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GP Cluster Network Action Plan2015-16
City Cluster
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Welcome to the City Health Network Cluster Plan for 2015/16. The City Health Network, based in Swansea, comprises ten general practices working together with partnersfrom Social Services, the voluntary sector and the ABMU Health Board.
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The City Network Practices, in line with other networks in Swansea, 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 communitybased services and vice versa.
In order to support the development of the Network Cluster Plan, information has been collated on a wide range of health needs within the City Network area. The summary belowhighlights the key points and this information has been used to inform the development of priorities for the plan.
The 10 Network Cluster practices serve a varied population of 51,372 that has:
• High deprivation levels; with 24,833 (49%) residents living in the most deprived fifth of areas in Wales (see Deprivation Comparison below)
• Large student, asylum seeker and multi-racial/multi-cultural groups
• A large proportion of young parents
• 7,920 patients aged 65+ (16%) and 1,060 aged 85+ (2.2%)
• A 8% obesity rate (ABMU average is 9%)
• The highest percentage of smokers (30%) across Swansea (20%) {GP register data}
• An Incidence rate of 195 per 100,000 population for referrals to drug and alcohol treatment services
• Bowel Screening uptake of 43.4% (Target 60%) – Lowest in Swansea
• Cervical Screening uptake of 70.3% (Target 80%) – Lowest in SwanseaThe highest number of A&E attendances of any network in Swansea
• The second highest rate in Swansea of emergency inpatient admissions
• The highest rate of prescription of anxiolytics and hypnotics, antidepressants, opioid analgesics, tramadol, NSAIDs in Swansea
The Network area is served by:
• 4 General Dental Practices
• 1 Specialist Orthodontic Practice
• 1 Specialist Dental Practice (Sedation and Oral Surgery)
• 15 Pharmacies
• 6 Opticians
• 4 Nursing/Residential Homes
• 10 Schools
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The Network area, together with Penderi network area, forms the geographical area for one of three integrated community hubs within Swansea.
This is the second Network Development Plan for the City Health Network which will build upon progress made in year one. It encompasses a range of priorities identified in PracticeDevelopment Plans and via a multi-agency prioritisation session held at the July Network Board.
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Strategic Aim 1: To understand the needs of the population served by the City Cluster Network
No Objective Action Key partners For completionby:
Outcome for patients Progress to Date / CurrentPosition
RAG
1a To improve Primaryand Communityservices for FrailElderly/Falls
Ensure continued strong links aremaintained with Chronic Care Nurses
Continue to promote the fallsprevention service.
Continue to distribute Falls Preventionguide.
Hubs
Networks toliaise withCCNs
Ongoing –Quarterly checks.
To improve communitycare and reducenumber of falls
Falls prevention guide has beenproduced and has been deliveredto all practices for patients toprevent and support individualswho are at risk of falling.
1b Support CommunityServices.
Network to act as pilot in supportingdelivery of comprehensive patientdischarge summaries to BonymaenHouse.
NetworkPracticesHealth BoardCommunityServices
Dec 15 Safe and appropriatecare.
Agreement reached withNetwork to support.
1c To improve SexualHealth services forpatients.
To provide specialist services e.g. IUCT,UCD, Implanon with abilities to cross-refer between practices.
Establish who currently provides whatand which practices will be providers.
Network
Network ChairHealth Board
Dec 15 Allow patients to accesscontraception servicesin a local generalpractice.
Services agreed in principle.
LARC spec issued and distributedto practices. Details of claimprocess/structure recentlycirculated.
Practices listed below whoprovide IUCD insertions.
• St Helen’s
• Brunswick
• Kingsway
• Greenhill
• Harbourside
• Cockett
• SA1
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High Street – Implants
1d Smoking Signpost smokers to Public Health Level3 Pharmacy Scheme and support withPublic Health materials.
Public HealthWales &Network
Ongoing Reduction of smokingrates within theNetwork
Practices auditing progress.
