
It is recommended that additional staffing will be required within medicines management teams to provide accredited training to domiciliary care workers.
HDUHB Operational Delivery Plan 2015-16 - Ceredigion Page 20 Draft and Confidential NHS Wales Ambulance Services Trust (WAST) Paramedic Pathfinder – Developments and Opportunities The Health Board has collaborated with WAST to implement 3 Care Pathways. These Pathways support WAST paramedics to see and treat –patients with resolved hypoglycaemic episodes, resolved epileptic seizure and non-injury fallers. There is an opportunity to collaborate on a further pathway and the Counties will be working closely with WAST to develop a Community Care Pathway. This pathway has been developed in North Wales between BCUHB and WAST. Adopting and implementing this pathway will support Paramedics at scene to access local health and social care services for patients they have clinically assessed and find to be clinically suitable for community based management. Examples of this might be for the paramedic to access emergency care packages, step up residential facilities or mobilise third sector support. This approach to keeping patients in the community when it is appropriate to do so, if we get it right, will reduce the demand on emergency departments and inpatient beds.
The other area of development is the introduction of Individual (Community) Care Plans, this is a plan developed and supported by GPs and shared in advance with WAST. These plans will be developed for patients identified as being as high risk of 999 calls. This approach would be suitable for patients in nursing and residential homes, those with severe COPD, palliative care and end stage dementia. The current situation is that if an ambulance is called to a nursing or residential home and a patient is unwell, the paramedics aren’t allowed to do anything other than convey the patient to a hospital emergency department. With an ICP it can be specified that the appropriate ceiling of care is for the patient to remain in the care home and be reviewed by the primary care team, this approach would benefit those patient who we often see admitted to hospital at the end of their life or for those with advanced dementia who could be managed in community by the ART teams, community nurses and the GP.
Patient Flow The term ‘flow’ describes the progressive movement of people, equipment and information through a sequence of processes. In healthcare, the term generally denotes the flow of patients between staff, departments and organisations along a pathway of care. Flow is not about the what of clinical care decisions, but about the how, where, when and who of care provision. How services are accessed, when and where assessment and treatment is available, and who it is provided by, can have as significant an impact on the quality of care as the actual clinical care received.
Redesigning our systems to maximise flow will require a different way of working across the whole organisation, not just at the level of the patient and the front line services that surround them. Improved flow will necessitate all clinical and non-clinical departments and corporate directorates to refocus on their contribution to improving flow, not on self-contained objectives which can in fact be counterproductive.
Many support systems do not facilitate the focus on flow. Policies governed by support functions, such as HR, finance, IT, estates and procurement, can inadvertently constrain the flow of patients, staff, information and supplies, causing variations in capacity and the mismatch between those variations and the predictable variations in demand. These factors need to be addressed in parallel with clinical care processes if change is to be sustainable and adopted organisation wide.
Designing services to meet the need of our patients requires a disciplined scientific approach to ensure that 1) we measure demand 2) we understand the sequence of clinical tasks (processes) that patients required to get a diagnosis, prognosis and plan 3) we measure the time it takes to perform these tasks and 4) we test and measure the impact of the change both quantitatively and qualitatively.
HDUHB Operational Delivery Plan 2015-16 - Ceredigion Page 21 Draft and Confidential As part of the National Patient Flow Collaborative the Service Improvement and Business Intervention team established a “Big Room” on one DGH site. The Big Room is a weekly multi-agency and multidisciplinary meeting utilising a robust problem solving methodology supported by pertinent timely analysis to evidence and develop needed changes / improvements to the system to unblock flow constraints.
Through the problem solving methodology it was identified that the greatest impact for improvement of patient flow would be achieved by focusing on the frail, elderly pathway. This is evidenced by the following analysis demonstrating that over 50% of beds are occupied by 75 years and older and that patients in this age group are more likely to experience long lengths of stay. 1. The Role and Function of Multidisciplinary Teams and their impact on discharge planning 2. Processes for Mental Capacity assessment and the utilisation of assessments across the multidisciplinary team 3. Joint Records and record Sharing 4. Comprehensive Frailty Assessment at the Front Door 5. Discharge summaries to GPs 6. Comprehensive nursing assessments in ED
In addition to the above an Innovations Forum will be established. This will be an opportunity to bring together front line staff from across the health board who have undertaken patient flow projects to share learning and celebrate success.
