bay gp cluster network action plan 2015-16 update 30.09 gp cluster... · 2016-07-06 · services...

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GP Cluster Network Action Plan 2015-16

Bay Cluster

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Welcome to the Bay Health network/cluster plan for 2015/16.

The Bay Health Network is one of five community network areas in Swansea, geographically covering Uplands, Sketty, WestCross, Mumbles, Killay, and Gower, also serving students resident at Swansea University.

Bay Health is made up of eight general practices working together with partners from social services, the voluntary sector, and theABMU health board, with practice populations ranging from 3,726 to 21,496, amounting to a cluster network total of 74,446.

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Networks aim to work together in order to:

• Prevent ill health enabling people to keep themselves well and independent for as long as possible.

• Develop the range and quality of services that are provided in the community.

• Ensure services provided by a wide range of health and social care professionals in the community are better co-ordinated

to local needs.

• Improve communication and information sharing between different health, social care and voluntary sector professionals.

• Facilitate closer working between community based and hospital services, ensuring that patients receive a smooth and safe

transition from hospital services to community based services and vice versa.

In order to support the development of the network cluster plan, information has been collated on a wide range of health needswithin the Bay area. The health needs information has been taken into account when developing the priorities for this plan.

The summary below highlights characteristics of the Bay network:

• Increasing list sizes, approx 3,814 patients between 2009 - 2015

• A high elderly population requiring community base care for multiple and complex ailments. One fifth of persons registered

in the Bay network cluster are aged 65 + years (21.5%); the fourth highest % of patients 65 + years of all networks within

ABMU Health Board area. One tenth of patients registered in the Bay network cluster are aged 75 + years (10.7%)

Bay Health Cluster% Male/Female Aged

65+ and 75+

Age Band Female Male Persons % Female % Male

Aged 65+ 8,942 7,863 16,805 53% 47%

Aged 75+ 4,662 3,654 8,316 56% 44%

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• Large student numbers living in the surrounding areas to the Swansea University Campus meaning practices need to

address multi racial/cross cultural needs.

• High numbers of 20 – 24 year old males and females

• A comparatively low % of patients (6.4%) live within the most deprived areas.

• 14.8% of Bay health population live in areas classed as rural.

• Fewest number of Emergency Department attendances across Swansea network areas

• Obesity (6%), ABMU Average 10%

• Uptake on Bowel Screening, 56.8%, Target 60% - the highest uptake of all networks across ABMU Health Board.

• Uptake on Cervical Screening, 79.4%, Target 80%

• Uptake on AAA Screening 76.6%, Target (80%)

• Uptake on Breast Screening Uptake 76%, Target (70%)

• Proportion of known smokers for persons aged 15 years and over with a recorded smoking status, 13%. This is the lowest

within the Swansea and ABMU areas; however, smoking remains the biggest cause of premature death.

This is the second cluster plan that has been produced by the network and it is the aim to further develop the plan over the comingyears. The network will be regularly monitoring progress against the actions contained within the plan.

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

No Objective KeyActions

Key partners For completionby: -

Outcome forpatients

Progress toDate/CurrentPosition

RAGRating

1 To understand theprofile of the BayCommunityNetwork and theeffect thatdeprivation has onthe practicepopulations.

To consider the demographicsof the community network andthe impact on service delivery

Local Public Health TeamPublic Health ObservatoryHealth Board

September 2015 To ensure thatservices aredeveloped accordingto local need

Demographics havebeen consideredduring formulation ofcluster network plan.

2 To increase bowelscreening uptake

To continue to raiseawareness of bowel screeningprogramme:

Advertising via posters &leaflets provided by bowelscreening Wales in variouspublic sites including GPpractices, communitypharmacists and local authoritybuildings. Also addinginformation to practicewebsites regarding bowelscreening.

To explore opportunisticprompting for non respondersto a screening programmebased on information providedby clinical systems.

To explore the potential tocontact patients by telephonewho have not participated in

GP practicesCommunity PharmacistsLocal Authority buildingsBowel Screening Wales (forinformation)

March 2016 Early detection ofcancers

Measurable outcome:increased uptakefigures

Current screening rate:56.8%

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the programme. (Dependanton funding)

3 To increasecervical screeninguptake

To continue to raiseawareness of cervicalscreening programme:

Advertising via posters &leaflets provided by cervicalscreening including GPpractices, communitypharmacists and local authoritybuildings

To explore the potential tocontact patients by telephonewho have not participated inthe programme. (Dependanton funding)

GP practicesCommunity PharmacistsLocal Authority buildingsCervical Screening Wales (forinformation)

March 2016 Early detection ofhealth risks

Current screening rate:79.4%

4 To increaseattendance ofdiabetic retinopathyreviews

To prompt patientsopportunistically

To explore the potential tocontact patients by telephonewho have not participatedattended reviews. (Dependanton funding)

GP Practices

LHB

March 2016

5 To evaluate thealcohol screeningpilot and agreerecommendationsfor future schemes

To review completedscreening questionnaires andgather evidence of briefintervention provided topatients and referrals toappropriate services.

