The way ahead A strategic framework for health and social care Consultation Report June 2008 For a period of more than 12 weeks following the launch of the strategic framework on 5th March 2008, Devon Primary Care Trust and Devon County Council have been consulting on this document’s contents. This consultation has included members of the public, patients, service users, carers, service providers and policymakers as well as the many other stakeholder organisations and groups with an interest in health and social care. As a result, we are now ready to update and finalise the strategic framework for the future of health and social care in Devon. This report provides an account of the consultation. It explains the range of approaches to participation and summarises the main messages received. As a summary it is an interpretation of a vast amount of feedback. It covers the positive feedback and also the challenges which are just as, if not more, important. Clearly not every point can be included in a summary document but every effort has been made to convey the balance of meaning and messages from the consultation. As well as consulting on the contents of the strategy, we have been running a parallel consultation regarding the data we have prepared as part of our joint strategic needs assessment. Feedback related to the needs assessment is also included in this report. Many people gave considerable time and commitment to the consultation process and their input has been greatly appreciated. The detailed notes of discussions and meetings highlight the depth of consideration given by people in Devon to the important issues of ‘the way ahead’. Our objective is to take this feedback on board. It will contribute the updated framework, the five year strategic delivery plan and more importantly the implementation of service improvements in the future.

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Consultation report contents

1. The way ahead 2. An outline of the consultation

3. An overview of the feedback

4. Feedback headlines: Staying healthy

5. Feedback headlines: Birth and maternity

6. Feedback headlines: Children and young people

7. Feedback headlines: Urgent care

8. Feedback headlines: Planned care

9. Feedback headlines: Mental health and wellbeing

10. Feedback headlines: Long term conditions and disability

11. Feedback headlines: Older people

12. Feedback headlines: End of life care

13. Feedback headlines: Joint Strategic Needs Assessment

14. Summary and next steps

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111... The way ahead ‘The way ahead’1 sets out the five year strategic direction for health and social care in Devon. It considers the health needs the population, describes strategic intentions to meet those needs and proposes how services will develop in the future. Described as a strategic framework, ‘the way ahead’ spans health and social care for adults and children: • Staying healthy • Birth and maternity • Children and young people • Urgent care • Planned care • Mental health • Long term conditions and disability • Older people • End of life care The background to ‘the way ahead’ was a comprehensive joint strategic review and needs assessment2 to understand health, wellbeing and use of care services in Devon. This assessment considered a vast amount of population and health data. It also gathered views of key stakeholders and members of the public through an extensive engagement exercise conducted during 2007. This engagement included Devon wide conferences, reviews of past feedback and surveys, and a specially designed residents’ questionnaire specifically related to developing the strategy3. The information gathered from this early engagement assisted in shaping ‘the way ahead’ document for consultation. The consultation was conducted between 5th March and 31st May 2008, although feedback was accepted up to 11th June. This consultation enabled further checks on the applicability and appropriateness the strategic framework contents. The wealth of commentary received, along with the latest national thinking will now contribute to finalising the strategic direction and action plan for health and social care in the county. The Devon feedback will also contribute to the wider NHS South West Strategic Framework4 consultation presently underway. Our intention now is that the strategic direction will continue to reflect local aspirations and national ambition to promote health and wellbeing and support the best possible care with clear, measurable and sustainable improvements in services over the coming years. 1 The way ahead, strategic framework for health and social care 2008 2 Joint strategic needs assessment, 2008 3 Improving health and wellbeing - involving You: Engagement Report 2007 All above documents were produced jointly by Devon PCT and Devon County Council Adult Care Services and Children

and Young People services and are available on www.devon.gov.uk/haveyoursay4 Improving health: Ambitions for the South West 2008 www.southwest.nhs.uk

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222... An outline of the consultation The consultation was designed to engage organisations that represent interests of different sections of the population, as well as reaching out more directly to individual members of our community by supplying information to a number of public locations across Devon. 2.1 Approach The consultation included: Planned events Six half day events were held during April and May with a total attendance of 381 people (of just over 1000 invited) representing a range of stakeholder organisations and groups including carers and patient groups, voluntary sector, parish councils, district councils and others. These events gave time for presentation and in depth discussion of each of the care sections in the strategy.

Focus sessions A small number of focus or briefing sessions were held to discuss the overall strategy or core strategic issues relevant to a specific area or client group.

