Making Swansea a Healthier City

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					                  Contents

Chapter One     - Introduction and Overview

Chapter Two     - How we Developed the Draft
                  Strategy 2011 - 2014

Chapter Three   - About our Local Area

Chapter Four    - Key Priority Areas for Action
                  2011 - 2014

Chapter Five    - Next Steps in Developing the
                  HSC&WB Strategy

Appendices      - Appendix 1 – WHO European
                  Healthy Cities Network Phase V




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CHAPTER 1




            2
Chapter One

Introduction and Overview

Welcome to the draft Health, Social Care and Well Being Strategy for
Swansea.

Swansea is a vibrant place with some of the most beautiful natural
surroundings in the country. Our ultimate aim is that the 229,100 people
who live in Swansea will be supported to live longer, healthier lives. This
plan sets out how partners will seek to work together and with
communities to improve health and well being over the next three years.

Health is a state of complete physical, mental and social well-being and
not merely the absence of disease or infirmity. (World Health
Organisation) 7 April 1948.

This plan is being drafted at a very challenging time.

Major challenges include; the unprecedented economic climate which will
result in less money being available to provide public services, increasing
demand through an ageing population, increasing numbers of vulnerable
children that need safeguarding, technological advances, and increasing
public expectations. Public sector expenditure and services will therefore
be put under increasingly significant pressure.

These challenges mean difficult decisions will have to be taken along with
more radical and urgent steps to ensure that our health and social care
services are delivered in the most effective and efficient way. This will
involve shifting the balance to a more sustainable model of care with less
reliance on institutional settings. We will also need to ensure that
individuals and communities are encouraged to play their part, taking
more responsibility for protecting their own health and well being.

An additional key challenge is the current inequality in the level of health
and well being experienced by different parts of the population in
Swansea often due to factors associated with deprivation. This is set out
in more detail in chapter three. Both life expectancy and levels of ill
health are different across parts of Swansea and this is set to continue
into the next generation unless current trends are reversed. For example,
information suggests there could be a 13 year difference in longevity
between the East and West parts of Swansea.
This means that during these difficult and challenging times we have to
double our efforts to protect the most vulnerable, ill and disadvantaged.




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There may also be further political and policy changes which affect the
way in which services are delivered. For example a White paper on the
future of Social Services expected early next year.

An exciting development that will help to address these challenges, is that
partners recently committed to seeking Healthy City Status for Swansea.
This will make Swansea part of the World Health Organisation Network of
European Healthy Cities. To achieve this we will have to demonstrate
that all partners are working together to ensure that health and health
equity is in all of our policies and actions. In turn, Swansea will benefit
from worldwide learning, expertise and support in helping us to make
Swansea a Healthier City and County. Our application for this status has
informed and influenced our thinking in developing this draft strategy.
More information on the overall goals and themes of Healthy City are
included in Appendix One.

Our commitment to achieving Health City Status demonstrates a clear
understanding that improving health and well being lies beyond the remit
of just health and social care services. There are many factors that affect
health and well being which are often referred to as ‘Determinants of
Health and Well Being. These are shown in the diagram below.

Figure 1: Determinants of Health and Well-being




                                          Source: An Independent Inquiry
                                          into Inequalities in Health Report,
                                          Sir Donald Acheson




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Our Vision and Long Term Strategic Aims


Our vision is that by 2020 Swansea will become a Healthier City for All
and will be a place where:-

     Everyone has an equal opportunity to achieve the best level of
      health and well being possible, living longer healthier lives.
     Appropriate high quality care is jointly delivered in the best location
      at the right time by a range of organisations working together.
     Communities and individuals are well informed and take
      responsibility for their own health and well being.


Our long term strategic aims are to:-

     Promote healthy lifestyles and personal responsibility.
     Reduce inequalities in health and well being.
     Increase people’s independence.
     Deliver high quality, safe and accessible services.
     Improve the protection and safeguarding of vulnerable adults and
      children.

This draft plan concentrates on the next three years and has a narrower
focus than in previous rounds. It sets out the priority areas that partners
will work on jointly to progress towards our vision and long term strategic
aims. We will concentrate on:-

     Working towards making Swansea a Healthier City, focusing on
      including health in all our policies and achieving a more equal
      standard of health across the population.

     Ensuring our health and social care services are organised and
      delivered more efficiently, effectively and jointly.

The partners in Swansea that work together to produce this plan include
the City and County Of Swansea, ABMU Local Health Board, the National
Public Health Service for Wales, Swansea Community Health Council,
Swansea Council for Voluntary Services and Swansea University. This
partnership is currently known as Health Challenge Swansea.

Partners recognise that only by working with a range of other people and
organisations will we achieve our vision and aims for the future. This
includes recognising the crucial role of individuals, communities, service
users, carers and the voluntary sector as well as other agencies and
partnerships in Swansea.




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National and Local Policy Context

This plan has been influenced by both the national and local policy
context. The key national policies and frameworks include:-

     One Wales - which sets out the ambition to transform Wales into a
      self-confident, prosperous, healthy nation and society, which is fair
      to all.

     Our Healthy Future - the strategic framework for public health in
      Wales. It sets the overall context and direction for action to improve
      and protect health in Wales. The aims are to improve the quality
      and length of life and achieve fairer outcomes for all.

     Designed for life - a 10 year strategy for the health service that sets
      out a vision and plan to make NHS Wales a world class service.

     Setting the Direction Primary and Community Services Framework -
      a strategic framework for developing primary and community
      services that sets out a vision that all people will receive high
      quality integrated health and social care services tailored to their
      individual needs and where possible delivered close to home within
      their communities. The framework identifies a preventative primary
      and community led NHS as being the fundamental approach in
      driving improvements in health and social care.

     National Five-Year Service Workforce and Financial Strategic
      Framework for NHS Wales – a framework for integration and
      transformation aiming for better for health for all and services as
      good as any in the world.

     Fulfilled Lives, Supportive Communities – a 10 year strategy for
      social services which sets out key themes and the future direction of
      social services.

     National Service Frameworks and Service Development and
      Commissioning Directives – long term strategies for improving
      specific areas of care. They set national standards, identify key
      actions and put in place agreed timescales for implementation.

     Health Gain targets – targets and indicators that aim to improve
      health and reduce health inequalities in Wales by 2012.




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The overarching local policy context is provided by the Swansea
Community Plan. This Health Social Care and Well Being plan is strongly
based within the ten year community plan framework, working along side
other key partnerships to deliver seven key ambitions for Swansea to:-

      Improve health, social care and well being in Swansea of everyone.
      Improve Swansea’s environment for everyone.
      Make a better Swansea for all children and young people.
      Ensure excellent education opportunities for everyone in Swansea.
      Make Swansea safer for everyone.
      Make Swansea a more prosperous for everyone.
      Make better use of our resources.

Whilst working towards these ambitions partners have agreed to address
four cross cutting challenges, sustainable development, equality and
diversity, social inclusion and community regeneration.

Improving health and well being plays a key part in achieving these
ambitions. In turn education, the environment, economic prosperity and
community safety can all have a significant effect on an individual’s health
and well being. These links are explored more fully in chapter three.
Working successfully with the partnerships that lead these areas will be
key to making Swansea a Healthier City.           These key partnerships
include:-

Figure 2 : Key strategic partnerships delivering the Swansea Community
Strategy




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The local policy context is also set out in:-

The ABMU Health Board’s Quality, Service, Workforce and Financial
Framework 2010-2015 Changing for the Better. This five year plan sets
out an ambitious programme of action to enable a high quality,
responsive and sustainable NHS across the Health Board area. It clearly
states that patient safety will be afforded number one priority status.
More detail on the programme of work is included in Chapter Four.

The City and County of Swansea Adult Services Strategic Delivery Plan
2010/11 - which sets out the strategy for the transformation of Adult
Services. Promoting the core values of social work and social care and
setting out an ambitious transformation programme to achieve five
strategic outcomes which are to support people with social care needs to
achieve health, well-being, social inclusion, independence and personal
responsibility. A copy of the plan can be found at www.swansea.gov.uk.

The City and County of Swansea Child and Family Services Strategic
Delivery Plan – which sets out how social services for children will be
developed and improved to support the aim of ensuring that children and
young people who may be disadvantaged by their needs or circumstances
are supported to enjoy a happy, healthy and productive childhood. Having
the opportunities they need to reach their potential. A copy of the plan
can be found at www.swansea.gov.uk.

Importantly the links with the Children and Young People partnership and
plan are also key. The start that children and young people have in life
and the choices they make can influence their health outcomes for their
whole life. For example, there is growing recognition of the effects of child
poverty on the likely health of children and also the significant effects of
housing, educational attainment and lifestyle behaviour and choices
including attitudes towards sexual relationships, alcohol and drugs. We
are working in Swansea with the Children and Young People partnership
to develop jointly owned priorities that both partnerships will progress.
Initial areas that have been identified as particularly important to both
partnerships are improving safeguarding, tackling inequalities, reducing
substance misuse and increasing the number of young people with a
healthy lifestyle.




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CHAPTER 2




            9
Chapter Two

How we developed the draft Strategy

Improving the health, social care and well being of the population is a
long term aim that we expect will take many years. This is the third plan
that has been produced by partners aimed at improving health and well
being. We are therefore building on the foundations of the joint work
undertaken over previous years. To develop this draft plan partners
have:-

       Undertaken a review of the progress made over the previous five
        years.
       Updated information on the current health and social care needs of
        the population.
       Considered the key priority areas needed to improve health and well
        being.
       Developed proposals for and engaged on a number of service
        changes.

Further detail on these is included below.

Review of progress made over previous years

The review showed that partners have made steady progress by working
together over the last few years. Improving health and well being is a
long term goal, it is hoped that the resources and efforts already invested
in the last five years will pay dividends in years to come. Some of the
particular achievements are:-

Working to prevent ill health and reduce inequalities

The partnership has achieved an enhanced focus on prevention of ill
health and the reduction of inequalities which has remained a key priority
area throughout previous years. Key achievements include:-

o   Implementation of a multi agency action programme to tackle healthy eating in
    schools.
o   Development and implementation of the ‘Climbing Higher Strategy’; some early
    successes are a 31% increase in adult physical activity usage, an increase of 1000
    Active Swansea monthly members, and a 17% increase in junior usage.
o   Implementation of the Positive Steps programme that has supported nearly one
    thousand people through a sixteen week exercise programme.
o   The continued success of the Healthy Schools Scheme, with 88 primary and 10
    secondary schools participating in Swansea.
o   The targeting of actions with primary care has resulted in an increase in the levels of
    childhood vaccinations (MMR) of 10%.
o   Implementation of smoking cessation programmes have supported over 600 people



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        to quit smoking, together with robust enforcement of the no smoking ban.
    o   Facilitation of National Healthy Living Week in Swansea, with over 1500 people
        participating in activities and over 800 health checks carried out.
    o   Tackling of health inequalities at a geographical level, through working with
        Communities First partnerships.
    o   Reduction of workplace (3 day) injuries, through working in partnership with the
        Health and Safety Executive.
    o   Undertaking of a comprehensive programme of involvement and consultation that
        has supported the strategy process and encouraged people to take responsibility for
        their own health and well being. Includes the development of a Health Challenge
        Swansea Website, receiving up to c. 7,500 hits per month, work to expand and
        publicise a self help directory of services with NHS direct – now contains over 250
        organisations.


    Health and Social Care Service Change

    The approach to service improvement and change in Swansea has been
    two-fold – four high level change programmes have been identified along
    with a range of priority areas for particular population groups or service
    areas. Good progress has been made in laying solid foundations for the
    continued redesign and improvement of services in future years. Many
    service improvements have already been made over the last five years
    many of which have been taken forward jointly by health and social
    services. Most of these have a clear focus on early intervention, the
    promotion of independence, and the reduction of pressure on acute
    services and address key issues identified through the needs assessment.
    Some key achievements are:-

    o   Developing and agreeing an overall model of care for acute and community services
        in Swansea.
    o   Development of a range of strategic and outline business cases to provide new and
        improved healthcare facilities including significant upgrades to Morriston hospital that
        will facilitate the redesign of hospital services across Swansea, and eight interrelated
        mental health projects.
    o   Agreeing three sub localities within Swansea which now enables community nursing,
        the chronic disease management team and social services teams to be co –
        terminous with groupings of GP practices.
    o   Significant progress in the re-engineering of mental health services combining plans
        for upgraded facilities with fundamental service redesign (see below for service
        changes made).
    o   The establishment of a chronic disease management nursing service and its
        evaluation and rollout across general practices in Swansea.
    o   The establishment of a GP led minor injuries unit.
    o   The establishment of a crisis resolution/home treatment team in mental health.
    o   The establishment of an assertive outreach service in mental health.
    o   Reshaping of the older people’s social services teams into extended assessment
        teams.
    o   Significant work on the development of care pathways across primary and secondary
        care for COPD, Stroke and Diabetes.
    o   The expansion of supported accommodation for mental health service users in the
        community (10 additional units).
    o   The enhancement to local mental health services to enable 26 patients to be
        ‘repatriated’ to receive services more closely to home.



