Agenda Item: 3.8 Appendix Two

Aneurin Bevan Health Board

Neighbourhood Care Network

Strategic Plan

2013 - 2018

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CONTENTS 1 Purpose & Scope 3

2 National and Local Context 6

3 The Vision 10

4 Strategic Themes

• Helping people to live a healthy and independent life

• Detecting health problems quickly • Delivering timely, effective local

integrated care and support • Involving people in decisions about local

services and their care • Planning, organising and delivering local

integrated care

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5 Delivering the NCN Strategic Plan 19

6 Resourcing the NCN Strategic Plan

• Workforce Development • Finances • Estates

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7 Performance Managing the NCN Strategic Plan

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1. PURPOSE & SCOPE

This document sets out the draft Neighbourhood Care Network Strategic Plan for Aneurin Bevan Health Board. It sets out the vision and priority areas for the future of primary and community services for the Local Authority areas of Blaenau Gwent, Caerphilly, Monmouthshire, Newport and Torfaen. It mirrors the draft National framework ‘Together for health and sustainable social services: Delivering Integrated Care’ and forms the basis of an ambitious programme of development, integration and redesign between 2013 and 2018.

Effective primary and community care services are critical to the delivery of sustainable, whole system services that span all care settings and consider the needs of patients and delivery of high quality, effective care as paramount. The Health Board has invested in twelve Neighbourhood Care Networks, with clinical leadership and management support. Collaboration and integration are firmly embedded in all network activities. Quality and patient safety is a key component of the Neighbourhood Care Networks work programmes. The Neighbourhood Care Networks have been established to incorporate representation from public health, local authorities, hospital consultants, housing and third sector organisations. As a result they are in ideal positions to act as vehicles for change to ensure delivery of service, which are patient focused and fit for purpose to meet the future needs of the local population they serve. This will require formal integration of services across health and social care and will include the third sector organisations working in local areas. Neighbourhood Care Networks are ideally placed to drive improvements in patient pathways as all patient care, with the exception of emergency care, begins and ends in primary care. The networks have already demonstrated the importance of providing primary care clinical leadership to improve the following care pathways: chronic obstructive pulmonary disease, diabetes, end of life care, oral surgery and eye care. From a Health Board perspective cross divisional working is essential to create a positive culture with everyone taking ownership for both horizontal and vertical integration throughout the organisation, working to a common goal, with patients being central to all actions.

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Improving health and wellbeing is at the heart of all primary care interventions. Every opportunity to improve health and reduce inequalities needs to be maximised and primary care consultations are uniquely placed to provide this. Delivering public health priorities in primary care will need further integration with local public health teams. Individual patients also need to be empowered and supported to become co-producers of care and take responsibility for their own health and wellbeing. This includes full involvement in informed decision making about their care and treatment and will require a different approach to patient consultations together with the delivery of ongoing effective patient information and education programmes.

Primary Care is often seen as the gateway to other services. In respect of service scope, the document lays a gauntlet for a new healthcare system; one of recognising that primary care, through the establishment of Primary Care Delivery Units will be the central tenet of the future healthcare system. Where through developing a dual approach to public health and the treatment agenda, a comprehensive and co-ordinated system of care at a locality level, based on a philosophy of teamwork will enable ownership of patient care at a community level. Within this model hospitals and specialists will support the pathway of care determined for a patient as much as possible in the community or patients home.

Whilst it is essential that we develop and deliver care as safely and as locally as possible, it is a priority for the Health Board to ensure that there is a consistency and equity of service provision across the five local authority areas/12 Neighbourhood Care Network arrangements. The plan itself will therefore adopt the principle of whole system pathway development. Aspects of service delivery that are within the scope of this strategic plan therefore, are:

• Community Well-Being (eg health promotion & protection) • Core Primary Care (eg those included in General Medical

Services, General Dental Services, General Ophthalmic Services and Community Pharmacy contracts)

• Enhanced Primary Care (eg advanced practitioner roles and the development of resource centre models)

• Enhanced Community Care (eg Community Nursing Services, Nursing with extended skills and resource, Nursing Home provision)

• Intermediate Care (eg Community Resource Teams) • End of Life care (eg ensuring that patients have access to high

quality care, at the place of their choice and end their lives

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through advanced care planning initiated at a primary care level)

• Utilisation of Community Hospital provision (eg future plans for the use of community hospitals ensuring the patient pathway is aligned with the acute in-patient episode and maximising rehabilitation both in a hospital setting and then home)

• Specialist response to the pathways defined within primary care.

