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Cluster Network Action Plan 2016/17
Newport West NCN
Our network: - We are a Network with six main Practices (Grange Clinic, Isca Medical Centre, Malpas Brook Medical Health Centre,
Richmond Clinic, St Julian’s Medical Centre, The Rogerstone Practice).
There are good working relationships with our Partners from
the Local Authority, Third Sector Organisations and Secondary Care Colleagues.
2
Strategic Aim 1: To understand the needs of the population served by the Cluster Network Health Care Standard 1.1, Health Care Standard 3.1
Objective For
completion/
Key partners
Outcome Actions / Progress to Date RAG
1.1 Managing Obesity
1.1.1. To establish a
baseline to measure the
size of the obesity
challenge and demand
for obesity services.
Supports Newport SIP
– Food & Nutrition /
Physical Activity /
Active Travel /
Alcohol and
Substance Misuse
31.03.17.
Public
Health,
NCN,
One Newport,
ABUHB –
Dietetics,
GAVO.
NCN membership and stakeholders
will be able to plan for integrated
service provision across the
Newport NCN areas.
Identify baseline data for NCN area.
Develop Directory of available services.
Ensure referrals are made to the reconfigured Adult
Weight Management Service.
Develop pathways for available Childhood Obesity
Services.
Progress
20.9.16 – Obesity evidence collation started. Contacts
identified to approach for quantitative and qualitative evidence.
A
1.2 Dementia Services
1.2.1 Updated –
Ensure web based portal
is maintained and used
regularly by patients,
families, carers and
professionals.
Supports Newport SIP
– Mental Wellbeing
and Resilience
31.03.17.
PC & ND,
Dementia
Friendly
Community
Coordinator.
Patients and their families / carers
can access up to date information
on services available to them
relating to dementia support.
Raise awareness of Road Map.
Measure usage.
Progress
20.9.16. – GAVO approached for usage statistics on web
usage.
A
1.3 Public Engagement
1.3.1 To support the
work of the ABUHB
Engagement Team in
implementing the
Engagement Strategy.
Supports Newport SIP
On-going.
NCN,
NM / NSO,
C1st,
GAVO,
One Newport,
Formal and informal consultation
opportunities for all residents to
influence the development and
improvement of all services
(including integrated services)
across ABUHB.
NCN and PC & ND to be represented at at least two
Listening Events in the NCN area during 2016/17.
Feedback findings from Listening Events to NCN and
ABUHB Engagement Teams.
Where possible build feedback in to actions for future
NCN Plans.
A
3
Objective For
completion/
Key partners
Outcome Actions / Progress to Date RAG
– Integration of
Health and Social Care
ABUHB. Progress
20.9.16. – Discussions held with Engagement Team. Standing
invite to attend regular events in NCN areas. Also to develop
NCN specific engagement events for individual NCN areas.
1.4 Alcohol Treatment
Pathway
1.4.1 New - Increase
awareness of the harm
to health from alcohol
through local
enhancement of national
social marketing
campaigns.
31.03.17.
PHW,
NCN Lead,
NCN,
GDAS.
An integrated Alcohol Treatment
Pathway process to deliver
appropriate interventions and
support for residents across the
NCN.
To develop the Alcohol Treatment Pathway.
Scope a business case for GP enhanced service for
alcohol misuse and GPwSI roles.
Establish an Alcohol Care Team at RGH and NHH, in
conjunction with GDAS in-reach provision, and
telephone support at YYF (subject to funding being
identified).
Progress
20.9.16. - Initial scoping meeting with PHW arranged to
develop the NCN role of implementing the developing Pathway.
A
1.5 Screening
Programmes
1.5.1 To achieve
National Targets for
eligible patients to be
screened (breast,
cervical, bowel, prostate
cancers).
31.03.17
PHW,
NCN,
National
Screening
Services,
GP Practices.
Earlier detection of cancer with
improved chance of survival.
Baseline established within
PHW to liaise with national screening services
regarding providing practices with a list of specific
Programme non-responders.
Identify achievements against national targets.
Practices to complete work according to protocols.
Progress
20.9.16. – Links strengthened with PHW Screening Programme
Team. Discussions underway to relocate mobile Breast
Screening Units for the next scheduled Newport Programme.
