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Cluster Network Action Plan 2016-17

(second year of the Cluster Network Development Programme)

Dwyfor Cluster Sept 16

The Cluster Network1 Development Programme 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 Action Plan should be a simple, dynamic document and in line with CND 002W guidance.

The 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.

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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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To understand the needs of the population served by the Cluster Network

The Cluster Profile provides a summary of key issues. Local Public Health Teams can provide additional analysis and support. Consider

local rates of smoking, alcohol, healthy diet and exercise – what role do Cluster practices play and who are local partners. Is action

connected and effective? What practical tools could support the delivery of care? Health protection- consider levels of immunisation and

screening- is coverage consistent- is there potential to share good practice? Are there actions that could be delivered in collaboration-

e.g. Community First to support more effective engagement with local groups

No Objective For completion by: - Outcome for patients Progress to Date

1 To review the needs of the

population using available data

Annually in September to

review an variation against

last year data

To ensure that services are

developed according to local

need

All practices have been supplied with

population profile resources which

together with the GP Cluster profiles

are being used to interpret local needs.

Priorities identified jointly with PHW

August 2016

2 To identify additional

information requirements to

support service development

November 2016

Improved support for service

development

Data received ongoing discussions

during the year

3 To consider learning from

previous analyses to identify

any outstanding service

development needs

September 2016

Improved support for service

development

To be discussed during cluster

meetings and also at an Area

Management Team and Health Board

level.

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Overview of Dwyfor Cluster

Although a small area, Dwyfor has a relatively high proportion of older people; 26.5% of residents are aged 64 and over, and 4.3% are aged 86 and over. This compares with only 21.4% and 2.8% respectively for BCU as a whole. The prevalence of frailty increases steadily with age and is estimated to affect 25% of those aged over 85 years or over. Health Profile of Gwynedd in Infographics North Wales Public Health Team Internet http://www.wales.nhs.uk/sitesplus/888/page/65092

Statistics produced by the Public Health Wales Observatory using the Welsh index of multiple deprivation 2011, show that Dwyfor has relatively low numbers of people living within the most deprived 40% of areas in Wales. According to ONS data, 57.5% of patients in Dwyfor live in rural LSOAs, against a BCU average of 21.3%. At the same time, it is estimated (from Census data) that around 34.7% of people aged 65 and over are living alone, a slightly higher figure than the BCU average. The area has a high proportion of Welsh speakers (71.7% against a BCU average of 30.6%), meaning that services need to be delivered through the medium of Welsh where required. 2.8% of the registered population are resident in care homes, lower than the BCU average of 4%, however this figure varies with 3 practices identified as having relatively high proportions of care home residents registered. Key to the development of services in Dwyfor is moving care closer to home based on appropriateness and need. In addition, integration and collaboration of services is at the forefront of priorities leading to more streamlined and person-centred care for all our population. Other priorities for Dwyfor include safety, quality and inequalities of health. The Welsh Government advocate adherence to the principles of prudent health care and these are also features of our cluster plan which will be advanced with the development of services within the Dwyfor area.

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Developments – ( information taken from Practice Development Plans and locality plans) Single point of access – Ffordd Gwynedd project within Porthmadog/Criccieth area may influence current working models Care homes – Extension planned in one home near Criccieth with EMI beds planned. Change in use of residential home beds – Plas y Don reablement and respite beds opened last year Audit+ data 2013/2014 for Cluster: Audit+ data shows that cluster prevalence for identified conditions is around the middle 50% for Asthma, Hypertension and Heart failure, and in the lowest 25% for CHS, COPD, Diabetes and Epilepsy. 58.3% of adults in Dwyfor are overweight or obese, as compared with the BCU average of 57.8% Percentage of practice patients over the age of 15 who smoke is slightly lower than the BCU average of 20.4%, at 19.8%. 24.4% of patients over age of 16 heavily (binge) drink, compared with the BCU average of 26.1%. According to GP Practice Registration data extracted July 2014, around 26.5% of the registered population are aged 65 and over. This is higher than the BCU average of around 21.4% of the population but represents only around 6,632 people. Around 4.3% are aged 85 and over, the highest percentage in BCU (where the average is around 2.5%) but represents only around 1,089 individuals.. Deprivation is relatively low with an estimated 7.1% of the registered population living in the most deprived two fifths of areas in Wales, against a BCU average of 30.6% Rural isolation and access to transport – Dwyfor has the highest level of rurality in BCUHB,. 72% (18,030 people) live in a rural area (village/hamlet/isolated dwellings); and 0% (less than 5 people) live in an urban area. Limited transport links: There are limited transport links in Dwyfor. For those without transport, access to secondary care can be significant issue. Bryn Beryl and Alltwen are the closest community hospital, and some outreach services such as physiotherapy are provided there. Limited transport

