primary and community care delivery plan 2015 - 2018

Agenda item 3.2 Appendix 1

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PRIMARY AND COMMUNITY CARE DELIVERY PLAN

2015 - 2018


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1. Scope of the Primary and Community Care Delivery Plan

The Primary Care and Community Delivery Plan will address the development of services delivered across the whole scope of primary care independent contractors, as well as those services provided by the Localities Directorate within the community. As with all plans, not everything can be developed simultaneously and priorities for development have to be agreed. Many of our core services as described below already have wider joint Delivery Plans with our acute care colleagues such as ‘The Oral Health Plan’ and ‘The Eye Care Delivery Plan’ as well as a detailed ‘Medicines Management Plan’. The plan for this year 2015/16 is therefore focussed on the General Medical

services (GP’s) as this is currently the area of our wider planning

that is least strategically developed and described. The other areas have not been neglected and work is on-going to progress these often through joint mechanisms such as work with our Local Authority partners to develop the ‘integration of @ Home services’ and work with pharmacy to progress many localised schemes with our GP’s. This work should therefore be read in conjunction with other key UHB plans such as: • Local Oral Health Plan; • Local Eye Care Plan; • Local Medicines Management Plan; • Local End of Life Care Plan; • Local Delivery Plan for Diabetes; • Local Delivery Plan for Stroke; • Local Delivery Plan for Cancer; • Local Delivery Plan for Heart Disease; • Local Delivery Plan for Respiratory Disease; It must be therefore be recognised that this is an iterative process and the plan will be regularly up-dated to encompass the areas as the joint working with others develops. The full range of services that we will include over time is described in brief below: 1.1 Core Primary Care Team

Within core primary care provision there are four practitioner services; medical, dental, pharmaceutical and optical. These practitioners are independent of the Health Board and the services are contracted by the Health Boards to deliver their defined service areas.


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The key role of primary care services in Cwm Taf is to: • provide a first point of contact with healthcare services; • offer continuity of care (diagnosis, prescribing and care management); • provide a universal service, co-ordination of care 24 hours a day, 7

days per week across primary, secondary and social care systems; and • improve the health of the population through health promotion and

primary prevention.

1.1.1 General Practitioners (GP’s)

In Cwm Taf we have 46 GP practices, supported by a total of 170 general practitioners. The Primary Care and Community Services healthcare team consists of General Medical Practitioners (GP’s), Practice Nurses & Healthcare Assistants (HCA’s), Phlebotomists, Managers and Reception staff that are employed by the GP practice. They then work very closely with other health staff they do not employ such as Health Visitors, District Nurses, Community Midwives, and other community staff such as Community Psychiatric Nurses and Therapists. Our GP ‘in hours’ service provides acute as well as routine provision and our community services are supported by an ‘Out of Hours’ GP service (OOH’s). The OOH’s service is for those patients who are ill and feel that they cannot wait for an appointment with their GP the next day.

1.1.2 General Dental Services (Dentists)

In terms of general NHS dental services, we have 35 dental practices (GDS) supported by 107 Dentists. In addition to dental services being provided by Independent Dental Practitioners there are 2 Community Dental Services (CDS) practices, a Dental Teaching Unit based in Porth, and 10 Community Dental Services Clinics providing treatment to children and adults with special needs. Our Dental ‘in hours’ service provides acute as well as routine provision and our community services are supported by an urgent ‘Out of Hours’ emergency Dental service. The emergency Dental service is for those patients who have an acute immediate need that cannot wait for an appointment with their Dentist the next day. 1.1.3 General Ophthalmic Service (Optometrists) Our general ophthalmic services contracts ensure a comprehensive eye examination, appropriate to individual need, symptoms and general health. There are 28 optician premises in Cwm Taf supported by 69 optometrists. The ophthalmic service also provides acute input for eye conditions as well as planned routine examinations on a daily basis. 1.1.4 Community Pharmacy Service (Pharmacists)

We have 77 NHS Community Pharmacies within Cwm Taf Health Board. They provide a core provision of dispensing medication in a wide range of


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community settings. They also provide many other services to the population such as blood pressure checks, a range of blood tests such as blood glucose levels along side on-going specialist advice and support to all members of the public. 1.1.5 Wider Primary Health Care Team Alongside the four contractor professionals as above are a range of other services provided by employed University Health Board staff from the Primary and Localities Directorate. They work as part of the primary care team. These include District Nurses, Health Visitors & School Health Nurses. These professional groups provide core/generic services, as well as specialist services delivered within a variety of community settings, as well as patients/families own homes. They provide services across the whole age spectrum and link very closely also with other service across the UHB the Local Authority, third sector and private providers. There are other key professionals within this sphere such as community mental health staff, community midwifery etc their work is not included in this scope as it is covered in other speciality specific delivery plans. 1.2 Community Care

The generic community services within Cwm Taf are wide and varied. This plan will address those services currently described as part of the Community Resource Team, the @Home service, and Continuing Health Care. As listed below:

• The Community Integrated Assessment service (CIAS) • Home IV Service • Nursing Home Support Service • Multi Professional Reablement Service • The Continuing Health Care and Funded Nursing Care • Community Palliative Care provision • Lymphoedema Service • Tissue Viability Service • Aural Care Service • Diabetes Nurse Facilitator Service • Respiratory Nurse Facilitator Service • Parkinson’s Disease Clinical Nurse Specialist Service • Home Oxygen Therapy Service • Immunisation Coordinator service • Clinical Practice Educator Service

1.3 Hospital Based Rehabilitation

Our Rehabilitation facilities within our hospitals are now focussed on 3 sites; Ysbyty Cwm Cynon, Ysbyty Cwm Rhondda, Royal Glamorgan. These beds are used for rehabilitation of patients to ensure that they are able to function appropriately to manage within their ‘home setting’. The key


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quality initiative for these sites is to maximise ‘flow’ and to reduce the average length of stay (ALOS) within these hospitals to ensure that patients are transferred home as quickly as possible, to reduce dependency. 2. Timescales of the Primary and Community Care Delivery Plan

This plan will span a 3 year period and is aligned with the University Health Boards Integrated Medium Term Plan (IMTP). This plan should be read in conjunction with the Primary and Community Service section of the IMTP which gives more detail on the services above. Diagram 1 illustrates the three year timeframe and sequencing of our proposed development focus: Diagram 1 – three year timeframe

As noted and illustrated above, the development of the General Medical (GP) component of the plan has been the key focus for 2015/16, which links to the key priorities in the Welsh Government document ‘Our Plan

for a Primary Care Service for Wales up to March 2018’.

2016/17 will see the detailed introduction of the key deliveries from the Eye Care and Oral Health Plans as well as the priorities for Community


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Pharmacy inputs. It will also see the introduction of the joint working with our local authority partners around a new and integrated @ home services. More detailed work on the role of our Community hospitals will be included as well as a more enriched role and functioning with our third sector partners. 2017/18 will be a major evaluation year although this will of course be an on-going process. This year we would expect to see key products / deliverables emerging from our Research and Development activity and key outcomes from the changes that we have put in place. This work will bring rich data for service sustainability / change in our own area but also worthy of sharing with our wider UHB colleagues and beyond. 3. Contexts of the Primary and Community Care Delivery Plan

3.1 National Context

Welsh Government has made it clear, for Wales to realise its ambition to deliver a Primary Care and Community-led NHS, the current systems for commissioning and delivering services must change. Prevention, early intervention and avoidance of hospital admission need to form the basis for redesigning integrated systems of health and social care. Managing increasing demand in the context of existing and future resource and medical manpower constraints requires an innovative approach to the development of new models of care and workforce planning. ‘Setting the Direction’ is a key policy driver in ensuring that services can be provided safely within peoples own homes, or as close to home as possible. Our plan has been developed based on local need, but also taking into account the Welsh Government document ‘Our Plan for a Primary Care Service in Wales up to March 2018’, as well as the ‘Social Services and Wellbeing’ (Wales) Act 2014. Whilst the focus on development of integrated care pathways will continue to be an important feature of service and quality improvement, transformational change is urgently required to meet the challenges of the future. Further incremental shift of services from hospital to community-based delivery or indeed simply extending the role of enhanced services within the GMS contract will not deliver the scale or pace of change necessary to meet demand. This is the focus of the Cwm Taf Primary and Community Services delivery plan and the basis of our 3 Year Integrated plan (IMTP).


