evaluation of preventative models and approaches in west wales

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WEST WALES CARE PARTNERSHIP

Evaluation of Preventative Models and Approaches in West Wales

Practice Solutions Ltd

Authors:

Heulwen Blackmore

Tony Garthwaite

Catrin Awoyemi

April 2018


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Contents

Introduction .................................................................................................................................................... 3

Universal Services and Interventions ................................................................................................................ 6

Support for Carers .......................................................................................................................................... 8

Effective Information Advice and Assistance ........................................................................................... 10

Supportive Children’s Services ................................................................................................................... 12

An emphasis on Independence .................................................................................................................. 13

Collaboration and Partnership ................................................................................................................... 15

Recognising Rurality .................................................................................................................................... 16

Prevention as part of a Continuum of Support ........................................................................................ 17

Sustainability ................................................................................................................................................ 19

Co-production ............................................................................................................................................... 21


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Introduction

This section provides a narrative evaluation of preventative approaches within the area covered by the

West Wales Care Partnership. With evidence from data, documentation, interviews, meetings and self-

assessment returns, we have built a high-level picture of the current position in region using ten themes.

It is important to point out that this picture is at a specific moment in time. What is very clear is that the

situation has developed rapidly since the project began only a few months ago, and continues to develop.

For example, Ceredigion is introducing new arrangements to complement its existing preventative

approaches in the form of Porth Y Gymuned and Clic; Delta Wellbeing has been launched in

Carmarthenshire; Pembrokeshire has worked with Swansea University to develop a set of outcomes for

prevention. DEWIS CYMRU is being populated apace, to provide an online repository of information which

will include initiatives that provide “low level” prevention and intervention. Nationally, the Association of

Directors of Social Services Cymru (ADSSC) has published principles for Information, Advice and Assistance,

and Social Care Wales has developed a competency framework for IAA which is yet to be published. This

snapshot provides a taster of the significant changes occurring.

Preventive services1 represent a continuum of support ranging from “primary prevention” aimed at

promoting wellbeing, through to secondary or early intervention, to the most intensive, 'tertiary services’

such as intermediate care or reablement. Primary prevention is generally designed for people with few

social care needs or symptoms of illness. The focus therefore is on maintaining independence and good

health and promoting wellbeing. The range of these 'wellbeing’ interventions includes activities to reduce

social isolation, practical help with tasks like shopping or gardening, universal healthy living advice,

intergenerational activities and transport, and other ways of helping people get out and about.

The scope of the evaluation

Prevention and Preventative Services at the “lower level” end of the continuum is what we have explored

in undertaking this work. Our focus has been on the West Wales region as defined within the SSWBA – the

region covered by the Hywel Dda Health Board. We are very mindful of the important relationships, historic

and current, with other areas and regions, and understand that this will form part of the consideration in

taking this work forward.

The definition we use of prevention and preventative services is that they:

Are a means by which people are enabled to live full and active lives, maximising their well-being, and

maintaining the degree of independence of their choice.

Prevent, delay and reduce the development and escalation of needs by ensuring people receive the

right information, advice and support in the right way and at the right time, and engaging effectively

with individuals and communities.

Ensure the risk of developing specific health or adverse living conditions, or experiencing certain

negative events, is identified at the earliest possible time.

Support people to recover from the problems they have experienced as quickly as possible, helping

them to regain skills, resume purposeful lives and successfully manage ongoing debilitating conditions.

1 https://www.scie.org.uk/publications/briefings/briefing39/


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Overview

Our overall evaluation suggests that there is a clear desire and commitment to adopt a preventative

approach to care and support in the West Wales region evidenced by some statements of strategic intent

and a number of collaborative initiatives. Communities are being increasingly supported to be more

resilient and people presenting as needing support are receiving appropriate and supportive information,

advice and assistance. External funding is being used to provide preventative services and kick start new

ideas.

However, the approach being followed is not yet consistently embedded in practice and the ability to

sustain it over the long term is uncertain because of the absence of permanent core funding. The benefits

of regional working are not universally understood and are being hampered by fears of it leading to an

inappropriate “one size fits all” approach. Opportunities to adopt prevention via regional collaborative

working have not yet been optimised and important ingredients of the prevention agenda, such as

providing robust support for carers, need strengthening. The use of Technology Enabled Care is limited and

needs a clear strategic direction and funding in order to enhance the preventative approach.

Fundamental and familiar challenges around addressing issues affected by rurality and the availability of

sufficient funding are inherent in the West Wales region and will continue to need bespoke and innovative

attention to overcome. The need to be clear about what works and build on best practice will be

increasingly important and will need to be based on a co-productive approach whereby the assets of

communities are fully utilised and citizens are supported effectively to find their own solutions to the issues

they face.

Emerging findings

An interesting dimension of our research has been the need to examine initiatives within the three local

authority areas and across the region as a whole. This has brought into sharp focus the challenges of

regional, cross boundary and cross sector working, and the complex issues of balancing the need to

recognise local accountability and initiative with the potential advantages of working on a wider

geographical and organisational footprint. We wish to make clear that our definition of an effective

regional approach is not synonymous with notions of “one size fitting all”. Operational service delivery is

inevitably a local activity but its design and strategic approach can be arranged on a broader basis.