Managing patient flow through continuous improvement needs to be embedded in the organisational culture. In order to move towards a situation where this is the standard way of managing services the following immediate steps are proposed: 1. Roll out of “big room” to all four DGH’s 2. Consider how flow and continuous improvement methodology will be used in other areas such as Cancer and Scheduled Care flows 3. Review of the Service Improvement and Business Intervention team’s capacity to support this work
Three Top Conditions presenting at A&E Chronic Condition Management – The top 3 recorded conditions on presentation as an unscheduled care admission through A&E and ACDU.
Top 3 GGH PPH WGH BGH Presentations on Admission To DGH 1 UTI Lobar Pneumonia UTI UTI
2 # NOF UTI Atrial Fibrillation Lower Respiratory Infection 3 Lower Respiratory COPD Chest Pain Acute MI Infection Unspecified
The above represents the conditions which present as being recorded as the highest ‘top 3’ presentations for unscheduled care admissions into acute hospital beds over the last 12 months.
HDUHB Operational Delivery Plan 2015-16 - Ceredigion Page 22 Draft and Confidential Urinary Sepsis Urinary sepsis is often avoidable and manageable in the community, the development of a community integrated pathway will support early detection, rapid intervention and acute management in the community. Support and education to the independent sector, residential and care home provision should reduce avoidable admissions from care homes. The Care Home Support Team within existing resource will provide this level of intervention to support the development of an ICP in this area.
Respiratory Lower respiratory infection, lobar pneumonia and COPD and other respiratory related conditions comprise a significant number of unscheduled admissions in Carmarthenshire and Ceredigion. The provision of respiratory related self management programmes, assistive technology, 23 Telehealth and support groups such as Breathe Easy need to be improved to support a targeted intervention programme across all of the 7 GP Clusters.
Cardiac The third largest presentation is cardiac conditions, community services have varied availability if clinical nurse specialists and there is not one unified model in place across the Health Board. There is a need to consider how we target resources and expertise to address this. Over time specific posts have been developed in some instances because of funding opportunities, bids, grants or third sector sponsorship such as the British Heart Foundation.
Out of Hours/Unscheduled Care Out of hours primary care service are currently provided as a stand alone service, the service needs to be integrated to interface with other OoH Health and Social Care service responses and form an integral part of the unscheduled care model in each county. The service needs to interface with the ART team, palliative services, community nursing team, MAST, TOCALs and rapid response domiciliary care out of hours service. A more integrated approach will provide a comprehensive service response, currently much of the unscheduled care activity is generated through the out of hour’s period.
The 111 model will be rolled out across Wales from October 2015, this will have an impact on call handling and triage in the first instance, it is not yet clear how this will be managed and the impact on current provision has yet to be assessed, this can only be done when the final proposed service model is known.
A common theme that prevents an integrated, co-ordinated approach to 24 hour primary care service is information- sharing and access to systems, particularly the GP record. Much work has been done on the Individual Health Record – IHR, despite this there are no joined up systems across 24 hours which enable the workforce to appropriately manage the patient and understand what factors represent a risk and which factors provide resilience. There needs to be a task and finish group established to identify what current systems can be enabled to improve the situation, underpinned by clear information sharing protocols. The will be an Internal service review undertaken with recommendations for a future service model for OOH GP services.
IM&T Effective Information Technology infrastructure is essential in delivering care closer to home. The IM&T Strategy will address the following: A community information system, mobile devices with access to clinical records; Improved interface between acute and primary care;
HDUHB Operational Delivery Plan 2015-16 - Ceredigion Page 23 Draft and Confidential Improved access to integrated systems i.e. Social Services, A&E, Primary Care and community services.
Information can be a significant enabler and driver of improved information flow, allowing the Health Board to effectively measure what we do and how we can improve. The extended use of videoconferencing and telemedicine to support remote clinical contacts reduces the need for patients and clinicians to travel long distances, enabling access to specialist services.
