Disease Register Bay Health Register Total 2017 Bay Health Register Changes 2011 – 17 (%) Swansea Total ABMU Total Cancer 2,247 69.2% 6,620 15,040 Dementia 568 47.5% 1,734 3,925 Mental Health 757 21.% 2,704 5,955 Chronic Obstructive Pulmonary Disease 994 3.3% 4,886 12,212 Obesity 4,579 6.1% 21,608 54,284 Diabetes 3,224 4.3% 14,181 33,851 Hypertension 9,170 12.2% 1,425 3,596 Rheumatoid Arthritis 380 0.5% 1,425 3,596 Bay Health Practice Development Plans Consistent Themes Identified 2017 As a result of the analysis of the 6 Practice Development Plans within Bay, the following have been identified by most, if not all of practices. These will be addressed within the Cluster Development Plan: Access: To reduce nurse appointment DNAs To review and monitor skill mix within practice Increase the use of SMS text reminders Promote and encourage use of MHOL for booking appointments online and ordering repeat prescriptions Planned Care: Increase flu immunisation uptake Increase electronic referrals via WCCG and monitor rates by specialty Increase the use of CO2 monitors, increasing referrals to Stop Smoking Wales. In addition, promote the Help Me Quit Service Unscheduled Care
Nurses to refer appropriate patients to this programme. To develop a range of activities and groups in the Bay Health Cluster area aimed at older people who are experiencing loneliness and social isolation To develop and routinely update/redesign a range of display boards for update to inform patients of cluster news, Bay priorities and health matters. Health Board / SCVS / Voluntary Sector Organisation – Red café Health Board / SCVS / Public Libraries / GP Practices April 2018 (funding will cease) September 2017 overall sense of Prevention of ill health enabling people to keep themselves well and independent for as long as possible. Developing the range and quality of services that are provided in the community. To highlight health matters and Bay priorities to members of the community. Posters have been cascaded to practices for display in practice receptions or waiting rooms advertising Red Café groups, the details of when and where groups will be held, including the aims of attending. SCVS have assisted in the display of material on notice boards that have now been placed in public libraries (Oystermouth, Killay, Sketty, Pennard) and Swansea University. Year 2 To evaluate the impact and effectiveness of voluntary sector organisations Red Café and Action for Elders on patients within the cluster. 6 To obtain patient and carer views on network services and priorities programme. Patient members to receive the cluster action plan for review and consideration of Bay priorities. Comments and feedback to be welcomed as well as any project engagement. Continued development of the patient and carer forum. SCVS / GP Practices / Health Board September 2017 Responsive services taking into account service user and carer feedback. The cluster have agreed to allocate £1,000 to support future patient group meetings during 2017/18. Business Manager to assist in arrangements and matters relating to the Patient and Carer Forum.
No Objective Key Actions Key partners For completion by: - Outcome for patients Progress to Date RAG Rating 1 To review the sustainability of core GP services across practices Year 1 All practices within the cluster to complete a sustainability matrix, pre populated by the Health Board. To share workforce pressures and the shortage of locums as a cluster and consider potential local workforce plans or resource to assist in sustaining services. To discuss increasing peer support within the cluster during time of extreme pressure To ensure multi-disciplinary professionals employed by the cluster are used appropriately to assist the management of demand and capacity GP Practices / Health Board GP Practices / Health Board GP Practices / Health Board GP Practices / Health Board June 2017 September 2017 September 2017 September 2017 To provide a more sustainable service for patients and GP practices The Health Board has received completed matrices from all 8 practices within the cluster. Practices to bring any vacancies, recruitment of posts and locum arrangements/difficulties for discussion at the September meeting for sharing as a cluster. The nursing team have agreed to share pressures with the cluster also. To be explored and discussed as a cluster during the meeting due to be held September 2017 Practices have been encouraged and reminded of the available resources within the multidisciplinary team that can be utilised by all. An activity report to be shared at the meeting scheduled September to highlight work undertaken and outcomes for patients. Use of cluster CCN highlighted; to be monitored to ensure workload is appropriate.