The main features we would expect to see in good regional working are evidence amongst all the

constituent bodies of a shared vision and purpose, a clear mutual understanding of the benefits, challenges,

risks and potential disadvantages of a regional approach, a commitment to, and demonstration of, learning

from each other, and collaborative leadership at the political and executive level. We believe that a shared

approach to some of the structural issues like shared governance and pooling of resources will help to

create an environment where more complex matters such as generating trust and sharing sovereignty can

be tackled.

Our view is that there is a desire within West Wales to explore and adopt regional approaches where

appropriate but this needs to mature to a point where consideration of regional solutions to problems and

challenges is implicit within the work of all the agencies. The rationale for differences in operational

approaches will then become clearer and a sense of “either local or regional” will be replaced by one of

“both local and regional”.


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Evaluation themes

The themes are based on the requirements and the spirit of the SSWBA. Under each theme is a standard in

the form of a statement. The first five statements describe “what” an effective prevention framework

should comprise and the second set describes “how” it should be planned and delivered.

We have included a small number of examples taken from data, documentation, interviews and meetings

and self-assessment to highlight the rationale for our evaluation.

Theme Statement

Universal services and interventions

We will promote well-being via effective universal services and interventions, such as developing community resilience and connectivity, Technology Enabled Care (TEC), promoting individuals’ strengths, public health campaigns and healthy living initiatives.

Support for carers We will support carers to lead fulfilled lives alongside their caring role.

Effective information, advice and assistance

We will proactively identify individuals who would benefit from preventative support, and help people access such support via good quality information advice and assistance.

Supportive children’s services

We will promote the upbringing of children by their families, where that is consistent with the well-being of those children, and avoiding the need for children to become looked after by the local authority.

An emphasis on independence

We will enable people to live their lives as independently as possible.

Collaboration and partnership

We will create and manage our approach collaboratively involving the whole of the local authority and health service, including GPs, and the third sector.

Recognising rurality We will build in to our design approaches to overcome barriers in specific communities, e.g. rural communities.

Prevention as part of a continuum of support

We will view prevention as part of a ‘continuum’ of different support, and linking elements provided by the third sector and other partners to that which is provided or commissioned by local authorities.

Sustainability We will ensure our approaches are sustainable.

Co-production We will support people to engage as fully as possible with finding their own solutions.


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Universal Services and Interventions

There is clear evidence of a strategic and operational approach to promoting a range of universal services

and interventions across the region. Asset based approaches are used, along with the “What matters”

conversation. There are examples of effective joint working within and between agencies – local

authorities, health and the third sector. The fact that there is a multi-agency Board with a senior person

leading this agenda is significant, as is the role of the third sector as a partner on the Board.

The scope and range of universal services goes wide, including, for example. housing, education, leisure,

primary care. These all contribute to well-being and have a key role to play in prevention. However, for the

purposes of this project, we have deliberately kept a focus on the role within the WWCP of the Health

Board, Social Services and the Third Sector.

Several impressive initiatives are supporting communities to be more resilient. The importance of the third

sector in supporting and developing community resilience has been highlighted. In each local authority

area, the third sector works with statutory partners to directly deliver services. The role of the CVCs has

been identified as a central plank of this work at a strategic level, however the role differs in local authority

areas.

There have been positive successes in accessing finance from the Integrated Care Fund (ICF) which has

helped to provide services and kick start initiatives. Local authorities have successfully accessed funding to

support community projects and the input of the health board has enabled projects like social prescribing

and Investors in Carers.

We were provided with many examples of the work done to support and promote community resilience.

These include approaches, campaigns and projects such as:

Working with schools to teach children and young people techniques to look after themselves

Team around the Family

Healthy lifestyle advisers and healthy heart advisers

Pembrokeshire Intermediate Voluntary Organisations Team (PIVOT)

Community Connectors in Pembrokeshire and in recruitment in Ceredigion

Community Resilience Co-ordinators in Carmarthenshire

Carmarthenshire United Support Service (CUSP)

Social prescribing

Lifestyle advocates

Timebanking

Findings

The role of Community Connectors and Community Resilience Co-ordinators has been identified as key to

supporting and promoting community resilience. However, we are not clear that there is common

understanding more widely across the region of their role. Issues have been identified with respect to

capacity and coverage. Within the parameters of this project, there is insufficient evidence to conclude that

all those initiatives affecting community resilience add up to a cohesive prevention strategy. There are

opportunities to consider how CVCs could and should be further involved at a strategic level to underpin

community resilience in a consistent and equitable way across the region. Continued access to the ICF will


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help but it is important that the learning opportunities provided by the fund are maximised to ensure that

best practice is rolled out across the region.


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Support for Carers

There is clear evidence of support for carers in each local authority area, with a range of resources to

support carers to lead fulfilled lives alongside caring. Priorities have been identified within the area plan

which are identifying and recognising carers, supporting carers to lead fulfilled lives alongside their caring

role and providing information, advice and assistance to carers when they need it.

All authorities and the health board have identifiable carer leads and demonstrate a commitment to

supporting carers. IAA staff have had training to identify and signpost carers. There is engagement with

young and adult carers, education, school and community events and a dedicated young carers

worker/team.