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3.2 Local Context

3.2.1 A key driver at a local level is the Inequalities in Health of our population. Throughout the document are references to the ‘Inverse Care Law’ and activities to address this within this plan are a key feature. The plan is based on the health needs assessment undertaken by Public Health Wales ‘A profile of health and lifestyle in Cwm Taf – Nov 2013’ produced to support the Cluster Plan development at GP and Cluster level. A summary of the document is attached at Appendix 3 which shows the key drivers for Cwm Taf which include:

• A reduction in Smoking • Increase in Physical Activity • Reduction in Obesity • Support for Mental health and Well-being • Improve activities in Chronic Disease Management especially around

Cardio Vascular Disease, Respiratory Disease and Diabetes 3.2.2 The historical footprint for the delivery of Primary Care has been the GP Surgery, Dental Practice, Community Pharmacy or Optometric Practice delivered principally through independent contractor arrangements. There is significant work to be undertaken across the Health Board within a workforce context to deliver on the Health Board plan to move services out of acute settings into the community and for more care to be provided close to or in patient’s homes. This is a task for the whole organisation not just that of Primary Care and Community Services. There are significant differences and therefore challenges specifically within our General Practice workforce and the issues that this creates both for in-hours and out of hours services. Some specific details/challenges associated with our GP workforce are outlined below: • We have the highest percentage of single handed partnerships, 17.4%

compared to a Welsh Average of 10.8%. • We have the lowest percentage of GPs per 10,000 population, 5.8%

compared to Welsh Average of 6.5%. • Female practitioners as a percentage of GP workforce is the second

lowest, this being 45.3% compared to Welsh average of 48.6%. • Percentage of the Cwm Taf GP workforce aged 55 and over is by far

the highest at 31.2% compared to a Welsh average of 23%. It must be noted that since 2004 there is no mandatory retirement age for GPs and therefore many decided to work beyond 55.

• Despite the above statistics we have made the most significant progress over the last 7 years in reducing the average patient list size per GP. In September 2006 the average number of patients per GP was 1,982 compared to 1,785 recorded in 2014.


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Currently the variation in practice size and the range of enhanced

services available to each patient population varies greatly. This variation is often aligned to the “inverse-care-law” – where those with greatest need experience poorest access. Under the GMS contract, the delivery of ‘enhanced’ services by GPs is voluntary and dependent on GPs having identified needs for their patient population and having acquired the necessary skills to deliver the service. As a result, not all GP’s provide the same range of services, with larger practices often having the ability to provide more extended services than their smaller counterparts. Over recent years, in the context of the GMS contract, attempts have been made to reduce variation and drive up standards through incentivising enhanced services to be delivered within federated arrangements across GP Practices. However, collaboration is, to a large extent, limited by the business consequences for the independent contractor. Where there are incentives to share services, this can work well but where there could be a threat to practice income, opportunities can be restricted. More recent amendments to the GMS Contract provide further incentives for Locality or Cluster-based working but the likely impact on variation is assessed as being marginal in the overall context of independent contractor status. There has been considerable debate at a national level (UK and Wales) regarding the development of salaried services versus independent

contractors within Primary Care. Given the complexity of the issue and the practicalities of any such changes, it is argued that a mixed economy approach, if effectively introduced and managed, can provide the optimal solution to improve quality, capacity and reduce variation. Our current focus is on recruitment and retention of our GP workforce rather than the other contractor professions or indeed our wider community based staff, as at present however we are not experiencing the same demands on these professions or indeed the difficulty in recruiting into these vacancies when they arise. The Cwm Taf delivery plan takes into account the factors as outlined above and aims to build on the strengths of the existing systems and skills whilst building capacity and capability to address growing demand. 4. Proposed Service Delivery Model

The Health Board has worked with the key clinical leaders to develop the model for taking this work forward.


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4.1 Five Key Underpinning Areas of Focus In broad terms the Health Board has reflected strongly on its experience of serving this population since its inception and has focused its delivery plan on five areas: • Performance: managing core primary care services to ensure that we

deliver against our standards, drive out variation and aspire to improve;

• Coproduction: building the best possible relationships with people to help them stay healthy;

• Research, evaluation and development: ensuring that we work from an evidence base and constantly learn and reflect on our day to day practice and the outcomes it achieves for people in their communities.

• Clusters and Cluster Hubs: introducing the best possible strategic approach and organisational form to link local needs to the full range of Health Board services

Diagram 2 – five areas for focus

4.2 The ‘What’ in the Service Delivery Model

This section attempts to outline what type of services the model is trying to provide and develop. We believe our model should be based on the following trajectory of how service delivery should be considered and provided/accessed by patients and their families. Throughout every element of this provision, health promotion and illness prevention are an integral component. Educating our citizens / patients / families / other professionals is a key challenge which will form part of the over arching plan


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4.2.1 Self-care and staying healthy A fundamental part of our plan is to ensure that ‘Integrated Plans’ are in place with our partners to support our population to maintain their health and to self care for minor ailments. Our developing plans for self care and staying healthy will aim to ensure: • our population will have the knowledge, and confidence to look after

their own health and to prevent ill health through targeted public health interventions across all age ranges;

• our population will have an increasing healthy life expectancy so we are not just living longer but have a better quality of life;

• our population will be aware and linked into wider communities through the work of the 3rd sector to improve their health and wellbeing;

• our population will have targeted advice and support to those who already have poor health or are at high risk of ill health;

• our population will have reduced levels of obesity & smoking; • our population will have targeted support for people who are out of

work. Being out of work is strongly associated with increased overall mortality and poor physical and mental health. In the Cwm Taf area, the proportion of the population in employment is lower than for Wales as a whole;

• our older people will have the knowledge and support needed for “active ageing”, enabling them to live healthy lives for as long as possible; and

• through all professional contacts, residents will be encouraged to take exercise, eat a healthy balanced diet, stop smoking and reduce drinking below the recommended limits. This can add a potential fourteen healthy years to life which is imperative for our population.

4.2.2 Advice and support Despite keeping as healthy as possible there will be times when everyone needs more advice and guidance to deal with health related issues. We need to empower our population to access robust reliable information as the first course of action before accessing a health professional. Current examples include Choose Well campaign; UHB website; NHS direct; social networking tools such as Twitter and Facebook; signposting from personnel such as Community Co-ordinators; carer’s champions. Other examples include: • The “Add Life to Years” on-line health check for people over 50 years

provides individuals with their own profile of health and advice on how this could be improved by adopting healthy lifestyle changes. Currently this is being delivered by Communities First and Age Cymru targeted at our more deprived communities


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• A cancer-related health check tool, developed and operated by Tenovus is being piloted, providing information and advice to reduce cancer risk

• The Community Pharmacy Common Ailments Scheme pilot in the Cynon Valley provides people with an alternative to a GP consultation and an accessible source of advice and support.

Our plans for advice and support will progress an ‘Integrated Provision’ with our 2 local authorities and our third sector partners to ensure: • the use of NHS Direct will be increased and seen as a helpful first point

of contact for immediate health advice; • the population will start to feel confident in using the 24/7 111

telephone/website advice service that will become available; • the large carer population will be supported to undertake their role by

accessing a carer assessment to identify their needs and the support available from all agencies;

• the population will access the range of services provided by the third sector to provide general support and advice with the aim of reducing the stress that many people experience; and

• the third sector Community Co-ordinator role within each locality will be utilised fully and expanded as appropriate.

One clear example of a programme that we are currently involved in under this area is Your Medicines Your Health (YMYH). This is a broad umbrella term that encompasses a range of interventions aimed at increasing the responsible use of medicines by patients and the public. YMYH is a holistic approach straddling health, social care and education. Focussing on some areas of deprivation (e.g. social housing) it will work to improve equity and reduce variation in care. This piece of work is led by the Medicines Management Directorate within the organisation. 4.2.3 Early Intervention

Timely access to all of our Core Primary Care Contractors and our range of community @ Home and Community Resource Services is the priority focus for ensuring early intervention when health problems arise. A brief description of these services has been provided earlier in the paper and it is the GP element of this range of services that we are targeting for development in 2015/16. Many of the schemes that are described for priority this year within the clusters are targeted at early intervention. Our plans in this area will focus on schemes that ensure: • Quality Standards such as improved access will be fully developed and

understood for every GP practice, with improvements where indicated • There will be targeted recruitment of a number of salaried GP’s to

support workforce development and aid recruitment and retention • Developed GP mentorship schemes will be in place


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• Practice Nurse development/recruitment will be enhanced by facilitating acute care nurses to work alongside / gain training within GP practices

• Practice Nurses will be supported to undertake Advanced Community Skills training

• Dental Practices will target the actions developed by the Cwm Taf Oral Advisory group as outlined in its ‘Local Oral Health Plan’ which focuses on early intervention

