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1 | P a g e
GP Cluster Network Action Plan 2015-16
Llwchwr Cluster
Llwchwr Primary & Community Network Cluster Plan
Nov 2015
2 | P a g e
Welcome to the Llwchwr Primary and Community Health network/cluster plan for 2015/16. 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 46,800.
3 | P a g e
4 | P a g e
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.
5 | P a g e
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
6 | P a g e
Strategic Aim 1: To understand the needs of the population served by the Llwchwr Cluster Network
No Objective Action Key partners Forcompletionby: -
Outcome forpatients
Progress todate/currentposition
RAGRating
1 To continue to understandthe profile of LlwchwrCommunity Network and toreview the needs of thepopulation using availabledata
To create a LlwchwrCommunity profiledocument
• PHW• Primary and
Community Unit• Health Board
Informatics
Profilecompletebut will beannuallyreviewedandupdated
To ensure thatservices aredevelopedaccording to localneed
All practicesreviewed therevised data tocomplete theirpracticedevelopmentplans in July 2015and to inform thedevelopment ofthe cluster planfor 15/16
2 Respiratory Disease
• To continue toeducate patients onthe causes of asthmaand preventativemeasures
• Pulmonary Rehab
To signpost patients torelevant voluntaryorganisations.
Increase the number ofpatients accessing thePulmonary Rehabservice
To be aware of theinclusion/exclusioncriteria for patientreferrals
• CCM• GPs• 3rd Sector
CommenceJuly 15 andongoing
Less patientsdevelopingasthma
Higher number ofpatientsaccessing thePulmonary Rehabservice.
Funds wereidentified withinthe Network, butsupport no longerrequired assufficient fundingreceived from theHealth Board
7 | P a g e
To explore any otheropportunities to supportPulmonary Rehabservice through use ofcluster funding
3 To provide CBT sessions forLlwchwr patients
To use funds to employprivate professionals toprovide CBT sessions
• GPs March 2016 Will improveaccess to CBT forLlwchwrpopulation ascurrent waiting listis >1 year
Will improve thequality ofmanagement ofdepression inprimary care
Professionalsidentified.Fundingapproved,protocol agreedand practicesable to refer
4 To support patients includingnewly diagnosed diabeticpatients (and those pre-diabetic patients) inundertaking lifestylechanges which will benefittheir health and wellbeing
To embed the WeightWatchers/Positive Stepsprogramme across theNetwork
To proactively review thenumber of patients beingreferred by the practiceto NERS/WeightWatchers
To increase numbers ofreferrals byreviewing/reducingreferral criteria to makeservice available to otherpatients who wouldbenefit
• GPs• Weight
Watchers• Positive Steps• PHW• Health Board
CommenceAugust2015 andOngoing
Better health forthose patientswith chronicdiseases
Improved lifestylechoices leading toa lessmedicalisedmodel of care
Practices arereferring patientsto WeightWatchers andpatients showingweight loss.Projectprogressing well
8 | P a g e
5 To increase cervicalscreening uptake
To continue to raiseawareness of cervicalscreening programme:
Advertising via posters &leaflets provided bycervical screeningincluding GP practices,community pharmacistsand local authoritybuildings
To explore the potentialto contact patients bytelephone who have notparticipated in theprogramme. (Dependanton funding)
GP practicesCommunityPharmacistsLocal AuthoritybuildingsCervical ScreeningWales (forinformation)
March 2016 Early detection ofhealth risks
Current screeninglevels identifiedand areas of lowlevels targeted
6 To improve access to mentalhealth services
To increase mentalhealth nursing input
To provide in housecounselling services
To further develop theSCVS Mental Healthclinic within the LlwchwrNetwork and explorenew ways of working e.g.Development of MentalHealth focussed Noticeboards/InformationProvision within the GPPractices
SCVSHealth BoardGP practices
December2015
Improved, timelyaccess to mentalhealth services
Improved accessto counsellingservices forpatients whoneed Tier 0support either viapractice ornetwork level
Link in to MentalHealth officer inSCVS
Signpostingpatients to Tier 0servicesFurtherdiscussion to beundertaking atNetworks toprogress further
9 | P a g e
To review and be awareof referral mechanismsto CAMHS
7 Reduce the number of fallswithin the network byproactively identifying andmanaging those patients atrisk of falls and furtherassociated complications.
