Cluster Network Action Plan Neath Cluster. Abertawe Bro Morgannwg University Health Board Neath Cluster Action Plan

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1 Cluster Network Action Plan Neath Cluster 1

2 Introduction The Neath Cluster Network includes a cluster of 8 GP practices, seven of the practices are engaged in GP training. The cluster network estate includes eight main practices, two of which are located within the new purpose built Briton Ferry Health Centre. Four practices are in Neath town centre and two are in the Skewen area of Neath Port Talbot. The Neath Cluster Network area contains 9 Nursing/Residential Homes. There are 10 community pharmacies and 7 dental practices. The cluster serves a registered GP population of 56,700 (a slight increase from 56,470 in 2015). The registered population changes have varied between practices with 4 out of the 8 practices showing an increasing list size and 4 a decreasing list size between January 2011 and January ADD deprivation data The cluster achieved a number of priorities during 2015/16 including: The development of the Neath Primary Care Hub, with NHS Pacesetter status. The Neath Hub supports GP practices in their efforts to respond to increasing patient demand whilst achieving quality of access for the patient. The hub provides a range of services including physiotherapy and a mental health support worker role from a central point in Neath, as well as a prescribing pharmacist and technician working in practices throughout the cluster. GPs are able to refer directly into from the point of triage and to support this the cluster has commissioned V360 a shared appointment and clinical system to enable GPs to book directly into the hub and give practitioners in the hub access to the practices clinical record. 2

3 The Neath Cluster Action plan will support practices and multi-agencies to work collaboratively to: Understand local health needs and priorities. Develop an agreed Cluster Network Action Plan linked to elements of the individual Practice Development Plans. Work with partners to improve the coordination of care and the integration of health and social care. Work with local communities and networks to reduce health inequalities. The Cluster Network Action Plan includes: - Objectives that can be delivered independently by the network to improve patient care and to ensure the sustainability and modernisation of services. Objectives for delivery through partnership working Issues for discussion with the Health Board For each objective there are specific, measureable actions with a clear timescale for delivery. The Cluster Action Plan compliments individual Practice Development Plans, tackling issues that cannot be managed at an individual practice level or challenges that can be more effectively and efficiently delivered through collaborative action. This approach supports greater consistency of service provision and improved quality of care, whilst more effectively managing the impact of increasing demand set against financial and workforce challenges. 3

4 4

5 Neath Cluster 2016/17 including 8 GP practices serving a population of 56,693 KEY THEMES & PRIORITIES IDENTIFIED FROM PRACTICE DEVELOPMENT PLANS Sustainability: Recruitment of GP s, retirement, locums remains an issue. Need to assess the workforce skill mix and the development of a wider clinical team. Recruit advanced practitioners, pharmacists, minor illness specialist. Look into local courses and online courses available to improve skill set. Improvement of premises to accommodate growing list sizes High levels of deprivation, with high levels of low income and unemployment Increasing elderly population High prevalence of obesity and low levels of physical activity Continue within the cluster to implemented and develop the telephone triage improving access for and enabling the practice to manage patient demand Clear protocols and pathways for referrals Discharge summaries need in improvement and timeliness to ensure continuation of care Collate data within the cluster to progress pre-diabetes program Increasing patient base due to new housing developments Work closer with 3 rd Sector to signpost Care Homes which need increasing support. End of Life and Palliative care- review and collect information within cluster to improve care 5

6 Waterside Dyfed Road Castle Surgery Skewen Medical Centre Victoria Gardens Dr Wilkes Briton Ferry Tabernacle Street Alfred Street Neath Cluster Directed Enhanced Services Childhood Immunisations Influenza for those 65 and over and others at risk groups (2-3 year olds) Extended Minor surgery N Care of People with Learning Disabilities Care of People with Mental Illness N N N N N N National Enhanced Services Anti Coagulation (INR) Monitoring LARC Shingles Catch-Up Programme Services to who are drug/alcohol misusers N N N N N N N N Local Enhanced Services Shared Care N Gonadorelins/Zoladex Immunisations during outbreaks (MMR) Care Homes N N Care of Homless Patients N N N N N N N Hep B Vaccination of At-Risk Groups N N Wound Management N N N Wound Management Part B N N N N N N N N Men C Catch-up for University Phlebotomy N N 6

