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Cynon Cluster GP Network Action Plan 2014-17

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CYNON NETWORK CLUSTER ACTION PLAN 2014-17

This plan has been developed by the following 11 practices which operate in the Cynon Cluster Area, through facilitated discussion with the Local Medical

Director and Primary care LHB Locality Management :-

• Hirwaun Surgery

• The Foundry Town Clinic and Aberaman Surgery

• St John’s Medical Practice

• Park Surgery

• Maendy Place and Abercwmboi Surgery

• Cwmaman and Cwmbach Surgery

• Hillcrest Surgery

• Cynon Vale medical Practice (Cynon view and Cardiff rd surgeries)

• Rhos House Surgery

• Penrhiwceiber Surgery

• Abercynon Health Centre

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The Plan The plan has been informed by the practice development plans produced by practices; public health information on key health needs within the

area; information provided by Cwm Taf uHB re current activity/referral patterns; an understanding of our localities baseline services (current service

provision) and identification of potential service provision unmet needs. The plan also embraces key UHB priorities for the next three years. The plan details

cluster objectives for years 1-3 (2014/2017) that have been agreed by consensus across practices, providing where relevant background to current position,

planned objectives and outcomes and actions required to deliver improvements. The plan is by its very nature fluid /flexible and evolving over the next 3

years the plan itself will be reviewed and updated in response to changes in cluster planning. The RAG rating score indicates progress against planned action

(Red-future work, Amber- in progress, Green- completed). A number of key principles underpin the plan:

• Management of variation/reducing harm/sharing good practice: in acknowledgement of the fact that healthcare must be delivered on the basis of

safety, effectiveness and efficiency, the practices have considered and analysed variation in performance and where appropriate have considered

steps by which to map standardise practice based on clinical guidelines.

• Maximising use of Local Cluster Resources: practices have taken into account the capacity, capability and expertise that exists within primary care,

community services and voluntary/third sector services to deliver more care closer to home and reduce unnecessary demands within the acute care

services.

• Promoting integration/better use of health, social care and third sector services to meet local needs: practices have considered current

arrangements/links with RCT Council and the voluntary sector and will also consider any action plans from stakeholders that evolve over the 3 year

cycle of this plan.

• Considering and Embedding New Approaches to Delivering Primary Care: this includes increased use of technology, new roles and service models

considering an embedding new approaches to delivering primary care: this includes increased use of technology new roles

• Maximising opportunities for patient participation: this includes consideration of models of good practice that exist with within/locality/cluster

and nationally and within the rest of the UK.

• Maximising opportunities for more efficient and effective use of resources: this includes consideration of current resources, opportunities to

utilise and current and new services more efficiently and effectively

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Additional contributors to the plan/potential evolving contributors to the plan subject to evolution of plan

• Health and social care facilitators.

• Primary care practice managers.

• Practice Nursing and allied health professions representatives.

• Local voluntary sector providers and third sector.

• Relevant secondary care consultants e.g. potentially diabetic and cardiology secondary care teams.

• Prescribing advisers.

• Potential educator partners including third sector TEDS for brief alcohol intervention training, podiatry for foot assessment training for Health careassistants.

• Primary Care Support Unit Nursing advisory expertise/local university school of health care re Health care assistant initiatives and informingcommunity care planning e.g. diabetes.

• Acknowledgements SW Cardiff cluster plan authors re layout.

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

Outline of Cluster Population Profile

The Cwm Taf uHB population estimate in 2007 was 289.4 thousand with 233.7 thousand in the RCT locality .Approximately 10% of the population of Wales

live within Cwm Taf LHB,the LHb locality is the second smallest in Wales but the second most densely populated area (Cardiff is first) The Cynon Valley in

recent CMO for Wales reports and based on recent Public Health Wales data is an area of high social deprivation .We also due to our high deprivation status

have high rates of mental health issues long term disability/morbidity ,a high rate of poverty/benefits uptake and high rates of chronic illness from legacy

heavy industry particularly mining Recent CMO reports have indicated a low level of car ownership with an obvious impact on service planning. The

neighbourhood has a higher proportion of persons aged 0-15 and 30-44 than the Cardiff average. Public Health Wales indicate that our area consists mainly

of most deprived and next most deprived classifications.34% of Cwm Taf as a whole is designated most deprived on the Welsh Index Multiple Deprivation

Scale (WIMD).Within our cluster this figure rises to 38.2% in the northern Cynon Valley. The Public Health Observatory for Wales publications in the field of

child health highlight for our locality that: our rate of low birth weights is significantly higher than the welsh average 1 in 15 cf all Wales 1 in 18, That the %

of children (<20 years old) living in poverty is 26.6% cf all Wales 22.2%.Particularly relevant to our area is the identification of Penywaun as a particular hot

spot for children living in poverty in Wales by the public health observatory. All Wales public health observatory data on levels of unemployment in the 16-