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o   The substantial reduction in hospital waiting times over the period of the strategies.
o   Establishment of a telecare service and exploring the use of telemedicine in Swansea
    (850 telecare installations to date).
o   The merging of three separate intermediate care services into a single team.
o   Piloting implementation of the person centred approach to dementia care in
    partnership.
o   The introduction of primary mental health care liaison service across practices in
    Swansea.
o   The development of supported accommodation for those with a physical disability to
    allow more independent living in the community.
o   Reshaping of the joint equipment store, including the new MICE substore in Morriston
    hospital.
o   Substantial reduction in waiting times for CAMHS services.



Development of Joint Strategies and Action Plans

A number of strategies and action plans have been developed by partners
during recent years. In particular:-

o   The first Carers Strategy and action plan for Swansea.
o   The first joint statement of principles in relation to those with a physical disability/
    sensory impairment.
o   The development and implementation of the local mental health action plan in
    response to the revised mental health NSF.
o   Self assessment for both the Children and Young People and the Older People’s
    National Service Framework and associated action plans.
o   The development of a Healthy Weight Strategy for Swansea.
o   A mental health promotion plan.
o   A revised implementation framework for those with a learning disability.



Links to other Strategies and Partnerships

There has been a robust start to developing links between other key
partnerships and with the community strategy partnership. The
community plan as outlined above recognises improved health, social care
and well being as one of seven key ambitions for Swansea.

Links with other partnerships include:-
o   Joint working with the Children and Young People partnership to align the two
    strategies (specifically recognised and commended by the Welsh Assembly
    Government).
o   Inclusion of Older People’s Strategy within the second HSC&WB plan.
o   Exploring the links between Health and Well Being and the Environment through a
    joint workshop which is now part of an ongoing programme of work.
o   Linking in with the ‘Beyond Bricks and Mortar’ economic regeneration project and
    joint working with the City Centre Framework partnership and the Strategic
    Regeneration Programme identifying joint opportunities for meeting common goals.
o   Perhaps one of the strongest links has been forged with the Communities First
    Programme, which the Health Challenge Partnership is now working in three
    geographical areas in Swansea to design and deliver a programme of activities aimed
    at tackling some of the most significant inequalities in health in Swansea.



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These links will be comprehensively strengthened as the Community
Planning Partnership steer the drive for Swansea to become a Healthier
City.

The achievements outlined above have been facilitated by senior level
partnership arrangements and performance management processes which
have been established and maintained throughout the strategy period.

Updated the Health Social Care and Well Being Needs Assessment

To inform the development of this third plan partners also produced a
comprehensive health social care and well being needs assessment. This
gathers information on a wide range of topics and provides us with a
picture of the current state of health and well being in Swansea. The
needs assessment assists us in identifying the key areas on which we
need to concentrate on if we want to improve health and well being and
reduce inequalities. The results of the needs assessment are set out in
chapter three and have directly informed the identification of our priority
areas.

Reviewed the existing vision and aims and priority areas for
action

To develop the plan partners also reviewed the existing vision and aims in
light of the national and local policy context. It was agreed that the vision
and aims still reflect what partners want to achieve. However a stronger
emphasis has been included on achieving equal opportunity for all,
ensuring or services are safe and of a high quality, and ensuring that
we increase our efforts to safeguard the most vulnerable adults and
children in society.

Informed by the results of the needs assessment and the renewed local
and national policy context partners have identified a small number of
priority areas set out in chapter four that will form the basis of our joint
action over the coming years.

Developed proposals for and engaged on a number of service
changes

Partners have previously extensively consulted on both the first and
second Health and Social Care and Well Being plans which have laid out
our intentions to redesign services. Many of the service changes involve
improvement and transformation that will be part of an ongoing process
and some will take years to fully complete. In addition to the previous
consultations partners have continued to engage with a range of
stakeholders on the following areas to influence the way in which service


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change is implemented. This has included engagement on the provision
of children’s disability services, the Health Board five year plan and the
Transformation of Adult Services with a particular focus on the
personalisation agenda.




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CHAPTER 3




            15
Chapter Three


About our Local Area – Swansea

Swansea is a Unitary Authority located at the Western End of the former
industrial region of South Wales and is the regional centre of South West
Wales. It covers 378 square kilometres and is a mixture of coastal
landscapes, open moor land, rural villages and a university city. Over
80% of Swansea is some form of green space. Swansea has a population
of 229,100. The population has been gradually increasing since 2001
averaging increases of just over 800 people per annum.

For the third time a comprehensive needs assessment has been
undertaken on the health and well being needs of Swansea. Reflecting
the understanding that health outcomes are affected as described above
by a wide range of issues the needs assessment covers a broad range of
topics that affect health and well being.

The determinants of health include:-

      Genetics
      Impact of the natural environment
      Behavioural factors
      Social and economic circumstances and
      Cultural and political priorities

The social determinants of health refer to the full set of social conditions
in which people live and work. The 1following framework further explores
the underlying mechanisms that contribute to differential health outcomes
like the influence of power, wealth and risks. Power and wealth influence
social status that in turn influences differential exposure to health
damaging conditions and differential vulnerability to deal with them.


For example, an episode of illness like having a stroke, is likely to have
different consequences to the life of someone at the lower end of the
socio economic scale than for someone higher up the scale who has easier
access to material resources and support options (Detels, Beaglehole et al
2009 in the Oxford Textbook of Public Health 2009).




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Figure 2: Determinants of Health and Well-being




Taken from: Fig 2.21 Framework for understanding social determinants of health and health inequities. Source:
WHO Department of Equity, Poverty and Social Determinants of health (Solar and Irwin 2007 in the Oxford
Textbook of Public Health 2009)



Health inequities are health differences which are socially produced,
systematic in their distribution across the population and unfair (Dahlgren
and Whitehead 2006 in the Oxford Textbook of Public Health 2009)

The needs assessment has therefore taken a broad view of the factors
that affect health and health outcomes. As a result a wealth of
information has been collated on Swansea. In order to identify the key
issues that need to be addressed filters were used to analyse the
information. These filters were used to identify:-

       Where Swansea is significantly different compared to Wales, the UK
        or Europe?
       Where there are inequalities within Swansea?
       What the evidence tells us we can do something about?
       Where we believe there is harm, variation or duplication?
       Where the situation in Swansea may be getting worse?

In this chapter a high level summary has been provided of the emerging
themes and key findings from the needs assessment. In addition an


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     executive summary of the needs assessment has been produced which
     provides a more comprehensive overview of the key findings. This can be
     found at www.healthchallengeswansea.org.uk.

     Emerging themes from the 2010 Health Social Care and Well Being
     Needs Assessment

     The emerging themes are:-

           The inequalities in health experienced across Swansea both
            geographically due to socio economic deprivation and by different
            population groups persist.
           Evidence says that more can be done to prevent ill health through
            addressing the factors that perpetuate health inequalities through
            integrated policies across all sectors that ensure health equity is in
            all policies.
           There is a particular risk that the immediate economic climate and
            expected public sector cuts over the next few years could
            disproportionately affect Swansea.
           Risk to health experienced by children, young people remains.
           The impact on individuals and communities and health and social
            care services of alcohol and substance misuse and a dependant
            ageing population also remain.
           Over reliance on secondary care services, duplication, waste and
            variation in the service sector persist.
           More should be done to utilise the assets within communities and to
            build capacity so communities can influence policy design and
            implementation.

     Summary of key findings

General Socio Economic, Cultural and Environmental Conditions

Economic Prosperity, Social Inclusion and Poverty
Importance:
Income and socio economic factors are perhaps the most important determinants
of health in the United Kingdom. Poor health (perceived or diagnosed) is closely
linked to socio economic deprivation. Research suggests that unemployment or
poor working conditions is generally damaging for health, Children who are born
into poverty are more likely to be unhealthy, have poor education and limited
employment prospects. Fuel poverty is a significant health issues often experienced
by people over the age of 60 or living alone. It can contribute to excess winter
deaths.

Key findings:
 Unemployment rates doubled from 2.3% April 2007 to 4% Nov 2009.
 Unemployment rates are almost twice the Swansea average in Townhill and
   Penderry.
 Working age economic activity and employment rates are below the Wales and


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    UK average
   Swansea has the highest proportion of children in Wales who live in a workless
    household 24.8% compared to 18% for the Wales average.
   Swansea has a higher % claiming sickness incapacity benefits/severe
    disablement allowance at 11% compared to 10.5% for Wales and 7.1% for UK.
   Almost a third of people living in some wards in Swansea have long term
    limiting illness.
   Higher levels of households in fuel poverty are in Castle, Landore, St Thomas
    and Uplands.
   Swansea contains the third highest percentage of Lower Super Output Areas in
    Wales which fall into the most deprived ten percent for overall deprivation:
    Townhill 1, 2 , 3, 5, 6, Castle 1,2, & 8, Penderry 1,2,3,4,5 7, Mynyddbach 1,
    Bonymaen 1, Morriston 5 & 7, Sketty 4, Morriston.
   Swansea has two of the top three ranked Swansea’s Lower Super Output Areas
    in Wales for overall childhood poverty (both in Townhill). 18 LSOA’s in Swansea
    fall into the top 10% most deprived areas in Wales for the Child Multiple
    Deprivation Index 2008.


Housing
Importance:
Poor housing is associated with a range of physical and mental conditions. Each
year housing conditions are implicated in up to 50,000 deaths and around 0.5
million illnesses requiring medical attention, across the UK. Although short term
housing refurbishment can be disruptive and intrusive, in the longer term,
improvements have been reported in both physical and mental health. Social
renters are more likely to require funding if they need residential or nursing care
later in life.
Key Findings:
  Poor housing conditions are suffered disproportionately by low income
     households and older persons.
  Housing of poor quality is linked to physical and mental ill health like increased
     winter deaths, respiratory problems, accidents linked to poor repair,
     overcrowding.
  Swansea has 13.1% of dwellings rented in the social sector compared to 9.9%
     for all Wales with implications for future social care provision in terms of
     funding for residential or nursing care. Almost a third of households have self
     assessed support needs.

Environment
Importance:
There are close links between the environment and people’s health. Environmental
problems such a pollution and flooding can pose significant risks to our health if not
properly assessed or managed. Air quality has been shown to be linked to heart
disease and stroke as-well as respiratory problems. Conversely, access to and
enjoyment of a high quality natural and built environment can improve our health
and our quality of life.
Key Findings:
  Poor air quality in Swansea is primarily due to vehicle emissions and is getting
    worse in some areas as car use and congestion continues to increase.
  Poorer sectors of the community tend to use free standing LPG heaters which



                                                                                         19
     exposes them to far higher nitrogen oxides than would normally be the case.
    Swansea may be unusual in that road traffic pollution does not appear to match
     socio-economic status.
    Heavy rainfall can cause problems when untreated sewage overflows into rivers
     and coastal waters and it is anticipated that this may increase in the future as a
     result of climate change.
    Climate change has the potential to widen existing social inequalities, as the
     poorest sectors of society are not only more vulnerable to the impacts of
     climate change but are also likely to find it harder to recover when incidents
     occur.
    Fossil fuel supplies will become more limited and expensive, having greatest
     impact on the poorest sooner and to a greater extent.
    In certain western parts of Swansea, 10–20% of the buildings are believed to
     have a problem with radon.