1e Substance Misuse Health board to sign off revised versionof draft LESRelaunch once confirmation received.
Need to raise implications of SharedCare worker being withdrawn withBoard.
Network
Health Board
Health BoardCDAT
Apr 15
Oct 15
Improved access tosubstance misuseservices.
In discussion with LMT.
Discussion ongoing with UnitDirector and CDAT
1f To support newlydiagnosed diabeticpatients (and thosepre-diabetic patients)in undertaking lifestylechanges which willbenefit their healthand wellbeing
To embed the WeightWatchers/Positive Steps programmeacross the Network
To proactively review the number ofpatients being referred by the practiceto NERS/Weight Watchers
GPsWeightWatchersPositive StepsPHWHB
Oct 15
Quarterly
Better health for thosepatients with chronicdiseases
Improved lifestylechoices leading to a lessmedical model of care
Engage with Public Health/ThirdSector
Maintain links withWeightwatchers Programme toreceive progress reports atregular intervals
1g To improve access tomental health services
To increase mental health nursing input
To provide in house counselling services
To further develop the LMPHSSinformation clinic within the CityNetwork and explore new ways ofworking e.g. Development of MentalHealth focussedNoticeboards/Information Provisionwithin the GP Practices
SCVSHealth BoardGP practices
Dec 15 Improved, timely accessto mental healthservices
Improved access tocounselling services forpatients who need Tier0 support either viapractice or networklevel
Designation of Mental Healthofficer is SCVS
Signposting patients to Tier 0services
Develop service for all practicesto received LMPHSS andattendance and for all practicesto have the opportunity, TW toprovide option paper for all
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practices for visits and bestpractice.
All practices to use counsellingguides developed by SCVS as aresource.
1h Increase uptake ofbowel and cervicalscreening
Continue to raise awareness of boweland cervical screening programme.Advertise via posters and leafletsprovided by cervical screening;including GP practices, communitypharmacists and local authoritybuildings.
Compare actions of best-performingCity practices.
NetworkPracticesCommunityPharmaciesLocalAuthority
Mar 16 Early detection ofcancers. Increasedscreening uptake.
Current screening uptakes of:Bowel Screening 43.4% (Target60%)Cervical Screening 70.3% (Target80%)
1i Increase fluimmunisation uptake
Lower performing practices to workwith PHW
PHWNetworkPracticesCommunityPharmacies
Mar 16 Protect patients at riskand the widerpopulation.
PHW assisting St Helens andNicholl Street to improve uptake.
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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 (WORKFORCE)
No Objective Action Key partners For completionby:
Outcome forpatients
Progress to Date / Current Position RAG
2 Ensure that accessarrangements are inplace that meet thereasonable needs oflocal patients
Determine City practices to pilottelephone triage.
Network practices Dec 15 Services developedto reflect local needRelease morecapacity for patientcare.
Discuss further at Oct ’15 meeting.
Use SMS reminder system whenrolled out by NWIS.
NWISNetwork practices
Jan 16 NWIS roll out July 2015.
Continue to review accessarrangements.
Network practiceswith Kingsway aslink.
Quarterly Access more broadly discussed inPLTS 25/3/2015 (in addition totelephone triage)Discuss at future meeting.
Consider staffing/workforcepressures.
Establish Locum Bank.
Speak with Training Practices reretention of GPs.
Network practices Quarterly
Awaiting outcomeof bid
Nov 15
Board to discuss possibility of settingup informal co-operative locumbank to include nursing andreception staff in addition todoctors.
Bid gone to IMTP - Primary CareWorkforce funding.
Review report and action anyrecommendations from Primary CareFoundation to develop accessarrangements.
Network practices Nov 15 PC Foundation – All practices signedup. Analysis and site visits to beundertaken in Sept 15
Address Homelessness Servicecontinuation and improvement.
NetworkHealth Board
Ongoing Service currently operating fromCentral Clinic.
