Taff Ely GP Cluster Network Action Plan P a g e V 1 3

Transcription

1 Taff Ely GP Cluster Network Action Plan P a g e V 1 3

2 TAFF ELY NETWORK CLUSTER ACTION PLAN This plan has been developed by the following 8 practices which operate in the Taff Ely Cluster Area, through facilitated discussion with the Local Clinical Director and Primary care LHB Locality Management :- Ashgrove Surgery Eglwysbach Surgery New Park Surgery Old School Surgery Parc Canol Surgery Taff Vale Surgery Taffs Well Surgery Ynysybwl Surgery 2 P a g e V 1 3

3 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 Cwm Taf uhb re current activity/referral patterns; an understanding of our localities baseline services (current service provision) and identification of potential service provision unmet needs. The plan also embraces 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 plan is by its very nature fluid /flexible and evolving over the next 3 years the plan itself will be reviewed and updated in response to changes in cluster planning. The RAG rating score indicates progress against planned action: Red- future work Amber- work in progress Green work 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. 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 acute 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 RCT CBC and the voluntary sector and will also consider any action plans from stakeholders that evolve over the 3 year cycle of this plan. 3 P a g e V 1 3

4 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/potential evolving contributors to the plan subject to evolution of plan Health and social care facilitators. Primary care practice managers. Practice Nursing and allied health professions representatives. Local voluntary sector providers and third sector. Prescribing advisers. Potential educator partners including third sector TEDS for brief alcohol intervention training, podiatry for foot assessment training for Health care assistants. Primary Care Support Unit Nursing advisory expertise/local university school of health care re Health care assistant initiatives and informing community care planning e.g. diabetes. Public Health Acknowledgements Cynon cluster plan authors re layout. 4 P a g e V 1 3

5 Strategic Aim 1: to understand the needs of the population served by the Cluster Network Outline of cluster population profile The Cwm Taf uhb population estimate in 2007 was thousand with thousand in the RCT locality.approximately 10% of the population of Wales live within Cwm Taf uhb, the uhb locality is the second smallest in Wales but the second most densely populated area (Cardiff is first) The Taff Ely Valley in recent CMO for Wales reports and based on recent Public Health Wales data is an area of high social deprivation.we also due to our high deprivation status have high rates of mental health issues long term disability/morbidity,a high rate of poverty/benefits uptake and high rates of chronic illness from legacy heavy industry particularly mining. Recent CMO reports have indicated a low level of car ownership with an obvious impact on service planning. The neighbourhood has a higher proportion of persons aged 0-15 and than the Cardiff average. Public Health Wales indicate that our area consists mainly of most deprived and next most deprived classifications. 34% of Cwm Taf as a whole is designated most deprived on the Welsh Index Multiple Deprivation Scale (WIMD). Within our cluster this figure rises to 38.2% in the Taff Ely Valley. The Public Health Observatory for Wales publications in the field of child health highlight for our locality that: our rate of low birth weights is significantly higher than the Welsh average 1 in 15 c.f. all Wales 1 in 18; and the % of children (<20 years old) living in poverty is 26.6% c.f. all Wales 22.2%. Particularly relevant to our area is the identification of Rhydfelen and Glyncoch as areas of greatest deprivation in Wales by the public health observatory (ranked 17 th and 27 th respectively). All Wales public health observatory data on levels of unemployment in the yr old age group show a rate of 18.4% for CwmTaf c.f. all Wales 15.7%.With regard to our older population the data for those living alone at 43.9% is near to the all Wales average of 43%.Our localities Black and ethnicity population data suggest an LHB rate of 1.1% lower than the all Wales average of 2.1 % which in turn is lower than England s data. Finally Public Health Wales Data indicates that for Cwm Taf s population as a whole, life expectancy is reduced by 1.5 years for males c.f. the welsh national average i.e. 75.3yrs as opposed to 77 years old. Our locality has in recent years seen and will see several large scale residential developments with obvious impacts on primary care provision planning. Recent public health presentations to our locality identify several top challenges to morbidity and mortality: Malignancy (Cancer survival levels in Cwm Taf are amongst the lowest in Wales) Cardiovascular disease/circulatory disease Smoking levels Subsequent review of Welsh statistics highlighted further areas of concern (see next page) 5 P a g e V 1 3

