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Cluster Network Action Plan 2015-16
North Pembrokeshire Cluster
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The GP Cluster Network1 Development Domain supports GP Practices to work to collaborate to:
• Understand local health needs and priorities. • Develop an agreed GP 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 development of primary and community services is a key element of all LHB’s 3 year service delivery plans.
The Action Plan should be a simple, dynamic document. 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. This approach should support greater consistency of service provision and improved quality of care, whilst more effectively managing the impact of increasing demand set against financial and workforce challenges. Each cluster objective should be accorded a RAG (Red, Amber, Green) rating. This will provide a useful tool to enable the GP Cluster and the LHB to take an overview in terms of the progress of delivery of each objective.
1A 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
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Strategic Aim 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 collaboration- e.g. Community First to support more effective engagement with local groups. No Objective Key
partners For completion by: -
Outcome for patients
Progress to Date RAG Rating
1 To review the needs of the population using available data
Local Public Health Team Public Health Observatory
Sept 2014
To ensure that services are developed according to local need
Cluster Network serves a population that is : -
Older than Welsh average - potentially the greatest impact on
primary care (more chronic illness that will need active management).
Cluster is in line with the HB average for patients 65+ and 85+ it is higher than the Welsh average for both age categories.
Increasing/decreasing- population within North Pembrokeshire remains stable (63,950) - largest population of the clusters within
HDUHB. Up 2.4% in last 10 years. September 2013 saw approval by Pembrokeshire Planning Committee for some 900 new homes in Haverfordwest.(since
reduced to 720). Works commenced in 2015, completion due 2018. Haverfordwest Practices expressed again their concern with regard to capacity for these new patients alongside the current recruitment difficulties. They have received no planning information. Individual practice populations range from 2,500 to 14,200.
Established or transient - Cluster is a tourist area and the
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population significantly increases during holiday seasons.
Little mixed ethnicity
Deprivation greater/less than Welsh Average and
variable/consistent across the area North Pembrokeshire has the third highest deprivation rate out of the clusters within the HDUHB area with 8.4% of its population being classed as most deprived. Whilst this is significantly below the Welsh average of 20% it is above the HDUHB average of 8.1%. 55.7% of the North Pembrokeshire population are considered as living in a rural area.
Chronic condition burden is comparable to other Cluster areas within the HB but can vary against the All Wales Average.
2 To identify additional information requirements to support service development
Local Public Health Team NWIS
Improved support for service development
For example, High premature cardiovascular mortality – need local Dashboard to understand consistency of prevention and risk management Action: - for development with HB
Improvement in coding rather than use of “unwell”
3 To consider learning from previous analyses to identify any outstanding service developme
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nt needs
4 My Health Online (MHOL)
Free up resources within the practice and be more convenient for patients as they will not need to call the practice.
It was agreed that during 2015/16 all practices within the Cluster would implement My Health Online. To date 5 practices (Winch Lane, Barlow House, St Davids, St Thomas & Newport) are live, 3 practices offer both appointments and prescriptions and the two currently offer prescriptions only with a view to offering appointments in the future. The other practices have committed to implementing MHOL during 2015/16 (Fishguard, Solva & Robert Street). Goodwick will implement in 2016 as they have been advised that once the clinical system has been merged with the St Davids system all patients would need to register with MHOL again.
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Strategic Aim 2: To ensure the sustainability of core GP services and access arrangements that meet the reasonable needs of local patients
Consider the National Survey for Wales, local feedback and individual practice analysis. In the National Surveyor Wales 38% of people found it hard to get a convenient appointment – for a number of reasons such as Long wait for appointment ; early morning calls; Appointments not available on the same day ; Difficulty getting through to make the appointment ; Could not book appointment with doctor of choice ; Appointments not available at convenient times. Is there an accurate measure of demand- if not consider data collection to articulate the scale of action required.
