annex 3 cluster network action plan 2015-16 central vale ... vale cluster plan 2… · public...

Quality and Outcomes Framework guidance for GMS contract Wales 2015/16

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Annex 3

Cluster Network Action Plan 2015-16

Central Vale Cluster


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The Cluster Network1 Development Domain supports GP Practices to work to collaborate to:

• Understand local health needs and priorities. • Develop an agreed Cluster Network Action Plan linked to elements of the individual Practice Development Plans. • Work with partners to improve the coordination of care and the integration of health and social care. • Work with local communities and networks to reduce health inequalities.

The Cluster Network Action Plan should be a simple, dynamic document. The Cluster Neytwork Action Plan should include: -

• Objectives that can be delivered independently by the network to improve patient care and to ensure the sustainability and modernisation of services.

• Objectives for delivery through partnership working

• Issues for discussion with the Health Board For each objective there should be specific, measureable actions with a clear timescale for delivery. Cluster Action Plans should compliment individual Practice Development Plans, tackling issues that cannot be managed at an individual practice level or challenges that can be more effectively and efficiently delivered through collaborative action. This approach should support greater consistency of service provision and improved quality of care, whilst more effectively managing the impact of increasing demand set against financial and workforce challenges. The action plan may be grouped according to a number of strategic aims.

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A GP cluster network is defined as a cluster or group of GP practices within the Local Health Board’s area of operation as previously designated for QOF QP

purposes


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

No Current Position/

Objective Key partners

For completion by: - Outcome for patients

Progress to date Timelines RAG Rating

To cater for an increasing population. Central Vale Population 61725. This is expected to go up by 7-8% and increasing consulation rates need to be modified/ diverted. Increasing number of consultations. 15% increase older patients. How to cope with this growth?

PH Practices 3rd Sector UHB

All partners Cleo/ UHB

Resources are limited and becoming increasingly stretched. New ways of working will need to be found in order to preserve key services. Eg patients seeing other health care professionals

Two practices making significant changes to day to day work plans. All practices greed to allocate cluster money to Primary Care Foundation. Cleo is the link. Need to notify UHB formally as matter of urgency.

WQ expect to be able analyse by Dec 2015 and then report to group to share learning.

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Address health burden of Deprivation- 50% classified as “most deprived” or next most deprived,

Public health 3rd Sector Local

Clusters PH 3rd Sector

Reducing morbidity, both mental and physical Improving life quality and expectancy

In general, prevalances locally are higher that national averages. But there is some

6m to find from Jamie how best to receive referrals

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associated with increased incidence of smoking, diabetes, obesity and subsequence increase heart disease, lung disease, cancer etc.

Authority Practices

Better ability to work

significant variation in prevalence across practices that needs to be address. Coding etc. Share with buddy practices who have improved their prevalences? Practices need to actively review prevalence data. One year ago Jamie Lane presented data. NO follow up to date has been provided. Smoking prevalence falling in Wales but above average in all our practices ( bar one) . Increased referral rates from most

Need quit data from Dan Clayton


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practices. Need quite rates to complete the excercise Cleo to liase Development of wellbeing service for elderly at Golau Caredig- do we want to know about this?

High Mental Health Prevalance perceived. In fact 2014 data shows below ave. For C+V exc Court Road, Ravenscourt, VFP)

CMHT Communities First? Health and Well-Being Coordinators. PMHSS CAMHS

All AK

Group of patients identified with unmet needs. Often do not meet “criteria” for MH services but place frequent demands on general practice, OOH, A&E as limited sources of help. IN particular younger patients , before they become more unwell.

PMHSS in common use. Any difficulties accessing PMHSS?- camhs; would like them to come along. Reduced access. Difficulty in access. Confusion in redirecting patients. LV : counselling services. And interface in GP practices.

Largely beyond our control


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Awaiting new guidelines coming from CAMHS

Increase uptake of influenza vaccination. Last year was a struggle after media coverage confirmed that effectiveness of immunisation was poor. Some other practices beyond the cluster have made significant impact by use of targeted letters/ texts. So called “ nudging”. Especially in high risk groups.