6 Data from the combined Welsh Health Survey show that: 29% of adults in Cwm Taf reported binge drinking on at least one day in the past week, compared to 26% for the whole of Wales; 25% of adults in Cwm Taf reported being a current smoker with 21% in Wales reported being a current smoker; 27% of adults in Cwm Taf 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 29%, further those in CwmTaf reporting that they did no physical exercise in the survey was 38% compared with an all Wales figure of 34%.Those respondents classified as overweight or obese in Cwm Taf were 63% the all Wales average was 58%. 27% of adults in Cwm Taf had eaten five or more portions of fruit or vegetables on the day prior to the survey date compared to 33% for the whole of Wales. CwmTaf overall had statistically highlighted higher levels of mental illness Respiratory illness Hypertension arthritis and diabetes mellitus in the combined Welsh Health Survey compared with Cardiff and Vale UHB. References: Public Health Wales s presentations to Cwm Taf locality GP s (power point), Public Health Wales Observatory data web site, Health of Young Children and Young People Wales Report, Welsh Health survey reports. The areas of concern identified by the cluster through this analysis of our cluster populations health status and needs e.g. OBESITY/OVER WEIGHT STATUS, BINGE DRINKING/PROBLEMATIC ALCOHOL USAGE, HIGHER RATES OF CURRENT SMOKERS & its relationship to higher levels of respiratory illness in our cluster, LOWER LEVELS OF PHYSICAL EXERTION will be areas that we will initially address in our action plan (detailed in later tabulated form) 6 P a g e V 1 3

7 No Objective Key partners Completio n by: - 1 Review the Local Public November needs of the Health Team 2014 population using available data Outcome for patients To ensure that services are developed according to local need Progress to Date Analysis complete and outlined in detail above, subsequently used by cluster to develop action planning on key priorities. See above text. RAG Rating 1a Implement health promotion signposting and support mechanisms, which will help to address: Obesity Smoking Alcohol dependen ce Bowel screening Breast screening Patients with sensory loss GPs Health Board Primary Care 3 rd sector partners March point 1 completed. Point 2 to be completed March 2017 Health improvements Improved take-up by patients in funded services Increased collaboration between practices and 3 rd sector Increased engagement by practices in public health promotion Cluster practices feel that buy-in from patients to improving their health / lifestyle will be increased through obtaining support on a one-to-one basis from an individual (rather than being handed a leaflet / information from a GP). Proposal to be discussed with health board: Fund staff / representatives from specialist organisation to signpost patients to existing funded services. This could entail stands being set up in GP practice waiting rooms and manned by staff who would actively engage with patients. See also 1b below. This has been trialled by Ashgrove surgery & Parc Canol Surgery (in relation to the Supporting Carers project) and there is therefore experience to build on. This will support the engagement by practices with the third sector. Discussions are underway with Sara 7 P a g e V 1 3

8 Thomas, Public Health, to use cluster monies to appoint a community lifestyle co-ordinator. A working group has been set up to progress this (including Rachael Baker, Jane Taylor-Lloyd, Sarah Humphries) and is progressing the appointment of a co-ordinator for year old patients. 1b Collaborate across the cluster practices in order to encourage flu vaccination uptake by patients August 2015 Improved take-up of flu vaccination leading to protection of elderly and at risk patients and reducing risk of admission Practices to consider running joint flu clinics on Saturdays during the flu season in local council facilities e.g. leisure centre. Ensure that remote access is available so that patients records can be accessed. Combine this with health promotion stands run by 3 rd sector organisations so that patients can access services whilst attending for flu vaccination. 1c Ensure that healthcare staff maximise opportunities to provide health care advice September 2016 Increase staff awareness of key public health messages and signposting patients to useful resources It is recognised that not all practices in the cluster would wish to implement this as their current flu uptake is already good. All healthcare and nursing staff to undertake e learning on Making Every Contact Count This concept is an aspiration for Public Health Wales ( /65550). The concept, Make Every Contact Count (MECC), involves using every opportunity to deliver brief advice to improve 8 P a g e V 1 3

