Update on Healthcare Services in Carmarthenshire

Transcription

1 Update on Healthcare Services in Carmarthenshire 1. Introduction Carmarthenshire is a County of diverse geographical contrast including urban, rural and post industrial areas. The County is divided into three Clusters: Llanelli, Aman Gwendraeth and the 2Ts (Tywi and Taf). Each locality has an average population of around 60, Primary Care Services 2.1 General Medical Services (GMS) 25 Practices provide GMS services across the County. There are significant workforce challenges facing all practices across Wales and this is also felt locally. Practices across the County are looking at how they can optimise capacity through introducing new appointment systems as well as developing alternative workforce models including the employment of pharmacists and Advanced Paramedic practitioners to the primary care team. The Board will be aware of the retirement of a single handed GP Practice in Andrews Street, Llanelli on the 30 th September The Health Board awarded a new GMS Contract to the Rosedale Medical Group who took over responsibility for GMS services for the patients of Andrews Street surgery on the 1 st October. The Health Board has been working closely with the new Practice to develop new, modern, GP premises in the Dafen area. In the meantime the Practice continues to operate from the current GP premises with the aim to be in new premises by the summer of Amman Tawe Practice formed last year through the merging of Amman Valley and Cwmllynfell surgeries. The new Practice has embraced a new, diverse approach to workforce development by employing an Advanced Nurse Practitioner, Advanced Paramedic Practitioner and a pharmacist as part of the primary care team. Meddygfa Minafon, Kidwelly, became the Health Board s Managed Practice last year and since then has employed two Advanced Nurse Practitioners, along with two new GPs who will be commencing shortly. All GP practices have achieved the Bronze Level Medal Investors in Carers Award with one Practice having achieved silver while others continue to pursue this award Out of Hours (OOH s) The current GP out of hours service in Carmarthenshire is provided through a range of GPs on salaried and sessional contracts with telephone triage provided by Primecare. The Welsh 111 Service is being introduced across Wales. The unscheduled care system in Wales, indeed across the whole of the UK, is complex, 1

2 difficult to navigate, and often results in patients taking the easiest and most easily accessible route into our health services. The Welsh 111 Service must therefore be seen as a vital service to help people with urgent care needs get the right advice in the right place, first time. Ultimately, this free to use number will be an instantly recognised brand for NHS (and other parts of the wider health and social care system in Wales) which can offer support and advice to patients and their carers 24/7. The 111 Service will be going live in ABM UHB in the Spring of 2016, Carmarthenshire will go live on 1 st October An Implementation Group has been established to take this work forward. 2.2 Cluster Network Working The new Primary Care Plan for Wales sets out a clear vision and reform agenda for primary care. Welsh Government is supporting the implementation of the plan with a new 10m Primary Care Fund which is being allocated in 2 ways: 6m to Cluster Networks and 4m for pathfinder projects across Wales. The purpose of the cluster funding is to accelerate the development of primary care cluster networks to drive community focused service reform in response to identified local needs. The funding is intended to resource local solutions which improve access to and the quality of care, more effectively meet demand, and most importantly help redesign how services are delivered to ensure sustainable models. The funding has been distributed based on Global Sum weighted registered population. There are seven (7) Clusters/Localities in Hywel Dda. Each Cluster has a GP Lead, a Primary Care Locality Development Manager and a Practice Manager Representative. There are three Clusters in Carmarthenshire namely Aman Gwendraeth, Llanelli and 2Ts which are supported by Public Health Wales and Medicines Management. In partnership with Carmarthenshire s integrated health and social care services (which are outlined later), the aim is to ensure that the Clusters address the Ministerial priorities within the Primary Care Plan. As part of the 6m funding for cluster networks, Amman Gwendraeth received 122,407, 2Ts 114,110 and Llanelli 121,391 - this is recurrent funding for 3 years. The Clusters, in conjunction with partners, have agreed that the funding will be utilised on the following areas in and in some instances for the three year period: Amman Gwendraeth:- Frailty Pilot in Care Homes This service provides care home patients with access to the same level of high quality care, where the GP can be more pre-emptive. It provides a higher quality and more consistent level of care across local care homes by promoting proactive case management and therefore avoiding costly hospital admissions. It is delivered by a primary care team led by a named GP, Nurse Practitioner and Pharmacist who are responsible for ensuring the provision of an enhanced service for the frail and elderly patients resident in the specified Amman Gwendraeth cluster care homes. 2

