WORKING DRAFT FEBRUARY 2008
                 STRATEGY FOR CARERS
                       2008 - 2013

                                Executive Summary
This is one of nine Joint Commissioning Strategies for improving adult health
and social care community services in Torfaen. They are being developed
during 2008 as part of the Action Plan that underpins the Health, Social Care
& Well-being Strategy (2008-11).

The improvement of hospital-based services are set out in the Gwent Clinical
Futures Strategy and the improvements for meeting the health and social care
needs of children are being described in a separate commissioning strategy
via the CYP Framework Partnership.

The service area/client groups to be covered in 2008 include the following:

Learning Disabilities                   Physical Disabilities
Adult Mental Health                     Carers
Older People                            Older Person’s Mental Health
Long Term Conditions                    Intermediate Care services

The expected benefits of joint commissioning strategies are set out below:

Benefits for Users = Seamless services, single point of access, unified
assessment, avoid gaps between services, continuity across care pathway,
service development and expansion, increased choice and independence,
resources targeted to highest needs.

Benefits for Staff = Effective collaboration across organisations, multi
professional learning, increased skills and better skill mix, extended
employment opportunities, new ways of working.

Benefits for Providers = Service vision and development priorities shared,
opportunities to re-design services or redirect resources to meet future
demands, longer term and block contracts for sustainable local businesses

Benefits for Commissioners = Breaking down professional and organisational
barriers, better use of resources – statutory, independent and voluntary,
joined up needs assessment, gap analysis and service planning, managing
demand from demographic/technological changes.

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This is the first Joint Health and Social Care Commissioning Strategy for
Carers Services in Torfaen and provides an analysis of:

       Current and Future Demand
       How services are currently purchased and provided
       Details of the main service providers
       Gaps in service provision
       Future strategic commissioning intentions

The Strategy sets out the overall direction and joint commissioning priorities
for Torfaen over the next five years in line with the Social Care Plan, Health,
Social Care and Well Being Strategy, Gwent Clinical Futures and the
Council’s Corporate Plan and demonstrates a real commitment from all
stakeholders to work more closely together as a partnership to address the
needs of carers. The Strategy should also be read in conjunction with other
Torfaen Joint Commissioning Strategies for People with Physical Disabilities
(including sensory Impairment), People with Long Term Conditions, Mental
Health, Older People with Mental Health needs, Older People, Learning
Disability, and Intermediate Care Services.

The aim of this strategy is:

 “To plan for and develop the provision of services for carers in Torfaen
   that comply with national legislation and guidance, and meet local

This strategy has adopted the following definition of a carer, which was
developed by the Welsh Assembly in July 2000:

“Carers are people who look after family members or friends who need care,
help or support. Carers can be adults caring for other adults, parents caring
for ill or disabled children under the age of 18, or young carers under 18 who
care for another family member. There is not a typical carer. Carers may be
of any age, culture or religion, and from a diverse range of backgrounds.
Some carers do not see themselves as carers, but see themselves primarily
as a parent, child, wife or husband, partner, friend or neighbour.
This strategy encompasses all carers irrespective of age.

The development of joint commissioning strategies in Torfaen must be
considered in the context of national and local policy drivers which support the
modernisation of health and social care services. These policy initiatives have
identified a number of emerging themes relating to carers and give direction to
future preferred service development models.

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The key themes from national guidance that are essential for the
commissioning of services in the next five years are as follows:
    The user should be at the centre of service delivery and the
      commissioning of services
    Services and commissioning of services should focus on outcomes,
      promoting health and wellbeing and prevention as much as providing
      long term and acute services
    The locus of health and social care should shift from hospital and
      institutional settings to communities and closer to the user’s own home
    Services should help people stay safe, healthy and independent for as
      long as possible
    Work collaboratively to deliver high quality services jointly, using a
      common approach to assessment
    Increase the skill mix and develop the health and social care workforce
      in order to deliver consistent, high quality services across both health
      and social care
    Performance of services needs to be managed tightly to ensure that
      services are commissioned and delivered efficiently and effectively
      within a culture of improvement to enhance the quality of life and
      experience of the end user

