September 2016-version 1.5 SOUTH WEST CARDIFF NETWORK CLUSTER ACTION PLAN

Transcription

1 September 2016-version 1.5 SOUTH WEST CRDIFF NETWORK CLUSTER CTION PLN

2 Cluster Plan Version Control Log Date Version ID ction mendments Changed By 30 September 2014 Version 1.1 Submitted to PCT 4 December 2014 Version 1.2 Update of Public Health ctions/older People ctions/eol Care 20 September 2015 Version 1.4 ll completed actions that were assessed as Green in Sept 2015 have been removed 1.3b /1.3d/1.3e/1.4c/1.10/1.7 a/1.7b/1.8c/1.8d/1.8g L Topham L.Topham 29 September 2016 Version 1.5 K Pardy 2

3 SOUTH WEST CRDIFF NETWORK CLUSTER CTION PLN This plan has been developed by the following 11practices which operate in the South West Cluster rea, through facilitated discussion with the Community Director and Locality Manager:- Lansdowne Surgery Woodlands Surgery Kings Road Surgery St David s Court Surgery Greenmount Surgery Canna Surgery Westways Surgery Ely Bridge Surgery Caerau Lane Surgery Taff Riverside Surgery Llandaff fields The original 3 year plan was established by the cluster in 2014 and this update, reflects the current cluster priorities, based on progress since 2015 and GMS contract requirements for 2015/16. lthough 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 The latest area population estimates vary between 52,000 and 59,600, which is approximately 16% of Cardiff's total population. The clusterhas a higher proportion of persons aged 0-15 and than the Cardiff average. Conversely it has a lower proportion of persons aged and post retirement. ccording to the Census 2011 information 83.95% of residents were of white ethnic city. This is slightly lower than the Cardiff average of 84.7%. The area has higher than average levels for Cardiff of unemployment claimant rates whilst more than 50% of children aged 0-15 live in the most deprived decile of education domain in Wales according to the Welsh index of multiple deprivation. Similarly 44.6% of 0-15-year-olds live in the worst decile or tenth of communities in terms of income deprivation, more than four times the expected share. 3

4 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/) 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 RG rating score indicates progress against planned action (Red-work yet to start, mber- Some progress made, Green-action has been completed). 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 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 pproaches 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 dditional contributors to the plan Health and social care facilitators Local voluntary sector providers consultant geriatrician for the locality Relevant secondary care consultants Prescribing advisers 4

5 Cardiff and Vale CHC CE Neighbourhood Partnership References: Cardiff South West Neighbourhood Partnership ction Plan Dementia Plan 2014 GMS Contract 2015/16 5

6 Strategic im 1: Identified Health Care Need within Population Serve by the Cluster: In Cardiff, 9.5% of its total population live in the 10% most health deprived Lower Super Output reas (LSO s) in Wales (i.e. those ranked 1-190). This proportion varies greatly across the neighbourhood areas. Cardiff South West (23.2%) has the highest proportion of its residents living in these most deprived areas. ge standardised allcause mortality rates for the period for all persons, as well as those aged under 75, is 418 per 100,000 population in Cardiff South East, compared with a Cardiff average of 345 per 100,000 population. 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 mean number of healthy behaviours adhered to by adults in Cardiff was 1.9. Just 5% followed all four of the healthy behaviours, while 23% followed three, 39% followed two, 26% followed one, and 7% followed none. These were almost identical to the figures for Wales as a whole where the mean number of healthy behaviours was only 2.0. Data from the Welsh Health Survey show that : 26% 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; 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 29% 34% of adults in Cardiff 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. The latest ONS data indicates that the rate of teenage pregnancies in Cardiff is 8.6 per 1,000 for under 16s (Wales is 6.1 per 1,000), and 39.2 for under 18s (Wales 34.2) In producing this plan, 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. 6