9 patients health and wellbeing. It is about using every opportunity to ask individuals the right questions to find out about their underlying health needs and deliver brief advice to improve health and wellbeing. The e learning can be accessed at: ndex.html This will be linked with 1a. Above. 9 P a g e V 1 3

10 Strategic Aim 2: To ensure sustainability of core GP services and access arrangements that meet reasonable need (including new approaches to delivering primary care) Cluster practice members have considered this area already in their individual Practice Development Plans, with a range of access and sustainability issues considered including number of GP appointments provided, hours of services, inappropriate use of A+E, unscheduled admissions +GP Out of Hours services by patients, DNA rates, Promoting use of technology such as My Health on Line/Texts messaging etc. Further WAG briefing on primary care clusters also advocates use of new technology including ultimately via My Health patient access to their records online repeat prescription ordering, online appointment booking as well as new technologies for consultation, practices are at various stages with these developments within the cluster. In addition to practices individual development plans in this area those areas of common interest across the Cluster are identified in this section. No Objective Key partners 2a Develop Health transfer of board appropriate services from Secondary secondary to care primary care cluster hub GPs once the LHB NWIS & have created Digital proposed Development Hub at Dewi Team Sant including relevant infrastructure For completion by: - Health board to confirm timescales of the setting up of Hub. Cluster group timelines are dependant upon the LHB Dewi Sant Park programme Outcome for patients Improved efficiency in delivering services in primary care with improved access for patients closer to patient s home Progress to Date Progress will be dependant upon the setting up of the Hub and relevant infrastructure with the initial roll out of services as outlined below MSK Service which will consist of both Consultant, GPWSI, Physio Services, and MRI services to provide patients with a one stop shop Supporting the LHB with the creation of a Primary Care Support Unit which would be based at the Hub and to include GPs (using the academic fellowship model), Pharmacists, Nurse Practitioners, Nurses, HCP and Phlebotomists. The cluster group would help with the recruitment process RAG Rating 10 P a g e V 1 3

11 It should be noted that any services offered at the Hub should not conflict with current or the development of new services within the confines of a GP practice environment, they should remain there. 2b Facilitate increased use of My Health Online (MHOL) by patients to improve access to appointment booking and repeat prescription requests NWIS GP practices August 2016 There is varying patient and practice uptake of technology to improve access. Increased uptake will improve access to services for patients. Central patient record access will be key to making these services viable, and will form part of the core infrastructure required in the setting up of the Hub. The project is currently progressing slowly Discuss within the cluster and work towards agreement for all practices to implement MHOL for both appointments and repeat prescriptions. Collaborate across practices on promoting the service to patients. NWIS is progressing further developments to MHOL to provide easier registration and use of an App. 11 P a g e V 1 3

12 2d Work with the health board on devising solutions for the current issue of GP recruitment and succession planning Health board Dr Mair Hopkins lead GPs as required Health board to confirm timescales The issue is a significant one within the cluster as many practices are struggling to fill vacancies and replace retiring partners Dr Mair Hopkins has volunteered to act as lead for the cluster on a health board committee to review this issue. As an interim solution, the health board should consider how GPs can be shared across practices, which are short of resource. The issue has also led to a significant and unsustainable increase in locum rates, which is having a severe detrimental impact on those practices, which are forced through circumstances to employ locums. Note that the Cwm Taf practice manager forum is discussing the agreement of consistent locum terms and conditions across practices to ensure that a standard of locum tasks required by practices will be put in place (avoiding the current practice of locums dictating their own varying terms to practices). We would also look to link with neighbouring health boards to ensure regional consistency. 2e Improve retention of Practice managers March 2017 Maintaining a fully trained and KB to chase June Williams for update. Health board funding is available to backfill practice nurse positions to 12 P a g e V 1 3