The key national strategies and legislation that have influenced this strategy
are: (1a,1b etc. refers to links to strategies within the action plan)
    Carers (Recognition and Services) Act 1995
    Carers (Equal Opportunities) Act 2004
    Caring about Carers – a strategy for carers in Wales 2000 (1a)
    Department of Health White paper ‘Our health, our care, our say’ (1b)
    Fulfilled Lives, supportive communities – a strategy for Social Services
       in Wales over the next decade (1c)
    Designed for Life, 2005 (1d)
    Carers Strategy for Wales Action Plan 2007 (1e)
    CSCI report ‘The state of support to carers’ 2005-06 (1f)
    Challenging the Myth – Black and Ethnic Minority (BME) Carers (1g)
    In Poor Health, Carers UK 2004 (1h)
    The Carers Compass for Primary Care (1i)
    Valuing Carers – calculating the value of unpaid care, Carers UK (1j)
    National Service Frameworks

The key themes from local guidance (both in the section above and in the
overarching policies in the appendices) that are essential for the
commissioning of services in the next five years are as follows:

       A shift in the focus of health services away from secondary and tertiary
        hospital care to level 1 health and social care services

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       To improve services for vulnerable people and improve health
        outcomes for everyone by promoting healthier lifestyles
       Work in partnership to continue the shift towards a service direction
        that focuses increasingly on people’s independence
       A focus on health and social care outcomes through promoting
        independence and choice
       Ensuring that services are effective, efficient, accessible and prioritised
        to those in greatest need

The key local strategies that have influenced this strategy are:
    Health and Well Being Strategy 2008/11 (2a)
    Torfaen County Borough Council – Corporate Plan (2b)
    Torfaen Young Carers Strategy (2c)
    Torfaen Joint Review (2d)
    Gwent Clinical Futures (2e)


Needs Analysis
An evaluation of the current demographic profile for Carers in Torfaen and
forecasts for the changes in the local population highlighted the following key
     The population of Great Britain has been living longer over the past 20
        years, but the extra years have not necessarily been lived in good
        health. As a consequence many people could find themselves looking
        after older relatives at the same time as bringing up families and trying
        to hold down jobs
     It is estimated that there are 11,504 people providing informal care in
        Torfaen, placing it the third highest in Wales. Of these 11,504 people,
        2300 report they are spending over 50 hours per week on caring
     A Carers UK report 2007 suggests that the support that carers provide
        has been estimated at £87 billion per year for the whole of the UK. The
        estimate of replacement cost of care provided by carers in 2002 has
        risen by 62% in 5 years in Wales to £5.69 billion.
     Over a lifetime, 7 out of 10 women will be carers and nearly 6 out of 10
        men (Carers UK).
     There are nearly 80,000 people in England and Wales aged 54 and
        under providing more than 50 hours of unpaid care per week, who
        stated that their health was not good.
        The age group where the largest proportion of people provide care is in
        the fifties. More than one-in-five of people aged 50-59 are providing
        some unpaid care. About one in four (24.6 per cent) women in this age
        group are providing some care compared with 17.9 per cent of men.
     21% of carers have had to reduce the number of hours they have
        worked in order to care for someone
     The ward which has the highest percentage of carers is St Cadocs and
        Penygarn, with Wainfelin having the lowest proportion of carers. Other

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        wards in Torfaen where there are high percentages of carers are
        Croesyceiliog South, Cwmniscoy, and Llanyrafon North.

The following gives an outline of the current services available to Carers in
Torfaen that are provided by statutory and voluntary agencies:

       Dedicated Carers Centre in Pontypool that offers support and advice to
       Carers Support Worker who undertakes carers assessments, Health
        Advocacy Worker who helps service users attend GP and hospital
        appointments, a Planning Officer who helps develop services for
        carers, Dementia Support Workers, MH Carers Support Worker, a
        family support service and a Young Carers Team. From April 2008
        there will be a service user and carer facilitator in post that will
        encourage carers to be engaged with the planning and development of
        services and ensure that carers have a voice and are listed to.
       Respite facilities that are available are the adult placement scheme,
        and Caring for Carers. Torfaen County Borough Council also has block
        contracts with providers such as EMI care homes.
       Information that is currently available to carers is a Carers Handbook,
        which is soon to become a joint information pack where information
        such as posters, leaflets etc. can be inserted. A Carers Website is
        currently being developed that will give carers access to up to date
        information. There is also a support programme available to carers
        which is a 6 week training course that gives carers information on
        topics such as legislation and benefits.

