Annex 3 Cluster Network Action Plan 2016-17 Central Vale Cluster Highlight Park West Quay Waterfront Court Road Vale Family Practice of Health Sully Ravenscourt 1
Foreword This is the third annual Cluster Network plan for the Central Vale cluster of Cardiff and Vale UHB. The cluster comprises eight P practices within Barry, Sully and surrounding areas. Between them, the eight practices meet the primary care health needs of around 65,000. The Cluster Network is led by Dr Anna Kuczynska, who is the Director for the area, and supported by all eight practices. Over this period, there has been a substantial increase in the list sizes of the practices in the area, with Barry and its surrounding villages seeing an increase in house building and associated population inflows. In addition, the complexity of patient needs particularly for older and frail has also seen a marked change. Of paramount importance in cluster planning is how to sustainably continue to cope with increased demands at a time when resources are static at best. The last two years have seen a rise in coordination and cooperation between practices, with significant positive benefits for in the area. However, there are limits to the extent to which cooperation can improve efficiency, and this plan sets out issues that the network feels should be addressed at health board level. Each practice has worked over the last twelve months to fulfil the aims and objectives agreed in 2015. Some aims have been successfully delivered; some have been partly achieved and have been rolled forward; others are considered to be either no longer be achievable or to have been superseded so have been deleted. Finally, the cluster has reviewed the UHB Shaping our future wellbeing strategy to evaluate issues that require action through our combined efforts. Naturally, many of the issues facing the UHB are also of high priority for the cluster. However, the resources available are significantly different, so the cluster has identified its own local needs and priorities accordingly. 2
Central Vale Cluster key priorities Working together for the benefit of Central Vale Practices Tackling Health inequalities and promoting healthy lifestyles Adopting the principles of prudent healthcare Coping with increased patient needs and demands Focussing on key local and national health priorities 3
Strategic Aim 1: Coping with increased patient needs and demands Summary: Nationally, the population is ageing, and with it brings increased morbidity and complexity of treatment. At the other end of the demographic scale are younger people for whom immediate access to consultation or treatment appears to be a normal expectation. Central Vale in common with Cardiff is experiencing significant population growth, with the town expected to grow by 5% over the coming 2-3 years. It is therefore imperative that all practices work to reshape both demand and patient expectations, and divert inappropriate demand to more suitable services such as those provided by the voluntary sector. We will also support the education and training of doctors, nurses and health care assistants, and other professions allied to medicine, to create the next generation of healthcare professionals. Supporting with low/moderate impact mental ill health Self service for appointment bookings Improving health information and self help advice Liaison with UHB Coping with increased patient needs and demands Appointment systems Choose Well promotions Diverting demand to appropriate alternatives 4
Current Position/ Key activities Key partners Lead Outcome for Progress to date Timeline s RA iven expected increase of 7-8% in population in Central Vale, but difficulty in recruitment of Ps due to current workload, radical change is needed in how are looked after Undertake review of access arrangements to identify common themes, barriers to change, etc. Consider best ways of providing for acutely ill Attendance at UHB Frequent Flyers meetings for the Cluster Primary Care Foundation All Practices WAST Cleona Jones Practice of Health Better able to access healthcare when needed and reduced inappropriate demand Better Direction to more appropriate support services including non health Primary Care Foundation work completed M.s Jones continues to attend Frequent Flyers roup By Dec 2016 Ongoing Engagement with Well- Being coordinators and Third Sector partners United Welsh Welsh overnment Dr Anna Kuczynska Sustainable primary care. Right person, Right Place Social Prescribing work started Ongoing Perceived poor support from UHB on current state of general practice, issues faced, and sustainability problems Review current workloads at cluster level, identify common themes, and seek support from UHB sustainability framework UHB RCP in Wales Director Access to care for those who need it most Approach made to primary care support to support practices Recurring A 5
