Taff Ely Cluster Network Action Plan 2014 V13 Ely Cluster Network A… · TAFF ELY NETWORK CLUSTER...

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Taff Ely GP Cluster Network Action Plan 2014-17

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TAFF ELY NETWORK CLUSTER ACTION PLAN 2014-17

This plan has been developed by the following 8 practices which operate in the Taff Ely Cluster Area, through facilitated discussion with the Local Clinical

Director and Primary care LHB Locality Management :-

• Ashgrove Surgery

• Eglwysbach Surgery

• New Park Surgery

• Old School Surgery

• Parc Canol Surgery

• Taff Vale Surgery

• Taffs Well Surgery

• Ynysybwl Surgery

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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- work in progress

Green – work 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 CBC and the voluntary sector and will also consider any action plans from stakeholders that evolve over the 3 year

cycle of this plan.

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• 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

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.

• 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.

• Public Health

• Acknowledgements Cynon 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 uHB, the uHB locality is the second smallest in Wales but the second most densely populated area (Cardiff is first) The Taff Ely 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 Taff Ely 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 c.f. all Wales 1 in 18; and the % of

children (<20 years old) living in poverty is 26.6% c.f. all Wales 22.2%. Particularly relevant to our area is the identification of Rhydfelen and Glyncoch as

areas of greatest deprivation in Wales by the public health observatory (ranked 17th and 27th respectively). All Wales public health observatory data on

levels of unemployment in the 16-24 yr old age group show a rate of 18.4% for CwmTaf c.f. 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 c.f. the welsh national average i.e. 75.3yrs as opposed to 77 years old. 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

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

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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 Key partners Completion by: -

Outcome forpatients

Progress to Date RAGRating

1 Review theneeds of thepopulationusingavailable data

Local PublicHealth Team

November2014

To ensure thatservices aredevelopedaccording to localneed

Analysis complete and outlined in detailabove, subsequently used by cluster todevelop action planning on key priorities.See above text.

1a Implementhealthpromotionsignpostingand supportmechanisms,which willhelp toaddress:

• Obesity• Smoking• Alcohol

dependence

• Bowelscreening

• Breastscreening

• Patientswithsensoryloss

GPs

Health BoardPrimary Care

3rd sectorpartners

March2016 -point 1completed.Point 2 tobecompletedMarch2017

Healthimprovements

Improved take-up bypatients in fundedservices

Increasedcollaborationbetween practicesand 3rd sector

Increasedengagement bypractices in publichealth promotion

Cluster practices feel that buy-in frompatients to improving their health / lifestylewill be increased through obtaining supporton a one-to-one basis from an individual(rather than being handed a leaflet /information from a GP).

Proposal to be discussed with health board:

• Fund staff / representatives fromspecialist organisation to signpostpatients to existing funded services.This could entail stands being set upin GP practice waiting rooms andmanned by staff who would activelyengage with patients. See also 1bbelow. This has been trialled byAshgrove surgery & Parc CanolSurgery (in relation to the SupportingCarers project) and there is thereforeexperience to build on. This willsupport the engagement by practiceswith the third sector.

• Discussions are underway with Sara

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Thomas, Public Health, to use clustermonies to appoint a communitylifestyle co-ordinator. A working grouphas been set up to progress this(including Rachael Baker, JaneTaylor-Lloyd, Sarah Humphries) andis progressing the appointment of aco-ordinator for 18-65 year oldpatients.

1b Collaborateacross theclusterpractices inorder toencourage fluvaccinationuptake bypatients

August2015

Improved take-up offlu vaccinationleading to protectionof elderly and at riskpatients andreducing risk ofadmission

Practices to consider running joint flu clinicson Saturdays during the flu season in localcouncil facilities e.g. leisure centre. Ensurethat remote access is available so thatpatients’ records can be accessed.Combine this with health promotion standsrun by 3rd sector organisations so thatpatients can access services whilstattending for flu vaccination.

It is recognised that not all practices in thecluster would wish to implement this as theircurrent flu uptake is already good.

1c Ensure that

healthcare

staff

maximise

opportunities

to provide

health care

advice

September2016

Increase staff

awareness of key

public health

messages and

signposting patients

to useful resources

All healthcare and nursing staff to undertakee learning on Making Every Contact Count

This concept is an aspiration for PublicHealth Wales(http://www.wales.nhs.uk/sitesplus/888/page/65550). The concept, Make Every ContactCount (MECC), involves using everyopportunity to deliver brief advice to improve

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patients’ health and wellbeing. It is aboutusing every opportunity to ask individualsthe right questions to find out about theirunderlying health needs and deliver briefadvice to improve health and wellbeing.

