Health in Wales - GP Cluster Network Action Plan … - Llwychwr...Welcome to the Llwchwr Primary and Community Health network/cluster plan for 2016/17. The Llwchwr Health network based

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GP Cluster Network Action Plan 2016-17

Llwchwr Cluster

Llwchwr Primary & Community Network Cluster Plan

March 2017

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Welcome to the Llwchwr Primary and Community Health network/cluster plan for 2016/17. The Llwchwr Health network based in Swansea and

following the closure of one practice in 2015 is made up of 5 general practices working together with partners from social services, the

voluntary sector, and the ABMU Health Board. Llwchwr covers the area of Pontarddulais, Gorseinon, Gowerton and Penclawdd and has a

registered population of approximately 47,300.

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Table to show the current list size of GP practices in Llwchwr and the change in since 2011

Practice

Practice List

Size 2011

Practice

List Size

2012

Practice

List Size

2013

Change

2012 to

2013(n=)

Change

2011 to

2013(n=)

Sept

2014

List Size

July

2015

W98008 PrincessStreet 8,212 8,183 8,224 41 12 8,587 8,644

W98012Gowerton 11,897 11,978 12,098 120 201 12,040 13,930*

W98013 Tal yBont 8,461 8,627 8,827 200 366 8,900 9,000

W98034 Ty’ rFelin 9,789 9,863 10,055 192 266 10,483 10.764

W98787PenyBryn 5,207 5,296 5,367 71 160 5,052 4,840

*Practice growth reflects the contract change to provide GMS services to patients formally registered at Penclawdd Medical Practice

Networks aim to work together in order to:

• Prevent ill health enabling people to keep themselves well and independent for as long as possible.

• Develop the range and quality of services that are provided in the community.

• Ensure services provided by a wide range of health and social care professionals in the community are better co-ordinated to local

needs.

• Improve communication and information sharing between different health, social care and voluntary sector professionals.

• Facilitate closer working between community based and hospital services, ensuring that patients receive a smooth and safe transition

from hospital services to community based services and vice versa.

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This is the second development plan that has been produced by the network and it is the aim to further develop the plan over the coming years.

The network will be regularly monitoring progress against the actions contained within the plan.

In order to support the development of the network cluster plan, information has been collated on a wide range of health needs within the

Llwchwr area.

The summary below highlights the key points. The health needs information has been taken into account when developing the priorities for this

plan.

Llwchwr Network has:

• 7 Dental Practices

• 11 Pharmacies

• 6 Nursing Homes

• High numbers of Elderly population

• High numbers of Asthma patients

• High numbers of Care Home patients

• Low student population

• Low ethnic minority patient numbers

• Low asylum seekers numbers

• The smallest percentage of patients in the ‘most deprived’ category of all Swansea networks

• The highest percentage of patients living in areas classified as rural

• The second highest percentage of patients on GP Practice CHD or CHD related chronic conditions register amongst Swansea

networks.

• The second lowest rate of people who smoke in Swansea networks and is significantly lower than the health board average.

There is a significant overlap of registered patients who live in adjacent geographical areas of Carmarthen

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Strategic Aim 1: To understand the needs of the population served by the Llwchwr Cluster Network

No Objective Action Key partners Forcompletion by: -

Outcome forpatients

Progress todate/currentposition

RAGRating

1To understand theprofile of the LlwchwrCommunity Networkand the effect thatdeprivation has onthe practicepopulations.

To consider thedemographics of thecommunity network and theimpact on service delivery

• PHW• Primary and

Community Unit• Health Board

Informatics

Profilecompletebut will becontinuouslyreviewedandupdated

To ensure thatservices aredeveloped accordingto local need

All practicesreviewed therevised data tocomplete theirpracticedevelopmentplans in July 2016and to inform thedevelopment ofthe cluster planfor 16/17

2 Respiratory Disease

• To continue toeducatepatients onthe causes ofasthma andpreventativemeasures

• PulmonaryRehab

To signpost patients torelevant voluntaryorganisations.

Increase the number ofpatients accessing thePulmonary Rehab service

To analyse Public HealthData to evaluate if this hasbeen successful

• GPs• ABMU

Ongoing Less patientsdeveloping asthma

Presentationgiven at the Septmeeting by thePulmonary Rehabteam.