Closer workingrelationship with ChronicCare Nurses
Identify patients at riskof falls
Pro-active care
To promote the use ofthe falls prevention guide
• GPs• Chronic Care
Nurses• District Nurses• CCM Team• SCVS
Ongoing Pro-activeidentification andmanagement ofpatients at risk offalls and furtherassociatedcomplications
A falls preventionguide has beenproduced anddistributed widelywithin Llwchwr.Further copies tobe producedtogether with asmaller 2 pageversion
8 Frail ElderlyTo consider all relevantactions that will assist inreducing the number ofhospital admissions for thisvulnerable group of patients;facilitating care at homewherever possible.
Develop closer workingrelationship with ChronicCare Nurses
To develop step up/stepdown beds at Gorseinon
Rapid access to MedicalHOT clinics and supportfor Community Careteams
• AGPU• CCM• GPs• 3rd Sector• Community
Connectors• Locality• LA
Ongoing Reduceadmissions tohospital
ThroughDementiaFriendly practicesprovideappropriatesupport andawareness
DementiaTrainingundertaken atPLTS session.
Community Hubsestablished
9 Develop the Local Area Co
ordinator pilot project :
ABMU to work with LACsto provide clear eligibilitycriteria for referringpatientsPractices to actively referpatients where suitable:
• LAC• Practices• Health Board
August2015 andongoing
Improved supportand signpostingfor residentswithin parts of theNetwork
Local Area Co-ordinator hasattended aNetwork meetingand made linkswith the practices
10 | P a g e
(Unfortunately thisservice is only availableto some parts of theLlwchwr Network and notaccessible to allPractices and residents)
Local Area Co-ordinatorto attend clustermeetings
10 To increase the use of theHealthy City Directory withinthe network; signpostingpatients to the mostappropriate service
To promote the use ofthe Healthy directorywithin practices and topatients
• NHS direct• Health Board• SCVS• Voluntary
Sectororganisations
Ongoing Networkpopulation moreinformed onavailable healthand well beingservices
Further promotionof the use of theHealthy CityDirectory withinpractices and topatientsundertaken.Bannersproduced anddisplayed
11 To further develop the thirdsector support projectincreasing the use ofvoluntary sector services bythe Llwchwr Networkpopulation
Provide opportunities forthird sector organisationsto attend ProtectedLearning Time Sessionswith GPs and non clinicalstaff
Ensure that links aremade with voluntarysector organisationssupporting the agreednetwork priority areaswhere possible.
SCVS to map ThirdSector provision against
Led by Networkpracticessupported bySCVS
Led by Networkpracticessupported bySCVS
Led by Networkpractices
Ongoing
Ongoing
Dec 2015
Improved supportand access toservices for theLlwchwrNetwork
population
Up to date
information on
voluntary sector
services
displayed in GP
practices, e.g.
information
stands, notice
boards.
Develop theNetwork PLTSsessions todeliver training on
11 | P a g e
network priorities.
Ensure that up to dateinformation on voluntarysector services isdisplayed in GPpractices, e.g.information stands,notice boards.
To extend voluntarysector presence withinGP practices in thenetwork by increasingthe number of practicesparticipating, HealthyPartnerships andexploring new ways ofworking jointly such aspre bookableappointments wherepossible
supported bySCVS
Led by Networkpracticessupported bySCVS
Led by Networkpracticessupported bySCVS
Ongoing
Ongoing
issues pertinentto practices inLlwchwr
SCVS colleagues
regular attend
Network Meetings
All practices are
taking part in the
Healthy
Partnership
project
12 Increase flu immunisationuptake
Lower performingpractices to work withPHW
PHWNetwork PracticesCommunityPharmacies
Mar 16 Protect patientsat risk and thewider population.