Stakeholder meetings Primary care trust and Devon county council staff attended a range of meetings to present the contents of the strategy and encourage feedback. These meetings usually allowed discussions on aspects of the strategy of most interest or relevance to the specific meeting. The range of meetings was diverse and included attendance at Boards, council meetings, partnership forums and professional meetings, strategic partnerships and others with the intention of reaching out as widely as possible.

Feedback sheets Feedback forms were made available and these were completed by a further 92 people. Approximately one quarter were on behalf of organisations (mainly voluntary sector) and the remainder by individuals.

Displays and DVD There was an information display at the Devon wide Strategic Partnership Conference to encourage engagement of the many stakeholders present. Additionally a DVD was produced to encourage debate and was used at the larger events.

Web and hard copy document circulation More than 6000 hard copies of the document and information flyers were circulated as well as the document being posted with a link to both Devon Primary Care Trust and Devon County Council Websites. The web link also

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incorporates other ‘way ahead’ information including a range of relevant health and social care data for each of the Devon towns and their rural hinterlands.

Media communications News releases attracted a considerable amount of media coverage and including in depth radio interviews on key topics such as the role of community hospitals and end of life care.

Consultation with scrutiny Continuing on from the attendances at the Devon Health Overview and Scrutiny Committee in June and October last year, Devon PCT and Devon County Council Adult and Children service representatives attended Devon Health and Adult Services Overview and Scrutiny Committee in March 2008 to present and discuss ‘the way ahead’. The document was also considered at the Devon Children and Young Persons Scrutiny Committee in May 2008. Comments were received verbally and also through meeting minutes, letters and e-mails, completed feedback sheets and telephone contacts. All feedback has been reviewed in preparing this report. 2.2 Questions The broad consultation questions were: • Do you agree with the direction of travel? • Is it ambitious enough? • What do you like about it? • What is a cause for concern? • What are your ideas for taking this forward? These questions were used in three ways: • As prompts for general thinking prior to broad open debate • As questions for structured discussion • As questions for written feedback As a result there is wide feedback about the overall way ahead strategic framework as well as specific care sections within it. 2.3 Organisation A consultation co-ordinator was identified and arrangements put in place to organise events, collate the information and answer questions during the course of the consultation period. The intention was to ensure a systematic approach to create a range of opportunities to participate in this important strategic debate.

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2.4 Quality assurance To support the consultation, Devon’s independently chaired Stakeholder Reference Panel has raised questions and offered advice to achieve effective consultation and process. Additionally, joint management mechanisms in both organisations included overseeing the quality and extent of the consultation. 2.5 Reporting This consultation report will be presented to Devon Health and Adult Services Scrutiny Committee, Devon Children and Young Persons Scrutiny Committee, Devon LINks Host Organisation at the earliest opportunity. It will also be considered by Devon County Council Executive and Devon Primary Care Trust Board in July 2008. It will be placed on ‘the way ahead’ web link at www.devon.gov.uk/haveyoursay . This, along with the latest national thinking will contribute to the updating of ‘the way ahead’ and into the associated five year strategic delivery plan which is due for completion later this year. Most importantly, the detail of the consultation, as well as the many valuable points from the engagement conducted during 2007, will assist to ensure important aspects of feedback are carried forward into implementation in the future.

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333... An overview of the feedback 3.1 Do you agree with the direction and is it ambitious enough? The consultation indicated strong overall support for the strategic framework and the direction proposed for health and social care. Many positive observations were made regarding the clarity of the document, the appropriateness of the proposals and also the level of ambition. ‘Overall you have made great progress in producing ‘the way ahead’ and as I am involved in this work myself I can appreciate all you had to do to get to this stage – thank you to all concerned.’ ‘...the framework for health and social care is aspirational. If fully implemented it will provide a service to be proud of, in particular the emphasis on joined up services is a welcome new direction.’ ‘I am very impressed by the presentation and clear structure of the framework booklet and the wealth of information it provides. Your commitment and enthusiasm really shines through’ ‘....agree with strategic intentions, strongly support goals...’ At the same time there were observations that the direction is positive but there were some uncertainties about achievability. The feedback indicated this was largely due to the need to understand how the intentions would translate into action, and there were a number of requests to see concrete plans or descriptions of ‘how’ the changes will be taken forward. ‘It actually appears over ambitious and a bit pie in the sky unless these intentions can be realised. It would be good to think these things will happen.’ ‘Does not translate aspirations into resources, partnerships, staffing, how?’ ‘There are large and significant gaps between ‘we will’ and the current reality - and achieving this is a very significant task’ ‘We need a 12 month follow up to show what has changed.’ Some people wondered if the strategic framework may be too ambitious. Others expressed their views that the document appears ‘very safe’ and possibly not ambitious enough particularly in relation to partnership working and opportunities around the development of community hospitals.

