cluster network action plan 2016-17 neath cluster neath cluster...the cluster achieved a number of...

Abertawe Bro Morgannwg University Health Board Neath Cluster Action Plan 2016-2017

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Cluster Network Action Plan 2016-17

Neath Cluster


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Introduction

The Neath Cluster Network includes a cluster of 8 GP practices, seven of the practices are engaged in GP training. The cluster network estate includes eight main practices, two of which are located within the new purpose built Briton Ferry Health Centre. Four practices are in Neath town centre and two are in the Skewen area of Neath Port Talbot. The Neath Cluster Network area contains 9 Nursing/Residential Homes. There are 10 community pharmacies and 7 dental practices.

The cluster serves a registered GP population of 56,700 (a slight increase from 56,470 in 2015). The registered population changes have varied between practices with 4 out of the 8 practices showing an increasing list size and 4 a decreasing list size between January 2011 and January 2016. ADD deprivation data The cluster achieved a number of priorities during 2015/16 including:

The development of the Neath Primary Care Hub, with NHS Pacesetter status.

The Neath Hub supports GP practices in their efforts to respond to increasing patient demand whilst

achieving quality of access for the patient. The hub provides a range of services including physiotherapy

and a mental health support worker role from a central point in Neath, as well as a prescribing pharmacist

and technician working in practices throughout the cluster.

GPs are able to refer directly into from the point of triage and to support this the cluster has commissioned

V360 a shared appointment and clinical system to enable GPs to book patients directly into the hub and

give practitioners in the hub access to the practices’ clinical record.


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The Neath Cluster Action plan will support practices and multi-agencies to work collaboratively 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 includes: -

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 are specific, measureable actions with a clear timescale for delivery. The Cluster Action Plan compliments 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 supports 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.


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Neath Cluster 2016/17 including 8 GP practices

serving a population of 56,693patients

KEY THEMES & PRIORITIES IDENTIFIED FROM PRACTICE DEVELOPMENT PLANS

Sustainability: Recruitment of GP’s, retirement, locums remains an issue. Need to assess the

workforce skill mix and the development of a wider clinical team.

Recruit advanced practitioners, pharmacists, minor illness specialist. Look into local courses and

online courses available to improve skill set.

Improvement of premises to accommodate growing list sizes

High levels of deprivation, with high levels of low income and unemployment

Increasing elderly population

High prevalence of obesity and low levels of physical activity

Continue within the cluster to implemented and develop the telephone triage improving access for

patients and enabling the practice to manage patient demand

Clear protocols and pathways for referrals

Discharge summaries need in improvement and timeliness to ensure continuation of care

Collate data within the cluster to progress pre-diabetes program

Increasing patient base due to new housing developments

Work closer with 3rd Sector to signpost patients

Care Homes which need increasing support.

End of Life and Palliative care- review and collect information within cluster to improve care


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Neath Cluster

Wate

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Dyfe

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Castle S

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Skew

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edic

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Centr

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Vic

toria

Gard

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Dr

Wilkes B

rito

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Ferr

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Tabern

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Str

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Alfre

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Directed Enhanced Services

Childhood Immunisations

Influenza for those 65 and over and others at risk groups (2-3 year olds)

Extended Minor surgery N

Care of People with Learning Disabilities

Care of People with Mental Illness N N N N N N

National Enhanced Services

Anti Coagulation (INR) Monitoring

LARC

Shingles Catch-Up Programme

Services to patients who are drug/alcohol misusers N N N N N N N N

Local Enhanced Services

Shared Care N

Gonadorelins/Zoladex

Immunisations during outbreaks (MMR)

Care Homes N N

Care of Homless Patients N N N N N N N

Hep B Vaccination of At-Risk Groups N N

Wound Management N N N

Wound Management Part B N N N N N N N N

Men C Catch-up for University

Phlebotomy N N


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

No Objective Key partners For completion

by: -

Outcome for

patients

Progress to date

/ suggested actions

RAG

Rating

1. Engage with Pre-

diabetes scheme to identify

patients at risk of pre-diabetes

Community

network project

March 2017

(thereafter ongoing each

year)

