september 2016-version 1.3 cardiff west network cluster ... · the original 3 year plan was...

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September 2016-version 1.3

CARDIFF WEST NETWORK CLUSTER ACTION PLAN 2014-17

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CARDIFF WEST NETWORK CLUSTER ACTION PLAN SEPTEMBER

This plan has been developed by the following 10 practices which operate in the Cardiff West Cluster Area, through facilitated discussion with the Community Director and Locality Manager:-

Llywyncelyn Practice Bishops Road Practice Fairwater Healthy Centre Llandaff and Pentrych Surgeries Danescourt Surgery Llandaff North Surgery Radyr Medical Centre Whitchurch Village Practice

The original 3 year plan was established by the cluster in 2014 and this update, reflects the current cluster priorities, based on progress since March 2016 and GMS contract requirements for 2016/17. Although the strategic aims referenced within the document are reflective of guidance provided with the contract, the format primarily represents the strategic aims as identified by the cluster practices. Outline of Cluster Population Profile There are higher levels of deprivation in areas of Fairwater and Llandaff North. The area (MSOA) in the West Neighbourhood that most often displays significantly higher rates and severity of deprivation is Fairwater. These areas are known to experience lower life expectancy and higher rates of premature mortality caused by cancer, coronary heart disease, cardiovascular disease and respiratory disease. According to the ‘Experimental Life Expectancy’ estimates (ONS, 2007), people living in the affluent area of Radyr can expect to live 7 years longer than people living in Llandaff North (83.5 years and 76.5 years respectively) highlighting the negative effect of deprivation on population health. In 2012 the Welsh Government produced information on the combined lifestyle behaviour of adults (i.e. smoking, alcohol consumption, fruit and vegetable consumption, and physical activity). The available data offers an insight into healthy lifestyles within the city. The mean number of healthy behaviours adhered to by adults in Cardiff was 1.9, similar to the Welsh average of 2.0. Only 5% of adults followed all four of the healthy behaviours, while 23% followed three, 39% followed two, 26% followed one, and 7% of adults followed none. Data from the 2010-2011 Welsh Health Survey showed that:

28% of adults in Cardiff reported binge drinking on at least one day in the past week, compared to 27% for the whole of Wales;

just over a fifth (21%) of adults in Cardiff reported being a current smoker;

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only a quarter (25%) of Cardiff’s adults indicated that they did at least 30 minutes of at least moderate intensity physical activity on five or more days a week compared with an all-Wales figure of 30%;

35% of adults in Cardiff had eaten five or more portions of fruit or vegetables on the day prior to the survey date compared to 34% for the whole of Wales; It is therefore important to create opportunities for people to engage in healthy lifestyle behaviours in order to work towards improving the health outcomes of people in Cardiff West. Cluster Population/Key Population Features: Bishops Road - welsh speakers, isolation social housing Tongwynlais branch, potential impact of BUPA care home 70+ beds Llandaff/Pentyrch – 350-400 students, sheltered housing, 1 elderly RH, Creigau Park School-*dementia and increased workload Fairwater -cluster of asylum seekers in pentrebane, transient and hard to engage, little or no English (currently predominantly Chinese), deprivation (23/203 in WIMD) Llandaff North -LD “halfway house Velindre Road, high deprivation in Gabalfa (just outside top 10% WIMD so no Communities First/Families first) impact of BUPA care home 70+ beds Radyr – 2 NH, 1 elderly, 1 complex physical needs – significant workload for practice and HB.1 RH. High prevalence dementia. Approx 10% Welsh 1st language. Aging population, long life expectancy. Danescourt-Low numbers in care homes, pockets of deprivation (some registered patients in pentrebane – Flying Start and Communities First) Llwyncelyn- Mental Health needs, aging population – majority in own homes, Impact of BUPA care home, Learning Disability Units. Whitchurch Village – High elderly vulnerable in own homes. Isolation. Mental health needs. Ty Cryton – residential schooling children with autism. Park Hafod, Mental Health Unit. Some deprivation – Tongwynlais, Hollybush and Gabalfa. Impact of BUPA care home. The Plan The plan has been informed by the practice development plans produced by practices; public health information on key health needs within the area; information provided by NWIS and Cardiff and Vale UHB in respect of referral and activity levels; a knowledge of current service provision and gaps within the area and an understanding of key UHB priorities for the next three years. The plan details cluster objectives for years 1-3 (2014/2017) that have been agreed by consensus across practices, providing where relevant background to current position, planned objectives and outcomes and actions required to deliver improvements. The cluster views this plan is a dynamic and evolving document and therefore, the plan itself will be reviewed and updated as required. The RAG rating score indicates progress against planned action (Red-work yet to start, Amber- Some progress made, Green-action has been completed). A number of key principles underpin the plan: Management of variation/reducing harm/sharing good practice: in acknowledgement of the fact that healthcare must be delivered on the basis of safety, effectiveness and efficiency, the practices have considered and analysed variation in performance and where appropriate have considered steps by which to map standardise practice based on clinical guidelines.