13 practice nursing staff and facilitate replacement of retiring staff Health board Practice nurses resourced health care team within practices will ensure that patients chronic disease management is sustained and that a fully resourced range of nurse treatments is available for patients enable them to train nursing staff in secondary care, who wish to work in primary care. This issue needs to be discussed further within the cluster to identify which practices are able to take on this option. June Williams will need to gather data from practice nurse population in confidence to honest feedback. 2f Develop further GPs with Special Interests (GPwSIs) to support 2a Health board GPs March 2017 Develop an improved range of services available to patients within cluster practices Practices have already submitted data to the health board on current GP and nurse specialist interests as part of their practice development plans. The next stages are: Health board to identify gaps in skill sets across the cluster Health board to identify GPs, who would be interested in developing as GwPSI for gap specialist areas Health board to review and increase GPwSI rate and share revised pay scale with 13 P a g e V 1 3

14 practices, as current rate does not cover backfill requirement Health board to identify GPs, who can provide training for the gap specialist areas and facilitate training. This could be through health board funded training sessions in practice, via formal observation or by backfilling. It is proposed that a similar scheme be investigated for healthcare staff e.g. cryotherapy training for practices, who wish to offer this service. 2g Review GP visiting guidelines prepared by South Staffordshire LMC GPs Practice managers September 2015 Consistent approach to GP visiting across cluster practices, ensuring that priority is given to patients with same day / urgent visiting need Guidelines to be reviewed by practices and discussed at cluster meeting before considered implementation review at next cluster meeting 09 September. Practices have agreed in principle to implement and to utilise information provided by third sector regarding patient transport (to overcome key perceived issue). 14 P a g e V 1 3

15 Strategic Aim 3: Planned care- to ensure that patient s needs are met through prudent care pathways, facilitating rapid, accurate diagnosis and management and minimising waste and harm. No Objective Key partners 3a Standardise use of electronic and nonelectronic referral forms. Maximise ease of access and use Integration of forms with clinical systems Health board INPS EMIS Directorate leads NWIS For completion by: - December 2015 Outcome for patients More efficient referral process with improved communication and improved governance Progress to Date A number of templates have been stored on the Cwm Taf GP portal. These need to be reviewed and added to, to ensure that a comprehensive library of forms is available. This should be coupled with communication to practices of where and how to access and a process, which will ensure that practices no longer use locally stored copies. Accountability will need to be assigned by the health board for maintaining the library, which will require liaison with secondary care, as a central point of contact for any new / amended forms to be used by primary care. RAG Rating Current paper-based forms should be replaced by electronic version this will require health board / IT resource. Provide central repository of templates for clinical systems (Vision & EMIS) that would be accessed via the Portal. 15 P a g e V 1 3

16 This should include approval by the LMC with input from secondary care where necessary to agree pathways Use INPS & EMIS to create and maintain template versions 3b Improve access to minor surgery services within the community Linked to 2a above. Health Board GPs March 2017 Reduced waiting times and provision of care closer to the patient s home A number of improvements can be made to the minor surgery enhanced services process in order to improve services available to patients, namely: Add carpal tunnel decompression to the enhanced service (already available within the Enhanced Minor Surgery agreement Referral centre to route referrals in primary care i.e. other organisations (e.g. podiatrists) could use this route to refer procedures (e.g. toe nail removal) to practices signed up to deliver certain services (this has already been proposed by Ashgrove surgery to the Health Board) Identify further procedures which can be transferred to primary care, by involving consultants to agree transfer and deliver training A first phase has been rolled out to extend minor surgery but there is still a significant limit to what services can be delivered in primary care. 16 P a g e V 1 3