1.1 Service scope: In terms of existing services the scope is across:

• Community self management initiatives • Promotion and prevention services • Core primary care services • Core community care services • Enhanced primary care services • Enhanced community care services • Intermediate care services • Integrated health and social care services (including those

provided by statutory, community and voluntary organisations)

The plan does not include Out of Hours services.

To reflect the need for whole system change focused on pathways of care, this Strategic Plan is also concerned with entrance to, management through and exit from the secondary care system predominantly in the Health Board area, however recognising its interfaces with Cwm Taff and Cardiff and Vale Health Boards alongside some English providers. This Strategic Plan does not make particular reference to any one group within the population and includes all patients along the life course and disease trajectory. 1.2 Organisational scope: The Health Board has restructured lately in order to recognise the pivotal role of the Neighbourhood Care Networks in the future planning and delivery of healthcare. The model will therefore be clinically led from within primary care, however with interfaces across all Divisions within the organisation and partners from communities, Local Government and Third sector outside of the organisation. It is essential that the five Single Integrated Plans developed at a Local Authority level also reflect the priorities for primary and community services as articulated through this plan.

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Whilst implicit within the document, the following principles are consistent throughout the document:

• Collaboration • Integration at all levels (primary and community services, acute

services, Health and social care and with communities in the widest sense)

• Realising the opportunities that are presented within a collaborative environment which lead to good quality and safe services

• Neighbourhood Care Networks being seen as a vehicle to enable change

• Increased capacity in the workforce and estate to support more delivery in primary care

All of these are fundamental to the delivery of the plan to realise integrated health and social care services in the community by 2018.

2. NATIONAL AND LOCAL CONTEXT

Welsh Government published Together for Health in 2011, which set out a clear vision for the transformation of health and social care in Wales. Supporting this, has been the publication of a range of Delivery Plans for stroke, mental health, cancer, cardiac and quality. Together for Health and Sustainable Social Services, Delivering Local Integrated Care is due for publication imminently. These Delivery Plans set out the actions required by Welsh Government for the NHS and key partners to secure measurable improvements in the health outcomes for people affected by these conditions. This is especially relevant for the Health Board and partners due to the need and commitment to reduce the health inequalities which continue to exist across the population served by Aneurin Bevan Health Board The NHS in Wales is facing unprecedented times, in respect of increasing demographic changes and subsequent increased demand for services, whilst resources both staffing and financial are in real terms reducing. These issues are also facing Local Authorities and Third Sector organisations. Ninety per cent of all health care interventions take place in primary care. On a daily basis within the Health Board area there are 12,000 patient consultations with General Practitioners, 5,000 Patient consultations with Practice Nurses and approximately 600 patients visited at home.

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The findings of the Francis Report have a resonance for primary care and our key partners. It is essential that improving patient care is at the heart of all activities, this is especially pertinent when considering the integration agenda. The need for openness and transparency is as relevant to Primary and Community Care as it is to Hospital based care. Primary and community care, is embedded within local communities and as such, is in a unique position in understanding population and community needs. Primary and community care services are at the heart of local integrated care, with General Practitioners providing holistic, first access services to their registered population, addressing the complex physical, social and psychological components of care all within the context of individual family (or other support) networks and their local communities. It is well recognised that peoples needs, span organisational boundaries. Moreover that the provision of health and social care is increasingly being delivered through integrated teams, enhanced skill sets and reduced organisational boundaries. The aim is to safely and effectively provide care and support to meet people’s needs through the life course within the local community. This may either at home or as close to home as possible. The emphasis on the NHS being primary care led, enabled by a rebalanced health and social care system, has long been advocated in various health and social care policy documents. Gwent Healthcare NHS Trust and the five Local Health Boards developed the Clinical Futures Strategy. This described primary and community care services as level 1, Community Based Services. At this time, the emphasis was on managing patients in alternate parts of the system, reducing lengths of stay, reducing bed capacity through the development of services in the community. Whilst this work was very forward thinking at the time, it was based on historic practices and patterns of work and was focused around hospital services. This plan further develops that thinking and sets out the Neighbourhood Care Networks vision for the future, from a primary care and population needs basis.

