Anglesey GP Cluster Network Action Plan 2015 Final … GP Cluster...GP practices, West Area Management Team, developers, LA, and other stakeholders. See premises plan below. All Ongoing

2015 Version 0a 1

Cluster Network Action Plan 2015-16 (second year of the Cluster Network Development Programme)

Anglesey Cluster

The Cluster Network1 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 2

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 collaboration- e.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

2 To identify additional information requirements to support service development

Improved support for service development

3 To consider learning from 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

2015 Version 0a 3

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? Named Lead

Time Scale

2015 Version 0a 4

Smoking cessation

23% of adults smoke on Anglesey (2012/13). Although this shows a reduction from 2011/12, it is still above the North Wales average of 21%. Smoking is linked to social class and accounts for a high proportion of the inequalities in health outcomes. North and West Anglesey has the highest level of deprivation and had the highest level of smoking-attributable admissions in BCU. Quitting smoking offers better improvement to healthy life expectancy than almost any other medical or social intervention. 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. Variable referral rates and access to smoking cessation services on the island.

Implementation 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 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.

Clear model pathway for smoking cessation has been developed for practices to adapt to their own circumstances to support smokers in their efforts to quit. However recent audit suggests adoption and knowledge of this pathway varies. Steve to present findings of audit at future Cluster meeting and share smoking cessation success rates with practices

PHW are undertaking work to map smoking

cessation services across the island starting in

Holyhead first. The objective is to ensure an

integrated smoking cessation service across

community, secondary care, mental health,

social care, and other local settings. Steve to continue discussions with PHW and support their efforts to link with GP Practices.

Undertake audit of how many practice staff have undertaken smoking cessation brief intervention training and record %

Encourage all practices to sign up to the Smoking Cessation LES. Record % undertaking LES

Steve Sarah

6 m 3 m 6 m 6 m

2015 Version 0a 5

POPULATION NEED (Priority 2 to be chosen by Cluster)

Priority 2 The issues Aims and objectives How will this be done? Named Lead

Time Scale

Obesity

29% of boys and 23% of girls aged 4-5 are overweight or obese in Anglesey, which is slightly over the BCUHB average. 57% (2012/13) adults on Anglesey are either overweight or clinically obese. 23% of adults are clinically obese and this figure has risen from 21% the previous year. Increasingly significant public health challenge

To ensure that there is a clear locality pathway to support individuals trying to lose weight Provide education for practice nurses and other professionals

Map organisations on the island already providing weight loss support. To be discussed at Locality Leadership Team meeting and shared with practices. Ensure all practices aware of where to refer patients for exercise (NERS) and Hip and Knee Lifestyle Program. To be discussed at Cluster Meeting. Support development of obesity pathway in BCUHB including bariatric surgery Support weight loss research project on the island once funding obtained. Unfortunately to date funding for research has not been forthcoming. To continue discussions with Bangor University Sports Science team. Obesity is one of the priorities for the Locality Leadership Team. Action plan to be shared at Cluster Meeting.

Sarah Steve Steve Steve Steve

6 m 3 m 1 y 2 y 3 m

2015 Version 0a 6

ACCESS

(to ensure the sustainability of core GP services a nd access arrangements that meet the reasonable nee ds of local patients)

Priority The issues Aims and objectives

How will this be done? Named Lead

Time Scale

Availability of

patient

participation

group within

the practice or

locality

Practices are encouraged to consult closely with service users by WG

Provide peer support in

relation to setting up a

patient participation

group – methods

available – i.e. via

website, or by selection

Representatives from local groups to be selected: Specific groups and individuals already identified by practices. Review engagement progress at Cluster meeting

Discussion within cluster network in relation to

representation required from practice – i.e. clinicians,

senior administration, and patients?

Consider engagement group for whole island

instead: discuss with Locality Leadership Team

Steve

Steve

6 m 1 y

2015 Version 0a 7

Supporting Carers

Identification of patients that

are carers and offer them

support e.g. Carers outreach

services or similar +/or other

ways of supporting them

Promote Carers legislation and guidance Provide training to practices

Provide training for practices regarding Carers issues Provide literature for practices to give to patients and carers: to be discussed at Locality Leadership Team meeting Provide information on help available in Locality: mapping process underway Audit recording of Carers on practices IT systems

Cluster money to be used to appoint 3rd Sector liaison professional who will attend Patch MDTs and educate practices. This post should help with these challenges.

