Neighbourhood Care Networks Newsletter Welcome to the Neighbourhood Care Networks (NCN) Newsletter for ABuHB. This regular newsletter aims to keep you updated about how our NCNs are progressing their plans and working with partners to deliver community based services that meet the needs of the population served. Putting NCN Plans into action what we ve achieved so far... Across Gwent Annual Reports 2016/17 NCNs have finalised and submitted their Annual Reports to Welsh Government. Examples of NCN priorities, work-streams and funded schemes in 2016/17 include: Non-clinical and clinical training for GP Practices Bowel Screening to increase the opportunity for early detection of cancer Online Dementia Roadmap (Wales) Smoking Cessation services and Smoking Cessation Champions in GP Practices Dedicated sessions for End of Life Care, Early detection of Urgent Suspected Cancers and Poly-pharmacy (National Audits) Regular reviews of prescribing budgets, implementing appropriate switches and substitutions where identified Increased access to community based services to reduce demand on GP Practices e.g. Direct Access Physiotherapy, Dietician and complex wound care training. Primary Care Sustainability Workshops The NCN network supported a series of local workshops during February and March, delivered by the Primary Care Operational Support Team, to facilitate an in-depth conversation with GP Practices regarding a sustainable model of Primary Care in Gwent and development of new roles and ways of working. Recruiting for the future of Primary Care NCNs have supported 43 Gwent students wishing to study for a medical degree. Students received a day s training in April regarding the application process, which evaluation identified that 95% of the students would not have taken up the programme if this had not been organised and funded by NCNs. Dr Amanda Head, Torfaen South NCN Lead, led on the project supported by Bev Davies, she said that based on the positive evaluation it is intended to repeat this exercise next year. 30,000 funding has also secured ongoing mentoring with MediPrep (a BMA approved organisation providing medical school application support to Sixth Form students) and used to enable schools to Page1
purchase Health & Social Care related books and resources for their libraries. A further day s training is planned for October, which will focus on interview support. Welcome to Hannah Hutchison, NCN Independent Advisor Community Dental Lead Hannah Hutchison, who joined the team on 2 nd February, is a dentist at the Gateway Dental Practice in Abergavenny and also provides domiciliary dental care in the area. The practice was recently the first NHS dental practice in Wales to become an Employee Owned Trust, which we believe is a great model for sustainability in Primary Care. She is looking forward to building a dental thread into the work of the NCNs. Opportunity to join the Q Community Q is an initiative connecting people who have health and care improvement expertise across the UK. 1000 Lives Improvement, on behalf of NHS Wales, is working with the Health Foundation to recruit people with health and care improvement expertise to join the Q community (https://q.health.org.uk/). The aim is to reach people who aren t necessarily already involved in the quality improvement network in Wales. Q are looking for: those who can demonstrate knowledge and experience of improvement reflect on how they can benefit and contribute to the community Opportunities for people working or volunteering in Wales will be open from 11 May until 12 June 2017. Across Blaenau Gwent Blaenau Gwent NCNs Year in Review In 2016/17, Blaenau Gwent East and West continued the Living Well Living Longer Programme in addition to funding the following posts: Community Dietician Direct Access Physiotherapy Service Lead Nurse Quality Improvement & Clinical Governance Direct Access Physiotherapy The Direct Access Physiotherapy Service, funded by Blaenau Gwent East and West NCNs and based at Ysbyty Aneurin Bevan, has provided assessment for 1,455 patients, which is estimated to increase to approximately 1,650 by the end of the financial year. At present approximately 31 patients per week are accessing the service. The percentage of clinic slots utilised has risen over the past year to an average of 65%. Page2
