practice. A Health Board education campaign? To be launched

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1 W95045 Tony Pandy Health Centre Practice Development Plan Services Priority The issues Aims and objectives How will this be done? ( Practice; GP Cluster; Health Board) Access DNA rates on To reduce the DNA Continuing to educate patients about their behaviour via pre bookable rate. advertising and receptionists reminding patients within the appointments practice. A Health Board education campaign? To be launched 12 months Increasing patient demand for appointment to suit their convenience To allocate both urgent and nonurgent clinical issues in a timely manner using current resource With current appointment and Triage system which at present is working well for our practice as we do not have many complaints about access. The issues arise when a GP is away on holiday and the inability to find suitable GP cover due to the recruitment problems in the area. We are planning to use more Nurse time to see suitable minor illness cases which will free up GP appointments to see more complex cases. 12 months Planned Care:- Referral management and care pathways Inability to undertake some services in primary care eg Minor Surgery, administration of GLP1 agonists, Coil fitting Development of new services such GPSI Cardiology and Diabetes To improve practice premises. Undertake more specialised tasks in primary care. Review complex patients seen in primary care which may need secondary care referral Better investment in primary care to provide these services with appropriate resource and training. This will ultimately reduce the pressure on secondary care services to undertake these services. Collaborative cluster working may allow interpractice referral to undertake these services. We need suitable funding from WAG to secure investment in new premises. Development of new primary care service provision for specialist services eg Heart failure, Cardiology clinics. Management of complex diabetic patients etc. This could be offered by GPs with a special subject interest or specific skill mix as a networked pathway.

2 Redevelopme nt of CIAS service Allow better access to therapies in acute situations The current CIAS service needs re-design to ensure that all GPs can access timely urgent therapies assessment or secondary medical care input within the community to avoid unnecessary hospital admissions. This will need to include a single point referral system to all therapies including social services and mental health services for acute problems including emergency placement into a care setting. This will need to work 24/7 to ensure a quality and appropriate service is provided. Unscheduled care Under resource of the GP OOH Service including difficult recruiting. Provide a stable and efficient OOH GP service. Increase resource and funding to the OOH Service and consider changes in its structure to allow it to function and meet the modern day patient demands. The service is slowly deteriorating and no suitable provision or planning has been made to improve this service. Consider pooling resource with other service providers to ensure safe emergency cover is provided. Poor communicatio n with A+E Services and inappropriate re-direction to primary care Practice Developments e.g. New clinical services Teaching and training Collaborative arrangements National Clinical priorities End of life care Identify patients using the Palliative Care register and review the process of end of life care using the care pathway developed last year in Cwm Taf. Undertake individual case review including Audit. Use individual management plans in advance care planning. Improve on communication with Palliative care nurses, District nurse, OOH and relatives.

3 Cancers Review all new cancer diagnosis and undertake significant event analysis of cases. Look at the problems and best practice in relation to prevention and early detection of cancer. Address barriers and improve services by monitoring actions. Share learning with other cluster members. Increase use of Cancer Care Pathways and encouraging the uptake of screening services in at risk groups with patient education of harm reduction eg smoking cessation. Frailty and polypharmacy Practice identified 2.8%/93 patients > 85 years old Use NO TEARS tool for medication reviews. Minimise the harms of polypharmacy with regular medication reviews and reduction of unnecessary of medication with harmful side effects. Continuing development of anticipatory care plans for elderly at risk patients. Identify at risk patients and consider referral to CIAS services and other multidisciplinary teams to help unnecessary admissions eg OT, Physiotherapy services. Improve the DALS via computerisation ensuring safe discharges are provided. Better communication needs to be made between secondary care and primary care to ensure unnecessary discharge medication can be avoided. This may be facilitated by a prescribing team pharmacist.

4 Workforce Plan Issue Background What will be done? How will this be done? ( Practice ; GP Cluster ; Health Board ) Difficulties recruiting GPs Increasing problem of vacant GP posts due to retirement of GPs and lack of trainees entering General Practice. High work load demands in this area is a disadvantage to Need to make General Practice in the Rhondda more appealing to attract potential GPs to the area. This needs to be done at a Health Board level but may be achieved through working collaboration with our cluster group eg sharing of workforce where recruitment gaps exist. More funding to attract GPs to work in the area which can be led by the Health Board. Expansion of the PCSU service to provide a pool of suitably trained clinicians to include GPs, Nurses and HCAs at a subsidised rate allowing all practices to utilise this resource on a regular basis to plug gaps in vacancies. The current service cannot meet the demands of all practices at present. Consideration of sharing vital clinical staff between surgeries to cover holidays/sickness with mutual arrangements months Premises Plan Issue Why? What will be done? Practice premises remain outdated and unfit for modern practice Health Board owned and managed premises which has not been updated or maintained to modern requirements fit for practice. Need renewal of current premises or at least remodelling of current premises to conform to modern standards. How will this be done? ( Practice; GP Cluster ; Health Board h Support from the Health Board to apply to the Welsh Assembly to fund such a project which has previously been rejected or put aside due to lack of priority. Use of prescribing money incentive to invest in furniture and medical equipment to improve the practice furnishings.? 3-5years

5 Cluster Network issues LHB Issues