A Strategy for Adult Care Services
‘Making Personalisation A Reality’
Long Term Conditions 2008-11
Joint Local Delivery Plan
This 3 year plan describes the way in which Adult Social Care Services will carry forward it’s key aims and objectives as outlined in the
Adult Plan (www.rbwm.gov.uk) for people with long term conditions. There are a total of 10 different plans similar to this one, covering all
aspects of Adult Social Care. They are;
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Adult Mental Health
Autistic Spectrum Disorder
Carers
Drugs & Alcohol
Learning Disability
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Long Term Conditions
Older People
Older People’s Mental Health
Physical Disability
Sensory Impairments
The plans recognise the inter-relatedness of the actions, and work required to successfully implement them for all service user groups.
The 10 year Adult Plan identifies these 3 year delivery plans for commissioning activity particularly where there is:
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Need for urgent action, particularly regarding difficulty securing care
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Opportunities to test an approach to service delivery
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Partners seeking the chance to work together to achieve synergies
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Opportunities to test hypotheses that appear to have the potential to make a significant impact.
The aims of the Adult Strategic Plan are:
Putting people at the centre of everything we do - We will transform the way in which we work by placing people who need to use our
services at the centre of everything we do.
Promoting healthier communities - We will seek to form new and different types of relationships with our communities.
Focusing on outcomes - We will concentrate on those things which people tell us makes a real difference to their lives.
Making a difference - We will develop structures, processes and the way we use resources to ensure that everything we do adds value.
Delivering better commissioning - We will work in partnership to better understand the needs of the whole population.
There are eight broad and overarching objectives that will ensure that we are better able to deliver the vision for adult social care and
meet the strategic aims outlined above and describes what we think is the right approach to delivering the Adult Plan.
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Promoting Independence and Preventing Dependency
Dignity and Respect
Joint Commissioning
Choice and Control
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Effective Commissioning & Procurement
Equality of Access
Workforce Development
Economic Well-being and Sustainability
Some of these are a continuation of work already underway; some may be subject to evaluation and others are based on emerging
national and local evidence. Each objective sets out what the overall outcome will be and what the commissioning implications are.
There are a number of cross cutting themes identified within the Adult Plan that need to be addressed in each of the three year
development plans. The following have been identified:
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Advocacy
Assistive Technology / Telecare & telemedicine
Care Breaks/Respite
Day Opportunities
Dignity in care
End of Life Care
Health & Well-Being
Housing and Accommodation
In-control – Individual Budgets
Safeguarding Adults
Single Assessment Process/Common Assessment
Framework
 Transition Services (16-25 year olds)
Health, Our Care, Our Say: A New Direction for Community Services’ White Paper, published in January 2006 encompasses community
health and social care delivery, and a key theme across health and social care includes the shift to: More focused support for people with
long-term conditions
For RBWM purposes the definition of a Long Term Condition is:
A patient with a diagnosed condition, for which there is no cure, and that has (or is likely to have) an impact on their life from
the patients’ and/or carers’ perspective. These patients will require a holistic and frequent intervention in order to manage their
condition.
Some examples of Long Term Conditions are: Stroke, Multiple Sclerosis, Diabetes, long term neurological conditions, HIV & Late stage
HIV. Please note this is not a definitive list:
“Delivering improvements for people with long term conditions isn’t just about treating illness, it’s about delivering personalised,
responsive, holistic care in the full context of how people want to live their lives. Our journey to achieve this has started, our challenge is
to continue to take it forward and the evidence compels us to do this” David Colin-Thomé, National Director for Primary Care – Raising
the profile of long term conditions a compendium of information, January 2008
There are over fifteen million people in this country reporting that they are living with a long term condition. Long-term conditions are
those conditions that cannot, at present, be cured, but can be controlled by medication and other therapies. Improved health and
emotional well-being and support in managing long-term conditions is a key aim of the adult plan.
There are huge benefits to the population and financial savings if health and social care communities invest in effective LTC
management
Locally in RBWM as with much of the UK we know that we have an increasingly aging population. We know that:
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Long -term illness rates are lower in the Royal Borough than the national average
In the 2001 Census, one in six people in the UK (10.3 million) living in a private household reported having a limiting long-term
illness (LLTI)
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Between 2005 & 2006 the number of people living with HIV in the UK increased by 15% to 73,000 and it is estimated that 30% of
those are as yet undiagnosed
There was a 36% increase in the number of people heterosexually infected with HIV in the UK in the year 2006
Between 2005 & 2006 the number of people needing HIV care in the South Central Strategic Health Authority increased by 8.4%
to 2,407
People with LTCs are the most intensive users of the most expensive services. The Department of Health best estimate is that the
treatment and care of those with LTC’s account for 69% of the total health and social care spend in England, or almost £7 in every
£10 spent.
