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ATISN 13427 – Written Submissions
Public Services Ombudsman
I welcome the opportunity to respond to the Welsh Government’s Parliamentary Review of Health and Social Care. As Public Services Ombudsman for Wales (PSOW), I investigate complaints made by members of the public that they have suffered hardship or injustice through maladministration or service failure on the part of a body in my jurisdiction. As such, I have a unique perspective on the provision of public services in Wales, driven from the views of members of the public who have been dissatisfied with the service they have received. I can only respond to a review based on evidence from my investigations. It is in this context, therefore, that I am responding to the consultation and my comments on various aspects of the Parliamentary Review of Health and Social Care are set out below. 1.Complaint procedures need to be better aligned. The current social servicesprocedure states that local authorities should coordinate their investigations andresponses with other public bodies involved unless there is a good reason not to. TheHealth Board’s procedure ‘Putting Things Right’ is currently silent on this. I believethe process needs to be better coordinated, for example to include a requirement forboth sides to inform each other when a complaint is received, and to jointly agree onwho will lead on the complaint response. If the Assembly passes the new draft Ombudsman Bill this year it will give me thepower to act as a Complaints Standards Authority which would facilitate public bodiesstandardising their complaints procedures. This will also allow the gathering andreporting of consistent and comparable data across public services and,subsequently, areas of improvement to be identified. 2.Fairness in access – In respect of independent care providers e.g. care homes, thereis a different process in place depending on whether health or social services isinvolved. If I receive a complaint about care funded via social services I cannot lookdirectly at the care home itself, just at the council that funds the care. In the case ofcare funded via the NHS I can look directly at the care home which means theservice I can provide is inequitable. 3.Evidence from my office’s caseload suggests that greater coordination betweenhealth and social care might contribute to improving issues around hospital flow andaddress delayed transfer of care. Cases include a failure to move patients fromemergency departments due to lack of available hospital beds. 4.I currently see a very small volume of social care complaints. With the introduction ofthe Social Services and Wellbeing (Wales) Act 2014 I was given additional powers toconsider complaints from self-funding residents in care homes and those in receipt ofdomiciliary care, yet I still haven’t seen a significant increase in complaints in thissector. The own initiative powers I have requested under the new draft Bill wouldhelp me identify if there are systemic failings in the social care sector even if serviceusers themselves are not raising complaints.
5. In my recent thematic report on out of hours care in hospital, I proposed a number of areas for considerations by the NHS in Wales including electronic handovers and an improved culture of escalation, as well as a peer review of out of hours care which I’m pleased that the Welsh Government is undertaking this year. However I am of the view that improved coordination with social services is also essential to ensuring consistent, around-the-clock care is available to people in Wales. 6. The outcomes of many of my investigations support the need for closer joint working and joint planning of services. Some of the cases I have seen suggest that integrated services and pooled funding could support more timely and appropriate care packages. Public Services Ombudsman for Wales April 2017
Response from the Older People’s Commissioner for Wales
to the
Parliamentary Review of Health and Social Care
April 2017
For more information regarding this response please contact:
Older People’s Commissioner for Wales, Cambrian Buildings, Mount Stuart Square, Cardiff, CF10 5FL 02920 445030
About the Commissioner
The Older People’s Commissioner for Wales is an independent voice
and champion for older people across Wales, standing up and speaking
out on their behalf. She works to ensure that those who are vulnerable
and at risk are kept safe and ensures that all older people have a voice
that is heard, that they have choice and control, that they don’t feel
isolated or discriminated against and that they receive the support and
services they need. The Commissioner's work is driven by what older
people say matters most to them and their voices are at the heart of all
that she does. The Commissioner works to make Wales a good place to
grow older - not just for some but for everyone.
The Older People’s Commissioner:
Promotes awareness of the rights and interests of older people in
Wales.
Challenges discrimination against older people in Wales.
Encourages best practice in the treatment of older people in
Wales.
Reviews the law affecting the interests of older people in Wales.
Contents:
Introduction
Part A: Key areas of work
GP Services in Wales: The Perspective of Older People,
Older people’s experiences of accessing and using GP
services in Wales
Dementia: more than just memory loss, The experiences of
people living with dementia and those who care for them
A Place to Call Home? A Review into the Quality of Life and
Care of Older People living in Care Homes in Wales
Social Services and Wellbeing (Wales) Act 2014
Regulation and Inspection of Social Care (Wales) Act 2015
Loneliness and Isolation
Safeguarding
Part B: What this tells us
The achievement and implementation of prudent health and
social care principles in reality, including co-production,
requires further development
Continued focus across the whole health and social care
sector is needed to move towards a consistent and improved
understanding of older people’s outcomes and strengthened
Health Board governance
There needs to be a greater recognition of the role, and
support provided for carers
The integration of health and social care, with housing and
the third sector as key players is still a ‘work in progress’
There is a need for consistent improvement in the training,
skills and support given to the health and social care
workforce as a whole
Forward planning for the health and social care workforce
has not been sufficient
Part C: Conclusion
Annex A: Further links to relevant statements & submissions
Introduction
1. As the Older People’s Commissioner for Wales, I welcome the
opportunity to respond to the call for evidence from the
Parliamentary Review of Health and Social Care (the Review).
2. There are almost 800,000 people aged 60 and over in Wales,
over a quarter of the population; in the next twenty years, this
figure is expected to exceed one million. The fact that Wales is
a nation of older people should be seen as something positive.
3. Older people are the main users of health and social care
services across Wales, and these services have a duty of care
for older people. In my view, primary care serves two important
functions. First is that of working with and supporting older
people to meet and maintain their desired independence,
wellbeing and quality of life. Second, but equally as important,
primary care must work with older people to prevent ill health
and help them to get better or prevent further deterioration if an
individual becomes unwell or is in need of support.
4. The growth in the number of people living with dementia, and
the increase in the number of the ‘oldest old’ who are living with
complex and high acuity needs means that older people using
health and social care services may be increasingly vulnerable.
Public services therefore have a duty to deliver timely and
appropriate health and social care support to a growing number
of older people across the length and breadth of Wales.
5. The Review’s Terms of Reference are broad and outline four
areas that the Review wishes to address:
Defining the key issues facing health and social care
Identifying where change is needed and the case for
change
Setting out vision for the future, including moving health
and social care forward together, developing primary care
services out of hospitals
Advising on how change can be delivered, building on the
positive aspects of the current system
6. In order to address these areas, my response will be based on
the work I have undertaken as part of my work programme1,
linked to my Framework for Action2, the ongoing case support
that I provide to individuals and my extensive engagement with
older people.
7. Through my work and the reports I have published, I have
identified a range of issues and barriers currently experienced
by older people when accessing health and social care.
8. My response includes a number of high level observations that
have been lifted from my work. It explores key themes and what
they tell us in relation to the health and social care sectors as a
whole. These comments will be particularly relevant to the
question laid out in the Review’s call for evidence, ‘what do you
see as barriers to improvement?’.
9. However, to reduce duplication, and as stated in the call for
evidence, I have not re-iterated all of the relevant matters raised
in my previous publications or ongoing work. I have instead
1 http://www.olderpeoplewales.com/en/news/news/16-06-22/Commissioner_s_Work_Programme_2016-17.aspx#.WM-xvG-LTcs http://www.olderpeoplewales.com/en/news/news/15-06-08/Work_programme_2015-16.aspx#.WM-xzW-LTcs 2 http://www.olderpeoplewales.com/en/news/news/13-05-23/Framework_for_Action.aspx#.WM-xPW-LTcs
provided a brief overview alongside references and hyperlinks
that the Review Panel will be able to follow should they wish to.
Part A: Key areas of work
GP Services in Wales: The Perspective of Older People, Older
peoples’ experiences of accessing and using GP services in Wales3
10. The Review’s Terms of Reference clearly identify the need to
set a vision for the future, including developing primary care
services out of hospitals. It also asks, ‘do you agree that the
strategic direction of increasing primary, community and social
care in local communities is the right approach to better meeting
the needs of particular populations?’.
11. Of clear relevance here is the report I published in February
2017, which looks into the perspectives and experiences of
older people accessing GP services in Wales.
12. Overall, it is clear that GP services and the wider primary care
offer is highly valued by older people across Wales. However,
while many older people reported positive experiences of using
GP services, reflecting the good practice and innovation that
exists in some areas, there is an unacceptable level of variation
in people’s access to and experiences of using these services.
Furthermore, a significant number of older people felt that their
access to GP services was not sufficient, and that their
experience of using these services was not positive.
13. A number of barriers were highlighted by older people,
including: challenging and inflexible appointment systems,
concerns over the continuity of care, the accessibility of
buildings, responsiveness to individual communication needs,
3 http://www.olderpeoplewales.com/Libraries/Uploads/GP_Services_in_Wales_-_The_Perspective_of_Older_People.sflb.ashx
concerns over one issue, ten minute appointments, access to
Welsh language services and a lack of awareness about the
existence of appropriate alternatives to seeing a GP. These
challenges were amplified for older people who were living with
a dementia, cognitive impairment or sensory loss, as well as for
carers.
14. I understand the significant pressures being faced by GP
services and the wider primary care sector, and the real
challenges that these pressures can create. But at a time like
this, it is more important than ever to listen to and understand
older people’s experiences in order to address any concerns
and deliver continuous improvements to ensure that a greater
cost isn’t paid further down the line.
15. I produced formal guidance alongside the report, using my
powers under the Commissioner for Older People (Wales) Act
2006, which Health Boards must have regard to when
discharging their functions. The guidance sets out expected
outcomes for older people using GP services and includes
examples of good practice and suggested scrutiny questions for
Health Board members.
