· Contact Cardiff Health Alliance: Telephone: 029 2087 3870 Fax: 029 2087 3851 Address: Cardiff Health Alliance, Room 337, County Hall, Atlantic Wharf, Cardiff. CF10 4UW Website:

Working Towards a Healthy CityWorking Towards a Healthy City

Cardiff Health, Social Care andCardiff Health, Social Care andWell Being StrategyWell Being Strategy 2008-20112008-2011

Working Towards a Healthy City

Cardiff Health, Social Care and Well Being Strategy 2008-2011

Contact Cardiff Health Alliance:

Telephone: 029 2087 3870 Fax: 029 2087 3851 Address: Cardiff Health Alliance, Room 337,

County Hall, Atlantic Wharf, Cardiff. CF10 4UW

Website: www.cardiffhealthalliance.orgEmail: [email protected]

This Strategy and Summary documents are also available on the following web sites:

Cardiff Health Alliance Cardiff Council

www.cardiffhealthalliance.orgwww.cardiff.gov.uk

Cardiff Local Health Board www.cardifflhb.wales.nhs.ukVoluntary Action Cardiff www.vacardiff.org.uk

Foreword

Foreword

Cardiff has developed as an ambitious and vibrantCapital City of Wales and now faces an excitingnew agenda of partnership working. The LocalService Board is committed to achieving a highquality of life for local residents and communitiesand recognises that health and well being arefundamental elements of this aspiration.

‘Cardiff – working towards a healthy city’ is thesecond Health, Social Care and Well Being Strategyfor Cardiff and outlines the plans to bring healthimprovement to citizens and reduce healthinequalities in the city. As with its predecessor‘Meeting the Challenge’, it is very much apartnership approach to improving the health ofthe local population.

Cardiff Council and Cardiff Local Health Board(LHB) are continually working to develop betterhealth, social care and well being for residents byproviding the right treatment at the right time inthe right place and this vital work has continuedduring 2007-2008 with the development of thesecond Health, Social Care and Well Being Strategyfor 2008-2011. This three year plan describes thestrategic vision and direction for the Council andLHB and builds on the real progress already made.It aims to ensure that residents of Cardiff are ableto enjoy a healthy, active and long life, withprompt access to appropriate health and socialcare services when needed, by:

� keeping people fit and healthy by promotingfactors that can help develop and maintain ahealthy lifestyle

� tackling areas of deprivation and socialinequality

� improving access to health services to ensure

everyone in Cardiff can receive an equitablelevel of care

� helping people to live independently in theirown homes for as long as possible

� developing new services in community settings� providing continuity of care by working in

partnership with organisations� reducing admittance to hospital where feasible

by providing the most appropriate treatmentas close to home as possible

� developing and strengthening services to helpsupport vulnerable children.

The Cardiff Health Alliance provides a strongpartnership framework and the Strategy outlinesthe key challenges and priorities and how therelevant organisations, working together, plan toaddress them. The priorities have been developedusing the findings of a health needs assessmentand through the involvement of key stakeholdersincluding the Council, LHB, Cardiff and Vale NHSTrust, Voluntary Action Cardiff and the voluntarysector. It also takes into consideration prioritiesidentified by the Welsh Assembly Government.

The draft Health, Social Care and Well BeingStrategy has been subject to a 12 week publicconsultation. This provided the opportunity toengage with a wide range of professionals, serviceusers, carers and the public to discuss theproposals. Feedback has been invaluable and theStrategy has been amended to reflect consultationresponses where possible and other comments willbe considered during the lifetime of the Strategy.The consultation responses have enabled us toensure that this Strategy will meet the needs ofCardiff citizens and help the development ofCardiff as a ‘healthy city.’

1

Councillor John DixonExecutive MemberHealth, Social Care and Well BeingCardiff CouncilChairCardiff Health Alliance

Fiona PeelChairCardiff Local Health Board

Vice ChairCardiff Health Alliance

2

Contents

Contents 3

Foreword 1

Contents 3

Introduction – Health, Social Care and Well Being Strategy 4

1. Cardiff – Working towards a healthy city 5

2. ‘A Tale of Two Cities’ - The Cardiff Needs Assessment 17

3. Promoting and Improving Health 32

4. Programme for Health Service Improvement 46

5. Children and Young People 51

6. Mental Health 60

7. Older People 67

8. Physical and Sensory Impairment 76

9. Learning Disability 82

10. Carers 90

11. Sexual Health 96

12. Prison Healthcare 102

13. Substance Misuse 110

14. Homelessness 118

15. Asylum Seekers and Refugees 125

16. Gypsies and Travellers 133

17. Delivering the Vision 140Financial Planning 140Workforce Planning 154Implementation and monitoring 160

Appendices

1 Cardiff Health, Social Care & Well Being Partnership Structures 162

2 Health, Social Care and Well Being Strategy Development-Engagement and Consultation 164

Glossary 167

Policy Framework and References 173

Figures 182

Introduction - Health, Social Care and Well Being Strategy

Health, social care and well being are key factorsthat impact on the city, the community andindividuals. Cardiff is a thriving, developing cityand its aim is to become a world class quality of lifecity.

Proud Capital: The Cardiff Community Strategy2007-17 outlines the Cardiff common agenda toenhance the quality of life for local communities.The Health, Social Care and Well Being Strategy,‘Cardiff, working towards a healthy city’ providesthe vision and approach to health, social care andwell being services over the next three years.

The Strategy development has been guided by theHealth, Social Care and Well Being Strategies(Wales) (Amendment) Regulations and Guidance (2007).

Through local partnership working, the aim of theStrategy is to significantly improve the health andwell being of the citizens of Cardiff and to deliverhigh quality, citizen focused services.

The Strategy aims to interpret the developingagenda in relation to health, social care and wellbeing and focuses on the wide range of clientgroups, considering the variance in need andservices required. The Strategy cannot describe allthat will need to be achieved during the period, butdescribes the direction of travel between 2008 and2011 and beyond. Consequently, it does not setout the detail of every related service but providesthe overall vision and commitments that will helpshape the more detailed Implementation Plans,which will support the Strategy’s proposals.

City Hall, Cardiff

Introduction4

1. Cardiff - working towards a healthy city

Cardiff - working towards a healthy city 5

Crown copyright material is reproduced with the permission of the Controller of HMSO and the Queen’s Printer for Scotland

Figure 1.1 Cardiff – Geographical Areas

Cardiff has developed dramatically over the lasttwenty years, with major regeneration andeconomic development transforming the city into aconfident, ambitious capital city, committed toachieving a high quality of life for local residentsand communities. The NHSAR (National HealthService Administrative Register) represents thenumbers registered with a GP, and reports a Cardiffpopulation of 353,000 in 2006. However the ONSmid-census identifies a population of approximately317,500 in 2006. The population has increasedrapidly over the last five years and it is anticipatedthat this trend will continue.

As the Capital City of Wales, Cardiff is the regionalhub and metropolitan centre for many activitiesincluding sport, culture and tourism. It attractslarge numbers of visitors on both a regular andspecial events basis, as well as approximately72,000 commuters daily. Cardiff has a diversecommunity, with a wide range of minority ethnicresidents (over 10% of the population) comingfrom more than 100 countries around the world.

In addition, the number of migrant workers isincreasing and full-time students numberedapproximately 30,000 in 2007. The resultantdiversity makes Cardiff a city of opportunity and anexciting place in which to live, work and play.

Whilst prosperity and a thriving economy are keyfeatures of Cardiff’s success, the city experiencesserious inequalities. Cardiff is ‘a tale of two cities’,with a prosperous northern area and a ‘southernarc’, which experiences high levels of multipledeprivation. The Wales Index of MultipleDeprivation (2005) identifies that 56,000 Cardiffresidents live in those communities across Cardiffwhose multiple deprivation levels (income,employment, health, education, housing andaccess) are in the worst 10% in Wales. The mostdeprived area, within the Butetown ward, has thehighest ranking in terms of multiple deprivations inall Wales, whilst the Penylan ward includes theleast deprived area in Wales (refer to Figure 2.9).

Under the Assembly’s Plan Rationalisation,the strategic planning requirements on local authorities have been reduced and replacedwith a framework of 4 high-level strategyrequirements (see below) with effect from2008-09, consisting of:

� Community Strategy, the local overarching document with 3 prescribed strategies:

� Health, Social Care & Well Being Strategy

� Children and Young People's Plan � Local Development Plan.

The National Health Service (Wales) Act 2006 provides for a duty to be placed on each Local Health Board (LHB) and Local Authority (LA) in Wales to jointly formulate and implement a strategy for the health and well being of the local population.

The Cardiff Health, Social Care and Well Being Strategy aim is to improve the healthof the population and to reduce health inequalities in Cardiff. The Strategy outlines the partnership approach to be taken towards ensuring citizens experience a highquality of life, and are supported with appropriate, quality, health and social careservices when required.

The development of the second Health, Social Care and Well Being Strategy, has been seen as an opportunity to strengthen collaboration and integration between health, local authority and voluntary sector partners. The Strategy focuses on delivering excellent, client focused services, planned and developed by listening to and involving the wider range of stakeholders, in particular service users, carers, and the public.

Figure 1.2 Local Strategic Planning Framework

The legislative framework and the strategic policy direction introduced by National Government and the Welsh Assembly Government around health and social care is still extensive. In addition, overarching legislation such as the Human Rights Act, the Race Relations (Amendment) Act and the Disability Discrimination Act will have impact. The equality agenda is of increasing importance and brings a new understandingto the needs of individuals and the development of appropriate facilities, approaches and policies.

Recent policy relating to public bodies has been dominated by the need to develop new ways of working to achieve greater efficiency and effectiveness. The Review of Health andSocial Care in Wales (2003) and ‘Delivering Beyond Boundaries’ (2006) endorses these ideas. ‘Beyond Boundaries’ focuses on the importance of delivering citizen centred services and this approach is central to the work of the newly established Local Service Boards (LSB).

COMMUNITY STRATEGIES

HEALTH, SOCIAL CARE ANDWELLBEING STRATEGIES

CHILDREN AND YOUNG PEOPLE’S PLANS

LOCAL DEVELOPMENT PLANS

OTHER LOCAL AUTHORITY PLANS/STRATEGIES

Cardiff - working towards a healthy city6

NATIONAL STRATEGIC CONTEXT

DEVELOPING HEALTH, SOCIAL CARE AND WELL BEING STRATEGIES

Cardiff - working towards a healthy city

The Cardiff LSB and Programme for Health Service Improvement are both key developments in response to

this changing agenda and will impact on future policies and the planning and deliveryof services (see pages 14-15).

‘Meeting the Challenge’ was Cardiff‘s first Health, Social Care and Well Being Strategy published in April 2005. Welsh Assembly Government guidance required that the Strategy be developed with partners. In Cardiff the Health Alliance, as the key strategic partnership for health, social careand well being, directed this work and linked with the wide range of organisations and

stakeholders. Details of partnership structures can be found in Appendix 1.

An inclusive and robust consultation process was conducted to inform the Strategy,identifying the needs and priorities of the citizens and communities of Cardiff.

The key local priorities were agreed as:

Local Priorities Underpinning Principles

� Mental Health � Older People� Children and Young People � Communities with Specific Needs� Improving Lifestyles � Maximising the use of Health and Social

Care Resources

� The need to reduce inequalities in health � Engagement with, and empowerment of,

individuals and communities � Early intervention � Whole systems approach � Links to other services to ensure health and

well being needs are taken into account

The Strategy focused on improving healthand reducing health inequalities as an equal priority alongside effective and efficient health and social cares services. The Strategy provided the foundation for a strengthened commitment to joint workingacross the broad health agenda.

‘Meeting the Challenge’ focused on a wide range of client groups, with proposals for action being implemented through joint

planning arrangements. A summary document was published in 11 community languages and was made available on the Health Alliance’s and partners’ web sites.

Progress towards implementation of the Strategy has been detailed in the Annual Reports 2006 and 2007. Delivering long termhealth improvements takes time, but the first Strategy has been considered a success and achievements include:

2005 - 2008 � Developed the Crisis Service for patients with mental health problems, and opened the Crisis House and

the Crisis Recovery Unit as alternatives to hospital admission. � Improved supply of community beds in cost effective ways. � Reviewed palliative care services within the voluntary and public sectors. � Established the Joint Equipment Service, with partner agencies, to ensure timely access to equipment for

people receiving care in their own home. � Opened Phase 1 of the Children’s Hospital for Wales in Cardiff. � Re-procured Learning Disability Supported Living Services. � Eliminated the use of bed and breakfast establishments for the homeless. � Secured multi-agency funding for a Sexual Assault Referral Centre (SARC) and centre under

construction.� Developed an effective partnership approach to raising public awareness of ‘No Smoking Days’ and the

ban on smoking in public places. � Achieved Local Service Board pilot status in Cardiff, which included a focus on integrating health and

social care services.

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KEY ACHIEVEMENTS

‘MEETING THE CHALLENGE’ 2005-2008

The second Health, Social Care and Well Being Strategy builds on the Strategypublished in 2005. It describes the areas of planned activity for the next three years through a continued client group focus. The diversity of the city is reflected in the scope of the Strategy, which considers a broad range of service users including gypsies and

travellers, asylum seekers and homeless people. The chapters examine the strategic context, current service provision, identified needs and strategic aims for each client group. Promoting health improvement and reducing social inequalities in health are alsoconsidered by all groups.

The second Health, Social Care and Well Being Strategy is informed by both the vision and strategic direction laid out by the

Assembly Government and the Cardiff Community Strategy and is influenced by thefollowing:

THE WELSH ASSEMBLY GOVERNMENT’S VISION

‘Wales: A Better Country’ sets out the Welsh Assembly Government’s guiding vision and more recently ‘One Wales’ informs thestrategic framework and provides commitment to improve services and investin the prevention of ill health as well as treatment and care services.

This Strategy adopts the values of the Welsh Assembly Government, recognising that new ways of working across public services are needed if health improvement for all is to be achieved. Key areas of influence include:

� The Wanless ‘Review of Health and SocialCare in Wales’, (2003) provided the backdrop to the first Health, Social Care and Well Being Strategy, supplying aframework for refocusing health and social care services.

� The Beecham Review, ‘Beyond Boundaries’ (2006) called for public services to be creative in their approach, increase collaboration and required a

citizen centred focus to service delivery toensure increased effectiveness.

� ‘Designed for Life’ (2005) describes the Assembly’s ten year plan to create ‘world class’ health and social care in Wales and the partner document ‘Fulfilled Lives,Supportive Communities’ (2007) provides the vision for social care.

� Health Challenge Wales (2004) demonstrates the Assembly’s commitment to health improvement by supporting individuals to focus on their own health and for opportunities to be available to all, through a co-ordinated and informed approach.

� ‘The Community Services Framework’ (2007) describes community focused services aimed at keeping people fit and healthy; helping people to live independent lives at home; and tackling effectively and locally wherever possible, problems that may arise.

CARDIFF’S VISION

Proud Capital: The Cardiff CommunityStrategy 2007-2017 outlines the new agenda for Cardiff and is the result of wide consultation among public, private and voluntary sector organisations. The Strategy represents a common focus for Cardiff and provides the overarching framework to

support the strategic direction of the city. It sets out the overall vision and commitments of partners that will help shape other strategies and plans, building upon the principles of equality, social justice, and the health and well being of local citizens.


THE VISION FOR HEALTH, SOCIAL CARE & WELL BEING OF CARDIFF RESIDENTS

HEALTH, SOCIAL CARE AND WELL BEING STRATEGY 2008-2011


Health and well being is a key factorunderpinning the quality of life in Cardiff and a priority of the Cardiff Community Strategy 2007-2017. The social vision of the Community Strategy is: ‘To create a safe, healthy and learningcommunity which celebrates diversity and promotes genuine opportunities for all.’

Partner organisations have committed to work towards achieving health for all. Poor health has an impact upon Cardiff’s economicperformance. Census data revealed that in

2001, almost 14,500 residents wereeconomically inactive as a result of chronic illness or disability and a further 13,000 were economically inactive as a result of care responsibilities. Therefore, improved health will result in increased activity and prosperity for the individual and city alike. In addition, there is commitment to taking forward the health and well being agenda through developing Cardiff as a World HealthOrganisation (WHO) Healthy City (see page 15) and joint commissioning of a wide range of health and social care provision to meet the needs of the population.

The Community Strategy is structured around the key themes as illustrated: Figure 1.3

Cardiff Health Alliance’s vision and direction for the development of health, social care and wellbeing services is described below as:

Vision for Health, Social Care and Well Being 2011

� Improved health and well being of local people � Life chances improved by increased focus and co-ordination of preventive services � Reduced inequalities in health and social care provision � People taking responsibility for their own health and well being � Services that provide the most appropriate treatment, locally and in a timely manner � Increased independence of service users � Service user and carer focused services with informed residents involved in planning future services � Healthy Public Policy incorporated into a range of services including Planning, Economic Development,

Education, Transport, Housing, Leisure and Recreation � Joint ‘Cardiff’ approach to areas such as engagement, needs assessment and commissioning processes � Integrated services between primary/community health and social care services where appropriate,

particularly in mental health, learning disabilities and community services. This integration is to be supported by a seamless care management process and IT system providing: * Single point of contact for public services

* Unified Assessment * Sufficient, skilled and supported workforce that feels valued, involved and committed.

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What will this vision mean in reality for the citizens of Cardiff?

The Health, Social Care and Well Being Strategy 2008-11 will deliver:

� Cardiff designated as ‘Healthy City’ status, with partner organisations working together on the broad health improvement agenda.

� Cardiff Royal Infirmary site functioning as the first Locality Health Resource & Treatment Centre, providing a range of community health services locally, with other centres under development.

� Less reliance on hospitals, with delayed transfers of care no longer a key issue impacting upon hospital beds and waiting times.

� Comprehensive and expanded integrated health and social care services delivered as close to a person’s home as possible.

� Community mental health services fully operational and the current Whitchurch Hospital closed and re-provided.

� More diverse range of accommodation available for older people.

� The development of the second phase of the Children’s Hospital.

� New arrangements available for respite care for children with physical and sensory impairments.

� More effective services based on carer assessment outcomes available to support carers.

HOW THE PRIORITIES WERE AGREED

An innovative approach was initially adopted, developing the qualitative element of theNeeds Assessment in 2004. The Community Orientated Primary Care Process was utilised, based on the King’s Fund model. This enabled stakeholders to participate inmapping, assessing the needs and prioritising needs, through consensus building. This work and the agreed priorities remain highlyrelevant and provide the evidence base for the Strategy for 2008-11.

There are many ‘givens’ that have informed this Strategy. The current key policy drivers

that have been considered in the development of the Strategy, along with a host of service specific strategic plans which impact on health, social care and well being services and are detailed in the Policy Framework and References.

Recognising that over the last three years the priorities of the city, in relation to health and social care, have not changed dramatically, and there is still much to be achieved, the partners agreed that the priorities for the next Strategy will remain as those identified in the 2005-08 Strategy.

PARTNERSHIP APPROACH

The development and implementation of theHealth, Social Care and Well Being Strategy is dependent on effective partnership working.The emphasis on increased partnership working, as outlined in ‘Making the Connections’ and a greater integration of social care and primary health care in order to provide cost effective, seamless services for service users and carers is paramount to the success of this Strategy.

Further development of joint commissioning and utilisation of the established strategic health and social care framework will be instrumental in taking forward this agenda across Cardiff.

Commitment to the Health, Social Care and Well Being Strategy is demonstrated at the highest level through Chief Executives’ endorsement of the partnership agreements:


DEVELOPING THE HEALTH, SOCIAL CARE AND WELL BEINGSTRATEGY 2008 - 2011

Cardiff - working towards a healthy city 11

� Building Strong Bridges Programme (2006-2009) supports the delivery of ‘Designed for Life’ through partnership working between Health, Social Care and the voluntary sector, including activelyengaging the voluntary sector in the production of the Health, Social Care and Well Being Strategy.

Further details of Partnership Structures and Relationships diagram included in Appendix1.

In addition, there are strong linkagesbetween the Strategy and other strategic plans and key partnerships have contributed to the development of the Strategy including:

� Strategic Commissioning Group

� Advisory Planning Groups

� Health Alliance Task Groups

� Cardiff Voluntary Sector Compact Liaison Panel

� Building Strong Bridges initiative

� Local Service Board

� Children and Young Peoples Partnership

� Joint Commissioning Group for Children

� Community Safety Partnership

� Communities First

In developing the Strategy there is commitment to ensuring synergy betweenthe plans of other partners, particularly in considering strategic direction, engagement and to reflect the principles of the WHO ‘Healthy City’ approach.

� A Memorandum of Understanding agreedbetween Cardiff Local Health Board and Cardiff Council

� A ‘Procedure of Co-operation’ agreed between the Health Alliance and key partner organisations.

In Cardiff, the strategic partnership arrangements continue to be provided by the Health Alliance, on behalf of the statutory partners. The Alliance is committed to ensuring the planning structures are ‘fit for purpose’ and able to take forward the secondStrategy and support implementation.

Production of the Strategy and development of the implementation and monitoring plans have been the responsibility of the following partnerships:

� The Strategy Steering Group directs the development of the Strategy with senior representation from Cardiff Council, LHB, NPHS and Voluntary Action Cardiff.

� The Health Partnership Team, a joint ‘flexibilities’ funded team, supports the joint planning arrangements in Cardiffand the development and monitoring of the Strategy.

� The Advisory Planning Groups (APGs)provide the expertise for the development of the client specific content of the Strategy and the opportunity for service user input. The APGs are responsible for implementation of the agreed actions.

� The Health Alliance Task Groups focus on partnership working to address

NEEDS ASSESSMENT

The Cardiff Needs Assessment has been updated by the National Public HealthService, together with the Cardiff ResearchCentre. The 2007 Needs Assessment builds on the data contained in the 2004 assessment, acknowledging that the nature of the diseases/ill-health profile has remained similar in the intervening period. It provides a demographic update and specific, focused in-depth assessments.

In addition in-depth ‘vertical’ assessments have been conducted to compliment the 2004 assessment. These include:

� Butetown/Grangetown Needs Assessment

� H.M. Prison Cardiff Needs Assessment

� Population Trends and Projections for Older Persons in Cardiff 1989-2019

� A Picture of Oral Health in WalesSurvey of 5 year olds 2005-2006

� Cardiff Summary of the Wales Index of Multiple Deprivation 2005.

Summary details are contained in chapter 2 and the full assessment is available on CD Rom and on the Health Alliance web site.

lifestyle and health behaviour issues, such as smoking, physical activity and food.

ENGAGEMENT AND CONSULTATION

The importance of involving and engagingstakeholders in the development and deliveryof the Health, Social Care and Well Being Strategy is paramount. An extensive consultation was conducted over a 12 week period and a variety of approaches and media were utilised. The main focus of

consultation was the use of existing networks and fora, where it was possible to focus on specific client groups and areas of concern.Details of the approach to engagement in the development process are included inAppendix 2.

ASSESSMENTS

Public bodies have a duty to assess and consult on the impact that their proposed policies have in a range of areas. The Health Social Care and Well Being Strategy has been subject to a series of assessments.

� Strategic Environmental Assessment

The draft Health, Social Care and Well Being Strategy has been screened to establish whether an environmental assessment is required in accordance with the Environmental Assessment of Plans and Programmes (Wales) Regulations 2004. The determination of the Council, in consultation with Cadw, Countryside Council for Wales

and Environment Agency Wales, is that the Strategy does not require an environmentalassessment.

In addition the following assessments have been conducted:

� Equality Impact Assessment � Cardiff Council’s Policy Integration

Assessment� Sustainability Appraisal � Health Impact Assessment

The assessment reports can be viewed on the Health Alliance web site.

FINANCIAL OUTLOOK

Funding pressures over the duration of the Strategy will be extremely challenging for all partners due to increased demand and increased expectation, and the need to meet annual financial and performance targets inconjunction with facing reduced financial growth levels in coming years.

Therefore, the significant financial challenges facing the statutory partners from 2008-09 to 2010-11 cannot be underestimated. There needs to be planned service change to deliver the recurrent savings required tocover cost pressures. The statutory partners will need to remain focused on the

achievement of overall financial delivery. Continued management attention will focus on areas of service modernisation, budget re-alignment and cost reduction, so that a successful financial outcome can be deliveredacross the community over the next three financial years. The Financial Plan detailed in chapter 17 tosupport the Health, Social Care and Well Being Strategy illustrates the challenges faced by the Council and LHB, the financial processes, current budget levels and the impact these have on the development of future services.

IMPLEMENTATION

Details of the implementation of the strategic aims for each client group, with associated milestones and targets, are contained in theImplementation Plans which are linked to therelevant action plans and strategic drivers, such as Substance Misuse Action Plan, where appropriate.

Implementation will be monitored on a regular basis and published as an annex tothe Health, Social Care and Well Being Strategy Annual Report. The ImplementationPlans are available on the Health Alliance web site.



WELSH LANGUAGE

The Welsh Assembly Government’s policy,‘Iaith Pawb’ A National Action Plan for a Bilingual Wales’, aims to ‘ensure that the Welsh language can be used freely in social,leisure and business activities’. Cardiff shares the ambitions and objectives of the Assembly in promoting the culture and aspirations of Wales. Cardiff Council and Local Health Board in response to the Welsh Language Act 1998, have adopted the principle that in the

conduct of public business they will treat the English and Welsh languages on a basis of equality and to this end have developed Welsh Language Schemes. Linguisticassessments form an integral part to policy development and new policies and initiatives will facilitate and promote the use of Welsh wherever possible. The Health Social Care and Well Being Summary will be available in English and Welsh.

HEALTH IMPROVEMENT

The Assembly Government recognises the need for a focus on prevention and healthpromotion in order to achieve improvements in health and a reduction in healthinequalities. There has been extensive effort in Cardiff to develop targeted programmes onlifestyle issues, at both strategic and operational levels by partners and on community health development over the

course of the 2005-08 Health, Social Care and Well Being Strategy. Targeted programmes continue, but the funding for community health development projectsceased by October 2007. Elements of the projects have been sustained within communities, but further investment in health improvement work across communities is required.

TACKLING INEQUALITIES IN HEALTH

The vision of this Strategy incorporates the WHO ‘health for all’ principles, including a commitment to reducing inequalities in health. The term ‘inequalities in health’ refers to the variation in health indicators, for example mortality, life expectancy and morbidity (levels of illness), associated with social and economic circumstances, which are major factors in influencing the public’s health.

Cardiff’s Health, Social Care and Well Being Needs Assessment highlights considerable health inequalities between geographical localities. In addition, the first Health, Social Care and Well Being Strategy identified a range of communities with specific needs. The Strategy highlighted the challenges that these groups may face which include:

� Inequalities in factors which affect health such as poverty

� Inequalities in health status – communities can experience poorer health and often multiple and complex problems

� Inequalities in access to services – communities often find access to mainstream health and social care services difficult due to various factors, including language and cultural factors.

WAG guidance for the development of the Strategy includes the need for consideration of inequalities with regard to disability, race, gender, language, age, sexual orientation and religion and belief. In each of the clientfocused chapters, explicit consideration has been given to the following:

� Health needs and the impact on health of proposed interventions and services for those on low incomes, older people, minority ethnic communities and childrenand young people

� Impact on the health of these groups in terms of access to and quality of services, living and working conditions, social and community influences affecting health, socio-economic factors and lifestyle.

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EMERGING POLICY DIRECTION

Whilst priorities for health, social care and well being remain unchanged, it is recognised that the health, social care and well beingagenda is rapidly developing and in Cardiff new developments promise to bring excitingchanges which will help in the delivery of improved health, social care and well being services for the city’s residents. However,this new agenda is still developing and the delivery of this Strategy will be affected by a range of factors over time.

KEY EMERGING POLICIES

Local Service Board

Healthy City

Programme for Health Service Improvement

LOCAL SERVICE BOARD

An exciting development in the partnership agenda, which will impact on the ability of organisations to deliver the future vision for health, social care and well being services, is the development of the Local Service Board in Cardiff. In response to the Beecham Report ‘Delivering Beyond Boundaries’, the Welsh Assembly Government invited expressions of interest for areas to become Local Service Board development project sites in 2007-08. Cardiff’s Local Strategic Partnership, the Proud Capital Vision Board,submitted a proposal and was successful in this application. Local Service Board (LSB) partnership structures have been established:

� Proud Capital Forum providing vision andstrategic leadership

� Executive Local Service Board providing systems and strategic management

� ‘Cardiff Connections’, the Operational Forum providing co-ordination andimplementation of projects and programmes.

These programmes represent a new way of planning and delivering public services in Cardiff, with ambitious, innovative ideas which will impact positively on the quality of life of Cardiff residents. The recognition of the importance of health in the partnership agenda and the willingness of the partner organisations to work together to tackle the ‘wicked issues’ provides opportunities for success. Initial programmes and projects include:

� Integrating Health and Social Care services with a focus on delayed transfer of care

� Neighbourhood Transformation � Ask Cardiff Project � Scrutiny & Performance Project

It is anticipated that this increased focus oncollaborative working across Cardiff will enhance the opportunities and achievements presented by the Health, Social Care and Well Being Strategy.



Figure 1.4 CARDIFF LOCAL SERVICE BOARD STRUCTURE AND THE ‘CARDIFF CONNECTIONS PROGRAMME’

DEVELOPING CARDIFF AS A WORLD HEALTH ORGANISATION HEALTHY CITY

The Cardiff Community Strategy 2007-2017 highlights the commitment to improving health and well being through developing Cardiff as a World Health Organisation (WHO) Healthy City. The Healthy Cities programme, launched by the WHO in 1986, provides an overarching strategic frameworkfor promoting and improving the health of the population of Cardiff. Working towards becoming a Healthy City requires high level partnership collaboration and sign-up by all sectors.

The Healthy Cities programme is a dynamic approach and the programme has evolved over 5 year phases, which have specific themes. Cardiff has committed to applying

for phase five of the programme, once the guidance is launched in spring 2008. This will provide the umbrella to a wide range of health improving activities. The programme will provide a co-ordinated, high profile approach and will raise the importance of health and well being across many aspects of city life. It will cover all major health determinants (well beyond, but including health and social care services), and bring together existing health and well being activities. It will also influence areas that impact on health including strategic planning, healthy urban planning, economicdevelopment, transport, housing andeducation.

PROGRAMME FOR HEALTH SERVICE IMPROVEMENT

The Programme for Health Service Improvement (PHSI) was established in 2006 by the Cardiff and Vale NHS Trust and Cardiff and the Vale of Glamorgan Local Health Boards. In response to the WAG requirement for improved and efficient health services, the programme reflects a joint health

community commitment to improving local health services and developing opportunities to integrate health and social services.

The Programme recognises that there is a need to develop a new approach to service planning, focusing on the needs of local

Executive Local Service Board Membership:

Chief executives of Cardiff Council, Local Health Board , Cardiff & Vale NHSTrust, plus BCU Commander for South Wales Police, Deputy Chief Fire Officer

of South Wales Fire & Rescue Service and Director of Voluntary Action Cardiff.

Cardiff Connections Operational Forum Membership:

Programme and Project Managers Supported by Health Alliance, Children and Young People’s Partnership,Community Safety Partnership, Voluntary Sector Compact and Others

PROUD CAPITAL VISION FORUM Membership:

Strategic public, private and voluntary sector partners, strategic partnership chairs, Director of Public Health and others

Chaired by Leader of the Council

Statutory PartnershipsCommunity Safety Partnership

Health Alliance Children & Young People’s Partnership

NEIGHBOURHOOD TRANSFORMATION

PROGRAMME

LSB SCRUTINY &

PERFORMANCE PROJECT

ASK CARDIFFCITIZEN

CONSULTATION PROJECT

INTEGRATING SOCIAL CARE &

HEALTHPROGRAMME

15

communities and committing to develop new ways of providing services that help people maintain their health and independence. Getting the balance right between the services provided in local communities and the services that need to be provided in acute hospitals is central to the Programme’s work, which is detailed in Chapter 4.

The Programme aims to:

� Improve access

� Re-balance the current system � Provide continuity of care� Organise services effectively � Offer best outcomes for patients.

The health and social care community has developed a detailed response to HSC&WB Strategy in the form of PHSI. The proposals for PHSI will be subject to a 12 week long consultation period from May-July 2008.

CARDIFF VOLUNTARY SECTOR COMPACT

The tri-partite Voluntary Sector Compact was launched in March 2006, between the voluntary sector and the NHS and Cardiff Council. Its purpose is to optimise working relationships between the voluntary sector and its statutory partners with a view to enhancing public services.

The key themes of the Compact are:

� Community Development

� Consultation

� Funding and Commissioning

� Partnership working

� Volunteering

The Compact has facilitated increased involvement of the voluntary sector in the health, social care and well being agenda andthe development of the second Strategy will provide increased engagement with the sector.

The disparity between timetables for local strategic plan development means that the Health Social Care and Well Being Strategy cannot be fully informed regarding specificareas of activity, including Public Health, Children and Young People, Substance Misuse, Older People and Housing as the publication of guidance and/or the localstrategies are evolving and do not align with those of the Health, Social Care and Well Being Strategy.

In particular the detail of strategic plans for Children and Young People and the relevant responses to consultation feedback will be contained in the Children and Young People’s Plan, to be published September 2008.

The various issues and factors that impact on the health and well being of individuals and the needs of communities are influenced by a wide range of factors. It is a constantly changing, complex, developing agenda and the resultant services will need to respond accordingly. In Cardiff the desire to provide high quality, local services, in a timely and effective manner is the key aim of all partner

organisations. The Health, Social Care and Well Being Strategy 2008-11 describes a collaborative approach to the issues currentlyfacing public services.

The Strategy’s approach is to focus on service users and the services they need. Indeveloping the second Strategy the Health Alliance has recognised the importance of involving and engaging stakeholders and consequently the Strategy continues with the client group focus and describes its plans for target groups in the following chapters.

The factors described in this introduction, as well as others still to develop, will impact on the Strategy’s described pathway over the next three years. The Strategy cannot, at this stage, anticipate the effect these various factors will have on the emerging agenda between 2008 and 2011, but describes the planned direction in the knowledge that this is a developing agenda that will need to be flexible in order to be responsive to the changing needs, opportunities and potentialthat may arise.


THE WAY FORWARD

‘A tale of two cities’ - the Cardiff needs assessment

Guidance from the Welsh Assembly Government(WAG) required each Local Authority and LocalHealth Board (LHB) to jointly produce acomprehensive assessment of the needs of theirpopulation as the foundation for the developmentof the statutory Health, Social Care and Well BeingStrategy. The Public Health Director, NationalPublic Health Service in each LHB was to lead thedevelopment of the needs assessment.

Cardiff’s first Health, Social Care and Well BeingNeeds Assessment was published in 2004. Itbrought together a large quantity of detailed dataon health and deprivation in Cardiff along withsome more qualitative information captured atgrassroots level through locality based ‘Have YourSay’ workshops.

In 2007, the needs assessment was updated totake into account changes within the population ofCardiff. The information, both quantitative andqualitative, has informed the development of theCardiff Health, Social Care and Well Being Strategy2008-11. The full 2007 assessment is available onthe Cardiff Health Alliance web site.

Geographies used in the report

This report contains information, classified bydifferent geographical boundaries:

� Electoral divisions (also known as wards), anadministrative geography;

� Lower super output area (LSOA), a statisticalgeography;

� Middle super output area (MSOA), also astatistical geography.

There are 47 MSOAs and 203 LSOAs within CardiffLHB. The map on page 7 illustrates the differentareas.

A summary of the key points follow:Demography

The full needs assessment contains detailedstatistical analysis of the city’s population in relationto age, location and special needs population groups.Summary information is contained within therelevant chapters.

� Cardiff contains 29 Electoral Divisions with a totalpopulation of 317,500 persons according to the2006 Mid Year Estimate published by theRegistrar General’s Office at ONS, or 353,000persons according to the NHSAR at Mid 2006,demonstrating a significant difference in thepopulation estimates from the two separatesources.

� The distribution of population by age group inCardiff is in stark contrast to the rest of SouthEast Wales. Of particular significance is thenumber of young people because of the studentpopulation, which represents around 10% of thecity’s residents.

� The population of people aged 65 and over willincrease by approximately 11% over the next 13years. The number of people aged 75+ however,will remain relatively constant.

Communities with special health needs:

� Cardiff’s two formal gypsy traveller sites provideresidential accommodation for 77 families areboth located in the east of the South Eastlocality.

� The majority of Cardiff’s homeless are located inHostels in Central, the southern portion of SouthEast Cardiff and in the West locality ElectoralDivisions closest to the city centre.

� Cardiff has a minority ethnic population (non-white) of 11.7% (2006 Annual Population Survey,ONS). There is a higher concentration of ethnicgroups in Grangetown, Riverside, Plasnewyddand Butetown than elsewhere.

� 58% of Cardiff’s 30,000 students areconcentrated in Central Cardiff.

� Most of Cardiff’s asylum seeker population arelocated in the Central and South East Cardiffareas.

2. ‘A tale of two cities’ - the Cardiff needs assessment

17


Cardiff has an increasing migrant workers population, particularly from EasternEurope. The numbers in 2006-2007 were given as 4,400 but in reality numbers are considerably higher due to lack of registration etc.

Most of the sex industry in Cardiff islocated in the Central and South East and (to a lesser extent) West localities.

Key Determinants of Health

There is a distinct North West versusSouth East division with regard to deprivation within Cardiff.

There is a tenfold variation in unemployment rates between electoral divisions in the city with the highest rates in the Butetown (8.6%) and Adamsdown (7.1%) areas and the lowest in Lisvane and St Mellons. 5 of the 10 ElectoralDivisions with the worst unemployment are in the South East locality.

The two areas with the highest reported community safety problems are Cathays and Butetown.

Approximately 27% of the population in Cardiff smoke.

More than half of adults self-reported being overweight or obese with higher levels in the most deprived areas.

In Cardiff the reported average weekly alcohol consumption was in line with the Welsh average but the people who reported binge drinking was higher.

Men admitted to hospital for drug-related conditions was lower than the Welsh average but for women this was higher.

Cardiff had a lower proportion of adults who met the physical activity guidelines than the Welsh average.

The incidence of sexually transmitted diseases is rising rapidly.

Health Status

The areas of Cardiff with the highest percentage of households within which one or more persons has limiting long term illness are within Ely, Caerau, Llanrumney and Rumney.

There is a North West vs. South East divide in mortality rates across Cardiff. The areas within the South East region generally have higher mortality rates in comparison.

Cardiff as a whole has a lower mortality rate for circulatory disease but this masks the huge variation in MSOA. The areas with the highest mortality are clustered around the central and South East district.

Cerebrovascular (stroke) and respiratory disease mortality rates are highest in the West, Central and Southern districts.

The Cardiff Welsh age standardised rate (WASR) was 620.3, higher than the Wales rate of 580.33 of Cardiff’s 47 MSOAs had a higher WASR than the all Wales rate.

WASRs for the male population were higher than those recorded for the female population. The highest recorded male WASR were recorded within the city’ssouthern arc.

The percentage of low birth weight (LBW) babies is higher in the South East than in Cardiff as a whole. Areas with the highest percentages of LBW babies are located within the Central and South East.

Current Population

The latest estimates of Cardiff’s populationare Mid Year Estimates from 2006. The 2006mid year population estimate was 317,500 persons. This estimate was produced by the

Registrar General’s office at the Office for National Statistics (ONS) and represents 10.8% of the total population estimate for Wales.

18

DEMOGRAPHY

Figure 2.1 Current population in Cardiff’s electoral divisions

ONS Experimental Small Area Population Estimates for Mid 2004

Electoral Division Total Persons Electoral Division Total Persons

Adamsdown 8,403 Llanishen 16,677

Butetown 5,496 Llanrumney 11,175

Caerau 10,541 Pentwyn 14,300

Canton 13,246 Pentyrch 3,597

Cathays 15,383 Penylan 11,732

Creigiau/St. Fagans 4,850 Plasnewydd 16,535

Cyncoed 10,420 Pontprennau / Old St. Mellons 9,116

Ely 14,754 Radyr 5,244

Fairwater 12,277 Rhiwbina 11,281

Gabalfa 9,352 Riverside 12,009

Grangetown 15,264 Rumney 8,977

Heath 11,864 Splott 12,564

Lisvane 3,350 Trowbridge 15,422

Llandaff 8,826 Whitchurch and Tongwynlais 15,825

Llandaff North 8,317

Population Density

The areas of Cardiff with the highest population density are illustrated below.

Figure 2.2 Population density (persons per square hectare) by LSOA: 2001


The areas around the city centre have the highest population density.

‘A tale of two cities’ - the Cardiff needs assessment 19


Population age structure

In Cardiff 48% of the residents are male and 52% female. The distribution of population by age group in Cardiff is in stark contrast to the rest of South East Wales. Cardiff’s student population represents around 10% of the city’s residents. Most full-time students

are aged between 18 and 29 and almost 19% of the total population are agedbetween 20 and 29 compared with less than11% of total population in the rest of South East Wales.

Figure 2.3

Cardiff Population Age Structure in 2005(Source: 2005 MYE from the RGO at ONS)

6.00 4.00 2.00 0.00 2.00 4.00 6.00

0 to 45 to 9

10 to 1415 to 1920 to 2425 to 2930 to 3435 to 3940 to 4445 to 4950 to 5455 to 5960 to 6465 to 6970 to 7475 to 7980 to 8485 to 89

90+

Ag

e G

rou

p

Percentage of Total Population

Males Females

This age profile masks the huge variation in population structures in different parts of Cardiff. These range from the student age

group dominated areas of places like Cathays and Maindy to the Northern suburbs where close to 30% of residents are aged over 65.

Figure 2.4

Cathays MSOA Population Age Structure from 2004 Experimental MYE(Source:Registrar General's Office at ONS)

35.0 25.0 15.0 5.0 5.0 15.0 25.0 35.0

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85+

Age

Percent

Males Females

20

Pontprennau MSOA Population Age Structure from 2004 Experimental MYE(Source:The Registrar General's Office at ONS)

8.00 6.00 4.00 2.00 0.00 2.00 4.00 6.00 8.00

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85+

Age

Percent

Males Females

Lisvane MSOA Population Age Structure from 2004 Experimental MYE (Source:The Registrar General's Office at ONS)

5.00 4.00 3.00 2.00 1.00 0.00 1.00 2.00 3.00 4.00 5.00

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85+

Age

Percent

Males Females

Pontprennau and Thornhill have a population where over 40% of persons are aged 25 to 44 and those aged 0 to 9 years are significantly higher than those aged 10 to 19.

Areas like Lisvane has a population where over 30% of the population are older working

age adults, between 45 and 64 years old, and the second post war baby boomers also peak around the 35 to 44 age group reflected by the peak in their offspring aged 10 to 19 years.

Figure 2.5

Figure 2.6

Young People and Students

The areas of Cardiff with the highest proportion of young people aged 0-24 yearsare striking when mapped. Central Cardiff’s Cathays, Gabalfa and Plasnewydd areas are traditionally popular residential areas for

Students. The other MSOAs with the highest proportion of young people can be found in the Ely and Fairwater areas and MSOAs overlapping the Electoral divisions of Rumney, Llanrumney, Trowbridge and Pentwyn.



58% of Cardiff’s 30,000 students are concentrated in Central Cardiff particularly in

Cathays (7,785), Plasnewydd (3,605) and Penylan (1,740). A large number are also resident in Gabalfa (3,110).

Figure 2.7 Proportion of population aged 0-24 by middle super output area (MSOA): 2003


Minority Ethnic Populations

Cardiff has a minority ethnic population of 37,100, mid-year estimate 2006, representing the highest proportion of non-white people inWales.

The various ethnic minorities form a higherproportion of the population in Grangetown, Riverside (West locality), Plasnewydd and Butetown than elsewhere. Many of these populations live in the poorest inner city areas and rank amongst the most impoverished of the city’s inhabitants. There is evidence that demonstrates the poor health of these populations, for example, low birthweight, high incidence of diabetes and complications of same, high level of iron deficiency amongst infants. Health status and access to health and social care is generally diminished in most ethnic minority populations.

The difficulties of language and cultural barriers are most evident when individual patients require consultations.

Butetown /Grangetown Health Care Needs Assessment

During 2006, a health care needs assessment was undertaken across Butetown and

Grangetown. These two wards in the southern arc of Cardiff are well-recognised as containing some of the most socio-economically deprived areas in Wales. However, they also contain some of the newest and most rapidly developing housing developments in the city. The population inboth wards has been growing rapidly and is predicted to continue to grow dramatically, with a greater proportion of younger people and children and smaller proportion of older people than Cardiff and Wales. There is a high proportion of residents from non-white ethnic groups in both wards, some of these groups are well established in Cardiff while others are new arrivals.

Mortality rates for all causes are relatively high in both wards and life expectancy is 10years lower than in the affluent areas of Cardiff. Some conditions are more common than in the rest of Cardiff and Wales, particularly heart disease, respiratory disease, mental illness, diabetes and injuries. Deprivation is closely linked to poor health and increased mortality, and is significantly higher in these two wards. Deprivation may be at risk of becoming hidden in small pockets as areas of new housing cause an influx of people with different socio-economic status.

22

Additionally, the needs assessment found little evidence of targeted increased mainstream services to areas of higher needor of an increase in local health services inresponse to an increasing population. The concerns with regards to access to services included lack of sufficient primary care, services to overcome language differences, preventive services and lack of leisure facilities.

The needs assessment concluded that there is evidence of poorer health status among many groups in the area and little evidence of the targeting of mainstream local health care to address increased needs. There is evidence of inequality in health status and inequity in health service provision.

The full report may be accessed in the Needs Assessment on the Health Alliance website.

Figure 2.8 Ethnicity within Cardiff’s Electoral Divisions

Please refer to the relevant chapters for information on other target groups such as Gypsies and Travellers, Older People, People with Mental Health Problems, Homeless People, Asylum Seekers and Refugees and Carers.

Socio-economic deprivation Income and socio-economic factors are perhaps the most important determinants of health in the United Kingdom. This is because they have a direct bearing on many of the other determinants (NPHS, 2004a).

Townsend Index The Townsend Index is a summary score providing an indicator of small area deprivation. It is calculated from four 2001 census-based variables: proportion of households with no car; proportion of households not owner occupied; proportion of unemployed economically active persons

aged 16 59 years (females) and 16 64 years (males); and proportion of households overcrowded.

The following map shows deprivation by electoral division for Cardiff, with the darkest colour denoting the most deprived areas. There is a distinct North West versus South East division with regard to deprivation within Cardiff.

The Welsh Index of Multiple Deprivation 2005 is an alternative index of deprivation and confirms the high levels of deprivation across parts of Cardiff.


KEY DETERMINANTS OF HEALTH


Figure 2.9 Townsend deprivation score fifth by electoral division: 2000


Unemployment and other Income Deprivation Indicators

There is consistent evidence from different types of studies that unemployment and other income deprivation indicators are associated with adverse health outcomes including poorer mental health, cardiovascular disease and increased mortality. Prolonged periods of unemployment, or income deprivation, in general have a direct effect upon health beyond the effects of social-economic status, poverty, risk factors, or prior ill-health.

Cardiff has consistently higher levels of unemployment and other income deprivationindicators than the Wales average and there are stark variations across Cardiff in terms of unemployment proportions. Historically there has been a tenfold variation in rates from the highest in places like Butetown (currently 6.4%) in the South East locality to the lowest in places like Lisvane (currently 0.6%)in the North Cardiff locality by the working age population.

Receipt of income related benefits by the working age population show similar variations i.e. areas in the southern arc like

Ely (34.0%), Butetown (29.3%) and Caerau (29.2%) have higher uptake to areas like Lisvane (5.5%) and Cyncoed (6.6%) in the Northern and Central localities.

Analysis of the proportion of households living in relative income poverty shows that in Cardiff’s southern arc levels are as high as other local authorities such as Merthyr Tydfil and Blaenau Gwent. This suggests that the southern arc represents one of the three most deprived areas in Wales. In addition there are pockets of deprivation across Northand Central Cardiff, as well as a few areas of relative affluence in the South of the city.

Education

People with low levels of educationalachievement are more likely to have poorhealth (Department of Health, 1999). Compared with the rest of the UK, Wales has a higher proportion of young people with noqualifications. Proportions are lower in Cardiff than in Wales. However, within Cardiff, there is considerable variation. Ely is the area with the highest percentage of young people with no qualifications; Caerau, Llandaff North, Trowbridge and Llanrumney have 26-34% of young people with no qualifications.

24

Low birth weight babies

Low birth weight (LBW) has commonly been associated with maternal factors such as poor general health, poor education, poor nutrition, lower maternal age, smoking and alcohol consumption, both pre-conceptually

Figure 2.10 Percentage of singleton live born babies with low birth weight by middle super output area (MSOA): 2002-2004


Child Poverty

Cardiff’s southern arc clearly demonstratesthe highest proportions of children living in households dependent upon worklessbenefits. However, a few areas in more Central and Northern locations within the city, for example Pentwyn, Fairwater and Llandaff North contain very high proportions of children living in relative poverty.

The benefits referred to as ‘workless’ for this indicator include one or more of the following:

Income Support

Job Seekers Allowance

Incapacity Benefit

Severe Disablement Allowance &

Pension Credits.

According to benefit data for 2006 Cardiff is ranked 6th out of 22 Welsh local authorities in terms of the number of children aged 0 to 15living in households in receipt of ‘workless benefits’. The Welsh average figure was 23.3%. Cardiff’s ranking of 6th in terms of child poverty has not changed from 1998-1999 and therefore, in relative terms, there has not been a material improvement in the levels of ‘child poverty’ within the city using this set of variables as an indicator (WIMD 2000).

and during pregnancy. Birth weight is also animportant determinant for the future health of the baby, LBW being associated with adverse outcomes in terms of poor healthand education.



Figure 2.11 Percentage of children aged under 16 living in households dependent on worklessness benefits by electoral division: 2005


As with many other indicators, the southernarc has a higher proportion (39.4%) and number (11,000) of children living in relative

income poverty than any other Welsh local authority.

Figure 2.12

Percentage of Children Aged 0 to 15 living in Households Dependent Upon 'Workless Benefits' By Welsh Unitary Authority and Cardiff's North South Split

(Source: Derived by CRC from data Supplied by DWP for 2006)

0

5

10

15

20

25

30

35

40

45

South

Cardiff

Merthy

r Tyd

fil

Blaena

u Gwen

tRCT

Neath

Port Talb

ot

Caerph

illy

Cardiff

Newpo

rt

Bridge

nd

Swanse

a

Torfae

nW

ales

Carmart

hens

hire

Denbig

hshir

e

Isle o

f Ang

lesey

Pembro

kesh

ire

Wrex

ham

Conwy

The V

aleof

Glamorg

an

Flintsh

ire

Gwyned

d

Ceredig

ion

North C

ardiff

Powys

Monmou

thshir

e

Per

cent

26

Community Safety and Crime

The two areas with the highest reported community safety problems are Cathays and Butetown. These areas contain the City Centre and Cardiff Bay, both of which experience very enhanced population levels during the day and in the evenings, as a

combination of the workforce and leisureseekers are present in large numbers. Therefore the rates (which are calculatedusing residents population as the denominator) for these areas are artificially elevated.

Limiting long term illness (LLTI)

The 2001 Census ascertained that 18.5% of Cardiff’s household population suffer from aLLTI. The South East (21.33) and West (19.50) have the highest percentages. When evaluated by MSOA, the areas of Cardiff with the highest percentage of households where one or more persons with a LLTI reside can

be identified as areas within Ely, Caerau, Llanrumney and Rumney.

All Cause Mortality

In general, mortality rates for all causes are higher in the South East than the North. The European Age Standardised Mortality rates for all causes confirm this (see below).

