Cluster Network Action Plan

Cluster Network Action Plan 2015-16 (second year of the Cluster Network Development Programme) South Wrexham The Cluster Network 1 Development Programme supports GP Practices to work to collaborate 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 Action Plan should be a simple, dynamic document and in line with CND 002W guidance. The Plan should include: - Objectives that can be delivered independently by the network 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. Cluster Action Plans 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. 1 A GP cluster network is defined as a cluster or group of GP practices within the Local Health Board s area of operation as previously designated for QOF QP purposes 2015 Version 0a 1

To understand the needs of the population served by the Cluster Network The Cluster Profile provides a summary of key issues. Local Public Health Teams can provide additional analysis and support. Consider local rates of smoking, alcohol, healthy diet and exercise what role do Cluster practices play and who are local partners. Is action connected and effective? What practical tools could support the delivery of care? Health protection- consider levels of immunisation and screening- is coverage consistent- is there potential to share good practice? Are there actions that could be delivered in collaboratione.g. Community First to support more effective engagement with local groups No Objective For completion by: - Outcome for patients Progress to Date 1 To review the needs of the population using available data To ensure that services are developed according to local need??all practices have been supplied with population profile resources which together with the GP Cluster profiles are being used to interpret local needs. Further work is ongoing to complete the analysis of this information to help inform both the cluster plan and the Health Board IMTP. 2 To identify additional information requirements to support service development Improved support for service development Practices are currently being provided with information on referrals, waiting times, admission rates etc which will be sued in cluster meetings starting in October. This will inform what additional information is required. 3 To consider learning from To be discussed during cluster 2015 Version 0a 2

previous analyses to identify any outstanding service development needs 4 To develop a plan to contribute to the reduction in prevalence of smoking Improved health outcomes Improved quality of life meetings and also at an Area Management Team and Health Board level. Draft plan is shown below which is for discussion and agreement in the cluster meeting in September PLEASE NOTE THIS PIECE OF WORK WILL BE SUPPORTED BY PUBLIC HEALTH WALES AND YOUR LOCAL AREA TEAMS POPULATION NEED (Priority 1 Smoking Cessation) Priority 1 The issues Aims and objectives How will this be done? Smoking cessation Smoking is linked to social class and accounts for a high proportion of the inequalities in health outcomes. Quitting smoking offers better improvement to healthy life expectancy than almost any other medical or social intervention. Patients are 4 times more likely to quit if they access support from specialist services. Implementation of BCUHB smoking cessation pathway in all Practices Increase demand for specialist smoking cessation services Offer timely and appropriate support for all adult smokers who wish to make a quit attempt All Practices to ensure all staff implement BCUHB smoking cessation pathway. Sign up to the Smoking cessation audit LES from October 2014 and use the CO Monitors (supplied free) All staff to undertake training (brief intervention training for clinical staff and ask/assist/advise training for administrative staff) Share smoking cessation data: Cluster March 2016 2015 Version 0a 3

NICE guidance is that 5% of adult smokers should be treated every year. This is now a Health Board Tier 1 target, with 40% quit rate. There are concerns in relation to variable practice and accessibility to services Ensure tailored interventions and equity of access and outcomes for specific groups, such as pregnant women, manual workers, people with mental health problems and socioeconomically disadvantaged communities. POPULATION NEED (Priority 2 to be chosen by Cluster) referrals to specialist services, numbers of treated smokers and quit rates Work in partnership with SSW / PHW / WG to provide improved quantity and quality of services. Ensure an integrated smoking cessation service across community, secondary care, mental health, social care and other relevant settings. Priority 2 The issues Aims and objectives How will this be done? Influenza vaccinatio n Influenza vaccination for at risk individuals remains one of the most effective interventions for preventing morbidity in our population. To exceed the 75% target for patients at risk. Cluster development funding will be available to send invite letters via docmail to every eligible patient. Practices will share good practice and ideas on how to improve vaccination rates e.g. Saturday morning clinics, opportunistic vaccination, drop in clinics, etc. 12m 2015 Version 0a 4