Good practice
discussed and
key areas for
progression
identified. Public
Health colleagues
attended Network
meeting to
promote flu jabs
12 | P a g e
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
Progress todate/currentposition
RAGRating
1 Ongoing review ofcurrent demand forappointments andclinical capacity
Identify any potentialstreamlining systems andprocesses including theuse of anytoolkits/software available
Work with the PrimaryCare Foundation toassess access anddemand
• Practice• Primary
andCommunity Unit
Ongoing Services developed toreflect local need inline with capacity todeliver safe andeffective services
Individualpractice plansand feedbackfrom PCF inSeptember2015.
Cluster meetingundertaken withfeedback fromPCF
2 To investigate the
possibility of
developing the
Network as a
Federation
To look at the possibility of
Llwchwr Network
becoming a Federated
Network
Network
ABMU
March 16 Decisions taken bythe Network
Reviewing thework undertakenby a Network inBridgend. Eventto be arrangedin March 2016
3 To review workforcepressures and
To consider successionplanning arrangements at
• Practice Ongoing Seamless serviceprovision for patients
To explore thepossibility of
13 | P a g e
develop localworkforcedevelopment plans
practices to be betterprepared for leavers
Increase peer support
Consider use of networkmonies to develop a GPresource for practices toaccess.
Consider developing skillmix across the network todeal with patient demandand GP pressures
employing aParamedicPractitioner.Informationreceived fromHywel Dda andcirculated tocolleagues withLlwchwr
4 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 Responsive servicestaking into accountservice user and carerfeedback.
A communityevent has beenheld highlightingthe priorities ofthe Cluster Plan.Work Plan forthe CommunityVoices Groupdeveloped toinclude prioritieswithin the Plan
14 | P a g e
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
Progresstodate/current position
RAGRating
1. To ensure that theneeds of patients andcarers are reflected inthe work of thenetworks
To continueimplementation ofthe patient andcarer participationgroup as part ofthe CommunityVoice Programme
To undertakeCarers trainingthrough PLTS
• GP Practices• Community
Nursing• Social Services• Third sector• Patient and Carer
ParticipationGroups
Established andongoing
Patients betterinformed ofpriories withinthe Network
CommunityVoiceProgrammeestablishedandprogressingwell withinLlwchwr
PLTSsession toraiseawarenessof CarersNeedsarrangedJanuary2016
15 | P a g e
3 To improve awarenessof pathways on the GPportal
All clinicians andlocums to bemade aware ofpathways on GPPortal
Assess potentialto access GPportal frominternet ratherthan intranet
To receive alertswhen newtemplates areissued and toreceive feedbackfrom secondarycare colleagues
• GP Leads• PM’s
Established andOngoing
Ongoing
Ongoing
Improvedawareness andcommunicationwill result inmore effectivecommunicationwith secondarycare resulting inswifter and moreeffectivereferrals forpatients
GP Portalestablished.Continuedlinks withsecondarycarecolleagues
4 PMS Plus – RespiratoryPrescribing – to beconsidered on anetwork basis
To undertake arange ofprescribinginitiatives asrequired toimproverespiratoryprescribing
To make ScriptSwitch availablefor practicenurses
• GP’s• Practice Nurses• Medicines
Managementteam
Established andongoing
Improvement inpatient symptomcontrol
Investment inother serviceareas for patientbenefit.
OngoingmedicationswitchesbeingundertakenbyMedicinesManagement team
16 | P a g e
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
Progress todate/currentposition
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
• GP OOH• A&E• MIU• HB• Community
Voices
Ongoing Better educationon how to accessservicesappropriately tomeet their needs
Progression ofthe AGPUserviceincluding thenew OutreachserviceChoose WellCampaignmaterial eg:posters and zcards madeavailable topractices.(September2015).
2 Improve partnership withAmbulance Service
Improve patient education
Improve communicationbetween practices and theAmbulance service
• GPs• Welsh
AmbulanceService
Ongoing Betterunderstanding ofthe services thatare available forpatient transport
Discussionsongoing toimprove theservice.OperationsManager atWAST to beinvited to
17 | P a g e
attend futureNetworkmeeting
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
18 | P a g e
Strategic Aim 5: Improving the delivery of end of life care
No Objective Action Key Partners Forcompletionby: -
Outcome forpatients
Progress todate/currentposition
RAGRating
1 To review thenumber of deaths asper guidelines
Undertake reviewof number ofdeaths as perguidelines
GP LeadsSecondary CareColleaguesPMs
March 2016 andongoing.
