Cluster Network Action Plan 2016-17 Monmouthshire South ... South NC… · programme with stakeholders Aligned with SIP-People are confident, capable and involved/Nobody Is Left Behind

Cluster Network Action Plan 2016-17

Monmouthshire South - Neighbourhood Care Network (NCN)

2

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

Objective For completion

by: -

Outcome for patients Action/Progress to Date RAG

Rating

1.1 Dementia

1.1.1

Work towards a whole

system approach for

people with

dementia/failing physical

health in a frail growing

older population

Aligned to Primary Care Plan Aligned with Monmouthshire SIP-Nobody Is Left Behind Healthcare Standard 1.1/3.1/3.2/5.1 Links to SCP2/8 Adopted as population needs priority

On-going

Public Health

NCN

Third Sector

Dementia Friendly

Communities

Team

Local Authority

ABUHB

Patients with dementia and

their families have access

to local support, advice

and services

Patients are supported by

multi-agency staff trained

in dementia awareness

Action:

To continue joint working initiatives established 2014-

2016

To hold a multi-agency workshop to formally accept

dementia as a joint priority

To undertake referral pathway review to identify barriers

Scope potential for an ‘Early Warning System’ for front

line professionals initiating dementia assessments

To raise awareness of on-line Dementia Friends training

Progress:

- On-going promotion of the Dementia Roadmap

- Consider impact of carers 2016-19 strategy key themes 3 &

7 (Primary Care/Mental Health) – action plan developed

- Discussion needed to agree how to progress against

specified actions

A

1.2 Obesity

1.2.1

New: To tackle obesity and

work towards a reduction

in the number of ante-

natal women & children

aged 0-4 years old in

defined geographical

areas, who are

overweight/obese

Aligned with Monmouthshire SIP-

On-going

Local Authority

Public Health

NCN

Housing

Adult weight

Management

Service

National Exercise

Referral Scheme

Midwifery

Families have access to

children and young

people’s services,

initiatives and projects

addressing obesity issues

‘Place Based Working’

Principles underpin work-

streams

Action:

To establish a task & finish group to support delivery of

key actions:

Establish baseline position to measure progress

To map level 2 services for weight management &

refer/recommend following brief intervention

To increase awareness & access to level 2 services for

target groups

Raise issue of weight & health routinely with brief

advice/intervention & refer to level 2 (community) /

3 ABUHB Adult Weight Management Service (AWMS)

A

3

Nobody Is Left Behind Healthcare Standard 1.1/3.1 Links to SCP2 Adopted as population needs priority

Flying Start

Families First

Community Based

projects

Attend a Childhood Obesity Strategy (COS) event &

support implementation / delivery of local action plan

Progress:

- NCN Management Team themed meetings focus on clear

action for NCN/MT delivery

- Joint COS workshop held to inform 3 year action plan

- Making Every Contact Count (MECC) training undertaken

with GPs, Practice & District Nurses & planned for Health

Visitors & School Health Nurses

- NCN funding considered for ante-natal & junior referral

scheme with NERS

- Linked to NUTRITION SKILLS FOR LIFE™ training

- 2015-16: 92 referrals to the AWMS (ranked 6th out of 12

NCNs) with a projection of 92 in 2016/17 (Green)

- Public Health exercise:

Adult obesity1

Estimated percentage of the registered practice population

(aged 16+) that are overweight or obese, as recorded by

the Welsh Health Survey. A person is described as

overweight if their BMI is 25+ and obese if their BMI is 30+

Monmouthshire South NCN: 56%

Childhood obesity2

Children aged 4-5 years who are overweight or obese -

Monmouthshire wide: 21% Source: 1Public Health Wales (2015) General Practice Population Profiles update 2016 2 Public Health Wales (2016) Child Measurement Programme for Wales 2014/2015

1.3 Engagement

4

1.3.1

To be a central source of

information, identifying

gaps in service locally and

sharing its work

programme with

stakeholders Aligned with SIP-People are confident, capable and involved/Nobody Is Left Behind Healthcare Standard 1.1 Links to SCP2

On-going

NCN

ABUHB

Practices

Third Sector

Public Health

Severnside Trust

Mechanisms are in place to

ensure patients, services

and partners are informed

of the work of the NCN

Shared learning &

communication leads to

improved services & local

knowledge

Action:

