Monmouthshire South Network Action Plan 2015-16 South... · 2016-04-12 · Monmouthshire South Draft Action Plan 2015-16 ... WORD Version - English.pdf DN service target: ... practice

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Monmouthshire South Network Action Plan 2015-16

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Monmouthshire South Draft Action Plan 2015-16

Strategic Aim 1: To understand the needs of the population served by the Network (identified by Public Health)

No Objective Agreed Actions Outcomes Key

partners

Time-

scales

RAG

1.1 Bowel Screening

1.1.1

NEW: To increase up-

take of bowel screening

to achieve 60% target

Adopted as Population

Needs priority 2015-16

Links with Supporting People Needs Mapping 9th June 2015 Links to ABUHB Service Change Plan No. 3/4/5

To achieve national target of

60% for eligible patients;

PHW liaise with national

screening to provide list of non-

responders to Practices

quarterly;

PHW to calculate predicted

increase in referrals for follow

up colonoscopy for each %

increase in uptake of screening;

Identify potential funding to

support Practices in targeting

non-responders: Follow up

letter +/- telephone contact

etc;

PHW data by NCN to monitor %

of non responders who

subsequently submit a sample

after follow up by Practices

Numbers of non responders by

NCN is available to work out

administrative costs of follow

up by Practices if needed

Complete significant event

audits

Carry out thematic analysis to

identify potential causes of

diagnostic delay

Earlier detection of

bowel cancer –

data supports

improved survival

rates;

Published

evidence shows

Practice level

interventions have

achieved clinically

significant

increase in

uptake;

Evidence shows

that high % of

people responding

once to bowel

screening will

respond again

NCN

(Public

Health

led) /

national

Screening

/ Practices

/ ABUHB

Divisions

31.3.16 http://qir.bmj.com/content/3

/1/u205661.w2324.full

u205661.w2324.full.pdf

Bowel screening up-take 2013-14.docx

Screening For Life 2015 by

Public Health Wales -

https://www.thunderclap.it/p

rojects/27059-screening-for-

life-2015 information

circulated to NCN members

PH meeting AWBS team

08.09.15 – take outcome

forward

All Practices have received

list of non-responders from

PH team and targeting with

NCN agreed funding

1.2 Immunisations

http://qir.bmj.com/content/3/1/u205661.w2324.full

http://qir.bmj.com/content/3/1/u205661.w2324.full

https://www.thunderclap.it/projects/27059-screening-for-life-2015



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partners

Time-

scales

RAG

1.2.1

People in at risk groups

will be actively

encouraged to receive a

flu vaccination, to

achieve the national

target of 75% for

immunisation against

influenza

Supports Monmouthshire SIP / ABUHB Flu Plan Links with Supporting People Needs Mapping 9th June 2015 Links to ABUHB Service Change Plan No. 3

NCN to target local

organisations businesses e.g.

MCC at Magor / Supermarkets

/events / local press / schools

(Adults/CYP with

asthma)/contractor services etc

Practices / DNs to identify

community ‘hotspots’ to target

Practices share good practice

and participate in training

Liaise with Public Health

colleagues to agree

approach/information to be

distributed (contact vaccine

companies also)

Utilise Third Sector networks to support the campaign

NEW: Impact of new

phlebotomy service providing

DNs with capacity (See 2.1.4)

NEW: DN service success

against 100% offer target

NEW: Identify issues between GP & Community

Pharmacy LES provisions

Decrease in

hospital

admissions;

Decrease in

morbidity

GP

Practices /

NCN /

Contract-

or

Services /

DNs

31.3.16 IVOR latest report to be

considered for both target

groups

‘Vaccination In Practice’ pack

information circulated to all

Practices

WHC-2015-028 - National Influenza Immunisation Programme 2015-16 - WORD Version - English.pdf

DN service target: 100% of

housebound people to be

offered flu vaccination

2 x band 6 nurses employed

to support up-take of

immunisations

Flu road shows for practice managers 2015 handout-Sept 2015.docx

Seasonal influenza vaccine uptake in Wales 201415_v1a.pdf

School fluenz programme

started

Flu up-take at 26 October

2015: 65+ 59.5% / <65

years 38.8% (All Wales figs

for comparison - 42.4% in

65+ / 25.2% in <65 years)