Possibly develop theNetwork as aFederation
Use slippage money to set upadditional PLTS session to discuss.Invite facilitator.
NetworkABMU
Dec 15 Information documents circulated.
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Strategic Aim 3: Planned Care- to ensure that patients needs are met through prudent care pathways, facilitating rapid, accurate diagnosis and management andminimising waste and harms
No Objective Action Key partners Forcompletionby:
Outcome for patients Progress to Date / CurrentPosition
RAG
3a To implement a MinorSurgery service
Draw up SLA allowing cross-referral. Health Board,Network
Nov 15 Improved local and user-friendly access to Minorsurgery
Network Chair to e-mailpractices to establishmechanism.
3b To work to removeservice barriers whichimpair treatment forpatients with MentalHealth issues
Need to consider CMHT response. Network/CMHT
Network, HealthBoard
Oct 15 Better more supportivemental health service forpatients
CMHT representatives atDec 14 meeting.Written response to issuesraised circulated forinformation.
3c PMS Plus –RespiratoryPrescribing: to beconsidered on anetwork basis
This is a new initiativewhich will operatewhere opportunitiesarise for specific targetareas to releasesavings throughintegrated workingacross CommunityNetworks and AcuteCare sectors.
Each scheme will beindividually designed
To undertake a range of prescribinginitiatives as required to improverespiratory prescribingClose liaison with expanding communityresource and medicines managementteams to facilitate suitable medicinesmanagement arrangements for peoplebeing cared for at home
Close liaison with communitypharmacists undertaking Medicationusage Reviews and Discharge reviews
GP’s within networkssupport fromMedicinesManagement to bedetermined onpractice level
Mar 15 andongoing
Improvement in patientsymptom control
Medicines management toassist all practices incompleting
All practices have agreed toundertake PMS Plus
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and may crossfinancial years. Anypayments will be non-recurrent.
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Strategic Aim 4: To provide high quality, consistent care for patients presenting with urgent care needs and to support the continuous development of services toimprove patient experience, coordination of care and the effectiveness of risk management (UNSCHEDULED CARE)
No Objective Action Key partners For completionby:
Outcome forpatients
Progress to Date / Current Position RAG
4a To reduce theinappropriate use ofA&E and GP Out ofOurs
To improve patient education e.g.display posters
Link in with alternative services e.g.AGPU
Analyse emergency admission rateson GP portal in greater detail andconsider where improvements canbe made.
Signpost patients to ensureattendances are appropriateincluding e.g. ”choose well’’ posters
GP OOHA&EMIUHBCommunity Voices
Ongoing Better education onhow to accessservicesappropriately tomeet their needs
ABMU Communication Team hasbecome involved with surgeries andassist in getting correct informationout
“Choose Well” campaign
4b To improveantimicrobialstewardship
Antibiotic audit at all practices. Medicinesmanagement team
Ongoingquarterlymonitoring oftrends
Reduced resistance
Reduced C.Diff
Increasedknowledge andempowerment toself care
Discussed at all annual practiceprescribing visits. Cluster level data tobe shared at forthcoming clustermeeting
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Strategic Aim 5: Improving the delivery of end of life care
No Objective Action Key partners Forcompletion by:
Outcome forpatients
Progress to Date / Current Position RAG
5 Palliative Care-Adopt principles ofend of life care withfocus on continuityof care relating topatients withpalliative conditionin last two weeks oflife.
Develop relationship between Practice/and Secondary Care:
Topic arose following discussion aroundpoor discharge summaries and raisedexpectation of patient.
Network Chair produced a template toaudit summaries. Practices to completeand agree approach to Medical Director.
Network practicesSecondary Care
Ongoingand inQOF15/16
Reduce significantrisks associated withmanaging dischargedpatients withno/inadequateinformation
Lead Clinician in Palliative Careattended July 15 meeting.
PLTS presentation on Discharge -copy of presentation given to eachpractice May 2015, no issues raised.