3 GP Dementia Service This service is a GP led post diagnostic clinic in a community setting, aimed at reducing the stigma of dementia and increasing early diagnosis, reducing admissions to hospital and care homes, with the aim for people to live independently for longer Primary Care Phlebotomy This service is delivered by Phlebotomists to support GP practices in improving the delivery of patient care. The service is held in GP practices across the cluster and provides a much more convenient service for patients, who require blood tests and supports the pressure on the secondary care service Ts:- Frailty Frailty is the most significant growth area of patient need within the Health Board and was identified as one of the main challenges in the 2014/15 Cluster Plan. These are the patients most likely to be admitted and re-admitted to hospital. Managing these patients more effectively and pro-actively in their own home will enhance their experience of care, improve their outcomes and reduce acute care costs and bed days. As part of the funding proposal, practices are being asked to nominate a clinical frailty lead and to identify frail patients utilising a practice based IT Risk Stratification System. The MSDi (software) tool will be used to risk stratify patients. Patients identified are to have a written Stay Well Plan which includes details of carer, health and social care summary, optimisation and maintenance plan, and escalation and urgent care plan. To date 516 stay well plans have been developed. The proposal also identifies optimising Multi-disciplinary Team (MDT) working through the adoption of the MDT best practice guidance and the appointment of a generic Occupational Therapy/Physiotherapy (OT/PT) technician who will attend all MDT meetings, accepting referrals to undertake low levels assessments Llanelli:- Community Phlebotomy The Cluster has developed a community based phlebotomy clinic in Llanelli through the funding of an additional 2 WTE phlebotomists within the UHB staffing for a 12 month period. Accommodation was secured in January 2016 in the Antioch Centre, Llanelli from which the appointment system is also currently run. Further accommodation has been identified in Burry Port and the service will commence there at the end of March The Antioch Centre accommodation also provides a hub for other community services that are identified as a priority by the Cluster including a Leg Ulcer clinic. The Cluster funding is for a 12 month period with a view to the Health Board continuing the service thereafter, including the running of the appointment system. One of the aims of the service is to reduce waiting times and demand at the Prince Philip Hospital phlebotomy site and thus reduce complaints and increase patient satisfaction. Initial feedback has confirmed that they are already seeing this benefit. 3

4 Chronic Obstructive Pulmonary Disease (COPD) Plus Exercise Programme The Cluster has invested in order to expand the programme it developed using Prescribing Savings Money. The aim is to improve access to community based combined education and exercise classes for people with COPD in order to slow progression of the disease process. All three Clusters are also investing in the Lifestyle Advocates Project whereby a nominated representative from each GP practice within the cluster participates in a Lifestyle Advocate Development Programme to become skilled as an advocate in lifestyle intervention. The advocate identifies the health promotion needs and priorities of the practice and disseminates learning outcomes from the development programme to key stakeholders. 2.3 Community Pharmacy There are 49 Community Pharmacies within Carmarthenshire which represents almost 50% of the 99 pharmacies within Hywel Dda. Community pharmacies provide a range of essential, enhanced and advanced services and are very often the only regular contact that individuals have with a health care professional. The traditional role of community pharmacists as dispensers of pills and creams is becoming outdated with the profession eager and keen to play a more involved part in developing services that can support the health and wellbeing of their community. Pharmacies are often best placed to deliver services for patients as they offer local access to healthcare without the need for appointments and many are open on Saturdays and some on Sundays. Across Carmarthenshire, we have a number of pharmacies who have worked with the Health Board and with the wider Community Pharmacy agenda to deliver new services over the last few years. Examples of services being delivered by Community Pharmacy in Carmarthenshire include: Community Pharmacy Influenza Vaccination Service- 22 of the 49 pharmacies in Carmarthenshire provide an NHS influenza vaccination service for patients over 65, those that are in at Risk Group, and Health Board Staff. This service provides an additional access point for patients to receive their flu vaccination. Over 1,500 patients have been vaccinated to date at pharmacies in Carmarthenshire for this season which commenced on 1 st October Community Pharmacy Smoking Cessation Service- 35 pharmacies provide a service in conjunction with Stop Smoking Wales which allows the supply of nicotine replacement therapy (NRT) to patients who wish to give up smoking. Additionally 12, pharmacies are able to offer a one-stop smoking cessation service which includes both counselling and supply of NRT products. Further training has been scheduled during February and March 2016 for pharmacists so this new service can be offered in more pharmacies Return of Patients Sharps 47 of the 49 pharmacies accept 1 Litre sharps boxes for safe disposal. This provides for good access for patients Emergency hormonal contraception 70% of the pharmacies provide access to the morning after pill (subject to specific criteria), to women aged 13+. The long opening hours of pharmacies, together with weekend opening, is vital in areas where access to Family Planning Clinics might be limited. 4