Across Caerphilly Caerphilly NCNs Year in Review In 2016/17, Caerphilly NCNs have funded: GP Practice Based Pharmacists Primary Care Based Social Workers The Living Well Living Longer Programme was launched in Caerphilly North NCN and the Complex Wound Care Service was funded by Caerphilly South NCN. Across the North... NCN Clinical Lead revealed! Jayne Billington Jayne Billington, who joined out team on 10 th March, has worked as a Practice Manager in the borough of Caerphilly for the last 22 years. She has seen many changes during this time and is looking forward to the next chapter of all the changes that working in Primary Care will bring. Jayne is looking forward to continuing the good relationships that she has with practices in the North NCN and getting to know all of her colleagues, within the wider sector, in order that the highest standard of healthcare is provided to patients within the NCN. Monmouthshire Across the North... Year in Review Across the South... Year in Review In 2016/17, Monmouthshire North NCN funded: GP Practice based Pharmacists Remote working laptops for GPs to allow access to patient records away from the surgery A Dietician post was also funded, which has led to 151% increase in Adult Weight Management Service referrals (compared to 2015/16) and provided a Dietician-led Diabetes Prevention service for people with a BMI >30 and HbA1c of 42-47. In 2016/17, Monmouthshire South NCN funded: GP Practice based Pharmacists The ongoing partnership-led Pulmonary Rehabilitation Programme and team training Severnside Community Engagement ( Social Prescribing ) event Patient call systems in GP Practices Severnside Community Trust Engagement Event Severnside Community Trust hosted a lifestyle event, funded from NCN monies to support the NCN priorities of obesity and community engagement, at Severn View Club in Caldicot on Saturday 28 th January 2017. The public event was attended by Monmouthshire Housing Association, Gwent Drug & Alcohol Services and third sector organisations including Gwent Association of Voluntary Organisations and Age Cymru, included activities and refreshments designed to encourage exercise and healthy diet Page3
including a smoothie making bicycle. A consultation exercise regarding the activities and services that the public consider key to improving Health and Wellbeing was undertaken, of which the preliminary results have highlighted the following areas for action: Promoting good Mental Health (loneliness, accessibility) and Stress Management services within the community Provide more facilities for, and involve, young people in the community Provision of more group activities for young mothers and healthy cooking classes. Alan Davies, Severnside Trust advised We also feel that involving the local schools and young people in general is essential identifying and training Community Champions is one of our identified key next steps. New Practice-based Pharmacists join Monmouthshire South NCN Thomas Willgoss has worked across South Wales as a Community Pharmacist for 8 years. He is looking forward to demonstrating the versatility and value of the Practicebased Pharmacist, building on the achievements displayed in the role by the first cohort of Pharmacists. Emma Carey has spent fifteen years working in Secondary Care as a Clinical Pharmacist. She is excited to be starting work as a Practice Pharmacist in South Monmouthshire NCN and is looking forward to supporting her GP Practices by providing medication reviews and pharmaceutical care. Across Newport Cabinet Secretary Visit Older Persons Pathway Vaughan Gething, Cabinet Secretary for Health, Wellbeing and Sport and Jayne Bryant, Assembly Member visited Bellevue Surgery in Newport on 30 th March 2017 to receive a formal evaluation of the Older Persons Pathway Programme. Utilising funding from Primary Care, Newport NCNs and ICF monies, Aneurin Bevan University Health Board, Newport City Council and Age Cymru have jointly developed an integrated pathway for older people in Newport who are identified as being at risk of admission to institutionalised care and/or becoming frequent users of high cost care. The project aims to: Keep people living safely and independently in their own homes; Avoid unnecessary admission into institutionalised care; Develop effective anticipatory care planning with care wrapped around the individual; Develop a continuum of multi-agency provision, holistically deploying the right resources at the right time; Develop capacity for effective early prevention; Develop outcome focused service provision within communities as an alternative to Primary Care. The initiative uses a locally developed risk stratification tool which identifies those on the GP Practice register who are most at risk of admission to hospital. A Stay Well Plan is developed by a 3 rd Sector Co-ordinator, who visits to assess those identified (if they wish) with the aim of keeping the person safe and well at home and mobilising health, social and wellbeing interventions as appropriate. This is truly an early intervention and prevention initiative, deploying the wider Primary Care Team to wrap around the person and their family and enable good health and wellbeing. Page4