All local authorities have, or are in the process of developing, a Carers’ Strategy or Action Plan.

Carers are a priority in the Population Needs Assessment and the Area Plan. There are Carer Information

Centres, Carers’ Units, peer groups, carer forums, support and activities for young carers, and newsletters.

Investors in Carers, which support the identification of carers, is one important example which also

demonstrates positive integrated working in the region. Investors in Carers is in place in all authorities and

has been cited as an exemplar by Welsh Government. Feedback is gathered from carers routinely to inform

future support. Some comments on a rest and relaxation day indicate the impact of “low level” prevention:

“I feel supported for what I do”.

“Means a day where I don’t have to keep thinking - I must do this, that and the other today”.

“Reflection and self-care”.

Carers identified some key challenges around transport and rurality, identifying lack of choice with respect

to domiciliary care as impacting in some areas. Direct payments were cited as an important way of

supporting carers, however, the challenges in managing arrangements could put additional burdens on

carers.

The number of unpaid carers (see table 1) are predicted to increase in Wales and West Wales from 2017 to

2035. The numbers of younger adult carers (aged under 65) are predicted to decrease while the numbers of

older carers are predicted to increase. We can assume that older carers may need more care and support

themselves to be able to provide unpaid care, and we know that being in a caring situation puts carers own

well-being under threat. Preventative services for carers will be key in reducing their own likelihood of

needing care and support.

Carers aged 65-74 are predicted to increase by about 10%, carers aged 75-84 by more than a third and

carers aged 85 and over to double by 2035. There will be an additional one thousand people aged 85 and

over providing unpaid care in West Wales by 2035.


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Table 1

Findings

Supporting carers is fundamental to any preventative approach. We identified a commitment to supporting

carers, committed staff and some imaginative ways of supporting the identification of carers. However,

there is some, albeit limited, evidence that carers are not fully aware of the range of resources available to

them, and therefore not taking full advantage of the support available. This may be due to the nature of the

pressures they face in their caring role or problems with communication systems.

The WWCP well-being survey findings 2016 showed that many people needing care and support are

receiving this from their families. The proportion of respondents who said that this was the case was 81% in

Carmarthenshire, 71% in Ceredigion and 85% in Pembrokeshire. This contrasted strongly with the numbers

reporting to be in receipt of LA care, the corresponding figures being 6%, 8% and 11%. Given the

demographic predicted, the importance of supporting carers is highlighted.

To get prevention right you must get support for carers right and we advise that current strategies and

initiatives to support carers should be reviewed to ensure they form a central plank of any prevention

strategy. Strategies need to be followed by concerted and coordinated action. Building on the good work

across the region to support and empower carers, it is important to work co-productively with carers to

ensure that points of access and the type of support available is clear and easy to find.

Unpaid carers, 2017 and predicted 2035

Hywel Dda Wales Hywel Dda Wales 2017 2035 2017 2035 2017 to 2035 2017 to 2035

Number 000s Number 000s % change No change

000s % change No change

000s

Under 65

Providing 1-19 hours of unpaid care 21 21 171 169 -3 -0.7 -1 -2.3 Providing 20-49 hours of unpaid care 5 5 41 40 -3 -0.2 -1 -0.5 Providing 50+ hours of unpaid care 8 8 63 62 -3 -0.3 -1 -0.9

65-74 Providing 1-19 hours of unpaid care 4 4 29 32 5 0.2 13 3.6 Providing 20-49 hours of unpaid care 1 1 9 10 5 0.1 13 1.1 Providing 50+ hours of unpaid care 3 4 25 28 5 0.2 13 3.2

75-84 Providing 1-19 hours of unpaid care 1 2 10 13 34 0.5 37 3.5 Providing 20-49 hours of unpaid care 1 1 4 6 34 0.2 37 1.6 Providing 50+ hours of unpaid care 2 3 16 22 34 0.7 37 5.9

85+ Providing 1-19 hours of unpaid care 0 1 2 4 112 0.3 107 2.0 Providing 20-49 hours of unpaid care 0 0 1 2 112 0.1 107 0.9 Providing 50+ hours of unpaid care 1 1 4 8 111 0.6 107 4.3

All ages 48 50 375 397 4 1.8 6 22.4

Source: Daffodil


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Effective Information Advice and Assistance

Each local authority provides its own Information, Advice and Assistance (IAA) Service as required by the

SSWBA. The approaches are designed around outcomes and the “What matters?” conversation. Careline is

delivered by Carmarthenshire and used across the region.

Staff receive training to support the crucial first conversation. The design of the IAA Service, the number of

staff, the type and level of training, the numbers of contacts and onward referrals are different in each

area. The rationale for the differences is not entirely clear. DEWIS Cymru provides a repository for

information on services and providers and is an important tool for practitioners but must be supplemented

by local intelligence to be effective.

Evidence demonstrated that training to support this vital first conversation varies in the statutory and third

sector and in different authorities. We have not seen evidence of the use of tailored training designed to

support Community Connectors or Community Navigators, inevitably people have been resourceful and

used trusted skills and expertise, and identified and adapted suitable training material. The training

resources available through Social Care Wales has been used in some cases, and NVQ level 4 training in

others. We have not seen evidence of a regional approach to training or resourcing training, but

understand that SCDWP resources are a possible source.