New servicebeing embeddedwithin theNetwork andgoing well

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To explore any otheropportunities to supportPulmonary Rehab servicethrough use of cluster funding

3 To continue toprovide CBTsessions for Llwchwrpatients and tobroaden to includechildren and youngpeople

To continue to use funds toemploy private professionalsto provide CBT sessions

To use questionnaires toascertain the views of thepatients accessing theservice

To look at providing CBTsessions for Children andYoung people

• GPs• Practice

Managers• Health Board

Ongoing Will improve accessto CBT for Llwchwrpopulation ascurrent waiting list is>1 year

Will improve thequality ofmanagement ofdepression inprimary care

Further fundingagreed by theNetwork tosupport theprovision.Funding agreedvia Grant schemeto provide acounsellingservice andsessions forchildren andyoung people

4 To support patients inundertaking lifestylechanges which willbenefit their healthand wellbeing andimprove the obesityrate in the Networkarea

To embed the WeightWatchers/Positive Stepsprogramme across theNetwork

To fund further vouchers andcontinue to encouragepatients to lose weight

To evaluate the patients thathave already accessed thescheme

To increase numbers ofreferrals byreviewing/reducing referralcriteria to make service

• GPs• Weight Watchers

• PHW• Health Board

Ongoing Better health forthose patients withchronic diseases

Improved lifestylechoices leading to aless medicalisedmodel of care

Practices arereferring patientsto WeightWatchers andpatients showingweight loss.Projectprogressing well.Further vouchersbought

Continuedfunding from theNetwork.Large numbers ofpatients havebeen referred

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available to other patientswho would benefit

5 To increase cervicalscreening uptake

To continue to raiseawareness of cervicalscreening programme andbuild on previous success.

To evaluate figures

Advertising via posters &leaflets provided by cervicalscreening including GPpractices, communitypharmacists and localauthority buildings

To link in with Public Healthscreening officers

• GP practices• Community

Pharmacists• Local

Authority• Cervical

ScreeningWales

March2017

Early detection ofhealth risks

Uptake figures tobe analysedwhen end of yearnumbers becomeavailable

6 To improve access tomental healthservices

To increase mental healthnursing input

To provide in housecounselling services

To further develop the SCVSMental Health clinic within theLlwchwr Network and explorenew ways of working e.g.Development of MentalHealth focussed Noticeboards/Information Provisionwithin the GP Practices

To review and be aware of

• SCVS• Health Board• GP practices• LAC

Ongoing Improved, timelyaccess to mentalhealth services

Improved access tocounselling servicesfor patients whoneed Tier 0 supporteither via practice ornetwork level

Link in to MentalHealth officer inSCVS

Signpostingpatients to Tier 0servicesFurtherdiscussion to beundertaking atNetworks toprogress further

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referral mechanisms toCAMHS

CAHMSpresentationgiven at PatientCarer Forum

7 Reduce the numberof falls within thenetwork byproactively identifyingand managing thosepatients at risk of fallsand furtherassociatedcomplications.

Identify patients at riskof falls

Pro-active care

To further promote the use ofthe falls prevention guide

Work closer with otherorganisations such as LocalAuthority, Fire Brigade,Library, and many thirdsector organisations

• GPs• Community Staff• SCVS

Ongoing Pro-activeidentification andmanagement ofpatients at risk offalls and furtherassociatedcomplications

Further copies ofthe FallsPrevention guidedistributed via theGP practices andacross theNetwork. Furtherwork ongoing viathe Ageing Wellprogramme andFalls preventiongroup

8 Develop the work of

the Local Area Co-

ordinator pilot project

:

ABMU to work with LACs toprovide clear eligibility criteriafor referring patientsPractices to actively referpatients where suitable:

Further LACs to beappointed to cover thePontardulais area of theNetwork

Local Area Co-ordinator toattend cluster meetings

• LAC• Practices• Health Board

Ongoing Improved supportand signposting forresidents withinparts of the Network

Local Area Co-ordinator isattendingNetwork meetingsand has madelinks with all thepractices in theNetwork andidentified andhelped patients.Further LACappointed for thePontardulais area

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29 Patientsreferred to date

9 To increase the useof the Healthy CityDirectory within thenetwork; signpostingpatients to the mostappropriate service

To evaluate the use of theHealthy City directory withinpractices.

