TCI 2014 Colombian Cluster Network and Colombia’s cluster development efforts
Health in Wales - GP Cluster Network Action Plan … - Llwychwr...Welcome to the Llwchwr Primary and...
Transcript of Health in Wales - GP Cluster Network Action Plan … - Llwychwr...Welcome to the Llwchwr Primary and...
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GP Cluster Network Action Plan 2016-17
Llwchwr Cluster
Llwchwr Primary & Community Network Cluster Plan
March 2017
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Welcome to the Llwchwr Primary and Community Health network/cluster plan for 2016/17. The Llwchwr Health network based in Swansea and
following the closure of one practice in 2015 is made up of 5 general practices working together with partners from social services, the
voluntary sector, and the ABMU Health Board. Llwchwr covers the area of Pontarddulais, Gorseinon, Gowerton and Penclawdd and has a
registered population of approximately 47,300.
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Table to show the current list size of GP practices in Llwchwr and the change in since 2011
Practice
Practice List
Size 2011
Practice
List Size
2012
Practice
List Size
2013
Change
2012 to
2013(n=)
Change
2011 to
2013(n=)
Sept
2014
List Size
July
2015
W98008 PrincessStreet 8,212 8,183 8,224 41 12 8,587 8,644
W98012Gowerton 11,897 11,978 12,098 120 201 12,040 13,930*
W98013 Tal yBont 8,461 8,627 8,827 200 366 8,900 9,000
W98034 Ty’ rFelin 9,789 9,863 10,055 192 266 10,483 10.764
W98787PenyBryn 5,207 5,296 5,367 71 160 5,052 4,840
*Practice growth reflects the contract change to provide GMS services to patients formally registered at Penclawdd Medical Practice
Networks aim to work together in order to:
• Prevent ill health enabling people to keep themselves well and independent for as long as possible.
• Develop the range and quality of services that are provided in the community.
• Ensure services provided by a wide range of health and social care professionals in the community are better co-ordinated to local
needs.
• Improve communication and information sharing between different health, social care and voluntary sector professionals.
• Facilitate closer working between community based and hospital services, ensuring that patients receive a smooth and safe transition
from hospital services to community based services and vice versa.
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This is the second development plan that has been produced by the network and it is the aim to further develop the plan over the coming years.
The network will be regularly monitoring progress against the actions contained within the plan.
In order to support the development of the network cluster plan, information has been collated on a wide range of health needs within the
Llwchwr area.
The summary below highlights the key points. The health needs information has been taken into account when developing the priorities for this
plan.
Llwchwr Network has:
• 7 Dental Practices
• 11 Pharmacies
• 6 Nursing Homes
• High numbers of Elderly population
• High numbers of Asthma patients
• High numbers of Care Home patients
• Low student population
• Low ethnic minority patient numbers
• Low asylum seekers numbers
• The smallest percentage of patients in the ‘most deprived’ category of all Swansea networks
• The highest percentage of patients living in areas classified as rural
• The second highest percentage of patients on GP Practice CHD or CHD related chronic conditions register amongst Swansea
networks.
• The second lowest rate of people who smoke in Swansea networks and is significantly lower than the health board average.
There is a significant overlap of registered patients who live in adjacent geographical areas of Carmarthen
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Strategic Aim 1: To understand the needs of the population served by the Llwchwr Cluster Network
No Objective Action Key partners Forcompletion by: -
Outcome forpatients
Progress todate/currentposition
RAGRating
1To understand theprofile of the LlwchwrCommunity Networkand the effect thatdeprivation has onthe practicepopulations.
To consider thedemographics of thecommunity network and theimpact on service delivery
• PHW• Primary and
Community Unit• Health Board
Informatics
Profilecompletebut will becontinuouslyreviewedandupdated
To ensure thatservices aredeveloped accordingto local need
All practicesreviewed therevised data tocomplete theirpracticedevelopmentplans in July 2016and to inform thedevelopment ofthe cluster planfor 16/17
2 Respiratory Disease
• To continue toeducatepatients onthe causes ofasthma andpreventativemeasures
• PulmonaryRehab
To signpost patients torelevant voluntaryorganisations.
Increase the number ofpatients accessing thePulmonary Rehab service
To analyse Public HealthData to evaluate if this hasbeen successful
• GPs• ABMU
Ongoing Less patientsdeveloping asthma
Presentationgiven at the Septmeeting by thePulmonary Rehabteam.
