Mid 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 Ref. No Objective Key Partners To be completed by April 2017 Assess the Virtual Ward in relation to unscheduled Care rates in the Mid Cluster and discuss any improvements that can be made within the service. GP Cluster and Unscheduled Care Board Expected outcome for patients Progress to date RAG rating Ensure quality outcomes of relatively new service delivery in the Mid Unscheduled Care rates haven t decreased in the Mid as predicted, although there is some movement. Needs some analysis an further input from Practices as to why that is.lack of social services input is the main issue here. Highlight the need for additional Social work staff to attend Virtual Ward within the Mid Cluster. and Local Authority April 2017 Care packages delivered in a time efficient manner patients receiving support and care at home, reducing risk of falls etc. Addresses the high population of frail and elderly in the Mid Cluster and their care needs. Social Care input on the Virtual ward is sporadic across the patch. Not enough staff members to cover sickness and holidays etc.
Employ a Health & Wellbeing Facilitator for the Mid Powys Cluster to implement Invest in Your Health (self management programme for patients with long term health conditions. Implemented utilising Lifestyle Advise Enhanced Service funding for Cluster. Chronic Pain Management Team to employ individual. This individual will run 6 weekly programmes in Rhayader, Builth, Presteigne, and Knighton. Llandrindod Wells have decided to implement this independently using their health care assistants. Develop and improve the scope of health promotion within the Cluster - MECC training to all staff - Supporting the above initiative Invest in Your Health programmes by actively referring and promoting the service as it becomes available. - Chronic Illness Management Team, Cluster Lead, Individual practices to arrange Dec 2016 Dec 2016 Having a designated employee to deliver this health promotion/self management programme to patients will ensure there is a focus on illness prevention and positive behaviour change. GP s and nurses, and other health professionals can refer patients to the service. Their workload may be decrease and therefore capacity may increase over time due to an increase in better self management of chronic illnesses with less demand. Better health outcomes. Improve health and well being of the population. Improve provision of information supporting healthy lifestyle choices. Cluster agreed to implement. Job Description approved. Banding approved. Currently awaiting approval from Finance. 3 out of 5 Practices currently have received the MECC training
Utilise current health intelligence available from local Public Health Powys team within the PDP s and current cluster Plan. Follow up meeting with PHW to go over the data again and discuss Primary care measures NWIS demonstration of information portal. Utilise patient data sets now available to Practices to inform on Unscheduled Care, High Cost Users etc. Increase Information sharing ability implementation of electronic referrals and discharges within Wales and cross border. Link all 5 EMIS systems in the Mid, and Llandrindod and Knighton hospitals. Develop relevant protocols to enable sharing of patient information Individual Practices support PHW GP Cluster lead NWIS Individual Practices support ` NWIS WVT support NWIS support Cluster Ongoing Dec 2016 Oct 2016 Ongoing Review situation end of 2016 July 2017 Ensuring an informed approach to planning patient services and identification of need. Supporting Practices to produce robust practice development plans based on current information pertinent to their Cluster and Practice. As above Assured timely decision making, well informed medical interventions and quality clinical outcomes With the prospect of health professionals being employed to support the Cluster practices, there may be a need to access patient information from different sites, eg triage work or medicines GP Practices have been in receipt of huge amounts of data question for Clusters is how to make effective use of this information? Cluster able to indentify specialties that dominate Unscheduled care respiratory, cardiac, WVT aim to address this Nov 2016 Initial enquiries have been made to NWIS who have supported this happening in the South