24 yr old age group show a rate of 18.4% fro CwmTaf cf all Wales 15.7%.With regard to our older population the data for those living alone at 43.9% is near

to the all Wales average of 43%.Our localities Black and ethnicity population data suggest an LHB rate of 1.1% lower than the all Wales average of 2.1 %

which in turn is lower than England’s data. Finally Public Health Wales Data indicates that for Cwm Taf’s population as a whole, life expectancy is reduced

by 1.5 years for males cf the welsh national average i.e. 75.5yrs as opposed to 77 years old. Further in the 2 WIMD classifications of most deprived and next

deprived (the 2 majority classifications for our cluster area) this falls to 71.5 and 73 years respectively .Our locality has in recent years seen and will see

several large scale residential developments with obvious impacts on primary care provision planning. Recent public health presentations to our locality

identify several top challenges to morbidity and mortality:

• Malignancy (Cancer survival levels in Cwm Taf are amongst the lowest in Wales)

• Cardiovascular disease/circulatory disease

• Smoking levels

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Subsequent review of Welsh statistics highlighted further areas of concern (see next page)

Data from the combined 2012-2013 Welsh Health Survey show that:

• 29% of adults in Cwm Taf reported binge drinking on at least one day in the past week, compared to 26% for the whole of Wales;

• 25% of adults in Cwm Taf reported being a current smoker with 21% in Wales reported being a current smoker;

• 27% of adults in Cwm Taf did at least 30 minutes of at least moderate intensity physical activity on five or more days a week compared with an all-Wales figure of 29%, further those in CwmTaf reporting that they did no physical exercise in the survey was 38% compared with an all Wales figureof 34%.Those respondents classified as overweight or obese in Cwm Taf were 63% the all Wales average was 58%.

• 27% of adults in Cwm Taf had eaten five or more portions of fruit or vegetables on the day prior to the survey date compared to 33% for the wholeof Wales.

• CwmTaf overall had statistically highlighted higher levels of mental illness Respiratory illness Hypertension arthritis and diabetes mellitus in thecombined 21012-2013 Welsh Health Survey compared with Cardiff and Vale UHB.

References: Public Health Wales’s presentations to Cwm Taf locality GP’s (power point), Public Health Wales Observatory data web site, Health of

Young Children and Young People Wales Report.Welsh Health survey reports.

The areas of concern identified by the cluster through this analysis of our cluster populations health status and needs e.g. OBESITY/OVER WEIGHT

STATUS, BINGE DRINKING/PROBLEMATIC ALCOHOL USAGE, HIGHER RATES OF CURRENT SMOKERS & its relationship to higher levels of respiratory illness

in our cluster, LOWER LEVELS OF PHYSICAL EXERTION will be areas that we will initially address in our action plan (detailed in later tabulated form)

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No Objective Keypartners

completionby: -

Outcome forpatients

Progress to Date RAGRating

1 To review theneeds of thepopulationusingavailable data

Local PublicHealthTeamPublicHealthObservatory

November2014

To ensure thatservices aredevelopedaccording to localneed

Analysis complete and outlined in detailabove in document free text ,subsequentlyused by cluster to develop action planningon key priorities see above text

1a ObesityScopingmeasures toreduce thelevels ofobesity in ourcluster

Lead GP +PracticeManagerXxx SurgeryPrimaryCareMedicalDirectorateScopingmeetings?3rd sector?Localmedicaldirector?Exercise onprescription? Primarycaredietician??New LeisureCentreAberdare

Lead Gp andPracticeManagerxxx Surgery

Date April2017

Effectiveidentification of andtargeting of existinghealth promotion forweight reduction atthose identified asobese

xxx surgery to scope this area e.g. .potentialareas; the prime opportunity re new sportscentre in development; taking forwardsuggestions from Dr Rhodri Martin’s recentpresentation at LHB CPD event discussingNERS national exercise referral scheme;Possible LHB funding for lifestyle screening(BMI Blood Pressure Lipid and Glucose) viahealthcare assistants allowing targeting ofhealth promotion. This latter developmentwould also facilitate, Identification ofcardiovascular risk to allow targeting of highrisk individuals. Update November 2015XXX surgery engaged with pilot publichealth scheme to identify and supportpatients at risk to make lifestyle changes.?Ultimately whole cluster funded.

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1bEffectivelinking with3rd Sector

XXXSurgery

IntermediateCare Fund(ICF)communityco-ordinators

Park Surgery

Date May2015

Engaging with the3rd sector to seekfunding forinnovative schemesto improve patientcare/public healthmeasures/socialwellbeing

XX Surgery team to scope and report tocluster May2015 provisional findings clusterto then consider how to utilise funding e.g.possible funding practice public healthTVdisplays. Update November 2015progress cluster interaction with carersforum and involvement in 2016 carers roadshow event

1c

Address Five

Key lifestyle

behaviours of

the

population of

CYNON

VALLEY

CLUSTER

effecting the

clusters

population

health:

smoking,

alcohol,

physical

activity, diet

and

immunisation

Public

Health

Wales

Practice

Staff

Practice

managers

All clusterpractices

November2016

Staff awareness of

key public health

messages and

signposting patients

to helpful resources

All relevant Practice staff to undertakeMaking Every Contact Count (2.5 hours)training

PLAN contact Public Health Wales re thistraining supply details to individual practicemanagers to co-ordinate delivery in thecluster.FOR DETAILS:http://www.wales.nhs.uk/sitesplus/888/page/65550CONTACT:POD@Wales.nhs.uk

UPDATE NOVEMBER 2015 yet to beaddressed.