5 2.3.5 Triage and Treat Service- provides a framework for community pharmacies to triage patients with low level injuries and provide treatment if appropriate. The service was piloted in 2 pharmacies in South Pembrokeshire in 2014 and is now being extended to other areas. Expressions of interest have been received from 4 pharmacies in Carmarthenshire. The aim of the service is to offer patients a local service for low level injuries reducing the need to attend a GP practice or A&E service. The service has had positive feedback from patients who have appreciated the locally provided service and the professionalism of the staff involved. It should be noted that this is the first service of its kind in Wales Investors in Carers - Two of the pharmacies within Carmarthenshire have achieved the Bronze Level Award for Investors in Carers. 2.4 Dental Services A commissioning process is currently underway for the provision of additional General Dental Services in Carmarthenshire. It is expected that new services will be in place from 1st April 2016 and will provide long term care for around 1300 patients. There are a number of practices across the county that have recently experienced a shortage of Dentists. A number of successful recruitment processes have taken place, and most practices expect to return to normal staffing levels over the coming weeks and be fully staffed from April Patients that do not have a dentist and seeking routine care, are advised to contact the Health Board s Dental Services Team. Urgent care remains available across the county Monday to Saturday. Community Dental Services maintains services from Elizabeth Williams Clinic, Llanelli (5 days per week), with outreach sites at Pond St Clinic, Amman Valley Hospital, and Llandovery Hospital. 3.0 Community Health and Social Care Services for Adults in Carmarthenshire The case for Integrated Care is well documented in national and local policy. It presents the need to develop whole system working across our services to address the demands and heterogenic care requirements arising from increases in the number of people with multiple long term conditions and the increasing prevalence of frailty associated with our most elderly. Integration has also been further reinforced recently with the imminent implementation of the Social Services and Wellbeing (Wales) Act which places a duty on our organisations to formalise partnership arrangements specifically in relation to Part 9 of the Act. Carmarthenshire has had a Section 33 agreement in place since This provided the necessary governance to develop an integrated community health and social care service infrastructure to support the health and wellbeing of older adults and adults with physical disabilities and / or sensory impairment. This legal agreement also places Carmarthenshire in a robust position to explore further opportunities for pooling of health and social care budgets in the near future. There 5

6 is an integrated health and social care management structure at county and locality level. In planning to deliver Care Closer to Home, the County strives to efficiently manage the significant pressure on healthcare provision due to the increased prevalence of chronic conditions and level of frailty. It cannot achieve this without effective collaborative working with our public and voluntary sector organisations. To manage the health and wellbeing of the population of Carmarthenshire s Clusters and to mitigate the pressure and improve outcomes in the acute setting, the Health Board s Primary Care and Community Services, in partnership with Carmarthenshire County Council and the voluntary sector, provide a wide range of services and interventions. These broadly fall into three tiers: Tier 1 Community, Universal & Prevention Tier 2 Early Intervention, Reablement & Intermediate Care Tier 3 Long Term Tier One: Services and Interventions that promote independence, wellbeing, community engagement and social inclusion. These services include: Vibrant Third Sector and community led support services (see also Community Resilience section below). Single point of access to Information, Advice and Assistance. Range of public funded community based services including leisure, regeneration, housing departments of the County Council that support health promotion and reduction in health inequalities. Self Care programmes such as Expert Patient Programme (EPP) delivered by lay members, and XPert which is disease specific and currently delivered by registered nurses. Tier Two: These services provide targeted intervention for individuals to regain previous levels of independence and wellbeing following an acute episode or injury and can also support avoidance of hospital admission. These services work closely with Tier 1 services to ensure ongoing health and wellbeing support from their own community (see figure 2 below). 6

7 Tier Three: Provision of service at this level focuses on supporting individuals who have long term and specialist care needs. Services in this tier will liaise with services in tier 2 to ensure that, at times of injury or acute episodes of illness, people regain their previous level of independence. Services in tier three also ensure that where possible individuals remain connected to their communities (see figure 2). Localities provide a geographical context within which each Cluster approaches. The GP practices in each Cluster are supported by their own Community Resource Teams which support the delivery of this tiered care and support within the cluster and which acknowledges the existence of each Cluster s diverse demographic and epidemiological profile and associated health and social care needs. The Community Resource Teams consist of Community Nursing Services, Occupational Therapy, Physiotherapy and Social Work practitioners who work as a multidisciplinary team to support the assessment and care planning for individuals requiring support. Multi Disciplinary Team Working (MDTs) Comprehensive Geriatric Assessment (CGA) provides optimum care and outcomes for frail adults, moreover CGA supports anticipatory planning for those individuals who are pre frail. CGA is dependent on clinicians and the multidisciplinary team working cohesively to assess and plan care. As such, the multi disciplinary teams within each Community Resource Team attend regular scheduled and unscheduled meetings with their GP colleagues in the GP practices to support CGA of patients in their care. Following assessment, the teams are able to access care provision in their community. This includes: Reablement domiciliary care that is provided for a maximum of 6 weeks following a period of acute ill health or injury which aims to return the individual to their previous level of independence Residential Reablement (Convalescence) 20 beds are available in two Local Authority residential care homes: Llys y Bryn in Llanelli and Maes Llewelyn in Newcastle Emlyn Long Term Domiciliary Care Long Term Residential & Nursing Care Extra Care Housing 7