Dementia: more than just memory loss, The experiences of people
living with dementia and those who care for them4
16. Dementia is a degenerative and life limiting brain disease that
impacts upon every level of an individual’s physical, cognitive,
emotional and social functioning, as well as the lives of family
and friends. My report, ‘Dementia: More Than Just Memory
Loss,’ placed a spotlight on the impact of dementia upon
individuals, those they care for and those who care for them,
and their wider families.
4 http://www.olderpeoplewales.com/Libraries/Uploads/More_Than_Just_Memory_Loss.sflb.ashx
17. I set out a range of actions for Public Bodies to deliver over the
next 3 years to address the issues that people affected by
dementia identified as most important. The following high level
observations have been drawn from the responses to the report
submitted by public bodies.
We are still not getting the basics right for many. Clear
and flexible national pathways are required which begin
pre diagnosis and take a full life course approach.
The importance of support from an individual who
understands what it is like to experience and live with
dementia cannot be underestimated. This extends
through the skills of a wide range of public service staff, to
specific dementia support staff, to key workers. This is
much more than just dementia awareness training and
goes to the heart of skills and competency frameworks,
pre-registration and post basic training.
Respite care remains a significant issue, with many public
services failing to grasp the importance of providing a
personalised approach to respite directly linked to the
daily challenges that face people and families affected by
dementia.
There is also clearly a lack of emotional and mental
health/wellbeing support to carers and people living with
dementia. The importance of the carer in orientating the
person with dementia to their surroundings is not yet
understood by some Health Boards in Wales. Carers
should not be being excluded from being part of the care
team when people with dementia are admitted to hospital
18. The new Dementia Strategy must take into account dementia
care in its breadth – this includes the commissioning of services
and the care of people in their own homes and in care homes;
there is currently a lack of consistency and focus on clear
wellbeing outcomes for people with dementia in much of the
commissioning that takes place.
19. All public bodies must take proactive and active roles in
changing wider public perception about dementia and working
through the new partnership arrangements to widen inclusivity
across our communities.
20. The National Outcomes Framework for Social Services must be
relevant to people living with dementia and making this a reality
is a key starting point for the new strategy. It is also important
that the language and narrative used within the new strategy is
developed in such a way that has clear relevance to people with
dementia and their carers.
21. Finally, it is my expectation that the new strategy directly
responds to these issues in a way that is meaningful and
relevant to people affected by dementia.
A Place to Call Home? A Review into the Quality of Life and Care of
Older People living in Care Homes in Wales5
22. In 2014, I published the findings of my formal Review into the
quality of life and care of older people living in care homes in
Wales, the biggest Review of its kind ever undertaken in Wales.
23. The Review found that whilst there are many examples of
excellent care being delivered across Wales, too many older
people living in care homes had an unacceptable quality of life.
The evidence showed that care home residents were often
unable to do the things that mattered to them, had little
meaningful choice and control over their lives and often found it
difficult to access health care.
24. At a system level, the Review found a lack of planning for future
needs in terms of available care homes and the skills and
availability of the care home workforce, as well as a lack of
5 http://www.olderpeoplewales.com/Libraries/Uploads/A_Place_to_Call_Home_-_A_Review_into_the_Quality_of_Life_and_Care_of_Older_People_living_in_Care_Homes_in_Wales.sflb.ashx
scrutiny about the delivery of healthcare in nursing and
residential care homes.
25. Following the publication of the Review report in November
2014, all of the statutory bodies subject to the Review submitted
action plans that set out how they would deliver the
improvements needed within care homes and across the wider
care home system in Wales.
26. I was clear that the commitments made by these bodies were
the beginning of a longer term process of change. Information
has therefore been requested from Health Boards, Local
Authorities, the Welsh Government and CSSIW to assess
whether the action they have taken against a number of the
Requirements for Action set out in the Review report has been
sufficient and is making a positive difference to the lives of older
people living in care homes across Wales. This follow up work
will be published in November 2017.
27. This follow-up work will include a particular focus on issues
such as falls prevention, dementia training for care home staff,
the inappropriate use of anti-psychotic medication, continence
care, inspection processes and workforce planning.
28. In addition to this scrutiny, I will continue to highlight the good
practice and innovations implemented since the publication of
my Review report in 2014 that could be rolled out more widely
across Wales.
Social Services and Wellbeing (Wales) Act 2014
29. In order to inform and support older people’s understanding of
the Social Services and Wellbeing (Wales) Act, I have produced
a leaflet, ‘Getting the help you need from social services’ on the
main duties under the act, and a ‘Navigating Social Services
Toolkit’ series of factsheets. These can be accessed on my
website6.
30. A number of my areas of focus when scrutinising the Social
Services and Wellbeing (Wales) Act, and also the Regulation
and Inspection of Social Care (Wales) Act are outlined below.
Independent advocacy
31. Ensuring appropriate access to independent professional
advocacy is vital if we are to allow people’s voices to be heard.
Local authorities have a duty under the Act to have regard to a
person’s views, wishes and feelings and to have regard to the
importance of providing appropriate support to enable people to
participate in decisions that affect their lives. Access to
Independent Professional Advocacy can help to ensure that
people receive the care and support that they need in a way
that is appropriate to them, and can aid the delivery of better
outcomes for individuals and subsequently for statutory bodies.
32. I am therefore undertaking a programme of work to assess to
what extent older people have access to Independent
Professional Advocacy. This work will include access to
Independent Professional Advocacy more broadly (e.g.
Independent Mental Health Advocate, Independent Mental
Capacity Advocate) and people’s entitlements under the Social
Services and Well-being (Wales) Act 2014. A report will be
published in February 2018 that details older people’s
experiences and makes recommendations on areas for
improvement to be published in February 2018.
Information, Advice and Assistance Service
33. The IAA Service is likely to be the first point of contact for
people who may be in need of care and support. It is therefore
vital that every IAA service across Wales is well equipped to
6 http://www.olderpeoplewales.com/en/publications/sswb.aspx
know what services are available in each area (as well as have
knowledge of other related areas such as housing and health)
in order to appropriately sign-post people and to understand the
overarching duties of the Act to ensure people’s rights under
this Act are upheld (such as access to Independent
Professional Advocacy). The extent to which people know
about and are able to access their local IAA Service remains a
concern.
Assessment & Meeting needs
34. Under the Act, everyone has a right to an assessment where it
appears they may have a need for care and support, including
carers. It is vital that individuals are fully involved in the
assessment process and are enabled to co-produce the
solution that is right for them. Local authorities will need to work
in partnership individuals to explore different ways of meeting
their care and support needs. It is therefore vital that the views
of older people, their families and those who support them play
an equal role in the decisions made and that working practice
fully reflects this new ethos so that the rights of older people are
upheld.
The National Outcomes Framework
35. The National Outcomes Framework reflects my Quality of Life
Model and its overarching outcome of ‘a life that has value
meaning and purpose’. It is vital that the outcomes included
within the Framework are not only used to measure delivery but
that they also sit consistently at the heart of regulation and
commissioning to ensure a single outcomes framework and to
avoid the unacceptable variations in the standards set for the
care of older people.
Regulation and Inspection of Social Care (Wales) Act 2015
Quality of life / New Standards of care
36. As highlighted by my Care Home Review, too many older
people living in care homes have an unacceptable quality of life.
The Regulation and Social Care (Wales) Act 2016 will introduce
new standards for care homes, replacing the current National
Minimum Standards from April 2019. The new standards under
Section 27 of the Act will be published for public consultation in
May 2017 and they must have quality of life, and dignity and
respect, at their core to ensure the change needed will be
delivered.
Market Oversight
37. Robust strategic overview at a national and local level is vital to
ensure that there is sufficient and appropriate care home
provision for older people in Wales. The RISC Act seeks to
establish an effective system of oversight of the social care
market in Wales through requiring both the service regulator
and local authorities to produce market assessment reports. It is
vital that population assessments are robust in their
assessment of an area’s current and future care and support
needs to accurately inform market oversight and any
subsequent action required.
Better information for the public
38. It is vital that older people, as well as their families and those
who support them, are able to judge the quality of life, care and
safety of the services that they depend on. The requirement for
all providers to produce an annual return must be accessible
both in its content and its availability. I raised concerns during
the scrutiny of the Act in relation to how the accuracy of the
Annual Returns would be checked and subsequently how
relevant offences would be triggered should returns be found to
be false in any way, given that the service regulator does not
intend to provide a statement of accuracy on each return.
Loneliness and Isolation
39. The scale and impact of the loneliness and isolation
experienced by older people in Wales is significant. 17% of
people aged 75-79 say they feel lonely, a figure that rises to
63% for people aged over 80, whilst half of all older people say
that their television is their main form of company7. Loneliness
has the same impact upon older people’s health as smoking 15
cigarettes a day, and is associated with poor mental health,
hypertension and cardiovascular disease8. Research has also
shown that loneliness can increase the risk of dementia by
64%9.
40. A preventative approach to tackling loneliness and isolation is
essential and reduces the need for more costly health and
social care services. An intervention such as a befriending
scheme, for example, that costs £80 per person per year could
annually save around £300 per person in health and social care
costs10. The NHS and social care providers simply cannot afford
to continue with the current approach towards addressing
loneliness.
41. Further schemes and programmes are needed to address the
growing issue of loneliness and isolation. However, these
interventions, largely delivered by the third sector, are not
enough in and of themselves to address many of the issues
leading to older people becoming lonely and isolated.