Current Position/ Key activities Key partners Lead Outcome for Progress to date Timeline s RA Ensure UHB is aware of current problems of workload, inappropriate consultations, public expectations PST Improve recruitment and retention issues. Reduce burnout. Sustainable workforce in the cluster Ensure wide awareness of MIND service for with mild / moderate anxiety and depression. Promote to all Ps, and monitor take up levels by each Practice Ensure all materials for referral, candidate etc are distributed to all Ps Ensure outcomes are monitored and reported to cluster / UHB Explore sources for sustainable funding and expansion of the service MIND in Vale PMHSS Director More appropriate and long term support for Rapid assessment Easier access to Ps for other Pilot is underway. Excellent evaluation. Need to explore sources to secure funding. Report on outcomes expected Feb 2017 A Improve coordination with other partners eg Vo council, voluntary sector, DWP to identify more efficient ways of working Consider forum for social care managers, housing managers, voluntary sector leaders and practice managers VO Voluntary sector PMs 3 rd Sector Champions Better overall outcomes Links in place within the cluster Ongoing 6
Strategic Aim 2: Working together for the benefit of Central Vale Summary: We have achieved a significant amount over the last two years, but wish to do more in working collaboratively for the benefit of in the area. This will also help us to provide a more sustainable primary care service in coming years. Sharing ideas, successes and failures Working with other healthcare professionals eg DN, HV, OOH, Ambulance etc Sharing resources eg Cluster pharmacist, smoking cessation Trialling new approaches eg MIND referral pathway Trialling new approaches eg MIND referral pathway Working together for the benefit of Central Vale LES/DES Coordination Improving consistency and commonality of approaches eg prescribing Co-ordinated campaigns eg antibiotic awareness, OTC medication 7 Inter-practice agreements
Current Position/ We will use the resources we currently have and of those we interact with - in a more coordinated and joined up way We will meet routinely with our partner agencies to discuss ways of reducing waste, targeting resources at those who need them most Out of hours service Local ambulance service District nurses Individual practices Cleo Jones POH Frequent Flyers More joined up service delivery Prioritising services for those most in need Progress to date Meetings held with relevant representatives, invited to Cluster meetings or in response to requests Timelines In Place to continue over next 12 months RA A Maternity and health visiting teams We will share resources or bid for additional resources where there is clear mutual benefit We will ask the UHB for funding to continue to use the winter flu nurse, as a good example of working together in a more cost Continue to make best use of cluster funded pharmacist Support each other in bidding for and sharing Enhanced Services funding, cluster funding etc Provide practice rooms, reception facilities, administrative support etc for smoking cessation, counselling and other community services UHB Public Health Wales Services eg PMHSS, United Welsh Cluster pharmacists Nicola ilbert (Waterfront) for flu nurse Higher / more targeted resources Ensure sustainability of Primary Care And succesful schemes Flu nurse has been evaluated and deemed a success. Money likely to become recurring from Cluster funds or from future bids. ongoing Cluster pharmacist - ongoing 8
Current Position/ effective way Continue to support principles of inter-practice agreements for enhanced services or where there is demonstrable expertise Progress to date All Practices PMs Little uptake to date but principle is accepted Timelines RA We will aim to achieve greater consistency of approach eg prescribing patterns, use of NHS resources etc Review prevalence and prescribing patterns to understand common themes and adopt common approaches; specifically targeting, smoking, obesity and diabetes Undertake public awareness campaigns across the cluster eg OTC medication, antibiotic usage Welsh Health Observatory Prescribing Advisors Practice Prescribing Leads United Welsh Wellbeing Coordinators MJ KJ Deborah Rees Consistency of treatment across cluster Better use of resources to target those most in need Resources identified, and implementation progressing through to Autumn 2016 With UHB for final launch and implementation Developed Practice Leaflet Antibiotic Use March 2017 Reduce strokes in Central Vale by targeted review AF and their medication Workshops and virtual clinics with practices and specialist All practices, AF leads, Consultant haematologist and consultant Stroke physician and Public Practice Leads Reduce stroke by 10% roup educational sessions, Audit plus tool, now more targeted sessions in each practice. 3 months 9
Current Position/ Trial new approaches to care, review local pathways, enhance the ability of the voluntary sector to contribute to health and wellbeing Continue the influenza nurse to vaccinate across the cluster who cannot attend surgery Support the trial of MIND Vale of lamorgan in supporting with mild / moderate depression and anxiety Contribute to wellbeing of carers through practice support Practices to identify in good time who will benefit Consider common text for use in letters, SMS messages, etc Health Wales Caroline Chapman MIND in Vale of lamorgan Director Linda Pritchard, VCSVO Public Health Wales Nicola ilbert Director Nicola ilbert Reduced medicalisation of relatively straightforward mental health issues Reduced risk of communicable disease to vulnerable Progress to date Launched to cluster group Referrals from PMHSS commenced Evaluation underway ood use made in 2015 and report on numbers shows repeating would be worthwhile. In place for Flu Season 2016 Timelines For Audit Sept 2016 then consider funding streams for 2017 By Aug 2016 RA 10