Setting the Direction: A Strategic Framework for Primary and Community services (2008) strengthened the Health Community approach and offered the first cohesive framework for the development of this range of services. Focussing on the whole system, but particularly how those services provided in a primary and community setting could work as a co-ordinated system of care. The system proposed required an expanded, integrated

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model of organised community services, which focused on the patient and not on the part of the system providing the care. The system needed to stratify risk and manage care in a proactive way for moderate to high risk patients who are being cared for in a community setting and through either increasing frailty or a deteriorating chronic condition require more complex care than may have traditionally been provided in that setting.

The core elements of the new model (whilst working in a cohesive manner) were presented in Setting the Direction as:

• Services organised in localities of 30,000 – 50,000 • Mechanisms to assess and direct people within the community • A communications hub which will fulfil both an information

support (based on the GP shared record) and a care co-ordination function.

• Core primary care services • Resource teams (including GPs with advanced skills,

community consultants and advance practitioners) operating at the previously outlined population level

• Out Of Hours services • Locality Networks (operating at population levels larger than

previously outlined) reflecting multi-disciplinary teams. Setting the Direction described a ‘seamless pull system’ where patients are cared for by enhanced primary and community care services delivered as close to home as possible, wherever safe and effective to do so. This is depicted in the following diagram:

HOSPITALBASED CARE

ASS

ESS

DIR

ECT

PRIMARY CARE

OOH

ORGANISED SYSTEM OF INTERGRATED COMMUNITY SERVICES

PULL

PULLPULL

PULL

SHARED INFORMATION BASED ON GP RECORD

Future System of Care “Seamless Pull System with Integrated Access to Information”

Locnet

Patient journey

COMSHUB

Resourceteam

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The Health Board has undertaken a significant amount of work in ensuring a focus on primary and community services, having reconfigured the previous five Locality Divisions into two divisions: Community Services and Primary Care and Networks. This has enabled a significant focus on clinical leadership within these two Divisions, placing clinical leadership from primary and community services at the heart of the health and social care system locally.

To implement Setting the Direction, the following has been developed:

o 12 clinically led Neighbourhood Care Networks (enabling services to be planned and delivered on population bases 30-50’000).

o The frailty model across Gwent (developing integrated community resource teams, mechanisms to assess and direct people within the community) responding to the resource team element of the framework.

o Continued emphasis on developing core primary care o Increased emphasis on the interface between primary

and community services and the acute sector (responding to the pull aspect of the framework)

o Implementation of new community services eg community resource teams and Primary Mental Health Services.

The workforce in primary and community care settings is changing and workforce development, specifically for Primary Care will be central to the future delivery of care. The role of the General Practitioner is changing, with interventions previously undertaken by specialists in hospitals now being undertaken in General Practices. Similarly, there are changes to the wider practice team. Nurse Practitioners and Health Care Support workers now deliver a range of assessments and interventions, which previously would have been the domain of General Practitioners.

Together for Health and Sustainable Social Services: Delivering Integrated Services is currently being consulted upon. This builds on the strengths of ‘Setting the Direction’ and reinforces the role of social services and other key partners in delivering the integrated model of services. The strategic development work undertaken by the Neighbourhood Care Networks over the past months is broadly aligned with this document.

All of this work presents a firm basis for this strategic plan which will help realise a clear vision for primary and community services by 2018.

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3. THE VISION

Welsh Government’s vision is stated as ‘to achieve the best possible health and well-being for all people in Wales, whatever their circumstances, or wherever they live’.