A
1.6 Learning Disability Enhanced
Service Annual Reviews
1.6.1 New - Increase
up-take of Learning
Disability Enhanced
31.03.17.
NCN,
Practices,
Reconciliation of GP Practice and
Social Services Registers for people
with Learning Disabilities.
Work with Social Services to reconcile Registers.
Use reconciled register to contact patients and invite
in for an annual review.
A
4
Objective For
completion/
Key partners
Outcome Actions / Progress to Date RAG
Service Annual Reviews
to deliver reviews to
target of 90% of all
eligible patients.
Social
Services.
Increased uptake of LD LES annual
reviews by participating Practices.
Progress
20.9.16. – Social Services colleagues approached to arrange a
date to meet and discuss client service criteria for both Social
Services and ABUHB. Update Report in Q3 NCN meeting.
Strategic Aim 2: To ensure the sustainability of core GP services and access arrangements that meet the reasonable needs of local patients Health Care Standard 7.1
Objective For
completion/
Key partners
Outcome Actions RAG
2.1 Access
2.1.1 New - Explore
the implications of the
Care Closer to Home
Programme (CCTH).
31.03.17.
NCN Lead,
Practices.
An initial option appraisal regarding
future provision of GP services
across Newport and within the
NCN, in particular.
Hold CCTH session for NCN.
Develop a work programme and action plan.
Progress
20.9.16. – Pan Newport presentation held in August 2016.
Write up from the day will inform developing Work Programme
for CCTH.
A
2.1.2 To increase the
usage of Patient Texting
resources.
31.03.17.
NCN Lead,
Practices.
Patients will be able to be
contacted directly to remind them
of appointments / invites to
screening programmes / reduce
DNAs. Complements existing
Welsh Government funding /
investment in patient contact
initiatives.
Practices to establish if currently pilot funded two
texts per patient will be sufficient for Practice needs.
NCN Lead to secure agreement to purchase additional
‘Text Bundles’, as appropriate.
Progress
20.9.16. – My Health On Line statistics being analysed re:
current usage of allocated texts before decision is taken to fund
additional text bundles.
A
2.1.3 To provide
accessible services for
Homeless and
Vulnerable Groups.
Supports Newport
SIP – Integration of
31.03.17.
Public
Health,
PC & ND,
NCN Lead.
Increase in availability and
accessibility of services for the
homeless and vulnerable groups
within the NCN area.
Assess the need for services from the homeless and
vulnerable groups.
Ascertain what is available locally.
Arrange a multi-agency meeting to discuss ‘needs’
Implement the HAVG Health Action Plan.
Progress
A
5
Objective For
completion/
Key partners
Outcome Actions RAG
Health and Social
Care
20.9.16. – Post consultation event analysis being undertaken
to inform next stage of implementation.
2.1.4 Monitor the
continuation and uptake
of My Health Online
(MHOL).
Supports IMTP SCP3
31.03.17.
NCN,
Practices.
Ease of access to GP services. All practices to offer appointment availability and
repeat prescription ordering via MHOL.
NCN Lead / NM / NSO to liaise with SCP Lead for
regular updates to feed back to NCN members.
Progress
20.9.16. – Latest statistical report shows continued uptake of
MHOL facilities by Newport West NCN.
G
2.1.5 Support Practices
in developing business
cases related to Phase 2
of the Access LES.
31.03.17.
NCN Lead,
Practices.
Ease of access to GP services. Advise and assist Practices with queries on
developing business cases, where requested.
Progress
20.9.16. – No requests received to date for assistance from
Practices.
A
2.1.6 Support the
continued
implementation of the
Local Oral Health Action
Plan.
31.03.17.
NCN Lead,
Dental Lead
Potentially clearer information for
access to Dental Services
treatment programmes and
pathways.
Work alongside dental colleagues to promote and
raise awareness of the Local Oral Health Action Plan.
Progress
20.9.16. -
A
2.2 Workforce
2.2.1 Re-worded - To
enable continued Peer
Support for Healthcare
Support Workers,
Practice Nurses and
Practice Managers via
their appropriate
Forums.
Supports IMTP SCP3
31.03.17. Potentially streamlining of services
at Practices through process
improvements for Practice based
Staff.
