Updated November 08

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CONTENTS

PAGE 1 Rationale

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2 Summary 4

3 Introduction 5

4 National and Local Guidance and Research 8

5 Future Demand 15

6 Market Analysis 22

7 Gap Analysis 42

8 Monitoring Arrangements

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9 Commissioning Intentions 57

10 Action Plan 64

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Appendices 76

12 Acknowledgments

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1. RATIONALE

The development of Commissioning Strategies in Torfaen must be considered in the context of national and local guidance of the modernisation agenda of the social care and health service over the coming years. The strategy sets out how the Local health Board, Torfaen County Borough Council and partner agencies will work together to deliver the high quality care that patients need and deserve The key national policies that over arch the Commissioning Strategies are attached as an appendix.

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2. SUMMARY This is one of nine Joint Commissioning Strategies for improving adult health and social care community services in Torfaen. They are being developed during 2008 as part of the Action Plan that underpins the Health, Social Care & Well-being Strategy (2008-11). The improvement of hospital-based services are set out in the Gwent Clinical Futures Strategy and the improvements for meeting the health and social care needs of children are being described in a separate commissioning strategy via the CYP Framework Partnership. The service area/client groups to be covered in 2008 include the following: Learning Disabilities Physical Disabilities Adult Mental Health Carers Older People Older Person’s Mental Health Long Term Conditions Intermediate Care services An additional strategy will be written for health improvement and wellbeing. The expected benefits of joint commissioning strategies are set out below: Benefits for Users = Seamless service provision, single point of access, unified assessment, avoid gaps between services, continuity across care pathways, service development and expansion, increased choice and independence, resources targeted to highest need. Benefits for Staff = Effective collaboration across organisations, multi professional learning, increased skills and better skill mix, extended employment opportunities, new ways of working. Benefits for Providers = Service vision and development priorities shared, opportunities to re-design services or redirect resources to meet future demands, longer term and block contracts for sustainable local businesses Benefits for Commissioners = Breaking down professional and organisational barriers, better use of resources – statutory, independent and voluntary, joined up needs assessment, gap analysis and service planning, managing demand from demographic/technological changes.

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3. INTRODUCTION TO COMMISSIONING STRATEGIES The development of joint commissioning strategies in Torfaen must be considered in the context of national and local policy drivers which support the modernisation of health and social care services. These policy initiatives have identified a number of emerging themes relating to older persons’ services and give direction to future preferred service development models. Service planning and commissioning has to be based on an assessment of health, housing and social care need (current and future) within the general population. The assessment should be thorough and based on local evidence, should identify any gaps or shortfall in services and reflect the aspirations of people using services. For the purpose of this Strategy commissioning can be defined as a formal statement of plans for securing, specifying and monitoring services to meet people’s needs at a strategic level. It applies to services provided by the local authority, the NHS, other public agencies and the private and voluntary sectors, (source: Developing a Commissioning Strategy in Public Care – Audit Commission) Welsh Assembly Government (WAG) Best Value, introduced through the Wales Programme for Improvement required Local Authorities to balance costs and quality. Knowledge of local providers and potential providers can provide information on service delivery, user preferences and the running of services. For specialist provision e.g. services for people with a brain injury, commissioners will have to have knowledge of national and UK service providers. This is the first Joint Health, Social Care & Housing Commissioning Strategy for Older People’s Mental Health Services in Torfaen and provides an analysis of:

• Current and Future Demand

• How services are currently purchased and provided

• Details of the main service providers

• Gaps in service provision

• Future strategic commissioning intentions The Strategy aims to involve all relevant service providers and this will provide the flexibility to:

• Manage existing services

• Deal effectively with transition

• Create new solutions to changing needs The future commissioning of services for older people will be based on a whole systems approach that actively encourages contributions from all stakeholders working to the following underlying principles:

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• The support and promotion of independence and self care

• Social inclusion and equitable access, based on need

• Rights and choices for people using services, reinforced by good information

• Commissioning informed by user and carer views

• Safe clinical care, to agreed standards

• Continuous improvement and higher standards

• Care at, closer to home where safe and sustainable

• Maximising efficiency of available resources

• The need for a range of carer support options

• Delivery through integrated working across sectors The Strategy sets out the overall direction and joint commissioning priorities for Torfaen over the next five years in line with the Social Care Plan, Health, Social Care and Well Being Strategy, Gwent Clinical Futures and the Council’s Corporate Plan. It demonstrates a real commitment from all stakeholders to work more closely together as a partnership to address the needs of older people. The Strategy should also be read in conjunction with other Torfaen Joint Commissioning Strategies for People with Physical Disabilities (including sensory Impairment), People with Long Term Conditions, Mental Health, Older People, Learning Disability, Intermediate Care Services and Carers. It is recognised that Mental Health Services for Older People have not been a high profile service, with little national focus or emphasis to increase its priority, and yet, faced with an ageing population with increasing mental health needs, it is an area requiring urgent attention. Through this separate Joint Commissioning Strategy for Older People’s Mental Health Services we seek to redress the balance. This strategy has been developed separately to the Strategy on Adult Mental Health but there has been cross membership of the working groups and the outcomes of each will be integrated at the point of implementation. Older People should have access to the same range of services as Working Age Adults including access to counselling and therapeutic services. Our vision is to develop Mental Health Services for Older People that are person centred and promote independence, well-being and choice. We will also seek to develop integrated services reducing the barriers between health and social care and engage fully with colleagues in the Independent and Voluntary Sectors in achieving a co-ordinated and effective service. We are committed to the development of integrated pathways of care to provide people with co-ordinated and consistent care Services should support people, as appropriate, in the community and preferably in their own homes as far as possible but with specialist support and in-patient or care home placement when necessary. We also recognise the importance of securing quick and accurate diagnoses at the earliest

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possible time and that means strengthening the skills and capacity within primary care. This strategy is being presented at an important time when the Trust is developing a model for Clinical Futures. Similarly the Local Authority is at a critical time in implementing its Older Person’s Strategy which addresses the need to develop new models of social care. The aim of this strategy is therefore to bring together the jigsaw of services for older people aged 65 and over with mental health needs into a strategic commissioning framework. This will recognise key care functions and goals in order to plan a pathway of services that will manage risk and meet need now and in the future.

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4. NATIONAL AND LOCAL GUIDANCE AND RESEARCH National drivers There are a number of recent national and local strategy documents which will drive the change required to commission outcome focussed and person centred services, creating frameworks for improvement and accessibility over the next ten years. A number of overarching reports and strategies and legislation that is applicable to all health and social care services can be found in the appendices. The key themes from generic strategies that will be applicable to the commissioning intention for older people’s services will form part of the summary of this section, together with client specific guidance detailed below. National guidance for older people’s services Forget-Me-Not (Audit Commission, 2000) This report set out the Audit Commissions analysis of mental health services for older people in England and Wales. The report made a total of 17 key recommendations based on audits of 12 areas in England and Wales. An underpinning recommendation was that every community needed to have a comprehensive strategy to support the development of mental health services for older people. When I’m 64…and More (WAG, 2002) A strategy advisory group was set up in June 2001 to inform and provide a basis for the national strategy for older people in Wales published in 2001. Over 100 recommendations were made based on the following key themes of the report: • Social inclusion: older people within the community; personal security

and safety; the role of the voluntary sector; ageing and ethnicity, age discrimination

• Transport, access, mobility; non-urban living

• Lifelong leaning and employment of older people

• Housing and housing services for older people; other local government services

• Health promotion and healthy living for older people:

• Health and Social Care for older people • Non Devolved issues: Better Government, benefits, pensions, and

savings, take up of the Minimum Income Guarantee

All Our Tomorrows (ADSS/LGA, 2003) A discussion paper produced in England by the Association of Directors of Social Services (ADSS)/Local Government Association (LGA) sets out a direction for services for older people, noting that organisations involved in the

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planning and delivery of care for older people need to change how they focus and allocate their resources. Most resources and spending for older people are targeted at those with the most severe needs. All our Tomorrow’s suggest that future services should reverse this trend by having the community strategy and promotion of the well-being of older people at the top of the triangle. Strategy for Older People in Wales (WAG, 2003) The Strategy was launched in 2003 and provides a framework for all public bodies in Wales to plan for an ageing society and to improve services to older people. The 5 key aims of the Strategy for Older People in Wales are:

• Tackling discrimination against older people, promoting positive images of ageing and giving older people a stronger voice in society.

• To promote and develop older people’s capacity to continue to work and learn for as long as they want, and to make an active contribution once they retire.

• To promote and improve the health and well-being of older people through integrated planning and service delivery frameworks and more responsive diagnostic and support services.

• To promote the provision of high quality services and support which enable older people to live as independently as possible in a suitable and safe environment and ensure services are organised around and responsive to their needs.

• To implement the Strategy for Older People in Wales with support funding to ensure that it is a catalyst for change and innovation across all sectors, improves services for older people and provides the basis for effective planning for an ageing population.

Designed for Life: Creating World Class Health and Social Care for Wales in the 21st Century (WAG, 2005) Further detail of the overall aims of this strategy can be found in the appendices. However, the national strategy for older people is embedded in this strategy and outlines the need for better integrated services for older people. It makes reference to the emerging requirements that were later set out in the National Service Framework for Older People in Wales. The National Service Framework (NSF) for Mental Health (2005) The strategy outlines key actions for commissioners and providers such as social inclusion, tackling stigma, service user empowerment, effective care pathways, providing equitable services and ensuring a well staffed and skilled workforce.

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Fulfilled Lives, Supportive Communities: A Strategy for Social Services in Wales over the Next Decade (WAG, 2006) Developed to complement designed for life; this strategy outlines the direction for Social Services over the next ten years. It notes that Councils and their partners will need to “greatly increase the extent of joint commissioning with health and other services”. Whilst more detail of this document can be found in the appendices, the strategy states that the resultant actions will mean that “older people affected by illness and impairments will be supported at home with the need for admission to hospitals or residential care greatly reduced”. National Service Framework for Older People in Wales (WAG, 2006) Requirements are that services will be developed in line with NSF standards. There are 9 standards: rooting out age discrimination, person centred care, promoting health & well being, challenging dependency, intermediate care, hospital care, stroke, falls & fractures, mental health in older people. The NSF emphasise the need to improve “existing services and to achieve a fundamental shift towards services which promote people’s health, wellbeing and independence and address their health and social care needs within the community wherever possible”. It notes that this “reflects the Welsh Assembly Government’s vision set out in Well Being in Wales, the aspirations of older people expressed in When I’m 64… or More, and Designed for Life of a society where:

• People stay safe, healthy and independent for as long as possible;

• Health and social care problems or potential problems are promptly

• Identified and the person’s holistic needs are assessed;

• Social care and health needs, including chronic health conditions, are managed effectively within the community - avoiding crises and inappropriate hospital or care home admission;

• Prompt access is available to quality diagnosis and specialist services when required, including acute hospital care;

• Transition from acute services to more appropriate care settings is timely and co-ordinated;

• Long term care provision is co-ordinated and effective;

• Opportunities for return to full or optimum health and independence are maximised, in whatever setting the person is living.

Securing better mental health for older adults (Department of Health, 2005) This document marks the start of an initiative to combine forces across mental health and older people's services to ensure that older people with mental illness do not miss out on the improved services that younger adults or those without mental illness have seen. It provides a vision for how all mainstream health and social care services, with the support of specialist services, should work together to secure better mental health for older adults.

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A New Ambition for Old Age – Next Steps for NSF a resource Document (Department of Health, 2006) This document details 10 programmes of work with one aimed specifically at Mental Health in Old Age. The four aims of this programme of work are:

• To ensure age equality in the development of mental health care for adults of all ages, with access to services on the basis of need, not age.

• To improve the skills and competencies of staff to enhance detection and management of mental illness in non-specialist settings.

• To secure comprehensive specialist mental health services for older adults with particular emphasis on CMHT’s, memory assessment clinics, and liaison services.

Dementia Strategy in Wales: a brief scoping review (Dr Charles Twining, 2008). Dr Twining’s scoping paper was commissioned by WAG to analyse relevant strategy and policy documents relating to mental health and older people and to identify gaps in policy and services provision. The main strategic drivers stated that people with dementia should:

• Have access to primary intervention and integrated services to ensure timely assessment, diagnosis and treatment,

• Not be discriminated against

• Be involved in the joint planning of services (along with their carers) so that delivery of health and social care services are coordinated

• Have access to memory assessment services The main points about the relevant national strategies highlighted in the review were as follows:

• The NSF for older people makes clear that the needs of dementia sufferers and their families must be based on more than a clinical service.

• Designed for Life contains no reference to dementia which is a little surprising given the population predictions for the next ten years.

• Nursing and residential care homes are a key element of care of those with dementia, particularly as it is difficult to keep those with dementia living at home. All care homes mostly look after those with dementia even though for many residents this is not the reason for admission. A skilled workforce is needed to provide appropriate dementia care.

• The Adult Mental Health NSF suggests that carers of people with dementia are at significant risk of depression and other psychological disorders.

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The review outlined the following priorities and needs:

• Increasing carers’ skills caring for someone with dementia.

• More support should be given to help people with dementia around the areas of housing (e.g. equity release) and assistive technology (as those with dementia do not find it easy to relocate). Allocation policies need somehow to allow for early relocation.

• Possibility of having dementia as a criterion for telecare services (currently nine Unitary Authorities which include those with dementia as an explicit target group).

• Range of concerning issues across Wales relating to Adult Protection which requires urgent attention as 61% of adult protection investigations in care homes relate to nursing care, and the most common vulnerability in nursing care homes is dementia.

• Need to promote health and well being for carers of people with dementia.

• A wider representation of the most vulnerable people is needed on patient and carer focus groups, particularly those with dementia in acute settings.

• Wider links need to be made across agencies including health and social care, housing, employment and life long learning and leisure.

• Giving staff specialist training so that they have the right sort of skills in dementia.

The review concluded that:

• The right level of dementia care is needed throughout adult services to deliver what the population requires.

• Some dementia services such as those for younger onset dementia require cross authority services and commissioning.

• There is ample strategy to take forward dementia services in Wales.

• Dementia is not just a concern for mental health services; it presents challenges throughout public services in Wales.

Summary of national drivers The key themes from national guidance (both in the section above and in the overarching policies in the appendices) that are essential for the commissioning of services in the next five years are as follows:

• The user should be at the centre of service delivery and the commissioning of services

• Services and commissioning of services should focus on outcomes, promoting health and wellbeing and prevention as much as providing long term and acute services

• The locus of health and social care should shift from hospital and institutional settings to communities and closer the user’s own home

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• Services should help people stay safe, healthy and independent for as long as possible

• Work collaboratively to deliver high quality services jointly, using a common approach to assessment

• Increase the skill mix and develop the health and social care workforce in order to deliver consistent, high quality services across both health and social care

• Performance of services needs to be managed tightly to ensure that service are commissioned and delivered efficiently and effectively within a culture of improvement to enhance the quality of life and experience of the end user

Local Drivers

Torfaen Older Persons Strategy Following the National strategy for older people in Wales, Torfaen developed a local strategy for older people, from which the following key issues were identified:

• Providing quality care and support when it is needed.

• Improving transport links

• Improving access to benefits and grants that can prevent poverty

• Widening opportunities to learn for pleasure as well as for those who want to achieve academic qualifications

• Supporting flexible employment and career changes after 50

• Working to improve community safety with the police as well as personal safety through home maintenance, alarms and accident prevention.

