Merthyr GP Cluster Network Action Plan 2015 V1 GP Cluster Network Action... · GP Cluster Network...

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GP Cluster Network Action Plan 2015-16

Version 1.1

Merthyr Tydfil Locality Cluster

The aim of the locality is to create an atmosphere of sharing without competition:

Sharing expertise and staff for the benefit of patients and practices alike

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Introduction

Practices within Merthyr Tydfil have worked ‘together’ for a number of years and network arrangements have been in place in respect of someenhanced services.

The GP Cluster Network Development Domain supports this arrangement and allows Practices to work collaboratively with support from theLocal Health Board.

Practices have engaged with the cluster process and regular meetings have been held both formal and informal. Meetings have been held withLocal Health Board, 3rd Sector Organisations, Merthyr Tydfil CBC, and Public Health Wales.

Members of the cluster group are:

W95072 Pontcae Medical PracticeW95086 Morlais Medical PracticeW95023 Keir Hardie Health ParkW95005 Keir Hardie Health ParkW95647 Keir Hardie Health ParkW95290 Oakland’s SurgeryW95032 Treharris Health CentreW95026 Troed y Fan AberfanW95028 Dowlais Medical CentreW95634 Brookside Surgery

Each practice has created a practice cluster plan which has been shared with the LHB, it should be noted that all practices within the clusterhave agreed that these plans should be shared with each other. This was facilitated by the LHB.

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Each practice was allocated a task, which was predominantly one Strategic Aim in 2014 and this has continued through the cluster network in2015/16

W95072 Pontcae Medical Practice – CHD Risk AssessmentW95086 Morlais Medical Practice – Workforce and RecruitmentW95023 Keir Hardie Health Park – Access and Demand ManagementW95005 Keir Hardie Health Park – Access and Demand ManagementW95647 Keir Hardie Health Park – Access and Demand ManagementW95290 Oakland’s Surgery – Smart Use of ResourcesW95026 Treharris Health Centre – Communication IssuesW95026 Troed y Fan Aberfan – Poly PharmacyW95028 Dowlais Medical Centre – Early Detection of CancerW95634 Brookside Surgery - End of Life Care

The creation of a dynamic Cluster action plan is crucial to moving the aims of the cluster forward and with the support of the LHB the clusterhad an opportunity to use existing practice skills to facilitate this.

The following cluster co-ordinators have continued in the role for 2015/16

Dr Sian Newman – Morlais Medical PracticeKevin Rogers – Pontcae Medical PracticeKate Francis – Morlais Medical Practice.

There was a significant change within the cluster in July 2015 when Dr Kevin Thomas stepped down as Locality Clinical Director.

Dr Thomas was replaced in the role on 1st September by Dr Stuart Hackwell of Morlais medical practice. Dr Thomas has been invited toparticipate in future cluster meetings in his role as LMC representative.

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A significant number of meetings have taken place to discuss both the practice action plans and strategic objective documents. The workloadof the cluster leads has been significant and whilst the assistance of June Williams at the LHB has been very welcome, the locality is without aprimary care development manager until December 2015; this has increased the burden on the cluster leads.

We have attempted to create a simple, dynamic document with objectives that can be delivered within a reasonable timescale. There is amixture of strategic objectives underpinned by the need to improve patient care and provide sustainability and modernisation of services withMerthyr Tydfil

• Some objectives can be undertaken independently by the cluster practices to improve patient care

• Some objectives require partnership working (LHB/3rd Sector/ MTBCBC / IT suppliers)

• Some objectives are longer term and will require resources and direction from the Local Health Board

Whatever the specific objective, there is a desire from practices to ensure we work for the benefit of all.

Creating a collaborative environment we aim to increase the quality of care provided for patients while managing the significant increase indemand within the cluster.

Each cluster objective has been accorded a RAG (Red, Amber, and Green) rating.

Green – The objective is performing to plan and should experience no significant problems

Amber – The objective in ongoing and may present some problems within reasonable tolerance. Objective should be achievable but may

require support of organisations outside of the cluster.

Red – The objective has significant problems and will require support of organisations outside of the cluster.

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Strategic Aim 1: to understand the needs of the population served by the Cluster Network

The Cluster Profile provides a summary of key issues. Local Public Health Teams can provide additional analysis and support.Consider local rates of smoking, alcohol, healthy diet and exercise – what role do Cluster practices play and who are local partners. Is actionconnected and effective? What practical tools could support the delivery of care?

Health protection- consider levels of immunisation and screening- is coverage consistent- is there potential to share good practice?Are there actions that could be delivered in collaboration- e.g. Community First to support more effective engagement with local groups?

No Objective Key partners Forcompletionby: -

Outcome for patients Progress to Date RAGRating

1 To review theneeds of thepopulationusing availabledata

Local PublicHealth Team

Public HealthObservatory

Ongoing – noend date

To ensure thatservices aredeveloped accordingto local needs

COMPLETED

The Cluster Network serves a population withina deprived area of Wales. This, combined with anumber of social and economic issues has animpact upon the needs of the local population.

A summary of the 2015 findings is listed below.

• The view of the Cluster group based onpatient registrations is that thepopulation is increasing. It has beennoted that this is not support by PublicHealth data.

• Our Cluster sits in an area of highdeprivation with figures for NorthMerthyr and South Merthyr being above

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the average for Wales and the LHB.North Merthyr has 46.3% and SouthMerthyr 38.8% of patients living in themost deprived fifth areas in Wales.