Telehealth supports the management of disability resulting from chronic disease. Research suggests that Telehealth can have a positive effect on patients with chronic disease, including improved patients experiences, clinical indicators, quality of life, ability to self manage and reduce use of secondary healthcare, avoiding unnecessary admission to hospitals.
The risk stratification electronic programme will be introduced across Primary Care, allowing greater awareness of those who are vulnerable, allowing the delivery of care in a timely manner.
Estates In addition to our community hospitals, we have 26+ other premises across all 7 localities. We have reviewed their current state and prioritised them using the same concept as with GP premise, but using Estates Department backlog maintenance as the key decision criteria.
Our proposed service and estate intentions are as follows: Premises in Green are well-advanced in terms of Business Cases and are lodged in capital programme already Premises in Amber represent where there is robust discussion with stakeholders has been significant and / or the service requirements are now significant. Therefore these need to be prioritised and finalised within our capital IMTP planning assumptions Premises in red are being seriously scoped for re-designation of their use / requirement as part of our service strategy.
With on-going austerity, we cannot afford to maintain poor estates infrastructure – much of which is denoted by Priority 1 / significant backlog maintenance costs. We are also retaining all 4 main hospitals which cost significant amounts to both run and maintain. Our aim is to grow community services with more community staff providing Care Closer to Home, in people’s homes. To this end, our estate solutions are proposed as follows:
HDUHB Operational Delivery Plan 2015-16 - Ceredigion Page 24 Draft and Confidential Ceredigion Locality Community Total Backlog Service action prioritised in Site £ IMTP & Link to Capital Programme North Ceredigion Aberaeron Hospital £1,972,750 Disposal & Lease option for community services Tregaron Hospital £3,392,415 Disposal & New Build: Cylch Caron Development Gorwelion £159,978 Ty Helyg £37,446.50 North Road Clinic £504,065 Disposal & relocate to existing estate. Y Wern £60,308 Dan y Coed x3 £58,770 South Ceredigion Cardigan Hospital £2,252,925 Disposal & New Build: Cardigan Integrated Care Development Cardigan Health £400,400 Disposal & New Build: Cardigan Centre Integrated Care Development Llys Steffan £93,969 Hafan Hedd £47,973
Commissioning Issues A structure is required to improve the commissioning of services across all tiers of service. There are clear challenges to delivery of high quality care for patients: Population changes are increasing demands on health care services and the resources available are not increasing at the same rate. As the population ages, the number of people with chronic diseases rises and people live longer and the way we currently use our hospitals is unsustainable; Improving our out of hospital services will improve patient care and will re-balance resources between acute and community care.
During this period of significant change and the development of the IMTP, it is essential that we provide clear specifications for clinical interventions, delivering equitable services across the health Board.
A commissioning process developed within the cluster arrangements will ensure that community and primary care will be central to the determination of every aspect of care. The emphasis will remain on keeping people healthy, preventing ill health and reducing health inequalities to reduce the burden of illness and demand on services. As commissioning improves, we will ensure that timely access to planned and urgent care needs are met; and clear specifications for transfer of care will be established to assist admission and early supported discharge into well organised community care.
Integrated health and social care commissioning will ensure the core services will be actively monitored.
Arrangements will be made with domiciliary care providers, the independent sector and continuing healthcare provision to ensure standards and governance arrangements are in place.
The ‘Health Asset’ approach includes factors that support individuals, communities and populations to maintain and sustain their health and wellbeing. The asset approach is a way of working that
HDUHB Operational Delivery Plan 2015-16 - Ceredigion Page 25 Draft and Confidential recognises and values the capacity, skills, knowledge, connections and potential in a community. There is a good research evidence for the positive impact of individual and community assets such as resilience, self determination, reciprocity, social networks and community engagement on health and wellbeing.
Examples of the application of health assets mapping includes the use of 3rd Sector brokers, guided interviewing by the 3rd sector (Age Cymru), influence on population health groups, commissioning at a local neighbourhood level, support on discharge from hospitals, patient led groups within primary care and the development of dementia friendly communities.
6. Savings Plans
The 3.5% savings of £470,000 will be met from a reduction in Continuing Healthcare spend and the reviewing of contracts and Service Level Agreements.
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