To address concerns in relation to population increase e.g. housing development, University student registrations. To continue to develop the skills and management within GP practices to ensure a sustainability provision of service, e.g. complying with HR, Employment Law and Health & Safety GP practices / Health Board GP Practices September 2017 March 2018 To continue to develop the skills and management within GP practices, complying with HR, Employment Law and Health & Safety To discuss any implications to practices within the Bay cluster during the September meeting. Work is ongoing with practices to develop skills and management of H & S, and employment law within practice. Year 2 To review practice sustainability scores one year on to compare differences To evaluate the impact of the professionals employed as part of the multidisciplinary tea, GP Practices / Health Board Year 3 To continue cluster development and peer support to help strengthen sustainability within general practice GP Practices / Health Board
Subject to evaluation of the multidisciplinary team within the cluster, take appropriate action to consider the continuation of employment. 2 To review and develop access arrangements in line with the ABMU Access Standards to ensure GP Practices meet the reasonable needs of local patients To continue to share good practice and learn from variations of access arrangements across GP practices, and to ensure levels of access are achieved on a practice/cluster basis in line with the ABMU Access Standards To increase the use of text messaging services for health invitations e.g. flu, and appointment reminders from IT systems to improve communication with patients and reduce DNAs To increase the use of My Health OnLine and patient sign up to encourage appointments and repeat prescriptions to be managed online to help reduce the number of calls received by practice. GP Practices / Health Board Health Board / GP Practice / NWIS Health Board / GP Practice / NWIS September 2017 March 2018 March 2018 To provide more accessible services for patients To reduce the number of DNAs/wasted appointments To allow patients access to an online system of available appointments and repeat prescription management, saving telephone calls and times to practice. To be discussed further, considering actions for any practices not meeting the reasonable standards. Support Manager to recirculate the Access Standards of 2015 to the cluster for review against provision. Practices are keen to utilise text messages to remind patients of appointments to assist in reducing nurse DNAs and assist with the increase of flu vaccination uptake. Some practices have advised of their plans to check mobile telephones contact details recorded to ensure messages can be sent appropriately. MHOL Uptake/Use as at June 2017: Appointments - 4/8 Practices Prescriptions – 6/8 Practices Cluster Population – 75,198 No. of Patients Signed Up – 6,469 % of Patients Signed Up – 8.9% No. of Apts Booked Online – 341 No of Patients on an Active Repeat – 21,993
4 To further establish a successful cluster multidisciplinary team of healthcare professionals, providing the Bay community with quick and efficient access to services. Cluster paramedic to respond to and triage house calls across the cluster. Cluster Chronic Conditions Nurse to educate patients and improve chronic conditions management. To consider the employment of a cluster physiotherapist to incorporate services into the community GP Practices / Cluster Paramedic GP Practices / Chronic Conditions Nurse Health Board / GP Practices / Paramedic / CCN Feb 2018 Feb 2018 March 2018 Quick access to health care in urgent situations. Assist in reducing pressures on emergency services and free up GPs to manage other demands as required. Providing a domiciliary and practiced based care in the Bay Health area for the coordination, management and monitoring of the care of housebound patients with long- term chronic illness. Better access and prompt triage for patients with MSK problems Bay Health Cluster Paramedic commenced 23rd January 2017, hosted by West Cross St Thomas Surgery. Work has been undertaken across the 8 Bay practices with positive feedback being received to date. Dr Matt Giles has been appointed as mentor. Initial feedback has been provided by the paramedic during a cluster meeting and PLTS. A minor illness clinic has been proposed, starting in The Grove Medical Centre; this is currently being explored the dedicated mentor. Bay Health CCN commenced February 2017, hosted by Mumbles Medical Practice. Induction is now complete with work being undertaken across the cluster. The CCN is due to report feedback on work undertaken to date at the cluster meeting during September 2017. The cluster have received a presentation providing information on a physiotherapy service model currently being used in Neath. A meeting is due to be held with the Senior Manager at MCAS, 25th July 2017 to discuss this proposal.
