caerphilly north neighbourhood care network action plan ... north ncn action... · towards the...

Caerphilly North Neighbourhood Care Network Action Plan & Progress Report 2015-16

Complete Started Not Started

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

No Objective Key Partners For Completion

by

Outcome Agreed actions / Progress to Date

RAG Rating

1.1 Smoking

1.1.1 Achieve/work towards the National

Tier 1 target of 5% of smokers make a quit

attempt via smoking cessation services, with at least a 40%

CO validated quit rate at 4 weeks

Supports Caerphilly SIP – Healthier Caerphilly H1, H2, H3, H4 Supports IMTP SCP3

NCN

PHW

Smoking Cessation Wales

Housing

Associations Communities

First

Community Pharmacy

31.03.16 Increased numbers of staff who have access to brief

intervention training

Increased access for patients to staff trained in brief intervention techniques

Patients will be motivated to

make a quit attempt and will receive effective treatment to quit smoking

Progress: 2014-15 Figures for Caerphilly

Patients scheduled to

attend a smoking cessation appointment = 441 (467 initial

assessments undertaken)

Number of treated

smokers = 263

% of patients who quit

at 4-weeks (CO-validated) = 54% (40% target level)

Actions

Develop local communication plan with the Communities

First Smoking Cessation Officers

Increase numbers of

staff who have access to

brief intervention training


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RAG Rating

Review data on uptake of smoking cessation services and quit rates

at NCN meetings including with non-

medical members

Continue to improve

referral rate through collaborative working

Ensure every practice

has appointed a

smoking champion

Increase number of pharmacies offering

Level 3 smoking cessation services

1.2 Obesity

1.2.1 To address Obesity issues within the NCN

Network through Partnership working

Supports Caerphilly SIP – Healthier Caerphilly H2, H3, H4

NCN

Social Services/ Communities First

Adult Weight

Management Service

PHW

GAVO

31.03.16 NCN membership and stakeholders will be able to plan

for integrated service provision across the Caerphilly NCN areas.

Families will have access to a

wide range of children and young people’s services, initiatives and projects

addressing obesity issues

Identify baseline data for NCN area regarding

the number of citizens attending services.

Map Level 2 services for weight management

and refer/recommend – Foodwise, commercial clubs, NERS, led walks

Increase in the number

of citizens attending the services.


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RAG Rating

Refer routinely to Adult Weight Management Service

To develop identify

existing service pathways to address childhood obesity needs

1.3 Bowel Screening

1.3.1 Achieve the National

Target of 60%

eligible patients

screened

Supports Caerphilly SIP –

Healthier Caerphilly H2,

H3, H4

NCN

PHW National

Screening Services

GP Practices

31.03.16 Earlier detection of bowel cancer with improved chance of

survival

PHW to liaise with national screening

services regarding providing practices with a list of non-

responders

Identify achievements against national

target of 60% and action to achieve

Practices to complete

work according to protocol

1.4 Public Engagement

1.4.1 To support the work

of the ABUHB Engagement Team in

implementing the Engagement Strategy and seeking /

collecting information

Network Team

NCN

GP Practices

Communities

On-going Formal and informal

consultation opportunities for all residents to influence the

development and improvement of all services (including integrated services) across

ABUHB.

To promote the work of

ABUHB & NCN where possible

To attend events to

provide a range of

information relating to


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RAG Rating

on service provision

and change from the wider Gwent resident population.