Discuss audit findings at Novembercluster meeting.
Liaise with lead clinician in palliative careregarding review of makeup of team andservice, including:Feedback of continuity of access to CNs;Feedback on issues with responses tocalls to CNs as they arise;Receive update on way forward forseparate palliative care dischargesummaries from hospital support team;Arrange follow-up session with SueMorgan for March 2016
Secondary CareCNsHealth Board
Mar 16 Improved palliativecare service
Lead Clinician in Palliative Careattended July 15 meeting.
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Strategic Aim 6: Targeting the prevention and early detection of cancers
No Objective Action Key partners Forcompletion by:
Outcome forpatients
Progress to Date / Current Position RAG
6a Secondary caredowngrading USCs
Review USC referral downgrades.Network to collate examples on anetwork basis to raise to relevantspecialties.
Have agreed for future to:Remind GPs to complete a USC referral incases of change of bowel habit;Remind GPs to refer as USC on suspicionof cancer rather than awaitinginvestigations and avoid falsereassurance of inappropriateinvestigations.
Network Mar 16 Potential earlieridentification forpatients with cancer
Chair has collated practiceinformation re downgrades.
Concerns confirmed and awaitingavailability of a representative fromsecondary care to discuss with us.Fiona Hughes/Linzi Thomas invitedto Sep ’15 meeting.
6b Address smoking as acause of cancer
PHW and Stop Smoking Wales developinga menu of options to compliment Level 3Pharmacy Scheme.
PHWTobacco ActionGroup
Mar 16 Improved stopsmoking support
Meeting held with TAG/PHW
6c To target theprevention and earlydetection ofdigestive, lung andovarian cancers
Review patients with lung, digestive andovarian cancer in line with ClusterNetwork Development Domain.
Network practices Ongoingand inQOF15/16
Better preventionand earlier detectionof cancers for ourpatients
National Pathway work to bediscussed and undertaken betweenOct 15 and March 16
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Strategic Aim 7: Minimising the risk of poly-pharmacy
No Objective Action Key partners Forcompletionby:
Outcome forpatients
Progress to Date / Current Position RAG
7a Polypharmacy Reviews& High Dose SteroidAsthma Reviews
Close liaison with expanding communityresource and medicines managementteams to facilitate suitable medicinesmanagement arrangements for peoplebeing cared for at home e.g.simplification of medication regimes,changes to medicines formulations,arrangements for warfarin etc.
Close liaison with communitypharmacists undertaking Medicationusage Reviews and Discharge reviews.
MedicinesManagement
Network Practices
Network Pharmacist
Ongoingwithin QOF15/16
Reduction inmedicationload/improvedsymptom controletc
leads pp4.ppt
7b Improvement/maintenance against targetprescribing indicators
Can consider and review practice andnetwork data forantibiotics/statins/hypnotics &anxiolytics and discuss howimprovements can be made if required.
MedicinesManagementNetwork PracticesNetwork Pharmacist
Ongoingwithin PMS15/16
Improvement inprescribing qualityto improve healthoutcomes
pms progress march15.ppt
7c Appointment ofClinical Pharmacist
Clinical Pharmacist to be appointed andshared across the Network focussing onpolypharmacy issues particularlyrelating to patients who have beendischarged from hospital or are residingin a care home.
Network PracticesHealth Board
Oct 15 Shared CP wouldreduce medicineswastage, ensurecompliance withmedication andreduce the risk ofdrug contraindications topatients across thenetworkAll patients acrossthe Network willbenefit fromenhanced provision
£54,000 allocated to implement theclinical pharmacist Service across thenetwork.Cluster pharmacist starting 12th
October.
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ensuring positivepatient outcomes
7d To provide accreditedtraining for prescribingclerks
Provide accredited training forprescribing clerks
MedicinesManagement team
Mar 2016 Improved repeatprescribing systems
Training packs in development
7e To ensure appropriateuse of the pharmacistand technicianresources to reducerisks frompolypharmacy
Network and individual practices toagree work agenda for clusterpharmacists. Support provided byexisting medicines management team
MedicinesManagement team
Clusterpharmacistavailable byOct 2015
Improved accessfor improvedpharmaceuticalcare
Cluster pharmacist starting 12th
October.
