Author: Bees Sarah

Contents

1.		Foreword	P.4
2.		Introduction	P.6
	2.1	Our Vision	P.6
	2.2	Area Plan Outcomes	P.9
3.		Background	P.12
	3.1	Strategic Context	P.12
	3.2	Population Needs Assessment	P.13
	3.3	Area Plan Guidance	P.14
	3.4	Focused work with minority groups	P.15
	3.5	Partnership working	P.16
	3.6	Who developed the plan?	P.17
4.		Integrated Working	P.18
	4.1	The role of the Regional Partnership Board	P.18
	4.2	Developing an integrated system of care and well-being for Gwent	P.19
	4.3	Integration of services – Part 9 Social Services and Well-being Act	P.20
	4.4	Integrated Care Funding	P.21
	4.5	Governance, assurance and monitoring the Area Plan	P.22
	4.6	Enablers	P.25
5.		Appendix 1 : Core Theme Action Plans	P.27
	5.1	Children & Young People	P.27
	5.2	Older People, including People with Dementia	P.31
	5.3	Health & Physical Disabilities	P.36
	5.4	Mental Health	P.38
	5.5	Learning Disability	P.44
	5.6	Sensory Loss & Impairment	P.46
	5.7	Carers	P.50
	5.8	Autism	P.57

6.		Appendix 2: Links to Well-being of Future Generations Act and other Strategic Partnerships	P.59
7.		Appendix 3: ABUHB Clinical Futures and Integrated system of well-being	P.63
8.		Appendix 4: Creating an integrated workforce	P.65
9.		Appendix 5: Welsh Government Principles of working action plans & acronyms
	9.1	Welsh Government Principles of Working and Acronyms	P.70
	9.2	Joint Commissioning and Pooled Budgets	P.71
	9.3	Prevention and Early Intervention	P.74
	9.4	Information, Advice and Assistance	P.76
	9.5	New models, user led services and third sector working	P.79
	9.6	Workforce Development	P.80
	9.7	Advocacy	P.81

1.		Foreword

At the very heart of this plan, is a clear commitment from health and social care leaders, to revolutionise how we deliver services to people with a care and support need.
This was the challenge placed firmly at the door of the Regional Partnership Board by the Parliamentary review, it is one that underpins this plan, and the achievement of a sustainable, integrated system of health, care and wellbeing across Gwent.
This plan is a clear statement of our intent to improve how we deliver services for those in need of health and care support. We have identified through our population needs assessment that for children with complex needs, older adults, carers and those with physical, mental and sensory disabilities, we must improve how we provide a seamless pathway of care, we have agreed that we must change, improve and deliver.
When I meet with local service user groups, and speak with families and patients I hear many wonderful stories about the difference our services make to the lives of people living in Gwent. Yet still too often, I also hear of the daily challenges they face of access and outcome. I want this plan to act as a catalyst for the revolution that is required within and across our services, so that more often than not the experience of patients and their families is positive and seamless.
To do this will require courage and strong collaborative leadership. We must tackle head on the challenges in maintaining our care workforce, particularly in areas like domiciliary care, where we know supermarkets can pay more and require less, and we must use our resources in different ways, making effective use of pooled budgets, so that it can provide greater reach in austere times.
I am confident that in Gwent, we have strong leadership and a shared vision for change. As leaders we are agreed that now is the time for decisive action to do things differently. In doing so we must not shy away from the challenges that integration brings, and we must no longer retreat behind our organisational boundaries.
Revolution must not be a word limited to these pages, it must direct transformational activity, across the region, for children and young people, for older adults, for our carers and for those with mental health and learning disabilities to deliver real improvement and lasting change.
Phil Robson
Chair, Greater Gwent Regional Partnership Board

1.		Foreword

We in the regional citizen panel have really appreciated the chance to interrogate officers (gently!) as they have sought to develop the Area Plan for the Gwent region, building on from a lot of good engagement with the Population Needs Assessment. I know that many groups were visited, had a chance to have their say – and joined in some discussions which could be lively at times (and all the better for it!)
It is good to see that some of this is reflected in the final Area Plan, and citizens who have different needs have had the chance to say what matters most to them. There is a challenge here for local authorities and the Aneurin Bevan University Health Board to deliver this – and we look forward to seeing the plan translate into actions, which will benefit people right across our region.
I am pleased to have the opportunity on behalf of my fellow citizen panel members, to support this work and endorse the Area Plan.
Chris Hodson
Citizen Panel Chair

2.		Introduction

2.1 Our Vision

The Gwent Area Plan for Health, Social Care and Wellbeing sets out our commitment to provide more services, closer to home. We will do this by building up a new wellbeing workforce based in the community, and developing a range of new service models, including 23 new wellbeing hubs and Neighbourhood Care Networks (NCN’s). The purpose of this plan is to describe how we will deliver these improvements, for specific groups of people in Gwent, who rely on health and social services to maintain their independence, and lead healthy, active and fulfilled lives.
Our plan focuses on adults, to ensure they are able to maintain their independence and physical wellbeing, on carers who provide invaluable care and support for loved ones, on children and young people, to ensure their needs are met and that they have the best start in life, and on those with mental health and learning disabilities, to ensure they are supported, empowered and respected. The other core themes under the Social Services and Wellbeing Act are also included as key priorities: sensory impairment, autism and violence against women and sexual violence (VAWDASV) which will be led on by a statutory regional board. We will also lead specific work on developing new housing models, creating a wellbeing workforce, and looking at how we maximise technology in this digital age.
We know that finding the right services and support can often be challenging, and sometimes daunting. We want people in Gwent to be able to access the right services, at the right time and to feel empowered and supported as they do. In this plan we have committed to reforming how we do that across Gwent, by establishing more services based in the community, such as physiotherapy, diagnostic treatments and social prescribing. We will also enable health, social care and housing professionals to work alongside each other, to better support patients and service users on their journey of care.
The new wellbeing hubs will enable more services to be based together in one place, and many more services delivered closer to home, rather than having to rely either on an appointment with a GP, or attending hospital. This is part of our ground breaking ‘Care Closer to Home’ work and will contribute to keeping people healthy and well, being better able to self-care and to better manage their conditions.
We will develop a new wellbeing workforce, to work in and alongside the new hubs, who will be able to support, advise and signpost service users, so that it will be easier for people in Gwent to access the care they need. Social prescribers and care navigators will be two key new roles, alongside changes in how GP’s and nurses work in the community alongside social care staff and third sector partners.

2.		Introduction

2.1 Our Vision

By working together collectively we intend to transform services, so that we put people at the centre of everything we do, co-producing their care and support packages, and making people and their families feel supported, listened to and safe in our care. The action described in this plan has been put together based on what you told us, from our ‘population needs assessment (PNA) which assessed the ‘care and support needs’ of our local population in Gwent. To do this we worked with our citizens groups, professional groups and community groups including the over 50’s forum, and we posted out 10,000 questionnaires.
The Plan will:
Set out the high level outcomes and priorities for regional working across health, social care and the third sector.
Focus on priorities that have been highlighted by citizens
Set out a blue print for the development of an integrated system of health, care and wellbeing. It sets out the success measures that will ensure collective accountability and effectiveness of partnership working under the Regional Partnership Board
Set the framework for all health and social care partners to work together to a common agenda for the regional planning, design and delivery of integrated services for those with a care and support need.
Focuses on areas of work across each of the priority themes areas that require partnership working
Aligns to the Well-being objectives in local Well-being Plans, under the Well-being of Future Generations (Wales) Act 2015, ensuring that improving population wellbeing, is delivered in tandem with that of those with a care and support need
Sets out how the principles of working under the Social Services and Well-being (Wales) Act 2014 will be delivered, especially in relation to integration and preventative working and transformational change
‘Signpost’ to other statutory and formalised actions plans where necessary

2.		Introduction

2.1 Our Vision

Outcomes we want to achieve through effective integrated and partnership working
1. People are identified early if they need care or support and they are prevented from ill health or decline in wellbeing wherever possible
A seamless pathway of care for patients, by integrating social services, health and third sector provision at a local level
The development of a new locality model of integrated care through the development of the Neighbourhood Care Network (NCN) model
Developing an appropriate skills mix within a modernised and more integrated workforce, aligned to the population needs assessment
The development of active signposting through Information Advice and Assistance (DEWIS) to empower citizens to make informed choices about their healthcare needs and actions
Enhancing self-care through social prescribing, and new consultation methods in line with the principles of prudent health care
Improving the sharing of information across health and social care
Improved community capacity to support improved health and wellbeing behaviours
9. Reduced unnecessary hospital admissions through the provision of integrated community capacity, that is responsive and accessible

2.		Introduction

2.2 Area Plan Outcomes

Citizen Outcomes we want to achieve and high level success measures
The measures below will form part of a comprehensive performance management framework and are included to provide a first iteration of success measures that will be monitored by the Regional Partnership Board and strategic partnerships - a more robust list of performance measures and qualitative data will be developed within the first year of the Area Plan.

Welsh Government Core Theme/Outcome Priority	Success Measures
Children & Young People
To improve outcomes for children and young people with complex needs through earlier intervention, community based support and placements closer to home / To ensure good mental health and emotional well-being for children young people through effective partnership working	Increase the number of Adverse Childhood Experience informed practitioners / Increase the support available to children and families with complex needs to reduce the number of out of county placements and increase number of young people provided skills for living. / Increase training and workforce development to support vulnerable children who have experienced complex developmental trauma and disrupted attachment histories.
Older People
To improve emotional well-being for older people by reducing loneliness and social isolation with earlier intervention and community resilience / To improve outcomes for people living with dementia and their carers / Appropriate housing and accommodation for older people	Reduce Delayed Transfers of Care through integrated working. / Increase support for number of people living with dementia at point of diagnosis / Increase number of Dementia Friends, Dementia Champions and Dementia Friendly Organisations
Health & Physical Disabled People
To support disabled people through an all age approach to live independently in appropriate accommodation and access community based services, including transport. / To help people reduce the risk of poor health and well-being through earlier intervention and community support	Decrease duplication of services for children with complex heath needs and disabilities through integrated services for children with additional needs (ISCAN). / Reduce duplication of resources to promote well-being through alignment with 5 Public Service Board Well-being plans

2.		Introduction

2.2 Area Plan Outcomes

Welsh Government Core Theme/Outcome Priority	Success Measures
People with Learning Disabilities
To support people with learning disabilities to live independently with access to early intervention services in the community; and greater public awareness and understanding of people with learning disabilities needs	Increase number of social opportunities through ‘My Mates’ / Increase employment opportunities for people with learning disabilities
Mental Health
Increased understanding and awareness of mental health amongst the public to reduce stigma and help people to seek support earlier. / To improve emotional well-being and mental health for adults and children through early intervention and community support.	Increase the numbers of service users accessing IAA services and being signposted onto the most effective intervention / Maintain the 12% of people in employment through Growing Space and the Gwent Mental Health Consortium / Increase emotional well-being support in schools through identified best practice
Sensory Impairment
Ensure people are supported through access to accurate information, assistance and ‘rehabilitation’ where required / Improve emotional well-being especially through peer to peer support	Reduce waiting lists for people to access eye tests / Increase enhanced Eye Health Examination
Carers who need support
Support carers to care through flexible respite, access to accurate information, peer to peer support and effective care planning / Improve well-being of young carers and young adult carers through an increased public understanding	Increase number of befrienders providing flexible respite for carers / Increase the number of schools involved in the Young Carers awards scheme / Increase number of GP surgeries that are ‘Carers aware’