The Neighbourhood Care Networks vision for primary and community care services is summarised as ‘delivering services in the community by primary and community care delivery units providing excellence in core primary care and a range of locally determined enhanced and extended community services. These will ensure that the population served will receive appropriate individualised care to promote as long and healthy a life as possible.’

What will be different?

• Care, when safe and appropriate, will be managed at a community level through the establishment of integrated primary care delivery units, that extend beyond existing primary and community care teams and include social care and other key partners.

• Teams will integrate both horizontally and vertically throughout the health board to deliver effective care to patients and reduce gaps and duplication in care.

• Patients will be central to all care planning and delivery and co-producers, through informed decision making.

• Resources, both staffing and financial, required to deliver the care will follow the patient.

• Services will be developed to reflect the unique needs of local communities.

How will this be different for patients?

• People in communities will be supported to look after their own health and well-being, through local ownership of public health issues to reduce their risk of developing chronic conditions.

• People with a chronic condition will be supported to manage their own condition, recognising when changes necessitate professional support and having access to this in a timely manner.

• People requiring an increasing range of services from their primary care teams in a general practice setting.

• People will be cared for and supported to remain at home, when care can be safely provided, thus reducing hospital admissions.

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• People will only be in a hospital, or other institutional care setting, for the minimum period of time and only when they cannot be cared for at home.

How will this be different for the Health Board and key partners?

• The focus will be to ensure as many patients as possible are managed at home when safe to do so.

• There will be vertical and horizontal integration of all health and social care professionals to ensure that services are delivered to meet the needs of patients, to enable them to remain at home.

• Evidence based integrated care pathways underpin all service delivery; these will include interventions provided by health, social care and third sector staff.

• The Primary Care Delivery Units will ensure that patients are in a hospital

• The organisation supports the shift of resources (whether staff or finances to support the provision of more care in a primary/community setting.

In considering the vision set locally and the National direction communicated through ‘Together for Health and Sustainable Social Services: Delivering Local Integrated Care’, there appears to be correlation between the two. Following publication of the document, this vision will be revised to ensure congruence with the policy direction. The Neighbourhood Care Networks have considered how this vision will translate into service delivery through a series of workshops. This has resulted in the following strategic themes being identified:

• Helping people to live a healthy and independent life. • Detecting health problems quickly • Delivering timely, effective local integrated care and support • Involving people in decisions about local services and their

care • Planning, organising and delivering local integrated care

These will be used as the basis for implementing Annual Neighbourhood Care Network Delivery Plans. Each theme will offer an overview, a set of aspirational outcome statements and some suggestions as to how they can be taken forward.

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4. THE STRATEGIC THEMES Strategic Aim 1: Helping people to live a healthy and independent life The need to balance a health treatment agenda with one of health promotion and protection is well documented. The Health Board’s Public Health strategy documents the following aspirations across the life course. They offer the basis of the outcome statements for this theme of the plan. Primary and community services also however play a key role in facilitating secondary prevention for those with a chronic condition and as such a further statement has been added: Strategic Aim: 1 Outcome Statements

• Babies are born healthy • Pre-school children are safe, healthy and develop their

potential • Children & young people are safe, healthy and equipped for

adulthood • Working age adults live healthy lives for longer • Older people age well into their retirement • Frail people are happily independent. • Those with a chronic condition are supported to make lifestyle

choices which may prevent further exacerbation of the problem.

To achieve these we will:

• Make every contact count, using any exchange with patients to share information that may aid their own well-being

• Engage through the Single Integrated Plan processes in each area to ensure priorities at an NCN level are reflected

• Engage with the missing 1000’s – those who do not engage with traditional primary care and health promotion programmes

• Deliver seamless services • Enhance preventative health activities, reduce clustering of

unhealthy lifestyle behaviours • Improve timely risk management • Improve detection and early diagnosis of diseases such as

cancers

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• Seek to realise the capacity in individuals and communities through empowering people to be in control of their own Health & Well-being

• Respond to Welsh Governments Chronic Condition Management programmes as they relate to health promotion and protection and the roles of community teams within this.

• Increase uptake of screening programmes • Improve the oral health of children and young people

through delivery of the national “Designed to Smile” programme whereby Community Dental Services work in partnership with Flying Start, Schools, Play Groups and Nurseries.