Regular activity reports to be shared detailing emergency admissions and A & E attendances for comparison prior to and since the employment Non-contract mobile telephones to be identified for distribution to the multidisciplinary team. GP Practices / Health Board GP Practices/ Health Board September 2017 and ongoing September 2017 Efficient care and service delivery to patients Quicker access to service delivery Activity has been requested from the Information Department – to be shared with the cluster once available. Handsets and costings have been retrieved by the Practice Manager at Kings Road. Non -contract phoned to be ordered for CCN and paramedic use to enable direct contact between patient and MDT team, including a message facility for patients. 5 To establish the role and responsibilities of the cluster business and implementation manager Year 1 To identify, develop and implement opportunities to align services between practices, share resources, and meet the day-to-day needs of the network population by working more closely together. A further programme of work is to be developed in line with agreed cluster action plan. Business Manager / GP Practices / Health Board March 2018 To guide and implement plans set by the cluster to improve the quality and efficiency of services for patients Business Manager has commenced in this role, 3rd July 2017. Initial discussions have taken place to progress work initiatives for the cluster. Year 2 Consider extension of employment, if extended, develop a year 2 cluster work programme Business Manager / GP Practices / Health Board May 2018 To guide and implement plans set by the cluster to improve the quality and efficiency of services for patients
Year 3 Dependant on outcome of year 2 Business Manager / GP Practices / Health Board To guide and implement plans set by the cluster to improve the quality and efficiency of services for patients 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. The cluster will, over a 3 year period, engage effectively and make improvements between the primary and secondary care interface; aim to reduce wastage of medicines and achieve better health outcomes through prudent prescribing; ensure
patients have access to newly designed enhanced services, namely care homes and oral anticoagulation with warfarin; and prolong independence of elderly patients through the development of anticipatory care plans. No Objective Actions Key partners For completion by: - Outcome for patients Progress to Date RAG Rating 1 To pilot electronic radiology request forms Year 1 To work with NWIS to pilot a newly designed All Wales electronic request forms within the Bay cluster for radiology referrals NWIS / GP Practices / Health Board March 2018 Benefits patient referrals and care outcomes The cluster has agreed to pilot electronic forms. NWIS are due to attend the cluster meeting during September 2017 to provide more detail of the forms and the outcomes to be achieved. Year 2 To evaluate the pilot; effectiveness and outcomes for primary and secondary care. To continue use of electronic referrals if deemed appropriate. NWIS / GP Practices / Health Board July 2018 Benefits patient referrals and care outcomes. Year 3 Encourage routine use of electronic referrals NWIS / GP Practices / Health Board July 2018 Benefits patient referrals and care outcomes. 2 To increase electronic referrals via WCCG Year 1 To increase the use of electronic WCCG referrals, communicating GP Practices / Health March 2018 The cluster to encourage use of WCCG referrals
more effectively between primary and secondary care. Board / Secondary Care Improved and faster referral route for patients within practice. To be discussed further during the cluster meeting scheduled September 2017. Electronic referral rates to be requested by specialty. Year 2 To monitor referrals via WCCG by specialty GP Practices / Health Board / Secondary Care March 2018 Improved and faster referral route for patients Year 3 To continue use of electronic referrals via WCCG GP Practices / Health Board / Secondary Care March 2018 Improved and faster referral route for patients 3 To deliver services effectively and efficiently using modes of technology To consider the cost implications and sign up to Vision 360 to allow healthcare professionals mobile access To use technology to increase IT/skype consultations to improve communication and provide a more efficient service to particular GP Practices / Health Board / NWIS GP Practices / Health Board / NWIS Ongoing January 2018 Quicker access to patient information. More sustainable services. Prompt service to patients The business manager has met with colleagues to discuss the system and potential costs to the cluster. Original quote in 2016 £22,500, a £1,800 reduction has now been offered to the cluster. Methods of good practice to be discussed between practices to encourage increased use of technology to enable skype/IT consultations.
