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December 2015: Chippenham/Raglan surgeries have merged with Chippenham as main site and Raglan as the branch therefore reducing total number to 8 Practices. The new practice will be known as Castle Gate Medical Practice and will use the current Chippenham W code of W93036, Raglan branch will use W93036a.
Monmouthshire North Draft Action Plan 2015-16
Strategic Aim 1: To understand the needs of the population served by the Network (identified by Public Health)
No Objective Agreed actions Outcomes Key
Partners
Time-
scales
RAG
1.1 Obesity
1.1.1 NEW: Tackling obesity
Adopted as
Population Needs
priority 2015-16
Supports Monmouthshire SIP Links with Supporting People Needs Mapping 9th June 2015 Links to ABUHB Service Change Plan No. 3/4/5
Identify baseline data for NCN
area
Measure height, weight and
electronically record BMI
Intervene more regularly, with
right information in the right
way – brief advice /
intervention
Map Level 2 services for weight
management and
refer/recommend – Foodwise,
commercial clubs, NERS, led
walks
Refer routinely to Adult Weight
Management Service
Increase AWMS capacity for
specific populations (e.g. Pre-
diabetes, pregnant women) e.g.
BG West
(See 2.1.4)
Number of people
who receive timely
and appropriate
support based on
their needs;
AWMS guidelines
are implemented
AWMS/NCN/
Public
Health/Practi
ces/Third
sector/ABUH
B Divisions
31.3.16 Actions to be agreed
Obesity by LA.docx Obesity slide.docx
Obesity slide 2.docx Childhood obesity slide.docx
Initial scoping meeting held with
service to agree role and budget
Diabetes presentation given at
NCN meeting:
Diabetes Consultants aligned to
NCNs
Consultant email advice line open
Consultant/DSN telephone advice
1.2 Bowel Screening
1.2.1 NEW: To increase up-
take of bowel
screening to achieve
60% target
To achieve national target of
60% for eligible patients;
PHW liaise with national
screening to provide list of non-
responders to Practices
quarterly;
Earlier detection of
bowel cancer – data
supports improved
survival rates;
Published evidence
NCN (Public
Health led) /
national
Screening /
Practices /
ABUHB
31.3.16 http://qir.bmj.com/content/3/1/
u205661.w2324.full
3
No Objective Agreed actions Outcomes Key
Partners
Time-
scales
RAG
Adopted as
Population Needs
priority 2015-16
Links with Supporting People Needs Mapping 9th June 2015 Links to ABUHB Service
Change Plan No. 3/4/5
PHW to calculate predicted
increase in referrals for follow
up colonoscopy for each %
increase in uptake of screening;
Identify potential funding to
support Practices in targeting
non-responders: Follow up
letter +/- telephone contact
etc;
PHW data by NCN to monitor %
of non responders who
subsequently submit a sample
after follow up by Practices
Numbers of non responders by
NCN is available to work out
administrative costs of follow
up by Practices if needed
Complete significant event
audits
Carry out thematic analysis to
identify potential causes of
diagnostic delay
shows Practice level
interventions have
achieved clinically
significant increase
in uptake;
Evidence shows
that high % of
people responding
once to bowel
screening will
respond again
Divisions
u205661.w2324.full.pdf
Bowel screening up-take 2013-14.docx
2014-15 audit: National bowel
screening picked up 7 of the 77
GI tumours
Screening For Life 2015 by Public
Health Wales -
https://www.thunderclap.it/proje
cts/27059-screening-for-life-
2015 information circulated to
NCN members
PH meeting AWBS team
08.09.15 – take outcome forward
All Practices have received list of
non-responders from PH team
and are targeting with NCN
agreed funding
1.3 Immunisations
1.3.1 People in at risk
groups will be actively
encouraged to receive
a flu vaccination, to
achieve the national
target of 75% for
immunisation against
influenza
Supports Monmouthshire SIP / ABUHB Flu Plan Links with Supporting People Needs Mapping 9th June 2015 Links to ABUHB Service Change Plan No. 3
Practices discuss and monitor
existing data on uptake, to