7 Ref No: Issue Current Position Objectives/nticipated Specific ctions Required Enablers/Partners Timelines RG Sept a lifestyle behaviour s of the populatio n of Cardiff South West These 5 key areas of lifestyle behaviours all have major implications on health and wellbeing for the residents of Cardiff West: smoking, alcohol, physical activity, diet and immunisations Increased basic understanding of key public health messages and where to go for further information on a topic ll relevant Practice staff undertake attend Making Every Contact Count (2.5 hours) training Completed at cluster CPET February 2016 Public Health Practice Staff Public Health/Practice Managers End 1.2a lcohol Consumpti on 43% of Cardiff population drink above recommended limits (39%-50% in Cardiff South West) 26% of Cardiff population binge drink (twice recommended limits on heaviest drinking day in past week) (25%-32% in Cardiff South West) PHW Observatory data Cardiff South West has high rates of alcohol-specific admissions to hospital and alcohol-specific mortality compared to the rest of Cardiff and the Vale To reduce excessive alcohol consumption among the cluster population ll relevant staff within practices to undertake brief intervention training so that they can provide brief advice & information to patients about reducing alcohol consumption Public Health Cluster IT consultant Practice Managers End of

8 Ref No: Issue Current Position Objectives/nticipated Specific ctions Required Enablers/Partners Timelines RG Mar b To improve screening for harmful drinking among patients Scope an IT mechanism within practices by which to embed clinical guidelines and demonstrate activity that supports reduction in alcohol consumption Public Health Cluster IT consultant Kings Road Surgery Community Director/Practice Managers IT guideline completed, Need to review alcohol data over next 12 months 1.3a ll practices should be aware of the Smoking Cessation pathway which includes referral to SSW or support at GP Practice level. Some practices use a combination of both methods. If preferring to support the client at Practice level, it is recommended that all staff are trained in Brief Intervention for Smoking Cessation and/or specific smoking cessation training to deliver a dedicated support programme. ll practices choosing to support clients directly should use CO testing to validate the quit attempt. To increase engagement of Practices in the Smoking Pathway ll practices to consider engagement in smoking cessation pathway Completed September 2016 To review data for referrals to SSW To promote STOPTOBER via practice information screens SSW/Public Health Ely bridge Surgery November b Updated Dec 2014 To develop smoking cessation guidelines/template link to e-referral system VIPC Helen Jessop/KP/NG 8

9 Cpmpleted September 2016 Plan to provide training in use of pathway for practice nurses and HCs. udit use of pathway by cluster practices Ref No: Issue Current Position Objectives/nticipated Specific ctions Required Enablers/Partners Timelines RG Mar a 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. To promote healthy lifestyle among cluster population Engage in public health pilot to increase referrals to exercise schemes & local physical activity opportunities Public Health/Communiti es First/c3sc/sw Neighbourhood Partnership Lansdowne surgery Ongoing G Only 34% of adults in Cardiff and Vale reported eating at least 5 portions of fruit and vegetables a day. Develop template to encourage referrals to NERS- completed 2016 Modify template and provide training for practice nurses and HC to encourage use during chronic disease reviews 9

10 1. 4 b Create computer templates to aid referral to services for practices in cluster to use. Letter detailing local activites promoting physical exercise linked to Vision guideline CD/ Public health 2016 G 1.4c Update Dec 2014 To establish Link with Community mbassador to maximise promotion of physical activity To work with third sector to develop this role Prescription pad for local activites available in Caerau and Ely July 2016 Need to scope services in other areas of cluster CE/Careau Lane Surgery Ref No: Issue Current Position Objectives/nticipated Specific ctions Required Enablers/Partners Timelines RG Mar a Teenage Pregnancy The latest ONS data indicates that the rate of teenage pregnancies in Cardiff is 8.6 per 1,000 for under 16s (Wales is 6.1 per 1,000), and 39.2 for under 18s (Wales 34.2) To ensure adequate provision of contraceptive services, ensuring appropriate targeting of younger women/reduce teenage pregnancy rates within SW Cluster Invite Public Health to cluster meeting to discuss opportunities to maximise targeting of young peoplecompleted YMC to attend cluster meeting to promote c card scheme completed September 2016 C card scheme training by practices and community pharmacies Public Health/Communiti es First/Local Schools via Neighbourhood Partnership/ Team round Family/Families First/ Sexual Health Outreach Team (SHOT) Public Health/ Westway Surgery G 10