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3.2 What do you like about it? Many people indicated their support for a wide range of aspects of the strategic framework with statements like ‘... very much support care in the community’ ‘... agree with strategic intentions, strongly support goals’ ‘... support integration as long as it is real integration and not just co-location’. There was considerable positive commentary regarding the twelve strategic intentions, although it was pointed out that these did not link clearly enough to the six aims for health and social care. The attention to hidden waits, the increased emphasis on care outside hospital and positive action to improve health and wellbeing were all recognised as important areas for development. The intention to reduce unnecessary appointments moving to national best practice levels, also received favourable feedback. The layout, quality and simplicity of the document itself, along with the vast amount of information provided in one place were all complimented. There were observations that the presentation was extremely good, although it was suggested the next edition should have a ‘younger look’ to attract a wider audience. 3.3 Is there a cause for concern? The strongest emphasis here was the question of how the strategy would translate into real action with suggestion that an implementation route map is needed. This highlighted the strength of overall support for the strategic intent and desire for implementation. It showed however the importance of making sure there is a drive to move forward to action, delivery and tangible results. Gaps were identified in the document content including: • Rurality • Transport • Infection control • Quality standards, clinical guidelines and performance • Transitions through age ranges and services • Local Involvement Networks (LINks) • Finance Additionally there were areas considered as needing more attention or emphasis. • Carers

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• Young people • Older people • Learning disability • Social care • Partnership working Stronger linkages were identified as being required in relation to: • Crime and health • Poverty and health • Other plans, for example the Children and Young Persons Plan 3.4 What are your ideas for taking this forward? There were many helpful suggestions. The main ones were: Build on the value of partnerships In promoting the value of partnerships, there were concrete offers of practical help by a number of organisations and individuals, and questions of ‘how can we help?’ from others. There were suggestions of how partnerships could be more co-ordinated in the future and a strong desire for collaborative care across organisations. There were also proposals that the roles of partners should be more clearly defined working towards true joined up thinking across different stakeholder organisations and community infrastructures. The role of foundation trusts, the contribution of primary care and the strong opportunities of inclusion of the voluntary sector embedding Compact principles, were particularly emphasised in the feedback.

Continue and increase communication and consultation People said they would like to be kept involved and informed so that this is not a one off consultation. The fact that so many people gave time and input to the strategy showed the strength of commitment of Devon people and the importance of ongoing relationships and communication networks. Points were made that the PCT and County Council had demonstrated they were listening and a desire for this to be continued. There was a suggestion of using simpler language in communications to improve transparency. Additionally there was a desire to extend involvement with local charities, churches, schools, police and social groups, as well as seeking out even more direct feedback about individual care from patients and carers.

Reach out to the hard to reach This strategic intention received strong support and groups specifically mentioned included: ‘the ordinary man in the street’, socially isolated people, people living in rural areas, children and young people. Ensuring the needs

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people with learning disabilities are not overlooked and considering them in all aspects of the strategy was another key point raised.

Develop a sound supporting infrastructure Training of the workforce to reach their full potential, establishing new roles and responsibilities, the need for sound resource infrastructure accompanied by reduction in wastage on drugs and operations were all highlighted as areas for attention.

Use standards and targets to best effect Although the point was made that targets could get in the way of real service change there was also appreciation of their importance in keeping the strategy focussed. There were questions about the achievability of some, how performance would be measured and the baselines to be used. Suggestions were made that it would be valuable to quantify minimum standards linked to disadvantage as well as introducing measures of social capital and quality of life to achieve a fuller picture of service outcomes.

Take the strategy forward with locally responsive plans The value of a cohesive Devon strategy, with plans and actions that also reflect the diversity of the county will need careful balancing. Attention to particular issues such as deprivation and isolation in older people were identified and several community representatives made specific local suggestions for improvement. There was debate about town based planning, with both the strengths and challenges being identified e.g. the value of this local focus and the risk of missing even more local rural needs.