Newport NCNs Year in Review In 2016/17, the 3 Newport NCNs collectively funded the majority of their initiatives, which included: Training for Practice Managers, District Nurses and HCSW A contribution towards the purchase of equipment for GP Practices to support agile working Digital dictation systems have been provided for GPs and secretarial staff IM&T Support and Guidance has been provided from a third party for Practices for a six month period to support consistency across Newport E-Consult Pilot and Ask My GP Pilot to triage patients to the most appropriate service Commissioned additional blocks of Counselling from Newport Community Counselling Service, South Wales Counselling and Psychotherapy (SWCAP) Digital Health Initiative provided by Melin Homes to assist patients to access My Health On-Line (MHOL) and other NHS information on the internet. Across the North... Year in Review In 2016/17, Newport North NCN continued to fund a full time Practice Based Pharmacist and purchased additional Community Pharmacy sessions on an ad-hoc basis to support GP Practices Across the East... Year in Review In 2016/17, Newport East NCN continued to fund a full time Practice Based Pharmacist in addition to purchasing additional Practice Based Pharmacist Support (0.4 WTE). New Practice-based Pharmacist joins Newport East NCN Emma Jones, Newport East s newly appointed Practice-based Pharmacist, has a background in Community Pharmacy. She joined the team in February and is very excited about taking on a more clinical role. Page5
Across the West... Year in Review In 2016/17, Newport West NCN continued to fund a full time Practice-based Pharmacist in addition to: An additional Practice-based Pharmacist (0.6 WTE) Prescribing Physiotherapist pilot in St Brides Surgery Community Connectors promotional materials for patient triage and Social Prescribing NCN Clinical Lead revealed! Sue Thomas: PhD, MSc, RGN, PGCE, PGCert Research, PGDip Therapeutics, Ind. Nurse Prescriber. Sue has worked in the field of primary health care and community nursing for many years, in clinical, leadership, research and university teaching roles, starting in 1987 as one of the first nurses to work in general practice. Until recently, Sue worked for RCN Wales as Primary Care and Independent Sector Adviser, leading and supporting the development of community nursing in Wales. Her PhD research focused on developing a clinical instrument for district nurses to use in assessing complexity of community-based patient needs. This research, undertaken with district nursing colleagues from across Wales, will contribute to all-wales district nursing workforce planning and to the Wales Community Care Information System (WCCIS). Sue s aim for the Newport NCN is to encourage active involvement of all personnel, from all sectors and agencies, who have an interest in and a contribution to improving the health and well-being of people living within the Newport West area. With a background in community nursing, Sue will contribute her expertise to addressing the sustainability and development of the primary care and community nursing workforce, alongside consideration of the needs for the broader primary care and community workforce in Newport. Sue is keen to meet all stakeholders and NCN members and partners at the earliest opportunity, and is looking forward to strong partnership working over the next few years. Across Torfaen Open Access Physiotherapy Service (OAPS) Increasing the availability of physiotherapy in Primary Care can benefit both patients and GPs. Musculoskeletal (MSK) health issues are the most common cause of repeat GP appointments and can account for up to 30% of a GP caseload, higher still among older patients. Around 85% of such cases could be dealt with effectively by a physiotherapist, without any need to see the GP. (Source: http://www.csp.org.uk/professional-union/practice/primary-care) The North & South NCNs have recognised this and agreed to combine funding to support the implementation of an Open Access Physiotherapy Service, expected to run out of Cedar Ward, County Hospital, Torfaen. It is anticipated that the OAPS will be a drop-in/ GP referral service from Spring 2017 and will provide dedicated assessments for people registered with a Torfaen GP. Page6
