Cluster Network Action Plan 2015-2016 Bridgend North North Cluster Net… · High levels of alcohol and drug abuse. High levels of teenage pregnancy High levels of unemployment and

Abertawe Bro Morgannwg University Health Board Page 1 Bridgend North Cluster Network Plan 2015/2016

Cluster Network Action Plan 2015-2016

Bridgend North

VERSION CONTROL:

30th September 2015


Introduction

The North GP Cluster Network comprises of eight GP practices, following the closure of Nantyffyllon surgery on 1st October and

dispersal of the 2,400 practice list to the three neighbouring practices. The cluster network estate includes eight main practices,

three branch surgeries and one dispensing practice. One practice has recently moved to a converted ward at Maesteg Hospital.

Four practices are engaged in GP training and one practice trains 5th year medical students. The North GP Cluster Network area

contains nine Nursing/Residential Homes and one Community Hospital situated at Maesteg. There are 13 community pharmacies

and 5 dental practices. The network covers mainly deprived valley, rural and urban populations, serving a population of 51,251

patients of which 49.9% are male and 50.1% female. According to the Welsh Index of Multiple Deprivation (Welsh Government

2014), Bridgend North Network contains five lower super output areas (5LSOA’s) that are in the top 10% (190) of Wales most

deprived. Caerau 1 lies within the top five most deprived Lower Super Output Areas. A significant reduction in life expectancy

exists for males and females between the Llynfi Valley (covered by three North Network Practices) and Bridgend residents, of 20

years and 18 years respectively.

The cluster network achieved a number of objectives during 2014/15 including:

Establishing a practice nurse training forum

Commenced planning for a Musculoskeletal Project within the community

Undertook a respiratory inhaler switch and improved data collection management and outcomes in Asthma and COPD

The Bridgend North Action plan will support the Practices to work collaboratively 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 Cluster Network Action Plan includes: -

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 are specific, measureable actions with a clear timescale for delivery. The Cluster Action Plan compliments 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 supports 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.



KEY THEMES IDENTIFIED FROM PRACTICE DEVELOPMENT PLANS

High area of deprivation

High levels of alcohol and drug abuse.

High levels of teenage pregnancy

High levels of unemployment and social

issues

High prevalence of chronic conditions,

particular within frail and elderly

High prevalence of obesity

High prevalence of smoking

Improved access to diabetes care

Increased prevalence of mental health

issues

Increasing demand and workload pressures

Limited counselling and cognitive behaviour therapy

Significant gap in life expectancy compared to the rest of ABMU HB

Long musculoskeletal diagnostic/therapeutic waiting times

Multicultural population with language

barriers

Need for improved antibiotic stewardship

Need for improved iron deficiency pathway

Opportunities to develop and strengthen service with WAST and other partners to prevent admissions

Patient care for isolated, socially excluded. housebound patients

Patient education and sign-posting

Primary and secondary care interface – USC Downgrades, discharge summaries, hospital generated pressures

Respiratory care and prescribing

Workforce and skill mix training opportunities to improve efficiency


North Network

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Tynycoed

Lynfi

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Directed Enhanced Services

Childhood Immunisations

Influenza for those 65 and over and others at risk groups (2-3 year olds)

Extended Minor surgery N N N

Care of People with Learning Disabilities

Care of People with Mental Illness N N N N N

National Enhanced Services National Enhanced

Services

Anti Coagulation (INR) Monitoring

LARC N N N N

Shingles Catch-Up Programme

Services to patients who are drug/alcohol misuse N N N N N N

Local Enhanced Services Local Enhanced Services

Shared Care N N N N

Gonadorelins/Zoladex

Immunisations during outbreaks (MMR)

Care Homes N

Care of Homeless Patients N N N

Hep B Vaccination of At-Risk Groups

Wound Management N N

Wound Management Part B N N N N N N N

Men C Catch-up for University N N N

Services Delivered


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

No Objective Key partners

For completion

Outcome for patients

Progress to date RAG Rating

1 To review the needs of the population using available data.

Practices Local Public Health Team Health Board

September 2015

To ensure that services are developed according to local need

Key themes discussed at Cluster Network meeting on 2/09/15. The cluster serves a population that has :-

Significantly more deprived than Welsh average with pockets of deprivation amongst the highest in Wales.

Chronic condition burden is higher than other Cluster areas.

High rates of teen pregnancy compared to other national averages.

High rates of drug and alcohol misuse.

High smoking prevalence.

High rates of obesity in adults and children.

2 Ensure a consistent approach to the implementation of the public health agenda in response to the needs of the network population.

Practices Public Health

March 2016 Improved Health especially regarding chronic conditions.

Key areas discussed at Cluster Network meeting on 16/09/15:

1. Smoking Action:

Proactively refer to the Level 3 Community Pharmacy Smoking Cessation Service.