2.		Introduction

2.2 Area Plan Outcomes

Welsh Government Core Theme/Outcome Priority	Success Measures
Autism
To provide more timely diagnosis of Autistic Spectrum Disorder and access to support services and information and advice	Reduce waiting times for adult diagnostic assessments / Increase awareness of the service (number of referrals) and going forward increase ‘how many people demonstrate improved outcomes’ / Individuals with autism and their families have increased direct access to specialist support through a self-referral model
Violence Against Women Domestic Abuse and Sexual Violence
Provide earlier intervention and safeguarding arrangements to potential victims through ‘Ask and Act’ / Safeguard victims, including men, through effective partnership support	Measures will be identified by VAWDASV Board

3.		Background

3.1 Strategic Context

The Plan has been written to reflect the national direction of travel established in Welsh Government’s ‘Prosperity for All’ and to translate the requirements of the Social Services and the Well-being (Wales) Act, Well-being of Future Generations (Wales) Act and the new national plan for health and social care into measurable and substantive action.
In line with Welsh Government’s ambition outlined in ‘Prosperity for All’ and the Parliamentary Review of Health and Social Care, there is a clear expectation of service transformation, to provide more integrated, sustainable and responsive care and support services. This includes an enhanced focus on prevention, early intervention and providing more care closer to home and the Area Plan is predicated on these services areas. The plan confidently articulates the intention to develop a range of new models of integrated services, e.g. ‘Integrated Wellbeing Networks’, further development of the Neighbourhood Care Networks model – which is unique to Gwent – models of care for children with complex needs, ‘Care Closer to Home’ and models of rehabilitation for sensory impairment and whole person model for mental health crisis. In addition, the infrastructure required to deliver the vision is a prominent commitment, with proposals to deliver new urgent care hubs, and primary care health and well-being centres including ones in Newport East and Tredegar by 2021.
The Social Services and Wellbeing (Wales) Act 2014 provides the new legal framework, for the development of a new statutory partnership landscape, in terms of planning, designing, funding and commissioning integrated services for those people with a care and support need in Gwent. It enables a stronger emphasis to be placed on the development of early intervention and prevention services, co-production with those in need of care and support, and improved wellbeing as the driver of all activity. Underpinning the plan are the principles of working established in the Wellbeing of Future Generations (Wales) Act 2015, to ensure that in the planning and delivery of services, we are actively considering how the wellbeing of future generations is improved.
As the plan has been developed, it has been done so in tandem with the development of the required Public Service Board’s (PSBs) Well-being Plans, to ensure duplication is avoided and a shared approach to improved well-being is established. To this end we will develop a Memorandum of Understanding between the PSB’s and the Regional Partnership Board, ensuring our activity is complementary and aligned.

3.		Background

3.2 Population Needs Assessment

The Social Services and Well-being (Wales) Act 2014 introduced a duty on local authorities and local health boards to prepare and publish a Population Needs Assessment (PNA) of the needs of people requiring care and support, including carers who need support. A code of practice was published to support the PNA process and set out 8 core themes for the population assessment
Children & Young People
Older People, including People with Dementia
Health & Physical Disabilities
Mental Health
Learning Disability & Autism
Sensory Loss & Impairment
Carers
Violence Against Women, Domestic Abuse & Sexual Violence
Core themes are not addressed in isolation and there is an element of cross cutting working. In addition to the above, the Regional Partnership Board identified other priority themes as cross cutting and include
Substance misuse
Adult protection, child protection and safeguarding
Housing
Autism
The PNA code of practice also sets out the statutory duty to undertake an assessment of need across the region, identification of the range and level of services required and the definition of Well-being, per the Social Services and Well-being Act. The regional PNA report also sets out, for each core theme:
What we know - what did the population assessment tell us?
What we are doing currently
How the priorities meet the principles of the Act and how this fits with well-being under the Act
Who helped us develop the priorities
High level key Actions
The PNA report was developed by the Regional Partnership Board and was published 1st April 2017 – a full report is included here and includes further detail in relation to above points, and the matrix used to identify the priorities under each core theme.

3.		Background

3.3 Area Plan Guidance

This Area Plan sets out the response of the Regional Partnership Board to the findings of the regional PNA report and has been prepared to meet the requirements of the statutory guidance in relation to Area Plans under section 14A of the Social Services and Well-being (Wales) Act 2014. The Act requires description of the range and level of integrated services proposed to be provided or arranged to deliver the priorities identified under each of the core themes. As part of this, joint area plans must include:
the actions partners will take in relation to the priority areas of integration for regional partnership boards;
the instances and details of pooled funds to be established in response to the population assessment;
how services will be procured or arranged to be delivered, including by alternative delivery models;
details of the preventative services that will be provided or arranged;
actions being taken in relation to the provision of information, advice and assistance services; and
actions required to deliver services through the medium of Welsh.
The RPB will undertake a full impact analysis and ensure the Area Plan meets requirements as set out in the Welsh Language strategic framework ‘More than Just Words’ and that a full Equality Impact Assessment is publish alongside this plan

3.		Background

We have engaged the views of those who would otherwise be hard to reach and marginalised including those of minority groups such as homeless people and travelers. We have used existing mechanisms to engage with vulnerable groups such as those set out below:
Looked After Children and young carers
People in secure estates and their families
Homeless people
Lesbian Gay Bisexual Transgender (LGBT) community
Black Minority Ethnic groups
Military veterans
Asylum seekers and refugees

3.4 Focused Work With Minority Groups

3.		Background

3.5 Partnership Working

The new legislative framework in Wales, requires a step change in the pace of integration, partnership working and collaboration. Whilst many challenges will remain in overcoming organisational boundaries, and cultures, a set of shared working principles in addition to the principles in the Act have been adopted by the Gwent Regional Partnership Board, to provide consistency and quicken the pace by which we can work collaboratively to transform and re model services.
Gwent RPB principles of joint working:
‘By working in collaboration, with a focus on long term sustainability we will transform services, to provide more care closer to home, improving well-being, and citizen outcomes.’
We will adopt:
An integrated approach to planning and service development
A shared approach to workforce development and sustainability
Development of shared financial arrangements
Enabling those with a care and support need to be informed and able to self-manage their care
A seamless service pathway of care which is truly citizen centred

3.		Background

3.6 Who Developed The Area Plan?

This Area Plan has been developed by the Regional Partnership Board through engagement with citizens, partners and providers across the region (Blaenau Gwent, Caerphilly, Monmouthshire, Newport and Torfaen). The views of citizens is paramount to the development of the Area Plan and to ensure the actions identified will be effective, and help develop support services required going forward to help people support themselves in the future. The regional citizen panel and provider forum have also been key partners in ensuring the identified actions are focussed on the needs of citizens and partners.
This Area Plan has been overseen by the Regional Partnership Board and third sector partners. The individual core themes sections have been developed by strategic partnerships and supported by the regional Leadership Group. The following strategic groups have coordinated related core theme sections
Other strategic partnerships such as the Substance Misuse Area Planning Board, Safeguarding Boards and the Health, Social Care and Housing Partnership will also play a lead role in ensuring cross cutting themes such as substance misuse, safeguarding and housing are aligned in this Area Plan. The Regional Partnership Board (RPB) will set the partnership framework for the above partnerships to link, align priorities and avoid duplication.

4.		Integrated Working

4.1 The Role Of The Regional Partnership Board

The Regional Partnership Board are the strategic leaders, whose role it is to deliver the ambitions in this plan into a lasting reality. Whilst the plan sets out the ambition and activity, a programme of organisational development has been established for the regional partnership board to ensure effective leadership, oversight and accountability in achieving the aims of the plan.
For the ambitions set out in the plan to be achieved it is crucial that there is an effective process of critical challenge and review to ensure that the pace of activity and the outcomes we want to see are being achieved. To do this a programme of organisational development has been established for the RPB and includes
Ongoing review of the area plan
Map and review the progress of partnership arrangements across the region
Explore potential models of more integrated governance becoming an enabler for change
Redirect resources across the region towards addressing challenges in workforce recruitment and retention,
Ensure the RPB has the right resources and capacity

4.		Integrated Working

4.2 Developing An Integrated System

The Parliamentary Review into Health and Social Care in Wales states that the:
“Growing demand for care in the face of modest economic growth means that health and care services must change and adapt to best meet need and help people achieve the outcomes they desire. As we will show, the health and care system is not sustainable into the future in its current form; change which delivers major improvement to services is urgently required much faster than in the past”.
The shared ambition of partners across Gwent is to create a new system of integrated services for those with a care and support need, where more care is provided closer to home in a seamless integrated pathway. We will do this by developing new health and wellbeing hubs, implementing and growing our network of neighbourhood community networks (NCN’s), developing regional integrated services for people with complex needs, and designing new more sustainable models of care for children, older adults and those with mental health or learning disabilities.
Our intention through the Gwent Area Plan is to re-model services to reduce unnecessary complexity and deliver a more integrated, inter-professional way of working across health and social care. We have developed a new ‘transformational’ model focused on ‘place based care’, with services operating on a local population basis, supported by more specialist expertise at a wider level. The delivery mechanism is the Neighbourhood Care Network Model (NCN), unique to Gwent, with local integrated partnership boards providing leadership, governance and accountability at a local authority level.
The system is predicated on the shared agreement by both Health and Local Government to provide more care closer to home, to reduce a reliance on primary care services, and prevent unnecessary hospital admissions. The system will build on the existing innovation across Gwent, and use the NCN footprint, as the basis from which services will be planned and delivered, around a model of community well-being.
The establishment of five strategic thematic partnerships provides an engine room for delivery, with dedicated programmes of work, and specific outcome measures in place across each. Delivery will be through the local ‘Integrated Partnership Boards’, and NCN model, ensuring a collaborative approach to planning and delivery from a regional level, to localities.
The plan articulates how we intend to do this, and deliver integrated services, which improve the well-being of the population of Gwent over the next three years; it establishes a set of outcomes, measures and milestones and appropriate governance arrangements, to provide assurance to the Regional Partnership Board and Cabinet Secretary (further details are included in the appendix 3).

4.		Integrated Working

4.3 Integration Of Services

The Well-being of Future Generations Act sets out integration as one of five sustainable development principles however there is no set definition for ‘Integration’ under the Social Services and Wellbeing Act or supporting codes of practice. Under Part 9 of the Act Regional Partnership Boards (RPB) are required to prioritise the integration of services in relation to:
Older people with complex needs and long term conditions, including dementia.
People with learning disabilities.
Carers, including young carers.
Integrated Family Support Services.
Children with complex needs due to disability or illness.
For the purpose of this Area Plan the Regional Partnership Board will adopt a principle of integration based on the following areas of working:
Joint commissioning of services and pooled budgets
Joint workforce development and training
Consistent and portable assessment processes including outcome and distance travelled toolkits
Co-located teams
Sharing of resources
Similar understanding of information provision and consistent key messages to citizens
The above definition of integration will be adopted when implementing the Area Plan and there is an expectation that the strategic partnerships charged with implementing the Area Plan will consider the above areas of work when delivering actions to achieve the identified outcomes.

4.		Integrated Working

4.4 Integrated Care Funding

4.		Integrated Working

4.5 Governance, Assurance and Monitoring the Area Plan

4.		Integrated Working

4.5 Governance, Assurance and Monitoring the Area Plan

Regional Leadership group

Blaenau Gwent Integrated Partnership

Caerphilly Integrated Partnership

Monmouthshire Integrated Partnership

Newport Integrated Partnership

Torfaen Integrated Partnership

2 x NCN's

3x NCN's

2 x NCN's

3 x NCN's

2 x NCN's

4.		Integrated Working

4.5 Governance, Assurance and Monitoring the Area Plan

4.		Integrated Working

4.6 Enablers

4.		Integrated Working

4.6 Enablers

5.		Appendix 1 : Core Theme Action Plans

Regional Priority / Outcome:
To improve outcomes for children and young people with complex needs through earlier intervention, community based support and placements closer to home &
To ensure good mental health and emotional well-being for children young people through effective partnership working (priority under Mental Health core theme)
How will we measure success? We will:
Development of new integrated support services through Integrated Care Funding coordinated by Children and Families Board & joint delivery of the Adverse Childhood Experience agenda.
Measures above will form part of a comprehensive performance management framework and are included to provide a high level indication of success measures. The Regional Partnership Board and strategic partnerships will develop a more robust list of performance measures within the first year of the Area Plan.