• Dental capacity within the Merthyr Tydfil Locality will be increased • Development of a sedation services for Dental Care will be in place • The UHB will work with local optometry practices to deliver the key

actions as outlined in the ‘Eye Care Plan’. • The new model for district nursing will be implemented which will

ensure that a wider skilled workforce is available with enhanced capacity to support new community development

• Integration of community pharmacists into the extended primary care team, with services aligned to improve standards of pharmaceutical care and medicines management

• The role of clinical pharmacists will be implemented within the community pharmacy setting. These pharmacists will be Independent (non-medical) Prescribers who will work across boundaries, increasing the capacity within Primary Care

• The skills of pharmacy technicians and pharmacy assistants will be developed to support the delivery of innovative services

• The role of community pharmacists will be extended in delivering the public health agenda, building on the successes of the smoking cessation and emergency contraception community pharmacy services

A good example of a scheme where early intervention is important and draws on a multi professional approach is the work on Neurodevelopmental services for children and young people with conditions such as ASD. A multi-disciplinary neurodevelopmental team is being developed to provide earlier assessment by the most appropriate person who will then work with wider professionals to pool their skills and knowledge to achieve the best possible outcomes for the child / young person and their family. Families would be supported at all stages as opposed to the current situation where families are often on a waiting list for over a year before assessment and intervention is offered. The Neurodevelopmental Community Team features strongly in the CAMHS & Paediatric IMTP’s but is highlighted here as there is a core GP component to deliver the service differently. The GP element is the provision of on going prescribing and monitoring of medication and associated physical review as part of a shared care Locally Enhanced Service. This scheme is referenced in the action plan at Annex 3.


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4.2.4 Long Term Conditions

Much of the work detailed later in the plan for this year focuses on Long Term Conditions. The growing need for these interventions across disease specific groups is a focus for the GP clusters. Participation in the UHB Long Term Conditions Delivery plans is essential from a primary care perspective much of which has also been highlighted in the Public Health Needs Assessment work prepared for cluster development. We have agreed two key underlying models of care targeted at addressing Long Terms Conditions as outlined below: 4.2.4.1 Inverse Care Law Programme - As part of our work with GP’s in particular, we have a dedicated programme targeted at reducing early deaths from cardiovascular disease in Cwm Taf. Cardiovascular disease is a major cause of premature mortality in Cwm Taf and is the highest in Wales (see Chapter 3 population health and challenges, Public Health Wales 2013). The Programme forms part of disease prevention and early intervention through primary care and community services which will realise benefits across the whole pathway. It is proposed that investment upstream in primary care and the community will in time realise reduced demand on services in secondary and tertiary care.

The Inverse Care Law Programme is central to the University Health Board’s commitment to driving up standards through service remodelling based on the needs of the population and the best available evidence of clinical and cost effectiveness. A structured approach to cardiovascular disease risk identification and management has been piloted in practices serving our most deprived communities (January – March 2015) which will be evaluated and rolled out across Cwm Taf in a phased approach from April 2015. Reducing the burden of cardiovascular disease in Cwm Taf will increase the number of years lived in good health, free of disability and limiting long term illness. This will enable the working age population to remain economically active and improve outcomes for families and the community. There will also be benefits to the health and social system realised through the reduced burden of ill health and disability. As a commitment to addressing health inequalities in the Cwm Taf Population and reversing the Inverse Care Law, the Primary and Community Delivery Plan identifies prevention and early intervention as priority areas. Encouraging healthy lifestyles and behaviours as part of this programme and related projects will not only reduce risk of CVD, but also cancer and dementia as illustrated in the Caerphilly Cohort Study. During 2015-18, the Inverse Care Law Programme will be implemented across Cwm Taf and will dovetail with other projects identified in the


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Primary and Community Delivery Plan. A detailed project plan underpins this work and is referred to in the action plan at Annex 3

4.2.4.2 House of Care Model for Long Term Condition Management Many people who have one long term condition commonly suffer from another (multi-morbidity) and yet opportunities to identify and manage these are often missed. Patients often receive care from multiple different teams in a disjointed way. This results in uncoordinated care, multiple different healthcare contacts and in some cases, confusing and contradictory information. We know that in less than half of routine consultations do people get any help to manage during daily life, and we also know that people would like more support to enable them to have the knowledge, skills and confidence to do this. A focus group with patients from a Rhondda General Practice (January 2014) confirmed this. A more co-ordinated and integrated approach is needed to assessment, treatment and care to improve outcomes, including patient experience and patient safety. The House of Care is a direct service response to this. It starts with making better use of service contact time – by what we call “care and support planning”, which links traditional clinical care with support for self management. It then ensures that the service people need in their daily lives to support the goals and plans they have identified during care planning are available in the community, known as “more than medicine”. In this way, care planning ensures that people with LTCs can have a uniquely personalised individual response, embedded within a whole systems approach. The Cwm Taf [Long Term Conditions] LTC model places the individual at the centre of their health whilst developing skills such as motivational interviewing and coaching amongst those interacting with the individual, allowing them to direct the individual to the support they require. It promotes team working across healthcare and other sectors and follows the House of Care Model supported by patient activation. 4.2.5 Rehabilitation within our Community Hospitals

Community hospital beds promote partnership in care with families and local services, ensuring a person centred approach to care. Patients are supported by the multi – disciplinary team to achieve their potential to lead an independent life according to their individual physical, cognitive and social abilities. Our Community Rehabilitation Beds are based in:

• Ysbyty Cwm Cynon – 4 wards • Ysbyty Cwm Rhondda – 4 wards

• Royal Glamorgan – 1 ward


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Future developments centre on clear agreed ‘patient pathways’ between Acute and Rehabilitation clinicians. These pathways will determine the detail and location of intervention as follows:

• Rehabilitation • Sustain and maintain health and well being • Medication trials • Palliative care • End of life care • Complex discharge planning

4.2.6 Out of Hours Urgent Care (OOH’s)

We are introducing a new model in three phases during 2015/16. In the first phase we have co-located our OOH centres with our A&E departments at Royal Glamorgan hospital and at Prince Charles hospital. This will start to address the shortage of available skilled staff to work in this service and will also streamline patients to the most appropriate member of staff and appropriate environment more quickly. Alongside this development we are progressing a different workforce model with the aim of integrating the OOH’s service with the A&E service in the longer term. The key elements of the proposal are summarised in diagram 3: Diagram 3 – OOHs service development

4.2.7 Prioritised Schemes by Cluster Section 4.2 has described in summary the type of services the plan is attempting to deliver and develop. The following give detailed examples of the priorities within each of the four clusters across Cwm Taf.


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Table 1 below shows the priority areas for 2015/16 developed through the GP Cluster Leads. Key areas of consensus amongst these projects are:

• Wound dressing service – centralisation at local cluster hub • Pharmacy investment to support medicines management within GP

Practices • Focus on information infrastructure • Support for lifestyle and behavioural modification

These priorities align strongly with wider organisational objectives including our corporate commitment to:

• wound innovation and developments within District Nursing; • innovations in medicines management through Your Medicines Your

Health; • modernisation of our patient records systems; and • learning from the Inverse Care Law project about patient activation

and management of lifestyle risk factors. Other projects are being tested in one cluster and then, if supported by evaluation, rolled out to others based on their local needs. Again these support corporate objectives such as shifting services from acute into locality settings with a focus on earlier intervention.

Table 1 – Cluster Priority Projects 2015/16

Priority

Cluster Rhondda Taff Ely Cynon Merthyr

S E

L F

C A

R E

Media Project – to communicate health education messages to the local population and promote a positive image of working within the Rhondda

√

Flu - training practice staff to become flu champions to improve the uptake of flu immunisation

√

BP Pods - for patients to opportunistically take their own blood pressure

√

A D V

I C

E

Lifestyle Co-ordinator – working within GP practices to signpost patients to relevant services

√ √

Behavioural support –Primary Care Mental Health service working within GP Practices

√

Web GP – online information and advice service for patients

√

NUMED – information system for patient education

√

Lung Cancer Early Detection √


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Table 1 – Cluster Priority Projects 2015/16

Priority

Cluster Rhondda Taff Ely Cynon Merthyr

E

A R L

Y

I N

T E

R V E

N T

I O N

Education – for primary care staff, to help improve timeliness of detection

Automated External

Defibrillators (AED) – enabling public access to potentially life-saving defibrillators

√

Vision Templates – creation of a central library of electronic referral templates

√

Recruitment & Retention – survey of GPs leaving General Practice

√

Clinical Governance Practice Self Assessment Tool

(CGPSAT) – identifying priorities for targeting improvement activities

√

HCA training – to enhance HCA skills and role to undertake additional new tasks

√

L O N

G

T E R

M

C O N

D I

T I

O N S

Pharmacist – working within the practice to support medicines management

√ √

Wound dressing service – centralised services for patients from local cluster hub

√ √ √

*Locality COPD service - to provide local services and interventions to COPD patients

√

*Locality MSK service - enabling shift of services locally for patients and alternative to surgery where appropriate

√

*Locality Diabetes Service –enabling shift of services locally as alternative to acute hospital admission where appropriate.