The e learning can be accessed at:

http://www.makingeverycontactcount.co.uk/index.html

This will be linked with 1a. Above.

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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

For completionby: -

Outcome forpatients

Progress to Date RAG Rating

2a Develop

transfer of

appropriate

services from

secondary to

primary care

cluster hub

once the LHB

have created

proposed

“Hub” at Dewi

Sant

including

relevant

infrastructure

Healthboard

Secondarycare

GPs

NWIS &DigitalDevelopmentTeam

Health board toconfirmtimescales ofthe setting up of“Hub”.

Cluster grouptimelines aredependant uponthe LHB DewiSant Parkprogramme

Improved

efficiency in

delivering

services in

primary care with

improved access

for patients closer

to patient’s home

Progress will be dependant upon thesetting up of the “Hub” and relevantinfrastructure with the initial roll out ofservices as outlined belowMSK Service – which will consist ofboth Consultant, GPWSI, PhysioServices, and MRI services to providepatients with a “one stop shop”

Supporting the LHB with the creationof a Primary Care Support Unit whichwould be based at the “Hub” and toinclude GPs (using the academicfellowship model), Pharmacists,Nurse Practitioners, Nurses, HCP andPhlebotomists. The cluster groupwould help with the recruitmentprocess

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It should be noted that any servicesoffered at the “Hub” should notconflict with current or thedevelopment of new services withinthe confines of a GP practiceenvironment, they should remainthere.

Central patient record access will bekey to making these services viable,and will form part of the coreinfrastructure required in the settingup of the “Hub”.The project is currently progressingslowly

2b Facilitate

increased

use of My

Health

Online

(MHOL) by

patients to

improve

access to

appointment

booking and

repeat

prescription

requests

NWIS

GPpractices

August 2016 There is varying

patient and

practice uptake of

technology to

improve access.

Increased uptake

will improve

access to

services for

patients.

Discuss within the cluster and worktowards agreement for all practices toimplement MHOL for bothappointments and repeatprescriptions.

Collaborate across practices onpromoting the service to patients.

NWIS is progressing furtherdevelopments to MHOL to provideeasier registration and use of an App.

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2d Work withthe healthboard ondevisingsolutions forthe currentissue of GPrecruitmentandsuccessionplanning

Healthboard

Dr MairHopkins –lead

GPs asrequired

Health board toconfirmtimescales

The issue is asignificant onewithin the clusteras manypractices arestruggling to fillvacancies andreplace retiringpartners

Dr Mair Hopkins has volunteered toact as lead for the cluster on a healthboard committee to review this issue.

As an interim solution, the healthboard should consider how GPs canbe shared across practices, which areshort of resource.

The issue has also led to a significantand unsustainable increase in locumrates, which is having a severedetrimental impact on those practices,which are forced throughcircumstances to employ locums.Note that the Cwm Taf practicemanager forum is discussing theagreement of consistent locum termsand conditions across practices toensure that a standard of locum tasksrequired by practices will be put inplace (avoiding the current practice oflocums dictating their own varyingterms to practices). We would alsolook to link with neighbouring healthboards to ensure regionalconsistency.

KB to chase June Williams forupdate.

2e Improveretention of

Practicemanagers

March 2017 Maintaining afully trained and

Health board funding is available tobackfill practice nurse positions to

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practicenursing staffand facilitatereplacementof retiringstaff

Healthboard

Practicenurses

resourced healthcare team withinpractices willensure thatpatients’ chronicdiseasemanagement issustained andthat a fullyresourced rangeof nursetreatments isavailable forpatients

enable them to train nursing staff insecondary care, who wish to work inprimary care.

This issue needs to be discussedfurther within the cluster to identifywhich practices are able to take onthis option.

June Williams will need to gather datafrom practice nurse population inconfidence to honest feedback.

2f Developfurther GPswith SpecialInterests(GPwSIs) tosupport 2a

Healthboard

GPs

March 2017 Develop animproved rangeof servicesavailable topatients withincluster practices

Practices have already submitteddata to the health board on currentGP and nurse specialist interests aspart of their practice developmentplans.

The next stages are:

• Health board to identify gaps inskill sets across the cluster

• Health board to identify GPs,who would be interested indeveloping as GwPSI for gapspecialist areas

• Health board to review andincrease GPwSI rate andshare revised pay scale with

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practices, as current rate doesnot cover backfill requirement

• Health board to identify GPs,who can provide training forthe gap specialist areas andfacilitate training. This could bethrough health board fundedtraining sessions in practice,via formal observation or bybackfilling.