Steve Ann

Steve

Steve

Steve

Sian

2 y

6 m

6 m

1 y

Oct 2015

Patient

Appointments

Increasing demand for appointments. Some attendances could be dealt with other than by face-to-face consultations with GP/Nurse. Need for improved patient education and promotion of self-care.

Reduce unnecessary

appointments

Improve patients and

families self-reliance

Offer on-line booking of

appointments and

requests for repeat

prescriptions.

Practices to learn from each other and share examples of different appointment systems and approaches. Formation of EMIS Users Group on island. First meeting to be held in Protected Time session in November

Improvements in website information particularly regarding self-management to patients both at practice, locality and BCUHB website levels. To be discussed at Locality Leadership Team meetings

Individual practices to apply for funding from Cluster Fund to purchase software including patient electronic arrivals screen and submit to Steve Enable use of internet for appointments and prescriptions

Dyfrig Steve Steve Dyfrig

3 m 1 y 1 m 3 m

2015 Version 0a 8

in all practices. Record %

I.C.T. access to

hospital

investigation

reports

GP Practices do not currently have access through IT links to hospital investigation reports which leads to duplication, time wasted in chasing up reports, and poorer patient care

To support the

implementation of GP

IT access to

investigation reports

Practices have already expressed interest in being involved in roll-out of GPTR ICT programme and have attended demonstrations of software. Hopefully will be rolled out to all practices soon.

Steve 6 m

2015 Version 0a 9

Wylfa and other commercial developments on the island population

A number of developments are being planned for Anglesey including Wylfa B nuclear power station, Land and Lakes tourist destination, and Lorry Terminal It is predicted that this could result in as many as 6000 workers and their families moving onto the island This will have an implication for provision of community care on the island including workforce and premises issues

To assure regular dialogue with developers, PHW, BCUHB and other agencies to ensure community services supported with this predicted increase in population

Continue current series of meetings involving relevant GP practices, West Area Management Team, developers, LA, and other stakeholders. See premises plan below.

All Ongoing

48 hour Ambulatory ECG (AECG) Service in the community

Currently long waits for patients to have ambulatory ECG (AECG) investigations in secondary care

To enable GP Practices to have direct access to AECG recording for their patients

4 AECG machines leased from Cardionetics and put into Amlwch, Llanfair, Coed Y Glyn, and Holyhead GP practices. Guidelines for use done. Self reporting software installed. Audit of use and outcomes to be undertaken at end of 12m use. Training session to be arranged with Mark Payne

Steve

12 m 3 m

2015 Version 0a 10

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.



Time Scale

Recruitment in

General

Practice

Reduced availability of trained GPs to fill vacancies in practices. Potentially this could get worse over the next few years with expected GP retirements. Small pool of available GP locums. Increasing workload in primary care and fairly static GP numbers

To improve GP recruitment in BCUHB with particular reference to Anglesey

Use of Cluster Fund to develop a combined GP and Care of the Elderly post on the island. 12-24 month post. Post-holder to rotate through different GP Practices on the island to gain experience, support care of the elderly in the community, and hopefully stay to work on the island in future. (See Cluster Fund Application). Job advert has been out and interviews for post due soon. Individual practices can use the time they host the post holder to pursue relevant projects which could include visiting local schools to promote primary care and also have 6th formers attend the practice for work experience.

Steve Appoint by Jan 2016

2015 Version 0a 11

Practice Nurse and Community Nurse Development

Need to develop highly trained primary care and community nursing workforce including health care support workers (HCSW), practice nurses with specialist skills, community nurses with specialist skills, and ANPs including prescribing Nurse Practitioners

Loss of ANPs would be

detrimental.

Employment of more ANPs

would be beneficial.

To promote practice nursing and health care support working as a career locally and provide high quality training for all levels.

Retention of ANPs by

enhancing their

portfolio and training

Support clinical placements for student nurses (3rd Years) in primary care.

Organise regular evening training sessions for Practice

Nurses and HCSWs in Ysbyty Gwynedd. Draft program has been developed and sessions due to start in Jan. 2016. Evening sessions. Payment to HCSWs and Nurses to attend through Cluster Fund.

Produce Nurse training resources booklet for practices. Draft produced and awaiting final version before circulation to practices and community nurses.