Figure 2.13 European age standardised mortality rates (EASMRs) for all causes (persons, all ages) by MSOA: 2000-2004


The single largest cause of death in Cardiff is cardiovascular disease. One of the major determinants is smoking, which is increasing in young women, and another is obesity, which is increasing rapidly throughout the population. Other risk factors include high blood pressure, high blood cholesterol, unhealthy diet, physical inactivity, diabetes, advancing age, inherited (genetic) pre-disposition, poverty, low educational status,

poor mental health (depression),inflammation and blood clotting disorders, long periods of immobility e.g. while travelling, alcohol and use of oral contraceptive (WHO, 2006).

The areas of Cardiff with the highest mortality rates ‘from all circulatory disease’ are mostly around the Central and Southern South East localities.


HEALTH STATUS

CIRCULATORY DISEASE(including stroke and coronary heart disease)


Coronary Heart Disease

Coronary heart disease (CHD) accounts for over 6,000 deaths in Wales per year. The European Age Standardised Mortality Rate (EASMR) for coronary heart disease for Cardiff is lower than the all Wales average of 133.1 per 100,000.

It is a largely preventable cause of ill health and premature death. The incidence of CHD increases with age and is higher in men than in women. Within Cardiff, mortality from coronary heart disease is most prominent in the Central and Southern South East Regions.

Figure 2.14 European age standardised mortality rates (EASMRs) for coronary heart disease(persons, all ages) by middle super output area (MSOA): 2000-2004


Cerebrovascular Disease (Stroke)

Cerebrovascular mortality rates are highest in the West, Central and Southern South East Districts.

Figure 2.15 European age standardised mortality rates (EASMRs) for cerebrovascular disease (persons all ages) by middle super output area (MSOA): 2000-2004


28

Respiratory Disease

‘Respiratory disease’ encompasses acute and chronic conditions. Mortality associated with respiratory disease is higher in Cardiff than the overall Welsh rate of 82.8 per 100,000

population. The highest rates are found in the West, Central, and Southern South East Districts. The areas of Whitchurch and Tongwynlais in the North also have high mortality rates.

Figure 2.16 European age standardised mortality rates (EASMRs) for respiratory disease (persons, all ages) by MSOA: 2000-2004


Cancer Incidence Rates Cancer Research UK estimates that 1 in 3 people in England & Wales will develop some form of cancer during their lifetime (CRUK, 2003). Whilst the exact causes of many types of cancer remain uncertain, casual and contributory links for certain types of cancerare well established e.g. the causal link between tobacco smoking and lung cancer.

All malignancies incidence rate excluding non-melanoma skin cancer The Cardiff WASR for males was 620.3, higher than the Wales rate of 580. The three areas with the highest WASRs were Splott (872.3), Trowbridge (859.7) and St Mellons (784.6). The highest WASR are found around Cardiff’s southern arc.

The Cardiff WASR for females was 511.0, lower than the Wales rate of 520.0. In general female WASR are lower than male WASR and the Cardiff rate is slightly lower than the all Wales rate. The two MSOAs with

the highest WASRs were Cathays (695.5) and Llandaff North (646.6). The spatial concentration of higher WASRs is not restricted to the southern arc.

Specific Cancers The incidence of colorectal cancer in Cardiff WASR was 52.1, lower than the Wales rate of 66.8. There are incidences of concentrations of higher WASRs in the North, and not restricted solely to the southern arc.

The incidence of lung cancer in Cardiff (60.6) was lower than the Wales rate (73.3). The incidence rates were highest in the areas of the South East.

The spatial distribution of breast cancer does not conform to the pattern experienced inCardiff for most other health outcomes, that of higher incidence rates in the southern arc.


CANCER


This is due to the higher risk of breast cancer in women who give birth later in life, typically from ‘middle-class’ socio-economic backgrounds. Some of the lowest rates were recorded in the contrasting areas of Ely, Thornhill and Tremorfa.

Cardiff has a higher incidence of prostate cancer (167.3) than the all Wales rate (137.6). 38 of Cardiff’s 47 MSOAs recorded a higher WASR than the all Wales rate, and are widespread across Cardiff as a whole.

Cancer Mortality Rates Whilst many forms of cancer, especially if detected early enough, can be treated successfully, about one in four of all annual

deaths have been attributed to cancer in England & Wales (Coleman et al, 1999). The Cardiff WASR was 317.8, higher than the all Wales rate of 305.0 with 28 of Cardiff’s MSOAs recording a higher WASR than the all Wales rate.

Nine of the ten highest rates are found withinthe southern arc. Thornhill had the lowest WASR followed by other MSOAs in Cardiff Central North and West Locality areas.

The map below highlights the spatialvariation in male mortality rates for all malignancies excluding non-melanoma skin cancer in Cardiff at MSOA level for the period 2000 - 2005.

Figure 2.17 WASR per 100,000 Population All Malignancies excl NMSC (Male)

The Cardiff WASR for females was 266.7, slightly lower than the all Wales rate of 267.3. The spatial distribution of the MSOAs with the highest mortality rates centres on

the southern arc, however the highest female rates are slightly more dispersed than that for males.

30

Figure 2.18 WASR per 100,000 Population All Malignancies Excl NMSC (Female)

The areas of highest mortality following injury are located in MSOAs within the

Central locality and across the southern arc as detailed in the map below.

Figure 2.19 European age standardised mortality rates (EASMRs) for injuries (persons, allages) by middle super output area (MSOA): 1996-2004



INJURIES

Targeted health improvement partnership programmes are being delivered across the city and are adopting the Healthy Cities concept. This approach will enable key partners to work together in providing a city-wide approach to improving health through five complementary key areas for action:

� Developing personal skills

� Supporting community action

� Creating supportive environments

� Building healthy public policy

� Re-orienting health services.

The drive towards Healthy City status will incorporate much of the existing and plannedwork and create further momentum andenthusiasm for the health improvement agenda across agencies and partnerships, coupled with the Health Challenge Cardiff promotion.

3. Promoting and improving health

Promoting and improving health32

Improving health and well being has been identified as the key strategic priority and overarching principle for the Cardiff Health, Social Care and Well Being Strategy. In developing the Strategy the Health Alliance recognises that social, environmental and economic factors impact on the health of the population and in addition acknowledges the

impact the city’s environment has in relation to health. Consequently, the Health Alliance has agreed to adopt the Healthy Cities concept which utilises the World Health Organisation’s (WHO) Ottawa Charter as a framework for action to improve the healthand well being of Cardiff residents.

The Welsh Assembly Government has clearlyset out its goals and policy framework for improving health and well being through a number of strategy statements, including:

� Better Health Better Wales (1998)

� Well Being in Wales (2002)

� Health Challenge Wales (2004)

More recently, the Chief Medical Officer forWales has set out a vision for public health and a Public Health Strategic Framework forWales is in the process of being developed.

In Cardiff, organisations and communities work in partnership to address the key healthissues and needs, focusing on priority groups. The majority of the work concentrates onareas of greatest need, mainly in the southern arc of Cardiff and particularconsideration is given to the health needs of those on low incomes, older people, minority ethnic communities, children and young people.

In recognition of the importance of health and well being and the need for individuals totake responsibility for improving and maintaining their own health, Cardiff will be developing a local response to Health Challenge Wales. During 2008 Health Challenge Cardiff will focus on well being and will be launched to provide the co-ordination of health improvement activities across the city, to fit within the Healthy Cities framework.


REGIONAL AND LOCAL STRATEGIC CONTEXT

HEALTH IMPROVEMENT

This co-ordinated approach will facilitate further links between the task groups of the Health Alliance in order to address joint issues. The health and well being task groups within the Health Alliance are:

� Food and Health Steering Group � Physical Activity and Health Steering

Group � Smoke Free Cardiff � Mental Health Promotion Sub-Group � Cardiff Healthy Ageing Planning Group

Key elements to ensure success will include:

� Promoting the inclusion of healthimprovement into key strategies andpolicies

� Partnership working

� Support to agencies to incorporate healthimprovement into service provision

� Capacity building to raise awareness and develop competence in tailoring healthand social care delivery to meet the needs highlighted by inequalities in health

� Resources to facilitate community/public participation and clear links with community development initiatives.

2008 - 2011

1. Develop action to meet the requirements of becoming a World Health Organisation designated Healthy City.

2. Increase awareness and build capacity of partnership groups contributing to the Health, Social Care and Well Being Strategy in the principles and practice of developing Cardiff as a Healthy City.

3. Develop and promote Health Challenge Cardiff.

Health improvement work around the target groups of children and young people and older people and on the issues of mental health, sexual health and substance misuse are detailed in the relevant chapters.

FOOD AND HEALTH

A poor diet is one of the main causes of ill health and premature death. It has been estimated that about one third of deaths from heart disease and one quarter from cancer in the UK can be attributed to poordiet (Food Standards Agency, 2003).

For several years a partnership approach tofood and health has operated in Cardiff, ledby the Food and Health Development Group.

The Food and Health Strategy (2006)identifies five overarching themes:

� Nutrition

� Food provision

� Food safety

� Food sustainability

� Food education and training.

Eight action areas have been developed,which are currently being reviewed and updated. The Strategy builds on the nationalperspective ‘Food and Well Being’ (FoodStandards Agency Wales/Welsh Assembly Government, 2003), ‘Food and Fitness for Children and Young People’ (WAG 2005) and will now be informed by ‘Appetite for Life’ and ‘Quality of Food Strategy’ (WAG 2007-08) and local priorities.

In Cardiff the multi-agency Strategy encourages links across food initiatives to provide strength and ensure consistency of approach through collaboration betweencommunity dietetics, public health, foodsustainability, regulatory services, trading standards, social services, schools catering, further/higher education and the voluntary sector.

Promoting and improving health 33

PRIORITIES AND KEY STRATEGIC AIMS

2005 - 2008 � Cardiff Food & Health Network established in 2006 to promote and share best practice in food provision,

food safety and food education throughout Cardiff. � Consideration of health impact assessment through a multi-agency workshop focused on ‘Health Impact

Assessment on Food in Schools’. Targeted Age Groups � BIG Lottery funded Food Matters/Bwyd o Bwys 3 year project with children and young people in Ely and

Caerau delivered with national recognition and development of evidence base. � BIG Lottery funded Young People Matter project commenced September 2006 in St Mellons. Education and Training� Implementation of standardised and accredited OCN Community Food Nutrition skills training

programme, delivered by dietitians. � WAG and Flying Start funding secured to increase dietetic capacity to inform, train and support

communities in developing food and nutrition skills. Sustaining work with early years and schools through continuation and rolling of good practice and policy development across Cardiff.

� Further development of the community food worker role to support service delivery at local level. Access to Food � Activities delivered through community health development initiatives, for example, three food co-ops,

cooking skills courses. Reward Excellence � Piloted Healthy Option Award established for businesses in Cardiff. � Healthy Snack Award Scheme for early years establishments piloted.

2008 - 2011

Enabling and supporting people to access a healthy balanced diet through a holistic and co-ordinated approach 1. To increase the procurement and provision of safe, nutritious and sustainable food for the whole

population through large public organisations, businesses, community groups and events organisers. 2. To increase the uptake of safe, nutritious and sustainable food through policy development, education

and training and food provision in the identified target groups. 3. To identify and influence policies and strategies that could impact on food and nutrition/health issues

where appropriate.

PHYSICAL ACTIVITY AND HEALTH

Physical activity not only contributes to well being but is also essential for good health(Department of Health, DoH, 2004). People who have a physically active lifestyle have approximately 50% less risk of developingcoronary heart disease (CHD), stroke and type 2 diabetes compared to those who have a sedentary lifestyle, and can reduce their risk of premature death by about 20-30% (DoH, 2004). Regular physical activity is also associated with reduced risk of obesity, osteoporosis and colon cancer and with improved mental health and increased functional capacity in older adults (DoH, 2004).

‘Climbing Higher’ (2005), the Welsh Assembly Government’s long term strategy for sport and physical activity, sets out the strategic direction in Wales for the next 20 years. The supporting document ‘Climbing Higher - Next Steps’ (2006) provides guidance on how to achieve the set targetshighlighted in the strategy.

In Cardiff, the multi-agency Physical Activity and Health Steering Group directs local implementation of the national strategies. The Cardiff Physical Activity and Health Strategy and Action Plan provide the direction for local development and delivery.


KEY ACHIEVEMENTS


2005 - 2008

� Development of the Cardiff Physical Activity and Health Strategy and Action Plan.

Physical activity and community health development initiatives developed and delivered including:

� Walking for Health (encouraging sedentary people to participate more in walking).

� Exercise Referral Scheme (encouraging referred clients with various mild to moderate medical conditionsto participate in physical activity).

� Healthy Living Centres in St Mellons, Llanrumney and Butetown/Grangetown.

� ActiveLife (BIG Lottery Funded project to encourage community participation in physical activity).

� Dragon Sport, PESS (Physical Education and Schools’ Sport) introduction of 5x60 minutes officers (increasing school children participation).

� Sport Cardiff (sports and community development work around increasing physical activity).

� Two Mentro Allan Projects (BIG Lottery Fund, outdoor physical activity projects).

� Free Swimming Initiative (8 – 16 year olds and 60+).

� Minority Ethnic Communities – Barefoot Health Workers Project, Food and Fitness small grant and Women Only Swimming.

Only 22% of adults within Cardiff are currently participating at the recommended level of 5x30 minutes of physical activity, which is well below the national average of

34% (The Sports Council for Wales, 2004-5 Adult Participation Survey). Climbing Higher has a recommended target of increasing participation of 1% per year.

2008 - 2011

A diverse and inclusive provision of physical activity opportunities to enable more people to bemore active, more often

1. To influence National and Local Policy that can contribute to improving health through physical activity, ensuring an effective and efficient approach to delivery Through a co-ordinated approach across all health agendas, in particular Food and Health; and through ensuring that physical activity is considered and promoted during the development of relevant strategies that impact on health.

2. To enable people to access opportunities to a physically active lifestyleThrough improving services and amenities; having a targeted approach to delivery; and through the promotion of consistent, valid and accurate advice and training.

3. To promote the health, social and well being benefits of physical activityThrough the improvement of two way communication between providers and the community; and the delivery of clear and consistent health messages through identifying appropriate marketing tools.


KEY ACHIEVEMENTS


OBESITY

Nearly a quarter of people across the UK are obese and the annual rate of increase in theprevalence of childhood obesity is now 10 times higher than in the 1970s (World Health Organisation, 2006), suggesting that today’s children may have a shorter life expectancy than their parents. Overweight and obesity contribute to approximately 80% of cases of type 2 diabetes, 35% of ischaemic heart disease and 55% of hypertensive disease among adults in Europe (World Health Organisation, 2006). They also increase the risk of some cancers, affect pregnancyoutcome and impact on well being, quality of life and ability to learn. In Wales, more than half (54%) of adults self reported being overweight or obese, with higher levels in the most deprived areas (National Assembly for Wales, 2007). This trend is reflected in the statistics for Cardiff.

This rapid increase in numbers of people who are overweight and obese has occurred too quickly for genetic changes to be the cause. It is more likely that behavioural andenvironmental changes in society have beenthe major influences. Evidence from recentobesity reports (WHO, 2006 and 2007) recommends that work should focus on thewider determinants of health, together with creating supportive environments and developing personal skills in local communities. The World Health Organisationidentifies target groups as women, youngpeople and those of low income status.

In Wales, the obesity agenda forms an element of the Welsh Assembly Government’s Public Health Strategic Framework. The Physical Activity Network for Wales and the Nutrition Network for Wales have joined forces to contribute to a more cohesiveapproach to the issue. In Cardiff, the Proud Capital Vision Forum, the Cardiff Health Alliance and the Children and Young People’s Partnership have all identified obesity as a key priority area.

Much work already focuses on obesity prevention through the action plans of the Food & Health Strategy and the Physical Activity & Health Strategy. The inclusion of obesity within the Strategic Environmental Assessment of the Local Development Plan is a recent development. To ensure co-ordination and synergy, it has been agreed that a Cardiff-wide Obesity Prevention Strategy and Action Plan be developed thatfocuses on creating supportive environments and combines key elements of the food andphysical activity strategies. This obesity strategy will be developed and implemented in partnership with key statutory andvoluntary organisations, to build on currentwork and address the broader issues and gaps. Appropriate treatment and care for those already overweight and obese will also require consideration.

2008 - 2011

1. Cardiff-wide Obesity Strategy and Action Plan to be developed and implemented in partnership with key statutory and voluntary organisations.

2. Develop the role of Sustainability Appraisal/Strategic Environmental Assessment to drive action and engage all relevant agencies in improving the environmental, social and economic determinants of health, with a particular focus on factors influencing obesity.

SMOKE FREE CARDIFF

Smoking is well known to be the single biggest avoidable cause of disease and early death in Wales. It kills around 114,000 people in the UK every year (Peto et al,2003). Most die from one of the three main

diseases associated with cigarette smokingi.e. cancer, chronic obstructive lung disease (bronchitis and emphysema) and coronary heart diseasee. Smoking in pregnancy is linked to spontaneous abortion, pre-term birth, low



2005 - 2008 � Prevention – including work in schools and with young people, such as Smokebugs (primary schools)

and the ASSIST programme (selected secondary schools, including several in deprived areas of Cardiff).

� Cessation – BIG Lottery funded projects were implemented from 2005-2007, including the 2Tuff2Puff programme, providing adolescent smoking cessation support, the development of successful models for cessation with the Pakistani and Bangladeshi communities in Cardiff and support to businesses.

� Protection – smoke-free public places have successfully been introduced, and advice and guidance has been developed for premises with specific exemptions from the legislation, such as hotels and care homes.

2008 - 2011

Promote a supportive smoke free environment and reduce smoking prevalence within Cardiff

1. To prevent people from starting smoking, particularly children and young people, by minimisingexposure to factors which are likely to contribute to the initiation of smoking.

2. To reduce health inequalities by reducing the exposure of the most disadvantaged and vulnerable members of society in Cardiff to the harmful effects of environmental tobacco smoke.

3. To increase numbers of people accessing specialist smoking cessation services, especially those from lower socio-economic groups, pregnant women, BME groups, and adolescents.

4. To ensure effective regulatory enforcement measures are implemented and maintained in relation totobacco control (including age of sale, smoke free public places, advertising and promotion of tobacco, and smuggling).

ALCOHOL

takings in pubs and clubs of £1.15 billion annually (Directors of Public Protection Wales, 2006).

Alcohol plays an important role in our society.Over 90% of adults in the UK population consume alcohol and it is widely associated with pleasure and relaxation. It also makes a substantial contribution to the Welsh

birth weight and stillbirth (Royal College of Physicians of London, 2002). Smoking has also been identified as the primary reason for the gap in healthy life expectancy between rich and poor. According to the 2003-05 Welsh Health Survey, more than a quarter(27.1 per cent) of adults across Wales reported being smokers, with the proportionin Cardiff just above the Welsh average.

The key recent development in tobacco control has been the introduction in April 2007 of comprehensive legislation prohibiting smoking in enclosed workplaces, public places, and transport and work vehicles. A programme of education and enforcement activity has ensured high levels of compliance in all sectors, particularly the licensed trade.


Other policy developments include the increase in the legal age for sale of tobacco products from 16 to 18, introduced inOctober 2007, and forthcoming requirementsfor graphic images of health effects on all tobacco products.

For several years a partnership approach totobacco control has been taken in Cardiff, currently led by the Smoke Free Cardiff Partnership. The Smoke Free Cardiff Strategy has recently been reviewed and updated, covering period 2008-2011. The Smoke Free Cardiff Strategy focuses on three distinct areas of activity – prevention, cessation and protection.

KEY ACHIEVEMENTS


economy – estimated at 50,000 jobs and

However, alcohol has recently been identified as the third highest risk to health in developed countries (Alcohol Concern, 2006). Alcohol is a contributory factor to crime, fearof crime and ill health, with over 5,000 deaths each year in England and Wales directly caused by alcohol, and alcohol is implicated in a further 40,000 deaths. It is estimated that one in six attendances for treatment at accident and emergency departments (rising to eight out of ten at peak times) are due to high levels of alcohol consumption (Welsh Assembly Government, 2007).

In Cardiff, the percentage of adults who drink more than the recommended guidelines is 39.4% (equivalent to the Welsh average), with 21.4% binge drinking in the past week (higher than the Welsh average of 19.3%).Binge drinking – defined as drinking eight or more units of alcohol in one session for men, and more than six units in one session for women – is becoming a major problem in the UK.

Consumption of alcohol has a cost to the taxpayer and to the economy. Every year alcohol costs the National Health Service around £1.7 billion in treatment. In Wales the estimated cost to the health service is between £70 million and £85 million.

Alcohol also has a major impact on industry through lost productivity arising from underperformance, absenteeism and accidents (Welsh Assembly Government, 2007).

Young People and Alcohol Young people in Wales report higher levels of drinking and drunkenness than in other parts of Europe. Most young people drink alcohol without experiencing serious harm. However, there are risks for young peopleunder the influence of alcohol, including:

� Unplanned and unprotected sex, thusrisking pregnancy or sexually transmittedinfections.

� The association of drinking and sexual assault and rape.

� Alcohol is estimated to be a contributoryfactor in 20-30 per cent of all accidents.

� Young, inexperienced drivers are over-represented in deaths from drink-driving.

� About one third of pedestrians aged 16-19 killed in accidents had been drinking.

Priorities and actions for tackling alcohol-related harm are addressed in the Cardiff Community Safety Partnership’s Substance Misuse Action Plan. Please refer to the Substance Misuse chapter for further details.

WORKPLACE HEALTH

It is estimated that work related ill health costs the Welsh economy £500 million per year. The Health and Safety Executive estimates that 12.8 million working days were lost in 2003-04 in the UK due to stress, depression or anxiety and 1.1 million peoplewere affected by a musculoskeletal disorder (MSD). Sickness absence due to back painalone costs the economy in Wales £85 million per year.

Having a healthy workforce is crucial to the success of business in terms of increased productivity and staff retention, or in reduced sickness absence and better customer service. A study in 2004 concluded that investment in workplace health promotioncould bring about cost savings of ten pounds for every pound spent.

Employers and service providers can make a difference to the health of the people of Cardiff by considering the impact on the environment and people's health and well being through alternative products, services,ways of working, healthy alternatives or incentives that could help improve health or reduce any negative impact on people’s health. Some examples of good practice include:

� Encourage staff to become morephysically active, e.g. by commuting on foot or by bike, going out for a walk at lunchtime, taking the stairs and not the lift

� Staff catering to follow healthy eatingguidelines, and remove less healthy vending machines


� Insisting that staff take a lunch break away from workstations

� Provide stress awareness and risk assessment training to managers to support staff struggling with the pressures of work or personal life

� Run occupational health events or themed health days

� Provide literature about healthy lifestyles

� Ensure staff are fully trained in manual handling and to use equipment appropriately

� Provide a safe and tidy environment to work in.

The Deputy First Minister (2007) hasapproved:

� The development of the Welsh Assembly Government's workplace healthprogramme to provide free and impartial occupational health and safety advice to small businesses

� Extension of the Corporate Health Standard to small businesses

� Development of a joint action plan on health, work and well being

� Consideration of the potential to strengthen current legislation foroccupational health in Wales.

Initiatives to promote the health ofemployees across Wales, such as the Welsh Assembly Government’s Corporate Health Standard award scheme, are important in helping to maximise the productivity of the workforce. The Corporate Health Standard has been developed to recognise good practice and to target the key preventable ill-health issues and the Health Challenge Wales priorities. The Corporate Health Standard promotes best practice and supportsorganisations in taking active steps to protect and promote the health and well being of their staff.

Cardiff Council and Cardiff Local Health Board have both attained the Corporate Health Standard and are actively reviewing their polices.

Over recent years Cardiff has taken major steps in regenerating and improving the physical and urban environment in the city.

Such regeneration has clear benefits for health and well being, but also presents challenges.

HOUSING

Having access to good quality affordable housing is a key element of the foundations on which the health and well being of individual households depends. Cardiff’s draft Local Housing Strategy 2007-2012 sets out the strategic direction and priorities forhousing, focusing in particular on increasing the supply of affordable accommodation to address housing need and the development of housing-related services for vulnerable people. It incorporates the prioritiesidentified in its sub-strategies and plans, including the Homelessness Strategy, the BME Housing Strategy and the SupportingPeople Operational Plan.

Guidance issued by the Welsh Assembly Government identifies the Local Housing Strategy as one of the key thematic strategic plans that feeds into the Health, Social Care and Well Being Strategy.

The connection between good quality housing and good health is evident in many of the priorities identified in the draft Local Housing Strategy. These include:

� Carrying out physical and environmental improvements to social housing to meetthe Welsh Housing Quality Standard by 2012.


TRANSFORMING NEIGHBOURHOODS AND ENVIRONMENTS


� Increasing the supply of affordable housing, especially for families, to address housing need and provide options for households living in unsatisfactory conditions.

� Providing accommodation for homeless households to whom the Council has a legal duty and providing high quality advice and support services to prevent homelessness from occurring.

� Implementing the actions identified inCardiff’s Affordable Warmth Strategy to tackle fuel poverty and improve the energy efficiency of housing.

� Using enforcement powers provided by the Housing Act 2004 to improve housing standards, especially in privately rented accommodation.

� Providing adaptations to properties toenable people to live independently and safely at home.

Effectively addressing housing priorities relies on a multi-agency approach with health and social care services playing a key role. There is a need to continue to develop the links between all of these services to support a partnership approach towards addressing the related priorities.

SUPPORTING PEOPLE PROGRAMME

Supporting People is the Welsh Assembly Government’s policy and funding frameworkfor delivering housing-related support to vulnerable people, to enable people to live independently and to maintain a tenancy.

Supporting People is a key driver to improve the quality of life for a number of vulnerablegroups within the community, by enabling people to develop the skills and confidence necessary to live independently, without support or to maintain independent living with ongoing support. The Programme also helpsprevent the problems which often lead tohospitalisation, institutionalised care, custody and/or homelessness.

The Supporting People Operational Plan is a mechanism for identifying priorities for futurefunding for housing related Support Services. It also identifies the need, demand, supply and gaps in existing services and the benefitsof the programme. Matrix Research and Consultancy, on behalf of the WelshAssembly Government, undertook a study onthe costs and benefits of the Supporting People Programme (Welsh Assembly Government, 2006). This research indicated that the total financial benefit, as a result of Supporting People across Wales modelled in this study, is equivalent to £1.68 for every £1 spent. The health benefits account for 26% of the total calculated savings and relate toimproved or maintained status or appropriateaccess to services. The potential savings modelled include admissions to hospital, length of stay and delayed discharge from

hospital, mental health services, visits to A&E and the use of treatment services (forexample, drug treatment services).

The aims for the Supporting PeopleProgramme are for Housing Related Support services that are:

� Flexible, accessible and appropriate for vulnerable people in our communities.

� Supporting service users to obtain the optimal security of tenure and level of independence.

� Needs led, innovative and respondent tochanging needs and aspirations.

� High quality, cost effective and sustainable.

� Complimentary to existing care services.

The delivery of these aims should be planned and developed through strong partnership working and be co-ordinated and strategically relevant, meeting identified needs and aligned with the strategic objectives of theSupporting People (SP) Programme and partners.

The Supporting People Planning Group (SPPG) consists of Heads of Services fromHousing, Adult and Children Services, Health and Probation Services and their role is todevelop the Supporting People OperationalPlan (SPOP), which details how the SP Programme can deliver Housing Related Support Services to a range of vulnerable clients living within the community.

The various Advisory Planning Groups and the Supporting People Team presentproposals to the SPPG who agree and prioritise the recommendations forcommissioning new services for Housing Related Support funding, whilst also considering the needs and demand for services. Responsibility for remodelling or de-commissioning existing services also lies with the SPPG.

The Supporting People Operational Plan sets out how the programme will begin to reshape the housing-related support sector in Cardiff to ensure that local and national priorities are met for cost effective, good quality, flexible and accessible support services. The Plan will provide the priorities action plan and monitoring framework for the programme. The Plan should be considered as complimentary to a range of key planning activities within the wider health, social care, housing and community safety arenas and is a working partnership between Local Government, service users, health, probation and support agencies. In Wales there are two funding streams, Supporting People Revenue Grant (SPRG), managed by the Welsh Assembly Government and Supporting People Grant (SPG), which is administered by the Local Authority.

The strategic responsibility for these services remains with the SPPG, supported by the Supporting People Team.

The Programme aims to provide assistance to a range of vulnerable members of society,including:

� People fleeing domestic violence� Homeless people (including families)� People with alcohol and drug problems � Young vulnerable people including those

leaving care � Ex-Offenders � Older Persons � People with physical and sensory

impairments or learning disabilities � People with mental health problems � Refugees � People with HIV and AIDS.

A recommendation by the Welsh Assembly Government, was to complete a strategic review of Supporting People Revenue Grant services within Cardiff to ensure that these services continue to meet the wider aims andobjectives of the Local Authority whilst continuing to deliver Housing Related Support Services. A process is currently being developed to undertake these reviews within the next 18 months.

Through the Supporting People Programme many service areas have managed to develop a range of new services and enhance existingservices through remodelling or service development. These services have met the needs, demand and gap in supply, whilst meeting the wider strategic priorities for suchservices. A few examples of achievement are detailed below and further examples of projects being developed are contained within the SPOP.

2005-2008

� Mental Health Services – the development of additional 14 units of move on accommodation and support.

� Homelessness Service – the development of Nightingale House, 26 units of accommodation for homelessness families and single clients with the provision of Housing Related Support Services. Through the development of this project Cardiff has achieved a status of ‘no families living in Bed & Breakfast accommodation’.

� Learning Disability Services – the joint re-commissioning of Learning Disability Supported Living Services has resulted in an increase in clients receiving Housing Related Support Services.

� Older Persons’ Services – the development of an Older Persons’ Floating Support Service providing Housing Related Support Services to vulnerable clients living within the community.

� Drug and Alcohol Services – Croes Ffin project is a cross boundary, with the Vale of Glamorgan Council, development of 18 units of accommodation and support to drug and substance misuse clients for a maximum of 9 months.


KEY ACHIEVEMENTS

NEIGHBOURHOOD IMPROVEMENT

While the transformation of the city througheconomic growth and urban regeneration has benefited many communities across the city, neighbourhoods with high levels of deprivation and symptoms of decline continue to exist. Deprived communities are typically affected by a range of problems such as neglected environments, substandard housing, unhealthy lifestyles, low economicactivity, low educational attainment and high levels of crime. Such communities also havepositive qualities and are often characterised by a strong community spirit and identity. Neighbourhood renewal is, therefore, not just about physical improvements to an area, butalso about ensuring that renewal activity reflects the needs and aspirations ofcommunities and addresses the barriers thatprevent people from leading full and rewarding lives.

Cardiff’s Neighbourhood Improvement Programme (2007) aims to tackle disadvantage at a local level by providing a framework for regeneration in Cardiff. The Programme supports national and local objectives for identifying and addressing the needs of deprived communities.

Neighbourhood priority areas will be targeted for regeneration, supported by local action plans to facilitate a co-ordinated partnership approach to change. The future of the programme and improvements to priority areas will be reliant on the continued involvement and commitment of key stakeholders in the community, service deliverers and the community themselves.This approach will be enhanced by the Local Service Board’s ‘Transforming Neighbourhoods’ programme.

COMMUNITY HEALTH DEVELOPMENT

A community health development approach is a central part of the process to achieve sustainable changes in community health and well being, particularly in tackling issues of health inequity. The Cardiff Health Alliance prioritised this overarching approach and a number of programmes have been developed

with communities to promote health and well being at a local level.

Future work during 2008-2011 will concentrate on engaging with communities through the Communities First programme and support to community fora.

2005 – 2008

The implementation of 3 Healthy Living Centres funded by the BIG Lottery Fund: � St Mellons Healthy Living Centre (2001-2006) delivered activities focusing on children and families,

young people, food and health and environmental issues � Butetown/Grangetown Healthy Living programme (2002–2007) focused on food and health, physical

activity, emotional health and well being, access to services and youth health � Llanrumney Healthy Living Project (2002–2007) worked with young people on sexual health and access

to services issues.In excess of £2.3m was accessed to work with the communities through: � Implementation of the ‘Barefoot’ Health Workers Project (2001–2007) with the African Caribbean,

Bangladeshi, Pakistani, Somali and Yemeni communities of South Cardiff, to develop health enhancing activities with these communities.

� The delivery of Surestart in South Riverside/Butetown/Grangetown, Ely and St Mellons� The implementation of the Triangle Health Action Research Project in Riverside � Support to five community forums (St Mellons, Llanrumney, Butetown/ Grangetown, Ely and

Adamsdown).

KEY ACHIEVEMENTS


COMMUNITIES FIRST

Communities First is the Welsh Assembly Government’s Programme that aims to improve the lives and living conditions of those living in the most disadvantaged areas of Wales. The programme focuses on the themes of environment, active community,health and well being, crime and community safety, education and training, jobs and business. The strategic direction is set by the Communities First Guidance.

Communities First Partnerships in Cardiff have been established in the mostdisadvantaged wards - Butetown, Splott, and Ely-Caerau. In addition, a non-geographical scheme, focusing on minority ethnic groups

has been established. All partnerships involve the public, voluntary, statutory and community sectors, working together to make co-ordinated and locally informed decisions, with an emphasis on sustainability. Through local partnerships and consultation, community audits and community action plans are being developed to allow localpeople the opportunity to influence servicedelivery so that services are delivered according to need.

The Communities First Programme will contribute to the delivery of this Strategywith its broad focus on social, economic and environmental determinants of health.

2005 – 2008

� Development of a number of specific health-focused initiatives, led by the Health and Well Being Group in Splott and Adamsdown and the Health Action Team in Ely and Caerau.

� In Butetown, the community have been involved in the Loudoun Square and Dumballs Road Regeneration Programmes. The Public Health Reference Group has been working in partnership with Cardiff Community Health Council, providing a platform for the community to raise and address their concerns around health service delivery.

� The Ethnic Minorities Scheme has introduced a Physical Activity Challenge (£10,000 grant from the Sports Council for Wales) that has supported small community groups to increase health enhancing physical activity opportunities and has contributed to the Changing Lifestyles Project (BIG Lottery Fund project with a focus on improving access to physical activity in the outdoors by minority ethnic communities).

2008 – 2011

1. Completion of community audits

2. Development, implementation and evaluation of community action plans

3. Expansion of the scheme to incorporate the 17 Lower Super Output Areas in Cardiff identified as qualifying for Communities First status

4. To engage with health and social care sectors, enabling them to respond to Cardiff’s Community First communities’ views and needs in respect of health and well being and to identify opportunities for partnership working.


KEY ACHIEVEMENTS


COMMUNITY SAFETY

Crime and disorder and poor health and well being are all symptoms of the same social, economic and environmental problems within communities. The only way to solve these problems is by working in partnership to transform and better manage these communities at a neighbourhood or locality level.

Health and social care partners provide prevention, treatment and support to address drug/alcohol misuse or emotional and mental health issues that so often result in crime and disorder. By successfully tackling crime, anti-social behaviour and other quality of life concerns for communities the police, council, fire service and other partners help reduce fear and anxiety of crime that leads to significant levels of stress and ill health. Partnership working to reduce levels of violence and substance misuse also reduces the demand on health and social careservices.

Cardiff Community Safety Partnership (CCSP) provides the local strategic framework for action and priorities on this agenda, with the aim of making Cardiff a safer place to live, work and visit. This strategic leadership is supported by practitioner and thematic task groups on priority issues, including several that have direct relevance to health and well being (e.g. substance misuse, anti-social behaviour, domestic violence, community cohesion and reassurance).

The CCSP is responsible for the developmentof the Community Safety Action Plan which will provide the detail of implementation and monitoring of activity. The strategic aim for2008 and beyond is to develop and implement a sustainable programme of multi-agency neighbourhood management in order to address holistically the problemsassociated with anti-social behaviour, crime, behaviour adversely affecting the environment and substance misuse across Cardiff.

IMPROVING THE CITY ENVIRONMENT

Physical and environmental factors have major impacts on health. How cities are built, the urban environment designed, andaccess to the natural environment provided,can be a great encouragement to physical activity and active living. This involves access to the countryside and urban green spaces and also includes issues such as provision for pedestrians and cyclists in city centres, the design of buildings, and the layout of towns and cities.

The Local Development Plan anddevelopment control process provide the policy framework for new development.

Strategic Environmental Assessment (SEA) and Sustainability Appraisal of the LocalDevelopment Plan will consider the environmental, social and economic effects ofthe strategy, policies and proposals to ensure that the decisions made will accord with the principles of sustainable development andinclude consideration of the impact on health and obesity.

The physical environment can also have potentially adverse effects; the link between poor air quality and respiratory problems is well established and many ‘brown-field’ sites earmarked for regeneration are contaminated by potentially harmful substances.

Neighbourhood and environmental noise may lead to annoyance, sleep disturbance, increased stress and loss of quality of life. The environment is also associated with deprivation – the most disadvantaged people tend also to suffer the worst environmental conditions.

Whilst specific health protection interventions are available to deal with many of these issues, appropriate consideration in strategic planning and development can help prevent problems arising. Noise, air quality and landcontamination are all material considerations in the development control process.


Air QualityThe National Air Quality Strategy sets health-based standards and objectives for key pollutants, together with measures designed to cut emissions and improve air quality in coming years. Further local action must be taken where national measures alone will not be sufficient to meet the objectives.

Following recent reviews and assessments of air quality in Cardiff, two Air Quality Management Areas (AQMA) have been declared, one in respect of St MaryStreet/High Street, and one centred on Cowbridge Road West at Ely Bridge. In August 2007, an experimental traffic orderwas introduced in St Mary Street/High Street, prohibiting all traffic except buses, taxis, emergency vehicles and cyclists. There is a clear link here with the physical activity agenda – action resulting in increased levels of walking and cycling should also lead to beneficial impacts on air quality.

Land DevelopmentIncreasing population, city development and regeneration will continue the demand for sustainable redevelopment of brown-field sites. Cardiff Council has developed a

Contaminated Land Inspection Strategy, investigating and identifying sites where immediate remediation is required. The Strategy is implemented using a risk-based approach, utilising opportunities through the development control process, appropriate use of enforcement powers and access to Assembly Government funding to supportfurther investigation and remediation work.

NoiseIncreases in population density, economic developments and the thriving entertainment industry in Cardiff have presented new challenges for noise control. The introduction of the 101 Single Non-Emergency Number service in 2006 introduced a full 24-hour contact centre for noise complaints for the first time in Cardiff. This has led to a doubling in the number of complaints made to the authority and a similar increase in formal enforcement action. There is a pressing need to strengthen the noise control service to enable it to respond effectively and efficiently to these issues at all times.

2008 - 2011

1. Continued monitoring of air quality in the St Mary Street AQMA to identify whether national air quality objectives will continue to be exceeded following introduction of the traffic order.

2. Strengthen the noise control service to enable effective and efficient response to increased demand and need, particularly outside usual office hours.



4. Programme for Health Service Improvement

Programme for Health Service Improvement46

Ensuring that effective and efficient hospital andcommunity based health services to care for peoplewith immediate and long term health needs is a keycomponent of the Local Health Board’s

responsibilities. This section highlights the areaswhere the local health community will focus its plansfor service development during the operationalperiod of the Strategy.

The Review of Health and Social Care in Wales,advised by Derek Wanless, described the challengesthat face Local Health Boards, Local Authorities andtheir partners in planning and delivering sustainableand affordable services for the future. The Assemblypublished its Strategy, ‘Designed for Life’ in 2005, asa national 10 year plan for the NHS in Wales toachieve world class standards of service delivery.Central to this plan were both the modernisation ofservice delivery in line with the principles of thereview of health and social care, supported by a

capital programme to take forward the renewal ofthe NHS estate.

‘Designed for Life’ also set out the Assembly’s targetsfor achieving substantial and sustained reductions inthe length of time patients wait for in-patient andout-patient, diagnostic and therapy services andimprovements to cancer treatments and services, inline with national standards. Collectively this isknown as the Access 2009 project, the annualtargets for which are set in the Assembly’s AnnualOperating Framework.

The local NHS community has recognised the needfor significant changes in the way in which localhealth care is provided, and is working with a widerange of partners to define and implement anextensive programme of change. This programme,known as the Programme for Health ServiceImprovement (PHSI) has been established to driveforward the modernisation and transformation oflocal services in response to ‘Designed for Life’. TheProgramme aims to support the development of localservices to meet current and future health careneeds, within available resources, by modernisingand improving the way services are planned anddelivered. The PHSI has been developed through acomprehensive process of ongoing engagement withNHS staff, the public and partner organisations. Thisis to ensure that any opportunities to integratehealth and social care services, in particular, aretaken in line with WAG policy direction.

Cardiff Local Health Board alongside the Vale ofGlamorgan LHB and Cardiff and Vale NHS Trust arethe three local NHS bodies responsible for theProgramme. A Programme Project Board has beenestablished with representation from key partnersand stakeholders. The programme forms a keyfocus for delivery of NHS service improvement withinthe wider context of the Health, Social Care and WellBeing Strategy. The local health community is alsoworking with other Local Health Boards and NHSTrusts in South East Wales to ensure that plansaddress those specialist services which need to beplanned and provided on a regional basis, includingsurgical and non-surgical cancer services and thefuture development of the regional cancer centre,critical care and cardiac services.



The objectives of the Programme are todeliver:

A network of locally based primary and community based services that meet the needs of individuals and communities. The LHB and Trust recognise that there is a need to improve access toprimary care services to offer more comprehensive care as close to patients’ homes as possible. This will involve developing new models of care to achieve the right balance between primary care, community services and hospital care. In particular, this will ensure that people with complex conditions will have access to education, support and care that helps themmaintain their independence, thereby avoiding unnecessary admission or lengthy stays in hospital.

Alignment with social care support services and other local authority services including housing, education and leisure is alsorecognised as being central to this objective,

as is close working with non-statutory, voluntary sector and independent providers of health and social care.

Improved, sustainable access to planned hospital treatment to achieve theWelsh Assembly Government target of a maximum total waiting time of 26 weeks by December 2009 for in-patient care. This will require new ways of working to manage demand and provide care.

A reduction in unplanned admissions and delayed transfers of care through, for example, ensuring arrangements are in place as an alternative to admission throughout the day and undertaking patient education. Patients who no longer need to be in hospital will be discharged appropriately and with the necessary support in place based on their needs, and the needs of their family/carer.

Joint working with partner organisations to provide services in an integrated way, based on the needs of the individual.

A major formal consultation exercise will be undertaken, commencing in May 2008, on the PHSI proposals to improve health services in Cardiff and the Vale of Glamorgan.

A Communication and Engagement Strategy has been developed and the Action Plan provides guidelines for the approach to support successful consultation.

The majority of community and hospital services, including mental health services, are provided to the residents of Cardiff by Cardiff and the Vale NHS Trust, the largest Trust in Wales and the third largest in the UK. The Wales College of Medicine, Cardiff University is also an integral part of the Trust with approximately 35% of Specialist Registrars in Wales employed through their association with the college.

The Cardiff Needs Assessment, which has been undertaken for the Health Social Care and Well Being Strategy, clearly highlights significant scope for improving the health and well being of the local community, and for ensuring that local services are responsive,

appropriate and sustainable.

Services in the Trust are provided from 8 hospitals and 17 health centres and clinics across Cardiff and the Vale of Glamorgan. These include a number of buildings that donot meet modern building standards including Cardiff Royal Infirmary, RookwoodHospital and Whitchurch Hospital. Cardiff has one purpose built community hospital, St David’s Hospital.

Residents of Cardiff also access secondary care services through referrals made to Pontypridd and Rhondda NHS Trust, Bro Morgannwg Trust and Gwent Healthcare NHS Trust.

Programme for Health Service Improvement 47

CONSULTATION

CURRENT SERVICES

Cancer services for Cardiff residents are provided by Cardiff and Vale NHS Trust and Velindre NHS Trust and are commissioned in conjunction with LHBs across the South East of Wales.

The LHB also holds contracts with 52 GP Practices, 57 Dentists and 76 Pharmacy outlets and there is the potential for a newOptometry contract to be implemented in the life of this Strategy relating to the 41 Optometry outlets in Cardiff.

The key achievements within the period of the first Strategy predate ‘Designed for Life’ and the Programme for Health Service

Improvement and provide the strategic workon which these new plans build.

2005 - 2008

� Reduction in waiting times for elective out-patient and in-patient specialities.

� Opening of the orthopaedic surgical centre at Llandough Hospital, allowing for local treatment of all patients and contributing to reduced waiting times.

� Partial achievement of ‘referral to treatment times’ for newly diagnosed cancers.

� Opening of Midwifery led units at Llandough and UHW and a combined obstetric unit on the UHW site.

� Development of integrated care pathways for chronic disease such as diabetes and respiratory disease.

� Completion of public consultation on services for central and eastern Cardiff.

� Initiation of review of healthcare services through the Programme for Health Services Improvement.

� Expansion of access to NHS dental services through introduction of a new contract.

� Agreement of a model of care for rehabilitation services by clinicians, that will allow many services currently provided in a hospital setting, to be moved to new locations in the community.

The basis of the identified needs for service improvement is the totality of the needs assessment undertaken in 2004 and updated in 2007. The Cardiff Health Alliance reconsidered the original qualitative and quantitative needs assessment and agreed that the 2005-08 priority areas should remainthe focus for service planning.

The following principles also underpin these priorities:

� The need to reduce inequalities in health and promote positive health

� The need to plan service delivery for a growing population

� Engagement and empowerment of individuals and communities

� Early intervention � Whole systems approach � Links to other services (housing,

transport, etc).


KEY ACHIEVEMENTS

IDENTIFIED NEEDS FOR THIS SERVICE AREA

A central theme for the delivery of service change and improvement, during the life of this Strategy, will be to continue and strengthen the emphasis placed onpromoting health and well being through all

services in the NHS. This focus, delivered in partnership as well as targeted preventative action, will include moving services away from hospital settings and closer to home.

Reducing inequalities in health and service provision will be a key component of the future service models and development, as more services are provided in the communityand are both targeted and allocatedaccording to the greatest levels of identified

need in the city. This approach will take account of both geographical differences inhealth need as well as increasingly providing services tailored to meet the requirements of the most deprived in Cardiff.

2008 - 2011

1. To develop rehabilitation and re-ablement services to maximise individual’s independence to include the implementation of locality based consultant led rehabilitation services which will enable the replacement of Rookwood Hospital and West Wing (CRI) Hospitals.

2. Continued implementation of the mental health strategy to deliver community based models of mental health services leading to the closure and re-provision of Whitchurch Hospital.

3. To improve hospital based services for children through the development of the second and final phase of the Children’s Hospital for Wales.

4. Implementing a strategy for primary care and community services in new purpose built premises to replace existing health centres and clinics and some GP practices.

5. Opening Cardiff’s first Locality Health Resource and Treatment Centre on the Cardiff Royal Infirmary site and plan for two similar facilities serving the north and west of the city.

6. Implementing new models of supporting people with chronic disease and improving performance of emergency care services.

7. Further develop cancer services in conjunction with the South East Wales Region that meet all Wales cancer standards and targets.

8. Reductions in waiting times for patients accessing in-patient, day-case, out-patient, therapy and diagnostic and cancer services in line with the Access 2009 Waiting Times Targets for the NHS by December 2009.

A specific Implementation Plan relating toPHSI has not been developed as part of the Health, Social Care and Well Being Strategy

process. However, detailed proposals will be published in May 2008 by the health andsocial care community.

Programme for Health Service Improvement 49

PROMOTING HEALTH IMPROVEMENT

REDUCING SOCIAL INEQUALITIES


PLANS

Velindre NHS Trust provides a range of specialist services at local, regional and all Wales levels. The Trust comprises of a variety of divisions who specialise in a diverse range of services, including caring for cancer patients in Velindre Hospital, Cardiff.

Velindre NHS Trust submitted a business caseto the Welsh Assembly in January 2005 requesting capital funding for the future provision of cancer services for the population served by Velindre Cancer Centre.

This investment sought to address the requirements to meet the demand for non-surgical cancer services for South East Wales for the next 10 years.

A Strategic Outline Programme (SOP) was developed to address the need for investment to improve non-surgical cancerservices (i.e. radiotherapy & chemotherapy).

The development of the SOP was formalised

by the establishment of a Programme Board.The draft SOP, submitted to WAG inNovember 2006, outlined five high level options for models of service delivery for consideration.

Wide engagement with ‘Informed Stakeholders’ was conducted, including five events held across different locations in S.E.Wales during June 2007.

The outcome from the Stakeholder Events was strong support for taking forward option‘E’, i.e. to develop Velindre Cancer Centre byacquiring additional adjacent land toaccommodate seven linear accelerators and improved in-patient and day case facilities, research and development facilities and other associated patient services. In addition,option ‘E’ relies on the development of asatellite radiotherapy centre somewhere in S.E. Wales (location to be determined).

The draft Capital Programme ImplementationPlan (CPIP) was submitted to WAG in July2007, and included detailed plans addressing radiotherapy and chemotherapy expansion; Velindre Cancer Centre (VCC) sitedevelopment and the development of a satellite radiotherapy unit.

Velindre NHS Trust is working on the development of the Velindre Cancer Centresite in Cardiff with a view to accommodating seven linear accelerators & improving

facilities on the VCC site. This first step of the SOP implementation (Phase 1) will help achieve the urgent requirement to meet the Ministerial targets for 31/62 cancer waiting time. Planning permission for Phase 1 of the site development has been granted.

Expressions of Interests have been received from Trusts in a position to host a satellite radiotherapy unit. Work is ongoing to develop a robust analysis process prior tofurther stakeholder engagement.


NON-SURGICAL CANCER SERVICES

PLANS

5. Children and young people

Children and young people 51

In 2006, there were a total of 55,272 children inCardiff aged 0 – 14. Just under 16,000 children inCardiff are living in relative poverty using thepercentage of children aged under 16 living inhouseholds dependent upon workless benefits as aproxy measure of need. This represents over aquarter of the under 15 age population, which is 3%higher than the Welsh average and places Cardiff 6thout of 22 in Wales, in relation to this indicator ofchild poverty.

The health and well being of children and youngpeople is a priority for the Welsh AssemblyGovernment, Cardiff Local Health Board and CardiffCouncil. Cardiff Health Alliance has identifiedchildren and young people as a key priority for thisStrategy.

Investing in children and young people provides thefoundation for the health and well being of thefuture adult population. It is often the most effectivepoint of intervention. In a drive to improveoutcomes for children and young people, the WelshAssembly Government issued regulations andguidance in July 2007 requiring the publication of aChildren and Young People’s Plan (C&YP Plan), ineach local authority area, in accordance with section26 of the Children Act (2004). The C&YP Plan will bea 3 year strategic plan developed and owned by themulti-agency Children and Young People’sPartnership (C&YPP), providing the details ofplanning intent for children and young people in

Cardiff. It will act as the reference point for all otherplans and will thus function to give effect to theHealth Social Care and Well Being Strategy (HSC&WBStrategy), as it relates to children and young people.It will provide strategic vision and agreed prioritiesthat will direct the work of all partners, seeking tostrengthen co-operation across public services andwith voluntary and private sector partners and to putin place effective integrated services for all childrenand young people.

The initial C&YP Plan is required for the financialyears 2008-09 to 2010-11, aligned with the planningcycle of the HSC&WB Strategy. However, inrecognition of the need for partners to becomefamiliar with the new process and undertake robustneeds assessment, service provision mapping andconsultation, the statutory guidance requires the firstPlan to run from September 2008. This is sixmonths behind the date of publication of thisHSC&WB Strategy, so the content of this chaptershould be regarded as a description of work inprogress; an account of the latest iteration of theC&YP Plan at this point in time. It describes broadstrategic direction, identifies achievements againstpriorities already established for children and youngpeople and highlights some of the key challenges.The detail of how those will be addressed will becontained in the C&YP Plan through the identificationof target improvements in outcomes for children andyoung people and the agreement of keycommissioning priorities.

