Advertising via posters & leaflets provided by screening Wales in various public sites including GP practices, community pharmacists and local authority buildings. Also adding information to practice websites regarding bowel screening. To participate in the bowel screening programme to improve uptake (subject to discussion, appropriate funding and available resource) GP practices Community Pharmacists Local Authority buildings Bowel Screening Wales (for information) GP Practices (excluding The University Practice) March 2017 and ongoing 2017 and ongoing Early detection of cancers Measurable outcome: increased uptake figures Early detection of health risks Various practices have received screening resources for display and promotion to encourage patient uptake. PHW screening team have been contacted with a request to any new literature for distribution during 2016/17. Evaluation of the programme has been shared with the cluster network lead. Individual practices have requested screening data from PHW in order to commence contacting non responders. 3 To increase cervical screening uptake. To continue to awareness of cervical screening programme: Advertising via posters & leaflets provided by cervical screening including GP practices, community pharmacists and local authority buildings GP practices Community Pharmacists Local Authority buildings Cervical Screening Wales (for information) The University Practice March 2017 and ongoing March 2017 and ongoing Early detection of health risks Early detection of health risks Current screening rate: 79.5% Various practices have received screening resources for display and promotion to encourage patient uptake.
To participate in the cervical screening programme to improve uptake (subject to discussion, appropriate funding and available resource) Evaluation of programme has been shared with the cluster network lead. The University Practice has been advised to request screening data from PHW in order to commence contacting non responders. 4 To increase attendance of diabetic retinopathy reviews To continue to prompt patients opportunistically GP Practices March 2017 To ensure patients are reviewed and managed effectively as part of their diagnosis. Data has been shared with individual practices to demonstrate the number of referrals of newly diagnosed patients into the diabetic retinopathy service during 2013/14 & 2014/15. Practices have been asked to note, understand the importance of each referral into the service and encourage patient attendance. Recent figures have been requested for sharing with practices and to compare referrals with previous years. 5 To introduce opportunistic screening for: AF screening AF screening: Utilise consultations and flu surgeries as opportunity to opportunistically screen for AF using assessment of pulse To purchase alivecor monitors for GPs and Nurses which will allow a 30 second ECG trace of a patient to be recorded. Community pharmacists (for AF proposal) GP Practices Community Nurses Ongoing November 2016 AF screening: To reduce risk of CVAs In line with national priority around AF and CVA An ECG can be emailed quickly to the patients GP for diagnosis and if necessary, referred to Opportunistic screening is being undertaken on an ongoing basis within practices 100 alivecor monitors have been ordered for distribution between the 8 practices. Monitors will also be provided to the Bay health paramedic, pharmacists and CCNs once
currently being prepared and will be shared with the network at a later date. 7 To further develop the third sector support project increasing the use of voluntary sector services by the Bay Network population Ensure that links are made with voluntary sector organisations supporting the agreed network priority areas where possible. Led by Network practices supported by SCVS Ongoing Provide useful education and resource to patients and GP practices Develop the Network PLTS sessions to deliver training on issues pertinent to practices in Bay. Ensure that up to date information on voluntary sector services is displayed in GP practices, e.g. information stands, notice boards. Led by Network practices supported by SCVS Ongoing Practices are hosting third sector organisations within GP Practices Relevant information boards and other materials are being displayed and updated within GP practices. To consider possible arrangements to CBT counselling services to offer support and information to patient in practice. Sector March 2017 Provide valuable support and information to patients. Arrangements are being explored by the network. To evaluate the pre bookable appointments system and the presence of voluntary sector that has been trialled in the Bay network. GP Practices/Third Sector March 2017 & Ongoing Improved service to patients Evaluation currently being undertaken on the system to be reported back to the Bay cluster. Awaiting detail from SCVS 8 To increase the use of the Healthy City Directory within the network To continue to promote the use of the Healthy City directory within practices and to patients. NHS Direct/Health Board/SCVS/Voluntary Sector organisations March 2017 and ongoing Network population more informed on available health and well being services Continued promotion of the Healthy City resources within practices.