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Maximising use of Local Cluster Resources: practices have taken into account the capacity, capability and expertise that exists within primary care, community services and voluntary/third sector services to deliver more care closer to home and reduce unnecessary demands within the cute care services. Promoting integration/better use of health, social care and third sector services to meet local needs: practices have considered current arrangements/links with Cardiff Council and the voluntary sector and have also considered action plans that have been developed by the local neighbourhood partnership group. Considering and Embedding New Approaches to Delivering Primary Care: this includes increased use of technology, new roles and service models considering an embedding new approaches to delivering primary care: this includes increased use of technology new roles Maximising opportunities for patient participation: this includes consideration of models of good practice that exist with within/locality/cluster and nationally and within the rest of the UK. Maximising opportunities for more efficient and effective use of resources: this includes consideration of current resources, opportunities to utilise and current and new services more efficiently and effectively Additional contributors to the plan

Health and social care facilitators

Local voluntary sector providers

Lead consultant geriatrician for the locality

Relevant secondary care consultants

Prescribing advisers

Cardiff and Vale HC References: West Neighbourhood Partnership Action Plan 2014 Cardiff and Vale Dementia Plan 2014 GMS contract 2015/16

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Strategic Aim 1: Identified Health Care Needs within Population Served by the Cluster: All of the cluster practices have reviewed their population needs, taking into account public health demographic data; disease registers; data provided in terms of emergency admissions/elective care referrals; review of risk patient cohorts etc.. The plan seeks to address the primary areas of health need common to the majority of practices within the cluster, acknowledging that for some practices, more specific work is required internally to meet the needs of some patient groups.

Ref No:

Key Issue

Current Position Objectives/Anticipated Outcomes for Patients

Specific Actions Required Key Enablers / Partners

Lead Responsibility

Timeline RAG March 16/Progress

1.1a Older People / Dementia

Given demographic profile of Cluster Area, levels of older people and thus dementia are greater than any other cluster area within Cardiff and Vale UHB- this brings significant health and social care challenges on a number of levels. Higher than UHB average prevalence in Radyr, Fairwater and Llandaff north New BUPA care home with 70 + beds recently built in Heol Don – likely to increase dementia prevalence in practices East of River Taf Cardiff West has been recognised as a Dementia Champion Cluster due to the work done by all practices. The area is also designated as ‘dementia friendly’ – with local shops being able to apply for recognition of being dementia friendly

To ensure service provision and expertise is sufficient in terms of expertise and capacity to deal with known and growing demand with the focus on enabling individuals to remain as independent as possible for as long as possible, living in a community setting

All practices to complete relevant training as part of the Mental Health Enhanced Service

Third sector Practice Managers Ongoing work in place to maintain this status

G

1.2a Older People / Falls

Significant morbidity from falls. Falls a predictor of hospital admission There is an agreed C&V Falls Pathway – all practices have

Improved management of patient with identified falls risks through use of pacesetter pathway

GPs throughout the cluster to consider adoption of the polypharmacy and falls pacesetter pathway that will be available this year

Day hospital /ECAS / CRTs / NERS

LSD Lead GP September 2016 G

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now adopted this pathway and use it in daily practice

Ref No:

Key Issue


Specific Actions Required

Key Enablers / Partners Lead Responsibility

Timelines RAG March 16/Progress

1.2b Care and Repair- Healthy at Home Project. This project offers individuals (at 75 years) the opportunity for specialist support in relation to repairs, adaptations and general home maintenance, thus enabling them to remain independent at home for as long as possible and reducing risks’ such as falls. The scheme has been presented to all practices within the cluster. All practices are now engaged with this work. There are ongoing referrals and sending of birthday cards etc.