There are 10 objectives/gaps which the strategy aims to address:

1. Ensuring that carers are fully informed
Carers need to have the right information available to them so they can make
informed decisions about themselves and the people they care for.
2. Recognising and assessing carers needs
Carers need to understand and have confidence in the benefits of
assessment, what is involved and how they can obtain one.

3. Quality of Services
Carers say they are best supported where services, either for themselves or
for the person cared for, are of a quality that gives them peace of mind and
are adaptable to suit both their needs.
4. Opportunities for a break
Opportunities for a break are stated to be one of the highest priorities for
5. Emotional support
Recognise that although each caring role is unique, carers often have a sense
of isolation and there is a need for some kind of emotional support.

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6. Training and advice to carers
Recognise that carers in Torfaen may be expected to carry out caring duties
that may include, for example - managing long term conditions
7. Financial security and carers in employment
Carers often find themselves at a financial disadvantage due to the caring
commitments associated with their caring role.
8. Ensuring carers have a voice
Promoting and supporting the participation of service users, carers and the
public in the planning, monitoring and delivery of local health care services
9. Support access to leisure and educational opportunities
Carers often struggle to find the time or respite to search for or access leisure
and educational opportunities
10. Improving carers health
Because carers spend a lot of their time caring for someone their own health
becomes a second priority and therefore their own health suffers


Managing Performance
The local authority has a duty to collect information and measure performance
against the following 5 performance indicators:

       % of identified carers of adult service users who were offered an
       % of identified carers of adult service users who had an assessment
       % of identified carers of adult service users who had an assessment in
        their own right
       % of identified carers of adult service users who had an assessment
        and provided with a service
       % of identified carers of adult service users who are waiting for an

Information on the above indicators is collected on a quarterly basis and is
sent back to the Welsh Assembly Government at the end of every financial

Within all contracts with providers and voluntary organisations there are
performance management systems in place to ensure that the contract is
being fulfilled. With all contracts regular review meetings are held to ensure
that organisations are providing best value services.

One of the aims of the newly revised carers planning group, the carers
commissioning group will be to ensure that effective performance
management targets are set in all contracting arrangements relating to carers


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The commissioning priorities over the next 5 years will be to ensure that the
10 identified gaps in the action plan are addressed. To ensure that the action
plan is delivered, all organisations that develop or provide services to carers,
will need to work more closely together. Therefore the current planning group
for carers will be restructured into a commissioning group that has the power
to make joined up decisions regarding services for carers. The revised
Carers Planning group will take a lead on the action plan and small working
groups will ensure that any necessary work is undertaken to ensure the action
plan gets completed. The commissioning group will also have more influence
over how the carers grants are allocated, which will help meet the priorities
listed below.

The priorities for Carers over the next 5 years:
    Ensuring that carers are fully informed.
    Recognising and assessing carers needs
    Quality of Services
    Opportunities for a break
    Emotional support
    Training and advice to carers
    Financial security and carers in employment
    Ensuring carers have a voice
    Support access to Leisure and educational opportunities
    Improving Carers Health

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      Aim                         Action Required                      Timescale    Progress                                     Identified Need               Lead
                                                                                                                          The Carers Strategy Action Plan
1. Ensuring that      Improving the quality of Information by                                                             for Wales suggests that carers

                                                                                                                                                               Carers Strategic Commissioning
    carers are         audit of current information                                               Staff time              should have access to the right
  fully informed      Provide information, advice and advocacy                                   Publishing/             information at the right time to
                      Equipping staff through training and                                       translation/            support them in their caring role
(links to national     awareness training to provide information       To be        To be           alternative format    The Joint review identified the
     and local         and training at time of diagnosis and at        completed    completed      costs                   need to providing information

strategies – see       critical times                                  by the       by the        Training                which clarifies the standards for
Section 3 above)      Ensure access to information is available in    Carers       Carers         costs/resources –       users and carers
  1a, 1b, 1c, 1d,      relevant formats e.g. Braille, languages etc.   Strategic    Strategic      development of         There are 11,504 carers in
  1e, 1i, 2a, 2b,     Develop carers information sessions within      Commissio    Commissio      working groups          Torfaen
      2c, 2d           new integrated health/social care units         ning Group   ning Group    IT development         St Cadocs and Penygarn has the
                       (level 1 developments)                                                      support                 highest percentage of carers in
                                                                                                                           Torfaen, with Wainfelin having
                                                                                                                           the lowest proportion of carers.