The Welsh Assembly Government set out its visionfor children and young people in `Children andYoung People: Rights to Action and ExtendingEntitlement: support and services for young peoplein Wales’. This has since been supported by‘Stronger Partnerships for Better Outcomes’ (July2006), which provided guidance in line with theChildren Act (2004) on local duties to co-operate andlead roles in local authorities, LHBs and NHS Trusts.It highlighted the role of Children and YoungPeople’s Partnerships as the forum through which theduty to co-operate should be delivered.

Further guidance issued in July 2007, ‘SharedPlanning for Better Outcomes’, set out requirements,under section 26 of the 2004 Act, for local authoritiesto work through the Partnerships to publish aChildren and Young People’s Plan. The scope of thePlan extends across services for all children andyoung people from the ante-natal stage to the age of19 years, together with care leavers up to 21 andthose receiving youth support services up to the ageof 25. Planning for the C&YP Plan is to be the leadplanning mechanism for health, social care and wellbeing issues for children and young people and


Children and young people52

over time, as the planning cycles align, its priorities will be reflected in the HSC&WB Strategy.

A National Service Framework for Children, Young People and Maternity Services in Wales (NSF) was launched at the end of 2004, which aims to drive up quality and reduce variations in service delivery through the setting of national standards. The completion and analysis of a self assessment

The Cardiff C&YP Partnership Board isdeveloping a vision that will ensure that the Assembly’s seven core aims for all children and young people are further translated into action. To facilitate this, the Partnership has re-modelled itself to construct and implement the CYP Plan. Five multi-agency groups are working on developing the Plan which will be structured in accord with the seven coreaims. The core groups cover the areas of:

� Health and Social Care � Nurturing Families and Communities � Leisure, Play and Culture � Participation and Involvement � Purposeful Learning

There will be an emphasis in the work of these groups on early intervention and the provision of preventative services. In accord with this, the Partnership has developed a number of strategies in relation to its work which have, or are developing, delivery plans. These will be overseen in future by the above groups. The Family Support Strategy and aPlay Strategy are examples of such plans.

The Cardiff Family Support Strategy, (launched on 13th February 2008) was developed to improve the well being andopportunities for children and young people (and the confidence and self-esteem of parents/carers), through provision of better integrated, more comprehensive family support. Among the needs identified byparents and professionals was the requirement for improved transitionalarrangements for young people who have ongoing service requirements into adulthood. The strategy states that protocols will be developed between children’s and adults’

services wherever there is likely to be anongoing need.

The C&YP Partnership is involved closely in the work of the Cardiff Local Service Board (LSB) development projects. One aspect ofwork ongoing under the framework of theLSB is to better link and rationalise the partnership work undertaken across the Community Safety Partnership, the Health Alliance, the Voluntary Sector Compact and the C&YP Partnership. In addition, members of the C&YP Partnership are actively involved in three of the LSB projects. The ‘Ask Cardiff’ project, the Neighbourhood Transformationprogramme and the Scrutiny and Performance project will all be contributed to by the Partnership, with the aim of strengthening and better aligning work on participation, on tackling inequality and on performance management.

Current work of the Partnership is focussed on three major areas of priority:

� Purposeful Learning � Furthering Emotional and Mental Health

and Well Being � Family Support Strategy Implementation.

These areas of work are underpinned by a set of underlying priorities of which the most significant is participation work with children and young people; work required so that plans are genuinely responsive to their expressed needs. A range of other work underpins different parts of service delivery including the development of information sharing protocols and implementation of the National Service Framework (NSF).

audit tool by partner agencies, on an annualbasis, highlights areas of strengths and weaknesses and will inform the priorities set in the C&YP Plan. In addition, various national and local topic based strategies and plans influence the health improvement agenda that focuses on children and young people, for example regarding food and health, physical activity, emotional and mental health, substance misuse, tobacco control and sexual health.

REGIONAL & LOCAL STRATEGIC CONTEXT

There is also development on specific issues including Young Carers, Healthy Schools and respite care for children with complex needs.

A significant new development in 2007-08 is the establishment of the Flying Start Programme providing intensive support for 0-3 year olds in targeted areas of the city.

All needs assessment and service profiling work undertaken within the C&YP planning process will be analysed by the five core groups set up within the Partnership. Gap analysis will be used to set local targets as required by the Plan and development requirements fed into the Joint Commissioning Group. This work will incorporate all other strategic planning andservice review processes affecting children and young people. An example of such workis a review of children’s community health services being led by the Cardiff and ValeNHS Trust, with input from partners, with the aim of developing a shared vision for the direction of these services and opportunitiesfor improved partnership working in order to inform future commissioning priorities.

Comprehensive audits on the range of services provided across the statutory, voluntary and independent sectors to children and young people in Cardiff have previouslybeen commissioned through the Partnership and this information will be updated and provided in more detail in the C&YP Plan, to be operational from September 2008. The following summarises the areas across which services are provided:

Health � A range of health improvement work

around topic issues including: emotional and mental health, sexual health, nutrition, substance misuse, smoke free work and settings work such as the Healthy Schools scheme, delivered through the Children and Young People’s Health Action Plan.

� Primary care services including: health visiting, school nursing, Sure Start.

� Secondary care services including: community based child development services, child and adolescent mentalhealth services, children’s community nursing services providing care forchildren at home with complex needs.

� Phase 1 Children’s Hospital for Walesproviding dedicated wards for children’s medical services and a cancer unit, with future plans for Phase 2 to consolidate the provision of hospital services for children in a single setting including a new building.

� Children’s Tertiary Services including the following specialities: renal services, neurology, surgery, cardiology, respiratory, gastroenterology.

Children’s Social Care � Assessment, case management &

reviewing services.

� Services for children in need (including children with physical and sensory impairments and/or complex health needs) including: parenting programmes, practical support, domiciliary support,respite care, packages of support enabling transition from child to adulthood, support for young carers.

� Services for children at risk of serious harm including the co-ordination of child protection enquiries and plans, specific interventions to manage and reduce risk of harm, ensuring arrangements for long term security of children.

� Looking after children who cannot remain with natural families including short and long term fostering, residential care, secure care, support and therapy packages for children with complex needs, preparation for adoption.

� Services for children and young people who have been looked after including post adoption support, supported accommodation, mentoring.

Schools and Lifelong Learning � A range of educational settings across

Special Schools, Specialist Resource Bases (SRB) and mainstream settings that are offered support, training and capacitybuilding across all aspects of the inclusion


CURRENT SERVICES

agenda, to support vulnerable young people.

� An Integrated Children’s Centre (ICC) that is a working model for the developmentand delivery of integrated services for young people, working in collaboration with the development of the Foundation Phase.

� Identified and targeted teams to supportthe achievement of identified vulnerablegroups – LAC (Looked After Children), EMAS (Ethnic Minority Achievement Service), HEC (Health and Exceptional Circumstance), TES (Traveller Education Service), SEN (Special Educational Need), ASD (Autistic Spectrum Disorder), HI (hearing impaired), VI (visually impaired), and SLCD (speech language communication difficulties).

� Early years processes and panel thatsupports early identification of need and joint problem solving of individual vulnerable young people.

� Training and support on safeguardingarrangements co-ordinated by a Child Protection Officer.

Leisure, Libraries & Play � For looked after children free Stretch

Cards give access to a range of activities at local authority leisure centres and pools.

� A range of activities and programmeswithin the leisure centres and community halls, plus purpose built areas such as a BMX track, skate parks and active play equipment.

� Targeted schemes including school holiday provision, play inclusion project for children with physical or sensory impairments, minority ethnic communities, play provision for gypsy andtraveller communities.

� Sports development work with children and young people in various ways e.g. Dragon Sports, Active Schools & Active Communities.

� Seven open access play centres and play scheme provision – after school and school holidays via the outdoor activity team.

� Parks provide playground facilities,educational opportunities via the Park Ranger Service, apprentice scheme,motor bike track.

� Libraries provide a dedicated children’s librarian, bookstart scheme and activities for children such as story times (e.g.Summer Reading Scheme and Children’s Book Week), dedicated computers, youth workers in three libraries.

� Arts provision via numerous programmes covering all ages e.g. the Children's Prom Schools Gamelan Projects, pre-school music workshops, a comprehensive work experience programme, summer youth events in dance and rock/pop music.

Voluntary Sector There are an estimated 2,500 voluntary organisations in Cardiff, many working in areas of social welfare often with the most disadvantaged groups and communities. A large proportion of these organisations workwith children, young people and families providing a diverse range of services:

� Universal services including purposeful activity, promotion of cultural heritage, information and advice (on subjects such as substance misuse, sexual health, health fitness, volunteering, children’s rights and global citizenship), purposeful learning, out of school childcare, play opportunities.

� Specialised or targeted services including advocacy and self advocacy, parenting programmes, targeted family support,anti-bullying work, therapy for children with specialist health needs, respite services, counselling services, personal development, supported housing, mentoring schemes, support for children with physical or sensory impairment and learning disabilities, family group conferencing, anger management, childand parent support services, supervised contact services.

� Work with children from all geographical communities and communities of interest (such as children from minority ethnic families, children with physical or sensory impairments, young carers, bereaved children, families with issues around substance misuse, single parent families,


children with learning disabilities, young parents, Not in Education, Employment or Training (NEET) children and youngpeople, children with specialist health needs or chronic illness, families from

gypsy and traveller communities, homeless families, adopted or fostered children, children with behavioural difficulties).

2005 – 2008 Emotional & Mental Health � ‘Cardiff Against Bullying’ project established – first steps taken towards developing an anti-bullying

strategy and action plan � ‘Bounceback’ project underway, working in 4 High Schools to provide personal support to vulnerable

young people, supporting emotional resilience � ‘Pyramid’ project re-established, working in primary schools to increase confidence and self-esteem of

vulnerable children � Primary Mental Health Team established, work programme developed and Book Referral Scheme

launched � Barnardos focus group research on children’s understanding of their emotional and psychological well

being undertaken in 2 schools. Purposeful Learning � Exceptional provision panel fully operational � Work on accreditation of learning in informal settings led to production of report on the youth service � New young parents service implemented� Mentoring support scheme for primary/secondary transition set up � Young offenders returning from detention receiving new provision � Somali Achievement project launched and varied elements of provision implemented. Family Support Strategy � Full strategy mapped out and implementation begun � New posts set up and recruited � Major conference held March 2007. Flying Start � Planned through assessment stage � Senior staff recruited � Delivery programme agreed � School catchment areas selected. Participation and Engagement � U-Share network developed � Adoption of ‘Hear by Right’ across partnership sectors and organisations to measure progress on

participation � Young consultants delivered entitlements workshops in schools and youth settings. Information Sharing � Protocols agreed and signed up to by main C&YP Partnership organisations. Young Carers� Strategy and Action Plan developed � Development Officer appointed � Leaflet and information booklet developed � Social and Support Club running once a week. Other � Health improvement components of C&YP Partnership plans implemented, including the Youth Health

Action Plan (by C&YP Health Task Group): - Cardiff Network of Healthy Schools Scheme: This WAG funded programme operates in 80 schools,

providing support to develop and deliver health promoting action plans focussing on food and fitness, mental health, sexual health and smoke free issues.

- Sexual Health: Priority actions delivered include implementation of the community based Condom-card scheme, provision of sexual health training and resources to teachers, youth and community workers, piloting a co-ordinated approach to Sex and Relationships Education in a group of secondary schools.


KEY ACHIEVEMENTS

- Substance Misuse: priority actions delivered, including substance misuse prevention projects and substance misuse education in schools and community settings.

- Smoke Free: priority areas delivered include ‘2Tuff2Puff ‘ Adolescent Smoking Cessation scheme and the provision of smoking cessation skills training to youth, health and community workers

� National Service Framework self assessment audit tool completed and development plan agreed � Estyn Inspection of Youth Support Services undertaken � Youth Health Action plan implemented by C&YP Health Task Group � Expansion of the Community Children’s Nursing Service, utilising Wanless funding to increase respite

care to families with children meeting Continuing Health Care eligibility criteria.

The first phase of development of the C&YPPlan was to undertake a needs assessment. Building on previous work, the C&YP Partnership co-ordinated an up to date and comprehensive identification of need, drawing on data from a wide range of sources and partner agencies. Relevant research, information and data was utilised including data routinely collected by agencies; information on need included inother plans such as the Local Safeguarding Children Board Business Plan; data collected by services and practitioners; baseline assessment against NSF; consultation with children, young people and their families; inspection reports.

The information gathered has been organised and analysed against each of the seven core aims; analysis includes trends over time, anassessment of future demand and consideration of the needs of particular groups of children and young people. This has enabled appropriate target outcomes tobe set and with service profile information, has been used to identify gaps in serviceprovision and overlap or duplication. This will provide an indication of opportunities for new and existing services to be jointly commissioned, brought together andcommissioned differently, or decommissioned.

The Priorities and Key Strategic Aims section of this chapter sets out some of the key service development needs already identified, which have been further informed by the output of the Partnership’s self assessment against the National Service Framework (NSF) standards. A more comprehensive setof priorities will be identified through the development of the C&YP Plan.

Needs Assessment work undertaken to inform the HSC&WB Strategy has identified data around the age structure within different areas of the city, which will inform how services for children and young people are targeted to meet the needs of particular communities. The distribution of children inCardiff is:

Just under 20% of Cardiff’s children live in the Central locality: � Pentwyn is the only Central area with a

proportion of children higher than the Cardiff average, containing almost a third of Central’s children

� Cathays (the City Centre) has a very low proportion of children and contains only 7% of Central’s children

Just over 26% of Cardiff’s children live in South East Cardiff:� Trowbridge contains over one quarter of

this locality’s children

� Grangetown contains approximately 22%

Just under 30% of Cardiff’s children live in West Cardiff:� 24% of the West locality’s children live in

Ely

� 14% live in each of the electoral areas ofRiverside, Caerau and Fairwater

Just under 25% of Cardiff’s children live in North Cardiff: 2% of the North locality’s children live in Llanishen � about 18% live in Whitchurch/

Tongwynlais

� just over 5% live in Gabalfa

� around 4% live in Lisvane.



Children and young people are a key target group for health improvement and service delivery. In addition to the strategic direction set by the NSF, Cardiff has a Children and Young People’s Health Action Plan which sets out how national strategies for promotinghealth improvement will be implemented locally. Future work will focus on the following:

Healthy Schools Recruiting further schools to the Cardiff Network of Healthy Schools Scheme to ensure all schools are recruited to the Scheme by 2010.

Sexual HealthIncreased focus to ensure that vulnerable young people (Looked After Young Peopleand those with learning disabilities) have opportunities and support to access sexual health information, advice and services. A reduction in the number of teenage pregnancies will be a focus for this programme.

Emotional & Mental Health and Well BeingIncreased focus on developing a co-ordinated approach to informal and formal personal support and counselling for children and young people, targeted in disadvantagedareas and with vulnerable groups. Increasing primary mental health support to Tier 1 workers.

Substance MisuseCo-ordinated activity to address alcohol misuse in young people is required.

Smoke FreeThere remains limited focus upon the youngpeople’s cessation agenda and further local work and work with the All Wales Smoking Cessation Service is required.

Health Improvement Training Training for practitioners (teachers, youthand community workers).

The Partnership will arrange for the self-assessment and review procedures in Plan implementation, to include an evaluation ofequality impact. There are significant geographical variations within the city in terms of deprivation affecting children and young people and the intention is to address these by targeted community programmes such as Flying Start and through the LSB Transforming Neighbourhoods programme. The C&YP Plan will contain a statement setting out how the relevant partners will discharge their responsibilities under requirements of equality legislation.

Race The Partnership will make full use of available data in shaping services. Support for the needs of minority ethnic communities is set as a priority for Communities First in Cardiff and also for the C&YP Partnership in terms of its use of the discretionary Cymorth Fund.

GenderNeeds assessment indicates some instances in which young people fare less well according to their gender. This will be addressed in the C&YP Plan.

Disability Needs assessment indicates that service developments are required in order that children with physical or sensory impairments and young people can access their entitlements. The Plan will include details of jointly commissioned improvements to services.

Sexual Orientation The Partnership has funded local research into the needs of lesbian, gay, bisexual andtransgender young people and will use the results in shaping service delivery.

Language of ChoiceThe Partnership will ensure that language of choice is recorded and contributes to interpretation of service level decisions. Increase in accessibility to Welsh medium




services is part of the Young People’s action plan in response to Estyn inspection of youth support services.

Religion & BeliefThe Partnership is committed to engagingwith all faith communities in its participation and involvement work so that its anti-discriminatory activity is well informed and is not merely passive.

Age Integral to the Partnership’s work is enabling all children and young people to access their entitlements. The re-structured Partnership is not organised according to age and this change is intended in part to help assist children and young people through important age transitions in their lives.

The priorities listed below are based on some of the key service development needs already identified, further informed by the output ofthe Partnership’s self assessment against the

NSF standards. A more comprehensive set of priorities will be identified through the development of the C&YP Plan.

2008 - 2011 1. To promote health improvement � Each of the Partnership’s five multi-agency groups working to deliver the seven core aims is to consider

health improvement as a core element of their agenda2. To reduce inequalities

Each of the Partnership’s five multi-agency groups working to deliver the seven core aims is to consider the need to reduce inequalities as a core element of their agenda

3. That the C&YP Partnership is fit for purpose to deliver improved outcomes for children and young people To develop and publish the first Children and Young People’s Plan by September 2008

4. That all children have a flying start in life and the best possible basis for their future growth and development Full implementation of the Flying Start programme in Cardiff

5. That all children and young people have access to a comprehensive range of education, training and learning opportunities, including acquisition of essential personal and social skills

� All children, including those with complex/special needs, or who are in hospital/ experiencing illness, are supported in appropriate education

� Further development of Keeping in Touch arrangements, providing evidence of a reduction in young people who are not in education, training and employment

6. That all children and young people enjoy the best possible physical, mental, social and emotional health, including freedom from abuse, victimisation and exploitation

� Build on improvements in multi-agency co-ordination & delivery of child protection services and to follow up work commenced in respect of children at risk of significant harm as the result of neglect

� Improved access and co-ordinated provision of health improvement support and specialist services tovulnerable young people, including sexual health, emotional and mental health and substance misuse

� Build on improvements in multi-agency working in assessment, care planning, intervention and review for children with physical or sensory impairments and complex needs

� Identify and secure funding to progress the next phase of the Children’s Hospital for Wales 7. That all children and young people have access to play, leisure, sporting and cultural

activities � Full implementation of the Cardiff Play Strategy 8. That all children and young people are listened to, treated with respect, and are able to

have their race and cultural identity recognised. Improved policies and mechanisms for the inclusion and participation of children/parents/carers in services they receive

� Independent advocacy services in place for children and young people



9. Provision of a safe home and a community that supports physical and emotional well being � A sufficient range of fostering and residential placements within Cardiff to meet the needs of children &

young people who are looked after � Implementation of the Family Support Strategy 10. That all children and young people are not disadvantaged by child poverty � Foundation Research project undertaken as part of the LSB Neighbourhood Transformation programme,

to review and analyse service delivery to children and young people in different parts of Cardiff.

Work has been undertaken at a national levelto describe a range of priority outcomes for children and young people together with relevant outcome measures. The resulting outcome measures framework, set out in Children’s Act Guidance, uses measures that are currently available and collected. The Partnership will set local measures to augment these national outcome measures setting targets through the work of coregroups. This will take account of any developments to the national performance measurement framework and the

development of Demonstrating Success forassessing impacts on 11-25 year olds.

In addition to the above, each statutory partner will need to ensure delivery against designated statutory targets, including those identified in the NHS Annual Operating Framework and performance targets agreed between the Welsh Assembly Government and the Local Authority covering care and permanency planning and number of school placements for looked after children.


6. Mental health

Mental health60

The World Health Organisation (WHO) states thatthere is no one definition of mental health andcultural differences. Subjective assessments andcompeting professional theories all affect how mentalhealth is defined. The positive dimension of mentalhealth is stressed in the WHO’s definition of healthas ‘a state of complete physical, mental and socialwell being and not merely the absence of disease orinfirmity’.

Mental health problems are very common withinsociety. The National Public Health Service for Wales‘Needs Assessment Update’, 2007, states that thebest evidence of the prevalence of psychiatricdisorder is provided by the National Survey ofPsychiatric Morbidity. Estimated numbers of people

aged 15 - 64 with psychiatric disorder in Cardiff are:psychoses (938 people), alcohol dependence(11,018), drug dependence (5,157), all neuroses(37,507), and depressive episode (5,626).

The modernisation of mental health services anddevelopment of mental health promotion initiativesare a priority for the Welsh Assembly Government,Cardiff Council, Cardiff Local Health Board andCardiff and Vale NHS Trust.

This chapter focuses on adults of working age andolder people. Mental health services for children andadolescents are considered within the Children andYoung People section.

Cardiff Health Alliance identified mental health as akey priority for health and social care services.Cardiff and Vale NHS Trust is the biggest localprovider of mental health services, with CardiffCouncil as the other statutory provider. Theseorganisations work together, with Cardiff LHB, theNational Public Health Service, the voluntary sector,service users and carers to plan and provide mentalhealth services. This is conducted formally throughthe Mental Health Advisory Planning Group (APG).The Mental Health APG is responsible for developing,planning and implementing improvements in mentalhealth services for adults and older people. Itcomprises representatives of service users, carers,

the voluntary sector, Cardiff Council, Cardiff & ValeNHS Trust, Cardiff LHB, Cardiff Community HealthCouncil and the National Public Health Service. Muchof the planning and delivery of services is carried outjointly with the Vale of Glamorgan LHB and the Valeof Glamorgan Council. The Cardiff Mental HealthPromotion sub-group is a multi-agency group, set upto develop a partnership approach to thedevelopment and delivery of a mental healthpromotion action plan in line with the Adult MentalHealth National Service Framework (NSF).

Local plans that inform this Health Social Care andWell Being Strategy include:


Due to its priority status, a number of strategies,policies and action plans for mental health arepertinent to this Strategy:� Adult Mental Health Services for Wales - Equity,

Empowerment, Effectiveness, Efficiency StrategyDocument, (2001)

� Adult Mental Health Services in Wales – Strongerin Partnership, (2004)

� Adult Mental Health National Service Framework(NSF) and Action Plan, (2005)

� National Service Framework for Older People inWales, (2006)

� Mental Health Promotion Action Plan for Wales:Consultation Document, (2006)

� Race Equality Action Plan for Adult Mental HealthServices in Wales, (2006)


The Programme for Health Service Improvement sets out the Cardiff and Vale health communities plan for modernising health services.

Cardiff and Vale NHS Trust’s Strategic Outline Programme for Mental Healthwas drawn up by the NHS, describing the developments and changes in mental health planned for the next few years. This has been approved by Cardiff LHB and means that Cardiff and the Vale NHS Trust can start the process of accessing funding for new buildings (e.g. new Cardiff Adult In-patient Unit) from the Welsh Assembly Government.

The Cardiff and Vale Adult MentalHealth National Service Framework (NSF) Action Plan In 2005, the Welsh Assembly Government produced its revised Adult Mental Health NSF ‘Raising the Standard’, which required LHBs, NHS Trusts and Local Authorities to produce an action plan showing how these bodies intend toimplement the 44 key actions set out in the Adult Mental Health NSF.

Cardiff Mental Health Promotion Action Plan is required under the Adult Mental Health NSF.

The multitude of mental health services available in Cardiff across all sectors, are listed in the On-line Directory of Services compiled by the Cardiff and the Vale Mental Health Development Project: www.cvmhdp.org.uk/content/public/online_directoryThis includes the Directory of Older People’s Mental Health Services.

Cardiff and Vale Mental Health Development Project (CVMHDP) supports the developmentof networks to ensure a voice for their members. These can represent interest groups such as the voluntary sector, service users and carers such as the Black & Minority Ethnic Older People’s Mental Health Forum,South East Wales Mental Health Network, Cardiff & Vale Mental Health Forum, Cardiff & Vale Service Users Forum, Carers’ Involvement Group and Hafal Cardiff Carers’ Group.

During the last few years, mental health services have been developed in order tostrengthen community services and reduce reliance on in-patient care. This is in line with the All-Wales Mental Health Strategy and National Service Framework. An example of this has been the development of the Crisis

Service (detailed below), which has enabled a reduction of in-patient beds at WhitchurchHospital. However, it is important to note that the move to community services is further developed in Adult Services than in Older People’s Mental Health services.

The vast majority of services are planned and developed through partnership working between Health, Cardiff Council, service users and carers and the voluntary and private sectors. All partners recognise the importance of this approach and will continue to work in this way in the future.

Services are funded from a wide variety ofsources including the Welsh Assembly Government, Local Authority, the Joint Working Special Grant, Wales Council for Voluntary Action Grant, Support for Peoplewith Disabilities Fund, Carers’ and Mental Health Carers’ Grants, Supporting PeopleGrant, Big Lottery and other charitable funding.

The following are examples of some of the services provided to people with mental health problems, as well as to those who may be vulnerable to mental health problems:

ADULTS

In-Patient Services: Hospital beds for adults at Whitchurch Hospital and Llandough Hospital.

Community Services: Community Mental Health Teams (CMHTs) Social work staff are an integralpart of the Community Mental Health Teams,

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CURRENT SERVICES

which are led by Cardiff and the Vale NHS Trust and provide specialist assessment and treatment for people with more severe mental health problems.

Crisis Service comprises the Crisis Resolution and Home Treatment (CRHT) Teams, a Crisis House and a Crisis Recovery Unit (CRU). The CRU provides assessment, therapeutic intervention and support in asafe environment for individuals experiencinga mental health crisis. It is designed to provide a flexible and responsive assessment and treatment service. The service will provide respite for both service users and carers. In some circumstances it will enable carers to return to work, if necessary. The service operates 7 days a week.

Counselling services are provided in GP surgeries by health staff and by a wide variety of voluntary organisations.

Day Services are provided in hospital and community settings by Health, Social Services and the voluntary sector. Increasingly, the focus is on supporting people to access employment, leisure and educationalservices. Resource/drop-in services are provided by the voluntary sector and Cardiff Council.

Liaison services are available, offering specialist assistance to Elderly, Primary Care and General Medicine.

Housing services are provided by Health,Cardiff Council, Housing Associations, the voluntary and private sectors, ranging from floating support to 24 hour staffedaccommodation.

The voluntary sector also provides a wide range of other services in the community including welfare rights, drug and alcohol support services, bereavement services,minority ethnic services, mental health awareness raising and self-help and supportgroups.

Specialist Services: Low Secure and Community Forensic Services supplied by multi-professional teams including social workers, providingspecialist mental health assessment, treatment and support to male mentallydisordered offenders and those at risk ofoffending. Both in-patient beds and community services, including high supportaccommodation, provided in partnership with the private sector.

Mother and Baby Unit consisting of a 3-bedded unit, based on the University Hospital of Wales site, providing care for mothers and babies up to one year old.

OLDER PEOPLE

In-Patient Services: Hospital beds at Whitchurch and St Davids Hospitals.

Community Services:Community Mental Health Teams Multi-disciplinary teams supporting older peoplewith mental health problems in the community.

Day services provided by the voluntary sector, Health and Social Services.

Liaison services providing support to primary care and community services.

Memory Team a multi-disciplinary team specialising in the early identification and assessment of people with memory problems.

Counselling services provided by the voluntary sector.

OTHER SERVICES FOR ADULTS AND OLDER PEOPLE

Information and Advocacy provided by anumber of statutory and voluntary organisations to both adults and older people.

Cardiff Befriending Forum was set up in 2006 as part of the Cardiff Mental Health Action Plan, for people running befriending schemes throughout Cardiff.

Mental health62

The forum gives the opportunity for a variety of statutory/voluntary sector organisations such as Gofal Cymru, Inroads, Cardiff Council Children’s Services, Age Concern and Cardiff Mind to network with others running differentbefriending projects, gain support from the group, exchange information, share resources, explore different training and funding opportunities available.

Cardiff Book Prescription Scheme The scheme aims to provide primary carebased treatment for people with mild to moderate mental health problems. Through the scheme, a range of practitioners including GPs, counsellors and community mental health team staff can prescribe specially selected and approved self-help books as

part of their treatment, which are available toborrow at local libraries.

Cardiff & Vale Service Users Forummeets for user involvement in the development planning and delivery of mentalhealth services and is supported by the Service User Involvement Development Worker.

Carers’ Involvement and Support The Carers Involvement Group is open to any Carer (or former Carer) of any person with mental health needs. Hafal Cardiff Carers Group meets monthly to ensure that carers of adults with mental health needs are able to have a voice in the development, planning and delivery of mental health services.

Significant progress has been made in relation to the objectives set out in the first Strategy, although progress has been more rapid in Adult’s than Older People’s services. In particular, the development of the Crisis Service has enabled more people in crisis to be supported in their own homes, rather thanbe admitted to hospital and, as a consequence, it has been possible to close beds at Whitchurch Hospital. This has shiftedthe balance of services away from in-patient beds to community services. Several preventative and early intervention services have been developed to support people in the community and to assist in reducing

pressure on secondary care services. The other major achievement has been the opening of the Llanfair Unit at Llandough Hospital, which has enabled 2 wards to be moved from Whitchurch Hospital into fit for purpose, modern accommodation.

Plans for further improvements to mental health services have continued to be developed and the Mental Health Strategic Outline Programme (SOP) has been approved by Cardiff LHB. The SOP includes the development of a new Adult In-patient Unit to replace Whitchurch Hospital and a new Older People’s Assessment Unit at Llandough Hospital.

2005-2008� Primary Care Mental Health Services strengthened and a service model was agreed by relevant partners.

These proposals include the development of a Primary Care Mental Health Lead post and the roll out of mental health staff working within primary care.

� Second Crisis Resolution and Home Treatment Team started work in June 2006, resulting in all areas of Cardiff having access to the Crisis Team service. As a result of the new Crisis Service, a ward at WhitchurchHospital was closed in August 2006.

� The Crisis House (the first in Wales), a partnership between the NHS and Gofal Cymru, opened in August 2006.

� 5 bed high support accommodation unit for men was opened in partnership with the private sector. � Llanfair Unit at Llandough Hospital opened, providing 2 adult in-patient wards in purpose built

accommodation, plus a third ward opened, which has replaced the adult in-patient ward at the Rawnsley Unit (University Hospital Wales).

� TOPSHAPE pilot project, implementing national guidelines for common mental health problems in primary care, was successfully concluded.

� Sealock and Riverside Community Mental Health Teams merged and moved to new fit for purpose accommodation.

� Proposed Rehabilitation Unit in Canton Health Centre was granted planning permission. � Planning commenced for Assessment Unit for Older People at Llandough Hospital. � Planning commenced on new Cardiff In-patient Unit for Whitchurch Hospital site.

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KEY ACHIEVEMENTS

The over-arching identified developments needed for mental health include:

� Developing environments and services which encourage people to be emotionally and mentally healthy

� Further shifting the balance of services away from hospital care and into primary and community care (this process has already begun with the development of the Adult Crisis Service and the consequent closure of an in-patient ward)

� Strengthening existing primary care and community services and developing services which currently either do not exist or do so only at a very basic level e.g. eating disorders, personality disorders and early intervention services

� Replacing buildings and hospitals which are not fit for purpose (e.g. Whitchurch Hospital) with modern facilities

� Continuing to improve quality of life issues and meeting social care needs.

Some of the key proposed developments for the next 3 years include:

� Mental Health Promotion via further development of key priorities within the Mental Health Promotion Action Plan,including promoting self-help and further enhancing preventative and early intervention services

� Ensure that all relevant organisations, staff and service users are ready for the implementation of the Mental Health Act 2007

� Development of Primary Care Mental Health Services, making use ofpsychological therapies to assist people with common mental health problems

� Obtain sustainable financial support from April 2009 to enable the Crisis House (part funded by the Big Lottery Fund) to continue to operate

� Modernise day services for adults,ensuring that they support people tointegrate into ordinary community facilities and services and that they provide vocational support

� Agree the design and size of the new Cardiff Adult In-patient Unit and commission its construction on former Whitchurch Hospital site

� Open the new Older People’s Assessment Unit at Llandough Hospital

� Re-commission a 45 bed community facility for older people

� Work with independent providers to increase capacity of EMI nursing and residential care beds

� Close the existing Whitchurch Hospital

� Obtain agreement on those developments within the Strategic Outline Programme that can be taken forward, subject toavailable resources, for example, eating disorder services; personality disorder services; young onset dementia services and assertive outreach services

� Working with Welsh Assembly Government on workforce issues within mental health, including the implications arising from the Mental Health Act 2007.

Refugees, asylum seekers and homeless people are likely to experience high levels of mental health problems and work needs to be undertaken to ascertain the needs of these user groups and ensure that there is equitable access to appropriate mental health services.

Mental health64


A lack of mental well being in society is a key public health issue. In addition there is differential experience of mental health problems across society. Mental ill health, as with other health issues, is higher in populations who experience poverty and disadvantage. Vulnerable groups, for example older people and people fromminority ethnic communities, are also athigher risk of experiencing mental health problems.

Mental Health promotion is implemented via the delivery of priority actions within the Mental Health Promotion Action Planincluding:

� Anti-Stigma work

� Promotion of education and skills through training provision

� Improved access to services and amenities

� Community and primary careinterventions delivered, including the books on prescription scheme (enabling access to specially selected and approved self-help books as part of treatment) andstress control course

� Support provided to befriending schemes to encourage a standardised and quality approach.

The gaps in service development are:

� Lack of awareness and understanding of mental health issues leading to stigma around the issue

� The need for a consistent approach to directing new service developments to disadvantaged areas of the city, as well as to vulnerable groups

� There is a need for a more co-ordinatedapproach to community, primary care and workplace initiatives that promote positive mental health and provide early intervention for mental health problems

� The need for increased focus on self-help as one approach to supporting mental well being

� Promoting good physical health for people experiencing mental health issues

� A need for initiatives that support minority ethnic groups.

Different social groups are affecteddisproportionately by mental health issues. Local data is available on some groups, butthere is need for a commitment to routinely gather additional data to inform these areas:

Race More work is needed in terms of the appropriateness of current mental healthservices for minority ethnic communities. Cardiff and Vale NHS Trust has introduced a mandatory field on ethnic origin in its computerised case note system. The NHS Trust and Cardiff LHB are also developing Race Equality Mental Health Action Plans, as required by WAG. The Black & Minority Ethnic Older People’s Mental Health Forum is a new network started by the BME OlderPeoples Mental Health Involvement Development Worker.

GenderExisting and planned new services are sensitive to the needs of women, for example, there are ‘women only’ areas builtinto the new in-patient units, as well as a Mother and Baby Unit. Currently, there are no low secure female in-patient beds. There is also a lack of services for eating disorders which affect more women than men. Cardiff ‘Women in Mind’ provides a range of mental health services for women such as free counselling, support and activity groups, outreach, a directory of female counsellors/therapists and training.

Disability The new in-patient units at Llandough and Cardiff are planned to be wheelchair accessible. The Disability Discrimination Act covers mental health problems and awareness of this needs to be highlighted across Cardiff agencies.

Mental health 65



Sexual Orientation There is currently a lack of information about mental health needs within the gay, lesbian and bisexual community. Discussions are required to explore whether it is possible to routinely gather this information through the Care Programme Approach and Unified Assessment processes, to provide some baseline information.

Language of Choice There are arrangements in place for face-to-face interpretation as well as Language Line services in hospital and community settings.

Religion & Belief Both new in-patient units have been built with these issues in mind and include multi-faith rooms, meal options etc.

Age Children and Adolescent Mental Health Services (CAMHS) and Older People’s Mental Health services are not as well developed as adult services.

2008 - 2011

1. Supporting the development of environments and services which encourage people and communities tobe emotionally and mentally healthy through a mental health promotion action plan.

2. Reducing inequalities by strengthening the information base with regard to mental health issues for particular groups within society.

3. Strengthening mental health services within primary care and the wider community to ensure people receive appropriate care in a timely fashion.

4. Commissioning the new adult in-patient unit.

5. Commissioning the new older people’s assessment unit at Llandough Hospital.

6. Re-commissioning a 45 bed community facility for older people.

7. Work with independent providers to increase capacity of EMI nursing and residential care beds.

8. Developing a comprehensive Low Secure Forensic Service for women, including both in-patient beds and high support accommodation in the community.

9. Taking forward developments within the Strategic Outline Programme, subject to available resources for example, eating disorder services, personality disorder services, young onset dementia services and assertive outreach services.

10. Implementing the NSF Mental Health Action Plan.

11. Implementing the Day Services Strategy for adults.

Mental health66


7. Older people

Older people 67

Over the last century changes in lifestyle, livingconditions and health and social care have led toimprovements in health and life expectancy. Whilemany older people continue to lead fit and activelives, increasing age is associated with a higher riskof chronic and disabling conditions. This representsa major challenge to health and social care services.The planning for services therefore needs to enablean increasing number of older people to maintaintheir independence as well as meet the steadilyincreasing demand for health and social careservices. The needs and service responses relevantto older people with mental health problems are notaddressed in this section but are included in theMental Health section.Key statistics from the study of ‘Population Trends

and Projections for Older Persons in Cardiff’ showthat: � The population of people of 65 and over in

Cardiff will increase by about 11% over the next13 years. However the group that relies mostheavily on health and social care services, thoseof the age of 75+, will remain reasonablyconstant with only a 0.9% increase.

� The position in Cardiff is therefore atypical andcontrasts with other areas in Wales, which showan approximate 32% increase in numbers ofpeople over 64 with about a 27% increase in 75+age group.

� Between 2019 and 2029 the 65+ age group inCardiff will increase in size by about 23%compared with an increase of about 55% forWales as a whole.

The Welsh Assembly Government’s Strategy forOlder People in Wales has prioritised the needs andaspirations of older people, both in terms ofimprovements in services and in terms ofinvolvement and participation. This Strategy,coupled with the publication of the National ServiceFramework (NSF) for Older People in Wales,established the context by which servicedevelopment and national standards are designed,implemented and monitored, to enable older peopleto maintain their health, well being andindependence for as long as possible.Against this background, substantive and farreaching reforms of health and social care have beensignalled through the Cardiff and Vale healthcommunities’ Programme for Health ServiceImprovement (PHISI) and Cardiff Council’s Business

Plan for Adult Services. Both plans have beendeveloped in response to the key national documentsthat provide the framework for older people’sservices in Wales including:� The Strategy for Older People in Wales (WAG,

2003)� Designed for Life: Creating World Class Health

and Social Care for Wales in the 21st Century(WAG, 2005)

� Healthy Ageing Action Plan for Wales: a responseto Health Challenge Wales (WAG, 2004)

� The National Service Framework for Older People(WAG, 2006)

� Fulfilled Lives Supportive Communities: aStrategy for Social Service Over the Next Decade(WAG, 2007)


Figure 7.1

Projected changes in Total Persons in Cardiff from 2004 to 2019

2004 2009 2014 2019 TotalChange % change

65 - 74 22,200 21,700 24,500 27,000 4,800 21.62

75 + 22,100 22,800 22,600 22,300 200 0.9

Total 65+ 44,300 44,500 47,100 49,300 5,000 11.29Source: Population trends for post retirement age groups in Cardiff from 1989 to 2019 (December 2006)

The distribution of older people varies across the city, with the North locality containing the greatest proportion with around 30%. Whitchurch/Tongwynlais and Rhiwbina both have the highest number of older people. In contrast, the South East and Central localities contain around 21% of the older population with Butetown housing only 8% of these residents.

The Health Alliance has recognised Older People as a key priority client group for health and social care services. Cardiff Council, Cardiff LHB and partners willcontinue to develop local strategies to co-ordinate the range of services to older people across health, social care and other services. The plans, developed to take forward the implementation of the Health, Social Care and Well Being Strategy, include:

Programme for Health Service Improvement (PHSI)

Older People’s National Service Framework Action Plan

Cardiff Healthy Ageing Action Plan

Joint Commissioning Strategy and Plan for Older People 2005-2008 (Cardiff Council & LHB)

Commissioning Strategy for Older Peoples’ Accommodation 2007-2017 (Cardiff Council and LHB)

Carers’ Strategy & Plan (Cardiff Council 2005) – New strategy to be published in 2008

Older People’s Strategy (Cardiff Council, to be published 2008)

South Wales Area Adult Protection Committee (AAPC) Guidance

These plans for health care services within the city clearly highlight the significant needs of older people. In developing proposals, the PHSI strategic outline case has recognised the need to radically reconfigure current health and social care service delivery to ensure that older people are able to access appropriate services as close to their home as possible and to maximise their health, independence and well being.

Figure 7.2 Proportion of population aged 65 and over by MSOA: 2003


Older people68


The LHB is responsible for commissioning an extensive range of core universal health care services, within hospital and community settings, that are routinely accessed by olderpeople. However, both the LHB and Local Authority are also responsible for the commissioning of enhanced care for Cardiff residents who have a higher level of need. The Unified Assessment process has been implemented as the basis for identifying the needs of these service users and carers.Within this framework, eligibility for services is determined by ‘Fair Access to Care and Continuing NHS Health Care’ criteria. The delivery of services in Cardiff relies heavily on the development of sustained partnerships between Health, Social Care and Voluntary and Private Sector providers. This needs to be supported by further progress towards integration of services including joint commissioning and pooled budgets. The list below is indicative of progress made towards this model of working and is not intended to be exhaustive:

Health Promotion initiatives are in place throughout Cardiff including: Exercise Referral, Memory Clinics, Extend Exercise, Walking for Health, Keep Well This Winter Campaign.

Cardiff Healthy Ageing Planning Grouphas developed the Cardiff Healthy AgeingAction Plan with delivery of priority actions, including training to professionals, social groups for older people, campaign work and falls prevention.

Encouraging Independence via a range of projects across Cardiff, which include: Welfare Rights Counselling and Advocacy Services, Community Groups, Lunch Clubs, Good Neighbour Schemes, Support Groups, Mencap Cymru Shopping Service, Telecare, Community Alarm, Befriending, Domiciliary Care Packages, Expert Patient Schemes and Mutual Support Groups. Many of these are provided by voluntary sector organisations.

Primary Health Care is provided by GPs,(Chronic Disease Management is monitored via the Quality & Outcomes Framework of the GMS contract) Community Nursing and Therapy services.

Intermediate Care and Rehabilitation Services provide short term Domiciliary Intervention, Clinical Nurse Specialists, Telecare Services, Day Treatment Services, Day Care Services, Elderly Care Assessment Service, Acute Response Team, Community Respiratory Resource Unit, Community Based Therapy Services, Cardiff Rapid Response and Re-enablement Team, Equipment, Adaptation Services and Hospital Discharge Service.Acute Medical/Surgical/Trauma Care is provided at the University Hospital of Wales and Llandough Hospital. Most of these services are of a generic nature, althoughthere are some that are specifically focused on meeting the needs of older people. In addition, a range of medicine out-patient clinics are provided across the University Hospital of Wales, Cardiff Royal Infirmary and Rookwood Hospital sites. Long Term Care includes long-stay hospital beds, independent nursing and residential homes and continuing health and social care packages in the community, Extra-Care Housing Schemes and Commissioning Care Home Placements. Respite Services are commissioned on an individual basis, either in care homes or inthe individuals own home. Capacity building needs to be undertaken to increase capacity and choice. Voluntary Sector Provision includes a broad range of support to older people andtheir carers, across each tier of the care pathway. AgeWise+ Directory lists the full range of voluntary services to older people in Cardiff. The Capacity Building Project supports the voluntary sector in delivering services to older people, in particular preventative measures and support to those who fall below the eligibility criteria. Cardiff Council has allocated funds under the Maximising Independence Grant for voluntary sector organisations for the same purpose. Housing for Older People encompasses a range of services including Sheltered Housing, Community Alarm Service, Telecare and development of Extra Care Services.

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CURRENT SERVICES

Care & Repair exists to help older people and/or people with physical or sensory impairments to repair and improve their homes to ensure their independence is maintained, with increased safety and comfort.

Services for Minority Ethnic EldersCardiff Council’s Minority Ethnic Older Person’s Outreach Worker works with people over the age of 50, of all minority ethnic communities and has recently re-launched the Ethnic Minorities Older Person’s Council.

Services for LGB Elders ‘Opening Doors’ is the umbrella title of Age Concern Cymru’s programme of publications, resources and events for and about older lesbians, gay men and bisexuals in the UK.

Protection of Vulnerable Adults Team (POVA) Adult Services, Cardiff Council, work with partners to determine the course of action when an allegation of abuse is made. A vulnerable person is defined as a personwho is 18 years of age or over, who is or may be, in need of community care services by reason of mental, physical or sensory impairment, age or illness and who is or may

be unable to take care of him/herself, or unable to protect him/herself against significant harm or serious exploitation.

Counselling Service Age Concern has been awarded 3 year funding from Comic Relief to set up a Counselling Service for older people who have experienced or are experiencing ill-treatment or abuse. The Cardiff Area Adult Protection Committee Annual Report for 2005/06 states that 496 referrals were recorded for the year, compared with 373 during the year 2004/05; an increase of 33%.

Cardiff & Vale Mental Health Development Project has an Older People’s Carer and Service User Development Officer, who ensures that views from older people who experience mental health services are heard, are acted upon and are used to change ways of working for the better. This also applies to carers, in their role as a carer, and as an individual with their own needs. ‘Directions: a guide to older people’s Mental Health’ has been produced by the Cardiff and Vale Mental Health Development Project with contributions frompartners.

Many of the objectives in the original HSC&WB Strategy are long term and will require concerted action over a period of

years. This Strategy is therefore committed to the same principles and objectives as set out in the original Strategy.

2005 - 2008 Developed the Cardiff Healthy Ageing Planning Group which subsequently led to the development of an action plan to implement the Strategy for Older People in Wales, at a local levelDeveloped the joint Commissioning Strategy for Older People’s Accommodation to inform the commissioning of long term care Completed the Joint Commissioning Strategy for Older People between Local Authority and LHB Completed the evaluation of existing domiciliary contracts Established the city wide Home Care short term intervention service Completed plans to commission a community based Continuing Health Care Unit for older people with mental health needs, as part of the re-provision of the Whitchurch Hospital site Developed high level Integrated Care Pathways for Stroke, Diabetes, COPD and CHD Increased the residential capacity for dementia care within the city Obtained ‘Making the Connections’ funding for a capacity building project for a voluntary sector Project Manager Obtained Wanless funding to take forward elements of the Cardiff Healthy Ageing Action Plan, utilised for falls prevention, Ageing Well Co-ordinator activities (Age Concern), increased public health capacity,a small grants scheme and a counselling service (Age Concern) Established the Joint Equipment Service Progressed the commissioning of an Extra Care Housing Project.

Older people70

KEY ACHIEVEMENTS

90% of all health and social care is provided outside of acute hospitals, mainly by health and social care professionals working in general medical practices, pharmacies, dentists and optometrists and traditional community services (district nurses, healthvisitors, social workers and allied health professionals).

Primary and community based services need to be supported and developed to enable them to meet the needs of patients effectively. In particular, there is a need to improve the care provided to people with long term conditions. This will mean more services being provided in local communities, services having a greater focus on maintaining health, promoting independence and preventing illness, as well as providing high quality treatments and care. For individuals with complex and ongoing healthand social care problems, they and their carers will have access to a named professional who will support and help them manage their needs more effectively. More professionals will be based in primary and community based settings, working jointly and more closely with voluntary sector colleagues where appropriate.

The PHSI proposals have recognised the requirement for a significant increase in workforce within the community and are proposing that new intermediate care teams will be located within a network of resource centres, providing an enhanced range of services for local communities supporting local primary care professionals.

There is also a need to do more to supportpeople maintain their own health and independence.

Rehabilitation and Intermediate Care serviceswill continue to play a vital role in helping people re-gain or maintain their independence. Changes in people’s expectations and the opportunities provided through new technology mean that there is a need to deliver rehabilitation and intermediate care very differently in future, enabling people to remain safely in their own homes where possible. This will mean more services being provided in local communities and in partnership with local authority social services. The LHB has recognised the need to invest in a health service model that enables people to live more independently and which can respond quickly to individual demands. Due to the need to refocus rehabilitation and intermediate care services, there is an opportunity to reconfigure in-patient rehabilitation services currently located at West Wing and Rookwood Hospitals. An alternative model of community based beds and consultant led intermediate care teams will be provided to reduce the requirement for extensive hospital in-patient stays.

There needs to be recognition of the increased need of service users with multiple impairments, synergy between the Older People’s agenda and the Mental Health, Physical & Sensory Impairment and Learning Disability service development agendas, as well as effective operational interfaces between services and transitional care arrangements.

Long Term Illness On average, between 2004 and 2019, an additional 138 people per year over the age of 65 will have a limiting long term illness. This is an average annual increase of about 0.7% as detailed in the following figures:

Older people 71


Figure 7.3

Age Group 2004 Base

Yearestimate

2009ProjectedEstimate



Change2004 -2019

Population 65 -74 22,200 21,700 24,500 27,000 4,800

Of which 41%# have a long term illness 9,102 8,897 10,045 11,070 1,968

Population 75+ 22,100 22,800 22,600 22,300 200

Of which 53%# have a long term illness 11,713 12,084 11,978 11,819 106

Total population aged 65+ with a long term illness 20,815 20,981 22,023 22,889 2,074

Total population all ages 316,797 325,766 339,040 353,415 36,618

# Percentage of people who reported a long term illness which limited their lifestyle Source: National Statistics 2004

Disability In the 65–79 age group 25% report a moderate level of disability and 11% report a severe level of disability. In the 80+ age group these percentages become 34% and 30% respectively as detailed in Figure 7.4.

On average between 2004 and 2019 an additional 50 people/year over the age of 65 will have a severe disability. This is an average annual increase of about 0.7%.

Figure 7.4

Age group 2004 Base

Yearestimate




Change2004 -2019

Population 65-79 31,541 30,437 32,898 35,452 3,911

Of which 11% have a Severe Disability 3,469 3,348 3,618 3,899 430

Population 80+ 12,807 14,037 14,197 13,880 1,073

Of which 30% have a Severe Disability 3,842 4,211 4,259 4,164 322

Total population aged 65+ with a Severe Disability 7,311 7,559 7,877 8,063 752

Total population all ages 316,797 325,766 339,040 353,415 36,618

Source: National Statistics 2004

With regard to residential long term care provision, Cardiff faces particular pressures on services due to the market capacity responding to high land costs. The joint Accommodation Strategy has recognised that currently the city does not have the correct configuration of long term care provision, e.g. extra care housing. There is also a need to build capacity for respite care within both residential and home based settings, to support carers and families offering long termcare to their relatives. The Local Service Board (LSB) has recognised this need for joint commissioning long term care, and has established a core project to increase the

capacity within the nursing home sector, initially to address problems identified and meet demand. Particular consideration needs to be given to meeting the requirements of older people who are homeless.

The Older People’s Advisory Planning Group has identified the following key service developments:

Care Home Provision via joint commissioning of long term care, by both statutory partners, to increase the available capacity to address the significant Delayed Transfer of Care (DTOC) problem within Cardiff and Vale NHS Trust.

Older people72

Integrated Health and Social Care to explore moving to joint commissioning and provision of integrated domicillary health and social care services, including therapies.

Respite to build capacity and range of respite options within home and care placements, supporting carers and to provide respite to carers.

Intermediate Care and Rehabilitation Services will require remodelling of in-patient rehabilitation and intermediate care services to re-provide locality community based care for the rehabilitation and re-ablement of older people.

Workforce Development to expand and develop an appropriately skilled workforce to support the new models of care.

Chronic Disease Management will require investment in skills development in the primary care setting, both in the management of Dementia care and in the implementation of integrated care pathways for Stroke, Diabetes, CHD and COPD.

Assisted Technology potential to be explored for expansion in order to supportpeople to live independently and safely withintheir own homes.

Day Service Provision will require a review of current services to provide a more flexible, individual centred approach to community living & independence.

Promote Welfare Benefits take-up toraise awareness and increase accessibility of information of entitlement to available benefits.