Arrange dates and venues for Forums with the
respective Group representatives.
Progress
20.9.16. – Practice Managers Forum held in Q1 with a further
Forum scheduled to be held on 6.10.16. Q1 Forum had a
presentation from NWIS to discuss IM&T support for Primary
Care Practices across Newport.
G
2.2.2 New - Recruit
additional Primary Care
Based Pharmacists.
31.03.17.
NCN Lead,
Practices.
NCN Pharmacists Project Team is
developing a suite of priorities and
outcomes for the Pharmacists.
Recruitment process undertaken.
Appointments made
Priorities and outcomes to be developed and
A
6
Objective For
completion/
Key partners
Outcome Actions RAG
Supports IMTP SCP3
Additional capacity and access
created for GPs.
finalised.
Integration of Pharmacists to be monitored.
Progress
20.9.16. – NCN is considering the option of using sessional
services from local Community Pharmacists to supplement the
existing Pharmacist employed through NCN funding.
Additionally there are interviews being held on 29/9 and 4/10
through which alternative candidates might be sourced.
2.2.3 New – To
investigate options for
introducing Social
Prescribing within
Practices / across the
NCN.
31.03.17.
NCN Lead,
NIP Officers.
Prudent health care principles
being adopted. Patient education
improved to ensure most
appropriate services are accessed
for the presenting issues – free up
GP appointments and increase
capacity for the most appropriate
patients.
Review service delivery options for Social
Prescribing.
Develop recommendations for the NCN membership
to consider.
Implement agreed recommendation.
Progress
21.9.16. – Option appraisal undertaken. Recommendations
due by mid October.
A
2.2.4 New – Direct
Access Physiotherapy.
31.03.17.
NCN Lead,
Practices.
Additional capacity for direct access
to physiotherapy services – free up
GP appointments and increase
capacity for the most appropriate
patients.
Develop a feasibility report for options to potentially
deliver direct access physiotherapy in the NCN.
Progress
21.9.16. – Initial outline service considered. More detailed
proposal being prepared.
A
2.2.5 New – Provision
of ANP training to
increase workforce
skills.
31.03.17.
NCN Lead,
Practices.
A completed pilot scheme to
employ nurses on training grades
to become Advanced Nurse
Practitioners.
Use successful outcome of pilot
scheme as basis for a business
case / submission for longer term
funding e.g. a bid to the
Intermediate Care Fund.
Develop a feasibility report for options to potentially
deliver support for ANP training within the NCN.
Progress
21.9.16. – Business Case being developed for consideration at
the November NCN meeting.
A
2.2.6 - IT 31.03.17. Improved Practice systems Receive outline proposals for consideration and
7
Objective For
completion/
Key partners
Outcome Actions RAG
Innovations: increase NCN
Practices IT options, operations and capabilities.
Practice Managers,
NCN Lead
operations.
Consistency in use of systems.
decision. Progress
22.9.16. – Two proposals received by NCN. One for a full time
post @ £26-£38k pa, the other for an NCN based services @
£5.4k for 6 months. Full time post rejected as unaffordable at
West NCN meeting on 8.9.16. NCN based service being
considered at NCN Leads meeting on 29.9.16.
2.2.7 Phlebotomy:
Increase access to
primary care
phlebotomy service.
Supports IMTP SCP3
31.03.17.
Community
Division
NCN
Increased capacity and access to
Phlebotomy services and within to
District Nursing service.
To implement local service closer to home and in care
homes.
Increase access to phlebotomy services.
Progress
21.9.16. – Evaluation Reports to be produced by Community
Division at six and twelve months. Six month evaluation due
at October NCN Management Team meeting.
A
2.2.8 To support
relevant education and
development
opportunities across the
NCN.
31.03.17.
NCN Lead
0515 Providing for the Future.pdf
Improved guidance, co-ordination
and development/skills &
knowledge.
Sharing education sessions across
practices providing up to date
enhanced skills to provide better
patient care.
Develop and deliver an NCN
Training Plan from NCN slippage
monies.
Develop a process for Practice staff to access
training.
Training providers and costs are identified.
Practices are informed of training options and
criteria.
Practices apply for funding.
Courses - Minor Illness Training, HCA Training
Etc.