A range of ways of accessing information, advice and assistance was identified. These included:

DEWIS Cymru and InfoEngine;

The IAA single point of access;

Community Connectors, co-ordinators within school and family centres;

Social prescribing

Front of house advice from Children's Referral Team, Family Information Service, Flying Start, Edge

of Care services.

Examples of a multi-agency approach and co-location are in place. In Ceredigion, Porth Gofal provides a

multi-agency approach. In Pembrokeshire the IAA team is co-located within the call centre; in

Carmarthenshire Dewis Sir Gar is an integrated multi-agency service.

When looking at the data (see table 2) there appears to be a significant difference in the use of the IAA

Service and the numbers having an assessment of need for care and support. The IAA Service in

Pembrokeshire appears to be dealing with a much higher volume of requests than Ceredigion and

Carmarthenshire and generally across Wales. For adults, information on the numbers of people receiving

advice or assistance from the IAA Service shows a large variability in the numbers of contacts made. This

may be because of the differences in design and approach of the services, the way of recording or a

combination, but requires further consideration.


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Table 2: Assessments 2016-17 IAA

Findings

We are not clear how the information gathered by each IAA Service informs strategic planning, thereby

fulfilling the potential of the IAA Service as a strategic as well as operational development. The work on

principles for IAA by ADSS Cymru2 provides a helpful resource supporting consistency of approach across

Wales. Taken together with the emerging work by Social Care Wales3 on an IAA Competency Framework for

staff delivering IAA, it is a basis for standards for the region. We have adapted these into a draft set of

standards for consideration as part of the proposed framework.

The strategic benefits of good information, advice and assistance need to be maximised.

Key to an effective system is making it as simple to access as possible. The significance of the IAA approach

is that it is much more than a replacement for previous traditional intake and duty systems or for that

matter, generic contact arrangements. IAA is a fundamental part of the prevention agenda and there is

evidence that this is understood in West Wales not least by the commissioning of this project. However,

whilst recognising both the relative infancy of IAA following the implementation of the SSWBA and the

value of locally led approaches, the task in the next few years will be to ensure that:

a) the resources attached to each IAA approach are appropriate to need;

b) opportunities are taken to explore the benefits of a regional or sub-regional approach to IAA;

c) data obtained via IAA should be consistent and used to improve the service and influence strategic

developments;

d) learning from the different approaches currently in place is shared regularly and routinely across

the region.

2 Principles for Information, Advice and Assistance, January 2017 3 IAA Competency Framework (draft)

Assessments 2016-17

1 Number of adults who

received advice or assistance from the

IAA service during the year

2 Number of

assessments of need for care and support undertaken during

the year

2.1 Of those, the number that led to a care and

support plan

2.1 Of those, the percentage that led to

a care and support plan

Rate of IAA contact per 10,000 population

aged 18+

Wales 53,464 70,303 20,886 30 215 Ceredigion 321 2,195 427 19 52 Pembrokeshire 4,323 3,193 1,315 41 433 Carmarthenshire 649 3,906 1,281 33 44

Source: Welsh Government, Adults receiving care and support


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Supportive Children’s Services

Several people advised us that the preventative approach for children’s services is long standing and well

understood through, for example, Team around the Family and Family Intervention Services. For example,

the “through age” approach in Ceredigion building on work with children and families around transition.

Organisational structures can support positive preventative working with children in the arrangement in

Carmarthenshire, where the Department for Education and Children is responsible for children’s services,

education services, curriculum wellbeing, school effectiveness and strategic development. This is

exemplified by the fact that challenges and problems that previously may have required organisational

solutions are now being addressed through conversations amongst colleagues. We were informed of the

range of successful activities for young carers in place; for example, projects working with siblings and

young adult carers. A new Community Connector role in Pembrokeshire has been established for children

and families and is reported to be having some success.

In considering available data, we have identified the fact that the number of households with dependent

children is predicted to rise between 2017 to 2035 in West Wales, that is an additional one thousand

families. This is despite the fall in in population of adults aged 18-64 and fall in number of children. The rise

is due to the rise in numbers of households with one adult and dependent children (increase of 19% or two-

thousand households) and converse fall in number of households with two adults and dependent children

(2% or 1 thousand households). See table 3.

It is difficult to be precise, but it seems reasonable to conclude that households with one adult and

dependent children may need more care and support than households with two adults as the challenge of

raising children is greater without a partner’s support.

Table 3: Family situation and parental health for children, 2017 and predicted 2035

Findings

Preventative approaches are part and parcel of the way in which services to children and families are

managed and will continue to be so. The challenge will be to ensure that operational performance matches

strategic intent evidenced by tangible better outcomes for children and reduced numbers of children

becoming looked after.