• NHS direct• Health Board• SCVS• Voluntary Sector

organisations

Ongoing Network populationmore informed onavailable health andwell being services

Further promotionof the use of theHealthy CityDirectory withinpractices and topatientsundertaken.Bannersproduced anddisplayed

10 Frail ElderlyTo consider allrelevant actions thatwill assist in reducingthe number ofhospital admissionsfor this vulnerablegroup of patients;facilitating care athome whereverpossible.

Develop anticipatory careplans in partnership withCommunity Services

Develop closer workingrelationship with ChronicCare Nurses and AcuteClinical Response Service

Work closely with CommunityNetwork Hubs to supportpeople at home

To develop step up/stepdown beds at Gorseinon tocomplement those atBonymaen House and TyWaunarlywdd

Rapid access to MedicalHOT clinics and support forCommunity Care teams

• AGPU• CCM• GPs• 3rd Sector• Community

Connectors• Locality• LA/HB Community

Network Hubs• Acute Clinical

Response

Ongoing Reduce admissionsto hospital

Through DementiaFriendly practicesprovide appropriatesupport andawareness

DementiaTrainingundertaken atPLTS session.

Community Hubsestablished andrange of servicesavailable tosupport people athome

Anticipatory Careproject has beenpiloted in Bay andis nowestablished inLlwchwr with keypersonnel inplace to helpmanage theproject

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Acute ClinicalResponseService now live

11 To further developthe third sectorsupport projectincreasing the use ofvoluntary sectorservices by theLlwchwr Networkpopulation

Small GrantC.A.B

Provide opportunities for thirdsector organisations to attendProtected Learning TimeSessions with GPs and nonclinical staff

Ensure that links are madewith voluntary sectororganisations supporting theagreed network priority areaswhere possible.

SCVS to map Third Sectorprovision against networkpriorities.

Ensure that up to dateinformation on voluntarysector services is displayedin GP practices, e.g.information stands, noticeboards.

To extend voluntary sectorpresence within GP practicesin the network by increasingthe number of practicesparticipating, HealthyPartnerships and exploringnew ways of working jointlysuch as pre bookableappointments where possible

Led by Networkpractices supportedby SCVS





Ongoing

Ongoing

Dec 2016

Ongoing

Ongoing

Improved supportand access toservices for theLlwchwrNetwork population

SCVS are

supporting the

implementation of

the Grant scheme

for the provision

of counselling

services for

Children, Young

People

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12 Increase fluimmunisation uptakespecifically targetingthe immunisation ofchildren

To continue to raiseawareness of the fluimmunisation programmeand build on previoussuccess.

To evaluate figures

To link in with Public Healthscreening officers

PHWNetwork PracticesCommunityPharmacies

Mar 17 Protect patients atrisk and the widerpopulation.

Good practice

discussed and

key areas for

progression

identified. Public

Health colleagues

attended Network

meeting to

promote flu jabs.

Figures produced

in November to

be analysed

13 To improve therecording of patientsmoking status

To better record/updatepatient smoking status

To promote access to level 3prescribing service offered bylocal pharmacies and StopSmoking Wales or establishan in house stop smokingservice.

GP Practices

GP Practices

Ongoing

Ongoing

A reduction in thenumber of patientssmoking.

Further work withPublic Healthcolleagues toidentify gaps andimprove theservice

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Strategic Aim 2: To ensure the sustainability of core GP services and access arrangements that meet thereasonable needs of local patients

No Objective Action Keypartners

Forcompletionby: -

Outcome forpatients


RAGRating

1 Ongoing review ofcurrent demand forappointments andclinical capacity

Succession planningof practice andcommunity staff

Identify any potentialstreamlining systems andprocesses including theuse of anytoolkits/software available

Follow up on work carriedout with the Primary CareFoundation to assessaccess and demand

Working with the HealthBoard to identify aresolution to indemnityissues

Review workforcedemographics withinpractices and withincommunity – particularemphasis on GPs andPNs

• Practice• Primary

andCommunity Unit

Ongoing Servicesdeveloped toreflect local needin line withcapacity to deliversafe and effectiveservices

Number of practicestransitioned totelephone triage inwhole or part to helpdeal with patientdemand. Generallythis has beenpositively receivedby patients, but thepractices continue toreview.

Indemnity issuesresolution offered byHealth Board tosupport potentialcross practiceworking.

