GOFAL A CHEFNOGAETH YN 2027

Ein nod yw i bobl dderbyn y gofal a'r gefnogaeth gywir ar yr amser iawn, yn y lle iawn. Gallai hyn fod yn y cartref, y gymuned neu ar draws Powys erbyn 2027.

Mae'r personasau canlynol yn egluro ymhellach sut y gallai gofal a chefnogaeth edrych nawr, a sut y bydd yn gwella erbyn 2027.

GOFAL A CHEFNOGAETH YN NORTH POWYS HEDDIW, A BETH Y GELLIR EU HOFFI YN 2027...

ANDREW’S STORY IN 2021...

Andrew is 13 and lives in Newtown with his mum and dad. He has an older brother who has recently left home to go to university. Both his parents work. The family has two cars.

Andrew has suffered with enlarged adenoids since he was ten. They cause him discomfort and interfere with his breathing which affects his daily life. In particular they can stop him taking part in physical activity, which is something he really enjoys. They also mean he suffers from frequent middle ear infections which have caused him to have some time off school. Although this hasn’t affected his academic performance, it does affect his parents who have occasionally had to take unpaid leave from work at short notice.

Andrew’s GP referred him to an ENT consultant at the Royal Shrewsbury Hospital. Before his appointment, the consultant asked Andrew to complete a sleep study which meant his mum had to drive to Shrewsbury to collect the study equipment and drive back to return it the following day.

After the appointment Andrew was told he would need to have an adenoidectomy. He had a pre-operative assessment in Telford which found he was fit for the surgery. However, it has been postponed several times and now more than six months have passed which means his pre-operative assessment has expired and he’ll have to travel back to Telford for another one.

These delays have upset Andrew as he has not been able to take part in the outdoor activities he enjoys. The visits to and from Telford have also been difficult for his mum and dad who have had to take time off work, sometimes unpaid, which has occasionally left their household finances a little short.

Andrew is still waiting to have his surgery.

ANDREWS STORY IN 2027

Improvements to his care and wellbeing include:

Andrew walks to school where he studies an extended curriculum that teaches him how to look after his health and wellbeing. He enjoys a healthy lifestyle playing sport and taking part in outdoor activities in the green spaces near to his home. Andrew’s older brother is studying adult nursing at the Rural Health and Care Academy in Newtown.

Andrew’s parents both have meaningful employment in the local area and the family enjoys a stable income. Andrew’s mum cycles to work on dedicated cycle paths and his dad walks.

They both also benefit from flexible working arrangements. This means that when Andrew has to take time off school because of his ear infections one of them can easily be at home to care for him.

Andrew’s GP referred him to a specialist ENT consultant at the Royal Shrewsbury Hospital. However, Andrew’s first appointment with her was held at the Rural Regional Centre in Newtown. And all his appointments since then have been held from Andrew’s home using video conferencing technology which his parents have on their laptop computer.

The sleep study equipment was available from the Rural Regional Centre in Newtown. Andrew also went there for his pre-operative assessment. The nurse who carried out the assessment recorded the results on his electronic patient record. Everyone involved in Andrew’s care has access to this record.

Andrew‘s surgery is due to take place in six weeks’ time at the Royal Shrewsbury Hospital.

CAROL’S STORY IN 2021...

Carol is 51 and lives in Caersws with her three children: Tom who’s 17 and goes to sixth-form college in Shrewsbury, Charlie who’s 12 and goes to school in Llanidloes, and Thea who’s 4 and goes to pre-school in Caersws. Thea has mild learning difficulties which Carol believes were caused by a convulsion she had when she was two. Although Carol called 999 there were no ambulances available and it was some time before Thea was admitted to hospital.

Carol feels guilty she couldn’t get Thea to the hospital herself and is angry at the system. She sometimes loses her temper on the rare occasions she sees Thea’s primary care team.

Carol works as a domiciliary care worker on a zero hours contract with a local care company. She took the job so she could work flexibly and balance her need to earn money while caring for her family. However, she’s often asked to work when it isn’t convenient but feels she has to say yes so she keeps her job and her tax credit payments don’t change.

Charlie is a talented footballer and has been asked to play for the Llanidloes under 13s team. However, training is the evening and although another parent has offered to share lifts Carol still struggles to get him there regularly.

Tom recently received a formal warning from both his college and the police after he was caught in possession of marijuana on the college grounds. It isn’t easy for Tom to get support with his drug misuse as the nearest centre is in Welshpool and he would have to go on the bus which is expensive and unreliable.

Carol is also worried about the effect spending time in a large town is having on Tom and would be happier if he could attend college closer to home. Getting to Shrewsbury is expensive and Carol can only claim back some of Tom’s daily train fare.

CAROL’S STORY IN 2027

Improvements to her care and wellbeing include:

The local multi-agency team for children and young people understand the importance of the first 1,000 days of a child’s life. Everyone involved in Thea’s care is actively helping her to develop and build resilience. Carol feels confident that although Thea has special needs she’s ready to start mainstream school.