Education and Lifelong Learning
Importance:
Health outcomes are affected by the quality and quantity of early education.
Educational attainment offers the greatest potential for improved social and
economic circumstances and is a key element in reducing poverty, deprivation and
exclusion and thus reducing health inequalities.
Key Findings:
  30.5% of the adult population have no formal qualifications compared to
    England 28.9%.
  One in 5 adults are estimated to have literacy skills below level 1.
  The WIMD for Child Deprivation 2008 shows that Swansea has 5 LSOA’s, all of
    which are in Townhill and Penderry which rank in the top 20 worst LSOA’s
    across Wales for deprivation in the Education Domain1
  Key Stage 4 (achieving 5 GCSEs ( a*- c) boys 10.2 % lower than girls

Social and Community Networks

Transport
Importance:
Transport problems can be a significant barrier to social inclusion, including access
to work, education, health care, food and cultural activities.
Key Findings:
  28.5% of Swansea households had no car compared to the Welsh average of
    25.9%
  There are significant inequalities in access to transport via car, with the most
    deprived areas having almost twice as many people (over 50%) with no car
    compared to the Swansea average from Census figures.

Crime and Safety
Importance:

         1
          The indicators used were: Key Stage 2, 3, and 4 average point scores, Primary and
         Secondary School all absence rate, Proportion of people not entering Higher
         Education aged 18-19, and Proportion of adults aged 25 – 59/ 64 with no
         qualifications.



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Crime or fear of crime can affect a persons well being. Street lighting has crime
reduction effects and reduces fear of crime in both targeted and untargeted areas.
Key Findings
   Ward level crime statistics for Swansea show that wards with the highest
     levels of deprivation also feature amongst those wards with the highest level of
     crime rates.
  Community based surveys in Swansea have consistently shown Crime or Fear
    of Crime as one of the top three things affecting health and well being.
  From 2002- 2010 overall recorded crime in Swansea has fallen by 37%.

Domestic Abuse
Importance:
Domestic abuse has devastating consequences for the people who experience and
witness it. Domestic violence is associated with psychiatric illness, including
depression, suicide, anxiety, alcohol and drug misuse and post traumatic stress
disorder. Domestic abuse can be hidden due to under reporting, so that the real
extent of the problem is not known.
Key Findings:
 Women who experience domestic abuse are up to 15 times more likely to misuse
  alcohol and 9 times more likely to misuse drugs than women generally.
 40% of Asian women who sought treatment for alcohol misuse were experiencing
  domestic abuse.
 The risk to children increases considerably when problem drinking or drug use
  co-exist with domestic violence.
 The reported prevalence of domestic abuse is higher in deprived areas.


Individual Lifestyle Factors

Weight, diet and exercise
Importance:
Many chronic and disabling conditions experienced by the population in Swansea
such as cardiovascular disease, diabetes, cancer and chronic respiratory disease
are linked by common preventable risk factors. An unhealthy diet, physical
inactivity and smoking are risk factors for these conditions. Many of the above
conditions are preventable and by eating healthily and being physically active, the
risk of developing many chronic conditions can be dramatically reduced.
Key Findings:
  Swansea is in the bottom 3 of LA areas in Wales for physical inactivity at 73%
    of the adult population not undertaking the 5x30 minutes moderate activity to
    reduce risk from chronic diseases like heart disease and improving mental
    health.
  From the latest Welsh Health Survey compared to the 2007 Needs Assessment:
    the % of the Swansea adult population that is overweight or obese has gone up
    5% from 52% to 57%.
  Lower income families have less variety in their diet, eat fewer essential
    nutrients but eat more fat and sugar.
  In Swansea, 25.7% of boys and 33.6% of girls in Year 4 were reported as
    overweight or obese22

     2
         Public Health Wales pilot heights and weight measurement programme, June 2009.



                                                                                          21
   Only 36% of adults in Swansea are eating the recommended daily quantity of
    fruit and vegetables.




Substance Misuse – Alcohol, Drugs and Tobacco
Importance:
People who misuse drugs, alcohol or other substances cause considerable harm to
themselves and society. This includes harm to their own physical and mental health
and well being, and possibly to their ability to support themselves. They may harm
their families lives and also there may be harm to the communities in which they live
through the crime, disorder and anti social behaviour associated with substance
misuse.

Alcohol is a depressant and many heavy drinkers have mental health problems.
Alcohol often contributes to problems with family, relationships, work, finances and
crime. Binge drinking is associated with accidents, violence and crime as well as a
hangover, headaches, vomiting and indigestion. Heavy regular drinking increases the
risk of stomach ulcers, liver cirrhosis, heart disease, strokes and some cancers.
Research suggests that heavy regular drinking is associated with 40% of domestic
violence and 20% of child abuse.

Much drug use is known to start at an early age. The total economic and social cost
of Class A drug use in Wales has been estimated to be around £780 million and drug
related crime accounts for 90% of this.

Smoking is the single biggest avoidable cause of early death and disease in Wales.
Smoking is identified as the primary reason for the gap in healthy life expectancy
between the rich and the poor. Smoking cessation has shown to be effective with
local quit rates at 70% after 4 weeks.
Key Findings:
  Hospital admission rates for adults due to alcohol and drugs is statistically
    significantly worse compared to the rest of Wales.
  26% of over 6,000 young people surveyed in Swansea had been seriously drunk
    at some stage and 47% had drunk alcohol at least once in the last 4 weeks. (A
    recent Communities that Care survey 2008).
  According to the 2009 WHS, nearly half of all adults in Swansea drunk alcohol
    above recommended guidelines on at least one day in the past week. 2% points
    higher than the Wales average and the joint second highest in Wales.
  Over a third of adults reported binge drinking on at least one day in the past
    week. This is above the Welsh Average of 28% and the third highest in Wales.
  Positive testing for heroin and cocaine in individuals arrested for trigger offences
    is consistently the highest in the UK.
  Child centred targeted approaches have been shown to be effective as is a single
    point of access for young people to substance misuse services.
  In 2009 Swansea had the highest number of drug implicated deaths in Wales
    (22) and the highest rates of drug implicated deaths in 2008 and 2009 (9 and 12




                                                                                      22
    deaths per 100,000 population respectively).
   Between 2006 and 2008, 100 adults died of alcohol related causes with the rates
    of alcohol-related mortality being highest in the city centre and surrounding area
    (Upper Super Output Area 007).
   Improvements in collecting and reporting data are urgently required as reports
    into HSW are still far from reliable due to lack of consistency and accuracy of
    information.
   The majority of hepatitis C virus infection in Wales is found amongst current and
    injecting drug users (IDU) – evidence of infection was seen in 43% of Swansea
    and Neath IDU (highest in S Wales).
   Approximately 30-50% of people misusing drugs have mental health problems.
   In one study half of alcohol dependant adults said they had a mental health
    problem.


   Although smoking prevalence has decreased Swansea’s ranking in Wales has
    remained the same – 12th highest out of the 22 local authorities in Wales.
   In Wales, results from the 2009 WHS would suggest that difference in smoking
    prevalence between higher managerial and professional groups and those who
    have never worked or are long-term unemployed has increased to 29 percentage
    points.
   There is a definite social gradient, with smoking levels much higher in the more
    deprived areas and certain client groups.
   A recent Communities that Care survey (2008) of over 6,000 children aged 11-
    16 showed that:
    -5% regularly smoke
    -Some areas were significantly more likely compared to the Swansea average to
    show that children smoked regularly (Penlan 12%, Mayhill and Townhill 9% and
    BlaenyMaes, Portmead, Penplas 8%).
   Nearly a quarter of adults (23%) in Swansea still smoke (WHS 2009).

Oral Health
Importance:
Emerging evidence suggests a possible ink between cavities and gum disease and
serious conditions like heart disease, diabetes, respiratory disease and premature
and low weight babies.
Dental caries is preventable not inevitable, it can be prevented by targeting multi
sectoral community and school based initiatives. Smoking, tobacco and drinking
alcohol have been identified as the major determinants of oral cancer risk.
Key Findings:
  Up to 63% (Welsh average is 53%) of 5 year olds in Llansamlet, Bonymaen, St
    Thomas, Mynyddbach, Cwmbwrla, Castle and Landore have tooth decay which on
    average is 3 or more decayed missing or filled teeth.
  Child dental decay is closely correlated to social deprivation.
  Steady decline in tooth loss within the middle age bands in particular, which is
    leading to more people retaining teeth into later life so when the population is
    both expanding and ageing, there will be a substantial increase in the pool of
    teeth at risk. With more adults retaining more teeth for longer, there will
    inevitably be increasing demands for more complex restorative treatment
    services. This is likely to be an added pressure on access to NHS dental services.
  The use of alcohol and tobacco together increase substantially the risk of oral



                                                                                     23
      cancer.
     Oral cancer (cancer of lip, oral cavity and pharynx) is largely preventable but
      there has been no improvement in the incidence of these death rates in Wales
      over last decade.

 Sexual Health
 Importance:
 Early age sex is associated with non consensual and regretted sex, lack of protection
 and a higher number of sexual partners. Health Development Agency recommends
 school based interventions linked to contraceptive services to reduce the number of
 teenage pregnancies. Effective ways to reduce sexually transmitted diseases are
 through unambiguous messages and behavioural skills training. Youth development
 programmes have also shown to be effective.
 Key Findings:
   The percentage of under 18 conceptions which lead to abortion is 41.6% in
     Wales, Swansea is higher at 45.8%. In 2009 in Swansea 20% of abortions to
     women aged under 25 were repeat abortions, Wales (20%) and slightly higher in
     England 24.7%.
   Swansea is statistically significantly better compared to Wales for under 16s
     teenage conception rate. Swansea’s under 16 and under 18 conception rates
     masks inequalities across the county. There were 496 under 18 conceptions in
     Swansea during 2005 -2007. Swansea wards with more than 20 conceptions
     during 2005-2007 are Townhill (65), Penderry (62), Morriston (54), Llansamlet
     (32), Clydach (26), Penyrheol (25), Castle (24), Cockett (24), and Mynyddbach
     (23).
   Steady increase in the incidence of sexually transmitted infections in Swansea
     and the UK. The burden of sexually transmitted infection are borne by young
     people, who account for more than 50% of STI diagnoses but only 12% of the
     population.
   Regular alcohol consumption is associated with both an early onset of sexual
     activity and multiple sexual partners, while alcohol use at first sex is associated
     with lower levels of condom use at first intercourse.
   The additional cost of providing Long Acting Reversible Contraception (LARC) is
     more than offset by the costs of unplanned pregnancies (reduced terminations or
     reduced births): Estimated savings of over £200, 000 per 100, 000 population.



 Screening
 Importance:
 The aim of screening is to reduce the incidence of morbidity and mortality form
 invasive cervical/breast cancer. Almost all abnormalities detected by screening are
 successfully treated.

  Key Findings:
   Swansea is still the 4th lowest LA area for cervical screening in last 5 years
     (73.5% vs. 75.5% Wales average).
   Swansea has the highest ‘Did Not Attend’ rate at 19.2% compared
     Bridgend(16.7%) and NPT (16.1%) for diabetic retinopathy screening.
    Variation in screening uptake with more deprived areas having the worst uptake;
     Patients of primary care practices covering the City Centre, Townhill and



                                                                                        24
      Fforestfach were the poorest attendees for diabetic retinopathy screening.
     Breast cancer screening rates have dropped by nearly 9% from 06/07 to 68%
      and are lower than the Wales average of 73.7%, as well as the 4th lowest LA area
      in Wales.

 Health and Well Being Profile

  Mortality, Morbidity and Chronic Conditions
  Importance:
  Mortality is a measure of a rate of death from a disease within a given population,
  location or other grouping. Morbidity is a state of being ill or disabled. It is the
  occurrence of a disease or condition that alters health and quality of life.

  Chronic conditions are those which in most cases cannot be cured, only controlled,
  and are often life-long and limiting in terms of quality of life. Many chronic
  conditions can be prevented or delayed if risk factors such as unhealthy lifestyles are
  tackled. The impact of chronic conditions on people’s lives and services in Wales is of
  growing concern. Wales has the highest rates of long-term limiting illness in the UK
  accounting for a large proportion of unnecessary emergency admissions to hospital.
  Chronic diseases have a large impact on the health and social care budget.

  Living with chronic condition can have a significant impact on a persons quality of life
  and on their family. The incidence of diseases increases with age. Many older
  people are living with more than one chronic condition and this means they face
  particular challenges.