Practices exploringalternativeemployment options

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Review thecommunication processesbetween GP practices andcommunity nursing team

to support GPs, egNurse Practitioners,Pharmacists, and/orParamedics

Improvedcommunication setup for communityhub and patientsnow redirected tocontact hub direct.

2 To investigate the

possibility of

developing the

Network as a

Federation

To further progress the

possibility of Llwchwr

Network becoming a

Federated Network

Network

ABMU

March 17 Decisions to betaken directly bythe Network

Reviewing the workundertaken by aNetwork in Bridgend.Discussed inNetwork PLTSMarch 2016. FurtherPLTS session to beundertaken March2017

3 To addressdifficulties inrecruiting partnersand the shortage oflocums

Address the pressurefacing general practice:

GPpracticesABMU HB

Ongoing More sustainableservices

Government/centralinterventions neededto incentiviseinterest in generalpractice

4 To review workforcepressures anddevelop localworkforcedevelopment plans

To consider successionplanning arrangements atpractices to be betterprepared for leavers

Increase peer support

Consider use of network

• Practice• ABMU

HB

Ongoing Seamless serviceprovision forpatients

As above – andexploration ofalternative methodsof working with otherkey professionals,eg NursePractitioners,Pharmacists,

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monies to develop a GPresource for practices toaccess.

Consider developing skillmix across the network todeal with patient demandand GP pressures

Paramedics, etc.

5 To obtain patientand carer views onnetwork servicesand priorities

To continue to work withthe patient/carer groupdeveloped throughCommunity Voices

To consider areas of workthat the CommunityVoices group can supportpractices in sharingappropriate messages e.g.waste management

• SCVS Ongoing Responsiveservices takinginto accountservice user andcarer feedback.

Regular meetingstaking placebetweenrepresentatives ofthe Network andpatients. Goodattendance at thesemeetings. Networkagreed to fund thePatient Carer Forumfor 17/18

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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 Action Key partners For completionby: -

Outcome forpatients


RAGRating

1. To ensure that theneeds of patients andcarers are reflected inthe work of thenetworks

To continueimplementation ofthe patient and carerparticipation groupas part of theCommunity VoiceProgramme

To undertake Carerstraining throughPLTS

• GP Practices• Community

Nursing• Social Services• Third sector• Patient and

CarerParticipationGroups

Established andongoing

Patients betterinformed ofpriories withinthe Network

Patient CarerForum is wellattended anda variedagenda takesplace

3 To improveawareness ofpathways on the GPportal

All clinicians andlocums to be madeaware of pathwayson GP Portal

Assess potential toaccess GP portalfrom internet ratherthan intranet

• GP Leads• PM’s

Established andOngoing

Ongoing

Improvedawareness andcommunicationwill result inmore effectivecommunicationwith secondarycare resulting inswifter and moreeffective

GP Portalestablished.Continuedlinks withsecondarycarecolleagues.Developmentof GP OnePortal

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To receive alertswhen new templatesare issued and toreceive feedbackfrom secondary carecolleagues

Ongoing

referrals forpatients

4 To engage in thePrescribingManagement Scheme(PMS) and PMS+respiratory schemes(which containpolypharmacyelements)

Undertake a rangeof prescribinginitiatives toimprove:respiratory,antibiotic,pain managementprescribing andyellow card reporting

GPsPractice NursesMedicinesManagement team

PMS 16/17 – byMarch 17(some Dec 17deadlines)

PMS +respiratory –by Nov 17

Improvedmedicinesmanagementincludingpolypharmacy

Investment inother serviceareas for patientbenefit

Discussed atall annualpracticeprescribingvisits

Practicesengaged andmakingprogress

Medicinesmanagementteamsupportingwherepossible

5 To engage as an earlyadopter in anticipatorycare to work withpeople at most risk oflosing independence

To act as the early

adopter for

anticipatory care,

establishing systems

to:

• Identifying those

most vulnerable

of losing their

independence

• Identify care

CommunityHubs/older peoplesmental healthservices

Commence June2016 and ongoing

Earlyidentification ofthose patientsmost vulnerableof losing theirindependence.Carecoordinator andcare plansystems willassist thosepatients most at

Keypersonnelappointed.Patientsidentified andMDTs havetaken place.CareCoordinatorhaspresented atPatient Carer

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coordinator and

care plan

systems

• Develop effective

means of

communication

risk. Forum.Projectprogressingwell

6 To introduce newmodels of effectiveand efficient deliveryof service supportedand facilitated bytechnology

To discuss and

consider uses of

technology such as I

pads and Skype with

informatics to agree

a more efficient

provision of service

to particular cohorts

of patients, or

patients in certain

settings, e.g. care

homes.

