Version 4: Updated September 2016 CARDIFF NORTH NETWORK CLUSTER ACTION PLAN

Version 4: Updated September 2016 CARDIFF NORTH NETWORK CLUSTER ACTION PLAN 2014 1

CARDIFF NORTH NETWORK CLUSTER ACTION PLAN SEPTEMBER 2016 This plan has been developed by the following 11 practices which operate in the North Cluster Area, through facilitated discussion with the Community Director and Locality Manager:- Cyncoed Medical Centre Roath House Surgery Penylan Surgery St David's Medical Centre North Cardiff Medical Centre Birchgrove Surgery Llanishen Court Surgery St Isan Road Surgery Whitchurch Road Surgery Crwys Road Surgery Cathedral View and Llywnbedw Medical Centres Outline of Cluster Population Profile The Cardiff North neighbourhood partnership area has a population of approximately 102,250 (27.2%) of the Cardiff total and is the largest neighbourhood partnership area in Cardiff in terms of population and land area. Although it is generally perceived to be a less deprived and a generally healthy area, according to most social economic, health and deprivation indicators there are significant pockets of deprivation, including areas of Llanedeyrn and Pentwyn and a part of Llanishen ward known as the Crystals Estate (See Welsh Government Tackling Poverty Action Plan Building Resilient Communities). Approximately 7,000 (7.2%) of Cardiff North residents live in the most deprived decline of income deprivation in Wales. Elderly - In Cardiff the population of older people aged 80-84 is predicted to increase by 6% from 6,870 in 2010 to 7,310 in 2020, and by nearly one half to 10,150 in 2030. In Cardiff North Cluster 15.1% are people aged > 65 (5th highest in C&V UHB) and 2.5% are aged > 85 years (2nd highest). Of people aged over 65 in Wales, two thirds reported having at least one chronic condition, and one third had multiple chronic conditions; and over three-quarters of people aged over 85 in Wales reported having a limiting long-term illness. As CNC has over a quarter of the total population of Cardiff residing in its boundaries this represents a large demographic challenge medically. C&V Dementia map suggests that currently 560 people in CNC have dementia with 1250 people remaining undiagnosed. The sharpest increase in numbers of people with dementia is in those aged 80 and over, where prevalence rates are estimated to be 1 in 6. The total number of people aged 65 and over with dementia in Cardiff and the Vale of Glamorgan is predicted to rise by nearly one half from 4,010 in 2010 to 5,990 in 2020, and to nearly double to 7,930 in 2030. Diabetes - The number of those aged 75 and over with diabetes is predicted to rise by around one half in Cardiff from 3,890 in 2010 to 5,660 in 2030. 2

Cluster Population: Practice list sizes growing across CNC Low deprivation statistics but high disease prevalence rates Older population but dementia rates not consistent with this demography Large number of sheltered accommodation (elderly; LD) not covered by the nursing home LES CNC has low planned referral rates across all specialties 4 practices have a high student population (Whitchurch Road, Cathedral View, St. Isan & Crwys) LDP will increase population size and service provision will need to be developed by the UHB in conjunction with practices Two practices have active Patient Participation Groups Service provision may be affected adversely by the majority of CNC practices change in MPIG over the next 7 years Only one practice is covered by Communities 1 st Programme Populations served by Cathedral View and Llywnbedwr Medical Centres, include Gabalfa as any area of deprivation Priority Health Needs Provide enhanced and co-ordinated services frail older patients in collaboration with local authority and third sector partners Improve Sexual health service provision across the Cluster and in particular for those practices with a high student population Increase and improve engagement in all aspects of the Community Diabetes Services Model in particular that between Diabetes Specialist Nurses and Practice Nurses Further develop patient education and peer support groups in chronic disease e.g. diabetes, heart failure and copd Improve the care of the patient with Dementia (all stages of the disease) Improve referral rates for Smoking Cessation, Bowel screening and AAA screening PHW Tier 1 Targets Provide ABI training to all PHCT s tier 1 Improve Flu Vaccination rates >75% - PHW Tier 1 Target Tackling Obesity PHW Tier 1 target e.g. increasing NERS referrals National Clinical Priorities Cancer; EOLP & Polypharmacy/Frail Elderly Greater involvement of the 3 rd sector in patient care Consider all opportunities to reduce waste and variation e.g. prescribing; lab testing, radiology referrals etc. Improve access through My Health On-line, Patient Participation Groups, decreasing waits for bookable appointments etc Access - Tier 1 Target Integration of Ambulatory Care Sensitive Pathways 3