                                                                                                                                                               Carers Strategic Commissioning group, supported by IT
                                                                                                  Board approval
                                                                                                  Training costs for
                                                                                                   staff and carers       A CSCI report identifies the need
                                                                                                  Staff time – review     for Carers’ engagement in
                      Local joint strategies and plans, formally                                  and develop             commissioning, service
2. Recognising         approved at Board level                                                     carers assessment       development and evaluation and
       and            Train professional staff on how to                                         Training                workforce training.
    assessing          undertake carers assessments                                                costs/resources –      Torfaen young carers strategy
  carers needs        Making carers aware of their rights as                                      development of          identifies the need to identify

                       outlined in the Carers Act                                                  working groups          young carers and their needs
                      Carers Assessments are undertaken by                                       Promotional costs      Many carers remain unknown to
 1c, 1d, 1e, 1i,       health and social care professionals                                        e.g. leaflets,          services and during 2006/07,
 2a, 2b, 2c, 2d       Build on and develop a universal                                            development of          254 carers had an assessment
                       assessment, monitoring and recording                                        joint websites         Carers Act 2004 places a duty
                       process across agencies, which can be                                      Development of          on local authorities to inform
                       shared                                                                      shared IT system        carers of their right to an
                                                                                                  Staff time              assessment

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      Aim                        Action Required                    Timescale   Progress       Resources                   Identified Need                 Lead
                                                                                                                    TCBC Corporate Plan identifies
                                                                                                                     the need to improve services for
                                                                                                                     vulnerable people and to
                                                                                                                     improve health outcomes for
                                                                                                                     everyone by promoting healthier
                      Develop focus groups to capture carers                                                        lifestyles
                       experience and test proposals                                                                The Joint Review identified the
                      Sensitive to carers needs                                                                     need to improve the support for
                      Carers are confident in the provision of                                                      carers
                       services to meet their needs                                                                 Fundamentals of Care 2003,
                      Carers have equitable access to health                                                        identifies sets out guidance on
                       care services                                                                                 the quality of care that service
                      Services are flexible to suit individual                             Training
                                                                                                                     users and patients should expect

                                                                                                                                                            Carers Strategic Commissioning Group
                       carers needs and circumstances                                                                from health and social care
                                                                                             costs/resources –
                      Services are able to respond to carers in                             development of
  3. Quality of        emergency/crisis situations                                                                  Making the Connections 2005,
     services                                                                                training group and
                      Support the development of a carers                                   research costs          identifies the need to provide a
                       register within GP practices                                                                  better coordination of services to
 1a, 1b, 1c, 1d,                                                                            Staff time
                      Mandatory ongoing training for all public                            Respite/travel/acc
                                                                                                                     deliver better quality services for
1e, 1i, 2b, 2c, 2d                                                                                                   people
                       sector staff                                                          ommodation costs
                      Develop quality standards to ensure the                                                      Torfaen’s health social care and
                                                                                            Development a
                       delivery of effective services                                                                well being strategy also identifies
                                                                                             position to improve
                      Develop an effective carers strategic                                                         the need to improve and deliver
                                                                                             access across
                       commissioning group (refocus planning                                                         better quality services and that
                                                                                             primary and
                       group) and working groups (to implement                                                       services should have a stronger
                       the action plan)                                                                              role in improving the quality of
                                                                                            IT development
                      Review current grant funding schemes to                                                       life for those who have health
                       ensure that it needs the needs                                                                and social care needs
                                                                                                                    Torfaen’s older persons strategy
                                                                                                                     identifies the need to develop
                                                                                                                     high quality services in areas of
                                                                                                                     increasing dependency
                                                                                                                     associated with age
                                                                                                                    Promoting Partnerships in Care
                                                                                                                     2003 promotes positive
                                                                                                                     outcomes and good quality care
                                                                                                                     for people using services and
                                                                                                                     their carers

