combined gp cluster network action plan 2016 v1 tydfil... · 2017-06-14 · gp cluster network...

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GP Cluster Network Action Plan 2016-17

Version 1.0

Merthyr Tydfil Locality Cluster

The aim of the locality is to create an atmosphere of sharing without competition:

Sharing expertise and staff for the benefit of patients and practices alike

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Introduction

Practices within Merthyr Tydfil have worked ‘together’ for a number of years and network arrangements have been in place in respect of someenhanced services.

The GP Cluster Network Development Domain supports this arrangement and allows Practices to work collaboratively with support from theLocal Health Board.

Practices have engaged with the cluster process and regular meetings have been held both formal and informal. Meetings have been held withLocal Health Board, 3rd Sector Organisations, Merthyr Tydfil CBC, and Public Health Wales.

Members of the cluster group are:

W95072 Pontcae Medical PracticeW95086 Morlais Medical PracticeW95023 Keir Hardie Health ParkW95005 Keir Hardie Health ParkW95647 Keir Hardie Health ParkW95290 Oakland’s SurgeryW95032 Treharris Health CentreW95026 Troed y Fan AberfanW95028 Dowlais Medical CentreW95634 Brookside Surgery

Each practice has created a practice cluster plan which has been shared with the LHB, it should be noted that all practices within the clusterhave agreed that these plans should be shared with each other. This was facilitated by the LHB.

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Each practice was allocated a task, which was predominantly one Strategic Aim in 2014 and this has continued through the cluster network in2016/17

W95072 Pontcae Medical Practice – CHD Risk AssessmentW95086 Morlais Medical Practice – Workforce and RecruitmentW95023 Keir Hardie Health Park – Access and Demand ManagementW95005 Keir Hardie Health Park – Access and Demand ManagementW95647 Keir Hardie Health Park – Access and Demand ManagementW95290 Oakland’s Surgery – Smart Use of ResourcesW95026 Treharris Health Centre – Communication IssuesW95026 Troed y Fan Aberfan – Poly PharmacyW95028 Dowlais Medical Centre – Early Detection of CancerW95634 Brookside Surgery - End of Life Care

The creation of a dynamic Cluster action plan is crucial to moving the aims of the cluster forward and with the support of the LHB the clusterhad an opportunity to use existing practice skills to facilitate this.

The following cluster co-ordinators have continued in the role for 2016/17

Dr Sian Newman – Morlais Medical PracticeKevin Rogers – Pontcae Medical PracticeKate Francis – Morlais Medical Practice.

The LHB Primary care team has been restructured and Imran Gilani has been appointed as Primary Care Development Manager for theMerthyr cluster.

A significant number of meetings have taken place to discuss both the practice action plans and strategic objective documents. The workloadof the cluster leads has been significant and the assistance of Imran has been very welcome.

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We have attempted to create a simple, dynamic document with objectives that can be delivered within a reasonable timescale. There is amixture of strategic objectives underpinned by the need to improve patient care and provide sustainability and modernisation of services withMerthyr Tydfil

• Some objectives can be undertaken independently by the cluster practices to improve patient care

• Some objectives require partnership working (LHB/3rd Sector/ MTBCBC / IT suppliers)

• Some objectives are longer term and will require resources and direction from the Local Health Board

Whatever the specific objective, there is a desire from practices to ensure we work for the benefit of all.

Creating a collaborative environment we aim to increase the quality of care provided for patients while managing the significant increase indemand within the cluster.

Each cluster objective has been accorded a RAG (Red, Amber, and Green) rating.

Green – The objective is performing to plan and should experience no significant problems

Amber – The objective in ongoing and may present some problems within reasonable tolerance. Objective should be achievable but may

require support of organisations outside of the cluster.

Red – The objective has significant problems and will require support of organisations outside of the cluster.

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

The Cluster Profile provides a summary of key issues. Local Public Health Teams can provide additional analysis and support.Consider local rates of smoking, alcohol, healthy diet and exercise – what role do Cluster practices play and who are local partners. Is actionconnected and effective? What practical tools could support the delivery of care?

Health protection- consider levels of immunisation and screening- is coverage consistent- is there potential to share good practice?Are there actions that could be delivered in collaboration- e.g. Community First to support more effective engagement with local groups?

No Objective Key partners Forcompletionby: -

Outcome for patients Progress to Date RAGRating

1 To review theneeds of thepopulationusing availabledata

Local PublicHealth Team

Public HealthObservatory

Ongoing – noend date

To ensure thatservices aredeveloped accordingto local needs

COMPLETED

The Cluster Network serves a population withina deprived area of Wales. This, combined with anumber of social and economic issues has animpact upon the needs of the local population.

A summary of the 2015 findings is listed below.

• The view of the Cluster group based onpatient registrations is that thepopulation is increasing. It has beennoted that this is not support by PublicHealth data.

• Our Cluster sits in an area of highdeprivation with figures for NorthMerthyr and South Merthyr being above

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the average for Wales and the LHB.North Merthyr has 46.3% and SouthMerthyr 38.8% of patients living in themost deprived fifth areas in Wales.

• Chronic condition burden is higher thanother Cluster areas

• Cwm Taf has the highest rate ofpremature mortality due to CVD inWales

• Cancer survival is the lowest in Wales.Significantly, the Cluster has the lowestuptake in Cervical screening and Bowelscreening programmes

• Lifestyle and socio-economic factorsaffecting the health of the localpopulation have also been recognised –such as high numbers of smokers; highunemployment levels; high number ofpatients with mental health issues. TheCluster has recognised that in MerthyrTydfil 65% of the population describethemselves as being overweight, 7%above the average for Wales of 58%.Alcohol consumption and alcohol relatedadmissions are high in the region.

Under the Quality and Outcomes Framework, all

general practices in Wales are required to produce

practice development plans which will in turn

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inform GP Cluster development plans.

We were provided with a link to the GP Population

profiles of Public Health Observatory. It is hoped

that this profile can play a part in the practice and

cluster

develop

ment

plans.

It is

estimate

d that

around

90 per

cent of

all NHS

patient contacts occur in general practices.

Therefore a better understanding of general

practice populations is of great use to many others

who are working to improve public health.

These population profiles build on the previously

published GP Cluster Profiles.