Increase awareness of care and repair services offered. Enabling older people requiring modifications at home to have option to make contact with local reliable partner to carry out rep[airs/modifications to their home

All practices within the cluster Practices to engage in Care and Repair Care Healthy@Home Project 2015/16

Project Leads/publicity/infrastructure to support scheme implementation provided by

Care and Repair Continuing work in this area

G

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Ref No:

Key Issue Current Position Objectives/Anticipated Outcomes for Patients


Lead Responsibility


1.2c There is varying use of Health/Social Care CRT resources across the cluster

To demonstrate increased levels of use of CRT across cluster practices

Ensure all GPS are aware of the intervention that is provided by the CRT, included expansion of CRT to 7 day service Issues have been raised about the lack of service at times due to staffing issues – this was addressed by the team at a cluster meeting

Jackie Davies/CRT Lead

March 2017 G

1.3 Smoking Cessation

Variable options to support patients wishing to quit. There is a new appointment of a smoking cessation PIH lead Access to Smoking Cessation support is easy, getting patients to attend is the hardest part

To increase the level of quit rates within the cluster

All relevant practice staff to undertake Brief Intervention Training-

Public Health Lead GPs within Practice / Practice Managers

March 2017 A

1.4 Diet and Exercise

53% of adults and 27% of children in Cardiff are reported as overweight or obese. Only 25% of Cardiff adults report being physically active on 5 or more days during the previous week. Only 34% of adults in Cardiff and Vale reported eating at least 5 portions of fruit and vegetables a day. Dr Datta to attend cluster meetings/CPET to

To promote healthy lifestyle among cluster population

All Practices to undertake

Making Every Contact Count

Training

Public Health / Communities First

Practice Managers

March 2017 A

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inform cluster about the Obesity service running in UHB – referrals over BMI 30 to the dieticians and >40 for more specialist assessment

Ref No:



Lead Responsibility


1.5 LARC / Menorrhagia

There is capacity in Cardiff West for provision of services for neighbouring practices for coil insertion and implant insertion – this is being offered and taken up across the cluster practices

Provision of choice of contraceptive options closer to home. Reduction in unplanned pregnancy

Scope the need for/feasibility of increasing the provision of implant and coil insertion provision within the cluster though development of interpretive referrals??

Cardiff west Practices Local arrangements / Primary Care Team.

Practice Manager Leads

Sept 2016 G

1.6a Alcohol Consumption

43% of Cardiff population drink above recommnede limits (39-43% in Cardiff West). 26% of population binge drink Some practices within the cluster have engaged with ABIT but not all

To maximise opportunities to identify and respond to issues of high alcohol consumption and ensure maximum use of support services. Reduce alcohol consumption levels within cluster area

All relevant Practice staff to undertake Alcohol Brief Intervention Training

Public Health Lead GPs/Practice Managers

March 2017 A

1.6b Cardiff West has high admission rates of alcohol specific admissions and alcohol specific mortality compared to the rest of Cardiff and the Vale Information for ‘Dry November’ to be publicised on the practice public health

Promote awareness of alcohol units, safe daily/weekly limits & responsible alcohol use at community events, in GP practices & during the annual Alcohol Awareness Week. and Dry January Campaign

Public Health Lead GPs/Practice Managers

November 2016

A

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screens

Ref No:

Key Issue





1.7a Diabetes High and increasing levels of diabetes prevalence. The Cluster Practices are currently engaged in the Community Diabetes Model. There is variation in experience of both Practices and Consultants in provision of the model

To maximise opportunities to increase the level of community based diabetes care

Practices will continue to engage in the Community Diabetes Model Scoping exercise of experience of Community model

Practice Diabetes leads Community Diabetologists / Fiona Kinghorn

Lindsay George Ongoing work in this area

G

1.7b Split services – different practices within the cluster having different specialist Consultants/Diabetic nurses makes ‘cluster working’ more complicated

Improve local expertise to maximise management of diabetes in the community

Scope the potential to have one lead Diabetologists per cluster as it is felt this will improve the model further

Secondary Care Consultants Community Director

March 2017 A

1.7c 3 out of 8 cluster practices currently offer insulin initiation

Improved diabetes management

Scope potential to centralise insulin initiation via 1-2 practices within the cluster, with follow up care via patient’s registered GP

Primary Care Contracting Team Diabetologists

Community Director

March 2017 A

1.8 Childhood Immunisations

Levels of childhood immunisations do not consistently meet 95% across Cardiff West, particularly completion of primary imms by 20 weeks, teenage boosters and HPV. Some practices achieve very high targets consistently The data recently circulated by public health is better in terms of timeliness than previous data, however issues relating to data entry at Lansdowne make it not 100% accurate.