It is proposed that a similar schemebe investigated for healthcare staffe.g. cryotherapy training for practices,who wish to offer this service.

2g Review GPvisitingguidelinesprepared bySouthStaffordshireLMC

GPsPracticemanagers

September2015

Consistentapproach to GPvisiting acrosscluster practices,ensuring thatpriority is given topatients withsame day /urgent visitingneed

Guidelines to be reviewed bypractices and discussed at clustermeeting before consideredimplementation – review at nextcluster meeting 09 September.

Practices have agreed in principle toimplement and to utilise informationprovided by third sector regardingpatient transport (to overcome keyperceived issue).

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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.


Forcompletionby: -

Outcome forpatients


3a Standardiseuse ofelectronicand non-electronicreferralforms.Maximiseease ofaccess anduse

Integration offorms withclinicalsystems

Healthboard

INPS

EMIS

Directorateleads

NWIS

December2015

More efficientreferral process withimprovedcommunication andimprovedgovernance

A number of templates have been stored onthe Cwm Taf GP portal. These need to bereviewed and added to, to ensure that acomprehensive library of forms is available.

This should be coupled with communicationto practices of where and how to access anda process, which will ensure that practicesno longer use locally stored copies.

Accountability will need to be assigned bythe health board for maintaining the library,which will require liaison with secondarycare, as a central point of contact for anynew / amended forms to be used by primarycare.

Current paper-based forms should bereplaced by electronic version – this willrequire health board / IT resource.• Provide central repository of templates

for clinical systems (Vision & EMIS) thatwould be accessed via the Portal.

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• This should include approval by the LMCwith input from secondary care wherenecessary to agree pathways

• Use INPS & EMIS to create and maintaintemplate versions

3b Improveaccess tominor surgeryserviceswithin thecommunity

Linked to 2aabove.

HealthBoard

GPs

March 2017 Reduced waitingtimes and provisionof care closer to thepatient’s home

A number of improvements can be made tothe minor surgery enhanced servicesprocess in order to improve servicesavailable to patients, namely:

• Add carpal tunnel decompression tothe enhanced service (alreadyavailable within the Enhanced MinorSurgery agreement

• Referral centre to route referrals inprimary care i.e. other organisations(e.g. podiatrists) could use this routeto refer procedures (e.g. toe nailremoval) to practices signed up todeliver certain services (this hasalready been proposed by Ashgrovesurgery to the Health Board)

• Identify further procedures which canbe transferred to primary care, byinvolving consultants to agreetransfer and deliver training

A first phase has been rolled out to extendminor surgery but there is still a significantlimit to what services can be delivered inprimary care.

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The GP Portal should be used to makepractices aware of which practices deliverwhat services and then enable referral to bemade via WCCG (as already happens forvasectomy referrals to Ashgrove andPontcae surgeries). LHB to ensure this iskept up to-date as more services are rolledout by the practices/hub.

Data provided to June Williams regardingpractice specialities via Hayley Pugh.

3d Extendsexual healthservicesacrosspractices

Linked to 2aabove

HealthboardGPs

November2016

Reduced waitingtimes and provisionof care closer to thepatient’s home

Some practices within the cluster alreadydeliver services for other practices and havethe capacity to extend this. Extending thisservice could allow provision of temporaryservices, whilst a GP is on maternity leave,for example, or to cover other staffing issuese.g. retirement.

In order to implement this, the following willneed to be in place:

• Treatment pathways will need to bealigned across the cluster

• Referral documents will need to bereviewed and agreed (pathwayalready drafted and submitted byAshgrove surgery)

• Processes will need to be defined,documented and communicated

• Referral mechanism will need to be inplace, using WCCG for consistency

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LHB to ensure this is kept up to-dateas more services are rolled out by thepractices/hub

See 3b.3e Develop a

shared carerecord for usebetweenPrimary andCommunityServices

NWISLHBGP Systemsuppliersi.e. INPS &EMIS

By March2017

Prevention ofduplication andimprovement ofcommunication.

Reducing risk topatients

This a dependency for a number of itemswithin the cluster plan

This development can be aligned to thework required by NWIS/Digital Developmentteam in 2a

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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


Forcompletionby: -

Outcome forpatients


Re Strategic Aim 4:

All Taff Ely 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.

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

No Objective Key partners Forcompletion by: -

Outcome forpatients


5a All practicesin the clusterto analysetheir palliativecarepresentations2014-2015QOF yearanddisseminatelessons learntandeducationalneedsidentified(seeAppendix 1below)

LHB

Individualcluster primarycare practiceteams

End March2016

Lessons learntfrom practiceanalysis of casesof palliativecare/end of lifecare analysedduring QOF year2014-2015 fedback into servicedevelopment andeducationaldevelopment whenrequired

All practices in the cluster engaged on inpractice national priority work on SEA ofend of life care presentations as pernationally agreed national priority work

Completed for 2014/15.