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1d OlderPeople/Management ofGeneralFrailty/MaintainingIndependentliving

Care &RepairRhonddaCynon TafLtd

April 2017 Maintainindependence in asafe homeenvironment withaccess to reliableadvice andmaintenance for theolder members ofour cluster

Care and Repair (Care & Repair Rhondda

Cynon Taf Ltd )- Healthy at Home Project.

This all Wales project has a RCT regional

team the all Wales funded scheme offers

individuals (at 75 years) in non local

authority accommodation the specialist

help with repairs, adaptations and home

maintenance. With several aspects to the

scheme including urgent adaptations to

facilitate hospital discharge. Overall this

aims to maintain independent at home and

via adaption’s minimise falls and self care

difficulties. Gp’s can refer to this service.

PLAN INVITE CARE AND REPAIR TO

CLUSTER MEETING.AIM PRACTICES TO

ENGAGE WITH SCHEME Care

& Repair Rhondda Cynon Taf Ltd

38-39 Duffryn Street

Ferndale

Rhondda

CF43 4ER

Telephone: 01443 755696

Email: enquiries@careandrepair-rct.org.uk

UPDATE NOVEMBER 2015 Cluster aware

of this service formal meeting yet to be

arranged

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1e Drug &AlcoholServiceimprovementsIncreasedCDAT and 3rd

sectorpartnersability to takeon drug andalcoholmisuseclients byconsideringan innovativeLES alreadysuccessfullypiloted andrunning inCardiff andthe Vale LHB

1)PrimaryCareDirectorateCDATdirectorateandinterestedGP’s willneed toliaise-potential forsuch a LES

FORDISCUSSIONAT CLUSTERMEETING

WILL ONLYPROCEED IFCLUSTERSCOPINGRESULTS INCLUSTERAGREEMENT

Proposed outcomefor patients a rapidresponse moreequitable service todrug and alcoholmisuse sufferers,satisfying thestrategic aim of careclose to home

WILL ONLY PROCEED IF CLUSTERSCOPING SUPPORTIVE-provisional suggestion for presentation toLHB re potential for further development.LES to promote stable maintenance drugmisuse clients(even if registered with GP’swithout an interest in drug misuse) beingtransferred to local GP’s with a specialinterest in drug misuse freeing up follow upappointments within the CDAT serviceincreasing new client capacity hopefully.Primary Care Directorate CDATdirectorate and interested GP’s will needto liaise-potential for a primary CareManager and CDAT manager and interestedGP’s+ LMC to form a scoping group to takethis forward .Including adequately fundingany LES assistance in obtaining RCGP drugmisuse certificates part 1 and 2 if neededand effective mentoring and support forreturning chaotic clients back to CDAT. Alsosupport to practices to provide cover forcore GP work or GP’s engaging in this workinstead. UPDATE NOVEMBER 2015 NOSUPPORT RE GP TIME RESOURCEISSUES

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1f ImproveHarmfulAlcoholconsumptionwithin ourlocal networkarea byscoping BriefAlcoholinterventionTraining forour cluster

1)PrimaryCareDirectorate iffunding issues2)TEDS/CDAT3)XXXX ClinicGp/practicemanager lead4)practicemanagers

JULY 2015

xxx ClinicGp lead andpracticemanager

All clusterpracticemanagers

Improved rates ofharmful alcoholconsumption with inour clusterpopulation at lowcost to the LHB withevidencehighlighting theeffectiveness ofBrief Alcoholinterventions.Hopefully resultingin decreasedmorbidity andmortality fromalcohol relatedillness

xxxx Clinic Practice have liaised withTEDS they could provide this training(i.e.third sector) next step is to discuss this atcluster meeting, and consider delivery ?atcluster meeting ?individual/groups ofpractices whole practice team andschedule dates for its delivery. UPDATENOVEMBER 2015,achieved October 2015third sector and NHS educational event onbrief interventions Heol Keir Hardie HealthPark organised by PUBLIC HEALTHmembers of cluster DAPSA and voluntaryagenices attended.GP’s Practice managersPractice nurses Health care assistantsreceptionists in attendance

1g Improvesmokingcessationrates withinour localnetwork areaby scoping e-referralsystem, forS.C.W(SmokingCessationWales)

1)SmokingCessationWales2)XXX Clinic3) IT supportto bediscussed4)all practicemanagers

October 2015 Improved uptake ofSmoking CessationWales services withhopefully increasedQuit rates with longterm morbidity andmortality benefits.Relevant re CwmTaf’s high rates ofcancermorbidity/mortalityas well as CHD andCOPD.

