torfaen north neighbourhood care network action plan 2015-16 north ncn action plan... · on-going...

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Torfaen North Neighbourhood Care Network Action Plan 2015-16

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Torfaen North Draft Action Plan 2015-16

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

No Objective Agreed Actions Outcomes Key

partners

Time-

scales

Progress/RAG

1.1 Smoking

1.1.1 Smokers in the NCN

area quit smoking (SEE

APPENDIX 1 – ACTION

PLAN)

Retained as a local

priority 2015-16 –

agreed 16.07.15

Links to Communities First Healthy Lifestyles project

Links to ABUHB Service Change Plan No. 3 Links to MIND – ‘you in mind’ project for young people

• Build on 2014/15

• Review data on uptake of

services and quit rates at

NCN meetings including

with non-medical members

• Recovery plan if progress

• Increase number of

Smoking Champions

Number of smokers is

reduced in line with

target i.e. 5% of smokers

make quit attempt with

at least 40% CO

validation quit rate at 4

weeks

PH/SSW

NCN

Third Sector

Social

Services

31.3.16 Torfaen action plan

developed

ABUHB R&D poster

developed

Networks team working

with PHW to secure

current data – issues with

SSW data systems

redesign leading to delays

Management Team

Priority

Highest number of

smoking champions in Pan

NCN area

Highest referral rate to

SSW in Pan NCN area

1.2 Engagement

1.2.1 NEW: Identify a range

of methods to increase

awareness of the work

of the NCN & partners

Links to Torfaen SIP

Map options

Continue to up-date ABUHB

intranet page

To support development of

a public facing web-page

To support the work of the

ABUHB engagement team

in implementing the

engagement strategy

To attend at least two

‘listening events’ in 2015-

16

Feedback analysis leads

to evidence to inform

improved service delivery

with increased patient

satisfaction

NCN /

TVA /

Commun-

ities First /

Bron Afon

Housing

31.3.16 Identified as a shared

outcome in the Torfaen

SIP

Links made with ABUHB

Engagement Team to

identify Torfaen specific

events

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

local patients


partners

Time-

scales

Progress/RAG

2.1 Access

2.1.1 Identify and share good

practice across GP

• Map which strategies have

been adopted to reduce

Maximise use of

appointment slots to

NCN /

Practices /

31.3.16 Gwent wide access SCP for

2015-16

3


partners

Time-

scales

Progress/RAG

Practices to reduce DNA

rates

Adopted as a local


agreed 16.07.15

Links to ABUHB Service Change Plan No. 3

DNAs

• Use PDP reports (28.11.14

– embedded) as a baseline

• Engage non-clinical

members

reduce wasted time

within Practices

AMD / NCN

leads / LMC Cluster Level Report - Measure 44 - GP DNA Rates -October 2015.docx

2.1.2 NEW: Contracted

Services: To engage

with and utilise skills of

other Primary Care

services i.e.

Optometrists,

Pharmacists & Dentists


NCN funding to facilitate

recruitment

Contractors act as advisors

to NCNs with

communication plan

established

Increased communication

leads to improved

understanding of Primary

Care issues

AMD / NCN /

CDs / NCN

leads

31.3.16 Funding agreed to support

this

Scope of contribution to be

discussed/agreed

All Gwent NCN Independent Contractor Support.docx

All 3 posts appointed to

2.1.3 NEW: Social Prescribing

post to increase access

to information relating

to health conditions

through dedicated role

Links to Communities First Healthy Lifestyles project Links to ABUHB Service Change Plan No. 5

Appoint Social Prescriber to

signpost people to local

services

Develop and implement

referral mechanism into

community services;

To map range of services

promoting mental wellbeing

and good health across

Third and Public Sector -

facilitate web based

database;

Identify priorities for people

based on referral

information and individual

circumstances;

Feed-back progress to the

NCN;

Develop promotional

materials;