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links can cause access problems and can make it more difficult for patients to access services Welsh language 65% of Gwynedd’s population aged 3 years and over speak Welsh (77,000 people). This is higher than the averages for North Wales (35%) and Wales (19%). In Dwyfor 71% of the population are Welsh speakers. Chronic Disease Registers as a Cluster Group: Data provided by PHW shows that while the crude burden of disease for Hypertension, CHD, Diabetes and Heart failure are all higher than the BCU average, the age adjusted data shows a lower overall burden than might be expected. Crude variation at practice level for identified registers is shown below:

Practice ID Practice name Practice List Size

CHD % HF % HYP % DM % AST % COPD % EP %

W94011 Treflan (Pwllheli) 7594 4.0 1.2 18.9 6.9 8.5 2.5 0.9

W94021 The Health Centre (Criccieth) 3827 4.3 1.4 20.9 6.5 7.1 3.0 1.1

W94025 Meddygfa Rhydbach (Botwnnog) 5284 4.8 1.7 19.4 6.0 6.5 2.1 0.8

W94037 Ty Doctor (Nefyn) 4331 3.5 0.9 17.3 6.4 5.8 1.7 0.8

W94612 Meddygfa Care 3910 4.5 1.6 19.5 8.3 7.3 2.9 0.7

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Comments from PDPs

Primary Care is faced with providing high quality services to a population who are dispersed around a rural area, leading to a burden of travel for practitioners

The influx of tourists to the area, particularly in the summer months means that practices often struggle to meet demand.

Practices will continue to support patients with chronic disease and continue good management. Cluster groups give GPs the opportunity to support one another and expand good practice and exchange ideas. Over the next three years Cluster Groups have the opportunity to help towards the improvement of services and the health of the County.

We hope the introduction of GP cluster groups will establish excellent working relationships and allow stronger strategic planning at all levels. We also hope the locality networking groups will provide a more effective delivery of local services with a focus on positive outcomes for patients.

POPULATION NEED (Priority 1 – Smoking Cessation)

Priority 1 The issues Aims and objectives How will this be done? Named Lead

Time Scale

Smoking

cessation

There are 19.8% smokers in the Locality. Smoking is linked to social class and accounts for a high proportion of the inequalities in health outcomes. NICE guidance is that 5% of

Implementation of BCUHB smoking cessation pathway in all Practices Increase demand for specialist smoking cessation services Offer timely and

All Practices to ensure all staff implement BCUHB smoking cessation pathway.

All staff to undertake training (brief intervention training for clinical staff and ask/assist/advise training for administrative staff)

Ongoing

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adult smokers should be treated every year. This is now a Health Board Tier 1 target, with 40% quit rate. In Dwyfor 4.2% accessed services last year.

appropriate support for all adult smokers who wish to make a quit attempt Ensure tailored interventions and equity of access and outcomes for specific groups, such as pregnant women, manual workers, people with mental health problems and socioeconomically disadvantaged communities.

Share smoking cessation data: referrals to specialist services, numbers of treated smokers and quit rates

Work in partnership with SSW / PHW / WG to provide improved quantity and quality of services.