Cluster meeting with Smoking CessationWales provisional plan:Cluster to designate a read code that can

be searched on a monthly basis in eachpractice for external referral to SCW+/-Liaise with S.C.W at cluster re providingeach practice with a spreadsheet to send ineach month that practices e-referrals withconsent from patient for referral format.Practice to send referrals to SCW by emailto contact patient directly.ACHIEVEDOCTOBER 2015

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1h ImprovesmokingcessationratesAndeffectivelymeasuringcessation byprovision ofco monitorsto allpractices(equitableprovision)

1)SmokingCessationWales

2) FoundryTown Clinic

October 2015

XXXClinicGp lead andpracticemanager

All clusterpracticemanagers

Improvement inquality of practicebased smokingcessation servicestranslating intobetter rates ofsmoking cessation.Best practice is comonitormeasurement ofcessation not allpractices have a COmonitor

Best practice in a smoking cessationservice is CO monitoring of patientAs in aim 1g above at cluster meeting withSmoking Cessation Wales to scopeprovision of CO monitors to practices in thecluster without current Carbon Monoxidebreath monitors? SCW funding? LHBFunding.-next step is meeting with SCW.UPDATE NOVEMBER 2015 followingmeeting proposal shelved refocus on e-referral to Stop Smoking Wales andsignpost to community pharmacy funded todirectly provide smoking cessationtreatment

1i Further areasmay beidentifiedduring 3 yearcycle ofcluster plan

To beconsidered bythe cluster iftime/resourcesallow

Adhoc/notime scale

Improvements incare delivered

For example:-flu/immunisation good practice examplesin cluster share this-Potential RCGP dementia practice basedall staff training.-Domestic abuse 3rd sector state agenciesimprovements in interactions/advertisinghelp availability

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Strategic Aim 2: To ensure Sustainability of Core GP Services and Access Arrangements that Meet

Reasonable Need (including new approaches to Delivering Primary Care)

Cluster practice members have considered this area already in their individual Practice Development Plans, with a range of access and sustainability issues

considered including number of GP appointments provided , hours of services, inappropriate use of A+E, unscheduled admissions +GP Out of Hours

services by patients, DNA rates, Promoting use of technology such as My Health on Line/Texts messaging etc. Further WAG briefing on primary care clusters

also advocates use of new technology including ultimately via My Health patient access to their records online repeat prescription ordering, online

appointment booking as well as new technologies for consultation, practices are at various stages with these developments within the cluster. In addition

to practices individual development plans in this area those areas of common interest across the Cluster are identified in this section.

No Objective Keypartners

Forcompletionby: -

Outcome forpatients

Progress to Date RAG Rating

2a I.T. Greater

use of My

Health Online

to improve

appointment

access; and

prescription

services and

satisfy WAG

planning

IndividualclusterPracticeManagers

August 2016 In the cluster there

is varying patient

+practice uptake of

technology to

improve access

Promotion of My

Health Online to

improve

appointment

access; and

prescription services

and drive forward

WAG planning

Individual practices are engagingwith the process and promotingparticularly repeat prescriptionmanagement , plan is to promotethis and ultimately consider practiceappointment management re thisprocess

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2b Establishlocal datacollectionsystems tomonitor trend

NWIS LHB LHB TODETERMINE

Capacity moreeffectively matchedto local demand

For example, Agreed data extractionvia Audit + to give comparative andtrend data to inform local planning-

Action via national DQS group

2c Identify wastein localsystems

LHB LHB TODETERMINE

Release morecapacity for patientcare

For action via LHB ongoingidentification of waste and liaisonwith primary/secondary care/LMC/third sector to deliverimprovements/efficiencies. Clusterto be briefed and consider measuresit can support if applicable

2d To developlocalworkforcedevelopmentplans

LHB LHB TODETERMINE

Servicemodernisation tomeet changingneedsEnsuresustainability oflocal services

Within the cluster there areincreasing reports of recruitmentdifficulties with a GP retirement timebomb. Previous pro-active LHB workhas included the establishment ofthe PCSU leading to some newGMS partners in the cluster howeverthe PCSU as well as individualpractices are now experiencingrecruitment and retention problemsthis area would benefit fromstrategic review:Actions

• Establish data collection tomonitor scale of difficulty andtrend

• Add issue to LHB RiskRegister

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2e InterfaceLimited use oftechnology tosupportinterfacebetweenprimary andsecondarycare Establishmore virtualconsultationprocesseswithSecondaryCare Services

Medicine

Clinical

Board/

LHB/Specifi

c

Directorate.