5.1 Children and Young People

Increase the number of Adverse Childhood Experience informed practitioners	Increase the support available to children and families with complex needs to reduce the number of out of county placements and increase number of young people provided skills for living.	Increase training and workforce development to support vulnerable children who have experienced complex developmental trauma and disrupted attachment histories.

6.		Regional Priorities & Core Themes

5.		Appendix 1 : Core Theme Action Plans

5.1 Children and Young People

What Action Are We Taking?	Support Children and Family Partnership Board’s review of local arrangements for children with complex needs and delivery of work programme with a focus on Looked After Children.
Who Will Be Taking Action?	Children & Family Partnership Board
How Will We Deliver?	Respond to recommendations in consultant reports and implement appropriate next steps / Expansion of integrated attachment service (preventing escalation of complexity for complex trauma). / Integrated assessment and planning (IAP) ISCAN for children with complex additional needs/disabilities through care coordination model / To provide alternative Gwent-wide residential provision (resource hub) supported by outreach attachment and trauma based service and an outreach skills for living team for care leavers (as part of a step up and step-down model). Considerations in relation to / Emergency, respite and crisis accommodation / Practical and psychological therapeutic support / Expand the provision of suitable move-on accommodation / Develop business case and appropriate service models (to include mechanism to identify cohort) where required and ensure linkage with the Health, Social Care & Housing Partnership so that this is included in their overall work plan. / Review and coordinate integration and alignment of existing programmes e.g Integrated Family Support Services
When Will We Deliver?	March 2019
What Resources Are Needed?	ICF – Capital, and appropriate link with HSC& H Partnership / ICF funded projects: / Resource Hub / ISCAN / Attachment Service
How Will We Measure Progress?

5.		Appendix 1 : Core Theme Action Plans

6.		Regional Priorities & Core Themes

5.1 Children and Young People

What Action Are We Taking?	To undertake a holistic mapping exercise to determine at what level services are best delivered
Who Will Be Taking Action?	Children and Family Strategic Partnership Board
How Will We Deliver?	Develop a mapping template and hold a specific board session designed to review all complex care pathways with a view to significant service re design and consider the future models of services within the scope of the board, and to agree the appropriate service footprint i.e. regional, borough, locality
When Will We Deliver?	September 2018
What Resources Are Needed?	N/A
How Will We Measure Progress?

6.		Regional Priorities & Core Themes

5.		Appendix 1 : Core Theme Action Plans

5.1 Children and Young People

What Action Are We Taking?	Consistent models of practice and alignment of Welsh Government’s early intervention and preventative programmes including development and delivery of a regional ACE approach with a focus on earlier intervention and mental health support for children and young people through community based assets.
Who Will Be Taking Action?	Regional Partnership Board & Public Service Boards
How Will We Deliver?	Explore consistent use of Social Services and Well-being Act assessment principles across all programmes (Families First, Flying Start and Supporting People) to aid ‘pass porting’ of assessments across agencies and local authority boundaries / Explore joint commissioning across all programmes / Align and develop joint training across programme workforces with common language and awareness / Explore consistent resilience model across the region / Link to ‘Flexible Funding’ pilot sites to explore good practice in maximising funding across prevention programmes / Develop a regional approach for organisations to become ACE aware and aligned to national ACE hub programme and to include / ACE awareness / ACE prevention/detection including the use of an ACE ‘lens’ when undertaking risk assessment included as part of assessment process / Develop and strengthen existing trauma services to ensure effective ACE intervention
When Will We Deliver?	March 2019 / National ACE grant (Gwent Police)
What Resources Are Needed?	N/A
How Will We Measure Progress?

5.		Appendix 1 : Core Theme Action Plans

6.		Regional Priorities & Core Themes

5.2 Older People

Regional Priority / Outcome:
To improve emotional well-being for older people and reduce loneliness and social isolation with earlier intervention and community resilience
To improve outcomes for people living with dementia and their carers
Appropriate housing and accommodation for older people

How Can We Measure Success?

Reduce Delayed Transfers of Care through integrated working.	Increase support for number of people living with dementia at point of diagnosis	Increase number of Dementia Friends, Dementia Champions and Dementia Friendly Organisations

By:
Development and delivery of Care Closer to Home in partnerships with Neighbourhood Care Networks and; delivery of Dementia Board and Health Housing and Social Care Partnership work programmes.
Measures above will form part of a comprehensive performance management framework and are included to provide a high level indication of success measures. The Regional Partnership Board and strategic partnerships will develop a more robust list of performance measures within the first year of the Area Plan.

5.		Appendix 1 : Core Theme Action Plans

6.		Regional Priorities & Core Themes

5.2 Older People

What Action Are We Taking?	Develop place based approach ‘Care Closer to Home’ including consistent delivery of community connectors across the region to reduce social isolation
Who Will Be Taking Action?	Adult Strategic Partnership
How Will We Deliver?	Development of a placed-based approach via Care Closer to Home Strategy which will include a focus on social isolation & include / Develop a sustainable work force. / Links to Housing Associations/RSL’s / Support to carers / To develop health and well-being hubs / To identify opportunities to "shift" care from secondary services to primary care, providing care closer to home. / Frailty Service - The future direction is captured as part of Care Closer To Home strategy. As the Borough action plans develop, the contribution of the Frailty service will need to be incorporated as part of the range of interventions available in each Neighbourhood Care Network and Borough. This development will tackle the “stand alone” issues. / Deliver and align Gwent Wide Integrated Community Equipment. Services (GWICES) action plans to be aligned to Care Closer to Home
When Will We Deliver?	Mar 2019
What Resources Are Needed?	Core funding supported by ICF funded projects
How Will We Measure Progress?

5.		Appendix 1 : Core Theme Action Plans

6.		Regional Priorities & Core Themes

5.2 Older People

What Action Are We Taking?	To undertake a holistic mapping exercise to determine at what level services are best delivered
Who Will Be Taking Action?	Adult Strategic Partnership
How Will We Deliver?	Develop a mapping template and hold a specific board session designed to consider the future models of services within the scope of the board, and to agree the appropriate service footprint i.e. regional, borough, locality
When Will We Deliver?	Sept 2018
What Resources Are Needed?	N/A
How Will We Measure Progress?

5.		Appendix 1 : Core Theme Action Plans

6.		Regional Priorities & Core Themes

5.2 Older People

What Action Are We Taking?	Develop and implement Health, Housing and Social Care Partnership delivery plan
Who Will Be Taking Action?	Health, Housing and Social Care (HHSC) Partnership
How Will We Deliver?	The Health, Housing and Social Care Partnership are updating their delivery programme in line with the regional Population Needs Assessment with the main focus of activity: / Older Persons wellbeing and housing needs, and aspirations / Analysis of current older person specialist accommodation provision and capability to meet forward needs / Regional accommodation needs identified by Children & Families Partnership / Regional accommodation needs identified by Learning Disability & Mental Health Partnership / Analysis and evidence base for Integrated Care Funding capital projects linked to the above
When Will We Deliver?	Sept 2018
What Resources Are Needed?	Identified in plan
How Will We Measure Progress?

5.		Appendix 1 : Core Theme Action Plans

6.		Regional Priorities & Core Themes

5.2 Older People

What Action Are We Taking?	Implement the Adult Strategic Partnership work programme to develop integrated practices and effective partnership working
Who Will Be Taking Action?	Adult Strategic Partnership
How Will We Deliver?	Work to scope and establish a Social Care Academy to co-develop a sustainable health and social care workforce; and develop a Domiciliary Care Commissioning and Workforce Programme. / Implement a system improvement review of patient pathway between hospital and social services to improve discharge: ‘Home to Home’. / Review and coordinate Integrated Partnership Board local plans in relation to adults.
When Will We Deliver?	Sept 2018
What Resources Are Needed?	ICF / Regional Transformation funding
How Will We Measure Progress?

5.		Appendix 1 : Core Theme Action Plans

6.		Regional Priorities & Core Themes

5.3 Health and Physical Disabilities

Regional Priority / Outcome:
To support disabled people through an all age approach to live independently in appropriate accommodation and access community based services, including transport .
Align with 5 local Wellbeing Assessments required under Wellbeing of Future Generations Act and explore joint action planning for wider detriments to health

How Can We Measure Success?

Decrease duplication of services for children with complex heath needs and disabilities through integrated services for children with additional needs (ISCAN).	Reduce duplication of resources to promote well-being through alignment with 5 Public Service Board Well-being plans

By:
Development and delivery of Care Closer to Home in partnerships with Neighbourhood Care Networks and; working with Public Service Boards to address wider detriments to wellbeing
Measures above will form part of a comprehensive performance management framework and are included to provide a high level indication and example of success measures. The Regional Partnership Board and strategic partnerships will develop a more robust list of performance measures within the first year of the Area Plan.

5.		Appendix 1 : Core Theme Action Plans

6.		Regional Priorities & Core Themes

5.3 Health and Physical Disabilities

What Action Are We Taking?	Align with 5 local Wellbeing Assessments required under Wellbeing of Future Generations Act and explore joint action planning for wider detriments to health
Who Will Be Taking Action?	Regional Partnership Board & Public Service Boards
How Will We Deliver?	Align this area plan with Public Service Board Well-being Plans to ensure objectives are aligned and avoid duplication / Map priorities across plans / Identify which board is best placed to deliver priorities / Develop common action planning and outcome framework / Develop governance and reporting framework between boards and a Memorandum of Understanding (MOU) / Explore joint development/workshop sessions
When Will We Deliver?	March 2019
What Resources Are Needed?	N/A
How Will We Measure Progress?

5.		Appendix 1 : Core Theme Action Plans

6.		Regional Priorities & Core Themes

5.4 Mental Health

Regional Priority / Outcome:
To improve emotional well-being and mental health for adults and children through early intervention and community support &
Increased understanding and awareness of mental health amongst the public to reduce stigma and help people to seek support earlier.

How Can We Measure Success?

Increase the numbers of service users accessing IAA services and being signposted onto the most effective intervention	Maintain the 12% of people in employment through Growing Space and the Gwent Mental Health Consortium	Increase emotional well-being support in schools through identified best practice

By:
developing a new regional Mental Health strategy that will:
review and use best practice to improve crisis support
be supported by third sector regional services and Integrated Care Funded projects with a focus on employment opportunities for adults; and
develop effective emotional well-being support in schools.
Measures above will form part of a comprehensive performance management framework and are included to provide a high level indication of success measures. The Regional Partnership Board and strategic partnerships will develop a more robust list of performance measures within the first year of the Area Plan.