8 Figure 2 Access to Services in Carmarthenshire The Community Resource Teams in each area are accessed via a single point of access known as Careline. This is a 24/7 service and is the only one of its kind in Wales. It is also the only contact centre that provides a service bilingually. Careline also hosts the Telecare call centre for Carmarthenshire and neighbouring authorities. Recent Developments Community services that support our core aims have been further enhanced over the last eighteen months through the Welsh Government Intermediate Care Fund (ICF). ICF has allowed us to strengthen services across the three tiers of care provision. Tier One Our current model of care in Wales is, in the main, reactive based upon provision of support when problems arise and this can lead to the creation of dependency. We recognise the need to continue to provide reactive services where appropriate but also the need to shift our focus more toward facilitating community based service development and signposting to alternatives which promote health and wellbeing, prevent or limit deterioration and support recovery following a period of crisis. Community Resilience is about communities using local resources and knowledge to help themselves. The Social Services and Wellbeing (Wales) Act acknowledges and makes explicit that investment is required in this way of working to ensure improved service availability and outcomes for individuals, communities and organisations. Moreover, the Act imposes a duty on public sector organisations to provide the public with robust access to Information, Advice and Assistance (IAA) regarding community and commissioned health and social care services. As such, Carmarthenshire has, in partnership with colleagues in Public Health, 8

9 developed a Framework for Action to progress and implement community resilience strategy in the County. To support, this model, Carmarthenshire recently secured the appointment of Community Resilience Coordinators for each Cluster area. The aim of these posts is to map health and social care needs of the Cluster population and available services in the community and voluntary sector to meet low level needs and promote / sustain wellbeing of the community. These post holders also identify gaps in service provision and work in partnership with grant funding organisations and Carmarthenshire Association of Voluntary Services to broker resources to meet this gap. A programme of redesign is currently progressing to transition our current single point of access (Careline) into a robust IAA service that will provide a gateway to commissioned health and social care provision and will host a directory of services outlining local community groups, support networks etc. Careline will also be a pathfinder site for the national 111 initiative and will go live in October Tiers Two and Three Transfer of Care Advice & Liaison Service (TOCALS) - Dedicated Multidisciplinary teams (MDT) are based at both acute hospital sites and support the rapid assessment, care & discharge planning for people who are at increased risk of long term reduced level of function as a result of a hospital admission. This initiative reflects prudent health care principles of do no harm. Rapid Response Domiciliary Care 24 wte Rapid Response staff in post, two staff on duty throughout the day in each of the three localities between 7am and 10pm working to ensure that frail adults who are functionally compromised following acute episodes of illness or trauma are able to recover at home. The Rapid Response service also supports admission avoidance where appropriate at the front door of the hospitals. Cartref Cynnes - Enabling the lease of 2 apartments within the Cartref Cynnes Extra Care Facility in Johnstown, Carmarthen. This increases the range and number of intermediate care beds available that provide a residential reablement service to the people of Carmarthenshire. The beds allow frail older adults to enhance functional capacity which has been compromised through acute episodes of illness or following trauma and support either admission prevention or timely discharge from hospital. This will be operational from March Step Down Residential and Nursing Assessment Beds Commissioned to support reduced delayed transfers of care for frail adults whose complex needs require ongoing care and support assessment and who do not require acute intervention. Integrated Health and Social Care Worker This initiative embraces prudent healthcare principles of only do what only you can do and provides the opportunity to challenge models of care delivery and tests the transferability of skills that have traditionally been provided by health care workers to social care workers. This has been successfully piloted in Llys y Bryn, Llanelli and an early evaluation is available. This initiative has been 9