Falls Prevention work to progress further to meet the standard in the National Service Framework for Older People.

Personal Support will need to be increased and ongoing personal support and social support / activities provided for older people.

Community Care Services capacity building for older people whose needs fall below the threshold for Community Care Services, to promote well being and prevent deterioration in health.

Awareness Raising on Elder Abuse asolder people face unique barriers to reporting abuse such as fear of loneliness, fear of being institutionalised, fear of not being believed, fear of being separated from family and fear for the impact on the abuser, particularly if they are a family member.

Demographic change and developments insociety, such as increased life expectancy, underpin the importance of supporting older people to continue to lead fit, healthy and active lives for as long as possible. Older people are therefore a key target group forhealth improvement work, as detailed in the Cardiff Healthy Ageing Action Plan. Developed by the multi-agency Cardiff Healthy Ageing Planning Group, the Action Plan provides the direction for local development and delivery of health improvement for older people. It encourageslinks between partners from the statutory and voluntary sectors to provide strength and consistency of approach. Underpinned by the United Nations Principles for Older Persons, the Action Plan aims to promote independence, participation, care, self-fulfilment and dignity. It also aims to promote positive images of older people and challenges ageism and discrimination. All

initiatives and activities reflect the evidence base for health improvement as detailed inthe Healthy Ageing Action Plan for Wales.

The gaps in service development are:

The need for ongoing and enhanced initiatives that focus on personal and social support for older people

The need to enhance the focus on falls prevention work to meet the standard in the National Service Framework for Older People

Continued development of campaignwork including Keep Well This Winter and the flu vaccination campaign

Re-enablement of older people who are institutionalised but who are now well enough to return to the community

Focus on the co-ordination of ongoing home injury prevention activity.

Older people 73


Older people74

Age discrimination is the practical manifestation of ageism, which is a form of prejudice, as unacceptable as racism or sexism. One of the five key aims of the Strategy for Older People in Wales is to address discrimination against older people wherever it occurs, promote positive images of ageing and give older people a stronger voice in society.

Decisions about treatment and care, however complex, should be made on the basis of each individuals needs, not their age. Denying access to services on the basis of age alone is not acceptable. As well as health needs, the overall health status of the individual, his or her own wishes and aspirations and those of his or her carers, must shape the package of health and social care.

Older people can also experience multiple disadvantages relating to different aspects of their identity.

The following priority areas have been identified:

RaceThere is a requirement for appropriate, accessible, targeted services to allowequitable access, with services tailored to need.

GenderResearch indicates a range of situations where age is likely to interface with gender to

create unequal opportunities or multiple disadvantages.

Disability The number and severity of impairments often increases with age. Services need to consider the requirements of older peoplewith chronic illness, physical and sensory impairments, co-existing mental health problems, learning disabilities and homelessness.

Sexual Orientation Most older Lesbian, Gay, Bisexual and Transgender (LGBT) people have lived a large part of their lives in less liberal times and their experiences have made them understandably wary and cautious. In practice, this means older people from the LGBTG community are less likely to access services and will do so on limited terms.

Language of Choice Although there are interpretation services available, work is needed to ensure that generic services are accessible, equitable and appropriate for everyone from point of assessment to service delivery.

Religion & Belief There is a need to provide appropriate, accessible, targeted services to allowequitable access.

Age & Carers The needs of older carers need to be considered.


2008 – 2011 The key priorities and strategic aims for older people are underpinned by the requirement to deliver and monitor the implementation of the National Service Framework for Older People 1. Promoting health improvement for older people by: - implementing the Cardiff Healthy Ageing Action Plan. 2. Reducing inequalities by strengthening the information base with regard to equality issues for older

people within society. 3. Enabling older people to live independently and safely in their own homes for as long as possible by: - supporting an increase in residential respite options to support carers looking after people at home - increasing the utilisation of assistive technology and Telecare. 4. Developing a range of intermediate care and rehabilitation services - provide locality based community health and social care services to re-able older people. 5. Improving care to individuals with a chronic disease by: - implementing the clinical evidence based high level care pathways for stroke, diabetes, COPD and Coronary Heart Disease - appointing clinical case managers to support individuals with chronic conditions in their own homes. 6. Increasing the available residential home capacity within the city to address the significant Delayed

Transfer of Care problem by: - establishing joint commissioning and block contracting arrangements with independent sector providers. 7. Delivery of the NSF standard on falls by: - Reviewing and developing an integrated care pathway for the prevention and management of falls and fractures across health and social care. 8. Increasing the uptake of Welfare Benefits by: - increasing the provision of information with respect to benefit entitlement.9. Ensuring all new service developments consider geographical disadvantage and particular vulnerable

groups.10. Developing personal and social support for older people by:

- working more closely with the voluntary sector

- increasing the capacity and skills within the voluntary sector to expand their services to older people.

Older people 75


8. Physical and sensory impairment

Physical and sensory impairment76

This Strategy adopts the Social Model of Disability,which recognises two concepts, ‘impairment’ and‘disability’. Impairments are medical issuesbelonging to an individual, such as sensory, physical,learning and mental health issues. ‘Disability’ relatesto barriers imposed upon people with impairments,including physical barriers, discriminatory attitudesand disabling structures.

‘A person has a disability for the purposes of this Actif s/he has a physical or mental impairment, whichhas a substantial and long term (at least 12 monthsor is likely to last 12 months) effect and that impactson his ability to carry out normal day-to-dayactivities’, (Disability Discrimination Act, 1996.)

In the absence of national and regional strategicdirection, planning for adults with a physical orsensory impairment is focused on the following:

Physical Impairment Plans:

� Cardiff Joint-Commissioning Strategy for PhysicalDisability 2005-2008 (Cardiff Council & LHB)

� Cardiff Physical Disability Commissioning ActionPlan 2005-2008 (Cardiff Council & LHB)


There is no single national policy framework thatprovides the context for the planning and provisionof services to people with physical and sensoryimpairments. However, there is a range of nationallegislation, initiatives and guidance that guide thedelivery of services for adults with a physical and/orsensory impairment.

Physical and Sensory Impairment:

� NHS Responsibilities for Meeting Continuing NHSHealth Care Needs: Guidance WHC (2004)

� The Disability Discrimination Act (DDA) places aduty on all public bodies to promote equality ofopportunity for people with physical or sensoryimpairments (2005)

� Further Advice to the NHS and Local Authoritieson Continuing NHS Health Care WHC (2006)

� Designed to Improve Health and theManagement of Chronic Conditions in Wales: anintegrated model and framework for action (WAG2007)

� The delivery of the 26 Week Patient Pathway isbeing planned through the 2009 Access Project.

Specific Sensory Impairment Drivers:

� Best Practice Standards considered for thisStrategy include ‘Progress in Sight, 2002’ and‘Social Services for Deaf and Hard of HearingPeople, 1999’

� Visual Impairment Benchmarking Study SummaryReport (Association of Directors of Social Servicesand the Welsh Assembly Government, 2006)

� WAG National Programme for Training Low VisionOptometrists

� The National Institute for Health and ClinicalExcellence (NICE) guidelines for sensory servicesinclude cochlear implants, auditory brain stemimplants and the treatment of Age RelatedMacular Degeneration (ARMD)

� Delivery In British Sign Language: Advice forPublic Services (Welsh Assembly Government,2006.)


� Draft Policy for Neuro-Rehabilitation (Health Commission Wales 2007) considered by National CommissionAdvisory Board September 2007.

Sensory Impairment Plans:

� Draft Cardiff Joint Commissioning Strategy for Sensory Impairment 2007-2010 (Cardiff Council & Cardiff LHB)

� Draft Cardiff Sensory ImpairmentCommissioning Plan (Cardiff Council & Cardiff LHB, 2007)

� Implementation of local work from the All Wales Visual Impairment Exercise

� Hearing Impaired Benchmarking has been initiated.

The material for guidance for some issues is broader than just physical and sensory impairment, such as:

� Carers’ Plan (Cardiff Council 2005), New Carers’ Strategy due for publication April 2008

� Cardiff Council Disability Equality Scheme (2007- 2010)

� Health Challenge Wales (WAG, 2004)

� The Programme for Health Service Improvement.

Cardiff Council and Cardiff LHB work in partnership with adults with physical and sensory impairments and carers to access appropriate health and social care services based on assessed eligible needs. Cardiff Council and LHB recognise that there are currently very few age appropriate and local services for people with a physical impairment. The Cardiff Physical Disability Joint Commissioning Strategy provides a commissioning framework for the development of more appropriate and flexibleservices. The services aim to support independence and develop life skills, promoting social inclusion by enabling access to community facilities, mainstream education and employment opportunities.

The development of dedicated Physical Disability and Sensory Teams at Cardiff Council has led to a more specialist and focused service. Within the Council, children with physical and sensory impairments under the age of 18 years are looked after in the Child Health and Disability Team. In Adult Services there are two Physical Disability Teams working with adults aged 18-64 years and one Sensory Impairment Team. The work of these teams also includes peoplewith long term health conditions. NHS Paediatric Services look after children with physical and sensory impairments and transfer their care at 18 years to adult health

services. The importance of efficienttransitional care arrangements is acknowledged. Services for physical and sensory impairment

Physical and sensory impairment 77

Services for physical and sensory impairmentin Cardiff are as follows:

Cardiff Council Adult Services The Contact and Assessment Team is a single point of access for physical and sensory impairment and older people services. After the initial assessment, the case is transferred to one of the physical or sensory teams for a full Unified Assessment and Carers Assessment. A range of services are offered to people with physical and sensory impairments and their carers:

� Unified and specialist assessmentsare designed to describe the risks to an individual’s independence. This includes consideration of the existence and management of risk, impact on a person’s autonomy and the management ofpersonal care and daily routines.

� Care Packages cover a range of service provision in a variety of settings e.g. personal care, domestic and or socialsupport in people’s own homes, orresidential or nursing home settings. This care may be on a long term or respite-care basis. These care packages can beprovided by Direct Payments or commissioned from providers.

CURRENT SERVICES

� Communications Support recognises people’s different communication needs, especially deaf people. Some homecarers and residential care staff have received BSL training to enable them to provide communication support alongside personal care. Cardiff & Vale NHS Trust and Cardiff Council also provide specific deaf awareness training.

� Direct payments are made to people with a physical or sensory impairment, to purchase their own care, enabling them to have more flexibility and choice inprovision of services. A contract with a voluntary sector service provider is inplace to provide advice and support to service users, promote direct payments and facilitate training to social workers.

� Community Day Services are provided by Cardiff & Vale NHS Trust and the Council, in conjunction with otherorganisations e.g. Headway and Vision 21.

� Occupational Therapy Services are provided by the Council to prevent hospital admissions and to maintain or increase daily living independence through the provision of equipment or adaptations. This includes risk assessments to prevent and manage accidents, such as falls in the home.

� Blue Badges are available for people subject to eligibility, providing free and accessible parking for driver or passenger.

� Community Alarm and Telecare Service is a 24 hour / 365 day service to support and reassure vulnerable people. Telecare can help users remain in their own home and stay independent byensuring their safety. Telecare incorporates flood detection, smoke detection, falls detection, gas cut-off valve and movement sensors.

Cardiff & Vale Joint Equipment Service is a support service to the Occupational Therapy Team. It provides equipment on loan to service users following an assessment. The equipment is intended to support people to live as

independently as possible in their own homes.

� The Disabled Facilities Service (DFS) manages the provision of financial assistance for service users with physical or sensory impairments in both the public and private sector. The service supports the Social Model of Disability by considering that the environment in which disabled people live is disabling. Byproviding an accessible environment, the barriers are reduced to enable a full inclusion in the life of the City. Additionally, the service can provide immediate solutions to prevent entry to, and enable discharge from, hospitals and institutional care.

In-patient and Community Services

Rehabilitation Services provide acute intensive rehabilitation and low technological/ ‘slow stream’ rehabilitation.

Cardiff Accessible Homes Project has developed systems and processes in partnership with Registered Social Landlords, enabling them to identify accessible and adapted properties, appropriate to the needs and choices of people with impairments. This service is closely linked with the Disabled Facilities Service.

Artificial Limb and Appliance Service (ALAS) is an all-Wales centre providing wheelchairs, artificial limbs and eyes, environmental controls, orthotics and a communication aids assessment service.

Driving Assessment Centre (ALAS) offers assessment and development of driving skills to individuals with physical impairments.

Psychology Service (ALAS) provides access to a psychology support and specialist psychologist for the M.S. service.

Stroke Outreach Service provides post-discharge support to patients in their own homes, including physiotherapy, occupational therapy, and speech and language therapy.

Community Brain Injury Service (STAR Project) supports people with acquired brain injury to access a variety of vocational opportunities, including voluntary work, education, training and paid employment.


Professionals Allied to Health provide a range of services including Occupational Therapy, Physiotherapy, Podiatry, Speech and Language Therapy, Nutrition and Dietetics. In addition there arespecialist nurses for Diabetes, Parkinsons, and M.S.

Specialist In-patient Service provides access to the regional unit for neurological, spinal cord injury rehabilitation at RookwoodHospital and an acute Stroke Unit provided atWest Wing.

Voluntary Sector Organisations in Cardiff reflect the range of impairments.Organisations such as Cardiff Institute for the Blind, Stroke Association etc, provide specificservices. The Cardiff and Vale Coalition of Disabled People is an equality campaigning and support organisation which is founded, run and managed by people with impairments.

The Cardiff Physical Disability Joint Commissioning Strategy and the draft Cardiff Sensory Impairment Joint Commissioning Strategy provide the framework for the commissioning of quality appropriate services

for people with a physical or sensoryimpairment. Many of the key achievements listed below relate to the Cardiff Physical Disability Joint Commissioning Strategy Action Plan:

2005 - 2008

� Development of Joint Commissioning Strategies for Physical Disability and Sensory Impairment � Development of day services from a day centre based model to a community day services model � Establishment of an Accommodation Sub-group of the Physical and Sensory Impairment Advisory

Planning Group � Service User Sub-group established to link with Physical and Sensory Impairment Advisory Planning

Group � Telecare Funding – process established and installations achieved � Review of telephone rentals completed � Joint Equipment Service established � Completion of regional review of Neuro-Rehabilitation Services � Completion of Management of Stroke Integrated Care Pathway � Achievement of 28 week waiting times targets across all areas of service provision � Establishment of Critical Friends Network – Disability Equality Scheme � Development of Intermediate Care Teams linking health and social care

Specific to Sensory Impairment: � Training of a group of home care staff in BSL signing and sensory awareness training � Completion of All Wales Visual Impairment Benchmarking Exercise� Awareness training for contact officers in relation to the total spectrum of sensory impairment.

Individual service users and carers were involved in the development of the Cardiff Physical Disability Joint Commissioning Strategy. There is a need to develop primaryand community based services to effectively meet the needs of service users in particular

those with long term conditions. There are plans to base health professionals in primary and community based settings, providing an enhanced range of services for local communities.


KEY ACHIEVEMENTS


Rehabilitation and Intermediate Care Services play a vital role in helping people maintain their independence and also to regain it. Changes in people’s expectations and the opportunities provided through new technology mean that rehabilitation and intermediate care will be delivered differentlyin future. There are plans to re-provide in-patient rehabilitation services currently located at West Wing and RookwoodHospitals within community settings, enabling people to remain in their own homes or asclose to home as possible.

The local focus for 2008-2011 will include:

� Gap analysis in Cardiff Physical Disability and Cardiff Sensory Impairment Joint Commissioning Strategies to be addressed in the action plans e.g.

o Local and age appropriate respite, residential and nursing home care

o Advocacy services o Community based day services

� Expansion of Reablement Service, currently only available to older people, to be made available to young people with physical impairments

� Expansion of Psychology and specialist Psychiatry services

� To promote the Direct Payments scheme � Further develop intermediate care and

community based therapy services � Commissioning of a wider range of age

appropriate respite care � A protocol and action plan has been

developed to improve the transitional arrangements between children’s and adult’s health and social care services

� Greater involvement of service users in service planning, design, monitoring and evaluation

� Develop better strategic and operational links with the Carers Strategy, Young Carers Strategy and associated services for carers.

Health promotion for people with physical and sensory impairment needs to become anarea of focus. Current initiatives have concentrated on developing physical activity schemes such as:

Disability Sport Wales is a joint initiative between the Sports Council for Wales, the Federation of Disability Sport Wales and local authorities. The national aim is to develop quality community based sporting opportunities for people with impairments throughout Wales.

Cardiff Council Sports Development Team (SPORT CARDIFF) provides a sports advisory service. Projects include:

� “Pedal Power” provides specialised cycling facilities for people with a range of impairments.

� “Venture Out” is part of the Mentro Allan scheme, led by Innovate Trust and aims to develop new opportunities for physical activity for people with impairments in local green spaces.

Rehabilitation Service is provided by Cardiff Council Adult Services and supports the physical and mental well being of individuals who have a visual impairment.

ICT Network Programme Cardiff is a major player in the Wales ICT Network funded by the Welsh Assembly Government. The programme is designed to set quality standards for assessment and training in relation to information, communication andtechnology for use by organisations and individuals. In Cardiff part of the assessor training is provided by Cardiff Institute for the Blind. Sports and Leisure. The Institute for theBlind and Wales Council for the Blind provide sport and leisure activities aimed at building the confidence, self worth, promoting health and developing sporting skills.

The local focus for 2008-2011 will include:

� Delivery of specific health improvement initiatives for people with a physicaland/or sensory impairment

� Improve levels of rehabilitation services to promote independence and well being.



Statutory authorities have a legal duty to achieve equitable access to their services, regardless of race, intellectual, physical or sensory impairment. Cardiff Council Adult Services provides equalities and disability awareness training to staff.

RaceCardiff and Vale Coalition for Disabled People in partnership with EQUAL & Curiad Calon Cymru are conducting a research project on impairment and race and will make recommendations to the Welsh Assembly Government.

GenderGender issues must be considered in the provision of physical and sensory impairmentservices, for instance recognition of increased vulnerability in cases of domestic abuse.

Disability The adoption of a Social Model of Disability facilitates empowerment, personal choice, independence and equality.

Sexual Orientation Services must recognise people with physical or sensory impairments as sexual beings and

ensure that appropriate services are available irrespective of sexual orientation.Consideration is needed to collecting data on sexual orientation of existing service users.

Language of ChoiceServices must ensure that information is available in accessible formats, e.g. Braille, BSL etc.

Religion & Belief Services must ensure that employees have appropriate cultural awareness in the provision of personal care and that service users are supported to practice their chosen faith.

AgeThe increase of impairments in older age can lead to multiple impairments. In comparison to services for adults, services for children with impairments are more extensive and comparatively well resourced. The shift from a traditional day centre model of providing services, to a community based day services model, ensures that services for younger people with physical impairments are more socially inclusive.

2008 - 2011

1. To promote health improvement for people with a physical and/or sensory impairment

2. To reduce inequalities for people with a physical and/or sensory impairment

3. To develop a service specification for an independent advocacy service

4. Expansion of the reablement service specifically for young people with a physical impairment

5. Develop, implement and respond to priority areas identified in phase 2 of developing day services

6. Evaluation of physical and sensory impairment awareness training already provided and development ofa rolling programme of awareness training for staff

7. Implementation of priority areas identified in the accommodation strategy

8. Commission appropriate service for respite, residential and Nursing Home provision

9. Development of the Transitions Action Plan for young people moving from Children’s Services to Adult Physical Disability Services

10. Implementing the action plan of the Commissioning Strategy for Sensory Services.




9. Learning disability

Learning disability82

There are 1.4 million people in the UK who have aLearning Disability. A Learning Disability is ‘thepresence of a significant intellectual impairment;deficits in social functioning or adaptive behaviour(everyday basic skills, which are present fromchildhood)’ (Joint Commissioning Strategy for Peoplewith Learning Disabilities, 2005).

This Strategy focuses on adults with a learningdisability aged 18 upwards, including those who haveadditional needs e.g. physical or sensoryimpairments, mental health issues and autisticspectrum disorder.

The original strategic objectives of the ‘All WalesStrategy’ were stepping-stones to modernise healthand social services decommissioning institutionalisedcare (locally Ely Hospital) and improving and

integrating the lives of people with a learningdisability within the community.

For people with learning disability, many of whomwill require life long service, this Strategy supportsthree key principles for planning, commissioning,delivery of services and monitoring:

� people have the right to an ordinary pattern oflife

� the right to be treated as an individual � to have the provision of additional help and

support so as to maximise potential.

People with learning disabilities have a range ofneeds directly arising from their impairment orcondition, and in addition economic, environmental,health or social barriers may also disproportionatelyaffect them.


The duty of partnership is enshrined in legislation,which sets the planning, commissioning andregulatory framework for present day services. Thekey national documents that inform the planning oflearning disability services in Wales are:

� Fulfilled Lives Supportive Communities: ImprovingSocial Services in Wales from 2008-2018 (WAG,2007)

� Statement on Policy and Practice for Adults with aLearning Disability (WAG, March 2007)

� Carers’ Strategy for Wales – Action Plan (2007)� Designed for Life: Creating World Class Health

and Social Care for Wales in the 21st Century(WAG, 2005)

The Autistic Spectrum Disorder (ASD) StrategicAction Plan for Wales describes how the Welsh

Assembly Government expects that individuals withASD and their families should have their needs metto ensure their potential is fulfilled in all aspects oftheir life. This consultation closed on May 25th 2007.

The draft document aims to build on a range ofother Assembly Government publications, such as‘Designed for Life’ and a series of National ServicesFrameworks. It seeks to lay the foundations forimproved commissioning and delivery of services toindividuals with ASD of all ages and stresses theneed for partnership working and service userinvolvement.

It is expected that the final strategy will be publishedin early 2008. Its guidance and direction will becarefully considered in the planning andcommissioning of local services.

The Local Authority has had the lead responsibility for commissioning learning disability services since 1983 and works closely with Cardiff LHB and a range of partners in the planning and delivery of these services. Within the city the framework for joint working, planning and commissioning takes place through the Advisory Planning Group structure. The APG has membership from a number of bodies whose purpose is to encourage and enable the involvement of parents/carers and service users as well as undertaking a consultative, supportive and lobbying role.

Specialist learning disability health staff are integral to the multi-disciplinary structure asa community learning disability support team.Specialist health services for people with learning disability are commissioned by the LHB on a South East Wales collaborative basis (South East Wales Learning Disabilities Partnership Board).

The Vale of Glamorgan LHB chairs the Partnership Board which has established a joint vision and strategy for health and social care services, demonstrating its commitment to partnership working, the commissioning of quality learning disability services and continuous delivery of service re-design and service improvement schemes.

The Partnership Board has a range ofstrategic areas of focus, one of which is the significant expenditure and associated service deficiencies of placing individuals with challenging behaviour inappropriately ‘Out of Area’. In 2003-04 the Partnership Board commissioned a mapping exercise to identify those people with challenging behaviour in ‘Out of Area’ placements and the associated costs of their care.

It identified the number of people coming through the system who were in danger of being placed ‘Out of Area’ at high cost, should appropriate services not be developed locally. As a result, a Strategic Outline Programme (SOP) was developed which set out a whole systems approach to:

Repatriation of those people for whom placements ‘Out of Area’ are deemedinappropriate. Development of locally based health and social care structures and services that remove the need for future ‘Out of Area’ placements.

Planned developments include the commissioning of low and medium secureforensic services, as well as increasing the number of challenging behaviour Continuing NHS Health Care residential beds, inconjunction with improving the community infrastructure to meet the needs of all who are/could come in contact with Criminal Justice Systems. The capital requirements for the SOP were submitted to the Welsh Assembly Government in 2006.

The key local strategic documents for Learning Disability Services are:

Joint Commissioning Strategy for People with Learning Disabilities 2005-2008 (Cardiff Council & LHB) Cardiff Carers Plan (2005, new plan underdevelopment) Supporting People Operational Plan 2007-2008Strategic Outline Programme ‘Closer to Home the Next Steps’ January 2006 Cardiff LHB’s Continuing NHS Health Care Policy‘Making a Difference’, South East Wales Partnership Board.

Cardiff Council and the LHB are responsible for commissioning health and social care services, within hospital and community settings, that are routinely accessed by individuals with a learning disability. Both the Local Authority and LHB are responsible

for the identification of need and the commissioning of specific services for individuals with a learning disability who have a higher level of need. The Unified Assessment process has been implemented as the basis for identifying the needs of these

Learning disability 83

CURRENT SERVICES


service users and their carers. Within this framework, eligibility for services is determined by Fair Access to Care and Continuing NHS Health Care criteria.

The delivery of services in Cardiff relies heavily on the development of sustained partnerships between Health, Social Care and voluntary and independent sector providers. The list below is indicative of progress made in developing integrated services and is not intended to be exhaustive:

The Council and LHB commission integrated multi-disciplinary Community Support Teamsincluding social workers, community nurses, speech and language therapists, physiotherapy, occupational therapy,psychology, dietitians, case managers, social work assistants and access officers.

The Community Learning Disability Teams and individuals are able to access tertiary specialist health services such as consultant psychiatrists, art therapies, Specialist Behavioural Teams as well as Move on Co-ordinators and Supported Accommodation Officers.

The LHB commission a range of health care services that can be accessed during acute health, social care crisis or for individuals requiring long stay Continuing Health Care including:

Acute NHS Assessment and Treatment UnitsSlow stream Treatment & Rehabilitation Unit (jointly funded by Council & LHB) Continuing Health Care placements for challenging behaviour-settings Access to psychiatric in-patient beds

There are also a range of services, funded by the Council, to support the integration and opportunities for individuals with a learning disability and their carers including:

Advocacy Emergency Accommodation Service Day Services Vocational Training and Sheltered EmploymentEducation Opportunities Supported Accommodation and Independent Living Schemes Residential and non-residential respite Home Support Service Disability Advisory Resource Team Independent financial advice.

In 2002 a Special Projects Team was commissioned by Bro Morgannwg NHS Trust to support development work of the SE Wales Learning Disability Partnership Board by:

Co-ordinating and developing existingspecialist tertiary services for challenging behaviour Developing a range of state-of-the-art demonstration projects at primary and secondary service levelsImproving front-line knowledge and competence in supporting people with challenging behaviour via the widespread dissemination of training and good practice at primary and secondary care levelsEvaluating the impact of interventions, and generally improving the knowledge base concerning people with learningdisabilities and challenging behaviour.

There are many voluntary sector groups thatsupport people with a learning disability and their families, relatives and friends, or who offer such help within their broader range of activities. The Cardiff and Vale Parents Federation has produced ‘Where You Stand’, a local guide to services listing the range of services available to people with a learning disability (www.parentsfed.org).


Many of the objectives in the first HSC&WB Strategy and the principles outlined in key strategic documents are considered to be

medium to long term. Therefore the principles and objectives remain applicable.

2005 - 2008

Development of a Joint Commissioning Strategy for Learning Disabilities (2005-08).

Procurement and re-commissioning of Supported Living Services and Emergency Accommodation and Support Services.

Development of a service specification for future requirements for respite and adult placement services and the implementation of a re-procurement process.

Tender process for remaining elements of the Local Authority’s learning disability services has been initiated and is scheduled for completion by March 2008 for Priority One projects and March 2009 for Priority Two projects.

Development of a new performance management framework for contract monitoring.

Successful Supporting People funding bids (2006-07) for the expansion of Adult Placement Service and Supported Living Schemes.

Obtaining grant funding for a review officer to map and assess service users in ‘Out of Area’ placements with a view to commissioning services to repatriate those who intend to return to Cardiff.

Implementation awareness & training which focuses on person centred planning across the sector.

Nurse Consultant post established utilising Section 7 guidance funding.

Provision of training sessions on the needs of individuals with a learning disability to all GPs in Cardiff.

Commissioning of a GMS locally enhanced service for annual health checks for individuals with a learning disability.

Review and mapping exercise of specialist health challenging behaviour services undertaken,contributing to the development of a strategic outline programme for the development of local services. This formed part of the submission to WAG in 2006 for support around the capital funding implications.

Contribution of the LHB and the Local Authority in the development of an integrated care pathway for challenging behaviour (although this has not as yet been implemented in Cardiff).

Supported the development of a new NVQ level training programme for people working with individuals with challenging behaviour by Bro Morgannwg NHS Trust.

Implementation of the multi-agency transition protocol and internal guidance for individuals making the transition from children to adult services.

PEARL Project-provided evidence base for continuing health care.


KEY ACHIEVEMENTS

The number of people registered with Cardiff Council Adult Services in January 2008 is 967 on the Learning Disability Register (adults over 18 years). It is recognised, however, that not every person with learning disabilities or their parents/carers would wish to be recorded on the Disability Register, sothese figures underestimate the population. Research by the Bro Morgannwg NHS Trust suggests a total population within Cardiff of 1200 – 1400 individuals with a learning disability. The table below details the age range of adults with a learning disability who live in Cardiff and are known to Adults and Children’s Services: Figure 9.1

Learning Disability Population2005

0

50

100

150

200

250

0-17

18-2

930

-39

40-4

950

-59

60-6

970

+

Not K

nown

Age

Num

ber

of P

eopl

e

The future incidence of learning disability is likely to increase. In 2005 the Association of Directors of Social Services (ADSS) commissioned a report on the pressures on learning disability services. It concluded that not only are there more people with learning disabilities in the population, but numbers of those who are likely to require high levels of support is growing faster than the overall trend. A number of significant factors were identified including: Increased life expectancy13% of people with learning disabilities in Cardiff are over 60 years old. This figure is projected to rise to 16-17% by 2008.

Emerson and Hatton (2004) have undertaken work for the Department of Health which seeks to estimate current and future need and demand. Their report concludes that there will be a 41% increase of people aged 60-79 by 2011 and a 56% increase in those aged over 80 with learning disabilities.

Increasing number of younger people with profound complex needs Emerson and Hatton project that there will be a ‘systematic increase in the prevalence of severe/complex disabilities among young children age 5-14.’

The Learning Disability APG has identified the following key developments and actions for the city:

Complete the re-commissioning process for remaining elements of the learning disability services, in particular: o Develop a range of alternative

approaches to supported living services

o Develop a range of innovative, flexible respite care options

o Expand the Adult Placement Service to accommodate people living in small residential care homes where required

o Specialist day activities.

Review progress of the Joint Commissioning Strategy and develop a follow-on strategy and action plan for 2008-2011 The roll out and adoption of Person Centred Planning by all partners Commissioning of appropriate, long term continuing health care, residential and respite provision, for individuals with a learning disability and associated physical problems Reviewing the role, function and operational framework of the current Community Learning Disability Teams to support the development of integrated health and social care services for people with a learning disability, with single line management, pooled resources and joint commissioning (Making the Difference, S.E. Wales Partnership Board 2007)



Increasing the availability of advocacy servicesTo ensure that strategic developments address the needs of people with a learning disability Undertake profiling of needs, current use of resources and identify priorities for future service provision for transitional care

Review existing specialist provision and utilise the commissioning process to encourage development of local servicesin response to local need Progress the SOP following the result of the WAG capital funding bid Awareness raising for all stakeholders of relevant legislation such as Mental Health Act and the Mental Capacity Act Re-establish annual health checks for 2008.

There is evidence that people with learning disabilities experience unequal access to primary health care. Similarly traditional models of health promotion do not generally engage people with learning disabilities effectively.

The health needs of people with learning disabilities form a broad spectrum. Whilst people with severe learning disabilities may be easier to identify and therefore participate in health surveillance, they may have more difficulty identifying physical health problems. There may be difficulties accessing effective health care in relation to their ability to participate whether through communication barriers or challenging behaviour. In contrast, those with milder learningdisabilities may not be known to statutory services and may not access conventional health screening programmes. Effective health care for people with learning disabilities must include robust measures to ensure health promotion, health surveillance and effective health care interventions and these must be at the core of person centred planning.

As highlighted by the Disability Rights Commission’s formal investigation into health inequalities (‘Equal Treatment: Closing the Gaps’, 2006), it is imperative to ‘promote health improvement and reduce inequalities’ with the aim of ensuring that cross cuttingissues of equality, health improvement and children/young people’s needs are addressed. The following areas highlight the needs and gaps:

Awareness raising of Autistic Spectrum Disorder (ASD), including Asperger

Syndrome, to reflect the variation in the nature and severity of the impacts and barriers posed by these disorders and to cover the consequent diversity and range of need posed for people with ASD, their families and carers and statutory, health, independent and voluntary servicesEnhanced primary health services – annual health checks aimed at reducing inequalities

Advocacy

People with learning disabilities (in particular the onset of Alzheimer’s disease in individuals with Down’s Syndrome)

Disability Discrimination – inadequate training of health and social care staff related to the needs of people with alearning disability and how to address difficulties that may arise in communication, judging capacity and consent

Lack of accessible information forindividuals with a learning disability and their carers about health promotion

Equal right of access to primary, secondary and specialist health care services and routine national health screening programmes that are available to other members of the public.

In 2006-07 the LHB piloted Local Enhanced Services from GPs to offer an annual health check to people with a learning disability and the LHB will consider the continuation of this following an evaluation of its implementation and health outcomes (due to be published in2007-08).



RaceThe 2001 census records a total population for Cardiff aged 18-64 as just over 190,000. The proportion of black and minority ethnic (BME) groups has increased from 6.2% in 1991 to over 8% by 2001. 5% of the total service users with learning disabilities known to Cardiff Council are from BME communities. Due to the higher prevalence of learning disabilities among some minority ethnic communities and the greater burden of care,families from minority ethnic communities with a member who has learning disabilities are doubly disadvantaged. The prevalence of learning disabilities among South Asians isthree times that in majority communities. Of these families, 19% have more than one member with a learning disability.

GenderIn 2004, Bro Morgannwg’s Special Projects Team identified 303 children and adults with challenging behaviour living in Cardiff. Of these, 66% were male and the average age was 29 years.

Disability People with a learning disability who have mental health needs should be able to access a comprehensive range of generalist and specialist local mental health services. More work is required to understand and establish the level of needs in Cardiff but it is recognised that an increasing percentage of

the learning disability population have complex health needs.

Sexual Orientation According to estimates in the UK, around one in ten people with a physical or learning disability are lesbian or gay. There isevidence that many lesbians, gay men and bisexuals feel excluded from mainstream services, isolated from services for peoplewith physical or sensory impairments as well as socially excluded from lesbian, gay or bisexual groups. Consideration should be given to collect local data on this issue.

Language of Choice People with learning disabilities have the right to access services in their language of choice, whether this is Welsh, another language or British Sign Language (BSL).

Religion & Belief People with learning disabilities will be supported to practice their chosen faith.

AgeAge related illnesses/conditions are becoming more prevalent e.g. early dementia may be expected in 45% of people with Down’s Syndrome. There must be robust transitional care arrangements between children’s and adult’s services.



2008 - 2011

1. To enable people with learning disabilities to access a health service designed around their individual needs, with fast and convenient care delivered to a high standard and with additional support where necessary. This relates to both mainstream (primary, acute and preventative care) and specialist learning disability health services, e.g. annual health check for people with learning disabilities in Cardiff.

2. Challenge discrimination and promote positive images of people with a learning disability across Cardiff and conduct equality impact assessments on all areas of service provision. Commissioners will need to ensure that the impact and effectiveness of their commissioning specialist learning disability services isintegral to Disability and Equality strategies and may need to carry out equality impact assessments in relation to disability, race, gender and other aspects. To ensure all information is accessible for people with a learning disability.

3. Supporting people to live within their own homes and communities wherever practicable, to promote health, independence and social inclusion.

4. Progressing the joint commissioning agenda for learning disabilities and developing a follow on strategy and action plan for 2008-11.

5. Integrating health and social care management, teams and services with intention to strengthen joint working through the ‘new flexibilities’ and promoting partnerships.

6. Ensuring people with a learning disability are at the centre of planning and participating in decisions and discussions that affect their lives.

7. Complete the re-commissioning process for learning disability services to achieve the expansion of Adult Placement Scheme, reconfiguration of respite services, reconfiguration of day services and specialist day service.

8. Implementing the health gain targets within the acute hospital services in Cardiff. 9. Remodelling and re-commissioning two existing Continuing Health Care community units to provide long

stay care and respite for individuals with profound and multiple disability. 10. To consider and take forward the recommendations of the Autistic Spectrum Disorder (ASD) Strategic

Action Plan for Wales.11. Implement the Transition protocol and guidance for young people moving from Children’s Services to

Adult Services. To co-ordinate the action plan designed to address the service.



10. Carers

Carers90

‘The Welsh Assembly Government recognises thevital contribution made to society by the manyunpaid carers in Wales who look after relatives orfriends who are frail, sick, disabled or vulnerable.We also recognise the importance of agenciesworking together and engaging with carers aspartners in the provision of care,’ John Griffiths,former Carers Champion, speaking at an event tomark Carers’ Rights Day, December 2006.

According to a report by Carers UK the value ofunpaid support that carers provide has now reached£87 billion a year – more than the annual total spendon the NHS, which stood at £82 billion in the year2006-07. A carer is someone who looks after apartner, relative, friend or neighbour who is unableto manage without help, because they are sick,elderly or experiencing physical or sensory

impairments or mental ill health. The care theyprovide is unpaid. There are an estimated 31,125carers in Cardiff and this is set to gradually increaseas people live longer. It is suggested that thenumber of people caring is greatly underestimated,as many do not identify themselves as carers.However, carers are becoming increasingly moreaware of their right to help.

Cardiff’s changing demographics need to beconsidered when planning services for both the carerand the people they care for. It is estimated thatfamily, friends and neighbours provide at least 70%of the care for vulnerable people. The sustainabilityof services relies on the contribution of care fromcarers. It is therefore essential that carers aresupported to enable them to continue their caringrole.

NATIONAL STRATEGIC CONTEXTThe key national document that provides theframework for carers is the Welsh AssemblyGovernment’s Carers’ Strategy for Wales ‘Caring forCarers’ (2000). The objective of this strategy was toachieve the long term improvement in the health andwell being of carers and those for whom they care.In 2007 the Carers’ Strategy for WalesImplementation Plan was developed to refocus theoriginal Strategy and set out the strategic directionfor carers, together with specific action points, toenable key objectives to be achieved over the nextfew years. Underpinning the ‘Carers Strategy inWales – Implementation Plan,’ are the three guidingthemes which the National Assembly has adopted forits work: � Sustainability � Tackling social disadvantage� Equal opportunities.

The Carers’ Strategy in Wales seeks to give effect tothe Assembly’s themes and values and to meet thelegitimate needs of carers for real practical means ofsupport and assistance. To this end it drawstogether, under five key priority headings, variousaspects of the Assembly’s work which have aparticular bearing on the lives and needs of carers.

Much of the Implementation Plan is about raisingawareness of service providers about carers and theirneeds. The priority areas for action are:� Health and Social Care� Information� Support� Young Carers� Carers and Employment.

For the first time, a question on carers was includedin the 2001 Census. This has led to reliableknowledge both locally and nationally about carers.In 2006 the Assembly Government issued the formalguidance regarding an additional £3m availablethrough the Mental Health Carer’s Grant.

Carers’ issues need to be considered across all clientgroups and therefore are addressed in many healthand social care national documents. Some of theother key documents are:� Fulfilled Lives, Supportive Communities: A

Strategy for Social Services in Wales Over theNext Decade (WAG, 2007)

� Designed for Life: Creating world class Healthand Social Care for Wales in the 21st Century(WAG, 2005)

� Caring for Carers (WAG, 2000) � ‘Stronger in Partnership’ the Welsh

Assembly’s guidance on mental health service user and carer engagement, (September, 2004)

� Stronger in Partnership 2’, the Welsh Assembly Government’s draft revised good practice guidance follows up‘Stronger in Partnership’ but with greater emphasis on the involvement of users, carers and the voluntary sector in the

initial strategic planning of services, subject to consultation, (WAG 2007).

In October 2007, ‘Achieving Change forCarers’, a national policy conference, was held. The achievements of Action for Carers and Employment (ACE), a nationalpartnership, were celebrated. However, the focus was on what still needs to be achieved to enable carers to have real choices and be able to access work, leisure and education.

Cardiff Carers StrategyThe Cardiff Carers’ Plan was launched in 2002, in response to the 2000 Welsh Carers’ Strategy that encouraged all areas to develop their own plan in consultation with localcarers. Following these consultations the following areas were prioritised: � Health � Active Support � Information� Awareness and Recognition � Skills Development � Employment � Participation and Consultation � Joint Working

The Cardiff Carers’ Plan, 2002 sets the framework for local provision of services to carers and began the process of improving the quality of carers’ lives.

The Cardiff Carers’ Plan will now be updated in line with the Health Social Care and Well Being Strategy and the updated Welsh Carers’ Strategy. The Plan looks at the diverse needs of carers in all situations and also recognises and discusses specific issues relevant to young carers, parent carers of children with physical or sensory impairments, carers of people experiencing mental health problems, older carers and minority ethnic carers.

Carers have a direct input into the development of the Strategy through the

Carers’ Forum, Advisory Planning Group and sub-groups and will reflect on achievements 2002-2007 and set priorities for the next five years.

Young Carers’ Strategy The Cardiff Carers’ Plan stated that a separate Young Carers’ Strategy would bedeveloped to reflect the very different needs of young carers. This strategy was launched in December 2007. The Young Carers’ Strategy, agreed by the Young People’s Partnership in 2006, has been developed by a multi-agency task group made up of representatives of statutory and voluntary sector organisations. The strategy addresses the specific issues experienced by young carers and:

� Aims to provide effective approaches to a range of issues affecting young carers in Cardiff. It supports effective joint working between organisations that comeinto contact with young carers, so that they respond efficiently and effectively tomeet needs.

� Forms the framework to provide greater opportunity and support for young carers both as children and in their caring role.

� In May 2007 a Young Carers’ Development Officer was appointed to raise awareness of the issues affecting young carers and to ensure that the key action points arising from the Strategy are fully implemented.

Carers 91


� Key milestones for 2007/08 will include the implementation of young carer’sleaflet and information booklet, the delivery of Young Carer Awareness Raising training to statutory and voluntary

organisations, the development of key posts within schools to support young carers and the development of a range oflocal support services for young carers.

Carers92

Carers’ services are identified through the Carers’ Assessment, which is an opportunity for the carer to consider what they need, whether they feel they can go on caring, and what services would be useful to both the carer and the person cared for.

Cardiff Council made a commitment to continue to support carers by ring-fencingthe carers’ budget until 2007-2008. This was essential in ensuring that carers were able tocontinue to support the person they care for. This range and quality of services relies heavily on continuation of this funding.

The potential range of services that can be provided to carers is vast and cannot be simply defined as respite or domiciliary services. From information gathered fromlocal and national research, consultations and carers assessments, a range of services are being provided to ensure the needs of carers can be met:

� Respite Care/Short Term BreaksThese are provided by voluntary sector organisations as well as via the NHS and social services in various settings dependant on the needs of the individual.

� Domiciliary Care Services are provided to the cared for person and can provide additional respite for the carer.

� Advice & Advocacy is provided througha variety of voluntary organisations to various client groups including carers of those with mental health problems including dementia and minority ethnic carers.

� Information is provided by both statutory and voluntary agencies to keep carers informed of services and support available. Information is given in various ways such as leaflets, stalls at events and information sessions.

� Carers’ Support Groups are mostlyprovided by voluntary agencies to provide support and social network for carers.

� Participation and Inclusion via consultations, events and participation groups, arranged by both the statutory and voluntary agencies to ensure thatcarers’ opinions are taken into account when planning services.

� Training available for professionals to raise awareness of carers’ issues.

CURRENT SERVICES

There have been many achievements over the last three years. The objectives set out in the last HSC&WB Strategy were broad and work has been undertaken to ensure thatprogress has been made in most of these areas. Some of the achievements over the

past year have been made possible through additional funding from the Welsh Assembly Government and this needs to continue andbe ring-fenced to ensure that carers continue to receive support.

KEY ACHIEVEMENTS

2005 - 2008

� Increased availability of specific information for carers has been provided by the Council and various voluntary organisations via regular newsletters and meetings.

� Young Carers’ Strategy has been developed and a Young Carers’ Development Worker has been appointed to implement the Strategy.

� Funding provided by Adult Services, Cardiff Council to provide carers with a dedicated drop in Carers’ Centre.

� Additional services for carers of people with mental health needs have been funded through Adult Services, Cardiff Council.

� Mental Health Development Project produced ‘Directions’ a guide for carers of older people with mental health needs.

� The minority ethnic carers ‘Upna’ Centre increased from fortnightly to weekly sessions and a development worker appointed.

� Adult Services funded a Cardiff Carers’ Forum, which is facilitated by the Carers’ Centre.

� A counselling and telephone advice service for relatives/carers of clients who suffer with dementia called SOLACE was launched in October 2006. The staff arrange regular support meetings for carers and important topics and speakers are also discussed/arranged for these meetings.

� Carers are now involved in student nurse training (mental health branch), talking to students of their experiences of being a carer.

� A specific bereavement suite is available at Whitchurch Hospital with nursing expertise to assist the bereaved in coming to terms with their loss, in confidential and appropriate surroundings.

The aim in health and social care to maintain the independence of service users will have a considerable impact on carers. Services for carers have historically been seen as secondary to the needs of the service user. In addition there is an increase in the age of carers, who, in turn, will need more support.

The Carers APG has identified the following key developments and actions:

� Respite services to provide improved access to respite facilitating a break fromcaring. This should include emergency respite provision

� Information to be readily available and easily accessible and provided in relevant languages and formats

� Training for carers to be developed toenable the carer to continue their caring role or to encourage them back intoemployment or further education

� Leisure Provision to be available via leisure services to facilitate health benefits or social interaction

� Health & Well Being awareness and support ensuring that carers consider and maintain their own health and well being

Carers 93


� Carers’ Assessments need to be reviewed to evaluate and review theeffectiveness of assessment

� Training for professionals to continue providing carer awareness training for all Adult Services social work staff. Training to be developed within Children Services

� Telecare support for carers is one of the priority groups in Adult Services, underthe WAG sponsored Telecare initiative. There are plans to develop the service specifically in relation to carers over the next 18 months.

Carers94



The Welsh Assembly Government’s strategyfor Health and Social Care ‘Designed for Life’envisages a transfer of services to people intheir own home or in the local community.This will require an expansion in prevention,screening and community based assessmentof need. It will also require a much greaterfocus on carers’ health and social care needs.

Overall� Establish a better understanding of

carers’ needs and explicitly include thosein service improvement proposals

Primary Care� GPs to provide regular preventative

health checks for carers

� GPs to provide joint appointments forcarer and cared for, if both parties agree

� GPs to provide better access to homevisits for carer and cared for

Secondary Care � Improved communication between

agencies for assessment of health needsand interventions (e.g. equipment)

� Involve carers in the discharge planningprocess, so that discharge is safe forboth carer and cared for, involving allagencies and include a full riskassessment of carer’s needs

� Consider increased priority for carers’health care, to maintain the health andwell being of carers, thereby avoidingadditional services for the cared for

� Out patient appointment notificationssent to carers and cared for

Domiciliary Care � Fast track equipment provision for carers

following risk assessment of carer’s needs� District Nurses joint appointment for

cared for and carer.

Carers are recognised for the role theyprovide in their family and the community asa whole, irrespective of age, race or gender.All carers’ support operates within equalopportunities guidelines. It is an isolatingrole for carers and all situations are uniqueand are treated in an individual way.Research by Carers UK shows that half ofcarers have to give up work to care, and athird are facing severe financial hardshipsuch as cutting back on food or unable topay bills.

RaceWithin Cardiff over 10% of the populationare from minority communities; their caringrole can be further isolated by cultural and

language barriers and the absence ofculturally appropriate services. Support willcontinue to identify hidden carers fromminority communities and look at ways ofsupporting them in a way that is sensitive totheir specific needs and respects theirculture, religion and beliefs.

GenderResearch indicates that there are morefemale carers aged 50+ caring for parents,older children with physical or sensoryimpairments and spouses. Employers will befurther encouraged to adopt carer friendlypolicies and flexible working so that thisexpertise is not lost from the workplace.

DisabilityNew research from Carers UK shows that twoout of three carers have to cover extra costsof physical or sensory impairment. Equallythere may be particular issues regardingphysical or sensory impairment relating tohospital discharge (Community Care (DelayedDischarge) Act 2003). Despite the fact thatmany children with physical or sensoryimpairments have very specific needs, manyparents experience barriers in accessingservices. It must be born in mind that carersthemselves may suffer chronic healthproblems or may be experiencing physical orsensory impairments themselves.

2008 - 2011

1. To promote health improvement for carers, identifying the main health issues affecting carers through the health task and finish group of the Carers APG.

2. To reduce inequalities for carers and promote equal access by continuing to look at ways of ensuring carers from all communities and backgrounds are able to access services to meet their individual needs.

3. Provide appropriate respite, identifying the type of respite appropriate for carers to ensure that their caring role can be sustained.

4. Further develop information to carers, in accessible formats, Plain English, and at appropriate times throughout their caring role.

5. Increase the number of carers known to health and social care services, in order to facilitate completion of Carer’s Assessments.

6. Increase knowledge and recognition of carers via Carers Awareness Training, particularly through social services induction training.

7. Implement carer friendly policies within the Council and NHS and use these as good practice for other Cardiff employers.

8. Implement the most practical and effective ways of involving carers in the planning and development of services.

9. To continue to encourage joint working between statutory, voluntary and private sector organisations to provide a range of services to carers and ensure that carers are considered in all service delivery.

Carers 95


Sexual OrientationCaring for a person can be an isolatingexperience. Some LGBT (Lesbian, Gay,Bisexual and Transgender) carers feel unableto access existing services and carerssupport, feeling that they may facediscrimination.

Language of ChoiceInformation needs of carers will be looked atin respect of language of choice and accessto interpreters, visual and audio formats.

Religion and BeliefServices need to ensure that while notexclusive in themselves, they seek to support

a person’s religion and/or belief in theprovision of personal care.

Age� Young Carers play a significant role

within a family. Their role will be furtheracknowledged and supported through aYoung Carers’ Strategy, which will alsoidentify where best to provide thissupport and educate the educators intoissues relating to young carers.

� The number of older carers is set toincrease with changing demographics aspeople live longer.

11. Sexual health

Sexual health96

Sexual health goes beyond the medical model oftreatment of disease. The World Health Organisationdefines sexual health as:

‘A state of physical, emotional, mental and social wellbeing related to sexuality; it is not merely theabsence of disease, dysfunction or infirmity. Sexual

health requires a positive and respectful approach tosexuality and sexual relationships, as well as thepossibility of having pleasurable and safe sexualexperiences, free of coercion, discrimination andviolence. For sexual health to be attained andmaintained, the sexual rights of all persons must berespected, protected and fulfilled.

’The Welsh Assembly Government’s Sexual HealthStrategy dates from 2000, as one of the measuresemerging from the ‘Better Health – Better Wales’Strategic Framework. The Strategy focussed onconcerns about the high rates of teenage pregnancyand sexually transmitted infections in Wales. It isanticipated that a new Public Health Strategy forWales will be published during the life of thisStrategy that will need a local response in relation tosexual health. In addition, a consultation documenthas been published by WAG on draft qualityrequirements for Sexual Health Services in Wales.The final published standards will be a key tool infurther developing high quality sexual health servicesfor the city.

The aims of the 2000 strategy were:� To improve the sexual health of the population of

Wales� To narrow inequalities in sexual health� To enhance the general health and emotional

well being of the population by enabling andsupporting fulfilling sexual relationships.

The objectives for the action plan to fulfil the aims ofthe strategy were as follows:� Ensure that all young people receive effective

education about sex and relationships as part oftheir personal and social development

� Ensure that all sexually active people have accessto good quality sexual health advice and services

� Reduce rates of teenage pregnancy� Reduce incidence and prevalence of sexually

transmitted infections (STIs)� Promote a more supportive environment, which

encourages openness, knowledge and

understanding about sexual issues and fostersgood sexual health

� Strengthen monitoring, surveillance and researchto support future planning of sexual healthservices and interventions.

