U DUMFRIES AND GALLOWAY INTEGRATION JOINT BOARD E FUT RE OF TH H R EA O L F T R H E A H N T D E G S O O T C I G A L N I C K A R R O E HEALTH AND W SOCIAL CARE LOCALITY PLAN DUMFRIES AND GALLOWAY Health and Social Care Wigtownshire 2016 – 2019 Contents Foreword 3 1 Introduction 4 1.1 What is this locality plan? 4 1.2 Who is this locality plan for? 4 1.3 What is included in this plan 4 1.4 Where does this plan fit into the wider picture? 4 1.5 What are we hoping to achieve? 5 1.6 What are our main challenges? 6 2 About the locality 8 2.1 Geography 8 2.2 The population and demographics 9 2.3 Health inequalities, equality and diversity 11 2.4 Community assets 12 2.5 Summary of key information and data 13 2.5.1 Carers 2.5.2 Sensory impairment, physical and learning disabilities and autistic spectrum disorders 2.5.3 Long-term and multiple long-term conditions: diabetes, mental health and well-being & dementia 2.5.4 Housing 2.5.5 Transport 2.5.6 People delayed in hospital 2.5.7 Prescribing in primary care 2.6 Where are we now? What is working well? 21 3 People and finances 24 3.1 Who makes up the locality management team? 24 3.2 How is the money spent? 24 4. What are people in the locality telling us? 27 4.1 Key messages from local consultations 27 5. What do we need to do? 33 6. How will we know we are getting there? 40 6.1 Measuring performance 40 If you would like some help understanding this or need it in another format or language please contact 030 33 33 3000 2 Foreword People from health, social care and community services have worked together to produce this Wigtownshire locality plan. This plan is for all of us in Wigtownshire and has been developed within the context of the Dumfries and Galloway Health and Social Care Strategic Plan. The Strategic Plan and all the supporting documents, including locality plans, have been informed by national and local policies and guidance, legislation, external inspections such as the joint inspection of older adults (early 2016) and builds on learning from programmes such as ‘Putting You First.’ Appendix 2 of the strategic plan includes details and links to some of these. It can be viewed at (www.dg-change.org.uk/strategic-plan). This is a time of change and challenge. We want to make sure that the health and social care services we arrange and pay for are safe and effective. At the same time, as a community, we must all support significant change and our plan reflects the actions we will take to make this a reality. Central to this is the need to shift activity and resources into the community. We will build on, and strengthen, what already exists and is provided by NHS, social services and third and independent sectors. These sectors will formally be working in partnership from the 1st April 2016 under the Dumfries and Galloway Integration Authority. With the increasing demand on services, resources and budgets comes the need to reshape the way we support people in our community. This will allow people to look after themselves, safe in the knowledge that health and social care services are there when needed. In short, we need to do things differently. Developing this integrated care partnership and producing this final plan together in that partnership, along with the strategic plan is aimed to help deliver this vision. You are a central part of this plan. This plan involves health, social work and third and independent sector services. This includes our hospitals, GPs, community nurses, occupational therapists, physiotherapists, podiatrists, speech therapists, social workers, housing officers, care homes, care providers and unpaid Carers, voluntary and charitable organisations. We believe that we can work with you to better organise care and support. With improved and increased communication and networking across the region, we aim to support you closer to home. Technology will be important in delivering this model of care. This locality plan sets out our direction for the next three years. A supporting Wigtownshire health and social care integration delivery plan will set out more specifically what we plan to do and how. This will continue to develop over time in a dynamic manner. This is a journey to which I am committed and together we will work to make sure we effectively involve everyone with an interest to make sure that the needs of our population are at the heart of this process. My overall aim, as Interim Locality Manager is to make a difference to you as an individual, so you can live a healthy and well life in Wigtownshire. I am certain the permanent incoming Locality Manager, June Watters, will have the same aim. Mhairi Hastings Interim Locality Manager 3 1 Introduction 1.1 What is this Locality Plan? This locality plan is about how health and social care integration will be taken forward in Wigtownshire as part of the new Dumfries and Galloway Integration Authority. It sets out specific locality data identifying what is working well, as well as some of the key challenges which need to be addressed. It is an appendix to the Dumfries and Galloway Health and Social Care Strategic Plan. For more