reconciliation. If health professionals are working within the community hospitals, access to patient s GP records would also be advantageous and improve clinical governance. Cluster. Strategic Aim 2: To ensure the sustainability of core GP services and access arrangements that meet the reasonable needs of local patients Ref. No Objective Key Partners To be completed by Utilising the Cluster Fund this year in the following ways to identify areas that can ensure sustainability within the 5 Practices. 1. Develop a model of nurse triage service delivery for the Mid Practices 2. Support Practices in training staff to ensure they are appropriately skilled in telephone triage. members Cluster Lead GP Cluster Leads Practice managers Other Primary healthcare Professionals as required. September 2016 Expected outcome for patients Urgent requests to see a GP/nurse the same day are assessed and dealt with in a safe and timely manner, with patient needs met. Patients access to the appropriate health care professional, or signposting to the appropriate service in the community is achieved. Progress to date Each Practice has different approach to triage, and therefore a collaborative approach is difficult. More discussion needed. RAG rating 3. Develop a model for pharmacist/technician Medicines Management team September- December A small team of Pharmacists to be Under discussion
employment within Practices to support GPs. Work can be around medicines reconciliation on discharge from secondary care, medication reviews, minor illness clinics, medication queries, the list is nonexhaustive and will ddepend on the skills of the individual employed and on the GP Practices needs. Cluster 2016 employed to circulate around the Mid Practices, providing face to face patient support in the form of minor illness clinics, medication reviews and discharge medication reconciliation. Other roles may develop 3. Source and implement call handling training for reception staff in the Cluster 4. Participation in the Physician Associates training programme support/cluster Lead Llandrindod, Presteigne and Rhayader Practices. Andrew Powell Dec 2016 Oct 2016 To support staff who have the initial patient contact, in confidently assessing patient need, and signposting appropriately. Training will enable staff to confidently inform patients of their options for receiving healthcare, and manage access patients will have their needs met by appropriate health professional. Shropdoc to provide training One day Date to be decided
Support a P. A in their training and subsequently receive some work commitment from the individual in the future. Adding another alternative health professional to the primary care teams in the Practices. By supporting this student we are supporting an emerging new role in General Practice, which addresses sustainability issues in primary care and encourages a mixed skill base of health professionals Addressing sustainability issues in our Practices and exploring new ways of working. Meeting being set up in September planning to commence. Practices to independently review demand and capacity and look at options for support from the Cluster as Cluster develops Each Practice April 2017 Good timely access to services. Engagement with Practice on patient Relates to triage development, call handling, multidisciplinary approach
Practices to review effectiveness of the WebGP project and share with Cluster Regular review of vacancies in secondary care services at Care Planning Meetings. Also highlight capacity issues in some specialties and discuss options for patient pathway to be redirected to ensure timely care. Address continuing issues with long wait lists for patients referred to Primary care Mental health counsellors. Escalate to executive team for awareness Builth, Presteigne to collate some data and report back to Cluster/locality. Commissioning team/locality/cluster Cluster lead Manager of Mental Health PtHB support Dec 2016 Regular Agenda item Nov 2016 needs Continue delivery of virtual GP service to the Mid to Jan 2017 Provision of an alternative service for patients, ensuring patients see appropriate health professional, encouraging self management behaviours in our patient populations. Maintains flow of information between Gps and. Gps can adjust referral pathways as advised/as required to optimise efficient patient pathways within specialties. Faster referral rates, more timely assessment and treatment. need to consult patient group? Some Practices benefitting more than others it s acknowledged that changing the culture of how patients access healthcare takes time, and promotion is key. Some communication between Operational manager for MH and Cluster Lead and a plan to meet.