The Plan The plan has been informed by the practice development plans produced by practices; public health information on key health needs within the area; information provided by NWIS and Cardiff and Vale UHB in respect of referral and activity levels; a knowledge of current service provision and gaps within the area and an understanding of key UHB priorities for the next three years. The plan details cluster objectives for years 1-3 (2014/) that have been agreed by consensus across practices, providing where relevant background to current position, planned objectives and outcomes and actions required todeliver improvements. The cluster views this plan as a dynamic and evolving document and therefore, the plan itself will be reviewed and updated as required. The RAG rating score indicates progress against planned action (Red-work yet to start, Amber- Some progress made, Green-action has been completed). The original 3 year plan was established by the cluster in 2014 and this update, reflects the current cluster priorities, based on progress since 2016 and GMS contract requirements for 2016/17. Although the strategic aims referenced within the document are reflective of guidance provided with the contract, the format primarily represents the strategic aims as identified by the cluster practices. A number of key principles underpin the plan: Management of variation/reducing harm/sharing good practice: in acknowledgement of the fact that healthcare must be delivered on the basis of safety, effectiveness and efficiency, the practices have considered and analysed variation in performance and where appropriate have considered steps by which to map standardise practice based on clinical guidelines. Maximising use of Local Cluster Resources: practices have taken into account the capacity, capability and expertise that exists within primary care, community services and voluntary/third sector services to deliver more care closer to home and reduce unnecessary demands within the acute care services. Promoting integration/better use of health, social care and third sector services to meet local needs: practices have considered current arrangements/links with Cardiff Council and the voluntary sector and have also considered action plans that have been developed by the local neighbourhood partnership group. Considering and Embedding New Approaches to Delivering Primary Care: this includes increased use of technology, new roles and service models considering and embedding new approaches to delivering primary care: this includes increased use of technology new roles Maximising opportunities for patient participation: this includes consideration of models of good practice that exist with within/locality/cluster and nationally and within the rest of the UK. Maximising opportunities for more efficient and effective use of resources: this includes consideration of current resources, opportunities to utilise current and new services more efficiently and effectively 4

Additional contributors to the plan Health and social care facilitators Local voluntary sector providers Lead consultant geriatrician for the locality Relevant secondary care consultants Prescribing advisers Cardiff and Vale HC Public Health Wales References: Cardiff North Neighbourhood Partnership Plan 2014 Cardiff and Vale Dementia Plan 2014 Version Control Record This document reflects changes to the 3 year cluster plan that was developed in 2014. Following a review in September 2016, the plan in addition to RAG Rating has been updated based on changes in priorities, progress in relation to key actions and changes within GMS contract. 5

Strategic Aim 1: Identified Health Care Needs within Population Served by the Cluster: Ref No: Key Issue Current Position Objectives/Anticipated Outcomes for Patients 1.1a Older Given demographic To ensure service provision People - profile of Cluster Area, and expertise is sufficient in dementia levels of older people terms of capacity to deal with and thus dementia are known and growing demand greater than any other of patients living with cluster area within dementia. To focus on Cardiff and Vale UHB- enabling individuals to remain this brings significant as independent as possible for health and social care as long as possible, living in a challenges on a number community setting. of levels 1.1b Older People managem ent of Frailty Given demographic profile, levels of frailty within the North Cluster are higher than other areas indicative of high rate of falls Reduce the risk of falls associated with polypharmacy 1.1c Enhance the level of clinical support to individuals identified as high risk of failing in the community through continued and increased investment in Primary Care Nurses for Older People (service to become available to all 11 Cluster practices from autumn 2016) Neighbourhood PM's of PHCT s All practices ensure non-clinical staff Partnership Team/ (Whole practice are trained as Dementia Friends (1 PHCT's/ PH Team based learning) hour training course) Practices to consider becoming part of a Dementia Friendly Community in North Cardiff Polypharmacy medication reviews undertaken in practices and in conjunction with Cluster Pharmacists and UHB Prescribing Advisors 2 PCNOPs in post Additional WTE Health Care Assistant to be recruited to provide step down support GP lead for programme GP lead in each practice Key outcome measures currently being developed in conjunction with CRT, WAST Locality Manager/Nurse Lead in CRT GP cluster Leads Identified GP leads for scheme 6