Consider what capacity could be released by minimising system waste- chasing appointments, discharge letters and specialist advice. If that is a significant issue ensure that data is captured to highlight the scale of the problem and include this as an issue to be taken forward by the LHB. Recruitment and retention- risk in some areas. Ensure risks are recorded and reported. Does this need a local plan to support concerted action? Potential to test new models/roles- are there volunteer practices or potential for roles across the Cluster area that could support the management of capacity. What potential is there for collaborative working with local partners- Communities First, Third Sector etc
No Objective Key partners
For completion by: -
Outcome for patients
Progress to Date RAG Rating
1 To review current demand and capacity
Patient participation groups if present CHC
Services developed to reflect local need
Consultation rates are increasing along with telephone
consultations and nurse contacts. Some practices report a significant increase. Consultation rates per 1,000 population per week vary across the cluster.
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0
10
20
30
40
50
60
Pre-bookable GP appts
Pre-bookable GP appts
0
5
10
15
20
25
30
35
Open access consultations with GP
Open access consultations with GP
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It should be noted that Newport Surgery has an Advanced Paramedic Practitioner whose access has been included in the nurse consultation activity.
All practices within the Cluster are meeting the WG Tier 1
target where appointments (GP or Nurse) after offered after 5pm on 2 or more days per week. 8/9 practices within the Cluster are meeting the WG Tier 1 target for the HB to work with practices to have their doors open to patients for a minimum of 47.5 hours per week.
0
20
40
60
80
100
120
140
Pre-bookable Nurse/HCA appt
Pre-bookable Nurse/HCA appt
0
2
4
6
8
10
12
Open access consultation with nurse
Open access consultation with nurse
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The number of telephone consultations per week range from 24 – 220 (slight increase to the previous year).
Whilst most practices report an increase in the number of home visit requests this increase is not at the same level
as consultations. All home visits are reported as appropriate.
0
50
100
150
200
250
Telephone consultations per week
Telephone consultations per week
0
1
2
3
4
5
6
Home visits per week per 1,000 pop
Home visits per week per 1,000 pop
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Home visits per week remains static to the previous year. The typical wait for an appointment booked in advance
with a GP varies from 1-2 days to 20 days.
The majority of practices report an increase in DNAs.
DNA rates range from 2.5% to 9%. This is an increase from the previous year.
0
2
4
6
8
10
12
14
16
18
20
Wait to see a GP
Barlow House
Robert Street
St Thomas
Winch Lane
Solva
St Davids
Goodwick
Fishguard
Newport
0.00%
1.00%
2.00%
3.00%
4.00%
5.00%
6.00%
7.00%
8.00%
9.00%
10.00%
Estimated DNA rate %
Barlow House
Robert Street
St Thomas
Winch Lane
Solva
St Davids
Goodwick
Fishguard
Newport
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The Practice Managers & LDM will meet to identify actions that can be taken to reduce the number of DNAs. One Practice within the Cluster has an established PPG and two are in the process of establishing a PPG.
2 Establish local data collection systems to monitor trend
NWIS Capacity more effectively matched to local demand
For example, Agreed data extraction via Audit + to give
comparative and trend data to inform local planning- 8/9 practice have historically engaged with Audit + but from 2014 all 9 practices have agreed data extraction. 5/9 Practices signed up to SAIL
3 Identify waste in local systems
Practices / HB
Release more capacity for patient care
For example, For action via LHB
Improve Discharge Summaries- X % to be received within 48 hours
Practices are often chasing outstanding referrals and having to write expedite letters which uses a large amount of unnecessary resource. Delay in receiving discharge information and lack of discharge information means increased workload for practices. Action: HDUHB to encourage more timely and fully completed discharge summaries. Work ongoing between Practices, LDM & Withybush Hospital. Peter Skitt, Director of Acute Services has agreed to address this issue with secondary care. 24 hour discharge summary rollout within Withybush commenced on 22nd June 2015. The medical wards more successful than surgical wards. Support provided to increase uptake on a regular basis. Staff
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trained on agreed process (discharge summary will be typed and printed out on the day of discharge). One copy on Myrddin, one to the patient and one to the GP (faxed the same day). At this time Pharmacy are not in a position to support this new process due to their capacity so discharge drugs will not be on the letter but will continue to be sent directly from pharmacy from the TTh prescription. Practices expressed their frustration that pharmacy information was not included within the discharge summary as they felt that this was one of the most relevant areas of the discharge summary. Dr Zangouras, GP Lead noted that GP Leads had written to Peter Skitt and Robert Street Surgery had written to Mr Paul Underwood at WGH.