7f To engage in thePrescribingManagement Scheme(PMS) and PMS+respiratory schemes(which containpolypharmacyelements)
Networks to consider role of clusterpharmacists in supporting respiratoryPMS +
MedicinesManagement team
PMS 15/16– by Mar16PMS +respiratory– by Nov 16
Improvedmedicinesmanagementincludingpolypharmacy
All practices engaged and makingprogress
7g To progresspolypharmacy issuesidentified in previouscluster network plan
Practices to continue to support thepolypharmacy agenda using clusterpharmacist where appropriate to targetcomplex patients
Practice teams Ongoing Improvedprescribing andmechanisms forpolypharmacyreview
Ongoing
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Strategic Aim 8: Deliver consistent, effective systems of Clinical Governance (Inc. PREMISES)
No Objective Action Key partners Forcompletion by:
Outcome forpatients
Progress to Date / Current Position RAG
8a To ensure thatpremises are fit forpurpose withinnetwork
To ensure that risks and opportunities areflagged are identified within the HealthBoard’s Primary and Community Estatesstrategy.
Health Board,Networks, LocalAuthority, Coastal,WG, Shared ServicesPartnership
Ongoing Premises fit forservice provision
Raised in Practice DevelopmentPlans. To address through EstatesStrategy.
8b Ensure robustsystems at practicelevel
Ensure that CGPSAT toolkit,significant event analysis are undertaken,results shared to ensure best practice.
Practices to share SEAs at Networkmeeting to share learning.
Networks/practices Ongoing Safe environment forpatients
Sharing event at each meeting.
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Strategic Aim 9: Other Locality issues
No Objective Action Key partners Forcompletionby:
Outcome forpatients
Progress to Date / Current Position RAG
9a To ensure thatimpacts ofpopulation changeare planned for
Scope for population increase – e.g.housing/student developments andinclude mitigating action in future plans,including workforce considerations. Riskparticularly to practices on east of clusterwho are at maximum capacity already
Consider practices collaborating toensure equitable distribution of newpatients
Use this as a focus to discuss/plan howthe network could share services infuture in a federated approach aroundpayroll, recruitment, admin etc.
NetworkHealth Board(through supportiveinformationprovision)
Network
Ongoing Ensuring suitableprovision available.
More cost-effectiveservices able tobetter provide forpatient needs.
Consider ways in which LHB mayhelp
9b INR service –ensuring dosing andprescribing are notseparated
Review of INRservice to ensureincludes NOACs
INR Enhanced Service to becommissioned across practicesORConsideration given to mechanisms tonot separate INR monitoring fromprescribinge.g. use of pharmacists or medicalscientists in community doing dosing &prescribing OR secondary care prescribingas they do monitoring and dosing.
LHBGP practices +/-secondary careservices +/- HBmedicinesmanagement teams
Ongoing Safer servicesthrough notseparating roles ofmonitoring andprescribing – in linewith MHRA
PBMA (Programme Budgeting &Marginal Analysis) exercise ongoingwithin the Health Board, looking atthe AF pathway, with a particularfocus on Anticoagulation ServiceModels. Engagement exercisesundertaken with both GPs andpatients. Currently analysingexisting and suggested servicemodels based on cost and quality.
9c To continue tosupport thedevelopment ofintegrated health
To act as a key stakeholder in informingthe ongoing development of integratedhealth and social care teams deliveringservices for older people.
Social Services,community nursing,third sector, primarycare, domiciliary
March 16andongoing
More effective,timely and co-ordinated healthand social care and
Hub Manager and Lead Nurse
attending all Network meetings.
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and social careservices for olderpeople and youngerdisabled adults inSwansea.