Process in place via proposal applications.
Progress
21.9.16. – Proposals for training being sought from Practices
for potential funding via Small Grant Scheme process.
Currently considering Wound Management Training for District
Nursing Team members in Newport West.
A
2.2.9 Early warning for
practices anticipating
difficulty with
recruitment / filling
31.03.17.
Practices,
NCN Lead,
CD.
Continuity of services.
Support against potential Practice
Fragility.
Practices to inform NCN verbally / in writing if
anticipating having difficulty and agree to meet with
NCN Lead and CD to discuss next steps.
Progress
A
8
Objective For
completion/
Key partners
Outcome Actions RAG
vacancies.
Supports IMTP SCP3 0715 Strengthening General Practice.pdf
21.9.16. – nothing reported to NCN Lead as at 21.9.16.
2.2.10 To embrace
future development of
the NCN Team and to
ensure it is adequately
resourced to deliver the
NCN agenda.
Supports IMTP SCP3
On-going. PC
& ND,
NCN Lead,
NM / NSO.
NCN will be able to deliver against
a fluid, integrated service,
transformational NCN delivery
agenda.
Regular NCN meetings to review performance,
actions for delivery and potential bottlenecks.
Report back to NCN.
Progress
21.9.16. – NCN Support staff have been equipped with laptops
and associated equipment to enable mobile, flexible working
across the Team.
A
2.3 Estates
2.3.1. Improve the
management of estate
issues, lack of space in
buildings, lack of grants
to increase the size of
premises.
Supports IMTP SCP3
31.03.17.
NCN Lead.
High quality facilities available to
best meet patient need.
Annual practice reviews and CHC
statutory visit reports
demonstrated facilities are to
required standard.
NCN Lead to clarify the position regarding East
Newport practices premises development and
refurbishment during Practice visits.
Primary Care Estates Strategy will highlight issues
for action.
Contact Local Authority Housing Department staff for
input re: expected housing development plans.
Progress
21.9.16. – Practice issues around estates identified from
Practice Development Plans. Formal process for discussing
estates issues and risks established via Newport NCN
Management Team.
A
2.3.2 To ascertain
accommodation
requirements within
primary care in relation
to wider delivery of
services.
Supports IMTP SCP3
31.03.17
NCN Lead
Patients are able to access local
services in high quality premises.
NCN determine wider team accommodation needs.
Progress
21.9.16. – Issues discussed and progressed via NCN meetings,
as and when raised. Option to raise via e-mail via NCN Lead /
Support Team if they arise between meetings.
A
9
Strategic Aim 3: Planned Care- to ensure that patient’s needs are met through prudent care pathways, facilitating rapid, accurate diagnosis and management and minimising waste and harms
Objective For
completion/
Key partners
Outcome Actions RAG
3.1 District Nursing
3.1.1 To support and
reinforce skills learned
on wound
management training
by DNs through
updating available
resources.
31.03.17.
Community
Division
NCN Lead,
Practices,
District Nursing
Team Leader.
Patients will be seen in Practice,
and ‘housebounds’ seen at home,
by trained Wound Management
DNs, freeing up GP time and
increasing available GP
appointment slots.
DN Teams to provide evidence to support purchase of
portable doppler machines for use at home visits and
clinic appointments.
Progress
21.9.16. – Business case provided by Community Division to
purchase two Doppler machines for NCN District Nursing
Teams. Funding approved by NCN. Initial evaluation report due
in Q4.
G
3.2 Health Visiting
3.2.1 To enhance
working relationships
between Health
Visitors and NCN
practices.
31.03.17.
NCN Leads,
Health Visitor
Manager,
Practices,
Family and
Therapies
Division.
Feedback from HVs and Primary
Care will demonstrate improved
communication.
Improved (and timely) services
for patients.
Develop an induction plan for new HVs to include
attendance at practice meetings and introduction to
practice staff.
Potential for HVs to link in and attend Practice
Manager Forum meetings.
Progress
21.9.16. – Health Visiting Service Manager regularly attends
the NCN meeting to provide updates on Team issues for the
Newport NCNs. Staffing challenges within the Team have been
identified and related to the NCN and an interim plan to deal
with the challenges has been developed and implemented.
Update due at September NCN Management meeting.