Promote Stoptober campaign within the practice. Explore options for partnership work with community pharmacies delivering the L3 service, including proactive identification and audit of Quit status



For completion


Progress to date RAG Rating

2. Obesity Action:

Utilise opportunity to train practice staff to Level 2 Food/Nutrition to support Obesity/Diabetes Education

3. Flu immunisation Action:

Engage with the third sector to maximise publicity and encourage take up.

Staff to complete PHW eLearning module on flu and consider opportunities for Myth Buster training for front line staff.

4. Screening Action:

Proactively encourage screening uptake across all screening programmes

3 Capture, process and report on patient feedback.

Practices Third Sector CHC

March 2016 Better understanding of the needs of the patients and quality of care

Action:

Consider means to develop an effective engagement mechanism to gather patients’ views and experiences.


Strategic Aim 2: To ensure the sustainability of core GP services and access arrangements that meet the reasonable

needs of local patients


For completion


Progress to Date RAG Rating

1. Improved communication and integration with the third sector

BAVO Practices Health Board

March 2016 Increased access and signposting to voluntary services that support self care and independence

Action:

Third sector champion identified.

Consider development of a direct referral mechanism to third sector organisations with live directory of services.

2. Increase wellbeing and resilience to reduce inappropriate appointments and home visits

Practices Third sector Health Board

March 2016 Access to support and information

Action:

Pilot Red Cross Brokerage scheme and review outcome measures for consideration of roll out across the network

Pilot Third Sector OT working within general practice – fast track interventions in the community

Promote choose well campaign

3. Consider workforce and skill mix training opportunities to extend the range of professionals within the cluster

Practices

December 2015

Enhanced skills and improved efficiency of services

Action:

Identify training and development needs of core practice staff

Consider opportunities for network based professionals



For completion



4. Consider opportunities for network based service provision

Practices

March 2016

Providing a local service and utilising Network skills to improve patient services

Action:

Referral process in existence within network for minor surgery and LARC

Consider other Enhanced Services that could be delivered at a network level by cross practice referral

Strategic Aim 3: Planned Care- to ensure that patient’s needs are met through prudent care pathways, facilitating rapid, accurate diagnosis and management and minimising waste and harms


For completion



1 To drive forward the development of a community based ultrasound-equipped musculoskeletal service that will enhance and relieve pressures on secondary care services.

Practices LHB Secondary Care

March 2016 Shorter waiting times and more convenient local service. .

Action:

Funding secured for the provision of ultrasound

scanner and training to deliver the service.

GWSPI identified in in the field of musculoskeletal

and sports / exercise medicine.

2 Improve access to mental health and wellbeing services.

Practices LHB

March 2016 Local enhanced management of patients that require counselling.

Action:

Commission a local based mental health counselling service

Promote ABMU Living Life Well Programme.



For completion



3. Prescriber Incentive Scheme/Inhaler switches

Medicines Management Team Local Pharmacy Prescribing Leads and Clerks

March 2016 More consistent cost-effective prescribing. Avoid generic prescribing.

Action:

Prescribing Incentive Scheme Plus has been agreed. Inhaler switches to start during October.

4 Extend the pathway of care for dementia support within primary care

Practices Dementia Support Workers

March 2016 Support for people living with Dementia

Action:

Embed ABMUs Community Dementia Support Worker within the network.

Consider dementia awareness training needs.

5. Drive changes in patient expectation/ prescribing culture

Health Board Practices

March 2016 Minimise potential risks of increasing antibiotic resistance and C.difficile infection.

Action:

Work in collaboration with community based pharmacy team – ‘Big Fight’.

Engage with patients through established forums e.g. attendance at community groups etc to raise awareness of the dangers of inappropriate antibiotic use and associated antibiotic resistance (ABM Pathfinder).

6. Develop and undertake a programme approach

Practices Health

March 2016 Improvement in antimicrobial stewardship

Action: Support the specialist antimicrobial North Network pharmacist (ABM Pathfinder) to develop and undertake



For completion



to improve antimicrobial stewardship .

Board a programme approach to improve antimicrobial stewardship through:

Comprehensive, regular and consistent analysis of practices progress (including feedback to practices)

Leading multidisciplinary prescribing reviews.

Providing education and awareness sessions with GPs and other relevant practice staff

Develop and co-ordinate a network of GP antimicrobial prescribing champions.

Develop and pilot a visible ongoing Cluster wide campaign to raise awareness of the dangers of inappropriate antibiotic use and associated antibiotic resistance.

Work in close collaboration with key-stakeholders such community pharmacies, care home staff, community teams etc through the development of engagement events and regular liaison.