New servicebeing embeddedwithin theNetwork andgoing well
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To explore any otheropportunities to supportPulmonary Rehab servicethrough use of cluster funding
3 To continue toprovide CBTsessions for Llwchwrpatients and tobroaden to includechildren and youngpeople
To continue to use funds toemploy private professionalsto provide CBT sessions
To use questionnaires toascertain the views of thepatients accessing theservice
To look at providing CBTsessions for Children andYoung people
• GPs• Practice
Managers• Health Board
Ongoing Will improve accessto CBT for Llwchwrpopulation ascurrent waiting list is>1 year
Will improve thequality ofmanagement ofdepression inprimary care
Further fundingagreed by theNetwork tosupport theprovision.Funding agreedvia Grant schemeto provide acounsellingservice andsessions forchildren andyoung people
4 To support patients inundertaking lifestylechanges which willbenefit their healthand wellbeing andimprove the obesityrate in the Networkarea
To embed the WeightWatchers/Positive Stepsprogramme across theNetwork
To fund further vouchers andcontinue to encouragepatients to lose weight
To evaluate the patients thathave already accessed thescheme
To increase numbers ofreferrals byreviewing/reducing referralcriteria to make service
• GPs• Weight Watchers
• PHW• Health Board
Ongoing Better health forthose patients withchronic diseases
Improved lifestylechoices leading to aless medicalisedmodel of care
Practices arereferring patientsto WeightWatchers andpatients showingweight loss.Projectprogressing well.Further vouchersbought
Continuedfunding from theNetwork.Large numbers ofpatients havebeen referred
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available to other patientswho would benefit
5 To increase cervicalscreening uptake
To continue to raiseawareness of cervicalscreening programme andbuild on previous success.
To evaluate figures
Advertising via posters &leaflets provided by cervicalscreening including GPpractices, communitypharmacists and localauthority buildings
To link in with Public Healthscreening officers
• GP practices• Community
Pharmacists• Local
Authority• Cervical
ScreeningWales
March2017
Early detection ofhealth risks
Uptake figures tobe analysedwhen end of yearnumbers becomeavailable
6 To improve access tomental healthservices
To increase mental healthnursing input
To provide in housecounselling services
To further develop the SCVSMental Health clinic within theLlwchwr Network and explorenew ways of working e.g.Development of MentalHealth focussed Noticeboards/Information Provisionwithin the GP Practices
To review and be aware of
• SCVS• Health Board• GP practices• LAC
Ongoing Improved, timelyaccess to mentalhealth services
Improved access tocounselling servicesfor patients whoneed Tier 0 supporteither via practice ornetwork level
Link in to MentalHealth officer inSCVS
Signpostingpatients to Tier 0servicesFurtherdiscussion to beundertaking atNetworks toprogress further
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referral mechanisms toCAMHS
CAHMSpresentationgiven at PatientCarer Forum
7 Reduce the numberof falls within thenetwork byproactively identifyingand managing thosepatients at risk of fallsand furtherassociatedcomplications.
Identify patients at riskof falls
Pro-active care
To further promote the use ofthe falls prevention guide
Work closer with otherorganisations such as LocalAuthority, Fire Brigade,Library, and many thirdsector organisations
• GPs• Community Staff• SCVS
Ongoing Pro-activeidentification andmanagement ofpatients at risk offalls and furtherassociatedcomplications
Further copies ofthe FallsPrevention guidedistributed via theGP practices andacross theNetwork. Furtherwork ongoing viathe Ageing Wellprogramme andFalls preventiongroup
8 Develop the work of
the Local Area Co-
ordinator pilot project
:
ABMU to work with LACs toprovide clear eligibility criteriafor referring patientsPractices to actively referpatients where suitable:
Further LACs to beappointed to cover thePontardulais area of theNetwork
Local Area Co-ordinator toattend cluster meetings
• LAC• Practices• Health Board
Ongoing Improved supportand signposting forresidents withinparts of the Network
Local Area Co-ordinator isattendingNetwork meetingsand has madelinks with all thepractices in theNetwork andidentified andhelped patients.Further LACappointed for thePontardulais area
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29 Patientsreferred to date
9 To increase the useof the Healthy CityDirectory within thenetwork; signpostingpatients to the mostappropriate service
To evaluate the use of theHealthy City directory withinpractices.