42. A renewed commitment to providing community services for
older people and others in Wales is needed and the
Commissioner has been clear that the provision of public buses,
toilets, libraries, day centres, lifelong learning, park benches,
etc. helps to keeps older people active, independent and
7 http://www.royalvoluntaryservice.org.uk/Uploads/Documents/How_we_help/loneliness-amongst-older-people-and-the-impact-of-family-connections.pdf 8 http://www.campaigntoendloneliness.org/threat-to-health/ 9 ibid 10 http://www.scie.org.uk/publications/briefings/briefing39/
engaged in their communities, and that removing these services
exacerbates the loneliness epidemic in Wales11.
43. I recently submitted more detailed evidence to the National
Assembly for Wales’ Health, Social Care and Sport Committee
as part of their Inquiry into loneliness and isolation. You can
read this evidence here:
http://senedd.assembly.wales/mgIssueHistoryHome.aspx?IId=1
6359
Safeguarding
44. More than 39,000 older people in Wales – a proportionately
higher figure than the rest of the UK – are said to be victims of
abuse (Prevalence Study, Department of Health & Comic
Relief, 2007). For many, this occurs in the place they call home.
45. There is not yet sufficient understanding of the nature of abuse
faced by older people and the circumstances that lead to older
people becoming at risk of, or experiencing, harm.
46. We know that the effects of abuse are significant, with its
eventual implications having the greatest impact on our health
services, particularly those working in mental health and
substance misuse services.
47. I have proactively engaged with organisations across Wales to
raise the profile of the various types of abuse being experienced
by older people. I also held a series of seminars for
professionals across Wales who work with and for older people,
to raise the profile of domestic abuse of older people. Further
similar events are planned for later this year.
48. I have worked with the Welsh Government to develop practical
guidance on domestic abuse of older people for front-line
11 http://www.olderpeoplewales.com/en/news/news/14-0225/The_Importance_and_Impact_of_Community_Services_within_Wales.aspx
professionals; this is due to be published in the next few
months.
49. Many older people have told me that they were unaware that
specialist domestic abuse services were also available for them.
Not being aware of these services menas that older people may
remain in an abusive relationship, something that puts them at
further risk of harm.
50. I am also concerned that Home Office data is showing an
increase in the number of Domestic Homicide Reviews where
the victim is an older person and would welcome a Welsh
Government media campaign which raises awareness of
domestic abuse of older people which I consider is long
overdue.
Part B: What this tells us
The achievement and implementation of prudent health and social
care principles in reality, including co-production, requires further
development
51. The Welsh Government, alongside NHS Wales and informed by
the Bevan Commission, has adopted the principles of prudent
healthcare as part of its response to the identified challenges of
rising costs, increasing demand and the need for continual
quality improvement.
52. The principles of prudent healthcare include achieving health
and wellbeing through decisions made between people and
professionals as equal partners, doing what is known to be
effective and stopping actions which have little or no benefit,
and reducing inappropriate variation.
53. The first of the principles highlighted above aims to involve
patients in designing their own care and services. A central part
of this is patient contribution and coproduction, where
individuals are supported to receive the most appropriate
course of action through discussion and agreement between
the individual and professional in ‘equal partnership’.
54. The Review’s Terms of Reference ask ‘what do you understand
by prudent health and social care?’ and ‘what steps are needed
to ensure the principles are embedded in routine practice?’. The
Terms of Reference also ask, ‘what needs to change to ensure
that co-production or co-design is routine in health and care
services, and that people are better able to stay healthy or
manage their condition?’.
55. Such a shift, both culturally and practically, will require
innovation, new approaches to service delivery, enhanced skills
by professionals and increased support provided to individuals,
professionals and services.
56. My report into GP services found that the quality of personal
interactions, the degree to which older people feel listened to
and understood, the degree to which older people have a say in
decision making, whether appointments run to time and the
sufficiency of the length of the appointment are all absolutely
critical to an older person’s confidence and trust in the
healthcare service.
57. For example, there is an understanding amongst many older
people, whether perceived or explicit, that you can only raise
one issue within a ten-minute appointment. This could
jeopardise individuals’ ability to have a say in decision making
as individuals feel rushed and that the professional is not
engaged, something that reduces their confidence. This is a
particular issue for older people who may need more time, such
as those living with a sensory loss, dementia or cognitive
impairment, or a complex condition.
58. Furthermore, concerns in relation to the awareness of different
communication needs of individuals and a service’s skills to
undertake thorough co-produced conversations were raised by
older people.
59. In terms of social care, the Social Services and Wellbeing
(Wales) Act 2014 places greater emphasis on services working
together with individuals to devise the support and potential
interventions needed to enable an individual to meet their goals
and outcomes –through ‘what matters’ conversations, for
example.
60. Access to Independent Professional Advocacy is one crucial
aspect of creating the appropriate conditions to support
individuals to take their full and equal part place in decision
making about their care and support.
61. As set out above, I am currently undertaking a programme of
work to assess to what extent older people have access to
Independent Professional Advocacy. The project will deliver a
report detailing older people’s experiences and
recommendations on areas for improvement to be published in
February 2018.
62. Combatting barriers such as those highlighted in my GP
services report, and any potential issues uncovered through my
advocacy work, are crucial to the successful realisation of the
prudent health and social care principles.
63. While I am supportive of the principles that sit behind prudent
health and social care, examples such as this do bring into
question whether there are the appropriate conditions and skills
present across the health and social care sector to currently
make co-produced decisions and wider prudent healthcare a
reality.
Continued focus across the whole health and social care sector is
needed to move towards a consistent and improved understanding
of older people’s outcomes and strengthened Health Board
governance
64. The Review’s Terms of Reference ask ‘to what extent should
services and processes be standardised across Wales, to
achieve the right balance between national level and local
decision making and allow room for innovation?’.
65. I expect all Boards and Trusts to have a fundamental grasp on
the safety, effectiveness and quality of their services, with the
views of patients and staff integral to this understanding. This
should then be able to be lifted up to a national level
understanding. Furthermore, they should be able to provide the
public with the assurance of what they have a right to expect:
either that care is acceptable or that areas for improvement are
recognised and improvement is being swiftly delivered.
66. As a result of my ‘Dignified Care?’ reports12, the ‘Trusted to
Care’ report by Professor Andrews, more recent events in the
Tawel Fan ward, and the ongoing case support that I provide, I
take a close interest in the effectiveness of reporting on the
quality and safety of health care services, and in particular the
understanding that Health Boards and Welsh Government have
of older peoples outcomes and experiences.
67. For example, in undertaking scrutiny work following the
publication of ‘Trusted to Care’, I was concerned to note a
number of Health Boards (in correspondence to myself) were
referring to:
“wards causing concern”
“some areas need improvement”
“areas for continuous improvement”
12 http://www.olderpeoplewales.com/en/Reviews/dignity-and-respect/Hospital-review.aspx
“some shortcomings”
“some variations between clinical areas which are being
addressed”
“potential for these standards not to be maintained in all
wards at all times”
“subject to further assurance work”
68. It is impossible to judge the scale or impact upon individuals of
these “shortcomings”, or when a “shortcoming” becomes
“systemic”. There was also little evidence of when these
“shortcomings” would be rectified or how the impact and risk in
the interim was being minimised.
69. As a result, I raised concerns that there are a number of
governance issues that the NHS in Wales as a whole must
address, such as:
The consistency and clarity of definitions of quality of care
and the extent to which these reflect the perspective of
older people.
The robustness and effectiveness of the mechanisms that
Health Boards and the Trusts have in place to evaluate
the quality of care.
The robustness and effectiveness of Board scrutiny
regarding the quality of the care provided by their
organisations.
The sources of Board assurance regarding the
identification and remedying of unacceptable care.
The openness and transparency of Board performance
against their core business.
70. I have also provided commentary to Health Boards on their
Annual Quality Statements, which can be found on my
website13, and will be doing so again later in 2017.
71. To complement this analysis and support the development of
accessible and understandable public reporting, I have outlined
a number of key outcomes based areas upon which I expect to
see focussed attention and discussion from Health Boards.
These include, but are not restricted to, the issues of
continence, hydration and nourishment, falls, and the impact
that such experiences can have on individuals.
72. I am not necessarily seeking the production of stand-alone data
sets solely for Board meetings. Rather, I expect a qualitative
narrative to be developed that is able to bridge the gap between
the technical discussion so often seen at Board meetings with
that which older people want and need to see take place. I am
pleased that Health Boards have agreed to begin having such
discussions at Board meetings, and will be reflecting this within
their Annual Quality Statements.
73. It is therefore clear that there is commitment and enthusiasm
across the NHS in Wales to better understand individuals’
experiences and to develop improved outcomes based
reporting at Board level, something that I welcome.
74. Furthermore, the development of the NHS Outcomes
Framework, the NHS Health and Care Standards, the Social
Services National Outcomes Framework and the Public Health
Outcomes Framework signals a welcome shift in focus towards
the achievement of outcomes and wellbeing on a national level,
away from a singular focus on system processes.
13 http://www.olderpeoplewales.com/en/Publications/pub-story/16-02-10/Scrutiny_of_Health_Board_Annual_Quality_Statements_2014-15.aspx#.WNE2am-LTcs ; http://www.olderpeoplewales.com/en/Publications/pub-story/15-03-26/Scrutiny_of_Health_Board_Annual_Quality_Statements.aspx#.WNE2m2-LTcs
75. This direction of travel is positive. However, the formal
Guidance that accompanies my GP Services report focuses on
the expected outcomes for older people and suggested scrutiny
questions for Health Boards. This demonstrates to me a need
for continued focussed work in this area, particularly in the
context of primary and community care, which has not to date
received the same degree of attention afforded to acute
settings.