• Chronic condition burden is higher thanother Cluster areas

• Cwm Taf has the highest rate ofpremature mortality due to CVD inWales

• Cancer survival is the lowest in Wales.Significantly, the Cluster has the lowestuptake in Cervical screening and Bowelscreening programmes

• Lifestyle and socio-economic factorsaffecting the health of the localpopulation have also been recognised –such as high numbers of smokers; highunemployment levels; high number ofpatients with mental health issues. TheCluster has recognised that in MerthyrTydfil 65% of the population describethemselves as being overweight, 7%above the average for Wales of 58%.Alcohol consumption and alcohol relatedadmissions are high in the region.

Under the Quality and Outcomes Framework, all

general practices in Wales are required to produce

practice development plans which will in turn

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inform GP Cluster development plans.

We were provided with a link to the GP Population

profiles of Public Health Observatory. It is hoped

that this profile can play a part in the practice and

cluster

develop

ment

plans.

It is

estimate

d that

around

90 per

cent of

all NHS

patient contacts occur in general practices.

Therefore a better understanding of general

practice populations is of great use to many others

who are working to improve public health.

These population profiles build on the previously

published GP Cluster Profiles.

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The population profiles include a population based

peer grouping exercise, allowing practices to

compare themselves with similar practices across

Wales. The peer groups were determined following

a statistical process which grouped practices

depending on their list size, proportion of older

people, deprivation and population in rural areas.

Further details on how the peer groups were

derived can be found in the technical guide (see

below). As this is the first time the Observatory has

produced general practice peer groups

http://howis.wales.nhs.uk/sitesplus/922/page/63747

Table A demonstrates the areas which can beanalysed by the pyramid

2 To identifyadditionalinformationrequirementsto supportservicedevelopment

Local PublicHealth Team

NWIS

Improved support forservice development

For example, High premature cardiovascularmortality – need local Dashboard to understandconsistency of prevention and risk management

Table B shows Chronic disease areas for NorthMerthyr, While Table C shows the South of thecluster.

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Action: - for development with LHB

3 To considerlearning frompreviousanalyses toidentify anyoutstandingservicedevelopmentneeds.

This area was considered in detail during thework completed for QP in the previous year.Service needs identified included:

I ) MAU unit open for longer hoursii)Promotion of CIASiii) Promotion of the exercise referral scheme?

4 Increase FluImmunisation

Practices

LHB

Public Health

31 March 2015& ongoing

Improved care /protection of patientsagainst Influenza.

Action taken to date:

We have a seat on the Flu immunisationproject board and this is ongoing.

Future Actions:LHB / Public Heath:i) Increase resources available to encouragePractices to invest in their flu campaigns? E.g.could provide template letters for Practices?Advertising campaigns?

ii) Further assistance with training to allowHCA’s to be appropriately trained to safely

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administer flu vaccines.iii) Continue with Flu facilitator role

5 IncreaseScreeninguptake rates

Practices

LHB

Earlier diagnoses,increased lifeexpectancy

The need has been recognised by the ClusterGroup.

Possible solutions to be discussed further.

See also work within Strategic aim 6 – Earlydetection of Cancer

Table A

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Table B

Table C

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Strategic Aim 2: To ensure the sustainability of core GP services and access arrangements that meet the reasonable needs of local patients

Consider the National Survey for Wales, local feedback and individual practice analysis.

In the National Survey for Wales 38% of people found it hard to get a convenient appointment – for a number of reasons such as Long wait forappointment ; early morning calls; Appointments not available on the same day ; Difficulty getting through to make the appointment ; Couldnot book appointment with doctor of choice ; Appointments not available at convenient times.

Is there an accurate measure of demand- if not consider data collection to articulate the scale of action required.

Consider what capacity could be released by minimising system waste- chasing appointments, discharge letters and specialist advice. If that isa significant issue ensure that data is captured to highlight the scale of the problem and include this as an issue to be taken forward by theLHB.

Recruitment and retention- risk in some areas. Ensure risks are recorded and reported. Does this need a local plan to support concertedaction? Potential to test new models/roles- are there volunteer practices or potential for roles across the Cluster area that could support themanagement of capacity.

What potential is there for collaborative working with local partners- Communities First, Third Sector Etc?


Outcome for patients/ Service

Progress to Date RAGRating

1 To reviewcurrentdemand andcapacity

LHBCHCAccess Group

31/3/16Services developed toreflect local needs ofpatient and practice

Merthyr Tydfil representation on LHB AccessGroup to review progress

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Individualpractices andcluster based

2 Activity DataCollection

LHB (Ongoing) Mapping accurateactivity data to reflectworkload

Initial objective completed - Practices withincluster are providing weekly activity data to LHB

This is published on the LHB Primary Care portal

3 Share ActivityData

LHB / LMC (Ongoing) Mapping accuratecluster activity

LHB / LMC Discussion with a view to accurateactivity data across Merthyr Tydfil

4 To developlocal workforcedevelopmentplans

(Link withStrategic Aim 9

LHB /LMCWG

OngoingMeet with WG todiscuss long termstrategic plans for MTin terms ofrecruitment andretention of GPs

Data Collection of recruitment issues to presentto WG

It has been noted that Merthyr Tydfil is in directcompetition with other clusters in terms ofrecruitment – Promotion of Merthyr Tydfil withother organisations ongoing. Further meetings

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– recruitment)

31/3/2017 Long term planning toattract GP to MerthyrTydfil Cluster

with WG have been planned for 2016.