identify variation and areas for
improvement
Utilise Third Sector networks
to support the campaign NEW: Impact of new
phlebotomy service providing
DNs with capacity (See 2.1.2)
NEW: DN service success
against 100% offer target
NEW: Identify issues
between GP & Community Pharmacy LES provisions
Decrease in hospital
admissions;
Decrease in
morbidity
GP Practices
/ NCN /
Contract-or
Services /
DNs
31.3.16 IVOR latest needed for both
target groups
WHC-2015-028 - National Influenza Immunisation Programme 2015-16 - WORD Version - English.pdf
DN service target: 100% of
housebound people to be offered
flu vaccination
2 x band 6 nurses employed to
support increased up-take
Flu road shows for practice managers 2015 handout-Sept 2015.docx
Seasonal influenza vaccine uptake in Wales 201415_v1a.pdf
4
No Objective Agreed actions Outcomes Key
Partners
Time-
scales
RAG
Links to 9.1.1 GDAS
School fluenz programme started
Flu up-take at 26 October 2015:
65+ 52.4% / <65 years 33% (All
Wales figs for comparison -
42.4% in 65+ / 25.2% in <65
years)
1.4
Engagement
1.4.1
REVISED: To support
the work of ENGAGE
and attend ’listening
events’ to gauge local
opinion
Supports Monmouthshire SIP
Links with Supporting People Needs Mapping 9th June 2015
Links to ABUHB Service Change Plan No. 5
REVISED: To attend minimum
of 2 events to capture local
views & provide a range of
information relating to e.g. Flu /
smoking cessation / ‘Choose
Well’
Lessons learned are used at
Practice level, reported at NCN
to highlight to secondary care
colleagues
Listening events capture
opinions to be shared with
Practices as necessary
Feedback from
engaged,
disadvantaged
groups
demonstrates
improved service
delivery and
patient/carer
satisfaction
NCN 31.3.16
SPPG needs mapping.docx
ABUHB engagement team event
in Monmouth Town held with
feedback reported via Primary
Care & Networks Division
Strategic Aim 2: To ensure the sustainability of core GP services and access arrangements that meet the reasonable needs of local
patients
Objective Agreed actions Outcomes Key
Partners
Time-
scales
RAG
2.1 Access
2.1.1 NEW: Phlebotomy:
Increase access to
primary care
phlebotomy service
Links to ABUHB Service Change Plan No. 3
To implement local service
closer to home and in care
homes
Increase access to phlebotomy
service for house bound
population
NEW: To identify District
Nursing impact on flu up-take
and progress against target
Increased capacity
and access
within/to DN service
NCN/ABUHB
Divisions
31.3.16 £4.4m funding to support this
Pan NCN initiative
5
Objective Agreed actions Outcomes Key
Partners
Time-
scales
RAG
(See 1.2.1)
(WAO report on district nursing indicates
that 30% of community nursing time could
be released, for example to manage LTCs, if
no longer required to take blood)
2.1.2 NEW: Contracted
Services: To engage
with and utilise skills
of other Primary Care
services i.e.
Optometrists,
Pharmacists & Dentists
Links with Supporting People Needs Mapping 9th June 2015 Links to ABUHB Service Change Plan No. 3
NCN funding to facilitate
recruitment
Contractors act as advisors to
NCNs with communication plan
established
Increased
communication
leads to improved
understanding of
Primary Care issues
AMD/NCN/C
Ds/NCN
leads
31.3.16 NCN funding agreed to support
this initiative
Scope of contribution to be
discussed/agreed
All 3 posts appointed to
All Gwent NCN Independent Contractor Support.docx
2.1.3 NEW: Obesity See 1.1.1 - Increase access to
AWMS
See 1.1.1 See 1.1.1 See 1.1.1 See 1.1.1
2.1.4 NEW: To implement a
Faecal Calprotectin
(FCAL) pilot for people
with Inflammatory
Bowel Disease (IBD)
To implement pilot in North
Monmouthshire (possibly
including South also) to reduce
number of referrals to GI
Consultants
To implement a request form
available to all Monmouthshire
GP Practices (pilot excludes
children)
Appropriate
requests are made;
Positive predictive
values based on
approx 100
requests estimated
over 3 months;
Proportion of
negative results
that might have
avoided a
colonoscopy
ABUHB
Divisions /
NCN lead /
NCN
TBC
Faecal Calprotectin Primary Care Request Form.pdf