Develop the role of community hospitals There was much supportive feedback about the idea of using community hospitals more and increasingly bringing activity out of secondary care settings. Early decision making on location of services was noted as important and as was the need to for activity mapping and clear criteria to support these decisions.

Achieve a sound model of care at home and close to home Again community care was supported but with important caveats and cautions. Carer support and well structured, skilled and resourced community care were identified as central to success. The issue of shift between health and social care and the potential means testing impact this could have on individuals was raised for attention. Clarifying how community support will work effectively has been highlighted as essential for building confidence for the future. 3.5 Recurrent themes Added to these suggestions there were recurrent themes raised time and again during the course of the consultation. These relate to the overall strategic

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direction as well as incorporating feedback with regard to different aspects of care. The main recurrent themes raised were: Attention to rurality and social isolation The importance of recognising and acting on the challenges of rurality was a core theme in care for older people, children and young people, helping carers and many other areas. Taking a wider view and recognising the potential of community networks and facilities was proposed with the suggestion that Devon’s strategic framework should aim to become a rural exemplar for the future. Serious joined up approaches to health including collaboration with the voluntary sector, parishes, education, adult education and others would raise the profile of health and wellbeing and maximise opportunities to support people in the community. A strategy for transport The challenges associated with transport and its impact on access to, and use of, services were flagged repeatedly for consideration. No easy solutions were identified but the proposed shifts of care away from acute to community settings, and increased outreach working were seen as one of the positive steps to address transport. There were other suggestions of voluntary schemes and a more cohesive approach to transport and an overwhelming message that the approach to transport needs to be considered in the strategic framework and action planning. An emphasis on the role of carers In identifying the requirement for more focus on carers, there were many suggestions regarding carer support. The needs of carers of all ages and assistance for new and short term carers as well as those with long term responsibilities were highlighted for attention. Early on the in the consultation process, due to the evident requirement, it was agreed that a dedicated section on carers needs would be added to the strategic framework. The developing role of primary care To make the shift to greater primary care focus the importance of ensuring skills development to match this was commented on in the feedback. Additionally, the opportunities of new developments in primary care added an important dimension for consideration. For example the potential role of pharmacy across the different aspects of the strategic framework merits attention, for example in promoting health, conducting screening appointments and urgent care support were possibilities suggested. Dentistry was also highlighted both for its role in prevention as well as in the continued requirement to improve access to NHS dentistry. Integration and collaboration Building on the suggestions in relation to partnerships and collaboration, there was support for the joined up approach to ‘the way ahead’ and comment on the

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desirability of integrated working across all aspects of the strategy. One point very well made was that we should work towards true integration and not simply co-location of services. The importance of open and transparent partnerships also featured in the feedback. A ‘how to’ specification There were numerous suggestions of how to achieve the ambitions in the strategic framework, along with understanding that for a number of areas we do not yet have the solutions. The importance of recognising the size of the challenge came through, for example how do we as a community find ways to engage people more in health? It was proposed that there should be good information for the public, service providers and others on the statistics and major issues for health and social care to achieve true community awareness. The need for attention to analysing actions that work and those that don’t was also identified as important in achieving effective change. Balancing short term versus sustainable There was concern about short term initiatives and the risk that short term funding will not achieve the sustainability necessary. Overall affordability is an issue: for individuals where costs of healthy activity may prohibit healthy lifestyle; and also for achieving the change needed. Linked to this is a need for consistency to address the present inequalities of health support across Devon and also to target attention to deprived communities.

