CONTENTS

IntroductionPage 4

Part A

Examples of joint work being undertaken

across health and social care in Wales:

Abertawe Bro Morgannwg University Health Board (ABMU HB)

and Bridgend County Borough Council (BCBC)

  • Social ServicesPage 5

Abertawe Bro Morgannwg University HB (Bridgend,

West Vale of Glamorgan, Neath Port Talbot [NPT],

Swansea and Ystradgynlais)

  • Mental HealthPage 8

Aneurin Bevan Health BoardPage 11

Betsi Cadwaladr UniversityHealth Board

  • Integrated Health & Social Care teamsPage 13
  • Adult Mental HealthPage 14
  • Integrated Health & Social Care ServicePage 15
  • Intermediate CarePage 16
  • Development of Integrated Locality Working in

Health& Social CarePage 18

Betsi Cadwaladr UniversityHealth Board and Wrexham CBC

  • Adult Mental HealthPage 19

Blaenau Gwent Locality Office Aneurun Befan Health Board

  • POVA/Contract Monitoring – Independent Sector Care HomesPage 20
  • Adult Vulnerable Group Services UnitPage 21

Caerphilly County Borough Council

  • Social ServicesPage 24

Cardiff & Vale University Health Board

  • Primary, Community and Intermediate Care DivisionPage 26

Carmarthenshire County Council

  • Social Care, Health and HousingPage 27

Ceredigion County Council

  • Health, Social Care and Wellbeing ServicesPage 29

City and County of SwanseaPage 35

Denbighshire Social Services

  • Hafan Lles co-located multi disciplinary teamPage 36
  • Social Services & Housing, Children and Family ServicesPage 38

Gwynedd County Council

  • Adult Social ServicesPage 40
  • SpecialistChildren’s ServicesPage 41

Isle of Anglesey Community Mental Health Service (CMHT)Page 42

Isle of Anglesey Betsi Cadwalader University Health BoardPage 43

Isle of Anglesey County Council

  • Complementary Purchasing Scheme for Health & Social CarePage 45
  • Tele-health ServicesPage 46
  • 24 hour Health & Social CarePage 48
  • Intermediate CarePage 50
  • Joint Community Equipment ServicePage 51
  • Learning Disability ServicePage 52

Pembrokeshire Health, Social Care & Well being Partnership

  • Health, Social Care and well-beingPage 53

Powys Teaching Health Board and Powys County Council

  • New Model of Integrated Health & Social Care

Rhondda Cynon Taff County Borough Council

  • Reablement ServicePage 56
  • LearningDisabilityPage 57
  • Intergrated Community Equipment ServicePage 58

WCBC Adult Social Care,Betsi CadwaladrUniversity Health Board,

Supporting People, Housing Associations and Hafal

  • Registered Recovery Service for Adult Mental HealthPage 59

PART B

Benefits and barriers to integrationPage 60

INTRODUCTION

Detailed below are examples of jointwork being undertaken across health and social care in Wales. These examples were submitted by local health boards and local authorities following a request by the Care Council for Wales and NLIAH in the summer of 2010.Whilst by no means an exhaustive set of examples, the projects and services described provide a helpful picture of the current range of practice in Wales.

Section A contains brief summaries of specific projects and services. Section Bis a collated list of the benefits of and barriers to this integration identified and what organisations perceive would be helpful at a national level to facilitate this work in the future.

PART A

Organisation: / Abertawe Bro Morgannwg University Health Board (ABMU HB) and Bridgend County Borough Council (BCBC)
Service Speciality: / Social Services
Details of joint working between health and social care

Posts:

Joint Locality Director for Health and Adult Social Care (Well-being Directorate),

employed by ABMU HB and BCBC leading a programme to integrate services for older people and those with a physical or sensory impairment

Joint Integrated Services Manager post, employed by ABMU HB and BCBC (with

adult social care)

Joint Substance Misuse Development Managerpost across ABMU HB and BCBC Well-being Directorate – substance misuse lead officer post for both organisations and the Community Safety Partnership

Joint Health, Social Care and Well-being Coordinator, employed by BCBC Wellbeing Directorate in partnership with Locality Office

Joint Intermediate Care Development Manager post, employed by BCBC Wellbeing Directorate in partnership with Locality Office

Partnership Falls Service Coordinator appointed to build upon the Never Too Old Action Team’s review of existing services to support independence at home/out of hospital prevention, the Community Integrated Intermediate Care service, link into the work currently being undertaken by ABMU Musculoskeletal and Arthritis Service Development Steering Group on in hospital falls and the 1000 lives + collaborative developments. Hosted by Care and Repair. Integration across Health, Social Care and Third Sector.

