South Powys Cluster Plan 2016-17
The Cluster Network Development Domain with the Quality & Outcomes Framework supports medical practices to work collaboratively 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 Plan should be a simple, dynamic document and include: Objectives that can be delivered independently by the Cluster members 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. The Cluster Plan 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. These are as follows:
Strategic Aim 1: To understand the needs of the population served by the Cluster Network 1 Identify and review Clinical Outcomes for GPs and This will be both primary and secondary care within primary care ongoing the Cluster teams Review of primary and Clinical data secondary care clinical outcomes are being outcomes forming base line collected for service data to support any future developments service changes and identify including In house best practice within Acute practices/providers Physiotherapy, Nurse Triage & Active Monitoring Risk stratification for identifying patients most at risk of emergency admissions and or unmet social needs 15 Working closely with Public Health colleagues to fully understand our Cluster population profiles, identify areas of greatest prevalence & ensure service provision is adequate to meet demand EMIS clinical software Cluster and Public Health Software still under development in Wales On going Identification of services which make a difference to a patient s wellbeing/outcome and the review of clinical outcomes for any new services Timely access to the appropriate clinician for care and management of the patient s chronic disease We have established that we currently have the highest prevalence in Powys and are higher than the Wales average in 19 of the disease registers 16 To continue to provide non core GMS services from within the primary care setting by introducing primary care technicians to provide this activity GPs,primary care teams & LHB 31.3.2018 To continue to receive a range of clinical services within the rural primary care setting which are usually provided within secondary care A review of the type of procedures and activity which is currently being provided within primary care is underway across the Cluster
Strategic Aim 2: To ensure the sustainability of core GP services and access arrangements that meet the reasonable needs of local patients completed by 3 Social Enterprise Company to provide a vehicle for sharing resources without any one practice taking all the employment risks, thus enabling future clinical service developments. In order for this to proceed it is imperative that the CIC employees obtain access to the NHS Pension Scheme Practices 31.12.2016 Sustainable services provided within the local community by sharing of clinical expertise sharing cost of some administration functions and expertise therefore supporting the financial viability of rural primary care and branch surgeries where ever feasible opportunity to consider amalgamating health & social care Company has been set up Red Kite Health Solutions CIC Employers liability insurance obtained Bank account set up PAYE registration Employment of 5 staff 4 Nurse Triage to further develop and direct patients to the most appropriate clinician/care provider which is not necessarily always a GP. Total Nurse Triage one practice would like to take forward the concept and provide Total Nurse Triage to ensure appropriate and timely access to a clinician 31.3.2017 Access to the most appropriate clinician to meet their clinical need within an appropriate timescale, thereby ensuring better access for those patients who do clinically need to access a GP Practice Nurses have been trained and are now developing their role and skills within primary care with the ongoing support of the GPs 5 Acute Physiotherapy assessment within primary care throughout South Powys 31.3.2017 Patients usually automatically access a GP when they have back pain and are then subsequently referred to a physiotherapist. Patients should be triaged and directed to a physiotherapist thereby ensuring The acute physiotherapy service is being offered for 2 sessions a week in one practice in
6 Retain GP registrars at the end of training or engage GPs who move into the area even when there isn t a vacancy to safeguard future medical staffing in the area. Provide the different perspectives of a rural GP by working across the 4 practices and the community hospitals and encourage GPs to work in the rural setting Retain all clinical staff wherever possible and encourage others to join our organisation 2 Working with the Third Sector to enhance patient services and deliver appropriate waiting times MIND & Haygarth Practice early treatment/advice and saving a GP appointment. 30.3.2017 Encourage new and retain clinical staff within our cluster to safeguard and support the future of rural general practice and also provide cover for clinical absences to safeguard patient access and GMS sustainability. 30.3.2017 Appropriate and early access to the MIND National Active Monitoring service to ensure patients receive appropriate access to a self help mental health service without having to endure long waiting times to see a counsellor South Powys. Clinical outcomes have demonstrated that 48% of patients who accessed this service were discharged with advice all of these patient contacts would have been a GP consultation if the service had not been available Discussion and agreement at Cluster level in respect of current GP registrars but funding needs to be identified. Commitment with Swansea University to offer bursaries for Physician Associates to train and work within our Cluster Service has commenced and has been welcomed by the patients but currently excludes 16 18 year olds. It is anticipated that the service will be extended shortly to include this age group.