LHB TO

CONSIDER

TAKING THIS

FORWARD

LHB TODETERMINE

Maximiseopportunities toimprove interfacewith secondary carespecialist

We already have a e-mail cardiologyconsultant led Q&A service for GP’swhich often provides the expertise toavoid referral/further investigation.This beacon service could beexpanded including designatedconsultants per practice/cluster. Adirectory would need to be creatednhs email address coverage wouldneed to be optimised ,e-mailreceipts would be required and aclinical governance robust systemwould need to be in place

2f Infrastructure Cynonlocalitycurrent andfuturedevelopmentis leading tosignificanthousingdevelopmentsin the Cluster

LHB toconsidertaking thisforward

NHSWALESINFORMATICSSERVICEDATA

PUBLICHEALTHWALESDATA

LHB TODETERMINE

For our clusterpatient populationwe need to maintainhigh levels ofaccess toappropriate healthcare professionals.

The LHB is already actively planningfor the future the following areasneed addressing/scoping:

• increase in cluster population• Scope list sizes per practice?

Allocation rates? explicit safemaximal lists sizes?

• Primary care health teampremises development(theLHB in partnership with theprivate sector/GP’s hasexcelled previously with this?now needs review)

• Review Primary Care HealthTeams personnel needsbetween 2014/7 with thepopulation increases.

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Strategic Aim 3: Planned Care- to ensure that patient’s needs are met through prudent care pathways,

facilitating rapid, accurate diagnosis and management and minimising waste and harm.

No Objective Keypartners

Forcompletionby: -

Outcome forpatients

Progress to Date RAGRating

3a Joint and Soft

Tissue

Injections

Inequitable

service

provision

across cluster

e.g. types of

injection

offered/ skill

sets in each

practice.

Cwm TafGP’s withthe requiredskill set

PrimaryCareDirectorateLHB

IndividualPracticeManagers

April 2016 Local rapidprovision ofprocedure withoutthe need to attendhospital freeing upcapacity insecondary care inrheumatology andorthopaedics

The LHB have already identifiedpractitioners willing to engage in this serviceand circulated a list of these practices. Thecluster proposes that this list be re-circulated to all cluster practice managersand that the practice managers then remindall staff re the availability of this service toensure it is utilised.In addition to joint injections these practicesalso provide a specified list of minor surgicalprocedures which again could be re-iteratedby the LHB and individual practicemanagers.

3b Mirena/coil/Nexaploninequitableaccess forpatients’ in aGP setting inour cluster

TBC TBC Local provision ofservice for thepatient freeing upcommunitygynaecologyservices/familyplanning /secondarycare gynaecologyservices

Potential future scoping by the cluster of thisservice ?sustainability ?resources ONLY TOPROCEED IF CLUSTER SUPPORTUPDATE NOVEMBER 2015 NETWORKEDSERVICE NOT POSSIBLE RE LIMITEDGP TIME AVAILABILITY

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3c Local Pipellebiopsyservice

scopeinterestedparties

TBC Local Provision ofservice at practiceswith the appropriateskill set for patients

Cluster discussion + RCGP Walesguidance+ local clinical directorsindicates a clinical governance issue thecluster has withdrawn this proposal.

3d Developmentof a systemto remindGPs ofavailablepathways atthe point ofdiagnosisperhapsavoidingreferral/improving referralprogression

TBCLead GP

LHB andindividualdirectorates

Vision/otherGP softwareproviders

Provision ofvalidated/agreed referralpathways inelectronicformat

TBC?LHB

RESOURCES

Local care perhapswithout need foronward referral, or ifreferred a morerapid progressionthrough secondarycare as pathwayfollowed and preoutpatient tests andtherapy trialsalready complete.

Development of a system to remind GPs ofavailable pathways at the point of referral.The Vision system has the ability to haveGuidelines triggered by read codes. Thiswould require co-ordination and funding.There are many pathways in thedirectorates e.g. acne vulgaris, prostatismetc which are difficult for the practitioner toeasily refer to or to be aware of revisions topathways. THIS IS A LARGE AREA OFWORK AND WOULD REQUIRE A LHBLEAD. UPDATE NOVEMBER 2015 TAFELY Cluster are developing this we willliaise with them re CYNON adoption

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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 Keypartners

Forcompletionby: -

Outcome forpatients

Progress to Date RAGRating

4a DentalPatients oftenaccess GP’sto assist withurgent dentalcomplaints.Can this beimproved on?

LHB

DentalDirectorate/local dentalsurgeries/University ofCardiffDentalschool

IndividualPracticeManagers

TBC by LHB To ensure patientsaccess rightcare/right time/rightplace/one stop. Withless frustration forthe patient andresource savings forGP care.

The LHB has been pro-active in addressingNHS dental provision, e.g. help line tofacilitate patients to find a NHSdentist/emergency dentist, innovative NHSdental care provision with University ofWales co-operation for dental hubs includingin Porth etc. How can we build upon this?

• LHB to re-circulate material to Gp’sand dentists advertising helpline tofind a regular/emergency NHS dentistand/or HUB access. Practicemanagers to arrange display insurgery of these contacts and remindstaff of provision.