There needs to be a greater recognition of the role of carers and the
importance of the support provided to them
76. The work that I have undertaken and the conversations I have
with older people have consistently demonstrated to me the
need to improve the support that is provided to carers across
Wales.
77. For example, my report into the experiences of people living
with dementia highlighted the importance of carers being fully
involved when a person living with dementia is admitted to
hospital, from the moment of admission to the moment of
discharge. Carers must have a right to remain with the person
they care for and support their care unless this is clearly not in
the patient’s best interest14, and a carer must be made aware of
the support that may be available to them locally and their right,
under the Social Services Wellbeing (Wales) Act, to a carer’s
assessment.
78. My report into GP services found a number of challenges
experienced by carers. For example, carers in particular talked
about the challenges in getting a home visit, and the frustrations
in having to explain their situation multiple times when
requesting any type of appointment. Furthermore, despite the
practical difficulties involved in taking the person for whom they
care to an appointment, or the challenges in securing last
14 Also see John’s Campaign, http://johnscampaign.org.uk/#/
minute respite for the person for whom they care in order to
attend an appointment, there appeared to be little flexibility in
the appointments process to respond to this clear need.
79. Many of the carers I have met as part of my Engagement
Roadshow are at breaking point - they feel that no-one listens to
them, despite asking for so little. Without the care provided by
carers in Wales, many of our statutory services would, quite
simply, be unable to cope. Carers should therefore be seen and
treated as one of our greatest assets.
The integration of health and social care, with housing and the third
sector as key players, is still a ‘work in progress’
80. The Review’s Terms of Reference ask ‘what do you understand
by integration and what steps are needed to further integrate
services?’
81. Older people often say things to me like ‘why don’t people talk
to each other?’ and ‘why does a crisis have to occur before
anything happens?’. That is why I have taken a close interest in
the agenda for integration of our health and social care
systems.
82. I have previously welcomed the increased focus on improving
integration by Health Boards and Local Authorities, through the
publication of the Welsh Government ‘Framework for Integrating
Health and Social Care for Older People with Complex Needs’,
for example, and the publication, by public bodies, of
‘Statements of Intent for Integration of Health and Social Care
for Older People with Complex Needs'.
83. In 2014, I reviewed these statements from the perspective of
older people. This analysis can be found on my website15. In
that analysis I was clear that:
In order to effectively move away from a focus on
systems, there needs to be a consistent and outcomes
focussed way of measuring both the success of
integration in itself and the impact this has had on older
people.
A truly seamless and integrated experience of health and
social care will not be achieved without housing and the
third sector being treated as full and equal partners.
Using the voices and experiences of older people should
be central to the ongoing planning and delivery of public
services, and not ‘done’ for a specific event.
There needs to be an increased focus on prevention,
understanding needs and recognising the impact of
factors such as frailty, loneliness and isolation, and
information and advice.
84. It is almost three years since the publication of these
statements, and there needs to be an increased focus across
the health and social care sector on whether these integration
efforts have made a difference to older people. Is the impact of
these efforts being measured and, crucially, how do we know if
they have been successful?
85. The Intermediate Care Fund has introduced some impactful
innovations into the health and social care sector at a local
level, and I have been lucky enough to visit a number of positive
examples. However, in terms of a whole system approach with
a focus on prevention, I do not currently have the information I
need, to make an informed judgement of the large scale
success of the integration efforts.
15 http://www.olderpeoplewales.com/en/publications/scrutiny/15-05-06/Scrutiny_of_Statements_of_Intent_for_Integration_of_Health_and_Social_Care.aspx#.WNEv02-LTcu
86. I am, however, clear that integration is not the output in itself. A
sole focus on integrated processes or systems, which is blind to
the impact this can have on the achievement of outcomes, will
not achieve the large scale change needed. The aim must be to
achieve a more seamless experience, so that older people can
access the care and support they need, at the time they need it,
without ‘falling through the cracks’.
87. Furthermore, not only is sufficient investment needed in the
third sector to support the delivery of many services, there also
needs to be continued and increased inclusion of housing as a
key factor within the health and wellbeing of our older people.
88. In terms of long term transformation, the focus needs to shift
away from the integration of health and social care in isolation
towards a wider public service perspective that includes a
preventative approach across health, social care, housing, and
the third sector, as well as community services, leisure services
and transport.
There is a need for consistent improvement in the training, skills
and support given to the health and social care workforce as a
whole
89. The Review’s Terms of Reference ask ‘what actions are needed
to ensure services have a sustainable workforce for the future
that matches the strategic direction?’.
90. A number of the areas of work that I have prioritised in recent
years have highlighted the need for an appropriately trained,
skilled and supported health and social care workforce to
support and care for older people.
91. For example, my care home review found that current basic
mandatory training for care staff was not sufficient. There is also
often disparity between the standards of nursing in the NHS and
the standards found in nursing care homes, and there is a clear
need for effective and on-going support for Care Home
Managers, both in the form of additional training and specialist
and peer support.
92. My report into the experiences of people living with dementia
found there is a widespread lack of knowledge and
understanding of dementia amongst professionals.
93. My recently published report into GP services found that, for a
number of older people, GP services are not sufficiently aware
of, or responsive to, their individual communication needs.
94. Findings in relation to the training, skills and support given to
the health and social care workforce have therefore been
present across a number of different health and social care
settings.
95. While there are measures such as the registration and
regulation of social care workers that should drive up the status,
identity and value placed on delivering care and support for
older people, the consistency with which this issue has
presented itself across my work means that it remains an
ongoing concern and key factor in delivering high quality,
effective and appropriate health and social care and support for
older people in Wales.
Forward planning for the health and social care workforce has not
been sufficient
96. The Review’s Terms of Reference ask ‘what actions are needed
to ensure services have a sustainable workforce for the future
that matches the strategic direction?’.
97. Without effective forward planning for the health and social care
workforce, there will not be the appropriate, trained and present
workforce needed to deliver high quality care to older people in
Wales.
98. Unfortunately, my work has found that workforce planning has
not always been sufficient to ensure there are enough of the
right staff, in the right place, to deliver health and social care
services without there being a negative impact on the
experiences and quality of life of older people.
99. My report into GP services recognised the current pressures
facing GP services and the wider primary care sector, such as
the retirement of partners with no identified successor and the
difficulty in recruiting GPs.
100. However, my focus in this area is ensuring that the impact that
such pressures can have on older people’s experiences of
health and social care services are recognised and that any
appropriate mitigating action is taken. For example, the
awareness that older people have of the current workforce and
other pressures within GP services and primary care is a cause
for concern for older people in relation to the implications this
may have for their continuity of care.
101. My care home review found that workforce planning is
challenging due to a lack of demographic projections about
future demand for, and acuity levels within, care homes. It is
therefore not possible to quantify the ‘right’ number of care staff
needed in the future. The unregulated nature of the care home
workforce in Wales, which means that data is not held on the
number of care home staff in Wales, can also lead to difficulties
around effective workforce planning.
102. In relation to nursing staff, workforce planning is not effective as
it is based only on the needs of Health Boards and does not
consider the needs of residential care. My care home review
follow-up work will look further into progress in this particular
area.
103. Incoming measures such as the regulation of the social care
workforce, and enhanced market analysis, should provide
improved tools for workforce planning within the care home
sector. Despite this, I still feel this is an area that requires
significant ongoing focus given the clear links between the
sufficiency of workforce planning and the ability of our health
and social care sector to deliver safe, effective and quality care
and support for older people in Wales.
Part C: Conclusion
104. I recognise and welcome the current policy drivers and
legislation that has been introduced to move forward our health
and social care sectors. For example, the increased focus on
the achievement of wellbeing, prevention and co-production
with a drive to further integrate delivery and shift services into
the community.
105. However, my work has highlighted a range of issues that mean
I am currently unsure about the extent to which these are being
achieved. Policy makers must be guarded against the mistaken
belief that the existence of a policy, framework or plan, is of
itself sufficient to deliver the change needed. After the
publication of such documents there needs to be a relentless
focus on whether implementation and progress is sufficient,
whether policies are effective in reality, and whether they are
having a measurable impact on the health and wellbeing of our
nation.
106. For example, as a result of the Social Services and Wellbeing
(Wales) Act 2014, there has been an increased focus on the
role of the third sector and our communities in supporting
individuals and, in some cases, providing services
commissioned by public bodies. However, this can only be
delivered in reality if those third sector bodies and our
communities are appropriately and realistically resourced and
supported to enable them to do this. This is also true of the role
that carers play in providing priceless care and support to some
of our most vulnerable in society, without which, our public
services would quite simply collapse.
107. Resource challenges across the health and social care sectors
are well documented, and I recognise the pressures that this
can place on both maintaining current delivery and realising
improvements. However, many of the changes that I identify
through the course of my work do not require significant
amounts of additional money, but rather a shift in resources,
focus and time at both a national, regional and local level.
Furthermore, it is crucial that health and social care resourcing
is viewed as a whole and that national discourse does not slip
into the trap of pitting one funding stream against another.
Finally, the costs in these sectors should not be viewed as a
burden, but as an investment in the continued and long term
health and wellbeing of our nation: the costs of not investing in
this area far outweigh the costs of doing so both for individuals
and the public purse.
108. While this Review is looking at the direction of the health and
social care sectors over the next 5-10 years, the barriers and
challenges that I have identified have taken many more years to
develop, and may take many more years to tackle and realise.
Furthermore, issues such as workforce planning and training
must take a much longer term view of the shape of the sector in
order to truly deliver for our current and future population. The
fundamental shape and role of our health and social care sector
over the next 25-30 years should therefore now be the focus of
policy makers in Wales.