Recognition and support for particular practices as nurse

training practices through creation of LES. Proposal for such a LES has already been submitted. Decision awaited. Improve integration between Practice and District Nursing

by development of combined posts. Proposal paper for such posts has been written and is being presented to WG. Decision awaited. Make a 4 day course in the School of Nursing specifically for new practice nurses available to practices on Anglesey

Locality Matron will continue to identify senior

nurses working on Anglesey who should be encouraged

and supported to apply for ANP Training. One nurse has

already been successful in her application and will be

joining Mon Enhanced Care (MEC) soon.

Nicky

Nicky

Nicky

Nicky

Nicky

Steve

Tina

3 years Start Jan 2016 3 m 6 m 6 m 3 m Ongoing

2015 Version 0a 12

Develop training

networks that will be

able to deliver formal

structural educational

programme and

support for practices.

Review workforce modelling – scope for HCSWs to

undertake nursing tasks (based on competencies). Arrange

training course accordingly. Draft program has been developed and sessions due to start in Jan. 2016. Evening sessions. Payment to HCSWs to attend through Cluster Fund.

Development of rotational training post in community

nursing: Community Hospital, Community Nursing, and

Practice Nursing. Draft proposal written.

Diabetes Education Programme for primary care

professionals being developed in association with Anglesey

Diabetic Plan. Debra Hughes (Specialist Diabetic Nurse) due to start in community on island in September.

Nicky Nicky Debra

6 m 1 y 3 m

Community Nursing

There seems to be an increasing workload for District Nurses coinciding with a reduction in numbers of District Nurses on the island.

Increasing workload partly due to drive to look after people in their own homes, earlier discharge from hospitals, and ageing population

To support the development of the community nursing teams on the island

Locality Matron has and will continue to attend Cluster

Meetings to discuss plans for community nursing.

Successful recent meeting has led to clear plan based on 3

Band 7 led teams on the island with improved integration

with GP Practices with smaller teams of community nurses

based in specific practices (Beaumaris, Llanfairpwll,

Bryngwran, Tal Y Bont, and Amlwch) Improve integration between Practice and District Nursing

by development of combined posts. Proposal paper for

such posts has been written and is being presented to WG.

Decision awaited.

Tina Nicky

6 m 6 m

2015 Version 0a 13

Development of management and reception teams in primary care

No clear education structure for Practice Managers and other staff

To develop a clear education plan to support Practice Managers and other staff in their work

Education needs document has been circulated and

completed by practices to identify their training needs.

Steve to analyse information

Arrange training sessions for practice management and

administration teams based on identified training needs

Steve Jan 2016

2015 Version 0a 14

REFERRAL MANAGEMENT AND CARE PATHWAYS



Time Scale

Complex patients including those with several co-morbidities

With the current workload and available workforce it is difficult for practices to give enough time to patients with “complex” problems Practices would benefit from education and support in looking after patients with multiple comorbidities

Encourage development of specialist services in the community closer to GP practices Support specialist nurse mentoring of Practice Nurses and GPs looking after these patients

Provision of more specialist services in the community

such as outreach respiratory clinics. To re-open

discussions with

respiratory consultant

Development of Diabetes Service on Anglesey. Debra

Hughes has been appointed as has Ruth Edwards

(Dietician). Diabetes project will include mentoring,

education, outcome measurements, focus on high risk

patients etc

Objectives include:

- Targeting patients with high HbA1c, polypharmacy, or

risk of hypo’s

- Xpert training / structured education

- Insulin initiation

- Joint clinics

- e-learning

- National diabetes audit at practice level

Appointment of GP/COTE salaried post (see above)

Steve Debra Steve

6 m 3 m Jan 2016

2015 Version 0a 15

Dementia Training in recognition, assessment, and management for primary care team

Provision of specific dementia training to practices

Development of dementia services on island

Provide directory of educational resources for practices on dementia topics Practices to take part in Dementia RED programme. Record % taking part. Discussions on dementia services occur regularly in Locality Leadership Team meetings. Dementia strategy under development. Practices to be informed of developments at Cluster Meetings Cluster money to be used to appoint 3rd Sector liaison professional who will attend Patch MDTs and educate practices

Bethan Steve Steve Sian

1 y 6 m 6 m Oct 2015

Referral performance feedback

GPs and other primary care professionals would value feedback on their referrals

To put in place a system to facilitate timely feedback from specialists to primary care as part of an educational process

Develop system for feeding back issues by specialists

such as “appropriateness” of referrals back to GP

practices by ongoing discussions at Primary Care / Secondary Care meetings.