Ref No: 1.1d Key Issue Current Position Objectives/Anticipated Outcomes for Patients To ensure older people at risk of falls are supported to make improvements to their home environments so as to reduce risk of falls. All Practices within the PM's PM's cluster to engage in Care and cluster PHCT's Repair Care Healthy@Home Project 1.1e 1.1f 1.2a Public Health Promotion Citizen Driven Health (CDH) / Locality Working Falls Prevention strength & balance classes offered in North Cardiff Not all staff working with practices are skilled and knowledgeable in communicating public health massages 3 Practices working in conjunction with Public Health and 3 rd Sector in CDH project since early 2016. This is now set to evolve into a Locality Working pilot with Cardiff City Council Preventative Services programme in the Llanishen/Thornhill neighbourhood, with the addition of Llanishen Court practice Increase numbers of patients attending strength and balance classes To enhance the level of skills and knowledge within practices to support public health activity Engagement of 4 practices covering the Llanishen/Thornhill neighbourhoods with local authority All practices to signpost appropriate patients to strength & balance classes All practices to engage in Making Every Contact Count Training and relevant Brief Intervention Techniques Public Health lead Local authority lead Public health lead PM CMC Public Health GP leads and PMs in each practice PH lead Practice Manager 1.2b Smoking Cardiff and Vale UHB area has the lowest number of treated smokers in Wales 2012-2013Over 10,000 referrals to smoking cessation services are needed to meet the Tier 1 target. Less than 1,200 referrals were received to Stop Smoking Wales Cluster practices to maximise referral to services that support smoking cessation Cluster practices to continue to refer to SSW Public Health Brief Intervention And VBA training (On-line) National Centre for Smoking Cessation (Cessation) Training Cluster Lead GPS 7

(2012-2013) 8

Ref No: 1.3a Diet and Exercise Key Issue Current Position Objectives/Anticipa ted Outcomes for Patients Physical activity levels across Cardiff and the Vale of Glamorgan are low with just 26% of adults meeting the guidelines for being active Over half of adults (54%) and over a quarter (26%) of children aged 4-5 years are overweight or obese in Cardiff and Vale. To improve knowledge of local service provision/access routes to support individuals in improving their diet and levels of exercise Work with key partners to develop widespread use of the DEWIS directory of support services for use by cluster practices Practices with TV screens can download posters with PA and healthy eating advice from GP One Practices with Vision software utilise the physical activity Vision template to signpost patients to local activities Support from Health/social care facilitators in C3CS Council/C3SC lead 1.3b To increase referral rates to NERs READ Code Referrals Database of NERS attendances Access NERS referral forms online Public Health/Communities First NERS GP s (READ Codes) GP Cluster Leads 1.4 Young People / Student Sexual Health Concern regarding lack of Sexual Health Services within the cluster Improve access to Sexual Health Services for patients in North Cluster. Work with University to maximise support for students To have a focus on sexual health at Cluster Educational Sessions CD for DOSH PHW Designated Cluster Leads Sept 9