11 1.5b Reduction in unplanned pregnancy rates Establish interpractice referral system for LRC within the cluster-. Interpractice referals started between 2 practices in early Scheme now being rolled out to other practices. Plan to use Vision 360 once set up for cluster to streamline referral process. IT provider Woodlands Surgery 1.6 Child Health Significant levels of young families, requiring support on a number of issues To maximise support to young families so as to ensure maximum potential /outcomes are achieved Practices to maximise use of Team round the Family/Flying Start Services provided within the cluster. TF/Flying Start/Communitie s First/ Family Point Community Director Plan to invite further support agencies to cluster meetings and promote referral to services 11

12 Ref No: Issue Current Position Objectives/ntic ipated Outcomes for Patients Specific ctions Required Enablers/Partn ers Responsibili ty Timelines RG Marc a Health Screening lthough the cluster performs reasonably well for breast screening, screening for bowel cancer and cervical screening can be improved upon 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/Com munity Director 1.7b To demonstrate improved screening uptake rates within minority ethnic communities To continue to work with Community ers to discuss ways to improve screening uptake rates. St Davids Court surgery are organizing community events to promote bowel screening. n open day was held on in the Riverside area with another planned for October 2016 where there will be an opportunity to discuss a variety of health topics including screening with the Bengali community. Public health Screening Wales BRG communities first St Davids court Surgery Taff Riverside Surgery Riverside surgery are engaging with female members of the Muslim community to promote cervical screening. 12

13 Ref No: Issue Current Position Objectives/nticipated Specific ctions Required Enablers/Partn ers Responsibili ty Timelines RG Mar a Support for patients with dementia and their carers There is a need for practice staff to have specific training to best support the needs of patients with dementia 3 of the 10 practices within the cluster have received specialist training To ensure all relevant staff have the skills to support patients with dementia ll relevant practice staff undertake Dementia wareness Training To engage with local support services for people with dementia and their carers Public Health/ Communities First, Wellbeing coordinators Practice Managers 2 years 1.8b To develop a cluster guideline to standardise annual review of patients with dementia according to UHB guidance Cluster IT consultant Cluster CD 2016 R 13

14 Ref No: Issue Current Position Objectives/nticipated Specific ctions Required Enablers/Partn ers Responsibili ty Timelines RG Mar a Older People/Falls Significant morbidity from falls. Falls a predictor of hospital admission There is an agreed C&V Falls Pathway, which has not been adopted consistently across the cluster- how many practices are using pathway Modifiable risks are addressed reducing morbidity from falls To ensure that patients identified at risk of falls (including notifications via WST/Emergency Unit) are assessed for falls risk and referred for relevant diagnostics/referred to relevant community services to maximise opportunities to reduce falls risks GPs throughout the cluster will seek to increase the utilisation of C&V Falls Pathway to identify falls risk and refer to appropriate services Day hospital/ecs/ CRTs/NERS GP within practices 6 months 1.9b template will be developed to record activity specific to falls management within the cluster including risks associated with Polypharmacy. Cluster IT consultant CRT Cluster pharmacist Community Director 6 months Completed as part of CS pathway which has been adopted by all practices September 2016 To promote use of pathways and provide training in use of IT guidelines as needed. 14

15 Ref No: Issue Current Position Objectives/nticipated Specific ctions Required Enablers/Partn ers Responsibili ty Timelines RG Mar c 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. Some practices are already engaged 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 ll practices within the cluster Practices to engage in Care and Repair Project for 2015/16 Ongoing promotion of scheme to be promoted within the cluster in conjunction with wellbeing coordinators. Project s/publicity/ infrastructure to support scheme implementation Practice Mangers/ Wellbeing coordinators November 2015 G Currently only 4 practices within the cluster are engaged Reduce falls risk within the home Updated Dec all practices now engaged 1.9d lthough the growth in older population is not as great as in some areas, the Cluster has a number of nursing and residential homes, not all of which are covered by the Nursing home enhanced service To ensure adequate levels of proactive support to people in care homes Cluster practices to consider uptake of newly released NH LES to enhance levels of input into all NHs within cluster Completed September 2015 New Nursing home within cluster area is due to open in November Community Director/Localit y Manager ll practices to consider uptake of LES ongoing G 1.9e Practices to consider adoption of frailty scale to direct referrals to community services LSD GPs 15