Implement effective

monitoring systems to

evaluate project progress

Evidence shows increased

access to information /

advice & support leads to

improved well-being

NCN /

Communities

First / Public

Health

31.3.16 Slippage funding agreed at

NCN to develop Social

Prescribing role

Public Health Wales co-

production lead

presentation at NCN

meeting

Linked to ‘Bridging The

Gap’:

Bridging The Gap - May 2011.pdf

Post appointed to with

project group established

4


partners

Time-

scales

Progress/RAG

2.1.4 NEW: Dementia

Roadmap: To raise

awareness of

information available in

relation to accessing

dementia care support

Links to ABUHB Service Change Plan No. 3/4/5

Implement and promote

Dementia Roadmap

Dementia Friend training is

made available

Number of dementia

friends / number of

Practices completed

WAMHS training

NCN / Phil

Diamond

DFC lead

31.3.16 £0.24 million for national

dementia nurse led

programme to train care

home staff and respond

better to their needs and

ensure their diagnosis is

recorded on GP registers

NCN funding allocated to

support implementation of

an on-line dementia

Roadmap – steering group

in place

2.1.5 NEW: To build

communication links

between Education and

Primary Care

To liaise with Torfaen CBC

Team Around the Family

(TAF)/Families First

programme to scope issues

and develop an action plan

Improved access to

Primary Care/Community

services for CYP in full

time Education

NCN Lead /

TCBC /

Partnership

Manager /

NCN

31.03.16 NCN agreed to adopt this

as a objective / NCN lead

liaising with Divisional

Partnership Manager /

TCBC Education lead

To be considered by LMC

2.1.6 NEW: Early warning for

Practices anticipating

difficulty with

recruitment/filling

vacancies


Practices to inform NCN

verbally/in writing if having

or anticipating difficulty

Agree to meet with the NCN

lead to discuss next steps

Continuity of services;

Support against potential

Practice fragility

Practices /

AMD / NCN

lead

31.3.16

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

QOF

2.1.7 NEW: Practices in

difficulty have access to

NCN salaried support

team to ensure

continuity of service in

the short term

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

As above Continuity of services

Support against potential

Practice fragility

As above 31.3.16

2015 plan for primary care.pdf

QOF

2.1.8 NEW: Monitor the

continuation and uptake

of My Health Online

Links to ABUHB Service

Change Plan No. 3

All practices to offer

appointment availability and

repeat prescription ordering

via MHOL

Ease of access to GP

services

NCN /

Practices /

Pharmacy

Advisors

31.03.16

Clinical Director appointed

as lead with NCN support

5


partners

Time-

scales

Progress/RAG

2.2 Workforce

2.2.1 NEW: Training: Practice

staff can access timely,

relevant training


Establish a Divisional/NCN

Task & Finish group –

training plan developed

Develop a process for

Practice staff to access

training

Training providers and

costs are identified

Practices are informed of

training options and criteria

Quality of care / skilled

workforce – enables

sharing of ideas/skills

and good practice

NCN /

ABUHB /

Practices

31.3.16 Process in place via

proposal applications £1.1m allocated to NCNs:

Training options

considered from slippage

funds year on year – T&F

group established

2.2.2 NEW: Increase access

to primary care based

Phlebotomy service

Links to ABUHB Service

Change Plan No. 3

Implement local service

closer to home and in care

homes

Increase access to

phlebotomy service for

house bound population

(WAO report on district nursing

indicates that 30% of community

nursing time could be released, for

example to manage LTCs, if no longer

required to take blood)

Increased capacity

within/ access to District

Nursing service

NCN /

ABUHB

Divisions /

District

Nursing

service

31.3.16 £4.4m funding approved

for new Phlebotomy

service

2.2.3 NEW: Ensure local

support structure is fit

for purpose to meet

demands of strategic

NCN development

Implement a

NCN/Integrated

Management Team

Agree local framework /

membership to underpin

strategic NCN development

Terms of reference

developed and ensure all

members/partners have

equal standing in decision

making process

Improved guidance, co-

ordination and

development to meet the

needs of the local

population

NCN lead /

HoPN /

PC&ND /

ISPB / NCN

31.3.16 Workshop held with key

stakeholders to agree

membership of

Management Group, remit,

immediate action required

and next steps

Action Plan developed

Strategic Aim 3: Planned care - to ensure that patients’ needs are met through prudent care pathways, facilitating rapid, accurate

diagnosis and management and minimising waste and harm

6


partners

Time-

scales

Progress/RAG

3.1 Mental Health

3.1.1 To improve integration

at Practice level

between Primary Care

(PCMHSS)