Dr Burrell to be feedback to secondary care. Sian Anson, Project Manager attended GP Leads meeting and reported that the pilot had now been rolled out across the whole of WGH and the time in getting out a discharge summary had reduced from an average of 80 days to 1.7 days. It was acknowledged that there was still a frustration due to the pharmacy information not being received on the summary and that investment was required in the IT system currently used. An electronic solution to this was being piloted in Wales (MTED) with rollout due in 2017. Practices to work with the Med Man team to educate patients on compliance with medication and reducing
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waste.
HB to confirm whether they would support a review of all practice boundaries with a joint approach of moving
patients within practices working within Regulations.
4 To develop local workforce development plans
Practice / HB
Service modernisation to meet changing needs Ensure sustainability of local services
For example, Increasing reports of recruitment difficulties Actions
Establish data collection to monitor scale of
difficulty and trend – completed in joint effort with the LMC, recorded on Dashboard and included in the annual return and PDPs.
Add issue to HB Risk Register – actioned
Within North Pembrokeshire it is predicted that 23.3% of GPs and 22% of Practice Nurses will retire within the next five years. This does not factor in the current vacancy rate, intelligence about existing local pressures, the size and number of GP practices and the current skill mix within practices. Recruitment and retention difficulties within primary care.
OOH are struggling to fill their rotas. Actions
Increase number of CCNPs within the County
and ensure equity of access across the patch – a bid had been submitted as part of the IMTP to ensure coverage in all localities.
Explore alternative routes to attract applicants for the Rural Health GP Fellowship post
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which was not previously appointed to.
Review skill mix within practices
A recruitment DVD had been made for the HB in order to attract GPs to the area. The HB and a local GP would be attending the Primary Care Conference in Birmingham and the BSJ Conference in London in October 2015. All practices with current vacancies asked to submit an info sheet for the conferences.
5 Referral data / Waiting list information
HB/NWIS / Practices
December 2014
More efficient service to patients ensuring fewer consultations with GP Practices. Managing patient expectations
Patients frequently return for additional GP appointments for the same problem they have already been referred for and also request further expedite letters and additional medication/pain relief. Practices would be in a position to make informed decisions on where to refer a patient if they were aware of the waiting list times for different specialities.
Action:
Practices to specify which particular specialities they would be interested in receiving information on.
HB to establish what reporting information is available to practices to ensure they are kept informed and request data from the Informatics Department.
Practices have provided a list of specialities they would like information on and a request has been submitted to the informatics department. Practices did not feel that the report provided them with the information they required and was not specific enough. Further detailed request to be sent to the Informatics
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Department. Chris Hopkins, General Manager for Scheduled Care
across the Health Board attended GP Leads to discuss
reporting information on waiting times. The priority areas
agreed by the cluster have since been shared with him.
These were Orthopaedics, Gynaecology, ENT,
Dermatology.
6 Cluster funded projects
Practices/HB
Ongoing 3 projects were supported with the North Pembrokeshire Cluster Funding of £123k. These were the appointment of Community Phlebotomists to provide timely intervention that will be supported with appropriate intervention from the GP in terms of treatment etc. (£54k) Pembrokeshire Counselling Service - to improve access to patients referred. The vision of the organisation is to obtain sustainable funding to work towards fully trained counsellors being employed and to further develop the training and development of counsellors. (£11k). Pembrokeshire Counselling to link in with the Comms team within the HB with regard to issuing a media release for the service. Paul Sartori for Advanced Care Planning Nurses (£58k)
– (See EOL Section)
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Strategic Aim 3: Planned Care- to ensure that patients needs are met through prudent care pathways, facilitating rapid, accurate
diagnosis and management and minimising waste and harms
No Objective Key partners
For completion by: -
Outcome for patients
Progress to Date RAG Rating
1 Collaborative working
Practices / HB
March 2015
Access services closer to home within primary care
A number of practices are unable to offer IUCD fitting or Nexplanon services due to not having an accredited clinician. Not many trainers within the area. Action:
Practices to explore networking arrangement with a view to providing IUCD/Nexplanon services for other practices within the Cluster.