cohorts of patients, or patients in certain settings, e.g. care homes. To maintain, update and improve the use of the Bay Health Cluster Website To increase promotion of the Bay health cluster, good news stories and experiences to local patient through the use of social media i.e. Bay health Facebook page. GP Practices / Health Board / NWIS GP Practices / Health Board / NWIS Ongoing Ongoing Enable patients to access Bay health news and priorities within the community. Practice Manager at Gower Medical Practice has agreed to update and maintain the Bay health website going forward. Bay health have started to upload information and news using this method to educate patients and the local community on various matters. Increased use and planned headlines to be considered for the months ahead. 4 To engage effectively and highlight improvements between the primary and secondary care interface to plan patient care. To invite key secondary care colleagues by specialty to future meetings to discuss methods of engagement and to assist the strategic aim, ensuring patients needs are met through planned care. GP Practices / Health Board / Secondary Care March 2018 To ensure patients needs are met through prudent care pathways, facilitating rapid accurate diagnosis and management, and minimising waste and harms. Specialty colleagues to be considered for invitation to future cluster meetings. To discuss further September 2017. 5 To reduce the wastage of medicines in care homes Cluster pharmacists to undertaken care home medication reviews and administration records for individual patients to highlight any issues with prescribing and to minimise waste resulting from patient refusal or non-adherence. Cluster Pharmacists / Care Homes / GP Practices March 2018 Improved care Cluster pharmacists are in the process of undertaking medication reviews for patients within the cluster who are registered at care homes to determine whether medication is still
Cluster pharmacists to discuss medicines wastage with carers to retain (Pro Re Nata) PRN medicines. Prescribed nutrition drinks to be reviewed for need and effectiveness. effective/appropriate for the patient and discuss further with the appropriate GP. To be undertaken and findings fed back to the cluster routinely. To be undertaken and findings fed back to the cluster routinely. 6 To address the complex medical needs and to provide an enhanced provision of care for residents in Care Homes. Delivering treatment and services to ensure a decrease in unplanned transitions of care and poly pharmacy. To consider the provision of the care home enhanced service via the cluster to those practices not participating in the DES Assessments and regular reviews of the mental and physical health of the residents Health Board / GP Practices / Cluster Pharmacist / GP OOHs Ongoing Collaborative working with other local health services throughout the primary care clusters to provide overarching leadership of teams. Wraparound services provided for the patient, i.e OT, Podiatrist, Dental, Optometry, Audiologists, Dieticians, Mental health care. A decrease in Unscheduled admissions A decrease in Polypharmacy Cluster Uptake : 7/8 Practices 7 To ensure, with the Health Board, that all network patients have access to the To consider the provision of the enhanced service for oral anticoagulation with warfarin via Health Board, GP Practices, May 2017 Safer services through not separating roles of monitoring and A GP has attended the Bay cluster to present and discuss the proposed
new Service for Oral Anticoagulation with Warfarin the cluster to those practices not participating in the DES secondary care, medicines management team prescribing – in line with MHRA model to GP practices, for information/consideration. Cluster Uptake: 6/8 Practices 8 To prolong independence of older people through identifying those people most at risk of losing independence and developing anticipatory care plans. To continue with active involvement in the anticipatory care programme To participate in a full evaluation when the programme rolls out to all clusters GP Practices, Health Board, Community Hubs, Mental Health March 2016 and ongoing Early identification of those patients most vulnerable of losing their independence. Care coordinator and care plan systems will assist those patients most at risk. Bay cluster has acted as an early adopter. . Practices have continued their involvement in the anticipatory care programme establishing systems to: Assist in making it core business Identifying those most vulnerable of losing their independence Identify care coordinator and care plan systems 9 To review the effectiveness of dermatology services offered within the community To consider an appropriate evaluation process following the purchase of dermatoscopes across the cluster GP Practices / Health Board March 2018 Better service to patients. Fewer secondary care referrals. Secondary care dermatology referrals have been requested for review and evaluation during 2017/18. 