1.3 Engagement

1.3.1 Attend Monmouthshire

wide ’listening events’ to

gauge local opinion

Supports Monmouthshire SIP

Links with Supporting People Needs Mapping 9th June 2015

To analyse findings and

feedback at NCN meeting

To attend minimum of 2 events

to provide a range of

information relating to e.g. Flu /

smoking cessation / ‘Choose

Well’

Feedback from

engaged,

disadvantaged

groups

demonstrates

improved service

delivery and

patient/carer

NCN

Support

team

31.3.16

SPPG needs mapping.docx

NCN liaising with new ABUHB

engagement team to

consider local events/options

4


partners

Time-

scales

RAG

Links to ABUHB Service Change Plan No. 3

satisfaction

1.3.2

To support the work

carried out through

Monmouthshire ENGAGE

projects


Links with Supporting People Needs Mapping 9th June 2015


To promote the work of

ENGAGE where possible

People with

sensory/other

physical

impairments can

communicate with

providers about

services they need

and receive;

People isolated for

whatever reason

will have

opportunity to be

involved in

development of

services that meet

their needs;

Parents can be

more involved in

planning and

delivery of

services for them

and their children

Engage

projects /

NCN

31.3.16 Pan Gwent event supported

by NCN team

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

patients

No Objective Agreed actions Outcomes Key

partners

Time-

scales

RAG

2.1 Access

2.1.1 Border practices to clarify

data capture

requirements and

understand service

constraints


Establish working group (IST

rep/GP rep/PM rep/North NCN

lead/finance team) to respond to

issues e.g. data/service specific etc

Data informs

improved access

to services

ABUHB

Finance /

Performan

ce Teams

/ Practice

Managers

31.3.16

NCN team to discuss with local

stakeholders and agree action

to take forward

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partners

Time-

scales

RAG

2.1.2 NEW: To improve

engagement and

interaction between

Primary Care and School

health nursing service

Links with Supporting People Needs Mapping 9th June 2015 Links to ABUHB Service Change Plan No. 3

School Health Nurses identify

barriers to communication with

primary care

Invite SHN rep to NCN meeting

Improved

communication

leads to improved

access

NCN/SHN

s

31.03.16 Discussed at NCN meeting with

action agreed to progress this

objective

2.1.3 NEW: Contracted

Services: To engage with

and utilise skills of other

Primary Care services i.e.

Optometrists,

Pharmacists & Dentists


NCN funding to facilitate

recruitment

Contractors act as advisors to

NCNs with communication plan

established

Increased

communication

leads to improved

understanding of

Primary Care

issues

AMD /

NCN /

CDs /

NCN leads

31.3.16 Funding agreed to support this

Scope of contribution to be

discussed/agreed

All Gwent NCN Independent Contractor Support.docx

All 3 posts appointed to

2.1.4 NEW: Phlebotomy:

Increase access to

primary care phlebotomy

service


To implement local service

closer to home and in care

homes

Increase access to phlebotomy

service for house bound

population

NEW: To identify District

Nursing impact on flu up-take

and progress against target

(See 1.2.1)

(WAO report on district nursing indicates

that 30% of community nursing time could

be released, for example to manage LTCs, if

no longer required to take blood)

Increased capacity

and access

within/to DN

service

NCN/ABU

HB

Divisions

31.3.16 £4.4m funding to support this

Pan NCN initiative

Confirmed regular weekly

service out of Chepstow

Hospital OPD, for patients

referred out of Secondary Care

– communicated to NCN

members

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partners

Time-

scales

RAG

2.1.5 NEW: Pulmonary

Rehabilitation: Develop

local access

Supports Monmouthshire SIP Links with Supporting People Needs Mapping 9th June 2015 Links to ABUHB Service Change Plan No. 3