‘Designed for Life’ (2005) identified that there shouldbe access to services for STIs and HIV and routinecontraception within 2 working days and access toemergency contraception within 24 hours, asmilestones to be achieved by March 2006 andmaintained thereafter. These aims and objectivesstill have relevance to tackling the ongoing need toimprove sexual health as identified within thischapter.

The National Service Framework (NSF) for Children,Young People and Maternity Services in Wales (2006)includes a standard on ‘Promoting Health & WellBeing: all children, young people and their parentsand carers have access to a range of services thatpromote health and well being and prevent ill-health’,and includes key actions relating to sexual health asfollows:� Schools are supported to provide effective sex

and relationships education, drawing on bestpractice as set out in Sex and RelationshipsEducation in Schools (WAG, 2002)

� Children and Young People’s FrameworkPartnership plans include rapid access toconfidential contraceptive and sexual healthadvice services, including emergency hormonalcontraception as set out in best practice adviceon the provision of effective contraception andsexual health advice services for young people(WAG, 2001).


Cardiff and the Vale of Glamorgan’s Programme for Health Service Improvement is at the heart of modernisation of local service provision to deliver a sustainable health service as indicated in ‘Designed for Life’. The PHSI programme holds two key elements that support the delivery of improved sexual health services. These are: � The re-provision of Cardiff Royal

Infirmary as a Locality Health and Resource Centre which will provide an improved environment of care forintegrated sexual health services.

� Integrated sexual health services will be provided on eight sites across the city as part of plans to provide an integrated andflexible network of community health facilities leading to the re-provision and closure of outdated health centres and clinics.

There are two key delivery plans that form the background to progress in improving sexual health:

1. Integrated Sexual Health Service Cardiff and Vale NHS Trust have been working with stakeholders to consider an appropriate service delivery model. The Zipper Model is a novel clinical modeldesigned to support the integration of Family Planning and Genito Urinary Medicine (GUM) services. The aim is to provide a model for integration that will enable all those involved in commissioning and provision to work together towards a common goal, ensuringefficient and effective use of resources andhigh quality evidence based services for patients. The model is based on three service levels as follows:

� Level I services will be available to patients at all points of contact with the integrated sexual health service (ISH) and all clinical staff will have the basic skills required to provide them. It is anticipated that these services (e.g.

chlamydia and non-complex testing for sexually transmitted infection) will be delivered as an extension to, and integrated with, Family Planning clinics. In the longer term, GP practices wishing to provide sexual health services will work in partnership with the ISH service to deliver this level of service.

� Level II services are extended services that will be provided alongside Level I services in Locality Health Resource and Treatment Centres. The location of services will take account of available and appropriate accommodation, geography and local health needs addressing health inequality as central to service planning.

� Level III services will include complex services provided by senior clinicians for patients requiring more specialist care. This service will be based with the integrated sexual health service at Cardiff Royal Infirmary and will include outreach services. Implementation of a managedcare pathway will ensure rapid referral for follow-up between levels for those patients requiring more or less complex care.

Delivery of this model will be within Cardiff’s implementation plan for primary care services that will see the development of better access to health services in the community.

2. The Cardiff Multi-Agency Young People's Sexual Health Action Plan This is Cardiff’s response to the NSF for young people in relation to sexual health. The plan aims to deliver activity to reduce the prevalence of sexually transmitted infections and unintended teenage pregnancy, by ensuring that all young people receive effective Sex and Relationships Education (SRE) and have access to appropriate sexualhealth information, advice and services. The objectives of the plan are detailed in the Promoting Health Improvement chapter.

Sexual health 97


Health Promotion and Prevention Services The National Public Health Service leads and co-ordinates a range of services provided bystatutory, voluntary and community agencies to provide a range of targeted interventions and provide a link to national campaigns.

Contraceptive and Family Planning ServicesCardiff and Vale NHS Trust contraceptive (family planning) services are provided in a range of contraceptive clinics, some of which attract young people in particular. There are also several clinics that specifically target young people. In addition to specialist provision, certain sexual health services, such as contraceptive advice and prescription, pregnancy testing, emergency hormonal contraception and STI advice are alsoprovided in general practice, although the level of provision differs across practices. Sexual health information, condoms and signposting to primary care and specialist services are provided through trained workers in some Cardiff Council youth settings through local projects co-ordinated by Cardiff Public Health Team. Young people’s sexual health services are offered through family planning and GUM services. The Condom-card scheme offers young people access to confidential sexual health advice and information and free condoms via a co-ordinated Cardiff-wide service.

STI Testing and Treatment ServicesCardiff and Vale NHS Trust Sexually Transmitted Infection services are currently provided in the Genito Urinary Medicine (GUM) clinic in Cardiff Royal Infirmary. There are also facilities and staff to provide support to people with HIV and AIDS. Specialist in-patient sexual health services are provided atthe University Hospital of Wales, primarily for people with HIV/AIDS.

Abortion Services The Trust is commissioned to provide abortion services up to and including 15 weeks of pregnancy, currently within hospital settings. Beyond 15 weeks, patients are referred to the British Pregnancy Advisory Service.

Sexual Dysfunction ServicesSexual Dysfunction and treatment of male and female psychosexual disorders are provided by a General Practitioner with special interest in sexual medicine and within the family planning clinic setting. In addition, private, non-NHS services for both male and female sexual dysfunction are available.

Community Pharmacy ServicesCommunity Pharmacies in Cardiff LHB areasupply against prescription and provide advice on oral contraceptives, contraceptivedevices and drugs for erectile dysfunction. Inaddition they provide convenient access to condoms, pregnancy testing, Emergency Hormonal Contraception and in somepharmacies Chlamydia testing and treatment as private services. Emergency Hormonal Contraception and Chlamydia Testing & treatment services have not beencommissioned to date as an NHS service.

Voluntary Sector Services The main voluntary sector provider of sexual health services in Cardiff is Terrence Higgins Trust Cymru, which is an HIV and sexualhealth charity that provides education, support, advocacy and campaigns for HIV vulnerable populations and people living with HIV. There are other voluntary sector providers such as the Family Planning Association that provide sexual health services from information, education and advice to provision of condoms.

Sexual health98

CURRENT SERVICES

The main focus of achievement for the 2005-2008 Strategy has been in two areas:

� Development and delivery of Young People’s Sexual Health Action Plan in line

with the Children’s and Young People Partnership Framework

� Organisational merger of family planning and GUM services.

2005 - 2008

� Sexual Health Joint Planning process re-established

� Independent review of local GUM services undertaken by the Royal College of Physicians

� World Aids Day campaign supported

� C-card scheme implemented with young people and C-card assessors via two under 18s club nights and extended to include Coleg Glan Hafren, Housing Associations and homeless hostels

� Support provided to 18 schools and training delivered to 12 secondary school PSE co-ordinators to deliver quality Sex and Relationships Education

� Research study on how young people access information and advice on sex and relationships completed; dissemination event held and papers written and published. Research undertaken into needs of LGBT young people.

The needs assessment undertaken in 2003 has been broadly updated to reflect the fastchanging nature of trends in infection rates for sexually transmitted infections, HIV and trends for abortion. According to the statutory reports collated from genito-urinary clinics across the UK, the rates of all sexually transmitted infections have been rising considerably in the last 5 years, including:

� Increased diagnosis of chlamydia partly due to increased awareness and testing.

� Rising rates of gonorrhoea in population sub-groups at increased risk of infection including women aged 16-19, heterosexual males, men who have sex with men and minority ethnic communities, particularly Black Caribbean.

� Continued rising diagnosis of HIV in gay men and through heterosexual contact primarily through people living overseas or having had contact with a person who had lived abroad.

� Rising numbers of people living with HIV due to increased effectiveness of drugtherapy and a rising number of new diagnoses.

The overall burden of the disease is likely tobe understated, due to the asymptomatic

nature of many sexually transmitted infections and the stigma associated with seeking diagnosis and treatment.

The health needs assessment has also identified that whilst teenage conceptions appear to be falling in Cardiff, rates remain unacceptably high and there is an ongoing need to meet the demand for abortions and at an earlier stage in pregnancy. The LHB has also acknowledged the lack of a locally provided Sexual Assault Referral Centre (SARC) for all ages, with Cardiff residents having to currently access the service in Merthyr Tydfil. This has led to a multi-agency project to develop a local service onthe Cardiff Royal Infirmary site as part of the Integrated Sexual Health service for the city.

Overall sexual health is an area of increased demand for diagnosis and treatment that presents an incremental growth in the demands placed on local services. The challenge for the local health community is to provide access to services for this group of people in an environment where there can beno planned investment in services due to the prevailing financial constraints on allorganisations.

Sexual health 99

KEY ACHIEVEMENTS


The following key public health trends have been highlighted as priorities for the sexual health services to address:

� Levels of HIV infection and other STIs inspecific high risk groups including Gay Men and people from overseas

� Rising levels of STIs specifically among young people – there is a particular need to consider action supporting vulnerable young people

� Unwanted pregnancy in young people� Generally poor sexual health in lower

socio-economic groups and deprived areas

� Access to psycho-sexual services � Services to manage female genital

mutilation � Services to support people who have

been sexually assaulted.

Regarding young people’s sexual health, areas of focus within the Young People’s Sexual Health Action Plan are as follows:

� Raise awareness of sexual health issues via national and local campaigns

� Support the provision of sexual healthinformation to young people

� Support the provision of quality Sex and Relationships Education in schools - as set out in NSF for Children, Young Peopleand Maternity Services (WAG) - linking with the Cardiff Network of Healthy Schools Scheme and Community Focused Schools

� Support development of provision of sexual health services for young people in Cardiff, particularly for vulnerable youngpeople

� Provide support, advice and information for parents and carers on sex and relationships

� Develop and deliver multi-agency sexual health training (focusing on life skills, refusal skills, substance misuse and alcohol)

� Work in partnership to reduce inequalities for the lesbian, gay, bisexual and transgender community

� Disseminate work of Young People’s Sexual Health Task Group.

Poor sexual health as evidenced by increasing rates of STIs, HIV and levels of unintended pregnancy are experienced differentially across the population. Whilst specific evidence of some of these issues is not available at local level, or the incidence is too small to provide reliable data at locallevel, there is no reason to believe that national trends do not apply to the Cardiffsituation.

Race Research on how ethnicity relates to sexual health remains unclear. Sexual behaviour is embedded in a cultural context. It isnecessary for staff to be culturally sensitive and knowledgeable.

GenderCultural norms and social roles shape women's sexual health. Women can be vulnerable to sexual exploitation, violence, unwanted pregnancies and sexually

transmitted infections. However, men are less likely to access health services overall. It is necessary for services to be provided thatare gender specific.

Disability Where sexually transmitted infection results in chronic ill health or physical or sensory impairment, Cardiff Council and health services will undertake appropriate assessments and provide services where appropriate.

Sexual Orientation There is evidence to suggest that some gay,lesbian or bisexual people do not disclose their sexual orientation for fear of discrimination. Staff training is needed to raise awareness. Specific targeted services, particularly preventative services, are required to address the needs of these groups.

Sexual health100



Language of Choice Service users should be able to access sexual health services in their preferred language. Services are in place to facilitate face-to-face interpretation or telephone interpretation via Language Line where necessary.

Religion & BeliefStaff working in sexual health services must have appropriate cultural awareness. Whilst

service users must be supported to practice their chosen faith, staff must deal sensitively with risk issues such as female genital mutilation.

Age Cardiff’s sexual health services pay particular attention to the different sexual health needs of different age groups.

2008 - 2011

1. To promote the sexual health of young people through further development and delivery of the Young People’s Sexual Health Action Plan

2. To undertake targeted HIV prevention with high risk groups

3. To improve access to integrated sexual health services (STI and contraceptive services) for the general population and plan for anticipated growth in demand

4. To promote access to abortion services at an earlier gestational age

5. To plan service development to accommodate anticipated growth in the HIV positive population

6. To consider opportunities to extend service provision for people with psycho-sexual health needs

7. To review arrangements for managing Female Genital Mutilation

8. To implement a SARC service for children and adults who have been sexually assaulted.

Sexual health 101


12. Prison healthcare

Prison healthcare102

The World Health Organisation (WHO) Health InPrisons Project (HIPP) was established in partnershipwith the UK Government in 1995, because of therecognition that there was a gap between healthservices for the public and prison health, and thePrison Service was failing to address the publichealth needs of prisoners. It acknowledged thatprison populations in general suffered from worsehealth, but realised that prisons offered anopportunity for improving health and tacklinginequality.

HMP Cardiff is a category B local prison and remandcentre, housing approximately 750 adult maleoffenders aged over 21. Until 2001 the prisonmainly housed remand prisoners and prisoners withrelatively short sentences. In 2001 the PrisonService changed the remit of the prison and HMPCardiff now houses a population with longersentences including a ‘lifer’ unit of up to 100prisoners. The prison receives up to 2500 newreception prisoners per year, drawn predominantlyfrom the surrounding court catchment area in SouthEast Wales. There were 1500 new receptions ofconvicted prisoners in custody at Cardiff in 2007,excluding remands: 944 were sentenced for less than12 months, 520 were sentenced to over 12 months,and 36 prisoners were sentenced to life, or anindeterminate number of years.

HMP Cardiff does not house female prisoners whoare sent to England to serve their sentences.

Similarly, young offenders from Cardiff are housedwithin HMP Parc near Bridgend or in Englishestablishments.

Improving the Prison Health Service is an importantelement of the wider approach to the improvementof the health and well being of all Cardiff residents,given that recent surveys indicate that up to 65% ofprisoners released from HMP Cardiff do remain withinthe city. The need to provide appropriate healthcare for all vulnerable groups including prisoners,their families and dependants has been identified asa key aim within the health needs assessmentprocess undertaken by Cardiff LHB to support thedevelopment of the Health, Social Care and WellBeing Strategy for 2005-08.

Prison Service Order 3200 (PSO 3200, HMP Service,2003) is the result of the formal partnership betweenthe Prison Service and the NHS, and states explicitlythat prisoners should expect to have access to healthservices that are broadly equivalent to those thegeneral public receives from the NHS. The PSO alsostates that there should be clear line managementarrangements in place, which indicate an individualwith explicit responsibility for leading healthpromotion work across the prison.

Five major areas are covered by this order, namely:

� Mental health promotion and well being

� Smoking

� Healthy eating and nutrition

� Healthy lifestyles, including sex and relationships

and active living

� Drug and other substance misuse.


Figure 12.1 Types of offences committed by HMP Cardiff prisoners 2006

Current offences of prisoners Number %

Violence 174 23.8

Burglary 102 13.9

Drugs 95 13.0

Murder & Manslaughter 75 10.2

Theft 60 8.2

Driving Offences 56 7.7

Robbery 46 6.3

Other 124 16.9 Source: HMP Cardiff, EDS Services

On a local level Cardiff LHB established a Prison Health Care Steering Group (PHCSG) in 2004, which included key personnel from HMP Cardiff, Cardiff LHB together with Cardiff and Vale NHS Trust, Bro Morgannwg NHS Trust, Serco Health (as the providers of the medical services) and the Independent Monitoring Board. By 2006, the devolution of commissioning responsibility was completed to the LHBs and the existing Cardiff PHCSG evolved into the Cardiff Health Care Prison Partnership Board (PHCPB) that retains its inter-agency membership and is now formally responsible for the monitoring of health care service commissioning and provision. A framework for the work plan for the Board was developed within the Health Care Delivery Plan for HMP Cardiff for 2005-08 in line with the key strategic aims of the Health Social Care and Well Being Strategy for the same period.

A health needs assessment by Bro Taf Health Authority with HMP Cardiff was initially carried out in 2001. This led to a Prison Health Improvement Programme in 2003 and a Health Delivery Plan for 2005-08. The strategic aim of the 2005-08 Prison HealthCare Delivery Plan is to set out a clear strategy within which HMP Cardiff will work with others to develop and improve health and health care services for their prisoners by:

Setting out the health needs of prisoners in HMP Cardiff

Setting out a strategy to develop planning mechanisms and ensure collaboration within and outside HMP Cardiff Setting out a strategy to develop clinical services, together with the resource implicationsProviding a framework enabling joint commitments to be drawn up by HMP Cardiff and the NHS, local authorities and voluntary organisations Contributing to meeting the all Wales targets for health gain Providing the framework for the establishment of long term agreements with providers of health and social care.

In developing the Health Care Delivery Plan the LHB considered a number of common themes within the prison population that required specific attention. These included:

The incidence of those suffering from mental health problems The number of prisoners with a history of substance misuse Poor educational attainment Poor employment prospects 50% of prisoners having at least one child left behind in the community.

The HCDP for 2005-08 is currently being evaluated by the PHCPB to assess progress made to date and to identify the key issues to be incorporated in the second plan thatwill implement the key service developments identified within this strategy.

In April 2003, the responsibility and funding for the health services in public sector prisons in Wales transferred to the Welsh Assembly (WAG). The structure used to subsequently manage the transfer of health carecommissioning to LHBs was facilitated via a central Welsh Assembly Government Prison Health Project Board that was responsible for ensuring appropriate preparation was

undertaken to ensure a seamless transfer of responsibility.

Joining Together in Wales – The recent ‘Joining Together in Wales – Reducing Re-offending Action Plan 2007-08’published jointly between NOMS (National Offenders Management Service) Wales and the WAG sets out a clear set of priorities in terms of the main offender pathways for the current twelve months and beyond.


Prison healthcare 103

The majority of prisoners’ health care in HMPCardiff is currently delivered by Prison Service health care staff. Health services to prisoners at HMP Cardiff are provided within the Healthcare Centre, a separate building with 18 designated (16 useable at any one time) in-patient beds, caring for the physical,mental and social needs of the prisoners. Health care provision is based on a ‘Type 3’ facility and provides 24-hour primary care to the prison population within extremely limited and outdated accommodation. However, the Prison Service has procured a purpose built facility which was commissioned in winter 2007. The new facility will ensure that a wide range of current services will be able to be delivered in line with national guidance, as well as offering opportunities to deliver a number of new services that have historically required access to NHS services outside the prison.

The following core services are provided:

Prisoner Reception All new prisoners are seen by a nurse or healthcare officer on entering the prison and an initial medical questionnaire is completed, mainly through consulting the prisoner. Depending on the outcomes of the assessment, referrals can be made to chronic disease management clinics, immunisation clinics, follow-up clinics, regular prison GPappointments, mental health services and detoxification services (see below for details).

Primary Care Services This service is commissioned by the LHB, managed and partly provided by the Prison Healthcare Department and partly out-sourced to Serco for the GP medical services, through a service level agreement with the LHB. Access to services, which are run by nurses and a pharmacist, are available twice daily. If the prisoner is too ill to attend the treatment hatch, then arrangements can be made, via the prison officers, for the nurse to visit and assess the patient.

General Medical Services A GP surgery is held every weekday morningand additionally on two afternoons each week. Self-referrals occur through the ‘treatment hatch’ appointment system. One generic chronic disease management clinic is

held weekly but chronic disease management within the Prison has been historically hampered by the lack of IT support. In addition there is recognition of the significant gap in the current workforce’s training in delivering evidence based care for the increasing number of older prisoners.

Optometrist ServiceThis is only provided for prisoners who are serving a sentence of more than 3 months. It is accessed through self-referral and via other healthcare professionals. Sessions occur once or twice a month.

Podiatry ServiceA quarterly session is commissioned from Cardiff and Vale NHS Trust with prisoners with diabetes having priority.

Dental ServiceSince early 2007 the dental care at the prison has been provided by the Community Dental Service of Cardiff and Vale NHS Trust. Much of the work is self-referred emergency work, which involves largely extractions as antibiotics are prescribed by medical staff. Conservative and denture work is also undertaken to make patients ‘dentally fit’.

Services for Mental Health At the reception screening a Department of Health mental health questionnaire is applied. This assessment considers past psychiatric diagnosis, psychiatric drug treatment andpast and current self-harm. Ten of the nurses employed in the Healthcare Department are Registered Mental Nurses (RMNs). In line with the mental health care pathway the RMNs provide a Primary Care Mental Health service to prisoners, each carrying a small caseload alongside their other general duties.

Detecting and Managing Mental IllnessA Mental Health In-Reach Team, which is community psychiatric nurse-led, is provided by the Cardiff & Vale NHS Trust for severe mental illness, but is limited to supporting prisoners who have a diagnosable severe mental illness, those with psychosis and those posing a risk to themselves or others as a result of their mental illness. Referral to the In-Reach Team is through a weekly referralmeeting with the Primary Care Mental


CURRENT SERVICES

Health Team, although the In-Reach Team also accepts referrals from all sources, both within the prison and the wider community. A forensic psychiatry service is provided by a consultant and junior doctors from Bro Morgannwg NHS Trust’s Caswell Clinic. The service cares for those with psychosis and the need for court reports and fitness to plea.

Prevention and Management of Self-Harm and SuicideThe range of issues, prison regime and factors affecting psychological well being and mental illness, are vitally important in preventing and alleviating self-harm and suicide. The HMP Cardiff Safer Custody Team chaired by the Deputy Governor has a broad multi-disciplinary membership. Its role is to ensure compliance with the Prison Service Baseline Standards on self-harm and suicide. The team utilise ACCT (Assessment, Care in Custody and Teamwork) to assess prisoners identified at risk of self harm or suicide-assessments.

CounsellingPrisoners are seen by need for a variety of problems from bereavement, coping skills, loss of self-esteem and anxiety management etc. There is a referral system that includes self-referral and referrals from multi agencies. There is noclinical psychology service at the current time.

Substance Misuse ServicesPrisoners are asked about their drug use during the prison health screen. All prisonersstating they have used any drugs are requested to undergo a voluntary urine drug screen. A nurse-led detoxification service on the Detoxification Unit is also provided for addiction to certain substances detected at reception. Much of the substance misuse work is carried out by CARAT (Counselling Assessment Advice and Throughcare) workers. CARAT also has a remit to liaise outside the prison as the prisoner prepares to leave. This is predominantly with the Drug Intervention Programme (DIP), which takes overall care of a prisoner with substance misuse issues once facing release.

Sexual Health Services Sexual health promotion and prevention of sexually transmitted infections is incorporated into group educational work in the detoxification programme, which all prisonersundergoing a detoxification take part in. It is led by an in-reach nurse from the genito-urinary clinic. This secondary care service for screening, diagnosis and management of sexually transmitted infections is provided by Cardiff & Vale NHS Trust genito-urinary clinic. There are 2 sessions per week: 1 consultant and 1 nurse advisor. There is also a nurse advisor session at the detoxification unit. The waiting list is roughly 4 - 6 weeks, about the same as in the community.

Discharge Procedures from HM Prison Cardiff (in line with Prison Order 6400) Prisoners are interviewed, prior to release. This includes an explanation and agreement to the terms of any licence that they are being released on. Every effort is made to ensure that prisoners released into the community from HM Prison Cardiff have suitable accommodation to go to, or they have contacts with people who can providesuch accommodation. All prisoners are asked if they are registered with a GP and the Business Service Centre is contacted to allocate a GP to those who are unregistered.

Medication supply on discharge from prison Once a prisoner has a planned release date, a take home supply of medicines is arranged. All supplies will provide between 7 and 28 days, dependant on individual circumstances. Pharmacy records are used in conjunction with the clinical record to prepare GP dischargesummaries and direct queries from GP surgeries post release. No controlled drugs (including benzodiazepines) are dispensed for discharge supply. Any patients on methadone, for example, will have an appropriate NHS prescription supply arranged by detoxification unit staff and/or the CARAT team for collection on day of release.

HMP Cardiff core staff provide support to prepare prisoners prior to their release into the community. HMP Cardiff alsocontracts directly with a number of key


support agencies (eg Citizens Advice Bureau) to provide a wide range of

general advice regarding welfare rights to support prisoners during their transition back into their community.


In 2005, HMP Cardiff was given generally good reports by both the HM Chief Inspector of Prisons and the Independent Monitoring Board (IMB), in so far as they assessed health and health care services. The formernoted much improvement on the previous inspection and concluded that Cardiff provided a generally safe, healthy environment for prisoners and singled out good work in healthcare and resettlement. The latter noted that the Prison Improvement

Plan had had a positive effect on improvingconditions in the prison and again highlighted good work carried out by healthcare, resettlement and education.

The Prison Health Partnership Board recognises that progress has been made inestablishing robust working arrangements between the LHB and NHS and independent sector providers.

2005 - 2008

Set the parameters and agreed the rules of engagement between the Prison Health Service and NHS in further developing an effective partnership based on mutual priorities, whilst recognising and addressing cultural issues/differences between the NHS and prison healthcare service.

Clarified the individual financial baselines prior to transfer in April 2006.

Changed prescribing practices within the prison for treating prisoners with substance misuse problems within the substance misuse detoxification unit, by utilising appropriate treatment regimes.

Provided a comprehensive sexual health service. Introduced a skill mixed Genito-Urinary workforce resulting in reduced waiting times within the service with the use of Health Advisor sessions to complement the Consultant in-reach service.

Identified opportunities to develop services within existing and growth funding sources, including securing increased funding for in reach mental health services.

Minimised the impact of the prison regime and the Prison Service's Performance Improvement (PIP) targets so that they do not compromise individual health needs.

Developed a workforce plan for the HMP Cardiff and Cardiff and Vale NHS Trust health care staff. This resulted in the recruitment of a number of ‘B’ grade staff to release qualified nurse time in line with workforce planning within the NHS, to provide a primary care mental health service.

Used an external consultant to carry out an extensive health needs analysis of HMP Cardiff prisoners and to evaluate the current services available to prisoners for the prevention, detection, harm reduction, treatment and amelioration for the key health problems, as well as the underlying social and behavioural causes.

Secured a new provider for Medical Services following a national tendering exercise.

Secured funding to double the previous dentistry service via Personal Dental Services (PDS) funding, and re-tendering for the service following the resignation of the previous Dental Practitioner. Introduction of additional dentistry sessions has reduced the waiting time for access to the service for those with acute symptoms.

Building a new clinical unit within HMP Cardiff undertaken, which will comprise of a 20 bed in-patientarea on the ground floor, mostly as single cells, as well as one negative pressure cell for the management of tuberculosis. There are auxiliary clinical rooms, offices and various other rooms for staff associated with the in-patient area. On the first floor there will be primary care and day care areas, which will include consultation rooms, waiting rooms, dental suites, a pharmacy, treatment areas and a variety of administrative rooms. The new clinical environment will provide excellent clinical facilities to allow new models of care, as well as service gaps, to be addressed.

KEY ACHIEVEMENTS

The prevalence of mental health illnesses within Prisoners is clearly demonstrated within the Need Assessment and is summarised in the following table:

Figure 12.2 Prevalence of neurotic disorders among a predominantly young male prison population

Male

Disorder Remand Sentenced CommunityPrevalence

Mixed anxiety and depression 26% 19% 5%

Generalised Anxiety Disorder 11% 8% 3%

Depressive episode 17% 8% 2%

Phobias 10% 6% 1%

Obsessive-Compulsive Disorder 10% 7% 1%

Panic Disorder 6% 3% 1%

Any neurotic disorder 59% 40% 12% Source: Psychiatric morbidity among prisoners in England and Wales. ONS, 1998

The Prison Health Care Partnership Board (PHCPB) has acknowledged that the reconfiguration and development of existing mental health and substance misuse services within the prison is their highest priority. The new service model will need to replicate the evidence-based service developments thatare occurring for Cardiff residents as well as developing robust clinical interfaces betweenthe prison and the NHS to ensure prisoners receive appropriate after care once released from prison.

The PHCPB has identified the following key service developments that are required to meet service gaps:

The need to implement the Welsh Assembly Government’s Prison Mental Health Care Pathway as well as reviewing the current use of HMP Cardiff in-patient beds.

Better co-ordination of holistic, effective, evidence based treatment services for substance misuse, tailored to need,

across all departments and substance misuse programmes in the prison including: Drug Strategy and the Detoxification Unit, Resettlement, Healthcare Services and importantly with outside substance misuse agencies.

Developing the range of chronic disease management services offered to prisoners in line with the recently developed care pathways for Cardiff residents.

Identifying an interim solution for HMP Cardiff to address the information technology required to provide evidence based prison health care.

Exploring the commissioning of primary care-based, nurse-led and managed sexual health services, which have been shown to be a more cost-effective way of delivering sexual health services in prisons.

Implementation and ongoing monitoring of a local performance framework in line with national recommendations.

The recently published Health Needs Assessment concluded that: ‘if the poor health of prisoners is to have any chance of improving, a holistic, proactive and comprehensive approach is required at the

whole community level, at the whole criminal justice system level, and at the whole prison level, based on an overall framework, with proven effective interventions. Underlying socio-economic factors such as housing,




education, skills, unemployment, low income and benefit should be addressed as far as possible.’

The importance of the WHO Health in Prisons Project approach of health promotion within a prison setting is to provide a framework for health improvement, and is particularly important in improving psychologicalwellbeing and mental health, and provides a foundation for more specific efforts to prevent self-harm and suicide.

To move forward this approach the Partnership Board intends to:

Review the current membership and accountability arrangements to provide a new, broader, Health Promotion Action Group for HMP Cardiff, to take forward the WHO Health in Prisons Project approach. This will allow a more appropriate model of health care within the prison to provide a holistic and innovative service that is proactive to the identified health needs of the prison population. This model to be based on primary care, multi-disciplinary teamwork, integrated with other services in the prison and community, with better information technology, that embracesmodern health promotion and disease prevention.

Include a prison-wide holistic mental health promotion strategy, within a WHO Health in Prisons Project approach. Self-harm and suicide prevention should be incorporated within such a strategy.

Develop an electronic patient information system and disease register at the prison (ideally compatible with primary care and systems across the prison service) to help increase relevant vaccination coverage for all prisoners. Such a system would be beneficial in ensuring better coverage of influenza and pneumococcal vaccination and all other relevant vaccines.

Expand a co-ordinated multi-intervention, evidence based, sexual health promotion programme across the whole prison, tailored to the needs of young deprived men, to subsume the small amount that occurs within the Detoxification Unit or those presenting to specialist services.

Update the prison’s Communicable Disease Policy to improve the management of a wide range of communicable diseases.

Develop an effective smoking cessation programme which is systematic and a comprehensive part of routine healthcare.

Prison can affect health in many ways, especially psychological well being and mental health, adding to the effect of poor social circumstances. Being imprisoned brings its own factors that can seriously affect mental health through the loss of liberty, autonomy and the right to self-determination; through other factors related to the prison regime; and through bullying, loneliness and separation from family and children. Many offenders, within and outside prison, come from some of our most socially excluded communities. For their age, on average, prisoners tend to have much worse physical and mental health and well being compared to most in society. Their present and future health contributes to the wide and

widening social health inequalities within Wales.

The WHO has published the following principles for healthy prisons:

All prisoners, regardless of situation, should have the opportunities for healthy physical, social and mental development.

People in custody should expect to live in a positive care environment that is stimulating and promotes their health, wellbeing and development.

People should be consulted and listened to concerning their health and well being, both as individuals and as groups.



People in custody should have the opportunity to develop and maintain relationships with one or more suitable adults in the community to which they will return.

Prisoners should have their cultural and religious beliefs, identity and ethnic backgrounds respected.

People in custodial settings should have the right to education, training and healthy lifestyle skills and works skills opportunities.

People in prison have a right to privacy.

The Prison Health Care Partnership Board recognises the need for Prison Health Care Services to become more focussed on providing proactive high quality modern services, tailored to their patient’s circumstances and individual health needs. There is a need for greater emphasis on providing effective interventions by multi-agency and multi-disciplinary action inappropriate and innovative ways and settings. Importantly, a new emphasis on effective health promotion, diseaseprevention and the early detection and treatment of disease is required.

The Prison Health Care Partnership Board will utilise the recently completed health needs

assessment to develop the second Health Care Delivery Plan (HCDP) for 2008-11 to ensure that services are provided within a healthy prison culture to meet the diverse needs of the ever changing prison population. The HCDP will in particular consider the needs of ethnic minority prisoners when implementing the mental health care pathway and in providingappropriately accessible drug treatment and sexual health services.

Figure 12.3 Country of origin of prisoners Country Number Percentage

UK 673 89.0

Jamaica 12 1.6

Pakistan 6 0.8

Irish 4 0.5

Somalia 2 0.3

Afghanistan 1 0.1

Guinea 1 0.1

Iraq 1 0.1

Israel 1 0.1

Kuwait 1 0.1

Malta 1 0.1

Netherlands 1 0.1

South Africa 1 0.1 All other nationalities 48 6.4

Source: HMP Cardiff, Skinner 2007

2008 - 2011 1. To promote health improvement utilising the WHO Health in Prisons Project approach to health

promotion within a prison, to provide a framework for health improvement. 2. The Prison Health Partnership Board will aim to reduce inequalities by ensuring the provision of

accessible health care services in line with the recommendations of the 2007 Health Needs Assessment. 3. To commission the new health care facility and explore opportunities to offer new health care service

models within the prison. 4. To implement the Welsh Assembly Government’s mental health care pathway.5. To develop a comprehensive substance misuse care pathway incorporating all elements of service

delivery within HMP Cardiff and follow up care within the community. 6. To develop a chronic disease management strategy for the prison in line with local community pathways

for diabetes, coronary heart disease, stroke and chronic obstructive airways disease. 7. To update the Prison’s Communicable Disease Policy to include the recommendations of the Health

Needs Assessment report.8. To develop interim Information Technology solutions to support the delivery of modernised health care

services. 9. To develop an effective and comprehensive tobacco control programme within the prison, as part of the

implementation of the WHO Health in Prisons Project. 10. To implement the workforce plan for the prison and secure appropriately qualified staff to deliver the

above services. 11. To utilise the recently developed performance framework to evaluate the impact of health care services

on the health of prisoners within HMP Cardiff.



13. Substance Misuse

Substance Misuse110

‘Tackling Substance Misuse in Wales: a PartnershipApproach,’ (April 2000), identifies substance misuse in Wales as a ‘complex, dynamicand multi-faceted problem. It involves both illegaland legal substances and its effects are far-reaching.Not only does it impact upon the lives of those whomisuse substances, from those who experiment tothose who are heavily dependent, but also upon theirfamilies and communities.’

In this Strategy the term ‘drug’ is used to refer toany psychotropic substance, including illegal drugs,illicit use of prescription drugs and volatilesubstances. Drug taking is often linked with theconsumption of alcohol, therefore the term‘substance’ refers to both drugs and alcohol, but nottobacco. Substance Misuse is substance takingwhich harms health or social functioning.

The reduction of substance misuse and relatedproblems in Wales is currently the joint responsibilityof both the Welsh Assembly Government and theMinistry of Justice.

The Cardiff Substance Misuse Action Plan 2005 -2008 provides a clear framework for the delivery ofthe key strategic aims and objectives set out in‘Tackling Substance Misuse in Wales: a PartnershipApproach’ and also the implementation of the WelshAssembly Government Substance Misuse TreatmentFrameworks. The Plan focuses on the promotion ofhealthy lifestyles, developing safer communitiesthrough enforcement and the improvement of healthand support services for those people affected bysubstance misuse and/or its knock-on effects. Thepurpose of the plan is to provide a set of strategicobjectives to direct the local work of all partneragencies involved in the substance misuse arena andto provide a realistic and achievable set of actionsdesigned to:� Promote healthy lifestyles for our local

population, including education about the effectsof substance misuse

� Consolidate the work undertaken in recent yearsin order to provide a secure service basis to thendeliver further developments and innovation

� Develop safer local communities.

Working Together to Reduce Harm - TheSubstance Misuse Strategy for Wales 2008-2018

This consultation sets out and invites views on thenew substance misuse strategy, entitled ‘WorkingTogether to Reduce Harm’. It is a 10 year strategywhich aims to set out a clear national agenda fortackling and reducing the harms associated withsubstance misuse in Wales. Consultation closes inMay 2008.

‘Tackling Substance Misuse in Wales: aPartnership Approach’ 2000-2008

Was developed following a review of the previousstrategy ‘Forward Together (1996)’ and the launch ofthe UK strategy ‘Tackling Drugs to Build a BetterBritain (1998)’. The key aims of the strategy are:

� To help children, young people and adults resistsubstance misuse in order to achieve their fullpotential in society, and to promote sensibledrinking in the context of a healthy lifestyle

� To protect communities from anti-social andcriminal behaviour and health risks related tosubstance misuse

� To enable people with substance misuseproblems to overcome them and live healthy andfulfilling lives, and in the case of offenders,crime-free lives

� To stifle the availability of illegal drugs on ourstreets and the inappropriate availability of othersubstances.


At present there are seven Substance Misuse Treatment Frameworks that have been produced by the Welsh Assembly. The Framework provides guidance on delivering high quality needs-based services for substance misusers and is directed at responsible authorities and their partners in Community Safety Partnerships:

1. Service Framework for ResidentialRehabilitation

2. Service Framework for Community Prescribing

3. Service Framework for In-patient Treatment

4. Service Framework to Meet the Needs of People with Co-occurring Substance Misuse and Mental Health Problems

5. Needle Exchange Service Framework

6. Psychological Therapy and Psychosocial Interventions in the Treatment of Substance Misuse

7. Good Practice Framework for the Provision of Substance Misuse Services to Homeless People and those with Accommodation Problems.

National Key Performance Indicators apply to services for individuals who misuse alcohol, drugs and other substances. The Welsh Assembly Government has developed eight national key performance indicators, which will be complemented and refined by performance indicators set locally, to reflect local circumstances. Community Safety Partnerships should incorporate the Key Performance Indicators and related indicators into all Service Level Agreements or contracts.

The Cardiff Community Safety Partnership (CSP) ‘Substance Misuse Action Plan 2005 – 2008’ addresses each of the four aims identified above. A key theme underpinning the Plan is the need to balance the treatment and prevention agendas, and the Planconcentrates on balancing this dual focus.

The current Cardiff Substance Misuse ActionTeam (SMAT) structure has five sub groups:

1. Treatment and Rehabilitation

2. Accommodation

3. Families and Communities

4. Black and Ethnic Minorities

5. Children and Young People

Each sub group is currently reviewing their key aims within the Substance Misuse ActionPlan with the intention to revise the relevant elements of the local action plan.

Cardiff currently provides both statutory and voluntary provision for substance misuse across the four tiers identified by the Welsh Assembly. This four tier model should be reflected in the structure of both HSC&WB and CSP strategies.

1. Tier 1 - Non Substance Misuse Treatment Specific Services: These services work with a wide range of clients including substance misusers, but their sole purpose is not simply substance misuse.

2. Tier 2 - Open Access Services: These services provide accessible services for a

wide range of substance misusers referred from a variety of sources, including self-referrals. The aim of this tier is to help substance misusers to engage in treatment without necessarily requiring a high level of commitment to more structured programmes or a complex or lengthy assessment process.

3. Tier 3 - Structured Community Based Services: These services are provided for substance misusers in a structured programme of care primarily by statutory agencies.

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CURRENT SERVICES

4. Tier 4 - Residential and In-patient Services: Theses services are aimed at those individuals with a high level of presenting need.

The services currently available in Cardiff are:

National Health Service

Cardiff & Vale NHS Trust: In-patient and detox services are provided at Whitchurch Hospital and the Community Addictions Unit. Integration of the NHS and Local Authority services is currently being undertaken with the assistance of outside facilitation funded through the Joint Working Special Grant.

General Practitioners: A Shared Care Scheme is currently operational in Cardiff to enable substance misusers to access their substitute opiate prescribing needs in GP surgeries rather than attendance at formal hospital/clinic settings.

Community Pharmacists: A supervised administration of Methadone scheme is operational with local pharmacies.

Cardiff Council

The Community Alcohol and Drug Team (CADT) offers a range of community based services including counselling, social care and rehabilitation.The team also provides training to substance misuse service providers.

Option 2 is an intensive intervention where children are ‘at risk’ due to parental substance misuse. Therapists work closely with the family to enable them to continue to stay together.

Family Support Development work is being led by the CADT with the introduction of the Strengthening Families Programme which is delivered by a multi-agency team.

Drug Intervention Programme (DIP)is a consortium led by the CADT in partnership with the Community Addictions Unit and NewLink Wales, to provide an intervention to clients leaving custody or treatment in a planned way and to provide access to limited time prescribing.

Non-Statutory Services Cardiff benefits from a range of non-statutoryservice provision from agencies such as:

Inroads offering, support, needle exchange, mobile outreach, crisis intervention, information and advice services, drop-in, young peoples service, service user group, advocacy service, family support, and complementary therapies.

Pen-yr-Enfys

o The Fitzhammon Alcohol AdviceCentre offers counselling, advice, entertainment, alcohol education,limited treatment for alcohol dependence and a drop-in service.

o Dyfrig House offers a direct access residential and resettlement service for homeless people with alcohol problems.

o Glan yr Afon offers supported housing in a 6 bed property for people with alcohol problems.

o Pathway to Change is a therapeutic day service designed to meet the needs of vulnerable people with alcohol problems.

The Wallich provides a range accommodation for substance misusers across Cardiff.

The Salvation Army through Ty Gobaith provides a detoxification facility for homeless people.

Tai Trothwy provides floating support to substance misusers in a range of accommodation settings.

ASFA (Alcohol Services for All) is a user-led advisory and representativegroup.

Ashcroft House provides a 26 week rolling programme with individual and group therapy for mothers with drugand/or alcohol problems and their children (normally up to 8 years old).

Crime Reduction Initiativecommissioned by the Probation service to provide Drug Referral Requirements across Cardiff & the Vale of Glamorgan.

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NewLink Wales recruit and trainvolunteers to be placed with existing treatment service providers. They also provide a comprehensive set of training programmes to suit all levels of workers.

MILE is a specific programme for ex-users and drinkers to give them additional skills and knowledge prior to accessing the NewLink Wales core volunteer programme.

AXIS is a service for minority ethnic communities that provides information about substance misuse that can alsosupport people in accessing appropriate treatment, if necessary.

DAN 24/7 – 0800 633 5588 is the all Wales drug and alcohol helpline that offers support and advice to existing and potential drug users, families, parents and carers.

In the last three years the Welsh Assembly Government has published a wealth of guidance, which has to be taken into account when reviewing existing services or developing new ones. There has also been a very strong steer towards working within a commissioning cycle and stronger performance management in light of the

development of the Welsh National Database for Substance Misuse.

The introduction of Ministry of Justice initiatives at a regional level has also been a challenge locally, due to their impact on locally commissioned ‘core services’.

2005 - 2008

Established the Substance Misuse Joint Commissioning Group.

Commissioned a population needs analysis to inform the development of a substance misuse commissioning strategy.

Supported the implementation of the regional Drug Intervention Programme.

Secured grant funding from the Alcohol Education Research Council to support the ‘Lions Breath’ project into drinking behaviour in the city centre.

Secured a capital grant from the Welsh Assembly Government to enable NewLink Wales to purchase a new headquarters building.

Appointed a Family Support Development worker.

Delivered training to multi-agency professionals to carry out the Strengthening Families Programme.

Developed a substance misuse policy for the Youth Service, including a ‘young people’s’ poster version and subsequent audit of Youth Centres in relation to the policy.

Developed a substance misuse toolkit for Healthy Schools programme.

Secured funding for the AXIS service to have a permanent base within the community.


The Welsh Assembly Government identifies priority areas for funding when announcing annual allocations. Currently they are:

Reducing waiting times and waiting lists

Services for Children & Young People

Alcohol Services.

Locally the Substance Misuse Joint Commissioning Group is focussing on:

Sustaining the existing levels of service

Minority Ethnic Communities

Workforce Development.

KEY ACHIEVEMENTS


A Substance Misuse Needs Analysis across all tiers of service provision was commissioned for Cardiff, which will inform the Commissioning Strategy and subsequent implementation plans.

Data from the Welsh Health Survey shows that 40% of adults reported that their alcohol consumption was above the recommended guidelines of no more than four units a day formen and no more than three units per day for

women. The standardised proportion of adults who reported binge drinking on at least one day in the past week, shows that 19% of adults report binge drinking in the past week. Binge drinking means men drinking more than eight units in a day, women more than six units. In Cardiff the proportion of people that reported binge drinking on at least one day in the last week was higher than the Welsh average.

Figure 13.1

Adults who reported binge drinking on at least one day in the past week, 2003/05

Source: Welsh Health Survey, 2003/05

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This chart below shows prescribing levels for Methadone and Buprenorphine between April 2004 and March 2006. The data are from the Comparative Analysis System forPrescribing Audit (CASPA), and are expressed as items per 1,000 prescribing units. A number of factors are likely to affect the levels of prescribing and may include for

example, availability of GP shared-care schemes for opioid substitute therapy, availability of community pharmacies for supervised ingestion services, prevalence of opioid misuse, prevalence of injecting drug use and availability of home detoxification services.

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Figure 13.2

Methadone & buprenorphine prescribing by GPs in WalesSource: Comparative Analysis System for Prescribing Audit (CASPA), Health Solutions Wales

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A sub-group of substance misusers that is particularly vulnerable are homelesssubstance misusers. The major problems are gaining access to specialist services, avoiding a return to the circumstances that led to theiroriginal problem, securing support for a range of other needs mainly substance misuse dependence and/or mental illness and avoiding premature death. This group also has a problem being retained in treatment. This is currently one of the main focuses of the Accommodation Task Group.

Future service development and priorities will be influenced by the national strategy, to be published in 2008. The local focus for 2008-2011 will include:

To consider the recommendations of the population needs analysis for substance misuse treatment services commissioned for Cardiff

To develop a substance misuse commissioning strategy

To develop standard service level agreements for all services

To develop robust performance monitoring tools for all services

To pilot and evaluate the Substance Misuse Toolkit for the Healthy Schools Scheme

To develop a training programme for youth workers to support the ‘guidelines for dealing with incidents’.

In the substance misuse field there are two main approaches to ‘promoting health’. The first is education to prevent the initiation of substance misuse and the second is harm reduction or minimisation to reduce the harm to existing substance misusers.

The evidence base to support education to prevent substance misuse is poor. However,

there is evidence that ‘shock’ tactics are not effective but that approaches that providefactual information, by credible messengers, have better outcomes. Approaches that also enhance self-esteem and address other known risk factors, have more positive outcomes along with programmes that engage with children and young people rather than traditional teaching styles.



The current substance misuse database is limited due to the lack of information on individuals being shared by agencies. This is currently being addressed through Service Level Agreements, which will ensure that future information is provided in far greater detail. All Cardiff SMAT task groups address social inequalities through their membership. It should also be noted that substance misusers themselves are often discriminated against by the very fact that they misuse substances.

RaceThere is evidence that people from minority ethnic communities are under-represented in drug treatment services and that substance misuse is under-reported. The Minority Ethnic Task Group is aware of this and is addressing the problem. NewLink Wales provide training in cultural awareness. However, the take up for the course has been poor. Outreach work informs minority ethnic groups of treatment options and associated services available to support these communities. UCLAN and DIP are currently conducting BME community research on substance misuse in relation to the Criminal Justice System with NewLink Wales which is funded by the Welsh Assembly.

GenderThere are links between substance misuse and the sex industry. However, it should be noted that drug markets and sex markets are separate and that the links will depend on local circumstances. Drug use can be areason for someone entering prostitution. The Streetlife project is working with ‘working girls’ in Cardiff.

Disability Substance misuse is often linked with co-occurring mental health problems, and individuals are often caught betweenservices. Prolonged use of alcohol can also cause Korsakoffs Syndrome, which is brain damage resulting in severe short term memory loss. Other problems associated with heavy drinking are peripheral nerve damage to arms and legs, head injuries due to accidents, fights or epileptic seizures.

Sexual OrientationThere is currently no evidence that sexual orientation has any impact on treatment, orthat the Lesbian, Gay, Bisexual and Transgender (LGBT) community are any more likely to misuse substances. However, there is anecdotal data to suggest that somedrugs may be more prevalent in the gay community.

Language of Choice The establishment of the AXIS Project in2005 provides minority ethnic communities with information on drugs and alcohol in various languages and has a number of volunteers that speak a variety of languages.

Religion & Belief NewLink Wales provides opportunities for users to talk in confidence with women only and men only sessions and also provides a prayer room.

AgeCurrently there are limited treatment optionsfor children and young people. Regionally work is underway to develop a service specification for an ideal service, for potentialimplementation locally. Stronger links with the older people’s agenda would facilitate identification of issues around potential problematic alcohol and drug use by olderpeople.

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With regard to harm minimisation the provision of needle and syringe exchange schemes in a variety of settings across Cardiff assists in the prevention of the spread of numerous blood borne viruses.

Areas of focus to promote health improvement in substance misuse will be to:

Clarify the role of school health nursing in relation to substance misuse Develop a co-ordinated needle & syringe exchange service across voluntary, statutory and pharmacy outlets Improve needle and syringe returns and reporting Continue to explore safe injecting facilities for homeless people.


2008 - 2011 1. Promote health improvement by engaging in harm reduction and prevention initiatives.

2. Reducing inequalities by strengthening the information base with regard to substance misuse issues for particular groups within society.

3. Increase local service capacity for people who misuse drugs, alcohol and other substances in line with the stated priorities in the local/regional commissioning plans in respect of; open access services; structured community based services; residential and in-patient care.

4. Reduce the number of incidences of unplanned ending of contact with services.

5. Achieve a waiting time within 10 working days between referral and assessment.

6. Achieve a waiting time of within 10 working days between assessment and the beginning of treatment.

7. Young people referred from YOT to receive an appropriate assessment within 5 working days of referral.

8. All young people referred from a YOT to have commenced an agreed care plan no later than 10 working days from the completion of the assessment.

9. Reduce the number of incidences of reported acquisitive crime (defined as those listed as ‘trigger offences’ for Drug Testing on Charge areas) (Linked to Home Office Public Service Agreement 1).

10. All clients who are injecting drug users to be offered information, counselling, screening and where appropriate immunisation against Hepatitis B.



14. Homelessness

Homelessness118

The term ‘homeless’ generally conveys an image of aperson sleeping in a cardboard box on a city highstreet. This is compounded by the images typicallyused by the media and some charities. However, thevast majority of homeless people are actually familiesor single people who are not literally sleeping on thestreet but living with relatives and friends, or in anumber of different types of temporaryaccommodation. For some, this means living in poor

quality accommodation that is detrimental to theirhealth and well being. It is often difficult todisentangle the support needs that people developas a result of homelessness from issues that madethem vulnerable to homelessness in the first place.However, there is a clear correlation between severalaspects of social exclusion/ vulnerability andhomelessness, which then in turn impacts on suchissues as education, employment and health.

Nationally the policy response to issues ofhomelessness falls under the National HomelessnessStrategy for Wales 2006-08. The key themes areprevention, ensuring equality of access to services,the need to plan services strategically and topromote a joined-up, partnership approach betweenlocal authorities and key service providers. Itparticularly emphasises the key roles of otherstatutory services in delivering the strategy andrequires constructive engagement from other policysectors including health, social services andeducation. This strategy expires in 2008 and willpossibly be replaced with a 10 year HomelessnessPlan, but at present this has yet to be confirmed.

In 2008, the Welsh Assembly Government introducedthe consultation document ‘Improving the Health ofHomeless and Specific Vulnerable Groups Standards2008/09’. This document will inform the developmentof the Homeless and Vulnerable Groups HealthAction Plans (HaVGHAPs). These action plans willalso offer a national context to the strategic work

that takes place within Cardiff in developingappropriate healthcare services which meet theneeds of particularly vulnerable groups.

The standards are very much focused on developingstrong strategic partnership working among the leadagencies, including Local Health Boards, LocalAuthorities, and NHS Trusts. The aim is to establishnational standards against which local health needsand areas of service development can be identified.

The standards for improving the healthcare provisionfor vulnerable groups are also included within theNHS Annual Operating Framework (AOF) and theService and Financial Framework (SaFF) and arecentral to local service development and planning.