5.		Appendix 1 : Core Theme Action Plans

6.		Regional Priorities & Core Themes

5.4 Mental Health

What Action Are We Taking?	Review and align regional strategies to Together for Mental Health Delivery plan and develop new regional strategy
Who Will Be Taking Action?	Mental Health & Learning Disability Partnership
How Will We Deliver?	The MH&LD Partnership are currently reviewing the regional Mental Health Strategy and emerging priorities include / Communicate and work alongside service users, carers, staff and communities on the planning, monitoring and provision of mental health services / Develop a wide range of services that support community well-being / Enable the provision of a wide range of accommodation options / Ensure services based in the community offer support, advice and where necessary assessment and treatment within this environment / To ensure the best use of mental health resources / To work across the 6 organisations to establish a set of rules and a structure that supports our working together, to plan and deliver excellent mental health services (governance) / The regional strategy will also set out how priorities will be delivered in partnership to take forward national priorities included in / ‘Together for Mental Health’ / ‘Talk 2 Me’ and / ‘Together for Children and Young People’ / The MH&LD partnership will also support delivery of a whole school approach to emotional well-being linked to other strategic partnerships and Public Service Boards including ACE agenda.
When Will We Deliver?	April 19
What Resources Are Needed?	To be included in strategy
How Will We Measure Progress?

5.		Appendix 1 : Core Theme Action Plans

6.		Regional Priorities & Core Themes

5.4 Mental Health

What Action Are We Taking?	Coordination of consistent community based services such as community connectors/social prescribers
Who Will Be Taking Action?	Heads of Adult Services, ABUHB officers / Gwent Mental Health Consortium (GMHC)
How Will We Deliver?	Respond to recommendations from Integrated Care Funding (ICF) evaluation of community connecter projects across the region. / To align with ‘Ffrind I Mi’ befriending programme / Deliver coordinated community based programme that delivers the following across all 5 Gwent Boroughs / Community Counselling / Information, Advice and Assistance / Community Well Being Services / Vocational pathways and employment routes / Social Enterprises / Art and Drama Therapy / Anxiety Management / Mindfulness / Confidence Building / Depression Management Courses
When Will We Deliver?	April 2019
What Resources Are Needed?	ICF / ABUHB / Joint Third Sector commissioned contract
How Will We Measure Progress?

5.		Appendix 1 : Core Theme Action Plans

6.		Regional Priorities & Core Themes

5.4 Mental Health

What Action Are We Taking?	Multi-agency place based models which include wider partners such as Housing Associations, employment support and community programmes
Who Will Be Taking Action?	ABUHB/ Integrated Partnership Boards/ / Neighbourhood Care Networks/Housing Social Care Network
How Will We Deliver?	Development of a placed-based approach via Care Closer to Home Strategy which will include a focus on social isolation & include / Develop a sustainable work force / Links to Housing Associations / Support to carers / To develop health and well-being hubs / To identify opportunities to "shift" care from secondary services to primary care, providing care closer to home.
When Will We Deliver?	Mar 2019
What Resources Are Needed?	Core funding
How Will We Measure Progress?

5.		Appendix 1 : Core Theme Action Plans

6.		Regional Priorities & Core Themes

5.4 Mental Health

What Action Are We Taking?	To undertake a holistic mapping exercise to determine at what level services are best delivered
Who Will Be Taking Action?	Mental Health & Learning Disability Partnership
How Will We Deliver?	Develop a mapping template and hold a specific board session designed to consider the future models of services within the scope of the board, and to agree the appropriate service footprint i.e. regional, borough, locality
When Will We Deliver?	Sept 2018
What Resources Are Needed?	N/A
How Will We Measure Progress?

6.		Regional Priorities & Core Themes

5.		Appendix 1 : Core Theme Action Plans

5.4 Mental Health

What Action Are We Taking?	Accurate Information, Advice and Assistance through DEWIS and Five Ways to Wellbeing
Who Will Be Taking Action?	DEWIS regional group & GAVO & TVA / Public Service Boards / Gwent Mental Health Consortium (GMHC)
How Will We Deliver?	DEWIS regional group will continue to coordinate accurate IAA with a focus on mental health / Continue to deliver 5 ways to well-being and consider roll-out in schools / Consider a communication campaign to raise awareness of mental health amongst public and in schools / The Gwent Mental Health Consortium has its own dedicated IAA service that is designed to specifically support people with Mental Health Issues and will link to DEWIS provision. The GMHC has a comprehensive MIS system (Lamplight) that can evidence all the IAA interventions through the Consortium and will also support wider evaluation
When Will We Deliver?	Sept 2018
What Resources Are Needed?	Funded post between Neighbourhood Care Networks and Transformation Team
How Will We Measure Progress?

5.		Appendix 1 : Core Theme Action Plans

6.		Regional Priorities & Core Themes

5.5 Learning Disability

Regional Priority / Outcome:
To support people with learning disabilities to live independently with access to early intervention services in the community; and greater public awareness and understanding of people with learning disabilities needs

How Can We Measure Success?

Increase number of social opportunities through ‘My Mates’	Increase employment opportunities for people with learning disabilities

By:
implementing new regional Learning Disabilities strategy and Integrated Care Funded projects with a focus on employment opportunities
Measures above will form part of a comprehensive performance management framework and are included to provide a high level indication of success measures. The Regional Partnership Board and strategic partnerships will develop a more robust list of performance measures within the first year of the Area Plan.

5.		Appendix 1 : Core Theme Action Plans

6.		Regional Priorities & Core Themes

5.5 Learning Disability

What Action Are We Taking?	Support Mental Health and Learning Disability Partnership Board review Gwent Strategy for Adults with a Learning Disability 2012/17 and set out key regional commissioning, and integration actions
Who Will Be Taking Action?	Mental Health & Learning Disability Partnership / Growing Space / Gwent Mental Health Consortium
How Will We Deliver?	The MH&LD Partnership are currently reviewing the regional Learning Disability Strategy and provisional key priorities and objectives are set out below / Enabling people to have more control over their lives through Person-Centred Planning, Self-Directed Support and Access to Advocacy - People with a learning disability will have more choice and control over their life / Employment, Education, Leisure, Day Activities and Life Skills - To enable people with a learning disability to have choice regarding how they spend their time during the day / Housing - People with a learning disability should be able to have a choice about where they live and who they live with – and ensure this is reflected in Health, Social Care & Housing Partnership work plan. / Access to Generic Healthcare - People with a learning disability will have better health outcomes and appropriate access to healthcare / Transition - The transition from child to adult services will be smooth, planned and effective for all people with a learning disability / Supporting Carers - The families/carers of people with a learning disability will receive timely and appropriate support / Promotion of Social Networks and Emotional Well-being - People with a learning disability will receive support and proactive interventions that promote social and emotional well-being / Specialist Groups - Individuals with complex needs are able to access the range of appropriate specialist health and social care services in a timely manner / A Pathway and Planning for the Future - People with a learning disability will receive a co-ordinated, safe and timely service and appropriate support to plan for the future / Accessible Information - People with a learning disability and their carers will receive clear information regarding generic and specialist learning disability services
When Will We Deliver?	Sept 2018
What Resources Are Needed?	ICF funded projects: My Mates, No More Barriers, Transition project
How Will We Measure Progress?

6.		Regional Priorities & Core Themes

5.		Appendix 1 : Core Theme Action Plans

5.6 Sensory Loss and Impairment

Regional Priority / Outcome:
Ensure people are supported through access to accurate information, assistance and ‘rehabilitation’ where required and to include the need to Improve emotional well-being especially through peer to peer support

How Can We Measure Success?

Reduce waiting lists for people to access eye tests	Increase enhanced Eye Health Examination

By:
ensuring an effective and coordinated services through the regional Eye Care Board and Hearing Care Collaborative Board
Measures above will form part of a comprehensive performance management framework and are included to provide a high level indication of success measures. The Regional Partnership Board and strategic partnerships will develop a more robust list of performance measures within the first year of the Area Plan.

5.		Appendix 1 : Core Theme Action Plans

6.		Regional Priorities & Core Themes

5.6 Sensory Loss and Impairment

What Action Are We Taking?	Support and Deliver Integrated Eye Care Collaborative Board Eye Health Delivery Plan which will include a focus on / Use good practice and effective pathways to develop regional commissioning principles especially / Work in partnership with third sector to identify new models to support rehabilitation process and supply of low vision tools. / Close working with Low Vision Service Wales and explore use of All-Wales Integrated Pathway for Children and Young People and Adult UK Sight Loss Pathway
Who Will Be Taking Action?	Integrated Eye Care Collaborative Board, Joint Commissioning Group, GAVO/TVA, Wales Vision Forum
How Will We Deliver?	Eye Health Delivery Plan 10 priorities / Work with Public Health Wales to develop a plan to raise awareness of eye health and the need for regular sight tests to detect and prevent sight loss especially for groups of people at high risk of eye disease. / Deliver quality assured vision screening service to children in mainstream schools on school entry and a service that provides an annual sight test to children with special educational needs in schools. / Work with key partners and primary care clusters to ensure good quality eye care is provided to frail older people, those with dementia and to people in care homes and residential care. / Ensure all optometrists practising in Wales are providing the enhanced Eye Health Examination Wales service to enable more people to be managed closer to home. / Work with Medical Directors and patients to revise targets for ophthalmology services in hospitals to incorporate measures for all patients (new and follow-up) based on clinical need and risk of irreversible sight loss / Support integrated, efficient working and improve the safe communication of information by rolling out electronic optometry referrals and their prioritisation in hospitals across Wales, starting in January 2017. Appraise the options for an all Wales electronic patient record by March 2017 with a view to rolling it out across Wales. / Implement the priority actions of the Wales Ophthalmic Planned Care Plan including the National Cataract Audit. / Develop workforce plans and identify training needs to deliver ophthalmology led multi-disciplinary teams and care closer to people’s homes in primary care, where it is safe to do so. / Work to ensure that everyone entitled is offered certification as sight impaired. / Work with Local Partnership Boards and Local Authorities to support the implementation of the Social Services and Well-being (Wales) Act 2014. Key to this is the provision of rehabilitation and habilitation services in every authority that prevent loss of independence, loss of mobility, falls, isolation and depression in people with sight loss/impairment.
When Will We Deliver?	The plan will monitored bi monthly and included as part of annual review
What Resources Are Needed?	Details in delivery plans

5.		Appendix 1 : Core Theme Action Plans

6.		Regional Priorities & Core Themes

5.6 Sensory Loss and Impairment

What Action Are We Taking?	Support Hearing Care Collaborative Group to enhance the understanding of public sector providers so that people who are deaf living with hearing loss have equitable access to services.
Who Will Be Taking Action?	Hearing Care Collaborative Group
How Will We Deliver?	The Hearing Care Collaborative group will deliver the Hearing Care action plan with a focus on information/advice, workforce development, effective third sector commissioning and joint systems and processes.
When Will We Deliver?	April 2019
What Resources Are Needed?	Details in delivery plan
How Will We Measure Progress?

6.		Regional Priorities & Core Themes

5.		Appendix 1 : Core Theme Action Plans

5.6 Sensory Loss and Impairment

What Action Are We Taking?	Ensure accurate, accessible and timely Information, Advice and Assistance through DEWIS and other means (with a focus on sensory impairment).
Who Will Be Taking Action?	DEWIS regional group & GAVO & TVA
How Will We Deliver?	DEWIS regional group will continue to coordinate and update accurate IAA with a focus on sensory impairment
When Will We Deliver?	Sept 2018 and April 2019
What Resources Are Needed?	Funded officer for 1 year through NCN and Transformation funding
How Will We Measure Progress?	Number of DEWIS website hits

5.		Appendix 1 : Core Theme Action Plans

6.		Regional Priorities & Core Themes

5.7 Carers

Regional Priority / Outcome:
Support carers to care through flexible respite, access to accurate information, peer to peer support and effective care planning
Improve well-being of young carers and young adult carers through an increased public understanding (this is a priority highlighted in Together For Mental Health)

How Can We Measure Success?