Torfaen Health Social care and Wellbeing Strategy 2008 - 2011 Further detail of the overarching aims of the strategy can be found in the appendices. There are a number of generic actions that will affect the commissioning of services for older people. However, there is one key action that relates directly to older people: • To develop and deliver falls prevention initiatives for older people to

reduce the risk of injury and hospitalisation as a result of a fall

Sainsbury Centre for Mental Health – Review of Adult Mental Health Services in Torfaen (September 2006)

The overall conclusion of this review was that “the biggest challenge facing Torfaen is the integration of health and social care spanning all partner organisations across Torfaen. Without this the development of a new service will not be successful”

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Summary of local drivers The key themes from local guidance (both in the section above and in the overarching policies in the appendices) that are essential for the commissioning of services in the next five years are as follows:

• To improve services for vulnerable people and improve health outcomes for everyone by promoting healthier lifestyles

• Work in partnership to continue the shift towards a service direction that focuses increasingly on people’s independence

• Work in partnership across health and social care to develop and effective service for people with mental illness

• A focus on health and social care outcomes through promoting independence and choice

• Ensuring that services are effective, efficient, accessible and prioritised to those in greatest need

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5. FUTURE DEMAND

Demographic Overview General demographic information relating to Older People with mental health needs has been included in the Older Persons Commissioning Strategy. The key themes from the Older Persons Needs Analysis can be summarised as follows: Age and Ethnicity In Wales there is a higher proportion of older people than in the rest of the UK. Torfaen has a similar proportion of older people to the rest of Wales. Seventeen percent (17%) of the Torfaen population is over 65. There is a lower proportion of BME older people in Torfaen. Gender and health There is a slight gender gap in Torfaen, with more women than men. Some health differences exist according to gender. Services will need to be available equally whatever the gender or ethnicity of the individual but where gender specific conditions exist services may need to be focussed in that way. Population distribution There are higher numbers of older people in areas of low deprivation in the South of the borough. However, there is an increasing number of older people in the North of the borough which are areas of higher deprivation. Limiting long term illness Torfaen has a greater proportion of people with LLTI than the rest of Wales, this particularly in the 65 – 69 age group. The greatest concentration of people with LLTI corresponds to wards with higher deprivation. If this proportion remains static then an increase in population of older people will lead to an increase in demand for services. Population growth By 2013 there will be a large increase in the numbers of older people particularly in the 85 + age group. It is estimated that there will be a 14% rise in the number of older people to around 18,000. Population shift If there is no significant movement of people, the shift in the population density of older people in the next 5 years is likely to be towards the south east (Croesyceiliog and Llanyrafon) and far North of the borough (Blaenavon and Abersychan)

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In the UK as a whole, greater numbers of older people are living longer with poor health.

Prevalence and incidence of ill health and conditions requiring support Sensory impairment The likelihood of sensory impairment increases with age and can limit independence, creating a need for health and social care services. The impact of increased risk of falls resulting from such impairments may create greater demand. Parkinson’s An average of 1.5% of older people in Torfaen will develop Parkinson’s disease. This equates to 237 people with the condition and this could rise to 270 by 2013 (using population growth predictions). Strokes The number of older people suffering a stroke is likely to increase by as much as 17% over the next 10 years. The disabling effects of strokes increases the need for health and social care services, from low level interventions to complex packages of care. Tackling stroke is one of the Minister for Health and Social Services’ top priorities (WHC (2007) 082). Heart disease Torfaen has a slightly higher than average incidence of heart disease. Women are more likely to suffer from circulatory diseases. Overall the number of deaths from coronary heart disease is beginning to fall. However, the prevention of and recovery from heart related illness increases the demand for specialist primary health services and such social input as support and advice for improving health and wellbeing. Falls Fractures as a result of falls remain a significant cause of death and permanent disability for older people in Torfaen. A large proportion fails to regain the same level of pre-fall independence creating an increased demand for services. According to sample data, 21% of referrals to intermediate care services and 16% of older people’s team’s caseloads can be attributed to falls. Social services targets Torfaen has had a high level of delayed transfers of care since June 2006. Tackling DTOC is a priority for the local authority to meet is improvement targets.

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Whilst help to live at home figures have improved and Torfaen is exceeding its targets, the focus of community services has been on improving quality and there will need to be a shift to outcome focussed services to facilitate independence. There are a high number of older people awaiting a placement in a care home often due to limited supply. Whilst Torfaen is meeting its targets for reducing the ratio of people in care homes capacity will need to increase to meet demand from both hospital and the community for those in most need. Mental health conditions There are a number of organic mental health conditions, particularly different types of dementia, which will create demand for integrated health and social care services. The following list is not exhaustive:

• Alzheimer’s disease

• Vascular dementia

• Dementia with lewy bodies

• Fronto-temporal dementia

• Alcoholism with dementia

• Brain damage with dementia

• Parkinson’s with dementia

There are also a number of functional mental illnesses, such as:

• Schizophrenia

• Bi polar disorder

• Depression

• Anxiety

It should also be noted that a number older people will present with more than one of the above conditions, requiring significant and specialist support.

Prevalence of mental health conditions

People over 50 are more likely to be treated for depression and anxiety than under 50’s. Mental heath scores were significantly lower in Torfaen than the Wales average

Age % treated for depression/anxiety Under 50 12% 50-59 16% 60-69 15% 70-79 14%

80+ 18% (Welsh Health survey 1998)

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Self reported prevalence of mental health conditions in 1995 and 1998 show an increase over time:

Year / Age 65-74 male 65-74 female 75+ male 75+ female 1995 8.8% 13% 8.7% 12.6% 1998 11.75% 15.2% 11.6% 18%

A recent case load analysis of the Older Persons Mental Health Team within Torfaen Social Care and Housing, suggests that the most common mental health conditions for older people in Torfaen (over 65’s) are Alzheimer’s disease, dementia and depression. Services which relate to functional mental illness for older people will be detailed in a separate action plan. Table 5.0 As at the 30th June 2007, the Older Persons Mental Health Team had 425 open cases. This is the 3rd highest number of open cases in the community care division. Alzheimer’s disease and Dementia The Alzheimer’s Society estimates that in 2007 there are 683,597 people with dementia in the UK, which represents one person for every 88 people (1.1%) of the entire UK population. The total number of people with dementia in the UK is forecast to increase to 940,110 by 2021 and 1,735,087 by 2051, an increase of 38% over the next 15 years and 154% over the next 45 years. The Alzheimer’s Research Trust estimates that there are 163,000 new cases of dementia occur in England and Wales each year - one every 3.2 minutes. The Dementia UK report stated that 5% of the UK total is people in Wales with dementia. This equates to 34,180 people with dementia in Wales (which is

Numbers of people with a specific condition

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equivalent to the 1.1% of the total population – the same as the overall figure for UK). The Alzheimer’s society estimates that the total number of people in Torfaen with dementia is 1106, which is predicted to rise by 28% to 1412 by the year 2021. The Alzheimer’s society also estimate that 2% of the population aged between 65 and 70, 5% of the population between the ages of 70 and 80 and 20% of people over the age of 80 have a form of dementia. If these estimates are applied to the Torfaen population, it can be estimated that there are:

• 86 people between the ages of 65 and 70,

• 393 people between the ages of 70 to 80

• 627 people over the age of 80 with some form of dementia. Table 5.1 below shows the percentage of the UK population with late onset dementia by gender and age. The table shows that with increased age, the greater the prevalence of dementia. The data also suggests that women are more likely to have the disease than men. This is important in relation to Torfaen, as the borough has 3.2% more women than men. Table 5.1 - consensus estimates of the population prevalence of late onset dementia. Source: Dementia UK report, Alzheimer’s society

Age (years) Female % Male % Total % 65–69 1 1.5 1.3 70–74 2.4 3.1 2.9 75–79 6.5 5.1 5.9

80–84 13.3 10.2 12.2 85–89 22.2 16.7 20.3 90–94 29.6 27.5 28.6 95+ 34.4 30 32.5

The Dementia UK report also outlined the average cost per year for providing services to someone with dementia is £25,472 which takes into account the financial value of unpaid informal care as well as health and social care input. The total annual cost per person with dementia in different settings is estimated as follows:

• people in the community with mild dementia – £16,689

• people in the community with moderate dementia – £25,877

• people in the community with severe dementia – £37,473

• people in care homes – £31,296

If the above cost is applied to those caseloads as at June 2007 (425) alone then the total cost per year can be estimated at £10,825,600 (inclusive of unpaid carer input). The total number of people in Torfaen with dementia is 1106, which is predicted to rise by 28% to 1412 by the year 2021. In June 2007, 425 of the

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total number received services through the community mental health team. The cost of supporting people with dementia is high and will put an additional strain on resources as the prevalence increases. Depression Depression is common among people who live in residential care, and anecdotal evidence suggests that only a few are properly diagnosed or receive adequate care. Depression is a major cause of suicide, and reducing the suicide rate in Wales is a key health target (Audit Commission 2004). According to the Welsh Audit Commission, depression is more common among older people than in any other age group. People over 65, particularly older women are more prone to depression than any other age group. A study published in the Cambridge journal of psychological medicine in 2007 suggests that 8.7% of older people in the UK suffer with depression. This figure rises to 9.7% if older people with dementia is included. The study concluded that the prevalence of depression in the elderly is high and remains high into old age, perhaps due to increased functional disability. If the figure of 8.7% is applied to Torfaen’s population of older people, then it can be estimated that there are currently 1,361 older people in the borough who suffer from depression. If dementia is included then this figure rises to 1,533. However only a small proportion of these estimates are being fully supported for their depression by health and social care services. An average of 8.7% of older people suffer with depression. This equates to 1,361 older people (using RKW’s 2005 figures) and could rise to 1,551 by 2013 (using estimates of population growth). Falls and dementia Falls reduction is included in the NSF for Older People as standard 6. It is also a key aim within the Health Social Care and Wellbeing Strategy that falls are prevented and a falls strategy for Torfaen is in development. There is evidence to show that dementia type illnesses increase the risk of falls. Medication required to control dementia also has an effect on balance, especially at times when medication doses are being altered. Increases in falls will often lead to an increase in demand for primary and secondary health services and often lead to the need for large social care packages where reablement has been difficult in the past. The Intermediate Care Commissioning Strategy examines falls in more detail and will aim to better integrate intermediate care services for people with mental health needs. Carers The number of people in Torfaen that claim a carers allowance is 1,100. The number of carers in Torfaen is 11,500 according to National Statistics and of those around 3,000 provide 50 or more hours of care. Full details of the number of carers can be found in the Carers Commissioning Strategy and an

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action plan will be developed specifically to address the needs of carers in the borough. Summary of main points from analysis of need

• The population of older people is set to rise by 14% in Torfaen by 2012/13.

• The age range of older people with the highest population increase over the next 10 years are the 85 and over age group.

• The wards in Torfaen with the highest number of older people are New Inn, Panteg and Pontnewydd, but this is likely to shift to higher density in wards in the south east and far north of the borough over the next 5 years.

• The wards with the highest levels of older people with a Limiting Long-Term Illness are Cwmyniscoy and Trevethin.

• Some areas of Torfaen are areas of high deprivation, according to both health and social indicators.

• Although healthy life expectancy is set to rise over the next 10 years, the number of older people that will expect to live in poor health is set to increase at a faster rate than that of healthy life expectancy. This means that in 2013 the number of older people living in poor health will be greater than it is today.

• The number of referrals to the Older Persons Social Work teams has risen by 9.8% over the past year and the number of assessments being completed is steadily increasing, leading to an increase in demand for all services.

• As the number of older people is set to rise over the next ten years, the prevalence of conditions typically associated with this age group will also rise. As the number of older people living in poor health will increase, it can be assumed that the number of reported conditions such as strokes, falls, sensory and mobility impairment etc. will also increase, with the effect of increased demand for health and social care services.

• Dementia (including Alzheimer’s) and depression are the most common mental health need problems amongst older people.

• The prevalence of dementia increases with age and over 27% of people aged over 85 are likely to develop dementia.

• As the population ages the prevalence of dementia type illnesses will increase.

• The current number of people with dementia in Torfaen is estimated to be 1,106. As at June 2007 there were 425 older people with mental health needs on the caseloads of the community mental health social work team.

• It is estimated that the number of older people with dementia type illnesses will increase to 1412 by 2021 (a rise of 28%).

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6. MARKET ANALYSIS Care home provision In Torfaen the average stay in an EMI nursing & residential home as at 30th June 2007 was 2.4 years, compared to an average of 2.6 years for the average total stay in general nursing and residential care homes. The average stay in an EMI residential home was 2.6 years and the average stay in an EMI nursing home was 2.2 years. A District Audit report in 2001 showed a shortage of both residential and nursing beds for OPMH service users across Gwent, resulting in many placements in non-EMI registered accommodation. In September 2004 there were 28 OPMH service users who were placed out of county, in residential (13) and nursing homes (15) at an annual cost of approximately £533,936. By 2007 this has risen and in September 2007 40 service users were placed outside of Torfaen. EMI out of county placements are often due to lack of provision or insufficient capacity within Torfaen. Appendix 2 shows a map of nursing and residential homes in Torfaen. The majority of care homes are located in the south and central areas of the borough around the Cwmbran and Pontypool areas. The EMI registered residential and nursing homes are also mainly located in the south and central areas of Torfaen. There are no EMI registered homes in the far north of the Borough in Blaenavon. However, Ty Ceirios and Regency House are accessible. The total number of care home beds in Torfaen as at January 2008 is 614 beds. However, details below are based on reports generated before 31st March 2007. Chart 6.1 below shows percentage of beds per category of care and Table 6.2 shows the number of beds per category in each home in the borough as at the 31st March 2007. Chart 6.1

Beds per category from 1st April 2007

DOUBLE RES.

3%

SINGLE EM I RES.

12%

SINGLE EM I NURS.

13%

SINGLE NURS.

34%

SINGLE RES.

27%

DOUBLE NURS.

8%

DOUBLE EM I NURS.

2%DOUBLE EM I RES.

1%

23

Table 6.2 Bed Capacity Care Homes for Older People as at 1st April 2007 HOME CURRENT TOTAL BEDS 2007

Brynawelon Nursing Home 4 Res. / 26 nursing 30

Emlyn Care Home 17 nursing 17

Leadon Court Care Centre

35 dual residential/nursing 35

New Inn Nursing Home 3 dual / 22 nursing 25

Panteg Nursing Home 3 dual / 38 nursing (operating 39 only)

39

St. Dunstans Care Centre

39 EMI nursing 39

Thomas Gabriel Nursing Home 3 dual / 40 nursing 43

Thistle Court Nursing Home

36 EMI nursing 36

Ty Ceirios Nursing Home 19 nursing / 20 EMI nursing 39

Llanyrafon Court 37 nursing 37

Hollylodge

4 residential / 21 EMI residential 25

Mayflower Residential

23 residential 23

Regency House1 38 EMI Res 38

Ty Bryn

22 residential 22

Arthur Jenkins

28 residential 28

Cwmbran House 2 Resp / 6 IC / 42 Res / 6 EMI Res 56

George Lansbury None 0

Plas-y-Garn 16 Res / 1 Resp / 16 EMI Res 33

Ty Gwyn

32 Res / 2 Resp 34

TOTAL 599

It is important to note that no care homes in Torfaen are owned by Torfaen County Borough Council. The Council transferred its care home provision to form a strategic partnership with Hafod Care Association in 2002.