• NHS direct• Health Board• SCVS• Voluntary Sector
organisations
Ongoing Network populationmore informed onavailable health andwell being services
Further promotionof the use of theHealthy CityDirectory withinpractices and topatientsundertaken.Bannersproduced anddisplayed
10 Frail ElderlyTo consider allrelevant actions thatwill assist in reducingthe number ofhospital admissionsfor this vulnerablegroup of patients;facilitating care athome whereverpossible.
Develop anticipatory careplans in partnership withCommunity Services
Develop closer workingrelationship with ChronicCare Nurses and AcuteClinical Response Service
Work closely with CommunityNetwork Hubs to supportpeople at home
To develop step up/stepdown beds at Gorseinon tocomplement those atBonymaen House and TyWaunarlywdd
Rapid access to MedicalHOT clinics and support forCommunity Care teams
• AGPU• CCM• GPs• 3rd Sector• Community
Connectors• Locality• LA/HB Community
Network Hubs• Acute Clinical
Response
Ongoing Reduce admissionsto hospital
Through DementiaFriendly practicesprovide appropriatesupport andawareness
DementiaTrainingundertaken atPLTS session.
Community Hubsestablished andrange of servicesavailable tosupport people athome
Anticipatory Careproject has beenpiloted in Bay andis nowestablished inLlwchwr with keypersonnel inplace to helpmanage theproject
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Acute ClinicalResponseService now live
11 To further developthe third sectorsupport projectincreasing the use ofvoluntary sectorservices by theLlwchwr Networkpopulation
Small GrantC.A.B
Provide opportunities for thirdsector organisations to attendProtected Learning TimeSessions with GPs and nonclinical staff
Ensure that links are madewith voluntary sectororganisations supporting theagreed network priority areaswhere possible.
SCVS to map Third Sectorprovision against networkpriorities.
Ensure that up to dateinformation on voluntarysector services is displayedin GP practices, e.g.information stands, noticeboards.
To extend voluntary sectorpresence within GP practicesin the network by increasingthe number of practicesparticipating, HealthyPartnerships and exploringnew ways of working jointlysuch as pre bookableappointments where possible
Led by Networkpractices supportedby SCVS
Led by Networkpractices supportedby SCVS
Led by Networkpractices supportedby SCVS
Led by Networkpractices supportedby SCVS
Led by Networkpractices supportedby SCVS
Ongoing
Ongoing
Dec 2016
Ongoing
Ongoing
Improved supportand access toservices for theLlwchwrNetwork population
SCVS are
supporting the
implementation of
the Grant scheme
for the provision
of counselling
services for
Children, Young
People
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12 Increase fluimmunisation uptakespecifically targetingthe immunisation ofchildren
To continue to raiseawareness of the fluimmunisation programmeand build on previoussuccess.
To evaluate figures
To link in with Public Healthscreening officers
PHWNetwork PracticesCommunityPharmacies
Mar 17 Protect patients atrisk and the widerpopulation.
Good practice
discussed and
key areas for
progression
identified. Public
Health colleagues
attended Network
meeting to
promote flu jabs.
Figures produced
in November to
be analysed
13 To improve therecording of patientsmoking status
To better record/updatepatient smoking status
To promote access to level 3prescribing service offered bylocal pharmacies and StopSmoking Wales or establishan in house stop smokingservice.
GP Practices
GP Practices
Ongoing
Ongoing
A reduction in thenumber of patientssmoking.
Further work withPublic Healthcolleagues toidentify gaps andimprove theservice
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Strategic Aim 2: To ensure the sustainability of core GP services and access arrangements that meet thereasonable needs of local patients
No Objective Action Keypartners
Forcompletionby: -
Outcome forpatients
Progress todate/currentposition
RAGRating
1 Ongoing review ofcurrent demand forappointments andclinical capacity
Succession planningof practice andcommunity staff
Identify any potentialstreamlining systems andprocesses including theuse of anytoolkits/software available
Follow up on work carriedout with the Primary CareFoundation to assessaccess and demand
Working with the HealthBoard to identify aresolution to indemnityissues
Review workforcedemographics withinpractices and withincommunity – particularemphasis on GPs andPNs
• Practice• Primary
andCommunity Unit
Ongoing Servicesdeveloped toreflect local needin line withcapacity to deliversafe and effectiveservices
Number of practicestransitioned totelephone triage inwhole or part to helpdeal with patientdemand. Generallythis has beenpositively receivedby patients, but thepractices continue toreview.
Indemnity issuesresolution offered byHealth Board tosupport potentialcross practiceworking.