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The population profiles include a population based

peer grouping exercise, allowing practices to

compare themselves with similar practices across

Wales. The peer groups were determined following

a statistical process which grouped practices

depending on their list size, proportion of older

people, deprivation and population in rural areas.

Further details on how the peer groups were

derived can be found in the technical guide (see

below). As this is the first time the Observatory has

produced general practice peer groups

http://howis.wales.nhs.uk/sitesplus/922/page/63747

Table A demonstrates the areas which can beanalysed by the pyramid

2 To identifyadditionalinformationrequirementsto supportservicedevelopment

Local PublicHealth Team

NWIS

Improved support forservice development

For example, High premature cardiovascularmortality – need local Dashboard to understandconsistency of prevention and risk management

Table B shows Chronic disease areas for NorthMerthyr, While Table C shows the South of thecluster.

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Action: - for development with LHB

3 To considerlearning frompreviousanalyses toidentify anyoutstandingservicedevelopmentneeds.

This area was considered in detail during thework completed for QP in the previous year.Service needs identified included:

I ) MAU unit open for longer hoursii)Promotion of CIASiii) Promotion of the exercise referral scheme?

4 Increase FluImmunisation

Practices

LHB

Public Health

31 March 2017& ongoing

Improved care /protection of patientsagainst Influenza.

Action taken to date:

We have a seat on the Flu immunisationproject board and this is ongoing.

Future Actions:LHB / Public Heath:i) Increase resources available to encouragePractices to invest in their flu campaigns? E.g.could provide template letters for Practices?Advertising campaigns?

ii) Further assistance with training to allowHCA’s to be appropriately trained to safely

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administer flu vaccines.iii) Continue with Flu facilitator role

5 IncreaseScreeninguptake rates

Practices

LHB

Earlier diagnoses,increased lifeexpectancy

The need has been recognised by the ClusterGroup.

Possible solutions to be discussed further.

See also work within Strategic aim 6 – Earlydetection of Cancer

Table A

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Table B

Table C

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

Consider the National Survey for Wales, local feedback and individual practice analysis.

In the National Survey for Wales 38% of people found it hard to get a convenient appointment – for a number of reasons such as Long wait forappointment ; early morning calls; Appointments not available on the same day ; Difficulty getting through to make the appointment ; Couldnot book appointment with doctor of choice ; Appointments not available at convenient times.

Is there an accurate measure of demand- if not consider data collection to articulate the scale of action required.

Consider what capacity could be released by minimising system waste- chasing appointments, discharge letters and specialist advice. If that isa significant issue ensure that data is captured to highlight the scale of the problem and include this as an issue to be taken forward by theLHB.

Recruitment and retention- risk in some areas. Ensure risks are recorded and reported. Does this need a local plan to support concertedaction? Potential to test new models/roles- are there volunteer practices or potential for roles across the Cluster area that could support themanagement of capacity.

What potential is there for collaborative working with local partners- Communities First, Third Sector Etc?


Outcome for patients/ Service

Progress to Date RAGRating

1 To reviewcurrentdemand andcapacity

LHBCHCAccess Group

31/3/17Services developed toreflect local needs ofpatient and practice

Merthyr Tydfil representation on LHB AccessGroup to review progress

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Individualpractices andcluster based

2 Activity DataCollection

LHB (Ongoing) Mapping accurateactivity data to reflectworkload

Initial objective completed - Practices withincluster are providing weekly activity data to LHB

This is published on the LHB Primary Care portal

3 Share ActivityData

LHB / LMC (Ongoing) Mapping accuratecluster activity

LHB / LMC Discussion with a view to accurateactivity data across Merthyr Tydfil

4 To developlocal workforcedevelopmentplans

(Link withStrategic Aim 9

LHB /LMCWG

OngoingMeet with WG todiscuss long termstrategic plans for MTin terms ofrecruitment andretention of GPs

Data Collection of recruitment issues to presentto WG

It has been noted that Merthyr Tydfil is in directcompetition with other clusters in terms ofrecruitment – Promotion of Merthyr Tydfil withother organisations ongoing. Further meetings

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– recruitment)

31/3/2017 Long term planning toattract GP to MerthyrTydfil Cluster

with WG have been planned for 2016.

The Rhondda cluster have taken the lead on thisand planned advertising campaigns to promotethe Rhondda Valley. While we are broadlysupportive of the needs of the Rhondda Valley itmust be considered that with the limitednumber of GPs available , each one attracted tothe Rhondda will be one less available for theMerthyr cluster.

We must take a pro active view to encourageGPs to want to work within the locality – linkswith PCSU need to be re-established and LHBcommitment will be required.

5 InappropriateWorkload

‘pass to GP’

(Link withStrategic Aim 9–Communication)

LHBLMC

31/3/17 Significant proportionof primary careworkload falls withinthe ‘pass to GP’category –

We need to ensurethat secondary carework is not passed toGp’s for completion.Currently too many

LMC Data collection supported by practices –suggests minimum 10% of work inappropriate –it was noted this was a conservative estimate

Examples of inappropriate requests werecollected by the cluster which supported thisview.

The BMA has published a document whichcontained example letters for documents to bereturned in the event they have been sent to

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staff members feel it’sok to ‘pass to Gp’ –this needs to stop asthis impacts on thepractice ability toprovide services andthe long term healthpriorities of thecluster group.

the GP inappropriately

This work is ongoing – It has come to lightrecently that consultants feel it appropriate tosend test results to GPs for action ‘ on theirbehalf’ clearly this is not the case and discussionwith medical director of LHB is planned for late2016 around this topic.

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

No Objective Keypartners

Forcompletionby: -


1 To increaseawareness and useof e-mailcorrespondencewith consultants insecondary care foradvice andreferrals.

SecondaryCare / LHB

Completed Rapid, appropriate diagnosis andtreatment which will improvepatient care.

This will also achieve the aim ofreducing inappropriate referralsthus minimising waste and harms.

Objective agreed and plan ofaction to be confirmed.

Will require assistance fromSecondary Care / LHB

2. To set up a systemwhereby clear andprescriptivemanagement plansare provided whena patient is seen inSecondary Care.

SecondaryCare / LHB

31 March2017

Improved patient care by negatingthe need for ongoing hospitalfollow up appointments. Suchmanagement plans could result inthe patient being referred safelyback to Primary Care much soonerand avoid repeated hospitalappointments.