GP practicesCDATVoluntary sector – AA /WGCADA

March 2016 Health promotion andimproved lifestyle.

Intervention offered tothose who requireintervention.

Pilot commenced 1st

December 2014.Questionnairescompleted by all newregistrations inpractice. Pilot to runfor 1 year, untilNovember 30

th2015.

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6 To introduceopportunisticscreening for:

AFscreening

AF screening:Utilise consultations and flusurgeries as opportunity toopportunistically screen for AFusing assessment of pulse

Consider somematerials/advertising tosupport AF screening

Community pharmacists (forAF proposal)

Ongoing

AF screening:To reduce risk ofCVAsIn line with nationalpriority around AF andCVA

7 To increase fluimmunisationuptake

(adult & childhoodprogramme)

Discuss schemes inplace/share good practiceacross practices that increasehigh uptake and how theymanage defaulters.

GP practices March 2016 To protect patients atrisk and the widerpopulation.

Good practicediscussed.Key success factorsidentified as :• GP Immunising• Flexible clinic

times• Personal contact

to patients

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Practices to completeseasonal influenza plans andsubmit to HB for review andsharing of good practice.

GP Practices September 2015

Two practices in Bayhave accepted furthersupport andpartnership workingwith PHW to helpmonitor flu planningand improve uptakefigures. Practices toshare learning points,progress andachievements.

8 To further developthe third sectorsupport projectincreasing the useof voluntary sectorservices by the BayHealth networkpopulation

Provide opportunities for thirdsector organisations to attendfuture Protected Learning timeSessions with GPs and nonclinical staff.

Ensure that linkages are madewith voluntary sectororganisations supporting theagreed network priority areaswhere possible.

Ensure that up to dateinformation on voluntary sectorservices is displayed in GPpractices, e.g. informationstands, notice boards.

To evaluate the pre bookableappointments system and thepresence of voluntary sector

GP practices/Voluntary SectorOrganisations/ SCVS

GP Practices/Third Sector

March 2016 andongoing

March 2016

Improved support andaccess to services forthe Bay healthpopulation

Presentations weredelivered on alcoholawareness andsupport services, andin addition mentalhealth during January2015.

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that has been trialled in theBay network.

Network to work with LocalArea Coordinators to agreeclear eligibility criteria in orderfor practices to refer suitablepatients.

To assist in the promotion ofLAC project in relevantpractice areas.

Business supportmanagers/Practices/LACs

March 2016 Better signposting toservices that can meetpatients social needs

LAC attended JulyNetwork meeting tointroduce themselvesand discuss theproject.

9 Access to CitizensAdvice Bureauwithin GeneralPractice

CAB to provide an advice

service resource in the GP

practices within the Network,

through the provision of advice

workers for Bay, 1.5 days per

week.

The pilot will also be fullyevaluated following the end ofthe pilot

Locality/CAB/GP Practices Funding until March

2016.

Full evaluation willthen be undertaken

Better support forpatients with welfare/social problems thatneed dedicatedsupport and guidance.

Funding has been

given to C.A.B to start

a pilot, providing

information and

support to patients

10 To increase the useof the Healthy CityDirectory within thenetwork

To continue to promote theuse of the Healthy Citydirectory within practices andto patients.

NHS Direct/HealthBoard/SCVS/Voluntary Sectororganisations

March 2016 andongoing

Network populationmore informed onavailable health andwell being servicesleading to increasedusage.

11 To obtain patientand carer views onnetwork servicesand prioritiesprogramme

To work proactively with theBay Health Patient CarerParticipation Group onpriorities for 2015/16, inparticular, waste managementand flu immunisationscampaigns of which the grouphave agreed to support andfurther promote.

SCVS/GP Practices/HealthBoard

Ongoing through2015/16

Responsive servicestaking into accountservice user and carerfeedback.