Supports Caerphilly SIP – Healthier Caerphilly H4, H5

First

GAVO

e.g. Flu / smoking

cessation / Health initiatives

Feedback findings from Listening Events to NCN

and ABUHB Engagement Teams

Where possible build feedback into actions

for future NCN plans

1.5 Influenza

1.5.1 Achieve the national

target of 75% for

immunisation against

influenza

GP Practices

NCN

Contractor Services

DNs

31.03.16 Decrease in hospital admissions

Decrease in morbidity

Progress:

69% achieved in 2014-15 for immunisation against influenza for 65yrs and

older for Caerphilly North NCN

55% achieved in 2014-15 for immunisation against

influenza for 6months to 64yrs for Caerphilly North

NCN

Hold discussions

between practices regarding best practice

Receive regular practice

updates during flu

season

Hold discussions with DNs regarding


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RAG Rating

immunising

housebound patients

Hold discussions with

Midwifery regarding immunising pregnant

women

1.6 NCN Management Team

1.6.1 Establish a

Management Team Structure for Caerphilly North NCN

NCN Lead

NCN Partnership

Teams

Network team

31.03.16 Improved guidance, co-

ordination and development / skills, knowledge and engagement

Implement

NCN/Integrated Management Team

Agree Priorities for 2015/16

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 Agreed actions /

Progress to Date

RAG

Rating

2.1 Access

2.1.1 Practices to review

performance against LMC agreed access figures

GP Practices

NCN Lead

31.03.16 Practices to engage with project

to optimise access in keeping with emerging guidance to be agreed with CHC, Health Board

and LMC

Practices to monitor

performance against LMC standards

Monitor & report performance to NCN

Lead on a


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RAG Rating

monthly/quarterly basis

2.1.2 Monitor the continuation and

uptake of My Health Online Supports Caerphilly SIP – Healthier Caerphilly H5

Supports IMTP SCP3

NCN, Practices

Pharmacy Advisors

31.03.16 Ease of access to GP services All practices to offer appointment availability

and repeat prescription ordering via MHOL

2.2 Workforce

2.2.1

Improve locum arrangements and

ensure that practices in difficulty have

access to NCN salaried support

team to ensure continuity of service in the short term.

Supports IMTP SCP3

ABUHB

GP Practices

PC&ND

31.03.16 Patients experience shorter waits for GP appointments and

increased patient appointment capacity

Increased access to

appointments, measured through audit

Continuity of services

Support against potential practice fragility

Practices to inform NCN verbally/in

writing if anticipating having difficulty, and

agree to meet with NCN Lead and CD to

discuss next steps

2.2.2 Long term viability and sustainability of Caerphilly north NCN

practices

NCN practices and ABUHB

31.03.16

Maintained availability of local primary care GP service provision

Meetings to be arranged to discuss possible future

configuration of GP practice provision

over the next 5 years in the NCN.

0715 Strengthening General Practice.pdf


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2.2.3 Diversify the range of

allied professional supporting GPs in practices through

training etc

Practices

ABUHB

31.03.16

Improved access to a more

diverse range of allied specialties within surgeries, i.e HCAs, NPs, minor illness trained

Nurses , Pharmacists, Social Workers etc

Ongoing training to be

accessed and active recruitment.

2.2.4 To support relevant

education and development

opportunities across the NCN

NCN Lead 31.03.16 Sharing education sessions

across practices providing up to date enhanced skills to provide

better patient care

Utilise the NCN Training Plan

from NCN slippage monies

Develop a process for

Practice and other staff to access training

Identify Training providers and costs

NCN practices and partners apply for

relevant funding

0515 Providing for the Future.pdf

2.2.5 To enhance the delivery of NCN based services,

specifically dental, optometry and

pharmacy. Supports IMPT SCP3

AMD CDs NCN Leads

31.03.16 Patients will benefit from the appointment of Independent Advisors and the value of

debate they will bring from across ALL Primary Care

Services in the development and delivery of NCN Work Programmes.

Allocate funding from NCN budget

Appoint Independent 1 x Dental, Pharmacy, Optometrist Advisors

2.2.6 Practice Based Social Workers (Pilot)

NCN Lead

Social Services

Identified

practices

31.03.16 A greater focus on achieving people’s well-being outcomes

through holistic integrated assessment and co-productive

solutions

Increased capacity for GP’s

Implement the service within the identified

practices so that Social Workers are integrated

and become a member of the multi-disciplinary


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where people can access the

right person, with the right skills and at the right time.