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444... Feedback headlines: staying healthy The strategic direction for ‘staying healthy’ received overall support and was generally seen as ambitious enough. In terms of key headlines for consideration: Being healthy and staying healthy It was noted the present title assumes health and we should think more widely and emphasise attaining as well as maintaining health. Lifestyle change needs to be clearly specified. People commented the approach should be proactive not reactive and recognise the solutions are wider than can be achieved by health and social services alone - rural isolation, accessibility, the impact of poverty and crime on health and a sense of community were all identified as important. Universal versus targeted health action The need to maintain the balance of appropriate services while people with the greatest need receive targeted support was identified. Targeting poverty, educating families, supporting key groups at risk including people with learning disabilities and young people in rural areas, were all noted as important. The in depth knowledge from the joint strategic needs assessment could enable local hospitals to better target preventive and long term conditions support for their areas. It was also thought to be possible to target very rural health through a range of approaches, including closer links with parish plans. Information and self care Taking a key health issue that all departments publicise at the same time was suggested. Pharmacies, GP practices, dentists, hospitals, social care staff and others could all then communicate a consistent, credible and strong health message. Health hubs need to be truly accessible including village halls, healthy living networks, social networking websites, and pharmacies. There were suggestions about self care including ‘Expert Wellbeing Champions’ (for example people living and coping effectively with alcohol addiction acting as models for others) as well as the use of information prescriptions. Health through life A lifecycle approach to health with dedicated attention to the needs of people different ages was preferred to a one size fits all approach. We should define the support for different age groups and use one stop contact points and health trainers in communities to share the information. Opportunities to reach people include for example: retirement preparation. Action and resources The level of resource shift needs to be right and the debate was: ‘Is a 5% shift to prevention is too modest?’ ‘What is the cost of making this shift?’ ‘Can resources be better focussed with more proactive plans?’

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555... Feedback headlines: birth and maternity The workshops in particular showed mixed responses in relation to birth and maternity. There was clear support for the direction of travel and the approach was considered ambitious enough, and possibly too ambitious. The feedback covered: Choice and continuity Maternity choice should have consistent, easily accessible information about the choices and support available. It was commented this needs to reach people especially in rural settings. There should be clarity on the freedom of choice and the circumstances where choice in not appropriate. The choice of home births was not adequately reflected by the case study of a hospital birth in the document. Consistent midwife staffing across the county and a policy of remaining with the mother were all identified as important for continuity. Support for younger people Young people in particular pointed out that education for teenagers needs to be earlier (10 – 16 year olds) to have an impact. Young teenagers need information and sex education that has a wider perspective such as, what having a child could mean at this time in your life. Effective reality checks like this were seen as important for young people. Younger support workers could be used to help make a service meaningful for younger people. A focus on teenage pregnancy in Exeter where the rate is significantly worse than the national average was highlighted as important. Breastfeeding Breastfeeding support is mentioned in the document but the question of what this would include was raised. Real help means local people accessible when they are needed so that mums don’t ‘just give up’. Peer support and local breastfeeding groups were seen as a key part of this service. Family involvement The strategy should positively promote partner involvement and also tackle high risk family issues such as teenage pregnancy; parenting; care for families of children with birth abnormalities; help for disabled mums; and support when there are infant deaths, including for grandparents. Effective parenting Action to destigmatise parenting support, with emphasis on the advantages of parent learning such as early years relationships, was suggested. Access to support in children’s centres was supported but for rural areas it was pointed out further solutions are needed.

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666... Feedback headlines: children and young people Although again the contents were generally supported, there was question about how this could be achieved. The links between this document, the Children and Young Person’s plan and Children’s Trust were noted to be unclear. Attention to inequalities in children’s health was welcomed. Involving young people The style and presentation of the overall document could improve to engage young people too. Consultation with young people on matters that affect them is important and young persons’ agencies should be used more to help with this, for example using recognised voluntary sector organisations to directly contact young people and solicit their views. Clarifying partnerships The work with the Children’s Trust, schools, police and primary care was not clearly specified and needs to be addressed in updating the strategic framework. Other partnership opportunities such as engaging GP surgeries in providing information and signposting about young persons care were identified as important to help ensure young people know what services are available to them. Improving children’s health The need for parenting support to help to improve children and young peoples’ health was discussed and it was proposed this should include information for parents about the impact of family lifestyles and training for GP’s and front line staff in children and young persons issues. The emphasis on diet should be wider than obesity and recognise the impact of other eating disorders. Emotional health is important, as is consideration of important issues like bullying. Achieving effective transitions This was highlighted as a gap in the document and particularly important for young people with disabilities moving between services. There should be well managed transitions and support for families coping with the special needs children with plans of care in place for all children with complex needs. Focussing on specific groups and services More information was needed on early years education and parenting. Similarly clarity on pathways for children with special needs, drugs, alcohol, smoking and children’s mental health were thought to be helpful to overcome the challenge of engaging with large semi-anonymous organisations. Targeting key issues for younger people The needs of rural young people, especially in low income families were noted with the concern that town located Children’s Centres will not serve this need. One option proposed was to work with neighbour and community networks, using social capital to best effect to support rural young people.