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      Aim                        Action Required                      Timescale   Progress       Resources                  Identified Need               Lead

                      Ensure accessible information about the                                Staff time
                       opportunities from a break from caring                                 Training              Carers UK suggests that the

                                                                                                                                                          Commissioning Group
                      The provision of effective and flexible,                                  costs/resources      economic value of the

                                                                                                                                                            Carers Strategic
                       responsive and reliable services which can                                – development        contribution made by carers in
4. Opportunities       be tailored to meet the needs of both the                                 of working           the UK is £87 billion per year,
    for a break        carer and cared for                                                       groups               which is equivalent to £3011 per
                      Staff across all agencies have the                                     Additional respite     year for each tax payer in the UK
 1b, 1c, 1d, 1i,       knowledge to signpost to appropriate                                    costs                 The Joint review identified the
  2a, 2b, 2c           services and support                                                   IT development         need to increase the range and
                      To implement a joint commissioning                                      support                quality of respite
                       strategy for carers which support respite

                                                                                              Staff time            The Carers Strategy Action plan

                                                                                                                                                               Carers Strategic Commissioning Group
                      Responses at first contact will be timely                              Training               for Wales suggests that timely
  5. Emotional         and sensitive                                                           costs/resources –      and appropriate practical and
      Support         To develop and implement a training a                                   development of         emotional help and support is
                       strategy which meets the needs of all                                   working groups         provided to carers to both to
1c, 1d, 1i, 2b, 2c     health and social care staff, employers,                               Additional respite     sustain them in their caring role
                       and all relevant agencies                                               costs                  and also to help them to attain
                      Identify gaps and secure financial                                     IT development         their personal ambitions for
                       resources to address these gaps                                         support                accessing education, training
                      Identify, promote and cost local counselling                                                   and employment opportunities
                       resources                                                                                     Carers are more likely than non
                      To ensure that relevant agencies are                                                           carers to report high levels of
                       aware of carers issues                                                                         psychological distress and face
                                                                                                                      emotional and mental health

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      Aim                           Action Required                      Timescale   Progress       Resources                  Identified Need                Lead

                       To build into the carers assessment, the

                                                                                                                                                              Carers Strategic Commissioning
                        identification of carers training needs
                       Develop a training needs analysis for                                    Staff time            A CSCI report identifies the need
                        carers and database of appropriate training                              Training               for Carers’ engagement in
6. Training and         courses available                                                         costs/resources –      commissioning, service
     advice to         Through formal and informal training,                                     development of         development and evaluation and

       care             support carers to provide their caring role                               working groups         workforce training.
                        with confidence and with minimum risk to                                 Additional respite    21% of carers have had to
 1a. 1b, 1c, 1d,        their own health                                                          costs                  reduce the number of hours they
1i, 2a, 2b, 2c, 2d     Ensure that respite is available for carers to                           IT development         have worked in order to care for
                        access training where required                                            support                someone

                                                                                                                        Three-quarters of carers say
                                                                                                                         they are financially worse off

                                                                                                                                                              Carers Strategic Commissioning Group, supported by
                       To support carers to maintain or gain                                                            because of their caring
                        financial independence through                                                                   responsibilities.
                        employment                                                                                      The Joint review identified the
  7. Financial         To support employers to develop carer                                      Staff time           need to promote direct payments

                                                                                                                                                                         Human Resource Departments
  security and          friendly employment policies                                               Training             to carers
  employment           To encourage an audit of the number                                         costs/resources     21% of carers have had to
                        carers within organisations and assess                                      – development        reduce the number of hours they
 1c, 1d, 1f,1i, 1j,     impact of caring responsibilities on                                        of working           have worked in order to care for
   2b, 2c, 2d           employment and vice versa                                                   groups               someone
                       Review flexible working policies in line with                              Respite costs       33% of carers are, or have been
                        the Work and Families Act 2007                                             Consultation         in debt because of caring for
                       Carers are aware of their rights to a carers                                costs for            someone
                        assessment and all the benefits and                                         employers           30% of carers cannot afford
                        support that are available to them                                         IT development       essential repairs to their homes
                                                                                                    support             Carers are half as likely to be in
                                                                                                                         paid work as the national
                                                                                                                        On average carers retire 8 years
                                                                                                                         early, missing out on years of
                                                                                                                         income and pensions