• For those struggling to travel (low carownership in our cluster) Potentialfuture dental scheme for localpractitioners along the lines of thePEARS for opticians or utilise ourdental hubs better by addressingtransportation issues and advertisethe transport(?pre-existing) anddental hubs together(LHB)

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.4b

Access toSpecialistOpinionAs previouslyoutlinedimprovedaccess tosecondarycareconsultantsvia e-mailmay avoidemergencyadmission

Previouslyoutlined incluster planfor actionbyLHB/individual medicaldirectorates/GPlead/TRIP.(turningresearchintopractice)LHB TOSCOPETHIS

TBC Care deliveredclose to home andavoidance ofadmission withalternative treatmentoptions or outpatientmanagementinstead

As outlined before cardiology email serviceup and running working well

Re Strategic Aim 4:

All Cynon cluster practices are engaged with care pathways aimed at reducing emergency and elective unnecessary referrals to

Secondary Care/attendances at the Emergency Care Centre/Clinical decisions units. This follows on from prior annual Qof work.

The above suggestions are in addition to that ongoing work ,4b cross references a number of actions from section 2.

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

No Objective Keypartners

Forcompletionby: -

Outcome forpatients

Progress to Date RAGRating

5a All Practicesin the Clusterto analysetheir palliativecarepresentations2014-2015QOF yearanddisseminatelessons learntandeducationalneedsidentified

LHB

IndividualClusterPrimaryCarePracticeTeams

April 2015 Lessons learnt frompractice analysis ofcases of palliativecare/end of life careanalysed duringQOF year 2014-2015 fed back intoservicedevelopment andeducationaldevelopment whenrequired

All Practices in the Cluster engaged on inpractice QP work on SEA of end of life carepresentations as per nationally agreed QPwork. Update November 2015 achieved for2014-2015 ongoing for 2015-2016

5b Considereffectiveanalysis atpractice levelof end of lifecare andpalliative careregisters

Macmillanlocal charityfundedresources

ClusterPracticesLHBresources

To bediscussedfurther bycluster

Improvements toGP co-ordination ofpalliative care.Improvedidentification ofpatients by surprisequestion foradvanced careplanning (ACP)

Initial presentation already completed byMacmillan GP with a special interest inpalliative care and nurse to a clustermeeting. Offering assistance (limited)andtools for effective identification, registrationand audit of palliative care registersCluster members to discuss this furtherthrough out the three year life of this clusterplan and determine future engagement

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5cContinueQOF 2014-2015individualclustermemberspracticepalliative careteammeetings

IndividualClusterPrimaryCarePracticeTeamsDistrictNursingRepresentatives andPalliativecare teamrepresentatives

Ongoingindividualpractice work

Case reviewpatients identifyproactive end of lifeplanning forindividuals andadvice refuture/additionalmanagement of theindividual. Lessonslearned forindividual patientswill benefit andinform futurepatients care.

Continues in progress every QOF year.Update November 2015 achieved 2014-2015 ongoing 2015-2016.

Strategic Aim 5: Improving the delivery of end of life care continued see above

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

No Objective Keypartners

Forcompletionby: -

Outcome forpatients

Progress to Date RAGRating

6a All Practicesin the Clusterto analysetheir cancerpresentations2014-2015QOF yearanddisseminatelessons learntandeducationalneedsidentified

LHB

ClusterGP’s andCLUSTERprimaryCare HealthTeams

April 2015 Lessons learnt frompractice analysis ofcases of canceranalysed duringQOF year 2014-2015 fed back intoservicedevelopment andeducationaldevelopment whenrequired

All Practices in the Cluster engaged on inpractice QP work on SEA of cancerpresentations as per nationally agreed QPwork. Update November 2015 achieved for2014-2015 new criteria for 2015-2016 workin progress.

6b Education onsigns andsymptoms ofCancers andappropriateuse ofrequestingTumourMarkers

xxx MedicalCentre(Dr xx +PracticeManager)xxxx+xxxxxxSurgery (Drxx andpracticemanager

Provisionalreport toCluster ofprogress May2015Completionby December2015

Improvement onearly cancerdiagnosis with aview to curativetreatment ratherthan palliativeoutcomes.

Key Partners already teamed up to scopeeducational opportunities for the clustermembers including an initial specific aim ofaddressing appropriate use of tumourmarkers and their roles in cancer specificdiagnosis. Update November 2015 onepractice has attended and is to disseminatean educational update re tumour markers,one buddy practice has attended acolorectal screening update with a potentiallink in to work done by Merthyr cluster toimprove patient participation in thisscreening.

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Strategic Aim 7: Minimising the risk of poly-pharmacy

No Objective Keypartners

Forcompletionby: -

Outcome forpatients

Progress to Date RAGRating

7a Identify and

report the

number /% of

patients aged

86years or

more

receiving 6 or

more

medications

Lead GP ineach clusterpractice

LHBpharmacyadvisoryteam

April 2015 Decrease thepotential formedicationinteractions/morbidityby reviewing themedications currentlyprescribed againstpatients currentmedical conditionsand changes incondition relatedprescribingpractice/guidelinesi.e. optimisemedication andcondition.