HB to consider whether existing coil fitters could be trainers to GPs wishing to become accredited.
Mapping exercise to be undertaken on who currently provides service and what is currently available
Shared in-house policies & procedures to be developed
Barlow House, St Thomas & St Davids have circulated arrangements for IUCD networking arrangements. A list of claiming activity for Apr – Aug 2014 circulated for practices to see who was providing what service.
2 CRT/MDT WORKING
Practices / HB /LA
Ongoing Improved integrated care
Through MDT working there is the opportunity to improve
communication and strengthen links between GP Practices and community nurses, social services and the voluntary sector. Action:
Building on previous work undertaken to
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strengthen links and improve communication with CRTs.
Consider CRT Hub placements
Document and code CRT meetings
Integration of 3rd sector and importance of PAVS as part of the MDT
3 Pulmonary Rehab
Practices / HB / LA
Increase access to service to enable more patients to benefit from intervention
Pulmonary Rehab is a proven intervention in the
improved prognosis of pulmonary disease and reduction in hospital admissions. The cluster felt that this had been under resourced but were keen to develop the service for the future. It was reported that only18 patients pa access service - very long waiting list and it was felt that patients were often offered a place at the next available course which was not always local - issues with transport for patients, venues and capacity within the current service. Actions:
Work with voluntary sector ie British Lung Foundation
Link in with EPP to explore opportunities
John Davies of Physio Services to asked to attend the next Cluster meeting to discuss the issue with a view to resolving some of the barriers.
John Davies - Physio, Claire Hurlin – HDUHB Lead for Chronic Conditions and Bethan Lloyd - Psychology Lead for Chronic Conditions in General Health attended the November cluster meeting. John reported that following assessment suitable patients were invited to attend a 6 week course which was run at Tenby, Fishguard and Milford Haven on a rolling timetable Current capacity to see 70 patients pa but there was a
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capacity and demand mismatch (186 patients waiting). Some patients had been waiting over a year. Following a change in the QOF Indicators the service saw an increase in referrals. A survey was undertaken - approx 52% of patients wanted to access the service. Some of the patients referred were not engaged in the process and did not want to participate. The other element was capacity and it was noted that the County Team had identified this need in to the IMTP as a workforce requirement. It was noted that should the service be successful in obtaining funding to increase capacity it would need to recruit to the posts. John reported that they were currently trying to target admitted patients so that they could look at length of stay and readmissions. Claire Hurlin provided information to the Cluster on the COPD Self Management Programme which was run by
one lay member and one health professional. This would be an alternative programme for those patients who do not fit the criteria for Pulmonary Rehabilitation. Claire noted that if the practices could provide the number of patients then courses could be run anywhere as long as the venue had Disabled Access and good parking. In addition, the group were informed of the generic self management courses such as the Carers Course, Introduction to Self Management, Diabetes Self Management. The Expert Patient Programme team could be contacted on 01554 899 035. A minimum of 10 patients and a maximum of 16 would be
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required to run a course. Bethan Lloyd presented Living Well with COPD which
was an educational programme developed in Canada and had been adapted and adopted in Northern Ireland: - delivery was based on social learning.
It was felt that the current Pulmonary Rehab service was run in a similar fashion to Living Well with COPD and that some of the principles could be integrated into the current service. It was agreed that John Davies, Physio would meet with Bethan Lloyd outside of the meeting to discuss implementing some of the Living Well with COPD Principles into the current Pulmonary Rehab Service. It was noted that the GMS contract required GPs to refer patients with a score of 3 and above but there were often the patients we were not being admitted. The Cluster agreed to support COPD+ out of slippage
funding for 2015/16. The EPP+ exercise project aims to combine EPP with
exercise class for MRC <3, before they become functionally limited by their breathlessness. Aims
o to increase their individual exercise capabilities. The long term aim will be to promote regular exercise (to prevent muscle weakness). The EPP COPD+ exercise project aims to enable COPD patients
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o to maintain daily activities for longer thus slowing the progression of the disease reducing the need to become dependent on others.