Initial meeting held (NCN lead
sits on GI team)
Request form developed by GI
Consultant and shared with
group
Priorities for pilot success
discussed and agreed
6
Objective Agreed actions Outcomes Key
Partners
Time-
scales
RAG
2.1.5 NEW: Early warning
for Practices
anticipating difficulty
with recruitment/filling
vacancies
Links to ABUHB Service Change Plan No. 3
Practices to inform NCN
verbally/in writing if having or
anticipating difficulty
Agree to meet with the NCN
lead to discuss next steps
Continuity of
services
Support against
potential Practice
fragility
Practices /
AMD / NCN
lead
31.3.16
Strengthening General Practice_ Actions for a brighter future for patien .pdf
QOF
2.1.6 NEW: Practices in
difficulty have access
to NCN salaried
support team to
ensure continuity of
service in the short
term
Links to ABUHB Service Change Plan No. 3 / Primary Care Plan
As above Continuity of
services
Support against
potential Practice
fragility
As above 31.3.16
2015 plan for primary care.pdf
QOF
2.1.7 NEW: Monitor the
continuation and
uptake of My Health
Online
Links to ABUHB Service
Change Plan No. 3
All practices to offer
appointment availability and
repeat prescription ordering via
MHOL
Ease of access to
GP services
NCN /
Practices /
Pharmacy
Advisors
31.03.16
Clinical Director appointed as lead
with NCN support
2.2
Workforce
2.2.1 NEW: Practice staff
can access timely,
relevant training
Links to ABUHB Service Change Plan No. 3 Health and Care Standards: 7.1
Establish a Divisional/NCN Task
& Finish group – training plan
developed
Develop a process for Practice
staff to access training
Training providers and costs are
identified
Practices are informed of
training options and criteria
Establish Practice Nurse forum
Quality of care /
skilled workforce –
enables sharing of
ideas/skills and
good practice
NCN/ABUHB/
Practices
31.3.16 Process in place via proposal
applications
£1.1m allocated to NCNs:
Training options considered from
slippage funds year on year –
T&F group established
7
Objective Agreed actions Outcomes Key
Partners
Time-
scales
RAG
2.2.2 NEW: Ensure local
support structure is fit
for purpose to meet
demands of strategic
NCN development
Links to ABUHB Service Change Plan No. 3
To be appraised of South
Monmouthshire developments
Improved guidance,
co-ordination and
development to
meet the needs of
the local population
NCN lead /
HoPN /
PC&ND /
ISPB / NCN
31.3.16 Workshop held with key
stakeholders to agree
membership of Management
Group, remit and immediate
action required
Action Plan developed
2.3
Estates
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 harms
No Objective Agreed actions Outcomes Key
partners
Time-
scales
RAG
3.1 Mental Health
Services
3.1.1 To strengthen
integration with GP
Practices (PCMHSS)
Links with Supporting People Needs Mapping 9th June 2015 Links to ABUHB Service Change Plan No. 3 /4/5
Respond to work-streams from
Pan Gwent Working Group
Team co-ordinator to provide
performance information for
NCN meetings
Evidence shows
services collaborate
to ensure timely
access to support
NCN/Practice
s/PCMHSS/M
H Division
31.3.16
GAVO Mental Health Service Directory for Gwent.pdf
PCMHSS acts as member of NCN
with reports provided re progress
against waiting times
3.1.2 NEW: Dementia: To
make up to-date local
and national
information available
in relation to accessing
dementia care support
Adopted as a local
priority 2015-16
Supports Monmouthshire SIP
Links with Supporting People Needs Mapping 9th June
Implement Dementia Roadmap
Identify stakeholders e.g.
libraries etc
Promote ‘Dementia Friend’
training across partners
Increased access to
local and national
information sources
for people with
dementia, families
and carers
Phil Diamond
– DFC lead /
MH Div
/CMHT /
Community
Division /
3rd sector /
NCN
31.3.16
£4 million from WG to fund MH
related projects for primary care.
£0.24 million from for national
nurse led programme to train
care home staff and respond
better to their needs and ensure
their diagnosis is recorded on GP
registers.