√

*Locality Cardiology service -

–enabling shift of services locally as alternative to acute hospital admission where appropriate.

√

The schemes marked * now form part of the suite of Delivery Agreements being progressed through the Welsh Government Primary Care additional resources.


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Work is on–going between primary and secondary care as well as the local authorities and 3rd sector to progress the schemes above. The aim is to provide services as locally as possible through skilled professionals. We are developing patient pathway diagrams to show the new patient journey for our population. (See Appendix 1 - Cardio Vascular Disease as an example). Those relating directly to areas to be delivered by the Primary Care and Localities Directorate feature within our Implementation/Action Plan at Appendix 2. 4.3 Functional Model of Service Delivery The following shows where and how we propose to deliver services described in 4.2. 4.3.1 Diagram 4 – Functional Model

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The key objectives are: • to consolidate services at GP Practice level so as to strengthen

local provision. In some instances this might include rationalisation of premises (including closure of Branch surgeries) and supporting voluntary practice mergers.

• to reduce variation in access to core and more specialised services at GP Practice level. This may include one Practice within a cluster providing enhanced services through federated arrangements to the wider cluster population.


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• to develop four Cluster Hubs as centres for delivering more enhanced services and to transfer services out of the acute DGH. This will involve Contractor GPs from within the Cluster and PCSU salaried GPs working together with link secondary care consultants and the wider multi-disciplinary team to deliver a broader range of out-of-hospital services (see more detailed description below).

• to develop new systems of integrated community working that deliver greater prevention, ensure early intervention and avoid unnecessary hospital admission. One of the key collateral benefits of the new models of care will be the release of high cost clinical time in secondary care to increase in-hospital efficiency thus improving waiting times and unscheduled care performance.

4.3.2 Development of Cluster Hubs The development of Cluster Hubs is a new concept designed to provide a vehicle for interfacing and integrating Primary and Secondary Care services at a Locality level. Each of the 4 localities will have a Cluster Hub which will serve as a focus to develop a range of out-of-hospital services aiming to: • make best use of skills in an equitable way across all practice

populations; • provide opportunities for Independent Contractors to develop specialist

services, according to community need and in conjunction with the LHB, at no detriment to the core Primary Care function they must deliver;

• provide new portfolio career opportunities for Doctors, Nurses and AHPs across Primary and Secondary Care;

• create a system which will support the shift to community based care; reducing unnecessary hospital admissions; facilitating direct access to a greater range of diagnostics; enabling protocol-driven access to inpatient waiting lists reducing overall RTT; reducing outpatient follow-ups; improving patient experience; and

• defined outcomes for cluster hubs will be aligned to those service areas identified as needed for each locality.

It is proposed that each locality will have a Cluster Hub located in a key community facility, ie: Rhondda Cluster Hub – Ysbyty Cwm Rhondda Cynon Cluster Hub – Ysbyty Cwm Cynon Taff Ely Cluster Hub – Dewi Sant, to be developed as a Health Park Merthyr Cluster Hub – Keir Hardie Health Park The outline Cluster Hub model is represented by the following diagram.


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Diagram 5 – cluster hub model

The Cluster Hubs will support a range of services delivered across the whole of the Locality linked to the Secondary Care services in the designated District General Hospital as outlined in the figure below. This organisational form will make connections between the Health Board, Localities and Clusters organisationally; connect local consolidations and federations, primary care support activities, integrated community activities and academic research; and support the reach into and out from secondary care. Diagram 6 – cluster hub linkages to secondary care

The design of the service model will need to be influenced by all appropriate stakeholders including primary and secondary care colleagues and other potential partners. Meanwhile, the initial views of the Localities Directorate and GP Clusters are outlined below.


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Core Features of Cluster Hubs

The Cluster Hubs are likely to share some common features and services, which may include:

• base for the proposed Integrated Cluster Team, eg: Locality CD; Cluster Lead; Nurse Team Leader; Locality Development Manager; therapy Lead; local Authority lead

• base for the PCSU • access to the proposed integrated @Home service • some Primary Care services • Diagnostic services (NB – these are not currently provided at KHHP) • Outpatient services • Integrated Chronic Conditions services • Tissue viability / leg ulcer clinics • Therapy Services • Sexual health and maternity services • Health promotion • Patient Education

In addition to the above core features, each Cluster Hub will also deliver specific services as appropriate to the needs of the local population. Building on the existing services already provided from each cluster hub, specific new service developments will be implemented in each hub in 2015/16. Those marked * are Welsh Government funded and will be implemented in accordance with a Delivery Agreement. They will be tested in one hub with a view to rolling out to other hubs in future years. The 2015/16 priorities for each hub are as follows:

TAFF ELY CLUSTER HUB

DEWI SANT HEALTH PARK

• Health Park Project • GP Practice • *MSK service

CYNON CLUSTER HUB

YCC

• Integrated Day Services • *Locality Community Diabetes

Services

RHONDDA CLUSTER HUB YCR

• Dermatology Clinic • *Locality COPD Service

MERTHYR TYDFIL CLUSTER HUB KEIR HARDIE HEALTH

PARK

• *Locality Cardiology Service • Integration with third sector


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5. Key Enablers

In addition to the local and corporate projects, the service model and delivery plan are underpinned by several key enablers that are essential building blocks, as described below:

5.1 The Primary Care Support Unit (PCSU) currently assists in delivering a sustainable model of care by supporting GP Practices with salaried GPs and Nurses when they experience recruitment and retention problems or need support/management in the event of crisis. The extended work of the PSCU will allow either the staff from the PSCU to work out of the cluster hubs providing new innovative services or will backfill primary care staff to allow them to provide the service. The experience already accumulated by the PSCU will continue to complement this new work, as currently the PCSU supports areas of work including chronic pain clinics, mortality reviews, QOF visits, nursing home assessments, PCH dermatology service, YCR minor surgery clinics, educational ‘sessional’ cover and ‘sessional’ cover for GPs/CDs undertaking LHB projects/ development. We are also developing our Clinical Nursing Services to provide advanced clinical nurse skills and facilitation roles to support general practise and chronic disease


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management. These include Practice Nurse ‘Nurse Practitioner’ sessions; Specialist support and advice for discreet areas of practice such as anti-coagulation; and training and education tailored to the needs of GP Practice-based staff.

The Primary Care Support model has proven to be a very effective and flexible resource over recent years. It has been highly praised in our recent HIW review and it is an area prioritised for further strengthening and development – certainly locally, and potentially on a wider Health Board basis. 5.2 We intend to develop an Academic Primary Care Unit to enhance research, development and teaching. This will include appointing an academic chair and developing bespoke training opportunities for Doctors and other Allied Health Professionals wanting a portfolio career across community and hospital-based medicine. This could also potentially be a key component of the future recruitment and retention strategy for Primary and Community staff in South East Wales.

5.3 Cwm Taf has made very significant strides on development of performance data in recent years, but Primary Care Data is not as strongly represented in our dashboard as secondary care. Developing this element of the dashboard will be a priority over the coming year. Currently we report on the following areas that are aligned to our work, this is increasing month on month with further work with our performance colleagues: • Childhood Immunisation Rates • Flu Vaccination up-take • GP Access (all day opening & appointments available between 5pm-

8pm) • Quality and Outcome Framework achievement • Units of Dental Activity undertaken Dental Contract.