10 PMS Plus: respiratory prescribing To continue to undertake a range of prescribing initiatives as required to improve respiratory prescribing GP Practices / Medicines Management Team / Pharmacists Ongoing Improvement in patient symptom control Notification of cluster award during 2016 / 17 £26,006 11 To achieve better health outcomes and safer care through prudent prescribing To continue to promote the wastage of medicines campaign GP Practices / Health March 2018 and ongoing Reduced wastage of medicines and costs. To discuss what is being done during 17 / 18 to
1 To demonstrate governance within the practice through completion of the CGPSAT and Information Governance Self Assessment Toolkit All practices within the cluster to update and submit the CGPSAT and IG Toolkit by 31st March 2018. To participate in training facilitated by the Health Board on each of the toolkits. To utilise the toolkits to share learning and outcomes at cluster meetings GP Practices Health Board GP Practices / Health Board March 2018 and ongoing September 2017 Assurance that practices have clinical governance procedures in place To ensure systems of clinical governance are adhered to. To improve systems of clinical governance The Health Board has agreed to share cluster results following CGPSAT submission dated March 2017 The Health Board will arrange appropriate training for practice managers on the toolkits. To be discussed at future meetings 2 To undertake a peer review exercise To peer review designated inactive clinical QOF indicators in order to gain assurance on standards, providing feedback to the Health Board GP Practices / Health Board September 2017 & March 2018 To improve systems of clinical governance and enable identification of any specific cause for concern. To be discussed further Strategic Aim 8: Other Locality issues No Objective Actions Key partners For completion by: - Outcome for patients Progress to Date RAG Rating 1 To work closely with Local Area Coordinators to ensure relationships are strengthened within the community To support older people, people with mental health problems, the disabled, carers and other family members to remain strong and connected, feel safer and more confident. Health Board / GP Practices / Local Area Coordinators March 2018 and ongoing Better sign posting to services that can meet patients social needs LACs have attended network meetings to introduce themselves. Evaluation is conducted through
To assist in the promotion of Local Area Coordinator projects in practice areas promotion of patient stories. Jon Franklin has agreed to share service evaluation for review within the cluster. 2 To educate practice staff in line within cluster plans and Health Board and cluster priorities To develop a shared education programme for future cluster training sessions that will focus and assist priorities set out within the cluster plan. To participate in the Mental Health Directed Enhanced Service, securing a speaker who will focus training on selected training topic. on Eating Disorders in Adolescence and Early Adulthood Cluster Lead / GP Practices / Health Board / Community Teams / Voluntary Organisations Cluster Lead / GP Practices / Health Board / Community Teams / Voluntary Organisations Ongoing Throughout 17/18 January 2018 Staff will receive up to date information that can be filtered down to patients Educated practice staff will be in a position to offer adequate support and direction to patients An excellent programme has been run by the cluster over the past 12 months. Topics of education have included INR, Child and Adolescent Mental Health, Collaborative Working and Prudent Prescribing A revised mental health directed enhanced service specification has been circulated to the cluster. Links are now being made with B-eat organisation to source a speaker who will facilitate a training session on Eating Disorders in Adolescence and Early Adulthood. If unavailable, an alternative topic will be agreed within the cluster. Learning time for Mental Health training has been
To consider potential training programmes suitable for staff. Business Manager and Practice Manager at Mumbles Medical Practice to consider options for consideration within the cluster. To agree GP on call arrangements within the cluster should the Out of Hours Service be unable to provide adequate cover for the purpose of PLTS GP Practices / Health Board / Training Providers GP Practices March 2018 September 2017 Enhanced skill of practice staff Ensuring medical cover is in place for patients, creating little disruption to care during times of practice education. protected during January 2018. To be discussed further To be discussed