The standards will also support other cross-cuttingnational strategies such as `Tackling DomesticAbuse: The All Wales National Strategy, A JointApproach’ and the forthcoming strategy to tackleSubstance Misuse.

Local authorities were required to produce a 5 yearHomelessness Strategy in 2003 as laid out in theHomelessness Act 2002. Cardiff is currently workingon revising its strategy, taking into account the manychanges that have affected it since its inception. Aspart of Plan Rationalisation, the HomelessnessStrategy, along with the Supporting People

Operational Plan, will be incorporated into the LocalHousing Strategy from 2008. This will ensure thathomelessness is reflected in wider housing issuesrelevant to the city.Locally, the Homelessness Strategy is the key driverfor a strategic response for tackling rooflessness andassociated issues.



However, there are many other local policies, strategies and related action or business plans which overlap with this vulnerable client group including those relating to children, gypsies and travellers, mental health services, delayed transfer of care and community safety, which are discussed throughout this document. Each year a Homelessness Conference is attended by all stakeholders to discuss prevalent issues and to agree the priorities for the coming year. The delivery of Cardiff’s strategic response tohomelessness lies in the good working

relationships and partnerships between statutory and voluntary sector agencies and much good practice has been developed, including regular Multi-Agency RiskAssessment Conferences for offenders and relating to domestic abuse and the sharing of information under the Multi-Agency Public Protection Arrangements. These relationshipsare also extended regionally through the South East Wales Regional Homelessness Forum with the other nine local authorities in the area.

The number of households making enquiries to the Council’s homeless service for assistance was 1,533 in 2005/06, with 852 households being assessed as eligible for assistance, unintentionally homeless and inpriority need. The numbers have gradually

reduced since 2002, likely to have been the result of a revised focus on preventing homelessness, encouraging households to seek advice and assistance to avoid losing their home.

Figure 14.1 Number of households requesting assistance by priority category

The Council’s services for homeless people inCardiff have been restructured and realigned over the past few years to respond to the drive for a more preventative focus. This shift in emphasis has necessitated a different approach to how services are accessed and offered, including co-ordination of supported housing bedspaces and financial assistance. However, the delivery of health and socialcare services remain focussed on immediate need rather than a planned, even preventative environment. Over the next few years, services to homeless households can be strengthened to more positively respond to the Programme for Health Service Improvement agenda.

Housing Advice UnitThe Council’s frontline homelessness service has been divided into distinct functions relating to its statutory duties: General Advice Team, Prevention Team including WelfareRights, Temporary Accommodation Team and the Assessment Team. Working closely with other statutory and voluntary sector partners, the Council is attempting to fully implement a range of prevention options and where this is not possible, to ensure that the most appropriate service response is made to eachindividual case.

Priority Need by Category 2006/07

Households with dependent children 39% A person fleeing domestic violence/threatened domestic violence 13% A 16 or 17 year old 12% A former prisoner 11% Households where a member is pregnant 10% Other reason 10% Vulnerable due to mental illness/learning disability 3% A care leaver or vulnerable young person (18-21) 2% Vulnerable due to physical disability 1%

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CURRENT SERVICES

Other Advice Agencies The Council administers grant funding to a number of advice agencies in Cardiff and works closely with the Legal Services Commission (LSC), the other major funder of advice services, to ensure that services are accessible and are providing quality and meaningful advice services to the citizens of Cardiff. The LSC has recently introduced a modified funding regime and is also looking to restructure the way advice services are provided across England and Wales. Cardiff Council will continue to work closely with the LSC to develop appropriate services in Cardiff.

Housing Related Support SchemesThere are over 50 separate supported housing schemes and over 900 ‘floating support’ units in Cardiff, many of which provide generalist or specialist support to homeless people covering a range of issues from substance misuse to mental health. These services are provided by a number of different providers and for varying lengths of support. The funding mechanism for all such schemes in Cardiff is currently administered by the Welsh Assembly Government. However, there are proposals to pass this responsibility to local authorities in the nearfuture. Aligned with this handover is the potential for major cuts in funding, as the Assembly attempts to redistribute the available grant funding more fairly across Wales.

Allocation of Social Housing Access to permanent housing for statutorily homeless people is co-ordinated by the Council, utilising nominations from other Registered Social Landlords (Housing Associations) where possible. Provision for homeless people has increased in recent years to respond to the growing numbers. However, the available housing to meet this demand is reducing year on year. The Council has developed a number of innovative schemes to increase this supply, but this situation can only be improved with the Welsh Assembly making a major commitment to building more family-sized affordable homes.

Outreach Services to Rough SleepersCardiff is well-served with specialist outreach services, as a direct response to the numbersof rough sleepers drawn to the capital. TheWallich Clifford, in conjunction with the Council’s City Centre Team, provide a daily Breakfast Run, with the City Centre Team co-ordinating engagement with rough sleepers during the rest of the day. A number of voluntary soup runs and the Salvation Army’sBus Project operate in the evenings and into the night.

Access to Health and Social Care ServicesThrough the City Centre Team access to social care and assessments for both adults and children can be made whilst many supported housing schemes refer directly.The Single Assessment Centre development aims to strengthen these routes as well as developing a dedicated suite for healthcare services which will synchronise the existing disparate services, including the mobile dentistry services, the homeless nurse, access to mental health assessments and midwifery and health visiting.

Access to Primary Care Homeless people in Cardiff historically have difficulty in accessing many aspects of the health service. A dedicated GP practice inCardiff offers an open access surgery which welcomes homeless service users and provides access to the full range of primary care services. Cardiff Local Health Board alsocommissions a Local Enhanced Service (LES)which allows GPs to provide valuable support to the homeless nurse and to other frontline service providers in Cardiff. This practice has been able to develop a strong relationshipwith frontline service providers and is a valuable support mechanism to Cardiff and Vale NHS Trust’s nursing team and, in particular, the specialist team for the homeless.

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Within Cardiff there is a long-standingwillingness to work in partnership to address homelessness from both the statutory and voluntary sectors. Through such collaboration a number of joint working initiatives have

been developed which directly assist those in the most extreme form of housing need and some of these have received wider recognition across Wales.

2005 - 2008

Reconfiguring the Council’s homelessness services

The merger of the Housing Help Centre into the new Housing Advice Unit has provided a more focussed service response to those seeking assistance. The inclusion of voluntary sector partners in this revised Unit such as Llamau’s Housing Options Project for young people and Cardiff Bond Board has also proved beneficial in providing access to more appropriate assistance.

The development of a range of preventative options has assisted in reducing the number of applicationsfor assistance and the pressure placed on available housing. Financial assistance, reviewing accommodation options, working through relationship issues and practical assistance and support are all measures used to assist in the prevention of homelessness.

Elimination of the use of Bed and Breakfast establishments

The development of the 26-bed Nightingale House family hostel, closely followed by the acquisition of Adams Court 72 unit scheme, has contributed to the elimination of the use of bed and breakfast establishments as temporary accommodation. Additionally, the functions of managing temporary accommodation properties and the move-on of households placed, have been separated to give greater effectiveness.

Frontline Hostels working collaboratively to achieve wider strategic aims

The six direct access hostels in Cardiff have developed working arrangements to improve inter-agency referrals, which support the work of the reinvigorated Access Panel which seeks to facilitate access into services for the most chaotic service users. Additionally the hostels work together to provide emergency bedspaces for those who are more vulnerable, supported via a dedicated Emergency Bed Co-ordinator.

Expansion of resettlement options

Research undertaken into bed-blocking and problems with move-on in the city and the resultant report recommended that the existing Resettlement Strategy be overhauled. This work is currently ongoing under the guidance of a multi-agency steering group.

Changes have been made to the homeless application process, to include a fairer method for identifying where applicants want to be rehoused within existing resource constraints. Maps identifying the availability of Council re-lets within all wards in the city help to highlight the problems with high demand areas and the lack of turnaround of certain sizes of properties.

Access to the previously untapped resource of accommodation in the private rented sector has been made possible through joint working with Cadwyn Housing Association. The CalonAdref scheme leasesunfurnished properties to be used to resettle homeless families who have been accepted by the Council under the legislation and the CalonLettings scheme helps facilitate access to private lettings for families and single people, primarily those moving on from supported accommodation.

Raising the profile of homelessness and housing issues

Cardiff has been fortunate to have a Homelessness Champion who is very supportive of what is being achieved in Cardiff, and Elected Members are made aware of the housing pressures through the publication of ‘Is That All There Is?’ This outlines the availability of Council housing stock and levels of demand for specific areas.

Partnership working to develop and progress solutions to homelessness

The Multi-Agency Homelessness Strategy and Advisory Planning Group has been key to progressing the strategic response to homelessness in Cardiff. Agreement is reached on the prioritisation of applications for Council grant funding, a key resource in establishing innovative solutions to homelessness and the Group co-ordinates the Annual Homelessness Conference.

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KEY ACHIEVEMENTS

In a recent audit of the Council’s Homelessness Service, an external consultant commented that‘In any large city it is difficult to ensure that there is a strategic approach to tackling homelessness and its underlying causes through the involvement of all statutory and voluntary sector partners. What is impressive in Cardiff is the effectiveness of its strategic approach and success in implementing its strategy action plan. There are many aspects of partnership working that are excellent.There is a genuine commitment to partnership working and much of the work to tackle homelessness is provided through the Council’s partners.’ Although partnership working in Cardiff is very effective, much still remains tobe done to ensure holistic service delivery to homeless people. Better partnership working must be developed with health, social care, children’s and education services, if longer term solutions to tackle the underlying causes of homelessness are to be developed within the context of tackling social exclusion.

Permanent engagement of healthservices in both strategic planning and delivery of services The expected standards being published by the Welsh Assembly Government are welcome in their attempt to underline the healthcare needs of a growing vulnerable group and to develop a co-ordinated strategic and operational response. Homeless Link Cymru issued a report in April 2006 ‘Homeless People’s Healthcare Needs and Access to Healthcare Provision in Wales’ and its main conclusions found that few homeless people in Wales are able to readily access all healthcare services; dentistry, mental health and drug/alcohol services were particularly difficult to access. It is appreciated that healthcare resources can never stretch to providing dedicated services at all points of access for this client group alone. However, a joint approach to developing service delivery solutions can be explored together within this proposed framework.

Ongoing access to social care services Access to social care for both adults and children is currently ad hoc across the sector with no co-ordinated policy approach other than the discrete statutory and legal duties necessary for each area of responsibility. Work is needed to jointly tackle these issues together

and improve communication and policy-making. It is anticipated that the reconfiguration of the City Centre Team will go some way to assisting with this.

Improving the standards of temporary accommodationThe Homelessness (Suitability of Accommodation) (Wales) Order 2006, placed an emphasis on local authorities to exert extra consideration when placing homeless people into temporary accommodation with regards the standards of that accommodation. Cardiff has exceeded the requirement for the first phase relating to Bed and Breakfast accommodation as this is no longer used for homeless people. However, the third phase deals with supported housing schemes, with which the Council has a number of arrangements. Following an audit of all supported housing scheme’s abilities to meet the new standards, investigations are currentlyunderway to explore the cost and related implications of this.

Co-ordinating access into and from supported housing schemes Homeless people with additional support needs require the services of supported housing schemes, but it is often difficult to access the more specialist services. Additionally, due tothe lack of resettlement options there is often bed-blocking within schemes, resulting in reduced access for those requiring support. A more co-ordinated approach needs to be taken to assist with the smooth throughput of service users, through such schemes, with more explanation and awareness of all the resettlement options explored with support workers.

Increasing the supply of quality, affordable settled accommodationIssues of homelessness go hand in hand with the ability to offer suitable settled accommodation as part of the Council’s duties.However, with dwindling stock and reducing re-lets this requirement is getting harder to meet. Working closely with its partners, the Council isconstantly exploring ways of acquiring suitable alternative forms of accommodation.

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Health promotion and homelessness are often seen as separate services. This is partly because homelessness covers a wide range of client groups united only by a lack of accommodation. In many ways what is required is ensuring that promotion services currently targeted at any specific group in the community are practically accessible by ahomeless person or a homeless family.

Ongoing health visiting input at family hostels It is vital to continue to provide health promotion to families who move through a series of temporary accommodation and who run the risk of being excluded from standard health services and other health promotion services. Funding from Cymorth via the Family Support Strategy has enabled the formation of the Early Years Team (homeless). This Team has developed play sessions in Adams Court and Nightingale House. Three expert staff facilitate these sessions and also provide advice and coping strategies for challenging behaviour and other parenting issues. In addition to this, the Team, in conjunction with the health visitor, is beginning to address poor dental care and nutritional issues.

Healthy eating / nutrition This is an area which should be addressed across the supported housing sector and as part of any tenancy support service. Although addressed in some way through the health visiting service for homeless families and the Early Years Team, this still excludes a large

number of single people and couples in temporary accommodation.

Adequately resourced nurse service for homeless peopleThe LHB currently fund a number of specialist services for homeless people via one GP practice based in Butetown Health Centre. Work is ongoing to identify additional resources in this area to enable homeless persons to continue to access healthpromotion and preventative services.

Early access to mental health services for homeless persons where necessary This would appear to be a priority with regards health promotion for homeless persons. There is a need to ensure that existing services are practically available and responsive to this client group. There is currently a working protocol between frontline hostels and mental health services which is due to be reviewed. It is hoped that this review will consider access to mental health services in a wide context, including health promotion and readily available advice to hostel workers.

Substance misuse There is a need to ensure that health promotion services relating to substance misuse are available in all forms of temporary accommodation for homeless persons. Some hostels have excellent practices and there isa need to ensure that these practices are a standard across the sector.

In line with existing equalities legislation, theintroduction of Equality Impact Assessments is a way of systematically and thoroughly assessing and consulting on the effects that a proposed policy is likely to have. The Council will undertake an Equality Impact Assessment of the Local Housing Strategy 2007-12 (which includes the Homelessness Strategy, the BME Housing Strategy and the Supporting People

Operational Plan), as part of its ongoing wider consultation process. No inequalities have been identified through the existing needs assessment.

The following are areas of concern which will be addressed while extending both the needs assessment and user consultation:

Homelessness 123



RaceThere is a need to ensure that homelessness services are available to all minority ethnic groups and any perceptions of institutional exclusion will be challenged and addressed.

GenderHomelessness services will ensure that services, which are generally gender-specific,are accessible and appropriate to all.

Disability A review has been instigated on the suitability of homelessness temporary accommodation with regards to the newstandards, including wheelchair access issues.

Sexual Orientation There is a need to collect information on this issue to ensure that services are not institutionally exclusive.

Language of Choice The initial challenge is to ensure effective communication with service users whose first language is not English or Welsh. Cardiff Health Alliance is seeking to improve interpretation services to meet demand.

Religion & Belief There is a need to ensure that services, while not exclusive in themselves, seek to support a person’s religion and/or belief.

AgeThe homelessness legislation establishes a priority group, defined by age as 16-17 yearolds. Other duties are independent of age. Whilst not ignoring the general needs associated with a person’s age, a priority is to establish effective services for 16-17 yearolds.

2008 - 2011

1. To improve the health of homeless people, through joint working with the Local Health Board and the Cardiff & Vale NHS Trust in developing an appropriate service response assisted through the implementation of the Homeless and Vulnerable Groups Health Action Plan (HaVGHAP).

2. To promote equality and social cohesion for homeless people and to ensure that policies, strategies and services for homeless people do not discriminate or cause inequalities.

3. To develop a robust Homelessness Strategy, including a revised action plan and monitoring arrangements.

4. To develop and deliver services to meet the needs of homeless people, including the ongoing development of the Single Point Assessment Centre.

5. To promote the independence of homeless people, through exploring a range of initiatives to assist with accessing education, training and employment opportunities.

6. To meet the accommodation needs of homeless people, through identifying strategic relevance and cost effectiveness of temporary accommodation and supported housing services.

7. To safeguard the needs of both homeless families with children and young homeless people and develop services as appropriate.

8. To provide appropriate, accessible and readily available information to homeless people. 9. To raise awareness and provide training on homelessness issues to other professionals. 10. To involve homeless people in the planning and monitoring of services.

Homelessness124


15. Asylum seekers and refugees

Asylum seekers and refugees 125

The 1999 Immigration and Asylum Act introducedthe policy of dispersal of asylum seekers across theUK. This commenced in April 2001, with CardiffCouncil and other private providers in Cardiff offeringaccommodation and support to asylum seekers whowere then supported by the National Asylum SupportService (NASS). In 2007 a new department withinthe Border and Immigration Agency replaced NASS.Cardiff also became a centre for the New AsylumModel, which meant that asylum seekers were routedto Cardiff before being dispersed again within theWales and South West region. A team of Border andImmigration Agency (BIA) case owners are based inCardiff and deal with asylum claims and managecases from beginning to end. Home Office targetshave resulted in quicker decision making of asylumclaims. Overall, since 2001, there has been anincreasing number of asylum seekers living in the

city, with the additional increase in numbers whohave received ‘leave to remain’ in the UK and havechosen to remain living in Cardiff as settled refugees.As a result of the dispersal and settlement of asylumseekers and refugees in the city, there have beenvarious developments in services in response to thedifferent needs of this group in relation to housing,language, social care and health.

Unaccompanied Asylum Seeking Children (UASC) areasylum seeking children under the age of 18 who donot have an adult relative or guardian in the UK.This group of asylum seekers is supported by SocialServices and will be considered in the Children andYoung People’s Plan and therefore are not specificallydiscussed in this chapter although many of the issuesraised apply.

Powers and responsibilities relating to Immigrationand Asylum are not devolved to the NationalAssembly for Wales and remain the responsibility ofthe UK Government through the Home Office Borderand Immigration Agency (BIA). In terms of UKlegislation, the Immigration and Asylum Act (1999)introduced a policy of dispersal of asylum seekersacross the UK. Further legislation has included:

� Nationality, Immigration and Asylum Act (2002) � Asylum and Immigration (Treatment of claimants

etc.) Act (2004) � Immigration, Asylum and Nationality Act (2006)

The Wales Consortium for Refugees, Asylum Seekersand Migrants plays an important role in co-ordinatingthe work of relevant agencies in each dispersal areaand across Wales.


Figure 15.1

Number of Asylum SeekersDispersed in Wales

July 2007

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The following strategies and initiatives were considered in the development of thischapter:

� Wales A Better Country (2003) � Controlling Our Borders: Making Migration

Work for Britain (5 year UK strategy)(2005)

� New Asylum Model (NAM)(2006) � Refugee Housing Action Plan (2006)� All Wales Refugee Policy Forum (AWRPF) � Refugee Inclusion Strategy (Welsh

Assembly Government’s 3 year strategy)

It is government policy that asylum seeker and refugee children have the sameopportunities as other children to access education. This is governed by the Immigration and Asylum Act (2002) and the Education Act 1996. The Welsh Assembly Government recognises this by making provision for asylum seeking children in schools through the Ethnic Minority Achievement Grant. Recently the Welsh Assembly Government’s Ministerial Advisory Group has set up an Ethnic and Cultural Diversity Group through its Additional Learning Needs Panel. This discusses the needs of all minority ethnic groups in Wales.

In 2008, the Welsh Assembly Government introduced the consultation document ‘Improving the Health of Homeless and Specific Vulnerable Groups Standards 2008/09’. This document will inform the development of the Homeless and Vulnerable Groups Health Action Plans (HaVGHAPs). These action plans will also offer a national context to the strategic work that takes place within Cardiff in developing appropriate healthcare services which meet the needs of particularly vulnerable groups.

The standards are very much focused on developing strong strategic partnership working among the lead agencies, including Local Health Boards, Local Authorities and NHS Trusts. The aim is to establish nationalstandards against which local health needs and areas of service development can be identified.

The standards for improving the healthcareprovision for vulnerable groups are also included within the NHS Annual Operating Framework (AOF) and the Service and Financial Framework (SaFF) and are central to local service development and planning.

Cardiff Council has a contract with the HomeOffice to provide accommodation and support to asylum seekers. The initial contract ran from April 2001-March 2006. In April 2006 Cardiff Council was successful in obtaining a further 5 year contract to provide these services. The work of the Asylum team is incorporated into Cardiff Council’s Adult Services’ Business Plan. Two private providers, Astonbrook Housing Association and Clearsprings Management were also awarded contracts. The Welsh Refugee Council (WRC) has a 2 year contract (2006-2008) with the Home Office to provide a One Stop Service for asylum seekers andrefugees, and in addition were awarded the contract to provide the Initial Accommodation Wrap-around Service for Wales and the South West.

Figure 15.2

Top 8 Nationalities of Asylum Seekers inCardiff

July 2007

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Asylum seekers and refugees126


The implementation of the New Asylum Model (NAM) in early 2007, together with the establishment of an Initial Accommodation Centre in Cardiff, has greatly impacted on the support arrangements for asylum seekers and refugees. Due to the above accommodation contracts, there are likely tobe approximately 1,400 asylum seekers in Cardiff at any one time. This will vary over time according to the needs of the HomeOffice. The NAM process has resulted in asylum decisions being made more quickly and this in turn has increased the number of people obtaining leave to remain in the

country, of which some choose to remain andsettle in the Cardiff area. Those in priority need for housing, who have been living in the Cardiff area on asylum support, will establish a local connection and will be able to access social housing provision in Cardiff. Refugees with ‘leave to remain’ can access all mainstream services and benefits in the sameway as the wider community. Cardiff Council has a Refugee Support Team, funded through Supporting People, which aims to deliver advice and support to enable people to maintain their tenancies following the move to mainstream accommodation.

Figure 15.3

Overall Dispersal of Asylum Seekers and Refugees within Cardiff

July 2007

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The following local strategies, action plansand initiatives have been considered:

� The Welsh Refugee Council (WRC) has a 3 year strategic plan of action, which focuses on the need to provide high quality services to asylum seekers and refugees and to work with partner organisations to identify gaps in provision and develop new services in response to this.

� Cardiff Schools and Lifelong LearningEthnic Minority Achievement Service (EMAS) play a substantial role in ensuring that asylum seeker children are provided for, in line with Local Education Authority policies.

� Supporting People Operational Plan focuses on the provision of housing related support to vulnerable groups including asylum seekers and refugees.

Accommodation Services

The contractual arrangements that the HomeOffice has with various providers in Cardiff include the provision of transport from initial accommodation to the dispersal accommodation, the payment of all rents and utilities, the provision of briefing services within the initial accommodation and again within the dispersal accommodation, interim support tokens and vouchers for those receiving Section 4 support. Housing

providers also offer a range of services around the accommodation including a monthly inspection and repairs service. All services are contracted to provide the information in a language that the service user can understand.

Other services for asylum seekers include access to health care, schools, English for Speakers of Other Languages (ESOL), legal advice, etc.


CURRENT SERVICES

When a person receives ‘leave to remain’ in the UK, their needs change to include information on mainstream services such as housing, benefits, employment, ongoing health care, etc. Current services include:

Welsh Refugee Council: � Wrap-around services provided include

briefings for asylum seekers in initialaccommodation until their dispersalincluding: the asylum system, eligibility for support, legal advice, local orientation, health care (referring to Cardiff Health Access Team, assistance to obtain HC2,liaison with the LHB and other stakeholders with regard to health careentitlements for failed asylum seekers, referrals to mental health services), age disputes, relations with the case owners etc.

� One Stop Services provided include support and advice for asylum seekers in dispersal accommodation, resolving accommodation problems, facilitating payments and travel to attend interviews or court hearings, support if the claim is refused (section 4 support, voluntary return etc).

� Move on support includes assistance to access mainstream benefits and entitlements when granted ‘leave toremain’ (LTR). This includes IncomeSupport, JSA, housing & housing benefit etc, general advice on education and employment, assistance in family reunion, travel documents, naturalisation applications etc.

� English Language Assistance via ESOLto teach English to newly arrived asylum seekers.

� Policy and campaigns at the UK and national level in identifying gaps in service provision and develop polices to meet such needs.

Cardiff & Vale NHS Trust: Cardiff Health Access Team In November 2002 the Cardiff Health Access Team (CHAT) was established by Cardiff and Vale NHS Trust. The aim of CHAT was to break down structural and personal barriers to health and empower asylum seekers, refugees, single homeless people and families, gypsies and travellers to access holistic healthcare on anequitable level with the local population. The current service provision comprises:

� Part-time dedicated GP providing a minimum of 5 GP sessions per week

� Nurse practitioner � Health Visitor � Language support

The service performs comparably to a mainstream practice, though these services are not provided under the new General Medical Services (GMS) contract. The purpose of the clinic is to aid and facilitate access into mainstream primary care services. Asylum seekers should only expect to register with the clinic as a short term solution. The clinic is not designed to act asa substitute for mainstream services and asylum seekers are not prevented from accessing mainstream services immediately, should they wish to do so.

Cardiff Local Health Board:Health Screening Cardiff Local Health Board has developed a nurse-led screening service for all newly arrived asylum seekers in Cardiff to operate alongside the primary careclinic at Cardiff Royal Infirmary. The Welsh Assembly Government has providedadditional financial support to this service, allowing for the recruitment of additional nursing staff to support the existing asylum seeker team.

Cardiff Council: Refugee Housing Team Cardiff Council has a team funded by Supporting People who offer advice and practical support to refugeesto enable them to access and maintain their tenancies.Education: � Ethnic Minority Achievement Service

(EMAS) Support for asylum seeker pupils through additional specialist teachingstaff. Training to raise awareness in schools through INSET. Provision of free school meals, uniform and transport in line with LEA policy. School admission is made as quickly as possible within the catchment area of housing provision.

� English for Speakers of Other Languages (ESOL) There has been a growth in ESOL programmes in a range of new areas including workplace based ESOL, community ESOL classes etc.


Since the introduction of the dispersal scheme in April 2001, and the subsequent increase in the numbers of asylum seekers and refugees in Cardiff, there have been a number of new developments in response tothe identified needs of this section of the population, including a range of projectsaimed at assisting asylum seekers and refugees to access services and advice.

Legislative changes and operational changes within the Border and Immigration Agency have led to demands being placed on all

agencies in order to remain responsive to theneeds of the service users. The introduction of the new contracts in 2006 and the placing of Initial Accommodation for Wales and the South West of England have had manyimplications for Cardiff. The main service providers have responded positively and achieved a high standard of service delivery and good practice. There has been excellent communication through the multi-agency groups and this has helped identify gaps in service and maintain a strategic approach.

2005 - 2008

� Cardiff Council was awarded a new 5 year contract 2006-2011, through the competitive tendering process. The new contractual arrangements have been successfully implemented and the Council continues to work with a range of stakeholders to promote good communication and high quality service delivery. The Council was also successful in achieving the integration of the Temporary Accommodation Service within the work of the Asylum Team and this has lead to increased flexibility and the possibility of some people remaining in their accommodation when they get ‘leave to remain’.

� The continuation of the provision of primary care services for asylum seekers and refugees and the facilitation of improved access to mainstream health care services.

� The development of a range of voluntary sector projects designed to provide support and advice to asylum seekers, for example the SOVA ‘YANA’ project, the WRC ‘EQUAL’ project, and ‘Healthy Minds at Work’. Also Displaced People in Action (DPIA) have developed a ‘Readiness for Work’ scheme.

� The WRC secured funding to provide the ‘One Stop Service’ 2006-2008. This involved providing services to enable asylum seekers to deal with queries relating to their support, to access a variety of services and to provide a focal point for voluntary sector organisations working with asylum seekers and refugees, including the Refugee Community Organisations (RCOs).

� The WRC were awarded the Initial Accommodation Wrap-around service for Wales and South West England (NAM).

� A range of agencies contributed to the Welsh Assembly Government’s Refugee Inclusion Strategy.

� Awareness raising sessions were delivered to all GP Practice Managers in Cardiff, explaining the New Asylum Model process and the impact of this on health.

� There has been positive inter-agency working to promote social cohesion through good communication and joint working initiatives, for example South Wales Police have a dedicated liaison officer for asylum seekers and refugees.

� Cardiff Local Health Board has commissioned Cardiff and Vale NHS Trust to provide a nurse-led screening service for all newly arrived asylum seekers undertaking health assessments at Cardiff Royal Infirmary.

� Taff Housing Association set up transitional housing schemes for refugees in order to enable them to access housing in a short period of time after receiving ‘leave to remain’ and to receive further advice and guidance to move on to mainstream housing provision.


KEY ACHIEVEMENTS

In spite of the development over the past few years of different services in response to the dispersal scheme, there is still a high level of unmet need. The Welsh Assembly Government, in the Refugee Inclusion Strategy, identified six key areas, which are: 1. Language, communication and

information 2. Building strong communities 3. Fulfilling potential 4. Accessing core services 5. Understanding diversity and supporting

the most vulnerable6. Developing a framework for monitoring

and evaluation.

The Asylum Seekers and Refugee Advisory Planning Group has identified a number of service developments that are required tomeet service gaps:

� Language and communication There is a general lack of interpreters for different language groups available in various agencies. Also, there needs to beincreased capacity for ESOL providers, in order to respond to the increase indemand.

� Move-on accommodation and support for refugees who are not in priority need. There needs to be a reprovision of the Refugee Homefinder Project, which was previously funded by the Home Office Challenge Fund thatprovided assistance for single refugees to access private rented accommodation.

� Specialist counselling service for asylum seekers and refugees with mental health needs, in particular post traumatic stress disorder. There is no longer aCommunity Psychiatric Nurse post within the Health Access Team. People are referred to existing psychiatric facilities, which cannot respond as quickly as necessary.

� Health Development post based at WRC There are a number of healthrelated issues that could be addressed including the development of mental health services for both adults and children. Children in particular may be inneed of extra counselling and support. The entitlements of failed asylum seekers for health services need to be reviewed.

� Awareness training for agencies The Refugee Inclusion Strategy highlights the need for training, information and awareness raising amongst organisations working with asylum seekers and refugees to increase their understanding of the diversity of needs and the availability of specialist support. They also recommended the establishment ofan all-Wales resource to supply information and advice to those providing services to asylum seeking and refugee children and young people.

� Long term funding arrangements for the Health Access Team to fit with the length of BIA contracts with Cardiff providers. This would ensure a greater continuity of service and lead to improved staff retention. The loss of the Nurse Consultant post within this team has resulted in a gap in awareness raising and strategic input. The gap is solely for gypsies/travellers and homeless, awareness raising and strategic input remains in place.

� Child protection awareness and training for agencies in relation to asylum seeker and refugee children. This would include the provision of training to staff in agencies working specifically with asylum seekers and refugees andspecialist training for other professionals such as teachers and social workers in relation to the particular circumstances of asylum seekers and refugees.



The health care needs of asylum seekers and refugees are wide ranging and complex. Barriers to accessing health care exist due to language issues and lack of information.

All asylum seekers and refugees have the right to register with any GP practice. However, the Cardiff Health Access Team hasbeen set up to provide initial primary health care for asylum seekers.

On arrival in Cardiff, while staying in initial accommodation, all asylum seekers are invited to attend the health clinic at the Cardiff Royal Infirmary (CRI) for health screening and to obtain primary health care.

Dispersed asylum seekers remaining in Cardiff can remain registered with the asylumseekers clinic (Cardiff Health Access Team),

although they will have the right to register with a practice of their choice within their area. The staff at the asylum seeker clinic at CRI will also actively encourage and support patients in registering with mainstream practices as soon as it is deemed appropriate for both the patient and the service provider. Asylum seekers and refugee patients will only be directed into mainstream services when itis anticipated they will not have a disproportionate impact on practice time andresources to other patients. There is no timeframe attached to this process.

There may be limited awareness within health care services of the cultural background of asylum seekers and refugees and a limited knowledge of the asylum processes, legislation and entitlements within service provision.

The status and rights of asylum seekers andrefugees are set out under international law. Asylum seekers and refugees are not a homogenous group. They come from a wide variety of countries, with different life experiences and backgrounds. Therefore,they have complex needs, compounded by the language and cultural barriers that they face.

Race The Welsh Consortium for Refugees, Asylum Seekers and Migrants (WCRASAM) collects data on the origins of the asylum seekers dispersed to this area. Cultural awareness training across health and social care is necessary in order to provide an effective service to this group.

GenderGender roles of asylum seekers and refugees may vary depending on their culture of origin. Incidences such as female genital mutilation or domestic abuse must be assessed within a cultural context.

Disability Asylum seekers with physical or sensory impairments are entitled to access the same services as the mainstream population.

Sexual Orientation It is feasible that some asylum seekers and refugees suffer discrimination in their own culture as well as western society as a consequence of being lesbian or gay. Consideration may be given to collect local data to ascertain the present position.

Language of Choice Face-to-face interpretation is used where possible. In cases of languages or dialects where an interpreter can not be identifiedLanguage Line is available. Cardiff Health Alliance is seeking to improve interpretation services to meet demand.

Religion & Belief Asylum Seekers and Refugees usually adoptthe religion of their home country, and may suffer discrimination in western society. Cultural awareness training across health and social care is necessary in the provision of personal care and staff should support service users where possible to practice their faith.




Age The needs of unaccompanied asylum seeking children are addressed in the Children and Young People’s Plan.

An Older Persons Ethnic Minorities Officer is in post to ascertain the needs of elder asylumseekers and refugees.

2008 - 2011 1. To promote health improvement by implementing the Homeless and Vulnerable Groups Health Action

Plan (HaVGHAP).

2. To reduce social inequalities by strengthening the information base with regard to equality issues for Asylum Seekers and Refugees.

3. To develop additional housing resources for single refugees who are not in priority need, in particular move-on accommodation initiatives that provide accommodation for people when they first receive ‘leave to remain’.

4. To support the establishment of a post for health development work to include sexual health, mental health, physical and sensory impairment and access to community care and secondary care services.

5. To contribute to the development of the Cardiff Language and Communication Strategy.

6. To support the ongoing development of Refugee Community Organisations.

7. To support the provision of training, information and awareness raising about asylum seekers and refugees across a range of organisations and services.

8. To support initiatives that promote social cohesion.

9. To develop additional services to meet the identified mental health needs of asylum seekers and refugees (adults and children) by providing counselling and support.

10. To support the expansion of ESOL provision to enable asylum seekers and refugees to learn English which will facilitate inclusion.



16. Gypsies and travellers

Gypsies and travellers 133

Gypsies and Travellers are the oldest ethnic minorityin the UK. Romany Gypsies and Irish Travellers arethought to have lived in England since the early1500s. Gypsies and Travellers are defined by the1968 Caravan Sites Act as ‘persons of nomadic habitof life, whatever their race or origin’ and aregenerally represented in four main groups:

� Irish Travellers, Scottish, English and WelshGypsies

� Occupational Travellers - includes those whobelong to the traditional show and fairgroundcommunities, the circus communities and bargeand other waterway family businesses

� New Age Travellers - a UK group that emerged inthe 1960s. Some have dropped the use of ‘Age’ whilst others prefer to be known simply asTravellers

� European Roma (Gypsies) from Eastern Europe who started to arrive as refugees and asylum seekers in the 1900s. Under communism they were unable to carry out their traditional occupations and were forciblysettled and made to work in agricultural co-operatives and factories and the Roma were the first to be forced out. It is currently not possible to identify this ethnic group by the use of one ethnic code and cross-referencing with home language and/or names is required.

For ease of reading, the generic term Gypsies andTravellers will be used throughout this chapter whenreferring to all of the groups described. However,the distinctive identity and ethnic status of eachcommunity is fully recognised and acknowledged.

The Welsh Assembly Government in conjunction withthe Home Office released Guidance on UnauthorisedEncampments in 2005. This provides direction tolocal authorities on managing unauthorisedencampments and proposes that consideration begiven to make provision by way of developing transitsites or by identifying informal stopping places whereGypsies and Travellers could stop for short periods oftime without inconveniencing the local community.

The Welsh Assembly Government commissionedresearch on the accommodation needs of Gypsiesand Travellers in Wales. The subsequent NinerReport ‘Accommodation Needs of Gypsy Travellers inWales’, published in 2006, identified Gypsies andTravellers as one of the most socially excludedgroups in Britain and made a number ofrecommendations for consideration by the WelshAssembly Government.

Some work already underway includes:

• The Assembly Government is working to

enact sections 225 and 226 of the Housing Act2004, which will make it a statutory requirementfor local authorities to carry out an assessment ofthe accommodation needs of Gypsies andTravellers as part of their review of the housingneeds of their area.� The Welsh Assembly Government has agreedthat a ‘decent site standard’ should be developedfollowing consultation. This would incorporatelocation and environment as well as site design,facilities and infrastructure, and amenity unit size,design and facilities.� The Welsh Assembly Government will developa model site license agreement setting out rightsand responsibilities of both the landlord and thelicensee in plain and easy-to-understandlanguage which will be incorporated in theHousing Directorate’s Operational Plan.� The Welsh Assembly Government will developa national strategy for Gypsies and Travellersaccommodation provision which will be includedin the 2007/08 Housing and NeighbourhoodRenewal Operational Plan.


� The housing needs and service provision for Gypsies and Travellers in Wales will be reviewed by the Welsh Assembly Government within the National Homelessness Strategy.

The Gypsies and Traveller Bi-Annual Survey, was reintroduced in Wales in July 2006. This Gypsies and Traveller Caravan Count is carried out by local authorities in Wales during the months of January and July each year. Key results show:

� The January 2007 count found that there were around 836 Gypsies and Traveller caravans in Wales.

� In total there were 59 sites across Wales, giving an average of 14.2 caravans per site.

� There were 703 caravans on authorisedsites with planning permission, accounting for 84% of all caravans.

� There were 41 caravans on unauthorised sites, on land owned by Gypsies,accounting for 5% of all caravans.

� A further 92 caravans (11%) were on unauthorised sites, on land not owned by Gypsies.

� Local authority Gypsy sites in Wales had capacity for 548 caravans, as at 18thJanuary 2007.

The new Gypsies and Traveller Site Refurbishment Grant is an important element of the Welsh Assembly Government’s framework. Capital funding is provided forthe refurbishment of existing Gypsy and Traveller sites in Wales by local authoritiesavailable from 2007-08.

The refurbishment grant is intended to improve the quality of life for Gypsy Traveller site residents by modernising existingfacilities and providing new facilities on sites where needed. Nationally £1 million per year will be available for 2007-2010. The grant is for 75% of the estimated refurbishment costs with local authorities being required to meet the remaining 25% of costs.

In 2008 the Welsh Assembly Government introduced the consultation document`Improving the Health of Homeless and Specific Vulnerable Groups Standards 2008/09’. This document will inform the development of the Homeless and Vulnerable Groups Health Action Plans (HaVGHAPs). These action plans will also offer a national context to the strategic work that takes place within Cardiff indeveloping appropriate healthcare services which meet the needs of particularly vulnerable groups.

The standards are very much focused on developing strong strategic partnership workingamong the lead agencies, including Local Health Boards, Local Authorities, and NHS Trusts. The aim is to establish national standards against which local health needs and areas of service development can be identified.

The standards for improving the healthcare provision for vulnerable groups are alsoincluded within the NHS Annual Operating Framework (AOF) and the Service and Financial Framework (SaFF) and are central to local service development and planning.

Cardiff’s Community Strategy states thatequality of opportunity is fundamental to ensuring that all residents are able to realise their full potential as individuals. The city will seek to learn from the experiences of specificgroups by age, gender, ethnicity or physicaland sensory impairment, and will seek to develop new approaches that will place equalities firmly within the community planning framework.

There is no single local strategic framework that exclusively deals with all services provided to Gypsies and Travellers.

However, their health and social care needs are incorporated within a number of generic policies and strategies:

� Cardiff Community Strategy (2007-2017) � Cardiff Council’s Corporate Plan (2007-

2010) � Cardiff draft Housing Strategy (2007-

2012)� Traveller Education Service Business Plan

(2006-2009)� Cardiff Council Equality & Diversity

Strategy (2007)

Gypsies and travellers134


Cardiff Council – Site Management Cardiff Council was amongst the first local authorities in the country to respond to theirlegislative duties in relation to Gypsies and Travellers and developed the Rover Way and Shirenewton caravan sites. The sites are the responsibility of the Housing and Neighbourhood Renewal Service.

Rover Way is the older of the two sites, has a total of 21 pitches and is situated in a heavily industrialised area of the city. There are approximately 90-100 residents on the site. The site is in need of investment, but there are uncertainties in the locality that are currently preventing wholesale improvements. The caravan site occupies just over one hectare, with permanent washing facilities built between pairs of plots and a manager’s office on site.

Shirenewton has a total of 55 pitches, withapproximately 300 residents and is situated in a rural part of the city. The design of Shirenewton is more appropriate with a layout of 14 cul-de-sacs with four pitches each.

Cardiff Council – Traveller Education Service Operational since 1991, this specialist team assists the local authority to fulfil its statutory duty. The service is committed to inclusion,lifelong learning and ‘high achievement’ for all and is partly funded by a grant from the Welsh Assembly Government. The aims of the service are to provide additional supportto meet the educational needs of Gypsies andTravellers.

The Cardiff Traveller Education Service works in partnership with schools, the Gypsy and Traveller community and other appropriate agencies and services. The objectives of the service are to encourage Gypsies and Travellers to take full advantage of all educational opportunities by:

� Raising attainment and attendance at school of Gypsy and Traveller pupils

� Working in partnership with Gypsy and Traveller parents and pupils

� Supporting integration or re-integration into schools and other learning opportunities

� Working in partnership with schools to develop appropriate strategies for the inclusion and achievement of Gypsy and Traveller children

� Providing additional educational support to enable vulnerable children to achievetheir potential

� Raising awareness of the mostmarginalised group in society.

The work of the Traveller Education Service involves the provision of a wide range of support including:

� Teaching support where appropriate, for example Reading Recovery and the Transition to High School Project

� Advice and support to schools, parents and pupils

� Monitoring achievement and attendance � In-service presentations � Participation in research and inspections � Ongoing production of culturally reflective

reading books and exhibitions ‘Celebrating Success’

� The Annual Open Day on Shirenewton site

� Participation and liaison with Cardiff Museum Project

� Membership of the Gypsy and Traveller All Wales LEA forum

� Home-school liaison � Outreach to Roadsiders � Home Club – extends the school day, is

skills-based and delivered by project themes

� Transition and Lunch Time Clubs in two primary schools, which promote social inclusion and transition to secondary school

� Nurture Club in two primary schools � Support for pre-school children via the

provision of a playgroup on the Shirenewton site, originally funded by European Social fund - EQUAL

� Pre-employment training and advice for school leavers, adults and 16-18 year olds


CURRENT SERVICES

2005 - 2008

Cardiff Council Housing & Neighbourhood Renewal � Cardiff Council continued to fund the Gypsy and Travellers Project Co-ordinator Post � Continuation of the Gypsies and Travellers Provider Network � Development of a Gypsies and Travellers Advisory Planning Group � A Gypsies and Travellers Awareness Day was held � Installation of new sewerage facility at Shirenewton � Achieved registration for Care Social Standards in Wales (CSSIW) at Shirenewton� Adapted Community Hall at Shirenewton to achieve the following: Food Hygiene (new kitchen area

community hall); Play Group Registered for 12 pre-school age children; Homework Club; Art Club; Driving Theory classes; Women’s group

Cardiff Council Traveller Education Service � Production of culturally sensitive books with positive images of Gypsies and Traveller culture� Visits to Roadsiders within 5 days, offering educational support, access to schools/other agencies� Home Club at Shirenewton two evenings a week, themes included: teeth, healthy eating, exercise � More pupils transferring to high school and increased attendance and achievement � Liaison for families with children who have special educational needs (SEN)� Nurture Club set up in two primary schools, to increase participation and self-esteem � Work placement scheme and increased employment advice and activities provided via Traveller

Education Service and EQUAL � Weekly Women’s Group and Playgroup on Shirenewton Site, with two women from the site studying for

an NVQ level 2 in Childcare resulting from their playgroup involvement � Extended opportunities for NEET Gypsies and Traveller young people� Reward system for good attendance included a variety of physical activities such as rock climbing, ice

skating and zip wires Health � A forum established of school nurses, health visitors and midwives working with Gypsies and Travellers

to promote cohesive working practices, information exchange, peer support and professional development

� Regular attendance and contribution at Cardiff Gypsies and Travellers provider group � A health workshop held � Health and Safety protocols written for health professionals visiting Cardiff Gypsies and Traveller sites

and delivering care to Road Side Travellers � Shirenewton included in the WAG Flying Start Project attached to Greenway Primary School Cardiff Gypsy and Travellers Project � Establishment of drop-in advice sessions for families on a regular basis, two mornings a week� Involvement of local families in national seminars and conference events on Gypsies and Traveller issues


Not in Education, Employment or Training (NEET)

� Providing literacy support to the wider Gypsy and Traveller community.

Primary Care Gypsies and Travellers have access to the full range of primary care services in Cardiff and are able to register with the GP practice of their choice within their locality.

Cardiff & the Vale NHS Trust The Trust provides community and secondary health care provision to Gypsies andTravellers. This provision is linked to mainstream provision which ensures there is a wide access to expertise.

Voluntary Sector The Cardiff Gypsy and Travellers Service provides extensive information, advice and liaison service to Gypsies and Travellers and all relevant agencies/professionals. This includes casework support on all issues of accommodation and welfare benefits, and other issues affecting health, welfare, safety and living conditions. The project alsoprovides a youth service to 5-15 year oldsbased on weekly play and adventure sessions integrated with a range of local services andfacilities. Computer-based driving theory test sessions are also available every week to assist in overcoming literacy issues and developing IT skills. The Cardiff Gypsies and Travellers Project is funded by Cardiff Council.

KEY ACHIEVEMENTS

Approximately a third of Gypsies andTravellers in the UK have nowhere they can set up home legally. Under the Housing Act1996, a Gypsy or Traveller is homeless if they do not have a lawful place to put their caravan. If a homeless person is in priority need and is not intentionally homeless then the local authority will have a duty to ensure that the individual or family is provided with accommodation.

Cardiff Council has some 400 Gypsies and Travellers living on the two sites in the city. This figure is rising steadily due to family growth, resulting in a shortfall of suitable accommodation. At the time of writing there are 23 applicants on the waiting list for pitches. Travellers who are forced into conventional housing due to their homelessness situation can often suffer ill health and racial abuse from the settled community.

Cardiff has a long history of unauthorised Gypsy and Traveller encampments although the numbers have reduced over the last ten years. The majority of travelling Gypsy and Traveller families came to Cardiff at the time of special events, such as birth, deaths, marriage and shows such as the Royal Welsh in the summer. The Council’s general practice for dealing with unauthorised encampments has been to seek eviction afterundertaking an assessment of basic need. Recent encampments in the city havehighlighted the need for an agreed strategy for dealing with this issue.

The Housing and Neighbourhood Renewal Service are currently undertaking surveys to improve the quality of the sites in order to meet the needs of the community. These include:

� Improvements to the utility buildings external and internal

� Improvements to the concrete pitches to include improved drainage

� Upgrade electrics including externallighting, heating, water boilers and ventilation

� Improve road services to include traffic calming measures

� Upgrade street lighting

� Installation of a play area subject to the undertaking of a feasibility study by relevant partners.

Other areas of focus for 2008-2011 identified by the Advisory Planning Group are:

� It maybe necessary to develop a comprehensive accommodation strategy(this includes the availability of private and privately-rented sites, and housing, as well as unauthorised encampments/homeless accommodation and public sector provision) following the outcome of the Gypsy and TravellerAccommodation Assessment.

� To develop suitable living accommodation at Rover Way site

� To develop communal facilities at Rover Way site

� To identify a budget to covermaintenance costs for both sites

� To address the lack of accessible information for Gypsies and Travellers via funding from the Social Housing Revenue Grant

� The establishment of a specialistpractitioner post to improve liaison and co-ordinate health services

� Production of pictorial health promotion / information.

Studies indicate that the life expectancy and the general health experience of Gypsies and Travellers are lower than the settled population. Overcrowding is prevalent and

sanitation can be inadequate. Children are particularly susceptible to infectious disease and are often not immunised.




The prevalence of genetically inherited conditions is higher than average and there is a high level of infant mortality and low birth weight babies. Injuries among young children are high, especially road traffic accidents. Gypsy children are at particularlyhigh risk of lead poisoning.

A health workshop was held to consider the ‘Health ASERT Programme’ Report (NAW, 2005), research undertaken for the Welsh Assembly Government. The report reviewed different interventions that have been undertaken with Gypsy and Traveller populations in order to improve health. The four interventions that were examined were:

� Community Mothers: recruiting mothers from the Gypsy and Traveller communities to support other mothers

and promote preventative healthmeasures

� Peer Educators: recruiting young people from the community to promote healthy living messages, i.e. anti-smoking

� Outreach Clinic: provision of mobile outreach to improve access and uptake of health services

� Specialist Health Visitor: to improve access, promote health and work inpartnership with other agencies to promote joint working.

The LHB have not been able to progress the above recommendations to date but will explore opportunities to fund specialist services during the life of this strategy.

With EU membership by the four new Eastern European states, Gypsies and Travellers have become the largest ethnic minority in the EU. Despite this, Gypsies and Travellers experience more social exclusion than any other marginalised group in the UK. Gypsy and Traveller groups have specific cultural and life-style characteristics which may not be generally well understood and can contribute to the prejudice that they may experience from the non-Traveller population. Their long held culture is not static, and a feature of Gypsy and Travellercommunities is their ability to adapt tochanging economic and social circumstances whilst retaining their cultural identity. Recognition, understanding and acceptance of these cultural differences are key to effective support for Gypsies and Travellers.

Race All Romany Gypsies and Irish Travellers, whether they are nomadic, partly nomadic, orsettled in housing or caravans on public or private sites, are protected from unlawful racial discrimination and harassment, and public authorities must take account of their interests and needs when carrying out theirfunctions.

GenderMen and women have distinct and closely defined gender roles within the community where men are primary bread winners and form work partnerships and the women support each other in the care of children and other activities. Marriage is generally regarded as a way of life. Strong community connections and communication means that a woman leaving her husband virtually has to leave the whole community. Staff dealing with any incidences of domestic abuse would need to consider these cultural factors for Gypsies and Traveller women experiencingdomestic violence, as their difficulties are exacerbated.

Disability Cardiff Gypsies and Travellers have the sameaccess to necessary adaptations as other people with physical or sensory impairments. Cardiff Council has undertaken adaptations to shower facilities and adaptations to mobile homes where necessary.

Sexual Orientation Gypsy and Traveller culture assumes a heterosexual lifestyle and the disclosure of an alternative sexual orientation would be exceptionally difficult.



Staff working with the Gypsy and Travellercommunity would need to consider this cultural factor, as the difficulties of being gay,lesbian, bisexual or transgendered are increased by these attitudes.

Language of Choice Travellers usually speak the language of the country from which they come. Typically they are English speaking, but with the recent migration of Gypsies and Travellers from other EU countries, services may need to facilitate appropriate interpretation and children will require support to address language issues in an educational setting.

Religion & Belief Travellers usually adopt the religion of the country in which they live; therefore most Gypsies in the UK are Christian. The majorityof Irish Travellers are Catholic. With the recent changes in demographics of the Gypsy and Traveller population in Cardiff, Roma can be Muslim, Catholic, Orthodox or Protestant. Staff working with Gypsies and Travellers

must have appropriate cultural awareness and service users must be supported to practice their chosen faith.

Age Fewer Gypsy and Traveller children access pre-school and education provision than those from the settled community. Travelleryoung people mature early and are givenpositions of responsibility in childhood. It is therefore commonplace for young Gypsies and Travellers to marry from the age of 16. Old age is respected and there is a culture of providing care for immediate as well as extended family. It is virtually unheard of for Gypsy and Traveller senior citizens to beplaced in a care home. The life expectancy of Gypsies and Travellers is much lower than the settled population. Cardiff’s minority ethnic older persons outreach worker plans tohold meetings with older Gypsies and Travellers to find out their concerns /opinions to influence services to ensure theymeet their needs.

2008 - 2011

1. To promote health improvement to Gypsies and Travellers by educating health professionals with regard to culturally appropriate health care and by implementing the Homeless and Vulnerable Groups Health Action Plan (HaVGHAP).