Carol’s employer values its team and provides excellent opportunities for career progression. As a result Carol has recently been promoted into a management role. This has increased her sense of wellbeing and given her family extra stability and financial security.

Carol attends lots of community groups in Caersws so has robust social connections and feels her whole family is well supported.

Tom was recently caught in possession of marijuana on his sixth-form college grounds and was given a formal warning from both his college and the police. However, Carol is grateful that Tom attends sixth form close to home and feels sure that her robust connections in the community will help her look out for him and keep an eye on what he’s up to.

Tom told his GP that he got involved in drugs because he was feeling depressed. As a result his GP referred him to a nature-based intervention as an alternative to medication so Tom could benefit from being outside in the green spaces close to his home.

DAVID’S STORY IN 2021...

David is a 26-year-old farmer. He lives alone in a remote location in Llanwddyn, one of the most sparsely populated areas in Powys. His family live on another farm about twenty miles away. They bought David’s farm five years ago for the extra grazing land and so that he would have a home and business of his own.

Since moving to Llanwddyn, David has been feeling isolated and cut off from his family and friends. Because the farm is in a valley he has no mobile reception in the house and his broadband connection is via satellite which is expensive and unreliable.

Before moving to the farm, David used to enjoy going to the gym and swimming pool at his local leisure centre. Now his nearest leisure centre is a 40-minute drive away in Welshpool. He also used to enjoy going to the Young Farmers’ Club. However, because of the demands of the farm he is finding it difficult to go back.

Often David’s only social interaction is with his family, and this usually ends up as just a chat about work and money. He is concerned about cash flow and, while he wants to make his father proud and prove that he can manage a farm, market prices have been low and David is beginning to feel a sense of failure. He’s struggling with the maintenance costs on several of the vehicles he needs to run the farm and because his farmhouse is rated as band F, his council tax is high.

David tends to work late in the evening because he doesn’t like going back to an empty house where he has very little to do. He has also been suffering from aches and pains in his neck and shoulders for a while which he has yet to find time to visit his GP about.

DAVID’S STORY IN 2027

Improvements to his care and wellbeing include:

Although David lives alone in a rural area, he feels well connected to his family and friends via his reliable mobile phone signal and high-speed unlimited broadband.

Since moving to Llanwddyn, despite the demands of farming on his personal time, David has been able to enjoy an active social life and strong support networks. He attends a variety of local groups which he found out about after a quick search on his iPad.

Before moving to the farm, David enjoyed going to the gym and swimming pool at his local leisure centre. Although his opportunities to use these facilities are now more limited, David appreciates the acres of open countryside that surround him and uses the landscape to stay fit and healthy, both physically and mentally.

David’s close friends understand the demands of farming life and often lend a hand when they have spare time. For example, David recently suffered from aches and pains in his neck and shoulders but was able to visit his GP before his health deteriorated because one of his neighbours offered to carry out his morning duties on the farm.

CATHERINE’S STORY IN 2021...

Catherine is 35 and lives with her husband on their farm near Garthmyl, a few miles from Newtown. Some time ago Catherine discovered a lump in her left breast. She visited her GP who referred her to oncology at the Royal Shrewsbury Hospital where she was diagnosed with Stage 3 breast cancer, with 12 of her lymph glands also affected.

Catherine’s oncologist referred her to the Princess Royal Hospital in Telford for a lumpectomy. After the procedure she had to stay overnight in hospital. When she’d recovered she then had to go to the Royal Shrewsbury Hospital every three weeks for a course of chemotherapy. This made her feel very poorly. She also felt exhausted from all the travel to and from appointments. On several occasions her temperature spiked after her treatment which meant she had to travel back to Shrewsbury to be admitted to hospital.

After her chemotherapy, Catherine had to undergo 23 sessions of radiotherapy. Although each session only lasted 15 minutes, Catherine had to travel 40 miles each way to receive the treatment. This added to her exhaustion and, she feels, affected her recovery.

Although Catherine has now finished her treatment she still has to travel to Shrewsbury for regular check-ups. She finds this difficult, particularly as some of the appointments have only involved a conversation which Catherine feels could have happened just as well over the phone.

Catherine’s husband found it very hard to balance the demands of running the farm with supporting her at all her different appointments. He couldn’t always manage to be away from the farm, even for just a few hours. This meant Catherine sometimes had to travel alone or ask her friends and family to help out – something she found hard to do when she was feeling unwell from all her treatment.

CATHERINE’S STORY IN 2027

Improvements to his care and wellbeing include:

Before she had her lumpectomy Catherine had to have a pre-operative assessment. This was carried out at the Rural Regional Centre in Newtown. The nurse who completed the assessment recorded the results on Catherine’s electronic patient record which can be accessed by everyone involved in her care.

When Catherine had recovered from her surgery, she attended the Rural Regional Centre in Newtown every three weeks for a course of chemotherapy. Because she could receive the treatment locally, Catherine found it easier to tolerate as she was not exhausted from travelling long distances and had more time in the comfort of her own home, close to her network of care.