Identification oftrends across theNetwork
NationalPathway workdiscussed andundertaken atDecemberClustermeeting
2 Use of and beddingin of Principles ofEnd of Life Care
To review thenumber of deathsas per guidelines
Practice levelregular palliativecare reviews andcompletion ofEOL template
• Practice• Community
Staff
March 2016 andongoing
More appropriateand amenable care
NationalPathway workdiscussed andundertaken atDecemberClustermeeting
3 Undertake regularaudit; sharing resultson a cluster networkbasis
Regular audits tobe undertakenand learningpoints to beprogressed
• Practice• Community
Staff
Ongoing NationalPathway workdiscussed andundertaken atDecemberClustermeeting
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Strategic Aim 6: Targeting the prevention and early detection of cancers
No Objective Action Key partners For completionby: -
Outcome forpatients
Progress todate/currentposition
RAGRating
1 SEA of all newlung, stomachand GI cancers
Regular reviewand audit oflung, stomachand GI cancers
GP Practices
Secondary Care
March 2016 andongoing
To diagnose cancersas early as possible totreat
Improved access todiagnostics andendoscopy in timelymanner
National Pathwaywork discussedand undertaken atDecember Clustermeeting
2 Undertakeregular audit;sharing resultson a clusternetwork basis
Regular auditsto beundertakenand learningpoints to beprogressed
GP Practices
Secondary Care
March 2016 andongoing
To identify any issuesand improve thediagnosis of cancers
National Pathwaywork discussedand undertaken atDecember Clustermeeting
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Strategic Aim 7: Minimising the risk of poly-pharmacy
No
Objective Action Keypartners
For completionby: -
Outcome forpatients
Progress todate/currentposition
RAGRating
1 Appointment ofClinical Pharmacist
Clinical Pharmacist to be
appointed and shared across
the Network focussing on
polypharmacy issues
particularly relating to
patients who have been
discharged from hospital or
are residing in a care home.
• GPs• Practice
nurses
Ongoing withinQOF 15/16
Shared CP wouldreduce medicineswastage, ensurecompliance withmedication andreduce the risk ofdrug contraindications topatients across thenetwork
All patients acrossthe LlwchwrNetwork will benefitfrom enhancedprovision ensuringpositive patientoutcomes
£36,000allocated toimplementthe clinicalpharmacistServiceacross thenetworkPharmacistAppointedand will startin January2016
2 Improvement/maint
enance against
target prescribing
indicators
Can consider and review
practice and network data for
antibiotics / statins /
hypnotics & anxiolytics and
discuss how improvements
can be made if required
GPs Ongoing within
PMS 15/16
Improvement in
prescribing quality
to improve health
outcomes
3 To provideaccredited trainingfor prescribingclerks
To provide accredited trainingfor prescribing clerks
Medicines
management
team
March 2016 Improved repeatprescribingsystems
Trainingpacks indevelopment
21 | P a g e
4 To ensureappropriate use ofthe pharmacist andtechnicianresources to reducerisks frompolypharmacy
To ensure appropriate use ofthe pharmacist andtechnician resources toreduce risks frompolypharmacy
Medicines
management
team
Cluster
Pharmacist
available by
October 2015
Improved accessfor improvedpharmaceuticalcare
5 To engage in thePrescribingManagementScheme (PMS) andPMS+ respiratoryschemes (whichcontainpolypharmacyelements)
To engage in the PrescribingManagement Scheme (PMS)and PMS+ respiratoryschemes (which containpolypharmacy elements)
Medicines
management
team
PMS 15/16 – by
March 16
PMS +respiratory
– by
November 16
Improvedmedicinesmanagementincludingpolypharmacy
All practicesengaged andmakingprogress
6 To progresspolypharmacyissues identified inprevious clusternetwork plan
To progress polypharmacyissues identified in previouscluster network plan
Practice
teams
Ongoing Improvedprescribing andmechanisms forpolypharmacyreview
Ongoing
22 | P a g e
Strategic Aim 8: Deliver consistent, effective systems of Clinical Governance
No Objective Action KeyPartners
Forcompletionby: -
Outcome forpatients
Progress todate/currentposition
RAG Rating
1 To continue toreview SignificantEvent Analysishighlighting themesand trends