2017 2035 2017 2035 Change 2017 to 2035

West Wales Wales West Wales Wales

Numbers 000s % No 000s % No 000s

Households with dependent children

All households 43 45 366 374 3 1 2 7

2+ adults and dependent children 32 31 274 269 -2 -1 -2 -5

1 adult and dependent children 11 13 92 105 19 2 14 13

1 adult and 3+ dependent children 1 1 13 13 5 0 4 1

Parental health, mother with

Longstanding illness 20 19 166 164 -1 0 -1 -1

Smokes 10 or more cigarettes per day 17 17 146 145 -1 0 -1 -1

Drinks alcohol 5 or more times a week 4 4 37 37 -1 0 -1 0

Who misuses drugs 3 3 22 22 -1 0 -1 0

Depression or serious anxiety 8 8 65 64 -1 0 -1 -1

High psychological distress 3 3 23 23 -1 0 -1 0

Medium psychological distress 22 22 185 183 -1 0 -1 -2

Obese or morbidly obese 12 11 97 96 -1 0 -1 -1 Source: Daffodil


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An emphasis on Independence

Every local authority evidenced a tangible commitment to preventative approaches and to supporting

people to maintain their independence. The priority of prevention is re-enforced in the Population Needs

Assessment, in the area plan and in strategic documents. It is also demonstrated by the work in place at a

community resilience level and by the Information, Advice and Assistance Services in place.

We identified a range of ways of ensuring that people are supported to live independently. These included

the provision of domiciliary care, equipment, adaptations and Technology Enabled Care. There are projects

such as PIVOT and CUSP in place, Community Connectors and Community Resilience co-ordinators.

Networking and signposting, and supporting people to access low level and statutory services are evident

within the approaches we have seen. Carers identified attendance at a well-being and resilience course as

being beneficial to their own well-being and supporting their independence.

In discussion with stakeholders we were advised that accessing support is a challenge (which is also

highlighted under rurality) limiting choice. There were also points made around communication specifically

that you need to be aware of what’s available to be able to access it. Effective signposting is crucial to help

people navigate the system.

Interestingly, the data identified issues that may be more about recording or a need for discussion –

notably data around recreational, leisure and lifelong learning opportunities which are universal services

which can help maintain well-being and independence.

When considering the data at table 4, we can see a range of services that potentially promote

independence and can be part of the continuum of prevention: respite, reablement, adaptations, telecare,

advocacy and recreational, leisure and lifelong learning opportunities. These services are more than just

preventative services but could be major contributors to the prevention agenda. Looking at the proportions

of these services across the region and Wales, it appears that local authorities use these services in

different volumes, perhaps in relation to need or local strategies. For example, it is reported that 24% of

Ceredigion’s provided services are reablement, 8% in Pembrokeshire and none in Carmarthenshire.

Pembrokeshire is reported as providing many telecare services at 29%, compared to 15% across Wales, 3%

in Ceredigion and 23% in Carmarthenshire.

In considering the data, however, it’s worth noting that Welsh Government data on adults receiving

services is new for 2016-17; it has been developed to reflect the new Act. As the data collection is in

development it is imperfect. Not all local authorities were able to provide fully completed returns, due to

issues with implementing or preparing for the new Welsh Community Care Information System (WCCIS)

computer system. It also takes time for definitions to become embedded and recording to become

consistent across local authorities.


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Table 4

Findings

Promoting independence is a significant cross-cutting theme within the prevention spectrum. We are sure

that staff across the region have the aim of promoting independence at the front of their minds when

engaging with people about their care and support needs. We are less clear whether this translates into an

understanding that helping people to help themselves is fundamental to an effective preventions model.

We believe, therefore, that making the connection between independence and prevention and then taking

action to back this up will require continued commitment to embed.

As an example of what we mean, we would refer to the use of Technology Enabled Care (TEC). Informal

discussions amongst the local authorities are taking place with decisions on Technology Enabled Care

(TEC)’s future role and usage currently held in suspense pending decisions on what the shared vision of TEC

should be, and issues like the introduction of the Barcelona model. Some ideas being floated include having

a 3 to 5-year business plan in place which reflects the need for TEC to have been considered as an

alternative to a care package prior to a case going before an assessment panel.

Understanding the value of TEC, and using it as both an assessment tool and facilitator of independent

living, is not embedded in practice. It sometimes features as an operational solution but is not part of an

overall strategic approach. Current examples of TEC being used are Lifeline, community alarms, bed

sensors, epilepsy sensors, Canary home monitoring and Oyster watches. Rally Round is an innovative

development with potential for piloting which has been identified. There are examples of the use of TEC

across the region, but the rates of take up vary. This leads to the conclusion that overall, there is limited use

of TEC and its potential as a preventative aid is not being optimised.