10 identified as a Bevan Exemplar and as such shared across Wales as best practice. ICF is a recurring source of revenue to support vulnerable adult population. Administrating this fund and ensuring that it is used to meet population and organisational objectives is overseen by the County s Health and Social Care Board. This Board is jointly chaired by the County Director and Commissioner, Hywel Dda University Health Board, and the Director of Community Services (including Social Care), Carmarthenshire County Council and reports to the Regional Integrated Services Performance Board. 3.1 Community Nursing Services The Community Nursing Service is an integrated team of registered nurses and health care support workers (HCSW). For ease of reference, the teams within the service have specific functions to support the diverse needs of the population on a 24/7 basis to provide care within clients homes to reduce the risk of admission as well as facilitating early discharge. The teams comprise core community nursing, Acute Response Team, Chronic Disease Management Nurses, Continuing Care Team, and all work within one whole professional structure Community Nursing The core community nursing services operates 7 days a week 8am to 6pm. This service provides a broad range of nursing expertise within the home environment, private or local authority residential accommodation, health centres/clinic/hospital. The registered specialist practitioner (the District Nurse) holds the specialist practitioner qualification (SPQ), is the team leader for each team and is accountable for maintaining a high standard of registered nursing care, supporting patients and their families/carers. The service responds to both reactive and proactive health care needs. Community Nurses work in partnership with other community services to provide evidence based nursing care to meet identified needs. The community nursing teams within the County of Carmarthenshire are geographically located within localities. There are a total staffing of wte. During a typical month e.g. November 2015, there were 399 admission avoidances, 475 facilitated discharges, 4,585 clients on the caseload and 17,301 face to face contacts. Within the service, 6 wte additional appointments have been made for registered nurses to strengthen the service and to target specific areas of growth such as continence and tissue viability. The new nurses with a special interest in tissue viability will lead in the development of community leg ulcer clinics. The nurses with a special interest in continence will lead in the development of continence promotion and potentially reduce admission to hospital as a result of urinary tract infections. Both areas of expertise will have an educational element in their roles. A further 3 new senior health care support workers will be appointed to address the skill mix of the service to release the more senior registered nurses to undertake more complex assessments and interventions. This is an innovative workforce development. We are currently operating a single point of access for community nursing in the Llanelli locality which is proving successful and we are exploring opportunities for the other localities. 10

11 There is a Welsh Community Care Information Solutions (WCCIS) development underway across Wales. This IT technology is currently being promoted throughout Wales as a system to promote mobile working and more effective care. It provides the ability for IT to link with other systems, thereby ensuring that nurses have access to appropriate clinical, nursing and social care information Acute Response Team (ART) The Acute Response Team provides a 24/7 acute nursing service in the community. It provides acute nursing interventions to patients within the community who, without the service, would require inpatient treatment in a hospital bed. Interventions include intravenous antibiotics, re-hydration therapies, blood and platelet transfusions and rapid out of hour access to nursing support for palliative and terminally ill patients. The teams are based in each acute hospital to ensure effective and timely facilitated discharges or to support admission avoidances and work closely to bridge the gap between community and acute sector. There are a total staffing of wte. During a typical month e.g. January 2016, there were 1,005 interventions performed, 227 admission avoidances and 12 facilitated discharges Continuing Care Team (CCT) The CCT is a skilled team of senior HCSW offering a range of skilled interventions to patients in their own home who are eligible for Continuing NHS Healthcare (CHC) funding for their provision of care. The CCT provides a highly responsive service to patients at the end of their lives, patients who are entering terminal phase, and patients with long term chronic conditions. There are a total of 29.8 wte within the team who work in partnership with the Marie Curie Nursing Service to provide this service over the 7 day a week period. During a typical month e.g. January 2016, 12 long term clients and 18 end of life clients were supported (3.2 wte new staff in training). Additional investment from Welsh Government Together for Health Delivery Plans for Palliative Care has provided additional hours to support Hospice at Home. 3.2 Community Hospitals In Carmarthenshire there are two community hospitals, one in the Amman Valley and the second in Llandovery. The community hospital is intended for those patients who need medical, nursing, palliative/end of life care and/or therapeutic interventions over and above the level that can be provided within their own homes. This service is intended to support the effective patient flow from the acute hospitals once the patient s condition has stabilised but requires ongoing rehabilitation, therapy, nursing and medical care prior to discharge. This unit will also ensure timely and effective discharge planning for complex cases. The community hospitals also provide a step up facility directly from the community to avoid admission into the acute hospitals from the community Amman Valley Hospital This is a 28-bedded unit. There are 14 GP beds and 14 Consultant led beds. During a typical month e.g. January 2016, bed occupancy was 87%. During the period 1 st April th September 2015, the average length of stay was days. 11

12 Regular multidisciplinary team meetings ensure continuity of care and a focus on the management plans to support discharges Llandovery Community Hospital Llandovery Hospital is a 16 bedded unit. There are 8 GP beds and 8 consultant led beds. During a typical month e.g. January 2016, the average length of stay was 38 days and an 84% bed occupancy. Regular multidisciplinary team meetings ensure continuity of care and a focus on the management plans to support discharges. In addition the hospital has a Minor Injuries Unit which is open between the hours of 9am 5pm Monday to Friday. The X-Ray department has recently been refurbished and is effectively utilised to ensure patients do not need to be transported in excess of 25 miles to access this diagnostic support. There is capacity for this service to be further utilised as an outpatient service. 3.3 Chronic Disease Management (CDM) Team The aim of the CDM Team is to ensure patients receive high quality, evidence based specialist nursing care in the community setting. It is also to improve the management and care of patients with chronic conditions across primary and secondary care, working in partnership with the patient, carers and multi-professional teams including the voluntary sector. The team deliver education, support and high quality care to patients with chronic conditions in a variety of settings and work with carers and other health professionals to maintain a seamless approach to chronic conditions management. The CDM Team comprise 9 wte registered nurses. These staff integrate with GP practices and secondary health care professionals to provide a seamless service for those patients with a diagnosis of Diabetes, COPD and Heart Failure living within the Carmarthenshire area and registered with a GP practice in Carmarthenshire. This service is provided from 9am to 5pm Monday to Friday 3.4 Palliative Care Service Ty Bryngwyn This is a consultant led 6 bedded inpatient specialist palliative care unit based on the Prince Philip Hospital site in Llanelli This is a short term unit to support patients with complex and un-resolving symptoms either physical or psychological with the intention of supporting these patients to return to their homes or within the community. This service is well utilised with admissions from both the acute and community settings. A proposal is being developed for a 7 th bed to be funded by Ty Bryngwyn Hospice Committee to meet the needs of the younger adult. 12

