Annex 3 Cluster Network Action Plan North Ceredigion Cluster. 1 P a g e

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1 Annex 3 Cluster Network Action Plan North Ceredigion Cluster 1 P a g e

2 The Cluster Network 1 Development Domain supports GP Practices to work to collaborate 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 should be a simple, dynamic document. The Cluster Network Action Plan should include: - 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 should be specific, measureable actions with a clear timescale for delivery. Cluster Action Plans should compliment 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 should support 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. The action plan may be grouped according to a number of strategic aims. 1 A GP cluster network is defined as a cluster or group of GP practices within the Local Health Board s area of operation as previously designated for QOF QP purposes 2 P a g e

3 North Ceredigion Cluster The Cluster Network serves an approximate population of 48,000 with An older profile (18%), but also a high student population Population is increasing Recent property development within Aberystwyth potentially will change the population demographics and potentially population needs Discussions are taking place with reference to the Syrian refugee crisis and the possibility that Aberystwyth may have an allocation of refugees (10 per year) moving into the area Mixed ethnicity Welsh speaking is high within cluster, but there is difficulty in recruiting Welsh speaking GPs. Deprivation less than Welsh Average and variable across the area The cluster has an above average for people living within a Rural area (57.8%) Older patients having more complex needs. Big challenges with recruiting GPs and Practice nurses within the area. The North Ceredigion Cluster Network comprises of representatives from 7 GP practices ( Primary Care) County management team ( Secondary care) Medicines management team ( secondary care) Public health Wales Voluntary sector Local Authority 3 P a g e

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5 Key Themes and Priorities Identified from Practice Development Plans 1. Develop a shared BP protocol develop pathway for the management of BP. Arrange staff training 2. Develop shared asthma protocol capacity, backfill, specialist nurse, other professionals, to release specialist nurse time. 3. Pre-diabetes continue project 4. Depression particularly in the Young 5. Sexual health 6. Antibiotic Prescribing 7. Phlebotomy funding, All Wales policy 8. Admissions and discharges 9. Frail & Elderly pharmacists, enhanced service The cluster have agreed to focus on the following 10. Increase demand 7 priorities this year: 11. Joint care beds ICB 12. Hospice Workforce/service sustainability (2.1, 2.2, 4.1) Pre-diabetes ( 3.1) 13. MDT Frail and Elderly ( 3.2) 14. Lack of consultants Chronic conditions management ( 3.3) 15. Dental Vision Anywhere / 360 (4.5) 16. Sustainability and skill mix Antibiotic prescribing ( 4.3) 17. D/N capacity Physiotherapy pilot (3.4) 5 Page

6 Strategic Aim 1: To understand the needs of the population served by the Cluster Network No Objective 1.1 To review the needs of the population using available data Key partners Local Public Health Team Public Health Observatory Cluster For completion by: September 2016 Outcome for patients To ensure that services are developed according to local need Actions / Progress A review of the population health needs was under taken. The same as last year, with the additional property development and some refugee settlement. RAG status completed Public Health Wales Observatory General Practice population profiles Public Health Wales Observatory NCC Population profiles.docx Practice development plans from the 7 GP practices identified key themes. The cluster have agreed 7 priority areas for Each Practice takes a lead for 1 of the identified priorities. 6 Page

7 Strategic Aim 2: To ensure the sustainability of core GP services and access arrangements that meet the reasonable needs of local patients No Objective 2.1 To develop local workforce development plans Key partners Practice Lead For completi on by: March 2017 Borth Surgery Llanilar Health Centre Outcome for patients Action / Progress to Date Service modernisation to meet changing needs Within our Cluster we have a high % of GPs and PN retiring in the next 3 years. There are no new trainees coming through. Recruitment remains to be a challenge nationally. But is particularly problematic within our rural area. Ensure sustainability of local services Working with LHB 2.1 To review current demand and Practice lead Practices Services developed to reflect local Cluster: consider recruitment campaign, working in partnership Welsh Tourist Board and Aberystwyth University VTS Explore possibility of Hywel Dda VTS scheme and ensure equity of training across Hywel dda and Ceredigion. Agree and develop placements for Physician Associate roles Develop JD for the PA Role Explore opportunity for pharmacist to be assigned to Practice Identify opportunities for collaborative working between practices RAG Status Cluster felt that they provided adequate access for their patients. Consultation rates varied 7 Page

8 capacity Borth Surgery Llanilar Health Centre Working with need between the smaller and larger Practices. GP Practices, LHB, CHC develop new models of working increased GP triage within Practices Improve patient information to the changes to service delivery Cluster: to exploit use of IT to signpost and empower patients to gain information and signpost e.g. My Health on Line, GP to GP transfer of data within the cluster Practices to develop Patient Participation Groups to help educate patients on health & service issues 1 Practice 8 Page