All Gwent dementia roadmap.docx
8
No Objective Agreed actions Outcomes Key
partners
Time-
scales
RAG
2015 Links to ABUHB Service Change Plan No. 3/4/5
NCN funding allocated to support
implementation of an on-line
dementia Roadmap – steering
group in place
Strategic Aim 4: To provide high quality, consistent care for patients presenting with urgent care needs and to support the continuous
development of services to improve patient experience, coordination of care and the effectiveness of risk management
No Objective Agreed actions Outcomes Key
partners
Time-
scales
RAG
4.1
Integrated Services
Team (IST)
4.1.1 Increase the range of
services available
closer to home
Supports Monmouthshire SIP Links to ABUHB Service Change Plan No. 3/4/5
Clarify points of contact for
GPs/PMs & develop a Case for
Change to identify medical
model for IST (See 3.1.1)
Improve access to IV antibiotics
at home service
To consider ABUHB Policy re
management of infection in
exacerbations of COPD, with IV
antibiotics access
Data provided by CORE
performance report
On-going development of
Integrated Hubs at Monnow
Vale / Mardy Park
Review existing service and
work to identify a medical
model
Number of
avoidable
admissions is
reduced with care
managed at home
with Multi-
Disciplinary Team
HoPN/NCN/
IST
31.3.16 Work on-going as part of ‘Hub’
development team remit - paper
presented to Community
Transformational Group
Local action plans developed
Strategic Aim 5: Improving the delivery of end of life care [EOLC] (National Priority – to be discussed locally)
No Objective Agreed Actions Outcomes Key
partners
Time-
scales
RAG
5.1.1 Review delivery of
EOLC using Individual
NCN to support Practices to
review audit of patients who
Audit outcome leads NCN Leads/
Practices/
31.3.16 Year-end reporting requirement
9
No Objective Agreed Actions Outcomes Key
partners
Time-
scales
RAG
Case Review Audit
Links to ABUHB Service Change Plan No. 4
have died to be reflected
upon/inform future care
delivery.
to improved care
during End of Life
phase
NCN Support
5.1.2 Summarise case
review data, and any
arising issues and
actions identified, for
sharing with the
network and the
wider health board
Links to ABUHB Service
Change Plan No. 4
Highlight best practice for
improvement to be highlighted
and shared in a multi-
professional discussion
Learning through
shared experience
will inform
improvements for
patients on the EOL
pathway
NCN Leads/
St Davids/
Practices/
NCN Support
31.3.16 Year-end reporting requirement
5.1.3 Establish a review
cycle, to monitor
progress (or
maintenance of high
quality), report to NCN
and wider health board
as appropriate
Agreement of ‘best practice’ in
EOLC. Identification and
monitoring of areas for
improvement so that
appropriate education and
support can be delivered
Improved
consistency in
standard of care
delivered
NCN Leads/
Practices/
NCN Support
31.3.16 Audit outcomes reported to
ABUHB GP Macmillan co-
ordinator with learning points
included in the Palliative care
Delivery Plan. Monthly reports
also sent to all NCN leads
5.1.4 NEW: Themes
identified by audits
lead to agreed action
Links to ABUHB Service Change Plan No. 4
NCN to discuss +/- use of EOLC
template for all patients who
enter terminal stage of illness,
not just those with cancer;
NCN to discuss READ Code
training for Practice staff to
improve recording of diagnostic
symptoms;
Develop patient recording
protocols for Care Homes, by
using the Integrated Care
Pathway framework, to ensure
patient record consistency;
Practices identify carers and
record when patients are first
diagnosed / placed on the
register;
Improved
consistency in
standard of care
delivered.
Practices
NCN Lead
HoPN
31.3.16 Year-end reporting requirement
10
No Objective Agreed Actions Outcomes Key
partners
Time-
scales
RAG
Ensure Carer’s Packs are
available at all GP Practices;
To map/ensure access to
interpreter services for patients
whose first language is not
English;
Improve communication with
OOH Services re ‘Special Notes’
and use of Adastra to provide
up to-date patient records.