Increase number of befrienders providing flexible respite for carers	Increase the number of schools involved in the Young Carers awards scheme	Increase number of GP surgeries that are ‘Carers aware’

By:
ensuring an effective and coordinated Gwent Carers Support Service.
Measures above will form part of a comprehensive performance management framework and are included to provide a high level indication of success measures. The Regional Partnership Board and strategic partnerships will develop a more robust list of performance measures within the first year of the Area Plan

5.		Appendix 1 : Core Theme Action Plans

6.		Regional Priorities & Core Themes

5.7 Carers

What / Action Are We Taking?	Coordination of consistent community based services such as community connectors/social prescribers to identify and support carers.
Who Will Be Taking Action?	Heads of Adult Services, ABUHB officers
How Will We Deliver?	Respond to recommendations from Integrated Care Funding (ICF) evaluation of community connecter projects across the region.
When Will We Deliver?	June 2018
What Resources Are Needed?	ICF
How Will We Measure Progress?

6.		Regional Priorities & Core Themes

5.		Appendix 1 : Core Theme Action Plans

5.7 Carers

What Action Are We Taking?	Accurate Information, Advice and Assistance through DEWIS and Five Ways to Wellbeing
Who Will Be Taking Action?	DEWIS regional group & GAVO & TVA / Public Service Boards
How Will We Deliver?	DEWIS regional group will continue to coordinate accurate IAA with a focus on carers / Continue to deliver 5 ways to well-being and consider roll-out in schools to target young carers / Consider a communication campaign to raise awareness of carers amongst public and in schools to identify young carers / Review local authority IAA ‘front doors’ performance management information and identify good practice and lessons learnt 1 year on / Ensure accurate IAA is available to carers following discharge from hospital and for carers to be involved in discharge plans.
When Will We Deliver?	March 2019
What Resources Are Needed?	Neighbourhood Care Network and Transformation Fund
How Will We Measure Progress?

6.		Regional Priorities & Core Themes

5.		Appendix 1 : Core Theme Action Plans

5.7 Carers

What Action Are We Taking?	Ensure that the implementation of the care closer to home strategy increases the community level support for carers
Who Will Be Taking Action?	ABUHB/ Integrated Partnership Boards/ / Neighbourhood Care Networks/Housing Social Care Network
How Will We Deliver?	Development of a placed-based approach via Care Closer to Home Strategy which will include a focus on social isolation & include: / Develop a sustainable work force / Links to Housing Associations / Support to carers / To develop health and well-being hubs / To identify opportunities to "shift" care from secondary services to primary care, providing care closer to home.
When Will We Deliver?	March 2019
What Resources Are Needed?
How Will We Measure Progress?

6.		Regional Priorities & Core Themes

5.		Appendix 1 : Core Theme Action Plans

5.7 Carers

What Action Are We Taking?	Review of and align third sector commissioning principles to support befriending for carers requiring support
Who Will Be Taking Action?	ABUHB & Regional Commissioning Group
How Will We Deliver?	Work with Third Sector Partner / Carers Trust South East Wales (cross region survey of young adult carers and development of a sustainable model for supporting young carers in school); / Barnardos Cymru (scoping a regional Young Carers ID Card Scheme); use outcomes of the regional young carers id scheme to inform national agenda for such scheme / Dewis Centre for Independent Living (developing an evidence base for a regional advocacy for carers service model). / Befriending / Support ABUHB rollout ‘Ffrind I Mi’ befriending programme across partners and consider inclusion through wider regional commissioning priorities.
When Will We Deliver?	Sept 2018
What Resources Are Needed?
How Will We Measure Progress?

6.		Regional Priorities & Core Themes

5.		Appendix 1 : Core Theme Action Plans

5.7 Carers

What Action Are We Taking?	Consistent commissioning across health and social care to ensure equitable, region wide and effective models of carer support including / flexible respite / Training and awareness / Support to Young Carers / Advocacy provision
Who Will Be Taking Action?	Regional Commissioning Group
How Will We Deliver?	Welsh Government will be reviewing respite at a national level through new Dementia Strategy / Respond to national recommendations / Develop regional task and finish group / Rollout of small grants scheme / Link with Ffrind I Mi and Alzheimer’s Society to ensure provision of flexible respite through befriending / Sustaining staff awareness raising and training of staff / Consider bronze level Investors in Carers (IiC) scheme across GP / Rollout of Young Carers in Schools Award Scheme and Young Carers ID Card Scheme / Develop opportunities for peer to peer support / Advocacy for Carers / Develop a regional advocacy service model and service specification linked to Independent Professional Advocacy (IPA) for adults and ‘Golden Thread of Advocacy’ national model.
When Will We Deliver?	Sept 2018
What Resources Are Needed?
How Will We Measure Progress?

6.		Regional Priorities & Core Themes

5.		Appendix 1 : Core Theme Action Plans

5.7 Carers

What Action Are We Taking?	Review of medical prompting to better support carers
Who Will Be Taking Action?	Carers Board
How Will We Deliver?	Develop task and finish group to develop scope / Consider development of new models and assisted technology to support carers in the community.
When Will We Deliver?	April 2019
What Resources Are Needed?
How Will We Measure Progress?

6.		Regional Priorities & Core Themes

5.		Appendix 1 : Core Theme Action Plans

5.8 People With Autism Spectrum Disorders

Regional Priority / Outcome:
To provide more timely diagnosis of Autistic Spectrum Disorder and access to support services and information and advice
HOW WILL WE MEASURE SUCCESS? We Will

How Can We Measure Success?

Reduce waiting times for adult diagnostic assessments	Increase awareness of the service (number of referrals) and going forward increase ‘how many people demonstrate improved outcomes’	Individuals with autism and their families have increased direct access to specialist support through a self-referral model

By:
developing a new Autistic regional support service to deliver the new national strategic action plan
Measures above will form part of a comprehensive performance management framework and are included to provide a high level indication of success measures. The Regional Partnership Board and strategic partnerships will develop a more robust list of performance measures within the first year of the Area Plan.

6.		Regional Priorities & Core Themes

5.		Appendix 1 : Core Theme Action Plans

5.8 People With Autism Spectrum Disorders

What Action Are We Taking?	Local implementation of Welsh Strategic Action Plan including development of new Integrated Autism Service.
Who Will Be Taking Action?	New Regional AS Strategy Group
How Will We Deliver?	The development of the Integrated Autism Service is the main delivery objective of the refreshed ASD Strategic Action Plan which will include / development of a Regional Strategy Group / post diagnostic support & interventions for children/parents of children with autism / training program for parents/carers of children with autism. / Analysis of regional data
When Will We Deliver?	Plan to be reviewed quarterly
What Resources Are Needed?	ICF
How Will We Measure Progress?

6.		Appendix 2 : Links With Other Partnerships

The Regional Partnership Board will link and align priorities with other partnerships and strategic plans. There are a number of strategic partnerships which will share similar priorities and involve supporting the same cohort of people in local communities. It is paramount that there is not a duplication of services but a synergy between the partnerships, plans, workforce and resources. Partnership and priorities are set out below; and
‘the RPB will establish a widened governance to ensure all partnerships are well informed of priorities, and which partnership will lead an agenda and where they will complement and support an agenda’.
Links with Public Service Boards under the Well-being of Future Generations Act
The Social Services and Well-being Act shares similar principles with a number of national strategies and legislation. However, the Act shares almost identical principles with the Well-being of Future Generations Act with the main difference between the acts being the time frame: the Area Plan under the Act reflects the Population Needs Assessment and covers a 3-5 year period based on electoral cycle and the Well-being Assessment under the Well-being of Future Generations Act covers a longer period.

Social Services and Well-being / Act Principles	Sustainable Principles: / Well-being of Future Generations
Services will promote the prevention of escalating need and the right help is available at the right time	Prevention: How acting to prevent problems occurring or getting worse
Partnership and co-operation drives service delivery	Collaboration: how acting in collaboration with any other person or any other part of an organisation could help meet wellbeing objectives
	Integration: Consider how the proposals will impact on wellbeing objectives, wellbeing goals, other objectives or those of other public bodies
People are at the heart of the new system by giving them an equal say in the support they receive	Involvement: The importance of involving people with an interest in achieving the wellbeing goals, and ensuring that those people reflect the diversity of local communities.
The Act supports people who have care and support needs to achieve well-being	The importance of balancing short- term needs with the need to safeguard the ability to also meet long – term needs

6.		Appendix 2 : Links With Other Partnerships

A strategic network of PSB managers and partners has been established to ensure good practice is shared when developing individual Well-being Plans and an opportunity for PSBs to undertake joint planning against regional priorities. The Gwent Strategic Well-being Assessment Group (GSWAG) includes wider partners from Gwent Police, Public Health Wales, Welsh government, National Resources Wales and South Wales Fire Service. The Regional Partnership Team is also represented on the group and promoting a consistent approach to the plans where they can easily be read and referenced in tandem to promote alignment. A mapping of Well-being Plan priorities against the Area Plan and a common definition of terms used across the plans – which will be the basis of a Memorandum of Understanding. Going forward an alignment of success measures will be required with the ultimate aim to avoid duplication across the plans and apportion priorities across the RPB and PSBs.
Violence Against Women Domestic Abuse and Sexual Violence (VAWDASV) Board.
The Violence against Women, Domestic Abuse & Sexual Violence (Wales) Act 2015 focusses on the prevention of issues, the protection of victims and support for those affected by such issues. Welsh Ministers are required to prepare and publish a National Strategy in relation to these matters and appoint a National Adviser on Violence against Women and other forms of Gender-based Violence, Domestic Abuse and Sexual Violence. Relevant authorities are required to prepare and publish strategies to contribute to the pursuit of the purpose of the Act. A South East Wales VAWDASV Board has been established and supported by a VAWDASV regional team. The board has identified a number of emerging regional priorities and the RPB will support the work of the VAWDASV Board in achieving the required outcomes
Strategic Priority 1: Increase awareness and challenge attitudes of violence against women, domestic abuse and sexual violence across Gwent.
Strategic Priority 2: Increase awareness in children and young people of the importance of safe, equal and healthy relationships and that abusive behaviour is always wrong
Strategic Priority 3: Increase focus on holding perpetrators to account and provide opportunities to change their behaviour based around victim safety
Strategic Priority 4: Make early intervention and prevention a priority
Strategic Priority 5: Relevant professionals are trained to provide effective, timely and appropriate responses to victims and survivors
Strategic Priority 6: Provide victims with equal access to appropriately resourced, high quality, needs led, strength based, gender responsive services throughout the region.
Area Planning Board
The substance misuse Gwent Area Planning Board Board works across the Gwent region to reduce substance misuse through a combination of education, prevention, treatment and rehabilitation. The current priorities the board are working to address are below and the RPB will work in partnership to avoid duplication and create a synergism across partners.