13 3.4.2 Clinical Nurse Specialist (CNS) Palliative Care Specialist Palliative Care Services are provided for patients and their families with moderate to high complexity of palliative care need. This can be defined as anyone with a diagnosis of a serious life limiting disease and is not limited to cancer. Referral criteria to the team is that the patient has uncontrolled and un-resolving symptoms either physical or psychological. In addition, the team acts as a support and resource for anyone seeking information or help related to palliative care. The service is delivered by a team of 4 wte nurses with demonstrable expert skills, knowledge and education in Palliative Care. This Team participates in the Health Board wide 7 day working CNS service. Through direct and indirect interventions the CNS team will deliver and promote a holistic, supportive, caring and professional service. It is delivered anywhere within the primary or secondary setting to meet identified need and operates 09.00hrs hrs 7 days a week including bank holidays. The team works with the other health and social care professionals, especially the primary care providers such as the GP and District Nurse. Each nursing home in Carmarthenshire has a named CNS who they can contact for advice, support and to access education. Currently the service is providing education and training on the new Care Decisions for the Last Days of Life which will replace the Integrated Care Priorities for End of Life. In essence the team strives to constantly evaluate and improve the service. This is undertaken by developing and participating in initiatives such as the All Wales I Want Great Care questionnaire and local audit. The outcomes of these initiatives demonstrate that the service is valued and effective. Through Welsh Government One Wales funding, investment was secured to employ dementia nurses which was commissioned through our Marie Curie partners. The purpose of this investment was to increase access for patients with dementia to specialist palliative care. This has been successful as recent reports confirm that there is an increasing referral from patients with dementia to specialist palliative care Bereavement Service This service provides psychological support to bereaved individuals who have unresolved and ongoing symptoms following bereavement. This service operates 5 days a week. A new Anticipatory Grief Service has been developed. This service is available throughout Carmarthenshire to provide support to both adults and children who need support when someone close to them is approaching death. It is jointly funded with the 2 local Hospice Committees and a recent evaluation has identified the demand for the service has come from children Palliative Day Care This is a service which operates at Ty Cymorth on the Glangwili General Hospital site and Ty Bryngwyn on the Prince Philip Hospital site to support patients who have life limited conditions and require support. The service is currently under review with the intention being to move from a day care model to that of a support and therapeutic intervention service. 13

14 3.5 Carmarthenshire Integrated Community Equipment Services (CICES) The Carmarthenshire Integrated Community Equipment Service partnership (CICES) was established in 2009 as a partnership between Carmarthenshire County Council and Hywel Dda University Health Board, and a Section 33 agreement was set up between the two partners in The partnership is funded by a pooled budget with the split being CCC - (32%), HDdUHB - (68%) The service delivers community equipment into clients own homes within the county of Carmarthenshire. The range of equipment is used to keep clients safe in their own homes, to facilitate discharge from hospital or keep a person in their own home for longer, in order to avoid a residential care setting admission where possible. Table 1 below outlines the total number of clients receiving equipment in the community which has increased exponentially year on year. 3.6 Capital Schemes Within community services, the two key capital schemes related to developing Primary and Community Resource Centres. In Carmarthen, the plan was to replace Pond Street Clinic and a local GP Practice. The accommodation at Pond Street is in a very poor state of repair and there is an urgent plan to identify alternative accommodation for the Sexual Health Clinic, Community Dental Clinic and Podiatry as the plan for a Community Resource Centre in Carmarthen has not been included within the IMTP. Within the Gwendraeth, the scheme proposes the development of a Primary and Community Resource Centre at Cross Hands to replace the current Cross Hands Health Centre and 2 local GP Practices. Business cases have been developed for both schemes. The Cross Hands development is included within the IMTP. Confirmation of funding is still to be secured. These Resource Centres will be integrated health and social care providing medical, nursing, diagnostic and therapy services. 4.0 Carmarthenshire Mental Health Services Update 4.1 Transforming Mental Health Programme The Mental Health Programme Group (MHPG) held a number of engagement events in Carmarthenshire between October 2015 and January 2016 to advance the 14