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     Aim                          Action Required                     Timescale   Progress       Resources                  Identified Need               Lead
                                                                                                                     The Carers Strategy Action Plan
                                                                                                                      for Wales identifies a need for
                                                                                                                      “carer-proofing” policies to

                                                                                                                                                           Carers Strategic Commissioning Group
                                                                                                                      assess their impact on carers
                     Promote and support the participation of                                                        and to make adjustments where
                      carers in planning, monitoring and delivery                                                     necessary
                      of services                                                                                    The Carers Strategy action plan
                     Encourage participation of carers in                                    Staff time
                                                                                                                      for Wales identifies the need for
  8. Ensuring         specific events e.g. carers week                                        Training
                                                                                                                      involvement of carers in the
  carers have a      Provide opportunities for carers to fully                                costs/resources –
                                                                                                                      planning process of strategic
      voice           participate e.g. offer training, respite etc.                            development of
                                                                                                                      development. A CSCI report
                     Consult carers on key strategic and                                      working groups
                                                                                                                      identifies the need for Carers’
 1a, 1c, 1d, 1e,      development issues                                                      Respite costs
                                                                                                                      engagement in commissioning,
1g,1i, 2b, 2c, 2d    Carers have an input in setting and                                     IT development         service development and
                      monitoring quality standards                                             support                evaluation and workforce
                     Development monitoring system to                                                                training.
                      demonstrate effective involvement                                                             The Joint review identified a
                     Identify Hidden carers                                                                          need to implement processes
                                                                                                                      that identify ways in which users
                                                                                                                      and carers can comment on the

                                                                                                                    Designed for Life suggests that
                                                                                                                     support is needed for carers

                                                                                                                                                           Strategic Commissioning Group
                                                                                                                     when the person they are caring
   9. Support        To ensure carers assessments identify                                                          for access services
    access to         support and access requirements to                                                            Carers Strategy Action plan for
   Leisure and        promote leisure and education                                                                  Wales suggests that timely and
   educational        opportunities                                                                                  appropriate practical and
  opportunities      Carers are encouraged to maintain and                                   Respite costs         emotional help and support is
                      access leisure and educational activities                                                      provided to carers to both to
 1a, 1c, 1d, 1i,     Staff are able to signpost to relevant                                                         sustain them in their caring role
  2a, 2b, 2c          activities                                                                                     and also to help them to attain
                                                                                                                     their personal ambitions for
                                                                                                                     accessing education, training
                                                                                                                     and employment opportunities
                                                                                                                    9% of carers said that respite
                                                                                                                     breaks are the most important
                                                                                                                     thing to them

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    Aim                         Action Required                    Timescale   Progress       Resources              Identified Need                  Lead
                                                                                                             People caring for more than 50
                                                                                                              hours a week are twice as likely
                                                                                                              not to be in good health as those
                                                                                                              who are not carers
                                                                                                             Carers in the youngest age
                                                                                                              groups are significantly more
10. Improving      To ensure carers assessments identify                                                     likely to suffer from ill-health than

                                                                                                                                                       Strategic Commissioning Group
 carers health      when carers are in need of improving their                                                the equivalent non-carer
                    health and when their health is suffering                                                 population
1a, 1b, 1c, 1d,     because of their caring role                                                             Torfaen has a higher than
1h, 1i, 2a, 2b,    Promote and support regular health checks                                                 average number of carers in
    2c, 2e          for carers                                                                                poor health with 16.68% of
                   To ensure that carers have enough time to                              Respite costs
                                                                                                              carers in poor health compared
                    themselves so that they can look after their                                              to the Welsh average of 14.77%.
                    own health                                                                               TCBC Corporate Plan identifies
                                                                                                              the need to improve services for
                                                                                                              vulnerable people and to
                                                                                                              improve health outcomes for
                                                                                                              everyone by promoting healthier
                                                                                                             Poor health in carers can often
                                                                                                              lead to older persons greater use
                                                                                                              of health services, including
                                                                                                              readmission to hospital and
                                                                                                              delayed transfers of care

       C:\Docstoc\Working\pdf\28e3ce2e-a827-41df-9e13-fd2e339ccf31.doc                                                                                13

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