A
3.2.3 To resolve
Practice Nurse training
issues if
immunisations are no
longer given in
practices by Health
On-going
NCN Leads,
Health Visitor
Manager,
Practice Nurses,
Family and
Increase in the number of
Practices Nurses trained to deliver
immunisations.
Patients can access childhood
immunisations at GP practice
Work with service to ensure any changes are
communicated to practices in a timely fashion.
New HVs will be in post across Newport in September
2015.
Practice Nurse training to be delivered by HVs as
needed.
A
10
Objective For
completion/
Key partners
Outcome Actions RAG
Visitors.
Therapies
Division,
Public Health.
level. Progress
21.9.16. – Health Visiting Team continues to provide
immunisation services and training to Practices to undertake
immunisations. Services and support will continue to be
provided until training issues are resolved.
3.3 Mental Health
3.3.1 To strengthen
integration at practice
level between Primary
Care and the PCMHSS.
Supports Newport
SIP – Mental
Wellbeing &
Resilience
31.03.17.
MH&LD,
Practices,
NCN Lead,
Third Sector.
Reduction in the number of
referrals passed between different
teams within Mental Health
services, and PCMHSS.
Clearer care pathways, including
transparent, concise access
criteria, will be in place for
patients.
Better understanding of referral
arrangements.
Waiting lists demonstrate reduced
handoffs between services will
result in quicker access to
appropriate service.
PC&ND Leads to work with Mental Health Division to
raise Practice issues at a Gwent wide level to develop
and agree solutions and appropriate service
pathways.
Consider moving staff between scheduled sites when
they have capacity to deliver in another setting.
Progress
21.9.16. – Work programme being developed with Mental
Health and Learning Difficulties Division, ABUHB to address
challenges identified.
A
3.3.2 Refocused - To
deliver universal
counselling services in
conjunction with the
South Wales School of
Counselling and
Psychotherapy.
31.12.16.
SWCAP,
MH&LD,
Practices,
NCN Lead.
Access to high quality counselling
services delivered from accessible
venues, for an identified and finite
patient cohort.
Agree service levels for period 1.8.16 – 31.03.17.
Agree contract variation to existing SLA.
Finite level of service to be agreed.
Implement and monitor service.
Progress
21.9.16. – Service Level Agreement developed and agreed
between NCN, SWCAP and Mental Health and Learning
A
11
Objective For
completion/
Key partners
Outcome Actions RAG
Supports Newport
SIP – Mental
Wellbeing &
Resilience
Difficulties Division, ABUHB to provide Counselling Services.
First performance data expected in Q4.
3.4 CAMHS
3.4.1 Refocused - To
improve condition
specific referrals
between primary care
and CAMHS to meet
demand, particularly
for Specialist CAHMS.
Supports Newport
SIP – Mental
Wellbeing &
Resilience
31.03.17.
Families and
Therapies
Division,
NCN Lead,
Mental Health
and Learning
Difficulties
Division,
ABUHB,
Practices.
Reduction in the number of
referrals passed between different
teams within CAMHs.
Waiting lists demonstrate reduced
handoffs between services will
result in quicker access to
appropriate services.
GP feedback demonstrates that
access has improved.
Number of referrals responded to.
Improved access to CAMHS.
Gwent wide review to be undertaken by Children’s
Board.
Pilot Gwent triage in Monmouth and Newport.
Findings reported to ABUHB and NCNs.
Recommendations to be implemented.
Impact on service provision including referrals to
CAMHs to be reported to NCN on a monthly basis.
Establish an NCN wide Working Group to investigate
reducing barriers, improving urgent referrals and
signposting to CAMHs.
Progress
21.9.16. – MH&LD Division reports working in partnership with
the Greater Gwent Commissioning Group to deliver the pilot
triage initiatives. Update report expected at November NCN
meeting.
A
3.4.2 To improve
delivery of Services to
the NCN by PCMHSS.
31.10.16.
Mental Health
and Learning
Disabilities
Division,
NCN Lead,
Practices.
A more responsive PCMHSS
Team.
Improved, sustainable staffing
levels to meet demand on
Service, in particular for Children
and Young People’s services.
Division to develop a report to address recruitment
and provide options for Division to move forward
with recruitment.