Ensure an integrated smoking cessation service across community, secondary care, mental health, social care and other relevant settings.

Review practice based data on number of patients accessing service

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POPULATION NEED (Flu immunization)

Priority 2 The issues Aims and objectives How will this be done? Named Lead

Time Scale

Summary of health needs and priorities identified by practices and for discussion include:- Chronic Respiratory Diseases; Ageing population; Mental Health; Palliative care – develop services with partners; Obesity; Alcohol use;

Identified by others:

Flu vaccination rates, Frailty, hypertension and Atrial Fibrillation and Antimicrobial stewardship (Health Board)

Flu vaccination Variation in uptake rate for flu across cluster

To improve overall uptake rates of flu vaccine

Increase uptake of front line staff as

part of business continuity planning to

maintain front line service

Community hospital inpatient

administration

Community pharmacy flu vaccinations

– offer as an alternative to patients

initial practice clinics

Increase awareness of clinic dates –

advertisement, social media, text

reminders

Practice Hospital team

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Uptake Shared learning between practice on strategies used to increase uptake

Reduce variation in rates between surgeries

Ideas for discussion within practice

included – Saturday clinics, more

active follow up for nonattenders

including telephone follow ups

Investigate in HCA can give Fluenze

nasal spray for children

Share EMIS template for ease of data

entry

Use patient login screen to give

additional reminder for patient that

they should have the flu vaccine

all Flu team Explore if possible to set up

Jan 16

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ACCESS

(to ensure the sustainability of core GP services and access arrangements that meet the reasonable needs of local patients)

As the guidance on page 1 above states the following sections only include those areas ‘that cannot be managed at an individual practice level or challenges that can be more effectively and efficiently delivered

through collaborative action’

Priority The issues Aims and objectives

How will this be done? Named Lead

Time Scale

Service modernization

Service modernisation to meet changing needs and ensure sustainability of local services

Develop local workforce

Ongoing work with advance practice roles;

Advance nurse practitioners or minor illness nurses

Advance pharmacist role – clinics and repeat prescribing – input into some practices

Advance physio role – MSK clinics - input into some practices

Ongoing review and wider roll out/ funding

Maintaining patients at home

Intermediate care

To improve access to step up beds

Lack of careers to provide care packages delaying discharges – especially problematic with palliative patients

Area team

Identify waste in current systems

Delay in patient information arriving at surgery causing waste of time and resources

Improve communication regarding patients care

MTED discharges – surgeries to accept electronic discharges from secondary care – Informatics within BCU training practices

Use on EMIs mobile/INPS mobile to access patients records during home visits and reduce workload

Community hospital inpatients – EMIS/Vision terminal within hospital would improve access

Informatics

Awaiting practice training

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– bid written for IT to move on with installation, test run complete with installation on BCU laptop and system working

Consultant to consultant referral – still occurring at times – practice will collate examples

My health online

Increased choice in ways of accessing services

Improve patient access in line with WG objectives

All practice to have ordering repeat prescriptions and booking appointment live by end March 2016 – ordering live in all, appointment in 4/5

2016

Transport Poor public transport link in some areas due to rurality

Work with voluntary sector improve access

Explore options with Voluntary sector to bring patients into surgery to avoid GP house call

Appointments Ensure patients access the right service for their need

Increased signposting and utilization of local services that could support general practice

Awareness raising of local services within practices Maintain or increase referral to; (data available) Community pharmacy choose pharmacy

NERS

Others including community dental service,

voluntary sector services

Eye care Wales

MIU

NHS direct to support TRs

Ongoing use of services

Temporary resident central clinic

Population increase during school holiday and summer period

Provide additional clinical capacity in the area to deal with increased demand

Review outcomes of this summer’s clinics

Plan for future model and sustainability

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WORKFORCE

Important Note: Each Practice has submitted practice specific plans to detail what will be done in order to meet any practice specific workforce needs e.g to cover a period of maternity leave, recruit to a specific vacancy. The table below refers to matters that can be taken forward at a Cluster level and/or require HB input.