1 Capacity in Regency House increased to 53 in January 2008

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Graph 6.3

Torfaen Bed Vacancies - Monthly Average

Apr 06 - Jun 07

-1.00

1.00

3.00

5.00

7.00

9.00

11.00

13.00

15.00

Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07 May-07 Jun-07

Nu

mb

er

of

va

can

cie

s

Res monthly average

Gen Nurs monthly average

EMI monthly average

EMI Nurs monthly average

Graph 6.3 shows that the average monthly vacancy levels in Torfaen for all categories of care for older people has been low for the period April 2006 to June 2007. There was an increase in the general nursing bed vacancies in December 2006 – February 2007. For general residential care, there have been low vacancy levels throughout the period since July 2006 indicating low capacity within the borough. The low vacancy levels correspond to high occupancy in the block contracted residential homes. However, there are currently low occupancy levels of Torfaen funded residents in the other 2 spot contracted residential homes, which do not correlate to the low vacancy levels. EMI bed vacancy levels in both residential and nursing homes have been consistently low throughout the period. It is has been difficult to secure EMI beds. Efforts have been made to secure block contracts with local providers for EMI residential, nursing and respite placements. However, a tender in January 2006 failed to provide suitable provision at that time. There is a correlation between the low number of vacancies in all categories between August 2006 and November 2006 and the significant increase in delayed transfers of care in the same period. Evidence from Pan-Gwent vacancy lists suggests that the vacancy and capacity issues are similar in other authorities, with 5 local authorities

25

competing with each other and the Local Health Boards for a limited supply of certain beds. Working jointly to identify common themes and develop approaches to addressing the issues relating to capacity, performance and cost of care home beds should be explored further. There is a continued trend of low vacancies in Torfaen’s care homes at times when DToC levels are high. This indicates limited capacity, especially in residential, EMI residential and EMI nursing registered homes. Cross border commissioning arrangements should be explored in an effort to build capacity and work through common contracting issues. Table 6.4

HOME Registration No. of EMI Beds

No. OPMH Service Users

Percentage of OPMH Service users in EMI registered beds

ARTHUR JENKINS Residential 0 2 No EMI

BRYNAWELON Nursing 0 4 No EMI

CWMBRAN HOUSE Residential/EMI Residential 6 14 234%

EMLYN NURSING HOME Nursing 0 1 No EMI

HOLLYLODGE EMI Residential 21 9 43%

LEADON COURT Nursing 0 5 No EMI

LLANYRAVON COURT Nursing 0 4 No EMI

MAYFLOWER Residential 0 2 No EMI

NEW INN Nursing 0 4 No EMI

PANTEG NURSING HOME Nursing 0 3 No EMI

PLAS Y GARN Residential/EMI Residential 8 14 175%

REGENCY EMI Residential 38 9 24%

ST DUNSTANS EMI Nursing 39 26 67%

THISTLE COURT NURSING HOME EMI Nursing 36 20 56%

THOMAS GABRIEL Nursing 0 4 No EMI

TY BRYN Residential 0 1 No EMI

TY CEIRIOS Nursing/EMI Nursing 20 8 40%

TY GWYN Residential 0 7 No EMI

Grand Total 174 137

(Source: OPMH Team) Table 6.4 above shows the number of service users, whose cases are managed by the Community Mental Health Team, who are currently in residential or nursing care within Torfaen. The figures above suggest that there is a lack of EMI residential care available to Torfaen within the Borough. Block contracted residential care homes are being overused by mentally ill service users. However, beds within the independent sector care homes that specialise in EMI Residential care are being underutilised by Torfaen service users, and this can also be seen in Table 6.4 above. However, as the vacancy graph in Graph 6.3 shows this does not result in low occupancy. To the contrary there are limited opportunities for the Council to secure specialist EMI residential, nursing or respite care within the borough, despite having a significant number of beds of this type.

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In October 2007, a total of 25 service users were awaiting and EMI registered care home placement. This is broken down as follows:

• 3 service users awaiting an EMI nursing bed (all from hospital)

• 22 service users awaiting an EMI residential bed (7 currently on a hospital ward and 15 in the community)

Table 6.5 below shows that 40 service users were placed out of county as at July 2007. Whilst some service users will be placed through their own or their family’s choice, having expressed a preference to live in another county, the majority would have been placed out of necessity, due to lack of provision or capacity within the borough. Table 6.5

OOC HOMES No. OPMH Service Users

ASHBURY LODGE 1

BANK HOUSE 1

BEARWOOD NURSING HOME 1

CAERLEON HOUSE 1

DAN Y GRAIG 1

FLORENCE JUSTICE 1

GELLISEREN CARE HOME 1

GLANBURY 5

GLASLYN COURT/LODGE 3

GLASLYN HOUSE 1

GLENMORE 1

HEATHERSIDE (Basingstoke) 1

OAKDALE MANOR 1

PLASGELLER 5

ROZELLE NURSING HOME 2

SHIREHAMPTON 1

THE ROOKERY 2

TREGWLLIM 2

TY CWM EBBW VALE 7 TY DERWEN RESIDENTIAL HOME 1

WHITE ROSE CARE CENTRE 1

TOTAL 40

(Source: OPMH Team) Evidence from Pan-Gwent vacancy lists also suggests that the vacancy and capacity issues are similar in other authorities, with 5 local authorities competing with each other and the Local Health Boards for a limited supply of certain beds. Working jointly to identify common themes and develop approaches to addressing the issues relating to capacity, performance and cost of care home beds should be explored further. There is a continued trend of low vacancies in Torfaen’s care homes at times when DToC levels are high. This indicates limited capacity, especially in EMI residential and EMI nursing registered homes. A high number of out of county placements are made out of necessity rather

27

than choice. Cross border commissioning arrangements should be explored in an effort to build capacity and work through common contracting issues. Care Homes Contracting Arrangements The majority of residential and nursing home placements in Torfaen are currently spot contracted, which means that when a vacancy arises the home is free to sell the placement to the host local authority, another local authority, the Local Health Board or private individuals. The disadvantage of this type of contracting, where there is limited capacity, is that the host local authority has no priority over placement in the homes. There is also uncertainty over the contract terms such as the fee, as these are set individually. Both market forces and a “first come - first served” basis apply in this type of contracting. The advantage is that the arrangement allows flexibility and should capacity be improved then there is no obligation on the local authority to admit to homes to ensure void placements are filled. Block contracting is the arrangement whereby a local authority can purchase a certain number of beds by way of a fixed term contract, at fixed rates. The advantage when there is limited capacity is the certainty that a number of beds are available to the local authority and certainty over the price of the bed as it is fixed from the outset through the contract terms. The disadvantage is that when there is limited demand for a certain type of bed (either residential or nursing) voids can arise and the local authority will be obliged to pay for this arrangement. In order to put in place short term measures to reduce the number of delayed transfers of care, a number of block contracts have been put in place with local care home providers in addition to the existing block contract with Hafod Care Association. The following is a breakdown of the number of beds currently being block purchased in EMI registered or general nursing homes:

• 6 EMI Residential - Pontnewydd

• 16 EMI Residential –Penygarn

• 1 EMI Residential Respite Beds – Pontypool

• 4 Transitional EMI Residential Beds - Pontypool

Discussions are also underway to secure 4 additional EMI transitional beds in Coed Eva, Cwmbran. The EMI respite bed and the Nursing Rehabilitation beds will allow for planned and unplanned periods of respite and rehabilitation, which in some cases will prevent unnecessary admission to hospital or earlier discharge from hospital. However, care home framework agreements and monitoring of contracts need to focus more on outcomes, to meet with the national guidance in Fulfilled Lives Supportive Communities, which requires local authorities to commission

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for outcomes. There are currently a number of quality measures within service specifications, but these need to be reviewed to ensure that outcomes are being stipulated and to allow a framework for measurement. Block contracts are operating at full or near full occupancy for both long term and short term placements. A review of the more recent block purchases should be undertaken after 12 months to assess the long term effectiveness for reducing and preventing system delays. Future Care Home Provision National Minimum Standards for Care Homes (Standard 37.13) requires that single beds in care homes make up 80% of resident placements by 1st April 2007 and at least 85% by 2010. Therefore, a telephone survey was undertaken to establish what effect this will have on the bed capacity in Torfaen homes up to 2010. A number of homes have planned extensions to their premises to increase capacity and therefore the percentage of care home beds. Following a telephone survey of local care homes it was established that, should plans be sought, obtained and realised that there will potentially be the following increase in the number of beds in Torfaen care homes for older people:

• 55 general nursing beds

• 20 – 40 EMI nursing beds

• 43 EMI residential beds

• 9 general residential beds There is both a shortage and under-utilisation of available beds in the Borough. This has led to a further reduction in bed vacancies available. There is a particular shortage of EMI beds in both categories; however some homes have plans to increase capacity. There could be an extra 127 care home beds. Respite Planned respite allows carers to have a break from their day to day caring role, so that they are able to continue to provide care without impacting on their own health and wellbeing or, for example, to allow them to attend appointments, functions etc. There are also occasions when a period of respite is unplanned for example due to either an emergency relating directly to the service user or where a carer has themselves been incapacitated or is unable to provide care for an unforeseen short period. Some care homes offer beds by way of spot contracts for respite purposes. However, this is often only where a vacancy has arisen and this is not often possible to plan in advance. It is easier to plan respite or react to the need for

29

unplanned respite where provision is guaranteed, usually by way of a block contract. The current provision in Torfaen is as follows:

• 1 EMI Residential Respite Bed – Pontypool Mental Health Team The Community Mental Health Team (Older person services) The Community Mental Health team for the Older Persons Services key role is to provide assessment, treatment and support for older people with mental health problems. An important element is to support the older person to remain in their own homes and promote independence. The team includes a range of professionals within services including the following: Treatment and assessment beds for people over 65 10 beds are available and currently are divided into 8 assessment beds for people with dementia and 2 beds for those needing assessment for related functional problems. A team of registered nurses and community psychiatric nurses (CPN) are available with input from Occupational Therapy. Day Hospital This can used be as an alternative to an admission to hospital and supports people to maintain skills in their own environment. Although the current model is the right approach for some patients, other patients might benefit more from community based activities or other models of day activity. Resources as follows: Functional

• 1 Senior Nurse

• 1 Qualified Nurse

• 2 Non-qualified support staff Dementia

• 1 Senior Nurse

• 2 Qualified Nurses

• 2 Support Staff Home treatment team 8am – 8pm. The team includes nurses and occupational therapists and offers an alternative to admission to hospital. The resources for this team are:

• 3 Community psychiatric nurses (CPN) (these will have been included in team information below)

• 2 CPN Assistants (these will have been included in team information below)

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The Community Psychiatric nursing team has strong links with colleagues in the social work Team and ward staff based at Ty Siriol to ensure that where long term intervention is needed the transition through Care Management and Review is a smooth one, as well as colleagues in the Intermediate Care Team and Community Intervention Team. They also forge strong links with Community Nursing Teams, external provider agencies and the voluntary sector. Medical staff resources are as follows:

• 1 consultant psychiatrist

• 1 associate specialist

• 1 clinical psychologist (not full time) Nursing staff resources are as follows:

• 1 Team Manager (split across older people and adult services) Ward staff

• Senior Nurse

• 9 WTE qualified nursing staff

• Support staff (non-qualified) Community

• 2 Senior Nurses

• 4 Generic CPNs

• 3 Non-qualified support staff

• 1 Psychiatric Liaison Nurse

• 1 RMN working in reach into care homes

• 2 Senior OT The social work team moved into Ty Siriol last year and this has improved communication, teams work very closely and with the introduction of the Care Programme Approach (CPA) this continues to be the case. The team consists of the following staff:

• 1 Team Manager (split across older people and adult services)

• 1 Assistant Team Manager

• 3 Approved Social Workers

• 4 Social Workers / Reviewing Officers

• 2 Community Care Workers

• 2 Administrators Torfaen is resourced with a co-located social work and NHS mental teams to meet the needs of older people with mental illness. Improvements have already been seen in this approach and further improvement could be achieved through greater integration.

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Domiciliary care provision and support at home

The WAG report “When I’m 64 . . . “(2002) reported that nearly half of all dementia sufferers are cared for in residential care. Greater numbers of people in the early stages of dementia could remain at home for longer periods, if adequate services were available in the community. Dementia care specialists can help arrange practical care and assist families to cope. Torfaen developed a specialist Support and Monitoring service (SAMS) in 2002.

An exercise undertaken in October 2006 identified the number of service users and contracted hours provided by both independent sector domiciliary care agencies and in house home care. Table 6.5 below shows the number of service users and hours provided in total to older people with mental health needs in Torfaen by area.

Table 6.6 – Domiciliary Care for older people mental by area2 (October 2006)

Area No. service users Hours Per Week

Abersychan

Blaenavon 6 63

Blaendare

Coed Cae 1 15

Coed Eva 2 15.25

Croesyceiliog 9 57.25

Cwmavon

Cwmbran 5 64.5

Cwmfields

Cwmynyscoy 1 7

Fairwater 4 46.5

Forgeside 1 5.25

Garndiffaith 1 3

Greenmeadow 1 1

Griffithstown 4 27

Henllys 1 21

Hollybush 1 2

Llanfrechfa 2 9

Llantarnam

Llanyravon 6 55.5

Lower Cwm

New Inn 6 40

Northville 4 19.25

Oakfield 3 31

Old Cwmbran 2 11.25

Penygarn 1 20

Ponthir 3 21.5

Pontnewydd 16 88.25

Pontnewynydd 1 0.5

Pontrhydyrun

Pontymoile 1 3.5

2 Areas used are taken from the entry in DRAIG (Torfaen’s database of service users) and do

not necessarily match the wards of Torfaen

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PONTYPOOL 1 7

Sebastopol 2 24.5

Southville

St Dials 4 33.25

Talywain

Thornhill

Trevethin 2 6.25

Two Locks 3 44.5

Ty Canol

Ty Coch

Upper Cwmbran 2 18

Upper Race

Varteg 1 5

Wainfelin 2 13

Unknown 5 42.75

Grand Total 104 821.75

It can be seen from the table above that services are currently higher in those areas with high numbers of older people, such as Blaenavon and Pontnewydd but also in Croesyceiliog where it is estimated that there will be growth in the population of older people in the next 5 years. Of the figures above the number of hours and service users can be broken down as follows: Table 6.7 – Hours provided to older people with mental health needs by domiciliary care providers in Torfaen through Social Care and Housing (October 2006)

Provider No. Service users Hours per week

Torfaen CBC 11 72.25

Block contract Dom Care 25 181.75

Block contract ISS 1 48

Other independent provider 67 749.5

Grand Total 104 821.75

The 821.75 hours provided to people whose care is purchased by the mental health team when this snapshot was taken represented 13.5% of the total hours purchased for older people and 10% of the 8265 hours provided to all client groups. Providing domiciliary care to people with dementia requires specific skills and training and this could be developed further to make further use of domiciliary services for this client group. 10% of domiciliary care services purchased by the authority is provided to mental health team service users. This supply could be increased with workforce development linked to the reconfiguration of the in house team which will provide specialist dementia services.