Progress
21.9.16. – MH&LD Division to develop options appraisal paper
to address recruitment issues and sustainability of services.
Update report expected at November NCN meeting.
A
3.5 Diabetes
3.5.1 Continued 31.03.17 Access to advice from a multi- • To implement the Diabetes Integrated Service Model G
12
Objective For
completion/
Key partners
Outcome Actions RAG
implementation of the
Diabetes Integrated
Service Model across
the NCN.
Supports IMTP
SCP5
NCN,
Public Health,
ABUHB
Divisions,
Diabetes
Nurse.
disciplinary team &
implementation of the Diabetes
Integrated Service Model and
work plan will lead to improved
outcomes for patients and
increased diabetes services being
provided from GP Practices, led
by a team of Primary Care
Diabetes Nurse Specialists.
Delivery of in-house led training
opportunities for Staff.
across the NCN.
Intervene more regularly, with right information in
the right way – brief advice / intervention.
Discuss increasing Adult Weight Management Service
capacity for specific populations (e.g. Pre-diabetes,
pregnant women) with dieticians.
Progress
21.9.16. – PCDSN Team is delivering services in Practices and
training Practice based staff. Team is also initiating insulin
treatment with patients at Practices reducing the need for
patients to attend secondary care venues for this service.
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
Objective For
completion/
Key partners
Outcome Actions RAG
4.1 Urgent Access
4.1.1 To maximise the
utilisation of
alternative avenues for
advice prior to
referral, adopting
Prudent Healthcare
Principles, ensuring
increased
appropriateness of
referrals.
31.03.17.
Primary Care
and Networks
Division,
ABUHB
Divisions.
Reduced waiting time for
appointments demonstrated by
secondary care waiting list data.
Maximise the utilisation of alternative avenues for
advice where these exist.
Health Board to continue to work with Divisions to
develop alternatives to traditional referral processes.
Progress
21.9.16. – This objective will progress alongside the work of
under 2.2.3. above which relates to Social Prescribing.
A
4.1.2 To improve
utilisation of available
data sources to review
On-going.
NCN Lead /
NM / NSO,
Informed understanding of urgent
access referrals for NCN Patients
to secondary care services.
Regular deep dive analysis of the Newport Core NCN
Performance Report and Single Sheet Reports.
Identify make up of urgent access referrals.
A
13
Objective For
completion/
Key partners
Outcome Actions RAG
urgent access activity
for the NCN.
Practices. Share findings at NCN meetings and instigate
remedial action where appropriate.
Progress
21.9.16. – Performance Reports are continuously being
reviewed and honed. NCN Management Team have been
analysing the Reports to inform strategic and operational
direction within the NCN footprint.
4.2 Frailty
4.2.1 To improve
communication
between Practices and
Frailty and between
Frailty and the OOH
Service.
Supports IMTP
SCP4
31.03.17.
NCN Lead,
Frailty Team,
District Nurses,
OOHs,
Integrated
Forum.
Less hand offs between services,
and improved communication
about the needs of the individual
will result in better quality, more
timely care.
Frailty run charts will show
improvements.
Establish feasibility of co-locating services on the
NCN patch i.e. creating an NCN Hub.
Gain better understanding of pressures that all
services are working under, especially OOH.
Further develop established working relationships,
especially between NCN and Frailty Services.
Monitor at Monthly NCN Management Team meetings.
Progress
21.9.16. – Frailty Team Manager is currently undertaking a
review of the Service and is looking to involve staff on a more
NCN oriented work programme. Update report expected at Q4
meeting.
A
4.3 Social Services
4.3.1 To ensure
improved
communication
between Social
Services Older Adult
Teams and Primary
Care / District Nursing
/ Community Nursing.
Supports Newport
SIP – Integration of
Health & Social Care
31.03.17.
NCN Lead,
Newport
Integrated
Partnership.
Feedback from practices / Health
Visitors / District Nurses /
Community Nurses will
demonstrate improved
communications.
Patients will receive seamless
service transition between
primary care and social services.
NCN links with Social Services
enhanced via named Team
Recent correspondence from a DN Team that they
were having to take up to an hour to reach the
correct contact in the LA in relation to SS
requirements for patients.