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ACCESS (to ensure the sustainability of core GP services and access arrangements that meet the reasonable needs of local patients) Priority The issues Aims and objectives How will this be done? Rising demand Patients cite difficulties in getting through to the practice Patients cite difficulties in getting quick appointments Need for greater understanding of issues and priorities across primary care and social care To improve access to primary care appointments To improve equity of access across the cluster To improve communication with patients within the cluster To improve communication with partners All practices to submit details of the demand analysis from the access LES All practices to consider optimum staffing levels and skill mix Investigate and promote use of My Health Online to book and cancel appointments and order repeat prescriptions to improve any contact issues Complete a thorough demand analysis to inform decisions on skill mix and appointment systems Ruabon to look at recruiting additional cover for triage nurse Cluster Decem ber 2015 All to share examples of good practice Cluster to consider options to gain patient feedback Investigate gaps in service provision Review use of locums and consider setting up a locum chambers or practice buddying 2015 Version 0a 6

Investigate gaps in service provision for cross border patients Support appointment of pharmacists and physiotherapists in primary care Consider possible role of paramedics, physician assistants and social workers Involvement of social care representatives at Cluster meetings Missed appointment s The number of missed appointments within the cluster are a concern Patients failing to attend an appointment impact on other access for other patients and inefficient use of staff time To reduce the number of missed appointments therefore improving access overall Gardden Road surgery to review DNA rates and follow up policy All to review DNA rates 2015 Version 0a 7

WORKFORCE Important Note: Each Practice has submitted practice specific plans to detail what will be done in order to meet any practice specific workforce needs e.g to cover a period of maternity leave, recruit to a specific vacancy. The table below refers to matters that can be taken forward at a Cluster level and/or require HB input. Priority The issues Aims and objectives How will this be done? Recruitment There are problems recruiting GPs within the locality (and nationally) To improve recruitment in primary care To discuss with Area Management Team To consider alternative approaches to support recruitment and retention at practice and cluster level Cluster lead Consider funding use of head-hunting firms to recruit to vacant posts Collaborate with ED and OOH Paucity and high cost of locums To reduce costs of locums Consider development of locum chambers or federal model of practices Administratio n training There is a lack of funding for the training of nonclinical staff To improve access to training Discuss at future cluster meetings Beech Avenue nurse replacement Nurse is retiring To cover vacancy to prevent loss of access Submit bid to Health Board 2015 Version 0a 8

Llangollen rebalance clinical skill mox between nurses and HCA s Changes to staffing over the last 2 years has resulted in changes to the skill mix To improve the skill mix and increase efficiency Analyse demand for nurse and HCA appointments and distribute work more effectively Alison Hughes Overton replace GP Salaried GP has resigned leaving a vacancy To fill vacancy and maintain access levels Practice to advertise as necessary Overton Practice REFERRAL MANAGEMENT AND CARE PATHWAYS Priority The issues Aims and objectives How will this be done? Long waiting times for appointments in secondary care Patients re-attend the surgery whilst they are waiting for further advice, information on their referral or asking for another letter to be sent To reduce the number of reattenders whilst patients are waiting for secondary care input To improve waiting times and provide a more local service Identify activity that could be performed in primary care rather than outpatients e.g. PSA monitoring, colorectal cancer follow up, endometrial biopsy, 24 hour ECG s, skin lesion, pain management, carpel tunnel diagnostics, hearing tests, ABPIs, etc Identify any training or equipment that would reduce the need for referral to outpatients Identify any unfunded work being carried out by primary care Cluster 2015 Version 0a 9

Discuss pathway development with secondary care Discuss referral and follow up management schemes e.g. peer review and timely feedback Discuss how best to use the skills across the cluster e.g. cross referral or cluster based commissioning Prepare business case to support peer review of dermatology referrals, expansion of services e.g. cryotherapy/ minor ops/ skin lesion clinics Explore primary care assistance with waiting time initiatives and commissioning of services outside of BCUHB Invite secondary care colleagues to attend cluster meetings to discuss issues with waiting times etc Ensure information on referral processes is up to date Agree on a universal approach with regards to duty of care as recommended by the BMA and LMC Encourage development of WCCG to improve efficiency e.g. electronic hospital letters and discharge summaries 2015 Version 0a 10