6.		Appendix 2 : Links With Other Partnerships

Priorities
Improving emergency service substance misuse training and Naloxone roll out
Increasing alcohol prevention both in terms of treatment and education
Improved primary prevention including raising awareness of Minimum Unit Pricing (MUP)
Co-occurring mental health and substance misuse services
Improved housing options
Securing capital estates funding (impact to service delivery if reduced)
Safeguarding Boards
As of the 6th April 2016, the Gwent-wide Adult Safeguarding Board and South east Wales Safeguarding Children Board became statutory boards as set out in the Social Services and Well-Being (Wales) Act 2014. The boards were formed in 2011 covering the local authority areas of Blaenau Gwent, Caerphilly, Monmouthshire, Newport and Torfaen. Both boards have developed work programmes which ensuring the continued effectiveness of safeguarding practice during the implementation and transition of the Social Services and Well-being (Wales) Act 2014. The individual priorities are set out below and the RPB will support the delivery of priorities through joint working.
Adult Board Priorities
Targeting Interventions towards adults who are at risk of specific types of abuse
Improving the Quality of Care across the region
Improving the effectiveness of the Regional Adult Safeguarding Board
Children Board Priorities
Reducing the effects of compromised parenting on children’s well-being
Improving our work with adolescents who exhibit risky behaviours
Improving the effectiveness of the Regional Safeguarding Children Board
Police Crime Commissioner and Gwent Police
The Chief Constable for Gwent Police will provide a detailed annual Delivery Plan of the activities proposed to achieve the outcomes required to meet the Police Crime Commissioner’s priorities from a policing perspective. The office of the Police Crime Commissioner will also produce a Business Plan which will detail its contribution towards delivering the priorities. The results of the progress against all activities will be reported each year in a PCC annual report. The priorities for policing are set out below
Crime Prevention – Taking action to prevent and reduce crime by working partners organisations and communities to tackle crimes that present the greatest threat, harm and risk and especially those crimes committed against the most vulnerable.
Supporting Victims – Provide excellent support for all victims of crime with a particular focus on preventing further serious harm

6.		Appendix 2 : Links With Other Partnerships

Community Cohesion – Ensure that the Police, partners and my office engage with communities to encourage help and support them to work together to keep themselves safe
Tackling Anti-Social Behaviour – Ensuring the Police work closely with partner organisations to tackle anti-social behaviour effectively
Efficient and Effective Service Delivery – Ensuring that Gwent Police and my office are high performing organisation which value and invest in our staff to achieve value for money in delivering impressive services that meet the needs of all communities.
The full plan can be found here:
http://www.gwent.pcc.police.uk/fileadmin/documents Gwent_Police__Crime_Plan_English_WEB.pdf

7.		Appendix 3 : ABUHB Clinical Futures

ABUHB’s ambition is to create a new system of primary, community care and well-being across Gwent, in partnership with local government and the third sector. They aim for people to be able to access the care they need in their own community and homes, improving independence and wellbeing, and avoiding the need for unnecessary hospital admission. To do this they will require a radical transformation of services, and the development of new models of care, based in the community. ABUHB’s vision in is to create a system of primary, community and well-being services, based around the Neighbourhood Care Network (NCN) footprint, where there is a consistent regional service offer, and effective locality based multi-disciplinary teams. A framework has been developed to set out a vision, with a 5 year programme plan developed from 2018/19 to deliver change.
The four stages are:
Keeping people healthy and well
Self-care
Primary Care and NCN Team
NCN Hub with specialist and enhanced services
ABUHB we will draw on the findings of the Parliamentary review, recognising their expectations of a community focused, seamless service. Integrated commissioning, and a clear set of service principles will underpin the development of a consistent NCN model which includes:
Establishing a Gwent wide unified vision for health and social care
Increasing the pace of transformative change and integration
Developing new models underpinned by the principles of prudent healthcare and the Social Services and Wellbeing Act
The system is predicated on the shared agreement by both Health and Local Government to provide more care closer to home, to reduce a reliance on primary care services, and prevent unnecessary hospital admissions. The system will build on the existing innovation across Gwent, and use the NCN footprint, as the basis from which services will be planned and delivered, around a model of community well-being. To drive action, a set of 10 high impact actions will be adopted to drive forward change, and which are focused on partnership working, the development of more productive flows, and the creation of a standard model of multi-disciplinary teams. Taken together, these principles can be translated into high impact actions including:
The development of a new model of integrated care predicated on improved wellbeing, based on an NCN/IWN footprint
The development of active signposting through Information Advice and Assis-tance (DEWIS) to empower citizens to make informed choices about their healthcare needs and actions
Greater partnership working to deliver a consistent specification for NCN’s across organisational boundaries to provide a seamless pathway to accessible local community services.
Developing an appropriate skills mix within a modernised and more integrated workforce, aligned to the population needs assessments.
Enhancing self-care through social prescribing, and new consultation methods in line with the principles of prudent health care.

7.		Appendix 3 : ABUHB Clinical Futures

Further pathways establishing secondary care and primary care responsibilities and enhancing the leadership of primary care, particularly for chronic conditions.
Proposed Outcomes for ABUHB Integrated System
People are identified early if they need care or support and they are prevented from ill health or decline in wellbeing wherever possible
Improved community capacity to support improved health behaviours
Reduced unnecessary hospital admissions through the provision of integrated community capacity, that is responsive and accessible
A seamless pathway of care for patients, by integrating social services, health and third sector provision at a local level
Improving the sharing of information across health and social care

8.		Appendix 4 : Creating An Integrated Workforce

Purpose
A critical component of an ‘integrated system of health, care and wellbeing’ across Gwent is the development of an integrated wellbeing workforce, designed around the emerging requirements of the system and sustainable for the future. This has been identified by the programme board as a vital component of the out of hospital service delivery that is needed for the future and as such sees workforce (along with estate, ICT, etc.) as a key enabler as well as a distinct work stream. This short paper looks to ‘take stock’ of the current position, to determine how we can best utilise existing structures and ensure current work is aligned to achieve the vision set out in the relevant planning frameworks across health and local government as we move towards the delivery of an integrated system.
Background and Scope
Workforce planning is vital for Health and Social Care – in fact nothing can be done if there is not the workforce to do it. Having sufficient workforce is becoming a real issue, with local, regional and national shortages of more and more key professionals being reported – from therapists to medical specialists, from nurses to domiciliary care workers.
In the context of the design of an ‘integrated system for health, care and wellbeing’ across Gwent, this paper focuses on those roles necessary to deliver an enhanced community model of care, support and wellbeing, and as such those specialist and clinical roles such as doctors, nurses, therapists or social workers are out of scope.
The focus is on those first line staff who deliver care and or support directly to citizens, whether they are called health and wellbeing workers, domiciliary care workers, social prescribers, community connectors, and older people outreach workers or one of many other terms. The key common characteristics include:
face to face interaction with vulnerable citizens and their families
seeing people in their own homes, or close to home in settings that are not specialist health premises (hospitals, health centres, GP practices)
not having formal professional, academic qualifications in a health or social care discipline
having a need for personal skills to work with people and understand their needs – moving to an emphasis on ‘doing with’ rather than ‘doing to’.
The introduction of the Social Services and Wellbeing (Wales) Act brings in expectations for how social care – and health – service delivery need to change to be sustainable and effective in the future. This includes:
An increased emphasis on prevention and early intervention in providing services to citizens
Effective provision of information, advice and assistance to citizens, in that order so they can make informed decisions around their care and support
A focus on ‘what matters to you’ rather than ‘what is the matter with you’

8.		Appendix 4 : Creating An Integrated Workforce

In addition, the creation of a wellbeing workforce, is a key priority of the Future Generations Commissioner, and is further enabled by the Act through its focus on:
Prevention
Collaboration across organisational disciplines and;
Long term planning
All these elements are exactly what the wellbeing workforce looks to address, so staff in these roles need to be fully supported to know their roles and just how important they are in the future health and care system.
The term ‘wellbeing workforce’ usefully expresses how traditional roles need to change to cover future needs and aspirations
Current Position
At present there are a number of concerns as to both workforce quantity and quality, with many local authorities in the region and private service providers finding it difficult to recruit care staff.
For social care and independent providers, the implementation of the Regulation and Inspection of Social Care (Wales) Act (RISCA) means that the domiciliary care workforce, irrespective of employer, will need to be registered and undertake an accredited training and competency framework. This has been seen by employers as both an opportunity and a threat. The opportunity is that this provides, for the first time, a prospective career pathway and gives a national framework of competencies that should be recognised across all employers, so aiding movement across the sector. The threat is that many of the older members of the current workforce will not be comfortable to go through a qualification framework in order to do a job that they have considerable practical experience in.
For health, social care and private providers some of the newer type of roles – such as community connectors are funded through specific short term funding streams (such as Integrated Care Fund), and so workforce planning here is often short term and quite fragmented.
In addition these newer types of role do not have an agreed competency and standards framework, although Social Care Wales have started a consultation process on a competency framework for IAA (Information, Advice and Assistance)
As noted, there are workforce shortfalls in many clinical roles including nurses and therapists, so there is some loss of good, experienced wellbeing workforce personnel to these professions if staff have the requisite entry qualifications to go alongside their practical experience. In other words, there is an informal or unofficial career pathway that a proportional of staff follow from wellbeing worker (particularly if making a career change) to registered clinical work as a therapist, nurse or allied health professional. The registration and qualification process for domiciliary care workers that is being introduced (and which also affects residential care workers and advocacy workers) should make career pathways more explicit and formal – for those who want to follow that route.
Pay and conditions are also an important factor in attracting and retaining people in the wellbeing workforce. It is important to distinguish between these two elements.

8.		Appendix 4 : Creating An Integrated Workforce

Pay for care workers – seen as an unqualified sector – has historically been low. As such the expansion of the retail sector – exemplified by the opening of new larger supermarkets – tends to draw in some of the existing care workforce to jobs that pay as well or better, and which can offer better fringe benefits (such as staff discounts) and better hours of work. It also has an impact on new recruitment as fewer people are attracted to carer jobs if an alternative is available.
The drive to cut costs of care has often meant that as well as pay staying low, conditions of service have been poor – with a ‘time and task’ focus often not allowing adequate time to move from one care visit to another, and in some cases travel time not being paid.
Key links
As workforce is such a pivotal issue for Health and Social Care, it is not surprising that there are a number of different bodies looking at this and a spread of national and regional work streams that involve workforce.
Some of these include:
a. Social Care Wales Work
Social Care Wales (SCW) came into being in April 2017, taking over the previous Care Council for Wales (CCW) and the Social Services Improvement Agency (SSIA).Following a period of engagement and consultation, a number of work stream priorities were established for the new organisation, and these are:
Care and Support at Home
A five year strategy has been developed, working with a range of partners, running from 2017 – 2022. This highlights actions for SCW, but also Public Health Wales, Regional Partnership Boards, Local authorities, NHS Wales, National Commissioning Board and others. The strategy sets out 6 high level outcomes, of which ‘Outcome 5: Make sure the workforce has the knowledge, skills and values to deliver outcome focused care and support at home’ particularly focuses on workforce.
Supporting the development and implementation of a Careers, Recruitment and Retention Framework
This work has started to try and find out what regional initiatives have been started and aims to bring together a national ‘task force’ in the spring of 2018.
Raising awareness and supporting engagement in the development of learning materials for the Regulation and Inspection of Social Care (Wales) Act 2016
The RISCA legislation broadens the requirement for registration and associated professional development and core qualifications to the whole of the residential care (care home) workforce and the whole of the domiciliary care work force, as well as to such as advocacy providers. Registration is over a rolling programme to 2021, but is a massive step change to what has been an unregistered works force, and as noted at 3.2 presents significant risk to current workforce retention.
b. ADSSW (Association of Directors of Social Services Wales)
ADSSW received some Delivering Transformation Grant funding from Welsh Government in the run up to the introduction of the Social Services and Wellbeing Act in April

8.		Appendix 4 : Creating An Integrated Workforce

2016. A number of national work streams are in place, including one for workforce and one on prevention and early intervention. This latter work stream has three high level objectives:
Objective 1 – To build community resilience, engaging the third sector to consider what outcomes we need to deliver for people, reducing the need for statutory services.
Objective 2 – To develop rehabilitation and reablement services engaging staff across the health & social care professions
Objective 3 – To develop solutions legislative and practice issues between the SSWB Act and other legislation.
c. Health Education Improvement Wales
As with the creation of Social Care Wales, Welsh Government took forward the creation of a new body, Health Education Improvement Wales, to commence on 1st April 2018. This new body took over the former roles of the Wales Deanery and the Welsh Centre for Postgraduate Pharmacy Education (WCPPE).
This decision came from the Welsh Government’s review in 2014 into investment of health professional education and workforce development. The review recommended developing a new single body to support the development of the health workforce in Wales, with elements including education and training, planning, leadership, careers, improvement, and widening access.
In addition, the Workforce, Education and Development Services (WEDS) Team within NHS Shared Services, which focuses on workforce planning and modernisation in NHS Wales, also transferred into HEIW.
The focus for this body is on NHS clinical roles and training, looking demand and recruitment but there is a recognition that the support workforce has to be fully considered – noting that training time is short (compared to medical and nursing pathways) and numbers are significant, with a focus on patient focused care that could do more to reduce the workloads of more highly qualified staff.
This whole approach is underpinned by the Wales Prudent healthcare approach, and the concept of ‘only do what only you can do’.
d. Integrated Care Fund (ICF)
The ICF has been used in the Gwent region for a wide range of projects and initiatives to provide care and support closer to home, with an emphasis on older adults – given that the fund was initially the Intermediate Care Fund and targeted to the ‘frail elderly’ demographic.
ICF funding supports a wide range of ‘wellbeing workers’, including community connectors, social prescribers and others. A structured evaluation process has now been taken forward across all ICF projects in the region and decisions now need to be made as to whether projects should continue, and if so how they can be funded as part of mainstream services, so releasing ICF for its purpose of taking forward new and innovative approaches to care and support.