Ref No: Key Issue Current Position Objectives/Anticipa ted Outcomes for Patients 1.5 Mirena Coil insertion Variation in service provision across the cluster group of practices Increased provision of implant and coil insertion/utilise interpretive referrals so as to reduce referral rates to secondary care Arrange inter-practice referral for Mirena / IUCD and Nexplanon insertion within the Cluster group NWSSP/PM s from participating practices PM, St Isan- Lead PM 1.6a Alcohol The North Cluster has the 4 th highest rate of emergency admissions within the 9 cluster groups To maximise opportunities to identify and respond to issues of high alcohol consumption and ensure maximum use of support services 1.6b Raising Public Health Awareness on Alcohol Issues 1.7 Diabetes The Cluster Practices are currently engaged in the Community Diabetes Model 9 practices signed up to Diabetes Pacesetter Pathways Enhance the level of diabetes care within the cluster All relevant Practice staff to undertake Alcohol Brief Intervention Training across CNC Promote awareness of alcohol units, safe daily/weekly limits and responsible alcohol use at community events, in GP practices and during the annual Alcohol Awareness Week in November To work with secondary care specialists and newly appointed DSNs to establish a sustainable cluster based model of care to support the needs of complex patients. Practices to integrate the Diabetes Pacesetter Pathway Cheryl Williams PHW CNC PHCT's PHW CNC PHCT s CD lead for Diabetes/Community Director PM's PHW PM s Community Director As per dates. 10

Ref No: Key Issue Current Position Objectives/Anticipa ted Outcomes for Patients 1.8 Childhood Immunisat ions Although childhood immunisations rates are satisfactory amongst the cluster, there appears to be a potential decline in uptake at 15 years. To meet WG immunisation targets Practices to demonstrate improvements to achieving targets PHW GP leads 1.9 Flu Immunisat ion The cluster has not been able to achieve all immunisation targets 10 practices signed up to Flu and Pneumovax (At Risk Groups) Pacesetter Pathway To show demonstrable improvements in meeting tier 1 flu immunisation targets All cluster practices to integrate the flu and pneumovax (At Risk Groups) pacesetter pathways GP Leads Strategic Aim 2: To ensure Sustainability of Core GP Services and Access Arrangements that Meet Reasonable Need (including new approaches to Delivering Primary Care) As part of their Practice Development Plans, all practices within the cluster have reviewed issues such as number of GP appointments provided to practice population, hours of services, inappropriate use of GP OOhrs services by patients, DNA rates, use of technology such as My Health on Line/Texts messaging etc. This plan identifies areas of commonality across the Cluster Practices, accepting that some practices will have identified specific internal developments that they will take forward as part of PDPs. Ref No: Key Issue Current Position Objectives/Anticip ated Outcomes for Patients 2.1a Community Phlebotomy Currently, District Nursing resources are being used to undertake phlebotomy for house bound patients. This is considered an unnecessary use of valuable DN resources More District Nurse time for Direct Patient care Scope opportunities to deliver community phlebotomy Services- funding now secured for development-options being scoped by PCIC CB. Further consideration by Cluster practices to develop cluster wide service Lead Nurses Vale Locality Lead Nurses/PCIC GP leads / PMs 11

Ref No: Key Issue Current Position Objectives/Anticip ated Outcomes for Patients 2.2a Primary/ Secondar y care Interface All dermatology are now made electronically by WCCG and practices are encouraged to provide photographs. Practices have been provided with additional cameras to facilitate this. To further develop and enhance use of teledermatology Work with lead CD for dermatology to develop the infrastructure Lead CD for dermatology Community Director 2.3a Patient Participat ion Other than CHC patient satisfaction questionnaires and GMC revalidation exercises there is little patient involvement other than Patient Participation Group set up by CNMC in 2008 2.3b Currently, there is no coordination of information provision to patients regarding self help groups, 3rd sector agencies etc 2.4 Infrastruc ture Cardiff LDP when passed will lead to significant housing developments in Cardiff North Cluster 2.5 IT Varying use of IT across practices to ensure maximum access to services Improve Patient Participation and Influencing Service Delivery- scope possible future work Use of technology e.g. PHCT s websites, Facebook or Twitter to promote access for patients to relevant 3rd Sector agencies Maintain high levels of access to appropriate health care professionals for all patients of CNC To maximise the use of IT and improve collaboration and efficiencies across Cluster Practices and with other practitioners and organisations All practices to confirm their chosen model for PPG Integrate DEWIS into everyday activity Establish a list of "go to" 3rd sector agencies to aid PHCT's with service delivery and improve patient outcomes Scope increase in population; list sizes per practice, PHCT premises development; growth in PHCT personnel between 2014/7 Clinical Software developments National Association Of Patient Participation (Danny Daniels) C&V CHC RCGP Neighbourhood Partnership PM's LSD GP's PM s PCIC Locality CD s GP/PM leads Neighbourhood Partnership Officer/C3SC Community Director/Localit y Manager Ongoing Practice Managers LSD Lead GP 12