Numbers are increasing due to factors such as an ageing population, health inequalities and certain lifestyle choices that people
make. 17% of those aged under 40 say they have a LTC
People with long term conditions are not just high users of primary and specific acute services but also social care, community
services and urgent / emergency care. Over 30% of all people say that they suffer from a LTC, this group accounts for 52% of all
GP appointments, 65% of all out-patient appointments and 72% of all in-patient bed days
We know that many of those adults with a long term condition:
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Are likely to have a mobility problem
Are at greater risk of stroke
Are at greater risk of coronary heart disease
60% of those age 65 and over say they have a LTC
UK and RBWM demography and demand
 There will be growth in the number of adults with complex long-term conditions
 One in six people in the UK who are living in a private household report having a limiting long-term illness
 12.5% of the population reported having a LTC according to 2001 census of which 7.9% are of working age
 The Public Health annual report 2007 for the South East confirms that health problems increase with ageing, such as arthritis,
back pain and high blood pressure. Self reported long-term limiting illness in over 65s is 41% in South East, in RBWM at 38%.
Policy Implications
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Development of Long Term Conditions integrated service
Increase in respite provision
Expansion of self assessment
Access to technical aids reduces future needs and in some cases delays the need for high level equipment / support
Accessible housing / transport (improved funding for specialist transport services / environment
Equal access to employment
Need for development of Advocacy services
Increase capacity for preventative intervention (To reduce crisis involvement and plan towards known disease development stages)
Timely provision of equipment & Adaptations prevent physical health problems
Access to appropriate local health care
Increase in self operated care
Supporting people – floating support / house clearance assistance when moving into residential care)
Promoting independence – smart homes / Telecare
Accessible information
Stroke Services
HIV Policy Implications
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HIV operational work to be reviewed
With partners review funding arrangements for HIV services
Specific HIV service actions to be identified within the LTC plan
Processes for HIV citizens to be reviewed and clearly mapped pathways agreed and communicated
Partnership work to be further developed to include health, service providers and RBWM directorates.
Please find below the Joint Local Delivery Plan for Long Term Conditions, with the actions separated by the strategic objectives identified in the
Adult Plan.
Outcome 1: Promoting Independence and Preventing Dependency
Promote a healthy, safe and sustainable locality that seeks to maximise the impact on the health and well being for all adults living within the borough through
developing services that respect a person’s independence.
Proposed Action
Proposed
Partner(s)
Proposed Lead
Target date
Proposed Outcome
1) To have a range of suitable
accessible housing for people with LTC
to enable them to remain independently
in their own homes for as long as
practicable. (Including heating and
insulation improvements)
RBWM:
Housing /
Service
Providers
RBWM
(Housing)
Ongoing
Suitable housing and
support independence,
people continue to live
in their own
environments with
support to make this an
effective option
2) Telecare – Increase access to & use
of Telecare systems / Ensure that
assistive technology is taken into
consideration during an assessment and
review
RBWM: Tele
care lead
MDHA Telecare
Officer
RBWM
Ongoing
Service users have
access to Telecare
equipment and support,
routinely considered with
assessments and reviews.
Actively promoted
independence.
3) Tele-Health (Medical) care
BE PCT
Commissioning
BE PCT
Ongoing
4) To have a range of accessible
information, in a variety of formats for
service users, self funders and all adults
in the Borough.
Provide strategic information to
RBWM, Policy
& Planning /
BEPCT
Community
Health Services
Joint: RBWM
BEPCT
On-going
Service users have
access to tele-health
care systems with
specialist support.
Increase independence
and reduce the use of
services.
People who use
services feel informed
about options and
needs. Information
readily available with
Comments
Outcome 1: Promoting Independence and Preventing Dependency
Promote a healthy, safe and sustainable locality that seeks to maximise the impact on the health and well being for all adults living within the borough through
developing services that respect a person’s independence.
Proposed Action
Proposed
Partner(s)
Proposed Lead
Target date
professionals to deliver public sector
reform aligned with national policy.