Monthly Ynys Mon Medical Society Meetings programme to continue. Topics discussed often cover referral management and give general feedback on referrals

Steve Steve

Ongoing Ongoing

2015 Version 0a 16

Provision of open access for primary care to specific investigations

There are some investigations provided by secondary care that are not open to GPs and require referral to consultants first. This can on occasion cause delays in patient care and may also be less cost-effective

To develop open access pathways for (1) Faecal calprotectin (2) Echocardiogram (3) MRIs/CTs

Continued discussions at Primary / Secondary Care

Meetings

Business plan to be developed for Faecal Calprotectin

For discussion with Community Echocardiography / HF

Team regarding increasing GP access

Outcome of discussions has already highlighted that consultant radiologists very happy to discuss specific investigations with GPs

Avril Steve

6 m 3 m

CAMHS There is uncertainty about the referral process to CAMHS and school nursing services

Uncertainty regarding responsibilities for prescribing of drugs such as SSRIs in young people

Enable clear

understanding by GP

Practices of referral

route for various Tiers

in CAMHS

Education session has occurred and main outcome is awareness of SPOA telephone number in CAMHS 1-3pm Mon-Fri allowing access to CAMHS professional for advice.

CAMHS to be invited to sit on Locality Leadership Team to improve locality awareness and feed in to locality plans Meeting with CAMHS to be arranged to discuss prescribing responsibilities

Steve

3 m 6 m

2015 Version 0a 17

Community Mental Health Services

Access to low level mental

health support within the

community.

Ongoing uncertainty on

who to refer to for mental

health support (Parabl,

CMHT, practice counselling

etc)

Uncertainty over

responsibilities when anti-

psychotics and other

medication being

recommended by

consultants

Establish a coherent

mental health service

with clear

management structure

and guidelines

Cluster Meeting has occurred with CMHT Management and Parabl to discuss issues. Further meeting has been arranged for October 2015.

Development of clear shared care guidelines for anti-psychotic medication. To be discussed in October meeting.

CMHT Manager to be invited to Locality Leadership Team

Steve Oct 2015 Oct 2015

Care Home Admissions

Lack of patient information provided regarding patients

admitted to a Care Home

out of their usual practice

area

To develop a system to ensure timely provision of all relevant information about a patient admitted to a Care Home to that Home and the relevant General Practice

Development of e-communication process

Embed communication pathway and documentation into

everyday practice

Audit use of Care Home Admission Pathway Use of tablet devices to allow access to GP records in Care Homes

Elin Steve Endaf

1 y 1 y 1 y

2015 Version 0a 18

UNSCHEDULED CARE (To provide high quality, consistent care for pati ents presenting with urgent care needs and to suppo rt the continuous development of services to improve patient experien ce, co-ordination of care ad effectiveness of risk management)



Time Scale

Supporting provision of Near Patient Testing (NPT) in practices

Some tests can be used more effectively if result available without delay

To trial the use of a CRP NPT machine in primary care Quick access to CRP result will inform patient care including appropriate use of antibiotics

Installation, and trial of a CRP NPT machine in Amlwch

Surgery to see if it aids management decisions and

allows better informed prescribing of antibiotics.To

review outcomes after 6 month trial including reduction

in antibiotic prescribing and appropriate referral to

secondary care.

Alison Oct 2015 onwards

ED Attendance Some patients attend ED

inappropriately

Some frail elderly patients

end up attending ED and

AMU inappropriately

To develop a system where patients can be safely referred from ED back to their own GP for advice or appointment To support the Treatment Escalation Plan (TEP) pilot as a Cluster and support wider implementation

Discussion between GPs and ED Consultant Team on best mechanism to do this. Options include provision of on-line booking of GP appointments by ED staff.