This links with the EDAL / Mtedproject which is ongoing. Clusterhas a seat on the EDAL project

Objective agreed and plan ofaction to be confirmed.

Will require assistance fromSecondary Care / LHB

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board and roll out / evaluation isongoing.

3. Re: Mental Healthand Alcohol - Topromote and raiseawareness ofcounsellingservices for adultsand young people.

Also, promotion ofself referral to thecommunity basedMindfulness &Stress Controlworkshops

ClusterGroup

Third Sector

PrimaryCare/LHB

ongoing Patients will gain access to servicesin the community.

Links with the Behaviouralsupport that we anticipateintroducing 2016 (SA10)

Objective agreed and actiontaken.

Assistance from Cluster group,third sector / organisationsproviding such services required.

4. To promoteservices availableto help reduceobesity, smokingprevalence

Cluster

Third PartyOrganisations

ongoing Patients will have greater optionsto support them in changing theirlifestyle / habits.

Links with the CVD riskassessment project which isongoing and with the Behaviouralsupport that we wish to introducein SA10

Objective agreed. This is to beachieved by:

a) Use of Exercise ReferralProgramme

b) CVD risk assessmentc) Behavioural Supportd) Community Co-ordinators

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


Outcome for patients/ Service


1OOH Serviceredesign

LHB / Out ofHours service/ A&E

(Ongoing) Improved access toappropriate OOHServices

Engagement with LHB in discussions arounddesign of service (Also link with Access Group)

Recent communication suggests that progresshas been made by the HB – Shift bundling andchange of sites has begun

2A&E

(Link with OOHServiceredesignmodel)

LHB / Out ofHours service/ A&E

(Ongoing) Out of Hours – moreappropriate use ofA&E

In Hours – Link withAccess Plans –education for patientsto use a&e only whenappropriate

Engagement with LHB in discussions arounddesign of service (Also link with Access Group)

As 1 above

3NetworkServices

LHB / Cluster Ongoing31/3/17

Access to high qualityclinical care in a

Networking of services initiated –Minor SurgeryAdvanced Minor SurgeryVasectomy

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timely andappropriate manner Investigation of further network services encouraged

and currently being investigated.

We wish to introduce a Wound Management facilitywithin KHHP as cluster hub.

Also on the horizon is the development of ClusterCommunity Clinics in Cardiology. The funding forthese clinics will come from a separate pot from thecluster money although they are integral to the kindof services the cluster might be expected to deliver.

The idea is that this will be based in KHHP. Someinitial conversations have taken place with theCardiology Department about how it could supportthis clinic with equipment so now is the time for ourcluster to shape what kind of service we envisagewould help our patients the most. Some ideasalready mentioned include an AF andanticoagulation clinic. It is anticipated that this willbe run by GPs from Merthyr Practices or the PCSUwith a Special Interest in Cardiology.

Support is available from the UHB to back fill coverany absences and then help set up and run the clinic

The shift of resources needed to provide networkservices is still unresolved. The initial example ofNOAC funding is proving problematic and is beingdealt with by the LMC – We await this decision toensure practices are properly resourced

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4 3rd Sector /

Social Services

LHB / mtcbc /OtherOrganisations

31/3/17(Ongoing)

Improved Linkbetween practicesand 3rd sector / socialservice / MTCBCresources to signpostpatients to moreappropriate services

Community co-ordinator to linkbetween primary care/ patient and otherservices

Links with theBehavioural supportthat we wish tointroduce in SA10

We know that many patients attend the GP practicewhen they have no immediate medial need and weneed to enable patients to make an informed choiceof appropriate attendance

A fixer / co-ordinator role is required to -

• provide Behavioural Support for Patients

• provide Financial Support for Patients

• Modify behaviour without the need to seeGP

Meetings organised with 3rd sector / VAMT October2016

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



1Support

practices to

identify patients

for their

palliative care

registers

Secondary

care

District

nursing

Macmillan

nurses

Nursing

Homes

OT

Physiotherapy

LHB

31st March2017

In order to provide high

quality end of life care it

is important to identify

patients who are likely

to be in their last year

of life. By identifying

these patients it allows

their care to be planned

and co-ordinated to try

and reduce the chances

of crisis arsing which

can result in unplanned

admissions.

GP Facilitators Nicola and Rachel are engaged with

cluster and information regarding palliative care

registers and what support they can offer underway

Guidance available on the Cwm Taf UHB intranet –

the cluster to raise awareness of where practices can

access this information and ensure all practices have

easy access to the intranet

New template has been circulated to practices toimprove data collection Aug 2015– evaluation latter2016 required.

The end of life pathway has also been includedwithin the primary care portal.

2 Increase use of

JIC boxes

It is important

to use other

members of

the health

31st March2017

This can help to reduce

delays in medication

being available OOH for

adequate symptom

Check each surgery within the cluster has a JIC pack.

Increase awareness of this scheme and where

information can be obtained.

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care team

particularly

District

Nurse’s,

Macmillan

nurses and

Nursing home

matrons in

identifying

patients for JIC

boxes

control and may reduce

crisis admissions. It will

enable better, more

timely control of

symptoms such as pain

and vomiting.

New template has been circulated to practices to

improve data collection Aug 2015– evaluation

latter 2016 required.

Evaluation of use of JIC boxes by 31/3/16 required

Increase communication with rest of health care

team

http://howis.wales.nhs.uk/cwmtaf_resource/palliati

ve-care

3Collaboration /Advice

Cluster / LHB 31st March2017

Increase awareness of how to access advice on

individual patient management when required.

Cluster to provide info for all practices with useful

phone numbers / websites so they can access advice

on any aspect of end of life care at all times as it can

be difficult to know how and where to get advice.

The end of life pathway has also been includedwithin the primary care portal.

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

We have significantly progressed the engagement with screening services in order to progress this Strategic Aim.

Including a presence on the Reducing Cancer inequalities working group. The Cwm Taf cancer inequalities group is working to reduce the higher cancer

incidence, mortality and poorer cancer survival in our more deprived communities. The uptake of screening follows a similar pattern with uptake decreasing

with increasing deprivation.