Proposed Outcome
translation and
specialist
communication utilised
as appropriate
5) Provide services that promote health
& well-being for all adults in the Borough
and provide a range of specific services
for those requiring additional support
BE PCT /
RBWM, Policy
& Planning
Joint: RBWM
BEPCT
Ongoing
Community assisted to
stay healthy and have
healthy lifestyles (Physical
& mental). Preventative
services are promoted
and accessed
6) Commission community based
services that encourage re-enablement
and rehabilitation, promoting
independence and lowering dependency
on services.
RBWM Adult
Services (Joint
Commissioning,
Intermediate
care team,
Service
providers
RBWM: Access
Forum,
Disability
Partnership
Board
Joint: RBWM
BEPCT
Ongoing
Access to services across
the Borough. People
(re)gain life skills and
increase life chances
through use of services
RBWM:
Transport Policy
Officer
Ongoing
Improved outcomes for
individuals using public
transport and taxis.
Reduced Social Isolation
and increased use of
community resources
BE PCT/PALS
BE PCT
Ongoing
To improve individuals
quality of life through
7) Enhance personal mobility and
transport choices. Increase awareness
to transport partners of those who need
additional assistance and their needs
Continue to develop Expert Patient
Program
Comments
Outcome 1: Promoting Independence and Preventing Dependency
Promote a healthy, safe and sustainable locality that seeks to maximise the impact on the health and well being for all adults living within the borough through
developing services that respect a person’s independence.
Proposed Action
Proposed
Partner(s)
Proposed Lead
Target date
8) People have improved quality of life,
health and well-being and are enabled
to be more independent through the
promotion of healthy life styles
RBWM, Head of
Leisure
Services / PCT
Public Health
development
group
RBWM – adult
service manager
Ongoing
9) People are supported and enabled to
self care and have an active
involvement in decisions about their
care and support through integrated
service planning.
RBWM,
Service
Managers / BE
PCT
Managers
Joint: RBWM
BEPCT
Ongoing
Proposed Outcome
supporting people to
understand and take
control of their condition
to include medication
training (self care)
Range of innovative
initiatives to promote
healthy activities and
choices. Clear
information and easy
access to health
Increased numbers of
Direct Payments /
Individual budgets held by
individuals
Individual Needs
Assessment to identify
personal outcomes for
people
Person-centered &
integrated care planning
Access to information
made easier for people
Comments
Outcome 1: Promoting Independence and Preventing Dependency
Promote a healthy, safe and sustainable locality that seeks to maximise the impact on the health and well being for all adults living within the borough through
developing services that respect a person’s independence.
Proposed Action
Proposed
Partner(s)
Proposed Lead
Target date
Proposed Outcome
through preferred
communication means
Increased access to
community contact &
support networks
Access to self care tools
monitoring equipment &
assistive technologies
10. Support people to access a range of
day opportunities that support their
needs
Day Service
Providers
Joint:
PCT Locality
Director
RBWM Adult
Services
Commissioning
Team
Within 1 year
Access to self care skills
training programs &
courses
Individual outcomes are
improved through
supportive day activities.
Interpersonal relations are
developed with reduced
social isolation. Daily
living and learning skills
are promoted through
energised programmes of
activities to which
members of day services
participate in the design of
Comments
Outcome 1: Promoting Independence and Preventing Dependency
Promote a healthy, safe and sustainable locality that seeks to maximise the impact on the health and well being for all adults living within the borough through
developing services that respect a person’s independence.
Proposed Action
Proposed
Partner(s)
Support the National Screening program
for LTC (40-74yrs)
BE PCT
Commissioning
BE PCT
A comprehensive evidence-based HIV
prevention program, integrated with
other initiative to promote sexual health
and reduce transmission of blood borne
viruses, should complement and involve
HIV treatment and care services
PCT
Commissioning,
Public Health /
RBWM, Policy
& Planning
BE PCT
PCT
Commissioning,
Public health
/Providers /
RBWM
BE PCT
Proposed Lead
 Encourage use of condoms for sexually
transmitted infections
 Work with the DAAT to raise awareness
of HIV in relation to drug taking
Work with pregnant women (and
families) to support and maximise life
opportunities
Target date
Proposed Outcome
Ongoing
Increase the
opportunities for early
identification and
management for LTC.
Prevent crisis points
being reached through
early interventions
promoting preventative
actions
Immediate
Standard 1 of
start – Ongoing recommended
Implementation standards for NHS HIV
services – Evidence
based HIV prevention
programme to promote
sexual health and
reduce transmission of
blood borne viruses.