Up to 16 patients attend the EPP programme at any one time in each locality and this number is also manageable for an exercise class. The EPP COPD Self Management for Life programme is currently a 7 week programme that is led by one lay tutor and one health professional tutor. Both these tutors will support the physiotherapist with the exercise element attached to the programme and will in time deliver the exercise programme Pre and post assessment for exercise will need to be done therefore it is suggested that an extra two weeks be added to the beginning and end of this programme where exercise capacity for individuals can be assessed by the physiotherapist and health assessment questionnaires for the evaluation of the impact can be completed at the same time. The project aims to run two courses by the end of March 2016.
4 Following on from last year’s QP work – Falls & Frailty
Practices / HB
Ongoing Improving patient care
Maintain and develop referral pathways agreed in QP 2013/14
2013/14 showed an increase in the number of frail patients who had received an annual assessment and also the number of patients with a social care status recorded.
Need consistent service provision across the HDUHB area to ensure equity ie falls clinics
2 Consultants have been appointed to WGH.
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o Dr Angela Puffett - Consultant Physician (Care of the Elderly), from August 2015
o Dr Will Backen - Consultant in Orthogeriatrics, from October 2015.
5 Following on from last year’s QP work – Dementia
Practices / HB
Ongoing Improving patient care
Maintain and develop referral pathways agreed in QP
2013/14.
2013/14 showed a slight increase in patients who had an annual assessment and patients with a social care status recorded. There was also a significant increase in the number of patients with a care plan. Continue to support this trend.
6 Voluntary sector (third sector)
Better availability of information to enable patients to be aware of and access additional services.
Strengthen relationships with the Voluntary Sector and increase knowledge of voluntary sector services available to the North Pembrokeshire population. Action:
Third sector broker to be invited to Cluster meetings to identify where voluntary sector may assist in service development and also identify and make practices aware of existing services. Regular Third Sector attendance at meetings agreed.
Practices to refer patients to the PIVOT which is a scheme where voluntary organisations within Pembrokeshire work together preventing inappropriate hospital admissions and reduce support required from statutory agencies
7 Flu Practices, Health Board, PHW
Increased uptake in immunity
For 2014/15 PHW reported that the cluster’s uptake of the flu vaccination for at risk patients under the age of 65 was 47% against a WG target of 75%, and for patients aged 65 and over the cluster uptake was 68.6% against a WG target of 75%. Individual uptake for 2014/15 by practice was as follows:
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Practices will work to continue increasing uptake.
0
10
20
30
40
50
60
70
80
90
Practice uptake - eligible under 65 at risk
Practice uptake - 65 & over
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Strategic Aim 4: To provide high quality, consistent care for patients presenting with urgent care needs and to support the
continuous development of services to improve patient experience, coordination of care and the effectiveness of risk management
No Objective Key
partners
For completion by: -
Outcome for patients
Progress to Date RAG Rating
1 Out of Hours
Integrated service with seamless provision for patients
Strengthened communication with Out of Hours
Increased use of Just in Case boxes with
prescription initiated
Practices to encourage write up PRN
Practice to continue to notify OOH of DNACPRs
2 CRT/MDT WORKING
Practices / HB /LA
Ongoing Improved integrated care
Action:
Practices to continue to improve MDT/CRT working identifying patients who are most at risk of admission and applying a multi disciplinary approach to prevent hospital admission.
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Strategic Aim 5: Improving the delivery of end of life care
No Objective Key
partners
For completion by: -
Outcome for patients
Progress to Date RAG Rating
1 Death Reviews
Practices / HB/ Voluntary Sector / LA
Practices to continue holding Palliative Care meetings
Practices to continue collaborative working with
the palliative care team, district nurses, Paul Sartori voluntary sector and the Chronic Condition Nurse Practitioners.