ABMU HB Locality Medicines Management Nurse working across Health and Social Care to support Domiciliary Care Homes with Meds Mgt and service improvement.

Teams/Services:

Joint Community Drug and Alcohol Team comprising of ABMU HB nursing, and psychology and BCBC social work staff. This team is managed by a joint service manager who is an ABMUHB employee as well as having reporting links into adult social care in BCBC

Similarly joint Community Mental Health Teams for Adults and separate teams for Older People. Comprise ABMU HB Nursing, OT, psychology and support staff and BCBC social work staff. Teams are managed by integrated health and social care managers (please refer to response from Mental Health Directorate).

Integrated Adult Mental Health Daytime Opportunities Services (ARC – Assisting Recovery in the Community) governed through a Section 33 Agreement. ABMU HB Mental Health and BCBC Well-being Directorate Adult Social Care staff integrated into a single team, joint management, integrated care files, single point of access. (please refer to response from Mental Health Directorate).

Joint Adult Learning Disability Community Support Team assessment and care management, across ABMU HB (LD Directorate) and BCBC Well-being Directorate, Adult Social Care (please refer to response from LD Directorate).

Joint/integrated Children with Disabilities Team (CwD). Nursing, Therapy and Social Worker team (ABMU HB and BCBC Children’s Directorate). Integrated base, single point of access, integrated files.

Community Integrated Intermediate Care Service (CIIS) between ABMU HB and BCBC Well-being Directorate, Adult Social Care. Nursing, Therapy, Social Workers, Technicians and Support Staff, integrated administration and case files, integrated management, single point of access. Encompasses, Reablement, Early Response Service, Disability Rehabilitation, Telecare, 24/7 Mobile Response Service and Bridgestart Homecare service.

Telecare and Mobile Response Service–a partnership between ABMU HB Bridgend Locality, BCBC Well-being Directorate, Adult Social Care, and the Third Sector Organization Care and Repair. Integrated assessment for Telecare, installation and support, 24/7 mobile response service. Scoping work to develop service further to encompass community falls work; (part of CIIS service listed above).

Integrated Community Equipment Service (ICES), governed through a Section 33 Agreement. Health and Social Care short/long term loan equipment service, plans to include all health beds within the contract too. Linked to this service is an ongoing initiative to rotate health and social care OT staff between the two organizations.

In development - multi agency substance misuse service base for health, social care, third and private sector staff in Maesteg, due to open 2011

Emerging project ‘Connecting Families’ an Local Service Board (LSB) led initiative across Health, regeneration, community Safety, Children’s Services and Adult Social Care – targeted multi-agency multi-professional response to support ‘problem’ families

What was key to success?
  1. Time to enable teams to integrate and evolve
  2. Clear line management arrangements for teams, commitment on the part of service managers to making the joint team work, shared work processes e.g. assessment and allocation, an appreciation within both organisations of the importance of the other
  3. Clear line management arrangements for joint posts, regular communication between managers, clear goals and work programme
  4. Shared vision and development of new service models and an awareness and commitment of the importance of multi-agency working, regular communication between team members and between organisations
  5. Service managers co-ordinating access to resources and smooth operation of joint buildings
  6. Developing and adopting service protocols for services which may have been developed from the “best of both” from the partner organisations
  7. Respecting each other professions
  8. Involving all staff at all levels and continuously engaging with service users along the pathway to integrated team / service development
  9. Effective communication throughout the whole process – even when there was nothing new to say to teams just keep them informed of progress
  10. Staff as well as the organisation could see and identify the need for working differently
  11. Commitment and sign up at the highest level of each organisation and strong leadership
  12. Recognition of the importance of personal relationships to assist in removing barriers and providing clear messages about the value of working together to resolve common problems and issues
  13. Not to underestimate the impact of organisational change where common objectives need to be reaffirmed and new relationships established
  14. Ensuring that the capacity is available to both manage the planning process and to deliver change
  15. The importance in setting aside sufficient time to establish the value base, key objectives and timescales for delivery in relation to work programmes and projects
  16. Recognising the cultural issues that may exist
  17. Learning from frontline staff who will often informally find solution to barriers that prevent the effective joint delivery of services
  18. Constantly appraise progress and to be open to challenge to ensure any barriers to progress are identified and solutions found