  Managed care programmes that share knowledge and involve patients in decision
  making are good practice in chronic disease management. People with chronic
  illnesses like cancer, neurological and renal disease and chronic pain are at a greater
  risk of suicide than the general population.
  Key Findings:
    Leading causes of death (all ages) are circulatory, respiratory and cancer.
    Life Expectancy for males and females (2006-8) in Swansea is 77 years and 81.1
       years respectively, this is line with the Wales levels of 76.9 and 81.2.
    Rates of adults reporting Long Term Limiting Illness are 28%.
      Rates of emergency hospital admissions are statistically significantly high in 18 of
       the 31 small areas in Swansea.
    Many health outcomes are statistically significantly worse than Wales as a whole
       in areas of high deprivation like Bonymaen, Penderry, Castle and Townhill.
    There is an estimated 13 year age difference in experience of longevity between
       the east and west parts of Swansea.
    Rates of premature mortality from circulatory disease are more than 4 times
       higher in the Castle area than in the Gower and Pennard areas



       The diagram below shows MSOA’s in the ABM area with high rates of death from
       circulatory disease for under 75’s, with the areas in Swansea in the worst fifth
       being in: Landore (13), St Thomas (11), Castle (14), Pontardulais (8), Penderry
       (10), Townhill (12).




                                                                                          25
Communicable Disease
Importance:
Significant advances have been made in the control of communicable disease during
the last one hundred and fifty years, largely through improvements in sanitation,
housing, nutrition and other social advances, but infectious diseases remain a public
health challenge. Multi-agency collaborative working arrangements are required to
prevent the spread of communicable disease and so minimise their impact on the
health of the local population. Improvements in immunisation rates can be achieved
by national/local guidance through targeted immunisation campaigns to high risk
groups.
Key findings:
 For MMR 2 by age 5 years, Swansea was in the bottom 4 of LA areas in Wales in
  2008/9 COVER annual uptake at 79%.
 There were 83 measles and 130 mumps notifications in 2009 in Swansea from
  outbreaks as 95% coverage is required to prevent wild virus circulation and
  protect population health.
 Seasonal influenza rate in 2008/9 season in those less than 65 years with one or
  more clinical risks was 38% - in the lowest 6 of LA areas in Wales.

Injuries
Importance:
Injuries and their consequences produce a heavy burden in terms of short and long
term disability, mortality, economic loss and health care costs. Child resistant


                                                                                        26
packaging has been shown to be effective at reducing child poisoning/overdose, area
wide traffic management and urban safety schemes like pedestrian priority walking
routes and male driver education can all help to reduce traffic accidents and reduce
health inequalities.
Key Findings:
 Road traffic injuries in 2008 are 7% less than the average for 1994-2008 (R&I
  Unit, C& Swansea), though this masks an increase in 2008 of the number of killed
  and seriously injured. There has also been a 28% reduction in the number of child
  injuries for the same period.
 Twice as many children are pedestrian casualties from deprived areas, and up to
  4 times as many from deprived areas are admitted to hospital as a result of their
  injuries.


  Mental Health
  Importance:
  One quarter of the population is expected to suffer significant mental health
   issues at some time in their lives. That is one in four individuals in Swansea
  at any one time. While mental health issues can be classed s mild, moderate or severe
  the impact for most sufferers and their families can be devastating,
  and may lead to loss of jobs, relationships, homes and identity. Evidence
  shows that many mental health problems are preventable/treatable and
  that their impact can be reduced through appropriate care and support. There
   will be increased demand for specialist services particularly for people with cognitive
  impairment as dementia cannot be prevented only delayed. There is emerging
  evidence of effective interventions that can have a positive impact on suicide rates.
  Key Findings:
   The mental health score in Swansea is 49.7, below the mean score for
      Wales of 49.9 (Welsh Health Survey 2008-9). A higher score means better self
      reported mental health.
   The average suicide rate for Swansea is 14.6 per 100,000 of the population which
      is higher than the national average for Wales.
   Swansea currently has the lowest provision of psychologists in adult
      services in Wales.
   There is a strong social gradient in mental health illness in relation to
      income and education.
   Almost three quarters of sentenced prisoners have two or more mental
      health disorders; 14 times the level of males in the general population
      and 35 times the level of females.
   Studies have consistently shown that between 30 and 50 % of rough
      sleepers have mental health problems.
   About 50% of people who experience common mental health problems
      recover within 18 months but of those still affected there is a higher
      proportion of lower socio economic status.
   There is need for better liaison between mental health services and
      learning disability services, substance misuse services and physical
      disability services in order to provide more effective and co-ordinated care
   A recent review has identified that the increasing demand for advice and
      interventions within the primary care setting means existing resources
      are wholly insufficient to address need.




                                                                                     27
Specific Population Groups

Children and Young People
Importance:
The foundations of good health are laid during pregnancy and infancy and built upon
in the school-age years. A range of risk factors, such as maternal smloking and poor
nutrition in pregnancy, poverty in childhood, poor educational attainment, and
neglect and rejection by families, have been associated with negative health and
wellbeing outomes both in the short term and over the lifespan. Conversely, positive
outcomes have been linked to a number of protective factors, such as a supportive
family environment. Tackling risk factors for lifelong health and wellbeing in the early
years and building children’s resilience to adversity will therefore be central in
improving health outcomes. Intervening in the early years has also been shown to be
a good investment, as it provides a greater rate of return than that for later
intervention.
Key Findings:
    There is a significant geographical bias in terms of deprivation rankings to be
      found in Swansea in relation to children; Townhill, Penderry and Castle feature
      in 9 of the top 10 LSOA’s in Swansea in the overall index of multiple deprivation
      for children.
    Swansea has two of the top three ranked LSOA’s in Wales for overall childhood
      poverty, according to the index; Townhill 1 and Townhill 3.
    In Penderry and Townhill the % of children on benefits is twice the national
      average and over 20% of households are lone parent with dependent children
      compared to Swansea average of 11%.
    Swansea has the fifth highest rate in Wales for children in need per 10,000.
    26 % of secondary school pupils surveyed in Swansea had been seriously drunk
      at some stage and 47% had drunk alcohol at least once in the last 4 weeks.
    51% of 16-18 year olds who are not in education, employment or training live
      in SA1 and SA5.
    Between 2005 and 2009 the number of looked after children in Swansea
      increased by 19% compared to an increase of 7% across Wales (All Wales Data
      Unit).
    Risk factors such as family conflict, family history of problem behaviour,
      community disorganisation and neglect have been seen to be worse in certain
      areas.
    Characteristics of children with a mental disorder compared to other children
      are that they are more likely to be boys, live in a lower income threshold, or
      live in social sector housing with a lone parent. (ONS 2000).
    There are a number of resilience factors including at least one good parent child
      relationship, schooling with strong academic and non academic opportunities
      and positive behaviour policies, joint working between health and social care
      for those with needs, and clearly defined care pathways.
    Local specialist Child and Adolescent Mental Health Services only see children
      up to their 16th birthday. Comprehensive services are not in place.
    There is a higher rate of live births in certain areas (Townhill, Penderry,
      Cockett) of Swansea – this can have an influence on demand for services,
      education provision and workforce.




                                                                                       28
                                      LAC Population by Year


                570


                520


                470


                420


                370


                320
                      2004/05   2005/06   2006/07    2007/08   2008/09   2009/10



          2010 Health Needs Assessment, Children in Need and Children and Young People

Older People
Importance:
Currently nearly one in five people are over 65 years in Swansea. The population is
expected to age further as life expectancy increases. Many older people remain
healthy, active and independent with little or no reliance on health and social care
services. However increasing age is generally associated with increasing disability
and loss of independance and functional impairments such as loss of mobility, sight
and hearing, meaning that there are growing demands for health services and social
care support.
Key Findings:
  A rise in the older population, 75 yrs and over, from 9% to 13% (29,000) of the
    total population is estimated by 2031 for Swansea, Neath and Port Talbot.
  An increase in chronic conditions such as circulatory, respiratory diseases,
    cancers and in the economically and care dependent populations is therefore
    likely.
  Over one third of households in Swansea contain at least one older person with
    26% of households being occupied solely by older residents – this will
    undoubtedly have implications for future caring and service provision
    requirements.
  Admissions for pedestrian injuries in 70-89 year old remain higher in those from
    the most compared to the least deprived areas as the gap remains unchanged.
  The crude hip fracture admissions rate in Swansea residents over 75 years has
    remained largely unchanged over the last decade with women being roughly
    double the rate of men.

BME Groups
Importance:
These groups suffer inequalities in health and well-being and need services and
information tailored to their needs.
Key Findings:
  Higher levels of specific conditions amongst certain minorities include coronary



                                                                                         29
    heart disease, some cancers, haemoglobinopathies, mental illness and diabetes.
   Asian populations have a higher proportion of body fat in comparison to people of
    the same age, gender and BMI in the general UK population, and thus have an
    increased risk for cardiovascular diseases and type 2 diabetes.
   Swansea has a slightly higher proportion of person’s from BME backgrounds
    compared to Wales, with a particularly high proportion of people of Bangladeshi
    origin compared to other ethnic groups.
   Swansea is one of the four main areas in Wales, designed to receive asylum
    seekers. Updated estimates of population (ONS) since 2001 indicate that non-
    white ethnic groups in Swansea may have increased by more than 1%.


Physical and Sensory Impairment
Importance:
Physically disabled people experience inequalities in health and well being and
services may need to be tailored to meet their needs. Statutory partners have a
responsibility to meet the obligations under the Disability Discrimination Act 2005
Key Findings:
  Access to dentists is a fundamental issue of concern for disabled people – not
    only problems with physical barriers but information, transport and language.

Learning Disability
Importance:
People with a learning disability from birth or early childhood have an impairment of
intellectual functioning that significantly affects their development and leads to
difficulties in understanding and using information, learning new skills and managing
to live independently. They are more likely to require support and services to lead
an ordinary life. Person centred community based services have been shown to
promote independence and social inclusion and a focus has been directed towards
the improvement of access and experience within the health care system.
Key Findings:
 Dementia is higher among older adults with a learning disability compared to the
     general population (21.6% compared to 5.7%)
 Early onset dementia, epilepsy, mental health problems, obesity and sensory
     impairment and poorer dental health are more common amongst people with a
     learning disability
 Mild to moderate learning disability has a link to poverty and rates are higher in
     deprived urban areas.
 Studies show that people with a learning disability suffer with poorer health than
     the general population. Research shows people with a learning disability have an
     increased risk of early death. The risk of dying before age 50 is 58 times higher
     than the general population. The risk of early death increases with the severity of
     disability
 The rates of people with a severe learning disability are projected to rise by 15-
     25%. This will have an impact on the type and range of services required.
 Research would indicate that there will be a 41% increase in people aged 60 -79
     by 2011 and a 50% in people aged over 80. The increasing numbers living into
     old age will have implications for service provision.
 Lack of suitable provision for younger people who need something in between
     fully staffed accommodation and independent living.
 There is a need for general secondary care services to have a better



                                                                                       30
    understanding of the needs of people with a learning disability when people are
    admitted to hospital.
   Many people with a learning disability are overlooked when it comes to diagnosis
    of dementia. The consequence tends to be late diagnosis and decreasing benefits
    from existing treatments more effective in the early stages.
   People with a learning disability suffer from higher levels of sexual, physical and
    emotional abuse.
   Disabled or ill respondents reported domestic violence twice as often and clinical
    negligence four times as often as others.
   Access is a fundamental issue of prime concern to disabled people and affects all
    aspects of life on a daily basis. Access encompasses both the physical
    environment and information, transport and language.
   An increase is being reported in the number of economically active disabled
    people who are unemployed: 18.5% (from 7.3% in 2006).
   Research indicates that in Wales as a whole only 20% of people with complex
    needs who would be eligible for a social service actually receive it

Carers
Importance:
Carers make a significant contribution to the support and care of people with health
and disability problems enabling them to continue to live in their own homes.
Studies suggest that caring is likely to be associated with inequalities in mental and
emotional health including fatigue and physical health problems, which can result in
social exclusion. Support needs to be directed to carers to enable them to continue
with this valuable work.
Key Findings:
  As a proportion of the total population Swansea has the highest number of
    Carers in Wales.
  Almost 10% more children in Swansea are carers compared to Wales with 17.7
    per 1,000 children.
  The proportion of children who provide 20 hours and more care per week is over
    20% higher than in Wales.
  Young Carers are a particularly vulnerable group.
  Carers have difficulty making and keeping appointments as they find it difficult to
    leave the person being cared for and thereby tend to neglect their own health.
  Services providing support improve quality of life and reduce /delay the need for
    institutional care.

