Torfaen North Neighbourhood Care Network Action Plan

Torfaen North Neighbourhood Care Network Action Plan 2015-16 1

Torfaen North Draft Action Plan 2015-16 Strategic Aim 1: To understand the needs of the population served by the Network No Objective Agreed Actions Outcomes Key 1.1 Smoking 1.1.1 Smokers in the NCN PH/SSW area quit smoking (SEE NCN APPENDIX 1 ACTION Third Sector PLAN) Social Services Retained as a local priority 2015-16 agreed 16.07.15 Links to Communities First Healthy Lifestyles project Links to MIND you in mind project for young people Build on 2014/15 Review data on uptake of services and quit rates at NCN meetings including with non-medical members Recovery plan if progress Increase number of Smoking Champions Number of smokers is reduced in line with target i.e. 5% of smokers make quit attempt with at least 40% CO validation quit rate at 4 weeks Progress/ 31.3.16 Torfaen action plan developed ABUHB R&D poster developed Networks team working with PHW to secure current data issues with SSW data systems redesign leading to delays Management Team Priority Highest number of smoking champions in Pan NCN area Highest referral rate to SSW in Pan NCN area 1.2 Engagement 1.2.1 NEW: Identify a range of methods to increase awareness of the work of the NCN & Links to Torfaen SIP Map options Continue to up-date ABUHB intranet page To support development of a public facing web-page To support the work of the ABUHB engagement team in implementing the engagement strategy To attend at least two listening events in 2015-16 Feedback analysis leads to evidence to inform improved service delivery with increased patient satisfaction NCN / TVA / Communities First / Bron Afon Housing 31.3.16 Identified as a shared outcome in the Torfaen SIP Links made with ABUHB Engagement Team to identify Torfaen specific events Strategic Aim 2: To ensure the sustainability of core GP services and access arrangements that meet the reasonable needs of local patients No Objective Agreed Actions Outcomes Key Progress/ 2.1 Access 2.1.1 Identify and share good practice across GP Map which strategies have been adopted to reduce Maximise use of appointment slots to 2 NCN / 31.3.16 Gwent wide access SCP for 2015-16

to reduce DNA reduce wasted time AMD / NCN rates within leads / LMC Adopted as a local priority 2015-16 agreed 16.07.15 DNAs Use PDP reports (28.11.14 embedded) as a baseline Engage non-clinical members Progress/ Cluster Level Report - Measure 44 - GP DN 2.1.2 NEW: Contracted Services: To engage with and utilise skills of other Primary Care services i.e. Optometrists, Pharmacists & Dentists NCN funding to facilitate recruitment Contractors act as advisors to NCNs with communication plan established Increased communication leads to improved understanding of Primary Care issues AMD / NCN / CDs / NCN leads 31.3.16 Funding agreed to support this Scope of contribution to be discussed/agreed All Gwent NCN Independent Contrac All 3 posts appointed to 2.1.3 NEW: Social Prescribing post to increase access to information relating to health conditions through dedicated role Links to Communities First Healthy Lifestyles project Change Plan No. 5 Appoint Social Prescriber to signpost people to local services Develop and implement referral mechanism into community services; To map range of services promoting mental wellbeing and good health across Third and Public Sector - facilitate web based database; Identify priorities for people based on referral information and individual circumstances; Feed-back progress to the NCN; Develop promotional materials; Implement effective monitoring systems to evaluate project progress Evidence shows increased access to information / advice & support leads to improved well-being 3 NCN / Communities First / Public Health 31.3.16 Slippage funding agreed at NCN to develop Social Prescribing role Public Health Wales coproduction lead presentation at NCN meeting Linked to Bridging The Gap : Bridging The Gap - May 2011.pdf Post appointed to with project group established