17 The GP Portal should be used to make practices aware of which practices deliver what services and then enable referral to be made via WCCG (as already happens for vasectomy referrals to Ashgrove and Pontcae surgeries). LHB to ensure this is kept up to-date as more services are rolled out by the practices/hub. 3d Extend sexual health services across practices Linked to 2a above Health board GPs November 2016 Reduced waiting times and provision of care closer to the patient s home Data provided to June Williams regarding practice specialities via Hayley Pugh. Some practices within the cluster already deliver services for other practices and have the capacity to extend this. Extending this service could allow provision of temporary services, whilst a GP is on maternity leave, for example, or to cover other staffing issues e.g. retirement. In order to implement this, the following will need to be in place: Treatment pathways will need to be aligned across the cluster Referral documents will need to be reviewed and agreed (pathway already drafted and submitted by Ashgrove surgery) Processes will need to be defined, documented and communicated Referral mechanism will need to be in place, using WCCG for consistency 17 P a g e V 1 3

18 LHB to ensure this is kept up to-date as more services are rolled out by the practices/hub 3e Develop a shared care record for use between Primary and Community Services NWIS LHB GP System suppliers i.e. INPS & EMIS By March 2017 Prevention of duplication and improvement of communication. Reducing risk to patients See 3b. This a dependency for a number of items within the cluster plan This development can be aligned to the work required by NWIS/Digital Development team in 2a 18 P a g e V 1 3

19 Strategic Aim 4: To provide high quality, consistent care for patients presenting with urgent care needs and to support the continuous development of services to improve patient experience, coordination of care and the effectiveness of risk management No Objective Key partners For completion by: - Outcome for patients Progress to Date RAG Rating Re Strategic Aim 4: All Taff Ely cluster practices are engaged with care pathways aimed at reducing emergency and elective unnecessary referrals to Secondary Care/attendances at the Emergency Care Centre/Clinical decisions units. This follows on from prior annual Qof work. 19 P a g e V 1 3

20 Strategic Aim 5: Improving the delivery of end of life care No Objective Key partners For completio n by: - 5a All practices in the cluster to analyse their palliative care presentations QOF year and disseminate lessons learnt and educational needs identified (see Appendix 1 below) LHB Individual cluster primary care practice teams End March 2016 Outcome for patients Lessons learnt from practice analysis of cases of palliative care/end of life care analysed during QOF year fed back into service development and educational development when required Progress to Date All practices in the cluster engaged on in practice national priority work on SEA of end of life care presentations as per nationally agreed national priority work Completed for 2014/15. Completed for 2015/16 RAG Rating 20 P a g e V 1 3

21 5b Consider effective analysis at practice level of end of life care and palliative care registers Macmillan local charity funded resources Cluster practices LHB resources Third sector organisations September 2015 Improved adopted of EOL care pathways will lead to improved EOL care for patients Implement an EOL care checklist across the cluster, to ensure that all elements of the pathway have been considered and addressed, where appropriate, for a palliative patient (template provided by Old School practice) Target early involvement by Macmillan staff in the care of palliative patients measure to be agreed with Macmillan team Implement a communication skills framework (to be developed in collaboration with Macmillan staff) across the cluster for GPs to use when discussing EOL care with palliative patients, to ensure that GPs are using appropriate communication techniques General guidance is available on Cwm Taf health board intranet. Discuss with health board replicating this advice on the GP portal and ensure that this includes useful phone numbers / websites. 5c Continue QOF individual cluster members practice palliative care Individual Cluster primary care practice teams District Nursing representatives and palliative care team Ongoing individual practice work Case review patients identify proactive end of life planning for individuals and advice re future/additional management of Continues in progress every QOF year 21 P a g e V 1 3

22 5d team meetings Increase use of JIC boxes representatives September 2015 the individual. Lessons learned for individual patients will benefit and inform future patients care. More timely control of symptoms and may reduce crisis admissions and unplanned care Check that all practices in cluster have access to JIC system and that all relevant staff are aware of the process.. 22 P a g e V 1 3