Data is essential to show our baseline activity, to measure the impacts of our new initiatives and to prove or not the beneficial outcomes of new schemes. We need more robust support / inputs and outputs to be in place to really measure the benefits of this work 5.4 Our community is full of examples of Coproduction. The valleys communities are incredibly resourceful and mutually supportive and increasingly those communities are working more closely with the Health Board. Our Public Forums have long been vehicles for generating better approaches to healthcare in Cwm Taf and we have started to think much more clearly about how the feedback drawn from these regular interactions should influence our service plans. In the immediate term we


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are thinking about how coproduction can be strongly supported by pragmatic and concrete service developments in the following three areas: • advice and support services; • self care models; and • behavioural science approaches 5.5 The organisation has started to pay significant attention to the Behavioural Science Initiatives that have been instigated by the University of Bangor and more widely in the UK; and in terms of immediate implementation we are proposing to take forward Your Medicines, Your Healthcare and to influence this on a Wales wide basis. This type of approach will feature more and more strongly as we develop our delivery of the primary and community care plan. 5.6 Cwm Taf has started to engage with its Research community to develop its Academic and Evaluative Approach to primary care. Our recent discussions with lead academics and practitioners have underlined how important it is to focus on proper evaluation during a period of austerity. We have paid attention to recent studies on Noncommunicable Diseases (NCDs) and have taken key messages from the World Health Organisation. The next immediate and practical steps are to establish: • an academic primary care unit; and • the scoping of a research framework/cohort study for the Cwm Taf

area. This work will also allow us to: • contributes to the Health Board’s University status; • provides a focus on short term, evidence based and purposeful

interventions that will have an impact on long term patient and population outcomes;

• lays out a long term plan for population health over the course of several assembly cycles;

• creates the opportunity for meaningful portfolio career structures for GPs across practice, enhanced practice and research and teaching;

• bridges the broad academic endeavours of Cwm Taf’s primary and community workforce into a shared body of knowledge, with a sense of alignment towards population health outcomes;

• supports the development of Kier Hardy and Dewi Sant Health Parks as academic and practitioner hubs; and

• re-establishes the academic reputation that links back through Archie Cochrane and Julian Tudor-Hart.

Our emerging priorities for research activity in 2015/16 are focussed on key local population health issues and include, amongst others:


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• Cancer diagnosis - exploring the Danish model of No/Yes Clinics to help more timely investigation of patients with ‘low-risk-but-not-no-risk’ cancer symptoms;

• Blood pressure self management – potential participation in the TAMSIN-SR randomised control trial whereby patients with hypertension monitor their own blood pressure and adjust their own medication – which has resulted in improved control of blood pressure, a key risk factor in cardiovascular disease;

• Joint Care programme – research to evidence the effectiveness of the community joint care and weight/lifestyle management programme;

• Reducing cardiovascular risk – research to evidence the effectiveness of the Inverse Care Law project;

Diagram 7 – research framework

5.7 Partnership Working is a key enabler for this work as much of the answer to addressing the health needs of our population sit outside of the gift of health to influence. We believe that we therefore need to develop a Social Model of Health. Evidence suggests that many of our health problems have their origins in society. We know that socio economic circumstances drive inequality in health. In response we need to have a range of options to offer when people seek help for symptoms and illness that arise from these situations. As part of our work on ICL and the House of care we will strive with our partners to develop a ‘Social Model of Health in Primary Care’. Such a


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model will involve stakeholders form across health, social care, housing, leisure and the third and independent sector all working in an integrated and person centred fashion. The model will pick up on the themes outlined by the Minister; • Developing a distributed model for leadership where all take

responsibility for what they can improve • A remodel of the current workforce and service toward one that is

multidisciplinary and based on a social model of health • Developing primary care clusters as the engines of delivery for local

health and social care The partnership opportunities within Cwm Taf are, and always have been strong and these principles will be used to test all of our development work moving forward. Working with other UHB’s - We have 2 major projects working across several UHB’s which have been submitted to Welsh Government for consideration as part of the ‘Pathfinder’ proposals. The first is the Enhanced PSCU which is described in the enablers section above. The second project is Your Medicines, Your Health (YMYH); this is also described in the section on advice and support in the service model section above. Our work on the Inverse Care Law programme has also been supported as a joint venture with another UHB

6. Wider Cwm Taf University Health Board Support

For this plan to work, there are many different linkages to key departments within the UHB that will need to support the plan going forward. The benefits from the changes will also be experienced much wider than the immediate primary and community care workforce. As an Integrated Organisation, this plan will enhance the pathway approach for the whole of the Cwm Taf population and wider. 6.1 Information Technology & Communications

We have outlined in detail our IT and Communication requirements within our IMTP, which signals our priorities for 2015/2016. We will need to work closely and be supported by the Information and Performance Departments to progress key elements of this work as this work will be fundamental in developing this plan. Our priorities include:

• The development of integrated systems across health, social care and the 3rd sector

• Programmes that schedule and record the work of all our community services aligned to dependency tools


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• Support for GP's to access their information outside of practice premises

• Data reporting / analysis and presentation in a way that is available for review and monitoring

6.2 Financial Plans We have prepared a detailed financial plan, which is aligned to our core funding but also to the new investment streams from Welsh Government to develop Primary Care. We also have financial plans aligned to the Intermediate Care Fund and an Invest to Save Scheme. This work has been progressed in partnership with our finance colleagues within the UHB and is detailed within our IMTP and the UHB's overall financial plan. We will need to continue to work closely and be supported by the Finance Department to progress key elements of this work as their support will be fundamental in developing this plan within allocated resources. Delivery agreements for key elements of this plan have been developed and aligned to the Primary Care funding allocation and shared with Welsh Government. The key deliverables are included within our overall implementation plan as outlined in Appendix 2. 6.3 Estates & Capital Requirements

High quality primary and community care is dependent in part upon the availability of suitable GP and Community premises. During the period 2003 to 2013 the University Health Board, working with practices, had one of the most successful Estates Strategies across Wales. This resulted in the closure of 15 substandard surgeries which were replaced with 8 larger modern surgeries; funding for two large extensions, a major refit of a surgery, and improvement grants totalling £799,582. To support the delivery of this Primary & Community Care Delivery Plan, a new Estates Strategy is now to be developed to incorporate the wider primary care contractor professions, Health Board and community premises. The key drivers shaping the primary care landscape and necessitating improvements to the existing estate include: • Development of clusters and cluster hubs – the Hubs are focused

around high quality accommodation which is eminently suitable for the delivery of a wider range of primary care and community based services and will facilitate delivery of services on behalf of all practices in the Cluster. Advantage will be taken of using our existing Health Board premises, such as Ysbyty Cwm Cynon, Ysbyty Cwm Rhondda, and Keir Hardie located in 3 of the 4 Localities, all of which have opportunities for greater utilisation. Plans are also already underway to develop a Health Park model in Dewi Sant Hospital. The proposed new models of care will essentially create capacity and capability within Localities without putting additional pressure on already stretched primary care premises.


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• One and two Partner Practices - There remain a small number of single handed or two partner practices within Cwm Taf. It is likely, as GPs retire, that small practices will need to merge with neighbouring larger practices. This will in some cases require new, extended premises to accommodate the economies of scale that can be attained from larger practice teams and a wider range of service delivery.

• Sustainability – GP Practices are experiencing unprecedented pressure, with a significant and increasing gap between the workload demands on general practice and their capacity to delivery core GMS services to their registered population. There will be a need to support requests to consolidate services at GP Practice level so as to strengthen local provision. In some instances this might include rationalisation of premises, including closure of Branch surgeries where this is clinically appropriate and supporting voluntary practice mergers. There will be a need to balance the requirement for achieving more sustainable critical mass with the need to maintain local access.

• Recruitment and Succession Planning - Good quality Primary Care estates premises have an important role in the succession planning of the Primary Care GP and nursing workforce within Cwm Taf. Giving healthcare professionals the opportunity to provide and develop services from modern, up to date premises will be essential if we wish to retain enthusiastic committed health and social care professionals. It is known that GPs do not want to work, let along make a commitment to or invest in unpleasant, substandard premises.

• GP Premises – Of the 62 properties in Cwm Taf from which General Medical Services are provided, a detailed analysis has identified that 9 are requiring major refurbishment or are not viable in the longer term. Solutions are being sought in relation to these premises.

• Inverse Care – There is a continuing need to focus on reducing health inequalities and focus on the development and expansion of preventative services. The Health Board is developing a team which will work alongside GP practices and it is evident that many practices do not have the physical space to accommodate the additional staff.

• New Housing Developments - Significant increases in population in some areas of the Cwm Taf catchment area are planned over the coming years as indicated in Local Development Plans. This again will put pressure on existing services and teams and indeed their premises.

Opportunities for developing the primary care estate have been complicated by the changes to Welsh Government capital funding policy, whereby responsibility for primary care estates development has been devolved to Health Boards. This presents a challenge as Health Boards cannot spend NHS capital on premises it does not own, such as premises owned by GPs or rented from third party developers. Innovative solutions, such as shared use of premises with local authority partners, and alternative sources of funding, such as European grants or Third Party Developer (3PD) schemes, will therefore need to be explored.


29

A Primary and Community Estates Strategy is now being developed in conjunction with capital planning, estates and finance colleagues, which will inform the refresh of the IMTP.