2.1.4 NEW: Dementia Implement and promote Number of dementia NCN / Phil Roadmap: To raise Dementia Roadmap friends / number of Diamond awareness of completed DFC lead information available in Dementia Friend training is WAMHS training relation to accessing made available dementia care support /4/5 2.1.5 NEW: To build communication links between Education and Primary Care 2.1.6 NEW: Early warning for anticipating difficulty with recruitment/filling vacancies To liaise with Torfaen CBC Team Around the Family (TAF)/Families First programme to scope issues and develop an action plan to inform NCN verbally/in writing if having or anticipating difficulty Agree to meet with the NCN lead to discuss next steps Improved access to Primary Care/Community services for CYP in full time Education Continuity of services; Support against potential Practice fragility NCN Lead / TCBC / Partnership Manager / NCN AMD / NCN lead Progress/ 31.3.16 0.24 million for national dementia nurse led programme to train care home staff and respond better to their needs and ensure their diagnosis is recorded on GP registers NCN funding allocated to support implementation of an on-line dementia Roadmap steering group in place 31.03.16 NCN agreed to adopt this as a objective / NCN lead liaising with Divisional Partnership Manager / TCBC Education lead To be considered by LMC 31.3.16 Strengthening General Practice_ Act QOF 2.1.7 NEW: in difficulty have access to NCN salaried support team to ensure continuity of service in the short term As above Continuity of services Support against potential Practice fragility As above 31.3.16 2015 plan for primary care.pdf QOF /Primary Care Plan 2.1.8 NEW: Monitor the continuation and uptake of My Health Online All practices to offer appointment availability and repeat prescription ordering via MHOL Ease of access to GP services NCN / Pharmacy Advisors 31.03.16 Clinical Director appointed as lead with NCN support 4

2.2 Workforce 2.2.1 NEW: Training: Practice NCN / staff can access timely, ABUHB / relevant training Establish a Divisional/NCN Task & Finish group training plan developed Develop a process for Practice staff to access training Training providers and costs are identified are informed of training options and criteria Quality of care / skilled workforce enables sharing of ideas/skills and good practice Progress/ 31.3.16 Process in place via proposal applications 1.1m allocated to NCNs: Training options considered from slippage funds year on year T&F group established 2.2.2 NEW: Increase access to primary care based Phlebotomy service Implement local service closer to home and in care homes Increase access to phlebotomy service for house bound population Increased capacity within/ access to District Nursing service NCN / ABUHB Divisions / District Nursing service 31.3.16 4.4m funding approved for new Phlebotomy service (WAO report on district nursing indicates that 30% of community nursing time could be released, for example to manage LTCs, if no longer required to take blood) 2.2.3 NEW: Ensure local support structure is fit for purpose to meet demands of strategic NCN development Implement a NCN/Integrated Management Team Agree local framework / membership to underpin strategic NCN development Terms of reference developed and ensure all members/ have equal standing in decision making process Improved guidance, coordination and development to meet the needs of the local population NCN lead / HoPN / PC&ND / ISPB / NCN 31.3.16 Workshop held with key stakeholders to agree membership of Management Group, remit, immediate action required and next steps Action Plan developed 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 harm 5

3.1 Mental Health 3.1.1 To improve integration at Practice level between Primary Care (PCMHSS) Links to Torfaen SIP Links to Communities First Healthy Lifestyles project NEW: To receive regular performance reports to include referral data specific to North Torfaen, and to identify action required across NCN & Evidence shows services collaborate to ensure timely access to support NCN PCMHSS / MH Division Progress/ 31.3.16 Representation at Management Team meetings On-going dialogue and reporting via NCN meetings GAVO Mental Health Service Directory for G Links to MIND you in mind project for young people 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 Agreed actions Outcomes Key 4.1 Urgent Access 4.1.1 REVISED: To maximise utilisation of alternative avenues for advice adopting prudent healthcare principles To identify other sources for advice e.g. email / telephone (inc mobile access & new 111 service for urgent advice) To record secondary care email advice incidents CPD session on reducing referrals for inappropriate diagnostic tests Data shows reduction in reliance upon multiagency services; Contributes to reduced waiting times for secondary care services 6 PC&ND, ABUHB Radiology and USC Divisions Progress/ 31.3.16 Improving referral quality and maximising utilisation of alternative avenues for advice: Rheumatology/Cardiology telephone and email advice routes; Impact of Teledermatology service with reduction in secondary care waiting times; SEPSIS 6 guidelines adopted; Review of GP urgent referral letters Strategic Aim 5: Improving the delivery of end of life care [EOLC] (National Priority to be discussed locally) No Objective Agreed Actions Outcomes Key 5.1.1 Review delivery of EOLC using Individual Case NCN to support to review audit of patients Audit outcome leads to improved care during End NCN Leads /