The Health Board with partners will also prioritise targeted activity in the areas of greatest need. Based on needs assessment of the area, these areas have been identified through the Health Boards ‘Living Well, Living Longer programme’ as:

• Blaenau Gwent West • Caerphilly North • Newport East • Newport West

Strategic Aim 2: Detecting health problems quickly The ability to detect and therefore respond to health issues quickly is at the heart of modern healthcare. Early detection will lead to earlier care and advice and ultimately to better health outcomes. Together for Health ‘Delivering Local Integrated Care’ sets the following aspiration:

‘Health Boards will provide GPs with more rapid access to diagnostic tests, to accurately diagnose and deal with health problems at an early stage and will

make it easier for patients to see a GP or other professional and for GPs to get timely advice from

specialists when needed’ Strategic Aim: 2 Outcome Statements

• Individuals will have good and prompt access to healthcare provided through a variety of means

• Community teams will have access to a wide range of diagnostic tools to support early diagnosis and treatment

• Community teams will have prompt access to specialist advice

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• Staff in hospitals who could be providing their service in a primary/community setting will do so

• Those who have a condition for which a risk stratification approach can be enabled will be so

To achieve these we will:

• Continue to increase access and availability of core primary care services/teams

• Consider the feasibility of extending hours • Work across the Health Board to consider 7 day working

models • Implement 7 day working across Frailty Community Resource

teams (including medical teams) • Implement a fall strategy to promote general health

promotion and falls prevention followed by assessment and management of people at risk of falls or who have fallen.

• Provide a greater range of diagnostic tests and follow up checks and clinics closer to home, so people only travel to hospital for specialised services. Work with secondary care clinicians/teams to develop a hot clinic/rapid advice model

• Seek to move existing staffing resource from the acute to a community setting within agreed pathways of care taking a holistic approach to a patients needs rather than as a single/specialist service/pathway.

• Optimise and quality assure contractual arrangements to secure high quality and cost effective care from General Medical Services, pharmacists, dentists and the third sector.

Strategic Aim 3: Delivering timely, effective local integrated care and support The delivery of fast, effective and local integrated care and support is the cornerstone of the ABHB model and will be delivered through a wide range of professionals and traditional services working within integrated teams to meet communities and individuals needs. This will mean that all staff working at a community level will see themselves as part of an extended community team. NCNs will be strengthened as the basis for planning, co-ordination and delivery of Local services by multi-agency teams against individual needs and clinically agreed pathways. It is well recognised that when older people have protracted lengths of stay in hospitals this leads to poorer outcomes and increased dependency. It is therefore essential that integrated teams work

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together with the aim of avoiding unnecessary admissions to hospital. When a hospital admission is required, it is essential that the patient’s length of stay is minimised and community teams proactively case manage patients with complex needs to support and maximise timely discharges. The future role of community hospitals is also important in the vision for the future. The Community Division will be looking at the future use of Community provision, with a view to ensuring that pathways must reflect the full patient pathway across primary, community and secondary care, ensuring multiple pathways are aligned, and that a patients holistic needs are met (recognising that the majority of our patients in community hospitals are 65+ yrs old and those 75+ have 8 or more co-morbidities) Strategic Aim: 3 Outcome Statements

• Patients will receive care from a team within their

community and will not feel the boundaries that often exist between teams and sectors as those providing care will be seen as a single team regardless of professional background

• Neighbourhood Care Networks will be the locus of influence for the delivery and resourcing of community based services

• Care will be co-ordinated at a community level, with local teams holding responsibility for patient care and case management

• All patients with a chronic condition will have an individual care plan

• Services will be planned and delivered to support people to remain safely at home, or close to home, care will be delivered locally against agreed pathways and delivered by integrated teams across primary, community, social and third sector care with support packages tailored to the individual as necessary to their needs.