Raise issue with Newport Integrated Partnership for
resolution.
Continuously monitor impact with DN Team via NCN
meetings.
Progress
21.9.16. – Social Services Older Adult Teams have now altered
their ‘geographic footprint’ in the City to match the NCN Team
footprints, ensuring greater cohesion with each other’s
G
14
Objective For
completion/
Key partners
Outcome Actions RAG
Leaders. planning foci.
4.4 Out of Hours
4.4.1 Review usage of
Out of Hours services
provision by Newport
West NCN
On-going.
NCN Lead,
ABUHB.
Fewer inappropriate referrals in to
the OOH service
Receive quarterly performance reports from OOH.
Identify areas of high usage.
Develop plan to address.
Progress
21.9.16. – Review undertaken on a quarterly basis to ascertain
performance. Next report due at the November NCN meeting.
A
Strategic Aim 5: Improving the delivery of end of life care
Objective For
completion/
Key partners
Outcome Actions RAG
5.1 Review the
delivery of End of Life
Care using the
Individual Case Review
Audit.
31.03.17.
NCN Lead,
Practices.
0815 Gwent Palliative Care Strategy.docx
Improved care processes for
individuals and families / carers
regarding EoLC provision.
Summarise case review data, identify arising issues
and actions.
Establish a review cycle, to monitor progress.
Progress
21.9.16. – Practices collecting audit data for end of year
analysis.
A
5.2 To review and
implement actions
arising from 2015/16
Audit.
31.03.17.
Practices,
NCN Lead.
Improved consistency in standard
of care delivered.
READ Code training for all Practice staff.
Develop patient recording protocols for Care Homes.
Identify and record carer details.
Ensure availability of carers packs at Practices.
Ensure adequate available access to interpreter
services.
Progress
21.9.16. – Read coding has been provided for Practice staff via
NCN funding. Patient recording protocols are still being
considered, as are recording of carer details. Carers Packs
A
15
Objective For
completion/
Key partners
Outcome Actions RAG
have been distributed to all the NCN Practices. Interpreter
services adequacy is being reviewed. Report on progress of
the above expected in the November NCN meeting.
Strategic Aim 6: Targeting the prevention and early detection of cancers Health Care Standard 3.1
Objective For
completion/
Key partners
Outcome Actions RAG
6.1 Review the care of
all patients newly
diagnosed between 1
January 2016 to 31
December 2016 with
lung, gastrointestinal
and ovarian cancer.
31.03.17.
NCN,
NCN Lead,
Practices.
All lung, gastrointestinal and
ovarian cancer patients will have
their referral information
reviewed and o/p appointments /
results followed up.
Summarise case review data, identify arising issues
and actions.
Establish a review cycle, to monitor progress.
Progress
21.9.16. – Practices collecting audit data for end of year
analysis.
A
6.2 To review and
implement actions
arising from 2015/16
Audit.
31.03.17.
NCN,
NCN Lead,
Practices.
Findings from 2015/16 audit
reviewed and implemented, as
appropriate.
Ensure Practices refer patients as ‘USC’ rather than
‘Urgent’ if cancer was suspected.
Encourage patients to attend appointments with
Screening Programmes.
Ensure referring GPs are informed by Secondary Care
Consultants of downgrades to USC referrals.
Progress
21.9.16. – Progress report expected on the above at the
November NCN meeting.
A
16
Strategic Aim 7: Minimising the risk of poly-pharmacy Health Care Standard 2.6
Objective For
completion/
Key partners
Outcome Actions RAG
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.
31.03.17.
NCN Lead,
Practices,
Community
Pharmacists.
Identification of patients at high
risk or harm of either over or
under medication.
Undertake a review of practice clinical systems to
identify patients over the age of 85yrs in receipt of 6
or more medicines.
Undertake face to face medication reviews.
Progress
21.9.16. – Practices collecting audit data for end of year
analysis.
A
7.2 Medicines
Management
7.2.1 Appointment of
Pharmacists in Primary
Care to assist the
delivery of safe
prescribing to the NCN
population.
On-going.
NCN Lead,
Practices,
Community
Pharmacists
0715 Pharmacists in Primary Care.docx
Efficient use of resources that can
be re-invested more appropriately
into patient care.