GP PracticesLHBNWIS

March 2017 andOngoing

Moresustainableservices

Fundingidentified andpracticeshavepurchased ITequipment toimproveservices atthe surgeryand for theirpatients

7 To purchase CRPequipment and toundertake testingwithin the practice

To support the Big

Fight campaign and

improve patient

experience

GP PracticesPharmacists

Sept 2017 andongoing

Improve patientexperience andfaster testresults

CRPequipmentpurchased,trainingundertakenand Med Mgtteamundertaking areview of theproject

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Strategic Aim 4: To provide high quality, consistent care for patients presenting with urgent care needsand to support the continuous development of services to improve patient experience, coordination ofcare and the effectiveness of risk management

No Objective Action Key partners Forcompletion by: -

Outcome forpatients


RAGRating

1 To reduce theinappropriate use of A&Eand GP Out of Ours

To improve patienteducation e.g. displayposters

Link in with alternativeservices e.g. AGPU

Decrease the number ofunscheduled careattendances

Signpost patients to ensureattendances are appropriateincluding e.g. ”choose well’’posters

To improve patientknowledge of ‘over thecounter drugs’

• GP OOH• A&E• MIU• HB• Community

Voices

Ongoing Better educationon how to accessservicesappropriately tomeet their needs

AnticipatoryCare Projectrolled out in

Llwchwr

2 Improve partnership withAmbulance Service

Improve patient education

Improve communicationbetween practices and the

• GPs• Welsh

AmbulanceService

Ongoing Betterunderstanding ofthe services thatare available for

Presentationby AmbulanceService atLlwchwr PLTS

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Ambulance service • PLTS patient transport and contactdetails andadvicecirculated.Muchimproved butfurther work isneeded tomaintain thegood workalreadyundertaken

3 To improve antimicrobialstewardship

To improve antimicrobialstewardship

To consider CRP testingduring the winter monthsTo undertake the antibioticaudit by December 2015

Medicinesmanagementteam

Ongoing

Quarterly

Monitoring

of trends

ReducedresistanceReduced C.DiffIncreasedknowledge andempowerment toself care

Discussed atall annualpracticeprescribingvisits. Clusterlevel data tohas beenshared atNetworkmeeting

4 To educate patients inidentifying the mostappropriate place toreceive treatment andhow to manage self care.

Practices to promote selfcare education through useof resources such asbibliotherapy, choose wellcampaign, booklets forpatients and parents,newsletters in waiting roomor on notice boards.

GP Practices Ongoing To educatepatients how toself care andaccess servicesappropriately.

Furtheradvertising ofthe ChooseWellCampaignLaunch of the111 project

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Strategic Aim 5: Improving the delivery of end of life care

No Objective Action Key Partners Forcompletionby: -

Outcome forpatients


RAGRating

1 To review thenumber of deaths asper guidelines

Undertake reviewof number ofdeaths as perguidelines

GP LeadsSecondary CareColleaguesPMs

March 2017 andongoing.

Identification oftrends across theNetwork

Results ofaudit andlessons learntpresented atJanuaryClustermeeting

2 Use of and beddingin of Principles ofEnd of Life Care

To review thenumber of deathsas per guidelines

Practice levelregular palliativecare reviews andcompletion of

• Practice• Community

Staff

March 2017 andongoing

More appropriateand amenable care

Results ofaudit andlessons learntpresented atJanuaryClustermeeting

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EOL template3 Undertake regular

audit; sharing resultson a cluster networkbasis

Regular audits tobe undertakenand learningpoints to beprogressed

• Practice• Community

Staff

Ongoing Results ofaudit andlessons learntpresented atJanuaryClustermeeting

4 Ensure people areable to remain athome to die if theywish to do so

Work closely withCommunityServices toensure thatsupport isavailable at hometo support end oflife

• CommunityNetwork Hubs

• Health Boardcommissionedpalliative careservice

Ongoing Those who wish todie at home are ableto do so

Communityservices are inplace tosupport end oflife.

