Monmouthshire South GP Cluster Network Annual Report 2014-15 Our Network: - We are a Network with five main Practices and four branch surgeries; 5 Practices are engaged in training/research, for example: 2 Practices have secured Primary Care Research Incentive Scheme (PiCRIS) Level 1 research funding; IUD (Coil) fitting training undertaken; ST1 ST4s training; Dispensing, Nurse and HCA training; GPWSI Clinical Leadership in research GP; GP researchers and Lecturers at University of Cardiff Our community: - We serve a population of 46,740 in a predominantly rural area with approximately a quarter of the population residing in the two main towns of Chepstow and Caldicot. There are boundaries with England to the East and Newport to the West. Particular features of our population are: Growing older population; Rural isolation; Challenging transport links; Pockets of severe deprivation masked by perception of affluence 1
We looked at the needs of our community : - Our agreed priorities for 2014/15 were:- Prevalence of dementia equates to 0.6% of the registered population, joint 3 rd highest with Blaenau Gwent East. Prevalence of depression equates to 7.8%, 3 rd lowest in Gwent; To achieve a whole system approach to care for people with dementia To develop Chepstow Community Hospital (CCH) as a multi-functional Hub for services and information 45% of adults report drinking alcohol above the recommended guidelines in line with Welsh average; Low birth weight babies of all singleton live births is just under 5%, not significantly different to the Wales average. However, population clusters of Dewstow, Lane, West End and The Elms, Mill and Severn, show a range of low birth weight levels from 4.46% to 5.76%, and 5.76% to 7.06% respectively. 2
What we have achieved : - Highest Flu vaccination up-take in Gwent for over 75 year olds (1.1) 1 Smoking Champion identified; Dementia (3.2): Improved 3 rd Sector engagement and communication with regular themed meetings and action plan developed Chepstow as a hub (9.1): Introduction of a Tele-dermatology Service for local people; Initial scoping for local Pulmonary Rehabilitation Service; Our plans for 2015/16:- Immunisation (Flu) - to develop a communication plan to promote up-take in non-statutory organisations Suggested PCMHSS performance by Suggested To monitor anti-depressant prescribing (2014-15 baseline) to assess impact of PCMHSS in 2015-16) - Suggested Revisit Cross Border Access issues - Suggested Local priority to focus on Partner support e.g. public health focus - Suggested Urgent Care (4.1) establish priorities Suggested Outline paper presentation for developing Chepstow as Integrated Services and Information hub at relevant fora Improved levels of communication across agencies, Primary and Secondary Care and services; Dementia take forward action plan and evolving relationships Suggested On-going 3 rd sector meetings with specific local themes and priorities Dedicated sessions for national audit themes for Polypharmacy, End of Life Care and Early detection of Cancers Cross Border Care Access Group (2.1) Suggested To pursue development of local Pulmonary Rehabilitation service and associated funding Suggested To assess benefits to local population of WG funded Community Pharmacist - Suggested 3
Neighbourhood Care Network Action Plan 2014-15 Monmouthshire South 4
Strategic Aim 1: To understand the needs of the population served by the Network No Objective Key partners 1.1 Immunisations For completion by: - Outcome for patients Progress to Date RAG Rating Patients in at risk groups will be actively encouraged to receive flu vaccination Practices 31.3.15 The goal of 75% immunisation for immunisation against influenza to at risk groups up to the age of 65 is achieved Measure: Up-take in 2012-13 was 60% 2013-14 uptake: 60% (2,094 at-risk patients [40%] did not receive vaccine) 2013-14 target: 785 to attain 75% target (Total 3,626) 3 rd sector workers have identified vulnerable groups and promoted benefits of being vaccinated following discussion with Lead; Regular monitoring via IVOR reports at meetings with novel approached discussed; has highest up-take in Gwent for both target groups: 78% (target met) in 65+age group (All Wales: 68.1%); 59% (target not met) in common with all other s but highest up-take in Gwent (All Wales: 49.4%); Amber Linked to Single Integrated Plan for accessing services 5
1.2 Public Engagement 1.2.1 To support the work carried out through the ENGAGE projects to provide them with the opportunity to have their voices heard in the development and delivery of local services. 1.2.2 Establish evidence based good practice models of communication and engagement 31.3.15 Formal and informal input from engaged, disadvantaged groups demonstrates improved service delivery and patient satisfaction / ABUHB Corporate team Ad Hoc attendance at meetings with contribution to service planning discussions; attended ENGAGE workshop to raise profile of priority workstreams 31.3.15 Evidence base developed 3 rd Sector meeting with Lead and Health & Social Care co-ordinator, which led to on-going quarterly themed events with GP Practices and 3 rd Sector reps; and CRT staff attended and presented at GP Practice patient participation group re waiting list management and the role of the CRT Amber Total number of (Pan Monmouthshire) surveys received at ABUHB Listening Events to-date: 81 analysis to be shared with ; 6