This meeting with PHW Screening Services and Community Partners was arranged to support clusters to progress the actions in their plans relating to

increasing informed uptake of screening programmes.

No Objective Keypartners

Forcompletionby: -

Outcome forpatients /Service


1 EngagementwithScreeningServices

CSW

BowelScreening

Breast TestWales

PublicHealthWales

InitialEngagementby 31/3/15

Ongoing

Currently the

uptake in the

Merthyr

Clusters

See Tablesbelow

Cluster Representative has met with Bowel Screening Wales

with a view to implementation of new procedures to

increase uptake.

Screening programme uptake data by cluster was shared. The

apparently low figure for MT Cluster for breast screening was

explained by the 3 year cycle of screening by area.

Data at practice level is available and would be released to

individual practices on request. If the cluster wanted access to

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practice level data, Screening Services would need to have

practice agreement (from Senior partner) for data to be released.

The bowel screening pathway was described and clarification of

the process around spoiled kits and non-responders was given.

The Bowel Screening Programme could provide practices with a

list of eligible patients who had not responded to their invitation

to participate in bowel screening. This would be released four

times a year (Sept/ Dec/March/ June). A proposal is currently

being developed with AB Clusters to test this.

This data could be sent via the Screening Link person (currently

the point of contact for Cervical Screening Programme). Practice

Managers would need to brief the Link person to expect this data.

Bowel Screening Non-responder Data

o Each cluster to discuss how they would like to proceedwith the data that could be provided quarterly. MerthyrTydfil exploring a role within practice to follow-up non-responders.

o There is a READ code for bowel Ca screening declined8IA3 and not eligible 9OW3

o Screening Services will update the Screening Link Personat their next training event

Early RCGP / LHB In Cwm Taf in 2012 there were 18 cases of pancreatic cancer

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2 detection ofPancreaticCancer

CompletedRaise the

awareness of

how to

diagnosis

pancreatic

cancer by GP’s.

and 242 in the whole of Wales.

Pancreatic cancer is more prevalent than is often recognised

and earlier detection of symptoms will improve outcomes

for patients.

Gp’s to complete a CPD module on the RCGP website

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Strategic Aim 7: Minimising the risk of poly-pharmacy



1 To review theuse andeffectivenessof theSTOP/STARTTool.

Cluster March 2017 If the tool proves tobe effective, patientswill be taking theappropriatemedication.

Work in progress - GP Practices should be in theprocess of undertaking reviews of their patientsaged over 85 on six or more medications.

Review to take place 31/03/16 to assesswhether or not Practices have used the tool andassess its effectiveness.

2 Effective useand workingwith the LHBPrescribingteam toachieveconsistencyandappropriateprescribing.

Cluster

LHBPrescribingTeam

Ongoing Patients will receiveconsistent care.

It is proposed that a representative from theLHB Prescribing team is formally invited andattends all Cluster Group meetings.

Many of the cluster plans for other areasinclude the employment of a Pharmacist towork within the cluster practices. MerthyrCluster has not selected this as a priority for2015/16 however is keen to review the dataavailable from Taff Ely , Rhondda and Cynon inrespect of evaluation of this cluster priority.Clearly if there is evidence that this improvesaccess and efficiency then we will be keen toconsider this for 2016/17.

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



1 Each Practice to complete the ClinicalGovernance Toolkit by the end of March 2016

2 Updated GPSAT will be discussed at clustermeeting in November 2016 with arepresentative available to provide assistance.

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Strategic Aim 9: Other Locality issues



1 Recruitment &Retention

a) To achievecontinuity of careand services e.g.when Doctors retire.

b) To attract Doctorsto the area ofMerthyr Tydfil.

c) To provide highquality training toGP’s Trainees andmedical students.

ClusterLHBWAG

SeeStrategicAim 2

Continuity of qualitycare.

A follow up meeting with the Director of Workforce planningat the Welsh Assembly Government is required.

The problem of recruitment is highlighted within the area astwo practices are struggling to recruit GPs.

This is leading to potential mergers and sharing of resources.

The Rhondda cluster have taken the lead on this and plannedadvertising campaigns to promote the Rhondda Valley. Whilewe are broadly supportive of the needs of the Rhondda Valleyit must be considered that with the limited number of GPsavailable , each one attracted to the Rhondda will be one lessavailable for the Merthyr cluster.

We must take a pro active view to encourage GPs to want towork within the locality – links with PCSU need to be re-established and LHB commitment will be required.

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Clinical PracticeEducator – HeatherOwens

We need to evaluate the advertising campaign in the Rhonddato assess its effectiveness.

Concerns raised that LHB focus on recruitment in Rhonddaonly – other areas equally in need of assistance

Heather Owens Clinical Practice Educator has linked with the cluster

group.

Heather explained that her main goal was to get education back up

and running for Practice Nurses and Health Care Assistants.

The group were advised that in around 10 years a large number of

existing Practice Nurses would be retiring so it’s very important to

encourage new nurses to make a career choice and to choose a

career within GP Practices. (this fits with the cluster recruitment

and retention strategic aim)

At the moment pre-registration nurses come out for 2 weekplacements. It is now proposed that this placement is increased to12 weeks across practices within Cwm Taf this will enable thenurses to get more practice level experience.

It was noted that this was not going to be easy as any practice

interested in supporting a pre-registration nurse would firstly need

to have their existing Practice Nurse trained as a Mentor, this

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training is a 3 day course at Glamorgan University.

Cluster members were supportive of this project and agreed that

this is valuable training which should encourage nurses to remain

within Primary Care.

Further clarification is required around funding these proposals and

the extent of cluster involvement,

2 Access & DemandManagement

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a) To encourage asmany Practices aspossible to sign upto the Access LES,the objective ofwhich is to improveor retain currentaccess levels asappropriate.

b) To develop astandard Clusterresponse / system reDNA’s.

c) Educate patientswith help from theLHB and WAG tohelp manage patientexpectations.Constant negativemedia attention asto the availability ofGP appointmentsetc. fuels patientexpectations.

Practices

Practices /LHB / AccessGroup

Practices

LHB

WAG

Access Group– liaising withthe CHC.