Adults receiving services by service 2016-17 a) Numbers

Wales

West Wales

18-64 65+ 18+ 18-64 65+ 18+

Total of services (volume) 35,611 111,577 147,336 4,685 17,951 22,899

Domiciliary care 5,370 26,315 31,685 357 3,403 3,760

Day Care 3,206 4,951 8,157 589 812 1,401

Respite Care 1,482 3,982 5,464 190 722 912

Reablement 1,052 10,739 11,791 284 1,618 1,902

Equipment 5,744 18,147 23,891 852 3,481 4,333

Adaptations 3,113 7,084 10,197 356 546 902

Direct Payments 3,684 2,175 5,859 660 280 940

Supported Accommodation 2,393 725 3,118 283 54 337

Sheltered Accommodation 338 1,196 1,534 - - -

Adult Placements 445 79 524 108 16 124

Adult care home (without nursing) 1,709 10,521 12,230 396 1,974 2,370 Adult care homes with nursing 305 5,260 5,565 18 483 501

Telecare 2,262 15,270 17,532 373 3,500 3,873

Advocacy 328 286 762 9 3 12

Recreational, leisure and lifelong learning opp’s 2,270 350 2,620 - - - Other 1,910 4,497 6,407 473 1,059 1,532

Total number of adults supported (count) 19,963 62,598 82,561 1,845 6,230 8,075

Population 1,863,850 646,960 2,510,820 222,560 92,880 315,430

Rate of adults supported per 10,000 population 107 968 329 83 671 256


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Collaboration and Partnership

There are significant examples of collaboration and partnership in the region and strategies and plans

display a commitment to collaborative working around the prevention agenda (and wider). The region’s

own documentation supported the approach as collaborative. We noted a draft document developed

across the region which we understand currently has no formal status, but which sets down a common

approach to prevention for the region.

We recognise that resilience and wellbeing are rooted in our families and communities and we are

committed to enabling these supportive networks.

Adopting a continuum to meet a person’s care and support needs recognises that a person’s physical and

mental health and emotional well-being are best met by access to supportive universal services while in

some cases addressing the issues that may require more intensive intervention.

People will be able to make informed choices about the care and support they require based on information

and advice including that available from Social Care via DEWIS Cymru.

It is anticipated that most preventative activity and early intervention will be located and delivered in the

community. However, in some circumstances, some local authority services can be categorised preventative.

Sometimes these services will be more intensive assistance which requires a short-term response, other

times it will be long term low level care and support which prevents a person developing other care and

support needs or delays the development of those needs. As a result, Carmarthenshire County Council,

Ceredigion County Council and Pembrokeshire County Council have agreed a list of services which they

provide, that they believe fall within the definition of a preventative service. It should also be noted that a

number of these services have been discussed with Welsh Government who agree with the local authority’s

interpretation that these particular services are preventative in nature.

Source: draft/ working document WWCP

Findings

There are examples of good relationships between agencies and good practice in working together. For

example, there is a multi-agency, Regional Board for Prevention, a clear commitment to preventative

approaches and positive interagency working in each local authority area. There is also some pioneering

work around integrated commissioning. Collaboration is also with third sector partners who are involved at

a strategic and operational level.

However, we identified further opportunities to capitalise on working regionally which should be explored.

This includes developing a greater shared understanding of what working as a region means and

maximising its full potential. We believe there is further opportunity for mutual learning, staff

development, applying best practice, to share knowledge, information, and to systematically test out

strategic preventative approaches at a regional level. This more systematic approach can lead to

appropriate local initiatives, built on sharing resources and a consistent and clear overarching view on how

and where regional collaboration adds value, at the same time being clear where a more local approach is

required.


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Recognising Rurality

Covering a quarter of the landmass of Wales, the West Wales region is the second most sparsely populated

health board area in Wales, with areas of rurality and a small number of areas of deprivation, in parts of

Llanelli, Pembroke Dock and Ceredigion. There are issues linked to prevention associated with both rurality

and deprivation; research into ageing in rural communities has described a set of compounding factors

which result in ‘multiple disadvantage’ as rurality impacts on many factors including housing, deprivation,

access to services and, vitally, levels of physical and social isolation. Evidence indicates that rural areas are

also ageing faster. With regard to deprivation, in nearly all instances, people living in the more deprived

areas experience worse health than those in more affluent ones. There are therefore more likely to have

care and support needs.

The geography and demography of the three local authorities means that statutory and third sector staff

and carers inevitably identified rurality and transport as challenges. Some carers identified the length of

time it takes to travel to access services using public transport. Others identified the lack of choice of

service provider in that domiciliary care agencies would not operate in some more rural areas. The

challenge of meeting needs locally, given distances to travel and inaccessibility, was identified as significant.

One person said “Time and transport are challenges for everyone. Whatever you are arranging or whatever

services you are providing, time and transport are a real challenge.”

In looking across the region, we saw that each local authority provides telephone and online services, plus

Community Connectors or Community Resilience Co-ordinators. The “hub” in Llanelli provides general

advice and information in a central location. There are a range of third sector led and supported

approaches such as Carmarthenshire United Support Service (CUSP), Pembrokeshire Intermediate

Voluntary Organisations Team (PIVOT), and we also identified a LEADER funded project to support rural

volunteers in Carmarthenshire.

Some stakeholders told us that they routinely considered rurality and individual communities and transport

in their planning and delivery approaches. A commonly held view is that there are still barriers in rural

communities although much work has been done.

Findings

There is a clear understanding of the challenge of rurality and initiatives taken to ensure that access is

equitable across the region. We were uncertain whether these valuable initiatives had arisen from strategic

intent or opportunism and where, if at all, regional considerations were evident. For example, if a walk-in

hub is a relevant and important facility in Llanelli, should it also be the case in other major conurbations?