The Rhondda cluster have taken the lead on thisand planned advertising campaigns to promotethe Rhondda Valley. While we are broadlysupportive of the needs of the Rhondda Valley itmust be considered that with the limitednumber of GPs available , each one attracted tothe Rhondda will be one less available for theMerthyr cluster.

We must take a pro active view to encourageGPs to want to work within the locality – linkswith PCSU need to be re-established and LHBcommitment will be required.

5 InappropriateWorkload

‘pass to GP’

(Link withStrategic Aim 9–Communication)

LHBLMC

31/3/16 Significant proportionof primary careworkload falls withinthe ‘pass to GP’category –

We need to ensurethat secondary carework is not passed toGp’s for completion.Currently too many

LMC Data collection supported by practices –suggests minimum 10% of work inappropriate –it was noted this was a conservative estimate

Examples of inappropriate requests werecollected by the cluster which supported thisview.

The BMA has published a document whichcontained example letters for documents to bereturned in the event they have been sent to

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staff members feel it’sok to ‘pass to Gp’ –this needs to stop asthis impacts on thepractice ability toprovide services andthe long term healthpriorities of thecluster group.

the GP inappropriately

This work is ongoing – It has come to lightrecently that consultants feel it appropriate tosend test results to GPs for action ‘ on theirbehalf’ clearly this is not the case and discussionwith medical director of LHB is planned for late2016 around this topic.

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Strategic Aim 3: Planned Care- to ensure that patient’s needs are met through prudent care pathways, facilitating rapid, accurate diagnosisand management and minimising waste and harms

No Objective Keypartners

Forcompletionby: -


1 To increaseawareness and useof e-mailcorrespondencewith consultants insecondary care foradvice andreferrals.

SecondaryCare / LHB

Completed Rapid, appropriate diagnosis andtreatment which will improvepatient care.

This will also achieve the aim ofreducing inappropriate referralsthus minimising waste and harms.

Objective agreed and plan ofaction to be confirmed.

Will require assistance fromSecondary Care / LHB

2. To set up a systemwhereby clear andprescriptivemanagement plansare provided whena patient is seen inSecondary Care.

SecondaryCare / LHB

31 March2016

Improved patient care by negatingthe need for ongoing hospitalfollow up appointments. Suchmanagement plans could result inthe patient being referred safelyback to Primary Care much soonerand avoid repeated hospitalappointments.

This links with the EDAL / Mtedproject which is ongoing. Clusterhas a seat on the EDAL project

Objective agreed and plan ofaction to be confirmed.

Will require assistance fromSecondary Care / LHB

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board and roll out / evaluation isongoing.

3. Re: Mental Healthand Alcohol - Topromote and raiseawareness ofcounsellingservices for adultsand young people.

Also, promotion ofself referral to thecommunity basedMindfulness &Stress Controlworkshops

ClusterGroup

Third Sector

PrimaryCare/LHB

ongoing Patients will gain access to servicesin the community.

Links with the Behaviouralsupport that we wish to introducein SA10

Objective agreed and actiontaken.

Assistance from Cluster group,third sector / organisationsproviding such services required.

4. To promoteservices availableto help reduceobesity, smokingprevalence

Cluster

Third PartyOrganisations

ongoing Patients will have greater optionsto support them in changing theirlifestyle / habits.

Links with the CVD riskassessment project which isongoing and with the Behaviouralsupport that we wish to introducein SA10

Objective agreed. This is to beachieved by:

a) Use of Exercise ReferralProgramme

b) CVD risk assessmentc) Behavioural Supportd) Community Co-ordinators

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Strategic Aim 4: To provide high quality, consistent care for patients presenting with urgent care needs and to support the continuousdevelopment of services to improve patient experience, coordination of care and the effectiveness of risk management


Outcome for patients/ Service


1OOH Serviceredesign

LHB / Out ofHours service/ A&E

(Ongoing) Improved access toappropriate OOHServices

Engagement with LHB in discussions arounddesign of service (Also link with Access Group)

Recent communication suggests that progresshas been made by the HB – Shift bundling andchange of sites has begun

2A&E

(Link with OOHServiceredesignmodel)

LHB / Out ofHours service/ A&E

(Ongoing) Out of Hours – moreappropriate use ofA&E

In Hours – Link withAccess Plans –education for patientsto use a&e only whenappropriate

Engagement with LHB in discussions arounddesign of service (Also link with Access Group)

As 1 above

3NetworkServices

LHB / Cluster Ongoing31/3/16

Access to high qualityclinical care in a

Networking of services initiated –Minor SurgeryAdvanced Minor SurgeryVasectomy

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timely andappropriate manner Investigation of further network services encouraged

and currently being investigated.

We wish to introduce a Wound Management facilitywithin KHHP as cluster hub.

Also on the horizon is the development of ClusterCommunity Clinics in Cardiology. The funding forthese clinics will come from a separate pot from thecluster money although they are integral to the kindof services the cluster might be expected to deliver.

The idea is that this will be based in KHHP. Someinitial conversations have taken place with theCardiology Department about how it could supportthis clinic with equipment so now is the time for ourcluster to shape what kind of service we envisagewould help our patients the most. Some ideasalready mentioned include an AF andanticoagulation clinic. It is anticipated that this willbe run by GPs from Merthyr Practices or the PCSUwith a Special Interest in Cardiology.