Linking in with network to ensureappropriate and consistent linkages aremade.
Network to inform the review of thesingle point of access (Intake) for theintegrated teams
care, independentcare providers
a better ability tomanage demand.
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Strategic Aim 10: Third Sector/Partnership Working
No Objective Action Key partners For completionby:
Outcome for patients Progress to Date / CurrentPosition
RAG
10a To further developthe Third Sectorsupport project,increasing the use ofvoluntary sectorservices by the CityNetwork population
Ensure that links are made withvoluntary sector organisationssupporting the agreed network priorityareas where possible.
SCVS to map Third Sector provisionagainst network priorities.
Led byNetworkpracticessupported bySCVS
Mar 16 Improved support andaccess to services.
Practices invited to take part inHealthy Partnership project.
Ensure that up to date information onvoluntary sector services is displayed inGP practices, e.g. information stands,notice boards.
Led byNetworkpracticessupported bySCVS andVoluntarySectororganisations
Mar 16 SCVS liaising with practices.
To extend voluntary sector presencewithin GP practices in the network byincreasing the number of practicesparticipating, Healthy Partnerships andexploring new ways of working jointlysuch as pre bookable appointmentswhere possible.
Network andSCVS
Mar 16 Brunswick and Kingsway ontimetable for third sectorattendance and haveorganisations attend theirpractices.Mayhill promoting via leaflets.
10b To obtain patient andcarer views onnetwork services andpriorities programme
To establish a patient/ carerparticipation group within the networkarea in line with the Community Voicesprogramme
SCVS Oct 15 & Ongoing Responsive servicestaking into accountservice user and carerfeedback.
1 road show and 3 meetingsheld – no attendee at the lasttwo. Engagement with citizenshas been difficult.
SCVS provided practices withflyers for promotion and to
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attach to prescriptions.
SCVS linking with Central Hubmanager for patientinvolvement in patient/carerpanel.
Priority engagement / publicityevent to be held in the GrandTheatre
Further promotion
Support Network to promote apriority within their plan tocitizens.
Further roadshow planned forOctober.
10c Develop Local AreaCoordinator pilot
ABMU to work with LACs to provideclear eligibility criteria for referringpatients.Practices to actively refer patientswhere suitable.ABMU to assist in promotion of LACproject to practices.
Health BoardLACNetworkpractices
Jul 15 andongoing
Improved support LACs now working in Citypractices and making links.
10d Develop closerworking links withCommunities First
Increase the use ofCommunities Firstservices by the CityNetwork population
Ensure up to date information aboutCommunities First is displayed in GPpractices e.g. leaflets and posters
To ensure that practice actively referpatients to Communities First wheresuitable. Activities include learning,physical activity, volunteering andcommunity engagement
CommunitiesFirstNetworkPractices
Ongoing Improved support andaccess to services forthe City Networkpopulation
Referral scheme to be set upand piloted at practice.
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Explore the potential for joint projectswhere patients would benefit from anintegrated approach.
10e Access to CitizensAdvice Bureau withinGeneral Practice
CAB to provide an advice service
resource in the Network GP practices
through the provision of advice workers
for 7 days per week, six of which to be
provided as an outreach to Networks.
The pilot will be fully evaluated at yearend.
Lead GPsHealth BoardCAB
Funding until Mar16. Fullevaluation willthen beundertaken.
Better support forpatients withwelfare/social problemsthat need dedicatedsupport and guidance
Funding has been given to CABto start a pilot and they will bepresent in a City surgery for 1day each week to provideinformation and support topatients.
CAB in Kingsway and SA1.
10f To increase the use ofthe Healthy CityDirectory within thenetwork
To increase the use of the Healthy CityDirectory within the network
NHS DirectHealth BoardSCVSVoluntarySectororganisations
Mar 16 Network populationmore informed onavailable health andwell being servicesleading to increasedusage
To promote the use of theHealthy City Directory withinpractices and to patients