Strategic Aim 3: Improve Management of Planned Care (including use of Care Pathways) The Cluster Practices have, over the past 2 years engaged in a number of the elective care pathway developed within C&V UHB in an attempt to either reduce inappropriate referrals to acute hospital specialists/improve of the quality of referrals. All practices have given a commitment to continue to utilise pathways that were adopted previously, but there are clearly opportunities to extend the use of elective care pathways through further primary care development. Ref No: Key Issue Current Position Objectives/Anticip ated Outcomes for Patients 3.1 Anticoagulation Services and Stroke Prevention 3.2 Heart Failure Hospital INR clinic s closed April 2014. Increased monitoring and Slow Loading of Warfarin increasingly to occur in the Community / Warfarin and NOAC LES. The Cluster has engaged with the UHB Stroke and Haematology Teams as one of 3 Clusters focussing on stroke prevention through appropriate anticoagulation Not all PHCT s follow BNP & Heart Failure pathway (diagnostic for HF) but cant access ECHO testing in a timely fashion (after referral to Cardiology OPD) To develop a comprehensive anti-coagulation service across the cluster including warfarin monitoring and initiation of NOACS Ensure consistent approach to management of heart failure Continue to work with cluster practices to deliver a consistent model of care All practices working with the stroke prevention team to review audit data and implement change Practices to integrate Heart Failure pacesetter pathway GP and ANP leads PMs Stroke prevention team Community Director Cluster Lead GPs Timeline s 9 practices signed up to Heart Failure Pacesetter Pathway Establish a Community Cardiology Heart Failure Diagnosis and Management Clinic CD and lead GPs and PMs to engage with GP Champion for Cardiology GP Champion Cardiology Clinical Director for Cardiology CD 13

Strategic Aim 4: To provide high quality, consistent care for patients presenting with Urgent Care Needs/At high Risk of Admission and support the continuous development of services to improve patients experience, coordination of care All cluster practices engaged with a number of emergency care pathways aimed at reducing unnecessary referrals to Secondary Care/attendances at the Emergency Unit. As with elective care pathways, practices have committed to engage in the pathways adopted last year, however, further work can be undertaken within Primary care/community to appropriately meet the needs of individuals within the community setting. This section cross references a number of actions from section 1 Ref No: Key Issue Current Position Objectives/Anticipated Outcomes for Patients 4.1 Eye Care Patients often access To ensure patients access right GPs inappropriately to care/right time/right place assist with urgent eye complaints 4.2 Acute Dementia Care Perceived difficulties in accessing the REACT team and subsequent assessment and transfer of care 4.3 COPD 9 Practices signed up to COPD Pacesetter Pathway Improve access arrangements for people in Crisis with Dementia/ other EMI Through use of clinically agreed pathways, enhanced care to patients with COPD Establish a cluster based COPD rehab education pilot Working with optometry PCIC optometrist Community adviser agree mechanism for PHCT s Director/ developing pathway and Patients (education) Optometry Lead training and implementation PCT for practice staff and patient education Need to agree improved access pathway for REACT service To invite Clinical Director for REACT to cluster CPET meeting Practices to integrate COPD pacesetter pathway Work with CRRU and UWIC EMI REACT Team LSD Lead GP's CRRU / UWIC / GP champion COPD Community Director GP / ANP respiratory lead at CMC Timeline s Sept 4.4 Social Services Support Standardised patient access for acute Social services Support All PHCT members to be aware of access arrangements to SSD Invite SSD to CNC meeting to explain referral procedures Operational Manager SS/ Locality Manager Locality Manager 14