Increased patient safety and the

promotion of carer’s needs

Avoidance of admissions to

hospital through community support via Frailty, increased

care at home, innovative co-productive solutions or access to step up beds.

team

Progress Three social workers

appointed across Caerphilly, (1 in

Caerphilly North NCN based at Gelligaer Surgery).Feedback to

date extremely positive Funding allocated from

NCN budget

2.2.7 Recruit Primary Care

Based Pharmacists from NCN funding to integrated with NCN

and Partners (Also see 7.2.1)

Supports IMTP SCP3

NCN Lead

Pharmacy

NCN Practices

31.03.16 Example outcomes from Welsh

Governments Model of Care for

Pharmacy & Meds Management:

Medication review undertaken

Medicines optimisation releases GP time and works

towards GMS contract targets

Improve patient adherence

through co-production Medication is clinically

appropriate and effective (Polypharmacy)

Reduced hospital admissions

through better management of condition and safe use of

medicine Less waiting time as patients

signposted to appropriate

service at the start

Appointment made

July/August 2015 Report progress, on

outcomes and impact at NCN meetings

Identify opportunities

for Pharmacists to

further develop appropriate skills

Funding allocated from NCN budget


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RAG Rating

Good governance around

repeat prescribing Reduction in waste Provides link for community

teams dealing with complex patients needing advice and

support on medication Nursing Homes: Reduction in

waste and polypharmacy

2.2.8 Increase access to Primary Care

Community Phlebotomy Service

Supports IMTP SCP3

Increased capacity and access to Primary Care phlebotomy

services

Releasing DN time to focus on wound care, vaccinations and immunisations and other

interventions Releasing DN time to support

patients with complex needs who will require greater time spent with them and/or more

frequent interventions.

Enabling DNs to undertake specialist training to upskill to

support patients with complex needs eg wound care

Ensuring the core DN workforce has the capacity and skills to

respond to the ever growing demands, thus avoiding the development of short term or

bolt on specialist services.

£1.1 Million NCN funding agreed across

NCNs plus funding from £4.4 million for

Phlebotomy Service across Gwent. Work Programme to be

developed and agreed by NCN

2.3 Estates


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2.3.1 Improve the

management of estate issues, lack of space in buildings,

lack of grants to be able to increase size

of premises Supports IMTP - SCP3

Clinical Lead,

PC & ND

31.05.16 High quality facilities available

to best meet patient need Annual practice reviews and

CHC statutory visit reports demonstrated facilities are to

required standard.

NCN Lead to clarify the

position regarding Caerphilly North estate/premises

development and refurbishment during

practice visits

Primary Care Estates

Strategy will highlight issues for action

Contact Local Authority

Housing Dept staff for

input re expected housing development

plans

2.3.2 To consider accommodation requirements within

primary care in relation to wider

delivery of services Supports IMTP SCP3

NCN 31.03.16 Patients are able to local access services in high quality premises

NCN to consider wider team accommodation needs

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 harm


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RAG Rating

3.1 Secondary Care


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RAG Rating

3.1.1

To improve

communication with secondary care and explore obtaining

access to Cwm Taf CWS for data to be

available to Caerphilly North NCN practices

Practices, NCN

Lead, ABUHB

Cwm Taf LHB

and ABUHB

31.03.16 Discharge notes will be received

and updated to Practice notes in a timely fashion.

GPs are fully informed of patient history at time of appointment

thereby minimising the harm from incomplete or inaccurate information.

To identify poor quality

or absent discharge information

Audit data

3.2 Living Well Living Longer

3.2.1 Introduce the Living

Well, Living Longer Programme across the NCN

Supports Blaenau Gwent SIP – Theme 3 Supports IMTP SCP3

NCN, PHW,

ABUHB

31.03.16. Screening and assessment

services for cardiovascular

disease, diabetes and stroke will

be widely available to patients

over the age of 40

The Living Well Living

Longer Programme was launched by the Deputy Health Minister Vaughan

Gethin on the 12th of January 2015.