Annex A: Further links to relevant statements &
submissions
109. Below are links to a number of statements and submissions that
I have made which may be of relevance.
110. Consultation responses:
111. Additional relevant consultation responses from January 2016 –
April 2017 are listed below, and all consultation responses can
be found on my website16.
Health, Social Care and Sport Committee Inquiry into
loneliness and isolation
Welsh Government Draft national dementia strategy
Charging for social care
Community Health Council: Annual Planning Review
Health, Social Care and Sport Committee Consultation on
the General Principles of the Public Health (Wales) Bill
Talk Communities: Building resilient communities across
Wales
Regulations and statutory guidance on Area Plans
following the Population Assessment
Phase 1 implementation of the Regulation and Inspection
of Social Care (Wales) Act 2016
Priorities for the Health, Social Care and Sport Committee
Sustainability of the health and social care workforce
Proposed improvement priorities for Social Care Wales
Improving the recruitment and retention of Domiciliary
Care workers in Wales
Together for Mental Health Delivery Plan (2016-19)
Draft explanatory guidance on the professional duty of
candour
Blue Badge Scheme in Wales
‘How do we measure the health of a nation?’
16 http://www.olderpeoplewales.com/en/Publications/Consultation-responses.aspx
‘How do you measure a nation’s progress?'
112. Publications, scrutiny and statements
113. Additional relevant publications, scrutiny and statements can be
found on my website.
Best Practice Guidance for Engagement and Consultation
with Older People on Changes to Community Services in
Wales17
Effective Engagement with Local Authorities: Toolkit for
Older People18
Preparing Local Wellbeing Plans: Guidance for Public
Service Boards19
Guidance issued to Health Boards on NHS
Reconfiguration Plans and older people20
Scrutiny of care home ‘top-up fees’21
Housing for older people: Making it a national priority in
Wales22
Ageing Well in Wales: A partnership programme for
collaborative action across Wales and in Europe
i. Age friendly communities
ii. Dementia supportive communities
iii. Falls prevention
iv. Opportunities for learning and employment
Loneliness and isolation23
17 http://www.olderpeoplewales.com/en/publications/guidance/14-07-01/Best_Practice_Guidance_for_Engagement_and_Consultation_with_Older_People_on_Changes_to_Community_Services_in_Wales.aspx#.WNJl8m-LTIU 18 http://www.olderpeoplewales.com/en/publications/Engagement_Toolkit_copy1.aspx 19 http://www.olderpeoplewales.com/en/news/news/16-10-05/Preparing_Local_Wellbeing_Plans_Guidance_for_Public_Services_Boards.aspx#.WNJn_2-LTIU 20 http://www.olderpeoplewales.com/en/publications/guidance/13-02-06/Guidance_issued_to_Health_Boards_on_Reorganisation.aspx#.WNJmBG-LTIU ; http://www.olderpeoplewales.com/en/reviews/nhs-reconfiguration.aspx 21 http://www.olderpeoplewales.com/en/publications/scrutiny/16-03-31/Scrutiny_of_care_home_top-up_fees.aspx#.WNJmNW-LTIU 22 http://www.housinglin.org.uk/blogs/Housing-for-older-people-Making-it-a-national-priority-in-Wales/ 23 http://www.ageingwellinwales.com/en/home
Response from Cardiff Third Sector Council to the
Parliamentary Review of Health and Social Care:
Call for Evidence (Cardiff Third Sector Council)
1.0 Introduction 1.1 Cardiff Third Sector Council (C3SC) is a registered charity and umbrella body working to
support, develop and represent Cardiff’s third sector at local, regional and national level. We have over 1,000 members, and are in touch with many more organisations through a wide range of national and local networks. We are a part of Third Sector Support Wales (TSSW) – a body of membership organisations constituting WCVA and Wales’ CVC’s; our mission is to provide excellent support, leadership and an influential voice for the third sector and volunteering in Cardiff.
1.2 C3SC is committed to a strong and active third sector building resilient, cohesive, active
and inclusive communities, giving people a voice, creating a strong, healthy and fair
society and demonstrating the value of volunteering and community action.
1.3 We welcome the opportunity to respond to the Parliamentary Review of Health and Social Care in Wales. This response is structured in accordance with the questions in the consultation document.
1.4 This response is drawn together by C3SC’s Health and Social Care Facilitator from experience and knowledge of related issues through their working role, and contributions from C3SC’s Senior Management Team. C3SC promoted the consultation to members; we will confirm through Network meetings if member organisations, as is very likely, have contributed via other avenues.
Consultation response
2.0 Defining the key issues facing health and social care
2.1 There have been many advancements in medication, surgery and health services since
the NHS was formed. There have been district and community hospitals and a range of
other settings prior to the model that is currently in place where secondary care is
provided through the main hospitals. Throughout all of these advances in health
provision the model of care has remained consistently the same, with social care being
managed separately by the local authorities. With the advances in health services people
are living for longer frequently with chronic conditions which means that more people
need both health and social care services simultaneously and not in isolation. As a result
the current models need to be reviewed to ensure that both health and social care
services are sustainable and effective for the 21st Century, a review is likely to identify
areas for change and integration where this occurs there will need to be funding made
available to enable change to take place.
2.2 Involving the population in re-shaping the social contract around health and social care – with a greater emphasis on enabling public, health and social care services that are no longer involved in ‘doing to’ and ‘for’ the population – some of which will require de-politicising the debate and/or positively politicising asset based approaches, and involving education in the journey. In Cardiff and the Vale this approach is the basis for the Cardiff and Vale University Health Board’s (UHB) Shaping Our Future Wellbeing 10
year strategy document (http://www.cardiffandvaleuhb.wales.nhs.uk/sitesplus/documents/1143/10%20%2D%20UHB%20Shaping%20Our%20Future%20Wellbeing%20Strategy%20Final.pdf) with the workstreams being developed in partnership with the third sector, local communities and the Local Authorities. There are monthly newsletters which are issued to demonstrate progress and the partnership in action including the impact of third sector innovations and services (https://www.c3sc.org.uk/networks/networks-doc-lib/cardiff-health-social-care-network/cardiff-and-vale-uhb-updates/our-future-wellbeing-newsletter). This work is in its early stages and the need to remain focused and balanced across the partnership will be a key issue, with all partners being seen as part of the solution.
2.3 WPS2025 report on ‘A delicate balance? Health and Social Care spending in Wales’
gives information on the scale of the challenge around finances for both health and
social services. http://www.walespublicservices2025.org.uk/files/2017/03/Wales-health-
and-social-care-final_amended_04-2017.pdf
2.4 Cardiff growing population, including the increasing number of school aged as well as
older people (which is different to the rest of Wales) as demonstrated in the Population
Needs Assessment (http://www.cvihsc.co.uk/about/what-we-do/population-needs-
assessment/) which was released in March 2017.
2.5 Responding to a diverse population where health risks/outcomes and expectations of
health and social care services frequently differ. Evidence of this can be seen in the
AgeUK report ‘Fit as a Fiddle’ (http://www.ageuk.org.uk/Documents/EN-
GB/FaithGood%20Practice%20GuideWEB.pdf?dtrk=true), whilst the report provides
information specific to England, the issues for diverse communities and populations are
similar in Wales.
2.6 Funding for Health Services – lack of consistency across Wales, where you live depends
on amount per head of population that is funded. Cardiff and Vale have the lowest
funding per head of population of any health board in Wales.
2.7 Funding for social care – recognising the impact of reductions on the demand and costs
for health services.
2.8 Evidence-based preventative services to reduce the burden of raising populations and demand on services. It is difficult to evidence savings within preventative services, but can often demonstrate their benefits. Prevention has the potential to offer significant outcomes in the picture of pressures on services from an ageing population as well the costs of physical inactivity, smoking, obesity and alcohol related ill health.
2.9 Integration would also support the above, but integration of health and social care often focusses on integration between the Health Boards and Local Authorities but fails to acknowledge the equal and influential partnership role of other sectors.
3.0 Identifying where change is needed and the case for change
3.1 GP sustainability – Cardiff and Vale have not yet had a contract returned to them by a GP Practice most other Health Boards in Wales have. Therefore there is a need to ensure that there are enough GP’s who are supported to provide services. This should include the role of social prescribing which can empower people to improve their own health and mental health and reduce the demand on primary care and potentially on the need to prescribe as much medication or for as long a period as now. Social prescribing often involves prescribing to activities, groups and services provided in the community by the third sector to support the sustainability of the GP services it is therefore also important to ensure the sustainability of the third sector who are providing these services and running groups.
3.2 Perfect Locality – BIG2 in the Cardiff and Vale UHB and Locality Based Working in City of Cardiff Council. The Cardiff and Vale Regional Partnership Board have demonstrated through their work during 2016/17 that there is a need locally for services to be delivered differently for them to be sustainable. This requires partnership working between the statutory sector organisations but also partnership working with the third sector, private sector and through co-production. Whilst there may not be a perfect locality, the focus is to provide community appropriate services in new ways and as close to home as possible. If multiple services work together the outcomes for the individual can be greater and longer term, especially if the outcome has empowered the individual.