Undertake face to face medication reviewsusing the NO TEARS approach or similartool for at least 60% of the cohort definedabove. Use the agreed read code forpolypharmacy review. All practices in thecluster are committed to completion of thiswork by April 2015.Update November 2015Completed for April 2015.Criteria altered for2015-2016 but in progress once more.

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

No Objective Keypartners

Forcompletionby: -

Outcome forpatients

Progress to Date RAGRating

8a Engage witha robustvalidatedclinicalgovernanceprocessspecificallydesigned withClusterplanning inmind

Individualclusterpractices

PublicHealthWales

April 2016(manypracticeshavecompletedthis tool for2014-2015already)

Allmeasures/proposalsoutlined andassessed in avalidated all walesclinical governancetool

Clinical Governance Practice SelfAssessment Tool(CGPSAT) each individual cluster memberwill be entering their areas of responsibilityinto their PDP’s (practice developmentplans) and CGPSAT.Aspiration level 4/5 maturity on CGPSAT recluster network work. Update November2015,CGPSAT 2014-2015 completed, 2015-2016 in progress.

8b Continue toengage withstatutoryemergingclinicalgovernanceobligations

HealthInspectionWales

Ongoingrollingprogram ofinspections.

Clinical governanceoversight of theirlocal practice

Already some of the clusters practices haveengaged with this process taking part in theinitial pilot inspection tranche withfavourable feedback.

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Strategic Aim 9: Other Locality issues

No Objective Key partners Forcompletionby: -

Outcome for patients Progress to Date RAGRating

9a To increasethe uptake ofPrimary CareResearchwithin Cynon

xxx Lead GP andPractice ManagerLHBPiCRIS

xxx Lead GPand PracticeManager

October 2015

-innovative medicinelocally-Enhanced patient care-Greater attention todetail in conditionsstudied

Initially 1 practice in localityengaged in Primary CareResearchXxx surgery to scope and devisea plan to facilitate furtherengagement of cluster practicesin research in Cynon Clusterand to report beck tocluster/arrange event byOctober 2015,done ahead ofschedule disseminated details ofPiCRIS support for practices tobecome research practices.November 2015 updateachieved more practicesexpressing an interest inresearch UHB aiming toestablish a primary careresearch unit which will facilitatethis further.

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9b Developmentof a foot careassessmentprogrammeperformed byPracticebased HealthCareAssistants

1)Clusters Healthcare assistantsscope andrepresentation2)Local podiatrydepartment and/orlocal universityschool ofnursing(educationalcomponent)3)Local primarycare nursingmanagement andnursingrepresentative4)XXX Medicalcentre lead GP andPractice manager

July 2016

XXXXMedicalcentre leadGP andPracticemanager

Improvements inprovision of practicebased feet assessment,freeing up practice nursetime increased jobchallenge for HCA’s(right person right placeright time).

To be scoped by XXX MedicalCentre? local podiatrydepartment to be invited toprovide a training/advisory role.

This development has furtherpotential in latter years of theplan we may want to seekpractice nursing input re HCAdelegation of inhaler techniqueand other tasks.November 2015 update; someclinical governance issues rediabetic foot assessment butfurther training of HCA’sexpansion of role progressinge.g. wound care etc i.e. upskilling

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9c Education &efficientsignposting toreducedemands onGP, OOH &A&E viabettersignposting toCommonAilmentsService withpharmacy

GP reception staffUHB PharmacyAdvisersA+EOOHMediaPPGCommunitypharmacy

XXX HealthCentrePracticeManager

July 2015

Prompt convenientaccess for patientsregarding commonillnesses to free up GPappointments andreduce demands onooh’s and A+E

Service piloted in the UHBarea;Current thought is not enoughservice users concerns forsustainability of service and lossof its evident benefitsPlan:XXX Health centre to scope withLHB re uptake i.e. baselineXXX Health centre to devise anddisseminate methods toincrease signposting and accessto the common aliments service.Update November 2015 somepractical measures to increaseuptake including posters insurgery and receptionistssignposting service. Laterpossible 3rd sector provision TVpublic health advertising inwaiting rooms to include thisservice

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9dDevelopmentof services asa localityparticularlydiabeticservices

xxxx SURGERY“buddy up” withxxx+xxx Surgery

LHB

Localitymedical director

PCSU diabeticnurse

primary care LHBdirectorate

endocrinologistand medicaldirectorate

Cluster practices

July 2017 Services redesignedclose to home speedyinsulin initiation and easeof secondary care advicesupport and review.

Discussion re current diabeticservices ?link in with LHB workongoing to benchmark servicelevels at each practice and tailoreducationalresources/opportunities andsupport accordingly with practicenurse and GP educationalopportunities including supportand resources for primary careinsulin initiation (scope PCSUexpert diabetic nurse to beinvited to cluster meeting)update re hub vs. no hub ideas(?scope Prof xxx to feed back tocluster).Possible serviceredesign including consultantattachment to practices for e-mail advice and virtual notesward round monthly as perCardiff and Vale LHB LES.Update November 2015 buddypractices with Pcsu clinicalnurse specialist and localityClinical Director and scopingand meeting re this potentialHUB development.