Objective to reach 95% uptake of childhood imm, with primary imms course to be completed by 20 weeks.

Cluster to prioritise childhood nasal flu vacs 2015/16- demonstrate improvements in achievement targets

GPs Public Health Communities First Health Visitors / midwives Adequate access to vaccinations

Lead GPs March 2017 A

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Ref No:

Key Issue Current Position Objectives / Anticipated Outcomes for Patients




1.9 Flu Immunisation

Public Health influenza immunisation targets in at risk groups are not fully met in Cardiff West. The majority of practices achieve the targer of 75% for over 65s, but the uptake is less good for at risk groups. Cluster funding has been used to create a community event that will encourage patients to attend a social event where they can also have their flu vaccination. All over 75 year old patients have had an invitation + their carers. Other patients can also attend. Third Sector, District Nurses and VEST transport are also involved in this innovative project

Objective to reach 75% influenza immunisation target for all in at risk groups and over 65s

Cluster practices to consider adoption of new flu and pnemovax pathways to improve uptake

Communities First/Families First Public Health Promotional material from vaccine suppliers. Access to adequate levels of vaccines

Lead GPs / Practice Managers

December 2016

A

1.10 Health Screening

Although the cluster performs reasonably well for breast screening, screening for bowel cancer can be improved upon Meeting with Bowel Screening Wales arranged for December 2016 to discuss how best to target this group of patients

To achieve the target bowel screening target

Meet with Bowel screening Services to identify opportunities to improve uptake rates

Bowel Screening Team Public Health Wales / Community Director

December 2016

A

1.11 Patient vital health data

Wiggly Amps have been commissioned to provide ‘health pods’ to all practice via use of cluster funding These pods will link in with the practice information / welcome screens to provide a place for patients to record health data such as weight, BP, smoking status whilst also being able to access public health information regarding all health concerns

Increased amount of patient data to be recorded direct into patient records Reducing consultation time for both nurses and GPs

Close links with Wiggly Amps and Vision/EMIS systems to ensure this ‘pod’ will work well in practice

Wiggly Amps

Practice Managers (JM)

December 2016

A

1.12 Antibiotic National Antibiotic Awareness Week starts Reduction in UHB Pharmacist All Practices November A

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Prescribing 14th

November 2016 Practices to consider organising awareness campaigns within their waiting rooms during these date. GPs / nurses can also become ‘Antibiotic Champions’ Cluster / UHB and Community Pharmacists to offer support

antibiotic prescribing Education of patients as to the growing resistance to antibiotics

Community Pharmacists

Cluster Pharmacists UHB Pharmacists

2016

1.13 Mental Health Access

Practices to raise issues via the interface system or direct with CMHT when faced with problems with referring in patients to the CMHT Cluster to look at potentially working with CMHT to start a pilot service in a Primary Care setting – linking in with Third Sector Teams such as CAVMH

Better / swifter / more appropriate access to Mental Health Services

CD to meet with Avkash Jain (CD for Mental Health) and CMHT (Ian Wile)

RT March 2017 A

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Strategic Aim 2: To ensure Sustainability of Core GP Services and Access Arrangements that Meet Reasonable Need (including new approaches to Delivering Primary Care) As part of their Practice Development Plans, all practices within the cluster have reviewed issues such as number of GP appointments provided to practice population , hours of services, inappropriate use of GP OOhrs services by patients, DNA rates, use of technology such as My Health on Line/Texts messaging etc. This plan identifies areas f commonality across the Cluster Practices, accepting that some practices will have identified specific internal developments that they will take forward as part of PDPs.