8.		Appendix 4 : Creating An Integrated Workforce

It is also worth noting that some of the other regions in Wales have used ICF for partnership roles under their Regional Partnership Boards, with some form of pooled fund or partnership agreement to support this.
e. Gwent Workforce Development Board
This group brings together senior operational managers in social care (Heads of Adult Services and Heads of Children’s Services) along with social care workforce development managers, representation from Social Care Wales, and now representation from operational and workforce managers in ABUHB.
This group is now recognised as an integrated body under the Regional partnership Board, and is also the local link to the ADSSW work steam noted above.
Next Steps
This overview highlights that ‘workforce’ as a whole is a vital issue across health and social care, with many different groups having plans to take different actions forward.
It seems sensible to consider how best a regional and coordinated approach workforce should be taken forward – both within the Clinical Futures level 1 programme and to support the achievement of the strategic plans, within each of the partnerships under the regional board.
It is suggested that there are several key themes for ‘wellbeing’ workforce planning:
Attraction – explain and encouraging people to become part of the wellbeing workforce, whether new entrants to the job market or people looking to change careers, or to change their working patterns.
Recruitment – co-ordinating approaches and working jointly where possible to share approaches (and potentially costs) in recruiting across health and social care, and potentially with providers.
Retention – in a similar way as recruitment, share retention approaches and potentially enable staff to ‘move’ between different care settings yet remain in the overall wellbeing workforce. Look at key enablers for retention – such as pay progression, Continuous Professional Development, flexible working arrangements, etc
Development and succession planning – taking a co-ordinated approach to forward planning, using experienced staff to mentor colleagues to take forward career development (if wished) and allow for cross sector work placements to develop experience and competence.
An overall programme approach should usefully be considered for the wellbeing workforce, with an agreed key link to the Clinical Futures level 1 programme so as to be aware of the numbers of staff needed for ‘out of hospital’ care and support, and the range and type of activities that need to be covered.

9.		Appendix 5 : Welsh Government Principles of Working Action Plans and Acronyms

9.1 Welsh Government Principles of Working and Acronyms

Acronym	Full Description
ABUHB	Aneurin Bevan University Health Board
ACE	Adverse Child Experience
APB	Area Planning Board
ASD	Autistic Spectrum Disorder
BME	Black Minority Ethnic Group
CAMHS	Child and Adolescent Mental Health Services
CFPB	Children and Families Partnership Board
CYP	Children and Young People
DEWIS	National website
GAVO	Gwent Association of Voluntary Organisations
GNME	Gwent Needs Mapping Exercise
G+T	Gypsy and Traveller
IA	Integrated Assessment
IAA	Information Advice Assistance
ICF	Intermediate Care Fund
ISCAN	Integrated Services for Children with Additional Needs.
LGBT	Lesbian, Gay, Bisexual, Transgender Community
LVSW	Low Vision Service Wales
NCB	National Commissioning Board
NCN	Neighbourhood Care Network
NGO	Non-Government Organisation
NOMS	National Offender Management Service
PMLD	Profound and Multiple Learning Disabilities
PNA	Population Needs Assessment
PSB	Public Service Board
PTSD	Post-Traumatic Stress Disorder
RPB	Regional Partnership Board
RCC	Regional Collaborative Committee
RJCG	Regional Joint Commissioning Group
SIMS	School Information Management System
SLCN	Speech Language and Communication Needs
TVA	Torfaen Voluntary Alliance
VAWDASV	Violence Against Women, Domestic Abuse and Sexual Violence
VT	Veteran Therapist
WBA	Wellbeing Assessment
WCCIS	Welsh Community Care Information System
WFG	Wellbeing of Future Generations Act
YJB	Youth Justice Board
YOS	Youth Offending Service

9.		Appendix 5 : Welsh Government Principles of Working Action Plans and Acronyms

9.2 Joint Commissioning and Pooled Budgets

What Action Are We Taking?	Implement Regional Joint Commissioning Group / (RJCG) action plan to deliver joint commissioning arrangements for identified priorities for Act Part 9 requirements.
Who Will Be Taking Action?	Regional Joint Commissioning Group
How Will We Deliver?	The RJCG has been established with a Terms of Reference and outline Project Plan agreed. Task & finish Groups with briefs established have also been established. The RJCG will coordinate commissioning on behalf of the RPB / A Section 33 arrangement for Care Homes and Older People is being developed which will include the appointment of Pooled Fund Manager.
When Will We Deliver?	April 2018 / Sept 2018
What Resources Are Needed?	N/A
How Will We Measure Progress?

9.		Appendix 5 : Welsh Government Principles of Working Action Plans and Acronyms

9.2 Joint Commissioning and Pooled Budgets

What Action Are We Taking?	Develop domiciliary care joint commissioning process with National Commissioning Board and linked to Care Standards Social Improvement Wales ‘Above and Beyond’ Report and the ‘Care and Support at Home’ Strategic Plan currently being developed by Social Care Council for Wales.
Who Will Be Taking Action?	Regional Joint Commissioning Group – task and finish group
How Will We Deliver?	A task and finish group will develop regional approaches and consider: Medication and Falls policies, feasibility of developing a local social care academy, workforce challenges and alignment of contact management functions
When Will We Deliver?	June 2018
What Resources Are Needed?
How Will We Measure Progress?

9.		Appendix 5 : Welsh Government Principles of Working Action Plans and Acronyms

9.2 Joint Commissioning and Pooled Budgets

What Action Are We Taking?	Continue to link with National Commissioning Board to progress national work priorities and proposals across the region
Who Will Be Taking Action?	National Commissioning Board
How Will We Deliver?	To consider recommendations from NCB and respond as a region
When Will We Deliver?	April 2018 and ongoing
What Resources Are Needed?	N/A
How Will We Measure Progress?	N/A

9.		Appendix 5 : Welsh Gov Princliples

6.		Regional Priorities & Core Themes

8.		Process: Principles of Working

9.		Appendix 5 : Welsh Government Principles of Working Action Plans and Acronyms

9.3 Prevention and Early Intervention

What Action Are We Taking?	Explore a single prevention agenda across the region with PSBs and linked to Wellbeing of Future Generations and SSWB Acts which also includes Housing Associations.
Who Will Be Taking Action?	RPB and PSB / Health Housing and Social Care Partnership
How Will We Deliver?	Develop a task and finish group to identify common principles of prevention and align to Adverse Childhood Experience agenda
When Will We Deliver?	Sept 2018
What Resources Are Needed?	N/A
How Will We Measure Progress?

Align anti-poverty programmes across the region to set out a single preventative model based on consistent assessment principles, joint workforce and joint commissioning
See Children and Young People section

Through the implementation of the ‘Care Closer to Home’ strategy ensure that prevention and early intervention is supported and enabled in a consistent manner across the region
See Older People section

9.		Appendix 5 : Welsh Government Principles of Working Action Plans and Acronyms

9.3 Prevention and Early Intervention

What Action Are We Taking?	Delivery of Regional Joint Commissioning Group / (RJCG) work plan with third sector to maximise and align activity to prevent escalation of need and build on existing models of good practice such as befriending, social prescribing etc. and to promulgate the development of social enterprises and co-operatives where possible.
Who Will Be Taking Action?	RPB GAVO and TVA
How Will We Deliver?	*Work has started but will need to be revisited within year 2 of the Area Plan as limited capacity amongst partners
When Will We Deliver?	March 2019
What Resources Are Needed?	N/A
How Will We Measure Progress?

What Action Are We Taking?	Support Early Years Pathfinder pilot and use key messages to shape early intervention models
Who Will Be Taking Action?	Early Years Pathfinder group
How Will We Deliver?	Identify key messages and good practice from pathfinder project andshare with RPB and PSBs / Incorporate good practices across the region / Respond to recommendations from national EYP board
When Will We Deliver?	Sept 2018
What Resources Are Needed?
How Will We Measure Progress?

9.		Appendix 5 : Welsh Government Principles of Working Action Plans and Acronyms

9.4 Information, Advice and Assistance

What Action Are We Taking?	Further support and develop DEWIS website so it becomes the ‘go to’ place for information on support, advice and assistance.
Who Will Be Taking Action?	Dewis regional group
How Will We Deliver?	Deliver the regional Dewis action plan and review progress annually
When Will We Deliver?	April 18
What Resources Are Needed?	Transformation Funding and Neighbourhood Care Network
How Will We Measure Progress?

What Action Are We Taking?	Continue to support consistent information dissemination and stakeholder engagement through regional communications group
Who Will Be Taking Action?	Regional Communication Group
How Will We Deliver?	The Regional Partnership Team will continue to meet with Communication Managers to ensure consistent messages through regular newsletters etc. The Transformation Team will develop a new RPB website
When Will We Deliver?	April 18
What Resources Are Needed?	Transformation Funding
How Will We Measure Progress?

9.		Appendix 5 : Welsh Government Principles of Working Action Plans and Acronyms

9.4 Information, Advice and Assistance

What Action Are We Taking?	Use IAA performance management data to inform design of services
Who Will Be Taking Action?	Local Authorities
How Will We Deliver?	Annual review of IAA data and development of annual appraisal with local performance managers
When Will We Deliver?	Sept 18
What Resources Are Needed?	N/A
How Will We Measure Progress?

What Action Are We Taking?	To support further initiatives across the region that supports consistency of approach to IAA e.g. self-assessment exercises, peer reviews
Who Will Be Taking Action?	Citizen Panel
How Will We Deliver?	Citizen Panel to review IAA across region once per year and identify recommendations for RPB / Develop RPB website
When Will We Deliver?	April 18 and annually
What Resources Are Needed?	N/A
How Will We Measure Progress?

9.		Appendix 5 : Welsh Government Principles of Working Action Plans and Acronyms

9.4 Information, Advice and Assistance

What Action Are We Taking?	To work with regional workforce managers and Social Care Wales to ensure that cultural change programmes are embedded and on-going
Who Will Be Taking Action?	Workforce Development Board & Social Care Wales
How Will We Deliver?	Deliver and review WFD board regional plan in relation to IAA emerging themes
When Will We Deliver?	Sept 18
What Resources Are Needed?	N/A
How Will We Measure Progress?