Pump-prime service from non-

recurrent NCN funding

To facilitate integration with

Pan Gwent service / business

plan

Meets WG care

Closer to Home

initiative 2014

NCN Lead

/ NCN /

ABUHB

Divisions

31.3.16

Mon South Pulmonary Rehab.docx

Project Group established

Example of joint working/co-

production between community

nursing, leisure centre (NERS)

team and NCN

NCN slippage funding allocated

to support pilot

Pilot service launched 15th

January 2016 with 3 further

programmes indicated for

2016-17

Pilot evaluation to be shared

with NCN

2.1.6 NEW: Osteo-Arthritic

Knees (OAK): To provide

local support to OAK

patients via NCN pilot

scheme

Links to Prudent healthcare / SCP No.5

To promote access to NCN pilot

community groups via NCN

To increase referrals by Practice

To receive feedback from the

pilot relating to patient

satisfaction

Patients are fully

informed about

their options re

nature of knee

replacement

surgery if deemed

necessary

including the

active part they

need to play for

effective

rehabilitation;

Active in self

management

including weight

management,

smoking

cessation, optimal

management of

co-morbidities

ABUHB

Divisions /

ACD /

Practices /

NCN lead

/ NCN

31.03.16 Pilot on-going with reporting at

NCN meetings

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partners

Time-

scales

RAG

2.1.7 NEW: Early warning for

Practices anticipating

difficulty with

recruitment/filling

vacancies


Practices to inform NCN

verbally/in writing if having or

anticipating difficulty

Agree to meet with the NCN

lead to discuss next steps

Continuity of

services

Support against

potential Practice

fragility

Practices /

AMD /

NCN lead

31.3.16

Strengthening General Practice_ Actions for a brighter future for patien .pdf

QOF

2.1.8 NEW: Practices in

difficulty have access to

NCN salaried support

team to ensure

continuity of service in

the short term

Links to ABUHB Service Change Plan No. 3 / Primary Care Plan

As above Continuity of

services

Support against

potential Practice

fragility

As above 31.3.16

Primary Care Plan 2015.pdf

QOF

2.1.9 NEW: Monitor the

continuation and uptake

of My Health Online

Links to ABUHB Service Change

Plan No. 3

All practices to offer

appointment availability and

repeat prescription ordering via

MHOL

Ease of access to

GP services

NCN /

Practices /

Pharmacy

Advisors

31.03.16

Clinical Director appointed as

lead with NCN support

2.2 Workforce

2.2.1 NEW: Training: Practice

staff can access timely,

relevant training


Establish a Divisional/NCN Task

& Finish group – training plan

developed

Develop a process for Practice

staff to access training

Training providers and costs are

identified

Practices are informed of

training options and criteria

Establish Practice Nurse forum

Quality of care /

skilled workforce –

enables sharing of

ideas/skills and

good practice

NCN /

ABUHB /

Practices

31.3.16 Process in place via proposal

applications

£1.1m allocated to NCNs:

Training options considered

from slippage funds year on

year – T&F group established

8


partners

Time-

scales

RAG

2.2.2 NEW: Ensure local

support structure is fit

for purpose to meet

demands of strategic

NCN development

Implement a NCN/Integrated

Management Team

Agree local framework /

membership to underpin

strategic NCN development

Terms of reference developed

and ensure all

members/partners have equal

standing in decision making

process

Improved

guidance, co-

ordination and

development to

meet the needs of

the local

population

NCN lead

/ HoPN /

PC&ND /

ISPB /

NCN

31.3.16 Workshop held with key

stakeholders to agree

membership of Management

Group, remit, immediate action

required and next steps

Action Plan developed

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 harm


partners

Time-

scales

RAG

3.1

Mental Health Services

3.1.1

REVISED: To receive

and consider

performance against

PCMHSS targets

(See 4.1.2 ALSO)

Supports Monmouthshire SIP Links with Supporting People Needs Mapping 9th June 2015 Links to ABUHB Service Change

Plan No. 3

Team co-ordinator to provide

performance information for

NCN meetings

To consider performance and

work with stakeholders to

support the service deliver

targets – identifying alternative

pathways of care

People are

prioritised

appropriately to

receive urgent

assessment /

support

NCN /

Practices /

PCMHSS /

MH

Division /

PGWG

31.3.16

GAVO Mental Health Service Directory for Gwent.pdf

PCMHSS acts as member of

NCN with reports provided re

progress against waiting times

3.2 Dementia

3.2.1

Achieve a whole system

approach to care for

dementia

Retained as a local

priority 2015-16

Deliver local action plan

Implement Dementia Roadmap

Identify stakeholders e.g.