Support is available from the UHB to back fill coverany absences and then help set up and run the clinic

The shift of resources needed to provide networkservices is still unresolved. The initial example ofNOAC funding is proving problematic and is beingdealt with by the LMC – We await this decision toensure practices are properly resourced

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4 3rd Sector /

Social Services

LHB / mtcbc /OtherOrganisations

31/3/15(Ongoing)

Improved Linkbetween practicesand 3rd sector / socialservice / MTCBCresources to signpostpatients to moreappropriate services

Community co-ordinator to linkbetween primary care/ patient and otherservices

Links with theBehavioural supportthat we wish tointroduce in SA10

We know that many patients attend the GP practicewhen they have no immediate medial need and weneed to enable patients to make an informed choiceof appropriate attendance

A fixer / co-ordinator role is required to -

• provide Behavioural Support for Patients

• provide Financial Support for Patients

• Modify behaviour without the need to seeGP

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Strategic Aim 5: Improving the delivery of end of life care



1Support

practices to

identify patients

for their

palliative care

registers

Secondary

care

District

nursing

Macmillan

nurses

Nursing

Homes

OT

Physiotherapy

LHB

31st March2016

In order to provide high

quality end of life care it

is important to identify

patients who are likely

to be in their last year

of life. By identifying

these patients it allows

their care to be planned

and co-ordinated to try

and reduce the chances

of crisis arsing which

can result in unplanned

admissions.

GP Facilitators Nicola and Rachel are engaged with

cluster and information regarding palliative care

registers and what support they can offer underway

Guidance available on the Cwm Taf UHB intranet –

the cluster to raise awareness of where practices can

access this information and ensure all practices have

easy access to the intranet

New template has been circulated to practices toimprove data collection Aug 2015– evaluation latter2016 required.

The end of life pathway has also been includedwithin the primary care portal.

2 Increase use of

JIC boxes

It is important

to use other

members of

the health

31st March2016

This can help to reduce

delays in medication

being available OOH for

adequate symptom

Check each surgery within the cluster has a JIC pack.

Increase awareness of this scheme and where

information can be obtained.

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care team

particularly

District

Nurse’s,

Macmillan

nurses and

Nursing home

matrons in

identifying

patients for JIC

boxes

control and may reduce

crisis admissions. It will

enable better, more

timely control of

symptoms such as pain

and vomiting.

New template has been circulated to practices to

improve data collection Aug 2015– evaluation

latter 2016 required.

Evaluation of use of JIC boxes by 31/3/16 required

Increase communication with rest of health care

team

http://howis.wales.nhs.uk/cwmtaf_resource/palliati

ve-care

3Collaboration /Advice

Cluster / LHB 31st March2016

Increase awareness of how to access advice on

individual patient management when required.

Cluster to provide info for all practices with useful

phone numbers / websites so they can access advice

on any aspect of end of life care at all times as it can

be difficult to know how and where to get advice.

The end of life pathway has also been includedwithin the primary care portal.

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Strategic Aim 6: Targeting the prevention and early detection of cancers

We have significantly progressed the engagement with screening services in order to progress this Strategic Aim.

Including a presence on the Reducing Cancer inequalities working group. The Cwm Taf cancer inequalities group is working to reduce the higher cancer

incidence, mortality and poorer cancer survival in our more deprived communities. The uptake of screening follows a similar pattern with uptake decreasing

with increasing deprivation.

This meeting with PHW Screening Services and Community Partners was arranged to support clusters to progress the actions in their plans relating to

increasing informed uptake of screening programmes.

No Objective Keypartners

Forcompletionby: -

Outcome forpatients /Service


1 EngagementwithScreeningServices

CSW

BowelScreening

Breast TestWales

PublicHealthWales

InitialEngagementby 31/3/15

Currently the

uptake in the

Merthyr

Clusters

See Tablesbelow

Cluster Representative has met with Bowel Screening Wales

with a view to implementation of new procedures to

increase uptake.

Screening programme uptake data by cluster was shared. The

apparently low figure for MT Cluster for breast screening was

explained by the 3 year cycle of screening by area.

Data at practice level is available and would be released to

individual practices on request. If the cluster wanted access to

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practice level data, Screening Services would need to have

practice agreement (from Senior partner) for data to be released.

The bowel screening pathway was described and clarification of

the process around spoiled kits and non-responders was given.

The Bowel Screening Programme could provide practices with a

list of eligible patients who had not responded to their invitation

to participate in bowel screening. This would be released four

times a year (Sept/ Dec/March/ June). A proposal is currently

being developed with AB Clusters to test this.

This data could be sent via the Screening Link person (currently

the point of contact for Cervical Screening Programme). Practice

Managers would need to brief the Link person to expect this data.

Bowel Screening Non-responder Data

o Each cluster to discuss how they would like to proceedwith the data that could be provided quarterly. MerthyrTydfil exploring a role within practice to follow-up non-responders.

o There is a READ code for bowel Ca screening declined8IA3 and not eligible 9OW3

o Screening Services will update the Screening Link Personat their next training event

Early RCGP / LHB In Cwm Taf in 2012 there were 18 cases of pancreatic cancer

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2 detection ofPancreaticCancer

CompletedRaise the

awareness of

how to

diagnosis

pancreatic

cancer by GP’s.

and 242 in the whole of Wales.

Pancreatic cancer is more prevalent than is often recognised

and earlier detection of symptoms will improve outcomes

for patients.