16 Ref No: Issue Current Position Objectives/nticipated Specific ctions Required Enablers/Partn ers Responsibili ty Timelines RG Mar Diabetes The Cluster Practices are currently engaged in the Community Diabetes Model To maximise opportunities to increase the level of community based diabetes care Practices will continue to engage in the Community Diabetes Model Dr Lindsay George GPs Ongoing G 1.11a Flu Immunisati on Tier 1 target. Cluster practices have traditional achieved better uptake rates in patients aged 65 year + but uptake in high risk groups has been difficult to achieve To promote uptake of flu immunisation among target population within the cluster Provide promotional material to be displayed in community settings. To liaise with wellbeing coordinators and third sector to promote flu vaccination Public health, Communities first Wellbeing coordinators Public Health/Pract ice Manager ongoing G 1.11b Investigate IT support systems to allow recall of eligible patients Westways Surgery Sep c To adopt the pacesetter pathway for flu and pneumococcal immunisation in at risk groups- adopted by all practices September 2016 Primary care Practice Managers Sep 2015 G 16

17 Ref No: Issue Current Position Objectives/nticipated Specific ctions Required Enablers/Partn ers Timelin es RG Mar d Update Dec 2014 ll practices to identify immunisation champion within practice to coordinate immunisation activity and engage in a champions network group Practice Managers Practice Manager from Westway to coordinate updates from cluster on progress Dec Domestic Violence 27,537 Domestic buse incidents in South Wales To reduce incidents of Domestic buse in SW Cluster To ensure the cluster is appropriately engaged in SW Police and Crime Reduction ction Plan Iris Project. ll practices trained in IRIS project (September 2016) Ongoing funding of the project to be considered by the cluster. Caerau Lane LSD GP 1.13 Health needs of trans people Trans people face ignorance, prejudice and discrimination which impacts on general health and wellbeing. To improve access to primary health care for trans people The cluster have expressed interest in taking part in a project to evaluate current practice in supporting trans people and produce a model of best practice. Primary Care directors R 17

18 Strategic im 2: To ensure Sustainability of Core GP Services and ccess rrangements that Meet Reasonable Need (including new approaches to Delivering Primary Care) s 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 OOH services by patients, DN rates, use of technology such as My Health on Line/Texts messaging etc. This plan identifies areas of 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: Issue Current Position Objectives/nticipated Outcomes for Patients Specific ctions Required Enablers/Par tners Timelin es RG Mar Interface Limited use of technology to support interface between primary and secondary care Establish more virtual consultation processes with Secondary Care Services Maximise opportunities to improve interface with secondary care specialist (eg as per Paediatrics/Community Diabetes Model) Cluster plans to invest in Vision 360 to enable improved interface between primary and secondary care and streamline referral process Medicine Clinical Board/ Specific Directorate Community Director b Improve patient experience and reduce DN rates in outpatient clinics by providing care closer to home Establish integrated Child Health clinics within primary care setting Pilot clinics have been set up in one surgery involving shared consultations between the GP and Pediatrician im to roll out to other cluster practices. Child Health Clinical Board Community Director/ General Paediatrician Ref No: Issue Current Position Objectives/nticipated Outcomes for Patients Specific ctions Required Enablers/Par tners Timelin es RG Mar 15 18