Ref No:



Lead Responsibility


2.1 Increases in Demand for GP Services

Due to planned housing developments within the cluster (7500 additional houses planned for Radyr/Creigau/Fairwater, 5000 planned by 2026), a number of practices within the cluster will have insufficient capacity to meet demand (particular pressure in Fairwater)

To identify true capacity pressures associated with housing developments and provide for this additional need

Community Director / CD Locality Lead to ensure that GP issues/concerns are considered with estates strategic planning

Community Director

March 2017 A

2.2 Primary Care Estates

A number of practices within the cluster are at physical capacity in terms of estates infrastructures, representing capacity and potential clinical risks (Whitchurch, Llyncelyn, Fairwater,Llandaff and Pentrch)

To ensure adequate estates provision is sufficient to meet GMS demands of growing population in the West

Community Director / CD Locality Lead to ensure that GP issues/concerns are considered with estates strategic planning

Community Director

March 2017 R

2.3 Patient Involvement in Service Improvement

Currently, the Community Health Council Patient Questionnaire Process is the only uniform process by which practices can gauge patient feedback on the service practices provide .

To provide a consistent mechanism across cluster practices by which to engage patients in service developments

To explore the provision of a cluster wide patient participation group – team from North Cardiff Medical to attend a cluster meeting to discuss this

Locality Manager

Nov 2017 A

2.4 Text Reminders are used in few practices to help reduce DNAs

To maximise use of text messaging to reduce DNA rates

All practices using this service but raise concerns about not having enough text capacity per month in their packages

Practice Manager Lead (JM)

March 2017 G

2.5 Maximising Capacity

Primary Care Foundation have visited and audited all practices. Comprehensive report has been compiled and discussed amongst the cluster

To ensure all practices are supported to review current capacity management arrangements

To engage Primary Care Foundation in a review of current capacity management systems within practices

Community Director/PCIC

March 2016 G

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2.6 Cluster Funding to be used to purchase laptops for all clinicians/practice managers to enable easier working outside of the practice (home and home visits)

Procurement Locality Manager / Practice Managers (TE)

December 2016

A

2.7 Cluster Pharmacists

Cluster funding to be used to fund 3 pharmacists (1.8 WTE) to work across the cluster practices to support all areas of medicine management – polypharmacy, nursing home reviews etc.

To ensure that all practices are able to access practice focused support in medication management

All 3 pharmacists to be in post by November 2016

November 2017

G

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Strategic Aim 3: Improve Management of Planned Care (including use of Care Pathways) The Cluster Practices have, over the past 2 years engaged in a number of the elective care pathway developed within C&V UHB in an attempt to either reduce inappropriate referrals to acute hospital specialists/improve of the quality of referrals. All practices have given a commitment to continue to utilise pathways that were adopted previously, but there are clearly opportunities to extend the use of elective care pathways through further primary care developments

Ref No:



Lead Responsibility


3.1 Implementation of Elective Care Pathways

Practices have adopted a number of recommended care pathways and this year will be audited on the work done with these pathways within clinical consultations Practices concerned regarding how this work is to be audited and renumerated

Ideally, practices should engage in all recommended pathways in order to support consistent pathway development and ensure evidence based practice

All practices to start to implement new pacesetter pathways in clinical consutlations

GPs/Practice Nurses

LSD Lead GPs CD forum

March 2017 A

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Strategic Aim 4: To provide high quality, consistent care for patients presenting with Urgent Care Needs/At high Risk of Admission and support the continuous development of services to improve patients experience, coordination of care All cluster practices engaged with a number of emergency care pathways aimed at reducing unnecessary referrals to Secondary Care/attendances at the Emergency Unit. SAs with elective care pathways, practices have committed to engage in the pathways adopted last year, however, further work can be undertaken within Primary care/community to appropriately meet the needs of individuals within the community setting. This section cross references a number of actions from section 1.

Ref No:



Lead Responsibility


4.1 Implementation of Emergency Care Pathway

Practices have adopted a number of recommended care pathways.

Ideally, practices should engage in all recommended pathways in order to support consistent pathway development and ensure evidence based practice

Implementation of Emergency Care Pathways

GPs / Practice Nurses

LSD Lead GPs Ongoing G

4.2 Dental Care Patients often access GPs inappropriately to assist with urgent dental complaints

To ensure patients access right care / right time / right place

Identify cluster dental rep to attend meetings and assist with devising a pathway for dental emergencies

Primary Care Team to lead discussions to Dental Practitioners

Richard Holliday March 2017 A

4.3 Eye Care Patients often access GPs inappropriately to assist with urgent eye complaints

To ensure patients access right care / right time / right place

Ensure practices consider adoption of new pathways

Optomotrists March 2017 A

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Strategic Aim 5: Ensuring Effective Use of Diagnostic Services Cluster practices have, as part of the engagement with elective pathways, sought to improve their use of diagnostic services, they are however aware of the need to review the current variation in both radiological and laboratory testing and to modify practice best on clear clinical evidence/guidelines.