Flu Vaccine Companies UHB Public Health Midwives District Nursing Team Local Press Flu Nurse

All Cluster Practices Locality Manger Led by NG and CG

Vaccination to protect against flu to reduce to risk of infection/ serious complications during winter months.

Applications for flu funding projects submitted by practices – awaiting outcome. Vale advertising campaign arranged between practices for radio and local press. Sharing of disease specific invitation letters which can be used for at risk patients Expressions of interest for flu nurse to

October 2015


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administer domiciliary flus that would not be covered by DNs. And to include other residents at the same address. Paid for by slippage. Practices need to prepare lists so ready to start October 2015- NG update: NH happy. Proposal gone to LC. Estimated patient numbers. Prevalence numbers may influence numbers. PMs meeting to iron out logistics. Not to forget the money from VW. Option to sign up to the flu part of the ACS scheme


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will be voluntary.

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

needs of local patients

No Objective Key partners For completion

by: - Outcome for patients

Progress to Date RAG Rating

MHOL NWIS PCSD

All Cluster Practices

Flexibility to book, cancel and check appointments. Ability to request medication online

All practices in cluster now offering MHOL to patients. Is this finished? Can it come out?- yes. Any issues to be fed back to LV= practice

Succession Planning – GPs

Newly Qualified GPs School of Medicine Locum Bank UHB/ SSP Cluster Practices UHB/ SSP

Practices identifying recruitment needs All Cluster Practices

Continuity of care from GP Practice locally. TO ensure that patients still have good access in the right location in spite of difficulties recruiting replacement GPs or affordablelocums. Perhaps using different practices for

Continued need to highlight this with UHB with increasing difficulty of recruiting GPs, nurse with right qualifications, and retirement pending in several practices in the next 203 years.


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difference problems.

NO cluster wide workload analysis. age, skills, specific shortages. Cannot get HCA’s Cluster wise view difficult to collate. AB: WG intro sustainability document form UHB. To analysis particular pressues and help make a plan for struggling practices. Need to score more than 50 points. This will exclude a lot of our practices? AB feels not. Encourage practices to look closely as might score and get the input. CW feels the risk


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assessment is in depth but what to do if not scoring.

Explore integrated methods of working within the cluster through Collaborative Merger/ Coop ?

All UHB to approve process

Cluster Practices Where practices can work together, share resources and services patients will benefit locally through wider choice and access to a full complement of services that they may not otherwise benefit from where practices work in isolation.

Consider the impact of enhanced / non core services on core GMS. Consider the impact on other practices, of ES not being delivered locally?

Practice. UHB CW All practices CW

If replacement cannot be recruited, patients will have to go elsewhere to get additional services. As pressure grows on GMS , patients will still need these ES to come from somewhere.

Nil current , but UHB need to know that practices at saturation point


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and may become a risk

Inter-practice referral system within the cluster for Enhanced Services

Access to equitable services such as IUD fitting/ removal, Minor Operations, Nexplanon insertion/ removal where some practices do not have accreditation or appropriate skill mix to provide service

Devised template referral form for use within the cluster. Seeking approval from UHB for its use to commence inter-practice referral.

Primary Care Foundation – review of access across cluster practices

Primary Care Foundation UHB OOH

Cluster Practices with the exception of West Quay, Sully

Review of practice arrangements for access to services – if improvements or adjustments are identified and implemented potential for patients to benefit from those changes.

To date Central Vale Cluster have expressed interest in Primary Care Foundation review of access. Awaiting outcome from OOH Focus Group – timeframe: ? Sian Powell. CB

Secondary Care generated work continues to add pressure to Primary care daily work load.

Clinicians AB UHB clinical governance and prescribing

All Patient results as reported and interpreted by the person that requested them.

LMC audit Still do not get feedback from prescribing/ UHB about reporting.

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Last year there was an LMC audit. Was there ever feedback on this? Is it still something that we need to be highlighting?

Patients get medication initiated and stabilised by specialists where appropriate, thus reducing risk with GPs taking responsibility for complications of unfamiliar medication

Keep in aob.