Priority The issues Aims and objectives

How will this be done? Named Lead

Time Scale

Training Lack of skills in nursing homes

Identify training required and utilization of cluster care home support staff to support care homes –

Suspected UTI management

Ongoing work with practice development team

Health Board

Training Access to local training Improve access Develop list of core training needs for practices and possible source of training – pool resources locally? Central fund to release staff for training

- Ear care for nurses HCA -

practices

Recruitment There are problems with recruitment in this locality for both GP’s and Nurses. This will be further compounded by retirements in the next five years

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PLANNED CARE/ REFERRAL MANAGEMENT AND CARE PATHWAYS

Priority The issues Aims and objectives

How will this be done? Named Lead

Time Scale

Waiting Times Long waiting times for various specialism’s

Quarterly reports available from the information department on RTT waits

Area Team

Enhanced Care Not currently commissioned

Look after patients closer to home

GP Cluster Groups – take to area management team

Area team

Mental health Service continuity Confirmation from area team if there is a planned replacement for Dr Chandran in the community mental health role

Area Team

Referral Management

Extremely long waiting times for various specialism’s within Sec Care

Reduce waiting times.

Review referral rates within cluster once most recent data provided from demand management team

GP Cluster Groups

Oct 2016

IV therapy in the community hospitals

Increase utilisation and range of therapies delivered

Deliver care closer to home for patients and increase access

Increase awareness of current provision and

utilisation

Establish permanent IV suite within both Alltwen

and Bryn Beryl with referral criteria

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UNSCHEDULED CARE (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, co-ordination of care ad effectiveness of risk management)

Priority The issues Aims and objectives

How will this be done? Named Lead

Time Scale

Falls High levels of people falling and having to be admitted

To reduce people falling unnecessarily.

promote ‘Healthy Ageing’ e.g. Falls, accidents and the use of medication, to try to reduce the number of unscheduled care users. Discuss in cluster

MIU opening hours Variation in MIU hours across the cluster

Improved patients access

Ensure MIU service match GP practice core hours as a minimum

Area Team

Imminent once staff recruited

Care homes High number of homes in the area

Reduce demand on unscheduled care

VC link between Polish home and MAU – Cartref project

Planned autum 2016

COTE rapid access clinics

Improved access locally to consultant clinics

Community based rapid access clinics

COTE clinic Wed pm in Bryn Beryl – rapid access –

All GPs ongoing

Ffordd Gwynedd Integrated team health and social care

Integrated working Porthmadog and Criccieth area only at present. Practice awareness of service such as ABLE for low level needs

Joint meting oct 2016

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IMPROVING THE DELIVERY OF END OF LIFE CARE (Refer to National Priority Areas CND 007W)

Priority The issues Aims and objectives

How will this be done? Named Lead

Time Scale

National Clinical priorities

Improve end of life care

To review the experience of patients at end of life.

Practice clinicians to review the delivery of End of Life Care using individual case review audit tool – Appendix 2. To complete the exercise as laid out in requirements for cluster domain in QOF 2015/16. Results of this to inform cluster network annual report.

Complete end of March 2016

National Clinical priorities

Training and education

Improve end of life care Identify and training needs

GP education session on end of life care, local training session

Care home patients

Improve end of life care To maintain patients in their place of choice

Plas Gwyn – trial of treatment escalation plan paperwork

Criccieth palliative care team

June 16

St David’s hospice care co-ordinators

Increased access to support and resources early on after diagnosis

Increase access to non-clinical support for patients and families

Dedicated co-coordinator available to support with information, signposting, resources, benefits Report due from team end Sept 2016

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TARGETING THE PREVENTION AND EARLY DETECTION OF CANCERS (Refer to National Priority Areas CND 006W)