Steve to continue attending TEP Steering Committee

meetings

Use of some Cluster Fund monies to ensure the pilot

continues for further 6 months to ensure measurable

outcomes

Medwyn Dyfrig Steve

1 y 6 m

2015 Version 0a 19

AKI Acute Kidney Injury is a significant cause of unscheduled admissions

To provide information to patients on how to avoid AKI To audit episodes of AKI in YG involving primary care

Incorporate AKI Patient Information Leaflet into

everyday practice by ensuring practices all have an

electronic copy

Circulate copy to community pharmacies so that they

can attach to prescriptions

Arrange YMMS meeting on AKI (22/9/15)

Steve Alison Steve

3 m 3 m Sep 2015

Development of Enhanced Care Service / Mon Enhanced Care (MEC) I.V. Therapy provision Support of housebound patients with chronic disease such as COPD

Availability of nursing and social care support out of usual hours

Services to be developed more to provide more comprehensive 24 hour 7 day a week service

Difficulty recruiting nursing

professionals to take part in

MEC

Needs proper staffing and

resourcing and further

integration with district

nursing teams

To support development of effective Enhanced Care Service (MEC) on the island To support provision of IV therapy in the community To support the development of user friendly referral documentation using appropriate e-referral system

Regular meetings with Locality Matron and MEC Team including COTE consultant to discuss issues (see above)

Introduce “step-down” discharges from hospital through MEC once staffing levels sufficient

Support community nursing developments (see above) Support development of I.V. therapy provision through MEC and HB initiatives

Community services regularly discussed in Locality leadership Team meetings including use of ICF monies. Appointment of GP/COTE salaried post (see above)

Steve Sion Tina Iola

Ongoing

2015 Version 0a 20

Emergency

admissions

Viable alternatives for GPs

in relation to emergency

admissions

To develop clear alternative pathways agreed between GPs and consultant colleagues

GP to be able to discuss case with middle

grade/consultant and arrange clinic review

Some specialities currently have telephone advice

service (i.e. neurology) – scope to roll this out to other

specialities

Agreement between clusters and secondary care

clinicians in relation to nominal availability of sessions

available for advice in each speciality (i.e. diabetes)

Enter dialogue with Secondary Care on these issues through ongoing meeting program Up to date register of hospital services including consultants, wards, laboratories etc with contact numbers and emails

Steve Meinir

Ongoing 6 m

2015 Version 0a 21

TARGETING THE PREVENTION AND EARLY DETECTION OF CAN CERS (Refer to National Priority Areas CND 006W)



Time Scale

Referral of patients to other practices in the Locality for specific services

Some practices undertake specific procedures relevant to early detection of cancer that might be a useful referral option for other practices. Examples include sigmoidoscopy, dermatoscopy, minor surgery and indirect laryngoscopy.

Explore option of referrals from GP Practice to GP Practice for specific services

Map current services offered by practices Look at similar models adopted in UK elsewhere Consider funding options Provide training opportunities for practices

Steve 3 y

Cancer probability scoring systems

Early detection of cancer is very important but often difficult

To educate GPs and other health professionals in locality on how to use scoring systems such as Qcancer

To hold an education session as part of Ynys Mon Medical Society programme in 2016 on topic

Steve 1 y

Gastroenterology referrals

Long waiting lists for some investigations Instances of delayed diagnosis of gastrointestinal malignancies noted by

Improve early detection rates of gastrointestinal malignancies

Discussions have already been held in primary care / secondary care meetings with gastroenterology. Outcome of discussions was to arrange a workshop to

look at gastroenterology referral pathways

Steve

6 m

2015 Version 0a 22

practices

IMPROVING THE DELIVERY OF END OF LIFE CARE (Refer t o National Priority Areas CND 007W)



Time Scale

DNA CPR forms Advanced Decision Making

Confusion in relation to

DNA CPR status within

various settings – i.e.

hospital , care homes and

OOH - particularly when

patient transferred

Need to discuss end of life

issues more with patients

and their families

Everyone looking after a patient should be clear as to whether a DNACPR form is in place and when it was last discussed with the patient and family

Promote Advanced Care Planning to our patients and families

To support the Treatment Escalation Plan (TEP) pilot as a Cluster and support wider implementation

All practices will start using the All Wales DNACPR

form which will be transferable between settings

Ask Palliative Care Team to provide input into the organisation of GP practices palliative care meetings through End of Life Co-ordinator.