Completed

Completed

March2017

Improved access

Consistent message topatients throughout thearea.

Documentation re DNA’s has been developed via the AccessGroup. The aim is to ensure that this is communicated andshared amongst all Practices in the Cluster.

To date, organising a meeting with the WAG to discuss theissues surroundings recruitment and retention is underway.

Activity data being sent to the LHB will also assist this processas it will allow the reality of how many patients are being seenand the workload to be demonstrated and publicised whenappropriate.

Links with E-consult See SA9 (6)

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Access GroupThe cluster continues to engage with the Health Board andhas membership of the Access Group.

Representatives have been agreed:

• A Practice Manager or delegate from all clusters

• A member from the CHC

• A member from the LMC

• A Primary Care Development manager

• A member from OOH

• A Locality Clinical Director

• Other members to be co-opted as needed

The objective of the group aligns with the objective of the cluster

and includes -

• Improving the profile of General Practice with positivemessages - media /newsletters etc

• Patient education on when and where to access the correctservice for their needs

• Improving the expectations of patients

• Training schedule for practice staff - Sign posting etc

• Having a voice at local development planning

• More involvement in informing Primary Care Estates plans

• Explore outside the box thinking on Core Hour arrangements

• Have a Cwm Taf Code of practice for GP practices (mutualsupport, sharing resources, keeping to procedures)

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3 NETWORKING:

a) To improvecommunication sothat all members ofthe Cluster areaware of theservices availablefrom Third Sector /Voluntaryorganisations.

b) Practices to shareresources andinformation whenappropriate.Includes clinical andnon-clinicalassistance e.g.sharing of policiesetc.

c) Smarter Use ofexisting primary careresources

Cluster

LHB

Third SectorOrganisations

Clusterpractices /LHB

March2015

March2017

Patients being madeaware and able toutilise resourcesavailable to improvetheir lifestyles / socialwell-being.

Directing patients tolocal resources

The Cluster group has met with representatives from localorganisations who have promoted their services.

Ongoing – Links with Behavioural Support See SA9 (7)

The Cluster has already started this process. E.g. all Practicesin the Cluster agreed to share their PDP’s; the group havedeveloped links and a healthy spirit of co-operation andsupport to allow best practice to be shared and promotedwithin the Cluster group.

The cluster will also start sharing screening data for 2015/16 –this is to assist the development of the screening servicespriority.

Initially Questionnaire to be sent to cluster practices toidentify volume of joint injections, carpel tunnel etc referredto secondary care.

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Cardiology – Liaisonwith service

March2017

March2017

reducing waiting lists /improving quality

Shift from ‘day surgery’to primary care willallow capacity insecondary care toincrease thus reductionin waiting lists

Further analysis of questionnaire, shift of resources fromsecondary to primary care and those practices who want toundertake this service on behalf of the cluster.

Also on the horizon is the development of Cluster CommunityClinics in Cardiology. The funding for these clinics will come from aseparate pot from the cluster money although they are integral tothe kind of services the cluster might be expected to deliver.

Cardiology Clinic would commence at Keir Hardie on 9th October with

GPs referring stating what the patient needs on the referral. The

clinic will accept referrals for patients in need of assessment for

issues such as palpitations, and AF as examples.

• The cardiology clinic will be funded by WAG / Secondary Cardiologyand Primary Care fund.

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Vision 360

Improved access toservices

•

• The clinic will offer patients a 24 hr tape, 24hr Blood Pressure and a7 day Halter , echo and initiation (upon agreement with thePractice).

•

• Consultation will be uploaded on vision 360 so their GP will be ableto view results.

•

• There were no objections in principle to the use of Vision 360 forthe community cardiology clinics.

•Information sharing agreement to be circulated and signed bythose Practices happy to participate.

Share patient records and appointment details between GPpractices, hospital departments and unscheduled care providers.

Presentation from INPS on the introduction of Vision 360 to the

cluster and demonstrated of the functionality.

The following points were also noted:

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Vision 360

• Vision 360 been in used for over 12 months in the UK and iscurrently in use in Neath Port Talbot for a community hub

• Requires consent of the Practice and the patient

• Access can be restricted in a number of ways for different usergroups

• Facility for a centralised appointment book

• View detailed patient records from any GP practice within yourfederation or cluster, regardless of whether they use Vision orEMIS Web

• Consultation details added are written back to the patient’sregistered practice as coded data

• Make clinical decisions with confidence without having anyprior knowledge of the patient’s medical history

• Web browser interface, so there is no software to deploy andclient-side hardware requirements are minimal

• Access to records from any location using any web-enableddevice

• Full auditing including the reason for accessing records

• Typically used by extended access appointment hubs, 111service providers, out of hours services and A&E teams

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Vision 360

• Make or access appointments available across a federationor cluster

• Receptionists at any GP practice can book their patients’appointments at extended access hubs

• Mark patients as arrived• Integration with patient call display systems

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4

CHD RiskAssessment

LHBClinicalSystemSuppliers

31/3/17 Identification ofPatients at risk

Identification ofpatients where riskunknown

Once Identified Patients

receive passive and

active interventions

Optimised treatment –

Delivered by Dr / Nurse

/ HCA /Pharmacy /

Health Board / Dn’s

Improved database of

Risk

Reduction in numbers

of patients with > 20%

risk (pro rata)

Reduction in CHD

Events (Best Long term

Evaluation of initial pilot underway with the appointment of aprimary care development manager to look specifically at thisproject. The cluster will link with this evaluation to progressthings during 2015/16

Agreement of cluster to proceed

Use of additional resource (HCA) made available for Inversecare work to support this work – this should be for theexclusive use of Merthyr cluster and shared by all

Evaluation will determine which clinical system will be usedand what resources are available – this is an additional projectthat will be funded from outside of the cluster ‘pot’ for2015/17

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Indicator)

5 Communication

(a) DAL(DischargeAdviceletters)

LHB /MedicalDirectors /Cluster leads

31/12/15Phase I

illegible and hand

written DAL very poor

quality (Rarely mention

any planned follow up,

patient details missing

little or no information

about care given and

investigations

performed. Urgent

Improvement required

for patient safety

Intention of Cluster to no longer accept these poor qualityDALs –

Notification was sent to Medical Director of LHB that actionneeded in regard to quality of handwritten DALs

Supporting letters creased by BMA to help when returningthese documents

This must be a two way process and cluster practices mustensure Referrals are sent with high quality data and readable– continue to monitor this

Support / encourage LHB to plan and implement electronicDischarge Summaries

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Seat on project board for cluster – involved in evaluation ofEDAL project

Next steps -

• e-DAL roll out continues in YCC and YCR. Trainingwill take place in advance for all key staff.