7. Early identification and proactive management of respiratory patients

Practices Health Board

March 2016 Improved management of respiratory tract infections reducing the risk of associate

Action:

Introduce point of care CRP Testing. Work in collaboration with the antimicrobial North Network pharmacist to develop protocols and agreed outcomes,



For completion



infection and complications of antibiotic prescribing. Early diagnosis of COPD, access to education and pulmonary rehab

Refer patients to community Pulmonary Rehabilitation service

Consider opportunities to improve reporting and interpretation of spirometry results.

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


For completion



1. Provide proactive, timely care to those who are most vulnerable and complex to manage

Practices Health Board MDTs

March 2016 Co-ordinated and improved care. Less crisis appointments/attendances across the system

Action:

North Network identified as an Early Adopter network.

Introduction of an anticipatory model of care

Participate in MDTs to assist in identify patients for co-ordination.

Clinical medication reviews undertaken by cluster pharmacist and provide opportunities for better chronic conditions management.



For completion



Proactive support to address key issues

2.. Reduce unnecessary hospital admissions

Practices WAST

March 2016 Care delivered locally Minimising hospital admissions Shorter waiting times

Action:

Increased liaison with paramedics.

Plans to quantify frequency of contact with paramedics and audit data.

3. Improve transfer times to Acute Medical Unit

Practices Health Board

March 2016 Improved patient flow and reduction of overnight stays

Action:

Second pilot of Man and the Van scheme commences 7th September.


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


For completion



1 National Clinical priority for the management of End of Life Care. To support GPs to review the experience of End of Life care.

Practices March 2016 Improved end of life care

Actions: Identify all deaths occurring between 1st January 2015 and 31st December 2015 2 in 1000 patients Review significant event analysis approach to access delivery of end of life care (with particular focus on continuity of care).

Contacts by multi-disciplinary team in the last two weeks of life

The completion of DNACPR

Completion of Out of area

The availability of the just in case boxes

Emergency admissions of patients at the end of life

Identify any learning and action required which should be linked into the Practice Development plan Summarise themes and actions for discussion at cluster network meetings and share information with the HB as required. This should be achieved through completion of the proforma.


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


For completion



1 National Clinical priority for early detection of Cancer. Understanding cancer care pathways and identifying opportunities for service improvement.

Practices March 2016 Early detection of cancers

Actions:

1. Review the care of all patients newly diagnosed between 1st January 2015 and 31st December 2015 with lung (including mesothelioma) and digestive system cancer using a Significant Event Analysis tool.

2. Review the care of all patients newly

diagnosed with ovarian cancer between 1st January 2015 and 31st December 2015 using a Significant Event Analysis tool.

3. Summarise learning and actions to be shared with the network and the wider LHB.

4. Identify and include any relevant actions to be

addressed in the PDP

5. To try and understand how the NICE guidance ( NG12) can help us improve early cancer detection rates and improve cancer survival rates locally.


Strategic Aim 7: Minimising the risk of poly-pharmacy


For completion



1 To minimise the harms of Polypharmacy

Practices March 2016 Minimising the harm to patients by non compliance of essential medications and over prescribing of non-essential medications.

Actions:

Identify and record number the % of patients aged 85 years or more receiving 6 or more medications (including dressings)

Undertake face to face medication reviews, using “No tears” approach or similar tool as agreed within the cluster, for at least 60% of the cohort defined in 1 above (for a minimum number equivalent to 5/1000 registered patients. If the minimum number of reviews cannot be undertaken because of small size of cohort defined in 1 above, consider reducing the age limit until the minimum number is reached)

Identify and include any relevant actions to be addressed in the PDP

Summarise themes and actions for review with the cluster network and share information with the LHB as required.


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


For completion



1. Engage with a robust validated clinical governance process specifically designed with Cluster planning in mind

Practices

March 2016 Improved quality and patient safety

Action:

Complete the Clinical Governance Practice Self Assessment Tool (CGPSAT)

Work towards achievement of level 2 in

relation to the standards concerning:

- Safeguarding vulnerable adults - Adults with a learning disability - Safeguarding children

Identify improvement actions for inclusion in PDPs.

2. Produce and maintain a cluster risk resister

Cluster March 2016 Action: Identify and agree risks to include

USC downgrades

Discharge summaries

Impact of inappropriate transfer of work from secondary care


Strategic Aim 9: Other Locality issues

No Objective Key partners For completion

Outcome for patients Progress to Date RAG Rating

1. Create a sustainable general practice model for the Llynfi Valley

Health Board October 2015

Sustainable three practice model will secure the future provision of general medical services for the community and will provide opportunities to improve the range and quality of local services, patient safety and experience.

Action: Closure of Nantyffyllon Surgery on 1/10/15 and managed allocation of patients to the three Llynfi Valley Practices, including transitional support arrangements.

Documents

Cluster Network Action Plan 2015-2016 Bridgend North North Cluster Net… · High levels of alcohol and drug abuse. High levels of teenage pregnancy High levels of unemployment and