Gp’s to complete a CPD module on the RCGP website

3Rapid AccessReferrals

LHB /Cluster

OngoingPhase I

Raise

awareness /

create portfolio

of all available

Rapid Access

services.

Learning

Outcomes to

be shared to

benefit practice

/ Patients

Cluster Lead(s) to Liaise with LHB to create a portfolio of

services to be shared with Cluster. This data is available on

the primary care portal – this is ongoing work

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31/10/16

Phase II

Analysis of

Rapid Access

referrals from

Primary to

secondary care

– 1/12/14 –

30/11/15

Learning

Outcomes to

be shared to

benefit practice

/ Patients

How many referrals were sent as Rapid Access

How Many were Downgraded

How Many patients diagnosed with cancer following

referral.

Cluster practices continue to collect this data.

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Strategic Aim 7: Minimising the risk of poly-pharmacy



1 To review theuse andeffectivenessof theSTOP/STARTTool.

Cluster March 2016 If the tool proves tobe effective, patientswill be taking theappropriatemedication.

Work in progress - GP Practices should be in theprocess of undertaking reviews of their patientsaged over 85 on six or more medications.

Review to take place 31/03/16 to assesswhether or not Practices have used the tool andassess its effectiveness.

2 Effective useand workingwith the LHBPrescribingteam toachieveconsistencyandappropriateprescribing.

Cluster

LHBPrescribingTeam

Ongoing Patients will receiveconsistent care.

It is proposed that a representative from theLHB Prescribing team is formally invited andattends all Cluster Group meetings.

Many of the cluster plans for other areasinclude the employment of a Pharmacist towork within the cluster practices. MerthyrCluster has not selected this as a priority for2015/16 however is keen to review the dataavailable from Taff Ely , Rhondda and Cynon inrespect of evaluation of this cluster priority.Clearly if there is evidence that this improvesaccess and efficiency then we will be keen toconsider this for 2016/17.

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Strategic Aim 8: Deliver consistent, effective systems of Clinical Governance



1 Each Practice to complete the ClinicalGovernance Toolkit by the end of March 2016

2 Updated GPSAT will be discussed at clustermeeting in November 2016 with arepresentative available to provide assistance.

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Strategic Aim 9: Other Locality issues



1 Recruitment &Retention

a) To achievecontinuity of careand services e.g.when Doctors retire.

b) To attract Doctorsto the area ofMerthyr Tydfil.

c) To provide highquality training toGP’s Trainees andmedical students.

ClusterLHBWAG

See StrategicAim 2

Continuity of qualitycare.

A follow up meeting with the Director ofWorkforce planning at the WelshAssembly Government is planned forearly 2016.

The problem of recruitment ishighlighted within the area as twopractices are struggling to recruit GPs.

This is leading to potential mergers andsharing of resources.

The Rhondda cluster have taken thelead on this and planned advertisingcampaigns to promote the RhonddaValley. While we are broadly supportiveof the needs of the Rhondda Valley itmust be considered that with thelimited number of GPs available , each

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one attracted to the Rhondda will beone less available for the Merthyrcluster.

We must take a pro active view toencourage GPs to want to work withinthe locality – links with PCSU need to bere-established and LHB commitment willbe required.

We need to evaluate the advertisingcampaign in the Rhondda to assess itseffectiveness.

2 Access & DemandManagement

a) To encourage asmany Practices aspossible to sign upto the Access LES,the objective ofwhich is to improveor retain currentaccess levels asappropriate.

b) To develop astandard Clusterresponse / system re

Practices

Practices / LHB

Completed Improved access

Documentation re DNA’s has beendeveloped via the Access Group. The

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DNA’s.

c) Educate patientswith help from theLHB and WAG tohelp manage patientexpectations.Constant negativemedia attention asto the availability ofGP appointmentsetc. fuels patientexpectations.

/ AccessGroup

Practices

LHB

WAG

Access Group– liaising withthe CHC.

Completed

March 2017 Consistent message topatients throughout thearea.

aim is to ensure that this iscommunicated and shared amongst allPractices in the Cluster.

To date, organising a meeting with theWAG to discuss the issues surroundingsrecruitment and retention is underway.

Activity data being sent to the LHB willalso assist this process as it will allowthe reality of how many patients arebeing seen and the workload to bedemonstrated and publicised whenappropriate.

Links with Web GP See SA9 (6)

3 NETWORKING:

a) To improvecommunication sothat all members ofthe Cluster areaware of theservices availablefrom Third Sector /Voluntaryorganisations.

b) Practices to shareresources and

Cluster

LHB

Third SectorOrganisations

March 2015 Patients being madeaware and able toutilise resourcesavailable to improvetheir lifestyles / socialwell-being.

The Cluster group has met withrepresentatives from local organisationswho have promoted their services.

Ongoing – Links with BehaviouralSupport See SA9 (7)

The Cluster has already started thisprocess. E.g. all Practices in the Clusteragreed to share their PDP’s; the group

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information whenappropriate.Includes clinical andnon-clinicalassistance e.g.sharing of policiesetc.

c) Smarter Use ofexisting primary careresources

Clusterpractices / LHB

March 2016

March 2016

March 2016

Directing patients tolocal resourcesreducing waiting lists /improving quality

Shift from ‘day surgery’to primary care willallow capacity insecondary care toincrease thus reductionin waiting lists

have developed links and a healthy spiritof co-operation and support to allowbest practice to be shared andpromoted within the Cluster group.