7 Strategic Aim 1: To understand the needs of the population served by the Cluster Network No Objective Key partners For completion Progress to date / suggested actions RAG Rating 1. Engage with Prediabetes scheme to identify at risk of pre-diabetes Community network project March 2017 (thereafter ongoing each year) Improve quality of life and prevention development of diabetes Will start in October once training completed 2. Continue to tackle ongoing problems with obesity amongst in cluster Public Health Wales Dieticians Sports programmes March 2017 (thereafter ongoing each year) Improve education and reduce obesity in future ongoing 3. efforts to reduce smoking amongst Cluster Public Health Wales Stop Smoking Wales / ABMU Time-to-quit Hospital service March 2017 (thereafter ongoing each year) Smoking linked to many cancers and chronic disease - reduce local prevalence ongoing 4. Increase uptake of influenza vaccine in target groups ABMU Immunisation Coordinator/ Primary Care each year Reduce morbidity / mortality / hospital admissions due to 7

8 Team influenza and bacterial infections To engage with in order to reflect their needs Practice Patients To ensure that the practice objectives are in line with patient needs. To ensure good lines of communication between practice and. Questionnaires, Patient Participation Groups Green Strategic Aim 2: To ensure the sustainability of core GP services and access arrangements that meet the reasonable needs of local No Objective Key partners For completion Progress to date / suggested actions RAG Rating 1. Increase telephone triage of patient requests for appointments and home visits, direct to appropriate Health Care Professional GPs, clinical and admin staff Staff employed in Hub March 2017 (thereafter ongoing each year) Improved access to appropriate services Reducing GP workload that is not appropriate ongoing 8

9 2. To provide standardised training for prescribing clerks and seek opportunities to build on initial training to further develop staff Prescribing Clerks Medicines Management Team Practice Managers Completion of packs - June 2016 Further development - ongoing Improved repeat prescribing systems 38 clerks have completed training across the cluster. Pharmacist and technician supporting further development of target staff in collaboration with practices Green 3. To ensure appropriate use of the pharmacist and technician resources to aid sustainability, reduce risks from polypharmacy and improve other aspects of medicines management Pharmacist Technician Medicines Management Team Practice team Improved medicines related outcomes and reduced risk Both posts demonstrating benefits and supporting practices to improve medicines management through a variety of activities. review required to maximise outcomes and ensure appropriate training, support and indemnity arrangements 9

10 Strategic Aim 3: Planned Care- to ensure that needs are met through prudent care pathways, facilitating rapid, accurate diagnosis and management and minimising waste and harms No Objective Key partners For completion Progress to date / suggested actions RAG Rating 1. Use Pacesetter Physiotherapists and Wellbeing Support and Pharmacy Staff Neath Cluster Hub Staff March 2017 (then ongoing) Improve access to appropriate diagnostic / treatment services Varying levels of use / engagement between Practices 2. Engage further with Radiology re: downgrading of USCs Dept Radiology March 2017 Quicker response in care pathways 3. Review Psychiatric Services for anteand post-natal Dept of Psychiatry LHB Bridgend (liaise Jane O Kane) - PRAMS March 2017 Improve wellbeing in pregnancy Red Strategic Aim 4: To provide high quality, consistent care for presenting with urgent care needs and to support the continuous development of services to improve patient experience, coordination of care and the effectiveness of risk management 10