9 Strategic Aim 3: Planned Care- to ensure that patients needs are met through prudent care pathways, facilitating rapid, accurate diagnosis and management and minimising waste and harms No Objective Key partners 3.1 Cluster funds Project to reduce the risk of developing diabetes in high risk patients within the north Ceredigion Cluster Practice lead For completion by: March 2018 Church Surgery Outcome for patients Better health promotion and prevention of developing diabetes. Working with Action / Progress to Date LHB, Midwives, CCM nurses, PHW 3.2 Frail and elderly 3rd sector Aberystwyth University Practice lead Ystwyth Medical March 2018 Better collaborative working for patients health By Whom Link with Claire Hurlin re: expert patient programmes and Foodwise to promote patient self management. Link in with PHW to discuss Brief intervention training for HCP s / lifestyle advocates Encourage clinicians to refer to NERS and University exercise classes and liaise with providers Strengthen the link with Midwives to develop a clinical pathway on the management of gestational diabetes, including follow up in primary care. Target high risk groups such as polycystic ovary syndrome patients Liaise with PhD student and tutor to help identify and analyse data Develop MDTs - Cluster model Develop Cluster pharmacist role Job Description to undertake medication reviews in care homes completed Not started 9 Page

10 Group and social needs. Working with Community Pharmacy LHB and to work alongside the new specialist nurse post Develop job advert Advertise for cluster pharmacists Collate numbers of house bound and over 85s from Practices in cluster WAST 3.3 Develop services for management of Chronic conditions March 2016 Practice lead Improved service provision Tanyfron Surgery Working with Cluster County team Set up meetings to discuss developing plan / proposals for funding streams that may become available with Claire Hurlin. Explore use of cluster funds to pay for specialist nurse time in Primary care. Nurse Advisor to look into secondary care nurses having a taster in primary care. Develop training plan for primary care nurses. Develop BP protocol Develop asthma shared care protocol Develop an innovative model of care in Diabetes to include management across boundaries of 10 P a g e

11 3.4 Physiotherapy Pilot March 2017 Practice lead Padarn Surgery Reduce workload in Practice. More streamlined service for patients care throughout primary and secondary care & the wider community (i.e. local authority, PPGs, voluntary sector) To ensure sustainability of Diabetic care for our population Develop job plan Develop job description Advertise job vacancy Pilot physiotherapist role working in practice Working with Cluster County team 11 P a g e

12 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 4.1 Ensure sufficient Capacity and Access in primary care to accommodate urgent care needs as well as chronic care needs 4.2 Ensure appropriate use of A/E services Practices Community care Council Patient participation groups Public Health Wales, Media, Voluntary organisations, Paramedics, PharmacieS For completion by: March 2017 Outcome for patients Progress to Date Seen by the right professional at the right time Develop cooperative working with partners outside the present model such as with pharmacy and paramedics Develop placements / job plan for Physician associate role Agree placements for PA Promote Info engine Link to NHS website - GPONE Develop EPP programmes with Claire Hurlin Promote choose well, choose wisely within cluster RAG Rating lead SJ/ES Develop jointly with A&E and paramedics on clinical care pathways 12 P a g e

13 Working with Develop DVT pathway Purchase monitors CRP testing WEQUAS Registration Complete 2 CRP audits A&E consultants and staff 4.3 Antibiotic prescribing Practice lead Tregaron Working with Practices Analysis of impact on prescribing Medicines management 4.4 Improve cooperative working with out of hours Practices OOH doctors/service and ambulance service practices collecting data 25% reduction in 1st Quarter data Improve cooperative working through improved communication: - personal through educational provision Informational though IHR expansion and proactive communication from day service to OOH for patients who are at potential risk of requiring OOH care. 13 P a g e

14 4.5 install Vision 360 /Anywhere across the Cluster to enable sharing and effectiveness of combined surgery resources across the cluster and improve sustainability Practice Lead Sue Fish Dylan Williams Working with INPS and NWIS March 2107 Improved access to General Medical and Enhanced Services across the Cluster Scope project across North Ceredigion (NC) practices Obtain customised INPS quotation for N C Cluster Develop implementation plan in partnership with INPS and NWIS - Installation Plan - Training Plan Ongoing management/resources plan 14 P a g e

15 Strategic Aim 5: Improving the delivery of end of life care Key learning points 15/16 No District Nurses to input data onto GP systems. Link with care home support team re: standardising care To continue with McMillan specialist nurses attending Practice meetings. Feedback to GPs following visits Undertake joint visits with the specialist nurses. I want great care feedback for cluster Objective 5.1 Review deaths that occurred between and With a particular focus on deaths that might reasonably have been anticipated using the template Key partners For completi on by: 31/12/16 GP Practices Community teams Outcome for patients To improve the experience of the patient and families at end of life. Progress to Date RAG Rating To undertake review and feedback to cluster Audit care home patient deaths EOL REVIEW RESIDENT homes deaths or admissions 15 P a g e