SEAs reviewed byindividual practices on anongoing basisIncidents where there is adirect correlation tosecondary care are beingnotified to the HealthBoard
Practices to share SEAs atNetwork meeting to sharelearning
• GPPractices
• GPs• Practice
Nurses• Practice
Managers
March2016
Potential for changes toservices based onoutcomes of significantevents where there hasbeen positive/negativeaction
Practices topresent SEAs ateach of the 3Cluster meetingsbetween Oct 15and March 16Tal Y Bont,Princess Street,reported at Novmtg. Gowerton &Ty’r Felinpresented at Decmtg
2 To highlight thedowngrading ofcancer referrals
Practices to review allcancer referrals that havebeen downgraded thatwere subsequently foundto be cancer
GP Practices Ongoing Improvement tosystems to benefitfuture detection
Ongoingdiscussions.Issues need toraised with HealthBoard
3 Improve DischargeSummaries
To continue to raiseawareness of theproblems with practicesreceiving complete, timelydischarge summaries
• GPs• Locality
CD• Medical
Director
Ongoing Primary Care staff willbe better informed ofpatients condition andtreatment e.g.Medication
Issues raised withHealth Boardcolleagues.Furtherdiscussionscontinuing
23 | P a g e
Strategic Aim 9: Other Locality issues
No Objective Action Key partners Forcompletionby: -
Outcome forpatients
Progress todate/currentposition
RAGRating
1 Access to CitizensAdvice Bureau withinGeneral Practice
CAB to provide anadvice serviceresource in the GPpractices within theNetwork, through theprovision of adviceworkers for 7 daysper week, six ofwhich to be providedas an outreach toNetworksThe pilot will also befully evaluatedfollowing the end ofthe pilot
• Locality• CAB• GP Practices
Funding untilMarch 2016.Full 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
2 To ensure thesustainability of primarycare services within theLlwchwr network givenconcerns in relation torecruitment problems &locum availability,together with high levelsof concern in respect ofseveral large housingdevelopments includedwithin the LDP
Notify LHB ofconcerns and flagspecific issuesrelating to individualpractices
Ensure that bothLHB and LA are keptinformed of issuesand concerns
Explore ways todevelop an inter-practice support
Primary andCommunity UnitLALMC
Ongoing work Sustain and aimto improve thelevel of servicesbeing providedwithin primarycare across theLlwchwr Clusternetwork
LHB aware ofnetwork andindividual practiceissues/workforceconcerns
Follow up meetingwith LA takenplace for PMs incluster
Correspondencesent to LA/LHB onbehalf of network
24 | P a g e
network
Investigate how toinfluence locumcharges andavailability
Support training andrecruitment initiatives
Consider the nationalsustainabilityframework
Ongoing
Ongoing
Ongoing
notifying concernsFurther workongoing, includinginformationsharing
To consider thecontents of theWelshGovernmentstrategicdocument onPrimary CareWorkforce and tolink this to networksustainabilitypriorities.
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 INR service – ensuring
dosing and prescribing
are not separated
INR Enhanced
Service to be
commissioned
across practices
GP practices +/-
secondary care
services +/- HB
medicines
management
Ongoing Safer services
through not
separating roles
of monitoring and
prescribing – in
PBMA
(Programme
Budgeting &
Marginal Analysis)
exercise ongoing
within the Health
25 | P a g e
Review of INR service to
ensure includes NOACs
OR
Consideration given
to mechanisms to not
separate INR
monitoring from
prescribing
e.g. use of
pharmacists or
medical scientists in
community doing
dosing & prescribing
OR secondary care
prescribing as they
do monitoring and
dosing.
teams line with MHRA Board, looking at
the AF pathway,
with a particular
focus on
Anticoagulation
Service Models.
Engagement
exercises
undertaken with
both GPs and
patients.
Currently
analysing existing
and suggested
service models
based on cost and
quality.
5 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
26 | P a g e
Strategic Aim 10: Other Locality issues
No Objective Action Keypartners
For completion by: - Outcome forpatients
Progress todate/current position
RAGRating
1