All practices confirmed that they were holding palliative care registers.
Dr Burrell referred to the hospital Mortality Reviews and confirmed that in the last 7 months 2
had been undertaken for North Pembrokeshire where the hospital doctor had said that the patient should not have come in.
2 Need for Palliative Care Consultant provision
HB Clarity is required from the HB on the progress relating to the appointment of a Palliative Care Consultant.
David Morrissey reported that the HB had secured 4 sessions per week of Palliative Care Consultant time within WGH until the end of March 2015.
Practices stressed the need for the HB to continue
to look to appoint a Palliative Care Consultant and
not a locum position: - 3 Registrars would be ready
soon and the plan was to advertise in time to
anticipate this. 10 vacancies across Wales for
Palliative Care Consultants. In the meantime, it
was felt that there was a real need for some
service to be provided in secondary care for
palliative patients where appropriate..
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Concern was raised for the support currently provided to MacMillan nurses at the current time.
3 Following on from last year’s QP work – End of Life
Practices / HB
Pathway embedded into practice culture
Increase in both patients with an Advanced Care Plan and patients with a DNACPR during 2013/14
–continue to support this trend.
Cluster funding bid supported project working with Paul Sartori who would employ a nurse(s) to 1 WTE (2 part-time posts - each linked to specific practices). ACP Nurse Facilitators to the Paul Sartori Foundation. The posts will assist practices in identifying people for whom ACP might be most urgent and relevant, and working with those patients to complete ACPs. An obvious starting point will be patients already on the Palliative Care Register, but there will be more potential candidates among patients with chronic conditions The proposal also includes funding for a small amount of additional ad hoc counselling time for people in whom the process of ACP identifies a need for this support (this is rare, but not unknown). Staff have been appointed and will take up posts shortly. Sophie Thomas of Paul Sartori attended the July cluster meeting to report on progress against cluster funding. Interviews had been held and 2 part time nurses had been appointed and would take up post in the beginning of August. Training would be required and it was anticipated they would be working with patients by October 2015. It was suggested that practices start referring immediately. It was noted that both employees were not eligible for the NHS Pension which meant that there would be spare
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funding. It was intended that another appointment would be made to make the post 1.2WTE. Sophie stressed that the ACP nurses would not be broaching the subject of ACP with patients, this would need to be done by the practice or community team. ACP nurses to attend practice palliative care meetings. It was noted that a separate project would run alongside the cluster funded project within secondary care to pick up people in hospital. Paul Sartori can accept bereavement counselling referrals but had limited capacity to provide this service. Paul Sartori to link in with the Comms team within the HB with regard to issuing a media release for the service.
4 Consider themes and learning opportunities to ensure a move to higher quality end of life care
Practices / HB
Review what development is needed
Sharing of learning and actions at Cluster meetings
Dedicated meeting arranged as part of the Cluster Plan review
Paul Sartori are liaising with Practices and the Health Board to arrange a two day Palliative Care Course for GPs to be held locally on two separate days in consecutive weeks.
Practices reported that they felt that that Pembrokeshire had very good palliative care services but it was important to recognise that the patient’s family also needed to be considered as some of them can’t cope and provision needed to be made for this.
Dr Cath Burrell reported that there would be a
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rollout of a new DNACPR form with effect from
2nd February 2015 with full implementation by August 2015. Nurses would not be able to sign the forms in future and it was noted that any patient who currently had a DNACPR in place would need a new one
It was noted that communication between practices and the Out of Hours Service had improved with
practices setting up things in advance.
It was noted that the IHR in Out of Hours did not get free text within the special notes.
Sophie Thomas reported that due to the new policy which would be implemented with regard to resuscitation, if there was no form in place then the Paul Sartori Foundation would have to say “No form no care”.
It was agreed that practices would inform WAST if an ACP or a DNACPR was in place ( WAST fax 01267 225 771).
It was agreed that Dr Burrell would circulate the new policy from WAST and it was requested that any issues were put on Datix.