Completed for 2015/16

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5b Considereffectiveanalysis atpractice levelof end of lifecare andpalliative careregisters

Macmillan localcharityfundedresources

Clusterpractices

LHB resources

Third sectororganisations

September2015

Improved adoptedof EOL carepathways will leadto improved EOLcare for patients

• Implement an EOL care checklist acrossthe cluster, to ensure that all elements ofthe pathway have been considered andaddressed, where appropriate, for apalliative patient (template provided byOld School practice)

• Target early involvement by Macmillanstaff in the care of palliative patients –measure to be agreed with Macmillanteam

• Implement a communication skillsframework (to be developed incollaboration with Macmillan staff) acrossthe cluster for GPs to use whendiscussing EOL care with palliativepatients, to ensure that GPs are usingappropriate communication techniques

General guidance is available on Cwm Tafhealth board intranet. Discuss with healthboard replicating this advice on the GPportal and ensure that this includes usefulphone numbers / websites.

5c ContinueQOF 2014-2015individualclustermemberspracticepalliative care

IndividualCluster primarycare practiceteamsDistrict Nursingrepresentativesand palliativecare team

Ongoingindividualpracticework

Case reviewpatients identifyproactive end oflife planning forindividuals andadvice refuture/additionalmanagement of

Continues in progress every QOF year

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teammeetings

representatives the individual.Lessons learnedfor individualpatients will benefitand inform futurepatients care.

5d Increase useof JIC boxes

September2015

More timely controlof symptoms andmay reduce crisisadmissions andunplanned care

Check that all practices in cluster haveaccess to JIC system and that all relevantstaff are aware of the process.

.

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


Forcompletionby: -

Outcome forpatients


6a All practicesin the clusterto analysetheir cancerpresentations2014-2015QOF yearanddisseminatelessons learntandeducationalneeds (seeAppendix 3below)

LHB

ClusterGP’s andclusterprimary carehealthteams

End March2016

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

All practices in the cluster engaged on inpractice national priority work on SEA ofcancer presentations as per nationallyagreed national priority work.



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Strategic Aim 7: Minimising the risk of poly-pharmacy


Forcompletionby: -

Outcome forpatients


7a Identify and

report the

number /% of

patients aged

86 years or

more

receiving 6 or

more

medications

(see

Appendix 2

below)

Lead GP ineach clusterpractice

LHBpharmacyadvisoryteam

End March2016

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 end March 2015.



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


Forcompletionby: -

Outcome forpatients


8a Engage witha robustvalidatedclinicalgovernanceprocessspecificallydesigned withclusterplanning inmind

Individualclusterpractices

PublicHealthWales

End March2016

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.



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Strategic Aim 9: Other locality issues

No Objective Key partners Forcompletionby: -

Outcome forpatients


9b Improveefficiency ofworking byincreased useof practicepharmacist

March 2016 Improved access tomedication advicewithin the GP settingas a ‘one-stop’ shop

To be discussed at a future clustermeeting. This may be appropriate todevelop for practices, which employpharmacists. A consistent modelwould be agreed across relevantpractices in the cluster ifappropriate.

It is recognised that not all practicesin the cluster would wish to developthis objective depending on theircircumstances / size.

9c Identify andbuildrelationshipswithconsultants,who arewilling to runclinics inprimary care

March 2017 Knowledge and skillsharing betweensecondary andprimary care willresult in improvedpatient care andimprovedcommunicationchannels

As a consequence of the Healthboard sponsored COPD project withGSK, Dr Paul Neill has carried out anumber of COPD clinics with leadGPs and practice nurses in anumber of participating practices.

It would be beneficial to identifyother clinical areas and consultants,who would be prepared to put inplace a similar arrangement.

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The objective would be provideeasy access to advice for GPs forthe following clinical areas:

• Cardiology (service recentlywithdrawn)

• Neurology• General medicine• Respiratory• Care of the elderly• Mental health

9d Contribute topatients andstaff mentalhealthwellbeing

FOR FURTHERDISCUSSION ATCLUSTERMEETING

March 2017 Implement tool toassist patients toimprove their mentalhealth wellbeing andincrease theirresilience

Cluster to review materials availableunder ‘Five Steps to MentalWellbeing’ and considerimplementing across practices forrelevant staff (available athttp://www.nhs.uk/Conditions/stress-anxiety-depression/Pages/improve-mental-wellbeing.aspx#Evidence)This tool has been adopted byTorfaen Neighbourhood CareNetwork (equivalent of cluster) inABHB (contact Dr Alastair Roeves,Clinical Director, Gwent).