Strategic Aim 3: Planned Care- to ensure that patients needs are met through prudent care pathways, facilitating rapid, accurate diagnosis and management and minimising waste and harms No Objective Key partners For completion

by: - Outcome for patients Progress to

Date Time frames

RAG Rating

Prudent prescribing around antibiotics. Central Vale historically been high prescribers. Some evidence that this generates demand as patients believe that they need antibiotic to treat

Prescribing Support Team Antibiotic Champion per practice OOH Dr Jenkins to liaise with AK/ secondary care????

All practices in cluster

Better confidence in self management. Fewer s/effs inc C.Difficile Reduced resistance to antibiotics in future Reduced demand on service/ appointments

Two practices in cluster have demonstrated changes in this area. New dates from LIM ; ND to clinical lead on this Microguide

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all tonsilllits, mild LRTI etc. Reduce antibiotic seeking behaviour, thus improving prescribing in line with NICE and reducing demand as patient have unrealistic expectations

introduce last year. Subject for audit and “buddy” practices to compare their experience? LRTI discussed last year as possible subject for audit? Other / Tonsillitis? Can we agree on this? OOH prescribing an issue... Marianne? Amanda : antibs cases to correlate with cluster


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Consideration of implementation of “Canna Project” for managed prescribing systems

Anthony Hall Prescribing Team UHB Pharmacists

Reduced wastage of medicines Reduced inappropriate ordering of items such as dressings, gtn spray etc. As only ordered what patient needs within 7days of request made.

NICE be adopted by all through Winter 2015/16. Adoption of Medicines Management audits to reduce prescribing of antibiotics. Presentation from Anthony Hall on Canna Project. Await outcome of extension of scheme to wider area in Cardiff and audit June/ July 2016 for informed discussion at later date.

Embedding the Cluster Practices All Cluster Patient Safety Appointment August R


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Role of Cluster Pharmacist

UHB Prescribing Team Community Pharmacies Training in systems. DSMP for Ms Jones via UNiversty

Practices Appropriate prescribing with timely review Consistent approach to medication reviews across practices. Waste reduction

of 1.8 WTE Pharmacists. M.s Marion Jones. M.s Kate Jenkins IP Training application in hand for ms Jones. Awaiting HR C+V Ms Jenkins interviewed later, so awaiting recruitment advice.

2015 last interviews. IP course January 2016. December 2015 Ms Jenkins should be ready.

Use of medical technologies using cluster money. Waiting lists in

Cleo Practices UHB

Cleo

Meet NICE gold standard . Reduce unnecessary over -treatment More sensitive and specific.

With procurement

Imminent


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practice who have ABMP and some practices do not have at all. Difficulty with getting real time info on a patient in non-surgery setting

UHB procurement, DS

DS

Clinicians will have real-time current info when visiting patients at home. Deb S : need to make sure we order devices for pharmacists and flu nurse/ winter doctor

Items chosen. Sitting with procurement

Imminent.

Teledermatology - Does

everyone have this? invite to apply via cluster if need be to make available in all practices.

LV : to take WOUND healing and telederm

Review of pathology

Prescribing Support Team


Reduced unnecessary screening

Teaching was

December


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requests to reduce inappropriate requesting/ high screening volume Reduce patient ability to select tests once form has been completed by practice= come off

Pathology Labs Specialist Teams – e.g. lipids management NWIS Vision/ INPS Emis Pathology Labs

Cluster Pharmacists regarding tests associated with medication

Reduced financial costs which can then be re-invested in new services Tests based on prudent healthcare needs e.g. only request what needs to be and will be actioned. Investigate IT solution to enable test requests to be sent directly from practice to BCH phlebotomy to take away possibility of patients adding to screening form.

Done in 2014 But no

current.

Need current data

2015 IT solutions? Nwis test requesting

DRSSW – review

of “reduced onward referrals” to service for newly diagnosed diabetic patients

DRSSW All Cluster Practices

Ongoing care for diabetic patients through retinopathy screening.

