INTEGRATING HEALTH AND SOCIAL CARE FOR OLDER PEOPLE AND PEOPLE LIVING WITH FRAILTY IN THE CWM TAF MORGANNWG REGION

REGIONAL MEMORANDUM OF UNDERSTANDING

Purpose:

Over the next 20 years, the number of people living in our communities is predicted to grow further. Notably, we are expecting an increase in people aged 65 years and over, with the most significant rise in those aged 85 years and over. More people living longer is something to be celebrated. It is a trend that health and social care services have played a significant positive role over many decades in creating, and we are proud of this. We also acknowledge that from the perspective of the future planning of our services in a resource constrained environment, meeting increasing needs of greater complexity will require significant innovation and collective endeavour.

For the growing number of older people and people living with frailty, their interacting and cumulating health and social circumstances means continuity and coordination of their care is extremely important. It follows that health and social care services working separately in traditional ways cannot deliver optimal outcomes for people. Anyone with direct experience themselves, or in their family, of living with chronic conditions knows that seamless, accessible health and social care services are essential to maintain as much independence and quality of life as possible for that person. This is equally true for the wellbeing of their carer(s).

Our commitment then as Bridgend County Borough Council, Merthyr Tydfil County Borough Council, Rhondda Cynon Taf County Borough Council and Cwm Taf Morgannwg University Health Board is to work together and with wider partners to create an integrated community care system capable of meeting changing and increasing population need.

A key purpose of this Memorandum of Understanding (MoU) is to set out at a strategic level what our organisations are trying to achieve together through strengthened partnership working for older people and people living with frailty which will be embedded in our system.

In practical terms this will mean developing integrated delivery teams, joint management arrangements, close collaboration on demand and capacity planning, the optimal use of our collective resources and joint commissioning of services. However, as a local health board and councils we are not empowered to work in this way, without taking proactive steps. The Cwm Taf Morgannwg Regional Partnership Board is an important forum for coordinating this work, but it does not provide a legal basis for integrated operating arrangements between statutory organisations.

Therefore, we will work towards the development of a binding Regional Partnership Agreement (RPA) which will permit us to delegate functions between bodies and create a formal binding partnership, thus enabling the creation of joint operating arrangements. Through this agreement each partner will retain our respective statutory duties, whilst at the same time achieving greater synergy in the way our services work and avoiding significant organisational restructuring.

This MoU is a precursor to the RPA, acting both a statement of intent and as a means of agreeing areas of focus in the forthcoming RPA. As a confident first step on a much longer journey, this MoU is an important statement in its own right. We collectively sign up to the MoU through Part 9 of the Social Services and Wellbeing (Wales) Act 2014 which supports partnership arrangements in health and social care.

The Intended Scope of our Regional Partnership Agreement

Our forthcoming RPA will be scoped for integrated health and social care support in the community to older people and people living with frailty and their carers, but this can be a template for addressing the needs of other population groups in the years ahead. The RPA will be underpinned by the provisions of Section 33 of the NHS Act 2006 as this provides a clear basis for integrated management arrangements between local authorities and health boards.

In terms of the footprint of services being considered, through the Regional Partnership we are already cooperating on the development of two new community pathways, namely ‘Urgent Community Response’ and ‘Population Health Management’, supported by a Navigation Hub and delivered by integrated community teams largely on a cluster footprint. These pathways provide a basis for the services in the scope of a formal partnership agreement (see Annex A for a list of service areas potentially in scope).

In the context of developing these regional pathways, a single partnership agreement, rather than bilateral arrangements between partners, offers the greatest potential for improved service delivery. We intend to learn from our collective experiences of legal agreements which we are already party to, in order to develop an arrangement here that is flexible and ambitious in scope.

The Aims and Objectives of our Regional Partnership Agreement

Fundamentally we are seeking better outcomes for this population, and we intend to develop a measurement framework which will work at a number of levels in order to drive delivery and provide a high level of clarity that will enable effective scrutiny. This will comprise population indicators, system performance measures, service performance measures and quality performance measures.

Population outcome indicators will describe the improvements people should experience. Fundamentally we want older people living with frailty to have more healthy days in their home with as high a level of independence and quality of life as possible.

System output measures will reflect and support the structural changes to the health and social care system we want to make. By creating stronger community pathways, we aim to increase the count of people receiving enhanced community care, and reduce admission rates and unnecessarily lengthy stays in a hospital environment because of the deconditioning that results in for patients. This is especially important for older people who can be harmed by an admission which may end up being longer than necessary and lead to greater dependency in turn requiring more extensive social care arrangements.

Success here would reduce the intensity of social care support a person may need after a lengthy hospital stay. Such system output measures will help us identify if we are moving closer to or further away from the shape of system we need for the future.

Service output measures will track the performance in key service areas. Access to services, increasing the number of people with anticipatory care plans, reducing re-admission rates and appropriately sizing care packages will feature.

Quality of experience for people we support can be understood through feedback from them. For our workforce, indicators of recruitment/ retention and their own self-reported job satisfaction and wellbeing will be key. Research shows that staff engagement drives quality which in turn drives results and better outcomes for people. Our staff truly are our most important asset.

To enable this, we aim to work together as a single system across acute healthcare, primary and community care, social care including Independent Providers, the Third Sector and other partners to make best use of our financial resources.

Ways of working

We will strengthen governance at a regional level to oversee the delivery of our integrated service model. Each statutory organisation will be represented, and there will be a clear reporting line from each statutory organisations own governance and accountability mechanisms and into the Regional Partnership. Rather than reducing the level of accountability, our intention is to increase transparency by making health and social care delivery results more visible as this is essential to learning and improvement.

To support these changes to the ways we will operate our services, the continued growth of a positive enabling culture will be crucial. We will invest in the development of working relationships between our organisations at all levels: for Councillors and Board Members; for executive management, and for front line professional staff. This approach will apply across our wider regional partnership as well as in our own organisations. Integration has to work at an individual and team level, and we will invest time and other resources in this.

Delivery timetable

With this MoU in place, we are working towards the commencement of a formal RPA for the start of the operating year 2025-26. This agreement will evolve over the years ahead. We envisage annual updates as we reflect on progress and implement new elements of our new community pathways.

Annex A to the MoU – Services in scope for Section 33 Agreement

Urgent Community Response Pathway

Reablement

D2RA Beds

Dementia Specialist Services

Assistive Technology and Mobile Response

Short Term Professional Interventions

Hot Clinics

Palliative Care and Chronic Disease Management

Navigation

Closer alignment between CTMUHB Clinical Navigation Hub and Local Authority Single Points of Access

Population Health Management Pathway

Community Health and Wellbeing Teams

CTMUHB and LA Social Care commissioned Wellbeing provision