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Domiciliary Care Contracting arrangements Following the needs analysis in October 2006, a tender was undertaken in 2007 to contract for 3 blocks of 1000 hours domiciliary care in addition to the CCS domiciliary care block contract. One thousand (1000) hours of the existing block contract for generic domiciliary care was put out to tender in December 2007 and the process is ongoing. The ISS section of the contract is due to expire on 30th November 2008. The ISS service is a flexible service designed to help more vulnerable people with high needs to stay at home for longer and consideration will be given to how this service can work alongside generic care, intermediate care and complex health care provision to meet the needs of the ageing population in the borough. This service will be reviewed during 2008/09. Following implementation of new block contracts in 2008, 4000 hours of generic domiciliary care will be delivered by block contract providers (although this includes hours provided to people aged under 65). The brokerage team is tasked with ensuring allocation of care packages. Block contracting for domiciliary care will allow both stability and choice for the service users, whilst maintaining a spot purchase market to allow further flexibility. The in-house reconfiguration will allow more efficient use of the independent sector and will re-focus services to become more outcome focussed. NHS Continuing Health Care A total of 74 patients over the age of 65 years receive care packages through NHS Continuing Healthcare funding arrangements. Of this total, 4 patients are categorised under the “Mental Health” category in the following sub-categories: Table 6.8: Continuing Care Packages for older people mental health by sub category (December 2007)

Type Total

Mental Health (awaiting placement) 1

Community Package 1

Nursing Home Placement 2

Grand Total 4

It is likely that, due to their primary health needs being disability or illness, there may be a number of patients who have dementia type illnesses categorised under the Adult Physical Disabilities category. There is evidence that this is the case for at least 3 service users, who are placed in EMI registered nursing homes in Torfaen. The Local Health Board is responsible for commissioning and contracting for NHS Continuing Care placements in Torfaen and neighbouring authorities

34

(pan Gwent). Contracts and specifications are framework agreements with individual contract terms for each patient placed. There has been a significant increase in NHS Continuing Care Packages since the Local Health Board has become responsible for the commissioning and contracting of continuing care packages. Further increases are anticipated within the next 5 years. Extra Care Extra care accommodation, which uses dementia design best practice, can support a significant proportion of service users to remain within Torfaen, in a facility that maximises independence and adapts care support to their changing needs. The first extra care facility in Torfaen is being built on the site of the former George Lansbury residential care home, with the former residents having moved across to new wings built at the Cwmbran House care home in June 2006. The new scheme will have 35 extra care flats, of which 12 are two bedroom units for couples. Extra Care provides people with their own tenancy and front door, but with access to 24/7 support and a range of shared facilities, including IT suite, assisted bathroom, laundry facilities, catering kitchen and dining room for cooked meal, as well as secure landscaped outdoor environment. Extra care caters for a range of care needs, seeking to maintain a balance between low, medium and higher care requirements with the flexibility to adjust care packages to individuals on a week to week basis through an overall block contract for care and support. It is anticipated that the new build will be completed in early summer of 2008. The extra care scheme has featured in the Supporting People Operational Plan (SPOP) over the last three years, and is part funded through a successful Social Housing Grant (SHG) bid, working with local registered social landlord (RSL) housing consortium, GENuS. The scheme funding is based on all units for rental with local authority having 100% nomination rights Technology and Telecare Telecare can be summarised as the remote or enhanced delivery of health and social care services to people in their own homes by means of telecommunications and computer based systems. This would include alarms, that are either automatically or user activated (such as Lifeline pull cords, or Falls detectors), sensors that detect risks and give alarm to monitoring centre, such as flood detectors or extreme temperature sensors, and monitors, that enable the recording of movement information – such as leaving the house, getting up from bed – and which can be programmed to give alert if returns not within set time. There is opportunity to develop and extend the use of Telecare to help manage the risks attendant on both frail elderly people and those with levels of confusion in remaining within their own home. A Telecare pilot was run in

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Torfaen in 2005/06 with a small number of community users, and this has led to a range of recommendations following evaluation reporting. Torfaen’s social care adult performance indicators show the following supply of assistive technology as at March 2007:

• 1332 Lifeline alarms

• 893 Community alarms

• 17 REACT (now SMART) packages A rolling programme of equipment and extension upgrades for existing Lifeline users has gone forward. This has been undertaken by Torfaen Operational Services electricians and has not involved any assessment but replaced aging equipment with a base level package which allows for ready “add-on” should needs increase. As at end of December 2007, 143 had been installed. Telecare uses state of the art technology to assist people to live as independently as possible. The benefits of the project should be explored to see how this technology can fit with future accommodation provision for older people. Accommodation and adaptations The majority of older people in Torfaen own their own property. However, there is a significant proportion of rented accommodation for which support is available to 2,368 units through supporting people funding. To meet the requirements of Designed for Life and Fulfilled Lives, Supportive Communities the accommodation needs of older people will need to be reviewed to ensure there is sufficient supply to meet demand. Day Activities Dementia Group Dementia Group based at Cwmbran House offers social opportunities to older people with dementia and associated issues. There are 12 places available per day; referral initially is via social worker and will be submitted to panel. The group offers a range of activities to people with a mild to moderate dementia. Personal care issues can be addressed by the staff. Day Activities brokerage and support service The Day Activities team hosted by Torfaen MIND helps service users who are known the Mental Health team to access appropriate community based day activities, providing support where necessary. The service has been extended to people of all ages with mental health needs including older people. This will mainly apply to older people with functional mental illnesses. However, people with dementia will have equal access to the service.

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Advocacy The service provided by South Wales Mental Health Advocacy only covers people with mental illness up to the age of 65. People over 65 can access an advocacy service, but only if they are currently living in or considering a long term care placement (residential or nursing). Also this has not been as effective for older people with dementia. There is no advocacy service available for older people with dementia who wish to remain supported in the community. The role of advocates for people with mental health problems will become more critical following the implementation of the Mental Capacity Act and when the revised Mental Health Act is implemented. The LHB will have delegated responsibility for commissioning Independent Mental Capacity Advocates and they might also play a role in the commissioning of Independent Mental Health Advocates. Voluntary Sector Contracts Voluntary Sector services to older people The contracts with voluntary sector providers formalise grant funding arrangements, within the contracts a service specification outlines the purpose and objectives of the service, against which performance of the provider is measured The following information gives details of the voluntary sector agencies that provide services in Torfaen by way of a fixed period service contract (known as contracts with end date - CWED). The following information is taken from the service objectives of each of the CWEDs. Fuller details of the contracts can be found in Appendix 8 Voluntary sector organisations provide a valuable and flexible service and can often add value to the money available through local authority or NHS funding by accessing grants not available to statutory bodies. A review of the effectiveness of contracts is required on a rolling programme to ascertain value for money of each service to ensure that they effectively meet departmental and corporate priorities of both the Council and the Local Health Board.

37

Further funding is available to voluntary groups through grant funding arrangements facilitated by the Planning and Development Team (Social Care and Housing) or national grant schemes. A review of these services is also needed and service level agreements put in place to provide a framework for measurement to ascertain whether value for money is being achieved. Voluntary sector agencies can provide innovative flexible services. However, performance and value for money needs to be measured to ensure the services fit with national and local priorities.

Table 6.9: Voluntary sector contracts

Establishment Brief description of service

Alzheimer’s Befriending Project

To provide support to people with dementia and their carers from the time of diagnosis, throughout the course of the illness and until such time as the support is no longer needed.

Gwent-wide younger adults dementia service

To provide support to people under 65 who develop dementia.

BRC Medical Loans

Equipment Loan Service to meet the needs of those who need assistance on a short-term basis or provide temporary assistance to those with longer-term disabilities awaiting assessment and permanent supply of equipment.

Cwmbran House - Day Activity Support

To provide a structured programme of stimulating daytime activity for people referred to the scheme, as well as respite for their carers

Gwent Healthcare NHS Trust (Community Equipment Service)

Provision of a joint community equipment service

Day Activities Support Extended contract to link older people with mental health needs to meaningful day activities opportunities and provide support

38

Referral And Assessment

Social Care –Council

2006/07 outturn £

2007/08 budget £

2008/09 Budget

Total Net Expenditure Older People Mental Health EMI

6,975,923 2,068,888

8,175,759 2,575,117

Includes Gross

Older Persons Care Management Residential

393,492

Nursing VR Care Respite Nursing Meals

1,716,646 821,970 11,030 1,092

Home Care External 1,312,243

Respite – Residential Other Non Residential

11,911 16,437

Direct Payments 74,954

Total Block Contracts In House Home Care External block Contract Voluntary Sector Age Concern Gwent (HDS) Age Concern Advocacy Age Concern Torfaen Miners Group Torfaen Crossroads Client Income Residential and Nursing Care Database

4,359,780

1,426,190- 60% = 855,714

950,322 – 72.5% = 688,983

186,605

46,404 43,655 36,397 3,904 56,245

870,594

4,987,404

1,527,744 – 60% = 916,647

990,696 – 72.5% = 718,254 191,270 47,564 44,746 37,307 4,002

57,651

821,500

Mental Health EMI Residential

831,348

Nursing Day Care VR Care Respite Nursing

1,752,266 6,660 15,999 17,215

Home Care External 464,295

Respite – Residential Other Non Residential

112,410 3,536

Total Block Contracts In House Home Care Care Line Contract Client Income Residential and Nursing Care Database

3.203,728 Included under Older Persons

Care Management

1,007,965

3,471,117

896,000

39

VR Care 1,597

Home Care External 58,784

Other Non Residential 410

Direct Payments 2,117

Total Block Contracts In House Home Care Care Line Contract Client Income Residential and Nursing Care Database

62,889

N/A N/A

0

100,115

• Includes staffing costs which cover both Older Persons Care and EMI

Housing –Council 2006/07

outturn £

2007/08 budget £

2008/09 Budget

Total Net Expenditure is zero All Grant Funded

Supporting People

HRA Sheltered Schemes 615,615

HRA – Community Alarms 97,952

Torfaen Telecare Project External Providers Eastern Valley Housing Association Gwerin Housing Association Aelwyd Housing Association LINC Cymru HA Ltd Other TeSS Age Concern

11,302 9,750 4,699 656 10,670 204,325

Other Council Services 2006/07 outturn £

2007/08 budget £

2008/09 Budget

Total Net Expenditure

SMAT

Etc

40

Health 2006/07 outturn £

2007/08 budget £

2008/09 Budget

Total Net Expenditure

Continuing Care - Local

Continuing Care- Wales

Voluntary Sector etc

Service performance Contract compliance reviews undertaken in 2006/07 indicate that there has been an overall improvement in performance. Staff turnover continues to be an issue, particularly for domiciliary care providers. Improvement plans and care management feedback have identified trends which suggest various workforce development issues, most of which can be supported by the Council. It is significant that care management feedback has identified that nursing homes rate lower than other services. This has been reflected by the increased monitoring in 5 nursing homes in the borough following the suspension of new business at those establishments. Improvements have started to be made at these homes and there are currently no suspensions in place within Torfaen. Non-compliance or partial compliance with the contract terms and specification within the Framework Agreement generally indicates poor systems within the organisation and/or a lower standard of management than would be expected by Social Care and Housing. It is also evident from a number of the POVA issues that poor management is the route cause of the problems. Therefore, improving compliance and subsequently improving systems will be a key aspect of improvement plans when dealing with poor performance and POVA’s. Managing contracts with poorly performing providers can involve significant resources and impact on the capacity to make new placements. The quality of provision in some care homes has given rise to considerable concern. However, improvements have been made and there are currently no suspensions in place within Torfaen. Managing contracts with poorly performing providers increases the workloads of all those involved, including social workers, senior managers, Performance Team, Adult Protection Team and providers themselves. Improvement plans require regular monitoring and suspended business impacts on capacity, creating blockages in the system. However, improving the quality of services is critical to ensuring the safety and enhanced quality of life for older people.

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Summary of Service Quantity and Service Performance

• There is limited capacity of care home beds in the Borough. This has led to a further reduction in bed vacancies available to Torfaen County Borough Council. This is not sustainable and must be addressed.

• The quality of provision in some care homes gives rise to considerable concern.

• There is a particular shortage of EMI beds in both categories; however some homes have plans to increase capacity for EMI.

• There is limited availability of respite care in care homes or in the community

• There is a need to review the recently increased block purchase arrangements in care homes ensure they are meeting the needs of older people and helping to reduce and/or prevent system delays

• There is a clear strategy to build capacity in domiciliary care, but the service must become outcome focussed to concentrate more on re-ablement and specialist needs, including children’s services.

• Contracts and specifications need to be redrafted and made more outcome focussed

• Cross boundary commissioning arrangements must be explored to build capacity and make better use of available resources

• There is a need to explore and review the role of the voluntary sector in providing ‘signposted’ services and increase their preventative role

• There is a need to build on the role of the Social Care Partnerships Torfaen Group to further address workforce development needs and to engage providers further in the development and re-shaping of services

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7. GAP ANALYSIS Care home gaps Chart 6.3 shows the percentage of beds in Torfaen homes that were occupied by Torfaen Social Care and Housing funded residents or available to Torfaen residents as at July 2007, and those occupied by self-funded residents, other local authority service users or continuing healthcare funded patients. There were 181 beds EMI Registered beds as at March 2007. At July 2007 only 112 were available to or occupied by service users of Torfaen Social Care and Housing (62%) (Source: RICS database). The remainder (38%) were self-funded, funded by other local authorities of fully funded NHS continuing healthcare placements. A further 40 service users were placed out of county. Graph 7.1

% Beds occupied by / available to Torfaen at 3 July 2007

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Arthur

Jen

kins

Bryna

welon

Cwm

bran

Hou

se

Emlyn

Hol

lylod

ge

Lead

on C

ourt

Llan

yraf

on C

ourt

May

flower

New

Inn

Pante

g

Plas-

y-G

arn

Reg

ency

Hous

e

St Duns

tans

Thist

le C

ourt

Thom

as G

abrie

lle

Ty Bry

n

Ty Cei

rios

Ty G

wyn

% Beds occupied by

other

% Beds occupied by /

available to Torfaen

(Source: RICS Database)

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Graph 7.2 Care Homes registered for EMI

% Beds occupied by / available to Torfaen at 3 July 2007

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Cw mbran

House

Hollylodge Plas-y-Garn Regency

House

St Dunstans Thistle Court Ty Ceirios

% Beds occupied by

other

% Beds occupied by /

available to Torfaen

(Source: RICS Database) There is clearly a gap in the number of beds available to or occupied by Torfaen funded residents and the total number of beds in the borough. Graph 7.1 shows number of beds occupied by Torfaen service users in Torfaen Care homes since April 2006. Graph 7.2 is more specific to homes that are currently registered to provide services to older people with mental health problems. Cwmbran House and Plas y Garn operate under a block contract with Torfaen; therefore a higher occupancy level would be expected. Percentage of beds occupied by “other” could be privately funded, purchased by another local authority, NHS Continuing Healthcare funded or occupied by a respite placement. As respite placements have not been included in long term figures, the occupancy at Cwmbran House and Plas y Garn appears below 100%.

The following chart shows the current capacity for EMI residential and EMI nursing against forecast growth in demand for this type of service in 2012 (based on RKW figures).

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Graph 7.1

Although the figures above would suggest there is currently sufficient capacity in EMI residential care, as highlighted in the charts above the numbers actually available to the Council were significantly reduced. In both cases it is evident that the Council and the LHB need to work jointly with the providers to ensure future capacity can meet the demand, without causing an oversupply of long term care beds.

There is limited availability of care home beds in the Borough to Torfaen Social Care and Housing. In July 2007 61% of beds in the Borough were available to or occupied by Social Care and Housing service users. 40 older people with mental health needs placed in care homes in July 2007 were placed out of county. The growth in number of people with EMI nursing needs will mean that there will not be sufficient EMI nursing beds in the borough to meet the forecast demand.

Care Management consultation

Performance and Planning Officers attended meetings with the co-located Adult Mental Health team, which included both social work and clinical staff (consultants and CPNs), to ascertain the professional view of where there are gaps in current mental health service provision. Staff were asked to think about what services are currently available and any problems with existing service provision. However, the main focus was to identify what services staff felt were missing that could contribute to an improvement in provision to this client group. The main areas that were considered were as follows:

• Domiciliary Care provision

• Care homes and other accommodation

0

10

20

30

40

50

60

70

80

90

Placements05/06

Projections2011/12

Currentcapacity

Figure 1 – EMI Residential Care

88

90

92

94

96

98

100

102

104

106

108

Placements05/06

Projection2011/12

Currentcapacity

Figure 2 – EMI Nursing care

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• Respite

• Day activities

• Transport

• Voluntary sector services

• Health Services

• Direct Payments

• Aids and adaptations

• Joint working

• Internal health and social care services Domiciliary Care Provision The groups highlighted some issues with the current provision of domiciliary care, which is often generic in nature and focussed mainly on the needs of older people with no mental health needs. Problems noted in current provision were as follows:

• Services are not flexible and vary in quality

• Some calls are too long for simple calls e.g. medication prompts (not cost effective)

• Care staff are not sufficiently trained to address emotional need. Services are orientated more toward more physical aspects of care and are focussed on tasks rather than outcomes.

• Care staff training is not flexible with changing needs of older people with dementia (although this can be addressed by a specialist dementia service)

• Service delivery plans and review documentation do not provide sufficient information to inform effective care management.

• Generally poor communication between agencies and stakeholders The following areas were highlighted as gaps in domiciliary care provision:

• It is generally accepted that there is a need to move to an outcome based model of care service delivery.

• There is a general lack of male care staff in this sector

• A specialist domiciliary care/support service needs to be implemented for older people with dementia whose needs are complex

• Sufficient provision of supported living services which doesn’t integrate mental health service users inappropriately with learning disability service users

• Some night sitting services are available but not sufficient to meet demand (it is a very ad hoc service at the moment and therefore not able to build on continuity or provide consistency)

• Domestic only service which is a key need for some older mental health service users

• Whilst outcomes are an important area for development there is a need for short medication prompt calls. There is a real gap here, because when medication prompting is the only requirement of the package, it is

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not necessarily a social care call, but a health call. But the package would not be funded by LHB under complex care or continuing care.