libraries etc

Promote Dementia Friend

training across partners

Increased access

to local and

national

information

sources for people

with dementia,

families and carers

Phil

Diamond

– DFC

lead / MH

Div

/CMHT /

Communit

31.3.16

All Gwent dementia roadmap.docx

9


partners

Time-

scales

RAG

Supports Monmouthshire SIP Links with Supporting People Needs Mapping 9th June 2015 Links to ABUHB Service Change Plan No. 3/4/5

y Division

/ 3rd

sector /

NCN

£0.24 million for national

dementia nurse led programme

to train care home staff and

respond better to their needs

and ensure their diagnosis is

recorded on GP registers

NCN funding allocated to

support implementation of an

on-line dementia Roadmap –

steering group in place

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


partners

Time-

scales

RAG

4.1 Urgent care

4.1.1 REVISED: To provide

high quality, consistent

care for patients

presenting with urgent

Mental Health care needs

(SEE ALSO 3.1.1)


To review and refine systems

for accessing urgent Mental

Health assessments (adult and

CYP) – to reduce reliance on

A&E thereby improve access in

Primary & Secondary Care. To

reduce MH burden in A&E

NEW: To clarify & standardise

pathways & procedures for

urgent MH assessment

Data provided by CORE

performance report

Patients with

urgent MH needs

receive timely,

consistent care

ABUHB

Divisions

31.3.16 NCN supporting on-going Pan

Gwent work-streams

Discussed at NCN management

team workshop 8th Sept 2015

and agreed membership on

group to respond to local issues

and direction

QP assessment.doc

NCN lead to meet with MH

leads/Divisional Consultants to

discuss issues

10

Strategic Aim 5: Improving the delivery of end of life care [EOLC] (National Priority – to be discussed locally)


partners

Time-

scales

RAG

5.1.1 Review delivery of EOLC

using Individual Case

Review Audit


NCN to support Practices to

review audit of patients who

have died to be reflected

upon/inform future care

delivery.

Audit outcome

leads to improved

care during End of

Life phase

NCN

Leads /

Practices /

NCN

Support

31.3.16 Year-end reporting requirement

5.1.2 Summarise case review

data, and any arising

issues and actions

identified, for sharing

with the network and

the wider health board


Highlight best practice for

improvement to be highlighted

and shared in a multi-

professional discussion

Learning through

shared experience

will inform

improvements for

patients on the

EOL pathway

NCN

Leads / St

Davids /

Practices /

NCN

Support


5.1.3 Establish a review cycle,

to monitor progress (or

maintenance of high

quality), report to NCN

and wider health board

as appropriate


Agreement of ‘best practice’ in

EOLC. Identification and

monitoring of areas for

improvement so that

appropriate education and

support can be delivered

Improved

consistency in

standard of care

delivered

NCN

Leads /

Practices /

NCN

Support


Audit outcomes reported to GP

Macmillan co-ordinator with

learning points included in the

Palliative care Delivery Plan.

5.1.4 NEW: Themes identified

by audits lead to agreed

action


NCN to discuss +/- use of EOLC

template for all patients who

enter terminal stage of illness,

not just those with cancer;

NCN to discuss READ Code

training for Practice staff to

improve recording of diagnostic

symptoms;

Develop patient recording

protocols for Care Homes, by

using the Integrated Care

Pathway framework, to ensure

Improved

consistency in

standard of care

delivered.

Practices

NCN Lead

HoPN


11


partners

Time-

scales

RAG

patient record consistency;

Practices identify carers and

record when patients are first

diagnosed / placed on the

register

Ensure Carer’s Packs are

available at all GP Practices;

To map/ensure access to

interpreter services for patients

whose first language is not

English;

Improve communication with

OOH Services re ‘Special Notes’

and use of Adastra to provide

up to-date patient records.