• e-DAL roll out to commence in Surgical wards(orthopaedics).

• Deployment of DOCMAN improvements for those GPsurgeries using this software.

• IT hardware configuration/installation continuing(Laptops/mobile carts/zebra printers) in advance.

• National MTeD User Group (Chaired by Cwm Taf)due to meet in NWIS HQ Cardiff on the 27th

September 2016. One of the agenda items is areview of e-DAL RfC’s (Request for Change) thathave been submitted by HB’s across Wales.

• WCP v3.7.6 (minor bug fixes) will be deployed onthe 28th September 2016.

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(b)

A+E Notifications


31/3/17Phase II

Should be computer

generated and sent via

WCCG or electronically

like OOH / A&E

communications.


for patient safety

• Next local project board meeting is scheduled totake place in November.

• Develop performance dashboard

Cluster lead to contact LHB IT to organise electronic messages

Initial encouragement for a&e , however not all practices arereceiving electronic messages – this needs to be resolved by31/12/15 and evaluated 31/3/16

Cluster lead to write to Medical Director / A&E with a view toimproving quality of a&e letters

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C) PathologyMessaging


31/03/17

31/03/17

Phase I

Should be Electronic for

all Cluster practices and

sent with pathology

messages.


for patient safety

Phase II

A&E letters very Poor

Quality - sparse in

content, no information

regarding investigations

/ results Or follow up.

Urgent Improvement

required for patient

safety

Electronic A&E as a mechanism is fine – does not improve thequality of notifications. The LMC and assistant medicaldirector are aware of these shortcomings and this is beingprogressed.

Zero Tolerance project been implemented by UHB , this has tobe a two way process and the cluster leads have beeninvolved with this project. There is a clear understanding ofthe need for accuracy at both ends.

This must be a two way process and cluster practices mustensure path forms are sent with high quality data andreadable.

Practices to monitor and report to cluster all delayed / lostresults – particularly red flag results over a 6 month period.

LHB to provide individual data on rejected practice messages– with a separate data for District Nurses.

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31/12/16

31/03/16

Phase I

Patient Safety

compromised due to

pathology investigation

messages not returning

to practice or being

sent to incorrect GP.

Additional work

required on method of

notification of Red Flag

results.

Phase II

Update on Label Trace /

wccg test requesting

.Uniform agreed system

required to deal with

non Gp partner

requests (Locum /

Salaried GP / F2 /

Trainees etc)

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Chronic Pain Team

The cluster has established links with the Chronic pain team locally

– Dr A Wagle gave a brief presentation on the Cwm Taf Chronic Pain

Clinic at the cluster meeting in September

• Chronic pain clinic was set up using WAGdocumentation

• Aim to improve Primary & Secondary Care interface

• Aim to have a consultant led service

• Offer extra support for GP Practices

Further work was agreed around medication provision and the

requirements of an agreed plan – this will be discussed between

cluster and consultants.

It was agreed that the Pain Clinic would share with the practices a

flow chart of the protocols of what is offered at the Clinic.

A follow up meeting will be established in 6 – 12 months.

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6 Access – Web GP

To introduce Web GPto the cluster toimprove access ,education and use ofresources

31/3/2016

Links With SA2

The intention is that

patients would use Web

GP prior to contacting the

practice and be directed

to a more appropriate

option

We anticipate that this

will see -

• Significant

improvements in

patient

perceptions of

access to their GP

• Better health

outcomes

through earlier

detection of

significant

symptoms, earlier

intervention, and

particular health

We will incorporate the use of webGP which is a patient platform

that links from a GP practice’s existing website to a suite of online

offers including:

1. Symptom checkers and condition finders, so patients can

ensure they are using general practice appropriately

2. Self-help guides and videos, so a proportion of demand can be

top-sliced as patients are given the information to self-manage

3. Sign-posting to alternate local services, e.g. pharmacy, so

patients are aware of the range of resources available that

might help with their issue

4. A webform that patients can use to request a NHS Direct

clinician call back (24/7) if they feel their problem is more

pressing

5. Over a 100 webforms on common general practice conditions

that are sent from the website to the practice for advice and

treatment from the GP within 1 working day (e-consults). This

allows practices to rapidly triage patients, using these

structured histories, and manage 60% of them without a face-

to-face appointment.

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issues presenting

sooner online,

e.g. mental and

sexual health

• Better practice

efficiency with

shorter waiting

times and saved

appointments

(400 GP hours)

• Commissioner

savings as fewer

patients attend

urgent care

settings such as

A&E and OOH

Services.

Orders have been signed and we are awaiting release ofcluster funds.

Full evaluation of this project has been sent to LHB under aseparate cover.

7 Behavioural Support

Employment of abehavioural supportperson to assistpractices in directingpatients to the mostappropriate

CMHTAccess GroupLHBCluster

31/3/17 Links With SA2 / SA4 The aim of this project is to change the behaviour and culture of

clients who frequently visit their GP’s who do not need medical

Intervention.

The GP Support Officer (GPSO hereafter) will be based at every GP

Practice throughout the borough of Merthyr Tydfil . They will see

clients, assess their situation and offer alternative support and if

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resources needed follow this up.

The GPSO will look at the holistic situation to “enable” the client.

The aim and purpose of this role is to enact behavioural change

allowing the client to take responsible for their own health and

well-being. The GPSO will use resources and services within the

community to include the third sector, counselling, volunteering,

fitness, smoking cessation as examples.

Located within GP Practices, the GPSOs will create a fully integrated

service provision which supports the Local Authorities in their

workload allowing clients to be managed before their needs require

greater intervention. The GPSO will offer timely support to clients

to seek solutions and interventions which will enable them to

remain independent before the client requires greater support and

becomes a crisis situation such as admission to hospital or

residential care.