Strategic Aim 3: Adopting the principles of prudent healthcare Summary: The Welsh Assembly overnment has adopted 4 key principles for prudent healthcare: patient and professionals working together; care for those with greatest health needs first; do only what is needed; and reduce inappropriate variation through evidence based approaches. The cluster will gradually increase its focus on these issues as more is understood over how to best apply these principles. Supporting with low/moderate impact mental ill health Improving Patient information Improving health information and self help advice Tackling drug misuse Adopting the principles of prudent healthcare Promoting cancer screening and other early detection methods Supporting carers and joining services together Co-ordinated campaigns 11
Current Position/ MyHealth Online to all practices, and other technologies such as automated telephone systems, to improve the ability of to self-serve for appointment bookings and repeat prescription requests Continue to press NWIS / INPS for a solution for multi-site practices Investigate cost / benefit for telephone system introduction NWIS INPS System Suppliers Individual Practices Able to book appointments when practice telephone systems busy / unavailable Progress to date Timelines Meetings with INPS in attempt to progress In place in small number of practices To invite NWIS to future cluster meeting to discuss in 2017 2016/17 Ongoing implementati on RA R ain understanding of workforce issues so that UHB can understand likely changes over coming 5 years. This includes locum availability, training needs etc Undertake age profiling of Ps, nurses other health related staffing UHB Director Better planning of care workforce increases access to healthcare advice Preliminary work undertaken 2014. To be reviewed in Early 2017 as part of skill mix/ workforce reviews with the support of the UHB Primary Care Workforce Manager By January 2017 R 12
Current Position/ Progress to date Timelines RA Explore the potential of the multi-discplinary team Review and report on activities of physio and pharmacist Implement action Physio Pilot over Central Cluster Department of Physiotherapy, UHW Joanne Bell Delyth Jones Dr Anna Kuczynska Improved access to the multidisciplinary team Launch the pliot with regular evaluations throughout Evaluate March 2017 The cluster will explore ways of collaborating to ensure the needs of are met Explore desire to enter into interpractice agreements, collaboration even merger to ensure patient needs met Identify areas where collaboration most likely to lead to mutual gain UHB All practices Director Senior Partners Able to meet broader range of health needs in local area Reduction in referrals to secondary care Some discussions among individual practices 2016-17 ongoing A 13
Current Position/ Continued unnecessary generated work from secondary care - eg requests to send expedite letters, re-referral to another specialism still problematic Continue to send feedback to medical director on inappropriate work being generated in secondary care UHB All Practices More appropriate use of scarce primary care resources Progress to date Timelines Interface process in place agreed with LMC 07/2016 By end 2016 RA 14
Strategic Aim 4: Focussing on key local and national health priorities Summary: The NHS in Wales has identified a number of key priorities that affect all residents, including the early detection and treatment of certain cancers, the harms that can be caused to older people who are on multiple medications, and the ability of at the end of their lives to receive dignified care that accords with their wishes. In addition to these priorities, the cluster has identified a number of local priorities, including the relatively low take up of screening services, the high degree of drug misuse and abuse including antibiotics and opioids, and the ability of local residents to access secondary care services that are relatively remote or difficult to access. Supporting with low/moderate impact mental ill health Review SEAs for all three key national priorities Reduce emergency admissions Focussing on key national and local priorities Promoting cancer screening and other early detection methods Tackling drug misuse Improve referrals to MIND pilot service Co-ordinated campaigns eg antibiotics, OTC medication 15