Start date for Caerphilly

North NCN awaited

3.3 District Nursing


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RAG Rating

3.3.1 To maximise the

effectiveness of the District Nursing (DN) workforce by

appointing Community

Phlebotomists.

Practices

Community Division

District Nursing

Team Lead

31.03.16 Patients have improved access

to both DN Team services and to newly established Community Phlebotomy Team services.

See 2.2.8

See 2.2.8

3.4 Health Visiting

3.4.1 To build up

relationships between Health Visitors and practices

NCN, ABUHB

Colleagues

31.03.16 Feedback from HVs and Primary

Care demonstrates improved communication.

Improved services for patients

Consistency for patients in which members of staff they

see when having a visit from the Health Visiting Service.

Respond to work-

streams from Pan Gwent Working Group

Team co-ordinator to provide performance

information for NCN meetings

3.5 Mental Health


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RAG Rating

3.5.1 To strengthen

integration at practice level between Primary Care and the PMHT

Supports Caerphilly SIP – Healthier Caerphilly H1, H2, H4, H5

Practices,

PCMHSS, Third Sector, Statutory

Services

31.03.16 Reduction in the number of

referrals passed between different teams within Mental Health services, and PMHTs

Clearer care pathways, including transparent, concise

access criteria, will be in place for patients

GP’s to make use of the PCMHSS Flowcharts and

increase their use of the PCMHSS Practitioners for advice/guidance.

Work ongoing regarding

best working and sign posting.

Team co-ordinator to provide performance

information for NCN meetings

Evaluate effectiveness of Primary Care Flowchart

for use in practices and flowchart for CYP via annual audit of GP

satisfaction with the PCMHSS.

WG to fund in full the

proposals from Directors of Primary, Community and Mental

Health for a strategic programme of

pathfinder and pacesetting projects for primary care - £8m

allocated to MH. Feedback on how this

funding will be used in Caerphilly East to be given to the NCN


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RAG Rating

3.5.2 To ensure that

patients are seen by the ‘right person in the right place at the

right time’.

Practices,

PCMHSS, Third Sector, Statutory

Services

31.03.16 The usage of CCBT kiosks are

regularly monitored through the gathering of statistical information.

Computerised Cognitive

Behaviour Therapy (CCBT) kiosks are available for patients to

access at a number of accessible sites in the

Borough (telephone support is available)

Enhance the library of available local resources

for use within primary care.

3.5.3 To increase the uptake of psychological

intervention through the ‘Road to

Wellbeing’ programme.

Practices, PCMHSS, Third Sector,

Statutory Services

31.03.16 300 people to have accessed Stress Control and ACTivate your Life classes in Caerphilly

between September 2015 and March 2016.

Help to promote the Stress Control and ACTivate your Life

courses offered locally

NCN to receive regular feedback from service

3.5.4 Evaluate the

effectiveness of LEAP and feedback experiences and

outcomes to NCN

Leap team

members

31.03.16 Signposted care by the most

appropriate person

NCN to receive

feedback from LEAP and the NCN practices involved

3.6 Pulmonary Rehabilitation Services

3.6.1 To improve the provision of the Pulmonary

Rehabilitation Service in the NCN Network

ABUHB Divisional Colleagues,

Thematic Leads

31.03.16

Reduced waiting times Reduced DNA’s

Practices to encourage patients to attend by promoting the service


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RAG Rating


3.7 Diabetes

3.7.1 To improve diabetes services across the

NCN for Patients Supports Caerphilly SIP – Healthier Caerphilly H1, H3, H4 Supports IMTP

SCP5

As above 31.03.16

Improved management of patient diabetic service needs

across the NCN Access to advice from multi-

disciplinary team and implementation of the new

diabetes work plan leads to improved outcomes for patients

Improved access to DSNs via email/telephone for

initiation of injectable therapy

Improved access to Consultants for advice

Improved rapid assessment

of patients who need

consultation opinion

• To implement the Diabetes Integrated

Service Model across the NCN

• To use PH Observatory data as a baseline for

improvement Refer routinely to Adult

Weight Management Service

Consider increasing

Adult Weight

Management Service capacity for specific

populations (e.g. Pre-diabetes, pregnant women)