Similarly, could facilities in border towns like Cardigan also serve the people in the adjoining local authority

area? Whilst the transport challenges of the region are much greater than issues covered by this project,

the WWCP can at least explore whether it is minimising the problem by ensuring cross boundary working,

shared resources and a region wide approach to locating service delivery points. Additionally, there are

opportunities to make more use of technology to improve access to services which would benefit rural

areas.


Version 1.2 17

Prevention as part of a Continuum of Support

It is clear that a considerable amount of work has gone into laying a framework for prevention in the three

local authorities and health board individually, and regionally within the West Wales Care Partnership.

We looked at the approach in each separate local authority area and had the opportunity to discuss this

with a range of stakeholders.

Carmarthenshire’s approach, using the PEIPIL model4, sets out a three-tier approach to prevention,

prioritising well-being and taking an asset based approach. The tiers are:

Prevention – to provide help to help yourself; for anyone who wants to be as well as they can be.

Early intervention – to provide help when you need it which may reduce the impact of illness or

disability; support for people at risk because of specific health issues.

Promoting independent living – to provide ongoing specialist help to help delay dependency; to

ensure that well-being and independence is maximised.

Ceredigion has developed an approach where emphasis is placed on prevention and early intervention,

working with individuals, families and communities to source and develop their own solutions in supporting

and promoting independence5. It sets out the fact that it is at a key stage in its development, moving to a

model which will, with Porth y Gymuned, have a clear community based approach to prevention to

complement existing preventative arrangements. The relationship between all the elements of the

approach is based on prevention as a continuum of support.

Pembrokeshire uniquely has a multi-agency Preventions Programme Board which provides the lead and

focus for the development and implementation of a shared preventions vision, strategic framework and

delivery plan6. A vision for developing preventative services and resourceful communities in Pembrokeshire

is clear that prevention is part of a continuum – preventing or delaying the need for formal care and also

about preventing escalating need for people already receiving care.

We received feedback on developments taking place to transform clinical services within the region and

understand that partners were being kept abreast of these. We are less clear of the extent to which third

sector and local authority partners have been able to influence the proposed changes. Some discussions

identified question marks over whether some parts of health worked on the continuum approach or took

an alternative approach, and emphasised the importance of a common language and understanding

between health, local authorities and the third sector.

Findings

Our concern is not so much about traditional arguments surrounding the relevant appropriateness of

clinical or social models but more about the fact that different interpretations of strategic intent and

delivery are major barriers to efforts to working collaboratively. It is less about the fact that health

interventions can often be classified as episodic in nature whilst social care tends to span longer life periods

and more about the need for all partners to understand their respective roles, which includes clarity of

what they are unable to do as well as what they can contribute.

4 PEIPIL: Carmarthenshire: A Resilient Community 5 Ceredigion County Council Social Care Redesign Business Case 6 Vision and Plan for Developing Preventative Services and Resourceful Communities in Pembrokeshire


Version 1.2 18

This research project is focussed on the primary end of the prevention spectrum but the outcomes from it

will, of course, need to be seen and understood along the whole spectrum if it is to add value.

Overall our findings indicate that strategically there is an understanding of prevention as being part of a

continuum of support, but a little uncertainty about whether this understanding is shared by all partners.


Version 1.2 19

Sustainability

“Prevention is a new way of thinking and tough in current financial climate as there needs to be a spend to

save attitude. Savings might be in the long term”. This comment exemplifies the challenge of building and

sustaining preventative approaches while still dealing with the challenges of the day.

We have seen many examples of resourcefulness and creativity in developing projects and securing funding

across the region. Some key preventative projects rely on external and/or fixed term funding from e.g.

LEADER, the Big Lottery, the Integrated Care Fund. These projects are supporting community based

interventions. Concerns were expressed about maintaining up to date web based resources on DEWIS

Cymru after the initial work to identify and upload initiatives across the region. There has been

considerable work to map resources that support people to maintain their independence and lead fulfilled

lives. For example, lunch clubs, over 50 groups, peer support, the resources that libraries can offer,

activities in community halls.

Any evaluation of the position with regards to sustainability must reference the funding context. In 2017-18

the All Wales Councils’ net budget is £7,109m, the All Wales Social Services net budget for 2017-18 is

£1,729m, 24% of the Council budget (see graph below). When comparing budgets going back further in

time is it sensible to remove the effect of inflation from the monetary values. These figures are known as

‘real budget’ figures. Real net budget figures show that over the past ten years (2008-09 to 2017-18)

Council budgets have fallen by 11%. However, social services budgets have been protected, they have

grown by 5% in real terms over the same period.

Council budgets have fallen for all local authorities over the past ten years. Six local authorities saw a

decrease in social services budgets over the period, none of these in the West Wales area. The greatest fall

in Council budget has been for Pembrokeshire, an 18% decrease over the last 10 years. However, they also

had the highest increase in social service budget over the same period, at 16%. The Social Services budget

as a proportion of Council budget over the period for Pembrokeshire has increased from 18% to 26%,

among the highest proportions across all local authorities. Under difficult financial constraints

Pembrokeshire and other Councils are continuing to support social care. Over the past ten years Ceredigion

had a 12% decrease in Council budget and a 4% increase in social services budget. The proportion of social

services budget in Ceredigion and Carmarthenshire was 24%, the same as for the whole of Wales.