Review Audit who have died to be of Life phase NCN Support reflected upon/inform future care delivery Change 5.1.2 Summarise case review data, and any arising issues and actions identified, for sharing with the network and the wider health board Highlight best practice for improvement to be highlighted and shared in a multi-professional discussion Learning through shared experience will inform improvements for patients on the EOL pathway NCN Leads / St Davids / NCN Support Change 5.1.3 Establish a review cycle, to monitor progress (or maintenance of high quality), report to NCN and wider health board as appropriate Change Agreement of best practice in EOLC. Identification and monitoring of areas for improvement so that appropriate education and support can be delivered Improved consistency in standard of care delivered NCN Leads / NCN Support August 2015: Audit outcomes reported to GP Macmillan co-ordinator with learning points included in the Palliative care Delivery Plan. 5.1.4 NEW: Themes identified by audits lead to agreed action Change NCN to discuss +/- use of EOLC template for all patients who enter terminal stage of illness, not just those with cancer; NCN to discuss READ Code training for Practice staff to improve recording of diagnostic symptoms; Develop patient recording protocols for Care Homes, by using the Integrated Care Pathway framework, to ensure patient record consistency; identify carers and record when patients are first diagnosed / placed on the register Improved consistency in standard of care delivered. NCN Lead HoPN 7

Ensure Carer s Packs are available at all GP ; To map/ensure access to interpreter services for patients whose first language is not English; Improve communication with OOH Services re Special Notes and use of Adastra to provide up todate patient records. Strategic Aim 6: Targeting the prevention and early detection of cancers (National Priority) No Objective Agreed Actions Outcomes Key 6.1.1 Review care of all patients newly diagnosed between 1 January 2015 to 31 December 2015 with lung, gastrointestinal & ovarian cancer Change Audit tool Patient referral information reviewed and Outpatient appointments / results followed up NCN / NCN Leads / NICE issued: Suspected Cancer recognition and Referral NG12 (June 2015) GI Consultant attended NCN to discuss learning points and solutions impact of new NICE = WLIs / Weekend & evening clinics 6.1.2 Learning and actions to be shared with NCN and the wider health board as appropriate Change complete audit and discuss findings Audit tool ensures continuous review, reflection & improvement in processes/ care pathways for cancer patients NCN / NCN Leads / 6.1.3 Identify and include relevant actions to be addressed in Practice Development Plans Change Practice by practice NCN USC cancer data will be collated to provide better informed demographic data relating to cancers on a regular basis Improved patient information/ Patient choice & preferred place of death NCN / NCN Leads / 8

6.1.4 Summarise themes and NCNs to share learning As above NCN / NCN actions for review with with secondary care Leads / NCN / share information with wider health board as appropriate Change 6.1.5 NEW: Themes identified by audits lead to agreed action Change Develop protocol to refer patients as USC if cancer suspected with Practice based referral tracking system; encourage patients to attend Bowel Screening Programme; GPs are informed by Secondary Care Consultants when referrals are re-prioritised; Patients who DNA are contacted Improved patient information Appropriate treatment pathway initiated PC&ND / AMD / ABUHB Divisions / NCN lead / NCN Strategic Aim 7: Minimising the risk of poly-pharmacy (National Priority to be discussed locally and also Medicines Management) No Objective Agreed Actions Outcomes Key 7.1 Poly-pharmacy 7.1.1 Identify and record numbers and rates for patients aged 85 years or more receiving 6 or more medications Change Plan No. 3 Using audit +, a review of practice clinical systems to identify ( at-risk only) patients over the age of 85yrs in receipt of 6 or more medicines. NEW: Consider extending the audit age range to include lower starting age Identify patients at high risk or harm of either over/ under medicating NCN Leads 9