DSNs to cleanse lists to

ensure appropriate patients are managed in

primary and secondary

Diabetes Work Plan NCN comms 16 45.ppt


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RAG Rating

care

Monitor referrals to

diabetes secondary care

per practice

3.8 COPD

3.8.1 Improve Inhaler Technique for patients

Community Pharmacy

NCN

31.03.16 Patients using devices appropriately

To cascade inhaler technique training-

multidisciplinary strategy. NCN funding

identified.

Accredited training

provided by WCPPE, pre and post course

learning, plus take away pack of placebo devices.

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


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RAG Rating

4.1 Urgent Access

4.1.1

Practices to review

performance against

LMC agreed urgent

access figures

GP Practices

NCN Lead

31.03.16 Improved patient access to

primary care services

Practices to engage with project

to optimise access in keeping

Practices to monitor

performance against LMC standards

Practices to monitor &


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RAG Rating

with emerging guidance to be

agreed with CHC, Health Board

and LMC

report performance to

NCN Lead on a monthly/quarterly basis

Monitor A&E attendances per practice

4.1.2 To maximise

utilisation of

alternative avenues

for advice prior to

referral, adopting

prudent healthcare

principles

PC&ND

ABUHB

Radiology and

USC Divisions

31.03.16 Data shows reduction in reliance

upon multi agency services

Contributes to reduce waiting

times for secondary care

services

Identify other methods of contacting secondary

care e.g. email/telephone (incl

mobile) for advice

To record secondary care email advice

incidents

4.1.3 Appropriate utilisation

of WECS Scheme – Eye Health

Examination Wales (EHEW)

NCN

WECS

31.03.16 Reduction in avoidable

referrals/admissions

Education session for

NCN with regard to the WECS services by

ABUHB Optom Advisor

Baseline data for

attendance updated by Optom Lead

4.1.4 Appropriate use of

YYF Minor Injuries

Unit

NCN

YYF Minor

Injuries Unit

31.03.16 Clarification of MIU services

within YYF

Reduction in avoidable

admissions

Hold education session for NCN with regard to

services available

Obtain practice data

with regards to attendance at A&E and YYF MIU

Ensure YYF MIU has details of how to access


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RAG Rating

emergency/urgent slots

in each practice

Monitor data on

numbers redirected to YYF services

4.2 Frailty (CRT)

4.2.1 Improve appropriate

utilisation of the Frailty Service

Supports IMTP SCP4

NCN, Practices,

CRT Team

31.03.16 Improved access and

communication with Frailty and between Frailty and the OOH

Service Less hand offs between

services, and improved communication about the needs

of the individual will result in better quality, more timely care

Increased GP referrals

Reduction in rejection of referrals

Frailty run charts will show improvements

Work proactively to

improve communication and working

relationships through regular invitation to NCN meetings

Monitor referrals to the

frailty service per practice

Gain better understanding of

pressures that all services are working

under including OOH

Ensure appropriate use

of the SPA contact number by all practices

from 01.09.15

4.3 Social Services

4.3.1 To improve communication

between Health Services and Social Services

NCN Lead

Network Team Caerphilly

Integrated Partnership

31.03.16 Feedback from GP Practices, Health Visitors,

District/Community Nurses will demonstrate improved communications

Patients will receive seamless

Raise any issues with Caerphilly Integrated

Partnership

Continuously monitor

impact and consider best ways of working


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RAG Rating


service transition between

primary care and social services

and communication

issues at NCN meetings

Strategic Aim 5: Improving the delivery of end of life care (National Priority – to be discussed locally)


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5.1 Review the delivery

of End of Life Care

using the Individual

Case Review Audit

NCN Leads,

Practices, NCN

Support Teams

31.03.16 Better care received by

individuals at EoL.