23 Strategic Aim 6: Targeting the prevention and early detection of cancers No Objective Key partners 6a All practices in the cluster to analyse their cancer presentations QOF year and disseminate lessons learnt and educational needs (see Appendix 3 below) LHB Cluster GP s and cluster primary care health teams For completion by: - End March 2016 Outcome for patients Lessons learnt from practice analysis of cases of cancer analysed during QOF year fed back into service development and educational development when required Progress to Date All practices in the cluster engaged on in practice national priority work on SEA of cancer presentations as per nationally agreed national priority work. Completed for 2014/15. Completed for 2015/16 RAG Rating 23 P a g e V 1 3

24 Strategic Aim 7: Minimising the risk of poly-pharmacy No Objective Key partners 7a Identify and report the number /% of patients aged 86 years or more receiving 6 or more medications (see Appendix 2 below) Lead GP in each cluster practice LHB pharmacy advisory team For completion by: - End March 2016 Outcome for patients Decrease the potential for medication interactions/morbidity by reviewing the medications currently prescribed against patients current medical conditions and changes in condition related prescribing practice/guidelines i.e. optimise medication and condition. Progress to Date Undertake face to face medication reviews using the NO TEARS approach or similar tool for at least 60% of the cohort defined above. Use the agreed read code for polypharmacy review. All practices in the cluster are committed to completion of this work by end March Completed for 2014/15. Completed for 2015/16 RAG Rating 24 P a g e V 1 3

25 Strategic Aim 8: Deliver consistent, effective systems of Clinical Governance No Objective Key partners 8a Engage with a robust validated clinical governance process specifically designed with cluster planning in mind Individual cluster practices Public Health Wales For completion by: - End March 2016 Outcome for patients All measures/proposals outlined and assessed in a validated all Wales clinical governance tool Progress to Date Clinical Governance Practice Self Assessment Tool (CGPSAT) each individual cluster member will be entering their areas of responsibility into their PDP s (practice development plans) and CGPSAT. Aspiration level 4/5 maturity on CGPSAT re cluster network work. Completed for 2014/15. RAG Rating Completed for 2015/16 25 P a g e V 1 3

26 Strategic Aim 9: Other locality issues No Objective Key partners For completion by: - 9b Improve March 2016 efficiency of working by increased use of practice pharmacist Outcome for patients Improved access to medication advice within the GP setting as a one-stop shop Progress to Date To be discussed at a future cluster meeting. This may be appropriate to develop for practices, which employ pharmacists. A consistent model would be agreed across relevant practices in the cluster if appropriate. RAG Rating It is recognised that not all practices in the cluster would wish to develop this objective depending on their circumstances / size. 9c Identify and build relationships with consultants, who are willing to run clinics in primary care March 2017 Knowledge and skill sharing between secondary and primary care will result in improved patient care and improved communication channels As a consequence of the Health board sponsored COPD project with GSK, Dr Paul Neill has carried out a number of COPD clinics with lead GPs and practice nurses in a number of participating practices. It would be beneficial to identify other clinical areas and consultants, who would be prepared to put in place a similar arrangement. 26 P a g e V 1 3

27 The objective would be provide easy access to advice for GPs for the following clinical areas: Cardiology (service recently withdrawn) Neurology General medicine Respiratory Care of the elderly Mental health 9d Contribute to patients and staff mental health wellbeing FOR FURTHER DISCUSSION AT CLUSTER MEETING March 2017 Implement tool to assist patients to improve their mental health wellbeing and increase their resilience Cluster to review materials available under Five Steps to Mental Wellbeing and consider implementing across practices for relevant staff (available at This tool has been adopted by Torfaen Neighbourhood Care Network (equivalent of cluster) in ABHB (contact Dr Alastair Roeves, Clinical Director, Gwent). 9e Facilitate easy access to patient records when Individual cluster practices NWIS March 2016 Investigate implementation of Vision Anywhere (and EMIS This is linked to 1a delivery of training by Public Health. Hayley Pugh has commenced investigation. Investment proposal to be circulated and agreed by cluster practices 27 P a g e V 1 3