Strategic Aim 6: Targeting the prevention and early detection of cancers (National Priority)
No Objective Agreed Actions Outcomes Key
partners
Time-
scales
RAG
6.1.1 Review care of all
patients newly
diagnosed between 1
January 2015 to 31
December 2015 with
lung, gastrointestinal
& ovarian cancer
Links to ABUHB Service
Change Plan No. 4
Audit tool Patient referral
information
reviewed and
Outpatient
appointments /
results followed up
NCN/NCN
Leads/
Practices
31.3.16 Year-end reporting requirement
NICE issued: Suspected Cancer
recognition and Referral – NG12
(June 2015)
GI Consultant attended NCN to
discuss learning points and
solutions – impact of new NICE =
WLIs / Weekend & evening clinics
6.1.2 Learning and actions
to be shared with
NCN and the wider
health board as
appropriate
Links to ABUHB Service Change Plan No. 3
Practices complete audit and
discuss findings
Audit tool ensures
continuous review,
reflection &
improvement in
processes/ care
pathways for cancer
patients
NCN/NCN
Leads/
Practices
31.3.16 Year-end reporting requirement
6.1.3 Identify and include
relevant actions to be
addressed in Practice
Development Plans
Practice by practice NCN USC
cancer data will be collated to
provide better informed
demographic data relating to
cancers on a regular basis
Improved patient
information/ Patient
choice & preferred
place of death
NCN/NCN
Leads/
Practices
31.3.16 Year-end reporting requirement
11
No Objective Agreed Actions Outcomes Key
partners
Time-
scales
RAG
Links to ABUHB Service Change Plan No. 3
6.1.4 Summarise themes
and actions for review
with NCN / share
information with wider
health board as
appropriate
Links to ABUHB Service Change Plan No. 3
NCNs to share learning with
secondary care
As above NCN/NCN
Leads/
Practices
31.3.16 Year-end reporting requirement
6.1.5 NEW: Themes
identified by audits
lead to agreed action
Links to ABUHB Service Change Plan No. 4
Develop protocol to refer
patients as ‘USC’ if cancer
suspected with Practice based
referral tracking system;
Practices encourage patients to
attend Bowel Screening
Programme;
GPs are informed by Secondary
Care Consultants when referrals
are re-prioritised;
Patients who DNA are contacted
Improved patient
information;
Appropriate
treatment pathway
initiated
PC&ND /
AMD /
ABUHB
Divisions /
Practices /
NCN lead /
NCN
31.3.16 NEW: Themes identified by audits
lead to agreed action
Links to ABUHB Service Change
Plan No. 4
Strategic Aim 7: (Minimising the risk of poly-pharmacy (National Priority – to be discussed locally and also Medicines
Management)
No Objective Agreed Actions Outcomes Key
partners
Time-
scales
RAG
7.1 Poly-pharmacy
7.1.1 Identify and record
numbers and rates for
patients aged 85 years
or more receiving 6 or
more medications.
Links to ABUHB Service Change Plan No. 3
Using audit +, a review of
practice clinical systems to
identify (‘at-risk’ only) patients
over the age of 85yrs in receipt
of 6 or more medicines.
NEW: Consider extending the
audit age range to include lower
starting age
Identify patients at
high risk or harm of
either over/ under
medicating
NCN Leads
31.3.16 Year-end reporting requirement
12
No Objective Agreed Actions Outcomes Key
partners
Time-
scales
RAG
7.1.2 Undertake face to
face medication
reviews, using e.g.
‘No Tears’ approach
Links to ABUHB Service Change Plan No. 3
Using data from the review
audit book appointments for
medication reviews of patients
over the age of 85yrs receiving
6 or more medicines.
Reduced avoidable
admissions;
Identification of
untreated
condition(s);
Number of MUR
Consultations
NCN Leads/
Practices/
NCN Support
31.3.16 Year-end reporting requirement
7.1.3 Identify any actions to
be addressed in
Practice Development
Plans
Identify and record
numbers and rates for
patients aged 85 years
or more receiving 6 or
more medications.
Links to ABUHB Service Change Plan No. 3
Poly-pharmacy at NCN
meetings
Quarterly information to NCN
on utilisation of notional budget
As above NCN/
Prescribing
advisors/
Practices/
NCN Support
31.3.16 Year-end reporting requirement
Using data from the review
audit book appointments for
medication reviews of patients
over the age of 85yrs receiving
6 or more medicines.