Strategic Aim 6: Targeting the prevention and early detection of cancers (National Priority)


partners

Time-

scales

RAG

6.1.1 Review care of all

patients newly diagnosed

between 1 January 2015

to 31 December 2015

with lung,

gastrointestinal & ovarian

cancer


Audit tool Patient referral

information

reviewed and

Outpatient

appointments /

results followed up

NCN /

NCN

Leads /

Practices


NICE issued: Suspected Cancer

recognition and Referral – NG12

(June 2015)

GI Consultant attended NCN to

discuss learning points and

solutions – impact of new NICE =

WLIs / Weekend & evening

clinics

12


partners

Time-

scales

RAG

6.1.2 Learning and actions to

be shared with NCN and

the wider health board

as appropriate


Practices complete audit and

discuss findings

Audit tool ensures

continuous review,

reflection &

improvement in

processes/ care

pathways for

cancer patients

NCN /

NCN

Leads /

Practices


6.1.3 Identify and include

relevant actions to be

addressed in Practice

Development Plans


Practice by practice NCN USC

cancer data will be collated to

provide better informed

demographic data relating to

cancers on a regular basis

Improved patient

information/

Patient choice &

preferred place of

death

NCN /

NCN

Leads /

Practices


6.1.4 Summarise themes and

actions for review with

NCN / share information

with wider health board

as appropriate


NCNs to share learning with

secondary care

As above NCN /

NCN

Leads /

Practices


6.1.5 NEW: Themes identified

by audits lead to agreed

action


Develop protocol to refer

patients as ‘USC’ if cancer

suspected with Practice based

referral tracking system;

Practices encourage patients to

attend Bowel Screening

Programme (See SA1);

GPs are informed by Secondary

Care Consultants when referrals

are re-prioritised;

Patients who DNA are contacted

Improved patient

information

Appropriate

treatment

pathway initiated

PC&ND /

AMD /

ABUHB

Divisions /

Practices /

NCN lead

/ NCN


13

Strategic Aim 7: Minimising the risk of poly-pharmacy (National Priority – to be discussed locally and also Medicines

Management)


partners

Time-

scales

RAG

7.1 Poly-pharmacy

7.1.1 Identify and record

numbers and rates for

patients aged 85 years or

more receiving 6 or more

medications


Using audit +, a review of

practice clinical systems to

identify (‘at-risk’ only) patients

over the age of 85yrs in receipt

of 6 or more medicines.

NEW: Consider extending

the audit age range to

include lower starting age

Identify patients

at high risk or

harm of either

over/ under

medicating

NCN

Leads


7.1.2 Undertake face to face

medication reviews,

using e.g. ‘No Tears’

approach


Using data from the review audit,

book appointments for medication

reviews of patients over the age of

85yrs receiving 6 or more

medicines.

Reduced avoidable

admissions;

Identification of

untreated

condition(s);

Number of MUR

Consultations

NCN

Leads/Pra

ctices/NC

N Support


7.1.3 Identify any actions to be

addressed in Practice

Development Plans

Identify and record

numbers and rates for

patients aged 85 years or

more receiving 6 or more

medications.


Poly-pharmacy at NCN meetings

Quarterly information to NCN on

utilisation of notional budget

As above NCN/Pres

cribing

advisors/

Practices/

NCN

Support


Using data from the review audit

book appointments for medication

reviews of patients over the age of

85yrs receiving 6 or more

medicines.

7.2 Medicines

Management

14


partners

Time-

scales

RAG

7.2.1 NEW: Recruit Primary

Care based Pharmacist

from NCN funding to

integrate with GP

Practices, NCN and

partners


NCN priorities - outcomes.docx

Initiate recruitment process –

Summer 2015

Induct Pharmacists into GP

Practices

Integration and outcomes

measured/ monitored via NCN

meetings

NCN Pharmacists

project team

developing a suite

of priorities &

outcomes;

Patients and

professionals have

access to a named

Pharmacist in

Primary Care

NCN

leads/NCN

/PC&ND


Post appointed to July/August

2015

Integration and outcomes

measured/ monitored via NCN

meetings

Identify opportunities for

Pharmacists to further develop

appropriate skills

Funding allocated from NCN

budget

7.2.2 To monitor the NCN

prescribing budget and

delivery of the Medicines

Management plan


To receive regular prescribing

information (at NCN meetings)