To respond to findings from ABUHB Engagement Team

events relating to accessing Healthcare

To publish a monthly NCN newsletter

To support Severnside Trust community based event

(NCN funded) and evaluation process

Progress:

- GAVO Rep attends NCN meetings representing the Third

Sector

- NCN newsletter developed to share new developments and

current issues across ABUHB & partners

- Severnside Trust event being planned with public survey

development supported by Public Health

- Public Health scoping exercise identifying Lifestyle factors

that contribute to poor health, shared with Severnside Trust

A

1.4 Learning Disabilities

1.4.1

New: Increase up-take of

Enhanced Service Annual

Reviews

Aligned with Monmouthshire SIP-People are confident, capable and involved Healthcare Standard

1.1/2.7/3.1/3.2 Links to SCP1/2/8

31.03.17

Practices

ABUHB

Local Authority

NCN

90% of patients with a LD,

who are eligible, have

access to Annual Health

Reviews via Primary Care

Services

Increased access for

assessment to identify

healthcare needs

Action:

Liaise with Monmouthshire County Borough Council LD

lead to assess barriers against meeting the 90% target

Review number of claims made against number of

eligible patients assessed

Progress:

- Meeting needed to agree action

- 2014/15: 133 people (1.1605%) received GP Practice health

checks (Source CMWEB)

- Approximately 2,396 people have a learning disability in

Monmouthshire (Source: SIP)

A

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

reasonable needs of local patients

5


by: -


Rating

2.1 Access

2.1.1

New: To identify

opportunities for shared

working & good practise

across Practices

Aligned with Monmouthshire SIP-People are confident, capable and involved Healthcare Standard 3.1 Links to SCP2

On-going

Practices

NCN Lead

NCN

Patients benefit from

increased collaboration,

standardised and

streamlined processes;

Increased Practice capacity

Action:

Identify action following GP capacity survey

Undertake NCN lead annual Practice visits

Analysis of Practice Development Plans

Progress:

- Survey undertaken & shared with the NCN

- Agree two themes to take forward

- NCN leads attend Practice Manager meeting

- Practice visits undertaken early 2016

A

2.1.2

New pilot: To enable

implementation of the NHS

England Constitution for

patients resident in

England

Aligned with Monmouthshire SIP-People are confident, capable and involved Healthcare Standard 3.1 Links to SCP10

31.01.17

Practices

NCN lead

NHS England

NHS Wales

ABUHB

National guidelines are

adhered to

Patients in England,

registered with a GP in

Wales, access healthcare

in a Hospital of their choice

Action:

To overcome barriers impacting on cross border flow

changes

Referral pathways are tested and lessons learned prior to

full implementation

Progress:

- 6 month test phase with 5 North & South GP Practices

(starting July 2016)

- Training for Practice staff within the WCCG test facility

- Test phase to be evaluated before wider roll-out

A

2.1.3

New: To support the

development of a ‘Care

Closer To Home’ (CC2H)

strategy and action plan Aligned with SIP-Nobody Is Left Behind Healthcare Standard 1.1/2.3/3.1

On-going

NCN

ABUHB Divisions

ISPB

Local Authority

Third Sector

Patients benefit from a

clear strategy, which

underpins partnership

working, allowing for the

sharing of local skills,

expertise and resources,

leading to appropriate care

being provided either at

Action:

To facilitate a multi-agency workshop in each NCN

locality/borough

NCN to contribute to the development of joint local action

plans

Progress:

- CC2H team presentation at NCN meeting

A

6

Links to SCP4

home or close to it

- Scoping/planning workshop held August 2016

- Resource maps provided by all stakeholders during

workshop to understand what agencies can bring and

identify duplication of resources/skills

- Draft strategy in development

- Action plan progress reported at monthly Chepstow Hospital

Development Group meetings

2.2 Workforce

2.2.1

Early warning for Practices

anticipating difficulty with

recruitment / filling

vacancies

Healthcare Standard 7.1 Links to SCP7

On-going

Practices

Primary Care

Team

NCN Clinical Team

NCN

Continuity of services;

Support against potential

Practice fragility

Action:

Practices inform NCN if anticipating difficulty

Practices meet with NCN clinical team to discuss action

Progress:

- Practices reporting increased pressures & difficulties in

retaining and finding new partners/salaried GPs via PDPs

- ABUHB website developed to allow vacancies to be shared

A

2.3 Estates

2.3.1

New: To enable wider

delivery of services in

primary care

Links to SCP7

Healthcare Standard 5.1

On-going

NCN

Practices

ABUHB Facilities

ABUHB

Housing

Patients are able to access

local services in premises

which are fit for purpose

Action:

To engage with Practices via Practice visits, NCN

meetings and Practice Development Plans to understand

accommodation issues

Progress:

- Practice visits undertaken

- Assessing impact of new housing developments

- Practices engaged in development of the ABUHB Estates

Plan

- Analysis of PDPs undertaken

- Melin Homes presentation July 2016:

- Monmouthshire has largest population boom, with

increase in populate of 1.7 people per house built

A

7

- Significantly higher house prices

- Population is predicted to shrink, however trend has

been 15% increase since 1991

2.4 Performance

2.4.1

New: To reinforce links

between the NCN & NCN

Management Team

Healthcare Standard 5.1 Links to All SCPs (excluding 6)

On-going

NCN

Public Health

Service Leads

ABUHB Finance

Team


increased collaboration,

standardised and

streamlined processes

Action:

Management Team to agrees priorities & clear action to

support delivery of the NCN Plan

To monitor spend against NCN budget and agreed

processes

Progress:

- Agreement that Management Team meetings focus on lead

priorities from NCN Plans with themed meetings

- Action logs linked to NCN Plan Strategic Aims

- Quarterly (CORE) performance reports considered at

Management Team

- Key Performance Indicators reviewed to ensure links with

the NCN action plan are in place

- Small Grant Scheme implemented

- Monthly combined finance/NCN meetings implemented

A

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


by: -


Rating

3.1 Planned Care

3.1.1

Pilot: To implement a

sustainable Pulmonary

Rehabilitation Programme

Aligned to Monmouthshire SIP-

31.03.17

National Exercise

Referral Scheme

(NERS)

Community Long

term Conditions

Patients with COPD have

local access to, and benefit

from evidence based

interventions,

implemented by a multi-

agency team working in

Action:

Identify NCN funding to support 2nd year of pilot scheme

Consider on-going funding (2017/18) to cover potential

risk associated with business case

Business case status reported at NCN

A

8

Nobody Is Left Behind/People are confident, capable and involved Healthcare Standard 1.1/2.7/3.1/5.1 Links to SCP1/3/7/10

Nurses (CRT)

Specialist

Respiratory Nurse

(CRT)

NCN

NCN Lead

ABUHB

partnership

Progress:

- Programme one held with good attendance, positive

feedback & learning points

- ABUHB staff recognition award submitted to recognise

efforts of the Pulmonary Rehabilitation Team

- Promotional poster developed to raise awareness at

educational events



- Business case developed & going through Health Board

approval process

3.1.2

New Pilot: To improve

access to Childhood

Constipation advice for 1–

12 year olds

Aligned with Monmouthshire SIP-People are confident, capable and involved Healthcare Standard 2.5/2.7/3.1/3.3 Links to SCP3/10

31.03.17

Childhood

Constipation Nurse

Practices

NCN lead

NCN

Children have access to

care close to their home

Reduced reliance upon

Hospital based services

Action:

To support recruitment process

Undertake a 6 month review

To monitor GP referrals into Secondary Care (currently

2nd highest in ABUHB) & admission rates

Progress:

- Linked to ABUHB Paediatricians trialling community based

interventions

- Post recruited to 1st June 2016

- Reinforce well-being e.g. diet & exercise with families

- E.R.I.C training undertaken

- Progress reported to Chepstow Hospital Development Group

- Referral form implemented

A

3.1.3

Improve access to local

Phlebotomy for people

aged 14+

Aligned with Monmouthshire SIP-People are confident, capable and involved Healthcare Standard 6.1/3.1 Links to SCP3/10

On-going

Healthcare

Support Worker

Practices

Secondary Care

NCN Lead

NCN

Patients receive care by a

trained professional, close

to home on a drop-in

basis

Action:

To undertake 3 monthly reviews & consider impact

To liaise with Practices to overcome barriers

To consider expanding role to include ECG’s for MAS

patients pre dementia medication prescribing

Progress:

- HCSW training undertaken

- Initial 3 month review held in 2015/16 identified growing

A

9

demand and resolution of issues supported by NCN team

- Second review expected September/October 2016

- Continued communication with GP Practices at NCN

meetings

- Very positive feedback received

- ABUHB staff recognition award submitted to recognise

efforts of the HCSW



3.1.4

New: Improve access to

Young person’s

contraception service

Aligned with Monmouthshire SIP-People are confident, capable and involved Healthcare Standard 1.1/2.7/3.1 Links to SCP2/3/9 Source: PDPs

31.03.17

NCN

Practices

ABUHB Sexual

Health Service

Local Authority

Youth Service

Young People have access

to local Sexual Health

advice, treatment options,

which meet their needs

Action:

To consider option for daily appointments to be made

available to local schools for emergency contraception, in

response to the age restriction in place on community

pharmacies

Progress:

- NCN considering necessary action & identifying potential

barriers

- Liaising with Secondary Care Sexual Health Services

- Meeting to be held with ABUHB senior Clinical/Directorate

team November 2016

A

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

effectiveness of risk management Objective For completion

by: -


Rating

4.1 Frailty

4.1.1

New: To scope potential

for urgent diagnostics,

refuge beds & Hot-Clinics

On-going

NCN lead

ABUHB

Integrated

Supported management of

patients in primary care

setting;

Action:

To support the development of a 12 month ‘proof of

concept’ proposal for Consultant led service

A

10

across 3 sites

Aligned with SIP-Nobody Is Left Behind Healthcare Standard 2.5/3.1 Links to SCP9 Source: PDPs

Services (CRT)

Partnership Board

(ISPB)

NCN

Reduced admissions to

secondary care;

Improved access to

relevant diagnostics &

assessments

Progress:

- Action monitored via the Chepstow Hospital Development

Group

- Issues with Single Point of Access noted (Source: PDPs)

- Status and finance monitoring considered at Integrated

Services Partnership Board meetings

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


by: -


Rating

5.1 End of Life Care

5.1.1

Review the delivery of End

of Life Care using the

Individual Case Review

Audit

Aligned with Monmouthshire SIP-People are confident, capable and involved Healthcare Standard 3.1/4.1 Links to SCP3/10

31.03.17

NCN Lead

Practices

Palliative Care

Team

NCN

Improved care processes

for individuals and families

/ carers regarding End of

Life Care provision

Action:

Summarise case review data, identify arising issues and

actions

Establish a review cycle, to monitor progress

Progress:

- Audit findings shared with the NCN on an annual basis &

informs NCN lead year-end report

A

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


by: -


Rating

6.1 Suspected Cancer

11

6.1.1

Review the care of all

patients newly diagnosed

between 1 January 2016 to

31 December 2017 with

lung, gastrointestinal and

ovarian cancer

Aligned with Monmouthshire SIP-People are confident, capable and involved Healthcare Standard 3.1 Links to SCP3/9/10

31.03.17

NCN

NCN Lead

GP Macmillan lead

Practices

St David’s

Foundation

All lung, gastrointestinal

and ovarian cancer

patients will have their

referral information

reviewed and outpatient

appointments/results

followed up

Action:

Summarise case review data, identify arising issues and

actions

Establish a review cycle, to monitor progress

Progress:



- GP Macmillan lead attended NCN meeting & will facilitate

outcomes being shared with Secondary Care

- Gwent-wide Community Health Champions Project (funded

via Wellbeing Activity Grant in partnership with PHW)

awareness training module designed to help increase

knowledge and understanding of:

- The different screening services available

- Who is eligible for screening and when

- How to signpost to appropriate services

A

Strategic Aim 7: Minimising the risk of polypharmacy Objective For completion

by: -


Rating

7.1 Polypharmacy

7.1.1

Identify and record

numbers and rates for

patients aged 85 years or

more receiving 6 or more

medications

Aligned with Monmouthshire SIP-People are confident, capable and

31.03.17

NCN lead

Pharmacist

Practices

NCN

Patients at high risk or

harm, of over or under

medicating, are identified

and reviewed

Action:

Undertake a review of practice clinical systems to

identify patients over the age of 85yrs in receipt of 6 or

more medicines

Undertake face to face medication reviews

Progress:



A

12

involved Healthcare Standard 2.6/3.1 Links to SCP3/4/7

-

7.1.2

Continue to support the

role and integration of the

GP Practice based

Pharmacist

Aligned with Monmouthshire SIP-People are confident, capable and involved Healthcare Standard 3.1/7.1 Links to SCP3/4/7

31.03.17

NCN

Pharmacy

Practices

Patients have local access

to, and benefit from

evidence based

interventions;


reduced waiting times;

Increased GP capacity

Action:

Pharmacist to present progress against expected

outcomes at two NCN meetings

Pharmacist provides quarterly performance data

presented at NCN leads meeting

- Quarterly report to be shared with Community Nursing

Leads

Undertake annual evaluation of performance

Progress:

- Presentation given at NCN meeting 2

- Quarter 1 report submitted

A

7.1.3

To recruit an additional GP

Practice based Pharmacist

Aligned with Monmouthshire SIP-People are confident, capable and involved Healthcare Standard 3.1/7.1 Links to SCP3/4/7 Adopted as NCN Funding Priority

31.09.16

NCN

Pharmacy

Practices

As above Action:

Pharmacist to present progress against expected

outcomes at NCN meetings once recruited

Pharmacist to provide quarterly performance data

Undertake annual evaluation of performance

Progress:

- 0.75 funding agreed approx 28 hours

- Recruitment process started August 2016

- Quarterly reports to be submitted when in post

A

7.2 Medicines Management

7.2.1

To monitor the NCN

prescribing budget and

delivery of the Medicines

Management plan

Aligned with Monmouthshire SIP-People are confident, capable and

On-going

Prescribing

Advisors

Practices

NCN

Efficient use of resources

that can be re-invested

more appropriately into

patient care

Action:

To scrutinise prescribing budgets on Practice by Practice

basis at all NCN meetings;

To monitor NCN performance against all other NCNs

Progress:

- Targeted approach with prescribing advisor supporting

individual Practices

A

13

involved Healthcare Standard 2.6/3.1 Links to SCP3/4/7

- Up-dates provided at all NCN meetings

- Prescribing switch options discussed in the round

- Pharmacy Technician Practice visits undertaken to identify

potential efficiencies

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


by: -


Rating

8.1 Clinical Governance

8.1.1

To fully implement the

Clinical Governance Toolkit

Links to all SCPs All Healthcare Standards

On-going

QPS

NCN

Primary Care

Networks &

Community

Division

Practices

Consistency and safety in

Practices and NCN wide

Primary Care services

Action:

To remind Practices at NCN meetings to complete the

toolkit

To monitor progress via QPS reporting

Progress:

- Baseline: All Practices completed the toolkit in 2015/16 -

5 out of 5 Practices in progress 2016/17

- Practices have access to CPD sessions facilitated by ABUHB

- Monthly QP team reporting to NCNs shared with NCN lead

A

Strategic Aim 9: Other Locality issues


by: -


Rating

9.1 Chepstow Hospital

9.1.1

Continue to develop

Chepstow Community

Hospital (CCH) as a multi-

On-going

NCN

Integrated

Services

Patients receive care in the

right place, at the right

time, by the right people

Action:

To deliver the Chepstow Hospital action plan

To consider the influence & implications of the Care

Closer To Home Strategy

A

14

functional Healthy Living

Centre (Hub)

encompassing Integrated

Health & Social Care

services Aligned to Monmouthshire SIP-Nobody Is Left Behind/People are confident, capable and involved Healthcare Standard 2.3/2.7/3.1/5.1 Links to SCP1/2/3/4/5/7/8/10 Linked to Clinical Futures Linked to CC2H Strategy Adopted as local priority

Partnership Board

Public Health

Care Closer To

Home Team

Patients are supported to

remain at home by a

combined multi-

disciplinary/agency team,

to maximise recovery

Reduced reliance upon

Secondary Care based

services

Progress:



- Linked to NCN Management Team priorities

- CC2H draft strategy shared with the NCN & wider Integrated

Services Partnership Board

Documents

Cluster Network Action Plan 2016-17 Monmouthshire South ... South NC… · programme with stakeholders Aligned with SIP-People are confident, capable and involved/Nobody Is Left Behind