leading to increased usage. 9 To obtain patient and carer views on network services and priorities programme To work proactively with the Bay Health Patient Carer Participation Group on priorities for 2016/17. SCVS/GP Practices/Health Board Ongoing through 2016/17 Responsive services taking into account service user and carer feedback. The network lead has attended the patient participation group to present detail of the cluster plan and network news, discuss future plans and the groups involvement in supporting the network and projects. Discussions have taken place regarding the invitation of one of the patient and carer group members attending future network boards in order to feedback news and actions of the cluster. Draft Terms of Reference have been discussed during the Bay Patient and Carer Group held 13.12.2016. SCVS are collating all comments and feedback and will issue to the cluster lead and other members of Bay in readiness for the cluster meeting scheduled January 2017. 10 To ensure patient smoking status is recorded and regularly updated To better record/update patient smoking status To promote access to level 3 prescribing service offered by local pharmacies and Stop Smoking Wales or establish an in house stop smoking service. To undertake a project in conjunction with the ASH GP Practices GP Practices GP Practices Ongoing Ongoing Ongoing A reduction in the number of patients smoking. Practices are routinely updating patient’s records with smoking status. KT has updated practices within the cluster of this
Strategic Aim 2: To ensure the sustainability of core GP services and access arrangements that meet the reasonable needs of local patients No Objective Key Actions Key partners For completion by: - Outcome for patients Progress to Date/Current Position RAG Rating 1 To employ a paramedic to work within the Bay Cluster Network (0.8 WTE) To draw up a paramedic job description tailored to suit the of the Bay Cluster and recruit successfully to the position. To respond to and triage calls in the first instance followed by routine house calls across the cluster. GP Practices / Health Board Paramedic/ GP Practices September 2016 March 2017 Quick access to health care in urgent situations. Assist in reducing pressures on emergency services and free up GP to manage other demands as required. A job description and specification has been developed and tailored for work to be undertaken within the cluster. The job advert attracted 9 successful candidates. Following interviews on 16th December 2016 Andrew Jones was appointed into the role
4 To develop the skills and precise management within GP practices, complying with HR, Employment Law and Health & Safety To sign up to a service proposal to obtain support, direction and training in complying with HR, Employment Law, and Health & Safety within practice – Whittam/Peninsula GP Practices March 2017 To improve staff awareness, education and overall management within general practice. 8/8 practices have signed up to the service outline 5 To continue to develop access arrangements to primary care where appropriate and develop mechanisms to address workload and demand within primary care. Continue to share and discuss variations of access arrangements across practices e.g. triage systems Continue to adopt and monitor the use of text messaging service for health invitations and appointment reminders from IT systems to improve communication with patients and reduce DNAs. Increase practice use of MHOL for prescriptions/appointments and promote system to patients to help reduce number of calls received by practice. GP Practices Health Board/NWIS GP Practices / Health Board Ongoing 2017 2017 To provide more accessible services for patients To reduce the number of DNA’s (do not attend) / wasted appointments To allow patients use of an online system which will enable them to book appointments, manage repeat prescriptions, etc. This will reduce the number of calls received by the practice. Achieved, but remains ongoing for discussions if appropriate. New functionality has been offered to practices as part of the GP systems contract that will enable the generation of text messages via the clinical system. These can be used for appointment reminders and support the call/recall process for seasonal flu, QOF and other chronic disease management purposes. MHOL training session delivered during Practice Managers Forum held March 2015. MHOL Data June 2016:
MHOL Available: 8/8 Practices Appointments: 5/8 Prescriptions: 6/8 Both Appointments & Prescriptions: 5/8 6 Succession planning of practice and community staff Review workforce demographics within practices and within community – particular emphasis on GPs and PNs Review the communication processes between GP practices and community nursing team GP practices/ Locality staff/ Community nursing GP Practices, Community Nursing Ongoing Ongoing Increases the availability of experienced and capable employees to accept roles and maintain safe and effective services for patients both within and across practices and wider community. Better coordination of care Practices have included details of their workforce within individual practice plans. Communication between practice and community staff has been addressed within meetings, with suggested actions discussed to help resolve any issues. 7 To address difficulties in recruiting partners and the shortage of locums Address the pressure facing general practice: GP practices Ongoing More sustainable services Practices have been asked to consider recruitment difficulties and the shortage of locums. If appropriate due to sustainability of general practice, practices should apply individual to the HB for support.