6.4 Strategic and Operational Planning and Partnership Working

We will be working with our business partners within planning to utilise their skill and support in further defining the detail of this plan on an on-going basis. We will be relying on their links with our partner agencies to support us in addressing some of the integration agenda across health and social care but also our links with the 3rd sector. We will need to continue to work closely and be supported by the Planning and Partnerships team to progress key elements of this work as their support will be fundamental in developing and delivering on this plan. 6.5 Workforce and OD

There are key workforce re-design elements within this plan as well as major areas of work in relation to recruitment and retention especially for GP's. The change agenda is also extensive and therefore it is inevitable that we will need support for OD work with teams and individuals as services change and this impacts on roles and different ways of working. We will need to continue to work closely and be supported by the Workforce and OD team to progress key elements of this work as their support will be fundamental in developing and delivering on this plan.

6.6 Media and Wider Communications and Engagement There is a key component in relation to changing the behaviour of our public in relation to the services that they access currently. We want to work hard on improving the health intelligence of our populations and believe that much of this needs to be done through on-going links with our public through every form of communication. We also want to use wider communication to engage with the workforce and our staff about the exciting changes and the career opportunities that Cwm Taf offers. There are schemes within the plan that start to describe in detail this work. We will need to continue to work closely and be supported by the Communications Team within the UHB to progress key elements of this work as their support will be fundamental in developing and delivering on this plan. 6.7 Integrated Quality Agenda

There are elements within the plan about doing things differently to enhance sustainability, to improve quality and to embrace new technology and ways of working. Much of the plan relies on clinical engagement and ownership across the whole of the organisation not just from primary care as total pathways of care for our citizens are changing. We need the support of our clinical leaders within the UHB through an integrated agenda to make this happen. We will need to continue to work closely and be supported by our Clinical Leaders to progress key elements of this

work as their support will be this plan. A key element of our quality approach known as Cwm Taf Cares

is to promote compassionate care, starting with staff compassion for themselves and colleagues.a simplistic, yet multivalues based philosophy withcomponent parts which prioritises the values of Identity, Compassion,Awareness, ResponsibilityExperience. The essence of iCareunderstanding by investing time and space for staff to explore, experience and evolve. The values act as a guiding principle forbeen on ward based staff, we now intend to roll out the iCare philosophy to primary and community care. 6.8 Alignment of the work with University Health Board staimperative that the mechanisms in place to progress aligned to this work andcomponents in the plan to invigorate Research the Primary and Community context. and Audit departments as well as integral working with the lead for our 'U' status. We will need to continue to work closely these individuals and depas their support will be plan.

7. Time scales, Governance

Diagram 8 below shows a broad overview care plan. Our primary care projects will break across the year in three major phases, an enabling phase running between March and July to put in place solid foundations in terms of capability and support for ongoing project delivery; a project sewill see prioritised projects coming into place alongside our major projects which have drawn from our clinically led workshops in recent weeks; and an implementation

Agenda item 3.2

work as their support will be fundamental in developing and delivering on

A key element of our quality Cwm Taf Cares

to promote compassionate care, starting with staff compassion for themselves and colleagues. iCare is

, yet multi-faceted philosophy with five

component parts which prioritises Compassion,

Responsibility and

iCare is to deepen staff personal awareness and understanding by investing time and space for staff to explore, experience

articulate the attitude expected from our staff and as a guiding principle for our behaviour. Whilst the initial focus has

been on ward based staff, we now intend to roll out the iCare philosophy to primary and community care.

work with the 'U' in UHB University Health Board status affords significant opportunities, and i

mechanisms in place to progress the and harnessed to support its delivery.

plan to invigorate Research and Development within and Community context. We need the support of our R&D

and Audit departments as well as integral working with the lead for our 'U' We will need to continue to work closely and be supported by

departments to progress key elementsas their support will be fundamental in developing and delivering on this

Governance, Reporting and Monitoring

below shows a broad overview of the phasing of care plan. Our primary care projects will break across the year in three major phases, an enabling phase running between March and July to put in place solid foundations in terms of capability and support for ongoing project delivery; a project set up phase between July and October which will see prioritised projects i.e. OOHs and Neurodevelopmental services coming into place alongside our major projects which have drawn from our clinically led workshops in recent weeks; and an implementation


30

and delivering on

personal awareness and understanding by investing time and space for staff to explore, experience

attitude expected from our staff and Whilst the initial focus has

been on ward based staff, we now intend to roll out the iCare philosophy

tus affords significant opportunities, and it is 'U' in UHB are

delivery. There are key Development within support of our R&D

and Audit departments as well as integral working with the lead for our 'U' be supported by

elements of this work and delivering on this

porting and Monitoring

phasing of the primary care plan. Our primary care projects will break across the year in three major phases, an enabling phase running between March and July to put in place solid foundations in terms of capability and support for ongoing

t up phase between July and October which OOHs and Neurodevelopmental services

coming into place alongside our major projects which have drawn from our clinically led workshops in recent weeks; and an implementation


31

review phase in the final third of the year, where project delivery will be driven and assessed for continuation into 16/17.

Diagram 8 – 15/16 phasing of project delivery

Appendix 2 shows the schemes in more detail with key timescales and deliverables outlined. This action plan format will be used to report regularly by exception using a RAG rating system. The Gantt Chart shows the committees it is envisaged that the plan will be reported to on a regular basis. The directorate have a more detailed plan with clearly identified named leads to ensure that performance management and monitoring is in place and accountability is clearly defined. The detailed delivery of the schemes will first be reported to the relevant internal committees within the directorate i.e. Primary Care Delivery Group, Primary and Community Quality and Safety Group and then onwards to our Clinical Business meeting. Following detailed review and monitoring at these meetings they will be reported to the relevant UHB wide committees such as Finance and Performance and the Primary Care Committee. These committees perform a scrutiny role on behalf of the wider UHB Board and therefore through this route will be reported to the main Board as and when necessary.


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General up-dates will be presented to Executive Board on a regular basis. Any key risks or barriers to implementation will also be brought to the Executive Board as and when necessary. There are other very regular formal reporting mechanisms in place with their own schedules to be completed such as Welsh Government Returns against the Primary Care Investments and the Invest to Save Scheme. Also returns against the Intermediate Care Funds are in place.

8. Conclusions

In conclusion, this plan is a 3 yr plan which will cover the whole spectrum of primary and community service delivery. In the first year of development we have focussed on the General Medical (GP) element as it was felt that this was the area that was least less defined. Some of the more detailed work around the other contractor professions can be found in other delivery plans such as the Eye Care Plan, the Dental Health Plan and the Medicines Management Plan, elements of which do feature in this plan. The plan has been developed through the clinical leadership of our Clinical Directors. Engagement with the wider GP workforce through cluster meetings has progressed this year. Wider engagement has developed with other colleagues and will continue to be a priority. The plan needs to be read in conjunction with our IMTP where more detail can be found on areas such as Estates, Workforce and OD and Finance. We have pulled together the key elements for this year into an action plan with deliverables and times scales which is available at the end of the plan at Annex 3. We have highlighted the need to work with all of the wider departments within the UHB to develop and deliver on the plan as it is reliant on a broader set of skills and expertise than is available within the primary care team alone. The plan will be regularly monitored in detail through the internal mechanisms within the directorate but will also be reported and scrutinised through wider UHB committees as highlighted within Annex 2. The plan will continue to be developed over the next 3 yrs and therefore is a live document that is progressing through an iterative process. Regular up-dates will be provided as necessary through the leadership of the Director of Primary Care and Mental Health.