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777... Feedback headlines: urgent care The strategic direction for urgent care was supported with clear points of access and the development of urgent care centres. There was feedback that it is good the PCT is trying to get this right, although more detail about what this will mean across the health care spectrum was requested. Preventing urgent care Wide public understanding of the help available to avoid Emergency Departments being the first choice was identified as a priority action. Clearer definitions of urgent care and where it is best to go for different illnesses, injuries and conditions were all thought to be needed. The use of e-communities, patient resource packs and clarity of onward referral mechanisms could help. It was pointed out there should be education for the young on issues such as drugs and alcohol with action to prevent return attendances due to drugs and alcohol. Similarly there should be preventive health plans for people with complex needs Patient focus at the heart of planning The strategy to achieve an integrated urgent care plan was described as a good idea, although people will need to see this happening. GP practices have a part to play in urgent care as some people live too far away from other services and pharmacies are also important in more local care. Similarly visiting paramedics or specially trained nurses could help avoid urgent care and emergency admissions. Urgent mental health provision was identified as requiring attention. Clear roles for services Clear and consistent access and referral for urgent care were identified. It was suggested the role of the full range of services including NHS Direct and Care Direct should be specified. There should also be links between urgent care and key specialties such as self harm and acute mental health with whole system planning to give confidence in co-ordination and to ensure one service does not make changes that may inadvertently lead to more attendances in another. Links across geographical boundaries were also identified as important. Support for families and carers Practical actions were proposed such as shorter waiting times for carers using the service which would help. There could be a role of respite and/or home sitting and a directory of services to support carers in a crisis would also be useful. Location of urgent care centres There was a desire for early discussions to achieve the right mix in all parts of Devon, tackling some of the complex geography issues in the thinking. The question was raised as to whether access within 20 minute drive time of most communities is realistic due to the distances in Devon, and suggestion that a slightly longer time may be acceptable with good initial assessments.

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888... Feedback headlines: planned care The direction was generally supported again with the question of achievability being raised. There was an impression that this section was written for older people, but young people had a lot to say about planned care and especially the impact of unnecessary and cancelled appointments. Defining planned care In the document it appeared to relate to hospital care, but planned care can be primary care, respite care or care at home. It can also be anticipatory and support people to plan their own care. A description of the components of planned care was seen as necessary including planned care for people with disabilities. The role of planned care in avoiding admissions Health MOT’s, and medicines reviews, to identify and deal with problems earlier were important with more preventive measures to stop the need for people to be admitted to hospital, for example in the case of falls. The role of planned care in avoiding emergencies needed to be described in the document. Managing the patient experience Attention to wheelchair waiting was described as encouraging by a number of people. An area for attention also was communication and co-ordination of experiences for patients attending multiple appointments to avoid so many repeated journeys. Patient choice clarity was also required, for example who decides if a person can be seen in a local setting? Local care centres More information on these, how they will work and how decision making on location will be made was requested. The feedback indicated people were encouraged to have more local services and everything under one roof. It was stated the good targets need to be must be underpinned by sustainable resources and staffing, particularly nurses and frontline staff who must be up to date. It was pointed out that there will be a need to ensure services are stopped in one unit and moved to the other as the service changes. Role of specialists Care closer to home was positively received but the need for maintaining specialist skills and knowledge was emphasised. Can consultants be placed and have clinics in areas more suitable to patients and families? The gaps in specialist nursing and other specialist services should be considered there should be clear standards for planned care. It was suggested the approach to rare and specialist illnesses for the future should be explained. Mental health planned care also needed to be included in planned care considerations.

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999... Feedback headlines: mental health Again this received overall support although there was concern that the targets may raise expectations. It was suggested that aspects of the mental health part of the document were applicable across all sections of the strategic framework. The inclusion of Autistic Spectrum Disorder in mental health considerations within the way ahead was welcomed. Preventive strategies The emphasis on prevention was viewed as important with consideration being needed on the impact of emotional wellbeing on physical health. Partnership working with the voluntary sector could help with this. An explicit emphasis on a mental health and wellbeing promotion programme was proposed as were a wider range of approaches to self directed care. The role of primary care A specific point raised was the training of GP’s to enable them to take on the new role of supporting people with mental health problems in primary care. The approach was seen as the right direction but the skills gap an issue that could be helped with a specification or evidence based skills profile to work towards. This needs to include the role of primary care in signposting people to the correct services. Access to early intervention This proposal was viewed positively but in practice access, clear thresholds for specialist care and suitable primary care alternatives are important. All elements of care need to be in place for the shift in emphasis to be effective: accommodation; carer support; regular reassessment; continuity; housing support; urgent care in and out of hours all need to be considered. The community infrastructure should also be considered in shifting the balance from the traditional bed based model of care. Addressing hidden waits In support of the strategic intention to tackle hidden waits, attention to challenging behaviour therapy was indicated as an important consideration. Action on stigma Clearly state the organisations’ anti stigma commitment and define approaches to improved integration of people with mental health problems were suggested inclusions for the strategic framework. Advocacy and carer support, especially for older carers were also noted for attention.