• Where more specialist care is required, specialist roles will support the locality teams (eg Advanced nurse practitioner roles palliative care/Chronic Obstructive Pulmonary Disease/Diabetes) to access this in a timely way and ensure that the individual is supported through the specialist element of their need, returning where possible to community based care or indeed no need for further care

• Resource Centre Models will support co-ordination and pursuit of integrated team working

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To achieve these we will:

• Develop locality networks and community resource teams, so they rapidly become the essential mechanisms for planning and delivering a truly integrated set of services

• Remove the boundaries between teams moving towards single integrated teams managed at a locality level

• Develop a range of services to better manage patients within the community (eg diabetes, Chronic Obstructive Pulmonary Disease, palliative care) though recognising that many of these already exist, seek to co-ordinate and organise care better together

• Recognise that the older population have increasingly complex needs and co-morbidities. It is therefore essential that we treat the older person holistically rather than on an individual specialist based service/pathway.

• Systematically and proactively plan and co-ordinate packages of care using agreed care pathways and protocols, enabling all relevant professionals to talk to each other, utilising modern technology and case conferencing.

• Develop a more pro-active approach to the management of complex patients in the community

• Systematically and proactively identify the needs of people living within their local communities, including those at risk or requiring high levels of care and support to inform service planning and co-ordination.

• Optimise the use of modern technology to monitor, protect and communicate with each individual assessed as vulnerable, in their home.

• Consider the development of social enterprise models at an NCN delivery level

• Report on an all Wales agreed dashboard of service performance measures to demonstrate to Boards, Welsh Government and the public how people are better off as a result of local integrated care.

• Develop and implement models of care and services which increases the range of services available 7 days per week, 24 hours a day

Strategic Aim 4: Involving people in decisions about local services and their care Change is most effective when those that it affects are involved in bringing it about. A new approach to the involvement of individuals and communities should be enabled, one which engages people in formulating ideas about service development and change before any

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plans are made as well as seeks feedback on service experience. As such citizens become much more partners in the design of and quality of services rather than solely as recipients. The plan reflects upon the previous engagement models shared in Signposts public involvement documents of the past and sets it as a framework through which it would continue to engage

Influence

Information

Feedback

Strategic Aim 4: Outcome statements Influence

• Communities feel ownership of their local services and know they can influence them

• Communities are offered opportunity to engage in the future shape of services for a community

• Communities and individuals know where to go and who to speak to if they have ideas about service development

• Communities receive consistent and equitable service provision and care

• Social enterprises are in existence and people in communities are engaging with them

Feedback

• People receiving services know how they can give feedback on them

• People can see a direct link between their feedback and service improvement

• Every contact will count, local teams providing services will engage actively with people and seek their views on the services provided

Information

• Information (whether condition specific or related to service availability/improvement) is easily accessible to all

• Community infrastructure in the widest sense is used as a means through which information can be accessed

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To achieve these we will: Work with Communities First to develop Neighbourhood Care Network involvement programmes focusing initially on the areas with the highest levels of deprivation and resulting health inequalities through the Living Well, Living Longer programme. Strategic Aim 5: Planning, organising and delivering local integrated care The model of care proposed here is one which draws on all expertise within a community, individuals and communities themselves, all primary care contractors, social care teams, traditional community teams (ie health visitors, district nurses), third sector providers and private providers as they relate to the model. Effective planning systems are often the simplest, those that have the least bureaucracy, yet where everyone is clear on where decisions are made and how to influence this. The vision we have presented through the varying themes in this strategic plan, mean that a system of planning and organisation has to be enabled that engages a wide range of people, responds to National requirements but most importantly is able to reflect and respond to local needs. We have also advocated a model of devolved decision making and resource influence, as such it is possible that over time a pooled budget for community services could be developed to support the provision of care locally. Strategic Aim 5: Outcome Statements

• Expertise from communities and teams working within communities is harnessed and utilised to make local care as effective as it can be

• Local clinical leaders will set the vision for local care • Quality and safe care is at the forefront of localised service

delivery • The primary and community workforce will have a wide range

of skills developed across a team based concept of skill development

• Modern technology will be used where appropriate to support access to, and the delivery of local care

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To achieve this we will

• Develop local partnership teams with clear accountability relationships to the organisations that employ them

• Develop Partnerships for planning (via the Single Integrated Plan processes) and Partnerships for delivery via existing community resource teams and NCNs coming together and being recognised as one local team

• Enable pathways of care through clinical leadership from primary care to be developed

• Provide strong leadership and create capacity and capability for locality networks to plan and co-ordinate local integrated care.