Organisation: / Abertawe Bro Morgannwg University HB (Bridgend, West Vale of Glamorgan, Neath Port Talbot [NPT], Swansea and Ystradgynlais)
Service Speciality: / Mental Health
Details of joint working between health and social care

1)Integrated working across community mental health services (adult, older people, substance misuse and forensic services) across all localities to ensure seamless service. Includes:

  1. Integrated Community Mental Health Team (CMHT) Managers responsible for both health and social care staff
  2. Health and social care staff working alongside each other often sharing same base
  3. Joint operational policies
  4. Multi disciplinary team referral meetings
  5. Joint IT system (PARIS) in place in Swansea
  6. Joint arrangements around Care Programme Approach (CPA) and other processes
  7. Service Manager for ABM Substance Misuse service manages staff from health and social care

2)Multi-agency Locality Joint Mental Health Planning Groups (Bridgend, NPT and Swansea localities) for adult, older people and substance misuse services, including various sub groups such as Accommodation, Mental Health Promotion etc. to agree priorities around mental health services

3)ARC Day Service in Bridgend [section 33 agreement]

4)Health Board Occupational Therapists working in Local Authority managed Llanfair rehabilitation unit in Swansea [Joint working grant] to facilitate rehabilitation from inpatient specialist rehabilitation units back to the community

5)Accommodation Development Manager (joint health and social care funded) post in Swansea

6)‘Improving Futures’ Delivery Groups (Bridgend, NPT and Swansea)

7)‘Siaradwn Ni’ / ‘Let’s Talk’ Big Lottery fund (Bridgend and NPT)

8)Multi-agency Mental Health (MH) Meetings including:

  1. MH Directorate Board
  2. MH Cabinet
  3. Healthcare Governance Committee
  4. Annual Operating Framework (AOF) Project Board
  5. Complex Case Panel
  6. Low Secure Repatriation Group
  7. Multi-agency Joint MH and Social Care MH Partnership forum (all localities) with 1st meeting arranged for 16th September
  8. Other ad hoc workstreams as required

9)Joint training delivered across ABM

10)Create Solutions partnership - joint funded initiative to develop ad support employment projects in Swansea (section 33 agreement)

11)Various groups/agreements between health and the various Local Authorities around the protection of vulnerable adults, DoLS, Mental Capacity Act, implementation of the MH Act

12)Cwmbwrla Day Centre providing day/educational services (joint funded by health and social care). Service works with Cefn Coed Hospital ward staff to facilitate early in reach to users

13)Multi-agency approach to delivering Substance Misuse services in partnership includes delivery of integrated service with Substance Misuse Service Manager responsible for health and social care staff

What was key to success?