Practices exploringalternativeemployment options
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Review thecommunication processesbetween GP practices andcommunity nursing team
to support GPs, egNurse Practitioners,Pharmacists, and/orParamedics
Improvedcommunication setup for communityhub and patientsnow redirected tocontact hub direct.
2 To investigate the
possibility of
developing the
Network as a
Federation
To further progress the
possibility of Llwchwr
Network becoming a
Federated Network
Network
ABMU
March 17 Decisions to betaken directly bythe Network
Reviewing the workundertaken by aNetwork in Bridgend.Discussed inNetwork PLTSMarch 2016. FurtherPLTS session to beundertaken March2017
3 To addressdifficulties inrecruiting partnersand the shortage oflocums
Address the pressurefacing general practice:
GPpracticesABMU HB
Ongoing More sustainableservices
Government/centralinterventions neededto incentiviseinterest in generalpractice
4 To review workforcepressures anddevelop localworkforcedevelopment plans
To consider successionplanning arrangements atpractices to be betterprepared for leavers
Increase peer support
Consider use of network
• Practice• ABMU
HB
Ongoing Seamless serviceprovision forpatients
As above – andexploration ofalternative methodsof working with otherkey professionals,eg NursePractitioners,Pharmacists,
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monies to develop a GPresource for practices toaccess.
Consider developing skillmix across the network todeal with patient demandand GP pressures
Paramedics, etc.
5 To obtain patientand carer views onnetwork servicesand priorities
To continue to work withthe patient/carer groupdeveloped throughCommunity Voices
To consider areas of workthat the CommunityVoices group can supportpractices in sharingappropriate messages e.g.waste management
• SCVS Ongoing Responsiveservices takinginto accountservice user andcarer feedback.
Regular meetingstaking placebetweenrepresentatives ofthe Network andpatients. Goodattendance at thesemeetings. Networkagreed to fund thePatient Carer Forumfor 17/18
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Strategic Aim 3: Planned Care- to ensure that patients’ needs are met through prudent care pathways,facilitating rapid, accurate diagnosis and management and minimising waste and harms
No Objective Action Key partners For completionby: -
Outcome forpatients
Progress todate/currentposition
RAGRating
1. To ensure that theneeds of patients andcarers are reflected inthe work of thenetworks
To continueimplementation ofthe patient and carerparticipation groupas part of theCommunity VoiceProgramme
To undertake Carerstraining throughPLTS
• GP Practices• Community
Nursing• Social Services• Third sector• Patient and
CarerParticipationGroups
Established andongoing
Patients betterinformed ofpriories withinthe Network
Patient CarerForum is wellattended anda variedagenda takesplace
3 To improveawareness ofpathways on the GPportal
All clinicians andlocums to be madeaware of pathwayson GP Portal
Assess potential toaccess GP portalfrom internet ratherthan intranet
• GP Leads• PM’s
Established andOngoing
Ongoing
Improvedawareness andcommunicationwill result inmore effectivecommunicationwith secondarycare resulting inswifter and moreeffective
GP Portalestablished.Continuedlinks withsecondarycarecolleagues.Developmentof GP OnePortal
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To receive alertswhen new templatesare issued and toreceive feedbackfrom secondary carecolleagues
Ongoing
referrals forpatients
4 To engage in thePrescribingManagement Scheme(PMS) and PMS+respiratory schemes(which containpolypharmacyelements)
Undertake a rangeof prescribinginitiatives toimprove:respiratory,antibiotic,pain managementprescribing andyellow card reporting
GPsPractice NursesMedicinesManagement team
PMS 16/17 – byMarch 17(some Dec 17deadlines)
PMS +respiratory –by Nov 17
Improvedmedicinesmanagementincludingpolypharmacy
Investment inother serviceareas for patientbenefit
Discussed atall annualpracticeprescribingvisits
Practicesengaged andmakingprogress
Medicinesmanagementteamsupportingwherepossible
5 To engage as an earlyadopter in anticipatorycare to work withpeople at most risk oflosing independence
To act as the early
adopter for
anticipatory care,
establishing systems
to:
• Identifying those
most vulnerable
of losing their
independence
• Identify care
CommunityHubs/older peoplesmental healthservices
Commence June2016 and ongoing
Earlyidentification ofthose patientsmost vulnerableof losing theirindependence.Carecoordinator andcare plansystems willassist thosepatients most at
Keypersonnelappointed.Patientsidentified andMDTs havetaken place.CareCoordinatorhaspresented atPatient Carer
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coordinator and
care plan
systems
• Develop effective
means of
communication
risk. Forum.Projectprogressingwell
6 To introduce newmodels of effectiveand efficient deliveryof service supportedand facilitated bytechnology
To discuss and
consider uses of
technology such as I
pads and Skype with
informatics to agree
a more efficient
provision of service
to particular cohorts
of patients, or
patients in certain
settings, e.g. care
homes.