The network lead hasattended the patientparticipation group topresent detail of thecluster plan andnetwork news, discussfuture plans and thegroups involvement insupporting the networkand supporting

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projects.12 To improve the

recording of patientsmoking status

To better record/update patientsmoking status

To promote access to level 3prescribing service offered bylocal pharmacies and StopSmoking Wales or establish anin house stop smoking service.

GP Practices

GP Practices

Ongoing

Ongoing

A reduction in thenumber of patientssmoking.

13 To reduce obesityin children

To encourage referral tochildren’s services for obesityin children.

To promote existing servicesto support children with obesity

GP PracticesThird Sector LHB

March 2016 Improved health andlifestyle

Data on childhoodheights and weights tobe obtained for sharingwith the clusternetwork.

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


Keypartners

Forcompletionby: -

Outcome forpatients


RAGRating

1 To continue to develop accessarrangements to primary care whereappropriate

Develop mechanisms to monitorworkload and demand within primarycare to demonstrate the sheer volumeof work undertaken

Discuss accessarrangements acrosspractices and discussvariations i.e. any good ideasfor practices to considerimplementing

To work proactively with thePrimary Care Foundationcompleting tasks to assist inthe review of current accesssystems and capacity and toconsider any changes toprocess, appointments orclinic schedules on the basisof report findings.

To promote the choose wellcampaign and offer self careadvice through the delivery ofa Wave and Swansea Soundradio advert designed anddelivered by the network.

Explore mechanisms andbest use of text messagingservice for health invitationsand appointment remindersfrom IT systems – to improvecommunication with patients

GP Practices

GP Practices/PCF

GPPractices/LHB/Wave &SwanseaSound

HealthBoard/NWIS

Ongoing

March 2016

September2015

March 2016

To provide moreaccessible services forpatients

To provide patients withself care advice and directthem to the mostappropriate service tomeet their needs.

To reduce the number ofDNA’s (do notattend)/wastedappointments

7/8 practicesundertaken work setby the PCF with anarranged reviewmeeting scheduledwith each practices todiscussresults/findings.

Advert agreed and tobe broadcast 100times over a 4 weekperiod duringAugust/September2015.

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and intend to reduce DNAs.

Increase practice use ofMHOL and promote systemto patients to help reducenumber of calls received bypractice.

GP Practices

March 2016

MHOL training sessiondelivered duringPractice ManagersForum held March2015

2 Succession planning of practice andcommunity staff

Review workforcedemographics withinpractices and withincommunity – particularemphasis on GPs and PNs

Review the communicationprocesses between GPpractices and communitynursing team

GP practices/Locality staff/Communitynursing leads

GP Practices,CommunityNursing

Ongoing

Ongoing

Increases the availabilityof experienced andcapable employees toaccept roles and maintainsafe and effective servicesfor patients both withinand across practices andwider community.

Better coordination of care

3 To address difficulties in recruitingpartners and the shortage of locums

Address the pressure facinggeneral practice:

GP practices Ongoing More sustainable services

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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 harms


Key partners Forcompletionby: -

Outcome for patients Progress toDate/CurrentPosition

RAGRating

1 To improve care given to care homeresidents

To increase the numberof practices within thenetwork delivering thecare homes enhancedservice.

LHB March 2016 Improved quality of care

through pre-emptive

medical care, thorough

medical assessment,

regular medication reviews,

anticipatory care planning

and improved care at end

of life.

Education of staff will assist

in management of patients.

Should reduce 999 calls

6 of 8 practices inBay have nowsigned up to thenew care homeenhanced service.

2 Shared care/substance misuse –opportunity to cross refer

To explore the potentialfor Sketty & KillaySurgeries to provide theenhanced service for thenetwork.Contingencyarrangements forservice to be resolved.

LHBGP practices

December 2015 Consistency of serviceprovisionConvenience of serviceprovision closer to patientin community

3 To pilot a dementia friendly networkapproach

To undertake dementiafriendly training for allpractices in the Bayarea

To identify early signs of

Social Services,Third Sector

GP Practices

March 2016 andOngoing

Improved awareness andunderstanding of dementialeading to improvement inservice delivery.

5/8 practices in Bayhave undertakendementia friendlytraining to date.

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dementia, improvingread code in practiceand to encouragepatients to attendmemory clinics.

4 PMS Plus

Respiratory Prescribing: to beconsidered on a network basis

To undertake a range of

prescribing initiatives as

required to improve

respiratory prescribing

GP’s withinnetworks/support fromMedicinesManagement tobe determinedon practice level

November 2014onwards

Improvement in patientsymptom control

Decision of all 8 Baypractices to sign upto the scheme andretain 100 % of thesavings for thenetwork.