Choose Well leaflet developed to raise awareness of contact details for local health services, to help people get the best treatment in the right place and using health services wisely Strategic Aim 2: To ensure the sustainability of core GP services and access arrangements that meet the reasonable needs of local patients No Objective Key partners 2.1 Access Border practices to clarify data capture requirements and understand service constraints ABUHB Corporate Commissioning Team For completion by: - Outcome for patients Progress to Date RAG Rating 31.3.15 Baseline is established and regular audit shows reduction in patient waits Lead requested specific examples of Cross Border issues affecting patient care e.g. English population unable to access Frailty proposal to create working group to take forward. Amber 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 No Objective Key partners For completion Outcome for patients Progress to Date RAG Rating by: - 3.1 Secondary 7
Care To improve protocols for communication with secondary care to govern the transfer of activity into primary care 3.2 Mental Health Services 3.2.1 Manage referrals to PCMHSS effectively to ensure access is quick for urgent cases Practices / Lead / ABUHB Divisions / ABUHB Divisions / ABCi / PCMHSS 31.3.15 Reduced wasted appointments and improved access; GPs are fully informed of patient history at time of appointment thereby minimising the harm from incomplete or inaccurate information; Baseline established from audit. Further audit shows reduction in inappropriate transfers 31.3.15 Timely response to urgent referrals General Practitioners Committee Wales (GPCW) led audit (October 2014) to identify Secondary Care processes undertaken in Primary Care; Lead with responsibility for analysing outcomes from the audit, reported findings to a Pan Clinical Leads meeting. Outcome of audit presented to ; 53 out of a possible 87 returns Linked to Single Integrated Plan for accessing services; Standing agenda item with demand/capacity headline reporting from PCMHSS co-ordinator; Amber Amber ABCi review/process mapping exercise of PCMHSS undertaken with outcomes to be reported to ; Mental Health working group established to map alternative Pan Monmouthshire referral options; 8
Lead attended Pan Gwent MH Division / liaison meeting with aim to develop standardised data set and agree pathways for common presentations; 3.2.2 Dementia Achieve a whole system approach to care for dementia Identified as a local priority / ABUHB Divisions 31.3.15 Earlier access to diagnosis and care pathway, improved support for carers Review by Lead of returned referral data from S-CAMHS Local Dementia action plan developed; One Practice completed the Primary Care Dementia Toolkit attended by whole extended Primary Care team; Improved communication and relationship with the (CMHT) Dementia co-ordinator with increased training for Practices; Amber Caldicot area dementia service map developed and shared; GAVO Health & Social Care coordinator role building relationships with GP Practices; Extended group meeting with 3 rd Sector organisations involved in 9
3.2.3 Reduce delays with early identification and/diagnosis and improve access to and uptake of Memory Assessment ensuring support is available for carers 3.4 Pulmonary Rehabilitation 3.4.1 Develop local access to Pulmonary Rehabilitation / ABUHB Divisions / ABUHB Divisions 31.3.15 Earlier access to diagnosis and care pathway and improved support for carers dementia care. Raising profile of 3 rd Sector, improving communication and developing network of dementia champions within GP Practices Linked to Single Integrated Plan for accessing services; Regular attendance of dementia coordinator and CMHT Senior Nurse at meetings with improved communication and liaison with GP Practices and support offered/provided as requested 31.3.15 Locally available service Linked to Single Integrated Plan for accessing services; Meetings held with PR teams, chronic disease management nurses and NERS/leisure centre staff to scope business plan; Amber Business case in preparation to deliver local Chepstow service; Aligned to ABUHB 3 year plan (4.2 10
Service Transformation) 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 Urgent Care 4.1.1 To provide high quality, consistent care for patients presenting with urgent care needs ABUHB Divisions For completion by: - Outcome for patients Progress to Date RAG Rating 31.3.15 Baseline established from audit. Further audit shows Less delays in urgent treatment due to improved communication and processes Potential for consistent fast-track approach/pathway for urgent scans - radiology capacity issues not within influence of locality network; Shoulder Masterclass as part of CPD event September 2014; Amber MRI guidelines for patients >45 years with Osteoarthritis; Shoulder scan effectiveness review undertaken; Quarterly (Prudent) radiology performance reporting available to Lead for analysis and circulated to all Practices Strategic Aim 5: Improving the delivery of end of life care 11
No Objective Key partners 5.1 Review the delivery of End of Life Care using the Individual Case Review Audit 5.2 Summarise case review data, and any arising issues and actions identified, for sharing with the network and the wider health board 5.3 Establish a review cycle, to monitor progress (or maintenance of high quality), with further submission of reports to the Leads Practices Support Teams Leads, St David s palliative care team Practices Support Teams Leads Practices Support Teams For completion by: - Outcome for patients Progress to Date RAG Rating 31.3.15 Better care received by individuals at EoL. 31.3.15 Learning through shared experience will inform future care improvements for patients on the EOL pathway. 31.3.15 Improved consistency in standard of care delivered. meeting with Palliative Care Consultant and Specialist Nurse in attendance, to discuss EOLC issues including access to EoL drugs, good practice between Primary and Secondary Care and relationship between professionals, families and carers. Emerging data and themes will inform locality plan 2015-16 Locality reviews discussed at Leads meeting to inform Pan Gwent planning and delivery process 12