NCN to support

Practices to review audit of patients who have

died to be reflected upon/inform future care delivery.

0815 Gwent Palliative Care Strategy.docx

5.2 Summarise case

review data, and any arising issues

and actions identified, for sharing with the

network and the wider health board

NCN Leads, St

Davids Palliative Care Team,

Practices, NCN Support Teams

31.03.16 Learning through shared

experience will inform future care improvements for patients

on the EOL pathway.

Highlight best practice

for improvement to be highlighted and shared

in a multi-professional discussion

0715 EOLC All Gwent Summary.docx

Caer North National Priorities Audit Summary 0315.docm

5.3 Establish a review

cycle, to monitor progress (or

maintenance of high quality), with further submission of

reports to the GP network and wider

health board as

NCN Leads,

Practices, NCN Support Teams

31.03.16 Improved consistency in

standard of care delivered

Agreement of ‘best

practice’ in EOLC. Identification and

monitoring of areas for improvement so that appropriate education

and support can be delivered


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appropriate

Strategic Aim 6: Targeting the prevention and early detection of cancers (National Priority)


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6.1 Review the care of all patients newly

diagnosed between 1 January 2015 to 31

December 2015 with lung, gastrointestinal and ovarian cancer

NCN, NCN Leads,

Practices

31.03.16 All lung, gastrointestinal and ovarian cancer patients will

have their referral information reviewed and o/p appointments

/ results followed up

Audit Tool

6.2 Learning and actions

to be shared with the GP network and the

wider LHB

NCN, NCN

Leads, Practices

31.03.16 Audit tool to ensure continuous

review, reflection and improvement in processes and

care pathways for patients with a diagnosis of cancer.

Practices complete audit

and discuss findings


6.3 Identify and include any relevant actions to

be addressed in the Practice Development Plan

NCN, NCN Leads,

Practices

31.03.16 Improved patient information.

Patients preferred place of

death.

Practice by practice NCN USC cancer data will be

collated to provide better informed demographic data

relating to cancers on a regular basis


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6.4 Summarise themes

and actions for review with the GP network and share information

with the LHB as required

NCN, NCN

Leads, Practices

31.03.16 Improved patient information.

Patients preferred place of death.

NCNs to share learning

with secondary care

National Priority Target Audit Summary Cancer 14-15.docx

6.5 Develop protocols to

ensure Practices refer patients as ‘USC’ rather than ‘Urgent’ if

cancer was suspected and that Practice

based systems should be established to track USCs referred. Supports IMTP SCP3

NCN Lead Practices

30.09.15. Patients will be referred for

Secondary Care interventions with the appropriate level of urgency and seen accordingly.

Practices to discuss and

agree to use USC notation on suspected

Cancer patient referrals Develop an NCN

Standard

6.6 To ensure referring GPs are informed by Secondary Care

Consultants of downgrades to USC

referrals. Supports IMTP SCP3

PC & ND / AMD Secondary Care

Consultants GPs

31.03.16. Improved patient information. Appropriate treatment pathways

initiated.

PC & ND / AMD to contact Divisional Leads

to ensure consultants inform referring GPs of

downgrades. Practices to consider

processes to follow up all USC referrals and

subsequent potential downgrades.

Strategic Aim 7: Minimising the risk of poly-pharmacy (National Priority – to be discussed locally and also Medicines

Management)


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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.

NCN, NCN Leads, Practices

31.03.16 Identify patients at high risk or harm of either over or under

medicating.

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.

7.1.2 Undertake face to

face medication reviews, using the ‘No Tears’ approach

NCN, NCN

Leads, Practices

31.03.16 Reduction in unnecessary

admissions to hospital.

Identification of further

untreated conditions.

Number of MUR Consultations

Using data from the

review audit book appointments for medication reviews of

patients over the age of 85yrs receiving 6 or

more medicines.