3.3 Public Health Wales report ‘Making a Difference: Investing in Sustainable Health and
Wellbeing for the people of Wales’ 2016
(http://www.wales.nhs.uk/sitesplus/888/page/87106) offers research evidence and expert
opinion in support of preventing ill health and reducing inequalities to achieve a
sustainable economy, thriving society and optimum health and well-being for the present
and future generations in Wales. One of the areas is to promote physical activity which
is anticipated would safe the NHS money, the third sector are already involved in
encouraging and enabling physical activity whether this is through running groups,
encouraging cycling through Sustrans and Pedal Power, ElderFit providing Otago and
Strength classes, walking groups, gardening groups and a range of other activities that
take place in communities across Wales. In addition to this the work being carried out by
the Communities First teams in promoting physical and mental health and encouraging
healthy lifestyles will be missed when the Programme is phased out by Welsh
Government and leave a gap in enabling people to make informed healthy choices which
without funding may struggle to be filled across wide areas of depravation.
3.4 There is a general consensus that the growing numbers of individuals with long-standing
conditions and complex care needs are poorly served by the fragmentation of services
that has resulted from the historical structure of separate NHS and social care, and
between general and specialist practice. The Kings Fund provides one source of the
case for integration. The third sector are often bridging the current divide providing
slightly different services to people under a health contract and then under a social
services one, there are examples such as the Community Resource Teams in Cardiff
where the third sector are co-located within teams from health and the local authority
providing a range of support and services to enable people to return home from hospital
or stay out of hospital in the first place. The support provided is short term, but that is
because the individuals are able to live independently, if they need longer term support
to re-engage with their local communities then this is often done by referring to another
third sector service that can provide befriending support.
3.5 Identifying the policies, structures and opportunities that will promote and create successful integration, supported by a regulatory framework that supports closer working. Whilst there have been a number of attempts to encourage integration these have not been successful. The evidence and justification for change needs to be made clearer and needs to engage with politicians at all levels and be done cross party so it is no longer a political battle ground but that commonality is agreed. This will then provide the stable environment that is needed for the long term planning and change programme to be implemented that will enable change to take place.
3.6 An inspection and performance framework that focusses on the patient’s experience of
the whole system rather than on the services provided by individual organisations. This needs to include integration of the different regulations and regulators, as the current system is often costly and involves organisations being regulated for the same service in different ways depending on who has commissioned the service. The role of Social Care Wales, CSSIW, Community Health Councils and Healthcare Inspectorate Wales needs to agreed so that if there is duplication this can be reduced and where one inspection can be done jointly that this should be done.
3.7 Increasing the choice of services through a greater range of providers working to provide
well-integrated care in collaboration, avoiding the development of a culture of competition. Competition can in certain instances be used to ensure that public monies are being spent effectively, however the need to automatically recommission a service that is delivering outcomes and that meets the needs of individuals may actually be wasting money and leaving the workforce feeling undervalued and looking at alternative employment which takes away their skills and expertise. There have been a number of instances where commissioning and procurement have been undertaken in Cardiff and the Vale where there have only been one expression of interest or full tender, by the current provider. This is a waste of time and resources for all those involved. Services should be reviewed to make sure that they are delivering what people want and that meet their outcomes and only if this is not the case have a new service specification developed through coproduction with service users, carers and those delivering the current service which then goes out to tender.
3.8 There are already a number of Acts and strategies which point to the need for change.
These include the Social Services and Wellbeing (Wales) Act 2014, Wellbeing of Future Generations (Wales) Act 2015, Regulation and Inspection of Social Care (Wales) Act 2016, National Dementia Strategy ‘Together for a Dementia Friendly Wales 2017-2022’, The Strategy for Older People in Wales 2013-2023, and the Diabetes Delivery Plan for Wales 2016-2020.
4 Setting out a vision for the future including moving health and social care forward together, developing Primary Care services out of hospitals.
4.1 Most primary care services are already out of hospitals, there is increased evidence to develop Secondary Care services out of hospitals to align to Prudent Health Principles. This is supported by the Cardiff and Vale UHB’s 10 year strategy ‘Shaping Our Future Wellbeing’.
4.2 Good practice examples are available from elsewhere, such as Bromley-by-Bow which has a proactive and progressive social prescribing system, where health services are
only one part of improving people’s health and wellbeing, with the majority of other services being provided by community groups and the wider third sector.
4.3 In other parts of Wales hospitals have been forced to run GP surgeries after contracts have been handed back, this often leads to a whole service redesign as demonstrated in Prestatyn. There should also be greater opportunities for GP surgeries to employ hospital specialists, social workers, mental health practitioners etc, or for them to remain employed by secondary health and local authorities but be collocated within the GP surgeries. This will enable Primary Care to provide a full range of care outside of hospitals, including outpatients and encouraging wider knowledge of local services to enable improved social prescribing. There are already examples of the third sector supporting GP practices to enable social prescribing, in Cardiff and the Vale the Wellbeing4U coordinators run by United Welsh Housing Association which is beginning to provide evidence of the benefits of the collocated service and some of the resource savings that have been made.
5 Advising on how change can be delivered, building on the positive aspects of the current system.
5.1 Developing an effective strategy that articulates priorities and targets and how this will be achieved.
5.2 Health literacy – to empower people to make their own informed choices. Keep messages simple and clear, available in a range of languages, and open up choices by offering clear pathways. This needs to include better information and education on when to access different parts of the NHS, including pharmarcists, minor injury units, GP nurses, GP’s as well as Accident Units the Welsh Ambulance and Air Ambulance and alternatives including an increase in the number of people with a basic understanding of first aid.
5.3 Co-production – engaging with those who use the service, carers, staff and other stakeholders to develop new services or to improve existing ones. There is a lot of evidence from other countries such as Australia who have embraced coproduction and an increasing wealth of knowledge and information through the Coproduction Network here in Wales. Investment in coproduction is not only a matter of service user and provider engagement in service design and delivery, it is also an issue for Health Bodies and Professionals, for example to have time and resources allocated in order to facilitate and participate within processes of changes in practice, and service delivery.
5.4 Working in partnership – the Summer Holiday Enrichment Programme in Cardiff is a good example of a partnership working to improve child health and social engagement during the summer holidays. The evidence from the Programme has led to funding from Welsh Government to develop similar programmes in other areas of depravation where the provision of free school meals can be the only hot meal of the day.
5.5 Social Action Innovations – there are a number of examples, NESTA did a report in October 2016 on ‘People Helping People: Lessons learned from three years supporting social action innovations to scale’ http://www.nesta.org.uk/publications/people-helping-people-lessons-learnt
5.6 Public service facilitation of delivery rather than delivering everything ‘in-house’; the use of the Older Persons ICF and Children with Complex Needs and Adults with Learning Disability ICF in Cardiff and the Vale provides examples of this. However, the limitations placed on the Integrated Autism Service funding by Welsh Government provides additional limitations as the focus is purely on in-house provision from the statutory sector in integration and excluding other options, including third sector solutions and services.
6.0 Specific evidence in regards to aspects (page 2 of the call for evidence):
7.0 Over the next 5-10 years what should health and social care services prioritise to ensure
a sustainable approach to improved outcomes and best value in health and social care in
Wales?
7.1 Health Literacy, including promotion of the key Public Health Messages consistently promoted across the whole of Wales.
7.2 Improved integration and co-location of services, not just from statutory services but also the third sector. A good example of this is the Community Resource Teams in Cardiff and the Community Resource Service in the Vale of Glamorgan.
7.3 Public service facilitation of delivery rather than delivering everything ‘in-house’. 7.4 An effective strategy that articulates priorities and targets for moving towards an
integrated, person centred approach to service delivery and how this will be achieved.
7.5 One outcomes framework that covers health, social care and wellbeing (including Public Health) rather than the range of different ones which encourages silos and separation rather than integration and to meet outcomes that meet people’s longer term wellbeing needs.
8.0 What do you value about the service you deliver now and how could it be made better? 8.1 Third sector services offer cost effective, trusted, person centred solutions to
realising many of the aspirations, but if this is to be maximised it requires a move towards a clear strategy that might support this to be achieved.
8.2 Third sector can often respond to changes in need and develop innovative solutions faster than the statutory sector. Social enterprise, cooperatives and more tradition third sector organisations are able to lead the development of producing evidence-bases for future consideration by commissioners. The need for stronger links between the third sector and researchers is an area for further development, this should include the smaller local groups working in specific communities and often having positive impacts on wellbeing and social inclusion, as well as the tradition larger national charities who focus on some of the chronic and terminal illnesses.
9.0 What do you see as working well, and are there examples of innovation and good practice that could be replicated?
9.1 See Community Resource Teams above. 9.2 Bromley-by-Bow – whilst it could not be replicated the ethos and aims can be
used to develop what is needed in the local communities in Wales.
9.3 Volunteering has increased evidence of benefits to an individual’s wellbeing as well as to the community – there is a limit though to the availability of volunteers, especially if they are working as well and opportunities fail to respond to this. Volunteers are a valuable resource but often incorrectly seen by the statutory sector as a free resource…this is not the case, co-ordination, travel and since the Welsh Government stopped funding WCVA to do the DBS checks the cost of DBS checks for volunteers who are in contact with the vulnerable both adults and children. C3SC runs the Cardiff Volunteer Centre and can bring this resource to assist future arrangements.
9.4 The Cardiff and Vale Co-creating Healthy Change Project - enabling co-production and informing local practice to support this approach
9.5 Pooled budgets for health and social care, and integrated teams of staff, in Cardiff and the Vale has helped reduce hospital bed occupancy, and increased the number of individuals cared for in their own homes. There are good examples but there could be many more with better partnerships and understanding between sectors.
9.6 Development of joint services, such as the School Holiday Enrichment Programme which came from an identified need and was then developed in partnership between Communities First, Education, Public Health and community groups and sport providers to provide a wide range of activities to stimulate, educate and encourage healthy lifestyle choices for those who attend.