15 Transforming Mental Health Programme, a programme which aims to remodel mental health services across Hywel Dda University Health Board. The engagement events have been a platform to positively work with staff, service users, carers and stakeholders in order to help inform and co-produce a new service model for future mental health care. 4.2 The Local Primary Mental Health Support Service (LPMHSS) The LPMHSS service has begun to explore the amalgamation with the Child and Adolescent Mental Health Primary Care Service that will create a seamless, ageless approach and increase capacity. The additional funding allocated for Psychological Therapy will provide additional posts for the existing mental health primary care team. The funding is also enabling additional training for staff in Acceptance and Commitment Therapy and Solution Focussed Therapy over the next three months. This is in addition to the Post Graduate Certificate and Diploma in Cognitive Behavioural Therapy (CBT) that many practitioners are undertaking to improve access to and capacity to deliver CBT. The service will be delivering an increasing range of psychological therapies in the primary care mental health service, providing the patient referred from General Practice with a wider menu of options to choose from. 4.3 Community Mental Health Team Extended hours working within the Carmarthen Community Mental Health Teams (CMHTs) are being progressed to better support people to receive their care and treatment within community settings. The extended hours pilots will be closely monitored and reviewed to evaluate the impact to patients and families, and the wider acute and in-patient services. 4.4 Community S- CAMHS & Psychological Service Development Following the recent welcome announcement from Welsh Government in 2015 in respect of a recurrent 1.9 million revenue investment to develop new services the MHLD Directorate has approved the acquirement of a community property in Carmarthen for a long term lease in order to develop some of these key services within a local community setting. The recurrent funding has been approved for the following areas and will impact positively across the Health Board in these key areas: - Perinatal Mental Health Services - Psychiatric Liaison - Adult and CAMHS Psychological Services - Early Intervention Psychosis - SCAMHS Primary Care - S-CAMHS Crisis Assessment and Treatment Team - Neuro-developmental Services( joint development with Child Health ) - Dementia Support Workers - Occupational Therapy for Older Adults In order to facilitate the development of the services supported by this investment the current available estate across the Health Board has been reviewed and in particular the use of premises on the Glangwili General hospital site and therefore a proposal 15

16 has been supported to relocate some services currently based within the hospital to a community venue which will promote integration, reduce stigma and normalise the support we provide for people in psychological distress. A project team has been established and this development is in line with the Transforming Mental Health Programme and will further progress the co-location of seamless services and reduce artificial barriers for accessing services for people of any age as outlined in the Integrated Medium Term Plan (IMTP) to develop sustainable Specialist Child and Adolescent Mental Health Services. 4.5 Bryngolau Ward Refurbishment (Prince Philip Hospital) The capital programme of works for Bryngolau ward was approved in 2015 and a major refurbishment commenced on the 5 th October 2015 with the work completing on the 14th February The main focus of the work was to replace flooring throughout the ward and adaptations to key rooms and facilities. Opportunities were taken to develop a dementia friendly environment during this programme of work, including appropriate signage and colour zone areas on the ward to enable patients to identify specific areas. Comments and suggestions were taken from patients and relatives and incorporated into the works programme. The changes to the environment have also provided the ward team with better access to IT and workstations making more efficient clinical recording. During the refurbishment the service has also been able to source new furniture and dementia friendly wall art which has enhanced the environment. 4.6 Unscheduled care and Junior Doctor rota The recruitment of additional staff is underway to increase the Crisis Resolution Home Treatment team staffing establishment to enable commencement of Mental Health Unscheduled Care across Carmarthenshire. The service has experienced ongoing challenges in supporting its current two medical rotas in Carmarthenshire, therefore a project group led by the Medical Staff Committee has reviewed current activity and clinical practice and supported a move to the introduction of an Unscheduled Care service in Carmarthenshire supported by a single medical rota across both General Hospital sites. A reduced frequency of on-call for our most inexperienced medical staff allows for them to be embedded in the working patterns of a 24/7 Psychiatric team presence in our Hospitals. This enhances the quality and consistency of our services whilst also promoting the training experience that is so vital in producing our next generation of senior Doctors. As part of this system redesign the service is progressing a Tele-Medicine pilot project in psychiatry and are analysing the results of a proof-of-concept trial run on the 18 th February Initial reports are very encouraging and we can already foresee that Tele-Psychiatry assessments are likely to become a useful tool in delivering safe and timely unscheduled mental health care across hospital sites. A protocol/procedure will be developed before full implementation to ensure a robust structure is in place. 5.0 Acute Services in Carmarthen There are two acute hospitals serving Carmarthenshire, Prince Philip Hospital in Llanelli and Glangwili General Hospital in Carmarthen which are 26 miles apart. 16