Current Position/ We will use health promotion activity to educate around safe and effective prescribing of antibiotics We will meet with our partner agencies to discuss ways of reducing antibiotics We will take part in the national education campaign in winter to educate We will use mailshot, prescription attachment, SMS techniques etc to send relevant messages to Health Promotion Wales UHB Partner agencies eg Health Improvement Unit director Dr Louise Jenkins West Quay Chris Williams West Quay Individual practices Better education around the harms of antibiotic usage Long term benefit from reduction in antibiotic resistant illness Progress to date Local leaflet designed Waiting for translation. Date to be fixed as soon as translation confirmed Timelines Autumn 2016 RA A We will remind all prescribers of the need to follow the NICE guidance for common illnesses, and formal prescribing protocols 16
Current Position/ We will review the end-of-life care, polypharmacy, and cancer audits as a whole cluster to identify common themes and barriers to change Improve knowledge of processes surrounding palliative or end of life care, such as knowledge of DNACPR consent, advance care planning, etc. Undertake formal review in year CPET training to discuss how best to improve end of life care, consistency of approach etc Feedback to UHB / WA that current DNACPR process not fit for purpose Marie Curie nurses UHB OOH data providers Cluster Pharmacists Macmillan P leads Communications hub Dr Ceri Donaghy Dr Matt Crouch Kate Jenkins Dr Ceri Donaghy / Macmillan doctors/ New marie-curie nurse Director Improved End of Life Care and Patient Carer experience A better, more dignified end of life care plan Progress to date Cluster review undertaken by single doctor in aim for consistency of approach. Review completed 02/2016. Actions chosen to be replicated 2016-17 Training undertaken Timelines Annual process as national priority Annual RA 17
Current Position/ Undertake awareness and education campaigns to improve take up of common screening procedures such bowel screening, breast screening, AAA screening Identify appropriate education and awareness materials and methods, and target most at-risk patient groups Explore existing resources eg Merthyr mobile bowel screening vehicle All practices Wellbeing Coordinators Waterfront Medical Centre Early diagnoses, leading to better outcomes Progress to date Wellbeing coordinators to go live April targeting key areas with low uptake. Further roll out planned across other central practices in 2016-17 Timelines October 2016 RA Undertake analysis of Cancer Significant Event Audits to identify common themes Priority at Cluster Meeting UHB leads Macmillan Doctors Dr Ceri Donaghy Dr Ceri Donaghy reater chance of detecting cancer early, and better outcomes for diagnosed All practices have completed buy end of March 2017; to be revisited after 6 months Review January 2017 A Host educational services such Stop Smoking Wales, antibiotic awareness, and All practices to either host, or buddy with practices able to host, such services Secondary care providers Director PMs Better focus and improved knowledge leading to better overall care Most practices welcome additional support and 2016-17 A 18
Current Position/ also undertake P awareness such as hosting I learning sessions delivered by secondary care Undertake in-practice learning and invite guest speakers eg I consultants, oncologists Practice managers sharing learning opportunities and lunch / learn Progress to date provide facilities. Further promotion in cluster meetings Timelines RA 19
Strategic Aim 5: Tackling health inequalities and promoting healthy lifestyles Summary: Comparisons of disease prevalence, screening take up, illnesses such as those caused by smoking or unhealthy lifestyle choices, etc reveal that Central Vale has relatively high rates of preventable illness. The challenge is to educate to choose healthier lifestyles, whilst still providing sufficient resources for the treatment of. More can be done to use existing sources of health promotion to tackle the health education gap. Exercise, diet support Promotion of smoking cessation Improving health information and self help advice Tackling health inequalities and promoting healthy lifestyles Screening Services Improved P awareness and compliance Antibiotic awareness week 20 Using existing health promotion services, materials
Current Position/ Improve awareness of appropriate use of antibiotics, including when antibiotics are not appropriate Continue to improve practice websites and other sources of information Acquire practice materials Linked to Dr Louise including leaflets, SMS Strategic Aim 2 Jenkins messages etc to reinforce above key messages Target national / international awareness days to ensure Ensure adequate signposting - Choose Well, OTC medication etc Public Health Wales DEWIS Cymru Cluster Lead Practice Managers Reduced antibiotic resistance, more appropriate treatment including wait and see approaches More appropriate sources of information to reduce demand for appointments / improve access Progress to date Leaflets Developed ready for reproduction to distribute to practices Practices to continue to review Timelines By Nov 2016 March 2017 RA A Wellbeing coordinators have the ability to promote good health, and healthy lifestyles As above in Strategic Aim 2 As above in Strategic Aim 2 United Welsh Director As above in Strategic Aim 2 As above in Strategic Aim 2 For Audit Sept 2016 21