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Strategic Aim 6: Targeting the prevention and early detection of cancers

No Objective Action Key partners For completionby: -

Outcome forpatients


RAGRating

1 SEA of all newlung, stomachand GI cancers

Regularreview andaudit of lung,stomach andGI cancers

GP Practices

Secondary Care


To diagnose cancersas early as possible totreat

Improved access todiagnostics andendoscopy in timelymanner

All 5 practices havediscussed theCancers Audit atthe NovemberCluster meeting

2 Undertakeregular audit;sharing resultson a clusternetwork basis

Regular auditsto beundertakenand learningpoints to beprogressed

GP Practices

Secondary Care


To identify any issuesand improve thediagnosis of cancers



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Strategic Aim 7: Minimising the risk of poly-pharmacy

No

Objective Action Keypartners

Forcompletionby: -

Outcome forpatients


RAGRating

1 To progresspolypharmacyissues identified inprevious clusternetwork plan

To progress polypharmacyissues identified in previouscluster network plan

Medicinesmanagementteam andPracticeTeams

Ongoing Improvedprescribing andmechanisms forpolypharmacyreview

Ongoing workin practicesalso supportedby theMedicinesManagementteam

2 To ensureappropriate use ofthe pharmacist andtechnicianresources (clusterand non-clusterfunded) to reducerisks frompolypharmacy andimprove otheraspects ofmedicinesmanagement

Work with medicinesmanagement team to deliverand ensure appropriatetraining, support andindemnity arrangements

Medicines

management

team and

Practice

Teams

Ongoing Improved access tobetterpharmaceutical care

ClusterPharmacistappointed aswell as othersupport fromHealth BoardMedicinesmanagementteam

Work ongoing

to clarify roles,

training

requirements

and indemnity

arrangements

3 To providestandardisedtraining forprescribing clerksand seek

Nominated clerks to completetraining packs

Seek further opportunities todevelop staff

Medicines

management

team

Practice

Completion of

packs - June

2016

Improved repeatprescribing systems

Number ofclerkscompleted:Llwchwr: 17

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opportunities tobuild on initialtraining to furtherdevelop staff

Managers

Prescribing

Clerks

4 Improvement/maintenance againstnational prescribingindicators

Consider and review practice

and network data for national

indicators

Practice

teams

Medicines

management

team

Ongoing within

16/17

Improve prudent

prescribing leading

to better health

outcomes and

reduced

polypharmacy

Discussed atall annualpracticeprescribingvisits

Work ongoingwith theMedicinesManagementand Big Fightteam

5 Direct supply ofdressings toCentral Hub forcommunity nurses,reducing need forGP prescriptionsand aidingcompliance withABMU formulary

MedicinesManagementTeam &CommunityNurse Teams

Ongoing withreview at 6months

Timely access tomost appropriatewound caredressings, reducingdelays for patienttreatment and nursetime in sourcingproducts

ProjectcommenceJuly 2016

Awaitingoutcome ofreview

5 Renal Pacesetter -developing systemsand processes toreduce the riskassociated withChronic KidneyDisease and AcuteKidney Injury(AKI)-

Develop alert systems toreduce the harm caused by(AKI) through earlyrecognition of at risk patients

Specialistrenalpharmacist,practiceteams

Ongoing withregular review ofoutcomes

Improved medicinesmanagement forpatients at risk ofAKI with earlyidentification by aspecialistpharmacist.

Progress beingmade

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6 The Big Fight: Toimproveantimicrobialstewardshipthrough appropriateuse of antibiotics

Implement mechanisms toensure appropriate use ofantibiotics (see also PMS2016-17)

PracticeteamBig FightTeamMedicinesmanagementteam

Ongoing withmonitoring oftrends

See also PMS16-17 fordeadlines:Dec 16:• Overall

antibiotic useand choices

• Acute CoughAudit

• ImprovementPlan

March 17:• Evidence of

patientengagementactivities

ReducedantimicrobialResistance

Reduced C.DiffIncreasedknowledge andempowerment to selfcare

Discussed atall annualpracticeprescribingvisits.