28 9f GPs assessing patients away from surgery Improve Patients access Health board Cluster Health board NWIS Voice Connect March 2016 equivalent) software and mobile tablet hardware to enable this. Install Patient Partner Software to aid patient access to appointment system outside of core hours Four practices within the cluster i.e. Ashgrove, Newpark, Parc Canol and Taff Vale chose to pilot this on behalf of cluster. Hayley Pugh placed order with Voice Connect and practices ordered relevant hardware/software directly with their telephone providers to meet the requirements of Voice Connect NWIS and Voice Connect to agree access to NHS Network so that their software can access clinical system. Voice Connect have been informed that they would need to provide the windows and a/v upgrades as part of the agreement for access to NHS Network VC are still in discussions with NWIS for a work around regarding this dependency despite VC being made fully aware of this compliance at the time of order, which has led to a delay in the software being installed 28 P a g e V 1 3

29 Appendix 1 Lessons learnt from practice analysis of cases of palliative care/end of life care No. Key issues Actions 1 Refer to submission for Appendix 2 Lessons learnt from practice analysis minimising the risk of polypharmacy No. Key issues Actions 1 Refer to submission for Appendix 3 Lessons learnt from practice analysis of understanding cancer care pathways No. Key issues Actions 1 Refer to submission for Appendix 3 Action plan Objective Date Action Responsible Status 29 P a g e V 1 3

30 no. 1 November a March a 5a 8a 1b 5b 2g 5d 3a 1a March 2015 March 2015 March 2015 August 2015 September 2015 September 2015 September 2015 December 2015 March 2016 Review the needs of the population using public health data Complete review of prevention and early detection of cancers and include actions in practice development plan Complete review of minimising risk of polypharmacy and include actions in practice development plan Complete review of end of life care and include actions in practice development plan Complete CGPSAT tool at practice level and include actions in practice development plan Practices to investigate joint flu clinics to increase take up Implement EOL care checklist Target involvement of Macmillan staff in EOLC Implement EOLC communication framework for GPs Review GP visiting guidelines prepared by South Staffordshire LMC Review use of Just in Case boxes across cluster re EOLC Standardise use of electronic and paper referral forms and maximise ease of access via GP portal Health promotion signposting by 3 rd sector organisations in practice Local public health team Practices Practices Practices Practices Practice managers GPs Macmillan staff GPs Practice managers Cluster practices Health board GPs NWIS Practice managers 3 rd sector 30 P a g e V 1 3

31 9b 2b March 2016 August 2016 Improve efficiency of working by using practicebased pharmacy resource Promote increased take-up of MHOL by patients Health board GPs NWIS / practice managers 1c 3d 3b 2f 2e 1a September 2016 November 2016 March 2017 March 2017 March 2017 March 2017 Training for all healthcare and nursing staff on Making every Contact Count Extend sexual health services across cluster Improve access to minor surgery services within the community Development of GPwSIs Improve retention of practice nursing staff and replacement of retiring staff Appointment of community lifestyle co-ordinator HCP resource for year old patients Practice healthcare teams / practice mgrs Health board GPs/ Practice Managers Health board GPs/Practice Managers Health board GPs Health board Practice managers Practice nurse champions Practice managers Public Health 3e March 2017 Develop shared record for use by primary care and community services NWIS Clinical system suppliers Health board 2d TBA Work with health board on GP recruitment and Dr Mair Hopkins 31 P a g e V 1 3

32 succession planning 9c TBA Build relationships with consultants who are willing to run clinics in primary care and consider how this can link in with the proposed cluster hub work 9d TBA Consider using Five steps to Mental Wellbeing tool 2a TBA Develop transfer services from secondary care to primary care hub 9f March 16 Install Patient Partner Software to aid patient access to appointment system outside of core hours Health board GPs Practices Health board Practices Cluster Health board NWIS Voice Connect 32 P a g e V 1 3