information about health and social care integration see the strategic plan (www.dg-change.org.uk/strategic-plan). The plan is about health and social care services and support. It is also about how people and communities can be supported to help and support themselves. This is the first plan of its kind and sets out in broad terms how we will all work together using an asset based approach for the best possible outcomes for everyone living in the locality. An asset based approach starts with getting to know the strengths of individuals, groups and communities and building upon these. Importantly, much of the plan is based on what people who live in the locality and those currently involved in delivering health and social care in the locality have said about how things could be better and what would make a difference. There was a wide consultation on a draft version during the period of October to December 2015. This locality plan is supported by a Wigtownshire health and social care integration delivery plan that will be an evolving, developing document, setting out the activities, projects and work to be undertaken over the next three years to meet the required outcomes for people living in the locality. 1.2 Who is this Locality Plan for? This plan is for everyone who lives or works in Wigtownshire with a focus on adults. It is for those who currently use health and social care services, for example, people who need day to day help with personal care or who need more regular support to manage a long term condition and also those who may need to do so in the future. It is also for people who are well and wish to maintain or improve their current level of independence, health and well-being. 1.3 What is included in this Plan? All adult social care, adult primary and community health care services, most acute hospital services and some elements of housing are included within the new Dumfries and Galloway Integration Authority. Services relating to children are currently not included. 1.4 Where does this Plan fit into the wider picture? This plan is one of four locality plans for Dumfries and Galloway and forms an annex to the overarching strategic plan for the region www.dg-change.org.uk/strategic- plan There are also a number of other important national and local strategies which have informed this plan, for example, “The keys to life – Improving Quality of Life for People with Learning Disabilities 2013” and the “Dumfries and Galloway Joint Strategic Plan for Older People 2012 – 2022”. A more comprehensive list of these important strategies can be found in Appendix 2 of the strategic plan. (www.dg-change.org.uk/strategic-plan). 4 The strategic plan, this plan and the Wigtownshire health and social care integration delivery plan will be further informed by the findings of the joint inspection of adult services. At the time of writing this inspection is being carried out by the Care Inspectorate and Health Improvement Scotland across Dumfries and Galloway. The findings of the inspection will be developed into a Dumfries and Galloway partnership improvement plan and these improvements will be incorporated into the Wigtownshire locality development plan. Actions required following the pre inspection are already reflected within the Wigtownshire commitments (section 5) of this plan. 1.5 What are we hoping to achieve? There are nine national health and well-being outcomes agreed by Scottish Government that our locality will need to deliver against. A summary of the outcomes is set out here. Section 5 of this plan outlines the key issues for these locally and our commitments against each outcome. People, including those with disabilities or long term People who use health People are able to look after conditions, or who are frail, are and social care services and improve their own health able to live, as far as reasonably have positive experiences and well-being and live in good practicable, independently and of those services, and have health for longer at home or in a homely setting their dignity respected in their community People who provide Health and social care unpaid care are supported services are centred on Health and social care to look after their own health helping to maintain or services contribute and well-being, including to improve the quality of life to reducing health reduce any negative impact of of people who use those inequalities their caring role on their own services health and well-being People who work in health and social care services Resources are used effectively feel engaged with the work People using health and efficiently in the provision they do and are supported and social care services of health and social care to continuously improve the are safe from harm services information, support, care and treatment they provide 5 This plan is shaped around the vision for Dumfries and Galloway as set out in the Dumfries and Galloway integration scheme - “A Dumfries and Galloway - where we share the job of making our communities the best place to live active, safe and healthy lives by promoting independence, choice and control”.