Developmentof cluster leveldata availableon GP portal

Supportprovided topractices forWorldAntibiotic DayNov 2016

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Strategic Aim 8: Deliver consistent, effective systems of Clinical Governance

No Objective Action KeyPartners

Forcompletionby: -

Outcome forpatients


RAG Rating

1 To continue toreview SignificantEvent Analysishighlightingthemes andtrends

SEAs to continue to bereviewed by individualpractices on an ongoingbasisIncidents where there is adirect correlation tosecondary care are beingnotified to the Health Board

Practices to share SEAs atNetwork meeting to sharelearning

Share Practice Datix analysis

• GPPractices

• GPs• Practice

Nurses• Practice

Managers

March2017

Potential for changes toservices based onoutcomes of significantevents where there hasbeen positive/negativeaction

All practicespractices havepresented SEAsand identifiedlessons learnt atcluster meetings.

2 Demonstratinggovernancewithin thepractice:

Completion of theCGPSAT

Each practice to complete theCGPSAT

Practices March 2017and ongoing

Assurance thatpractices have clinicalgovernance proceduresin place

All practiceshave completedCGPSAT

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3 To highlight thedowngrading ofcancer referrals

Practices to review all cancerreferrals that have beendowngraded that weresubsequently found to becancer

GP Practices Ongoing Improvement tosystems to benefitfuture detection

Ongoingdiscussions.Issues need toraised with HealthBoard. NewABMU CancerCommissioningBoard established

4 ImproveDischargeSummaries

To continue to raiseawareness of the problemswith practices receivingcomplete, timely dischargesummaries

• GPs• Locality

CD• Medical

Director

Ongoing Primary Care staff willbe better informed ofpatients condition andtreatment e.g.Medication

Issues raised withHealth Boardcolleagues.FurtherdiscussionscontinuingSomediscussionsongoingregarding the rollout of ElectronicDischargesummaries

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Strategic Aim 9: Other Locality issues

No Objective Action Key partners Forcompletionby: -

Outcome forpatients


RAGRating

1 Access to CitizensAdvice Bureau withinGeneral Practice

CAB to provide anadvice serviceresource in the GPpractices withinLlwchwrThe pilot will also befully evaluatedfollowing the end ofthe pilot

• CAB• GP Practices• SCVS

Funding untilMarch 2017Full evaluationwill then beundertaken

Better support forpatients withwelfare /socialproblems thatneed dedicatedsupport andguidance.

Funding has beengiven to C.A.B tostart a pilot andthey will bepresent in aLlwchwr surgeryfor 1 ½ day eachweek to provideinformation andsupport topatients. This tobe evaluated

2 Assess potential list size

increase with growth of

further housing

developments

To engage with theLocal Authority overthe impact newhouses being built inLlwchwr will have onPrimary Careservices.

• HB• PMs• LA

Ongoing LA LDP currentlyout forconsultation.Meetings havetaken place.Practices affectedby thedevelopmentshave written to theLA outlining theirconcerns . No

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furtherdevelopments

3 Improving patient carewithin Llwchwr byworking with key partneragencies

Ensure cohesiveworking relationshipswith the Locality, EDcolleagues,secondary care,Local Authority,Pharmacy, thirdsector and toimprove patient carewithin Llwchwr

• SocialServices

• Communitynursing

• Third sector• Primary Care• Domiciliary

care• Independent

careproviders

Ongoing Integrated serviceprovisionprovidingseamless care forpatients

All key partnersattending Networkmeetings

4 Ensure that the workingarrangements of centralhubs for communitynursing do not have adetrimental effect onworking relationships

Participate indiscussions toensure that a safeand effective servicemodel is developedand communicationwith GP Practices istransparent.

Encourage thedevelopment of aphlebotomy servicefor domiciliarypatients

• GPs• Health Board• Local

Authority

Ongoing Improved accessto services forpatients withchronic conditions

Hubs establishedand two waycommunicationbeing facilitatedthroughcommunitynetwork meetings,and further links inplace. Problemshave beenidentified and fedback to Hubs andHealth Board

District nursingfunction to becoordinated viathe Intake Teamfrom October2016. This hasensured bettertwo way

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communicationgoing forward.

Strategic Aim 10: Other Locality issues

No Objective Action Keypartners

For completion by: - Outcome forpatients

Progress todate/current position

RAGRating

1

Documents

Health in Wales - GP Cluster Network Action Plan … - Llwychwr...Welcome to the Llwchwr Primary and Community Health network/cluster plan for 2016/17. The Llwchwr Health network based