The cluster will also start sharingscreening data for 2015/16 – this is toassist the development of the screeningservices priority.

Initially Questionnaire to be sent tocluster practices to identify volume ofjoint injections, carpel tunnel etcreferred to secondary care.

Further analysis of questionnaire, shiftof resources from secondary to primarycare and those practices who want toundertake this service on behalf of thecluster.

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Cardiology – Liaisonwith service March 2016

Improved access toservices

Also on the horizon is the development ofCluster Community Clinics in Cardiology.The funding for these clinics will come froma separate pot from the cluster moneyalthough they are integral to the kind ofservices the cluster might be expected todeliver.

The idea is that this will be based in KHHP.Some initial conversations have taken placewith the Cardiology Department about howit could support this clinic with equipmentso now is the time for our cluster to shapewhat kind of service we envisage wouldhelp our patients the most. Some ideasalready mentioned include an AF andanticoagulation clinic. It is anticipated thatthis will be run by GPs from MerthyrPractices or the PCSU with a Special Interestin Cardiology.

Support is available from the UHB to backfill cover any absences and then help set upand run the clinic

Arrange for Cardiology consultant tovisit cluster meeting to discuss access toinvestigations and services.

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4CHD RiskAssessment

LHBClinical SystemSuppliers

31/3/16 Identification ofPatients at risk

Identification ofpatients where riskunknown

Once Identified Patients

receive passive and

active interventions

Optimised treatment –

Delivered by Dr / Nurse

/ HCA /Pharmacy /

Health Board / Dn’s

Improved database of

Risk

Reduction in numbers

of patients with > 20%

risk (pro rata)

Reduction in CHD

Events (Best Long term

Indicator)

Evaluation of initial pilot underway withthe appointment of a primary caredevelopment manager to lookspecifically at this project. The clusterwill link with this evaluation to progressthings during 2015/16

Agreement of cluster to proceed

Use of additional resource (HCA) madeavailable for Inverse care work tosupport this work – this should be forthe exclusive use of Merthyr cluster andshared by all

Evaluation will determine which clinicalsystem will be used and what resourcesare available – this is an additionalproject that will be funded from outsideof the cluster ‘pot’ for 2015/17

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5 Communication

(a) DAL(DischargeAdviceletters)

LHB / MedicalDirectors /Cluster leads 31/12/15

31/3/17

Phase I

illegible and hand

written DAL very poor

quality (Rarely mention

any planned follow up,

patient details missing

little or no information

about care given and

investigations

performed. Urgent

Improvement required

for patient safety

Phase II

Should be computer

generated and sent via

WCCG or electronically

like OOH / A&E

communications.

Intention of Cluster to no longer acceptthese poor quality DALs –

Notification was sent to MedicalDirector of LHB that action needed inregard to quality of handwritten DALs

Supporting letters creased by BMA tohelp when returning these documents

This must be a two way process andcluster practices must ensure Referralsare sent with high quality data andreadable – continue to monitor this

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(b)

A+E Notifications

LHB / MedicalDirectors /Cluster leads 31/03/16

31/03/13


for patient safety

Phase I

Should be Electronic for

all Cluster practices and

sent with pathology

messages.


for patient safety

Phase II

A&E letters very Poor

Quality - sparse in

content, no information

regarding investigations

/ results Or follow up.

Urgent Improvement

required for patient

safety

Support / encourage LHB to plan andimplement electronic DischargeSummaries

Seat on project board for cluster –involved in evaluation of EDAL project

Cluster lead to contact LHB IT toorganise electronic messages

Initial encouragement for a&e , howevernot all practices are receiving electronicmessages – this needs to be resolved by31/12/15 and evaluated 31/3/16

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C) PathologyMessaging

LHB / MedicalDirectors /Cluster leads

31/12/14

Phase I

Patient Safety

compromised due to

pathology investigation

messages not returning

to practice or being

sent to incorrect GP.

Additional work

required on method of

notification of Red Flag

results.

Phase II

Update on Label Trace /

wccg test requesting

.Uniform agreed system

required to deal with

non Gp partner

requests (Locum /

Salaried GP / F2 /

Trainees etc)

Cluster lead to write to Medical Director/ A&E with a view to improving qualityof a&e letters

Electronic A&E as a mechanism is fine –does not improve the quality ofnotifications. The LMC and assistantmedical director are aware of theseshortcomings and this is beingprogressed.

Zero Tolerance project beenimplemented by UHB , this has to be atwo way process and the cluster leadshave been involved with this project.There is a clear understanding of theneed for accuracy at both ends.

This must be a two way process andcluster practices must ensure pathforms are sent with high quality dataand readable.

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31/03/15 Practices to monitor and report tocluster all delayed / lost results –particularly red flag results over a 6month period.

LHB to provide individual data onrejected practice messages – with aseparate data for District Nurses.