Steve to continue attending TEP Steering Committee

meetings

Use of some Cluster Fund monies to ensure the pilot

continues for further 6 months to ensure measurable

outcomes

All Jayne Steve

Oct 2015 3 m 6 m

2015 Version 0a 23

Use and availability

of Just in Case Boxes

Issues within care homes

particularly out of hours: no

palliative care medication

available

Sometimes a lack of

anticipatory prescribing by

primary care teams

Only a few pharmacies

provide Just in Case Boxes

To explore possibility of Care Homes holding a Just in Case Box even though not for a specific patient Promote use of Just in Case Boxes on the island Increase number of pharmacies providing Just in Case boxes

Discuss with Prescribing Management Team Audit current use of Just in Case boxes Audit instances where lack of anticipatory prescribing created problems for patient and their families

Alison Alison Jayne

1 y 1 y

Practice Palliative Care Meetings

Challenge is to make the meetings as productive as possible

To share good practice

Educate practices on alternative to using GOLD Classification Share palliative care templates in EMIS User group

Jayne Dyfrig

6 m 6 m

Palliative Care Education

Education for primary care professionals and Care Homes is important to improve palliative care in the community

Provide good quality education locally

Arrange palliative care educational sessions through discussions with palliative care team

Steve 1 y

2015 Version 0a 24

MINIMISING THE HARMS OF POLYPHARMACY (Refer to Nati onal Priority Areas CND 008W)



Time Scale

Falls prevention Anglesey had the second

highest Hip Fracture admission

rate in Wales, with 790 per

100,000 population in

Anglesey, against 636 in

Wales. There has been a

marked upward trend in

numbers since 2007, i.e. 300

to 500 per 100,000 in 2010.

One significant contributing

factor in the elderly is

polypharmacy

To use pharmacy colleagues to help rationalise treatment in patients on multiple medications particularly those likely to cause low blood pressure. To liaise with Falls Prevention Team on island

Falls prevention is a priority for the Locality Leadership Team. To discuss with Locality Leadership Team and in particular with Prescribing Team Record number of MURs undertaken by pharmacists both in practice, in patients’

homes, and in community pharmacies GP practices to continue medication reviews in over 85s and in those patients on several medications: review outcomes

Alison Alison

9 m 1 y

2015 Version 0a 25

AKI Polypharmacy can lead to acute kidney injury due to lack of awareness of risk

To provide information to patients on how to avoid AKI

Incorporate AKI Patient Information Leaflet into

everyday practice by ensuring practices all have an

electronic copy

Circulate copy to community pharmacies so that they

can attach to prescriptions

Arrange YMMS meeting on AKI (22/9/15)

Steve Alison Steve

3 m 3 m Sep 2015

2015 Version 0a 26

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; Healt h Board) Named Lead

Time Scale

2015 Version 0a 27

Capacity within

current buildings

including car

parking

Not enough

room for

existing

services

Other agencies

using rooms

within the

building

Practices keen

to house more

members of the

Patch MDT if

only they had

room

Practices keen

to develop

services

Difficult to

increase

training

capacity on the

island

Link budget for

spatial

development to

commitment to

training or

development of

specific services

Liaise with Local

Authority

Liaise with

BCUHB

1. New Primary Care building to be built on the Ysbyty Penrhos Stanley site to

incorporate all 3 Holyhead Practices

2. New Primary Care building to be built on the site of the proposed Extra-

Care Housing scheme in Llangefni to incorporate both Llangefni surgeries

3. Beaumaris Health Centre: Extension to provide more space for MDT

working and new services. Alterations to Reception area to improve

patient confidentiality.

4. Bodorgan, Llanfaelog, and Gaerwen: Working to full capacity and all 3

buildings would benefit from an extension.

5. Cemaes Surgery: Creation of additional room for HCA.

6. Coed Y Glyn: Funding for an extension if unable to proceed with new

building in Llangefni (see 2. above)

7. Dwyran: Disabled access needs improving. Additional space / extension

required for dispensing team.

8. Gwalchmai: Insufficient storage space for records: alternative storage

options to be explored.

9. Llanfairpwll Health Centre: Significant lack of space both in building and in

car park. HB owned building. Plenty of space to develop around the

building. Significant extension needed to fully develop services and MDT

working.

10. Longford House: Adaptations to surgery garage to store patient records.

Steve 3 y

2015 Version 0a 28

11. Star: Needs grant to improve disabled access

2015 Version 0a 29

MPIG Changes

Potential closure

of branch

surgeries

Loss of staff due

to costs

Funding

pressures in

line with loss of

MPIG

Plans to close

Transport

problems for

patient (in the

event of

branches

closing)

Identify cost

implications in

relation to loss

of MPIG.