Improve quality of

life and prevention

development of diabetes

Will start in

October once training

completed

Amber

2. Continue to tackle ongoing problems with obesity

amongst patients in cluster

Public Health Wales

Dieticians

Sports programmes

March 2017 (thereafter

ongoing each

year)

Improve education and reduce obesity in

future

ongoing Amber

3. Ongoing efforts to reduce smoking amongst Cluster

patients

Public Health Wales

“Stop Smoking

Wales” / ABMU “Time-to-quit”

Hospital service

March 2017 (thereafter

ongoing each

year)

Smoking linked to many cancers and chronic disease -

reduce local prevalence

ongoing Amber

4. Increase uptake of influenza vaccine

in target groups

ABMU Immunisation Co-

ordinator/ Primary Care

Ongoing each year

Reduce morbidity / mortality /

hospital admissions due to

Amber


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Team influenza and

bacterial infections

To engage with

patients in order to reflect their

needs

Practice

Patients

Ongoing To ensure that

the practice objectives are in

line with patient needs. To ensure good lines of

communication between practice

and patients.

Questionnaires,

Patient Participation

Groups

Green

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

reasonable needs of local patients


by: -

Outcome for

patients

Progress to date

/ suggested actions

RAG

Rating

1. Increase telephone triage of patient requests

for appointments and home visits, direct to

appropriate Health Care

Professional

GPs, clinical and admin staff

Staff employed in

Hub

March 2017 (thereafter ongoing each

year)

Improved access to appropriate services

Reducing GP workload that is not appropriate

ongoing Amber


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2. To provide standardised training for prescribing clerks and seek opportunities to build on initial training to further develop staff

Prescribing Clerks

Medicines

Management Team

Practice Managers

Completion of

packs - June 2016

Further

development -

ongoing

Improved repeat prescribing systems

38 clerks have completed training across the cluster. Pharmacist and technician supporting further development of target staff in collaboration with practices

Green

3. To ensure appropriate use of the pharmacist and technician resources to aid sustainability, reduce risks from polypharmacy and improve other aspects of medicines management

Pharmacist

Technician

Medicines

Management Team

Practice team

Ongoing Improved medicines related outcomes and reduced risk

Both posts demonstrating benefits and supporting practices to improve medicines management through a variety of activities. Ongoing review required to maximise outcomes and ensure appropriate training, support and indemnity arrangements

Amber


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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 / suggested

actions

RAG Rating

1. Use Pacesetter

Physiotherapists and Wellbeing Support and

Pharmacy Staff

Neath Cluster

Hub Staff

March 2017 (then

ongoing)

Improve access to

appropriate diagnostic / treatment services

Varying levels of

use / engagement between Practices

Amber

2. Engage further

with Radiology re: downgrading of USCs

Dept Radiology March 2017 Quicker response

in care pathways

Ongoing Amber

3. Review Psychiatric

Services for ante- and post-natal

Dept of Psychiatry

LHB

Bridgend (liaise Jane O’Kane) -

PRAMS

March 2017 Improve wellbeing in pregnancy

Red

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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by: -

Outcome for

patients

Progress to date

/ suggested actions

RAG Rating

1. To improve antimicrobial stewardship through appropriate use of antibiotics Implement mechanisms to ensure appropriate use of antibiotics (see also PMS 2016-17)

Practice team Big Fight Team Medicines Management Team

Ongoing with monitoring of trends See also PMS 16-17 for deadlines: Dec 16:

Overall antibiotic use and choices

Acute Cough Audit

Improvement Plan

March 17:

Evidence of patient engagement activities

Reduced antimicrobial resistance Reduced C.Diff Increased knowledge and empowerment to self care

Discussed at all annual practice prescribing visits. Development of cluster level data available on GP portal Good progress with reductions in overall use demonstrated (data up to June 2016 showing a 6.9% drop compared to previous year)