Dr Burrell presented the new DNACPR form to the practices and agreed to circulate the slides to all. It was noted that old DNACPRs no longer needed to be replaced by 31st July 2015 but should be replaced opportunistically. The new form could be completed in primary, secondary or tertiary care and would follow the patient in and out of hospital. Pack of the new forms had been received by the majority of practices that week.
5 Amber Care Bundle
Secondary Care
Rob Jones
Better communication and information
The AMBER care bundle provides a systematic approach to manage the care of hospital patients who are facing an uncertain recovery and who are at risk
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to provide the best possible support with any decision needed to be made if recovery is not expected whilst a patient is in hospital.
of dying in the next 1-2 months. It is an intervention
that can fit within any care pathway or diagnostic group for patients whose recovery is uncertain. It does not change a patient's treatment or care - it helps staff to realise when they should talk with the patients about what treatment and care they would prefer should the worst happen. It is a simple tool which combines identification questions, four clinical interventions and systematic monitoring that can be applied in adult ward settings. This project is being piloted within wards 7 & 12 at Withybush Hospital from 1st October 2015 and will be used when the outcome of treatment is uncertain. If the patient survives to discharge the fact that the patient was on the care bundle will be communicated to the practices for consideration with regard to the palliative care register. This pilot will link in with the Paul Sartori ACP project.
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Strategic Aim 6: Targeting the prevention and early detection of cancers
No Objective Key
partners
For completion by: -
Outcome for patients
Progress to Date RAG Rating
1 Review of all new lung or digestive system cancers
(01.01.14 – 31.12.14)
Summarise learning and actions
Summarise themes
Share outcomes with Cluster
Dedicated meeting arranged as part of the cluster plan review
2 Review downgrading of urgent suspected cancers (USCs)
Practices agreed to Datix every time they become aware of the downgrading of a referral that they were not informed about by the Consultant.
Practices are now receiving weekly reports
electronically confirming whether USC referrals have been downgraded, upgraded or upheld. Information is also circulated on who to contact should there be a query or concern relating to the referral.
Reports are now being received by practice and it was confirmed that these were useful. Further information was requested on what to do if a patient was downgraded and a letter was sent to the Consultant and reply was received. Dr Burrell asked for details of this to be sent to her and she would look into it further. It was requested that these incidents be logged on to Datix. Clarity to be sought on who is actually actioning the downgrading.
Where there is good communication between primary, secondary and community care speeds up
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investigations. When this is lacking there are delays
in diagnosis for patients.
Screening should be encouraged and promoted
Not all patients were within the screening age
Disappointment that the secondary care consultants had sent their apologies to the meeting to discuss this priority area
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Strategic Aim 7: Minimising the risk of poly-pharmacy
No Objective Key partners
For completion by: -
Outcome for patients
Progress to Date RAG Rating
1 Polypharmacy -
Identify and review patients aged 85 years or more receiving 6 or more medications
Summarise themes and actions for review
Dedicated meeting arranged as part of the cluster plan review
National priority area had very little impact over usual practice and the cluster felt that maybe a
different population such as patients who have carers or are in residential homes should be targeted
Weekly dosette boxes reduced waste medication
but it was acknowledged that this had an impact on workload for Community Pharmacy
Poor communication from secondary care upon discharge
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Strategic Aim 8: Deliver consistent, effective systems of Clinical Governance
No Objective Key partners
For completion by: -
Outcome for patients
Progress to Date RAG Rating
1 Downgrading of referrals
Effective clinical care
Action:
Practices to Datix any critical incident when they
become aware of the downgrading of a referral that they were not informed about by the Consultant which led to a serious outcome for the patient.
Health Board to identify communication process to ensure GP Practices are informed of any down grading of referrals.
Practices are now receiving weekly reports electronically confirming whether USC referrals have been downgraded, upgraded or upheld. Information is also circulated on who to contact should there be a query or concern relating to the referral.
Dr Burrell to pick up individual practice concerns regarding no response to consultant letters following a query of downgrading.