Prisoners
Importance:
The prison population is unlike the rest of the general population, it is a transient
population with rapid turnover poor general health and a high prevalence of serious
and resource intensive conditions such as mental health and substance misuse.
Key findings:
  Education attainment is lower than the average.
  From a survey of inmate medical records in 2008: nearly 80% smoke, 65%
   report having used drugs in the month prior to imprisonment and almost a third
   had self harmed during their life time.

Homelessness
Importance:


                                                                                        31
Being homeless can have a significant affect on health and well being. Inequalities
exist around mental and physical health for this client group and there can be high
rates of attendance at A&E departments. Access to health services is poorer for
homeless people than the local population. Mediation schemes for people asked to
leave accommodation have proved effective, housing market affordability issues. The
major causes of homelessness are parents not willing to accommodate , domestic
abuse and loss of rented accommodation.
Key findings:
  Difficulty in finding permanent housing solutions for certain groups – including
    young people under 18.
  Substance misuse including drugs, alcohol and tobacco is a key health issue
    amongst this population group.
  Depression and anxiety are common.
  Physical and mental health and access toa range of health services is poorer than
    the local population.
  Life expectancy of a rough sleeper is 42 years.
  Hepatitis C diagnoses are high.
  Discharge from hospital for people who are homeless is problematic
  The lack of a fixed address can affect access to and continuity of care.
  A lack of accommodation options for people with substance misuse issues is
    likely to have a negative impact of the success of treatment.
  Homelessness applications are at their highest level since 2004/05 when the
    prevention agenda was adopted. It is assumed part of this increase is
    attributable to the current economic climate.

Asylum Seekers
Importance:
Asylum seekers are a particularly vulnerable group who may have had haphazard
access to healthcare. Specific health issues include communicable diseases, mental
health problems relating to past experiences, and poor dental health.
  At the end of May 2009 Swansea had 562 asylum seekers (nearly a quarter of
    the Wales total). A high proportion of refugees live in Communities First areas .
    Over the previous 6 years, 88% of these were housed in Townhill, Bonymaen,
    Morriston and Penderry wards. There are unknown numbers of failed asylum
    seekers.
  Asylum seekers report experiencing housing problems, difficulties in accessing
    and understanding services, and high unemployment.
  There are an increasing number of births (projected 100% increase to 09/10 )
    placing added pressures on midwifery and health visiting services.

Migrant Workers
Key findings:
 Migrant workers can face problems of language barriers, lack of accessible
  information and difficulties in registering for healthcare provision (Equality of
  Opportunity Committee 2008).
 Migrant workers are particularly vulnerable to housing that could be damaging to
  their health and well being ( Equality of Opportunity Committee, British Red
  Cross Swansea).
 Difficulties in understanding the healthcare system and how and when it should
  be used leads to inappropriate use of Accident and Emergency.



                                                                                        32
Gypsy Travellers
Key findings:
 Compared to the settled population infant mortality and maternal death rates are
   higher and life expectancy significantly lower.
 Gypsy Travellers have a higher incidence of heart disease, strokes, accidents and
   mental ill health.
 There are higher rates of accidents amongst Gypsy Traveller children partly
   because they are very physically active and partly because they often live and
   play in unsafe areas.
 Take up of immunisations is reported to be lower than in the settled community.
 Provision of health services to this client group relies too much on individual very
   dedicated health workers.


Students

   The student population of Swansea University is significant (14,680), and with a
    largely transient population between terms, is assumed to have a varying impact
    on health services.
   There are specific identified health issues such as an ongoing mumps outbreak,
    related to inadequate uptake of 2 doses of the MMR2 vaccine.
   Over one quarter of students were from a household with an income level low
    enough to qualify for the maximum Assembly Learning Grant/Maintenance Grant.


People Living in Rural Areas
Importance:
People living in rural areas experience some differing health needs than the general
population. Swansea’s rural wards cover 60% of the land area surrounding a core
urban area.
Key Findings:
 Penclawdd 2 has the 17th worst score on the health domain (WIMD) out of the
  147 areas in Swansea
 In the Access to services domain (WIMD) Gower 1and 2, Bishopston 2 and Mawr
  are in the top ten most deprived in Swansea
 There are high numbers of people with no qualifications in Pontardulais 31% and
  Mawr 30% compared to Swansea average 18%.
 The population of older people within the traditional rural areas is projected to
  increase by an average of 33% by 2020 compared to 28% in urban areas

Health and Social Care Services
Importance:
Substantial resources are spent on providing health and social care services for the
residents in Swansea. Services face greater demands due to increasing number of
people needing safeguarding, an ageing population, technological advances and
increasing public and patient expectations. There is a need to ensure that these
resources are used as effectively as possible to maximise health outcomes for
individuals and communities.
Key Findings:
Primary, Voluntary, Social Services



                                                                                       33
 Swansea has the fifth lowest rate of outpatient referrals per 1,000 population
  from GPs out of 22 areas in Wales (2008- 2009).
 GP data would suggest that there is a large variation in the recording of
  prevalence of patients over 16 who are obese from just over 12% down to 6% in
  some practice populations.
 Many practices are unable to support both the range of services needed and the
  levels of activity they generate.
 There is inequality is the provision of in house services in primary care.
 There are differences in the capacity and services provided by different dental
  surgeries.
 There are a number of GP and Dental practice premises which are no longer fit
  for purpose.
 Access to dentists is a fundamental issue of concern for disabled people – not
  only problems with physical barriers but information, transport and language.
 National evidence suggests the current system means service quality and
  availability is highly dependant on location of residence.
 According to practice data there is variation in the percentage of patients with
  depression who have had a severity assessment at the outset of treatment using
  a tool validated for use in primary care from 18% to almost 0%.
 There is an unequal uptake by general practices in the range of enhanced
  services being provided to their patients in particular services to care homes,
  diabetes, and swine flu, and extended access hours. There are five practices in
  Swansea that do not provide near patient testing or shared care.
 Lack of integrated pathways between primary, secondary and social care.
 National evidence suggests there is fragmented and disorganized out of hospital
  care making navigation difficult for the citizen and professional alike.
 Inaccessible records resulting in limited exchange of information between
  different parts of the system.
 No robust and consistent governance framework.
 Significant pressures relating to the provision of equipment including the
  occupational therapy service and the equipment store itself.
 Third sector: short term funding makes it difficult to sustain the service and meet
  peoples expectations, competition in funding can breakdown partnership
  working.
 Poor communications between the third sector and the statutory sector.
 Views from voluntary organisations are that the statutory sector are not
  recognizing the importance of the third sector, lack of understanding about their
  role.
 The average package of care provided by the in house social care service in
  recent years has been steadily increasing.
 The most immediate pressure in the delivery of social care is to meet statutory
  obligations and take forward priorities within a new financial climate of reduced
  budgets at a time of growing demands (effects of any ageing population, more
  children with complex needs, changes in proportion between the number of
  people in work and the number of retired people, number of people, not in
  employment living in poverty, an increase in the number of children coming into
  care.
 Ending of the joint special working grant and the promoting independence and
  well being grant that supports a number of key services.
Secondary Care Services
 Hospital admission rates for adults due to alcohol and drugs are statistically
  significantly worse compared to the rest of Wales.


                                                                                    34
   Swansea emergency hospital admissions rate in those aged under 75 years is
    above the Wales average and highest in ABM U HB.
   Falls in patients – highest reported incident.
   Transport for patients remains an issue for accessing key services.
   Health system still gravitates services to hospitals
   Variations in patient discharge persist and closer working with social services
    needed
   30% of A/E attendances resulted in very short lengths of stay and majority of
    this care could have been provided in the community and primary care.
   DNA rates remain high and need to reduce unnecessary outpatient appointments
   Chronic conditions pathway to reduce lengths of stay needs to be progressed.
   Medical recruitment issues persist.
   Reduce duplication of services and increase consistency on the 3 hospital sites.
   Alternatives to hospital attendance needs signposting




                  CHAPTER 4
                                                                                   35
Chapter Four

Key Priority Areas

This chapter sets out the key priority areas of action that partners will
concentrate on over the coming three years. It also provides information
on a range of other work that will be ongoing and will also contribute to
better service provision and improved health and well being.

This is the third Health, Social Care and Well Being Plan produced by
partners. There is already a solid foundation of understanding on the main
areas that need to be progressed in order to achieve our vision and long
term aims. This has been widely and extensively consulted upon with a



                                                                        36
wide range of stakeholders during previous rounds. Over the next three
years partners will continue to work together to target health
improvement and a reduction in health inequalities and to deliver high
quality, streamlined and safe health and social care services.

This plan will have a narrower focus than in previous rounds as partners
concentrate on a fewer number of key areas that it is considered will best
enable us to protect and improve core services and tackle health
inequalities during these challenging times. Both the review of progress
carried out by partners last year and the key findings from the needs
assessment have informed the identification of these areas.

There are two main areas of action that partners intend to progress.
These are both interlinked and complementary.

Key Priority Area 1: Making Swansea a Healthier City – To achieve
Healthy City Status for Swansea

Partners have agreed that working towards making Swansea part of the
World Health Organisation’s Healthy City Network will be a key priority
area over the next three years and beyond. To achieve this we will need
to demonstrate that we promote health and health equity in all policies.
Central to this will be a newly invigorated approach to engaging with
individuals and communities to jointly identify and implement actions that
will improve health and well being and prevent ill health. Crucial as-well
will be the links that we can further build upon with other key
partnerships in Swansea.

The core themes set out by the Welsh Health Organisation that we will
work towards are:-

     Creating caring and supportive environments – A Healthy City
      should be a city for all its citizens, inclusive, supportive, sensitive
      and responsive to their diverse needs and expectations.

     Healthy living – A Healthy City provides conditions and opportunities
      that support healthy lifestyles.

     Healthy urban environment and design – A Healthy City offers a
      physical and built environment that supports health, recreation and
      well-being, safety and social interaction, easy mobility, a sense of
      pride and cultural identity and that is accessible to the needs of all
      its citizens.

Taken from – Welsh Health Organisation European Healthy Cities Network
Phase V (2009 – 2013)




                                                                           37
To address these key themes there are three particular areas that we will
concentrate on over the next three years:-

Key Priority Area 1a
   Tackling the growing problem of substance misuse (including
     drugs, alcohol and tobacco) that leads to harm and destruction in so
     many lives, including those affected by the substance misuse of
     others. This will be a key area of joint work with three other key
     partnerships who are responsible for Community Safety, Children
     and Young People, and Local Safeguarding. It will be steered by the
     overarching Better Swansea Partnership to maximise the
     identification of a wide range of action that partnerships and
     individual agencies can be take to ensure a more comprehensive
     and joined up approach.

Key Priority Area 1b
   Improving the nutrition and fitness of the population to
     reverse the current trend towards obesity and sedentary lifestyles
     that result in so much ill health and chronic conditions such as
     circulatory disease (including coronary heart disease and strokes)
     cancers and respiratory disease. There will be a particular focus on
     children and young people. This will a key area of joint work with
     the Climbing Higher partnership who are responsible for the
     development of physical activity in Swansea. This will reinforce the
     benefits of good nutrition and taking regular exercise, and ensure
     we use our joint resources more effectively.

Key Priority Area 1c
   Influencing the Council’s Local Development Plan for land use
     over the next ten years to ensure that our local environments
     support good health and well being. This will be a key area of joint
     work with the Local Planning Department who are responsible for
     the production of the ten year Local Development Plan that sets out
     the framework for land use in Swansea.

These areas can be significant in terms of improved health, research has
shown that by taking regular exercise, eating a healthy balanced diet, not
smoking and drinking below the recommended limits potentially 14
years can be added to life.

Action in these three areas will be complemented by a programme of
geographically based work that continues to target the prevention of ill
health. This will build on the range of work that has been undertaken
during previous years and will ensure that the prevention of ill health
continues to be afforded a high priority.




                                                                        38
The central focus for the next three years will be to engage with local
communities where the needs assessment informs us that the health
inequalities are greatest. This will include developing strong links with
schools in those areas to provide a particular focus on children and young
people. We know to have an impact on reducing health inequalities we
need to address children’s access to positive early experiences, later
interventions are much less effective. It will also include strengthening
links to primary and community services to promote an enhanced focus
on prevention of ill health.