Amber

2. Audit outcomes of

telephone triage in Neath

Modify processes to enhance outcomes

Neath Cluster

Craig Barker (IT Support)

March 2017

To ensure quicker

access for patients to the

appropriate healthcare professional

Early weeks of

triage for some Practices

Amber

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

http://howis.wales.nhs.uk/sites3/docopen.cfm?orgid=872&id=427857




http://howis.wales.nhs.uk/sites3/page.cfm?orgid=872&pid=55559

http://howis.wales.nhs.uk/sites3/page.cfm?orgid=872&pid=55559


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by: -

Outcome for

patients

Progress to date

/ suggested actions

RAG Rating

1. Audit EOL care

within Practice

Share outcomes

of Audits

Spread “best Practice” amongst

Practices in Cluster

Practice staff and

DNs

Cluster Members

“Anticipatory Care Team”

March 2017 (then

ongoing)

Improve EOL for

patient and patient’s family

Ongoing Amber

2. PHCT meeting Extended PHCT March 2017 (then ongoing)

Dissemination of patient information for

better patient care.

Ongoing Amber

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



Progress to date / suggested actions

RAG Rating

1. Continue to support bowel /

breast / AA screening programmes

Public Health Wales, Datix.

Cancer Hub

March 2017 (then ongoing)

Improve life expectancy by

early detection of CA

Heather Wilkes Cancer Hub Red


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and other Public

Health Wales Services

2. Streamline

pathway for all internal hospital

referrals for any abnormal results (all

cancers and anaemia)

LHB, Secondary

care, Radiology

March 2017

(then ongoing)

Faster transit of

referral through to diagnosis and

treatment. Improve patient outcome.

Ongoing Red

Strategic Aim 7: Minimising the risk of poly-pharmacy




actions

RAG Rating

1. Provide support to patients with known problems managing medicines in their own home without a package of care, through a collaborative approach with the

Practice Teams Medicines Management Domiciliary Care Team Community Pharmacies Anticipatory Care Teams

Ongoing Advice and practical support to help individuals manage medicines in their own homes will reduce risk from adverse drug events, reduce unscheduled care

Pathfinder being rolled out across 3 NPT clusters. Additional team member to support MMTDC took up post Sept 2016 Referrals steadily

Green


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medicines management domiciliary care team (MMDCT).

and improve outcomes from the treatment of chronic diseases.

increasing following early pilot

2. To engage in the Prescribing Management Scheme (PMS) and PMS+ respiratory schemes. (Undertake a range of prescribing initiatives to improve: respiratory, antibiotic, pain management prescribing and yellow card reporting)

GPs Practice Nurses Medicines Management team

PMS 16/17 by March 17 (some Dec16 deadlines) PMS+ respiratory by November 17

Improved medicines management including polypharmacy Investment in other service areas for patient benefit

Discussed at all annual practice prescribing visits Practices engaged and making progress Medicines management team supporting where possible

Amber

3. Explore opportunities for improved links with community pharmacy

Practice teams Community pharmacy Medicines management teas

Ongoing Improved medicines and public health related services and outcomes

Amber

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




RAG Rating


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actions

1. Continue reporting significant event

analyses

Practice and LHB March 2017 (then ongoing

Improve education of clinicians and

hence improve patient care.

Ongoing Amber

2. Continue use of CPGSAT

Practices and LHB

March 2017 (then ongoing

Continuing refinement of

services in Primary Care.

Ongoing Green

Strategic Aim 9: Other Locality issues


by: -

Outcome for

patients

Progress to date

/ suggested actions

RAG Rating

Plas Bryn Rhosyn to receive

necessary patient information with incoming patient.

Plas Bryn Rhosyn, Secondary Care

and Neath practices

December 2016 To inform GPs and minimise risk

to patients

None Red

Increase and improve

signposting to Third Sector

Practices and Third Sector

Wellbeing Health Worker

March 2017 (then ongoing

To provide more specialist and

appropriate support for

Ongoing Green


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services patients

cluster network action plan 2016-17 neath cluster neath cluster...the cluster achieved a number of...

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