Clients will only be referred to Social Services as their needs are

more significant and cannot be met by other networks or resources

and the 3rd sector in accordance with the HSSWB-Act.

This thinks with the following strategic aims –

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Carer’s Services

All Wales Healthy Programme

Wellbeing of Future Generations (Wales) Act 2015

Community Care Act

Social Services and Wellbeing Act 2016

Strategic Vision for Merthyr Tydfil

Primary Care Delivery Plan – up to 2018

Together for Health

Cwm Taf Integrated Medium Term Plan (IMTP)

Prudent Healthcare

The community will benefit from:

• Integrated service delivery which will improve access andquality

• Access to community resources and support

• Locally delivered services

• Partnership working

• Improved access to GP services due to more appropriateuse of appointments

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The individual will benefit from:

• The points above

• Improved self-esteem

• Sense of responsibility

• Healthier lifestyle

• Support

• Access to a range of resources and groups to guide andsupport

• Remaining independent for longer

The estimated costs are currently £323,000 (6 FTE) based upon 18

month project length

Evaluation framework to be developed to include such things as:

• Evaluation of Behavioural change – Demand forinappropriate gp appointments

• Number of patients and carers sign posted appropriately

• Reduction in failure demand, this is repeat referrals for thesame thing

• Development of network of “supported” patients andcarers

• Numbers of patients and carers accessing communityresources

• Increased use of the third sector

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8 Vision Anywhere

Emis Mobile

Improve patientsafety and increaseefficiency byproviding a mobilesolution enablingGPs to access livepatient data.

LhbClusterINPSEMISNWIS

31/3/16 Link with SA2 SA5 SA8

Safer for patients

More efficient for GPs &

practice staff

Improving access and quality for patients by ensuring that accurate

‘live’ patient data is available during home visits and nursing home

rounds.

Currently in procurement discussion with LHB – This has been

added as a contingency plan for the cluster

9 Wound Care LHBKHHPCluster Hub

31/3/16 Link with SA2 SA3

Improved access

Improved patient

outcomes

Another contingency plan – centralise wound care service to assist

practices in managing complex wounds. Envisaged outcome

improved access and link with welsh wound care better outcomes.

Further discussion with LHB and other clusters as sensible to link

together with this plan.

10Confident PrimaryCare Leaders

Following a Cluster Lead Survey (conducted in 2015) publichealth Wales commissioned this course aimed at cluster leadsacross NHS Wales.

Merthyr Tydfil Cluster is represented by Kevin Rogers

This bespoke programme of nine half-day sessions will be

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delivered by Primary Care Commissioning Community InterestCompany (PCC), a not-for-profit organisation which runsconfident leader sessions on a regular basis and with first-hand experience of working with primary care. Sessions willbe led by qualified coaches and expert facilitators.

Designed for those who will take or have a leadership role in

primary care, clusters or networks. Bringing together groups

of like-minded individuals in an environment to learn together

and share experiences, supported by facilitators who provide

context and expert input. It aims to give the knowledge and

confidence to become a leader – or a better leader – and

equip leaders with the resources to push on to the next stage

of the development journey.

The main aims of the course are –

•The role of primary care in Wales

•Understanding people and leadership styles

•Engaging and working with patients and the public

•Population Health and maximising patient experience

•Business planning and finance

•Governance and legal

•Building a culture; impact on quality and performance

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improvement, planning change

•Influencing, negotiating and chairing skills

•Review, continued application and development, how to continueworking together

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Strategic Aim 10: Other Locality issues



1

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Summary / Timetable -

StrategicAim

Topic CompletionDate

Action By: - Status Comments RAGRating

SA1 -1 PopulationNeeds

30/9/15 Cluster Completed New website used – Pyramid data

SA1 -2 Informationrequirements

30/9/15 Cluster Completed New website used – Pyramid data – tablesinserted into plan

SA1- 3 ServiceDevelopmentneeds

30/4/15 Cluster Completed

SA1-5 Screening 30/9/15 Cluster Completed See SA6

SA4-2 A&E 31/3/15 Cluster Completed Link with Access Group

SA3-3 Alcohol / MH 31/3/15 3RD Sector Completed CVD Risk project implementation

SA3-4 HealthPromotion

31/3/15 Cluster Completed Part of SA9-4 – CVD Risk

SA6-1 ScreeningServices

31/03/15 Cluster Completed Initial engagement completed – now in actionphase

SA6-2 RCGP ModulePancreaticcancer

31/03/15 Cluster Completed Completed by all practices

SA9-2 (a) Access LES 31/3/15 Cluster Completed LES implemented and position on Access groupfor cluster established

SA9-2 (b) DNA 31/3/15 Cluster Completed DNA policy agreed and implemented acrosscluster and wider Cwm Taf

SA9-5 (C) Pathology 31/3/17 Cluster Completed Currently no desire to increase use of Labeltrace – this may change when NWIS implementGPTR Solutions via WCCG

SA1 – 4 Influenza 31/03/17 Cluster /LHB Ongoing Improvement in 2014/15 – needs to be

60 | P a g e

Uptake continued

SA2 – 1 Access Group 31/3/17 LHB/CHC/AccessGroup

OngoingCluster representative at Access Meetings

SA2-2 Activity Data 31/3/17 PracticesOngoing

Cluster practices continue to send activity data

SA2-3 Activity Data 31/3/17 PracticesOngoing

Review activity data – Shared by LHB

SA2-4 (a) Workforce 31/3/17 WG / Practices Planned Further meeting with WG planned for late 2016

SA2 -5 InappropriateWorkload

31/3/17 LHB/LMC/Cluster

Ongoing Continue to share inappropriate requests withMedical Director – return to originator.Support around path results and other areasfrom LMC & GPC Wales

SA5-1 EOL Care 31/03/17 Cluster Ongoing Support / co-ordination between Dr Lewis andcluster to continue

SA5-2 EOL Care 31/03/17 Cluster Ongoing EOL Templates distributed including JIC Boxinformation

SA5-3 EOL Care 31/03/17 Cluster Ongoing Primary Care portal populated

SA6-3(a) Rapid Access 31/03/16 Cluster Completed Portfolio available on primary care portal –additional detail required and link to Taff Elycluster who are creating electronic templatesfor emis and vision practices

SA7-1 Start/Stop 31/3/16 Cluster Completed Evaluation required

SA9-3 (a) Awareness 31/3/16 Cluster Ongoing Improve awareness of Services / Creation ofdirectory – link with SA9(7) – Behavioural

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support and CMHT

SA9-3(b) Resources 31/3/16 Cluster Ongoing Cluster to discuss sharing screening data forbest practice – share resources to increaseuptake.