9.		Appendix 5 : Welsh Government Principles of Working Action Plans and Acronyms

9.5 New Models, User Led Services and Third Sector Working

What Action Are We Taking?	Work with Wales Cooperative Centre to increase and support number of voluntary led services in local communities through ‘Care to Co-operate’.
Who Will Be Taking Action?	Wales Cooperative Centre & Provider Forum
How Will We Deliver?	The Transformation team will facilitate region development of new models across the 8 core theme action plans and undertake an audit to identify good practice and publish case studies.
When Will We Deliver?	April 2019
What Resources Are Needed?	N/A
How Will We Measure Progress?

9.		Appendix 5 : Welsh Government Principles of Working Action Plans and Acronyms

9.6 Workforce Development

What Action Are We Taking?	Integration of care and support provision to key client groups as set out in Part 9 of the Act and emphasised through RPBs Statements of Strategic Intent for older people, children with complex needs and carers, as well as strategy statements for Mental Health and Learning Disability (including Autism)
Who Will Be Taking Action?	Workforce Development Regional Board
How Will We Deliver?	The regional Workforce Development Board will develop and implement an action plan and review progress annually. The key priorities are / Care and Support at Home / Supporting the development and implementation of a Careers, Recruitment and Retention Framework / Raising awareness and supporting engagement in the development of learning materials for the Regulation and Inspection of Social Care (Wales) Act 2016
When Will We Deliver?	April 19
What Resources Are Needed?	TBC
How Will We Measure Progress?	TBC

9.		Appendix 5 : Welsh Government Principles of Working Action Plans and Acronyms

8.		Process: Principles of Working

6.		Regional Priorities & Core Themes

9.7 Advocacy

What Action Are We Taking?	Work with the Golden Thread Advocacy Programme across the region through regional provider forum with focus on / Alignment of advocacy provision to identified priorities across partner agencies / Joint approach to advocacy provision with third sector partners especially in promotion of independent advocacy
Who Will Be Taking Action?	Golden Thread Advocacy Programme (GTAP) & Regional Provider Forum
How Will We Deliver?	Deliver regional Advocacy programme with GTAP / Establishing a Gwent Advocacy Commissioners’ Group. / Establishing a Gwent Advocacy Providers’ Forum. / Progressing towards a regional approach to advocacy commissioning. / Adopting a co-productive approach to advocacy commissioning, including a multi-stakeholder workshop in early 2018. / Developing a strategic plan for advocacy commissioning in the region in 2019-2024, covering both IPA and wider forms of advocacy
When Will We Deliver?	April 2019
What Resources Are Needed?	N/A
How Will We Measure Progress?

9.		Appendix 5 : Welsh Government Principles of Working Action Plans and Acronyms

9.7 Advocacy

What Action Are We Taking?	Support Children’s Services joint commissioning of a single advocacy service
Who Will Be Taking Action?	Heads of Children Service and National Youth Advocacy Service
How Will We Deliver?	Develop new service and review annually
When Will We Deliver?	April 2018
What Resources Are Needed?	TBC
How Will We Measure Progress?

Strategic Partnership	Core Theme
Children and Families Board	Children and Young People
Older People Strategic Partnership	Older People, Health and Physical Disabilities and Sensory Impairment
Carers Board	Carers
Mental Health & Learning Disabilities Partnership	Mental Health, Learning Disabilities and Autism
VAWDASV Partnership Board	Violence Against Women, Domestic Abuse & Sexual Violence

The Social Services and Well-being (Wales) Act 2014 sets out statutory duties for regional partnership boards which bring together health, social services, the third sector and other partners to take forward the effective delivery of integrated services in Wales. Welsh Government have provided an Integrated Care Fund to support regional partnership boards to work together to support: frail and older people, people with a learning disability, children with complex needs due to disability or illness and carers, including young carers. The fund helps support older people to maintain their independence and remain at home, avoiding unnecessary admissions to hospital or residential care and delays when someone is due to be discharged from care. It is also being used to support the Integrated Autism Service for Wales, and the roll out of the Welsh Community Care Information System across Wales.
Integrated Care Funding guidance states:
‘All schemes and activity that the ICF is utilised to support must address care and support needs identified in a region’s combined population assessment report’.
The RPB will ensure all ICF projects are aligned to the priorities and actions in the Area Plan.

The aspirations encapsulated within this plan are ambitious, and for a step change in the pace of collaboration, of partnership working and service transformation. It is therefore crucial that there is effective governance and assurance mechanisms in place through the Regional Partnership structure.
A regional Governance framework has been established to support the work of the Regional Partnership Board, and to provide assurance on the delivery of the activity committed to within the report. This framework will ensure all individual partner agencies are able to partake effectively in decision making, alongside their oversight and scrutiny roles.
The Regional Partnership Board, is supported by a strategic ‘Leadership Group’ comprised of senior offices providing a strong emphasis on collective leadership and ensuring the aims of the RPB are translated into core business back in partner organisations.
Five thematic strategic partnerships have now been formed, to direct and deliver the activity committed to in this plan for those specific population groups identified in the needs assessment. Each partnership is co-chaired by senior leaders from Health and Social Care, who are on the Leadership Group and have led on the development of the core theme action plans (see appendix 1). Each of the five strategic partnerships have a common set of terms of reference agreed, and are each developing a common mission statement, to articulate clearly their ambitions for delivery in the years ahead. This is supported by a common set of terms of reference for the integrated partnership boards.

Some pre-existing regional arrangements have now been brought into the new integration partnerships. This includes the Dementia Board, GWICES and Frailty – all of which now come under the Gwent Adults strategic partnership. Frailty previously had a Board providing strategic oversight, and an Officer Support Group, bringing together the operational lead staff. Most members of the Frailty Board are also members of the RPB, and it is recommended that the former is subsumed into the latter.
A new governance framework for Gwent is currently under development that will provide a clear process and line of sight between the 5 public service boards and the Regional Partnership Board, and to the Integrated Partnership Boards at a local authority level. In addition a Memorandum of Understanding will also be developed to align and coordinate work between the RPB and PSB’s.
Support to the RPB, Leadership Team and Strategic Partnerships is provided by the regional transformation team, who have an important role to play in connecting with the support officers for every integrated body here.
Locality Partnerships – ‘Vehicle for Delivery, Drivers for Change’
At a local authority level, Integrated partnership boards have been established to act as the local drivers of change, translating the regional commitments into appropriate locality based activity. For example the Newport Integrated Board will provide oversight on the development of the proposed Ringland Health and Wellbeing Hub.
Clearly integrated working needs to be considered at a regional level in terms of strategic direction, oversight and impact. However, implementation has to be taken forward at a locality (local authority) level, being mindful of those services, structures and demands. These bodies do have some oversight of Neighbourhood Care Networks (NCN’s) which are specific to ABUHB, having a management structure within that organisation, but needing to have strong partner connection at local level. This is represented in the diagram below

How we will monitor the Area Plan – Performance Management
It is crucial that the RPB monitor and evaluate the core theme action plan sections to ensure effective governance. Each core theme section will set out success measures to be reported to the RPB and a performance management framework and reporting structure will accompany the Area Plan and set out:
Position statement – where we are and the curves we have turned
Progress factors – story behind the curves
Successes – good practice identified
Challenges – barriers to progress
Next steps – what the RPB are being asked to support
The success measures identified in the core theme sections reflect performance measures in the National Outcomes Framework, Public Health Outcome Framework and the NHS Outcomes Framework. The RPB will also reference and align to the performance measures in local Well-being Plans and Local Authority Improvement Plans; and consider data development through the implementation of the Area Plan as some success measures may not be currently measured.
The RPB will produce an annual report on activity and outcomes and quarterly progress updates
The RPB will develop a programme of organisational development to ensure its effectiveness in leadership and oversight
The RPB will ensure reports are issued by the RPB to the appropriate health and local government assurance process
The strategic partnerships will be required to report quarterly to the regional partnership board on activity, and effectiveness
What is being done elsewhere in the region and how do we know it is being addressed?
The RPB will align the performance management process with existing reporting frameworks (Area Planning Board, VAWDASV Board, and Safeguarding Boards) to ensure priorities are being supported. The PRB will also explore governance arrangements and shared reporting with local Public Service Boards to ensure effective alignment across the Area Plan and 5 Well-being plans.

To deliver the ambition established within this Area Plan for Gwent, there are significant areas of challenge which must be overcome, to ensure ambition can be translated into reality. Whilst these are dealt with through the specific partnerships as overarching themes, it is prudent to identify them at the front of the plan.
Information Technology
There must be a strong emphasis on the ability of IT to help develop enhanced services including through the implementation of DEWIS, my health online, SMS reminder services, telehealth, telecare, the implementation of WCCIS, development of mobile working for professionals and ambulatory diagnostics. The WCCIS programme will deliver service redesign for care across health and social care. Mobility is being tested out as readiness to WCCIS, as part of patient flow evaluation and with corporate departments in the AGILE programme. A business case is being developed, this deliverable will be updated once the business case is complete. In addition Telehealth Pilots will be delivered for out of hours Care Homes, Prisons and Tele-swallowing (speech & language therapy). The pilots will provide the learning for scaling up delivery and support of telehealth solutions.
Integrated financial systems and incentives
The development of a statutory regional board, will enable funding decisions to be made strategically and in partnership, for health and social care services, where partnership activity is required. Continued austerity has presented challenges for both local authorities and health boards in managing demand, whilst investing in new services. In line with the spirit of the legislation pooled budget arrangements, will be a valuable tool for some services areas, where we can align financial resources with outcomes, to create value for the whole system. But this remains an area of significant challenge, with governance arrangements and different organisational boundaries. As part of the delivery of the plan work will continue to consider how across Gwent, resources can be better aligned physically, and virtually to allow for mechanisms to allow resources to flow across organisational boundaries to achieve change.
Workforce
Ensuring there is a strong and sustainable workforce across health and social care is imperative, and that the spirit of the Act is translated into regional shared organisational development programmes. This is why in Gwent we have established a regional workforce development Board, the Board will work in partnership with the four strategic partnerships to ensure that workforce development needs, recruitment and retention remain prevalent. Critical challenges will be around the domiciliary care workforce and the establishment of ‘integrated multi-disciplinary community teams’ – it is proposed that this is taken forward as the ‘wellbeing workforce’.

Housing
Welsh Government’s Prosperity for All: The National Strategy (2017) recognises that “good housing plays a critical role in healthy, independent ageing” Appropriate housing options can contribute to people living safely and independently in their own homes despite functional decline due to ageing. Providing graduated housing solutions, proportionate to individual need, has the potential to enable older people to realise their aspirations in later life and live happily, healthily, safely and independently in their own homes and prevent them from having to enter residential or nursing care homes.
Developing new models of care for vulnerable and older adults with complex needs is a critical need, it will ensure people are supported to remain in their homes, which are developed to accommodate the specific needs of an ageing population. The Health, Social Care and Housing forum, have started to develop a programme of work which will provide leadership and strategic direction from which to develop new service specifications, and the development of an older peoples housing needs assessment, taking account of forward aspirations, will be an important tool as a key step forward. ICF Capital funding will be an important enabler here, and the involvement of housing representation into the regional Leadership Group is in place for 2018.
Estates Infrastructure
There is a need for appropriate, effective and modernised capital infrastructure across Gwent, in order to deliver the services described in the plan. Both primary care services and adult social care provision present significant challenges, alongside questions on future viability. Whilst Integrated Care Funding has provided resources, alongside local projects this area remains one where considerable and focused activity is required. Integrated capital planning and making better use of the public sector estate are necessary, and these are shared issues that will be taken forward in partnership with Public Service Boards.

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