Links to Torfaen SIP Links to Communities First Healthy Lifestyles project Links to ABUHB Service Change Plan No. 3

Links to MIND – ‘you in mind’ project for young people

NEW: To receive regular

performance reports to include

referral data specific to North

Torfaen, and to identify action

required across NCN & partners

Evidence shows services

collaborate to ensure

timely access to support

NCN

Practices

PCMHSS /

MH Division

31.3.16 Representation at

Management Team

meetings

On-going dialogue and

reporting via NCN meetings

GAVO Mental Health Service Directory for Gwent.pdf

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

continuous development of services to improve patient experience, coordination of care and the effectiveness of risk

management

No Objective Agreed actions Outcomes Key

partners

Time-

scales

Progress/RAG

4.1 Urgent Access

4.1.1

REVISED: To maximise

utilisation of alternative

avenues for advice

adopting prudent

healthcare principles

To identify other sources

for advice e.g. email /

telephone (inc mobile

access & new 111

service for urgent

advice)

To record secondary care

email advice incidents

CPD session on reducing

referrals for inappropriate

diagnostic tests

Data shows reduction in

reliance upon multi-

agency services;

Contributes to reduced

waiting times for

secondary care services

PC&ND,

ABUHB

Radiology

and USC

Divisions

31.3.16 Improving referral quality

and maximising utilisation

of alternative avenues for

advice:

Rheumatology/Cardiology

telephone and email

advice routes;

Impact of Teledermatology

service with reduction in

secondary care waiting

times;

SEPSIS 6 guidelines

adopted;

Review of GP urgent

referral letters

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


partners

Time-

scales

RAG

5.1.1 Review delivery of EOLC

using Individual Case

NCN to support Practices

to review audit of patients

Audit outcome leads to

improved care during End

NCN Leads /

Practices /

31.3.16 Year-end report expected

7


partners

Time-

scales

RAG

Review Audit


who have died to be

reflected upon/inform

future care delivery

of Life phase NCN Support

5.1.2 Summarise case review

data, and any arising

issues and actions

identified, for sharing

with the network and

the wider health board


Highlight best practice for

improvement to be

highlighted and shared in

a multi-professional

discussion

Learning through shared

experience will inform

improvements for

patients on the EOL

pathway

NCN Leads /

St Davids /

Practices /

NCN Support


5.1.3 Establish a review cycle,

to monitor progress (or

maintenance of high

quality), report to NCN

and wider health board

as appropriate


Agreement of ‘best

practice’ in EOLC.

Identification and

monitoring of areas for

improvement so that

appropriate education and

support can be delivered

Improved consistency in

standard of care

delivered

NCN Leads /

Practices /

NCN Support


August 2015: Audit

outcomes reported to GP

Macmillan co-ordinator with

learning points included in

the Palliative care Delivery

Plan.

5.1.4 NEW: Themes identified

by audits lead to agreed

action


NCN to discuss +/- use of

EOLC template for all

patients who enter

terminal stage of illness,

not just those with

cancer;

NCN to discuss READ Code

training for Practice staff

to improve recording of

diagnostic symptoms;

Develop patient recording

protocols for Care Homes,

by using the Integrated

Care Pathway framework,

to ensure patient record

consistency;

Practices identify carers

and record when patients

are first diagnosed /

placed on the register

Improved consistency in

standard of care

delivered.

Practices

NCN Lead

HoPN


8


partners

Time-

scales

RAG

Ensure Carer’s Packs are

available at all GP

Practices;

To map/ensure access to

interpreter services for

patients whose first

language is not English;

Improve communication

with OOH Services re

‘Special Notes’ and use of

Adastra to provide up to-

date patient records.

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


partners

Time-

scales

RAG

6.1.1 Review care of all

patients newly diagnosed

between 1 January 2015

to 31 December 2015

with lung,

gastrointestinal & ovarian

cancer


Audit tool Patient referral

information reviewed and

Outpatient appointments

/ results followed up

NCN / NCN

Leads /

Practices


NICE issued: Suspected

Cancer recognition and

Referral – NG12 (June

2015)

GI Consultant attended NCN

to discuss learning points

and solutions – impact of

new NICE = WLIs /

Weekend & evening clinics

6.1.2 Learning and actions to

be shared with NCN

and the wider health

board as appropriate


Practices complete audit

and discuss findings

Audit tool ensures

continuous review,

reflection & improvement

in processes/ care

pathways for cancer

patients

NCN / NCN

Leads /

Practices


6.1.3 Identify and include

relevant actions to be

addressed in Practice

Development Plans


Practice by practice NCN

USC cancer data will be

collated to provide better

informed demographic

data relating to cancers on

a regular basis

Improved patient

information/ Patient

choice & preferred place

of death

NCN / NCN

Leads /

Practices


9


partners

Time-

scales

RAG

6.1.4 Summarise themes and

actions for review with

NCN / share information

with wider health board

as appropriate


NCNs to share learning

with secondary care

As above NCN / NCN

Leads /

Practices


6.1.5 NEW: Themes identified

by audits lead to agreed

action


Develop protocol to refer

patients as ‘USC’ if cancer

suspected with Practice

based referral tracking

system;

Practices encourage

patients to attend Bowel

Screening Programme;

GPs are informed by

Secondary Care

Consultants when referrals

are re-prioritised;

Patients who DNA are

contacted

Improved patient

information

Appropriate treatment

pathway initiated

PC&ND /

AMD /

ABUHB

Divisions /

Practices /

NCN lead /

NCN


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

Management)


partners

Time-

scales

RAG

7.1 Poly-pharmacy

7.1.1 Identify and record

numbers and rates for

patients aged 85 years or

more receiving 6 or more

medications


Using audit +, a review of

practice clinical systems to

identify (‘at-risk’ only) patients

over the age of 85yrs in receipt

of 6 or more medicines.

NEW: Consider extending the

audit age range to include lower

starting age

Identify patients at

high risk or harm of

either over/ under

medicating

NCN Leads


10


partners

Time-

scales

RAG

7.1.2 Undertake face to face

medication reviews,

using e.g. ‘No Tears’

approach


Using data from the review audit

book appointments for

medication reviews of patients

over the age of 85yrs receiving 6

or more medicines

Reduced avoidable

admissions;

Identification of

untreated

condition(s); Number

of MUR Consultations

NCN Leads /

Practices /

NCN Support


7.1.3 Identify any actions to be

addressed in Practice

Development Plans


Poly-pharmacy at NCN meetings

As above NCN /

Prescribing

advisors /

Practices /

NCN Support


Quarterly information to NCN on

utilisation of notional budget

7.2 Medicines

Management

7.2.1 NEW: Recruit Primary

Care based Pharmacist

from NCN funding to

integrate with GP

Practices, NCN and

partners


Initiate recruitment process –

Summer 2015

Induct Pharmacists into GP

Practices

Integration and outcomes

measured/ monitored via

NCN meetings

NCN Pharmacists

project team

developing a suite of

priorities &

outcomes;

Patients and

professionals have

access to a named

Pharmacist in

Primary Care

NCN

leads/NCN/P

C&ND


Post appointed to

July/August 2015

Integration and outcomes

measured/ monitored via

NCN meetings

Identify opportunities for

Pharmacists to further

develop appropriate skills

Funding allocated from NCN

budget

7.2.2 To monitor the NCN

prescribing budget and

delivery of the Medicines

Management plan


To receive regular prescribing

information (at NCN meetings)

Budget performance and

delivery of the savings plan

National Indicators / Clinical

Effectiveness Prescribing

Programme

Pharmacy and NCN Leads to

meet and decide on priorities

for NCNs to achieve in terms

of service improvement, costs

and quality

Efficient use of

resources leads to

re-investment &

more appropriate

care

NCN Lead /

Prescribing

lead /

Practices


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partners

Time-

scales

RAG

7.2.3 To review the variation in

prescribing compared to

national guidance in

relation to Diabetes and

Respiratory and deliver

the NCN savings target

for these work-streams

within the three year plan


NCNs to work with Primary Care

and Networks Division Pharmacy

staff to:

Arrange scheduled visits by

the NCN Lead to discuss

Dashboards and Practice

performance;

Monitor performance change

through actual prescribing

spend on high dose

corticosteroids and diabetes

drugs;

Identify prescribing leads rep

and identify progress

against the SCEP;

Prescribing guidance to be

developed by Pharmacy Team

Minimise avoidable

harm from adverse

effects of inhaled

steroids;

Undertake minimum

appropriate

intervention to

ensure prudent

prescribing aligned

with NICE Guidance

NCN Lead


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


partners

Time-

scales

RAG

8 Clinical Governance

8.1 To fully implement the

Clinical Governance

Toolkit

To ensure practices are

supported in completing the

CGSAT

Sessions to be established to

support GP practices in

completing the CGSAT

Target support for areas of

the CGSAT which are

identified as showing low

levels of achievement

Access arrangements - core

access arrangements; aids to

access user experience; the

impact of My Health On Line.

How practices respond to

urgent requests and same day

requests from care homes,

Welsh Ambulance Services

and Hospital emergency

departments.

Consistency and

safety in Practice and

NCN wide primary

care services

Practices /

PC&ND /

NCN

31.3.16

Year-end report expected

12


partners

Time-

scales

RAG

Actions to foster greater

integration of health and

social care.

Consideration of how

community resources can be

maximised to meet local

needs.

Consideration of how Third

Sector support may be

maximised

Map local GP services to

highlight where services are

delivered across practices (for

example, contraceptive

services, minor surgery)

How new approaches to the

delivery of primary care might

aid service delivery and

ensure sustainability of local

services

Consideration of the impact of

local care pathway work

relating to previous QOF work

Strategic Aim 9: Other Locality issues


partners

Time-

scales

Progress/RAG

9.1 See 2.1 NEW:

Access/DNA rates

9.2 NEW: Diabetes

9.2.1 Tackling the effects of

Diabetes (including

obesity)

Adopted as a local


agreed 16.07.15

Links to Communities First Healthy Lifestyles project Links to ABUHB Service Change

• To use PH observatory data

as a baseline for

improvement

Intervene more regularly,

with right information in the

right way – brief advice /

intervention

Map Level 2 services for

weight management and

refer/recommend –

Foodwise, commercial clubs,

NERS, led walks

Access to advice

from multi-

disciplinary team &

implementation of

new diabetes work

plan leads to

improved outcomes

for patients

NCN / Public

Health /

ABUHB

Divisions /

Diabetes

Nurse

31.3.16 Presentation given to NCN

at meeting

Agreed that diabetes

Practice Nurse will be a

member of the NCN

Primary Care diabetes

specialist nurses arranging

Practice visits

Diabetes Consultants

aligned to NCNs

Consultant email advice

13


partners

Time-

scales

Progress/RAG

Plan No. 3/4/5

Refer routinely to Adult

Weight Management Service

Consider increasing AWMS

capacity for specific

populations (e.g. Pre-

diabetes, pregnant women)

e.g. BG West/Mon North

Engage with non medical

members

line open

Consultant/DSN telephone

advice

Further action agreed

torfaen north neighbourhood care network action plan 2015-16 north ncn action plan... · on-going...

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