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Appendix 1

Patient Pathway Cardio Vascular Disease Risk Assessment


34

Appendix 2

Priority Areas as outlined in the Primary Care and Localities IMTP, aligned to Welsh Government funding streams and National Drivers

Primary Care and Localities Implementation/Action Plan 2015/16

Date of Report: Committee Reporting To:

Priority Area Key Milestones & Time Scales Red

Amber

Green

Exception Report

Welsh Government Delivery Agreements (population based allocation) Out of Hours Redesign

1. To ensure that the fill rate for GP sessions is increased and maintained to 70% by September 15

2. To achieve co-location to just 2 acute sites by end of September 2015 3. To change the skill mix within the service reducing the dependence on GP

sessions by January 2016 4. To achieve more integrated model between A&E and Out of Hours Service by

January 2016

Enhanced Primary Care Support Unit (PSCU) Recruitment and Retention Also a Pathfinder

allocation

1. Advertise for extended workforce – On-going review quarterly 2. Report on placement of workforce and outcomes – Report quarterly 3. Work with educational colleagues to enhance recruitment of GP’s to E-PCSU,

agree programme of interventions – September 2015 4. Evaluate E-PCSU workforce inputs into new developments Cluster Working –

March 2016


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Cluster Hub Locality Cardiology Service

1. Agreement with Acute care colleagues on the model and the delivery mechanism – August 2015

2. Identification of current staff with interest and recruitment of new staff – September/October 2015

3. Identification of clinical space /equipment etc – September/October 2015 4. Commence service delivery from Cluster Hub facility – December 2015 5. Evaluation of intervention as in 1-3 above– March 2016

Cluster Hub Locality COPD service

1. Agreement with Acute care colleagues on the model and the delivery mechanism – October 2015

2. Identification of current staff with interest and recruitment of new staff – November 2015

3. Identification of clinical space / literature / options for wider intervention – October 2015

4. Commence service delivery from Cluster Hub facility – January 2016 5. Patient evaluation of intervention as in 4 above– March 2016 6. Measurement of indicators 1-3 as above – January 2017

Cluster Hub Locality Community Diabetes Service

1. Agreement with Acute care colleagues on the model and the delivery mechanism – August 2015

2. Identification of current staff with interest and recruitment of new staff – October 2015

3. Identification of clinical space /equipment etc also reliable call and re-call service – October 2015

4. Commence service delivery from Cluster Hub facility – Dec 2015 5. Evaluation of data as in 1 & 2 above to set %targets for 2016/17 - March 2016

Cluster Hub Locality MSK Service

1. Agreement with Acute care colleagues on the model and the delivery mechanism – October 2015

2. Identification of current staff with interest and recruitment of new staff – November 2015

3. Identification of clinical space/ protocols etc – November 2015 4. Commence service delivery from Cluster Hub facility – January 2016 5. Evaluation of patient feedback on reduction in pain – March 2016 6. Agreed % reduction agreed for 1 & 2 above - April 2016. 7. Measurement of indicators 1&2 as above – June 2016

Research, Evaluation and Development

1. To develop an academic primary care unit with the expertise to support this work across primary care within Cwm Taf - November 2015

2. Create the opportunity for meaningful portfolio career structures for GPs across


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practice, enhanced practice and research and teaching – January 2016

3. Scope a research framework/cohort study for the Cwm Taf area – January 2016

4. Make linkages with other academic departments to align opportunities – January 2016

5. Prepare a long term plan for population health over the course of several years – March 2016

Community Eye Care Services

1. To review the pathway and referral process in light of any changes in legislation or guidance - Ongoing

2. Measure the reduction in cancelled out patient appointments since service commenced – Nov 2015

3. To continue to evaluate and measure the impact on hospital referrals and out patient - March 2016

4. To continue to evaluate and measure the patient satisfaction and improved experience for patients – March 2016

5. To look for opportunities to further progress these schemes through joint working and pathways – December 2015

Training and Development for Future Roles

Independent Prescribing 1. Identification of clinical pharmacists who can embark on the independent

prescribing scheme - end of July 2015 2. Identification of suitable number of GPs who can support and mentor the

identified clinical pharmacists - end of July 2015 Advanced Practitioner Training – deferred to academic year 2016/17 due to availability of spaces. 1. Identification of Nurses who are interested in undertaking the Masters course –

end of December 2015 2. Reserve appropriate number of spaces at the University for the Masters course

commencing December 2015 3. Signed commitment from employing GPs to release the individuals – December

2015 Behavioural Skills / Motivational Interviewing Course for Health Care Support Workers 1. Work with the University to identify a suitable course for Health Care Support

Workers – August 2015 2. Identify the Health Care Support Workers willing to participate in this course -

September 2015 3. Commencement of the course start date - to be confirmed


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GP Mentorship Scheme 1. Identify suitable mentees to participate - end of August 2015 2. Identify suitable mentors – end of August 2015

Primary Care Estates Investment

1. To review practice development plans to identify which practices have identified infrastructure improvements end July 2015

2. To request applications with detailed quotes for the practices by end of August 2016

3. To review the submitted applications by end of September 2015 4. To inform all the successful practices of the outcome of their applications by

beginning of end of September 2015 5. To evaluate the success and improvements as a consequence of the supported

schemes by end of March 2016

Cluster Initiatives (WG dedicated cluster allocation)

Support from UHB for GP Cluster Development Plans (see detail proposals for each cluster within the plan)

1. Support the development of priority areas for each cluster based on public health needs assessment – June 2015

2. Agree UHB support mechanisms to each cluster to help develop and deliver the schemes – July 2015

3. Agree governance / monitoring arrangements for delivery by each cluster – September 2015

4. Report as part of this implementation plan to agreed committees – on-going 5. Evaluate the 2015/16 schemes – March 2016

Inequalities in Health (WG dedicated allocation)

Cardio Vascular Disease – Inverse Care Law

1. Health Checks - Complete health checks in 8 pilot practices to include patients with no risk score due to missing / incomplete data : April – June 2015

2. Six month review - Review individual patient clinical management at 6 months (e.g. need for lipid management) & Review individual risk / lifestyle change at 6 months : Aug-Sept 2015

3. Pilot Evaluation - Quantitative data reporting & Conduct focus groups/ interviews with practices staff and patients to establish what has worked well and needs to be improved : April-June 2015


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4. Refine the model - Based on the data analysis, in light of other work e.g. the Cluster CVD Guide , experience of other Health Boards & Identify community venues to improve uptake: April – June 2015

5. Software - Evaluate experience in pilot sites, Link with the National Heart disease implementation Group plans to commission an All Wales system for CVD Risk Identification and Management & Arrange software provision pro term :

April 2015 6. Extend the model to other practices

Identify further practices in each cluster to be the next populations to undertake this work over 6 month periods: Oct- March 2016 Populations identified / prioritised by need (WIMD deprivation score): April- Sept 2016 Recruit and train HCSWs to undertake risk identification etc : April – Sept 2017

Intermediate Care Fund Supporting Complex Discharge through 4 x Flow co-ordinators

1. Review the outcome of the pilot at PCH to influence the model – June 2015 2. Agree the model with LA colleagues for a flow co-ordinator at both DGH sites and

the 2 community hospitals – August 2015 3. Develop Job Description and advertise openly to engage colleagues with skills

from LA – September 2015 4. Commence role out in a phased approach DGH’s first - Nov 2015 to March 2016

CAMHS Neurodevelopment ( WG funding) Develop a GP enhanced service for medication review/monitor for ADHD, with Paed’s and CAMHS

1. LES to be developed and agreed with LMC : May 2015 2. A GP in each cluster to be identified to deliver the service: April 2015 3. CAMHS to identify all patients and agree patient info to be sent to the delivering

GP’s : May 2015 4. Brief Training and communications mechanisms to be delivered : July 2015 5. Communications with families by CAMHS : July 2015 6. Service Commence: September 2015 Review Service: March 2016


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Invest to Save ( WG funding) Pilot and role out the use of mobile devices in District Nursing

1. Produce Project Plan and Risk Log: July 2015 2. Recruit Project Manager: August 2015 3. Establish project monitoring group: August 2015 4. Align with new CCIS implementation: November 2015 5. Identify and streamline admin process: November 2015 6. Systems for more robust call scheduling along with an electronic patient caseload:

February 2016 7. Access to GP clinical systems agreed and implemented: April 2016 8. Implement new working arrangements fully: October 2016

Other Key Locally Agreed priorities as identified in the IMTP (that have not been noted above) Introduce New Primary Care Indicators

1. Develop locally the new primary care indicators as outlined by WG 2. Work with the performance team to ensure that we have systems in place to allow

us to gather the data. 3. 3. provide to every F&P committee, PC Delivery Group & PC Committee

Review of @Home Services

1. Consider the outcome of the Alders work to influence the internal review of the service: June2015.

2. Work with the team to develop new model: August – October 2015 3. Continue to work with LA on Integrated model for future: On-going through

project approach

Delivery of the Oral Health Plan Actions

Deliver on the agreed actions within the Plan but specifically: 1. Increase the Dental activity in Merthyr Tydfil by 7,000 UDAs 2. Development of a dental sedation service 3. Development of dental domiciliary visits

Re-location of Y Bwthyn to RGH

1. Work with the Macmillan architects to refine the foot print on the building: Sept 2015

2. Agree the operational policy: October 2015 3. Support the detailed elements of the project plan through the Steering group and

operational groups : Monthly


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4. Work with the Executive Team on the options or a 2nd floor: August 2015 5. Support on-going programme management into 2016/17

Development of Integrated Assessment with LA and single point of access

1. Consider the outcome of the current work and the final report: April 2015 2. Agree with the Executive team the recommendations: April 2015 3. Support the on-going work with the LA : throughout 2015/16

Implement the key actions for 2015/16 from the Welsh Government Strategy (Review all quarterly)

1. With the Local Authority, 3rd Sector and other partners use a shared IT system to collect and share relevant information.