Strategic Aim 3: Planned Care- to ensure that patient’s are met through prudent care pathways, facilitating rapid, accurate diagnosis and management and minimising waste and harms No Objective Key Actions Key partners For completion by: - Outcome for patients Progress to Date/Current Position RAG Rating 1 To introduce new models of effective and efficient delivery of service supported and facilitated by technology To use purchased technology such as I pads, and enable Skype facilities to improve communication and provide a more efficient service to particular cohorts of patients, or patients in certain settings, e.g. care homes. GP Practices Health Board NWIS 2017 and Ongoing More sustainable services Technology equipment has been purchased across all 8 practices from funding that was made available to support processes and efficiency of service.
vunerable adult training. 6 To prolong independence of 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 establishing systems to: Assist in making it core business Identifying those most vulnerable of losing their independence Identify care coordinator and care plan systems Develop effective means of communication To participate in full evaluation when programme roles out. Community peoples mental health services 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 with lessons being learnt. To date: 19 ACP in place 42 identified for a potential ACP 7 To achieve better health outcomes and safer care through prudent prescribing To display stands/banners in each practice to promote the wastage of medicines campaign. Cluster pharmacists to assist practices in day to day work and help with sustainability issues GP Practices/ Health Board/ Pharmacist GP Practices/ Health Board/ Pharmacist Ongoing March 2017 and Ongoing Reduced wastage of medicines and costs. To provide efficient and effective healthcare and lead a cost effective and educational role. Banners are being displayed in reception or waiting areas of GP practices. Bay health pharmacists commenced role October 2015.
threatening primary care. to involve: undertaking face to face medications and polypharmacy reviews dealing with medication queries face to face or via telephone new patient medication reviews home medication review (upon request) care home medication reviews assist with medication queries from district nurses contraception checks asthmas reviews checking medication not received in the last 3 months To implement cluster based clinics for: hypertension acne asthma contraception GP Practices/ Health Pharmacist March 2017 and Ongoing Pharmacist to support provision of self care management, pharmacy reviews and chronic disease patient education. Medication reviews, polypharmacy reviews, medication queries, new patient medication reviews plus any medication related queries from all staff in primary care have been undertaken and remain ongoing. Pharmacists have met with Dr K Truman, Bay lead to outline a work plan to be implemented during 2016/17. Pharmacists have presentations to the network on areas of work undertaken. Further updates will be provided to the network at future meetings to share evaluation and potential outcomes. Protocols are currently being drafted by the cluster pharmacists.
8 To improve access to dermatology services within the community, therefore, reducing the number of patient referrals to hospital. Trained GPs to provide patients access to dermatology services within practice, and audit referrals to consider improvements made. GP Practices Health Board March 2017 and ongoing Less secondary care referrals. Better service for patients. Practices have purchased dermatoscope packages. Dermoscopy training session held 28th January 2016 to up GPs in the Bay network. Secondary care dermatology referrals have been requested for review and evaluation.
Strategic Aim 5: Improving the delivery of end of life care No Objective Key Actions Key partners For completion by: - Outcome for patients Progress to Date/Current Position RAG Rating 1 To review the number of deaths as per guidelines Undertake review of number of deaths as per guidelines GP Practices Secondary Care March 2017 and Ongoing Identification of trends across the networks National pathway work undertaken between October 2016 and March 2017. All practices have discussed and shared details of the reviews undertaken, learning points and actions to be undertaken. 2 Practice level regular palliative care reviews and completion of EOL template Undertake review of palliative care cases on a regular basis GP Practices Secondary Care March 2017 and Ongoing Identification of good practice and areas of concern 3 Undertake regular audit; sharing results on a cluster network basis Regular audits to be undertaken and learning points to be progressed Ongoing
Strategic Aim 6: Targeting the prevention and early detection of cancers No Objective Key Actions Key partners For completion by: - Outcome for patients Progress to Date/Current Position RAG Rating 1 SEA of all new lung, stomach and GI cancers Regular review and audit of lung, stomach and GI cancers GP Practices March 2017 and Ongoing To diagnose cancers as as possible National pathway work undertaken between October 2016 and March 2017. All practices have discussed and shared details of the reviews undertaken, learning points and actions to be undertaken. 2 Undertake regular audit; sharing results on a cluster network basis Regular audits to be undertaken and learning points to be progressed GP Practices March 2017 and Ongoing Identification of good practice and areas of concern