GP PracticesLHBNWIS
March 2017 andOngoing
Moresustainableservices
Fundingidentified andpracticeshavepurchased ITequipment toimproveservices atthe surgeryand for theirpatients
7 To purchase CRPequipment and toundertake testingwithin the practice
To support the Big
Fight campaign and
improve patient
experience
GP PracticesPharmacists
Sept 2017 andongoing
Improve patientexperience andfaster testresults
CRPequipmentpurchased,trainingundertakenand Med Mgtteamundertaking areview of theproject
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Strategic Aim 4: To provide high quality, consistent care for patients presenting with urgent care needsand to support the continuous development of services to improve patient experience, coordination ofcare and the effectiveness of risk management
No Objective Action Key partners Forcompletion by: -
Outcome forpatients
Progress todate/currentposition
RAGRating
1 To reduce theinappropriate use of A&Eand GP Out of Ours
To improve patienteducation e.g. displayposters
Link in with alternativeservices e.g. AGPU
Decrease the number ofunscheduled careattendances
Signpost patients to ensureattendances are appropriateincluding e.g. ”choose well’’posters
To improve patientknowledge of ‘over thecounter drugs’
• GP OOH• A&E• MIU• HB• Community
Voices
Ongoing Better educationon how to accessservicesappropriately tomeet their needs
AnticipatoryCare Projectrolled out in
Llwchwr
2 Improve partnership withAmbulance Service
Improve patient education
Improve communicationbetween practices and the
• GPs• Welsh
AmbulanceService
Ongoing Betterunderstanding ofthe services thatare available for
Presentationby AmbulanceService atLlwchwr PLTS
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Ambulance service • PLTS patient transport and contactdetails andadvicecirculated.Muchimproved butfurther work isneeded tomaintain thegood workalreadyundertaken
3 To improve antimicrobialstewardship
To improve antimicrobialstewardship
To consider CRP testingduring the winter monthsTo undertake the antibioticaudit by December 2015
Medicinesmanagementteam
Ongoing
Quarterly
Monitoring
of trends
ReducedresistanceReduced C.DiffIncreasedknowledge andempowerment toself care
Discussed atall annualpracticeprescribingvisits. Clusterlevel data tohas beenshared atNetworkmeeting
4 To educate patients inidentifying the mostappropriate place toreceive treatment andhow to manage self care.
Practices to promote selfcare education through useof resources such asbibliotherapy, choose wellcampaign, booklets forpatients and parents,newsletters in waiting roomor on notice boards.
GP Practices Ongoing To educatepatients how toself care andaccess servicesappropriately.
Furtheradvertising ofthe ChooseWellCampaignLaunch of the111 project
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Strategic Aim 5: Improving the delivery of end of life care
No Objective Action Key Partners Forcompletionby: -
Outcome forpatients
Progress todate/currentposition
RAGRating
1 To review thenumber of deaths asper guidelines
Undertake reviewof number ofdeaths as perguidelines
GP LeadsSecondary CareColleaguesPMs
March 2017 andongoing.
Identification oftrends across theNetwork
Results ofaudit andlessons learntpresented atJanuaryClustermeeting
2 Use of and beddingin of Principles ofEnd of Life Care
To review thenumber of deathsas per guidelines
Practice levelregular palliativecare reviews andcompletion of
• Practice• Community
Staff
March 2017 andongoing
More appropriateand amenable care
Results ofaudit andlessons learntpresented atJanuaryClustermeeting
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EOL template3 Undertake regular
audit; sharing resultson a cluster networkbasis
Regular audits tobe undertakenand learningpoints to beprogressed
• Practice• Community
Staff
Ongoing Results ofaudit andlessons learntpresented atJanuaryClustermeeting
4 Ensure people areable to remain athome to die if theywish to do so
Work closely withCommunityServices toensure thatsupport isavailable at hometo support end oflife
• CommunityNetwork Hubs
• Health Boardcommissionedpalliative careservice
Ongoing Those who wish todie at home are ableto do so
Communityservices are inplace tosupport end oflife.