19 2.2 Patient Participati on Other than the annual CHC patient satisfaction process, there is no structured, consistent means of seeking patients views within the cluster Improve Patient Participation and Influencing Service Delivery Scope the potential of third sector coordinating a patient participation group on behalf of the cluster. Plan in place to establish Cluster health and wellbeing group, with a working group set up in ugust im to link with third sector organisations to set up group. C3Cs Locality Manager/PMs from Ely Bridge, Lansdowne, St Davids Court 2.3 infrastruct ure Cardiff LDP when passed will lead to significant housing developments in Cardiff South West Cluster Maintain high levels of access to appropriate health care professionals for all patients of Cardiff South west Cluster Community Director, Locality Manager to continue discussions with PCIC Board and key stakeholders to identify opportunities to improve health access within SW Cardiff. PM s PCIC Locality CD s Community Director and Locality Manager R 2.4a IT Varying use of technology to improve access across the cluster Greater use of My Health Online to improve appointment access; and prescription services Greater adoption by PHCT s across Cluster Group. Consider ways of promoting scheme within practices. Practice Managers Practice Managers 2.4b Undertake a scoping exercise across the cluster to determine opportunities that IT brings for maximising access. Pilot scheme carried out in one practice to consider the potential benefits of using external review of access Practice Managers Primary Care Foundation Community Director Decemb er Use of Health Services Some Populations in South West cluster are very diverse, there are difficulties associated with language barriers and cultural views as to how health services should be used To ensure patients are fully aware of the services that can/ should be accessed to support them Utilise communities First to support education of local communities Increase access to information on Practice Information screens for minority ethnic population. Communities First/C3sc/ Llandaff Fields surgery Public Health Llandaf Fields Surgery Strategic im 3: Improve Management of Planned Care (including use of Care Pathways) to ensure that patients needs are met through prudent care pathways, facilitating rapid, accurate diagnosis and management and minimizing waste and harm 19

20 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. ll 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: Issue Current Position Objectives/nticipated Specific ctions Required Enablers/Partners Timelines RG Mar a Warfarin Pathway To provide a comprehensive community based pathway of care for a patient on Warfarin ll practices to consider adopting computerised dosing system and where appropriate, consider level 4 anticoagulation monitoring PCIC PHCT s IT system software providers LSD GP leads 3.2b ll practices to consider taking part in slow loading of warfarin enhanced service LSD GP leads Ongoing G 3.3 Mirena Coils Not all practices can provide Mirena Coil insertion defaults to secondary care referral (gynae or ISH) Equitable access for all patients living in Cardiff North Cluster wishing Mirena Coil insertion Scoping exercise to determine feasibility of interpractice referrals for Mirena insertion Completed January 2016 Increased uptake by cluster practices to be promoted PCIC Interested PHCT s (ISH/Gynea for training) PM s Woodlands Surgery 20

21 3.4 Joint and Soft Tissue Injections Inequitable service provision across cluster e,g, types of injection; skill sets etc Reduce secondary care referrals Identify service provision Engage in MSK pilot to rationalize referral to physiotherapy and orthopaedics PHCT GP s Rheumatology INPS (vision 360) LSD CD for MSK, 3.4b Repeat prescription ordering systems Current systems for reordering medication may compromise patient safety where requests are made prior to changes in medication eg post discharge from hospital Ensure patient safety when ordering repeat medications and reduce medicines waste Cluster pratices have all agreed to adopt the new repeat prescription ordering system in collaboration with community pharmacies. (pril 2016) The project will be evaluated through the use of prescribing date and patient feedback UHB prescribing advisors Cardiff University School of Pharmacy Community Pharmacies within cluster. Cluster pharmacists/ Canna Surgery Ref No: Issue Current Position Objectives/nticipated Specific ctions Required Enablers/Partners Timelines RG Mar Mental Health Currently there is a lack of counselling provision within practices- long waiting lists for access resulting in referral to secondary care services To provide sufficient counselling capacity within practices to meet demands To scope setting up social prescribing for voluntary sector mental health support CVMH Barnardos Community mental health team Wellbeing coordinators Community Director Lansdowne Surgery Caerau Lane Surgery Public Health 21

22 PMHSS 3.6 Mental Health and Wellbeing Need to promote health and wellbeing in vulnerable and socially isolated patients To set up community gardens in GP practices where groups of patients will meet and grow produce.. This will promote mental wellbeing, reduce isolation and promote a healthy lifestyle through physical activity and healthy eating Bid submitted to neighbourhood partnership fund in collaboration with Grow Cardiff to establish a garden in one practice. (September 2016) Scheme to be rolled out to other practices within the cluster Grow Cardiff Neighbourhood Partnership Officer Lansdowne Surgery Strategic im 4: To provide high quality, consistent care for patients presenting with Urgent Care Needs/t high Risk of dmission and support the continuous development of services to improve patients experience, coordination of care and the effectiveness of risk management ll cluster practices engaged with a number of emergency care pathways aimed at reducing unnecessary referrals to Secondary Care/attendances at the Emergency Unit. Ss 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: Issue Current Position Objectives/nticipated Specific ctions Required Enablers/Partners Timelin es RG Mar 15 22

