Torfaen South GP Cluster Network Annual Report

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1 Torfaen South GP Cluster Network Annual Report Our Network: - We are a Network with 7 main and one branch surgery; There are 3 recognised for GP training There are 5 offering placements to Cardiff University Student Doctors There is a GPWSI in Diabetes 1 x GP Appraisal co-ordinator and 1 GP MARS Clinical Leadership is provided by a Professor of General Practice at Cardiff University involved in policy discussion, prioritisation, and strategic implementation of primary care developments with Welsh Government and primary care medical directors 1 x Primary Care Research Incentive Scheme (PiCRIS) 1 x Primary Medical Care Adviser for Primary Care Quality Public Health Wales 1 x LMC and 1 x GMAG member, an Honorary Lecturer at Cardiff University Our community: - We serve a population of 45,559 in a predominantly urban area with 99.4% of the population residing in the main town of Cwmbran and surrounding areas. The has boundaries with Monmouthshire, Caerphilly and Newport. Particular features of our population are: Approximately a quarter of the population is aged under 18 which is significantly higher than the Wales average; There are high levels of digital inclusion; There are good transport links across Torfaen; Approximately 40% per cent of the resident population live within the Most or Next Most deprived areas in Wales 1

2 We looked at the needs of our community: Smoking: An average of 27.1%-31.5% of adults smoke daily or occasionally compared with 26% for Torfaen overall (24% in Wales). Torfaen has 2 nd highest smoking rate in Gwent; Asthma: 7.2% recorded prevalence, above Health Board and all- Wales levels and in the highest 25% in Wales; 5.3% to 18.3% of residents in South Torfaen assessed their own general health as bad or very bad, (7.6% Welsh average) What we have achieved: funded Bowel Screening pilot to increase opportunity for early detection of cancer funded Practice Manager s um to share best practice funded Practice staff to receive read-code training funded diabetic foot care training funded obesity strategy workshop funded GP Practice based Pharmacist funded GP Practice Pharmacist mentoring funded GP Practice Pharmacist Independent Prescribing training funded video for education promoting a career in Primary Care Diabetes service model communicated, shared and agreed across all stakeholders; Torfaen Smoking Action Plan promoted at Research & Development Conference 2015; Facilitated introduction of 8 Smoking Champions Dedicated sessions for Care Closer to Home/Access LES Our agreed priorities for 2015/16 were: Continue the work to reduce the number of people who smoke in South Torfaen To use funding across GP to increase uptake of bowel screening Tackling obesity: Patients receive timely and appropriate support based on their needs and AWMS guidelines are followed Our plans for 2016/17: To be agreed from meetings, PDPs, lead Practice visits, Public Engagement Events & Needs Assessment session To increase links between Management Team and action plan priorities To consider potential funding for a Social Prescriber To consider potential funding for Bowel Screening To facilitate Smoking Cessation Champions in all Tackling obesity: CYP & Adults who are overweight / obese have access to timely and appropriate support based on their needs and WMS guidelines are followed consider low level (universal) interventions as part of action planning process & role of Health Care Support Workers 2

3 Neighbourhood Care Network Annual Report Torfaen South 3

4 Strategic Aim 1: To understand the needs of the population served by the Network 1.1 Smoking Cessation Smokers in the area stop smoking To increase the provision of smoking cessation brief interventions by GPs and other practitioners Stop Smoking Wales Partners Number of people who smoke reduced in line with Tier 1 target i.e. 5% make a quit attempt with at least 40% CO validation at 4 weeks; People have scheduled appointments; Number of people treated People make a quit attempt and receive effective treatment to stop smoking; Number of staff who have access to brief intervention training Respiratory/COPD focussed CPD session held; Action Plan progressed; 8 Smoking Champions identified plus a PCMHSS trainee Health Visitors promoting SSW as part of home visits; Performance data not available from Stop Smoking Wales at time of reporting; promotion of pop up shops campaign to raise awareness of smoking cessation services; Health Visitors promoting SSW as part of home visits Midwifery service referral data/monitoring of pregnant women with BMI indicators submitted to Management Team Brief Intervention Training (BIT) e-learning package available to all professionals Up-take (baseline) of Brief Intervention Training (BIT) in Torfaen in : Physiotherapists - 8 Mental Health professionals 12 External 1 Midwives - Weight Management 3 Amber 4

5 1.1.3 To increase access to smoking cessation services 1.2 Bowel Screening To increase up-take of bowel screening to achieve 60% target 1.3 Engagement Identify a range of methods to increase awareness of the work of the and To build communication links between Education and Primary Care Comm Pharmacy Stop Smoking Wales PHW Bowel Screening Wales Increased numbers of Level 2 and Level 3 Community Pharmacies at which to access smoking cessation services Earlier detection of bowel cancer data supports improved survival rates; Published evidence shows Practice level interventions achieve clinically significant increase in uptake; Evidence shows high % of people who respond once to bowel screening will respond again mal and informal input from engaged, disadvantaged groups demonstrates improved service delivery and patient satisfaction TCBC LMC Improved communication leads to holistic care and appropriate interventions : 3 Level 2 Pharmacies 1 Level 3 Pharmacy : 6 Level 2 Pharmacies 5 Level 3 Pharmacies funding agreed GP lists provided by Bowel Screening Wales via PHW 762 contacts identified 714 contacts made Evaluation to be undertaken to show impact of service and achievement against 60% national target TVA (3 rd Sector) rep attends meetings Links made with Engagement Team to identify Torfaen specific events wide newsletter developed to share new developments and current issues across 12 s participates in Dementia Friend Community group work Presented at meetings On-going discussion between TCBC/ To support process for LMC involvement Strategic Aim 2: To ensure the sustainability of core GP services and access arrangements that meet the reasonable needs of local patients Amber 5