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Strategic Aim 6: Targeting the prevention and early detection of cancers
No Objective Action Key partners For completionby: -
Outcome forpatients
Progress todate/currentposition
RAGRating
1 SEA of all newlung, stomachand GI cancers
Regularreview andaudit of lung,stomach andGI cancers
GP Practices
Secondary Care
March 2017 andongoing
To diagnose cancersas early as possible totreat
Improved access todiagnostics andendoscopy in timelymanner
All 5 practices havediscussed theCancers Audit atthe NovemberCluster meeting
2 Undertakeregular audit;sharing resultson a clusternetwork basis
Regular auditsto beundertakenand learningpoints to beprogressed
GP Practices
Secondary Care
March 2017 andongoing
To identify any issuesand improve thediagnosis of cancers
All 5 practices havediscussed theCancers Audit atthe NovemberCluster meeting
All 5 practices havediscussed theCancers Audit atthe NovemberCluster meeting
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Strategic Aim 7: Minimising the risk of poly-pharmacy
No
Objective Action Keypartners
Forcompletionby: -
Outcome forpatients
Progress todate/currentposition
RAGRating
1 To progresspolypharmacyissues identified inprevious clusternetwork plan
To progress polypharmacyissues identified in previouscluster network plan
Medicinesmanagementteam andPracticeTeams
Ongoing Improvedprescribing andmechanisms forpolypharmacyreview
Ongoing workin practicesalso supportedby theMedicinesManagementteam
2 To ensureappropriate use ofthe pharmacist andtechnicianresources (clusterand non-clusterfunded) to reducerisks frompolypharmacy andimprove otheraspects ofmedicinesmanagement
Work with medicinesmanagement team to deliverand ensure appropriatetraining, support andindemnity arrangements
Medicines
management
team and
Practice
Teams
Ongoing Improved access tobetterpharmaceutical care
ClusterPharmacistappointed aswell as othersupport fromHealth BoardMedicinesmanagementteam
Work ongoing
to clarify roles,
training
requirements
and indemnity
arrangements
3 To providestandardisedtraining forprescribing clerksand seek
Nominated clerks to completetraining packs
Seek further opportunities todevelop staff
Medicines
management
team
Practice
Completion of
packs - June
2016
Improved repeatprescribing systems
Number ofclerkscompleted:Llwchwr: 17
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opportunities tobuild on initialtraining to furtherdevelop staff
Managers
Prescribing
Clerks
4 Improvement/maintenance againstnational prescribingindicators
Consider and review practice
and network data for national
indicators
Practice
teams
Medicines
management
team
Ongoing within
16/17
Improve prudent
prescribing leading
to better health
outcomes and
reduced
polypharmacy
Discussed atall annualpracticeprescribingvisits
Work ongoingwith theMedicinesManagementand Big Fightteam
5 Direct supply ofdressings toCentral Hub forcommunity nurses,reducing need forGP prescriptionsand aidingcompliance withABMU formulary
MedicinesManagementTeam &CommunityNurse Teams
Ongoing withreview at 6months
Timely access tomost appropriatewound caredressings, reducingdelays for patienttreatment and nursetime in sourcingproducts
ProjectcommenceJuly 2016
Awaitingoutcome ofreview
5 Renal Pacesetter -developing systemsand processes toreduce the riskassociated withChronic KidneyDisease and AcuteKidney Injury(AKI)-
Develop alert systems toreduce the harm caused by(AKI) through earlyrecognition of at risk patients
Specialistrenalpharmacist,practiceteams
Ongoing withregular review ofoutcomes
Improved medicinesmanagement forpatients at risk ofAKI with earlyidentification by aspecialistpharmacist.
Progress beingmade
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6 The Big Fight: Toimproveantimicrobialstewardshipthrough appropriateuse of antibiotics
Implement mechanisms toensure appropriate use ofantibiotics (see also PMS2016-17)
PracticeteamBig FightTeamMedicinesmanagementteam
Ongoing withmonitoring oftrends
See also PMS16-17 fordeadlines:Dec 16:• Overall
antibiotic useand choices
• Acute CoughAudit
• ImprovementPlan
March 17:• Evidence of
patientengagementactivities
ReducedantimicrobialResistance
Reduced C.DiffIncreasedknowledge andempowerment to selfcare
Discussed atall annualpracticeprescribingvisits.