Strategic Aim 5: Ensuring Effective Use of Diagnostic Services Cluster practices have, as part of the engagement with elective pathways, sought to improve their use of diagnostic services, they are however aware of the need to review the current variation in both radiological and laboratory testing and to modify practice best on clear clinical evidence/guidelines Ref No: Key Issue Current Position Objectives/Anticipated Outcomes for Patients 5.1 Laboratory There is variation both To ensure consistency in Testing/Rad within the Cluster and practice based on clinical iology across Locality/Cardiff guidelines Testing and Vale in respect of laboratory testing/radiology Requesting Cluster practices to continue to review Date provided by UHB Community performance data provided by UHB to Director identify areas for improvement Timeline s 217 15

Strategic Aim 6: To support Delivery of Improvements against National Priority Areas for Cancer Care, Minimising the Harms of Polypharmacy and Improving End of Life Care Ref No: Key Issue Current Position Objectives/Anticipated Outcomes for Patients 6.1 Targeting the Prevention and Early Detection of Cancer Identify opportunities for service improvement Practices to engage in completion of audit of all patients newly diagnosed between 1 January 2016 and 31 December 2016 with lung, digestive system and ovarian cancer and to summarise/share learning and feedback findings to cluster at annual review meeting All practices 6.2a Polypharm acy 6 Practices are signed up to the Poly Pharmacy related to Falls Pacesetter Pathway Improve the safety of care delivered to patients 1.Identify and record numbers and rates for patients aged 85 years or more receiving 6 or more medications ( excluding dressings etc) 2. Undertake face to face medication reviews, using the No Tears approach (Appendix 1) for at least 60% of the cohort defined in 1. above (for a minimum number equivalent to 5/1000 registered patients. If the minimum number of reviews cannot be undertaken because of the small size of the cohort defined in 1 above, consider reducing the age limit until the minimum is reached.) 3. Identify any actions to be addressed in the Practice Development Plan. 4. Summarise themes and actions for review with the cluster network and share information with the Health Board as required identify and report the number /% of patients aged 86years or more receiving 6 or more Cluster pharmacists Cluster IT consultant All practices 16

medications Practices to integrate the Poly pharmacy related to Falls Pacesetter Pathway. Ref No: Key Issue Current Position Objectives/Anticipated Outcomes for Patients Specific Actions Required Key Enablers/Partners Lead 6.3a End of Life Care Identify opportunities for service improvement Identify all deaths occurring between 1 January 2015 and 31 December 2015 and significant event analysis to assess delivery of end of life care for 2/1000 registered patients. Summarise and share themes/learning with other practices All practices 6.3b To adopt a cluster palliative care IT guideline developed by Macmillan GP Palliative care Cluster IT consultant GP Leads 6.4 Advanced Care Planning 8 Practices are signed up to the Advanced Care Planning Pacesetter Pathway To enable individuals living in nursing homes to have choice in terms of preferred place of death For those practices who provide an enhanced service to nursing homes, there will be a plan in place to ensure all current residents are offered the opportunity to engage in an advanced care plan This is part of the spec for the new enhanced service for NH s Macmillan GP facilitators GP leads PMs Practices to integrate 17

Advanced Care Planning Pacesetter Pathway CPET session on ACP 18

Strategic Aim 7: Deliver consistent, effective systems of Clinical Governance Ref No: Key Issue Current Position Objectives/Anticipated Outcomes for Patients Specific Actions Required Key Enablers/Partners Lead 7 Clinical Governanc e CGPSAT The contractor updates the Clinical Governance Practice Self Assessment Toolkit 121 (CGPSAT) and to confirm completion and submission to the LHB by 31. The contractor participates in a review of the appropriate healthcare standards in relation to the promotion of safeguarding vulnerable adults; adults with a learning disability; safeguarding children. Practices are expected to achieve at least level 2 CGPSAT assurance. Any improvement actions to be identified by 31, or actioned during the year if early identification Practices should consider key issues from the CGPSAT (CGSAT) for discussion at GP cluster meetings where there may be potential to identify common themes that might be addressed through agreed actions. All practices 19