6 2.1 Access To review the processes for missed appointments (DNAs) to avoid wasted appointment slots Raise awareness of information available in accessing dementia care and support To support the implementation of My Health Online DFC lead HoPN Divisions 3rd sector Clinical Director Patients benefit from reduced waiting times Increased access to information and support for people with dementia, carers and families Improved communication; 24 hour access to GP Practice functions with increased capacity for Practice staff funding agreed to support regular Practice Manager ums; Feedback from two meetings held in : Combination of Same Day appointments, MHOL, pre-booked and GP only bookable appointment slots has resulted in a significant reduction in DNAs Increased equity in access for patients Practice Manager project to consider innovative ideas in promoting MHOL WG funded text messaging initiative introduced To compare PDP rate submissions at year end 4 (57%) with 5 A s for Access compared with average of 77% meetings act as forum for information exchange to discuss ideas, issues and developments funding agreed to support development of a Dementia Roadmap, on-line support resource for people with dementia, carers and families Evaluation expected at 6 and 12 months A member of the Dementia Friendly Communities Group funded Practice Manager s um reviewed & shared good practice which led to a significant reduction in DNAs, and achieved greater equity in access for patients All 7 have access to MHOL 6

7 2.1.4 To assign funding for patient self check-in systems Increase access to a local Phlebotomy service 2.2 Workforce To support relevant education and development opportunities across the To recruit GP Practice based Pharmacists Pharmacy To increase capacity for Practice staff and improve the patient experience Patients have access to care closer to home; Increased capacity within District Nursing leads to improved responsiveness for complex patients Patients benefit from improved quality of care and a skilled workforce; Sharing of ideas, skills and good practice enabled Patients have local access to, and benefit from evidence based interventions; Patients benefit from reduced waiting times from increased GP capacity All 7 have appointment booking option All 7 have repeat prescription booking option Funded scoped with 7 systems assigned Survey data available 2016/17 IMTP funding agreed Year 1 to support implementation of service All posts appointed to at March to be funded from allocation Evaluation expected at 6 and 12 months funding agreed in support of a range of training e.g. communication skills and readcode training etc Process in place via proposal applications funding offered to all community teams via proposal process with WG guidelines shared Task and Finish group established to oversee process funding agreed to support role 1 full time Pharmacist recruited and in post Induction & training programme in place e.g. Independent prescribing Timetable of mentorship agreed and funded Outcomes and priorities agreed including face to face medication reviews with a specialist undertaken Practice pharmacists activities replaced 1842 hours of GP time over three months, equivalent to 110,460 minutes or 11,046 x 10 7

8 2.2.3 Utilise skills of Ophthalmology, Pharmacy & Dentistry advisors Promoting Primary Care Careers To establish an Management Team to ensure a delivery structure is in place to address operational demands/barriers in the delivery of plans Increased access to advice and support leads to improved quality and performance for patients Lead Careers Wales Partners Development of video; Communication plan to include promotion via Social Media advertising and schools engagement leads to sustainable Primary Care Barriers impacting on patient care are broken down and efficiencies identified minute appointments. Working on the assumption that a GP provides two 3-hour long surgeries per day [as suggested by the recent paper by Hobbs et. al in the Lancet], this equates to 4.72 GPs working for three months funding agreed All 3 advisor posts appointed to with Dental and Pharmacy advisors in post February 2016 Role and function in supporting workstreams agreed Evaluation expected at 6 and 12 months funding allocated Meeting with Education/Careers Wales Working with Communications Team Film company engaged Script being developed GP cast for video Development of an App to allow access via social media etc Evaluation expected at 6 and 12 months Initial scoping workshop held with key stakeholders to present the context for a Management Team Membership and remit agreed Core Report in development - Data to underpin work programmes to consider inclusion of joint Health & Social Care KPIs Action plan developed Agreed priorities include Flu up-take/smoking Cessation/Obesity/DTOC (contribution) 2.3 Estates 8