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 Ref. No Objective Key Partners To be completed by Dec 2016 Development of Frailty care Pathway Development of Respiratory care patient pathway - Look at specific role of the Specialist Nurses Review Diabetes Pathway work and develop links with the Powys GP Cluster/ and wider membership of Cluster including Social services. Expected outcome for patients Progress to date RAG rating Development of better integrated services for patients identified as frail ie those patients who (often elderly) have complex health and social care needs Frailty needs agreed definition across the Cluster. Reduction in unscheduled care rates. As above May 2017 A more streamlined service for those patients with respiratory illness, with an emphasis on care planning, patient collaboration and prevention. Reduction in unscheduled care rates. Cluster DDGroup June 2017 Ensure the Cluster is up to date with any First workshop planned October 6 th. First Workshop February 2017
Diabetes Deliver Group Remain informed re the patient education programmes promised to return to Powys. Develop a strategy for dealing with non GMS work carried out currently in medical practices eg phlebotomy services, spirometry without funding. Diabetes Clinical Lead Diabetes Lead Gp Cluster, Primary Care Dept, ongoing Waiting on outcomes of the new GMS contract. developments Powys wide, so that patients can benefit from any changes in service provision eg the patient education programmes and delivery of. Assurance for patients that certain aspects of their care will continue within primary care and the community close to home Been put on hold waiting for direction from WG and their position on non GMS work. 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 Ref. No Objective Key Partners To be completed by Development of the DVT patient pathway and protocol along with an enhanced service specification. - Cluster wide project use of D-Dimer kits to aid diagnosis and avoid unnecessary travel to DGH - Possible link to management of anticoagulation treatment (NOAC s, INR LES s) Gp Cluster, primary care department, December 2016 Expected outcome for patients Progress to date RAG rating A more informed and uniform approach to diagnosis of dvt s will result in less patients being sent in to DGH for scan s due to implementation of D-Dimer kits when risk is assessed as low. Also better planned care of anticoagulation treatment long term. Protocol and pathway written and LES specification also written needs more discussion at Cluster and with. Review of the Virtual Ward/CRT GP November Continued support from Practices report
enhanced service as a Cluster discuss changes/improvements that are needed going forward. Continue to assess unscheduled care rates and look for areas where patient care can reduce rates of emergency admissions. Rescue Packs for COPD pts explore option of rolling this out in the Mid. Cluster/ 2016 Gp Lead / Cluster/ support. Unscheduled care board Ongoing the MDT in the community of frail patients and those with complex needs. Decrease in emergency admissions? A more co-ordinated approach to discharge into the community More integration of care between health and social care professionals. Better care planning for patients around their conditions. Look to higher risk patients and their relative conditions. that the service is beneficial for patients and a better model of working for professionals, however more input is needed from Social Services Team Strategic Aim 5: Improving the delivery of end of life care Ref. No Objective Key Partners To be completed by GP Cluster Discuss Last days of Life Pathway- when is best time to place patients on the pathway? June 30 th 2016 Expected outcome for patients A more co-ordinated approach to end of life care. Progress to date Discussed agreed the pathway is better used for those patients on a longer RAG rating
phase of decline. Virtual Ward useful for discussion of patients on pathway. Just in Case boxes do they have a standardised list of drugs? Needs clarification Invite Medicines Management to a Cluster meeting to discuss. DNACPR forms still seems to be a lack of understanding re the forms esp in care homes Completion of End of Life Care Audit for third year and discuss at Cluster. Med Management/ Gp Cluster Protected Learning Time planners/ Individual Practices/Cluster/ Dec 2016 Dec 2016 Jan/Feb 2017 Clarification of supports in place for palliative care patients in the community. Education and support so that patient care isn t compromised. Improved service No action as yet. No action as yet. Due to be completed Jan 17 Strategic Aim 6: Targeting the prevention and early detection of cancers Ref. No Objective Key Partners To be completed by Risk factorssmoking/obesity/alcohol intake in patients address strategy to address with patients MECC training (as above) Expected outcome for patients Progress to date RAG rating
Highlight delays in diagnostics/investigations outside of 2ww system. Long waits for MRI/Ultrasound scanning can compromise patient outcomes. Poor communication between specialties, with GPs being used as a conduit to re-refer patients causes delay in diagnosis. Patients with haemoptysis cluster to carry out a peer review on management of. Cluster//Commissioning Ongoing Commissioning Department WVT and other Secondary providers. GP Cluster March 2017 Better service, shorter wait times. Reduced wait times for consultant appointments. A more direct pathway. Development of a pathway for this symptom. These issues are on agenda every Cluster meeting. Strategies to alleviate wait times are difficult due to lack of trained staff. Need to provide specific examples to Com Dept, for them to highlight to WVT etc. Feedback to All Wales Cancer Group In work plan Strategic Aim 7: Minimising the risk of poly-pharmacy Ref. No Objective Key Partners To be Expected outcome for patients Progress to date RAG completed by rating Look at/assess/consider the role of GPs Dec 2016 Regular medication To be decided