Priority The issues Aims and objectives

How will this be done? Named Lead

Time Scale

Cancer Referrals GP referrals – no GP access to diagnostic tests

Improve access Health Board to address issues with secondary care

AMT

National Clinical priorities

Promote best practice into the prevention and early detection of Cancer

Clinicians to complete individual case reports for patients newly diagnosed with lung, digestive system and Ovarian cancers via the Significant Event Analyses Templates (SEA) 2014/15 – Appendix 1. To complete the exercise as laid out in requirements for cluster domain in QOF 2015/16. Results of this to inform cluster network annual report

All GPs

Complete end of March 2016

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MINIMISING THE HARMS OF POLYPHARMACY (Refer to National Priority Areas CND 008W)

Priority The issues Aims and objectives

How will this be done? Named Lead

Time Scale

Frailty and polypharmacy

Safe and effective use of medicine

Identify patients – GP has to complete medication reviews of patients who are over 80years old and on more than four repeat prescription items.

All practices

End of March 2016

Prudent prescribing

Building on national policy

Safe and effective use of medicine

Sharing of educational resources and key identified intervention from polypharmacy reviews

All pracitces

Antibiotic prescribing

Cluster antibiotic items per 1000pu usage higher that surrounding clusters

Reduce overall use of antibiotics

Commitment form practices to target antibiotic use Resources available to support patient education

- Leaflets – get well without antibiotics - Emis templates - CPR machine - Eduction session for targeted groups –

care homes, DN teams

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PREMISES PLAN

Important Note: Each Practice has submitted practice specific plans to detail what will be done in order to meet any practice specific needs relating to premises. The table below refers to matters that can be taken forward at a Cluster level and/or require HB input.

Issue Why? What will be done at Cluster Level

How will this be done? (Practice; GP Cluster; Health Board) Named Lead

Time Scale

Abersoch branch

Practice in discussion with estates and BCUHB

Criccieth disabled toilet

None available

Grant had been achieved but work was held back

Porthmadog Space for clinicians

Practice development plan – for locality awareness

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CLUSTER NETWORK ISSUES

Issue Why? What will be done?

How will this be done? (Practice; GP Cluster; Health Board)

Named Lead

Time Scale

Primary/ Secondary care communication –

There is a lack of good contact/relationship between GPs and Consultants.

Discuss with Area Team

Develop forum between primary and secondary care Utilize local educational evening – Link in with Ynys mon/Arfon VC evenings

To be agreed

Transportation Many areas of Dwyfor are very rural with limited public transport

Explore opportunities to work with voluntary sector

Transportation to hospital clinics, also to surgery

Community hospitals

Service development

Scope out future service delivery from community sites

Alltwen –meeting with area team and local GPs Ultrasound service development Bryn Beryl – capital bid for site development

Area team

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LHB Issues

(in addition to any issues raised above requiring Health Board input)

TO BE DISCUSSED AND COMPLETED BELOW AT CLUSTER MEETING

Issue Why? What will be done?

How will this be done? (Practice; GP Cluster; Health Board) Named Lead

Time Scale

Practice boundaries

Practice areas in need of updating

Review LHB to work with practices to develop clearer boundaries

Information on BCUHB Intranet

Often difficult for primary care to access information on the BCUHB Intranet

Discussion between primary care and BCUHB on what needs to be developed

Issues to address include one clear point of access to all referral pathways

Specific Service Improvements in the community

There is documented concern about deterioration in provision of a number of services in the community affecting patient care

Discussion with BCUHB regarding concerns raised by GP Practices

Areas of concern include the following: Stroke Services in the community Speech Therapy Services Dementia Services particularly Day Care provision Mental Health Services particularly lack primary care counseling service Better access to DAPHNE in the West Better access to dietetic services for patients with low BMI Pulmonary Rehabilitation Services

Continuing Health Care Funding

CHC Funding applications bureaucratic and time-consuming

Streamline application process

Move forward with Ffordd Gwynedd model of working