10.0 What do you see as barriers to improvement and how could these be overcome? 10.1 Funding – with reduced real time funding to be able to fund something new
something else has to be stopped. The barriers are the risks that this raises. 10.2 Short term pilot innovations, which despite having excellent evidence-based
research outcomes, cannot find funding at the end of innovations. There are many examples of this, especially funded by the Big Lottery, such as Friendly AdvantAGE, but which then struggle to access sustainable funding at the end of the project. The financial situation means that unless there is a change with how funding is provided then there is no clear pathway to resolve these issues, an increase in social enterprises and co-operatives may assist but would be unlikely to be suitable in all circumstances and will require integration in the planning if an effective offer is to be developed.
10.3 Protectionism of budgets – unless pooled budgets are provided by the Welsh Government and other bodies the responsibility for monies remains with the budget holders, with local authorities and the health boards being under increased scrutiny of how they manage spend and the outcomes achieved can be an increased barrier. The Intermediate Care Fund does provide pooled funding which encourages partnership working and reduces protectionism of budgets.
10.4 An unwillingness to move away from traditional approaches – which is somewhat understandable in the picture of the pressures on services and budgets, and a regulatory, target focussed culture that develops an aversion to risk rather than an appetite for innovation
10.5 The inspection and performance framework that focusses on the services provided by individual organisations rather than on the individual’s experience of the whole system including opportunities for social prescribing rather than the more traditional medical prescribing and therapies.
11.0 What could be improved in current systems or in your area of work, and what needs to happen to enable change? What would be the benefits in terms of improved outcomes?
11.1 See previous comments about barriers.
11.2 The aim has to be placing people at the centre of the design and delivery of care (including health) improving outcomes for the people of Wales and value for money; meeting their individual needs for health and wellbeing rather than one size fits all.
12.0 What needs to change to ensure that co-production or co-design is routine in health and care services and that people are better able to stay healthy or manage their condition?
12.1 Improved health literacy, with improved leaflets which are designed with people and not by those ‘trained’, with fully accessible alternatives which are accessible to people with learning disabilities, with poor use of the English and/or Welsh language as well as with sensory loss.
12.2 Increased peer-to-peer support and groups that can provide feedback directly to commissioners.
12.3 Commissioning to begin with commissioning and not procurement, as unfortunately can often happen.
12.4 Provide resources for networks such as the Long Term Conditions Alliance & Health and Social Care networks which disseminate(d) information to third sector groups and local organisations to pass on to their members and can have direct input into service design through engagement.
12.5 Utilise the wide range of resources that are already available, for example the Cultural Competency Toolkit and the Connecting with People toolkit from Diverse Cymru.
12.6 Change the conversation with citizens and with clinicians to placing people at the centre of prevention and the design and delivery of their care with the aim of improving patient outcomes and satisfaction.
12.7 Recognise there is a general deficit in the number of people engaged in influencing policies and services, and include this in planning and commissioning, working with the third sector infrastructure (Third Sector Support Wales) to help to address this locally, regionally and nationally across Wales, and with schools
12.8 Those responsible for services within Health and Social Care require support (including targets and measures) to be involved in coproduction activities: support to ensure professionals (directors, managers) have time and resources allocated appropriately and to facilitate, and participate within, the processes of change that are demanded by the relevant strategic Acts (noted within 3.8)
13.0 Do you agree that the strategic direction of increasing primary, community and social care in local communities is the right approach to better meet the needs of particular populations?
13.1 Yes, it supports the move towards people centred services as the services can be geared towards the population and respond to specific issues which may not feature high enough numerically if a larger geographical area is being looked at.
13.2 More local services should enable better integration and understanding of other services in the community which should improve signposting and social prescribing.
14.0 To what extend should services and processes be standardised across Wales, to achieve the right balance between national level and local decision making and allow room for innovation?
14.1 The infrastructure should be standardised to reduce service inefficiencies in the ability to access and share information
14.2 The more a service is standardised across the less flexibility there is for innovation, as the funding requirements and outcomes laid down often determine
the services that can be provided. There could be a standardised set of options, but leaving it to local, shared decision making processes to determine which options best suit the local population. More local service options enable innovation at a local level.
14.3 The commissioning process should be clearly laid out and followed, but services should not be standardised unless there is good reason to do so. For example if there is only one best practice method then it should be adopted but if there are multiple it should be local choice with justification for reasoning.
14.4 There could be a move to a central commissioning body.
15.0 What do you understand by integration and what steps are needed to further integrate services?
15.1 Integration at a local level appears to focus on the integration between the health services and social care and social services in the local authorities. We think this integration whilst being important overlooks the benefits that can come from widening integration to include the third sector, as demonstrated by the Community Resource Teams above. The third sector includes charities, housing associations, local organisations and community groups. Housing is especially important as there is evidence of poor housing conditions having a negative impact on peoples health.
15.2 A move to increase integration and personalisation of care are likely to require health and social care professionals to adopt new roles and responsibilities that have a mix of health and social care competencies. This will need to be facilitated by consistent terms and conditions; single management structures in co-located teams; and single IT/Information systems. Currently we often see co-located teams who continue to operate in organisational silos with multiple HR/Finance/Information systems which often act as barriers to progress.
15.3 We agree with the Cardiff and Vale Integrated Health and Social Care Partnership response that there needs to a “redesign of existing roles and the development of new positions spanning health and social care which could facilitate greater integration.” There should be flexibility for this to be done at very local as well as local authority and regional levels and include where appropriate the third sector as well as the statutory sector.
15.4 For full integration the development of a single information system across health and social care is essential, and how those commissioned to provide services can link and engage with it also needs to be included in the planning stages. The sharing of information will require a culture change for many health professionals who often state that the health information is there’s and not to be shared, but this lack of sharing means that sometimes there is an unnecessary delay in the correct support and care being put in place.
16.0 What do you understand by prudent health and social care? What steps are needed to ensure the principles are embedded in routine practice?
16.1 The move from supply-focussed systems around healthcare professionals to people-centred services that focus on the most appropriate treatments and includes the contribution individuals can make to their own health and wellbeing in achieving positive health outcomes
16.2 Improved communication with the general public so they can make better informed choices.
16.3 Increased focus and funding on preventative services so people access the health and social care services that they need amongst a range of other information, support and services.
16.4 Workforce development to support the change of culture amongst traditional service providers.
16.5 Funding and commissioning that supports people to understand the new framework for health and social care and to develop the confidence to interact in that environment
17.0 What actions are needed to ensure services have a sustainable workforce for the future that matches the strategic direction?
17.1 Social Care Wales has a role in increasing the professionalism of the Social Care workforce.
17.2 Positive promotion of social care as a career, the City of Cardiff Council are currently running the #Beacareworker campaign supported by the local providers (third sector and private). More of these campaigns need to take place and the negative press that surrounds social care needs to be challenged with examples of the good practice that takes place.
17.3 A shared, co-produced strategy for how public services will facilitate sustainable service delivery at a community level.
17.4 Engage with those who access services to coproduce the support and services that they want, this can enable them to follow their own interests and engage with those who share the interests giving additional job satisfaction and enjoyment to the workforce.
17.5 Include the workforce in planning, commissioning and research and acknowledge the skills and information that they hold as well as carers and those who access the services.
18.0 Contact details
18.1 If you require any further information in regards to the responses to the
questions please contact Sarah Capstick, Health and Social Care Facilitator at C3SC
directly via email: [email protected] telephone: 029 2048 5722 or by post to:
Cardiff Third Sector Council
Baltic House
Mount Stuart Square
Cardiff
CF10 5FH
Parliamentary review of health and social care Care Council for Wales – Written evidence
The Case for Change
The key issues facing social care were in the Welsh Government’s
Sustainable Social Services report, which laid the ground for the Social
Services and Well-Being (Wales) Act 2014 and the current transformation of
services. Many of the issues are shared with the NHS as follows:
o The demography of our society is changing, with increased need for
public service support. We are an ageing society and we see many
more people in their middle years with significant disabilities who
expect to live fulfilled lives. We are seeing many more children with
significant disabilities or disadvantages who have high expectations of
support that protects them and helps them to achieve their full
potential.
o There are still social, economic and health inequities across Wales,
despite targeted programmes.
o Wales has relatively higher rates of Looked After Children than other
parts of the UK, linked to Adverse Childhood Experiences.
o Social care services are facing real and unsustainable increases in
demand to meet society’s needs.
o Social care practitioners and managers have caseloads that are
difficult to manage; leaving little time to focus on prevention, early
intervention and service re-design.
o Preventative support from community and third sector services are
reducing, arising from Councils and other bodies re-directing resources
to statutory functions and critical services, due to budget challenges
over recent years.
o Unpaid carers provide the majority of support to vulnerable and
disabled people, enabling people to remain living at home and
contributing to society.
o Health and social care services depend on the contribution of unpaid
carers, family, friends and neighbours and more could be done to
provide consistent information, advice and support.
o Domiciliary care and support workers provide essential care and
support, which prevents deterioration and avoids more expensive
hospital or residential/nursing care.
o Pay rates for this staff group are unattractive, creating recruitment and
retention difficulties, with turnover rates of 30% in this sector.
o The impact of fragile community based treatment, care and support
services, can be seen in the level of emergency hospital admissions
and delays in discharge home.
o Independent and third sector care providers should be regarded as
equal partners with public bodies.
o Care providers are “handing back” packages of care as they have
challenges in sustaining an adequate workforce, especially in rural
areas or where welsh language provision is required.
o The financial outlook is very difficult, with public spending constraints in
place for many years ahead, leading to difficult choices for government
and delivery bodies.
o Welsh policy is to promote people’s rights and increase choice. People
have higher expectations about their voice being heard and about
control over services they require. There are different expectations
about choice across health and social care.
o Social care practice and delivery models have not yet fully transformed
to meet new expectations set out in the Social Services & Wellbeing
Act, although there is consensus on the direction of travel and many
authorities are making good progress.
o There are good examples of social care services that are well aligned
with housing, health and education services, although evidence of
good practice is not held in one place or easily shared across Wales.
o People are confused about paying for social care when healthcare is
free at the point of delivery. This is particularly evident when people
have very complex and/or long term health and care needs, who may
also meet the NHS Continuing Healthcare threshold.
o There is inconsistent use of Direct Payments for jointly funded
packages of health and care support for people with complex needs.