Increased face to face meetings
with Pharmacists in Primary Care
thus releasing capacity for GPs.
Recruit and appoint additional Pharmacists, on either full
time, part time or sessional bases.
Consider working with Community Pharmacists on a
sessional basis.
Agree range of duties expected of appointees.
Reporting and monitoring activities and impact of
appointments to NCN Lead.
To review variations in prescribing.
Establish feasibility of extending age range for audit.
Provide consistency of medication reviews in
Practices/Home settings.
Progress
21.9.16. – Interview panels for additional Pharmacists in
Primary Care being held on 29/9 and 4/10. Suitable
candidates are expected to be recruited from the process.
Option to employ sessional Community Pharmacists still under
consideration by NCN. Existing Pharmacist performance
reports have been very positive and well received by Practices.
A
17
Strategic Aim 8: Deliver consistent, effective systems of Clinical Governance
Objective For
completion/
Key partners
Outcome Actions RAG
8.1 Clinical
Governance
8.1.1 To fully
implement the Clinical
Governance Toolkit.
31.03.17.
PC&ND.
Practices are supported in
completing the CGSAT
Practices to ensure completion of CGSAT.
Progress
21.9.16. – Practices have started to complete the toolkit.
Regular progress reports have been provided by the QPS Team
to show which Practices have started their toolkits or not and
how much they have completed.
A
Strategic Aim 9: Other Locality issues
Objective For
completion/
Key partners
Outcome Actions RAG
9.1 Managing
Obesity
9.1.1 See 1.1.1
above.
A
9.2 Smoking
Cessation
9.2.1 To maintain
brief intervention and
referral levels of
residents wishing to
quit smoking.
Supports Newport
SIP – Tobacco
31.03.17. Increased numbers of staff who
have access to brief intervention
training.
Increased access for patients to
staff trained in brief intervention
techniques.
Continue to access brief intervention training
courses.
Identify Smoking cessation Champions across the
NCN Partnership Network.
Monitor via Core Performance Reports.
Progress
21.9.16. – awaiting NCN based activity reports that are being
developed between Public Health Wales and Stop Smoking
A
18
Objective For
completion/
Key partners
Outcome Actions RAG
Control /Smoking
Supports IMTP SCP3
Patients will be motivated to
make a quit attempt and will
receive effective treatment to quit
smoking.
Wales.
9.4 Newport
Directory
9.4.1 Improve
information available
to the NCN.
DEWIS information
portal to be
investigated.
31.03.17.
NCN.
An on line information directory
will be developed.
Staff provides informed
information, advice and support
to patients.
Progress
21.9.16. – NCN Management Team members have received a
demonstration of the DEWIS information Portal hosted by the
Local Authority and will consider how it can be utilised, in
conjunction with the Community Connector’s Directory, to meet
the requirement of this objective.
A
9.5 Living Well,
Living Longer
9.5.1 To prepare for
the introduction of the
Living Well, Living
Longer Programme
across the NCN.
31.03.17.
PHW, NCN,
ABUHB.
Screening and assessment
services for cardiovascular
disease, diabetes and stroke will
be widely available to patients
over the age of 40.
It is expected that the Programme will be launched in
Newport in 2016/17.
Progress
21.9.16. – At the September meeting of the Newport Health
Network it was announced that the Programme had been
delayed for implementation until Q4 of 2016/17.
A
9.6 Newport
Regeneration Plan
9.6.1 To participate in
a targeted approach to
deliver integrated
health and social care
services in the most
deprived communities,
as defined by the Local
Services Board Unified
Needs Assessment and
On-going.
Local Authority,
PC & ND,
NCN Lead,
NM / NSO,
Other LSB
Partners.
Targeted integrated health and
social care services for the most
deprived communities in the NCN
area.
PC & ND and NM / NSO to keep up to date with
integrated planning developments and
implementation plans and report back to NCN
membership.
Progress
21.9.16. – Network Manager and Practice Manager both
attending SIP meetings, providing planning and support to the
Health, Social Care and Well Being Sub Group and other
related Community Groups.
A
19
Objective For
completion/
Key partners
Outcome Actions RAG
Ward Profiles.
Supports Newport
SIP – Integration of
Health and Social
Care
Supports IMTP –
SCP 3
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