1)Integrated working across community mental health services - The commitment of senior health/social care managers and team staff, development of joint policies, multi-disciplinary teams, joint funding of posts/services where required, work together to ensure organisational objectives of health and social care are met

2)Multi-agency Locality Joint Mental Health Planning Groups - The involvement of relevant stakeholders in equal partnership

3)ARC Day Service in Bridgend - Involving staff and users in the development of the new ARC service and ensuring the good practice in previous services was continued

4)Health Board Occupational Therapists working in Local Authority managed Llanfair rehabilitation unit in Swansea - Availability of funding, close working between senior health and social care managers

5)Accommodation Development Manager (joint health and social care funded) post in Swansea - Commitment of local partners and lead individual to drive the accommodation development process, knowledge of different funding streams (capital and revenue)

6)‘Improving Futures’ Delivery Groups - Commitment of all stakeholders

7)‘Siaradwn Ni’ / ‘Let’s Talk’ Big Lottery fund - Ensuring joint working arrangements are in place between all stakeholders. Reducing the stigma attached to mental health issues by promoting a more positive image within the community thereby lowering barriers to accessing support and promoting inclusion

8)Multi-agency MH Meetings – Shared commitment by health and social care partners to include other agencies

9)Joint training delivered across ABM – Identifying dedicated resources for training by both health and social care, appointment of joint training posts to lead this work

10)Create Solutions partnership - Pooling of budgets to develop the service

11)Various groups/agreements between health and the various Local Authorities - Commitment by health and social care to work through organisational boundaries and governance frameworks to agree joint processes

12)Cwmbwrla Day Centre providing day/educational services - Again, commitment to develop joint policies, procedures, operational policies etc.

13)Multi-agency approach to delivering Substance Misuse services in partnership – The commitment of senior health/social care managers and team staff was key as was the need for all parties to understand the role of each discipline. This facilitated the development of joint policies, establishment of multi-disciplinary teams working together to ensure organisational objectives of health and social care are met. All disciplines act as key workers with clients allocated based on need, joint working is often necessary due to the complex needs of this client group

Organisation: / Aneurin Bevan Health Board
Service Speciality:
Details of joint working between health and social care

Children’s Services Joint Working

1. Blaenau Gwent and Caerphilly – Youth Offending Service

The Blaenau Gwent and Caerphilly Youth Offending Service was developed in partnership between health, social services, police and probation with a multi-agency local management board, which provides all partner agencies with the ability to make joint decisions about the service at a local level. The team comprises multi-disciplinary staff with staff out-posted from a number of agencies. A pooled budget arrangement is in place.

2. Shift It/MEND programmes for childhood obesity

Following the implementation and successful evaluation of a multi-agency childhood obesity project in Blaenau Gwent which included nutritional support, counselling and activity for children and their families a further programme called Shift It was set up. This built on the first programme and the evidence from the Institute for Child Health at GreatOrmondStreetHospital which underpins the MEND programme currently being rolled out in England and Wales with an extended programme duration. This programme was also successful and Blaenau Gwent is now a pilot area for the MEND programme in Wales supported by the Welsh Assembly Government. These projects have only been possible through joint work across organisational boundaries and contributions of physical and staff resources. The programme is run by Dietetics staff from Aneurin Bevan Health Board, with Exercise Development Officer from the Local Authority providing the fitness and play activities. The courses are run from community settings, mostly Local Authority premises such as sports centres.

3. Delivery of a joint Sexual Strategy for Blaenau Gwent which enabled:

  • Reach Out for Sexual Health

This service was sustained through joint funding from Aneurin Bevan Health Board and Blaenau Gwent County Borough Council to provide advice, guidance and training directly to young people regarding positive relationships, sexual health and wellbeing, in addition to the provision of a condom-card scheme (providing free condoms). The service supports the delivery of Sex and Relationships Education in schools and provides training to professionals working with young people to enable the provision of consistent advice and support.

  • Sustaining the delivery of young person’s sexual health clinics
  • Implementing a free emergency hormonal contraceptive (EHC) scheme through pharmacies.

Whilst the EHC and sexual health clinic services were Health Board funded, they contribute to the full map of services for young people along with the Reach Out For Sexual Health Service and were supported by the multi-agency Sexual Health Strategic Planning Group.

4. Flying Start

Although funded from Welsh Assembly grant funding devolved via Local Authorities, this project involves multi-disciplinary teams, including Health Visitors, early years staff, parenting and basic skills facilitators working in partnership to improve outcomes for children 0-3 in designated Flying Start areas. A joint working group developed the Service Specification and contractual documentation to enable the Health Team to be developed and to review its impact on outcomes, for children.