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9e CardiologyClinic – openaccess ECHO& 24 hourtape service –opportunityfor the clusterto establish acardiologyclinic to allowcollaborativeworking withothersurgeries &review routineoutpatients

xxxxxxMedicalPractice to buddyup

Cardiologyconsultants&LHB medicaldirectorate(cardiology)

LHB primary caredirectorate

Xxxx HealthCentresGP lead andPracticeManager

Date August2017

Close to home promptechocardiogramAssessmentWhich if resourcedCould relievePressures onCardiology waiting listsespecially if combinedwith a link up withCardiac failure nursingresources/communitybased HF clinics

Scoping with interested partiesled by locality medical directorwent ahead. November 2015update after discussion withUHB this service to bedeveloped and hosted at HeolKeir Hardie Health Park inMerthyr Tydfil plans and scopingproceeding re UHB preference

9f Loss ofcommunityclinics –provide onnetwork basisin practice

FOR FURTHERDISCUSSION ATCLUSTERMEETING scopeinterested parties

IF time andresourcesallow to bediscussed atclustermeeting afluid possibledevelopment

Services close to homefor patient replacing lostservices

WILL ONLY PROCEED IFCLUSTER SCOPINGSUPPORTIVEPossible LHB INVOLVEMENTLES? Update November 2015GP recruitment resource issue

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9g Medicationreviews,smarterworking, useof pharmacist

FOR FURTHERDISCUSSION ATCLUSTERMEETING

IF time andresourcesallow to bediscussed atclustermeeting afluid possibledevelopment

Building communitypharmacy as a partner inprimary health caresome initial LHB workand the pilot in minorillness pharmacyprovision.

it may be helpful to invite thepharmacy leads to a clustermeeting to explore how we as acluster can support them inbuilding on their role to thebenefit of primary care.5community pharmacists trainingas independent prescribers atpresent

9h Appointmentof 2 WTEclinicalpharmacistsGrade 8a tofacilitatecluster work

All cluster GPmembers UHBand CwmTafPharmacydepartment

December2015

Providing medication

reviews: house

bound/residential/nursing

home patients/improving

repeat prescribing

processes. Freeing up

GP time to see patients.

Ultimately by further

postgraduate training

e.g. independent

prescriber status/ minor

illness consultations i.e.

service expansion with

pharmacists embedded

in primary care teams

with direct patient

benefit. Strategic Fit of

this proposal: “Improving

access and quality and

new ways of working.”

1/12/2015 2 WTE ClinicalPharmacists in post and startingthis new development

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9i Improvementsin wound carewithin thecluster localityfor non-houseboundpatients

District nursingserviceTissue ViabilityserviceGP and PracticeNurse clusterrepresentationUHB primary caremanagementProfessionalExternalFacilitation

December2016

Outcomes for patients:-7 day wound careservice-delivered by continueduse of LES wound carein practices and Districtnursing wound careclinics in Ysbty CwmCynon Hub.-Ability to providesickness/unexpectedabsence cover forpractice nurse woundcare at the hub forpatients.-Improved wound careeducation and updatesfor nursing team is along term aim via furtherdevelopment of thisservice.-Possible researchinvolvement by linking inwith local woundinnovation centre andproposed primary careresearch unit.

2 scoping and planningmeetings for the proposed newservice completed October 2015with external facilitation.Detailed proposal developmentprogressing

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9j Improvementsin availabilityof patientselectronicnotes onhome visitswith Visionanywhere ontablets andEMIS mobilesolution

GP CLUSTERVisionEMISlocality cluster

management

April 2016 We developed this ideato allowed improvedpatient safety represcribing andassessing patients withall information to hand incommunity settings andallowing home visit notesto be uploaded directlyinto the patients record.NHS England hassubsequently announcedplans to role this out inEngland there are noimmediate monies tofinance this in Wales.We anticipate clinicalcluster pharmacistsHCA’s& Practice nursesto benefit from this andcomplement our districtnurses use of chromenotebooks. Potentiallyout of hours servicescould also becomeinvolved. Mobile accesswould also be useful foremergency contingencyplanning e.g. premisesdestruction adverseweather etc.

As for 2015-2016 we havemonies available we areprogressing this plan for thebenefit of our clusters patients.Initial demonstrations andcluster discussions have takenplace and procurement areshortly to be involved (thiscomplements our immediateneighbouring clusters in theUHB pursuing this aim alsoproviding a UHB wide initiative)

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9k Provision ofexaminationcouches forhigher BodyMass Indexpatients

GP’s and Practicemanagers clusterwideCluster LocalityManager

April 2016 Practices have identifiedthe need for 1 couch perpractice specificallydesigned for high bodymass index patients toallow equitable accessfor all service users.

Final needs are beingassessed/scoped with a view toprocurement by April 2016.