Again, the initial focus will be on substance misuse, nutrition and fitness
and the local environment to contribute to the drive towards making
Swansea a healthier city. By concentrating on a fewer number of areas,
engaging more comprehensively with local communities and extending
the range of agencies involved, partners hope to make a real difference
over the coming years. There will be flexibility however to encompass
those areas where local communities identify priority areas that need to
be tackled to assist in improving health and reducing inequalities. Some
of the key areas that have been identified nationally that could make a
significant contribution to preventing ill health are reducing teenage
pregnancy, reducing accident and injury rates, improving mental well
being, improving health at work, and increasing vaccination and
immunisation rates to target levels.

Key Priority Area 2: To improve the delivery of our Health and
Social Care Services

In line with the findings of the needs assessment and national work we
understand that our services are not always currently organised or
delivered in the best way. Some of the key challenges include

     increasing demand and expectations in relation to both an ageing
      population with more complex needs and the numbers of children
      requiring safeguarding that make the current service models
      unsustainable.
     a lack of co-ordination so that services do not seamlessly deal with
      people’s needs.
     too much reliance on hospitals (the most expensive part of the
      system) with more than could be done to prevent hospital
      admissions or reduce the length of stay, caring or supporting people
      to be treated in the community.
     creating opportunities to reduce waste, harm and variation.
     unequal access for some particularly vulnerable groups in the
      population.
     significant workforce challenges, including particularly a UK wide
      shortage of hospital middle grade and junior doctor vacancies
      across many specialities.


                                                                         39
We have made progress over recent years in joining up to deliver our
services more effectively and to shift the focus onto prevention, early
intervention and the delivery of services within a community setting.
Many examples were highlighted in chapter two.

However, living within our financial resources is already a challenge for
both the Health Board and the Local Authority and we expect this will
become significantly more challenging as we are given less resources with
which to provide services. We therefore realise that over the next few
years more radical and urgent steps are required that will accelerate the
pace of change.

The key priority areas that we intend to concentrate on are outlined
below:-

Key Priority Area 2a
Transformation of Adult Social Services

We understand that the current service model is no longer sustainable in
light of the challenges outlined above. We have therefore embarked on a
transformation agenda that will radically change the way we conduct our
business. We aim to create meaningful and fulfilled lives for all, through
supportive relationships within sustainable communities. We will do this
by providing, arranging or facilitating the right support at the right time
and place, implementing plans to maintain independence and achieve
agreed outcomes.

Over the next three years we will concentrate on:-

Reshaping and remodeling services: both internally and externally to
become more personalised and relationship centred. Services will be
flexible, innovative, effective and better value for money. They will be
outcome focused and the emphasis will be on what service users can
contribute as well as what they need.

Redesigning our operating model: (Assessment and Care
Management process) to one of assisted self assessment and support
planning, where a resource allocation system and indicative budget are
the vehicles that will give service users and carers more choice and
control and where the emphasis is on outcomes and achievements and
not needs and requirements.

Refocusing on communities: to ensure that we are linking citizens into
local resources and networks, forming strong links with other community
organisations and introducing a local area coordination approach to lower
level intervention. We will work with key stakeholders to develop mutual



                                                                         40
support systems and will test out a number of concepts around time
banking, cooperatives and mutual societies.

To ensure we are developing a sustainable model for Adult Social Services
we will combine this work with a number of other strategic developments,
including:-

     The transformation of older people’s project. This project aims to
      transform services for intermediate care, older people’s mental
      health, day opportunities, locality planning, assessment and care
      management, re-ablement, and respite care, care at home and the
      older people’s accommodation framework
     The review of how directly provided services are managed across
      adult services.
     The reshaping of local health services.
     Regional collaboration initiatives.

Key Priority Area 2b
Transformation of Children’s services

This is an area that was identified as a key priority in the last Health,
Social Care and Well Being Plan and is part of an ongoing work
programme to improve social service provision in relation to children.
The CSSIW inspection of Swansea’s Child and Family Services in April
2007 identified serious concerns about the quality of these services
judging them to be inconsistent and with uncertain prospects. Following a
re-inspection in December 2008, the Deputy Minister decided to formally
intervene to support and oversee improvements in services. A further
inspection in January 2010 identified significant changes in Child and
Family Services which had consolidated and built on the improvements
identified previously, but further improvements have been required by the
inspectors. The drive of the past few years will continue to shape the
changes and improvements to achieve Children’s Services which protect
and safeguard the welfare of children in need robustly and which are
sustainable and capable of continuing to improve.

The challenge of improving Child and Family Services has to be achieved
against a context of considerable growth in the demands on them. There
have been increasing numbers of referrals and a large rise in the numbers
of Looked After Children that have been experienced in Swansea, in line
with the national trends, following the reporting on the death of Baby
Peter in Haringey. There has been a growing consensus about the need
to develop partnership working to support the reshaping of services to
ensure more effective responses and better outcomes for children.

Over the next three years we will continue to build on the changes made
concentrating on:-



                                                                       41
     Embedding locality focused work (teams will be organised
      around five areas).
     Improving access to services and improving assessments
      through joint agency working.
     Strengthening of assessment and case management
      (workforce stability and development).
     Improving the outcomes for Looked After Children.

Key Priority Area 2c
Development of Primary and Community Services – Primary and
Community Networks

A national review of the delivery of primary and community services has
been undertaken. This, together with findings from our local needs
assessment has shown that for people living in Wales the current
healthcare system is confusing, complex and often fails to meet their
needs. Current service models are often overly focused on medical
interventions in hospital settings. There is a need to rebalance the whole
system with a strong primary and community based approach and less
reliance on institutional forms of care.

Over the next three years we will be establishing a new and simplified
model of care that integrates primary and community services for adults
and older people. This will involve:-

     Establishing a range of primary and community services
      networks working together across agencies and professions,
      providing a range of services that help promote and maintain the
      health of their local population – such services could include health
      visiting, district nursing, school nursing, primary care the third
      sector, therapies, public health and social care. It is envisaged
      Swansea will have five community networks established. Functions
      could include providing care – co-ordination and case management
      for people with complex needs, providing a range of services from
      single interventions to continuing health care, providing a clear
      interface with the hospital system to ‘pull’ patients through in a safe
      and organised way.

     To complement this with the development of a specialist
      community resource team that will provide intensive intervention
      to assist in avoiding admission to hospital and to facilitate
      discharge. It is envisaged there will be one specialist resource team
      for Swansea.

     Establishing a single point of access (communications hub) to
      services for both staff and service users which informs and co-



                                                                           42
      ordinates care and focuses delivery at individual service user level.
      It is envisaged that there would be three aspects – a library of
      services care co-ordination for individuals and directing the care
      pathway in acute and urgent situations.

These priority areas will link to and be progressed in tandem with the
implementation of the Health Board’s Five Year Plan, Changing for the
Better. The plan sets out an ambitious programme of action and includes
key strategic developments such as redesigning the role of the local acute
(including Singleton and Morriston) and community hospitals. The
proposals are that Morriston Hospital will become the specialist centre for
all emergency and complex care, including tertiary services such as Burns
and Plastics and Cardiac care, serving the wider ABM area and beyond.
Singleton Hospital will develop as a specialist rehabilitation hospital with
general inpatient care and a centre for excellence in cancer, oncology and
radiotherapy services, along with specialist obstetric-led maternity care
(including a Level 3 Neonatal Unit). Even though the two acute Hospitals
will develop individual roles that will complement each other, a wide
range of core services will remain on both sites such as specialist
outpatients, critical care and diagnostic testing.

As part of the development of primary and community networks
(explained above), patients will increasingly be cared for closer to or in
their own homes. This significantly reduces the pressure on community
hospitals, where this type of care would normally be provided. As a result
the Five Year Plan proposes that some of the community hospitals will
change and some may no longer be needed. For example, recent capital
investment has seen Gorseinon Hospital take on more of a role with
regards services that do not need to be provided on an acute hospital
site, such as specialist physiotherapy and general inpatient care. The
proposals are that some community hospitals will therefore continue to
play a vital role but set in the new context of community-based care.

This will build on specific developments already being progressed in
relation to acute hospital sites and community settings in Swansea for
example:

The Health Vision Swansea – a multi million pound capital investment
programme aimed at improving hospital and community facilities in
Swansea. Major infrastructure improvements have already been
completed at Morriston Hospital, such as a new multi-storey car park.
Construction work has now commenced on a the new main entrance to
the hospital, which will include retail provision, an Integrated Education
Centre, Patient Services Hub and Endoscopy suites. Designs have also
been finalised regarding the second phase of the development, which will
see, among other clinical services, a new Outpatients Department.




                                                                          43
A review of the current location of health and social care provision in the
City Centre that will seek to establish a clear way forward for co-locating
where appropriate primary, community and social care services in the City
centre.

Further information on the Health Board’s five year plan can be found at
www.wales.nhs.uk.



What else will be happening to impact upon health, social care
and well being?

The priority areas set out above represent the key areas that partners
have agreed to have a specific focus on over the next three years. This
will affect a range of client groups that receive services from health or
social care in particular, children, older people, those with a learning
disability, physical disability or sensory impairment and carers. There will
however be a wide range of additional action that partners will individually
or collectively be involved in delivering over the next three years that will
also contribute to improved service health or social care provision. This
will often underpin and link closely with the priority areas described
above. Some of the other significant areas partners will work on include:-

      Introducing the new Carers measure which will require partners to
       work jointly, consulting with carers to prepare, publish and
       implement a joint strategy for Carers.

      Implementing a range of action to improve the health and access to
       services for the homeless, asylum seekers, and refugees, gypsy
       travellers and migrants.

      Responding to the new responsibilities to tackle Child Poverty
       contained in the Child Poverty Measure.

      Continuing work to improve access, and information to health and
       social care services for those who have a physical disability or
       sensory impairment and to further expand the range of independent
       living options available.

      Implementing the requirements of the National Service Frameworks
       and Service Development and Commissioning Directives for Older
       People, Children and Maternity Services, Renal, Coronary Heart
       Disease, Mental Health, Arthritis and Musculoskeletal Conditions,
       Respiratory Conditions, Epilepsy and Other Neurological Conditions,
       Non Malignant Pain.




                                                                           44
   Progressing an implementation framework between partners that
    improves services for those with a learning disability.

   Continue our work to improve mental health services – a priority in
    previous rounds which will include; Completing plans to provide a
    range of upgraded facilities for people with a mental health
    problem. Introducing the new mental health measure which aims
    to provide services at an earlier stage, extend advocacy, reduce the
    risk of further decline in mental health and ensure prompt access to
    services when mental health may be deteriorating.

   Developing the first joint Dementia Action Plan for Swansea that will
    set out a revised model of care and aim to improve services for
    those sufferers of dementia and their carers.

   Continuing a programme of work to meet the Health Care
    Standards Doing Well, Doing Better which provides a framework of
    standards to support the provision of effective, timely and quality
    services across all health care settings.

   Participating in the national Saving 1,000 Lives Plus campaign – a
    two year patient safety campaign which focuses on the reduction of
    harm, waste and variation.

   Implementing a range of action to strengthen our joint working with
    the voluntary sector, that further improves recognition and
    understanding of the valuable role the voluntary sector can play in:-

      o   Service planning.
      o   Supporting self care and independence.
      o   Improving access to services for specific communities.
      o   Promoting and improving health and well being.
      o   Providing volunteering for health and social care.
      o   Reducing hospital admissions and improving discharge.

   Improving our unscheduled care services, developing our 24 hour/
    seven days week capacity to facilitate a significant shift in
    unscheduled care activity from hospital to community and primary
    care settings, and improving our timeliness of care and our
    handover times from ambulance services.

   Building on our success in establishing chronic conditions
    management, improving services for people with, or at risk of
    developing long term conditions. Focusing on supporting self care
    and the maintenance of high quality services.




                                                                       45
      Reshaping our continuing care services, strengthening the joint
       approach between the Health Board and the Local Authority, aiming
       to deliver high quality care wherever possible as close or in the
       individuals home.

      Improving our medicines management, extending the role of
       pharmacists in prevention, enhancing patient involvement in the
       management of their medicines, and reducing where appropriate
       unnecessary spending

To achieve our aims, partners recognise the importance of reinforcing our
supporting infrastructure. We will therefore continue to improve our
workforce planning, informatics, procurement, research development and
training. Partners will actively seek opportunities to do this jointly where
possible.

The Financial Overview

Several references have been made throughout the plan to the
challenging economic climate. More detail is now provided below on the
current outlook for the Local Authority and The ABMU Health Board.