2. To reduce inequalities to Gypsies and Travellers by consulting with Gypsies and Travellers toascertain their views and concerns and to reduce inequalities by strengthening the informationbase with regard to equality issues.

3. To continue to provide and further develop the Traveller Education Service.4. To identify and progress improved site conditions for residents of Rover Way. 5. To regenerate Shirenewton site. 6. To increase playgroup places at the Shirenewton site. 7. To provide information that is accessible to Gypsies and Travellers in terms of reading ability. 8. To complete the first Gypsies and Traveller Accommodation Assessment, now required under

s225 of the Housing Act 2004. 9. To maintain the provision of a ‘one-stop’ information and advice service to Gypsies and

Travellers and service providing agencies. 10. To promote links between the Police and Gypsy and Traveller community in South Wales. Gain

trust and confidence with the communities on authorised sites. Assist with issues surrounding unauthorised encampments and roadside issues.



17. Delivering the vision

Delivering the vision140

The Health, Social Care and Well Being Strategy2008-11 has been developed in partnership. Theprocess has been challenging and demanding for themany people involved and their commitment andsupport is to be applauded. Whilst much has beenachieved, this is a continuum, with much still to bedone to make the vision of the Strategy a reality.The Strategy is intended to be seen as a livingdocument with sufficient flexibility to change andadapt over time. Its development, therefore, is verymuch a step along the journey to improve the healthand well being of the citizens of Cardiff. The deliveryof the vision outlined in this Strategy will requirecommitment and collaboration from all.

Engagement of all stakeholders and service users has

been fundamental to the formulation of the Strategyand their input will be essential duringimplementation and delivery of the proposals. TheHealth Alliance will lead the process and encourageownership through the joint planning structures.

In addition, the health, social care and well beingcommunities will need to engage with the delivery ofthe Strategy and the vision. This will require theutilisation of the Strategy to provide the strategicframework for the development of health and socialcare services in Cardiff over the next 3 years and theintegration of the Strategy into the core work of theLocal Health Board, Council and partners withpriorities and proposals reflected in the BusinessPlans of the partner organisations.

The Health, Social Care and Well Being Strategy hasbrought together the strategic plans for the LocalHealth Board, Cardiff Council and their partners forthe period 2008-11. It has proved difficult to identifythe financial framework that will support the deliveryof the wide range of services outlined in the Strategyand detail the allocation to particular client groupsand identified areas of need, from the differentpublic, voluntary and private sector organisationsworking across health, social care and well beingservices. However, there is recognition by thepartners that whilst their aims and aspirations areextensive, the reality is that plans will have to bedelivered within the resources available to thepartner organisations.

The LHB is dependent on an annual financial

framework with the levels set by the Welsh AssemblyGovernment each year. Local Government is financedin part by the Assembly via an annual grant and byraising local taxes, with an annual budget agreed byCouncil.

Both organisations, therefore, have complex financialarrangements, focussing primarily on annual budgetplans. Consequently, the forecast of a three-yearfinancial plan is not currently achievable, but thisplan seeks to describe the financial position of theLHB and Council and the planned approach inrelation to the delivery of the Health, Social Care andWell Being Strategy. The plan also provides a reviewof expenditure during the life of the first HSC&WBStrategy and the agreed level of spend planned forservices during 2008-09.

FINANCIAL PLANNING

RESOURCE STRATEGY

NHS Trusts, 60%

Continuing Healthcare, 3%

VoluntaryOrganisations, 1%

Other Healthcare, 2%GMS, 11%

Pharmaceutical, 5%

Dental, 4%

Ophthalmic, 1%

Other Primary care, Under 1%

Prescribing, 13%

The Health, Social Care and Well Being Strategy clearly states the six local prioritiesfor Cardiff as Mental Health, Older People,Children and Young People, Communities with Specific Needs, Improving Lifestyles and Maximising the use of Health and Social Care

Resources. As stated throughout this Strategy a significant amount of work has been achieved in these areas over the past three years and the LHB’s focus remains to address the significant issues which face these groups and service delivery in general.

The LHB has incurred the followingexpenditure for the years 2005-06 to 2007-08

in respect of delivering the health needs forthe residents of Cardiff.

Figure 17.1 Cardiff LHB expenditure 2005-08

2005-06£m

2006-07£m

2007-08£m

Total£m

Expenditure 337 (*1) 388 391 (*2) 1,116

(*1) – please note the expenditure figure for 2005-06 does not include the main dental allocation (circa £19m as this was centrally funded at this time)

(*2) – forecast outturn expenditure figure for 2007-08

Figure 17.2 Breakdown of LHB expenditure 2005-08

During the financial years 2005-06 and 2006-07, the LHB has achieved financial balance (and is confident of doing so again for 2007-08), which has been managed, in addition to

making £1m repayment to the Welsh Assembly Government in respect of the inherited deficit position.

Delivering the vision 141

CARDIFF LOCAL HEALTH BOARD

ACHIEVEMENTS APRIL 2005 TO MARCH 2008

MENTAL HEALTH

Figure 17.3 LHB expenditure on Mental Health services 2005-08

2005-06£m

2006-07£m

2007-08£m

Total£m

Expenditure 52.8 54.5 60.0 167.3

% change on previous year _ 3.2% 10% _

Mental Health expenditure per capita over the period remains significantly above the Welsh average (approx 15% of overall LHB expenditure – compared to the average across Welsh LHBs of 12%). The submitted financial returns made to the Welsh Assembly Government show that Cardiff LHB’s expenditure on Mental Health increased from£52.8m in 2005-06 to £54.5m in 2006-07. This is supported by a £1.53m increase over the same period for Learning Disability Services. The forecast outturn is expected tobe around £60m for 2007-08.

During 2007-08 the LHB has expended significant efforts in identifying the financial impacts of the Grogan judgement. Whilst identifying the additional activity that relates to the judgement has been difficult, the expected outturn for 2007-08 is forecast as being £11.6m (a 35% increase over the costs reported in 2006-07). It is therefore anticipated that the percentage of LHB expenditure represented by Mental Health will continue to increase significantly in futureyears.

OLDER PEOPLE

Whilst it is not straightforward to identify discrete funding for older people (as this is included in a number of other clinical specialty areas), the LHB has a number of schemes which can be attributed to this group. These include:-

The Funded Nursing Care beds, which in line with the increase in Continuing Healthcare, has increased from £3.18m in 2006-07 to a forecast outturn of £3.6m (a 13% increase) for 2007-08. Following the recommendations made in the Wanless review, the LHB has allocated resources to the value of £948,000 in 2006-07 and 2007-08 towards additional schemes for olderpeople.The Nursing Home Locally Enhanced Service was funded by £78,000 in 2006-

07 and an outturn of circa £80,000 is forecast for 2007-08. The Influenza and Pneumococcal Immunisation Scheme saw the LHB spend £427,000 in 2006-07 and a similarexpenditure sum is forecast for 2007-08. A number of voluntary organisations including the Alzheimers society who received £82,000 in 2006-07 and are due to receive £85,000 in 2007-08, and Age Concern who received £86,000 in 2006-07 and £89,000 in 2007-08.

In addition, previously short term funded services such as the Elderly Care Assessment service has been incorporated into core baseline funding for Cardiff and Vale Trust and this will secure the services’ long term position.

CHILDREN AND YOUNG PEOPLE

Expenditure incurred by the LHB is respect of Children and Young People has continued to grow over the three years. During the periodof the first Strategy the LHB commissioned:

Services within Cardiff and Vale NHS Trust which have cost in excess of £22m

over the three years across paediatric services.A new Community Nursing Service thathas enabled 23 children with complex needs to be cared for at home. The service spend has increased over recent years and has a forecast outturn


estimated to be around £200,000. The immunisation programme funding package cost £619,000 in 2006-07 and an expected outturn of £600,000 for2007-08 is forecast.

A number of voluntary organisations (including National Children’s Home,Bobath, Ely Homestart project and Ty Hafan) which have received funding to the value of £158,000 in 2007-08.

COMMUNITIES WITH SPECIFIC NEEDS

With the increasing complexities of the make up of Cardiff’s population, the LHB has responded by investing the appropriate resources to the following groups with specific needs:

Services for asylum seekers at a cost of £350,000 in 2007-08. Provision of GP services to those with a known violent history at a cost of £30,000 in 2007-08. The provision of primary care services to the homeless at a cost of £43,000 in

2007-08, through contracting with both GPs and with the voluntary sector. Tiers 1,2,3 and 4 substance misuse services that are provided by GPs as an Enhanced Service, Voluntary Organisations (such as Inroads) and Cardiff and Vale NHS Trust received over £765,000 via the LHB and Community Safety Partnership in 2007-08. The Non- English Speaking Pregnancy Advisory Service has received funding to the value of £18,000 in 2007-08, which is consistent with the funding made available in 2006-07.

IMPROVING LIFESTYLES

The National Public Health Service (NPHS) is the key body responsible for services aimed at improving the health and well being of the residents of Cardiff. The LHB funds the local activities of the NPHS to the value of £1.643m in 2006-07 and a forecast outturn of £1.701m in 2007-08.

The total General Medical Services budget for 2007-08 totals £41.7m and included funding to provide:-

Enhancements to the access mechanisms for primary care services for all Cardiff residents, which cost £1.085m 2006-07

and are forecast to cost a further £550,000 in 2007-08. Anti-coagulation monitoring expenditure(on haematological conditions and heart valve replacements,) incurred by the LHBamounted to £300,000 for 2006-07 and has a forecast outturn of £350,000 for2007-08.Near Patient Testing (also known as shared care drug monitoring) cost £103,000 in 2006-07 and has a forecast outturn of £124,000 for 2007-08.

MAXIMISING THE USE OF HEALTH AND SOCIAL CARE RESOURCES

As part of the Welsh Assembly Government’s initiative entitled ‘Making the Connections’, the LHB has identified that through a variety of schemes, recurrent annual savings to the value of £7.732m can be made. These schemes include prescribing initiatives which

are helping to influence prescribing patterns, Trust efficiency schemes and primary care service changes. These significant savings are set against the challenging financialbackdrop that the LHB faces.


Cardiff LHB faces a challenging financial context in developing its response to the 2008-09 Annual Operating Framework (AOF). The LHB is subject to a Financial Repayment Plan (FRP), which requires the generation of savings to repay brokerage received from the Assembly to cover the financial position of the LHB in 2003-04 and 2004-05.

The total resource limit made available to the LHB for 2008-09 is £391.491m. From this resource limit, the LHB will be funding 7 NHS Trusts through Long Term Agreements plus many more through the non-contracted activity route. In addition, 31 voluntary organisations will be supported, 67 dental practices, 76 pharmacies, 53 GP practices and 48 opticians.

Figure 17.4 Cardiff LHB Budget 2008-09

The LHB has received a 4.4% cash increase for 2008-09 and in terms of individualbudgets, the overall increases are as follows:-

4.0% increase for recurrent discretionary allocations 2.4% increase on certain ring-fenced funding No increase in GMS Contract and Dental Contract funding, pending the outcome of contract negotiationsAn interim uplift of 4.5% has been applied to the pharmacy contract, pending formal agreement of the PSNC/DH settlement for 2008-09 7% increase in drug prescribing. However this uplift has been abated by arecurrent top-slice of £2.366million in

respect of Category M Savings. The transfer of perceived Category M drug savings from the Hospital and Community Health Services (HCHS) prescribing allocation to the HCHS main discretionary allocation has had the effect of reducingthe LHB’s uplift on the prescribing allocation by 3% or £0.070million.

The National Finance Agreement (NFA) for 2008-09, which has been undertaken in conjunction with LHB and Trust Finance Directors, sets out the estimated increases inNHS HCHS costs to be used in the AOF process. The cost elements included in the NFA Agreement are outlined in Figure 17.5 below, recognising that LHBs have onlyreceived an overall allocation increase of 3.5%.

Dental Contract, £16.001m, 4%Community Pharmacy,

£11.026m, 3%

Drug Prescribing, £56.106m, 14%

GMS Contract (i.e. GPs),£41.348m, 11%

Other,£35.835m, 9%

Sexual Health Services, £2.973m, 1%

Mental Health Ringfenced, £45.137m,

12%

2008-09 Recurrent Allocation

(hospitals, non ringfenced mental health services,community services and

substance misuse),£183.065m, 46%


2008-09 ONWARDS

Figure 17.5 National Finance Agreement relating to HCHS

Estimated Cost Percentage increase on HCHS % Pay (including 2007-08 Full Year Effect) 1.82Non-pay 0.72Agenda for Change incremental drift 0.77Agenda for Change unsocial hours 0.36Consultants contract 0.07Compliance 0.26NICE 1.00Continuing care 1.50Total 6.50

The Assembly has allocated 4% or £8.777million additional cash for the management of 2008-09 additional pressures. The shortfall of 2.5% is expected to be managed through efficiency, this total £5.485million.

NHS Trusts have estimated that they will have additional costs of 4% during the yearand the NFA recommends that LHBs should fund Trusts a minimum uplift of 2.4% or£5.266million to meet these costs, with the

remaining balance of 1.6% being met from Trust efficiencies, equivalent to £3.511million.

Further work is ongoing with regard toidentifying the proposed inflation increases toother LHB providers and this will be incorporated within the LHB’s 2008-09 Financial Strategy. Ultimately this needs to deliver a balanced financial position, together with the loan repayment to the Welsh Assembly Government as detailed in the table below:

Figure 17.6 Cardiff LHB Loan Repayment Costs 2008-11

2008-09£m

2009-10£m

2010-11£m

Repayment to WAG 1.750 3.000 3.566

PROGRAMME FOR HEALTH SERVICES IMPROVEMENT (PHSI)

As described in the Strategy, the Health and Social Care community across Cardiff is currently engaged in the development of proposals to reconfigure health care services to improve the ability to meet the

population’s diverse needs. The programme will result in major capital investments in the health care infrastructure within Cardiff and includes the following schemes:-

MENTAL HEALTH

The Mental Health Strategic Outline Programme will deliver:-

The Outline Business Case has been prepared for the development of a Mental Health Assessment Unit forOlder People at Llandough as one of the three enabling schemes to the closure of Whitchurch hospital. This will require additional annual revenue of £2.71m for the scheme along with capital costs of just under £49.9m. It is anticipated that the scheme will be completed in 2011.

The Outline Business Case for a Mental Health in-patient unit for working ageadults in Cardiff has also been prepared. The proposed unit will complement the Trust’s other adult mental health in-patient unit, Llanfair which was opened in 2005. The scheme has proposed revenueimplications of £4.1m and capital costs of £59.5m. As with the Older People’s unit at Llandough, it is anticipated that


the scheme will be completed in summer 2011.The re-commissioning of the Iorweth Jones Residential Home to provide a 45

bedded unit for older people with mental health problems. The scheme has capital costs of £3.92m.

CHILDREN

The continued development of the Children’s Hospital remains a key project for the LHB.The LHB is committed to the development of children’s services across the city and the proposed phase 2 development is

progressing with the full support of the LHB and a financial commitment in respect of £5.045m annual revenue costs and £39.227m capital scheme.

SUBSTANCE MISUSE AND PRISON HEALTH CARE

The ring-fenced funding for substance misuse is made up of 0.4% of the overall discretionary funding to the LHB and equates to £975,000.

Prison healthcare is similarly ring-fenced and has a budget of £112,000 for 2008-09.

PRIMARY CARE

The LHB has a clear and detailed Primary Care Estates Strategy through which the provision of primary care will change to reflect enhanced integration with the services provided through the secondary care medium.

Whilst the financial regime that the LHB operates in remains challenging, all opportunities for further efficiencies will be fully explored in conjunction with partner agencies.

The Council has incurred the following net expenditure for the years 2005-06 to 2007-08 in respect of delivering social care needs for the residents of Cardiff.

Note: the expenditure only relates to specific Adults and Children’s services and excludes expenditure relating to housing, schools, leisure etc.

Figure. 17.7 Cardiff Council Expenditure on Social Care 2005-08

2005-06£m

2006-07£m

2007-08£m

Total£m

Cardiff CC Net Expenditure on Adults and Children’s Services 99 114 117 330

(Expenditure net of income, excluding capital financing charges. Projected expenditure for 2007/8)

Council net expenditure for Adults and Children’s services is anticipated to remain within budget in 2007-08. This follows a significant overspend on Adults budgets in 2006-07 and subsequent re-alignment of Council budgets for 2007-08.

The information in relation to budgets for services to children covers Children’s Services (social care), the contribution of the Council to the Youth Offending Service and the grantfrom the Welsh Assembly Government (Cymorth) that supports services arranged under the umbrella of the Children and Young People’s Partnership.


CARDIFF COUNCIL

ACHIEVEMENTS APRIL 2005 TO MARCH 2008

Childrens Services, 37,954,000, 32%

Supporting People, £976,000, 1%

Physical Disabilities, £7,157,000, 6%

Substance Misuse, £1,266,000, 1% Mental Health ,

£7,038,000, 6%Learning Disabilities, £21,952,000, 19%

Mental Health Services for Older People, £6,940,000, 6%

Older People, £33,841,000, 29%

Figure 17.8 Cardiff Council Social Care Budget 2007-08

Area of Spend Gross£’000

Income£’000

Net£’000

Adult Services

Older People 41,918 -8,077 33,841

Mental Health Services for Older People 8,136 -1,196 6,940

Learning Disabilities 33,705 -11,753 21,952

Mental Health 8,129 -1,091 7,038

Substance Misuse 1,534 -268 1,266

Physical Disabilities 7,632 -475 7,157

Supporting People 6,476 -5,500 976

Sub Total Adult Services 107,530 -28,360 79,170

Children’s Services

Fieldwork and Family Support 12,351 -1,369 10,982

Service Development & Support 8,743 -408 8,335

Looked After Children 17,647 0 17,647

Youth Offending Team 1,779 -789 990

Cymorth 4,462 -4,462 0

Sub Total Children’s Services 44,982 -7,028 37,954

Total Social Care 152,512 -35,388 117,124

Note: Figures include an apportionment of both departmental and central overheads. Figures exclude capital financing charges.

Figure 17.9 Breakdown of Council Social Care Budget 07-08 (net expenditure)


Social care budgets, particularly in Adult Services were subject to significant realignment in 2007-08 reflecting the increasing needs-led demands on the service

and historic levels of expenditure. Budgets over all categories showed significant increases compared to the previous year.

Figure 17.10 Increase in Social Care Budgets

Area of Spend Net ExpenditureBudget 2006/7

£’000

Net ExpenditureBudget 2007/8

£’000

PercentageIncrease

%

Adult Services

Older People 31,927 33,841 6.0

Mental Health Services for Older People 6,132 6,940 13.2

Learning Disabilities 18,053 21,952 21.6

Mental Health 5,149 7,038 36.7

Substance Misuse 1,150 1,266 10.1

Physical Disabilities 6,334 7,157 13.0

Supporting People 959 976 1.8

Sub Total Adult Services 69,704 79,170 13.6

Children’s Services

Fieldwork and Family Support 11,616 10,982 -5.5

Service Development & Support 7,454 8,335 11.8

Looked After Children 16,067 17,647 9.8

Youth Offending Team 993 990 -0.3

Cymorth 0 0

Sub Total Children’s Service 36,130 37,954 5.0

Total Social Care 105,834 117,124 10.7Note: Figures include an apportionment of both departmental and central overheads. Figures exclude capital financing charges.

The majority of the funding the Council receives is provided by the Welsh Assembly Government in the form of Revenue Support Grant (RSG) and National Non-Domestic Rates (NNDR), together known as Aggregate External Finance (AEF).

In addition to these main sources of funding, service areas also receive income from a variety of other sources, including government and other grants, fees and charges to users of Council services and facilities, rental income and interest.

The Council reviews and sets its budgets on an annual basis culminating in a report to Council in February to approve the budget

and the level of Council Tax for the forthcoming year. In doing so the Council reviews its anticipated commitmentsincluding pay awards, inflation and other financial pressures and these are thenbalanced against the available resources. Where necessary service areas are required to identify budget savings from within their areas to contribute to the overall position.

For 2008-09 Cardiff Council received an increase in AEF of 2.9% and this is reflected in the Council's budget. Although forecasts of increases for 2009-10 (+3.4%) and 2010-11 (+3.8%) have been provided by WAG these are indicative increases only and maybe subject to change.


2008-09 ONWARDS

COUNCIL BUDGET PROCESS

The provisional breakdown of the Council budget for 2008-09 is shown Figure 17.11. Note that initially the budgets for central support functions such as Finance, Law and Governance and People and Organisational development are shown separately, prior to their reallocation to the major spending heads such as Adults, Children’s, Schools etc. This explains why the budget allocations forAdults and Children’s in 2008-09 initially appear lower than in the previous year.

In addition, it should be recognised that the scope of Council activities is extensive and

many areas will impact on the health and well being agenda, and will contribute to the Strategy’s aim to improve health and reduce inequalities.

Services such as Schools & Lifelong Learning; Housing & Neighbourhood Renewal; Culture, Leisure & Parks; Waste Management;Transport; Economic Development; and Strategic Planning & Environment all make a substantial contribution to health and well being of Cardiff citizens.

The Council’s overall budget for 2008-09 is detailed below:

Figure. 17.11 Council Budget Allocation per Service Area 2008-09

Service Areas Gross

Expenditure£’000

Income£’000

Net Expenditure

£’000Adult Services 102,369 (25,975) 76,394

Children's Services 42,845 (6,435) 36,410

Corporate 26,134 (261) 25,873

Culture, Leisure and Parks 39,303 (15,997) 23,306

Finance, Property and ICT 26,112 (13,194) 12,918

Highways and Waste Management 70,862 (21,878) 48,984

Housing and Neighbourhood Renewal 140,351 (131,200) 9,151

Law and Governance 5,954 (1,032) 4,922

People and Organisational Development 4,614 (480) 4,134

Projects, Design and Development 4,487 (3,498) 989

Schools & Lifelong Learning 248,746 (43,779) 204,967

Scrutiny, Performance and Governance 1,190 (73) 1,117

Strategic Planning and Environment 15,223 (7,160) 8,063

Strategy and Enterprise 18,842 (7,582) 11,260

Capital Financing etc 32,107 (7,631) 24,476

NET EXPENDITURE 779,139 (286,175) 492,964

FINANCED BY:

Use of Reserves 2,755

Other Grants 13,269

Revenue Support Grant 280,721

National Non Domestic Rates 84,030

Council Tax 112,189

492,964Note: In the table above for the overall Council budget, internal recharges between different services (and within services areas) are netted off against expenditure.


Figure 17.12 Council Budget Allocation per Service Area 2008-09 (net expenditure)

Schools & LifelongLearning,

£204,967,000 , 42%

Adult Services , £76,394,000 , 15%

Children's Services, £36,410,000 , 7%

Corporate ,£25,873,000 , 5%

Culture, Leisure andParks, £23,306,000 ,

5%

Finance, Property and ICT, £12,918,000 , 3%

Housing andNeighbourhood

Renewal, £9,151,000 , 2%

Highways and WasteManagement,

£48,984,000 , 10%

Projects, Design and Development, £989,000 , 0%

People and OrganisationalDevelopment,

£4,134,000 , 1%Law and Governance,

£4,922,000 , 1%

Strategy and Enterprise,

£11,260,000 , 2%

Capital Financing etc, £24,476,000 , 5%

Scrutiny, Performance and Governance,

£1,117,000 , Under 1%

Strategic Planning and Environment,

£8,063,000 , 2%

In 2008-09 the anticipated budgets for Adults and Children’s Services, once central

support costs have been allocated, areanticipated to be as follows:

Figure 17.13 Social Care Budget 2008-09

Area of Spend Net ExpenditureBudget 2008/9

£000Adult Services Older People 33,819Mental Health Services for Older People 7,446Learning Disabilities 22,181Mental Health 6,952Substance Misuse 1,270Physical Disabilities 7,101Supporting People 938Sub Total Adult Services 79,707Children’s Services Fieldwork and Family Support 11,212Service Development & Support 8,043Looked After Children 17,848Youth Offending Team 1,037Cymorth 0Sub Total Children’s Services 38,140Total Social Care 117,847

Note: Figures include a notional apportionment of both departmental and central overheads. Figures exclude capital financing charges. Allowance made for an element of specific grant funding.


SOCIAL CARE BUDGET 2008-09

Children’s Services,£38,140,000 , 32%

Supporting People, £938,000 , 1%

Physical Disabilities, £7,101,000 , 6%

Substance Misuse, £1,270,000 , 1%

Mental Health, £6,952,000 , 6%

Learning Disabilities, £22,181,000 , 19%

Mental Health Services for Older People, £7,446,000 , 6%

Older People, £33,819,000 , 29%

Figure 17.14 Breakdown of Social Care Budget 2008-09 (net expenditure)

In addition to these core budgets the Council receives specific grant funding for various initiatives for example:

Mental Health Carers Grant Support for People with Disabilities Performance Management Vulnerable Children

Partnerships, such as Community Safety Partnership, Children and Young People Partnership, Health Alliance and Community First, also receive grants which enable them to take forward initiatives that will contribute to health improvement.

Figure 17.15 Social Care Grants

Key Grants to Social Care 2005-06£

2006-07£

2007-08£

2008-09£

Mental Health Carers Grant No grant 26,1090 347,905 349,059proposed

Support for People with Disabilities 117,113 148,938 160,567 Not yet indicated

Performance ManagementMain Grant Additional Component Consortia Grant Total

175,78069,50013,000258,280

217,963103,17113,000334,134

220,799177,44013,000411,239

Not yet indicated

Short Breaks/Vulnerable Children Short Break Early Support

No grant No grant 199,08485,322

Not yet indicated

Joint Working Special GrantThe Joint Working Special Grant (JWSG) is the mechanism by which Welsh Assembly Government, encourages the development of ‘flexibilities’, as described in section 31 of the Health Act 1999, providing financial incentives to improve collaboration between NHS and Local Authority services through

pooled budgets, lead commissioning and integrated provision. The grant supports a range of projects across partner organisations and the level of fundingis detailed in Figure 17.16. Key areas of grant spend have focused on the identifiedpriorities of Mental Health, Older People, and Children and Young People.


GRANT FUNDING

GRANTS TO FACILITATE JOINT WORKING BETWEEN THE LHB AND COUNCIL

In addition, there has been miscellaneous cross-cutting activity including the

development of the Health, Social Care and Well Being Strategy and Unified Assessment.

Figure 17.16 Breakdown of Joint Working Special Grant 2007-08

Figure 17.17 JWSG

2005-06£

2006-07£

2007-08£

2008-09£

Joint Working Special Grant 1,062,904 1,022,558 1,022,558 929,096

WANLESS LOCAL ACTION PLAN GRANT

The Welsh Assembly Government required LHBs and Local Authorities to develop a Local Action Plan in 2004 to explore opportunities to deliver more efficient and effective health and social care services, reflecting the recommendations of the Review of Health and Social Care by Wanless.

The Assembly provided grant funding to LHBs to support the delivery of local plans with the Local Authority and their partners. In Cardiff projects have primarily focussed on the identified priorities i.e. Mental Health, Older People, Children and Young People. Level of funding is detailed below:

Figure 17.18 Wanless Local Action Plan Grant

2005-06£

2006-07£

2007-08£

2008-09£

Wanless Grant 2,727,000 2,850,000 2,950,000 3,021,000

Children's Mental Health Services, £39,789, 4%

Children's Physical Disability Services,

£41,500, 4%

Children's Services,£63,690, 6%

Older People, £367,696,36% Mental Health, £291,895,

29%

Adult Services - CrossCutting, £217,688, 21%


Figure 17.19 Breakdown of Wanless Allocation 2007-08

VOLUNTARY SECTOR GRANTS

The Council awards grants to the voluntary sector for a wide range of activities. Inparticular, health and social care services are provided through voluntary organisations, making a substantial contribution to local provision. Grant arrangements have beendeveloped in partnership with the voluntary

sector and are allocated in line with the Council’s budget process and Corporate Planunder the auspices of the Voluntary Sector Compact. The allocation for social careservices are detailed below and the pie-chartillustrates grant spend in 2007-08 for health, social care and well being.

Figure 17.20 Social Care Grants to the Voluntary Sector

Social Care Grants 2005-06£

2006-07£

2007-08£

2008-09£

Adult Services 634, 767 567,170 794,960 844,960

Children’s Services 966,418 63,157 59,718 0

Note: many of the grants provided by Children's Services were transferred to contractual arrangements in 2006-07 and the remaining grants transferred for 2008-09

Figure 17.21 Health & Social Care Grants to the Voluntary Sector

Other, £358,000 , 12%

Children, £634,000 , 22%

Older People, £1,017,000 , 35%

Mental Health, £901,000 , 31%

Cross Cutting Total,£198,035 , 13%

Children and YoungPeople, £117,484 , 8%

Mental Health, £481,966 ,32%

Physical Disability,£51,716 , 3%

Carers, £290,309 , 19%

Substance Misuse,£21,390 , 1%

Homelessness, £317,298 , 21%

Gypsies and Travellers,£38,000 , 3%


This plan provides a framework ofexpenditure on health, social care and wellbeing services in Cardiff. The total spend for 2008-2009 is budgeted as; LHB £391m and Council social care services as £117m. With a combined fund of over £508 million,

supported by an extensive range of grants and provision by other Council services, partners and sectors, it is hoped that the plans and aspirations for delivery of the Health, Social Care and Well Being Strategy will be achieved.

Good workforce planning and development are central to improving health and well being services. Delivering good health and social care services depends on having high quality, motivated staff with the right skills. Currently organisations are attempting to address workforce planning individually, but all agencies involved in providing health, social care and well being services experience the same problems of recruiting, training and retaining staff. Consequently there is recognition that a partnership approach is needed in the development of a common framework to address workforce planning.

The Review of Health and Social Care inWales by Wanless (2003) identified some of the key issues relating to workforce planning:

Inconsistency of approach

Workforce planning undertaken in isolation from strategic and operational planning and the setting of service and financial plans

Discrepancies in timetables as service planning is often short term, but workforce planning is medium to longterm, because of the length of time it takes to plan for, educate and train staff

Workforce planning does not recognise the wastage rates throughout the system.

The NHS and Social Care workforce as a whole face a number of challenges to ensure staff are able to deliver quality andappropriate care and support:

The need to adapt knowledge and skills as new treatments and technology impact on the way services are provided

Recognising that skilled staff increasingly move around different organisations and parts of the country

The need to achieve the right balance between work, leisure and education,reinforced by European legislation

The need to develop, with staff, new roles and ways of working.

WELSH ASSEMBLY GOVERNMENT

During late 2007 the Health, Well Being and Local Government Committee of the Welsh Assembly carried out an Inquiry into Health and Social Care Workforce Planning.

The aim of the Inquiry was to examine the effectiveness of the current arrangements for workforce planning in the health and socialcare sectors in Wales and to make recommendations about future arrangements, with reference to:

The division of responsibility amongst organisations charged with workforce planning and the mechanisms they use

The availability and quality of intelligence to inform workforce planning The involvement of all relevant stakeholders in the planning process Changing patterns of demand (including an ageing population) and service provision in the health and social care sectors, (including reconfiguration of services, use of new technology, new public service delivery arrangements) Cross border arrangements with the NHS in England


WORKFORCE PLANNING


Changing professional roles and training programmesJoint working between health and social care agencies The workforce needs of the public,voluntary and private sectors The recruitment of a workforce thatreflects the diversity of the Welsh communities, including Welsh speakingstaff and those from minority ethnic groups Examples of good and innovative practice.

The Inquiry sought evidence from a wide range of organisations concerned with the health and social care workforce in Wales.

In relation to healthcare, the Inquiry looked at issues concerning the healthcare workforce in Wales such as shortages of GPs in some areas, levels of nursing vacancies filled by bank and agency staff, training places for junior doctors, and the availability of posts for newly qualified Allied Health Professionals (AHPs) e.g. physiotherapists.

The apparent ‘swings’ in the numbers of trained health professionals leading to surpluses some years and shortages in otherswas also considered.

The social care sector employs 70,000 people in Wales, with services provided by the public, voluntary and private sectors. An ageing population is likely to increase the demand for care services for the foreseeable future.

In the children’s sector concern has been expressed around the shortage of socialworkers to undertake child protection work.

The Inquiry looked at recruitment and retention difficulties for social care staff andthe impact of Government policies in these areas.

The Inquiry is expected to publish its findings, with recommendations forimprovement, in February 2008. The resultant report will inform the workforce planning by partners across the health, and social care agenda.

LOCAL AUTHORITIES

SOCIAL WORKERS

The National Strategic Advisory Partnership for Social Work Training has identified the need to improve the quality of data available in Wales to inform the future requirements for qualified social workers within the workforce.

A Steering Group has been established with representation from ADSS, CSSIW, WLGA, LGDU

and the Care Council. The Steering Group has developed a planning tool which will aim to gain a better understanding of the Welsh labour market for social workers and to determine the numbers required to be in training to meet the future needs of the sector. Consultation on this planning tool is currently taking place.

SOCIAL CARE WORKFORCE

The SSIW guidance ‘Planning for Caring’ published in 2003 was produced to assist Local Authorities and partner organisations in Wales draw up effective human resource plans for the social caresector in their area.

Plans were produced for 2008-09 and updates on progress are provided through the Social CareWorkforce Development Programme application for funding each year. One of the issues identified as having an impact on the effectiveness of workforce planning is the accuracy of workforce data in

respect of independent sector providers. Work isbeing undertaken between SCWDP co-ordinatorsand the Local Government Data Unit to develop a consistent model for the provision of workforce data, including progress against the Assembly’s qualification targets.

In addition, Local Authorities will need to be clear about their commissioning intentions to allow providers to shape their workforce to meet the needs of commissioners.


NATIONAL HEALTH SERVICE

The necessity for service redesign, the introduction of new contracts for medical consultants and independent contractors in primary care (GPs, dentists and pharmacists), together with the Agenda for Change and the full introduction of the European Working Time Directive in 2009 requires a comprehensive review of workforce issues across the NHS.

The ‘Designed to Work’ Strategy provides the workforce and people management strategy to support the delivery of ‘Designed for Life’.

The aim is to get the right people, with the right skills, at the right place, at the right time, to provide a world class, sustainable workforce for the NHS Wales. The strategy describes the process required to ensure the NHS has a competent workforce and highlights the need to modernise the way staff work. It recognises the need for innovation and collaboration in order to provide safe, effective services within available resources. The three key themes of the documents are:

1: Develop a new approach to role redesign and innovative work systems to meet patient needs

1. Redesign of services, new roles and the creation of innovative ways of working acrossboundaries to deliver the vision of the future workforce.

2. Benefits created by pay modernisation will be maximised to support the transformation of service delivery and role development.

3. Regional HR and workforce networks will be established to ensure that workforce plans are developed to deliver ‘Designed for Life’ reconfigurations and to ensure the development of shared service models for the provisions of support services.

4. Primary Care will be developed to support the chronic disease management model resulting from ‘Designed for Life’. New and widened roles to be established.

5. Plan for the impact of 48 hour working limit to be achieved by 2009 to meet the requirements of the Working Time Directive.

2. Create an organisational and workforce development planning system to deliver service change

6. Create innovative and responsive workforce planning and commissioning approaches inpartnership across the health and social care sector to ensure that the workforce of the future matches the needs of the service of the future.

7. Establish a culture of improvement, underpinned by lifelong learning and development to support the ongoing modernisation of services as well as continuing professionaldevelopment. Develop a national e-learning strategy and increase capability in line with the informing healthcare targets.


3: Develop a modern people management, human resources and organisational development service for the delivery of innovation

8. Human Resource capacity and capability across the service will be assessed to ensure maximum focus on delivery of organisational development and cultural change.

9. Realise the benefits of the Electronic Staff Record system through modernising systems and the development of shared services. Performance manage the implementation.

10. Ensuring that NHS Wales employers are employers of choice through the development and implementation of innovative employment practices and initiatives.

11. Develop and strengthen partnership working arrangements to support model employment practices, innovation, implementation of change, engagement of clinicians and patients and wider staff involvement.

12. Develop equality and human rights strategies to mainstream the promotion of diversity into all elements of organisational activity, ensuring compliance with legal requirements and best practice.

13. Implement flexible employment policies in all NHS organisations. 14. NHS organisations will implement agreed policies to support and manage staff to optimise

levels of attendance within a safe and healthy working environment.15. Develop a leadership strategy to include a development process which will deliver

innovation, clinical and non-clinical leadership including succession plans, HR capability forchange and modernisation of services and employment practices.

16. Develop robust individual organisational performance management processes aligned to service objectives and accountability frameworks to ensure delivery of ‘Designed to Work’.

The Health Social Care and Well Being Strategy Guidance (2007) states that the Strategies must drive the reshaping of the NHS Wales and social care workforce bydeveloping new ways of working to deliver service modernisation. The Cardiff HSC&WB Strategy recognises the importance and describes in its vision the aspiration to achieve: a sufficient, skilled and supported workforce that feels valued, involved and committed.

As the Local Service Board works towards greater integration of health and social careservices, the need for joint working to secure an efficient and effective workforce is fundamental. The redesigned infrastructures and care processes will require a different type of workforce, supported by planning to ensure that staff with the appropriate competencies are secured on a sustainable basis. This will require a workforce that can work across traditional boundaries, with leadership that can operate across organisations/sectors.

CARDIFF COUNCIL

Workforce planning has been identified as one of the top ten risks to Cardiff Council. As part of its business planning process, a workforce plan for the Council will be produced for 2008-09, with each Service Area being required to produce a workforce plan which identifies the human resources needed to deliver on its business objectives.

Adults and Children’s Services recognise the need to work with NHS partners to develop a consistency of approach.

A Council template has been developed to identify the gaps between the current workforce and the workforce likely to be needed in the future. Plans will identify how these gaps are to be addressed.



CARDIFF LOCAL HEALTH BOARD

The LHB is developing a workforce plan in response to ‘Designed to Work’ and has undertaken a self-assessment against the recommended model. The LHB recognises the need to ensure staff are available to:

Offer robust health promotion information to their patients

Apply the new assessment tools to ensure baseline information is available to formulate care plans

Deliver new models of intermediate care within community settings

Provide the required skills to delivercare to the standards described in the agreed care pathways for long term conditions

Offer a range of new roles to deliver new models of care, mental health care and generic support to meet the health and social care needs ofpatients within the community.

CARDIFF AND VALE NHS TRUST

In response to ‘Designed to Work’, the Trust has developed a Workforce Strategy with an Action Plan for 2008-09 containing detailed proposals under the 16 key objectives.

The Trust recognises the need to have staff with new skills in order to deliver the Programme for Health Service Improvement. Supporting the transfer of skills and roles from ‘secondary’ to

‘primary’ care locations will be fundamental in providing more services closer to where people live. The service changes will mean changes forstaff, for example staff who currently work in UHW and Llandough supporting diagnostic procedures and out-patient clinics will increasingly work in more local facilities.As services move out from the main hospitals, so staff will be required to move with them.

PARTNERSHIP APPROACH

The Local Health Board and Council with the Cardiff and Vale NHS Trust and other partners are committed to develop acombined approach to workforce planning todeliver the modernisation of services, with the detail taken forward within and across organisations. There is a need to engage with other partners and also with staff, trade unions, professional bodies and otherstakeholders.

It will be a high level plan which takes into account:

National strategic workforce planning

Local strategic workforce planning

Employer operational workforce development plans


Integration of health and social care services and the strategic direction of moving more care into the community and providing local services and support to help people remain intheir own homes will require a new skill mix for a generic workforce. Team working will

be promoted, including across professional and organisational boundaries, and staff will need to be flexible both in work locations and roles. The workforce will require key competencies which will include:

Prevention and Health Promotion skills Service user assessment skills

Re-ablement skills Risk assessment skills

Therapeutic skills Partnership working skills.

Training will be a prime focus of the plan, coupled with recruitment and retention policies. This will necessitate greater synergy across organisations in terms of Human Resource policies in terms of:

Pay and conditions of service

Qualification/training requirements

Induction training

Professional development

Work life balance

Health promotion and well being support

The workforce will require a range of skillsthat facilitate a new way of working as illustrated in Figure 17.23:

Figure 17.22 WorkforcePlanning Framework

National Strategic Framework

National Workforce Strategy

Health, Social Care & Well BeingStrategy

Local Workforce Strategy

Cardiff & ValeNHS Trust

CardiffLHB

CardiffCouncil

Partner Organisations


Figure 17.23 Skill mix required from workforce:

Workforce planning will be a challenge forpartners and will require sharing of plans and methods of working in order to develop greater synergy and joint approaches. The Health, Social Care and Well Being

Strategy will provide the framework for joint working and over the lifetime of this Strategyas integration of services is taken forward, the development of co-ordinated workforce planning.

Implementation Plans have been developed by the Advisory Planning Groups (APGs) to support the Strategy. They describe the key milestones to delivery and the monitoring mechanisms. The areas of activity described will link to the relevant Business Plans of the statutory partners.

Accountability for the overall implementation of the Strategy is the responsibility of the statutory partners i.e. Cardiff Council and Cardiff Local Health Board. The Health Alliance will monitor the Health, Social Careand Well Being Strategy implementation in its totality and will be accountable to the statutory partners.

The Health Alliance will quality assure the implementation of the Strategy in terms of:

Ensuring ongoing strategic alignment with the Proud Capital: The Cardiff Community Strategy 2007-17

Strengthening partnership working and monitor the effectiveness of joint working

Ensuring service user and stakeholderinvolvement in the detailed planning,implementation and monitoring of the proposals

Establishing strategic relationships and a co-ordination conduit to other major plans and establishing mechanisms across the NHS and local government

Sharing progress on implementation of the Strategy with key stakeholders.

The Strategic Commissioning Group will oversee the implementation process and receive regular monitoring reports from the APGs. Where targets and reporting structures are specified by external bodies such as Welsh Assembly Government and Home Office, plans will cross reference and detail the approach to be adopted.

Unified Assessment /

CareProgramme

CarePathway

Rehabilitation

Evaluation

Review

Prevention & Health

Promotion


IMPLEMENTATION AND MONITORING

In addition, the APGs will prepare annualreports to the Strategic Commissioning Group and Health Alliance, presenting progress, achievements, issues and identifying cross-cutting opportunities in the process.

The Welsh Local Government Association (WLGA) shared outcome indicators project will be utilised to assist in the monitoring of health improvement activity.

The Business Plans of the partner organisations will be informed by the Strategy and the performance management arrangements supporting the Plans will provide the basis of the detailed Strategy monitoring arrangements.

The Strategy Annual Report will be prepared collating the implementation progress and this will be available to all partners and stakeholders via the Health Alliance web site.

The Health Alliance will conduct a review of the Health Alliance partnership structure as directed by the Local Service Board, to include joint planning arrangements, with the aim of ensuring structures and mechanisms are ‘fit for purpose’ to take forward the detailed implementation and monitoring of the Strategy on behalf of the Health Alliance

statutory partners

An in-depth review of the process to develop the Strategy will be conducted in 2008 by the Strategy Steering Group. Lessons learnt from the development of this Strategy will be taken into account when formulating the approach to Strategy development for 2011.

2008 - 2011

1. Implementation Plans to be developed and implemented by APGs

2. Monitoring Plans to be developed from the Implementation Plans

3. Partnership structures and joint planning arrangements to be reviewed

4. Strategy development process to be reviewed and lessons learnt noted

5. APGs to provide written feedback on progress in May each year to inform the Strategy Annual Report

6. APGs to report to the SCG/Health Alliance or on annual basis detailing the achievements and any relevant issues

7. An Annual Report will be prepared for submission to the Health Alliance, statutory partners and WAG. The report will be made available to the wider stakeholders via the Health Alliance website.


REVIEW


Cardiff Health Alliance The Health Alliance is the key strategic health and social care partnership in Cardiff with local authority, health services and voluntary sector membership. Established in 2000, the initial focus was to consider factors which contribute tohealth and health gain, and reducing inequalities in health. Over time theHealth Alliance in response to WAG policies and initiatives, in particular the responsibility to develop and implement a Health, Social Care and Well Being Strategy, on behalf of the Council and LHB, widened its scope to include health and social care services. Consequently, the Alliance now provides the forum for strategic liaison between partnerorganisations on a range of health, social care and well being issues (see relationship diagram).

Strategic Commissioning Group The Cardiff Health Alliance delegated the responsibility for the detailed development and implementation of the Health, Social Care and Well Being Strategy to the Strategic Commissioning Group (SCG). The SCG is a multi-agency forum of representatives involved with the planning of health and social care services foradults in Cardiff. The key purpose of the group is ‘to ensure that the Health Social Care & Well Being Strategy is developed,implemented and monitored in line with the agreed objectives of thecommissioning authorities’ (SCG Terms of Reference, 2006), and to inform joint planning across health and social care.

Advisory Planning Groups The SCG provides the leadership anddirection to a range of Advisory Planning Groups (APGs). The Chairs of the APGs are constituent members of the SCG.These multi-agency groups each focus on a specific client group. They are tasked ‘to ensure the efficient and effective joint planning of agreed health and social care services for relevant service user groups,

as expressed within the Health, Social Care & Well Being Strategy, meeting need at an individual and population level in the medium and long terms’ (APG Terms of Reference 2006).

Children’s Joint CommissioningGroup A parallel structure to direct the joint commissioning of services for children and young people was established as the Children’s Joint Commissioning Group in May 2006. This Commissioning Group oversees the development of jointlycommissioned services, exploring opportunities for pooling budgets, lead commissioning and resource transfer between agencies and reports to the Children and Young People’s Partnership Framework Board.

Voluntary Sector There are an estimated 2500 voluntary organisations in Cardiff (national, regional and local). Of these, 1334 have an interest in health, social care and well being, working with children and families, young people, older people and communities. Of these 457 are national organisations, 142 are regional and 735 are local organisations.

Building Strong Bridges This Welsh Assembly initiative plays an important role in promoting voluntary sector involvement in planning and delivering citizen centred services. The aim is to identify opportunities tostrengthen partnership working at nationaland local levels. The Health and Social Care Facilitator, funded by the Assembly, via the Local Health Board, is based at Voluntary Action Cardiff. The remit includes actively engaging the voluntary sector in the preparation of the Strategy and the Facilitator works closely with statutory partners in the development of the Health, Social Care and Well Being Strategy.

Appendix 1

Appendix 1162

CARDIFF HEALTH, SOCIAL CARE AND WELL BEING PARTNERSHIPSTRUCTURES

Vision Forum

Community Strategy Voluntary SectorCompactCompact

Community Safety Plan

Community SafetyPartnership

Children and Young People’s Plan

Health, Social Care &Well Being Strategy

Local Development Plan

Health AllianceChildren and Young People’s Partnership

FoodFood&

HealthHealth

MentalMentalHealth

PromotionPromotion

SmokeSmokeFree

CardiffCardiff

CardiffCardiff Healthy AgeingAgeing

PhysicalPhysicalActivity & Health& Health

PhysicalPhysicalActivity NetworkNetwork

Food &Food &Health

NetworkNetwork

Health ChallengeHealth ChallengeCardiff Steering GroupCardiff Steering Group

Supporting PeoplePlanning Group

Adults Strategic Commissioning Group

Joint Commissioning Group for Children

Task Groups

KEY: Groups

Strategies/Plans

Asylum Seekers

APG

Older People APG

Substance Misuse

APG

HomelessnessAPG

Physical & Sensory

Impairment APG

Sexual HealthAPG

CarersAPG

Mental HealthAPG

Learning Disability

APG

PrisonHealthAPG

Gypsies & Travellers

APG

Appendix 1 163

CARDIFF HEALTH ALLIANCE PARTNERSHIP STRUCTURES

The importance of involving and engagingstakeholders to secure better services and improve health has been a cornerstone of theWelsh Assembly Government’s approach to policy development and integral to Cardiff’s development of the Health Social Care and Well Being Strategy.

ENGAGEMENT

The Community Orientated Primary Care Process utilised in the original consultation process in 2004 requires evaluation and reassessment to complete the cyclical process. Stakeholder involvement has therefore been vital during the implementation period, annual review and feedback events held regarding the 2005-08 Strategy. This commitment from stakeholders has been further developed during 2007 and has been critical to the approach to the next Strategy.

The ‘Delivering the Challenge’ event was held in October 2006 to relay progress to stakeholders from multiple agencies and consultees from the development of the first Needs Assessment and Strategy workshops in 2003-04. The event provided feedback on the achievements of the first half of the Health Social Care and Well Being Strategy period (2005-08), reviewed the implementation plans for the second 18 months and looked ahead to developing key messages for the next Strategy. The event utilised a variety of media to engage with individuals, including poster presentations on each area of work and provided a renewed interest and base on which to develop engagement for the development of the second Strategy. The provision of ‘stalls’ by APG members facilitated two-way debate and healthy discussion on the progress of the Strategy and the opportunity for informal, written feedback/comments.

The Cardiff Health and Social Care Network held an event called, ‘Need We Say More?’

in June 2007 to consider the progress of the first Health Social Care and Well Being Strategy and the development of the next Strategy. Stakeholders from a wide range of voluntary organisations participated in workshop discussion on the achievements to date and the areas needing attention in the second Strategy.

A Vision Setting Stakeholder Workshopwas held in March 2007 to agree the vision for health, social care and well being in 2011. The workshop considered the strategic framework and local priorities and discussed the future development of health, social care and well being services in Cardiff. The resultant vision demonstrated the synergy and correlation across partners. These outcomes have informed the development ofthe Strategy.

The Strategic Commissioning Grouphosted a workshop for the chairs of the Advisory Planning Groups (APG) in May 2007 to help inform and shape the chapter development of the second Strategy. In addition Equality Assessment training was held for APG chairs and representatives.

Recognising that public engagement and community involvement is a fundamental element of the Health, Social Care and Well Being Strategy and to aid the developmentprocess, a Consultation Group was established to lead on engagement and consultation for the 2008-11 Strategy. Collaborative working, informed by representatives from a range of partner organisations, has brought a new innovative and inclusive approach to the consultationprocess, in the following ways:

� Service User Representatives Panelprovided links with service users and public participation/involvement officers. This forum informed development of approaches to consultation and the opportunity to link with a wider range of service users.

Appendix 2

Appendix 2164

HEALTH, SOCIAL CARE AND WELL BEING STRATEGY DEVELOPMENT,ENGAGEMENT AND CONSULTATION

� Health, Social Care and Well Being Strategy newsletters were produced at regular intervals in order to ensure the public and stakeholders were aware of the Strategy development and keptinformed of progress and engagement opportunities. The newsletter was linked with the production of the Programme for Health Service Improvement newsletter to ensure readers were informed of both areas of development.

� ‘Your Opportunity - Giving the Public and Partners a Voice’ This involvement and consultation plan was

developed, setting out the local approach to engagement and consultation for the second Health, Social Care and Well Being Strategy.

� Capital Times, the Council newspaper, which is distributed to every household in the City included articles on the second Strategy, and the consultation period.

� The ‘Ask Cardiff’ Survey was utilised to consult with a random sample of 6000 members of the population on a broad range of services, including health and social care.

CONSULTATION

The draft Health, Social Care and Well Being Strategy was approved by the Health Alliance and was then subject to a 12 weekconsultation period which ended on 14th

January 2008. During this period a range of methods were used to secure the views of approximately 500 stakeholders, partners and residents on the proposals for future service developments.

� A launch event was held, attended by over 160 delegates and the programme included details of the partnership approach; needs assessment update; achievements DVD; workshops; and displays by Advisory Planning Groups and the opportunity to discuss specific chapter’s content.

� A Summary document, which included a pull-out questionnaire was published and widely distributed.

� The Internet was utilised and the fulldraft Strategy and Summary wereavailable on the Health Alliance and Partner websites. In addition the questionnaire could be completed and submitted online.

� Following feedback from stakeholders, it was agreed that the preferred approach to involvement was the utilisation of existing fora and networks. These fora were utilised to discuss the draft Strategy with informed groups who focused on specific chapters/client groups. In particular this approach engaged the voluntary sector via the Health & Social Care Network.