• In addition to prompting, there is a need for medication monitoring that requires more specialist training than prompting or administering, but does not necessarily require a nurse. However, there needs to be a greater number of non-nursing health care staff who have sufficient training/qualifications to administer medication

• There needs to be wider availability of flexible care at home packages for both health and social care for continuing care patients

• A specialist domiciliary care service which is in house so that it can work more closely with the mental health team to manage complex cases.

Care homes and other accommodation There were some problems highlighted with current market conditions, mainly around financing placements. The Council is continually having to compete on price and capacity for services with other authorities and self-funded residents. The following gaps in service provision were noted:

• Further development of extra care facilities for older people with dementia

• Sheltered accommodation that meets the needs of older people with functional mental health problems

• There no longer appears to be sufficient numbers of wardens in sheltered accommodation to reduce risks for older people with dementia

• The group considered the possibility of resident nursing staff in larger sheltered/extra care schemes that would complement district nursing teams i.e. dedicated staff in sheltered/extra care accommodation

• There is a lack of appropriate residential placements to meet the needs of people with functional mental illness and therefore not integrating these service users inappropriately with older people with dementia

• There needs to be further development of telecare services that can effectively meet the needs of older people with dementia in the community without increasing risk

• Specific care home and supported living service for people with co-occurring substance misuse and mental health diagnosis. This is a problem that is becoming more apparent as the older population increases

• There is not sufficient local bed capacity in EMI registered nursing and residential homes which is both affordable to the Council and LHB but which also offers quality services. Block purchase arrangements need to be revisited.

• Lack of availability of reablement services within private registered settings to encourage step down back into the community.

• There is a lack of safe outdoor facilities and activities for older people with mental health problems, in both care homes and supported housing schemes

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• There are low numbers of male care staff

• Improved activities within care homes which are meaningful and sufficient in priority. There need to be more dedicated activity staff in homes. Meaningful activities would include group activities, community access without extra cost to families, films. St Dunstans Nursing Home has a good example of a stimulating activity programme

Respite Staff highlighted that hospital wards are not an appropriate environment for respite in most cases unless there are complex nursing needs which cannot be met in the community. Furthermore some respite can be disruptive to the service user’s independence and for their carers when they return home. To prevent this some transition/reabling work could be undertaken towards the end of respite period to facilitate discharge home. Staff also highlighted that delays in the process for agreement for continuing NHS Healthcare funding following MDT can often delay the provision of respite care. The following gaps in respite provision were highlighted by groups:

• There is not sufficient general respite provision to enable carers to have a break

• There is not sufficient availability of EMI Residential and EMI Nursing registered care home based respite which are quality and affordable, in locations to suit individual choice and which are solely available to Torfaen residents (i.e. block contracted)

• There is not a variety of respite options for carers who work during the daytime and for those who only require some evening and weekend support

• Some night sitting services are available but not sufficient to meet demand

• There is limited availability of specialist training to support staff to improve skills in relation to working with complex mental health cases

• A Younger person with dementia Project (Alzheimer’s Society) has been running for two years and has been well supported in Torfaen. It has supported the development of effective carer support but current funding arrangements come to an end in March 2008. This has been seen as a successful project and would be beneficial to continue. It has strengthened relationships between the care providers in the borough.

Day Activities The groups noted that there is an inconsistency in the provision of meaningful, socially inclusive day activities for older people with both functional and organic mental health problems. The traditional model of centre based days services is not always appropriate. There also appears to be an inability to share information and there is insufficient feedback from providers to effectively inform care management.

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The following gaps in respite provision were highlighted by groups:

• There needs to be a review of the day hospital and how day activities can support this to be used appropriately and effectively

• There is a general lack of day activities specifically for older people with functional mental health problems

• There are few wellbeing activities covering diet, exercise etc.

• Services tend to operate during office hours (i.e. 9 to 5) and there are no evening activities available.

• There are no gardening and other safe outdoor activities for older people which are not just centre based but also in their own homes

• There is limited availability of specialist training to support day support staff to improve skills in relation to working with complex mental health cases

Transport Transport options are limited if the service user and/or carer does not have access to their own transport. Non-emergency transport for NHS patients often stretches ambulance services. The following gaps in transport provision were highlighted:

• There is a lack of transport available to service users and carers to access regular appointments, respite or day activities.

• There are no non-emergency transport options for NHS patients that would not stretch the ambulance services

Voluntary Organisations The voluntary sector can provide innovative and creative services to meet the needs of people with specialist or complex needs, and often have access to funding that the local authority cannot. However there is limited capacity and availability for all service users within existing services. Furthermore, short term grant funding can prevent ongoing development of projects. Voluntary sector organisations need to look for longer terms funding streams and improve sustainability of projects There were a number of gaps highlighted, as follows:

• There are limited evening and weekend services from voluntary organisations.

• There should be a development of a model of intent based on wellbeing and recovery rather than focussed on crisis management

• There needs to be a specialist advocacy service which can obtain the views of care home residents as part of the monitoring of care home quality

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• There needs to be a specialist advocacy service in the community for people in their own homes

• There is a lack of staff training or advocacy services available in the voluntary sector to support people who still have capacity to have control over decisions which will affect them at a later stage when their mental health deteriorates

• There needs to be an improvement in the interface with the voluntary sector whilst patient is in hospital to help transition arrangements.

• A similar model to the Young persons dementia project could be developed for older persons

• It would be beneficial to socially isolated service users to develop a telephone befriending service via the voluntary sector.

Health services Due to the merging of the two day Hospitals last year there is perhaps a need to remodel this service. The following gaps in health service provision were highlighted:

• There are no services to address older person specific eating disorders

• There could be further development of intermediate care services in sheltered housing style settings. These services currently focus mainly on meeting physical need rather than emotional need. Therefore intermediate care services should be developed to deal with mental health as well as physical.

• The group considered the possibility of developing a role for “health visitor style” health care assistants, who are not necessarily qualified nurses but whose training and experience helps them understand clinical issues

• There is a need for general home treatment services

• The mental health team needs to be better resourced with CPNs.

• The ward environment has the wrong balance of functional and dementia patients and the ward is not designed for functional patients

Aids and adaptations The limited availability of occupational therapists leads to delays in assessment and the pathway and referral procedures to obtain equipment are often not clear to service users or carers. There are significant risks associated with older persons who wander or are at risk of falling that can prevent discharge from hospital. The following developments or services were deemed necessary:

• There needs to be a cohesive falls support service

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• There needs to be further development of appropriately adapted supported housing opportunities to meet demand, which include telecare services

Joint Working The groups considered the joint working initiatives that could be developed to enhance or improve services, as follows:

• There should be a consistent and ongoing programme of joint training for health and social care services to ensure a mutual understanding and awareness of strategic priorities.

• There is a need to develop joint funding arrangements that are not just limited to intermediate care or continuing care for people living in the community.

• There is a need to further develop the integrated model of service delivery and single line management might be a way to achieve this

• There should be further development of a single point of entry to mental health services through the First Access model

• There is a need to develop transition between working between adults and older people services

• There needs to be further development of joint datasets for health and social care

• A dedicated mental health on-call service should be developed which comprises a team of health and social care professionals which is incorporated into the work stream for crisis services.

Internal The internal services section focussed on current staff and support structures within health and social care and identified the gaps that exist in those areas. Social workers felt that contracting arrangements are often difficult to put in place in sufficient time for the engagement of specialist services as many placements are out of county. There is a time delay for contracts when emergency placements arise. Furthermore, co-ordination of continuation care cases that require several agencies is not consistent and this can lead to breakdown in care arrangements The following gaps were identified:

• There is a model of assertive outreach which works well for younger adults and this could be extended to older people to work with service users whose needs are complex and who are difficult to engage

• There is a need to address certain workforce issues in relation to the number of social workers due to the increase in assessments and caseloads

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• There is a need to address certain workforce issues in relation to the number of clinical staff due to the increase in assessments and caseloads

Direct Payments There is limited awareness of how direct payments or other self-directed support can be applied to older people with dementia or their carers and limited promotion that can lead to underutilisation. Mental capacity issues will affect the availability of direct payments to mental health service users as one of the criteria for accessing Direct Payments is that an individual would need a bank account in their own right. Summary of Gap Analysis The gaps in services available to older people with dementia in the borough are also reflected in the national and local guidance, needs and market analysis of previous sections. Current care home provision shows us that there is an underutilisation of care home beds in the Borough by Torfaen Social Care and Housing. 57% of beds in the Borough were available to or occupied by Social Care and Housing service users. 53 service users of the 381 older people placed in care homes in July 2007 were placed out of county. The key areas for improvement and development, as highlighted by the mental health professionals in Torfaen are as follows:

• Outcome based model of care service delivery

• Sufficient provision of supported living services and night time domiciliary type services

• Gender specific staffing

• Improvement in medication arrangements for those being supported by health and social care workers at home

• Further development of extra care facilities for people with dementia

• Improvements in sheltered housing for older people with mental health needs

• Specialist residential care for functional illness and dual diagnosis illness

• Reablement services within private registered settings

• General respite provision

• EMI Residential and Nursing registered care home based respite

• Variety of respite options for carers who work

• Specialist training to support staff to improve skills

• A Younger person with dementia Project (Alzheimer’s Society)

• Day activities specifically for older people with functional mental health problems

• Gardening and other safe outdoor activities in their own homes

• Transport to access regular appointments, respite or day activities

• A range of non-emergency transport options

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• Evening and weekend voluntary sector services

• Specialist advocacy service which can obtain the views service users with dementia (in their own home or in care homes)

• A model of intent based on wellbeing and recovery

• Rehabilitative services to deal with mental health as well as physical

• Increased health and social care staff resources

• Falls support service

• Increased usage of telecare options for people with dementia

Service User Feedback A meeting was held with the three Torfaen Older People’s Forums on 30th January 2008 at Widdershins Centre. It was attended by circa 50 older people. A presentation of the commissioning priorities for older people and older people mental health was made and opportunity was given to the attendees to comment about the needs and priorities as they affected them. There was a constructive and healthy debate with the key themes emerging as follows: 1. Some people were concerned that palliative care was outlined in the

strategy 2. There was a strong consensus that the majority of people present did

not want to be admitted to residential care homes and wanted to remain at home and die at home. There was also an indication from the majority that people did not wish to die in hospital

3. There were concerns about the quality of care home provision in Torfaen following visits by some attendees to local homes. It was appreciated by many that commissioning and contracting arrangements were looking to address these issues

4. Some attendees enquired about services for older people with learning disabilities. There needs to be a link to the learning disability joint commissioning strategy in the older people commissioning strategy.

5. Transport arrangements for older people was another concern for attendees and they felt this needed a strong emphasis

6. Community safety was a concern where it is causing isolation and depression amongst older people.

7. There was little knowledge of the assistive technology provision (including the SMART house) suggesting this needs further promotion.

Generally the meeting was very positive, and there was general agreement for the service direction within both local and national guidance that will be reflected within the commissioning intentions of this strategy. Stakeholder consultation

During February 2008, 3 consultation exercises were undertaken on the eight commissioning strategies which focussed on whether the actions and priorities of the strategy met the identified and predicted future need. The four key questions that stakeholders were asked to consider were:

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• Do you agree with the priorities developed for this service area?

• Do you agree with the planned actions meet these priorities needs?

• What other priority needs would you like us to consider and why?

• What priorities do you think need to be tackled first? The key themes from the consultation for this strategy is:

• General agreement on the priorities

• The range and quality of needs driven service provision needs to be increased, allowing effective move on through the system

• A range of day activities and day hospital services which is person centred and offers choice

• Increased integration and joint working to ensure both physical and mental health needs are met seamlessly in both secondary and primary care

• Expansion of telecare and alternative care options for older people with mental health problems

• There needs to be a specific strategic implementation group focussing on older people mental health

• To ensure sufficient support and information for carers and broader access to direct payments where possible

• There needs to be a range of appropriate respite options available

• A community advocacy service needs to be developed for people with dementia

• Joint contracting arrangements should be explored across organisational and geographical boundaries

• Care Home fees should be consistent across health and social care

• Out of office hours services should be considered to tackle issues of social isolation

• Tackle issues related to social isolation such as safety in the community and fear of crime

Working closely with voluntary sector partners will be increasingly important to help address the gaps that might result from the need to focus priorities on those in greatest need. Therefore, the action plan will need to reflect a relationship with the voluntary sector that recognises their importance in providing community support services.

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8. MONITORING ARRANGEMENTS Managing External Service Performance Contract Compliance Methodology for framework agreements

Framework agreements are monitored once a year through contract compliance. The approach of the Performance Team has become more joined up with care management, finance, health colleagues and the Supporting People to become more joined up and to not just focus on systems but also on the actual operation of the service specification. Contract management arrangements will need to be reviewed to consider the ways in which outcome focussed contracting can be effectively monitored on a regular basis. A regular programme of contract compliance is scheduled each year and requires the input of Performance Officers, LHB nursing and contracting staff and care managers. The joined up process has begun to show positive results and further work on monitoring for outcomes will improve the system further. Block contract performance management

Block contract arrangements require a different approach to performance management. The Council works more closely, in partnership, with block contracted providers in order to develop services to deliver flexible, innovative and quality services to benefit all client groups. Block contracting has required intensive input from both managers and the Performance Team. The intensity of the input required can increase considerably during periods when performance issues are identified. Generally the quality of services delivered have been of a good standard. However, the performance management required, even when services are running well, requires significant resources and associated costs. The current arrangements for managing block contracts are as follows: Activity

Frequency

Officer involvement

Quarterly performance indicators

4 per year per contract

• Commissioning and Performance Officer

• Performance Officer

Quarterly performance meetings

4 per year per contract

• Commissioning and Performance Officer

• Group Manager

• Finance Manager

• Performance Officer

Six monthly strategy review 2 per year per • Commissioning and

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meetings contract Performance Officer

• Group Manager

• Head of Service

Ad hoc performance review activity (e.g. validation visits)

As required • Commissioning and Performance Officer

• Performance Officer

The key areas of resource intensive activity from the table above for each of the block contracts are those that require preparation, collating data and analysis of data. Collecting and analysing regular performance information is resource intensive, but can be planned. However, the ad hoc performance reviews that are required when shortfalls in performance are identified are resource intensive but cannot be planned from the outset of contracts. Block contract performance management is resource intensive but critical to ensuring that core services are delivering both value for money and agreed outcomes. Voluntary Sector Service Contracts Service contracts are monitored in a partnership focussed way, encapsulating the spirit of Promoting Partnerships in Care. Lead officers from the Performance and Planning & Development Teams and a lead operational manager are allocated to each contract. Partners are required to send regular performance information relating to the objectives of the service so that value for money and effectiveness of the service can be monitored. Two meetings are held each year with voluntary sector partners – a six-month interim partnership meeting and an annual review meeting. The outcomes of performance reviews, meetings and contract reviews is reported to senior management every 6 months, including recommendations for future commissioning arrangements. The quality, frequency and usefulness of information vary between the organisation depending on size and professionalism of the organisation. Some voluntary sector partners are small and administrative processes can be limited. This has made it difficult in the past to collate and analyse information in an efficient way, to inform future commissioning intentions and performance evaluation. Therefore, some further work is required to support organisations to provide regular informative data, where this isn’t happening already. Consideration should also be given within the Council to collating and analysing information regularly to work more efficiently and effectively with the information that the voluntary sector can provide. There are regular meetings with voluntary sector partners, but performance information varies in quality and usefulness to

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commissioners. More regular performance management is required to ensure value for money is being achieved and national and local priorities are being met. Managing Internal Performance The Council has a statutory duty to measure its performance against set targets. For Social Care services, there are two best value targets required through the Wales Programme for Improvement relating to the rate of DToC for older people and rate of older people helped to live at home. Further targets relate to assessment, care planning and service delivery for various services for all client categories. Targets are measured quarterly and reported to the department’s Senior Management Team and to the Welsh Assembly Government. A performance management group meets regularly to discuss performance management of the department and to make recommendations for future improvement. The performance of the department is also monitored corporately within the Council and by a Scrutiny Committee. These performance targets are built into individual teams’ Service and Operational Development (SOD) plans. SOD plans link to overall departmental and corporate objectives of the Council and provide a framework for performance of individual team members’ in their Annual Development Interviews. SOD plans are set for the beginning of each financial year (April) and reviewed annually, at an interim period usually 6 months into the financial year (i.e. October). The LHB manages performance against Service and Financial Framework (SaFF) targets Evaluating the Progress of the Commissioning Strategy This strategy sets out the commissioning intentions for older people’s services over the next 5 years. A number of actions are required to review the current commissioning arrangements and to focus services for older people in a way that meets those intentions. Resultant actions will need to be built into the Social Care and Housing’s departmental SOD plan and individual teams’ SOD plans and progress will be monitored through the SOD plan review. The action plan in section 10 below will need to be monitored regularly to ensure that progress is being made in each area. The Action Plan has a column for updating the progress of each particular area. Operational monitoring will be facilitated through the relevant planning groups and regular updates on progress will be made to the Joint Commissioning Steering Group.

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9. COMMISSIONING INTENTIONS It is clear from the demographic trends that the population of older people is set to rise by 14% in Torfaen by 2012/13 and the prevalence of mental health conditions will rise at a sharper rate. This will create demand for services, where there is currently limited capacity. National and local guidance states that the Council and the LHB together with its partners should:

• Ensure the user is at the centre of service delivery and the

commissioning of services

• Improve services for vulnerable people and improve health outcomes for everyone by promoting healthier lifestyles

• Commission services which focus on outcomes, promoting health and well being and prevention as much as providing long term and acute services

• Help people stay safe, healthy and independent for as long as possible

• Work in partnership to continue the shift towards a service direction that focuses increasingly on people’s independence

• Shift locus of health and social care from hospital and institutional settings to communities and closer the user’s own home

• Work collaboratively to deliver high quality services jointly, using a common approach to assessment

• Increase the skill mix and develop the health and social care workforce in order to deliver consistent, high quality services across both health and social care

• Manage the performance of services to ensure that service are commissioned and delivered efficiently and effectively within a culture of improvement to enhance the quality of life and experience of the end user

• A focus on health and social care outcomes through promoting independence and choice

• Ensuring that services are effective, efficient, accessible and prioritised to those in greatest need

Short term demand and the high level of delayed transfers of care experienced in 2006-2008 dictate that the focus for the first year of this strategy must be at reducing the level of DToC and developing services to prevent an increase to the levels in 2007/08. Care home capacity A piece of work undertaken in 2005 by consultants RKW to inform Gwent Clinical Futures showed the following increases in demand for long term and respite care home places, based on population predictions and shifts resulting from the Clinical Futures agenda: Figure 1 illustrates placements based on actuals in 2005/06, projections for 2011/12 and current capacity for EMI

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residential placements, figure 2 identifies the same for EMI nursing care. The numbers are based on a 2005 baseline numbers, so may differ slightly from actual figures in 2007/08.

2007/ 2008

2008/ 2009

2009/ 2010

2010/ 2011

2011/ 2012

2012/ 2013

Type Residential 58 59 61 62 63 65 Hafod 8 8 9 11 13 15

DTOC 1 1 1 1 1 1 Nursing 100 102 104 106 108 112

Respite 19 20 20 21 21 22 Respite (Nursing) 21 22 22 23 23 24 TOTAL 207 212 217 224 229 239

Based on RKW’s figures, if there is no change to the way in which care is delivered and purchased in the community the overall number of care home placements required would increase by 32 to 239 by 2013. The costs associated with this increase can be estimated as follows:

• Additional 12 nursing beds at £550 per week = £343,000

• Additional 15 residential beds at £450 per week = £351,000

• Additional 3 respite beds at £500 per week = £78,000

• Additional 3 respite nursing beds at £600 per week = £94,000 These costs are based on an estimate of care home weekly costs. There is no certainty about fees and work on a local fees model is required. Whilst the Older people’s joint commissioning strategy aims to reduce the number of residential placements actively purchased for long term care, it is clear from the graphs above that there is a need for EMI nursing. How this is delivered will depend on the future intentions of care home providers and the success of Clinical Futures in delivering a model of care in the community which incorporates the needs of people with mental health needs. The mix of services to meet both demand for high needs and the wishes of local people, and national guidance There can be no assumptions made about the availability of hospital beds or nursing home beds at this stage and the design of future provision will need to look at the gaps in capacity. However, community options needs to be explored for people with mental health needs who do not require intense nursing care in an institutional setting. Discussions with local care home providers are required to ensure that their plans incorporate the commissioning intentions of the Council and the LHB following a review of accommodation and care options available to older people in Torfaen.

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Community services

RKW recorded that in 2006/07 there were 140 packages of domiciliary care being delivered to people with dementia. This is likely to be more accurate than the figures used in the market analysis section above, which showed 104 service users attributable to the Older People Mental Health team. The 140 recorded by RKW would incorporate people with dementia who are on the caseload of other teams, normally because the dementia is in its early stages. However, the additional 36 would have been included in the Older People Joint Commissioning strategy. RKW predicted that by 2013 there would be an additional 32 packages of care required based on its population predictions. The domiciliary care strategy “Building Capacity in Domiciliary Care 2005-2010” has already addressed the future commissioning intentions for domiciliary care up to 2010. The intention is to build capacity and stability in the market and to refocus the service provided by the in house Personal Care team. The Torfaen Personal Care Team is being reconfigured to become both an intake team and a specialist provider of services older people with dementia. This will not result in less services being provided, but will be intended to make more efficient use of resources, promoting independence and allowing the Council to move to a more outcome based model of commissioning. The dementia service will aim to provide this type of service to older who might otherwise need EMI residential care. One of the key areas for development for domiciliary care up to 2010 will be to manage the new contracts and in-house service and work with partners to become more outcome orientated, facilitated by outcome focussed contracts. If the Council and LHB made no intervention in the current market the rate of people helped to live at home would remain static or decrease and the rate of people supported in care homes would increase.

Shifting the Balance of Care

The emphasis of the Council and LHB’s commissioning intentions is to shift the balance of care for older people in line with local and national priorities. There will be less emphasis on the use of hospital based or institutional care and more of an emphasis on providing services in the person’s own home or in the community, including the provision of Extra Care (a combination of specially designed housing and 24 hour care and support developed to offer older people an alternative to moving into a care home) and Telecare (using technology to enable people to remain within their homes) which effectively meets the needs of people with mental health needs, supported by a strong integrated community nursing and social care infrastructure.

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There will continue to be a need for EMI residential care in care homes, especially in the short term as the Council aims to reduce the number of people who are fit for discharge but are not yet able to transfer to another setting (known as Delayed Transfers of Care DToC’s), but also in the long term to support both the Clinical Futures programme and to support community based services through transitional, rehabilitative and respite beds. There will also need to be sufficient capacity in and EMI nursing care and transitional, rehabilitative and respite options in these homes. However, over the next five years the Council and LHB will actively seek to provide more community based care which promotes choice, improved health and independence and is supported by a structure of quality health, social care, independent and voluntary sector services. Day services and day hospital services will need to be more effective in delivering meaningful programmes of activities for people with mental health problems. Health and social care mental health teams will work closer together and services will be delivered through an integrated approach, where this adds value. There will need to be an emphasis on developing a health and social care workforce that can provide seamless services, with development opportunities that will benefit services users. Service users should expect an improvement in the way services are delivered, with a more joined up approach to jointly treating mental and physical health conditions. This will depend on the configuration/re-configuration of resources to effectively deliver services in this way. The Older People Joint Commissioning strategy demonstrates the effect of implementing a shift in the balance of care away from long term care placements to a service where people would remain in their own home for longer, either as owner/occupiers or as tenants within extra care or sheltered housing. It is clear that a certain reduction in care home placements will mean greater need for community based services, and it is the intention of the Council and LHB to move towards this model of care. For dementia support services, however, there is need for the mix of options available to take into account the demands of the illness. EMI residential will continue to be required. However, if the Council can secure a greater proportion of the available beds, it is likely that capacity is sufficient to meet the growing demand in the next 5 years. However, EMI nursing placements are in short supply and some work will be required to look at how this demand can be met in care home settings, hospital and in the community. Implications for Nursing The implications of the Clinical Futures and the shift in the balance of care would mean that more older people with mental health needs would be cared for outside of hospital settings. The resource implications need to be explored further, as the current mix of community and ward nurses might need to be reconfigured to support this shift. Furthermore there are implications for the

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type of nursing that a person will require in the community and both community psychiatric nurses and other community nurses will need to be organised in a way which presents no gaps in service to the individual whether their needs be physical or mental. A number of gaps within the gap analysis need to be explored through actions in the Action Plan at the end of this strategy, to ensure that this shift towards the Clinical Futures model can happen. Palliative Care As more patients are cared for at home it will be important to ensure adequate palliative care is available to all who want to receive their end of life care at home. Ensuring as much end of life care as possible can take place at home will also support the Clinical Futures Programme. A Palliative Care commissioning strategy is being developed on a pan-Gwent basis. Direct Payments One option for some service users will be to opt to make choices over their services through self directed support. Direct Payments (DP) is based on individuals having the choice of the service although many choose not to use it. It fits with the intention to empower service users to have independence and choice of services. However the implications of mental capacity need to be explored further to enable this option for people with dementia. Telecare The increase in provision of telecare will play an important role in helping to re-focus services to help people to live independently in their own homes. The availability of telecare options needs to be further explored and developed as part of an overarching accommodation strategy, and will link with the work already being undertaken by the Telecare Project. Extra Care

Demand for the first extra care facility is already high, with around 75 expressions of interest for 35 units by January 2008. If this is an indication of the future demand for this type of scheme further development of extra care should be explored as a means to meeting the future demographic demands and the shift described above. There is growing evidence to support this type of accommodation for people with dementia and this should be further explored as an alternative to long term institutional care. Day Activities Day activities can play an important role in the lives of older people. Effective services can prevent reliance on other services; promote independence, community inclusion and improvements in health and well being. Existing and newly commissioned services should be outcomes/needs driven and built on sustainable foundations. Priorities for the service include a review of transport

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arrangements, outcomes based commissioning of services, and community based alternatives to traditional services. Provision of meals Domiciliary care providers will be able to provide support to service users to prepare meals. However, this is unlikely to be 3 times per day for all service users. Furthermore, there will need to be increased development and awareness of the nutritional needs of service users within this workforce. A shift away from care home based service delivery might also result in higher demand for community meals services. Voluntary sector Working closely with voluntary sector partners will be increasingly important to help address the gaps that might result from the need to focus priorities on those in greatest need. Therefore, the focus for joint commissioning should be to further develop relationships with the voluntary sector that recognises their importance in providing community support services. Shifting the balance of care will require a commitment to increasing the availability of accommodation options and community based services available to future service users and patients in line with demographic trends. It will also require a reduction in the rate of long-term care home placements over the next 5 years, whilst maintaining capacity in this area to provide services to support community based care.

Joint Commissioning Priorities A number of key priorities have been identified under broad service headings and detailed in the Action Plan for 2008 to 13. To facilitate achievement of the Action Plan a forum will be established. Specifically the forum will discuss and develop plans for the future commissioning of Older Adult Mental Health Services and will ensure implementation of relevant NSF requirements and this Joint Commissioning Strategy. The Action Plan Key Priorities are:

• Dementia Scoping Review

• Service and Efficiency Review

• DTOC: Reduce number of bed days lost

• Improving Health Services

• Commissioning

• Service Users and Carers

• Workforce Development

• Promoting Independent Living

• Day Activities

• Supporting Financial Independence

• Community Respite

• Transport Strategy

• Prevention of falls

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• Joint Equipment

• Transition

• Mental Health Promotion

ACTION PLAN 1. Dementia Scoping Review Lead

Responsible Timescale Estimated Cost Progress

Consider the implications of “Dementia Strategy in Wales: A brief scoping review” (Dr Charles Twining OBE, January 2008) to ensure that commissioning priorities fit with the recommendations in the report

Gale Davies / Ian Cutler

2008 – 2009 SC&H and LHB officer time

2. Service and Efficiency Review Lead

Responsible Timescale Estimated Cost Progress

Use Social Care and Housing recent review into service and efficiency review to inform priorities for action over the next 3 to 5 years in the context of the 10 year demographic profile.

Sue Evans / Ian Cutler / Gill Pratlett

2008 - 2012 SC&H and LHB officer time

3. DTOC: Reduce number of bed days lost Lead

Responsible Timescale Estimated Cost Progress

To ensure that the model of care for older people ensures there are suitable options to facilitate timely discharge from hospital that promotes independence and quality of life – DtoC Target for Clinical Futures is 8. This currently requires additional 14 beds at a cost of £450 per week. Assume half beds for OP.

Gill Pratlett / Ian Cutler / Vicky Warner

September 2008

£450x52x7 Approx £200k full year

Ongoing

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Develop an accommodation strategy which:

• Links with Supporting People projects to ensure maintenance of tenure, both rented and owner/occupier

• Offers a choice of: o low level ‘designed for life’ type

accommodation within sheltered/ extra care settings as well as incorporating assistive technology

o moderate level extra care and residential choice and

o higher level high dependency nursing and NHS continuing health care provision

• Ensures accommodation that gives choice and support to participate in social activities, enhance learning opportunities and build and maintain physical activeness (as opposed to exercise activity) to improve health and well-being

Social Care & Housing / LHB

31st March 2009

SC&H and LHB officer time

Building Capacity in Care Home facilities To ensure sufficient but flexible capacity of care home beds available through:

• Block contracting arrangements for long term and short term needs. (This will need to link to the actions within the Intermediate Care Joint Commissioning Strategy)

• Block contracting respite arrangements incorporating a flexible rehabilitative and maintenance function within both Residential and Nursing including Older Persons Mental Health (This will need to link to the actions within

Mark Saunders Mark Saunders / Tanya Strange

2008-09 2008-09

£150k £60k

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the Older People Joint Commissioning Strategy)

• To further explore the possibility of step up / step down facilities in hard to let properties in sheltered accommodation taking into account the specific needs of people with mental health needs. (This will need to link to the actions within the Intermediate Care Joint Commissioning Strategy)

David Williams / Chris Hill

2008-09

SC&H, Trust and LHB officer time

DTOC Action Plan

• Consider and implement the multi-agency DToC Action Plan and the Wales Audit Office Report (This will need to link to the actions within the Intermediate Care Joint Commissioning Strategy)

Gill Pratlett / Ian Cutler / Chris Hill

2008-09 SC&H and LHB officer time

Outcome focussed working to increase independence and maintenance of routine

• Conclude the reconfiguration of the Council’s personal care team to become a specialist older people mental health provider (refer to Domiciliary Care Strategy “Building Capacity in Domiciliary Care”)

Joanne Kirrane Concluded by 2008 - 2009

SC&H officer time

• Qualitative and quantitative feedback processes in place 2008 - 2009

SC&H officer time

Service integration and clinical futures Lead

Responsible Timescale Estimated Cost Progress

• Review current physical health and mental health services on the County Hospital site with a view to establishing a suitable level of integration of the services. It is important to note that integration of

Gale Davies/Kevin Wood

2008/2009 SC&H, LHB and Trust officer time

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services will require there to be both Older Adults Mental Health and Care of the Elderly specialisms involved in order to provide joint services and shared care.

• Link in with the Clinical Futures Level 1 work programme.

Gale Davies/Kevin Wood/Sian Chard

2008 – 2009

LHB / Trust officer time

• Review and extend the provision of psychological therapies within older adult mental health services taking into account mild and moderate need and the stepped care approach.

Kevin Wood/Gale Davies

2008 – 2009

LHB and Trust officer time

• Review and develop the provision of physical therapy within older adult mental health services taking into account mild and moderate need and the stepped care approach.

Kevin Wood/Gale Davies

2008 – 2009

LHB and Trust officer time

• Act upon the recommendations of the Mental Health Act Commission and consider the organisation of inpatient beds according to functionality.