Local Authority Financial Outlook

Local authorities have a duty both to set an annual budget and to adopt a
Medium Term Financial Plan (MTFP) normally covering three forward
years. In normal circumstances this requires a degree of horizon scanning
and forecasting in terms of both service pressures and the economic
outlook.

At this time the prospects for local government finances, and indeed the
whole public sector, are inextricably linked with the bleak national outlook
arising from the banking crisis and recession. This overview sets the
Council’s forecast financial position in this broader context and highlights
the likely local impacts. The overview is intended to contextualise the
detailed budget proposals.

A number of publications have highlighted the pressures on public
finances and Local Government Finance in the period 2010-2014. The
document ‘In the Eye of the Storm’ published by the Welsh Local
Government Association (WLGA) in July 2009 is particularly relevant.

The key pressures on local government arise from:

          The indirect consequences of the banking crisis and recession.
           In particular, the need for the UK government to repay the


                                                                          46
          resulting national debt will reduce the level of revenue and
          capital funding available to local government for many years to
          come.
         Greater demand for Council services as a result of recessionary
          impacts (e.g. free school meals, lifelong learning, community
          support etc.) and demographic changes.

All commentators irrespective of political persuasion predict:

         real reductions in both revenue and capital funding over the
          next three to four years.
         the need to offset some of the impact by a continued drive for
          efficiency.
         the size of the challenge being greater than efficiency savings
          alone can meet. Radical choices and tough decisions are
          required in relation to which services are to be provided.
         the need for re-prioritisation at national, devolved and local
          level.

The Welsh Local Government Association document defined the national
priorities as:

         Waste management, sustainability and climate change
         Social Care
         Lifelong learning
         Strategic Housing
         Building strong healthy communities
         Transport and highways


 The starting point for setting the 2010/11 budget and reviewing the
 MTFP has to be the national outlook outlined above together with the
 pressures currently presenting themselves. At the half year the
 projected overspend for 2009/10 stood at £12m and in broad terms the
 key issues are:

   Additional Service Demands

         Child and Family Social Care. Increased referrals, higher
          numbers of court cases and the costs associated with providing
          additional workforce capacity.
         Adult Social Care. The impact of an ageing population leading to
          increased demand.
         Waste Management. Significant costs associated with the
          development of the national waste management strategy,
          landfill tax, recycling costs etc.




                                                                         47
        Special Education Needs. The additional costs of increased client
         numbers and complexity of cases.

    Recessionary Impacts

   The increased demand for services has been accompanied by financial
   consequences deemed to be direct recessionary impacts.

        Loss of income due to higher level of vacant property
        A reduction in interest on balances (partly offset by reduced
         borrowing costs)
        Impacts on fees and charges including car park charges,
         Planning and Building Control fees.

    Capital spending requirement

   The Council also faces significant challenges in terms of capital
   expenditure notably:

    Continued high levels of backlog maintenance
    A difficult outlook for disposals to create resources
    The need to facilitate developments , for example QED.

   Indications are that the Council’s capital allocation could reduce by up
   to 50% in 2011 and beyond impacting on current property and
   highways maintenance programmes and the Disabled Facilities Grants
   provision.


Financial Outlook 2010-14
In summary therefore, the Council must plan against a backcloth of:

        A real terms reduction in future revenue settlements
        A potential 50% reduction in Assembly support for capital
         spending
        A need to make efficiency gains
        A need to prioritise
        A need to cut some service provision and make radical choices
         on what and how services are provided in future.

Other factors that will also need to be taken into account include:

        The probability of a return to positive inflation in the planning
         period the impact of which is unlikely to be funded.
        The potential need, subject to actuarial valuation, to significantly
         increase contributions to the Pensions Fund.




                                                                           48
ABMU Health Board Financial Outlook

The financial outlook for health mirrors that of local government. It is
likely that a period of reductions in budgets will have to be managed by
the NHS. National work has identified that the potential range for
allocation annual changes could be between 0% and -3%, in each of the
years ahead. Given that NHS inflation, demand and cost pressures can lie
in the range of between +4% and +8%, it is evident that a prolonged
period of very substantial annual savings requirement is highly likely to be
required over the next 5 years or so. The Health Board have therefore
adopted a 7% savings scenario that forms the basis of the forward
Financial Plan and against which the service response captured in the 5
Year Quality and Service Framework needs to be considered.

Providing quality services that are appropriately delivered, in the right
setting by the right people, is at the centre of the approach taken by the
Health Board in planning and delivering services. This approach needs to
be developed and applied in the context of the financial resources that are
forecast as being available to the Health Board. It is important that the
forward Plan realises the opportunities, available to the Health Board in
being a new, fully integrated healthcare organisation, that were not
available in the previous NHS management arrangements in Wales.

Given the likely economic context, the Health Board’s 5 Year Quality and
Service Framework will need to develop plans that contain action in the
following areas:-

•       Strategic Service Changes
•       Improving Service Cost Efficiency
•       Reducing Waste and Harm
•       Transforming the Delivery of Services
•       Workforce Strategy and Controls
•       Rigorous Cost Containment.

It is evident that the actions that will flow from the above will need to be
planned, implemented and sustained over the whole 5-year planning
period. It is imperative for robust service and financial planning that each
activity is outlined, not only in its in-year contribution, but also in its
recurring contribution.

It is also critical that measures are taken forward with focus and strong
co-ordination of managerial and clinical resources. It is important to
commence the preparation of planning for, and stakeholder management
of, service changes, even though their full impact may fall in future years.
Partnership working with the Local Authority to plan and deliver
integrated service provision should underpin service planning.




                                                                           49
Additionally, close working with the third sector to maintain and improve
services for clients will continue to be a key part of plans.

The Health Board faces a major service redesign, transformation and
value for money agenda, arising from the challenging Public Finance
environment ahead. This will require the Health Board to significantly
enhance the initial work done to date to shape the Quality, Service,
Workforce and Financial Framework 2010 – 2015 that covers a medium
term period of up to five years.




            CHAPTER 5


                                                                         50
Chapter Five

Next Steps

This current draft plan is being prepared at a unsettled and challenging
time. Partners are aware of the very real challenges to improve the health
of the population of Swansea to the best level possible and the need to
reduce the current inequalities that exist. However, it is likely that public
sector services will see significant cuts in the amount of resources that
are available to deliver core services that will mean a sustained focus on
delivering services in the most effective and joined up way. Partners in
Swansea currently await the announcements of the spending review in
the Autumn to better understand the resources that will be available to
provide services to the people of Swansea.

The key challenge for the next few years will be to continue to engage
with communities and individuals to improve their health and well being
and prevent ill health and protect our core services, including those



                                                                           51
provided to the most vulnerable during these difficult and challenging
financial times.

There is some additional key information and developments awaited that
partners know will have an impact on the development and
implementation of the final plan. These include:

      The findings of the Commission looking at Social Services and the
       expected White Paper on the Future of Social Services
      How any future political changes will affect national policy
      Finalisation of national targets and performance indicators for
       2011/12 onwards
      More detailed resource allocations and financial plans across the
       health sector and local government which will become available
       during the consultation period
      Further guidance on the development of joint commissioning plans/
       strategies

Therefore, it has been decided that a flexible approach will be adopted to
the development of this plan recognising that it will need to change and
be adapted to meet differing future circumstances. This draft plan is being
published for a twelve week consultation exercise. During the consultation
period it is intended to seek feedback on the proposals and to develop our
plans more fully. This will also allow partners to have a clearer idea of the
financial resources that will be available with which services are provided.
It will also allow the plan to be shaped by views on the most effective way
some of the current challenges can be met.

A final plan will then be developed taking into account the consultation
feedback. Although this final plan will provide a framework for the next
three years, it will still be kept flexible so that it can be adapted to best
meet the current and new challenges. To achieve this it is intended that
the strategy, when finalised, will be subjected to a full review after one
year, when the financial climate in particular will be clearer. This will
allow us to check on progress and to amend plans depending on new
information.




                                                                           52
APPENDIX 1 - WELSH HEALTH ORGANISATION (WHO) EUROPEAN
HEALTHY CITIES NETWORK PHASE V (2009 – 2013)

Overall goals of the WHO European Healthy Cities Network

The WHO European Healthy Cities Network has six strategic goals:

• to promote policies and action for health and sustainable development
at the local level and across the WHO European Region, with an emphasis
on the determinants of health, people living in poverty and the needs of
vulnerable groups;

• to strengthen the national standing of Healthy Cities in the context of
policies for health development, public health and urban regeneration
with emphasis on national-local cooperation;




                                                                            53
• to generate policy and practice expertise, good evidence, knowledge
and methods that can be used to promote health in all cities in the
Region;

• to promote solidarity, cooperation and working links between European
cities and networks and with cities and networks participating in the
Healthy Cities movement;

• to play an active role in advocating for health at the European and
global levels through partnerships with other agencies concerned with
urban issues and networks of local authorities; and

• to increase the accessibility of the WHO European Network to all
Member States in the European Region.

Themes in Phase V of the WHO European Network

The overarching theme for Phase V is health and health equity in all local
policies. Health in all policies is based on a recognition that population
health is not merely a product of health sector activities but largely
determined by policies and actions beyond the health sector.
Health and well-being are increasingly becoming shared values across
societal sectors. Solid evidence shows that the actions of other sectors
beyond the boundaries of the health sector significantly influence the risk
factors of major diseases and the determinants of health. Health in all
policies addresses all policies such as those influencing transport, housing
and urban development, the environment, education,
agriculture, fiscal policies, tax policies and economic policies.

Further, health in all policies is not confined to the public health
community or to the national level. It is relevant and has a tremendous
potential for positive health outcomes at the local level, strengthening the
public health leadership role of municipal governments. Health in all
policies is a horizontal approach that seeks to engage all sectors of
society in integrating health and well-being considerations as central
values in their strategies and plans. Addressing the determinants of
health would not be comprehensive without an explicit commitment to
tackling inequality in health.

In addition to the overarching theme of health and health equity in all
policies, Phase V will focus on three core themes. These core themes
represent entry points to addressing important aspects of the urban
environment. All Phase V themes are interrelated, interdependent and
mutually supportive. Within these themes, cities will be able to identify
priority issues that are of particular concern to them. The scope for
strategic work and action of each of the core themes is very broad.
Several important issues are listed under each of the three core themes.



                                                                            54
The list is not meant to be exhaustive or prescriptive. The issues listed,
however, represent aspects that cities should consider seriously when
deciding how to approach each of the themes and how to assign priority.

Phase V offers cities the possibility to work both at the macro strategic
and policy level, encouraging and steering the city as a whole to actively
embrace health as a core value, but also at the action and operational
level on a wide range of public health issues. Cities will have the
opportunity to address old and new public health priorities systematically
and through approaches that are anchored in the most advanced public
health concepts. All cities in the WHO European Network, working
individually and collectively, will address the overarching theme and the
core themes.

Core theme 1

Caring and supportive environments. A healthy city should be above
all a city for all its citizens, inclusive, supportive, sensitive and responsive
to their diverse needs and expectations.

Important issues

• Better outcomes for all children. Providing early childhood services
and support to all young citizens and aiming to systematically improve the
lives of children. Investing in early childhood development is one of the
best ways to reduce inequality in health.



• Age-friendly cities. Introducing policies and holistic action plans
addressing the health needs of older people that emphasize participation,
empowerment, independent living, supportive and secure physical and
social environments and accessible services and support.

• Migrants and social inclusion. Systematically addressing the health
and social needs of migrants, promoting integration, tolerance and
cultural understanding.

• Active citizenship. Providing an effective infrastructure for community
participation and empowerment, utilizing community development
techniques as the catalyst for action and promoting social networking
opportunities.

• Health and social services. Advocating and supporting the
development of health and social services that are responsive, high
quality and accessible to all, based on systematic needs assessment of
the population and particularly for vulnerable groups.



                                                                              55
• Health literacy. Developing and implementing programmes aiming to
strengthen the health literacy skills of the population. Health literacy
means the degree to which individuals have the capacity to obtain,
process and understand basic health information and services provided by
complex health systems needed to make appropriate decisions to
maintain and promote their health.

Core theme 2

Healthy living. A healthy city provides conditions and opportunities that
support healthy lifestyles.

Important issues
• Preventing noncommunicable diseases. Scaling up efforts and
strengthening local partnerships to tackle the epidemic of
noncommunicable and chronic diseases through population-based
integrated approaches addressing the risk factors and social determinants
of these diseases.