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111000... Feedback headlines: long term conditions and disability The main message from this part of the strategic framework was the need to separate out learning disability and give it specific attention. Also it was highlighted there should be more information on approaches for different long term conditions including neurological conditions. The cross cutting transport and carer issues were clearly important for people with long term conditions and disabilities. Self care and self management The approach to increasing this was supported with suggestion of greater linkage with the voluntary sector, pharmacies and others for programmes of self help. Expert wellbeing champion roles, in addition to the Expert Patient Programme is one way to extend self management. Disability awareness This was not mentioned in the strategic framework yet disability awareness is of key importance for staff, including medical staff and should be considered in future planning. Targeted long term conditions support Opportunities for targeted support for people with different long term illnesses were identified such as the role of primary care, the importance of medicines use reviews and other strategies for people at high risk, and ongoing monitoring of conditions to prevent urgent situations arising. Issues related to specific neurological conditions were identified as a gap, including access to neurologists and considerations in relation to neurological rehabilitation. Implementation networks for people with long term conditions The importance of more local engagement in planning and implementation was highlighted with some people missing previous groups such as the Local Implementation Groups and being interested to see what the new arrangements will be for the implementation of the strategic framework. Community support For vulnerable adults it was stated that support for independent living needs to be considered and notably there was no mention of day care and the role of respite in the strategic framework. Issues of social inclusion were also identified as needing attention working in partnership across the range of statutory and voluntary services and with community networks to have an impact.

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111111... Feedback headlines: older people Again the overall direction of the strategy was supported but there were concerns particularly about loneliness and isolation of older people and how this could be addressed. The rising numbers of older people in Devon were also an issue for debate and the need to have an approach that prepares for this. Preventive strategies Good information on older people’s health and wellbeing, preparation through retirement planning courses and easily accessible preventive advice were all indicated. There were suggestions of using accessible rural venues to assist in engaging older people in their health as well as working in strong partnership with the voluntary and community sector. Community support for older people Moving care to home or closer to home was seen as good if there is available and quality community support. There were many areas identified for consideration including: the role of complex care teams, housing support, key working, the use of risk assessments, attention to supporting carers, and the importance of good care planning e.g. hospital discharge planning and admission avoidance systems that work for older people. Getting the balance between good care at home and affordable services was highlighted for attention. Quality standards Quality specifications for services were seen as important and good residential care home standards were discussed by many people as essential. Care for people with specific conditions was also highlighted including the importance of actions to prevent falls, high quality stroke care, and support services for people with dementia and their families. Challenges in older people’s care Issues of people not accepting care, the loneliness and isolation of being at home, choice, support for carers and the challenges of safeguarding were all raised. There was strong emphasis on the need for clarity of pathways and information and the role of pro-active supporting community networks as key important features for the future. There was a clear sense in the feedback on older people that addressing the challenges are wider than health and social care and whole systems have a part to play.