17 Tertiary services, for example complex cardiology, renal and neurology, are provided under Service Level Agreement (SLA) from ABMU. A typical year at Prince Philip Hospital Over 35,000 people attend A&E Over 4,000 people are admitted to a medical ward PPH Over 70,000 people are seen in outpatients Over 12,000 people receive an operation Prince Philip Hospital is a 210 bedded hospital providing acute medical, ITU, elective surgery, complex rehabilitation and a range of diagnostics and outpatient services. Elective surgery includes day surgery, general surgery, orthopaedics, breast surgery, urology and ENT. Within elective surgery Prince Philip Hospital provides a regional HDdUHB service for breast, lower limb and shoulder surgery. Prince Philip Hospital runs the Rapid Access Lung Clinic Carmarthenshire and the Health Board wide interventional bronchoscopy service. The new Prince Philip Hospital front of house service is due to commence on 6th April This has been clinically led and designed to streamline emergency care by separating minor injuries and acute medical illness into different areas. Patients arriving by ambulance or referred by their GP will be seen in the redesigned acute medical assessment unit. Walk in patients will arrive at the front door and will be triaged and treated by an Extended Nurse Practitioner (ENP) or GP. A typical year at Glangwili Hospital 17

18 Nearly 40,000 people attend A&E Over 5,000 people are admitted to a medical ward GGH Over 100,000 people are seen in outpatients Over 20,000 people receive an operation Glangwili General Hospital is a 392 bedded hospital comprising of emergency and general surgery, paediatrics, maternity services, ITU, ENT, ophthalmology, urology, general medicine, trauma and orthopaedics. It provides a regional HDdUHB service for emergency Gastro Intestinal (GI) bleeds, pacemaker insertion, Transesophageal Echocardiogram (TOE) and Dobutamine Stress Echocardiogram (DSE), thoracoscopy, ENT, ophthalmic emergencies, urological emergencies and consultant led maternity services. An additional 18 beds have been opened at Glangwili General Hospital on 12 th December 2015 which have been essential in managing Winter pressures and activity for Carmarthenshire. Temporary staff have been utilised to support the opening of these beds whilst substantive recruitment continues. Respiratory services are provided from Glangwili and Prince Philip Hospitals which also provide cover to Withybush General Hospital and as part of the respiratory plan this will include Bronglais General Hospital. Full diagnostic services are provided on both hospital sites with Glangwili General Hospital due to commence an Out of Hours MRI emergency cover this spring. Meetings have commenced with clinical leads and estates to review the Glangwili General Hospital site due to the age of the buildings built in 1949 and also due to the increased demand for emergency and routine medical, surgical and diagnostic services. The key areas for review are; Outpatient capacity Radiology footprint Pathology footprint Pharmacy footprint Surgical wards and day surgery Cardiology Catheter Lab 18

19 Office accommodation for increased clinical staff Phase 2 Womens and Children services Within the Prince Phillip Hospital estate the following areas have been highlighted for further development: Day surgical facilities Endoscopy unit to JAG standards The developments of specialist gastroenterology and cardiology wards this has been put in place temporarily due to the boundary changes and has facilitated the throughput of medicine through the Winter months as well as maintaining surgical output over the Winter period. Pre-assessment facilities Location for the discharge lounge Storage facilities in main theatre Office accommodation for increased clinical staff Both Glangwili and Prince Philip Hospitals have supported the boundary changes from Withybush General Hospital where there has been a need to reduce medical beds due to the shortage of medical staff. Glangwili General Hospital has increased the boundary to include Tenby, Saundersfoot, Kilgetty and Narbeth. Consequently Prince Philip Hospital has increased their boundaries to take form Glangwili General Hospital area which includes Ammanford and Gwendraeth Valley. 19 surgical beds were changed to medical and supported by additional medical staff to maintain flow and clinical quality of care. These are still in place and were due to change back in January 2016 however the medical staffing position has not improved sufficiently to enable the boundary position to revert back. The middle grade numbers in medicine at Glangwili General Hospital creates an ongoing risk to the provision of acute medical services on this site with a number of areas of focus in place to address this Recruitment is an ongoing area of focus as there is the need to recruit to nurse vacancies across both hospitals and reduce the need for bank and agency staff. January 2016 saw a recruitment campaign to the Philippines where staff have been recruited and currently going through the on-boarding process. There is a strong Consultant medical workforce and business plans have been developed to have a 2 nd Gastroenterology Consultant at Prince Philip Hospital. At Glangwili General Hospital the proposals are to increase A&E Middle Grades to proved 24/7 cover and an acute physician model for CDU. A 1:12 medical middle grade rota has been devised to enhance the senior medical cover at both hospital sites and reduce the reliance on locum staff. These are to be included for Board approval as part of the IMTP and budget setting. Currently in Glangwili Hospital the 1:12 rota is being operated by 8 doctors with a heavy reliance on locums. These were presented at the Business Planning and Performance Assurance Committee 23 rd February 2016 and will now be discussed at Board. 19