Reduce cost of using locum consultants and private sector to manage demand and instead look at far more cost effective solutions within primary care Enhanced Care Limited demand in cluster Increase demand for service to improve efficiency Promote service at cluster meetings All to promote service colleagues in practice Communicate issues to locality matron 2015 Version 0a 11

UNSCHEDULED CARE (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, co-ordination of care ad effectiveness of risk management) Priority The issues Aims and objectives How will this be done? Limited bed capacity Long waiting times in the Emergency Department Lengthy ambulance delays Reduce number of preventable admissions To focus on using enhanced care and the ambulatory care pathways Review hospital admissions and consider what would have been required in primary care to prevent an admission or to create a quicker discharge Consider patient education to prevent disease progression Consider using Hospital at Home for elderly patients requiring rehabilitation Llangollen to work with local care homes to ensure robust in-hours care for these patients to avoid admissions and consider solutions for out of hours care Discuss primary care working alongside ED Discuss primary care liaison with discharge planning. Discuss risk stratification & proactive case management. Discuss the use of telehealth. 2015 Version 0a 12

Consider using Near patient testing as part of an alternative DVT & chest pain pathway. Discuss primary care led IV therapy. Further analysis of ED attendance required by the unscheduled care team : comparison between practices & sitting in ED. To provide monthly feedback to practices regarding their rates of hospital admission and ED attendance. Consider peer-review & feedback for individual GPs. Develop the concept of urgent care clinics providing enhanced services within primary care. Circulate the enhanced care service bedstate regularly to all practices. Discuss with Area Management Teams IMPROVING THE DELIVERY OF END OF LIFE CARE (Refer to National Priority Areas CND 007W) 2015 Version 0a 13

Priority The issues Aims and objectives How will this be done? To improve patient care Significant event analysis performed annually by each practice To proactively discuss advanced care plans/ treatment escalation plans. Record them clearly in the notes and flag them up with the OOH and ambulance service To work collaboratively with the palliative care team to develop advanced care plans for our patients and use the documentation provided. Identify patients who would benefit from an end of life discussion (not just patients with cancer) and ensure that their wishes are respected. 2015 Version 0a 14

TARGETING THE PREVENTION AND EARLY DETECTION OF CANCERS (Refer to National Priority Areas CND 006W) Priority The issues Aims and objectives How will this be done? To improve patient care Significant event analysis performed annually by each practice. GPs to attend Early Detection Course (fast track) Liaise with radiology and pathology to develop pathways that would enable primary care clinicians to directly access the necessary investigations before seeing a consultant. PREMISES PLAN Important Note: Each Practice has submitted practice specific plans to detail what will be done in order to meet any practice specific needs relating to premises. The table below refers to matters that can be taken forward at a Cluster level and/or require HB input. Issue Why? What will be done at Cluster Level How will this be done? (Practice; GP Cluster; Health Board) Closure of It is no longer Support the Engagement with the health board and public as required. 2015 Version 0a 15

Hightown branch sustainable to keep this branch open formal process for closure. Alternative premises required for Hanmer There is a risk of eviction at short notice. A business plan has been submitted. Business plan for alternative premises needs to be agreed. Urgently needed. Beech Avenue lack of space for development All space is currently occupied so no room for expansion. Particular issues with space for administratio n staff Support engagement and communicati on with Health Board Business plan needs to be developed identifying risks Crane Medical Centre lack of space in reception area Not enough space for the reception staff and patients Support engagement and communicati on with Health Board Engagement with health board as required Investigate if funding for improvement s are available through 2015 Version 0a 16

Gardden Road small premises for practice size with not enough clinic rooms Gardden Road lack of parking space Llangollen branch surgery in Plas Madoc provides poor facilities Ruabon disabled access issues Overton lack of space for dispensary Small practice for list size with not enough clinic rooms to see the patients No room for additional spaces in particular lack of disabled parking The building is old and rented from Wrexham Council grants, etc Support engagement and communicati on with Health Board Support engagement and communicati on with Health Board Support engagement and communicati on with Health Board Lift is broken Determine who is responsible for fixing the lift landlord or practice Discuss options to extend Business plan needs to be developed identifying risks Business plan needs to be developed identifying risks Business plan needs to be developed identifying risks Engagement from Welsh Health Estates and support from health board Business plan needs to be developed identifying risks 2015 Version 0a 17

dispensary upstairs or to the back of the building Bangor on Dee staff car park Not enough space for staff parking Liaise with council for permission to convert the back garden into additional parking Practice to liaise with council for permission to convert the land to parking. 2015 Version 0a 18