5. DELIVERING THE NCN STRATEGIC PLAN The production of the Neighbourhood Care Network Strategic Plan is only the beginning of the journey. Much more important is the ability to realise its intent and translate the strategy to action. It is clear that the plan offers a vehicle for the implementation of many organisational objectives and the delivery of the Single Integrated Plans in each of the unitary authority areas. In each Local Authority area there are Integrated Partnership Teams being developed. These teams will bring together the clinical and managerial leads for primary and community services to ensure that any work programmes are taken forward as one, and resources deployed to best effect. This will also aid the reduction of unnecessary duplication. Operational Plans will be developed against the strategic themes and include actions from the Single Integrated Plans currently being finalised. 6. RESOURCING THE STRATEGY This plan views resources as more than simply the finances that supports service provision locally. Critical to the success of this plan is a workforce that is competent and confident, resources that are used to optimum effect and an estate that enables community level service delivery 6.1 The Workforce At the time of writing detailed work is on-going to understand the primary care workforce profile and development needs at a

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Neighbourhood Care Network level. The context for this work is best summarised as:

• An ageing GP workforce • Challenges to recruitment and retention • Changing profile (in sex and contractual status) of the

GP workforce • Changing skill mix and the development of Nurse

Practitioner and Health Care Support Worker roles • Limited training numbers in the future

Beyond the core workforce required to deliver primary care services, there is a need to ensure that the workforce of the future have the skill to respond to a wider profile of services. As such, workforce plans will be developed at a Neighbourhood Care Network level, they will have at their core, principles of team working and team based competencies, enabling the growth of a general set of skills supported by specialist roles and training as required. There is a commitment through this plan to see teams and professions that have traditionally delivered services in the hospital setting to begin to deliver the same (where safe and acceptable) in a primary and community setting. There is too a continued strong focus on ensuring core primary care 6.2 Primary Care Estate As more and more services are being provided in a primary and community setting, a key challenge is the availability of the estate to respond to the need to hold and deliver more services. As such the estate needs to be seen as a priority area of investment and development, if it is to be utilised for more and more services that have traditionally been delivered elsewhere. It is essential that in the period of this strategic plan, that there is a shift beyond seeing the only purpose of buildings being what their traditional origin was. There is great potential to move towards a concept of community assets across organisations that can be used for multiple purposes regardless of ownership. 6.3 Financial Flow Central to the entirety of this plan has been the inference of resource shift across the system to reflect the balance of where care is provided. Within the timeframe of this plan, it is envisaged that:

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o There will be a transfer of activity from acute to primary and community services relevant to agreed pathways of care

o To support such a transfer staff and financial resource will be released accordingly

o Resources to provide local care will be managed, and decided upon locally within an overall framework of organisational accountability

7. PERFORMANCE MANAGING THE STRATEGIC PLAN There is to be a national outcomes framework for Together for Health and Sustainable Social Services: Delivering Integrated Services’ (WAG 2013). Our plan will to need to reflect this. The Neighbourhood Care Network Delivery Plans will enable this and will be based on a results based activity model, developed against the outcome statements already contained within this plan. As such whilst there is room for differences in delivery across Gwent, reflecting local flavour and configuration, there will remain a consistency in outcome and performance reporting.

The primary and community services operational group will be the co-ordination and scrutiny point for all Neighbourhood Care Network Delivery Plans with the Primary & Community Services Board ensuring strategic alignment and delivery as follows:

Primary & Community

Services Board

Primary & Community Services Operational

Group

Blaenau Gwent Integrated Partnership

Team

Caerphilly Integrated Partnership Team

Monmouthshire Integrated Partnership

Team

Newport Integrated Partnership Team

Torfaen Integrated Partnership Team

NCN NCN NCN NCN NCN NCN NCN NCN NCN NCN NCN NCN

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