23 4.1 Dental Care/Eye Care Patients often access GPs inappropriately to assist with urgent dental complaints and eye problems To ensure patients access right care/right time/right place Explore options to improve pathways to access other independent contractor services (Dental services/ optomotrists) Primary Care s WECS Community Director R 4.2 ccess to Specialist Opinion GPS do not have ready access to specialist opinion and as a result feel referral to EU is only option To provide more seamless access to specialist opinion/reduction in referrals to EU (paediatrics/respirator) To meet with Consultant s for Secondary Care Specialties to identify mechanism for more effective/efficient communication im to promote use of e advice Secondary Care Consultants Community Director R 4.3 ccess to cardiology diagnostic services Limited access to cardiology services for diagnosis of heart failure. To provide a rapid access system for diagnosis and initial management for patients with suspected heart failure. im to improve patient care and reduce avoidable admission to hospital ll cluster practices have adopted the CS pathway for Heart Failure. Cluster to engage in e advice to cardiology Cluster to engage in newly established community cardiology clinics Cardiology department Cardiology GPSI VIPC Primary Care Strategic im 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: Issue Current Position Objectives/nticipated Specific ctions Required Enablers/Partners Timelin es RG MR 15 23

24 5.1 Laboratory Testing There is variation both within the Cluster and across Locality/Cardiff and Vale in respect of laboratory testing To ensure consistency in practice based on clinical guidelines To agree clinical guidelines for Vit D and develop Vision guideline to standardise adherence across the cluster Medical biochemistry VIPC Greenmount Surgery UHB prescribing team 5.2 Radiology Requests There is variation both within the Cluster and across Locality/Cardiff and Vale in respect of radiology requestingspecifically shoulder ultrasound To ensure consistency in practice based on clinical guidelines/reduce costs associated within unnecessary Xray Requests To agree pathway for shoulder ultrasound with Consultant s and discuss implement in a cluster meeting MSK team Radiology Community Director/ CD for MSK 24

25 Strategic im 6: To support Delivery of Improvements gainst National Priority reas for Cancer Care, Minimising the Harms of Polypharmacy and Improving End of Life Care Ref No: Issue Current Position Objectives/nticipated Specific ctions Required Enablers/Partners 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 with lung, digestive system and ovarian cancer and to summarise/share learning and feedback findings to cluster at annual review meeting VIPC CD leads ll practices im to engage in UHB cancer plan and adopt IT systems to support early diagnosis 25

26 Ref No: Issue Current Position Objectives/nticipated Specific ctions Required Enablers/Partners Timelin es 6.2a Polypharm acy 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 (ppendix 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 Cluster pharmacists Cluster IT consultant ll practices identify and report the number /% of patients aged 86years or more receiving 6 or more medications 6.2b To reduce the risk of falls associated with Polypharmacy To adopt the pacesetter pathway Primary care ll practices 26

27 Ref No: Issue Current Position Objectives/nticipated Specific ctions Required Enablers/Partners Timelin es 6.3a End of Life Care Identify all deaths occurring between 1 January 2015 and 31 December 2015 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 ll practices 6.3b To adopt a cluster palliative care IT guideline developed by Macmillan GP Palliative care Cluster IT consultant Woodlands surgery dvanced 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 ll practices / Macmillan GP 27

28 Strategic im 7: Deliver consistent, effective systems of Clinical Governance Ref No: Issue Current Position Objectives/nticipated Specific ctions Required Enablers/Partners Timelin es 7 Clinical Governanc e CGPST The contractor updates the Clinical Governance Practice Self ssessment Toolkit 121 (CGPST) and to confirm completion and submission to the LHB by ll practices 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 CGPST assurance. ny improvement actions to be identified by , or actioned during the year if early identification Practices should consider key issues from the CGST for discussion at GP cluster meetings where there may be potential to identify common themes that might be addressed through agreed actions. 28