Cluster practices reviewed DRSSW data provided to ensure that newly diagnosed diabetic patients have been referred to the

Ongoing. Awaiting new data (also in DM ACS pathway)


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DRSSW for screening. Software on audit plus

Promotion of Screening – Cervical, bowel, breast, AAA- off?

Public Health Screening Services


Ongoing promotion by practices to educate patients on the necessity for regular screening to prevent disease.

Promotion of services via waiting room information and websites.

Right time right place. Last year worked with DN around reducing phone call. KJ now inviting expressions of interest in providing the C+V home phlebotomy service providing around 3000-4000 blood tests per year with around £40k/year

KJ CLusters

For all clusters to consider and AK will respond on behalf of the practice

Ensure DNS are free to provide more specialiseservices, not phlebotomy.

Email from KJ.

Cluster to respond September 2015

Geriatrician of the day: Should this be on here at all? Or in


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strategic aim 4? 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 Key partners For completion by: -

Outcome for patients Progress to Date

Time frames

RAG Rating

Emergency Admissions: Central Vale (exc. Sully). High across all disciplines. Clear outliers in some areas that are worthy on closer inspection at a practice level. Cluster level? With buddy? General surgery, gynae, paeds general, copd, palliative care, (There was one area for Sully : febrile child, and tia/ stroke where above c+v average)

WAST OOH A&E OOH Focus Group

All practices in cluster

Education on appropriate use of OOH/ A&E/ WAST These emergency services are then available to deal with emergencies.

Data 2014 showed all practices to have higher than C+V ave attendances (all ages) at A+E and emergency referrals ( exc Sully). Data sent to practices. Practices to analyse data and where appropriate. Some practices contact patient

Review with next data set. Do we want to add an specific initiative here?eg GP leads to agree to budd commenty and

A


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nearly Review inappropriate usage of Unscheduled Care attendance by patients. TO consider if practices can influence this.

to provide education on appropriate usage. Should this become standard?Do practices want to buddy with similar practices with lower numbers to support change? Changing message on phone after 6.30?- wait for UHB feedback

Statement of intent regarding BMIU?

Statement of intent regarding poss “ step up wards at BH?

Winter pressures Dr Cluster Locality Secondary care to help with recruitment

AK SB LC JG?

Proactive approach rather than reactive A new doctor but one with expertise in elderly care.


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Strategic Aim 5: Improving the delivery of end of life care No Objective Key partners For completion by:

- Outcome for patients Progress to

Date Time lines RAG

Rating

Up skill Palliative Care delivered by Practices Improve confidence in delivery of ACP and DNAR Ensure smooth transfer of information from

OOH Marie Curie Macmillan GP Facilitators – Dr PC Secondary Care

All practices in cluster PC/ CD AK

Routine referral to OOH Early consideration of ACP tool. Awareness of Palliative care in non-cancer care. More confident Doctors. Timely referrals.

CPET session with Dr PC (Court Road), Dr MC ( POH) agreed in rinciple but dates to be arranged, . Also Dr Mark Taubert, Dr

Clinicians have been contacted and agreed in principle to offer some teaching , maybe at CPET session?

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Opportunity to be part of a research project to better understand the effectiveness of this type of intervention in patient care and, if effective, to form part of future bids for similar work in the future.

ACS pathways? A practice choice not cluster, but work may support the cluster


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primary care to ooh/ palliative care services etc

DNACPR.

Nikki Pease ( Cons Pall Care) have both agreed in principle to provide session on drugs in palliative care and DNAR

Implementation of GSF for palliative care

OOH Marie Curie Macmillan GP Facilitators

All practices in cluster MC

Consideration of implementation of GSF by cluster practices which will increase numbers of patients with end of life planning arrangements across multiple disease areas.

PoH working on GSF currently and will share progress so far with cluster group. For consideration of implementing part/ all of GSF across practices

Dr MC to present at Cluster meeting/ CPET as needed

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ACS pathways? A practice choice not cluster, but work may support the cluster

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


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No Objective/ where we are today

Key partners For completion by: -


RAG Rating

Significant delays in diagnosis of ovarian cancer be recognised for many years. Significant delays in getting uss pelvis in patient. Increase appropriate use of Ca125

All Practices in Cluster Zoha ( Biochem) CD’s FF Simon Short Ceri Donaghy?