Clarity sought on priorities ie downgraded to urgent when sent as urgent
2 Improve communication
HB / Practices
More streamlined service
Action: HB to improve communication with Practices to ensure they are aware of service changes
3 Datix Effective clinical care
Continue to report incidents on Datix
Strategic Aim 9: Other Locality issues
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No Objective Key partners
For completion by: -
Outcome for patients
Progress to Date RAG Rating
1 Leg ulcers
HB / Practices
Care provided in an appropriate setting close to home
It was felt that the TVN appointed in September 2014 should continue with original role of education and reducing prescribing costs, not providing care where a practice had given notice on a service not considered core GMS. Action:
HB to work with practices to identify a way forward
Opportunity to develop pilot scheme Notice had been received from 4 practices within the cluster. DN Team would be picking up the workload. The Health Board was looking to implement a service in line with the Lindsay Leg Club which is a community model run by the DNs, the third sector and volunteers.
2 Gaps in Service provision - Diabetes
HB / Practices
Care provided in an appropriate setting close to home
It was felt that there was poor provision of secondary care diabetic service at WGH leaving a gap in service
provision. Action:
Scoping exercise to be undertaken on current LES/DES provision and the possibility of implementing a networking arrangement.
Non-insulin dependents diabetics – increasing numbers of patients in primary care require regular follow ups leading to increasing workloads. Action:
HB to consider accreditation process after
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recently not allowing a practice to provide the service with a locum.
Dr Zangouras to explore enhanced service provision and education
HB to clarify current position on vascular surgery
provision and patient pathways.
HB to improve communication with Practices to ensure they are aware of service changes
Mr Colin Ferguson had taken over the lead for vascular services within Morriston Hospital. He had contacted Phil Kloer, Medical Director with regard to a central pool for referrals in Morriston who prioritise patients and arrange for them to be seen locally. It was noted that a Diabetes Self Management Programme had been run in the North of the County and feedback would be provided to the GP Practices soon. Winch Lane outlined a pilot scheme they were currently taking part in with regard to the use of digital films re self management of diabetes and reported good patient feedback.
3 Lifestyle Advocate
Project
Practice/HB/ Public Health Wales
Practice/PHW
Information The Cluster agreed to take part in the Lifestyle Advocate project where a member of the team will be trained in brief intervention. All practices to confirm who their Lifestyle Champion would be. 5/9 Practices signed up to the project. An offer to run a second programme was made but there would be a cost of £300 per practice to participate which would need to be met by either the cluster or the individual practice. Positive Feedback on the project was provided to the Cluster by one of the HCAs who participating.
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4 Pocket Medic
Practice/HB
Practice
Increased access to information and support along with self management of chronic conditions
The Cluster agreed to fund 12 months access to Pocket Medic from 2015/16 slippage on a one-off basis. It was noted that one practice had been a pilot site and found the service valuable as an additional resource.
5 Young People’s Counselling Service- Youth Counselling Service
Practice/HB/voluntary sector
Voluntary sector/practices
Increased access to a service that has limited capacity
The cluster agreed to fund the Young People’s Counselling Service to provide access to counselling services from slippage money for 2015/16 on a one-off basis. Funding will be for £2k. The service will provide the equivalent to one day’s additional counselling a week and will link in with the CRISIS Counselling Service covering the Point youth project in Fishguard, Garth Youth & Community Project known as the Hive based in Haverfordwest and the Tanyard youth project which is based in Pembroke. The service will support young people presenting with low self esteem, depression, sexual expressions, drug use, peer pressure, bereavement and anger issues. This links in with the funding of Pembrokeshire Counselling Service which has been put in place via cluster funding for the adult population.
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Strategic Aim 10: Other Locality issues
No Objective Key
partners For completion by: -
Outcome for patients
Progress to Date RAG Rating
1
RAG Rating
Red Successful delivery of the project/programme appears to be unachievable. There are major issues on project/programme definition, schedule, budget required quality or benefits delivery.
Amber Successful delivery appears feasible but significant issues already exist requiring management attention. These appear resolvable at this stage and if addressed promptly should not present a cost/schedule overrun.
Green Successful delivery of the project/programme to time, cost and quality appears highly likely and there are no major outstanding issues at this stage appear to threaten delivery significantly.