Catherine has now finished her treatment but still has regular appointments with her oncologist. Where possible these are held using a video link so Catherine does not have to make any unnecessary journeys.

Catherine and her husband are part of a thriving rural community. This means they have a strong network of support locally and found it easy to get help to run the farm so Catherine’s husband could support her at all her appointments.

MARIE’S STORY IN 2021...

Marie is 65 and lives in Machynlleth. She is an unpaid carer for her 87-year-old mum who has COPD. Marie’s mum lives in a second-floor flat in a sheltered housing complex near to the town centre. As well as caring for her mum, Marie also has a part-time job at the local supermarket. She walks to work and does not have a car.

Marie’s mum has become increasingly frail and short of breath recently and can no longer manage the stairs up and down to her flat, especially as she has to carry oxygen to help her breathe. This means she depends on Marie to do all her shopping and housework as well as some of her personal care. Her illness is also affecting her mental health and her mood is changing for the worse.

Recently, as she was leaving her mum’s flat, Marie fell down the stairs and fractured her hip. As a result she spent a week in Bronglais Hospital. Since being discharged from hospital Marie has had to attend a weekly appointment at the fracture clinic.

She sometimes struggles to get to this as hospital transport isn’t always available. There is a bus she could take but it runs at irregular times, is expensive and Marie finds it very uncomfortable to get on and off the bus with her sore hip.

While Marie is unwell an elderly neighbour is doing some shopping for her mum. However, there is no one to help with her care needs or housework and Marie is getting increasingly concerned about her. This is on top of Marie’s other worries about the amount of time she is having to take off work. She is struggling to manage her money and is worried she could lose her job.

MARIE’S STORY IN 2027

Improvements to his care and wellbeing include:

Marie was relieved when her mum was able to move into a residential care home where she can receive the care she needs to keep her safe.

Marie visits her mum regularly and they both enjoy spending time in the grounds around the care home. The trees and green spaces have a positive effect on both her mum’s respiratory difficulties and her mood.

Marie recently fell and fractured her hip. She had to spend a short time in Bronglais Hospital but was discharged as soon as it was safe for her to return home. She has to go to the fracture clinic every week and is given a lift there by the local community transport scheme.

While Marie was in hospital and recovering at home she found it difficult to visit her mum, but they’ve kept in touch through video calls. This has given Marie peace of mind that her mum is safe and well. Marie’s neighbours and friends have also helped her with shopping and cleaning while she recovers.

Marie was unable to work for a while after fracturing her hip but didn’t worry as she received sickness pay so could keep on top of all her household bills. Her employers have been very understanding and keep touch, asking if there is anything they can do to help.

FRANK’S STORY IN 2021...

Frank, 80, and his wife Sarah, 78, have been married for 55 years. They live in a large house in Welshpool which they own outright. However the house is in need of some modernisation and as a result is becoming cold and damp. As well as struggling to maintain their home, Frank and Sarah also find it hard to keep on top of their everyday cleaning and to look after their garden.

Frank worked as a spray painter for a local factory but had to take early retirement because he developed occupational asthma, brought on by his exposure to the spray paint. His breathing is gradually getting worse and he is finding it increasingly difficult to walk to the local shops.

Frank has also recently been diagnosed with lung cancer after he began to cough up blood. His doctors are confident they can treat his cancer so he has been offered therapeutic treatment rather than palliative care. However, this means he will have to be admitted to the Royal Shrewsbury Hospital which is 40 miles away.

Sarah has dementia and Frank cares for her so he is worried about what will happen to her if he goes into hospital or his health deteriorates quickly. Her symptoms include confusion and night-time wandering. She recently tripped and fell while wandering and was admitted to hospital with a fractured femur.

The couple’s only son died 15 years ago so they have no family nearby who can help them out. Although they are well-liked by their neighbours, because they rarely leave the house, Frank and Sarah also do not have a network of support in their local community they can call on.

FRANK’S STORY IN 2027

Improvements to his care and wellbeing include:

The local authority has clear evidence that well-maintained houses contribute to people’s overall health and wellbeing. As a result, in partnership with local third sector providers, they have funded and carried out work to modernise Frank and Sarah’s home.

The council also provide additional support to help Frank and Sarah with day-to-day cleaning and tidying. And a local voluntary group helps look after their garden. This means the couple can continue to live independently in their own home and community.

As a result Frank and Sarah are meeting more people and are also happy to invite visitors into their home. This has strengthened their sense of community belonging and helped them build up a strong local network of friendship and support.

Frank has been able to receive most of his cancer therapy in the regional care hub and has not had to travel out of county. He also receives support from the county’s Breathe Well Programme which is helping him manage the symptoms of his occupational asthma.

Frank has a shared care agreement in place with his primary care team. This means they are able to monitor his health using digital consultations and applications and have been able to adjust his treatment before any change in his symptoms becomes problematic.