Discussion with PCSU, BCUHB, GMC and WG through LMC Endaf Richard

Ongoing

Some practices are concerned regarding lack of confidentiality in their reception areas

Open plan

reception areas

causing concern

Sharing of

experiences of

different

reception area

design

Liaise with BCUHB regarding improvement grants

(see premises plan above)

PMs group 1 y

Disabled Access Some practice buildings are not disabled compliant including facilities for deaf

Map problems

regarding

disabled access

Discuss with BCUHB Estates Enquire regarding grants for specific equipment options to help patients with deafness access services

PMs group 3 y

Storage facilities for patient records in GP practices

Some Practices do not have enough room to store all their patient records

Explore

alternatives

Consider central BCUHB storage or storage on island Review National Guidelines regarding destroying paper records after scanning onto computer systems Provision of administration support to help practices scan all old paper records on to ICT system

Explore private firm provision such as Iron Mountain

Steve 1 y

2015 Version 0a 30

2015 Version 0a 31

CLUSTER NETWORK ISSUES

Issue Why? What will be done?


Time Scale

Administrative and project management support

A lot of Cluster ideas and projects are either not progressing or moving forward too slowly partly because of a lack of administrative and project management capacity

Support formation of new Area Team and Cluster Support Team

• Regular dialogue with senior Area Management Team at Health Board level

Steve 3 m

2015 Version 0a 32

LHB Issues

(in addition to any issues raised above requiring Health Board input)



Time Scale

Paperwork Too much paperwork for primary care

Reduce unnecessary paperwork

PCSU/HB review of paperwork that Practices have to complete “Paper!” to be produced on how this can be addressed

PCSU PMs

3 y

Welsh Language What support is available for practices?

Review current support and identify unmet needs

Discussion between BCUHB, Cluster, LA, and 3rd Sector Steve 3 y

Changing practice list sizes

Some practices feel under threat because of dropping list sizes, threatened closure branch surgeries and others are concerned regarding big influx of patients due to local developments such as Wylfa

Formation of clear strategy for the island regarding primary care provision and support of General Practice

Meetings between GP Practices and PCSU/BCUHB/Estates Primary Care Workforce strategy document being developed

Steve PMs group PCSU

18 m

2015 Version 0a 33

LHB Issues




Time Scale

Communication between primary and secondary care

Some issues mentioned above but worth repeating because patient care could be improved if communication was improved

Discussion of all aspects of communication in meeting between Ysbyty Gwynedd (YG) and GP Practices

Needs support from BCUHB Arrange attendance of YG team at future Cluster Meeting Further discussion in Primary-Secondary Care evening meetings program

Steve Ongoing

Information on BCUHB Intranet

Often difficult for primary care to access information on the BCUHB Intranet

Discussion between primary care and BCUHB on what needs to be developed

Issues to address include one clear point of access to all referral pathways Steve 1 y

IPFR GPs find IPFR process bureaucratic and question its necessity and its affect on patient choice

Clarification of need for IPFR for primary care patients

Meeting between IPFR Team BCUHB and GP Practices Steve 1 y

2015 Version 0a 34

LHB Issues




Time Scale

Specific Service Improvements in the community

There is documented concern about deterioration in provision of a number of services in the community affecting patient care

Discussion with BCUHB regarding concerns raised by GP Practices

Areas of concern include the following: Stroke Services in the community Physiotherapy Services in the community Speech Therapy Services Dementia Services particularly Day Care provision Mental Health Services particularly lack of substantive consultant psychiatry post on Anglesey Need for more Care of the Elderly specialist support in the community Better access to DAPHNE in the West Better access to dietetic services for patients with low BMI Pulmonary Rehabilitation Services Availability of equipment such as hip protectors

Continuing Health Care Funding

CHC Funding applications bureaucratic and time-consuming

Streamline application process? Leave responsibility in hands of Patch MDT? Nominal budgets for Cluster or Patch MDT?

Discussion at BCUHB level Steve 3 years

Documents

Anglesey GP Cluster Network Action Plan 2015 Final … GP Cluster...GP practices, West Area Management Team, developers, LA, and other stakeholders. See premises plan below. All Ongoing