Strategic Aim 7: Minimising the risk of poly-pharmacy No Objective Action Key partners For completion by: - Outcome for patients Progress to date/current position RAG Rating 1 To progress polypharmacy issues identified in previous cluster network plan To progress polypharmacy issues identified in previous cluster network plan Medicines management team and Practice Ongoing Improved prescribing and mechanisms for polypharmacy review Ongoing work in practices also supported by the Medicines Management team 2 To ensure appropriate use of the pharmacist and technician resources (cluster and non-cluster funded) to reduce risks from polypharmacy and improve other aspects of medicines management Work with medicines management team to deliver and ensure appropriate training, support and indemnity arrangements Medicines management team and Practice Teams Ongoing Improved access to better pharmaceutical care Cluster Pharmacist appointed as well as other support from Health Board Medicines management team Work ongoing to clarify roles, training requirements and indemnity arrangements 3 To engage in the Prescribing Management Scheme (PMS) and PMS+ respiratory schemes Undertake a range of prescribing initiatives to improve: respiratory, antibiotic, GPs Practice Nurses PMS 16/17 – by 17 (some Dec Improved medicines management including polypharmacy Discussed at all annual practice prescribing visits
(which contain polypharmacy elements) pain management prescribing and yellow card reporting Medicines Management team 16 deadlines) PMS +respiratory – by Nov 17 Investment in other service areas for patient benefit Practices engaged and making progress Medicines management team supporting where possible 4 To provide standardised training for prescribing clerks and seek opportunities to build on initial training to further develop staff Nominated clerks to complete training packs Seek further opportunities to develop staff Medicines management team Practice Managers Prescribing Clerks Completion of - June 2016 Improved repeat prescribing systems Number of clerks completed: Bay: 39 5 Improvement/maintenance against national prescribing indicators Consider and review practice and network data for national indicators Practice teams Medicines management team Ongoing within 16/17 Improve prudent prescribing leading to better health outcomes and reduced polypharmacy Discussed at all annual practice prescribing visits Work ongoing with the Medicines Management and Big Fight team 6 To improve antimicrobial stewardship through appropriate use of antibiotics Implement mechanisms to ensure appropriate use of antibiotics (see also ) Practice team Big Fight Team Medicines management team Ongoing with monitoring of trends See also for deadlines: Dec 16: Overall antibiotic use and choices Acute Cough Audit Plan March 17: Reduced antimicrobial Resistance Reduced C.Diff Increased knowledge and empowerment to self care Discussed at all annual practice prescribing visits. Development of cluster level data
Evidence of patient engagement activities Strategic Aim 8: Deliver consistent, effective systems of Clinical Governance No Objective Key Actions Key partners For completion by: - Outcome for patients Progress to Date/Current Position RAG Rating 1 Demonstrating governance within the practice: Completion of the CGPSAT Each practice to complete the CGPSAT GP Practices March 2017 and ongoing Assurance that practices have clinical governance procedures in place CGPSAT is now open and live to all practices for further completion and progression following the last submission March 2016. 2 Cluster wide discussion of significant analyses Each practice to bring one significant event to a cluster meeting during course of year Practices Health Board / Datix March 2017 Assurance that practice utilise significant events for ongoing learning Each practice has shared one SEA during cluster meetings held 17.11.2016 and 15.12.2016. Lessons learnt and actions taken have been shared between practices. Strategic Aim 9: Other Locality issues
No Objective Key Actions Key partners For completion by: - Outcome for patients Progress to Date/Current Position RAG Rating 1 Bay cluster to work closely with Local Area Coordinators To agree clear eligibility criteria in order for practices to refer suitable patients To assist in the promotion of Local Area Coordinator projects in relevant practice areas Health Board / Practices / Local Area Coordinators March 2017 Better sign posting to services that can meet patients social needs LACs have attended network meetings to introduce themselves to discuss the project follow up work will include linking to the Early Adopter Pilot. 2 To continue to support the development of integrated health and social care services for older people and younger disabled adults in Swansea. To act as a key stakeholder in informing the ongoing development of integrated health and social care teams delivering services for older people. Linking in with network to ensure appropriate and consistent linkages are made. Network to inform the review of the single point of access (Intake) for the integrated team Social Services, community nursing, third sector, primary care, domiciliary care, independent care providers March 2017 and ongoing More effective, timely and health and social care and a better ability to manage demand. Updates are regularly received at network meetings with opportunity for practices to feedback good practice or any concerns. 3 INR service – ensuring dosing and prescribing are not separated Review of INR service to ensure includes NOACs INR Enhanced Service to be commissioned across practices Bay cluster to agree whether INR service to be cluster based or provided by the Health Board Health Board GP practices +/- secondary care services +/- HB medicines management teams Nov 2016 – dependant on issuing of agreed Directed Enhanced Service Safer services through not separating roles of monitoring and prescribing – in line with MHRA Ian Harris attended the Bay cluster meeting held during July 2016 to present and discuss the proposed model to GP practices. 4 Education of practice & community teams Develop shared education agenda through community network PLTS GP practices, Health Board, Community staff Ongoing Staff remain up to date Network lead continues to secure a range of speakers