Kevin Wood 2008 – 2009

Building work Approx £4k 2 WTE Band 5 staff approx £50k

• To test integration across physical and mental hospital based health units for older adults and to ensure that learning from elsewhere is captured.

Gale Davies/Kevin Wood/ Clinical Futures

2010 – 2012

LHB and Trust officer time

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• Ensure that Older People Mental Health and Care of the Elderly integrated services figure strongly in the development of the Torfaen Local General Hospital.

Gale Davies/ Kevin Wood/ Clinical Futures

2011 – 2013

LHB and Trust officer time

4. Commissioning Lead

Responsible Timescale Estimated Cost

Progress

o Develop a specific planning and commissioning group for older people mental health in line with the Joint Strategic Framework, and Local Service Board development

Gale Davies / Maria Evans

2008 – 2009

SC&H, LHB and Trust officer time

o Develop a comprehensive whole system service model for older people mental health with specific regard to the roles of specialised teams and the development of integrated care pathways.

OAMH Planning Group

2008 – 2009

£20k for consultancy

• Tender for respite arrangements, block contract flexible rehabilitative and maintenance function (Residential and Nursing including Older People’s Mental Health).

Mark Saunders / Tanya Strange

2008 – 2009

SC&H and LHB officer time Costs of contracts in section 3 above

• To consider the development of a locally based fee model for care homes

Mark Saunders / Eunice Jones

2008-09 4 weeks WTE Corporate Finance Officer approx £3.5k

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• Contracts and specifications need to be outcome focused for service users.

Performance Team and LHB

2008 - 2009 SC&H and LHB Officer Time (cost of WTE post detailed in OP Joint Commissioning Strategy)

• Cross boundary commissioning arrangements need to be explored to maximise capacity or resources. Begin by sharing commissioning strategies across authorities and LHB’s to identify areas for collaboration.

Planning, Performance and LHB

2008 - 2009 SC&H and LHB officer time

• Remaining Tender CSS/ISS Scheme taking into account older people’s mental health needs.

Mark Saunders / Richard Williams

2008 - 2009 SC&H Officer time Additional cost for generic contract approx. £3x 52000 = £156k Cost of ISS not known until tender

• Ensure older people’s mental health services link in with all-Gwent complex care planning arrangements.

Tanya Strange 2008-09 LHB Officer time

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5. Service Users and Carers Lead

Responsible Timescale Estimated Cost Progress

• Ensure that actions within the Carers Joint Commissioning strategy that relate to carers of older people with mental health needs are considered within the implementation of priorities of this commissioning strategy

Gareth Cooke 2008-09 SC&H officer time

• Engage with service users and their carers to ensure that services continue to meet their needs and to ensure their views are represented within the Joint strategic framework

All Partners 2008 – 2009

0.1 WTE service user/carer facilitator approx £3k

• Develop community advocacy service.

Joanne Green / Mark Saunders

2008 -09 Approx £10k

• Develop and promote availability of IMCA service LHB 2007 Approx. £8k WAG funded

• Develop and promote availability of IMHA service

LHB 2008 Approx. £8k WAG funded

6. Workforce Development Lead

Responsible Timescale Estimated Cost Progress

• Develop generic roles to support integrated service delivery.

LHB / SC&H / Trust

2008-2011 Approx £50k training costs

• Develop a sustainable health and social care workforce with transferable skills and increase generic roles that

SC&H HR Manager/

2008 - 2009 Approx £50k training costs

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support qualified staff.

Trust

• Look at developing an accredited training passport type system that enables workers involved in social care to ‘travel’ across the sector to meeting capacity and demand in flexible needs based manner.

SC&H HR Manager/ Trust

2008 - 2009 SC&H, LHB and Trust officer time

• Need to build on the Social Care Partnership of Torfaen to further address workforce development needs, to engage providers into creating a culture of reablement and promoting independence.

Maria Evans / Wendy Rogers

2008 - 2009 Costs associated with SCWD Grant in OP Commissioning Strategy

• Promote positive images of independent older people by working with families, communities and care sector to prevent or delay dependence.

All Partners 2008 – 2009

7. Promoting Independent Living Lead

Responsible Timescale Estimated Cost Progress

• Review of the organisation of the Home Treatment Service at Ty Siriol to ensure its fitness for purpose and integration into the wider work of the older adult team.

Kevin Wood/ Amanda Phillips

2008 – 2009

SC&H, LHB and Trust Officer Time

• Jointly review statutory, voluntary and independent sector services on a rolling programme over the next 3 years using an agreed framework to determine priorities.

Commissioning Strategy Leads

2008 - 2011 SC&H and LHB Officer time

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• To crystallise the plans under the Clinical Futures Level 1 work programme with due regard to the Primary Care Estates development and to explore the feasibility of ‘one-stop’ clinics for older people where all their physical and mental health needs could be met in one visit.

Kevin Wood/ Gale Davies

2010 – 2012

SC&H and LHB Officer time

o Ensure access to services with particular reference to transport making use of GIS.

All Partners 2010 – 2012

SC&H and LHB Officer time

• Further development of integrated approach to promoting independence.

All Partners 2008-13 SC&H and LHB Officer time

8. Day Activities: Lead

Responsible Timescale Estimated Cost Progress

• To ensure that the mix of services available meets the needs of older people with mental health problems.

All Partners 2008-13 SC&H, Trust and LHB Officer time

• Use gap analysis to design new community based day services for older people with dementia

Jim Wright 2008 – 2009 SC&H, Trust and LHB Officer time

• A reconfiguration of the day hospital services from Ty Siriol, within a wider review of day care provision for older people with mental health problems.

Kevin Wood 2008 – 2009

SC&H, Trust and LHB Officer time

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9. Financial Independence Lead

Responsible Timescale Estimated Cost Progress

• To develop awareness and training amongst staff to recognise opportunities for direct payments or other self-directed support for older people with dementia and/or their carers

Zoe Williams 2008-09 SC&H Officer time

• Maximise service user and carer personal income through joint service developments with other agencies and corporate finance officers

Sue Brown 2008 - 2009

10. Community Respite Lead

Responsible Timescale Estimated Cost Progress

Review and build capacity and effectively resource an appropriate mix of services to include

• Night sitting

• Day sitting

• Day activity

• Outcome based care placement

• Adult placement

• Complex care

Amanda Phillips / Tanya Strange

2008 - 2009

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11. Transport Strategy Lead

Responsible Timescale Estimated Cost Progress

• To review transport for day service/day hospital service users

Jim Wright/Kevin Wood

2008 - 2009 SC&H, Trust and LHB Officer time

• Expand awareness of free public transport / carer support

Sue Browne 2008 - 2009 £1k

12. Prevention of falls Lead

Responsible Timescale Estimated Cost Progress

Ensure actions within the NSF for older people relating to falls are met:

• Develop and enhance services to prevent falls

• Develop and enhance services to respond to people who have fallen – Prevent hospital admission – Service to assist fallers getting up – Facilitate early discharge – Facilitate therapy and rehab to maximise and

maintain independence following a fall (This will need to link to the actions within the Intermediate Care Joint Commissioning Strategy and Falls Prevention Strategy)

Chris Hill / Jo Green

2008 - 2009 SC&H, Trust and LHB Officer time Promoting independence and wellbeing bid SC&H, Trust and LHB Officer time

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13. Joint Community Equipment Service

Lead Responsible

Timescale Estimated Cost Progress

Ensure that the needs of older people with mental illness feed into the design and development of the Gwent wide integrated community equipment service

Kevin Mayers/LHB/Trust

2008-09 Kevin Mayers/LHB/Trust

14. Transition Lead

Responsible Timescale Estimated Cost Progress

The development of services to enable a smooth transition care pathway between adult and older adult mental health services and the continuation of flexibility within the service so the needs of patients and service users are met within the most appropriate setting regardless of age.

Kevin Wood/ Amanda Phillips / Transition task and finish group

2008 - 2009

SC&H, Trust and LHB Officer time

15. Mental Health Promotion Lead

Responsible Timescale Estimated Cost Progress

Promote better mental health amongst older people through the delivery of a Local Mental Health Promotion Action Plan.

NPHS/LHB 2008 - 2009

16. Early Onset Dementia Lead

Responsible Timescale Estimated Cost Progress

Secure continuation for the Gwent-wide early onset dementia support project provided through the Alzheimer’s Society

Trust/LHB/LA 2008 £7k per year for Torfaen

Appendix 1 – Deprivation in Torfaen, Welsh Index of Multiple Deprivation

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Appendix 2 – EMI Nursing and Residential Care Homes

Red Triangles – Other Care Homes Blue Squares – EMI Care Homes

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Appendix 4 – Population Density Age: 45 - 59 Age: 60-64 Age: 65 – 74 Age: 75 - 84

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Appendix 5 – EMI Domiciliary Care

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NATIONAL AND LOCAL LEGISLATION AND GUIDANCE

An Overarching Summary of Relevant legislation and guidance for Torfaen’s Joint Commissioning Strategies LEGISLATION National Assistance Act 1948 The National Assistance Act places a duty on local authorities to provide residential accommodation for people in need of care and attention ‘otherwise not available to them’; and obliges local authorities to charge for this accommodation. Chronically Sick and Disabled Persons Act 1970 The Chronically Sick and Disabled Persons Act imposes a duty on local authorities to provide information about relevant services to assess the individual needs of everyone who falls within Section 29 of the National Assistance Act 1948 Sex Discrimination Act 1975 The Sex Discrimination Act makes sex discrimination generally unlawful in employment, training and related matters (where discrimination against married persons is also dealt with), in education, in the provision of goods, facilities and services, and in the disposal and management of premises. The Act established an Equal Opportunities Commission3 to help enforce the legislation and to promote equality of opportunity between the sexes generally.

• Hospitals, prisons, hostels, old people's homes and any other places for people needing 'special care'.

• Charities and non-profit-making organisations set up to provide facilities or services for one sex only. This does not mean such organisations may discriminate across the board - for example, by restricting their office workers to one sex only - but they may discriminate in the provision of services, including who is employed in

actually providing those services.

3 The Disability Rights Commission and Equal Opportunities Commission have been replaced

by the Equality and Human Rights Commission from October 2007

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Mental Health Act 1983 The Mental Health Act 1983 makes provision for the compulsory detention and treatment in hospital of those with mental disorder. It also places a duty on social services and the health authority to provide free after-care services to people being discharged after detention under sections 3, 37, 47 or 48 of the Act. After-care services can include residential care. NHS and Community Care Act 1990 The NHS and Community Care Act places a duty on local authorities to carry out a needs assessment for anyone who might require community care services and to decide whether their needs call for the provision of any services (including residential care). It also places a duty on local councils to notify health and housing authorities and invite them to take part in the assessment where it appears there may be a need for the provision of their services. WHC (2004)066 ‘Guidance on National Assistance Act 1948 (Choice of Accommodation) Directions 1993’ This provides guidance on what individuals should be able to expect from the local council which is responsible for funding their care and, when arranging a care home place for them, describing the minimum of choice that councils should offer individuals. Community Care (Direct Payments) Act 1996 The Community Care (Direct Payments) Act empowers local authority social services departments to make direct cash payments to people for the community care services that they have been assessed as needing. Human Rights Act 1998 The Human Rights Act 1998 gives legal effect in the UK to the fundamental rights and freedoms contained in the European Convention on Human Rights (ECHR). These rights not only affect matters of life and death like freedom from torture and killing but also affect people’s rights in everyday life. These human rights are as follows:

• the right to life

• freedom from torture and degraded treatment

• freedom from slavery and forced labour

• the right to liberty

• the right to a fair trial

• the right not to be punished for something that wasn't a crime when you did it

• the right to respect for private and family life

• freedom of thought, conscience and religion

• freedom of expression

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• freedom of assembly and association

• the right to marry or form a civil partnership and start a family

• the right not to be discriminated against in respect of these rights and freedoms

• the right to own property

• the right to an education

• the right to participate in free elections Some of these rights are fundamental to the services we commission as a Council on behalf of others, and should be taken into account when designing or contracting for services on behalf of vulnerable people.

Health Act 1999

The Health Act makes it possible for local authorities and health organisations to legally enter Partnership Agreements for joint or lead commissioning, integrated services and pooled budgets. The Care Standards Act 2000 The Care Standards Act specifies inspection arrangements and standards together with a code of practice for staff and the establishment of a National Register. The Act also extends the scope of regulation and registration to domiciliary care agencies, including in house providers. Carers and Disabled Children Act 2000 The Carers and Disabled Children Act places an obligation on local authorities to meet carers’ needs with any service that can help them to continue to care and to maintain their health and well-being. The Act gives carers the right to ask for an assessment of their own needs to help them to continue to care, irrespective of whether the person they are caring for has had or is having their own needs assessment. Race Relations (Amendment) Act 2000 The Race Relations Act 1976 set out legislation against discrimination by an employer against an employee due to their race. The Race Relations (Amendment) Act extends the application of the Race Relations Act 1976 to public authorities, who cannot discriminate against their users on the grounds of race. However, race discrimination remains lawful for:

• Any arrangement where someone takes a child, elderly person or someone needing special care and attention into his or her home to be looked after (for example, fostering children)

• Charities and voluntary organisations whose main purpose is to provide benefits for a particular racial group (but these organisations will not be allowed to discriminate on grounds of colour, only on grounds of race, nationality or national or ethnic origin).

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Health and Social Care Act 2001 and The Community Care, Services for Carers and Children’s Services (Direct Payments) (Wales) Regulations 2004’

The Health and Social Care Act provides a definition of registered nursing care and establishes that local councils cannot provide this type of care. Further guidance sets out the procedures for the assessment of entitlement to free nursing care (i.e. the ‘registered nursing care contribution’). Following the Health and Social Care Act local authorities were also obliged to offer Direct Payments to those potentially eligible. The 2004 regulations extend eligibility to all people aged 65 and over assessed as needing community care services, from March 2005. Previously, this duty only extended to disabled people and carers. Housing Act 2004 The Housing Act 2004 introduced several reforms to protect the most vulnerable tenants, bring empty homes back into use, and tackle antisocial behaviour. Disability Discrimination Act 2005 The Disability Discrimination Act (DDA) 1995 aimed to end the discrimination that many disabled people face. That Act has been significantly extended, including by the Disability Discrimination Act 2005. It now gives disabled people rights in the areas of:

• employment

• education

• access to goods, facilities and services

• buying or renting land or property, including making it easier for disabled people to rent property and for tenants to make disability-related adaptations

The Act now requires public bodies to promote equality of opportunity for disabled people. It also allows the government to set minimum standards so that disabled people can use public transport easily. Mental Capacity Act 2005 The Mental Capacity Act will generally only affect people aged 16 or over and provides a statutory framework to empower and protect people who may lack capacity to make some decisions for themselves, for example, people with dementia, learning disabilities, mental health problems, stroke or head injuries who may lack capacity to make certain decisions. It makes it clear who can take decisions in which situations and how they should go about this. It enables people to plan ahead for a time when they may lack capacity. The Act will cover major decisions about someone’s property and affairs, healthcare

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treatment and where the person lives, as well as everyday decisions about personal care (such as what someone eats), where the person lacks capacity to make the decisions themselves. Mental Health Act 2007 The main purpose of the 2007 Act is to amend the 1983 Act. It is also being used to introduce "deprivation of liberty safeguards" (Bournewood safeguards) through amending the Mental Capacity Act 2005 (MCA). The Act broadens the group of practitioners who can take on the functions currently performed by the approved social worker (ASW) and responsible medical officer (RMO). It also introduces supervised community treatment (SCT) for patients following a period of detention in hospital. It is expected that this will allow a small number of patients with a mental disorder to live in the community whilst subject to certain conditions under the 1983 Act. The Act also places a duty on the appropriate national authority to make arrangements for help to be provided by independent mental health advocates. NHS (Wales) Act 2006 The NHS (Wales) Act 2006, which came into force on 1 March 2007, consolidates a number of previous Acts. The consolidation is primarily one of the structure and operation of the NHS. It will include most, but not all, of the health legislation since 1977. Therefore, the NHS Act 1977 and much of the subsequent legislation will be repealed and replaced. Section 3 of the Act relates to the Welsh Ministers’ duty as to the provision of certain services, including:

• Hospital accommodation; • Other accommodation for the purpose of any service provided under

this Act; • Such other services or facilities for the prevention of illness, the care of

persons suffering from illness and the after care of persons who have suffered from illness as they consider are appropriate as part of the health service; and

• Such other services or facilities as are required for the diagnosis and treatment of illness.