2. Work with local authorities and the 3rd sector to phase in a national single point of access to online telephone and information advice and assistance called 111.

3. Demonstrate how we will provide increased capacity including: • Evening and weekend appointments with GP’s • Diagnostic tests • Increased professionals able to prescribe • Services for self care, rehabilitation, reablement & end of life care.

4. Phase in a national 24/7 single point of telephone access through 111 for access to urgent Primary Care.

5. Have a system in place to identify people at increased risk of poor health or exacerbations of existing conditions. Manage this through agreed individual care plans, with a named care coordinator when necessary agreed with the individual

6. Use the national set of primary care measures to drive and report on continuous improvement through. • ‘my local health service’ for the public • Regular reports to the Board • Regular reports to Welsh Government

7. Support primary care clusters to establish patient participation groups. 8. Ensure there are systems in place to improve access to those with specific needs:

• Welsh Language • Other languages and cultural needs • Physical and learning disabilities • Sensory loss • Low health literacy • Frail older people • Those who do not routinely seek help.


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Development of ‘Cluster Hubs’ within each locality

1. Work with each cluster to determine the services they believe could/should be provided from a locality cluster provision: June 2015

2. Agree priorities against primary care funding and work up plans: July 2015 3. Prioritise Dewi Sant this year for capital facilitate wider changes, establish project

approach: July 2015 4. Develop implementation plan for each cluster hub for 2015/16 – October 2015

Continue to improved Flow across community hospital sites

1. Time out session with all key players to review work undertaken by dedicated resource: April 2015.

2. Ensure all systems developed are embedded across both sites: June 2015 3. Agree local escalation policy and process: May 2015 4. Further review session, to evaluate change: Sept 2015 5. Report on-going, as part of UHB process but weekly to exec if in Silver Command 6. Evaluate impact of flow plan and flow coordinators – March 2016

District Nursing Wales Audit Office Review

1. R1: New/Revised DN Service specification – September 2015

2. R2 & R3: Improve the Capture, Recording & Quality of Referrals – Nov 2015

3. R4: Review and improve Patient facing time and activity – Review quarterly 4. R5: Review and improve Workload variation – Review quarterly 5. R6: Insure capture, review and reporting of robust Performance Measures –

Report monthly 6. R7: Ensure on going monitoring and robust Appraisal process (PDR) – Report

monthly


42

The Gantt Chart below shows all of the current key developments aligned to this plan and the committees they will be reported to Key: WG (Welsh Government); PCC (Primary Care Committee); CBM (Clinical Business Meeting); F&P (Finance and Performance Committee); PCD (Primary care Delivery Group); PCQSC (Primary and Community Quality and Safety Committee)

2015/16 2016/17

Report

To Apr May June Jul Aug Sept Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar

Welsh

Government

Delivery

Agreements

Training &

Development

for Future

Roles

PCD

PCC

WG

CBM

Primary Care

Estates

Investment

[Improvement

Grants]

PCD

PCC

WG

CBM

Evaluation Out of Hours

Redesign

Project

PCD

PCC

WG

CBM

Recruitment &

Retention via

enhanced

PCSU

PCD

PCC

WG

CBM Evaluation

Research,

Evaluation &

Development

PCD

PCC

WG

CBM Locality MSK

Service

PCD

PCC

WG

CBM Evaluation


43

2015/16 2016/17

Report


Locality

Cardiology

Service

PCD

PCC

WG

CBM Evaluation Locality

Diabetes

Service

PCD

PCC

WG

CBM Evaluation

Locality COPD

Service PCD

PCC

WG

CBM Evaluation Evaluation

Community

Eye Care

Services

PCD

PCC

WG

CBM Local Cluster

Initiatives UHB Support

for GP Clusters PCD

PCC

WG

CBM Evaluation Inequalities in

Health

Cardiovascular

Disease

Programme

PCD

PCC

WG

CBM Intermediate

Care Fund

Complex

Discharges/Flo

w

PCD

WG

CBM


44

2015/16 2016/17

Report


CAMHS

Funding

GP LES for

ADHD PCD

PCC

WG

CBM Evaluation

Invest to Save District

Nursing

Mobile

Devices

PCD

WG

CBM Local

Priorities

IMTP Primary Care

Indicators PCD

F&P

CBM

Review of

@Home

Services

PCD

CBM

PCQSC Evaluation

Oral Health

Plan

PCD

PCC

WG

CBM

Relocation of Y

Bwthyn to

RGH

CBM

PCD

Integrated

Assessment/

SPA with LA

PCD

Implement

WG Primary

Care Strategy

"Our Plan"

PCD

PCC


45

2015/16 2016/17

Report


Development

of Cluster

Hubs within

each Locality

PCD

PCC

Evaluation

Community

Hospital Flow

PCD

CBM Evaluation Wales Audit

Office District

Nursing

PCQSC

Evaluation


46

Appendix 3 A1: Summary of Measures – key illnesses or health m easures

Adults who reported key illnesses or health status (age-standardised), by USOA, 2003/04-2009

Per cent

USOA Name USOA codeHigh blood pressure

Any heart condition (excluding high blood pressure)

Any respiratory

illness

Any mental illness Arthritis Diabetes

Any chronic illness

Limiting long term

illness (%)

General health status: fair or poor

health (%)

SF-36 Physical

component summary

score (1)

SF-36 Mental

component summary

score (1)

Rhondda Cynon Taf 001 3000059 23 12 17 12 16 8 52 34 29 46.6 47.8Rhondda Cynon Taf 002 3000060 22 9 16 10 17 5 50 31 23 48.0 48.9Rhondda Cynon Taf 003 3000061 24 11 17 13 21 5 55 29 31 47.2 47.2Rhondda Cynon Taf 004 3000062 22 11 17 14 19 6 54 33 30 46.7 47.9Rhondda Cynon Taf 005 3000063 22 9 14 9 13 6 48 28 22 48.7 49.5Rhondda Cynon Taf 006 3000064 19 11 15 13 16 6 53 28 21 48.4 47.9Rhondda Cynon Taf 007 3000065 21 12 14 13 16 7 49 27 24 48.0 48.6Merthyr Tydfil 001 3000066 22 11 15 14 18 6 52 32 29 47.1 47.4Merthyr Tydfil 002 3000067 24 11 16 12 20 7 54 33 29 46.7 47.7WALES 19 9 14 10 14 6 48 28 21 48.7 49.8

Source: Welsh Health Survey. See WHS reports and webpages for full details of survey, methods and questions.

http://wales.gov.uk/topics/statistics/theme/health/health-survey/?lang=en

Statistically significantly worse than Wales

Not statistically significantly different (1) higher score indicates better heal th

Statistically significantly better than Wales

Statis tica l s igni ficance i s determined us ing the confidence interva ls (CIs ) of the loca l va lue. If the nationa l average fa l l s outs ide the loca l CI , the di fference i s deemed to be statis tica l ly s igni ficant.

Currently being treated for


47

A2: Summary of Measures – key health related lifest yles

Adults who reported key health related lifestyles (age-standardised), by USOA, 2003/04-2009Per cent

USOA Name USOA codeSmoker

(%)

Physical activity: meets

guidelines (%)

BMI: Overweight

or obeseBMI:

Obese

Rhondda Cynon Taf 001 3000059 30 29 62 23Rhondda Cynon Taf 002 3000060 23 28 58 22Rhondda Cynon Taf 003 3000061 30 22 62 26Rhondda Cynon Taf 004 3000062 28 22 62 24Rhondda Cynon Taf 005 3000063 21 28 62 23Rhondda Cynon Taf 006 3000064 29 27 62 26Rhondda Cynon Taf 007 3000065 26 27 57 23Merthyr Tydfil 001 3000066 30 31 58 21Merthyr Tydfil 002 3000067 27 28 60 23WALES 25 30 56 20

Source: Welsh Health Survey. See WHS reports and webpages for full details of survey, methods and questions.

http://wales.gov.uk/topics/statistics/theme/health/health-survey/?lang=en

Statistically significantly worse than Wales

Not statistically significantly different

Statistically significantly better than Wales

Statis tica l s igni ficance i s determined us ing the confidence intervals (CIs ) of the loca l va lue. If the national average fal l s outs ide the loca l CI, the

di fference i s deemed to be statistical ly s igni ficant.

primary and community care delivery plan 2015 - 2018

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