Across the North... Year in Review In 2016/17, Torfaen North NCN funded: Practice Based Pharmacist GP Practice based Social Prescriber, jointly funded with Torfaen County Borough Council to enable on-going access to a range of information and support relating to health, well-being, housing, benefits and social isolation Brief intervention training for 14 Smoking Cessation Champions and development of the local Smoking Cessation action plan. NCN Clinical Lead revealed! Eryl Smeethe, who joined our team on 10 th March, works in the locality as Prescribing Advisor, her pharmacy career has been varied with a background in the hospital and community sectors. She has worked in Primary Care for almost three years providing Medicines Management services to Torfaen North and South. Eryl is delighted to have been appointed as NCN Lead for Torfaen North and looks forward to helping the NCN develop and deliver high quality services. Eryl Smeethe Across the South... Year in Review In 2016/17, Torfaen South NCN funded: Practice based Pharmacist Social Prescriber, jointly recruited with Torfaen County Council Childhood Obesity Strategy workshop Practice Manager s Forum to share best practice, review protocols and promote consistent work-streams to increase efficiencies and underpin sustainability A DVD promoting career options in Primary Care for use in educational settings Complex Wound Care training was also implemented in all Practices. Page7
What s on? The Gwent-wide NCN meeting schedule for June is shown below. We would be grateful if all members could ensure that representation is provided. Date Time Meeting name Location Thursday 1 June 13:00-15:30 Newport East NCN (M0) Conference Rooms 1-2, HQ Building, St Thursday 1 June 09:00-11:00 Newport Integrated Partnership Board Conference Room 3, HQ Building, St Thursday 8 June Newport Practice Manager's Forum Conference Rooms 1-2, HQ Building, St 09:00-12:00 Thursday 8 June 13:00-15:30 Newport West NCN (M0) Large Boardroom, Victoria House, Newport Thursday 8 June 13:00-15:30 Torfaen South NCN (M0) Bron Afon Housing Association, Brecon Court, Industrial Park, William Brown Close, Cwmbran Tuesday 13 June 14:00-16:30 Monmouthshire Integrated Services Conference Room, County Hall, Usk Partnership Board Wednesday 14 June 13:00-17:00 Torfaen & North Monmouthshire CPD The Parkway Hotel, Ty Coch Lane, Cwmbran Drive, Cwmbran Wednesday 14 June 13:00-15:30 Blaenau Gwent Management Team Blaina Integrated Children s Centre, High Street, Blaina Thursday 15 June 14:00-16:00 Newport Management Team Facilities Meeting Room, Main Hospital, St Cadocs Wednesday 21 June 13:00-15:30 Blaenau Gwent Integrated Partnership Board Meeting Room A, Anvil Court Abertillery Wednesday 28 June 14:00-17:00 NCN Leads Conference Rooms 1-2, HQ Building, St Thursday 29 th June 09:00-11:00 Newport Integrated Partnership Board Conference Room 3, HQ Building, St Page8
About NCNs Area NCN Lead Network Team BLAENAU GWENT EAST Dr. Isolde Shore-Nye Jon Lewis Ian Haywood BLAENAU GWENT WEST Dr. David Minton jonathan.lewis@wales.nhs.uk ian.haywood@wales.nhs.uk Tel: 01495 241276 Tel: 01495 241252 CAERPHILLY NORTH Jayne Billington CAERPHILLY EAST Dr. Stuart Thomas Jon Lewis jonathan.lewis@wales.nhs.uk Stella Montgomery stella.montgomery@wales.nhs.uk CAERPHILLY SOUTH Dr. Alun Edwards Tel: 01495 241276 Tel: 01495 241275 MONMOUTHSHIRE NORTH MONMOUTHSHIRE SOUTH Dr. Brian Harries Dr. Andy Gray Steve McDonagh steve.mcdonagh2@wales.nhs.uk Tel: 01495 241239 Rachel Cook rachel.cook2@wales.nhs.uk Tel: 01495 241221 NEWPORT NORTH Dr. Graeme Yule NEWPORT EAST Will Beer Ian Fido ian.fido@wales.nhs.uk Kate Hopkins kate.hopkins@wales.nhs.uk NEWPORT WEST Susan Thomas Tel: 01495 241287 Tel: 01495 241231 TORFAEN NORTH Eryl Smeethe Steve McDonagh Clair Roper TORFAEN SOUTH Dr. Amanda Head steve.mcdonagh2@wales.nhs.uk Tel: 01495 241239 clair.roper@wales.nhs.uk Tel: 01495 241278 ALL 12 NCNs Hannah Hutchison High Street Dental Practitioners hannah.hutchison@wales.nhs.uk Stephanie Campbell High Street Optometry Practitioners stephanie.campbell@wales.nhs.uk Paul Mayberry High Street Community Pharmacists paul.mayberry@wales.nhs.uk Do you want to share what s happening in your NCN area? To submit an article, please contact your NCN. Page9