• Local health systems. Strengthening the capacity of local health
systems, including public health services and primary health care
services, to prevent, control and manage cardiovascular disease, cancer,
respiratory disease and alcohol-related disease.
Phase V (2009–2013) of the WHO European Healthy Cities Network: goals
and requirements page 5

• Tobacco-free cities. Implementing and enforcing city-wide smoke-free
policies in public and working spaces.
• Alcohol and drugs. Developing intersectoral plans of action to prevent
alcohol and drug abuse.

• Active living. Making active living, physical activity and pedestrian
mobility a core part of city development policies and plans.

• Healthy food and diet. Increasing equitable access to healthy food
and broadening the understanding of healthy eating habits.

• Violence and injuries. Introducing policies and plans to deal with all
aspects of violence and injuries in cities, including violence involving
women, children and older people, road crashes and home accidents.

• Healthy settings. Supporting programmes on healthy living and
mental wellbeing that would be implemented through the settings of
people’s everyday lives, such as neighbourhoods, schools and workplaces.




                                                                           56
• Well-being and happiness. Broadening the understanding of and
exploring and promoting the factors and conditions that support well-
being and happiness, reduce stress and enhance the resilience of
communities.

Core theme 3

Healthy urban environment and design. A healthy city offers a
physical and built environment that supports health, recreation and well-
being, safety, social interaction, easy mobility, a sense of pride and
cultural identity and that is accessible to the needs of all its citizens.

Important issues
• Healthy urban planning. Integrating health considerations into urban
planning processes, programmes and projects and establishing the
necessary capacity and political and institutional commitment to achieve
this goal. Especially emphasizing master planning, transport accessibility
and neighbourhood planning.

• Housing and regeneration. Increasing access through planning and
design to integrated transport systems, better housing for all, health-
enhancing regeneration schemes and to green and open spaces for
recreation and physical activity.

• Healthy transport. Promoting accessibility, by facilitating the ability for
everyone, including very young people and people with limited mobility,
to reach their required destination without having to use a car.

• Climate change and public health emergencies. Tackling the health
implications of climate change in cities and being vigilant about global
changes such as the impact of globalized economies, the free movement
of people and preparedness for and response to public health
emergencies.

• Safety and security. Ensuring that the planning and design of cities
and neighbourhoods allows social interaction, increases a sense of safety
and security and supports easy mobility for everyone, especially young
and older people.

• Exposure to noise and pollution. Promoting and adopting practices
that protect people, especially children, from toxic and health-damaging
exposure, including indoor and outdoor air pollution, tobacco smoke in
workplaces and public places and noise.

• Healthy urban design. Creating socially supportive environments and
an environment that encourages walking and cycling. Enhancing cities’
distinctive and multifaceted cultural assets in urban design and promoting



                                                                           57
urban designs that meet all citizens’ expectations for safety, accessibility,
comfort and active living.

• Creativity and liveability. Promoting policies and cultural activities
that encourage creativity and contribute to thriving communities by
developing human and social capital, improving social cohesion and
activating social change.




GLOSSARY OF TERMS

A

Air quality
The composition of air with respect to quantities of pollution. It is
routinely compared with "standards" of maximum acceptable pollutant
concentrations.

C

Cancer
Any malignant growth or tumour caused by abnormal and uncontrolled
cell division, it may spread to other parts of the body.

Care Pathways
An integrated care pathway (ICP) is a multidisciplinary outline of
anticipated care, placed in an appropriate timeframe, to help a patient


                                                                            58
with a specific condition or set of symptoms move progressively through a
clinical experience to positive outcomes.

Carers
A carer is a friend or relative who looks after an ill, disabled or older
person on an informal, voluntary and long term basis.

Carers Strategy
It is a ten year plan that includes £255m of new money for carers,
including local health trusts receiving £150m over the next two years for
breaks and respite.

Chronic Respiratory Disease
Chronic respiratory diseases are chronic diseases of the airways and other
structures of the lung.

Climbing Higher Strategy
This strategy is to maximise the contribution that sport, active recreation
and physical activity can make to well-being in Wales across its many
dimensions : health, prosperity, inclusion, access to opportunity, culture,
community and confidence.

Community First Status
Communities First is Welsh Assembly Government’s flagship programme
to improve the “living conditions and prospects for people” in the most
disadvantaged communities across Wales. There are 142 Communities’
First areas in Wales. The areas comprise the 100 most deprived wards in
Wales (as identified by the Welsh Index of Multiple Deprivation 2000), 32
smaller areas, “pockets of deprivation” and 10 sectoral initiatives. Every
county and county borough in Wales has at least one Communities First
area and many have several.

Community Services
Services provided to citizens by a local government and a NHS Health
Board, (see page 63).

Crisis Resolution and Home Treatment Service
Crisis Resolution/Home Treatment refers to a system for the rapid
response and assessment of mental health crisis in the community with
the possibility of offering comprehensive acute psychiatric care at home
until the crisis is resolved, and usually without hospital admission. Acute
care is delivered by a specialist team so as to provide an alternative to
hospital admission for individuals with serious mental illness who are
experiencing acute difficulties.

D




                                                                         59
Dementia
Deterioration of intellectual faculties, such as memory, concentration, and
judgment, resulting from an organic disease or a disorder of the brain.

Deprivation
The state of being deprived.

Determinants of Health
Determinants of health include the range of personal, social, economic
and environmental factors which determine the health status of
individuals or populations.

Diabetes
A disease in which the body does not properly control the amount of
sugar in the blood.

Disability
The condition of being unable to perform as a consequence of physical or
mental unfitness, reading disability, hearing impairment.

Disability Discrimination Act 2005
The Disability Discrimination Amendment Act (DDA) 2005 amends the
Disability Discrimination Act 1995. It widens the definition of disability
and introduces a general duty to promote disability equality for public
sector bodies.




E

Economic Activity
Economics is the social science that studies the production, distribution,
and consumption of goods and services.

Economic Prosperity
A period of sustained growth that often lasts for a decade or two.

F

Fossil Fuel Supplies
Fossil fuels are fuels formed by natural resources such as anaerobic
decomposition of buried dead organisms.

Fuel Poverty
Where a combination of poor housing conditions and low income mean
that the household cannot afford sufficient warmth for health and comfort
and which needs to spend more than 10% of its income on fuel used to


                                                                         60
heat its home to adequate standards of warmth. Severe fuel poverty
refers to spending more than 15% of total household income on fuel.

H

Health Gain Targets
Health gain is a way to express improved health outcomes. It can be
used to reflect the relative advantage of one form of health intervention
over another in producing the greatest health gain.

Health Inequalities
This is the term commonly used in Europe to indicate the virtually
universal phenomenon of variation of health by socioeconomic status.

Health Outcomes
The effect on health status from performance (or non-performance) of
one or more processes or activities carried out by healthcare providers.
Health outcomes include morbidity and mortality, physical, social, and
mental functioning, nutritional status and quality of life.

Healthy Weight Strategy
This strategy provides a high level overview of current issues around
healthy weight and has a focus on what will follow to achieve sustainable
change.

Heart Disease
A structural or functional abnormality of the heart or of the blood vessels
supplying the heart that impairs its normal.

I

Inequalities
The condition of being unequal, an instance of being unequal.

Integrated Pathways
Integrated care pathways are one means for improving the delivery of
care to patients. Increasingly, members are becoming involved in their
use.

Intermediate Care Services
Intermediate Care services enable people to improve their independence
and aim to provide a range of enabling, rehabilitative and treatment
services in community settings.

J

Joint Equipment Store



                                                                            61
Generic term for an activity of two or more people usually (but not
necessarily) for profit which may include partnership, joint venture, or
any business in which more than one person invests, works, has equal
management control and/or is otherwise involved for an agreed upon goal
or purpose.

L

Longevity
long life, great span of life.

M

Mental Health Action Plan
A plan detailing the strategies and activities that will be implemented to
realise the vision and achieve the objectives of a mental health policy.

Model of Care
The way care is delivered.

Morbidity
State of being ill or diseased.

Mortality
The number of deaths occurring during a specific time period.




N

National Service Frameworks
National service frameworks (NSFs) are long term strategies for
improving specific areas of care. They set measurable goals within set
time frames.

Needs Assessment
Health needs assessment (HNA) is a systematic method for reviewing the
health issues facing a population, leading to agreed priorities and
resource allocation that will improve health and reduce inequalities.

Neurological Disease
A physical condition in which there is a disturbance of normal functioning.

Nursing Care
Care by a skilled nurse.



                                                                         62
O

Outline Business Case
A detailed document providing the information needed to bid for capital
investment within the NHS.
P

Physical Disability
Incapacity to function normally caused by a bodily defect or injury.

Practitioners
A physician whose practice is not oriented to a specific medical specialty
but instead covers a variety of medical problems in patients of all ages.
Also called family doctor.

R

Renal Disease
Refers to damage to or disease of the kidney.

Residential Care
The provision of room, board and custodial care. Residential care falls
between the nursing care delivered in skilled or intermediate care facilities
and the assistance provided through social services.




Respiratory Problems
A sudden condition in which breathing is difficult and the oxygen levels in
the blood abruptly drop lower than normal.

Retinopathy Screening
A disease of the retina of the eye that can result in loss of vision.

S

Safeguarding
To make safe.

Secondary Care Services
Specialist services, usually provided in an acute hospital setting, following
referral from a primary or community healthcare professional.

Smoking Cessation



                                                                           63
Smoking cessation (colloquially quitting) is the process of discontinuing
the practice of inhaling a smoked substance.

Social Care Services
The term 'social care' covers a wide range of services, which are provided
by local authorities and the independent sector.

Socioeconomic Deprivation
Involving social and economic factors of extreme poverty.

Statutory Sector
Local government – councils - works with local government and councils
in a variety of ways to help them more effectively work with charities.

Stroke
The sudden death of some brain cells due to a lack of oxygen when the
blood flow to the brain is impaired by blockage or rupture of an artery to
the brain.

Swansea Community Health Council
Swansea Community Health Council (CHC) is a statutory organisation, the
independent voice of the public and the consumers of health services in
the Swansea area.

Swansea Council for Voluntary Services
SCVS is the umbrella organisation for voluntary activity throughout the
City & County of Swansea, supporting, developing and representing
voluntary organisations, volunteers and communities.


T

Telecare Service
Telecare is the continuous, automatic and remote monitoring of real time
emergencies and lifestyle changes over time in order to manage the risks
associated with independent living.'

Third Sector
The voluntary sector or community sector (also non-profit sector) is the
sphere of social activity undertaken by organisations that are for non-
profit and non-governmental. This sector is also called the third sector.

U

Unitary Authority
A territorial authority that exercises the functions, duties and powers of
both a regional council and a city or district council.



                                                                        64
V

Voluntary Sector
Organisations, often registered as charities, which operate on a non
profit-making basis, to provide help and support to the group of people
they exist to serve. They may be local or national, and they may employ
staff, or depend entirely on volunteers.

W

White Paper
A white paper (or "whitepaper") is an authoritative report or guide that
often addresses issues and how to solve them.

WHO Network of European Healthy Cities
The Healthy Cities approach was initiated by the World Health
Organisation. The Healthy Cities approach is based on the concept that
the social, economic and physical environment is the key to the health of
city dwellers.




DESCRIPTION OF SCHEME

Healthy Schools Scheme
Area Wide Traffic Management and Urban Safety Schemes
Mediation Schemes



KEY TO ABBREVIATIONS

ABMU HB    -   Abertawe Bro Morgannwg University Health Board
A&E        -   Accident and Emergency
BME        -   Black Minority Ethnics
CAMHS      -   Child and Adolescent Mental Health Services
COPD       -   Chronic Obstructive Pulmonary Disorder
CSSIW      -   Care and Social Services Inspectorate Wales
DNA        -   Deoxyribonucleic Acid


                                                                       65
GP       -   General Practitioner
HSC&WB   -   Health, Social Care and Well-being
LA       -   Local Authority
LARC     -   Long Acting Reversible Contraception
LSB      -   Local Service Board
LSOA     -   Lower level Super Output Area
MMR      -   Measles, Mumps and Rubella
NHS      -   National Health Service
NSF      -   National Service Framework
STI      -   Sexually Transmitted Infection
WHS      -   World Health Survey
WIMD     -   Welsh Index of Multiple Deprivation




                                                    66

				
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