9 2.3.1 Early warning for anticipating difficulty with recruitment/filling vacancies in difficulty have access to Primary Care Support Operational Team (PCOST) to ensure continuity of service in the short term To support development of the Care Close To Home Strategy Primary Care Primary Care Divisions Continuity of services; Support against potential Practice fragility Continuity of services; Support against potential Practice fragility Patients receive care in the right place, at the right time, by the right people and are supported to remain at home to receive appropriate care from a multi-disciplinary team, to maximise recovery reporting increased pressures via PDPs Difficulties in retaining and finding new /salaried GPs a growing concern 5 Pan Gwent have raised concerns with the Division regarding their sustainability which may require additional/direct support in the future A sustainability Framework Panel considers all submissions to determine if any additional resource/support is required Presentation given by the Associate Director for Integration and Innovation Scoping exercise undertaken to map the potential for buildings to be utilised/developed and considering community service and housing developments 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 harms 3.1 Mental Health To strengthen integration between GP and Primary Care Mental Health Support Service (PCMHSS) Divisions People have improved access closer to home, to Mental Health specialists GP satisfaction survey carried out October 2015: 125 GP questionnaires returned 28 questionnaires from GPs in Torfaen North & South areas Pan Gwent: 85% of GPs considered communication with the team was very good 13% disagreed Representation at Management Team meetings 9

10 3.3 Health Visiting Continue to build positive relationships between Health Visitors and GP 3.4 District Nursing To improve communication with General Practice Divisions Divisions Improved communication leads to quicker resolution and benefits to patients/carers and families Improved communication leads to quicker resolution and benefits to patients/carers and families On-going dialogue and reporting via meetings Waiting list initiatives undertaken to help meet both PCMHSS targets Single point of access panel being established CAMHS CPN aligned to s in Torfaen and available to PCMHSS//teams for advice and HVs have named contacts within both services to enhance liaison Evidenced via meetings Management Team representative Service remodelling on-going to align with integration agenda and reconfiguration of services at County Hospital Management Team representation 24hr 7 day service implemented 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 4.1 Frailty To improve access and communication with CRT/Frailty/Out Of Hours Service Division Improved communication and co-location leads to better working relationships & care planning Access to records now via Nadex (WCP) on-line patient record system Initial Scoping Assessment Tool developed with option appraisal & links to Clinical Futures Management Team member Improved communication by Rapid Medical assessments/discharge letters available on clinical workstation 10

11 Strategic Aim 5: Improving the delivery of end of life care 5.1 End Of Life Care Review the delivery of End of Life Care using the Individual Case Review Audit Leads Support Virtual integration with District Nursing teams has reduced the repetition of services Increased GP and Hospital referrals Frailty team working collaboratively improving responsiveness and quality for patients/clients & service users Better care received by individuals at End of Life phase Strategic Aim 6: Targeting the prevention and early detection of cancers Discussion held at meeting with learning points from audit findings shared Emerging data and themes to inform locality plan Completed audits used to inform year-end report by Lead Paper presented to relevant Boards within outlining what needs to happen system wide, including 10 lessons in improving patient care. The paper also demonstrates to GP that their work has had an impact. 6.1 Suspected Cancer Review the care of all patients newly diagnosed between 1 January 2015 to 31 December 2016 with lung, Leads All lung, gastrointestinal and ovarian cancer patients will have their referral information reviewed and outpatient Individual case studies presented at meetings identified local areas of concern and good practice Completed audits used to inform year-end report by Lead 11

12 gastrointestinal and ovarian cancer Strategic Aim 7: Minimising the risk of poly-pharmacy 7.1 Poly-pharmacy Identify and record numbers and rates for patients aged 85 years or more receiving 6 or more medications. 7.2 Medicines Management To monitor the prescribing budget and delivery of the Medicines Management plan Leads Pharmacy Prescribing Advisors Support appointments/results followed up Paper presented to relevant Boards within outlining what needs to happen system wide, including 10 lessons in improving patient care. The paper also demonstrates to GP that their work has had an impact Identify patients at high risk or harm of either over or under medicating Efficient use of resources that can be re-invested more appropriately into patient care Strategic Aim 8: Deliver consistent, effective systems of Clinical Governance 8.1 Clinical Governance To fully implement the Clinical Governance Primary Care and Outcome of audit shared at meeting and informs lead summary report Lessons learned shared at meeting leading to improvements for patients Completed audits used to inform year-end report by Lead Scrutiny of prescribing budgets on Practice by Practice basis at all meetings; Individual performance benchmarked against all other s Individual lead meeting held with Divisional Director and Head of Finance Targeted approach with prescribing advisor supporting individual out-lying Consistency and safety in Practice and wide Dedicated CPD session All completed the CG Toolkit 12

13 Toolkit Networks Division Strategic Aim 9: Other Locality issues 9.1 Obesity Tackling obesity (including diabetes) Smoking cessation See Bowel Screening See AWMS primary care services Patients receive timely and appropriate support based on their needs in line with AWMS guidelines Action plan being developed based on Public Health Wales advice Sub-group to take forward and establish clear outcomes with Public Health support Adult Weight Management Service referral and activity data under development Diabetes Consultants aligned to s Consultant advice line open Consultant/DSN telephone advice Management Team Priority: Public Health Making Every Contact Count training undertaken with GPs, Practice & District Nurses; MECC cascade trainer to arrange training for Health Visitors and School Health Nurses Joint stakeholder event between and Torfaen CBC organised with funding to formulate response to Gwent obesity strategy Primary Care diabetes specialist nurses - practice visits mid-august/early Sept 13

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