7.1.3 Identify any actions to be addressed in

the Practice Development Plan

NCN, NCN Leads, Practices

31.03.16 Poly-pharmacy at NCN meetings Quarterly

information to NCN on utilisation of notional

budget


National Priority Target Audit Summary Polypharmacy 14-15.docx

7.2 Medicines Management


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7.2.1 Appointment of

Primary Care Pharmacists to assist the delivery of safe

and cost effective prescribing to the

NCN population

NCN Lead,

Practices

31.3.16 Efficient use of resources that

can be re-invested more appropriately into patient care

Increased face to face meetings with Pharmacists in Primary

Care thus releasing capacity for GPs

See 2.2.6

Recruit and appoint

Pharmacists in Primary Care

Agree range of duties expected of appointees

Report and monitor

activities and impact of

appointments to NCN Lead

0715 Pharmacists in Primary Care.docx

7.2.2 To monitor the NCN

prescribing budget and delivery of the Medicines

Management Plan

NCN Lead

Prescribing Lead

GP Practices

31.03.16 Efficient use of resources leads

to re-investment & more appropriate care

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 priorities for

NCNs to achieve in terms of service

improvement, costs and quality

7.2.3 To review the variation in prescribing compared

to national guidance

NCN Lead

31.3.16 Patients and professionals have access to a named Pharmacist in Primary Care

NCNs to work with Primary Care and Networks Division Pharmacy staff to:


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RAG Rating

in relation to Diabetes

and Respiratory and deliver the NCN savings target for

these work streams within the three year

plan

GP Practices

Pharmacy

Efficient use of resources that

can be re-invested more appropriately into patient care

Minimise avoidable harm from the adverse effects of inhaled

steroids Undertaking the minimum

appropriate intervention to ensure prudent prescribing

aligned with NICE Guidance.

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

Strategic Aim 8– Delivery consistent, effective systems of Clinical Governance


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8.1 Clinical Governance

8.1.1 To fully implement the Clinical Governance Toolkit

NCN Primary Care &

Network Division

GP Practices

31.03.16 Consistency and safety in Practice and NCN wide primary care services

Ensure practices are supported in completing the CGSAT

Sessions to be

established to support GP practices in


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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 MHOL

How practices respond to urgent and same day

requests from Care Homes, WAST and

Hospital Emergency Depts

Actions to foster greater integration of

health and social care Consideration of how

Third Sector support may be maximised

Map local services to

highlight where services

are delivered across practices (e.g.

contraceptive services, minor surgery)


by


RAG Rating

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

Strategic Aim 9: Agreed Locality Priority Issues


by


RAG Rating

9.1 To establish a more

integrated service model of working for

practices and community based teams in the RIHSCC

NCN, NCN

Lead, partners based in

RIHSCC

31.03.15 More integrated working

providing care provided ‘by the right person at the right time’

Meetings to be arranged

9.2 To develop a 3-5 year

working plan for sustainability of GP practices within the

NCN

NCN, NCN

Lead, Practices, ABUHB Divisional

Colleagues

31.03.15 Appropriate General practice

service provision

Practice discussions

ongoing


by


RAG Rating

9.3 Establishment of an

NCN Web based solution that provides information for local,

available services for Dementia patients.

PC & ND

Phil Diamond - (Dementia Friendly

Community Lead)

31.03.16 Patients and their families /

carers can access up to date information on services available to them relating to

dementia support.

Implement and

promote Dementia Roadmap

9.4 Increase awareness

of dementia friendly community in Rhymney.

ABUHB,OAMH,

Social Services, LA, NCN

GP practices

31.03.16 Patients are supported in their

communities

Training practice staff

as Dementia Friends

Collate the number of

practice staff completed training

9.5 Work with new dementia primary

care support workers in the community supporting patients

and families with a new diagnosis of

dementia

ABUHB,OAMH, Social Services,

LA, NCN GP practices

31.03.16 Patients are supported in their communities

Invite DSW to feedback to the NCN on

management of caseload of patients who are supported post

diagnosis.

DSW to update the NCN on available dementia support services

caerphilly north neighbourhood care network action plan ... north ncn action... · towards the...

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