11 No Objective Key partners For completion Progress to date / suggested actions RAG Rating 1. To improve antimicrobial stewardship through appropriate use of antibiotics Implement mechanisms to ensure appropriate use of antibiotics (see also PMS ) Practice team Big Fight Team Medicines Management Team with monitoring of trends See also PMS for deadlines: Dec 16: Overall antibiotic use and choices Acute Cough Audit Improvement Plan March 17: Evidence of patient engagement activities Reduced antimicrobial resistance Reduced C.Diff Increased knowledge and empowerment to self care Discussed at all annual practice prescribing visits. Development of cluster level data available on GP portal Good progress with reductions in overall use demonstrated (data up to June 2016 showing a 6.9% drop compared to previous year) 2. Audit outcomes of telephone triage in Neath Modify processes to enhance outcomes Neath Cluster Craig Barker (IT Support) March 2017 To ensure quicker access for to the appropriate healthcare professional Early weeks of triage for some Practices Strategic Aim 5: Improving the delivery of end of life care 11

12 No Objective Key partners For completion Progress to date / suggested actions RAG Rating 1. Audit EOL care within Practice Share outcomes of Audits Spread best Practice amongst Practices in Cluster Practice staff and DNs Cluster Members Anticipatory Care Team March 2017 (then ongoing) Improve EOL for patient and patient s family 2. PHCT meeting Extended PHCT March 2017 (then ongoing) Dissemination of patient information for better patient care. Strategic Aim 6: Targeting the prevention and early detection of cancers No Objective Key partners For completion Progress to date / suggested actions RAG Rating 1. Continue to support bowel / breast / AA screening programmes Public Health Wales, Datix. Cancer Hub March 2017 (then ongoing) Improve life expectancy by early detection of CA Heather Wilkes Cancer Hub Red 12

13 and other Public Health Wales Services 2. Streamline pathway for all internal hospital referrals for any abnormal results (all cancers and anaemia) LHB, Secondary care, Radiology March 2017 (then ongoing) Faster transit of referral through to diagnosis and treatment. Improve patient outcome. Red Strategic Aim 7: Minimising the risk of poly-pharmacy No Objective Key partners For completion Progress to date / suggested actions RAG Rating 1. Provide support to with known problems managing medicines in their own home without a package of care, through a collaborative approach with the Practice Teams Medicines Management Domiciliary Care Team Community Pharmacies Anticipatory Care Teams Advice and practical support to help individuals manage medicines in their own homes will reduce risk from adverse drug events, reduce unscheduled care Pathfinder being rolled out across 3 NPT clusters. Additional team member to support MMTDC took up post Sept 2016 Referrals steadily Green 13

14 2. medicines management domiciliary care team (MMDCT). To engage in the Prescribing Management Scheme (PMS) and PMS+ respiratory schemes. (Undertake a range of prescribing initiatives to improve: respiratory, antibiotic, pain management prescribing and yellow card reporting) GPs Practice Nurses Medicines Management team PMS 16/17 by March 17 (some Dec16 deadlines) PMS+ respiratory by November 17 and improve outcomes from the treatment of chronic diseases. Improved medicines management including polypharmacy Investment in other service areas for patient benefit increasing following early pilot Discussed at all annual practice prescribing visits Practices engaged and making progress Medicines management team supporting where possible 3. Explore opportunities for improved links with community pharmacy Practice teams Community pharmacy Medicines management teas Improved medicines and public health related services and outcomes Strategic Aim 8: Deliver consistent, effective systems of Clinical Governance No Objective Key partners For completion Progress to date / suggested RAG Rating 14

15 actions 1. Continue reporting significant event analyses Practice and LHB March 2017 (then ongoing Improve education of clinicians and hence improve patient care. 2. Continue use of CPGSAT Practices and LHB March 2017 (then ongoing Continuing refinement of services in Primary Care. Green Strategic Aim 9: Other Locality issues No Objective Key partners For completion Progress to date / suggested actions RAG Rating Plas Bryn Rhosyn to receive necessary patient information with incoming patient. Plas Bryn Rhosyn, Secondary Care and Neath practices December 2016 To inform GPs and minimise risk to None Red Increase and improve signposting to Third Sector Practices and Third Sector Wellbeing Health Worker March 2017 (then ongoing To provide more specialist and appropriate support for Green 15

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