Ongoing
Standard 8 of
recommended
standards for NHS HIV
services - Develop,
implement and monitor
Comments
Outcome 1: Promoting Independence and Preventing Dependency
Promote a healthy, safe and sustainable locality that seeks to maximise the impact on the health and well being for all adults living within the borough through
developing services that respect a person’s independence.
Proposed Action
Proposed
Partner(s)
Children’s and
Families Team
Proposed Lead
Target date
Proposed Outcome
policies that seek to
empower and support
pregnant woman with
HIV to maximise their
health and reduce
mother to child
transmission of HIV
Comments
Outcome 2: Dignity and Respect
Support & Care will be provided that ensures dignity and respect are at the heart of services for everyone, so people are free from discrimination or prejudice
and are safe from harm.
Proposed Action
1) Joined up planning with service
users, carers, partners and stakeholder
for effective outcomes and services
2) To develop easily accessible,
independent advocacy services for
people of working age with a LTC
(Independent Living Strategy)
Proposed
Partner(s)
RBWM, JCM
Manager, Policy
& Planning
Officer / BE PCT
RBWM: Policy
& Planning
Proposed Lead
Joint: RBWM
BEPCT
RBWM
Target date
Ongoing
and in line
with PPM
Ongoing
Proposed Outcome
Efficient use of
resources
Clarity for Users and
Carers
Prompt assessments
which will reduce stress
for users and carers.
Established effective
and coherent joint
working practices with
partner agencies.
Evidence of wider
community, Service
User and Carer
involvement in day-today and strategic
service planning.
Promote independence
Ensure services are
appropriate for
individuals
Ensure users choices
are considered
People are supported to
express their own views
and wishes through
appropriate and
accredited groups /
Comments
Outcome 2: Dignity and Respect
Support & Care will be provided that ensures dignity and respect are at the heart of services for everyone, so people are free from discrimination or prejudice
and are safe from harm.
Proposed Action
Proposed
Partner(s)
Proposed Lead
Target date
Proposed Outcome
organisations. Wishes
are respected and
supported wherever
possible with evidence
available when wishes
are not followed.
Mental Capacity Act is
fully embedded into
daily practice and
procedures
Representation is
readily available for
those who lack capacity
within eligibility of the
MCA
3) Continued development and
implementation of the Mental Capacity
Act
RBWM: Mental
Health Locality
Manager /
service
managers
RBWM
As MCA
directs
3a) Ensure Independent Mental
Capacity Advocacy (IMCA) services are
meeting the needs as defined in the
Mental Capacity Act
RBWM, Mental
Health Locality
Manager /
Berkshire MCA
Implementation
Team
RBWM
Ongoing
Representation for
those individuals who
lack capacity and
have no natural
support.
Offered to all who
meet criteria
4) Provision of advice & support to help
people feel safe & secure from crime
and anti social behaviour and its affects
RBWM:
Community
Safety)/ Thames
Valley Police
RBWM
Ongoing
Improved quality of life.
Ensure that all Service
Users are given advice
and support regarding
Comments
Outcome 2: Dignity and Respect
Support & Care will be provided that ensures dignity and respect are at the heart of services for everyone, so people are free from discrimination or prejudice
and are safe from harm.
Proposed Action
Proposed
Partner(s)
Proposed Lead
Target date
Proposed Outcome
personal safety
People’s homes are
safe and secure, alarms
and other aids support
safety and give
reassurance.
Social integration is not
diminished through fear
of crime in
neighbourhoods
Safety advice available
through variety of
initiatives
Advice and
information readily
available to maximise
the options available
to people to remain
independent
Service Users feel
that they are treated
with dignity and
respect. Externally
commissioned care
services are of a high
quality, meeting
cultural and diverse
5) Provision of advice and support
regarding the use of assistive
technology to support daily living.
RBWM: Tele
care lead,
Policy &
Planning
RBWM
Ongoing
6) Ensure that dignity & respect are an
integral part of service commissioning:
including planning, delivery, quality
assurance, monitoring and review
RBWM:
Contracting
Team
RBWM
Ongoing
Comments
Outcome 2: Dignity and Respect
Support & Care will be provided that ensures dignity and respect are at the heart of services for everyone, so people are free from discrimination or prejudice
and are safe from harm.
Proposed Action
Proposed
Partner(s)
Proposed Lead
Target date
Proposed Outcome
needs of Service
Users and evidencing
good outcomes for
individuals.