Carmarthenshire had a 13% decrease in Council budget and a 5% increase in social services budget.

However, these figures cannot be considered in isolation as increased demand caused by issues like

austerity and changes in demography must also be taken into account. It is outside our brief to offer a view

of the extent to which resources are sufficient but other than to say that they will continue to be stretched

and under pressure for the foreseeable future.

It is also important to reflect the challenges of sustaining a skilled and sufficient workforce engaged in

preventative work. We have not examined turnover rates because of the difficulties in separating

prevention work from other activities and the dangers of drawing conclusions about retention issues based

solely on anecdotal evidence. However, it is worth noting the inevitability that funded providers will

struggle to retain a consistent workforce without long-term security in their funding.


Version 1.2 20

Real net social services budgets as a proportion of Council budgets, West Wales (adjusted for inflation)

2008-2018

Findings

Sustainability has been identified as a challenge across sectors. Capacity in the third sector has been

identified in a range of ways. While welcoming the opportunity to engage as partners, the challenge is then

of doing that within finite existing resources. If prevention at the “pre-front door” level relies on the third

sector and volunteers and time limited project based funding, is this sustainable? As much of the

prevention agenda, certainly at the primary end of the spectrum, is dependent on a strong third sector and

third sector workforce, and that sector is subject to so much volatility in its funding, it is difficult to argue

that prevention and preventative services have a strong sustainable base for progressing.

The pressures of demand and capacity mean that there are significant challenges in moving to and

maintaining a preventative approach. The challenge is to stop prevention being viewed as an “add on” to

people’s already busy schedules, but embedded in practice as an opportunity to use time and resources

more efficiently to achieve better outcomes.

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Version 1.2 21

Co-production

Supporting people to find their own solutions is an important aspect of co-production. We identified the

importance of the “What matters?” conversation in each local authority, and ways in which that approach

was used “pre-front door” in the community and “front door” in respect of IAA. Within the context of the

SSWBA, co-production is about citizens and professionals being valued equally. 7

Wide ranging engagement informed the production of the region’s Population Needs Assessment. There

has been further engagement in developing the Area Plan. Citizens are involved at a strategic level on the

Partnership Board, and importantly saw that the value of this is communicated by people themselves

appearing in short video clips. Work is underway to develop new regional arrangements to engage with a

cross section of the public and we understand that each local authority is working with citizens to further

develop the requirements set out in Section 16 of the Act. A new Innovations Forum is in development. The

Area Plan identifies a commitment to shining a light on co-production to further develop it as an embedded

approach.

Community Connector case study – Co-production in practice

An individual rang the contact centre asking for help to find a day centre placement for himself.

The call handler, after a conversation, thought that there were more options to explore as more

information was provided. The factors leading to the call were that the person had a physical impairment

with issues being investigated at the hospital which were a source of considerable stress and affecting his

mental health. He had stopped doing many of the things he used to do before, leaving him socially isolated

with no family in the area.

The individual was referred to a Community Connector. This led to a long discussion about the individual’s

experience, abilities as well as the problems. A range of community based opportunities were identified.

His past expertise and interest led to an application to volunteer to use his skills at the local museum on a

specific project. He met the project manager, and decided he would apply to volunteer on a regular basis.

Feedback was very positive. The initial potential solution presented as a request to the call handler,

through probing and appropriate referral and support from the Community Connector led to the comment

that the individual was very pleased with the outcome, and that it wasn’t at all what he imagined would

follow his phone call. He is now volunteering regularly at the museum and his feeling of well-being

improved dramatically. The museum is benefitting from his skills and expertise.

Stakeholders told us that there were many different levels of engagement in place in local authority areas

and many patient participation groups in Health. There was a view that it was moving in the right direction,

and it was important that those who needed care and support understand that they are part of the

process, not just 'passive recipients'. Other said that people are engaged and consulted but full co-

production has not yet been achieved.

Findings

Supporting people to find their own solutions is an important aspect of co-production. Co-production can

mean different things to different people. Arnstein’s Ladder of Participation illustrates the different degrees

7 http://gov.wales/docs/dhss/publications/151218part2en.pdf

http://gov.wales/docs/dhss/publications/151218part2en.pdf


Version 1.2 22

of involvement. Within the context of the SSWBA, co-production is about citizens and professionals being

valued equally and the obvious desire and intent we detected in West Wales to engage, consult and involve

people in determining what’s best for them, and planning appropriate responses to their needs, must

consistently translate into enabling them to have real voice and control and not end at a consultative stage.

Citizens are involved at a strategic level on the Partnership Board, and importantly saw that the value of

this is communicated by people themselves appearing in short video clips. Work is underway to develop a

citizen panel and we understand that each local authority is working with citizens in some way to further

develop the requirements set out in Section 16 of the Act.

We believe the region has some way to travel to achieve this not helped by the fact that there is a big

challenge in shifting thinking away from cure to prevention evidenced by people’s reluctance to give up any

existing services to redistribute resources. This means that it will be even more important in this context to

work co-productively with people in the future.

evaluation of preventative models and approaches in west wales

Documents