pharmacist in carrying out polypharmacy reviews for Practices. Pharmacists in post (pending) reviews carried out by appropriate clinicians High use of PPI s in Practices peer review and plan for a way forward if this is seen as something to target, Repeat prescribing protocols in Practices peer review Possibly wastage occurring? Making prescriptions as simple as possible for elderly patients and their carers GPs/med management support GPs/med management support Each Practice Med management support in practice. April 2017 June 2017 Jan 2017 Opportunity to discuss best practice better management of patients As above Less wastage in system Patients better informed Better understanding of medicines prescribed when / how much to take etc. To be decided. To be decided. To be decided. Strategic Aim 8: Deliver consistent, effective systems of Clinical Governance Ref. No Objective Key Partners To be completed by Increase Information sharing ability implementation of electronic referrals and discharges within Wales and cross border. ` NWIS WVT support NWIS support Cluster Review situation end of 2016 Expected outcome for patients Progress to date RAG rating Assured timely decision making, well informed medical interventions and quality clinical outcomes WVT aim to address this Nov 2016 Link all 5 EMIS systems in the Mid, Gp Cluster July 2017 With the prospect of health ICT have been
and Llandrindod and Kinghton hospitals Develop relevant protocols to enable sharing of patient information Completion of Clinical Governance Toolkits in the Cluster and discussion of learning points. Completion of Practice Development Plans 2016 GP Cluster Practice Managers Cluster Lead Dec 2016 professionals being employed to support the Cluster practices, there may be a need to access patient information from different sites, eg triage work or medicines reconciliation. If health professionals are working within the community hospitals, access to patient s GP records would also be advantageous and improve clinical governance. Good clinical governance measures at Practice level ensured Practices July 2016 Review and development of services at practice level feeding into Cluster meetings and then on to as needed. asked to advise. Similar has been achieved in the South Cluster Will arrange a meeting to discuss. All 5 Practices completed. Outcomes have informed the Cluster Plan. Strategic Aim 9: Other issues Ref. No Objective Key Partners To be completed by Ongoing Consultant Elderly care cover of GP beds at Llandrindod Hospital. Primary care Directorate Expected outcome for patients Progress to date RAG rating Continuation of Elderly Care Beds at Llandrindod Meeting Sept 22 nd to discuss
Consultant post will be unfilled as of Jan 2017. Advertisement to be circulated. Some discussion amongst practices around other models of care provision possibly GP led with remote consultant support. GPs Hospital. with GPsalternative models of care. Top-5 Priority Actions for the Cluster Ref. No (used to identify the action elsewhere in the plan) 1 Develop and Implement a Pharmacist Support Team for the Mid Powys Cluster 2 Review Web GP service implemented last year. 3 Ensure Sustainability and viability of Practices through:- Supporting Practices to provide staff with training to enhance skills within the primary Objective (replicate the description from where it s used elsewhere in the plan) Develop a model for pharmacist/technician employment within Practices to support GPs. Work can be around medicines reconciliation on discharge from secondary care, medication reviews, minor illness clinics, medication queries, the list is non-exhaustive and will depend on the skills of the individual employed and on the GP Practices needs. Need to review the uptake of the service and it s effectiveness in supporting Practices struggling with capacity issues. It s effectiveness as a triage service also. Effective triage of calls, ensuring patient is seen by appropriate clinician only do what only you can do principle. Ensuring access is timely and efficient. Ensure Cluster development funds support Practices to support staff with their training needs, and supporting a multi-disciplinary approach to services
care team, including call handling training for reception staff Development of a nurse triage model for implementation across the Cluster (where wanted) to relieve pressures on same day access and the knock effects. 4 Development of patient pathways DVT management protocol Frailty Respiratory Diabetes 5 Continue to review enhanced services contracts and develop where appropriate. Within this look at non GMS work and work with LHB to address services currently provided within general Practice without funding. Acknowledgement of vulnerable Practices and the implementation of practical support utilising the Cluster Development fund to implement change where needed to provide stability Ensure safe, co-ordinated patient care pathways, focussing on allowing patients to receive healthcare at primary and community level where possible. Attempting to integrate care across health and social care services with increase partnership working. Ensure Practices are supported to continue to provide patient services within primary care with consultation between LHB and Cluster. With recognition of vulnerability of some Practices Ref: 150724 mid powys cluster plan template 1516