Collection jan 2015-december 2015 then case reviews in cluster March 2016

Early diagnosis , Better survival

New cancer sea tool Need current data on CA125

Something around lung ca? Lung cancer is one of the four most common cancers in Wales and the most common cancer worldwide. It is the commonest cancer leading to death in the European Union. In Wales, each year it accounts for more deaths than breast

Engage with Respiratory CD ( Dr Ferner) And secondary care

Collection jan 2015-dec 2015. As above

Early diagnosis. Better survival


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and colorectal cancers combined. Most cases of lung cancer are non-small cell lung cancer. At an early stage it is potentially curable or survival can be improved with surgery and/or radiotherapy. However, at present, most people in Wales present with a late stage of disease or are diagnosed at death. The women’s lung cancer incidence rate in Wales is the third highest of 40 European countries4. The rate in men is higher than 11 of those 40 countries. Lung cancer incidence cannot be ignored anywhere in Wales.


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The annual number of cases and the incidence rate is increasing in women in Wales, especially amongst older women. Over ten years, annual numbers remained similar in men, but in women they increased by over a third. Overall, numbers increased by ten per cent. The annual number of cases in women is now slowly approaching that in men. In Wales in 2013 there were 1,343 new cases in men and 1,075 in women. Lung cancer has the strongest link to deprivation of all the most common cancers, mainly due to the link with


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smoking and past industries. Relative lung cancer survival in Wales is almost the lowest in Europe – 28th out of 29 countries in the Eurocare study1. Comparing Cardiff and Vale Clusters: Highest Prevalance in Central 9 (p 11,13,15 of C+V Cancer Report. )

Something around GI Ca? Something about bowel screening

Engage with Dr Simon Short (CD Gastro) And secondary care

Collection jan 2015-dec 2015 As above

Early diagnosis. Better survival. Patient better informed about benefits of bowel screening tool.

Complete audit tool All practices in cluster

December 2015 Increase Teaching 2014-15 Possible need to re visit teaching

Significant Event Analysis

PC ?


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To evidence if screening works

Public Health

Strategic Aim 7: Minimising the risk of poly-pharmacy No Objective Key partners For completion


Date RAG Rating

Recruitment of Pharmacist Support in-post training

Cluster Practices UHB Prescribing Team Community Pharmacies


Consistent approach to medication reviews across practices. Using poly-pharmacy medication review NO TEARS format to prudent prescribing/ do no harm.

Interviews of potential Pharmacists.

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ACS falls and polypharmacy?

UHB Cluster Practices

? October 2015-2017

Decrease unscheduled care For consideration

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Any teaching needs identified?

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

No Objective Key partners For completion by: -


RAG Rating

Shared Protocols All Cluster Practices Staff and Cluster Practice Managers to lead

March 2015 Consistent high standards across the Cluster

PMs meeting locally to review and share


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Clinicians policies where appropriate

DR: penicillin allergy audit. SW clster template.

Feb/ mar 2015?

Strategic Aim 9: Other Locality issues No Objective Key partners For completion


Date Time frames

RAG Rating

Dressing/ Wound Care/ Leg Club established to take burden of workload from practices into a community centred service focusing on patients well-being

Lindsay Leg Club Wound Clinic UHB Third Sector agencies – e.g. Age Concern District Nursing


Reduction of isolation during periods when affected by wounds that require regular nursing care but can cause patients to become housebound/ lose confidence

Audit carried within cluster practices to identify potential numbers of patients for the service. Review of potential facilities available at BCH – as a central location, where such a service could

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be hosted. Interest from Community Nursing expressed – to be explored further when numbers of potential patients known. Unlikely that Cluster Money will stretch to this so might need to consider funding streams

Better engagement with 3rd Sector

3rd Sector Champions Carers Champions ?Well being champion

Locality manager VCVS Linda Pritchard

Access to local services Reduce medicalisation of non medical problems

annex 3 cluster network action plan 2015-16 central vale ... vale cluster plan 2… · public...

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