Budget performance and

delivery of the savings plan

National Indicators / Clinical

Effectiveness Prescribing

Programme

Pharmacy and NCN Leads to

meet and decide on priorities for

NCNs to achieve in terms of

service improvement, costs and

quality

NEW: Prescribing lead to

provide breakdown by Practice

for anti-biotic prescribing in

South Monmouthshire (LINK TO

CORE REPORT)

Efficient use of

resources leads to

re-investment &

more appropriate

care

NCN Lead

/ Prescrib-

ing lead /

Practices


NCN meeting agenda item with

scrutiny of actual and projected

spend against prescribing budget

7.2.3 To review the variation in

prescribing compared to

national guidance in

relation to Diabetes and

Respiratory and deliver

the NCN savings target

for these work-streams

within the three year plan

Links to ABUHB Service Change

NCNs to work with Primary

Care and Networks Division

Pharmacy staff to:

Arrange scheduled visits by the

NCN Lead to discuss

Dashboards and Practice

performance;

Monitor performance change

through actual prescribing

spend on high dose

Minimise avoidable

harm from

adverse effects of

inhaled steroids;

Undertake

minimum

appropriate

NCN Lead


Regular updates at NCN

meetings

Prescribing switch options

discussed in the round

Pharmacy Technician Practice

visits to identify and discuss

potential cost efficiencies

Practice visits by NCN Lead

Regular updates at NCN

15


partners

Time-

scales

RAG

Plan No. 3

corticosteroids and diabetes

drugs;

Identify prescribing leads rep

and identify progress against

the SCEP;

Prescribing guidance to be

developed by Pharmacy Team

intervention to

ensure prudent

prescribing aligned

with NICE

Guidance

meetings

Pharmacy Technician Practice

visits to identify and discuss

potential cost efficiencies

Strategic Aim 8– Delivery consistent, effective systems of Clinical Governance


partners

Time-

scales

RAG

8 Clinical Governance

8.1 To fully implement the

Clinical Governance

Toolkit

To ensure practices are

supported in completing the

CGSAT

Sessions to be established to

support GP practices in

completing the CGSAT

Target support for areas of the

CGSAT which are identified as

showing low levels of

achievement

Access arrangements - core

access arrangements; aids to

access user experience; the

impact of My Health On Line.

How practices respond to

urgent requests and same day

requests from care homes,

Welsh Ambulance Services and

Hospital emergency

departments.

Actions to foster greater

integration of health and social

care.

Consideration of how

community resources can be

Consistency and

safety in Practice

and NCN wide

primary care

services

PC&ND

NCN

Practices

31.3.16

Year-end reporting requirement

16


partners

Time-

scales

RAG

maximised to meet local needs

Consideration of how Third

Sector support may be

maximised

Map local GP services to

highlight where services are

delivered across practices (for

example, contraceptive

services, minor surgery)

How new approaches to the

delivery of primary care might

aid service delivery and ensure

sustainability of local services

Consideration of the impact of

local care pathway work

relating to previous QOF work

Strategic Aim 9: Other locality issues


partners

Time-

scales

RAG

9.1

Chepstow Hospital

9.1.1 Develop Chepstow

Community Hospital

(CCH) as a multi-

functional Hub for

services and information


Retained as a local

priority 2015-16

Links with Supporting People Needs Mapping 9th June 2015 Links to ABUHB Service Change Plan No. 3/4/5

Established working group will:

Develop and deliver the local

action plan

Develop Terms of Reference

Report to Integrated Services

Partnership Board (ISPB)

Improved access

to care closer to

home based on

local need

NCN /

ABUHB

Divisions

31.3.16 Development Group established

Action plan developed

Terms of references adopted in

principle

See Dementia

17


partners

Time-

scales

RAG

3.2.1

Documents

Monmouthshire South Network Action Plan 2015-16 South... · 2016-04-12 · Monmouthshire South Draft Action Plan 2015-16 ... WORD Version - English.pdf DN service target: ... practice