and wider health board as appropriate Strategic Aim 6: Targeting the prevention and early detection of cancers No Objective Key partners 6.1 Review the care of all patients newly diagnosed between 1 January 2013 to 31 December 2014 with lung and gastrointestinal cancer 6.2 Learning and actions to be shared with the and the wider LHB Leads Practices Leads Practices For completion by: - Outcome for patients Progress to Date RAG Rating 31.3.15 All lung and gastrointestinal cancer patients will have their referral information reviewed and o/p appointments / results followed up 31.3.15 Audit tool to ensure continuous review, reflection and improvement in processes and care pathways for patients with a diagnosis of cancer. meeting held to discuss individual case studies and to identify local areas of concern and good practice in the Early Detection and Prevention of Cancer Primary Care (Macmillan) facilitator to act as conduit for learning across Primary and Secondary Care; Outcomes fed back to ABUHB Directorates via thematic leads 6.3 Identify and include any relevant actions to be addressed Leads Practices 31.3.15 Improved patient information. Patients preferred place of Anticipated submission date for PDPs 28.6.15 13
in the Practice Development Plan 6.4 Summarise themes and actions for review with the and share information with the LHB as required Leads Practices death. 31.3.15 As above Year-end report Strategic Aim 7: Minimising the risk of poly-pharmacy For completion by: - No Objective Key partners 7.1 Poly-pharmacy Identify and record numbers and rates for patients aged 85 years or more receiving 6 or more medications. 7.1.2 Undertake face to face medication reviews, using Leads/ Prescribing Advisors/ Practices/ Support Team Outcome for patients Progress to Date RAG Rating 31.3.15 Identify patients at high risk or harm of either over or under medicating. Practices 31.3.15 Reduction in unnecessary admissions to hospital. Identification of further untreated conditions. Presentation and advice from Prescribing Lead to support Practices Outcomes to inform planning and delivery process for 2015-16 14
for example, the No Tears approach 7.1.3 Identify any actions to be addressed in the Practice Development Plan 7.2 Medicines Management 7.2.1 To monitor the prescribing budget and delivery of the Medicines Management plan 7.2.2 To review the variation in prescribing compared to national guidance in relation to Diabetes and Respiratory and deliver the savings target Leads/ Practices/ Support Team Prescribing Advisors/ Practices/ Support Team Lead /Practices Other Partners: Primary Care and Networks Division Pharmacy Number of MUR Consultations 31.3.15 Anticipated submission date for PDPs 28.6.15 31.3.15 Efficient use of resources that can be re-invested more appropriately into patient care 31.3.15 As above Minimise avoidable harm from the adverse effects of inhaled steroids Undertaking the minimum appropriate intervention to ensure prudent prescribing aligned with NICE Guidance. meeting agenda item with scrutiny of actual and projected spend against prescribing budget; Prescribing advisor agreed to present factors impacting on budget e.g. increased medicine costs, high cost drugs etc Practice visits by Lead to present COPD dashboard and discuss prescribing issues; Regular updates at meetings by Prescribing Advisors; Prescribing switch options discussed in the round; Pharmacy Technician Practice visits to 15
for these workstreams within the three year plan identify and discuss potential cost efficiencies Strategic Aim 8: Deliver consistent, effective systems of Clinical Governance No Objective Key partners 8.1 Clinical Governance To fully implement the Clinical Governance Toolkit Primary Care and Networks Division / For completion by: - Outcome for patients Progress to Date RAG Rating 31.3.15 Consistency and safety in Practice and wide primary care services Primary Care and Networks Division Clinical Governance Team: Support offered to s and individual Practices; Attendance at CPD sessions; Offer of Practice visits to support completion of toolkit; Topics covered include safeguarding and infection control; Changes to CGSAT in 2015/16 will ensure monitoring and remedial advice can be offered to Practices; All 5 Practices completed 16
Strategic Aim 9: Other Locality issues No Objective Key partners 9.1 Chepstow Hospital 9.1.1 Develop Chepstow Community Hospital (CCH) as a multifunctional Hub for services and information / ISPB / ABUHB Divisions / Corporate Team For completion by: - Outcome for patients Progress to Date RAG Rating 2014-17 Right services in the right place at the right time Draft CCH Hub remodelling paper presented to the Community Transformational Group; Focus group convened to scope Terms of Reference for a CCH Hub Board to be established; CCH Hub management structure to be agreed via the Integrated Services Partnership Board; Amber Local Tele-dermatology clinic established May 2014 which has developed from a monthly 1 session clinic to weekly clinic with 8-10 patients from the local area; Lead sits on ABUHB Community Hospitals Strategic Committee; 17
Developing business case for development of Chepstow Hospital based Pulmonary Rehabilitation service To scope possibility of greater flexibility with bed usage to avoid unnecessary medical admissions to RGH 9.2 Dementia See 3.2.2 18