7.1.2 Undertake face to face Using data from the review audit NCN Leads / medication reviews, book appointments for using e.g. No Tears medication reviews of patients NCN Support approach over the age of 85yrs receiving 6 or more medicines Reduced avoidable admissions; Identification of untreated condition(s); Number of MUR Consultations 7.1.3 Identify any actions to be addressed in Practice Development Plans Change Plan No. 3 7.2 Medicines Management Poly-pharmacy at NCN meetings As above NCN / Prescribing Quarterly information to NCN on utilisation of notional budget advisors / NCN Support 7.2.1 NEW: Recruit Primary Care based Pharmacist from NCN funding to integrate with GP, NCN and Change Plan No. 3 Initiate recruitment process Summer 2015 Induct Pharmacists into GP Integration and outcomes measured/ monitored via NCN meetings NCN Pharmacists project team developing a suite of priorities & outcomes; Patients and professionals have access to a named Pharmacist in Primary Care NCN leads/ncn/p C&ND Post appointed to July/August 2015 Integration and outcomes measured/ monitored via NCN meetings Identify opportunities for Pharmacists to further develop appropriate skills Funding allocated from NCN budget 7.2.2 To monitor the NCN prescribing budget and delivery of the Medicines Management plan Change Plan No. 3 To receive regular prescribing information (at NCN meetings) Budget performance and delivery of the savings plan National Indicators / Clinical Effectiveness Prescribing Programme Pharmacy and NCN Leads to meet and decide on priorities for NCNs to achieve in terms of service improvement, costs and quality Efficient use of resources leads to re-investment & more appropriate care NCN Lead / Prescribing lead / 10

Change Plan No. 3 NCNs to work with Primary Care and Networks Division Pharmacy staff to: Arrange scheduled visits by the NCN Lead to discuss Dashboards and Practice performance; Monitor performance change through actual prescribing spend on high dose corticosteroids and diabetes drugs; Identify prescribing leads rep and identify progress against the SCEP; Prescribing guidance to be developed by Pharmacy Team Undertake minimum appropriate intervention to ensure prudent prescribing aligned with NICE Guidance Strategic Aim 8: Delivery consistent, effective systems of Clinical Governance No Objective Agreed actions Outcomes Key 8 Clinical Governance 8.1 To fully implement the Clinical Governance Toolkit To ensure practices are supported in completing the CGSAT Sessions to be established to support GP practices in completing the CGSAT Target support for areas of the CGSAT which are identified as showing low levels of achievement Access arrangements - core access arrangements; aids to access user experience; the impact of My Health On Line. How practices respond to urgent requests and same day requests from care homes, Welsh Ambulance Services and Hospital emergency departments. Consistency and safety in Practice and NCN wide primary care services 11 PC&ND / NCN No Objective Agreed Actions Outcomes Key 7.2.3 To review the variation in prescribing compared to Minimise avoidable harm from adverse NCN Lead national guidance in effects of inhaled relation to Diabetes and steroids; Respiratory and deliver the NCN savings target for these work-streams within the three year plan

No Objective Agreed actions Outcomes Key Actions to foster greater integration of health and social care. Consideration of how community resources can be maximised to meet local needs. Consideration of how Third Sector support may be maximised Map local GP services to highlight where services are delivered across practices (for example, contraceptive services, minor surgery) How new approaches to the delivery of primary care might aid service delivery and ensure sustainability of local services Consideration of the impact of local care pathway work relating to previous QOF work Strategic Aim 9: Other Locality issues No Objective Agreed Actions Outcomes Key 9.1 See 2.1 NEW: Access/DNA rates 9.2 NEW: Diabetes 9.2.1 Tackling the effects of Diabetes (including obesity) Adopted as a local priority 2015-16 agreed 16.07.15 Links to Communities First Healthy Lifestyles project Change To use PH observatory data as a baseline for improvement Intervene more regularly, with right information in the right way brief advice / intervention Map Level 2 services for weight management and refer/recommend Foodwise, commercial clubs, NERS, led walks Access to advice from multidisciplinary team & implementation of new diabetes work plan leads to improved outcomes for patients 12 NCN / Public Health / ABUHB Divisions / Diabetes Nurse Progress/ 31.3.16 Presentation given to NCN at meeting Agreed that diabetes Practice Nurse will be a member of the NCN Primary Care diabetes specialist nurses arranging Practice visits Diabetes Consultants aligned to NCNs Consultant email advice

Plan No. 3/4/5 Refer routinely to Adult Weight Management Service Consider increasing AWMS capacity for specific populations (e.g. Prediabetes, pregnant women) e.g. BG West/Mon North Engage with non medical members Progress/ line open Consultant/DSN telephone advice Further action agreed 13