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 4 Nurse Triage to further develop and direct patients to the most appropriate clinician/care provider which is not necessarily always a GP. Total Nurse Triage one practice would like to take forward the concept and provide Total Nurse Triage to ensure appropriate and timely access to a clinician 7 Pharmaceutical support with pharmacists and pharmacy technicians embedded within primary care Practice Nurses have been trained and are now developing their role and skills within primary care with the ongoing support of the GPs 31.3.2017 Access to the most appropriate clinician to meet their clinical need within an appropriate timescale, thereby ensuring better access for those patients who do clinically need to access a GP 31.3.2017 Safe & effective transfer of care of secondary care medication discharges : - to reduce medicines related errors and incidents by appropriate liaison between patient, community pharmacists & GPs - liaison between pharmacist and care home staff - timely review of discharges and coordination with community pharmacies and patients Sharing & co-ordinating best practice and cost effective prescribing across the Cluster As at 30/9/2016 we have 80% of the proposed team of pharmacists and pharmacy technicians in place. The team have started to identify prescribing savings and we have developed templates to record information on medication changes 8 Additional Specialist Nurses to provide clinics and see patients within the surgeries in additional to seeing housebound patients in their own homes Provide pharmaceutical support and advice to patients at the point of prescribing 31.3.2017 Practice nurses and specialist nurses working together within the surgery setting providing a team approach for patients and Specialist Nurse Clinics have recently commenced in the
5 Acute Physiotherapy assessment within primary care throughout South Powys enhancing practice nurse knowledge and skills whilst at the same time providing confidence to the specialist nurses to discharge appropriate patients back into the primary care setting 31.3.2017 Patients usually automatically access a GP when they have back pain and are then subsequently referred to a physiotherapist. Patients should be triaged and directed to a physiotherapist thereby ensuring early treatment/advice and saving a GP appointment. practices The acute physiotherapy service is being offered for 2 sessions a week in one practice in South Powys. Clinical outcomes have demonstrated that 48% of patients who accessed this service were discharged with advice all of these patient contacts would have been a GP consultation if the service had not been available
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 Nurse Triage to further develop and direct patients to the most appropriate clinician/care provider which is not necessarily always a GP. Total Nurse Triage one practice would like to take forward the concept and provide Total Nurse Triage to ensure appropriate and timely access to a clinician 6 Retain GP registrars at the end of training or engage GPs who move into the area even when there isn t a vacancy to safeguard future medical staffing in the area. Provide the different perspectives of a rural GP by working across the 4 practices and the community hospitals and encourage GPs to work in the rural setting Retain all clinical staff wherever possible and encourage others to join our organisation 10 Patient pathway to be identified for patients to attend Prince Charles Hospital s urgent assessment unit Cluster,Cwm Taff provider unit & Powys LHB Practice Nurses have been trained and are now developing their role and skills within primary care with the ongoing support of the GPs 31.3.2017 Access to the most appropriate clinician to meet their clinical need within an appropriate timescale, thereby ensuring better access for those patients who do clinically need to access a GP 30.3.2017 Encourage new and retain clinical staff within our cluster to safeguard and support the future of rural general practice and also provide cover for clinical absences to safeguard patient access and GMS sustainability. 31.3.2017 Patient attends urgent assessment unit for relevant diagnostics. An appropriate treatment plan put in place and patient discharged back to the GP when appropriate Discussion and agreement at Cluster level in respect of current GP registrars but funding needs to be identified. Commitment with Swansea University to offer bursaries for Physician Associates to train and work within our Cluster Pathways have been identified for Pulmonary Embolism, DVT and anaemia Constructive meetings have already taken place with Cwm Taff who are very supportive. Powys LHB &
Provider to draw up contracts for service Strategic Aim 5: Improving the delivery of end of life care Ref. No Objective Key Partners To be completed by 11 Ensure GPs who have a special interest in palliative care are encouraged and supported to obtain additional qualification/education e.g. Diploma In Palliative Care Regular palliative care meetings to ensure all members of the team are aware of terminally ill patients and that records including OOHs are updated accordingly 9 South Powys Cluster have identified a very high number of patients on our palliative care register 0.63% South Powys 0.40% Powys 0.28% Wales To review those patients on the palliative care reg and admitted to hospital as an emergency http://gov.wales.docs/dhss/publiccations/151113endolifereport15en.pdf GPs, Macmillan Care 4 South Powys Practices Expected outcome for patients 31.3.2017 Patients in their last days of life are treated with dignity, their symptoms are well controlled and if they so wish are kept in their own homes with the appropriate support 31.3.2017 Reduce total and emergency admissions in the final year of life Progress to date GP from Ystradgynlais has already commenced diploma and a further GP from Haygarth wishes to enrol Review of Jan to June 16 deaths on the palliative care reg to determine in appropriate emergency admissions and what went wrong RAG