5 To deliver consistency of provision ofEnhanced Services across clusterwhere appropriate(acknowledging differences of theUniversity population)

Cross cluster review of

Enhanced Services

provided – gaps in ES

delivery to be discussed

and outcome

documented.

To increase uptake of

the Mental Health DES

by organising a specific

cluster PLTS

Practices andLHB

GP practices,third sector,LHB

Ongoing

Ongoing

Identification of action plan resources needed

– training / staff IT requirements if

appropriate Accountability and

governanceframeworks inplace to enablecross practicereferrals

6 To engage as an early adopter inanticipatory care to work with peopleat most risk of losing independence

(subject to funding)

To act as the early

adopter for anticipatory

care, establishing

systems to:

• Identifying those

most vulnerable of

losing their

independence

CommunityHubs/olderpeoples mentalhealth services

March 2016 Initial workshop heldand preliminary datebeing obtained forfuture discussion.Outcome of bid toWelsh Governmentawaited.

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• Identify care

coordinator and care

plan systems

• Develop effective

means of

communication

7 To reduce the wastage of medicines -prudent prescribing

Cluster spending

plans/bids to include:

To purchase

stands/banners for

display in each practice

to promote the wastage

of medicines campaign.

Polypharmacy reviews

to be undertaken by a

Bay health pharmacist,

to include visits to care

homes and patient’s

homes to better

healthcare and lead a

cost effective and

educational role.

Pharmacist to support

provision of self care

management, pharmacy

reviews and chronic

disease patient

education.

GP Practices/LHB

Ongoing Reduced wastage ofmedicines and costs.

8 To introduce new models of effectiveand efficient delivery of service

To discuss and consider GP PracticesLHB


More sustainable services

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supported and facilitated bytechnology

uses of technology such

as I pads and Skype

with informatics to agree

a more efficient

provision of service to

particular cohorts of

patients, or patients in

certain settings, e.g.

care homes.

NWIS

9 To improve access to dermatologyservices within the community,therefore, reducing the number ofpatient referrals to hospital

GPS to be up skilled

and receive appropriate

training in the use of

dermoscopy and its

technique.

Use of cluster spending

to purchase

dermatoscopes and a

camera package for

each practice.

GP PracticesLHB

March 2016 Less secondary carereferrals.Better service for patients.

Quotes awaited forequipment.

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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



Outcome forpatients


RAGRating

1 To work in partnership withA&E staff to pilot the SeniorDoctor Advice Line Tel:01792 530700

Network to determine whatinformation needs to be collectedby the advice line - queries/advicegiven/outcomes

A&E Staff/GP’s Review postApril 2017

• Improvedsupport/advice forGP’s

• Appropriatereferrals toSecondaryCare

• Strengtheninglinks withSecondaryCare

Dedicated phone lineestablished within A & E.Backline phone numbersprovided by all practices.

2 To educate patients inidentifying the mostappropriate place to receivetreatment and how tomanage self care.

Practices to promote self careeducation through use of resourcessuch as bibliotherapy, choose wellcampaign, booklets for patients andparents, newsletters in waitingroom or on notice boards.

GP Practices Ongoing To educatepatients how toself care andaccess servicesappropriately.

3 To improve antimicrobialstewardship

Medicinesmanagementteam

Ongoingquarterlymonitoringtrends

Reducedresistance.Reduced c.diff.Increasedknowledge andempowerment toself care

Discussed at all annualpractice prescribing visits.Cluster level data to beshared at forthcomingcluster meeting.

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



Outcome forpatients


RAGRating

1 To review the numberof deaths as perguidelines

Undertake review of number ofdeaths as per guidelines

GP PracticesSecondary Care


Identification of trendsacross the networks

National pathway work tobe undertaken betweenOctober 2015 and March20162 Practice level regular

palliative care reviewsand completion ofEOL template

Undertake review of palliative carecases on a regular basis

GP PracticesSecondary Care


Identification of goodpractice and areas ofconcern

3 Undertake regularaudit; sharing resultson a cluster networkbasis

Regular audits to be undertaken andlearning points to be progressed

Ongoing

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


Keypartners

Forcompletionby: -

Outcome for patients Progress toDate/CurrentPosition

RAGRating

1 SEA of all new lung, stomach andGI cancers

Regular review and audit oflung, stomach and GIcancers

GPPractices


To diagnose cancers asearly as possible

National pathwaywork to beundertaken betweenOctober 2015 andMarch 2016

2 Undertake regular audit; sharingresults on a cluster network basis

Regular audits to beundertaken and learningpoints to be progressed

GPPractices


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Strategic Aim 7: Minimising the risk of poly-pharmacy



Outcome for patients Progress toDate/currentposition

RAGRating

1 Appointment of clinicalpharmacist

Clinical pharmacist to beappointed and shared acrossthe network focussing onpolypharmacy issues particularlyrelating to patients who havebeen discharged from hospitalor are residing in a care home.