Ref No:



Lead Responsibility

Timelines RAG March 15/Progress Progress

5.1 Radiology/Laboratory Requests

There is variation both within the Cluster and across Locality / Cardiff and Vale in respect of radiology requesting- specifically shoulder ultrasound UHB commitment to look at variance and appropriate testing Data not available for current action plan submission date

To ensure consistency in practice based on clinical guidelines / reduce costs associated with unnecessary Xray /Lab test Requests

Continue to review data re variance provided by UHB to identify areas for improvement

Info from UHB Community Director / AK

March 2017 A

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Strategic Aim 6: To support Delivery of Improvements Against National Priority Areas for Cancer Care, Minimising the Harms of Polypharmacy and Improving End of Life Care

Ref No: Key Issue Current

Position Objectives/Anticipated Outcomes for Patients

Specific Actions Required Key Enablers/Partners

Lead Responsibility

Timelines

6.1 Targeting the Prevention and Early Detection of Cancer

Practices to engage in completion of audit of all patients newly diagnosed between 1 January 2016 and 31 December 2016 with lung, digestive system and ovarian cancer and to summarise/share learning and feedback findings to cluster at annual review meeting

All practices March 2017

6.2a Polypharmacy

Improve the safety of care delivered to patients

1.Identify and record numbers and rates for patients aged 85 years or more receiving 6 or more medications ( excluding dressings etc) 2. Undertake face to face medication reviews, using the ‘No Tears’ approach (Appendix 1) for at least 60% of the cohort defined in 1. above (for a minimum number equivalent to 5/1000 registered patients. If the minimum number of reviews cannot be undertaken because of the small size of the cohort defined in 1 above, consider reducing the age limit until the minimum is reached.)

3. Identify any actions to be addressed in the Practice Development Plan.

4. Summarise themes and actions for review with the cluster network and share information with the Health Board as required identify and report the number /% of patients aged 86years or more receiving 6 or more medications

Cluster pharmacists Cluster IT consultant


6.2b To reduce the risk of falls associated with Polypharmacy

To adopt the pacesetter pathway Use of cluster pharmacist to support medication reviews

Primary care All practices March 2017

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Ref No: Key Issue Current Position Objectives/Anticipated

Outcomes for Patients Specific Actions Required Key

Enablers/Partners Lead Responsibility

Timelines

6.3a End of Life Care

Identify all deaths occurring between 1 January 2016 and 31 December 2016 and significant event analysis to assess delivery of end of life care for 2/1000 registered patients. Summarise and share themes/learning with other practices


6.3b To adopt a cluster palliative care IT guideline developed by Macmillan GP

Palliative care Cluster IT consultant Woodlands Surgery GP Lead is developing template

GP Cluster Leads March 2017

6.4 Advanced Care Planning To enable individuals living in nursing homes have choice in terms of preferred place of death

For those practices who provide an enhanced service to nursing homes, there will be a plan in place to ensure all current residents are offered the opportunity to engage in an advanced care plan

All practices engaged in nursing home enhanced service

March 2017

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Strategic Aim 7: Deliver consistent, effective systems of Clinical Governance

Ref No: Key Issue Current Position Objectives/Anticipated

Outcomes for Patients Specific Actions Required Key

Enablers/Partners Lead Responsibility

Timelines

7 Clinical Governance CGPSAT

Sharon Hopkins to be involved in looking at this area with a regard to reviewing bureaucracy within Primary Care

The contractor updates the Clinical Governance Practice Self Assessment Toolkit 121 (CGPSAT) and to confirm completion and submission to the LHB by 31 March 2017. The contractor participates in a review of the appropriate healthcare standards in relation to the promotion of safeguarding vulnerable adults; adults with a learning disability; safeguarding children. Practices are expected to achieve at least level 2 CGPSAT assurance. Any improvement actions to be identified by 31 March 2017, or actioned during the year if early identification Practices should consider key issues from the CGSAT for discussion at GP cluster meetings where there may be potential to identify common themes that might be addressed through agreed actions.


september 2016-version 1.3 cardiff west network cluster ... · the original 3 year plan was...

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