Strategic Aim 6: Targeting the prevention and early detection of cancers 12 Appropriate and timely access to Cluster & 2 nd diagnostics e.g. MRI & CT Care providers Timely receipt of scan result reports to ensure appropriate and timely onward referral is made 10 Patient pathway to be identified for patients to attend Prince Charles Hospital s urgent assessment unit Cluster,Cwm Taff provider unit & Powys LHB Mobile MRI scanner was commissioned and located locally during Spring 2015 and should be repeated during Spring 2017 31.4.2017 Early diagnostics will reduce anxiety for patients particularly those for whom no cancer is detected and an early positive diagnosis will ensure patients are directed into the appropriate care pathway resulting in better expected clinical outcomes 31.3.2017 Patient attends urgent assessment unit for relevant diagnostics. An appropriate treatment plan put in place and patient discharged back to the GP when appropriate Pathways have been identified for Pulmonary Embolism, DVT and anaemia Constructive meetings have already taken place with Cwm Taff who are very supportive. Powys LHB & Provider to draw up contracts for service
Strategic Aim 7: Minimising the risk of poly-pharmacy 7 Pharmaceutical support with pharmacists and pharmacy technicians embedded within primary care As at 30/9/2016 we have 80% of the proposed team of pharmacists and pharmacy technicians in place. The team have started to identify prescribing savings and we have developed templates to record information on medication changes 31.3.2017 Safe & effective transfer of care of secondary care medication discharges : - to reduce medicines related errors and incidents by appropriate liaison between patient, community pharmacists & GPs - liaison between pharmacist and care home staff - timely review of discharges and coordination with community pharmacies and patients Sharing & co-ordinating best practice and cost effective prescribing across the Cluster Provide pharmaceutical support and advice to patients at the point of prescribing Strategic Aim 8: Deliver consistent, effective systems of Clinical Governance 1 Identify and review Clinical Outcomes for GPs and This will be both primary and secondary care within primary care ongoing the Cluster teams Review of primary and Clinical data secondary care clinical outcomes are being outcomes forming base line collected for service data to support any future developments service changes and identify including In house best practice within Acute practices/providers Physiotherapy, Nurse Triage &
Active Monitoring Risk stratification for identifying patients most at risk of emergency admissions and or unmet social needs EMIS clinical software Software still under development in Wales Identification of services which make a difference to a patient s wellbeing/outcome and the review of clinical outcomes for any new services 13 Routinely sharing ideas & best practice within the Cluster and working together in respect of the Clinical Governance Tool Kit GPs and primary care teams This will be ongoing Continually improving the quality of primary care services and ensuring patients are safe and risks are managed Ongoing review of CGTK and sharing of protocols/ procedures Comparison of clinical outcomes will also identify any risks Strategic Aim 9: Other Locality issues 14 Future GP recruitment: Continue to work together with Medical Schools, providing placements for medical students to encourage future recruitment into rural general practice Encourage sufficient GPs to become GP trainers to provide opportunities to GP registrars GPs and Medical Schools GP trainers and VTS Coordinators On going Safeguarding local primary care services within the rural setting Medical students from both Cardiff and Swansea universities are being placed in our practices and GP registrars are choosing to be trained in practices within our Cluster 15 Working closely with Public Health colleagues to fully understand our Cluster population profiles, identify areas of greatest prevalence & ensure service Cluster and Public Health On going Timely access to the appropriate clinician for care and management of the patient s chronic disease We have established that we currently have the highest prevalence
provision is adequate to meet demand in Powys and are higher than the Wales average in 19 of the disease registers Top-5 Priority Actions for the Cluster Ref. No (used to identify the action Objective (replicate the description from where it s used elsewhere in the plan) elsewhere in the plan) 1 16 To continue to provide non-core GMS services from within the primary care setting by introducing primary care technicians to provide this activity 2 6 Retain GP registrars at the end of training or engage GPs who move into the area even when there isn t a vacancy to safeguard future medical staffing in the area. Provide the different perspectives of a rural GP by working across the 4 practices and the community hospitals and encourage GPs to work in the rural setting Retain all clinical staff wherever possible and encourage others to join our organisation 3 4 Nurse Triage to further develop and direct patients to the most appropriate clinician/care provider which is not necessarily always a GP. Total Nurse Triage one practice would like to take forward the concept and provide Total Nurse Triage to ensure appropriate and timely access to a clinician 4 3 Social Enterprise Company to provide a vehicle for sharing resources without any one practice taking all the employment risks, thus enabling future clinical service developments. In order for this to proceed it is imperative that the CIC employees obtain access to the NHS Pension Scheme 5 7 Pharmaceutical support with pharmacists and pharmacy technicians embedded within primary care Ref: 150724 south powys cluster plan template 1516