7) Access to better information and
support so that people can navigate
health & social care systems
(Independent Living Strategy)
RBWM / BE
PCT
Joint: RBWM
BEPCT
Ongoing
8) Work with RBFRS to reduce health
inequalities in the form of home fire risk
checks
RBFRS
RBFRS
Pilot start
Nov 08
9) Facilitate those within the eligibility
criteria to access Supporting People
services where appropriate
RBWM:
Supporting
People
Manager
RBWM
Ongoing
10) Palliative care arrangements shall
be based on personal choice with
RBWM Service
Manager
Joint: RBWM
BEPCT
Ongoing
Easy access to health
and social care systems
Access to information
for individuals and their
carers available in the
community
Service Users are
aware of risks and how
to negate them. People
are safe in own homes
with reduced associated
risks. Partnership
working at time of
Check supports access
to other services.
Active promotion of
services that reduce
chances of higher level
interventions being
required. Clear
information on eligibility
criteria for services.
Service Users choices
can be demonstrated as
Comments
Outcome 2: Dignity and Respect
Support & Care will be provided that ensures dignity and respect are at the heart of services for everyone, so people are free from discrimination or prejudice
and are safe from harm.
Proposed Action
Proposed
Partner(s)
Proposed Lead
support available for those bereaved.
(Older people)
/ BE
Community
Health
Service’s
11) Support & protect all adults from
abuse and neglect through pro-active
multi agency working.
RBWM, Policy &
Planning (LD),
Vulnerable
Adults coordinator / BE
Community
Health Services
12) Deprivation of Liberty Safeguards
(DOLS) - Ensure training for statutory,
voluntary and other stakeholder
organisations.
RBWM:
RBWM
Locality
Manager /
Mental Health,
Berkshire
Implementation
Group
/Training Team
PCT
BE PCT
Commissioning
/ Public Health
Supported provision of primary
healthcare for people with HIV diagnosis
Joint: RBWM
BEPCT
Target date
Proposed Outcome
being respected.
Holistic support services
are available and
supported for bereaved
Ongoing
Adult Protection
Committees are
effective and
arrangements upheld.
People are protected
against abuse
incidences are rare. All
staff in Health and
Social Care are trained
in VA processes
Joint needs assessment
completed to identify
provision required.
Followed by specialist
training ie. for Best
Interest Assessors
Training for staff across
all sectors
Fully
operational
from 1st
April 2009
Immediate
Standard 5 of
recommended
standards for NHS HIV
services - People with
Comments
Outcome 2: Dignity and Respect
Support & Care will be provided that ensures dignity and respect are at the heart of services for everyone, so people are free from discrimination or prejudice
and are safe from harm.
Proposed Action
Proposed
Partner(s)
Proposed Lead
Target date
Proposed Outcome
HIV should have
access to good
quality primary
healthcare provided
by local networks that
are sensitive to the
needs of those living
with HIV.
Comments
Outcome 3: Joint Commissioning
Where this will deliver better outcomes for individuals and cost-efficiencies for purchasing partners, we will engage in joint planning and commissioning of
services.
Proposed Action
1) Ensure Continuity between health and
social care through the provision of joint
holistic services where appropriate to do so.
Through the use of pooled budgets,
resources, management and governance.
Proposed
Partner(s)
RBWM, Head of
Adult Services /
BE PCT
Commissioning
Proposed Lead
Joint: RBWM
BEPCT
Target
date
Ongoing
and with
PPM
Project
Plan
2) Work in partnership with local agencies
and stakeholders to ensure effective delivery
of national strategies / frameworks and local
priorities relating to LTC.
RBWM: Joint
Commissioning
Manager / Policy
& Planning
Officers
RBWM
Ongoing
3) Embed into health and social care
communities an effective, integrated and
systematic approach to the case
management of people with a LTC
RBWM: Service
Managers
BE Community
Health Services:
Joint: RBWM
BEPCT
Ongoing
4) Continued development and
implementation of the single assessment
process
Service
Manager Older
People / Policy
& Planning (PD)
RBWM Policy &
Planning (MH) /
WMVA / BE
RBWM
Ongoing
Joint: RBWM
BEPCT
Ongoing
5) Jointly increase the use and support of
third sector and social enterprise service
providers who are able to offer required
Proposed Outcome
Health and social care
services work effectively
for the best outcome of
the Service Users by
offering seamless
transition through
services.