� The Community Health Council (CHC) supported consultation via meetings of Reference Panels, Junior CHC and a public evening meeting.

� A DVD illustrating achievements resulting from the first Strategy was made and shown at events.

� Local Press included articles advertising the draft Strategy events and the consultation period.

Appendix 2 165

RESPONSES

In total over 80 written consultation responses were received from the public, local and national organisations. Feedback was constructive and very useful. The range of responses was extensive and the majority could be categorised into themes detailed as:

� Process details such as style, format and approach, some of which could not be considered after the consultation had been conducted, but will be held forconsideration in the development of the next Strategy.

� Focused comments to inform specific chapters.

� Children & Young People comments which will be considered during the development of the Children and Young People’s Plan.

� Links and the importance of cross-referencing between APGs and across agendas was highlighted to ensure improved communication.

� Gaps were highlighted, in particular relating to specific initiatives and services, but it had been agreed that the range of services detailed in the Strategy had to be limited.Others advocated for the inclusion of information and plans on specific areas/medical conditions and treatment, but these suggestions did not fit with the agreed priorities and format of this HSC&WBStrategy.

� Details were requested relating to plans for implementation, finances and workforce.

Information relating to these supporting plans was scheduled for development when the consultation feedback hadbeen considered and would be included in the final Strategy, and further developed during the lifetime of the Strategy.

� Joint planning structures and arrangements The Health Alliance and SCG have considered feedback and committed to reviewing existing partnership arrangements during the first year of the Strategy implementation period.

The responses were collated, analysed and shared across the APGs and groups most appropriate to consider specific comments.The responses were then reviewed and agreement reached by partner representatives as to whether the comments were:

� statements of support, endorsing the planned actions

� useful comments to be incorporated into the relevant chapters

� comments which could not be included in plans as there were currently noidentified resources to facilitate implementation, but the suggestions would be considered during the lifetime of the Strategy

� ideas which were noted but could not feasibly be resourced over the next 3 years, or did not meet agreed local priorities.

All comments received were considered and respondents acknowledged.

FUTURE CONSULTATION

Cardiff LSB has given commitment to establishinga city-wide model of engagement and consultation that is recognised as best practice and to developa new online interface between citizens and publicservice providers. The ‘Ask Cardiff’ project and the bigger companion project ‘Enhanced ConsultationStrategies’ have at their core the development of joint consultation methods, support mechanisms

and guidance for service providers undertakingstatutory or other consultation mechanisms and activities. Future consultation phases arising from the HSC&WB Strategy will utilise the outputs of this work to enhance the approach to consultation and engagement on health, social care and well being planning.

Appendix 2166

A A Acute Care Medical or surgical treatment usually provided in a hospital.

Advisory Planning Groups (APGs)

Sub-groups under the Strategic Commissioning Group that inform the planning for particular client groups or service areas.

Air Quality Management Area

Local authorities are required to assess air quality against national targets and declare Air Quality Management Areas (AQMA) where improvement required.

Annual Operating Framework (AOF)

A framework which sets out the Welsh Assembly Government’s requirements for the NHS to deliver each year.

Artificial Limb and Appliance Service

A service provided in collaboration, by 3 NHS Trusts who run centres providingservices to people who have a permanent or long term impairment, (ALAS).

Ask Cardiff A citizen consultation project of Cardiff Local Service Board.

ASSIST A smoking cessation and health promotion programme for young people.

Asymptomatic Without obvious signs or symptoms of disease.

B B Beecham Review Review of the public sector in Wales, entitled “Beyond Boundaries.”

Big Lottery Fund Allocation National Lottery funds, currently £630m. p.a. for community projects.

British Sign Language(BSL)

UK sign language and the first or preferred language of many deaf or hard ofhearing people.

Bro Morgannwg NHS Trust

The NHS Trust (see below) covering the county boroughs of Neath Port Talbot, Bridgend and the western Vale of Glamorgan.

Building Strong Bridges

An initiative to strengthen partnership working between the voluntary sector and the NHS in Wales.

C C Cardiff Connections Local Service Board operational forum of managers from partner organisations,

which provides project management of agreed work programmes.

Cardiff & Vale NHS Trust

Provides hospital and community health services in Cardiff and the Vale of Glamorgan.

Cardiff Health Alliance The key strategic health partnership and provides the leadership for the development of the Health, Social Care & Well Being Strategy.

Cardiff Health andSocial Care Network

A forum of voluntary organisations, focussed on health and social care, providingopportunities for information exchange and collaboration.

Care Package The service(s) arranged for someone, following assessment.

Care Pathway A planned course through a health/ social care event e.g. illness or operation.

Carer A person providing unpaid care to someone at home who is ill or frail.

Child Poverty Index Calculated on the percentage of children living in households claiming worklessness benefits. Low income is only part of the index of child poverty.

Chronic Disease A long term illness or condition.

Circulatory Disease Disease arising from poor circulation such as coronary heart disease and stroke.

Climbing Higher WAG’s sport and physical activity strategy 2005-2025.

Clinical Governance A national framework through which NHS bodies are accountable for the quality and clinical effectiveness of the services they provide.

Commissioning Processes of planning and delivering health/social care services for people.

Communities First WAG funded initiative for the regeneration of deprived communities.

Community Care The provision of services to enable people to live independently in their own home,or in the community (including residential and nursing homes).

Community Health Council

A statutory body representing the health interests of local people by monitoring the quality of local NHS Services.

Community Oriented Primary Care (COPC)

A systematic approach to health care based on principles derived from best practise that has positive health planning benefits for communities.

Community Safety A statutory partnership working to reduce crime and disorder, increase public

GlossaryGlossary

GlossaryGlossary 167167

Partnership (CSP) reassurance, reduce fear of crime and make Cardiff a safer place.

Community Services Services provided to enable people to live healthy, fulfilled and independent lives, including GP services, district nurses, health visitors, day centres etc.

Community Services Framework

A plan issued in 2007 by WAG setting out the future for Community Services inWales.

Community Strategy Overarching strategy setting out the partnership future vision for a county.

Consultation Process to inform stakeholders of proposals and invite submit comments.

Continuing Care Health and social care that is provided over a long time or for an uncertain period of time. This care can be provided in a variety of settings.

Coronary Heart Disease (CHD)

Narrowing or blockage of the coronary arteries by atheroma, leading to angina, coronary thrombosis or heart attack, heart failure, and/or sudden death.

Cymorth WAG funds to provide targeted support for children and young people to improve the life chances of those from disadvantaged families.

D D Day Care Daytime care usually provided in a centre away from a person’s home.

Designed for Life WAG 10-year vision for health and social care.

Delayed Transfers of Care (DTOC)

When a patient is ready for transfer from hospital but is still occupying a bed. Delay can be due to health/ social care or patient/carer/family-related reasons.

District General Hospital (DGH)

A large hospital treating in-patients, out-patients and day-cases in the general specialties (eg. surgery and medicine) serving an identified local population.

Direct Payments Provides people with the money they need to employ the help to support them at home rather than accept fixed social care services.

Dispersal The relocation of asylum seekers to certain areas around Britain.

Domiciliary Care Services provided to people at home, to assist them live independently. E E

Empower Equipping people with knowledge and skills to enable them to make their own decisions and lifestyle decisions.

Enhanced Services Elements of essential or additional services commissioned and delivered to a higher specification; or medical services outside the normal scope of provision.

Equality Ensuring individuals equal access to service provision by appropriate means.

Equality Impact Assessment (EQIA)

Analysis of a proposed service/strategy to identify the effect on different groups, ensuring that as far as possible, negative consequences are minimised.

Estyn Office of the Chief Inspector of Education and Training, which raises standards and quality of education and training in Wales through inspection and advice.

Ethnic Minority Achievement Service

A learning support service to reduce the level of under-achievement of ethnic minority pupils, (EMAS).

Ethnicity A term which represents social groups with a shared history, sense of identity,geography and cultural roots which may occur despite racial difference.

Evidence–based The systematic analysis of information on the effectiveness of treatment to provide the best approach.

F F Flying Start Funding to work with 0-3 year-olds in disadvantaged school catchment areas. Fulfilled Lives, Supportive Communities

WAG strategy which sets out the role that social services play and proposes a vision for the next 10 years of how health and social services will contribute to a better Wales.

G G Gender The social dimension of being male or female.

General Medical Services (GMS)

Services provided by General Practitioners under national agreements.

General Medical Services contract

Contractual arrangements by which the LHB engages with providers of healthservices (such as doctors) agreeing service provision and costs.

General Practitioner (GP)

A family doctor who works from a local surgery to provide medical advice and treatment to patients registered with them.

Grogan Judgement, 1999

Concerned the assessment criteria used when deciding whether someone satisfied the continuing care criteria for NHS funding.

H H

GlossaryGlossary168168

Health Challenge Wales

WAG focus on better health, encouraging individuals and organisations to take responsibility for health improvement through a co-ordinated approach.

Health Commission Wales

An independent agency, responsible for planning and commissioning specialised health services, such as specialist cancer services and cardiac services.

Health Determinant Factors e.g. fitness, nutrition that impact on health and well being.

Health for All A principle of the World Health Organisation which underpins this strategy.

Health Gain The improvement of the health of the population.

Health Impact Assessment

Analysis of how a proposal will impact on people’s health. Recommends how to ‘increase the positive’ and ‘decrease the negative’ aspects of the proposal.

Health Visitors Health visitors are qualified nurses with specialist training in child health.

Healthy Living Centres BIG lottery-funded programme targeting disadvantaged areas. The centres offer a range of activities/support to the local community.

Healthy Schools A WAG Programme to support schools in providing a healthy environment and promote a co-ordinated approach to health for pupils.

Hear by Right A standards framework for organisations to assess and improve practice and policy on the involvement of children and young people in policy development.

Holistic A philosophy of that takes into account the total needs of service users. I I

Inequalities in Health Differences in health status or access to health services across population groups orgeographical areas.

In-patient Patient who is admitted to a healthcare facility in order to receive healthcare.

Integrated Children’s Centres

A centre-based network of services, which support children and families in ageographical area.

Integrated Health and Social Care

Joint planning and delivery of health and social services (across professions and organisations) to meet people’s needs.

Intermediate Care Services to help maintain people’s independence that act as a bridge between community and hospital services.

J J Joint Commissioning Group

Multi-agency group, which deals with cross-cutting issues in the joint health and social care planning structure.

Joint Funding Where 2 or more partners share the costs of running a project or service.

Joint Planning Structure

The system of committees and sub-groups that plan and monitor service development and delivery.

Joint Working Where 2 or more partners work together to achieve a common goal.

Joint Working Special Grant (JWSG)

Welsh Assembly Government funds to encourage joint working between health and local authorities.

K K Keep Well This Winter (KWTW)

WAG campaign which provides information and support to people aged 65+ to enable them to keep well, warm and safe through the winter.

Key Performance Indicator (KPI)

Quantifiable measurements which help to define and measure progress towards identified goals and the overall performance of an organisation.

L L Language of Choice The language an individual prefers to communicate in.

Leave to Remain The legal status of refugees or asylum seekers whose immigration status allowsthem to stay in the UK.

LGBTG The community of individuals whose sexual orientation is lesbian, gay or bisexualand persons who are transgender.

Limiting Long Term Illness (LLTI)

Any long term illness, health problem or physical or sensory impairment which limits the daily activities or the work a person can do.

Local Authority Elected council, which provides local services e.g. education, housing etc

Local Service Boards Wales' new model of partnership working across pubic services in an area, with the aim of improving services and focussing on citizens' needs (LSBs)

Health Resource & Treatment Centres

New health centres which will provide a range of community health services locally.

Looked After Children Children who are in the care of local authorities either with foster parents or in care


(LAC) homes. They are one of the most vulnerable groups in society.

Low Birth Weight (LBW)

Low birth weight is defined by the World Health Organisation as a birth weight less than 2500 grams.

M M Making the Connections

The Welsh Assembly Government's vision for public services which are citizenfocused, responsive, committed to equality and efficient.

Meeting the Challenge The title of Cardiff’s first Health, Social Care and Well Being Strategy 2005-2008.

Memorandum of Understanding

An agreement, for example between the Local Health Board and the Local Authorityon the protocols for developing the HSC&WB Strategy.

Mental Health Includes acute and chronic conditions, such as schizophrenia and clinical depression, dementia and other mental health problems.

Monitoring To observe and regularly check the progress of a service, project or action plan.

Morbidity An incidence of a particular disease or group of diseases in a given populationduring a specified period of time.

Mortality Incidence of death in a population (usually related to a particular cause and presented as a rate (e.g. per thousand population).

Multi-disciplinary A team which is made up of professionals from different statutory and/or non-statutory organisations, who all have different areas of expertise.

N N National Health Service (NHS)

Publicly funded health care system in the UK.

National Health Service Administrative Register (NHSAR)

A central record of NHS patients registered with a GP.

National Public Health Service (NPHS)

Welsh public health organisation, which includes input from the Public Health Laboratory Service and the Communicable Disease Surveillance Centre.

National Service Frameworks (NSFs)

Evidence based strategies providing national standards of NHS care that patients can expect to receive in major care areas or disease groups.

Needs Assessment The process by which information is collated to assess the health of a population group and determine what services are necessary to meet that need.

NEET Children The proportion of 16-18 year-olds not in education, employment or training.

NHS Trust A statutory body that provides NHS services – including acute services, mentalhealth services, secondary services, tertiary services.

NICE Guidelines National guidance by the National Institute for Clinical Excellence on promoting good health and preventing and treating ill health.

NOMS The National Offender Management Service provides correctional services and commissions interventions to protect the public and reduce re-offending.

Nutrition Network for Wales (NNW)

A forum for those involved in improving diet and nutrition in Wales, providing access to information, knowledge sharing and good practice.

O O Obesity Excess of body fat that can result in a significant impairment of health.

Ottawa Charter (World Health Organisation)

Statement of fundamental conditions and resources required for health such as shelter, education, food, income etc and that improvement in health requires a secure foundation in these basic prerequisites.

Out of Area Placements

When service users are placed outside their local area to receive a specialist service.

P P Participation The involvement of citizens in governmental decision-making processes.

Person Centred Planning

A process of life planning for individuals, based around the principles of inclusion and the social model of disability.

Physical Education and School Sport

WAG initiative aimed at raising standards in physical education and school sport and to promote an active and healthy lifestyle. (PESS)

Physical Activity Network for Wales

A forum for those involved in improving levels of physical activity in Wales, providing access to information, knowledge sharing and good practice (PANW)

Procedure of Co-operation

An agreement between partners to work together, for example between the Health Alliance and partners on developing the HSC&WB Strategy.


Primary Care Family health services provided by doctors, dentists, pharmacists, optometrists and ophthalmic medical practitioners.

Programme for Health Service Improvement

A plan by Cardiff and Vale NHS Trust and partners setting out how it will respond to‘Designed for Life,’ and deliver improved and efficient health services. (PHSI)

Protection of Vulnerable Adults

A multi-agency policy and procedure which investigates and addresses allegations ofphysical or psychological abuse of vulnerable adults (POVA).

Proud Capital The title of Cardiff’s Community Strategy 2007-2017.

Proud Capital Vision Forum

The strategic partnership for Cardiff, which oversees the Community Strategy development and implementation plan.

Providers Any person, group or organisation supplying a care service. R R

Race A human population considered distinct based on physical characteristics.

Re-ablement The development of alternative ways of carrying out daily activities e.g. washing, dressing and cooking, following an event such as a stroke or an accident.

Religion & Belief A set of common beliefs and practices generally held by a group of people.

Repatriation To return service users who had to live outside their local area to receive specialist services, back to their local community where possible.

Respite A short break away, providing ‘time off’ for a carer, to support carers to continuetheir caring role.

Ring-fenced Money that is set aside for a particular purpose e.g. Carers. S S

Secondary Care Health care that is normally provided within a hospital setting.

Service and Financial Frameworks (SaFFs)

A financial statement produced by Local Health Boards and NHS Trusts, which sets out their targets and resources for the financial year.

Service Level Agreement (SLA)

Agreement between organisations setting out what services will be provided and the agreed remuneration level.

Service Reconfiguration

Identifies how health services will be changed.

Service User Someone who uses voluntary or statutory services.

Service User Reference Panel

Forum of service users and involvement/participation officers which inform the various Advisory Planning Groups (SURP).

Sexual Orientation A combination of emotional, romantic, sexual or affectionate attraction to another person of the same, opposite sex or both sexes.

Smoke Free Cardiff A Cardiff strategy to implement smoking prevention, cessation and protection.

Social Care Services Services provided or purchased by local councils to their residents.

Social Exclusion A term describing when people or areas suffer a combination of problems such as unemployment, poor housing, high crime environments and poor health.

Social Inclusion The term used as the reverse of the above.

Socio Economic Deprivation

Social and economic factors that cause poverty. Some of these factors, such as unemployment, are also determinants of health.

Special Educational Needs (SEN)

Children who have learning difficulties or physical and sensory impairments that make it harder for them to learn or access education than most children.

Stakeholders Anyone with an interest/involvement in a specific service/project.

Statement of Special Educational Needs

The document that sets out a child’s needs for additional education support and the special help required to meet those needs.

Statutory Authority An organisation that is required to exist by law.

Statutory Duties The functions and responsibilities laid out in legislation for statutory bodies.

Strategic Commissioning Group(SCG)

Partnership forum which informs joint working in health and social care and directs the development of the Health, Social Care and Well Being Strategy in Cardiff.

Strategic Environmental Assessment (SEA)

A process to ensure that significant environmental effects arising from policies, plans and programmes are identified, assessed, mitigated, communicated todecision-makers, and monitored.

Strategic Outline Programme

A plan which described how services are to be developed, modernised or reconfigured.


Substance Misuse Misuse of drugs, alcohol or prescription medication which causes harm to the individual, their families or their community.

Super Output Areas (SOAs)

A new geographic hierarchy designed to improve the reporting of small areastatistics in England and Wales and used in the census.

Supporting People WAG programme and funding stream for the development of housing-related support services.

Sure Start A national initiative, which aims to give children the best possible start in life by.

Sustainability Appraisals (SAs)

A process to promote sustainable development into the preparation of revisions ofstrategic plans.

T T Telecare Technologies such as sensors placed in the home, providing links to emergency

response, which enable an individual to live independently in their own home.

Telemedicine The use of communication systems to provide remote diagnosis and healthcare.

Tertiary (Care) Services

Care of a highly specialised nature, typically provided as an in-patient in a centre of excellence. Referrals are normally made by other secondary care providers.

Townsend Index of Deprivation

An index devised to provide a material measure of deprivation and disadvantage.

TOPSHAPE A therapy options pilot project for primary care mental health services.

Transitional Care The transfer of an individual’s care from one service to another, for example from children’s services to adult services.

Travellers Education Service (TES)

A learning support service which works in partnership with schools to reduce the level of under-achievement of traveller pupils.

U U Unified Assessment Standardised assessment process to ensure service users receive appropriate,

effective and timely responses to their health and social care needs. V V

Velindre NHS Trust NHS Trust, which provides specialist services at local and all Wales levels. Voluntary Action Cardiff

The County Voluntary Council for Cardiff which supports a wide range of voluntaryorganisations.

Voluntary Sector Organisations, which operate on a non-profit making basis, to provide help and support to the group of people they exist to serve.

Voluntary Sector Compact

The compact is an agreement that sets out arrangements for joint working between the local voluntary sector, Cardiff Council and the local NHS.

Vulnerable Adult A person aged 18 years or over, in receipt or need of community care services and who may be unable to take care of him or herself.

W W Wanless Review A review of health and social care in Wales by Derek Wanless in 2003.

Welsh Ambulance Services NHS Trust

Wales-wide Trust which provides ambulance services.

Welsh Assembly Government (WAG)

The Welsh Assembly Government is the devolved government for Wales, with responsibility for issues including health, education, economic development etc.

Welsh Index of Multiple Deprivation (WIMD)

A measure of multiple deprivation across Wales. The index allows comparison between the 865 Welsh electoral divisions using the overall index or separate domains of income, employment, health, education, housing and access.

Welsh Health Survey A self-completion survey of health in Wales about use of health services, illnesses, general health and well being, smoking, alcohol, fruit and vegetables, exercise etc.

Welsh Local Government Association (WLGA)

The WLGA represents the interests of the 22 local authorities in Wales. It promotes local democracy and retains full autonomy in dealing with Welsh affairs.

World Health Organisation (WHO)

WHO is the directing and co-ordinating authority for health within the United Nations system.

Y Y Youth Congress An annual event in Cardiff for young people to comment on relevant issues.

Z Z Zipper Model A model for the integration of sexual health services in Cardiff.


STATUTORY INSTRUMENTS & LEGISLATION Asylum Immigration (Treatment of claimants etc) Act 2004 Caravan Sites Act 1968 Care Standards Act 2000Carers (Equal Opportunities) Act 2004 Carers and Disabled Children Act 2000 Children Act 2004 Children and Young Persons (Sale of Tobacco etc.) Order 2007 Community Care (Direct Payments) Act 1996 Disability Discrimination Act 1995 (Amendment) Regulations 2007 Disability Rights Commission Act 1999 Education Act 1996 Health Act 2006 Health Social Care and Well Being Strategies (Wales) (Amendment) Regulations 2007 Health Social Care and Well Being Strategies (Wales) Regulations 2003 Homelessness Act 2002 Homeless Persons (Priority Need) (Wales) Order 2001 Housing Act 2004 Housing Grants and Regeneration Act 1996 Human Rights Act 1998 ‘Iaith Pawb’ A National Action Plan for a Bilingual Wales2003 Immigration and Asylum Act 1999 Immigration, Asylum and Nationality Act 2006 Mental Capacity Act 2005 Mental Health Act 2007 Mental Health Act 1983 National Health Service (Wales) Act 2006 Nationality, Immigration and Asylum Act 2002 NHS and Community Care Act 1990One Wales 2007 Race Relations Act 1976 (Amendment) Regulations 2003 Race Relations (Amendment) Act 2000 Sex Discrimination Act 1975 (Amendment) Regulations 2003Smoke-free Premises etc. (Wales) Regulations 2007 Welsh Language Act 1993

OVERARCHING STRATEGIES AND PLANS FOR CARDIFF Cardiff Community Safety Partnership (2005) ‘Community Safety Strategy 2005-2008’ ‘Cardiff – A Proud Capital: Cardiff Community Strategy 2007-2017’ Cardiff Council (2007) ‘Neighbourhood Improvement Programme’ Cardiff Council (2007) ‘Competitive Cardiff – Cardiff Economic Strategy 2007-2012’ Cardiff Council (2007) ‘Local Housing Strategy 2007-2012’ Cardiff Council (2007) ‘Schools and Lifelong Learning Service Business Plan 2007-2010’ Cardiff Council (2006) ‘Cardiff’s Ecological Footprint’

Policy framework & references

Policy framework & references 173

Cardiff Council (2006) ‘Neighbourhood Renewal Schemes Programmes Review 2006-2007’ Cardiff Council (2006) ‘Supporting People Operational Plan 2006-2007’ Cardiff Council (2003) ‘Unitary Development Plan to 2016’ Cardiff Council (2000) ‘Local Transport Plan 2000-2016’ Cardiff Council (2007) ‘Draft Local Development Plan 2007’ Cardiff Council ‘Welsh Language Scheme 2006-2009’ Cardiff Local Health Board ‘Welsh Language Scheme 2003’ Cardiff Voluntary Sector ‘COMPACT Action Plan 2006-2008’

EQUALITY Cardiff and Vale NHS Trust (2006) ‘Disability and Gender Equality Scheme 2006-2009’ Cardiff and Vale NHS Trust (2005) ‘Race Equality Scheme 2005-2008’ Cardiff Council (2007) ‘Draft Gender Equality Scheme and Action Plan 2007-2010’ Cardiff Council (2007) ‘Disability Equality SchemeCardiff Council (2006) ‘Revised Race Equality Scheme’ Cardiff Council (2004) ‘Minority Ethnic Housing Strategy 2004-2009’ Cardiff Health Alliance (2004) ‘Language and Communication Strategy‘ Cardiff Local Health Board (2007) ‘Disability Equality Scheme’ Cardiff Local Health Board (2005) ‘Race Equality Scheme 2005-2008’

HEALTH, SOCIAL CARE AND WELL BEING – WALES / UK & WORLDWIDE Department for Environment, Food and Rural Affairs (2007) ‘Air Quality Strategy for England, Scotland, Wales and Northern Ireland’

Department of Health (2004) ‘The General Medical Services Contract‘ Townsend, P. (2001) ‘Targeting Poor Health: Wales NHS Resource Allocation Reviews’ Welsh Assembly Government (2007) ‘Local Service Boards / Local Service Agreements – Consultation Paper’ Welsh Assembly Government (2007) ‘Fulfilled Lives Supportive Communities: a Strategy for Social Service Over the Next Decade’ Welsh Assembly Government (2007) ‘The Community Services Framework’ Welsh Assembly Government (2007) ‘Communities First Guidance 2007’Welsh Assembly Government (2006) ‘Beyond Boundaries: Citizen-Centred Local Services for Wales’ Welsh Assembly Government (2006) ‘Delivering Beyond Boundaries: Transforming Public Services in Wales’ Welsh Assembly Government (2006) ‘Making the Connections Delivering Beyond Boundaries: Transforming Public Services in Wales’Welsh Assembly Government (2006) ‘Cost and Benefits of the Supporting People Programme’ Welsh Assembly Government (2005) ‘Inequalities in Health: The Welsh Dimension 2002-2005’ Welsh Assembly Government (2005) ‘Designed for Life: Creating World Class Health and Social Care for Wales in the 21st Century’ Welsh Assembly Government (2005) ‘Delivering the Connections: From Vision to Action - Our 5 Year Action Plan for delivering better services in Wales’ Welsh Assembly Government (2004) ‘Health Challenge Wales’ Welsh Assembly Government (2004) ‘Making the Connections: Delivering Better Services in Wales Beecham Review’

Policy framework & references174

Welsh Assembly Government (2003) ‘Wales: A Better Country - The Strategic Agenda of the Welsh Assembly Government’ Welsh Assembly Government (2002) ‘Well Being in Wales’

Welsh Assembly Government (2001) ‘Improving Health in Wales – A Plan for the NHS and its Partners’ Welsh Office (1998) ‘Better Health, Better Wales‘ World Health Organisation (1999) ‘The Health for All Policy Framework for WHO European Region’ World Health Organisation (1986) ‘Ottawa Charter for Health Promotion’

HEALTH, SOCIAL CARE AND WELL BEING – CARDIFF Cardiff Council (2007) ‘Cardiff – A Proud Capital: Cardiff Community Strategy 2007-2017’ Cardiff Council (2006) ‘Supporting People Operational Plan 2006-2007’ Cardiff Health Alliance (2005) ‘Meeting the Challenge: Cardiff Health Social Care and Well Being Strategy 2005-2008’ Cardiff Health Alliance (2004) ‘Cardiff Health, Social Care and Well Being Needs Assessment‘ Cardiff Health Alliance (2002) ‘Cardiff Community Profile‘ Cardiff Local Health Board (2004) ‘Wanless Local Action Plan for Cardiff’ Voluntary Action Cardiff (2007) ‘Need We Say More: Health Social Care and Well Being Consultation Even Report’ Voluntary Action Cardiff (2006) ‘Building Strong Bridges Action Plan 2006-2007’

‘A TALE OF TWO CITIES’ THE CARDIFF NEEDS ASSESSMENT Annual Population Survey 2006 ONS Cardiff Health Alliance (2002) ‘Cardiff Community Profile’ NHS Wales (2005) ‘Administrative Register NHSAR’ Townsend, P. (2001) ‘Targeting Poor Health: Wales NHS Resource Allocation Reviews’ Welsh Assembly Government (2007) Welsh Health Survey 2006-2006 Welsh Assembly Government (2005) ‘Welsh Index of Multiple Deprivation’ Welsh Assembly Government (2005) ‘Inequalities in Health: The Welsh Dimension 2002-2005’

PROMOTING AND IMPROVING THE HEALTH OF THE POPULATION OF CARDIFFAlcohol Concern (2006) ‘Wasted: Lives Lost due to Alcohol’ Alcohol Concern (2006) ‘Health Impacts of Alcohol: Factsheet’ Allender S., Peto V., Scarborough P., Boxer A., Rayner M. (2006) ’Diet, physical activity and obesity statistics’. British Heart Foundation: London Cardiff Health Alliance (2006) ‘Cardiff Smoke Free Strategy 2006-2008’ Cardiff Health Alliance (2006) ‘Cardiff Food and Health Strategy‘ Cardiff Health Alliance (to be published 2008) ‘Cardiff Physical Activity Strategy’

Cardiff Health Alliance (2004) ‘Cardiff Physical Activity Framework’ Directors of Public Protection for Wales (2006) ‘Addressing Alcohol Misuse Issues’ Food Standards Agency (2003) ‘Food and Well Being: Reducing inequalities through a nutrition strategy for Wales‘ Foresight (2007) ‘Tackling Obesities: Future Choices’ Government Office for Science, UK


National Institute for Health and Clinical Excellence (2006) ‘Quick Reference Guide 1: Obesity-guidance on the prevention, identification, assessment and management of overweight andobesity in adults and children: For Local Authorities, Schools and Early Years Providers, Workplaces and the Public’ National Institute for Health and Clinical Excellence (2006) ‘Quick Reference Guide 2: Obesity-guidance on the prevention, identification, assessment and management of overweight andobesity in adults and children: For the NHS’ Peto, R., Lopez A. D., Boreham J., and Thun M. (2003) ‘Mortality from Smoking in Developed Countries’ 2nd ed: Oxford University Press Price T. (2006) ‘National Public Health Service for Wales: Health Needs Assessment 2006: Smoking (Tobacco Use)’ Royal College of Physicians of London (2002) ‘Nicotine Addiction in Britain’, RCPL Smoke-free Premises etc. (Wales) Regulations 2007 The Children & Young Persons (Sale of Tobacco etc.) Order 2007 Ward M. & Aitken S. (2007) ‘National Public Health Service for Wales: Tackling Obesity in Wales: The Current Situation’ Welsh Assembly Government (2007) ‘Alcohol Prevention Policy’ [Cabinet Paper CAB (06-07)71]Welsh Assembly Government (2007) ‘Alco Facts – a guide to sensible drinking’Welsh Assembly Government (2006) ‘Climbing Higher – Next Steps’ Welsh Assembly Government (2003) ‘Climbing Higher’ World Health Organisation (2007) ‘The Challenge of Obesity in the WHO European Region and the Strategies for Response’ World Health Organization (2006) ‘European Charter on Counteracting Obesity’, European Ministerial Conference on Counteracting Obesity 15-17th Nov. 2006

PROGRAMME FOR HEALTH SERVICE IMPROVEMENT Cardiff and Vale Trust (2006) ‘Programme for Health Service Improvement in Cardiff and the Vale of Glamorgan: The Case for Change’Cardiff and Vale Trust (2006) ‘Programme for Health Service Improvement for Cardiff and the Vale of Glamorgan: Strategic Outline Programme’

Cardiff & Vale Trust (2006) ‘Programme for Health Service Improvement for Cardiff and the Vale: Full Technical Plan’ National Public Health Service for Wales (2006) ‘Health Needs Assessment’ NHS Wales (2006) ‘Reshaping your local Health Services: Developing a Plan for South East Wales’ NHS Wales (2005) ‘Access 2009: Waiting Time Targets for Wales’ Townsend, P. (2001) ‘Targeting Poor Health: Wales NHS Resource Allocation Reviews’ Velindre NHS Trust (2007) ‘Capital Programme Implementation Plan’ Wanless, D. (2003) ‘The Review of Health and Social Care in Wales’ Welsh Assembly Government (2006) ‘NHS Wales: Annual Operating Framework 2007-2008’

CHILDREN AND YOUNG PEOPLE Cardiff Council (to be published 2008) ‘Children and Young People’s Plan’ Welsh Assembly Government (2007) ‘Shared Planning for Better Outcomes: Planning Guidance and Regulations for Local Authorities and their Partners on Children and Young People’s Plans’ Welsh Assembly Government (2007) ‘National Youth Service Strategy for Wales’ Welsh Assembly Government (2006) ‘Children and Young People: Rights to Action – Stronger Partnerships foe Better Outcomes’


Welsh Assembly Government (2005) ‘Extending Entitlement – Working Together to Provide Young People’s Entitlements’ Welsh Assembly Government (2005) ‘National Service Framework for Children, Young People and Maternity Services’ Welsh Assembly Government (2002) ‘Children and Young People: Rights to Action’

MENTAL HEALTH Cardiff and the Vale Development Project (2007) ‘Online Directory of Services’ Cardiff and Vale Trust (2006) ‘Strategic Outline Programme for Mental Health Service Development’ Cardiff Council (2006) ‘Supporting People Operational Plan 2006-2007’ Cardiff Health Alliance (2007) ‘Cardiff Mental Health Promotion Action Plan 2007-2008’ Cardiff Local Health Board (2007) ‘Draft Adult Mental Health Race Equality Action Plan’ Cardiff Local Public Health Team (2007) ‘Report on the Delivery of Cardiff’s Mental Health Promotion Action Plan: Autumn 2003-Spring 2007’ Welsh Assembly Government (2006) ‘Mental Health Carers Grant Scheme: 2007-2008 Guidance’ Welsh Assembly Government (2006) ‘Adult Mental Health Services: Raising the Standards - Race Equality Action Plans for Adult Mental Health Services in Wales’ Welsh Assembly Government (2006) ‘Mental Health Promotion Action Plan for Wales: Consultation Document’ Welsh Assembly Government (2006) ‘Adult Mental Health Care in Primary Healthcare Settings inWales: Policy Implementation Guidance’ Welsh Assembly Government (2006) ‘National Service Framework for Older People in Wales’ Welsh Assembly Government (2005) ‘Adult Mental Health Services: Raising the Standard - The Revised National Service Framework for adult mental health services in Wales’ Welsh Assembly Government (2004) ‘Adult Mental Health Services: Stronger in Partnership - Involving Service Users and Carers in the Design, Delivery, Planning and Evaluation of Mental Health Services’ Welsh Assembly Government (2001) ‘Adult Mental Health Services: Equity, Empowerment, Effectiveness, Efficiency’

OLDER PEOPLE Age Concern (2007) ‘AgeWise+ Directory for Services for Older People’ Cardiff and Vale Mental Health Development Project (2007) ‘Directions: a Guide to Older People’s Mental Health’ Cardiff Carers Forum (in partnership with statutory agencies) (2002) ‘Cardiff Carers Plan: Improving the Quality of Carer’s Lives’ Cardiff Council (to be published 2008) ‘Older People’s Strategy’ Cardiff Council (to be published 2008) ‘Commissioning Strategy for Older People’s Accommodation’ Cardiff Council (2006) ‘Supporting People Operational Plan 2006-2007’ Cardiff Council (2006) ‘Population Trends and Projections for Post Retirement Age Groups in Cardiff from 1989 to 2019’ Cardiff Council & Cardiff Local Health Board (2005) ‘Joint Commissioning Strategy for Older People’ Cardiff Health Alliance (2007) ‘Cardiff Ageing Well Action Plan’Department of Health (2003) ‘Fair Access to Care: guidance on eligibility criteria for adult social care’


Department of Health (2003) ‘National Minimum Standards for Care Homes for Older People‘ Welsh Assembly Government (2006) ‘National Service Framework for Older People in Wales’ Welsh Assembly Government (2006) ‘Further Advice to the NHS and Local Authorities onContinuing NHS Health Care’ Welsh Assembly Government (2005) ‘Healthy Ageing Action Plan for Wales: a response to Health Challenge Wales’ Welsh Assembly Government (2003) ‘The Strategy for Older People in Wales’

PHYSICAL DISABILITY & SENSORY IMPAIRMENT Association of Directors of Social Services (2002) ‘Progress in Sight: National Standard of Social Care for Visually Impaired Adults’ Association of Directors of Social Services and the Welsh Assembly Government (2007) ‘Hearing Impaired Benchmarking Study’ Association of Directors of Social Services and the Welsh Assembly Government (2006) ‘Visual Impairment Benchmarking Study’ Cardiff Carers Forum (in partnership with statutory agencies) (2002) ‘Cardiff Carers Plan: Improving the Quality of Carer’s Lives’ Cardiff Council (2007) ‘Disability Equality Scheme 2007-2010Cardiff Council (2006) ‘Supporting People Operational Plan 2006-2007’ Cardiff Council and Local Health Board (2007) ‘Draft Cardiff Joint Commissioning Strategy for Sensory Impairment 2007-2010’ Cardiff Council & Cardiff Local Health Board (2005) Joint Commissioning Strategy for People with Physical Disabilities 2005-2008’ Welsh Assembly Government (2007) Designed to Improve health and the Management of Chronic Conditions in Wales Welsh Assembly Government (2006) ‘Further Advice to the NHS and Local Authorities onContinuing NHS Health Care’ Welsh Assembly Government (2004) ‘Low Vision Initiative’Welsh Assembly Government (2004) ‘NHS Responsibilities for Meeting Continuing Care Needs: Guidance’

LEARNING DISABILITY Association of Directors of Social Services (2005) ‘Pressures on Learning Disability Services: the Case for Review by Government of Current Funding’ Cardiff and the Vale Parents Federation (2006) ‘Where You Stand’ Cardiff Carers Forum (in partnership with statutory agencies) (2002) ‘Cardiff Carers Plan: Improving the Quality of Carer’s Lives’ Cardiff Council (2007) ‘Disability Equality Scheme 2007-2010Cardiff Council & Cardiff Local Health Board (2005) Joint Commissioning Strategy for People with Learning Disabilities 2005-2008’ Disability Rights Commission (2007) ‘EEqquuaall TTrreeaattmmeenntt:: CClloossiinngg tthhee GGaapp -- OOnnee YYeeaarr OOnn -- Report ofthe Reconvened Formal Inquiry Panel of the DRC’s Formal Investigation into the inequalities inphysical health experienced by people with mental health problems and learning disabilities’South East Wales Learning Disabilities Partnership Board (2005) ‘Closer to Home – The Next Steps’ Welsh Assembly Government (2007) ‘Autistic Spectrum Disorder (ASD) Strategic Action Plan forWales: Consultation Document’ Welsh Assembly Government (2007) ‘Statement on policy and practice for Adults with a Learning Disability’


Welsh Assembly Government (2006) ‘Further Advice to the NHS and Local Authorities onContinuing NHS Health Care’ Welsh Assembly Government (2004) ‘Learning Disability Strategy: Section 7 Guidance on Service Principles and Service Resources’ Welsh Assembly Government (1983) ‘All Wales Strategy for the Development of Services for Mentally Handicapped People’

CARERS Cardiff Carers Forum (in partnership with statutory agencies) (2002) ‘Cardiff Carers Plan: Improving the Quality of Carer’s Lives’ Cardiff Young People’s Partnership (to be launched 2007) ‘Young Carers Strategy’ Wales Carers Alliance (2007) ‘A Fair Deal for Carers: The Carers Manifesto for 2007’ Welsh Assembly Government (2007) ‘Carers Strategy for Wales: Action Plan 2007’

Welsh Assembly Government (2006) ‘Mental Health Carers Grant Scheme: 2007-2008 Guidance’

Welsh Assembly Government (2006) Carers’ Strategy in Wales: Implementation Plan’

Welsh Assembly Government (2003) ‘Challenging the Myth: they Look After Their Own – Black and Minority Ethnic (BME) Carers’

SEXUAL HEALTH Jeal, N. (2006) ‘Integration of Sexual Health Services in Cardiff & Vale’ National Assembly for Wales (2002) ‘Sex and Relationships Education in Schools: Circular 11/02’ National Assembly for Wales (2000) ‘Strategic Framework for Promoting Sexual Health in Wales’ Welsh Assembly Government (2007) ‘Draft Quality Requirements for Sexual Health Services inWales: Consultation Document’ Welsh Consumer Council (2006) ‘Sexual Health and Young People: Reducing Barriers to Services’

PRISON HEALTH British Medical Association (2007) ‘Prison Medical Services: Ensuring a Future for Services in Wales’ Bro Taf Health Authority and HMP Cardiff (2001) ‘Health Needs Assessment’ Cardiff Health Care Prison Partnership Board (2005) ‘Health Care Delivery Plan for HMP Cardiff’ HM Prison Service (2003) ‘Prison Service Order 3200 – Health Promotion’ National Offender Management Service (2006) ‘Joining Together in Wales: An Adult and Young People’s Strategy to Reduce Re-offending’ World Health Organisation (1995) ‘Health in Prisons Project’

SUBSTANCE MISUSE Cardiff Community Safety Partnership (2005) ‘Cardiff Substance Misuse Action Plan 2005-2008’ Welsh Assembly Government (2007) Working Together to Reduce Harm - The Substance Misuse Strategy for Wales 2008-2018: Consultation Document Welsh Assembly Government (2007) ‘Substance Misuse Treatment Good Practice Framework for the provision of Substance Misuse Services to Homeless People and those with Accommodation Problems’ Welsh Assembly Government (2006) ‘Key Performance Indicators for Substance Misuse Treatment Services in Wales’ Welsh Assembly Government (2005) ‘Guidance on Developing Local Confidential Reviews into Drug Related Deaths in Wales’ Welsh Assembly Government (2005) ‘All Wales Training Needs Analysis’


Welsh Assembly Government (2005) ‘Framework Guidance for Community Safety Partnerships to Commission Substance Misuse Services’ Welsh Assembly Government (2005) ‘Substance Misuse Treatment Framework for ResidentialRehabilitation’ Welsh Assembly Government (2005) ‘Substance Misuse Treatment Framework for Community Prescribing’ Welsh Assembly Government (2005) ‘Substance Misuse Treatment Framework for Inpatient Treatment’ Welsh Assembly Government (2005) ‘Substance Misuse Treatment Framework to Meet the Needs of People with Co-occurring Substance Misuse and Mental Health Problems’ Welsh Assembly Government (2005) ‘Needle Exchange Service Framework’ Welsh Assembly Government (2005) ‘Substance Misuse Treatment Framework for Psychological Therapy and Psychosocial Interventions in the Treatment of Substance Misuse’ Welsh Assembly Government (2000) ‘Tackling Substance Misuse in Wales: a Partnership Approach’ Welsh Assembly Government (2008) ‘Working Together to Reduce Harm: The Substance Misuse Strategy for Wales 2008-2018’

HOMELESSNESS Cardiff Council (2007) ‘Draft Local Housing Strategy 2007-2012’ Cardiff Council (2006) ‘Supporting People Operational Plan 2006-2007’ Cardiff Council (2004) ‘Cardiff Local Housing Strategy 2004-2009’ Cardiff Council (2004) ‘Minority Ethnic Housing Strategy 2004-2009’ Cardiff Council (2003) ‘Cardiff Homelessness Strategy 2003-2008’ Gale, A. (2007) ‘Report to City and County of Cardiff Council: Tackling Homelessness – A Review of Cardiff’s Homelessness Service’ Shelter Cymru (2007) ‘People and Homes: The Commission of Enquiry into Homelessness and Poor Housing Conditions in Wales’ Welsh Assembly Government (2007) ‘Improving the Health of Homeless and Specific Vulnerable Groups Standards 2008/09: Consultation Document’ Wales Audit Office (2007) ‘Tackling Homelessness in Wales: A Review of the Effectiveness of the National Homelessness Strategy’ Welsh Assembly Government (2007) ‘Substance Misuse Treatment Good Practice Framework for the provision of Substance Misuse Services to Homeless People and those with Accommodation Problems’ Welsh Assembly Government (2005) ‘National Homelessness Strategy for Wales 2006-2008’ Welsh Assembly Government (2005) ‘Tackling Domestic Abuse: the All Wales National Strategy, a Joint Approach’

ASYLUM SEEKERS & REFUGEES Borders and Immigration Agency (2006) ‘The New Asylum Model: Swifter Decisions – Faster Removals’ Cardiff Council (2006) ‘Revised Race Equality Scheme’ Cardiff Council (2006) ‘Supporting People Operational Plan 2006-2007’ Cardiff Council (2004) ‘Minority Ethnic Housing Strategy 2004-2009’ Home Office (2005) ‘Controlling Our Borders: Making Migration Work for Britain - Five Year Strategy for Asylum and Immigration’Welsh Assembly Government (2007) ‘Improving the Health of Homeless and Specific Vulnerable Groups Standards 2008/09: Consultation Document’


Welsh Assembly Government (2006) ‘Refugee Inclusion Strategy’ Welsh Assembly Government (2006) ‘Refugee Housing Action Plan’ Welsh Assembly Government (2006) ‘Health ASERT Programme: Enhancing the Health Promotion Evidence Base on Minority Ethnic Groups, Refugees/Asylum Seekers and Gypsy/Travellers – AReview of the Literature on the Health Beliefs, Health Status, and Use of Services in the Minority Ethnic Group Population and of Appropriate Health and Social Care Interventions’ Welsh Assembly Government (2006) ‘Health ASERT Programme: Enhancing the Health Promotion Evidence Base on Minority Ethnic Groups, Refugees/Asylum Seekers and Gypsy/Travellers – AReview of the Literature on the Health Beliefs, Health Status, and Use of Services in the Refugee and Asylum Seeker Population and of Appropriate Health and Social Care Interventions’

GYPSIES AND TRAVELLERS Cardiff Council (2007) ‘Draft Local Housing Strategy 2007-2012’ Cardiff Council (2006) ‘Supporting People Operational Plan 2006-2007’ Cardiff Council (2006) ‘Traveller Educations Service Business Plan 2006-2009’ Cardiff Council (2006) ‘Revised Race Equality Scheme’ Cardiff Council (2004) ‘Cardiff Local Housing Strategy 2004-2009’ Cardiff Council (2004) ‘Minority Ethnic Housing Strategy 2004-2009’ Cardiff Council (2003) ‘Cardiff Homelessness Strategy 2003-2008 Niner, P. (2006) ‘Accommodation Needs of Gypsy-Travellers in Wales: Report to the Welsh Assembly Government’ Welsh Assembly Government (2007) ‘Improving the Health of Homeless and Specific Vulnerable Groups Standards 2008/09: Consultation Document’ Welsh Assembly Government (2007) ‘Gypsy Traveller Sites Refurbishment Grant 2007-2008 Guidance Notes’ Welsh Assembly Government (2007) ‘Draft Circular – Planning for Gypsy and Travellers Caravan Sites’ Welsh Assembly Government (2006) ‘Health ASERT Programme: Enhancing the Health Promotion Evidence Base on Minority Ethnic Groups, Refugees/Asylum Seekers and Gypsy/Travellers – AReview of the Literature on the Health Beliefs, Health Status, and Use of Services in the Minority Ethnic Group Population and of Appropriate Health and Social Care Interventions’ Welsh Assembly Government (2005) ‘Health ASERT Programme: Enhancing the Health Promotion Evidence Base on Minority Ethnic Groups, Refugees/Asylum Seekers and Gypsy/Travellers – AReview of the Literature on the Health Beliefs, Health Status, and Use of Services in the Gypsy/Traveller Population and of Appropriate Health Care Interventions’


Figure 1.1 Cardiff – geographical areas 5

Figure 1.2 Local strategic planning framework 6

Figure 1.3 Proud capital vision – Cardiff community strategy 9

Figure 1.4 Cardiff local service board structure and the ‘Cardiff connections programme’ 15

Figure 2.1 Current population in Cardiff’s electoral divisions 19

Figure 2.2 Population density (persons per square hectare) by LSOA: 2001 19

Figure 2.3 Cardiff population age structure in 2005 20

Figure 2.4 Cathays MSOA population age structure from 2004 experimental MYE 20

Figure 2.5 Pontprennau MSOA population age structure from 2004 experimental MYE 21

Figure 2.6 Lisvane MSOA population age structure from 2004 experimental MYE 21

Figure 2.7 Proportion of population aged 0-24 by middle super output area (MSOA): 2003 22

Figure 2.8 Ethnicity within Cardiff’s electoral divisions 23

Figure 2.9 Townsend deprivation score fifth by electoral division: 2000 24

Figure 2.10 Percentage of singleton live born babies with low birth weight: 2002-2004 25

Figure 2.11 Percentage of children aged under 16 living in households dependent on worklessness benefits: 2005 26

Figure 2.12 Percentage of children aged 0-15 in households dependant upon workless benefits across Wales 26

Figure 2.13 European age standardised mortality rates for all causes: 2000-2004 27

Figure 2.14 European age standardised mortality rates for coronary heart disease: 2000-2004 28

Figure 2.15 European age standardised mortality rates for Cerebrovascular disease: 2000-2004 28

Figure 2.16 European age standardised mortality rates for respiratory: 2000-2004 29

Figure 2.17 WASR per 100,000 population all malignancies excl NMSC (male) 30

Figure 2.18 WASR per 100,000 population all malignancies excl NMSC (female) 31

Figure 2.19 European age standardised mortality rates for injuries: 1996-2004 31

Figure 7.1 Projected changes in total persons in Cardiff from 2004 to 2019 67

Figure 7.2 Proportion of population aged 65 and over by MSOA: 2003 68

Figure 7.3 Percentage of people with long-term illness 72

Figure 7.4 Percentage of people with severe disability 72

Figure 9.1 Learning disability population 2005 86

Figure 12.1 Types of offences committed by HMP Cardiff prisoners 2006 102

Figure 12.2 Prevalence of neurotic disorders among a predominantly young male prison population 107

Figure 12.3 Country of origin of prisoners 109

Figure 13.1 Adults who reported binge drinking on at least one day in the past week 2003/05 114

Figure 13.2 Methadone & Buprenorphine prescribing by GPs in Wales 115

Figure 14.1 Number of households requesting assistance by priority category 119

Figure 15.1 Number of asylum seekers dispersed in Wales July 2007 125

Figure 15.2 Top 8 nationalities of asylum seekers in Cardiff July 2007 126

Figure 15.3 Overall dispersal of asylum seekers and refugees within Cardiff July 2007 127

Figure 17.1 Cardiff LHB expenditure 2005-08 141

Figure 17.2 Breakdown of LHB expenditure 2005-08 141

Figure 17.3 LHB expenditure on Mental Health services 2005-08 142

Figure 17.4 Cardiff LHB Budget 2008-09 144

Figure 17.5 National Finance Agreement relating to HCHS 145

Figure 17.6 Cardiff LHB Loan Repayment Costs 2008-11 145

Figure 17.7 Cardiff Council Expenditure on Social Care 2005-08 146

Figure 17.8 Cardiff Council Social Care Budget 2007-08 147

Figure 17.9 Breakdown of Council Social Care Budget 07-08 (net expenditure) 147

Figure 17.10 Increase in Social Care Budgets 148

Figure. 17.11 Council Budget Allocation per Service Area 2008-09 149

Figure 17.12 Council Budget Allocation per Service Area 2008-09 (net expenditure) 150

Figures

Figures182

Figure 17.13 Social Care Budget 2008-09 150

Figure 17.14 Breakdown of Social Care Budget 2008-09 (net expenditure) 151

Figure 17.15 Social Care Grants 151

Figure 17.16 Breakdown of Joint Working Special Grant 2007-08 152

Figure 17.17 Joint Working Special Grant 152

Figure 17.18 Wanless Local Action Plan Grant 152

Figure 17.19 Breakdown of Wanless Allocation 2007-08 153

Figure 17.20 Social Care Grants to the Voluntary Sector 153

Figure 17.21 Health & Social Care Grants to the Voluntary Sector 153

Figure 17.22 Workforce Planning Framework 159

Figure 17.23 Skill mix required from workforce 160

Figures 183

Documents

· Contact Cardiff Health Alliance: Telephone: 029 2087 3870 Fax: 029 2087 3851 Address: Cardiff Health Alliance, Room 337, County Hall, Atlantic Wharf, Cardiff. CF10 4UW Website: