three year cluster network action plan 2017-2020 bridgend north ... - health … - north... ·...

Abertawe Bro Morgannwg University Health Board Bridgend North Cluster Network Plan 2017/2020

Three Year Cluster Network Action Plan 2017-2020

Bridgend North Cluster Network

VERSION CONTROL:

July 2017


Introduction The Bridgend North Cluster Network includes a cluster of eight GP practices. The cluster network estate includes eight main practices, three branch surgeries and one dispensing practice. One practice is situated in a converted ward at Maesteg Hospital. Four practices are engaged in GP training and one practice trains 5th year medical students. The Bridgend North Cluster Network area contains nine Nursing/Residential Homes and one Community Hospital situated at Maesteg. There are 13 community pharmacies and 5 dental practices. The cluster serves a population of 52,040 in rural and urban areas with pockets of severe deprivation. A significant reduction in the healthy life expectancy exists for Males and Females between the Llynfi Valley (served by Woodlands, Bron Y Garn and Llynfi Surgery Practices) and neighbouring Bridgend residents, of 21.5 years and 16.2 years respectively giving some idea of the challenges faced with healthcare provision in these areas.

The cluster network achieved a number of objectives during 2016/17 including:

Continued access to mental health and wellbeing services through provision of a local cluster counselling service.

Continue to progress the development of a community based ultrasound-equipped musculoskeletal service that will enhance and relieve pressures on secondary care services.

Enhanced skills of Practice Nurses in minor illness training, freeing up GP’s for more complex case management.

Further roll out of anticipatory care across the cluster.

Early identification and proactive management of respiratory patients Introduce point of care CRP Testing. Work in collaboration with the antimicrobial North Network pharmacist to develop protocols and agreed outcomes.

Ongoing collaboration with the specialist antimicrobial North Network pharmacist (ABM Pathfinder) to develop and undertake a programme approach to improve antimicrobial stewardship.

Ongoing communication and integration with the third sector.

Continued focus on increasing bowel screening uptake locally and subsequently improve early detection of bowel cancer.


The Bridgend North Cluster Network Action plan will support the cluster to work collaboratively to:

• Understand local health needs and priorities.

• Develop an agreed Cluster Network Action Plan linked to common themes of the individual Practice Development Plans.

• Work with stakeholders across the North Cluster to improve the coordination of care and integration of health and social care.

• Work with local communities and networks to reduce health inequalities.

The Cluster Network Action Plan includes: -

Objectives that can be delivered independently by the network to improve patient care and to ensure the sustainability and modernisation of services.

Objectives for delivery through partnership working, collaboration and co-production

Issues raised for discussion with the Health Board

For each objective there are specific, measureable actions with a clear timescale for delivery. The Cluster Action Plan compliments individual Practice Development Plans, tackling issues that cannot be managed at an individual practice level or challenges that can be more effectively and efficiently delivered through collaborative action. This approach supports greater consistency of service provision and improved quality of care, whilst more effectively managing the impact of increasing demand set against financial and workforce challenges.


Access Arrangements

Increased patients demand / lack of

clinicians to meet demand of complex

patients

Patients requesting emergency

appointments inappropriately/ Patient

education required

Reduce DNA rates

Increase use of minor illness nurses

Education & Training

GP training for USS and MSK injections

Palliative Care training for staff in Nursing

and Residential homes

Staff training on Welsh Clinical

Communications Gateway (WCCG)

Dermatoscope training

Workforce

Cluster pharmacist vacancy

Reduced access to District Nursing input

Sustainability of workforce (Retirements)

Demography

Areas of high deprivation, unemployment /

social issues, alcohol / drug abuse

Needs Profile

High rates of chronic diseases in comparison

to other ABMU clusters in particular COPD

and CVD

High rates of teenage pregnancy, smoking

and obesity

Service Provision

Improve service to frail elderly /

housebound patients

Anticoagulation monitoring

Reduce Antibiotic prescribing

The current CAMHS pathway is unclear/

lack of CAMHS service provision

Continue to monitor Urgent Suspected

Cancer downgrades

KEY THEMES & PRIORITIES IDENTIFIED FROM PRACTICE DEVELOPMENT PLANS


Services Delivered

Ab

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Su

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Bro

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Ga

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Wo

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lan

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Nan

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Og

mo

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ale

Cw

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Directed Enhanced Services

Childhood Immunisations

Influenza for those 65 and over and others at risk groups (2-3 year olds)

Extended Minor surgery N N N

Care of People with Learning Disabilities

Care of People with Mental Illness N N N N

National Enhanced Services

Anti Coagulation (INR) Monitoring

Shingles Catch-Up Programme

Services to patients who are drug/alcohol misusers N N N N N N

Local Enhanced Services

Shared Care

Gonadorelins/Zoladex

Immunisations during outbreaks (MMR)

Care Homes N N N N

Care of Homeless Patients N N N N

Hep B Vaccination of At-Risk Groups

Wound Management A N

Wound Management Part B N N N

Wound Care SLA Feb 17 to Jun 17 N N

Men C Catch-up for University N N N

Cross Border Patients N N N N N N N

Anti coagulation level 4


Strategic Aim 1: To understand and highlight actions to meet the needs of the population served by the Cluster Network

No Objective Outcomes Milestones Assigned to (key partners)

Progress to date RAG Rating

1 To review the needs of the population using available data.

To ensure that services are developed according to local need

Ongoing General Practice Local Public Health Team Health Board

Action:

Cluster planning to be informed by PDPs and public health profiles.

Proactively utilise the Primary Care Portal to identify areas for improvement.

Key themes discussed at Cluster Network meeting July 2017. The cluster serves a population that has:

Significantly more deprived areas than Welsh average with pockets of deprivation amongst the highest in Wales.

Chronic condition burden is higher than other Cluster areas.

High rates of teen pregnancy compared to other national averages.

High rates of drug and alcohol misuse.

High smoking prevalence.

High rates of obesity in adults and children.

2. Improve access to weight management interventions for overweight and obese patients within the cluster

Clinically beneficial weight change

31st March 2017

Health Board General Practice

Action:

develop a cluster lifestyle coach, based with HALO leisure services, to deliver a weight management programme, based on NICE guidance, delivering in the community, taking referrals via, but not exclusively, from the CVD Health Checks Project.




3. To ensure a consistent approach to the implementation of the public health agenda to support achievement of the NHS Tier 1 smoking cessation target

Support to the smoking population to make a quit attempt

Ongoing Stop Smoking Wales Community Pharmacy General Practice

Action:

Ensure all patients have an updated smoking status on practice records

Promote Stop Smoking Wales, Community Pharmacy Level 3 Service using available promotional material.

Promote stop smoking campaigns within practice

Consider opportunities for partnership work with Stop Smoking Wales and Community Pharmacies.

4. Continue to increase flu immunisation uptake within the cluster

Protect patients at risk and the wider population

31st March 2017

General Practice

Action:

Ensure practice flu plans are completed and submitted to Health Board

Practice staff to complete PHW flu e-learning module

Peer review IVOR flu vaccination uptake data on cluster basis

deliver fluenz parties in practices that feel this will increase uptake.

5. Improve uptake of screening programmes

Improved diagnosis and better outcomes

Ongoing General Practice

Action:

Proactively encourage screening uptake across all screening programmes - ongoing

6. Cluster planning and service delivery informed by patient views and experience.

Better understanding of the needs of the population

31st March 2017

General Practice

Action:

Develop effective engagement mechanism to gather patient views and experiences.




Ensure all future project and service development include a relevant patient satisfaction questionnaire

7. Cluster planning to develop support for alcohol and substance misuse

Availability of services to reduce addiction and reliance on Alcohol and substance misuse

31st March 2017

General practice Third sector Public Health

Continue with the work on developing a GP led primary care based service for alcohol and substance misuse

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

No Objective Outcomes Milestones

Assigned to (key partners)


1. Improved communication and integration with the third sector

Increased access and signposting to voluntary services that support self care and independence

Ongoing BAVO General Practice Health Board

Action:

Continue to link with BAVO and update local third sector resources for signposting

2. Extend the range of professionals and maximise the skill mix within the cluster

Increased access and signposting to voluntary

31st March 2017

General Practice Pharmacist

Action:

Evaluate the outcomes of the role of the pharmacist within the cluster

Consider future roles and responsibilities





through the development of a cluster pharmacist

services that support self care and independence

Health Board To employ a band 8a Pharmacist to work across the cluster

Developing a physiotherapist role

3. Increase wellbeing, resilience and early intervention to frail elderly individuals through a primary care occupational therapist

Enhanced skills and improved efficiency of services

Ongoing Bridgend Care and Repair General Practice

Action:

Using the Anticipatory Care Plans approach, identify individuals who are regular users of their service and are increasingly frail and isolated.

4. Consider workforce and skill mix training opportunities to extend the range of professionals within the cluster

Improved multi skilled multidisciplinary Practice team and improved efficiency of services

Ongoing General Practice Action:

Identify training and development needs of core practice staff Consider opportunities for network based professionals

Consider developing Practice Managers in terms of leadership and sharing best practice – Practice Managers forum.

Identify specific training needs for individual professions and support workers across the Cluster – development of a training needs analysis

5. Consider opportunities for network based service provision

Providing a local service and utilising Network skills

Ongoing

General Practice

Action:

Referral process in existence within network for minor surgery and LARC is ongoing





to improve patient services

Consider other Enhanced Services that could be delivered at a network level by cross practice referral

Strategic Aim 3: Planned Care – to ensure that patient’s needs are met through prudent care pathways, facilitating rapid, accurate diagnosis and management and minimising waste and harms. To highlight improvements for primary care / secondary care interface.



1. Support the development and implementation of a cluster based CVD Primary Prevention Programme

Increased primary detection of those at moderate and severe risk of developing CVD, triggering referral to appropriate local networks, contributing to the reduction of CVD inequalities in Bridgend North

31st March 2018

General Practice Health Board Public Health Third Sector

Action:

Work collaboratively and in partnership with the Health

Board to deliver CVD Health Checks

Recruit 3 HCSWs to deliver CVD Health Checks

– complete.

Collaborate with public health colleagues to

develop onward referral mechanisms for the

management of patients identified at increased

CVD risk via the Health Check project –

complete.

Engage with BHF and other appropriate third

sector organisations to deliver appropriate CVD

training to HCSWs employed to deliver Health

Checks– complete.




2. Support the development if the bespoke software to deliver the CVD Health Checks

Engage with software company Health

Diagnostics to develop a bespoke software

system to support CVD Health Checks–

complete.

Ongoing liaison with Information governance, IT

and IT infrastructure leads to ensure appropriate

governance around data sharing.

Ongoing engagement with practices across the

Cluster to roll out further across the cluster.

Developing social prescribing via the wider community

asset mapping

3. To drive forward the development of a community based ultrasound-equipped musculoskeletal service that will enhance and relieve pressures on secondary care services.

Shorter waiting times and more convenient local service.

ongoing General Practice Health Board Secondary Care

Action:

Plan developed to take forward MSK services

for the North Cluster population

Project currently progressing

4. Improve access to mental health and wellbeing services

Local enhanced management of patients

31st March 2018

General Practice Health Board

Action:

Evaluation of cluster based counselling service

Develop closer links with health board mental health services; especially services for those




that require counselling

with drug and alcohol addiction along with a Mental Health illness

Explore links with CAMHS to understand current care pathways and structures to help aid the recognition and treatment of mental illness in young people – carry this over to next year’s plan

Promote ABMU Living Life Well

5. Maximise identification, investigation and treatment of anaemia in primary care, ensuring GP’s have appropriate diagnostic and treatment guidance, and clear access to secondary care services and pathways

Improved service and appropriate treatment for those with iron deficiency anaemia

January 2017


Action:

Review current pathways in line with NICE Guidelines

Feed info into USCs feedback

6. Extend the pathway of care for dementia support within primary care

Support for people living with Dementia

Ongoing General Practice Dementia Support Workers

Action:

Roll out dementia awareness training across the cluster.




7. Drive changes in patient expectation/ prescribing culture

Minimise potential risks of increasing antibiotic resistance and C.difficile infection.

Ongoing Health Board General Practice

Action:

Work in collaboration with community based pharmacy team – ‘Big Fight’.

Engage with patients through established forums e.g. attendance at community groups etc to raise awareness of the dangers of inappropriate antibiotic use and associated antibiotic resistance (ABM Pathfinder).

8. Develop and undertake a programme approach to improve antimicrobial stewardship .

Improvement in antimicrobial stewardship

Ongoing General Practice Health Board

Action: Support the specialist antimicrobial North Network pharmacist (ABM Pathfinder) to develop and undertake a programme approach to improve antimicrobial stewardship through:

Comprehensive, regular and consistent analysis of practices progress (including feedback to practices)

Leading multidisciplinary prescribing reviews.

Providing education and awareness sessions with GPs and other relevant practice staff

Develop and co-ordinate a network of GP antimicrobial prescribing champions.

Develop and pilot a visible ongoing Cluster wide campaign to raise awareness of the dangers of inappropriate antibiotic use and associated antibiotic resistance.

Work in close collaboration with key-stakeholders such community pharmacies, care home staff,




community teams etc through the development of engagement events and regular liaison

9. Early identification and proactive management of respiratory patients

Improved management of potential respiratory disorders Early diagnosis of COPD, access to education and pulmonary rehab

31st March 2018


Action: Improve reporting and interpretation of spirometry results

10. Early identification diagnosis and referral for those presenting with Dermatological needs

Improved management of dermatological conditions and detection of malignancy

December 2017


Action:

Dermoscopy training to be arranged – both theory and practical.

GPs to Familiarise themselves with the new digital cameras

Implement the new digital photography referral pathway.

11. To improve the quality

and structure of

chronic disease

monitoring in Primary

care in particular

Addressing health inequalities existing for housebound patients with

1st October 2017


Action:

Recruitment process underway




access for non – acute

chronic disease

management services

amongst housebound

patients

chronic disease who are currently limited in their access to primary care support

Strategic Aim 4: To provide high quality, consistent care for patients presenting with urgent care needs and to support

continuous development of services to improve patient experience, co-ordination of care and the effectiveness of risk

management. To address winter preparedness and emerging planning.



1. Provide proactive, timely care to those who are most vulnerable and complex to manage

Co-ordinated and improved care. Less crisis appointments/attendances across the system Proactive support to address key issues

Ongoing General Practice Health Board MDTs

Action:

Continue to collaborate across MDTs to assist in identify patients for co-ordinated care plans




2. Reduce unnecessary hospital admissions through increased partnership working with the Welsh Ambulance Service

Care delivered locally Minimising hospital admissions Shorter waiting times

31st March 2017

General Practice WAST

Action:

Consider opportunities for increased collaboration and partnership working

Receive an update from WAST April – no representation at Jan/Feb or March meeting To re-invite.

3. Continue the use of C-reactive protein (CRP) tests before prescribing antibiotics for suspected respiratory infections, to help determine if treatment with antibiotics is required.

Reduction in prescribing of antibiotics unnecessarily

On going General Practice ABMU HB Path lab

Action:

Continue with POC testing

Evaluate antibiotic prescribing

Review patient feedback

Strategic Aim 5: Improving the delivery of Cancer and COPD.

No Objective Outcomes Milestones Assigned to (key

partners)


1. Prompt recognition and early referral of cancer

Improve cancer survival rates

2017 – 2020 with annual reporting

General Practice

Review current data regarding cancer presentations, referral and incidence for practice (and cluster).


No Objective Outcomes Milestones Assigned to (key

partners)


Review and critique your current practice regarding recognition and referral of cancer, with particular reference to NICE suspected cancer referral guidance, at risk groups and potential barriers to prompt referral.

Agree and carry out three actions/tests of change to enhance patient care using quality improvement methods.

2. Improve delivery of COPD

By 31.3.18 there will be higher percentage of accurate coding and recording of COPD consultations and more appropriate prescribing and referrals, with the improvement being measured by the practice and shared with the cluster.


General Practice

Reflection on National Clinical Audit.

Review spirometry results.

Collate outcomes of review and share learning.


Strategic Aim 6: Improving the delivery of the locally agreed pathway priority.



1. Increase MMR vaccination

To increase the percentage of children who have received two doses of MMR by age 5yrs.


General Practice

The practice will share practice performance data within its cluster and discuss performance so far, share lessons and learning.

At 3 months, share performance data within cluster and discuss performance so far, share lessons and learning. State what practices did differently to improve uptake.

At 6 months, share performance data within cluster and discuss performance so far, share lessons and learning. State what practices did differently to improve uptake

Strategic Aim 7: Deliver consistent, effective systems of Clinical Governance and Information Governance. To include actions arising out of peer review Quality and Outcome Framework (when undertaken).



1 Engage with a robust validated clinical governance process

Improved quality and safety and efficiency of services

31stMarch 2017

General Practice

Action:

To complete the Clinical Governance Practice Self Assessment Tool and achieve at least level 2 in the areas of safeguarding (CND 005W)

Participate in peer review and governance lead meetings.




2 Promote shared learning and good practice through increased incident reporting.

Improved quality and safety of services

Ongoing General Practice

Action:

Encourage use of DATIX for incident reporting

To explore a feedback mechanism to primary care

3. Update and maintain a cluster risk resister

Mitigate risks as appropriate

Ongoing Cluster Action:

Identify and agree risks

Strategic Aim 8: Other Locality issues



1. Premises improvement to enable capacity to deliver new pathways and increase capacity.

Improved facilities and sustainable services

31st March 2017

ABMU HB


RISK REGISTER

ID Number

Date Description of Risk and Impact Mitigation RAG Lead

1 July 2017

CAMHS service provision – unclear pathways

Cluster discussion with CAMHS.

SM

2 July 2017

GP Succession planning – Retirements Lack of clinicians to meet demand of complex patients

Practices to consider skill mix and succession planning, via the sustainability assessments.

Cluster

3 July

2017

Cluster pharmacist vacancy

Reduced access to District Nursing input

Recruitment process

Discussion between cluster /

District Nursing service

GS SM

4 July 2017

Lack of funding for new services, with project funding committed to ongoing projects

LHB commitment to fund successful services to release cluster funding for new projects.

GS

5 July 2017

Boundary Changes - ABMU / Cwm Taff Bridgend Primary and Community Services / POWH (as Per WG announcement July 2017)

Cluster engagement with health board to ensure any transitional arrangements are clear and transparent.

GS

three year cluster network action plan 2017-2020 bridgend north ... - health … - north... ·...

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