Transparency and
efficiencies in service
delivery
Effective delivery of
national strategies /
frameworks and local
priorities. Services
reflect national drivers
and direction
LTC integrated service
(+ people with a LCT
receive a long term
health & Social Care
plan / eligibility)
Integrated services
meeting the wider needs
of the individual
Increased effectiveness
through joint working
from private and
Comments
Outcome 3: Joint Commissioning
Where this will deliver better outcomes for individuals and cost-efficiencies for purchasing partners, we will engage in joint planning and commissioning of
services.
Proposed Action
specific support to those with a LTC
6) Provide services in the most convenient
settings that are throughout the Borough
boundaries
7) To work with Disabled Children’s team to
identify the LTC needs of transition age SU
for a seamless transfer into adult health &
social care
8) Support for the families of those with a
LTC, ensure that outcomes are reached
through joint working
Proposed
Partner(s)
PCT / RBWM
Partnerships
Manager
Joint :
Commissioners
BE PCT &
RBWM
RBWM: Adult
Service
Managers and
Teams.
Disabled
Children’s Team
/ BE PCT
BE PCT /
RBWM
Proposed Lead
Target
date
Joint: RBWM
BEPCT
Ongoing
Joint: RBWM
BEPCT
Ongoing
Joint: RBWM
BEPCT
Ongoing
Proposed Outcome
voluntary sector.
Convenient access to
local services. Wider
considerations taken into
account with service
planning (e.g. Public
Transport) Increased
take up of services can
be seen
Smooth transition from
children’s service to
adult services
Holistic support for those
effected by a LTC.
Standard 9 of
recommended standards
for NHS HIV services Families of those with
HIV should have access
to specialist adult and
pediatric multidisciplinary care
Comments
Outcome 3: Joint Commissioning
Where this will deliver better outcomes for individuals and cost-efficiencies for purchasing partners, we will engage in joint planning and commissioning of
services.
Proposed Action
To map local HIV & sexual health
services to highlight areas for
improvement and further work – to
include care pathway mapping
HIV operational work to be reviewed
along with funding arrangements for
services
Proposed
Partner(s)
Garden Clinic /
Thames Valley
Positive
Support
Garden Clinic /
Thames Valley
Positive
Support
Proposed Lead
Target
date
Proposed Outcome
including community
care and support
Joint: RBWM
BEPCT
Within 1
year
Identify gaps in
service and amend
action plan to meet the
gaps
Joint: RBWM
BEPCT
6-9
months
Further develop HIV
services, roles and
responsibilities including
integration with wider
council services and
other key partners
Comments
Outcome 4: Choice and Control
We will ensure that all adults living within the borough have significantly increased choice and control over the way they have their support and care needs
met and are able to make informed choices relating to the way their services are provided.
Proposed Action
Proposed
Partner(s)
Proposed Lead
Target
date
Proposed Outcome
1) Encourage the take up of
personalised / individualised budgets
and direct payments through a
supported process to enable people to
make informed choices.
RBWM: Direct
Payments
Team
RBWM
2011
Increased options for
self directed and self
managed care
through a range of
Direct Payments /
Individual Budgets
schemes. Support for
Service Users to
navigate the process
2) Work with partners to incorporate
assistive technology in housing
developments to support the needs of
people with a LTC and provide a
realistic alternative to residential care
RBWM: Housing
/ Tele care lead
RBWM
Ongoing
Increased independence
through Telecare
options are actively and
routinely promoted.
Reduced need for
domiciliary support for
some Service Users.
Innovative and
appropriate support
options for individual
outcomes
3) Empower people with long term
health and social care needs through
greater choice and control over their
care through a wide range of initiatives.
Individual choices are supported
through a positive risk management
process
RBWM: Service
Manager
RBWM
Ongoing
Evidence that
decision-making
processes are a joint
responsibility with
Service Users and
partners.
Development of
Comments
Outcome 4: Choice and Control
We will ensure that all adults living within the borough have significantly increased choice and control over the way they have their support and care needs
met and are able to make informed choices relating to the way their services are provided.
Proposed Action
Proposed
Partner(s)
Proposed Lead
4) People have choice and control over
their care and support needs as service
and care planning is focused and
assessed on individual outcomes
RBWM:
Service
Managers /
Policy &
Planning
RBWM
5) People can design their care around
health and social care services which
are integrated, flexible, proactive and
responsive to individual needs.
RBWM: Joint
Joint: BE PCT &
Commissioning RBWM
Manager /
Personalisation
Project
Manager
Target
date
Ongoing
Ongoing
Proposed Outcome
different services
based on local needs
assessments
Revised Care plans to
be outcome based.