7.2 Medicines
Management
7.2.1 NEW: Recruit 0.8 wte
Primary Care based
Pharmacist from NCN
funding to integrate
with GP Practices, NCN
and partners
Links to ABUHB Service Change Plan No. 3
Initiate recruitment process –
Summer 2015
Induct Pharmacists into GP
Practices
Integration and outcomes
measured/ monitored via NCN
meetings
NCN Pharmacists
project team
developing a suite
of priorities &
outcomes;
Patients and
professionals have
access to a named
Pharmacist in
Primary Care
NCN
leads/NCN/P
C&ND
31.3.16 Year-end reporting requirement
Post appointed to July/August
2015
Integration and outcomes
measured/ monitored via NCN
meetings
Identify opportunities for
Pharmacists to further develop
appropriate skills
Funding allocated from NCN
budget
13
No Objective Agreed Actions Outcomes Key
partners
Time-
scales
RAG
7.2.2 To monitor the NCN
prescribing budget and
delivery of the
Medicines
Management plan
Links to ABUHB Service Change Plan No. 3
To receive regular prescribing
information (at NCN meetings)
Budget performance and
delivery of the savings plan
National Indicators / Clinical
Effectiveness Prescribing
Programme
Pharmacy and NCN Leads to
meet and decide on priorities for
NCNs to achieve in terms of
service improvement, costs and
quality
For year-end review and final
report
Efficient use of
resources leads to
re-investment &
more appropriate
care
NCN Lead/
Prescribing
lead/
Practices
31.3.16 Year-end reporting requirement
NCN meeting standing agenda
item with scrutiny of actual and
projected spend against
prescribing budget
7.2.3 To review the variation
in prescribing
compared to national
guidance in relation to
Diabetes and
Respiratory and
deliver the NCN
savings target for
these work-streams
within the three year
plan
Links to ABUHB Service Change Plan No. 3
NCNs to work with Primary Care
and Networks Division Pharmacy
staff to:
Arrange scheduled visits by the
NCN Lead to discuss Dashboards
and Practice performance;
Monitor performance change
through actual prescribing
spend on high dose
corticosteroids and diabetes
drugs;
Identify prescribing leads rep
and identify progress against
the SCEP;
Prescribing guidance to be
developed by Pharmacy Team
Minimise avoidable
harm from adverse
effects of inhaled
steroids;
Undertake
minimum
appropriate
intervention to
ensure prudent
prescribing aligned
with NICE Guidance
NCN Lead
31.3.16 Year-end reporting requirement
Regular updates at NCN meetings
Prescribing switch options
discussed in the round
Pharmacy Technician Practice
visits to identify and discuss
potential cost efficiencies
Strategic Aim 8– Delivery consistent, effective systems of Clinical Governance
No Objective Agreed actions Outcomes Key
Partners
Time-
scales
RAG
8 Clinical Governance
8.1.1 To fully implement the
Clinical Governance
Toolkit
To ensure practices are
supported in completing the
CGSAT
Consistency and
safety in Practice
and NCN wide
Practices / PC&ND / NCN
31.3.16
Year-end reporting requirement
14
Sessions to be established to
support GP practices in
completing the CGSAT
Target support for areas of the
CGSAT which are identified as
showing low levels of
achievement
Access arrangements - core
access arrangements; aids to
access user experience; the
impact of My Health On Line.
How practices respond to
urgent requests and same day
requests from care homes,
Welsh Ambulance Services and
Hospital emergency
departments.
Actions to foster greater
integration of health and social
care.
Consideration of how
community resources can be
maximised to meet local needs.
Consideration of how Third
Sector support may be
maximised
Map local GP services to
highlight where services are
delivered across practices (for
example, contraceptive
services, minor surgery)
How new approaches to the
delivery of primary care might
aid service delivery and ensure
sustainability of local services
Consideration of the impact of
local care pathway work
relating to previous QOF work
primary care
services
15
Strategic Aim 9: Other locality issues
No Objective Agreed Actions Outcomes Key
partners
Time-
scales
RAG / Progress
9.1.1 NEW: To raise
awareness of and
tackle the effects of
Alcohol
Adopted as a local
priority 2015-16
Links with Supporting People Needs Mapping 9th June 2015 Links to ABUHB Service Change Plan No. 3/4/5 Links with 1.2.1 vulnerable groups for increased flu up-take
• Scope ways of identifying
hazardous and harmful drinkers
• Engage with the development
of the integrated alcohol
treatment pathway (Newport
NCN lead)
• GDAS to attend NCN / Practice
Manager’s meetings
• GDAS to liaise with GP Practices
to raise awareness of new
service and support available
• Identify training needs and how
issues can be shared across
secondary care mental health
service providers
Identified
approaches ensure
service users, and
carers where
appropriate, feel
involved and
engaged in the
identification and
achievement of
personal outcomes
NCN / GDAS
/ Public
Health /
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31.3.16
Assembly for Wales Alcohol report 2015.pdf
GDAS background.doc
NCN leads (N&S) meeting with GDAS:
• Alcohol brief intervention training
available for professionals
(midwives/community nurses –
NCN help to facilitate access to
GPs)
Refs received from any service
with consent of service user
5 year service for Monmouthshire
GDAS can refer to GSSMS directly
with regular meetings
All 18+ yrs D&A referrals engaging
in treatment detox / scripts /
recovery
GDAS to look into how GPs are
notified when people are engaged
in the service, outcomes and when
discharged
Simplified referral forms in place
but will take phone/GP own (e-)
referrals also
SPA email address
Data will be made available e.g.
referrals by Practice
Outreach campaign >65 group of
established alcoholics to engage
with service
Practices Flu campaigns would
help target >65+ year olds
starting October – GDAS team can
support flu campaign for any
queries
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