CLUSTER NETWORK ISSUES Issue Why? What will be done? How will this be done? (Practice; GP Cluster; Health Board) Smoking Tier 1 public health priority Increase the rate of smoking cessation Maintain an accurate register by using the automated log in system. Provide practice based smoking cessation clinics Targeted promotional material Seek recommendations from PHW Influenza Vaccination Tier 1 public health priority Increase the uptake of flu vaccinations Ensure all at risk patients notified of the need for vaccination. Provide easy access to flu jab appointments or walk in clinic. Consider evening and weekend flu clinics. Seek recommendations from PHW Antibiotic stewardship Medicines Management priority Reduce the volume of antibiotic prescribing Work with medicines management. Identify outliers and improve adherence to the current BCUHB formulary. Prescribing incentive scheme There is a desire for a more focussed approach. Develop an alternative scheme with a greater focus on providing excellent care Discussion with medicines management. Community nursing Cross border issues Enable shared notes Establish EMIS licence & remote access provided for community nursing. community nurse(s) for each practice Explore IT solution for excessive paperwork. Locality Matron 2015 Version 0a 19

CLUSTER NETWORK ISSUES Issue Why? What will be done? How will this be done? (Practice; GP Cluster; Health Board) practicebased community nursing. Include community nursing in cluster workforce plans. BMA workload guidance There may be further efficiency measures possible. Explore how to implement the various recommenda tions. Discuss at both a practice & cluster level. Consider setting up small working groups to look at each area of back office functions. Consider using some of the cluster funding to enable any changes. BMA workload recommendations Communication strategy The various issues needs discussion and agreement. Communicati on between the stakeholders across south Wrexham will be substantially improved. Regular updates from the locality lead. Shared meetings with the locality leadership team and wider primary care. Improve the email distribution list. Consider an online discussion forum on GPone Continue a quarterly professional newsletter Consider how best to inform patients / involve the patient participation groups. Locality lead Sharing good practice Duplication of work between Reduce duplication Arrange separate cluster meetings for Practice Managers to meet supported by cluster monies where appropriate and approved. 2015 Version 0a 20

CLUSTER NETWORK ISSUES Issue Why? What will be done? How will this be done? (Practice; GP Cluster; Health Board) practices when developing policies etc by Practice Managers working collaborativel y and sharing documents and processes. 2015 Version 0a 21

LHB Issues (in addition to any issues raised above requiring Health Board input) Issue Why? What will be done? How will this be done? (Practice; GP Cluster; Health Board) Running costs Increased use of practice premises for a range of services Establish some contribution towards the running costs. Reach an agreement with the finance department and PCSU. Locality lead June 2015 Unfunded work Recent publication by BMA. Identify any currently unfunded work and ensure that it is properly remunerated Work with the LMC & BCUHB to develop LES s for ECG + ABPM + Spirometry + Phlebotomy + 24hr ECG + Dopplers, etc. Locality lead June 2015 Datix feedback Feedback from Datix reports is delayed Identify any issues across the cluster Feedback issues to health board Public health priorities There are several key public health issues that need attention. Resources are needed for targeted screening of a variety of conditions including osteoporosis, cardiovascular disease, peripheral vascular disease, Diabetes and COPD. We will work with the Public health department to clarify exactly what is lacking 2015 Version 0a 22

LHB Issues (in addition to any issues raised above requiring Health Board input) Issue Why? What will be done? How will this be done? (Practice; GP Cluster; Health Board) Mental health services There is a paucity of counselling and psychological services We will work with our mental health team to ascertain the extent of the unmet need. Perform a demand analysis for these services and publish our findings. 2015 Version 0a 23