100% of service users
have an agreed care
plan that is regularly
reviewed
Individual Needs
Assessment
Person-centered &
integrated care planning
Integrated working:
health & social care,
with multi-disciplinary
teams
Partnership working
between primary &
secondary care
IT systems to support
information sharing
Comments
Outcome 4: Choice and Control
We will ensure that all adults living within the borough have significantly increased choice and control over the way they have their support and care needs
met and are able to make informed choices relating to the way their services are provided.
Proposed Action
Proposed
Partner(s)
Proposed Lead
Target
date
Proposed Outcome
Service redesign –
primary care, secondary
care and community
services to have
resources and capacity
to provide more services
in the community
Health & social care use
a holistic approach to
creating services around
individuals
24/7 cover
6) Expand the use of self assessment /
self review
RBWM:
Assessment &
review teams /
policy &
planning
RBWM
Within 1
year
Practice-based
commissioning & joint
commissioning for
outcomes
Evidence people are
actively involved in the
planning and design of
their care services and
supported through
advocacy services when
needed. Service options
are sensitive to
individual’s cultural and
Comments
Outcome 4: Choice and Control
We will ensure that all adults living within the borough have significantly increased choice and control over the way they have their support and care needs
met and are able to make informed choices relating to the way their services are provided.
Proposed Action
Expand the use of sexual health clinics
in the Borough and maintain access
rates for GUM clinics
Proposed
Partner(s)
RBWM / BE
PCT
Commissioning
Proposed Lead
Joint: RBWM
BEPCT
Target
date
Immediate
Proposed Outcome
gender requirements
JSNA identified need
– Clinic in Windsor
Comments
Outcome 5: Effective Commissioning and Procurement
We will commission services to clear standards of both quality and cost, by the most effective, economic and efficient means available. This will enable us to
increase capacity into the future by commissioning and procuring social care differently so as to meet the growing and changing need for a range of services.
Proposed Action
1) To facilitate a local market for a range
of services so that service users
accessing an individual budget / direct
payments can have a wide range of
service providers
Proposed
Partner(s)
RBWM: Joint
Commissioning
& Policy &
Planning
Target
date
Proposed Lead
RBWM
Ongoing
A thriving and varied
local provider market,
responsive to
individual support
needs and outcome
focussed.
Service Providers feel
supported by RBWM
through collaborative
approaches. Service
Users are confident in
the services
commissioned and
concerns regarding
services are low
Stroke service are in
place within the
Borough
2) Shape, build & support external
service providers to create a strong,
varied, flexible market in social care and
health.
RBWM, Joint
Commissioning /
BE PCT
RBWM
Ongoing
Develop a range of community based
Stroke Services reflective of the
particular needs of this group and in line
with the quality Markers within the
National Strategy
PCT / RBWM,
Joint
Commissioning
Manager /
Public Health
BE PCT
Commence
by April
2009
Proposed Outcome
Comments
Outcome 6: Equality of Access
Services will be accessible, responsive, non-discriminatory, and provided in line with the Fair Access to Care standards. We will work with partners to ensure
universal services are developed to which all adults can have access (e.g. sports, leisure, cultural, educational, training, transport and employment services).
Proposed Action
1) Work with transport service providers
to facilitate the use of specialist or
community based transport provision for
people with a LTC.
Raise awareness of the transport needs
of this group, to include access to
services and facilities by public
transport, walking or cycling.
2) Ensure that services are culturally
appropriate/sensitive to the needs of
service users
Proposed
Partner(s)
RBWM:
Transport Policy
Officer
Proposed Lead
RBWM
Target
date
Ongoing
RBWM / PCT
Joint: RBWM
BEPCT
Ongoing
3) Improve the social networks of those
with LTC to reduce social isolation and
improve community integration e.g.
supporting / facilitating access to
community services
RBWM / BE
PCT / Grow
Your Own
Joint: RBWM
BEPCT
Ongoing
4) Consult with stakeholders & partners
when developing services for people
with a LTC to ensure services are
RBWM: Joint
RBWM
Commissioning
Manager
Ongoing
Proposed Outcome
Independence and
access to community
services are
encouraged. Reduced
levels of social
isolation and
increased use of
services.
Service providers are
able to support individual
needs and wishes.
Communication of needs
and wishes are
encouraged and
supported through extra
provision when needed
Reduce social isolation,
encouragement of
volunteering and
involvement in
community schemes.