This is linked to 1a – delivery oftraining by Public Health.

9e Facilitateeasy accessto patientrecords when

Individual clusterpractices

NWIS

March 2016 Investigateimplementation ofVision Anywhere(and EMIS

Hayley Pugh has commencedinvestigation. Investment proposalto be circulated and agreed bycluster practices

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GPsassessingpatients awayfrom surgery

Health boardequivalent) softwareand mobile tablethardware to enablethis.

9f ImprovePatientsaccess

ClusterHealth boardNWISVoice Connect

March 2016 Install PatientPartner Software toaid patient access toappointment systemoutside of core hours

Four practices within the cluster i.e.Ashgrove, Newpark, Parc Canol andTaff Vale chose to pilot this onbehalf of cluster.Hayley Pugh placed order withVoice Connect and practicesordered relevant hardware/softwaredirectly with their telephoneproviders to meet the requirementsof Voice ConnectNWIS and Voice Connect to agreeaccess to NHS Network so that theirsoftware can access clinical system.Voice Connect have been informedthat they would need to provide thewindows and a/v upgrades as partof the agreement for access to NHSNetwork –VC are still in discussionswith NWIS for a work aroundregarding this dependency despiteVC being made fully aware of thiscompliance at the time of order,which has led to a delay in thesoftware being installed

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Appendix 1Lessons learnt from practice analysis of cases of palliative care/end of life care

No. Key issues Actions

1 Refer to submission for 2015-16

Appendix 2Lessons learnt from practice analysis minimising the risk of polypharmacy



Appendix 3Lessons learnt from practice analysis of understanding cancer care pathways



Appendix 3Action plan

Objective Date Action Responsible Status

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no.

1 November

2014

Review the needs of the population using public

health data

Local public health

team

6a March

2015

Complete review of prevention and early detection

of cancers and include actions in practice

development plan

Practices

7a March

2015

Complete review of minimising risk of

polypharmacy and include actions in practice

development plan

Practices

5a March

2015

Complete review of end of life care and include

actions in practice development plan

Practices

8a March

2015

Complete CGPSAT tool at practice level and

include actions in practice development plan

Practices

1b August

2015

Practices to investigate joint flu clinics to increase

take up

Practice managers

5b September

2015

Implement EOL care checklist

Target involvement of Macmillan staff in EOLC

Implement EOLC communication framework for

GPs

GPs

Macmillan staff

2g September

2015

Review GP visiting guidelines prepared by South

Staffordshire LMC

GPs

Practice managers

5d September

2015

Review use of Just in Case boxes across cluster re

EOLC

Cluster practices

3a December

2015

Standardise use of electronic and paper referral

forms and maximise ease of access via GP portal

Health board

GPs

NWIS

1a March

2016

Health promotion signposting by 3rd sector

organisations in practice

Practice managers

3rd sector

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9b March

2016

Improve efficiency of working by using practice-

based pharmacy resource

Health board

GPs

2b August

2016

Promote increased take-up of MHOL by patients NWIS / practice

managers

1c September

2016

Training for all healthcare and nursing staff on

Making every Contact Count

Practice healthcare

teams / practice mgrs

3d November

2016

Extend sexual health services across cluster Health board

GPs/ Practice

Managers

3b March

2017

Improve access to minor surgery services within

the community

Health board

GPs/Practice

Managers

2f March

2017

Development of GPwSIs Health board

GPs

2e March

2017

Improve retention of practice nursing staff and

replacement of retiring staff

Health board

Practice managers

Practice nurse

champions

1a March

2017

Appointment of community lifestyle co-ordinator

HCP resource for 18-65 year old patients

Practice managers

Public Health

3e March

2017

Develop shared record for use by primary care and

community services

NWIS

Clinical system

suppliers

Health board

2d TBA Work with health board on GP recruitment and Dr Mair Hopkins

32 | P a g e V 1 3

succession planning Health board

9c TBA Build relationships with consultants who are willing

to run clinics in primary care and consider how this

can link in with the proposed cluster hub work

GPs

9d TBA Consider using ‘Five steps to Mental Wellbeing’

tool

Practices

2a TBA Develop transfer services from secondary care to

primary care hub

Health board

Practices

9f March 16 Install Patient Partner Software to aid patient

access to appointment system outside of core

hours

ClusterHealth boardNWISVoice Connect

Taff Ely Cluster Network Action Plan 2014 V13 Ely Cluster Network A… · TAFF ELY NETWORK CLUSTER...

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