6 Access – Web GP

To introduce Web GPto the cluster toimprove access ,education and use ofresources

31/3/2016

Links With SA2

The intention is that

patients would use Web

GP prior to contacting the

practice and be directed

to a more appropriate

option

We anticipate that this

will see -

• Significant

improvements in

patient

perceptions of

access to their GP

• Better health

We will incorporate the use of webGP which

is a patient platform that links from a GP

practice’s existing website to a suite of

online offers including:

1. Symptom checkers and condition

finders, so patients can ensure they are

using general practice appropriately

2. Self-help guides and videos, so a

proportion of demand can be top-

sliced as patients are given the

information to self-manage

3. Sign-posting to alternate local services,

e.g. pharmacy, so patients are aware of

the range of resources available that

might help with their issue

4. A webform that patients can use to

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outcomes

through earlier

detection of

significant

symptoms, earlier

intervention, and

particular health

issues presenting

sooner online,

e.g. mental and

sexual health

• Better practice

efficiency with

shorter waiting

times and saved

appointments

(400 GP hours)

• Commissioner

savings as fewer

patients attend

urgent care

settings such as

A&E and OOH

Services.

request a NHS Direct clinician call back

(24/7) if they feel their problem is more

pressing

5. Over a 100 webforms on common

general practice conditions that are

sent from the website to the practice

for advice and treatment from the GP

within 1 working day (e-consults). This

allows practices to rapidly triage

patients, using these structured

histories, and manage 60% of them

without a face-to-face appointment.

Orders have been signed and we areawaiting release of cluster funds.

Full evaluation of this project has beensent to LHB under a separate cover.

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7 Behavioural Support

Employment of abehavioural supportperson to assistpractices in directingpatients to the mostappropriateresources

CMHTAccess GroupLHBCluster

31/3/17 Links With SA2 / SA4 Exploring a HCA level role that will be

trained by and have links with the

Community Mental Health team but funded

by the Cluster.

They would be there as a first or referred

port of call for patients who need some

handholding or signposting.

We are aware that this model has worked

well in ABM UHB.

We are awaiting a job description to enable

full castings to be provided.

Further discussion about the number of

support workers and distribution is

required.

8 Vision Anywhere

Emis Mobile

Improve patientsafety and increaseefficiency byproviding a mobilesolution enablingGPs to access livepatient data.

LhbClusterINPSEMISNWIS

31/3/16 Link with SA2 SA5 SA8

Safer for patients

More efficient for GPs &

practice staff

Improving access and quality for patients by

ensuring that accurate ‘live’ patient data is

available during home visits and nursing

home rounds.

Currently in procurement discussion with

LHB – This has been added as a contingency

plan for the cluster

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9 Wound Care LHBKHHPCluster Hub

31/3/16 Link with SA2 SA3

Improved access

Improved patient

outcomes

Another contingency plan – centralise

wound care service to assist practices in

managing complex wounds. Envisaged

outcome improved access and link with

welsh wound care better outcomes.

Further discussion with LHB and other

clusters as sensible to link together with this

plan.

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Strategic Aim 10: Other Locality issues



1

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Summary / Timetable -

StrategicAim

Topic CompletionDate

Action By: - Status Comments RAGRating

SA1 -1 PopulationNeeds

30/9/15 Cluster Completed New website used – Pyramid data

SA1 -2 Informationrequirements

30/9/15 Cluster Completed New website used – Pyramid data – tablesinserted into plan

SA1- 3 ServiceDevelopmentneeds

30/4/15 Cluster Completed

SA1-5 Screening 30/9/15 Cluster Completed See SA6

SA4-2 A&E 31/3/15 Cluster Completed Link with Access Group

SA3-3 Alcohol / MH 31/3/15 3RD Sector Completed CVD Risk project implementation

SA3-4 HealthPromotion

31/3/15 Cluster Completed Part of SA9-4 – CVD Risk

SA6-1 ScreeningServices

31/03/15 Cluster Completed Initial engagement completed – now in actionphase

SA6-2 RCGP ModulePancreaticcancer

31/03/15 Cluster Completed Completed by all practices

SA9-2 (a) Access LES 31/3/15 Cluster Completed LES implemented and position on Access groupfor cluster established

SA9-2 (b) DNA 31/3/15 Cluster Completed DNA policy agreed and implemented acrosscluster and wider Cwm Taf

SA9-5 (C) Pathology 31/3/16 Cluster Completed Currently no desire to increase use of Labeltrace – this may change when NWIS implementGPTR Solutions via WCCG

SA1 – 4 Influenza 31/03/16 Cluster /LHB Ongoing Improvement in 2014/15 – needs to be

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Uptake continued

SA2 – 1 Access Group 31/3/16 LHB/CHC/AccessGroup

OngoingCluster representative at Access Meetings

SA2-2 Activity Data 31/3/16 PracticesOngoing

Cluster practices continue to send activity data

SA2-3 Activity Data 31/3/16 PracticesOngoing

Review activity data – Shared by LHB

SA2-4 (a) Workforce 31/3/16 WG / Practices Planned Further meeting with WG planned for early2016

SA2 -5 InappropriateWorkload

31/3/16 LHB/LMC/Cluster

Ongoing Continue to share inappropriate requests withMedical Director – return to originator.Support around path results and other areasfrom LMC & GPC Wales

SA5-1 EOL Care 31/03/16 Cluster Ongoing Support / co-ordination between Dr Lewis andcluster to continue

SA5-2 EOL Care 31/03/16 Cluster Ongoing EOL Templates distributed including JIC Boxinformation

SA5-3 EOL Care 31/03/16 Cluster Ongoing Primary Care portal populated

SA6-3(a) Rapid Access 31/03/16 Cluster Ongoing Portfolio available on primary care portal –additional detail required and link to Taff Elycluster who are creating electronic templatesfor emis and vision practices

SA7-1 Start/Stop 31/3/16 Cluster Planned Evaluation required

SA9-3 (a) Awareness 31/3/16 Cluster Ongoing Improve awareness of Services / Creation of

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directory – link with SA9(7) – Behaviouralsupport and CMHT

SA9-3(b) Resources 31/3/16 Cluster Ongoing Cluster to discuss sharing screening data forbest practice – share resources to increaseuptake.