Increase interpersonal
relationships though
social integration
1. Efficient use of
resources
2.Clarity for Users and
Comments
Outcome 6: Equality of Access
Services will be accessible, responsive, non-discriminatory, and provided in line with the Fair Access to Care standards. We will work with partners to ensure
universal services are developed to which all adults can have access (e.g. sports, leisure, cultural, educational, training, transport and employment services).
Proposed Action
Proposed
Partner(s)
Proposed Lead
Target
date
outcome focused
Proposed Outcome
Carers
3. Services are proven
to be of benefit to
service users
5) Facilitate personal learning in regard
to the understanding and managing of
individual condition(s)
BE PCT
BE PCT
6) Provision of one stop approach to
access Information & Services
RBWM:
Service
Manager and
Team Managers
Joint: RBWM
BEPCT
By 2011
Support Sexual Health needs in the
community for people with a HIV
diagnosis
BE PCT
Commissioning /
Public Health
BE PCT
Ongoing
People are able to
manage their own
conditions.
Reduced need for
hospitalisation.
LTC integrated service
Comply with NHS and
social Long Term
Conditions model
(published 2005)
A range of clear,
accurate and accessible
information is available.
Signposting is minimal,
but effective and a “no
door is the wrong door”
policy is adopted
Standard 7 of
recommended
standards for NHS
HIV services - All
people with HIV
Comments
Outcome 6: Equality of Access
Services will be accessible, responsive, non-discriminatory, and provided in line with the Fair Access to Care standards. We will work with partners to ensure
universal services are developed to which all adults can have access (e.g. sports, leisure, cultural, educational, training, transport and employment services).
Proposed Action
Proposed
Partner(s)
Proposed Lead
Target
date
Proposed Outcome
should receive
comprehensive sexual
healthcare integrated
with their HIV
specialist care
Comments
Outcome 7: Workforce Development
With partners we will develop a workforce capable of delivering the vision of our strategic priorities
Proposed Action
1) Encourage staff innovation and new
ways of working in order to optimise
capacity of resources
Proposed
Partner(s)
RBWM: Service
Manager
Proposed Lead
RBWM
Target
date
Immediate
Ongoing
2) Develop shared approaches to
service development and training to
disseminate best practice across partner
agencies
3) Increase capability: to ensure people
working in Social Care have the skills
and support they need to deliver
services effectively to achieve personal
outcomes for service users.
RBWM:
Workforce
Development
Manager
RBWM
RBWM: Joint
RBWM
4) Workforce planning will be updated in
Joint:
Workforce
Development
Teams
line with national guidance (e.g.
Personalisation) to ensure that practices
are reflective of national strategies
commissioning
manager &
Workforce
Dev. manager
Ongoing
Joint: RBWM
BEPCT
Ongoing
Proposed Outcome
A comprehensive
workforce development
plan reviews how the
skills of the workforce
(at all levels) can be
utilised effectively. Staff
feel supported to
explore new ways of
working and
management of risks.
Efficient use of
resources and shared
expertise.
Staff are supported and
utilise training
opportunities.
Continuous professional
development is
encouraged to beyond
minimum standards
Flexibility of
processes of
workforce
development. New
developments can be
included in staff
Comments
Outcome 7: Workforce Development
With partners we will develop a workforce capable of delivering the vision of our strategic priorities
Proposed Action
5) Support continuous professional
development of staff in the health &
Social Care sector through shared
training opportunities
Proposed
Partner(s)
RBWM / BE
PCT Education
& Training
Depts
Proposed Lead
Joint: RBWM
BEPCT
Target
date
Ongoing
Proposed Outcome
planning with ease
Flexibility of
processes of
workforce
development. New
developments can be
included in staff
planning with ease
Comments
Outcome 8: Economic Well-being and Sustainability
We will work in partnership to ensure that the residents of the borough have access to economic opportunities such as income and resources for a healthy
lifestyle and feel able to participate in family and community life.
Proposed Action
1) Work with the Welfare Benefit /
Revenue & Benefits teams and partner
agencies to proactively distribute benefit
information and advice
Proposed
Partner(s)
RBWM: Head
of Revenues &
Benefits /
Proposed Lead
Target
date
Ongoing
Service users are
able to access all
benefits that they are
entitled to
RBWM
Ongoing
Increase training
opportunities and
employment
placements.
Welfare Benefits
team / Work &
Pensions
2) Encourage people with LTC to access RBWM: WIW
WIW services to enable financial
independence
Proposed Outcome
RBWM
Comments