Developmentof cluster leveldata availableon GP portal
Supportprovided topractices forWorldAntibiotic DayNov 2016
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Strategic Aim 8: Deliver consistent, effective systems of Clinical Governance
No Objective Action KeyPartners
Forcompletionby: -
Outcome forpatients
Progress todate/currentposition
RAG Rating
1 To continue toreview SignificantEvent Analysishighlightingthemes andtrends
SEAs to continue to bereviewed by individualpractices on an ongoingbasisIncidents where there is adirect correlation tosecondary care are beingnotified to the Health Board
Practices to share SEAs atNetwork meeting to sharelearning
Share Practice Datix analysis
• GPPractices
• GPs• Practice
Nurses• Practice
Managers
March2017
Potential for changes toservices based onoutcomes of significantevents where there hasbeen positive/negativeaction
All practicespractices havepresented SEAsand identifiedlessons learnt atcluster meetings.
2 Demonstratinggovernancewithin thepractice:
Completion of theCGPSAT
Each practice to complete theCGPSAT
Practices March 2017and ongoing
Assurance thatpractices have clinicalgovernance proceduresin place
All practiceshave completedCGPSAT
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3 To highlight thedowngrading ofcancer referrals
Practices to review all cancerreferrals that have beendowngraded that weresubsequently found to becancer
GP Practices Ongoing Improvement tosystems to benefitfuture detection
Ongoingdiscussions.Issues need toraised with HealthBoard. NewABMU CancerCommissioningBoard established
4 ImproveDischargeSummaries
To continue to raiseawareness of the problemswith practices receivingcomplete, timely dischargesummaries
• GPs• Locality
CD• Medical
Director
Ongoing Primary Care staff willbe better informed ofpatients condition andtreatment e.g.Medication
Issues raised withHealth Boardcolleagues.FurtherdiscussionscontinuingSomediscussionsongoingregarding the rollout of ElectronicDischargesummaries
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Strategic Aim 9: Other Locality issues
No Objective Action Key partners Forcompletionby: -
Outcome forpatients
Progress todate/currentposition
RAGRating
1 Access to CitizensAdvice Bureau withinGeneral Practice
CAB to provide anadvice serviceresource in the GPpractices withinLlwchwrThe pilot will also befully evaluatedfollowing the end ofthe pilot
• CAB• GP Practices• SCVS
Funding untilMarch 2017Full evaluationwill then beundertaken
Better support forpatients withwelfare /socialproblems thatneed dedicatedsupport andguidance.
Funding has beengiven to C.A.B tostart a pilot andthey will bepresent in aLlwchwr surgeryfor 1 ½ day eachweek to provideinformation andsupport topatients. This tobe evaluated
2 Assess potential list size
increase with growth of
further housing
developments
To engage with theLocal Authority overthe impact newhouses being built inLlwchwr will have onPrimary Careservices.
• HB• PMs• LA
Ongoing LA LDP currentlyout forconsultation.Meetings havetaken place.Practices affectedby thedevelopmentshave written to theLA outlining theirconcerns . No
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furtherdevelopments
3 Improving patient carewithin Llwchwr byworking with key partneragencies
Ensure cohesiveworking relationshipswith the Locality, EDcolleagues,secondary care,Local Authority,Pharmacy, thirdsector and toimprove patient carewithin Llwchwr
• SocialServices
• Communitynursing
• Third sector• Primary Care• Domiciliary
care• Independent
careproviders
Ongoing Integrated serviceprovisionprovidingseamless care forpatients
All key partnersattending Networkmeetings
4 Ensure that the workingarrangements of centralhubs for communitynursing do not have adetrimental effect onworking relationships
Participate indiscussions toensure that a safeand effective servicemodel is developedand communicationwith GP Practices istransparent.
Encourage thedevelopment of aphlebotomy servicefor domiciliarypatients
• GPs• Health Board• Local
Authority
Ongoing Improved accessto services forpatients withchronic conditions
Hubs establishedand two waycommunicationbeing facilitatedthroughcommunitynetwork meetings,and further links inplace. Problemshave beenidentified and fedback to Hubs andHealth Board
District nursingfunction to becoordinated viathe Intake Teamfrom October2016. This hasensured bettertwo way
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communicationgoing forward.
Strategic Aim 10: Other Locality issues
No Objective Action Keypartners
For completion by: - Outcome forpatients
Progress todate/current position
RAGRating
1