Opportunities for improvement
It is worth recognising that most people surveyed are satisfied with their
health and care services and public services are highly regarded in Wales.
There is always room for improvement and current arrangements are not
sustainable to meet future needs.
Most Social Services departments seem to be able to effectively manage
demand, through practice and service transformation, whilst avoiding
recurring budget overspends.
Significant policies and legislation are now in place and command broad
support from national and regional leaders. These provide a unique
opportunity for Wales to align policy and delivery with a common purpose and
include:
o Well-being of Future Generations Act, with a focus on prevention,
integration, long term thinking, collaboration and involvement
o Sustainable Social Services & Social Services & Well-being (Wales)
Act 2014
o Prudent Healthcare
o Helping people to help themselves, with the right information, advice
and assistance
o Services designed around the citizen
o Providing more care and support at or near home. Greater support for
people and their communities to manage their own health and care
needs and to choose well
o A focus on well-being outcomes, rather than activity targets which
create perverse behaviours
o A welsh consensus is desirable on the balance between the citizen and
the state regarding how much should we be expected to contribute to
meet our health and care needs. The exclusion of “over the
supermarket counter” medicines from NHS prescriptions is a useful
indicator of difficult choices required.
Wales can learn from the Scottish experience of a national performance
framework, focussed on well-being outcomes, which has been in use for 10
years. The Carnegie UK Trust has positively evaluated this approach, which
evidences a common purpose and shared pillars of Prevention; Partnerships;
Participation and Performance as a way of working across all public bodies
with their partners.
WB of Future Generations Act lends itself to a similar approach, recognising
that success is likely to emerge over the longer term, beyond an
administrative/political cycle. Cross party support to improve health and social
care is already evidenced in Wales and this can be built upon, to align policy
with delivery.
Regional Health and Social Care Partnership Boards are now established in
Wales, which provide an appropriate vehicle for aligning national policy with
local delivery, as a top down approach does not empower citizens or front line
practitioners to find sustainable solutions.
Alignment of public services in a “Team around the Citizen Approach” has
proven effective in Wales e.g., Integrated Family Support Teams, Integrated
Care services, Vanguard models, MASH units, which do not rely on
organisational re-structures but align professionals to a common purpose.
This enables professionals to retain their unique skills, professional status and
employment terms and conditions and does not necessitate pooled budgets,
which are challenging to agree and manage.
We need to learn from the experience of English integrated service models,
which have been disbanded eg. Recent London boroughs.
More could be done to develop joint learning and development opportunities
at the undergraduate, post graduate and leadership levels, so that health and
social care professionals better understand each other’s contribution to a
person’s well-being, whilst retaining their unique protection of title, registration
and regulation. Secondment and rotation of practitioners and managers to
other parts of the “system” would help foster a common purpose. It is still
unusual for professionals to leave the NHS to join local government and vice
versa. Multi-disciplinary team working is increasing, which helps to deliver a
prudent approach, where the best skills and knowledge are used effectively.
A stronger focus on community based responses is essential to reduce
reliance on acute forms of health and social care. Most people, no matter how
complex their needs, want to remain living well and independent in their own
homes for as long as possible. Most people’s healthcare needs are met within
a primary or community setting.
The potential to use technology to provide digital support to people is not
being fully harnessed e.g., virtual outpatient clinics or expert advice to co-
workers, electronic patient records. There is international evidence from less
densely populated countries which could be considered.
The use of the Wales Community Care Information Solution (WCCIS)
provides an opportunity for a single health and care record that can be owned
by the “customer” and shared with all relevant professionals, as well as
monitoring and directing resources.
The role of Local Authorities as community leaders, with a democratic
mandate, should be harnessed, so that local people are able to shape and
scrutinize all public service delivery, not just Council services.
The requirement for Populations Needs Assessments and citizen panels will
help citizens to understand and inform how resources are used to meet local
priority needs. This provides a vehicle for co-production and meaningful
engagement in the difficult choices ahead.
Health and social care services are major employers in Wales and need to be
considered as a significant benefit to the economy. Carers (paid and unpaid)
enable people to achieve and sustain employment, social and learning
opportunities. The health service enables people to return to work quickly,
following episodes of ill health.
o Ken Skates, the Cabinet Secretary for Economy and Infrastructure,
wants health and social care to become a priority economic sector for
the Welsh Government. He recognises the importance of high quality
health and social care in attracting families, employers and investors to
Wales.
The establishment of Social Care Wales provides a new opportunity to use its
regulatory functions (where standards are set and monitored) alongside
workforce and service improvement responsibilities, so that good practice is
developed and rolled out across Wales. An information hub will be developed
for showcasing good practice and evidence of what works.
Creating the vision for community based health and social care
We need to harness the vision of well-being, as set out in the WB of Future
Generations Act as the overarching common purpose for all public bodies,
with their partners in independent and third sector. Public Service Boards
provide the vehicle for delivery.
This provides the framework for housing, education, the economy, the
environment, leisure, public health and protection, as well as health and social
care, within a place based context at neighbourhood, community, local
authority, regional and national levels. In this framework, policy and standards
are determined nationally and delivery is focussed at the best footprint for
each specific service. Planning and Commissioning may lend itself to regional
or national working but delivery needs to be retained at the lowest efficient
level, so that citizens’ voices can be heard.
o The Social Services and Well-Being (Wales) Act 2014 provides the
vision for social care, working with health and other partners. All local
authorities across Wales have embraced the vision and are in the
process of implementation with their citizen panels providing a strong
voice. A strong emphasis on empowering citizens and encouraging
them to take greater responsibility for their well-being echoes the
aspirations of Prudent Healthcare.
There may be aspects of the social care practice approach which can provide
important insights to others in adapting their approach to well-being. These
include:
o A rights based approach for citizens
o A strengths based model of assessment
o Positive risk taking
o Helping people to help themselves, by providing the right information,
advice and assistance
Levers for change, using the current system
Integration is not an outcome and will achieve nothing if behaviours and
practices do not change.
Alignment will still deliver seamless services, if the focus is the team around
the citizen.
Alignment between health and social care and all local services that support
well-being may offer a more palatable, practical and sustainable solution.
Social Services functions do not always align neatly with clinical health
service delivery and there are significant benefits from close alignment with
local authority functions, where the responsibilities for community well-being
across the whole population are anchored.
Organisational change often creates power struggles and anxiety amongst
professionals and leaders and can suck away time and energy that could be
better spent on creating the right culture for seamless delivery. A common
purpose is essential (nationally, regionally and locally). This requires strong
partnership and collective leadership between primary care, community
health, public health and social care, as well as other services to meet future
demands.
Trust needs to be established between national bodies (who should focus on
policy and standards) and regional and local organisations, who are best
placed to focus on delivery. This should help create the right enabling
conditions for a culture of empowerment and accountability at the appropriate
levels.
Local Authorities provide the neighbourhood and community place framework,
which can be aligned to GP clusters to plan the right service models for their
population needs.
Unless the state is going to directly provide all social care services, we need
new models of commissioning that are based on mature partnerships
between health and social care commissioners and providers. This would
support longer term outcome based contracts in a more flexible approach,
providing more assurance that there will be adequate local capacity amongst
providers.
Priorities for Action
Resources and action targeted on prevention: Helping people to help
themselves with the right lifestyle advice and easy access to information and
support, from the school curriculum and into adulthood. Maximise the use of
DEWIS, 111 and on line information sources to help people choose well.
Resources and action targeted on care and support at home, to enhance
independence and improve well-being : This is a fundamental part of the
system, if we are to lessen the burden on the NHS and avoid institutional
social care.
o In order to achieve this we need a highly valued care at home
workforce which is adequately skilled, receives pay and conditions
which reflect the importance of their role.
o Social Care Wales has led on a new strategy for care and support at
home, which has recently been endorsed by Rebecca Evans, Minister
for Social Services and Public Health. The strategy was informed by
evidence from citizens and research and has been co-produced
through the efforts of many partners. An implementation plan is under
development and will be a key strategic priority for Social Care Wales.
o However, where health related tasks are shifting into community
settings, we need to ensure that effective clinical and corporate
governance arrangements are established, which protect professionals
and organisations. The Medicines Task Group is currently consulting
on this issue.
We also need to develop suitable housing for older people, where health and
social care can be delivered safely and efficiently, with new models of Extra
Care and Supported Housing, reducing the need for institutional care and
avoiding unplanned hospital admissions. Many parts of Wales are now
developing Accommodation Strategies that provide a pathway from home to
supported living and onto a residential setting, when needs become more
complex. There is good evidence in “Our Housing AGEnda”, the report from
the Expert Group on Housing and Ageing, February 2017.
Regional Health and Social Care Partnership Boards are in a unique position
to plan and design new models for the future, using the aspirations of the
Social Services & Well-being (Wales) Act 2014, Prudent Healthcare and the
national outcomes.
Recent examples of good practice Social Care Accolades, Wales, 2015
Welsh Language in Health, Social Services and Social Care Awards, 2015