GP PracticesHealth Board

Ongoing with2015/16

Shared clinical pharmacistwould reduce medicineswastage, ensurecompliance with medicationand reduce the risk of drugcontra indications topatients across thenetwork.

All patients across the Baynetwork will benefit fromenhanced service provisionensuring positive patientoutcomes.

£90,000 allocated toimplement the clinicalpharmacist serviceacross the network

2 Improvement/maintenanceagainst target prescribingindicators

Can consider and review

practice and network data for

antibiotics / statins / hypnotics &

anxiolytics and discuss how

improvements can be made if

required

GPs within practice

and networks

Improvement in prescribingquality to improve healthoutcomes

6 To improve medicinesmanagement

To provide accredited training

for prescribing clerks

Medicines

management team

March 2016 Improved repeatprescribing systems

Training packs indevelopment

To ensure appropriate use of

the pharmacist technician

resources to reduce risks from

polypharmacy

Medicines

management team

Clusterpharmacistavailable byOctober 2015

Improved access forimproved pharmaceuticalcare

To engage in the prescribing

management scheme (PMS)

Medicines

management team

PMS 15/16 –by March 16

Improved medicinesmanagement including

All practices engagedand making progress

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and PMS+ respiratory schemes

(which contain polypharmacy

elements)

PMS+respiratory –by Nov 16

polypharmacy

To progress polypharmacy

issues identified in previous

cluster network plan

Practice teams Ongoing Improved prescribing andmechanisms forpolypharmacy review

Ongoing

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



Outcome forpatients


RAGRating

1 Demonstratinggovernance within thepractice:

Completion of theCGPSAT

Each practice to complete theCGPSAT

Practices March 2016 andongoing

Assurance that practiceshave clinical governanceprocedures in place

2 Cluster wide discussion ofsignificant event analyses

Each practice to bring onesignificant event to a clustermeeting during course of year

Practices

LHB / Datix

March 2016 Assurance that practiceutilise significant eventsfor ongoing learning

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Strategic Aim 9: Other Locality issues



Outcome forpatients


RAGRating

1 To continue to support the

development of integrated

health and social care

services for older people

and younger disabled

adults in Swansea.

To act as a key stakeholder in

informing the ongoing

development of integrated

health and social care teams

delivering services for older

people.

Linking in with network to ensure

appropriate and consistent

linkages are made.

Network to inform the review of

the single point of access

(Intake) for the integrated team

Social Services,

community nursing,

third sector, primary

care, domiciliary care,

independent care

providers

March 2016 and

ongoing

More effective,

timely and co-

ordinated health and

social care and a

better ability to

manage demand.

2 INR service – ensuringdosing and prescribingare not separated

Review of INR service toensure includes NOACs

INR Enhanced Service to becommissioned across practicesORconsideration given tomechanisms to not separateINR monitoring from prescribing(e.g. use of pharmacists ormedical scientists in communitydoing dosing & prescribing ORsecondary care prescribing asthey do monitoring and dosing

Ensure INR servicecommissioned includes NOACs

LHBGP practices +/-secondary careservices +/- HBmedicinesmanagement teams

Ongoing Safer servicesthrough notseparating roles ofmonitoring andprescribing – in linewith MHRA

ABMU working groupestablished to reviewthe INR service.

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where appropriate3 Education of practice &

community teamsDevelop shared educationagenda through communitynetwork PLTS

GP practices, LHB,community staff

Ongoing Staff remain up todate

KT has secured arange of speakersand formed adetailed programmefor Practices withinthe network linked toBay Health andHealth Boardpriorities. Sessionshave been positivelyreceived and will besimilarly planned for2015/16.

4 To develop the skills ofreception staff to betterinitial patient experienceand improved outcome

To organise a network sessionfor admin and reception staff toundertake patient customer careand call handling training.

GP Practice Staff March 2016 To improve theservice provided topatients and bettertheir experience.

bay gp cluster network action plan 2015-16 update 30.09 gp cluster... · 2016-07-06 · services...

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