16 5.2 Improved communication between the agencies involved in endof-life care, GP Practices, OOHrs Community teams support patient choice regarding preferred place of death Development of information sharing protocols across agencies. DNs to work more consistently across the cluster and input onto the clinical system. Social services 16 P a g e

17 Strategic Aim 6 : Targeting the prevention and early detection of cancers Although the Hywel Dda University Health Board population has the second lowest incidence rate of lung cancer of all the health boards for both men and women, and statistically significantly lower rates than Wales as a whole, we should remember that Wales and the health boards still have high rates compared to many European countries. Hywel Dda has the third highest survival rate of lung cancer all health boards in Wales Key learning points 15/16 No 6.1 Liaise with the X-ray department to speed up the reporting List of protocols Referral criteria not clear for USC Need to use WCCG not forms Some found delays in patients presenting need to work with PHW to increase symptom awareness Use Macmillan tab on vision Increase in % of smokers / ex smokers developing lung cancer raise awareness CMAT back pain pathway needed Objective Key partners For completion by: To carry out LHB, 31st Significant PHW, 3rd December Event Analysis Sector, 2016 of newly other PC diagnosed with contracto lung or digestive rs cancers using a Outcome for patients Improve prevention and early detection of cancer Progress to Date RAG Rating To undertake review and feedback to cluster Share the learning Dr Shanbhag to be invited to cluster meeting 17 P a g e

18 SEA tool for all patients diagnosed between 1/01/16 31/12/ Target smokers to stop LHB, PHW, Preassessm ent clinic, midwives Improve chest health Stop smoking services need equity across cluster. Promote stop before your op Promote mums to be Midwives have been trained on smoking cessation Liaise with Sarah Hicks re: Telehealth Pilot in place with PHW 18 P a g e

19 Strategic Aim 7: Minimising the risk of poly-pharmacy Key learning points 15/16 Monitor Frail / housebound patients Community pharmacy to target those that can go into pharmacy. Cluster to be mindful of size of tubs etc when prescribing. Dermatology specialist nurse to give training in care homes GPs to link with pharmacists to receive feedback on Dosette box compliance/wastage. Encourage care home staff to report /document when patients become reluctant or refuse to take their medication. Liaise with eye clinic and pharmacy to ensure patients have a manageable regime with eye drops No Objective 7.1 Practices to undertake review of patients aged 85 yrs or more with 6 or more medications Key partners For completion by: Medicines 31st Management December 2016 Outcome for patients To identify and minimise the risk of poly-pharmacy Actions RAG Rating To undertake review and feedback to cluster Work with cluster pharmacist to Monitor Frail patients in residential homes GPs to link with pharmacists to receive feedback on Dosette box compliance/wastage. 19 P a g e

20 Strategic Aim 8: Deliver consistent, effective systems of Clinical Governance No Objective 8.1 Eye drops Key partners HB, Community pharmacists, Practices For completion by: - Outcome for patients Better compliance with eye drops Progress to Date RAG Rating Liaise with HB to ensure eye drops are prescribed from hospital clinic Patients / carers to be trained how to administer the eye drops 20 P a g e

21 Strategic Aim 9: Other Locality issues No Objective Key partners To explore stronger Lead collaborative / Dr Sue federated ways Fish of working Working with For completion by: March 2018 Outcome for patients Sustainability and continuity of service provision Actions / Progress to Date Practices LHB NWIS INPS RAG Rating Explore cluster use of time banking e.g. SPICE Work with IT department / NWIS to links Practices systems to see patients records when needed Explore advantages and disadvantages of the different models for federation 21 P a g e

22 Strategic Aim 10: Objectives carried forward from last year Due to workforce challenges emphasis has been put on the 7 priority areas for this year. These priorities aim to ensure sustainability of the workforce and test initiatives that will help reduce GP workload both short term and long term. Work is ongoing to achieve the objectives set last year. No Objective Key partners 10.1 To Increase influenza vaccination uptake to 75% in over 65's and under 65's in an at risk group PHW For completion by: ongoing Outcome for patients Increase herd immunization. Better protection for the whole cluster population. Actions / Progress to Date 10.2 Improve discharge summaries LHB GP Lead / LDM Ongoing Release more capacity for patient care Encourage all frontline Primary Health Care professionals to have the flu vaccine Work with Occupational health for GPs to be informed when their patients (staff) have been vaccinated. Target Care Homes Advertise in the University. Little improvement made last year. Cluster discussed the need for more timely and informative RAG Rating In discussion Flu leaflets handed out at Fresher s fair 26/09/16 completed 22 P a g e