SA9-3(c) Resources 31/3/16 Cluster Ongoing Review of Questionnaire to be undertaken toidentify resources available within group whichwould be appropriate for sharing

SA9-3(d) Cardiology 31/3/16 Cluster Ongoing Arrange for cardiology consultant to attendcluster meetings - link with additional fundingavailable for cluster hub model for cardiologyservices

SA9-5 (a) DAL 31/3/16 Cluster Lead Ongoing Letter sent to Medical Director – position veryclear – cluster and wider cluster groups workingtogether to improve quality and governance –links with EDAL project board, LMC established.

SA9-5 (b) A&E 31/3/16 Cluster Lead Ongoing Letter sent to Medical Director – position veryclear – cluster and wider cluster groups workingtogether to improve quality and governance –links with EDAL project board, LMC established

SA9-5 (b) A&E 31/3/16 Cluster Lead Ongoing Letter sent to Medical Director – position veryclear – cluster and wider cluster groups workingtogether to improve quality and governance –links with EDAL project board, LMC established.Many practices in cluster now receivingelectronic A&E letters. We need to ensure thiswill be available for all practices

SA9-5 (C) Pathology 31/3/16 Cluster Ongoing Link with LMC pathology Group to ensurecluster representation – Zero tolerance plans

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established by LHB – Link with cluster to ensureintroduction benefits all and is not detrimentalto practices. Principle established that this mustbe a two way process – practices must ensurequality of data submitted on forms – agreementon tick box to identify district nurse and othernon practice originators.

SA6-3(b) Rapid Access 31/12/15 Cluster Planned Collection of data ongoing – review to takeplace early 2016

SA3-1 Email 31/3/16 LHB Planned /Ongoing

Discussion around extending use of email foradvice

SA3-2 ManagementPlans

31/3/16 LHB Planned Implementation to be agreed – links with TaffEly cluster work for templates / guidelines

SA4-1 OOH Redesign 31/3/16 Cluster / LHB Planned Engage with LHB to plan OOH redesign –progress in respect of plan – links with accessgroup where cluster is represented – OOHmanagement on group also

SA4-3 NetworkServices

31/3/16 LHB/Cluster Ongoing Further enhance network services / shareresources – Cluster Hub ideas to be discussedwith LHB - Initially two – Wound Care serviceand Cardiology hub.

SA4-4 Community co-ordinators / 3rd

Sector

31/3/16 LHB/MTCBC/Cluster/3rd Sector

Ongoing Continued use of Co-ordinator role andenhancement of provision further than 31/3/15(end date) – project has been extended – linkrequired with SA9 (7) Behavioural supportworker (s)

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SA7-2 Collaborationwith LHBPrescribingteam

31/3/16 –ongoing

Cluster / LHB Ongoing Integration of prescribing team into clustergroup membership – Review of Rhondda andTaff cluster who are employing pharmacymember as part of cluster plan - revieweffectiveness with a view to implementing ifproves successful

SA9-2 (c) Education 31/3/16 Cluster /LHB /CHC

Planned Engagement with patient groups / access groupin respect of patient education – Links with SA9(6) – Web GP will provide a significant elementof patient education.

SA9-3(c) Resources 31/3/16 Cluster Ongoing Following analysis of Questionnaire - resourcesto be identified to support work in primary care– shift of resources from secondary care provingproblematic EG NOAC – Link with Dr KevinThomas and LMC who are currently looking intothis.

SA9-6 Web GP 31/3/16 Cluster / LHB /Hurley Group

Ongoing Orders placed – installation prior to 31/12/15with an initial 3 month evaluation / promotion –then 9 months to 31/12/16 – Links with SA2

SA9-7 BehaviouralSupport

31/3/16 Cluster / LHB /cmht

Ongoing Job description to be agreed and recruitmentwill begin asap – appointment prior to 1.1.16intended – Links with SA2 / SA4

SA9-8 VisionAnywhere

31/3/16 Cluster / Vision/ Emis / LHB

Ongoing Contingency 1 – As cluster funding will not befully utilised due to delays with recruitment andallocation of funding for Web GP , plan to alignwith other clusters and purchase Hardware andsoftware to enable remote ‘live’ patient data –Links with SA2 SA5 SA8

SA9-9 Wound Care 31/3/16 Cluster / LHB Ongoing Contingency 2 – As cluster funding will not befully utilised due to delays with recruitment and

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allocation of funding for a specialist Wound Careservice from the Cluster Hub KHHP. This alignswith the other cluster plans for a hub woundcare service and is intended to alleviatepressure from Practice Nurses – Links with SA2SA3

SA2-4 (b) Workforce 31/3/17 Cluster / WG /LHB

Ongoing Long Term planning to attract Gp’s to Merthyr

SA9-1 Recruitment 31/3/17 See SA2-4(b) Ongoing Long Term Planning for recruitment

SA9-5 (a) DAL 31/3/17 Cluster Lead Ongoing Electronic DAL – progressing very well – will beestablished by 31/12/15 in a pilot phase –evaluation and implementation should becompleted by 31/3/16

SA9-4 CHD Risk 31/03/17 Cluster /LHB /Systemsuppliers

Ongoing Primary Care development manager appointedto work with practices – evaluation ongoing

Project to be funded from additional resourcesoutside of that of the cluster

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