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111222... Feedback headlines: end of life care This section was very well supported in terms of the direction of travel although there were mixed views on whether it was ambitious enough or too ambitious. A point was made that this is good on paper but people need to see action. 24 hours/7 day a week This was seen as crucial with the need for good advance planning, for example effective use of community hospital beds and training and development for community nurses. With 17% of Devon’s population being lone pensioners the need for sitting services to support people to die at home was identified. It was emphasised that end of life resources should be directed to community and voluntary support, local hospitals and hospices rather than acute hospitals. A good death The need for more qualitative work was identified, for example in relation to spiritual support, pain control and avoiding people dying alone. Palliative care was seen as a priority with a pro-active approach and care being planned to avoid last minute panics wherever possible. There are systems that could be better used such as advance directives, special patient messages and just in case medicines. Staff skills and training were also seen as crucial with services that continue to learn, discussing afterwards ‘did we enable that death to be as good as it could be?’ Death in hospital There was a challenge about death in hospital being inadequately emphasised in the strategic framework, and the point was made that there are times where it is right for people and their families for an anticipated death to be in hospital and there should be focus on good hospital deaths also. Where people have chosen to be at home but require short term admission to hospital, systems need to be in place for services to be at their most efficient to enable early discharge home. Focus on key groups and conditions The importance of focussing on the special needs of key groups at the end of life was highlighted for example people with long term neurological conditions, rarer terminal conditions, learning disability young people, those with dementia. Bereavement support for families and carers was also identified for attention. Multi-organisation approaches It was stated that joint working could be better, particularly in geographical boundary areas. For best quality end of life care co-ordinated pathways with clarity of responsibilities and expected actions for primary care, ambulance services, social care, care homes, specialist end of life services were all important. The use of Gold Standards Framework and Liverpool Care Pathway would support consistency and quality.

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111333... Feedback headlines: Joint Strategic Needs Assessment

The population, health and social care needs information based on the 29 Devon Towns and their rural hinterlands was also consulted on during this process. This was included in the planned events and also 500 plus stakeholder contacts were made to share the information and request feedback. The questions and summary responses are described below. Overall the value and quality of information has been welcomed and these points relate to how we can continue to develop this for the future.

13.1 Do you recognise the community described within the profile?

Feedback largely acknowledged that the information within the profiles enables the reader to identify the Devon Town in question. A key improvement suggested for the future is to separate the rural hinterland from the Devon Town urban centre, still reporting both but acknowledging the differences between the areas within each community.

13.2 Is there any key information missing about health / social care need in the population?

Some very helpful ideas to improve the usefulness of the profiles for planning were suggested including:

• To define the parishes included within each Devon Town • Include population numbers not just percentages • Look at deprivation in far more detail - a challenge to summarise at a Devon

Town level • Find a reliable way to enable future population projections to take into account

local plans approved for new homes • Improve information on carers (particularly elderly carers) • Try to add voluntary sector support information, DAAT, housing quality,

transport infrastructures, economic contexts, staffing.

There was an overall comment that to truly understand the information, there needs to be a way to clearly overlay and display the service provision with the activity

13.3 Can any priority areas be identified from the story of this local area?

Generally people wanted to know more information, which was a positive indication that the profiles were prompting thought, discussion and understanding. To be fully useful in the future they need to become more comprehensive and actions are already well underway to address the points in the above feedback.

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111444... Summary and next steps In summary, there was considerable positive feedback regarding the contents of the way ahead with strong overall support for the direction for health and social care. Many people praised the clarity of the document and the appropriateness of the proposals. There were gaps identified in content and the key gaps and shifts of emphasis needed will be addressed in the updated strategic framework. The enthusiasm for the direction was shown with the invaluable implementation advice received. Much of the feedback related to how to take the ideas forward into action and to do this in the most effective ways possible. These ideas will inform the preparation of the strategic delivery plan. There were many offers of help signalling the potential to move to a stronger and wider partnership for health and social care. As the consultation is now complete the next steps will be: July 2008 Present the updated strategic framework accompanied by an

action plan for the year 1 commitments in ‘the way ahead’. Sept 2008 Publish the five year strategic delivery plan for health and social

care in Devon As indicated in the way ahead, actions for year one are underway in response to the early engagement conducted during 2007 where people told us they wanted to see early progress. These actions will continue and further preparations to support this plan will commence. It is important at the end of this consultation to note how helpful the input and feedback has been throughout both the preparation of the original strategic framework and now it’s updating. Building on the interest and relationships established so far, a central feature of taking this work forward will be continued communication and engagement. This will help to sustain and further increase the public and stakeholder voice in commissioning as the intentions begin to translate into delivery in 2008 and beyond.

On listening On engagement in implementation ‘....welcome the framework....real test will be production of clear action plans with associated targets and timescales. We look forward to being consulted about these.’

‘That you have and are listening to people’

On rurality ‘Whilst the ambitions of the strategic review are very sound and positive, they face failing to deliver unless far more attention is paid to the rural dimension’

..and on action ‘In the past people have not been included – so this is better more inclusive. Time to get on with it however.....’

On consistency (need) ‘...Devon wide consistency. Quality across the county.’

Report prepared by J.McNeill, Assistant Director of Strategic Development, June 2008

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