The Equality Act 2006 The Equality Act amends the Sex Discrimination Act of 1975 and the Equal Pay Act 1970 (as amended by the Employment Equality (Sex Discrimination Regulations 2005), and places a statutory duty upon public authorities when carrying out their public duties to have due regard of the need to:

• Eliminate unlawful discrimination and harassment.

• Promote equality of opportunity between men and women.

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The above requirements are known as the general duty. The general duty places a proactive responsibility upon all public bodies to ensure that their services, practices and policies are developed with the different needs of women and men in mind. This will lead to a more inclusive society with high quality contemporary services - targeted to meet the specific needs of men and women. NATIONAL GUIDANCE Wales: A Better Country (WAG 2003) The 2003 strategy for the Welsh Assembly government (WAG) sets out WAG’s vision (within the wider strategy for the assembly) of health and social care to support people to live healthy and independent lives. Echoing other social care strategies, this document set out 10 objectives to help work towards the objectives of the 2003-07 assembly government. Wanless Review of Health & Social Care in Wales (2003) The Wanless review concluded that the “present position is unsustainable” and that there should be strategic adjustment of services to focus on prevention and early intervention. Promoting Partnerships in Care: Commissioning Across Health & Social Services (WAG 2003) The guidance seeks to establish a way of working that:

• Promotes positive outcomes and good quality care for people using services and their carers

• Promotes mutual trust

• Encourages openness and transparency

• Is intended to result in fair treatment for all parties involved

• Five key areas are identified in the guidance:

� Focussing on people using health and social services and their carers

� Information for good commissioning � Strategic planning � Building capacity, confidence and stability. � Joint working and the workforce.

Fundamentals of Care (WAG, 2003) This document sets out guidance on the quality of care that service users and patients should expect from health and social care providers (public and independent) in Wales. It sets out a list of indicators that cover twelve fundamental aspects of health and social care: fundamental of health and social care for adults

• Communication and information

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• Respecting people

• Ensuring safety

• Promoting independence

• Relationships

• Rest and sleep

• Ensuring comfort, alleviating pain

• Personal hygiene, appearance and foot care

• Eating and drinking

• Oral health and hygiene

• Toilet needs

• Preventing pressure sores Designed for Life (WAG 2005) The strategy includes 3 strategic frameworks, each lasting about 3 years.

• Framework 1 (2005-2008) Redesigning Health Care

• Framework 2 (2008-2011) Delivering Higher Standards

• Framework 3 (2011-2014) World Class Services The strategy sets the following vision for health and social care, to:

• Improve health and reduce, and where possible eliminate, inequalities in health

• Support the role of citizens in promoting their health, individually and collectively

• Develop the role of local communities in creating and sustaining health

• Promote independence, service user involvement and clinical and professional leadership

• Re-cast the role of all elements of health and social care so that the citizen will be seen and treated by high quality staff at home or locally - or passed quickly to excellent specialist care, where this is needed

• Provide quality assured clinical treatment and care appropriate to need, and based on evidence

• Strengthen accountability, developing a more corporate approach in NHS Wales so that organisations work together rather than separately

• Ensure full public health engagement at both local and national levels. This vision (as well as creating world class services) aims to shift the locus of care from hospital and institutional settings closer to the community and the patient’s own home. “Fulfilled Lives, Supportive Communities” A Strategy for Social Services in Wales over the Next Decade (WAG, 2006) Developed to complement designed for life; this strategy outlines the direction for Social Services over the next ten years. It notes that Councils and their partners will need to “greatly increase the extent of joint commissioning with health and other services”.

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In a cabinet statement on 3rd August 2006, the Minister for Health and Social Services summarised that the “strategy will expect more consistent high quality services for those in need and greater links with the community to promote independence and well being” with the following key themes:

• Services should put the citizen at the centre of what they do and focus on earlier prevention rather than exclusively concentrating with those with the most intense needs.

• Users and carers will have simpler systems to improve access. The aim is to provide more personalised services which give a real say. There needs to be a greater emphasis on working “with people” rather than just “for people”.

• Social services should have a much higher profile, working across local government to champion the needs of families and vulnerable people.

• Adults and children’s social services should ensure that individuals and families are properly supported by coherent services that offer continuity of care for those with enduring needs.

• Local authorities should remain both commissioners and providers of services but take a more active role in shaping the mixed market of private, public and voluntary care.

• The draft strategy proposes a more diverse model for using the skills of a better qualified workforce so that we have people with the right skills mix to support the reshaping of services to meet the needs of the next decade.

The strategy also requires local authorities to put in place comprehensive commissioning frameworks, which focus on outcomes for the service user. Creating a Unified and Fair System for Assessing and Managing Care (UAP) The aim in developing unified assessment procedure is to ensure more effective joint working and to prevent unnecessary duplication of assessment and information gathering by different agencies and authorities who have a duty to work together. “Beecham Report” - Beyond Boundaries: Citizen-Centred Local Services for Wales (2006) Sir Jeremy Beecham’s review of local service delivery calls for public services to become more citizen focused and tougher on performance. He emphasises the need for public services to work together and modernise to meet growing expectations. His vision is that public services need to consider how they can be more effective and responsive and shaped by decision makers and service providers closely in touch with the public that they serve.

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Making the Connections (2005) Based on the position that public services must have shared common goals and the capacity to work across functional and organisational boundaries. The four key principles are:-

• That citizens should be at the centre – with services responsive to users and with people and communities involved in designing the way services are delivered.

• Equity and Social Justice – every person to have the opportunity to contribute, and connect with the hardest to reach

• Working together as the Welsh public Service- more co-ordination between providers to deliver sustainable quality and responsive services

• Value for money – making the best use of our resources.

Wales Programme for Improvement Best Value guidance in Wales has been superseded by the Wales Programme for Improvement (WPI). In 2002 the National Assembly for Wales (NAW) set out its revised guidance for achieving best value: “Local Government Act 1999: Wales Programme for Improvement - Guidance for Local Authorities”. This was set in the context of the local government policy in Wales being developed at the time by the NAW in partnership with Welsh local authorities.

Although the four principles of best value (challenge, compare, consult and compete) remain implicit in the overall guidance, the focus of the WPI has evolved. The underlying objective of the new WPI is to achieve the delivery of high quality services to the public which meet identified needs (NAW 2002). Further WPI guidance requires all local authorities in Wales to produce annual Improvement Plans and social services performance indicators form part of this overall plan. One Wales: A progressive agenda for the government of Wales (WAG, 2007) The WAG strategy sets out further progress for public services in Wales building on Wales: A Better Country (WAG 2003) to confirm the future direction of service delivery. For health and social care WAG states that it will deliver a programme of government that includes:

• Reviewing NHS reconfiguration

• Strengthening NHS finance and management

• Developing and improving Wales’s health services

• Ensuring access to health care

• Improving patients’ experience

• Supporting social care

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LOCAL POLICY AND GUIDANCE Joint Review of Torfaen County Borough Council Social Services (SSIW and WAO, 2006) A joint review of Torfaen Social Services was carried out between April and July 2005 by the Social Services Inspectorate for Wales and the Wales Audit Office. The review set out to answer two key questions:

• How good are the social services that people in the area receive?

• How well placed is the Council to sustain and improve services? How good are services in Torfaen? The Joint Review set out the strengths in the services received by people in Torfaen, as follows:

• Good arrangements for information, access and checking eligibility

• User involvement in assessment and care planning

• Sound assessment and care management systems for children

• A range of well managed community services

• Safe child processes for protecting children and vulnerable adults It also set out the following areas for development, as follows:

• Inconsistency of standards and process in adult services

• Costing care plans and service developments

• Poor transition for children with disabilities

• Fragmented support for carers

• Some gaps in service

• Cultural sensitivity How well placed is the Council to sustain and improve services? The Joint Review set out the strengths in service sustainability and improvement, as follows:

• Good staff development and training

• Strong performance agenda

• Established planning framework

• Evidence of cross boundary services

• Partnerships in children’s services

• Good financial management

• Investment in social services

• Strong leadership

• Political commitment

• Effective scrutiny

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It also set out the following areas for further development, as follows:

• Develop a learning culture for complaints

• Stronger partnerships for workforce planning

• User and carer participation in service planning

• Coherent framework for quality

• Clarity of vision

• Inclusive and outward looking leadership

• Consistent standards across all services

• Commissioning cycle

• Budget setting based on revised corporate priorities The overall conclusion of the Joint Review stated that “Torfaen County Borough Council is judged as having mainly good services and as being well placed to sustain and further improve services. Torfaen Corporate Plan

The Torfaen Corporate Plan is a borough-wide plan which was led through the democratic leadership of Councillors and took into account the needs and wishes of local citizens in order to prioritise those services that should be delivered and to set a framework for improvement for 2006 to 20011.

The Council published its first Corporate Plan at the end of October 2006. The first annual update of the Corporate Plan was published in October 2007. The annual update highlights the Council's planned improvements for the year ahead as well as the progress made in 2006/07 towards achieving the five key priorities of the original Corporate Plan. These are the five themes that the Council will be focusing on through to 2010/11 to improve the quality of life in Torfaen:

• To improve the quality, variety and affordability of housing, and reduce the level of homelessness

• To reduce crime and antisocial behaviour, and take action to help people feel safe in their neighbourhoods

• To improve the quality of teaching and learning for young people and other students and to equip citizens of all ages with the necessary skills for employment and the regeneration of their local communities

• To improve waste management and increase recycling, creating a cleaner, more energy efficient area

• To improve services for vulnerable people and improve health outcomes for everyone by promoting healthier lifestyles

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Torfaen Community Strategy

The Torfaen Community Strategy provides a shared vision of where we want to be by 2015 – specifically, to create opportunities that will make sure that;

• People are able to work, live and play because they are healthier.

• People of all ages and in all areas feel safe.

• Through education people are able to make informed choices about their lives.

• Residents and businesses have developed their skills to embrace new technologies and global competition whilst treasuring their past.

• People appreciate and enjoy the environment.

• People are able to find housing in the communities of their choice.

• Organisations have a citizen focus.

• People have an opportunity to make changes and influence organisations.

• Torfaen and its people are well networked with each other and with the rest of the world.

• People and organisations working together are the solution to achieving a better quality of life for people in Torfaen.

Torfaen Local Housing Strategy

Torfaen Local Housing Strategy is a locally agreed plan with a long-term vision outlining clear objectives and priorities, framed within and consistent with the Community Strategy.

The new housing strategy process is about ensuring a partnership approach to assessing and identifying local housing market issues and developing collective solutions to addressing them. This new approach is aimed at delivering solutions that meet the needs of the community and pooling time, energies and resources to do so. The new process looks towards the long-term and is based on a five year strategy or plan. In order to ensure that housing schemes are delivered to meet real needs and requirements, there is a need to demonstrate to the Assembly, partner organisations (housing associations, mortgage lenders, house builders and private landlords to name a few) and most importantly, to the communities, the necessary ‘evidence’. For example, local people were interviewed as part of the County Borough-wide Housing Needs Survey. This essentially looked at the need for additional affordable housing in Torfaen and identified the types of housing products the local housing partnership needs to deliver in order to meet need and demand. The Survey informed the council that more households wish to move into home-ownership; however, current house prices are preventing this. Therefore, the Strategy will focus on ways of introducing low-cost home-ownership schemes, based upon what is affordable for local people.

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The Strategy outlines the following strategic objectives:

• To ensure high levels of interaction between local housing organisations and the Planning Authority so that planning policies are compatible with housing objectives and planning agreements used to maximum effect.

• To continuously assess, identify and undertake all actions required to meet local housing requirements in order to ensure a home is available to all.

• To promote genuine partnerships between the local authority and Registered Social Landlords (RSLs’) in order to meet need for affordable housing and highlight housing’s role in community regeneration

• To deliver targeted assistance, advice and information to promote individual household and business investment in private sector housing, as a means of reducing unfitness and supporting community well-being.

• To develop and implement crosscutting approaches to tackling homelessness through providing quality advice, securing decent homes and delivering effective support.

• To harness wellbeing through linking housing, health, social care and support in order to address the full range of needs of vulnerable people.

• To improve performance amongst all local housing providers in order to better respond to the needs and aspirations of all cross-sections of the community, championing the rights of specific housing consumers.

• To work towards the attainment of quality standards in council housing and to promote effective and efficient social housing management through meaningful tenant involvement.

• To situate housing at the heart of wider area regeneration initiatives in order to create better places to live.

Torfaen Health, Social Care and Wellbeing Strategy

There is a statutory duty for all local authorities and Local Health Boards (LHB) in Wales to develop Health, Social Care and Wellbeing strategies. Torfaen’s first Health, Social Care & Well-being Strategy 2005 - 2008 was developed during 2004/05. During these three years there has been a settling in period, with new relationships across the organisations being built up – understanding what each other does and why and building up trust to make joint decisions and form joint services. New ways of working have developed with many pilot schemes helping us to understand the issues and what people really need. The second Strategy for April 2008 to March 2011 is currently in development and will be published in April 2008. The strategy sets out what we as a partnership of organisations including the Council, LHB’s, NHS Trust and other partners need to do to continue making improvements locally for the health and well being of people who live and work in Torfaen.

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All of Torfaen’s Health, Social Care and Well-being partners are committed to “Improving Together for a Better Torfaen”, and to

• Ensuring that all public policies, not just health policies, contribute in some way to improving our citizens’ health

• Creating social and physical environments that actively encourage and support well being

• Developing citizen’s personal skills and knowledge (including through the provision of information) to support and promote health and well-being

• Strengthening communities to support individuals

• Ensuring that services are effective, efficient, accessible and targeted to highest need

• Ensuring that services have a stronger role in improving the quality of life for those who have health and social care needs

No single approach or agency is capable of delivering the scale and pace of change that is needed in Torfaen. Through adopting a “four pronged” approach, a healthy balance of activity can be planned to address

• Life circumstances - the wider determinants…mainly through a concerted commitment to developing healthy public policy across all organisations…at the same time as…

• Promoting healthier choices to improve lifestyles…mainly through refocusing existing work and developing new evidence based projects…and

• Improving health and social care outcomes…mainly through promoting independence and choice

• Service provision . . . a focus on efficiency, outcomes and new service models to enable and support the above

This commissioning strategy will aim to put into operation this vision as it relates to the Council and LHB’s commissioned services. Gwent Clinical Futures Torfaen LHB has committed to the Gwent-wide programme for developing and delivering a new and different model of care in line with the vision set out in Designed for Life. It sets out a model which represents a shift in thinking about where and how services are provided, moving away from a system reliant on acute inpatient beds to one where the emphasis is on services provided outside hospitals in the community, closer to people’s own homes. This shift will have implications for community nursing and social care services in the future. (Source: Community Nursing in Torfaen: An Assessment of Need, 2007).

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Grant Thornton Service Efficiency Review Independent consultants Grant Thornton undertook a review of Community Care services for adults which proposed ways in which the Council, in partnership with others, could achieve efficiencies as well as continue the shift towards a service direction that focuses increasingly on people’s independence. A key action for the Social Care and Housing service in partnership with the LHB will be to use the review to determine priorities for action over the next 3 to 5 years in the context of the 10 year demographic profile.

ACKNOWLEDGMENTS We acknowledge the significant effort and input that has been provided by officers of Health and Social Care in producing this strategy. Their contribution has enabled the views of stakeholders to be fully incorporated into this document and aligned with national and local strategy and guidance to produce a way forward for the next five years. We would like to thank all those (too numerous to mention) that have contributed to the Older Persons Mental Health Joint Commissioning Strategy”.