23 discharge summaries Action: Liaise with LHB colleagues to Improve Discharge completed Summaries Letter to HB from cluster Progress: Work is ongoing and progress is being made Improve rheumatology March 2018 services for our population Cluster LDM Improved service provision Improve rheumatology services for our population Practices to Map out joint injections activity for previous financial year Establish HB plan for service Fund rheumatology education for cluster if needed Invite specialist nurses to train and advise the PN and GPs. To discuss as a cluster any significant events in relation to near patient testing and shared care drugs used in rheumatology 23 P a g e

24 10.4 People with Chronic Heart Failure patients are offered LHB personalised information, LHB education, support and opportunities for discussion Improve achievement of optimal medical management LHB Better management of symptoms / condition Replicate the information packs that are given to patients by the Specialist Heart Nurse for those who are diagnosed in primary care and those who require an educational update. Ensure that all the clinical generalists have the necessary skills and knowledge to follow the NICE guidance on Heart Failure through: Increased HF Specialist Nurse educational support for practice nurse by undertaking joint clinics in practice. Cluster audits to support education on HF Cluster to agree consistent coding to enhance searches Pilot in Tanyfron. Lessons shared Ensure call and recall systems in place 24 P a g e

25 Consider cluster model whereby a few practices are trained in HF management and could undertake shared working with those practices who do not have the capacity or skills to provide this work. Cluster to agree consideration of entry onto primary care palliative care register of any patient who requires supportive only care. Clinical assessment at least every 6 months Improve EOL care for patients with HF Secondary care to communicate when heart failure patients would no longer benefit from active intervention and invitation from primary care to the HF specialist nurse to attend PC meetings when patient being discussed. Feb 2015 Include EoLC for non cancer patients in MDT education provision in Ceredigion Cluster to ensure Advance Care Planning is in place for this group of Heart Failure patients. (eg preferred place of care, 25 P a g e

26 DNACPR, Just in Case box, ICD management) Refer to Specialist Palliative Care Team when there is a specialist PC need Improve overall MSK Health LHB, MSK PHG, March 2016 Midwives Improved MSK health and pain management Obesity PHW, HB Cluster To reduce prevalence of obesity within cluster through education Health benefits from maintaining a healthy weight Improve osteo-arthritis symptoms through optimising pain control and lifestyle changes Develop holistic MSK Made links service with Bethan Promote bone health in Lloyd. pregnancy Improve mental health with MSK conditions Optimal disease control in rheumatic conditions Consideration of a one stop back pain clinic run via CMAT, to include need for MRI Scope number of referrals for bariatric surgery Link with lifestyle advocates to promote healthy lifestyle Link with HB Obesity pathway work 26 P a g e

27 and signposting to activity groups 10.7 Depression PCMHT, HB, PHW, University Improved service provision Promote the Move more sit less campaign Work with other agencies to reduce 7 week waiting Establish counselling service referral criteria Improve process for patients re: if patient phoned 3 times and no answer taken off list Work with the university to Ongoing promote mental health and wellbeing Work with the HB to ensure service provision for 17yrs Discuss availability of Psychological support with chronic conditions with Bethan Lloyd Invite Bleddyn Lewis to attend cluster meeting ½ hr 27 P a g e

28 10.8 Frailty Develop MDT working Establish agreement for cover of Joint care beds Link into WAST frequent callers better understand health needs and reduce amount of call outs / admissions to hospital 28 P a g e

29 Strategic Aim 11: Objectives completed Mid Wales collaborative HB, Cluster MWC Increase level of Welsh Language provision HB, WG Installation of DMARDS software INPS / HB Dr Fish, GP Lead PM lead, GP Lead November Anticoagulation INPS / HB dosing software November Installation of the MSDI software November INR service MSDI/ HB HB, Cluster Elaine Lorton, Practices Development of sustainable service provision across Mid Wales Development of cluster plan to promote use of Welsh Language in area. Robust monitoring of Diseasemodifying antirheumatic drug Accurate dosing for INR levels. Predictive Risk Stratification tool to support the cluster pre-diabetic project and frailty identification More robust service provision Engage with the chairs of the MWC Link with MWC for support Support progression of the PA role Promote bilingual information for patients Comply with WG health circular. COMPLETED HB to sign off quotation Procure software package with PMS funds Inps to install and provide training HB to sign off quotation Procure software package with PMS funds Inps to install and provide training Sign off order MSDI to install and provide training Set up steering group completed All practices would like to sign up to level 4 INR Book training Cost the equipment needed COMPLETED COMPLETED completed completed COMPLETED COMPLETED 29 P a g e