SA9-3(c) Resources 31/3/16 Cluster Ongoing Review of Questionnaire to be undertaken toidentify resources available within group whichwould be appropriate for sharing

SA9-3(d) Cardiology 31/3/16 Cluster Completed Arrange for cardiology consultant to attendcluster meetings - link with additional fundingavailable for cluster hub model for cardiologyservices

SA9-5 (a) DAL 31/3/16 Cluster Lead Completed Letter sent to Medical Director – position veryclear – cluster and wider cluster groups workingtogether to improve quality and governance –links with EDAL project board, LMC established.

SA9-5 (b) A&E 31/3/16 Cluster Lead Completed Letter sent to Medical Director – position veryclear – cluster and wider cluster groups workingtogether to improve quality and governance –links with EDAL project board, LMC established

SA9-5 (b) A&E 31/3/16 Cluster Lead Completed Letter sent to Medical Director – position veryclear – cluster and wider cluster groups workingtogether to improve quality and governance –links with EDAL project board, LMC established.Many practices in cluster now receivingelectronic A&E letters. We need to ensure thiswill be available for all practices

SA9-5 (C) Pathology 31/3/17 Cluster Ongoing Link with LMC pathology Group to ensurecluster representation – Zero tolerance plansestablished by LHB – Link with cluster to ensure

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introduction benefits all and is not detrimentalto practices. Principle established that this mustbe a two way process – practices must ensurequality of data submitted on forms – agreementon tick box to identify district nurse and othernon practice originators.

SA6-3(b) Rapid Access 31/12/15 Cluster Completed Collection of data ongoing – review to takeplace early 2016

SA3-1 Email 31/3/16 LHB Planned /Ongoing

Discussion around extending use of email foradvice

SA3-2 ManagementPlans

31/3/17 LHB Planned Implementation to be agreed – links with TaffEly cluster work for templates / guidelines

SA4-1 OOH Redesign 31/3/16 Cluster / LHB Completed Engage with LHB to plan OOH redesign –progress in respect of plan – links with accessgroup where cluster is represented – OOHmanagement on group also

SA4-3 NetworkServices

31/3/17 LHB/Cluster Ongoing Further enhance network services / shareresources – Cluster Hub ideas to be discussedwith LHB - Initially two – Wound Care serviceand Cardiology hub.

SA4-4 Community co-ordinators / 3rd

Sector

31/3/17 LHB/MTCBC/Cluster/3rd Sector

Ongoing Continued use of Co-ordinator role andenhancement of provision further than 31/3/15(end date) – project has been extended – linkrequired with SA9 (7) Behavioural supportworker (s)Meeting with VAMT organised October 2016 to

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co-ordinate with 3rd sector in respect of therequirements of the behavioural change / GPSOpost.

SA7-2 Collaborationwith LHBPrescribingteam

31/3/16 –ongoing

Cluster / LHB Ongoing Integration of prescribing team into clustergroup membership – Review of Rhondda andTaff cluster who are employing pharmacymember as part of cluster plan - revieweffectiveness with a view to implementing ifproves successful

SA9-2 (c) Education 31/3/17 Cluster /LHB /CHC

Ongoing Engagement with patient groups / access groupin respect of patient education – Links with SA9(6) – Web GP will provide a significant elementof patient education.

SA9-3(c) Resources 31/3/17 Cluster Ongoing Following analysis of Questionnaire - resourcesto be identified to support work in primary care– shift of resources from secondary care provingproblematic EG NOAC – Link with Dr KevinThomas and LMC who are currently looking intothis.

NOAC ES progressing well – reviewed by LMCSeptember 2016

SA9-6 Web GP 31/3/17 Cluster / LHB /Hurley Group

Ongoing Orders placed – installation prior to 31/12/15with an initial 3 month evaluation / promotion –then 9 months to 31/12/16 – Links with SA2

Initial data from Pontcae very positive –estimated 300 patient appointments saved inJuly – Sep quarter 2016.

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Discussions with EMIS ongoing regardingrenewal of licence

SA9-7 BehaviouralSupport

31/3/17 Cluster / LHB /cmht

Ongoing Business plan / SLA Created – awaiting approvalfrom Council – recruitment a.s.a.p – Links withSA2 / SA4

SA9-8 VisionAnywhere

31/3/16 Cluster / Vision/ Emis / LHB

Completed Contingency 1 – As cluster funding will not befully utilised due to delays with recruitment andallocation of funding for Web GP , plan to alignwith other clusters and purchase Hardware andsoftware to enable remote ‘live’ patient data –Links with SA2 SA5 SA8

SA9-9 Wound Care 31/3/16 Cluster / LHB Ongoing –ON HOLD

Contingency 2 – As cluster funding will not befully utilised due to delays with recruitment andallocation of funding for a specialist Wound Careservice from the Cluster Hub KHHP. This alignswith the other cluster plans for a hub woundcare service and is intended to alleviatepressure from Practice Nurses – Links with SA2SA3

SA9-10 Primary CareLeaders

31/5/2017 Cluster lead Ongoing Representation of cluster at Confident Clusterleader program – 9 months collaborationbetween clusters and public health.

SA2-4 (b) Workforce 31/3/17 Cluster / WG / Ongoing Long Term planning to attract Gp’s to Merthyr

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LHB

SA9-1 Recruitment 31/3/17 See SA2-4(b) Ongoing Long Term Planning for recruitment

SA9-5 (a) DAL 31/3/17 Cluster Lead Ongoing Electronic DAL – progressing very well – will beestablished by 31/12/15 in a pilot phase –evaluation and implementation should becompleted by 31/3/16

SA9-4 CHD Risk 31/03/17 Cluster /LHB /Systemsuppliers

Ongoing Primary Care development manager appointedto work with practices – evaluation ongoing

Project to be funded from additional resourcesoutside of that of the cluster

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