2015-16 CITY GP Cluster Network Action Plan CITY GP Cluster N… · 2015-16 City Cluster. 2 | P a g e Welcome to the City Health Network Cluster Plan for 2015/16. The City Health

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GP Cluster Network Action Plan2015-16

City Cluster

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Welcome to the City Health Network Cluster Plan for 2015/16. The City Health Network, based in Swansea, comprises ten general practices working together with partnersfrom Social Services, the voluntary sector and the ABMU Health Board.

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The City Network Practices, in line with other networks in Swansea, aim to work together in order to:

• Prevent ill health; enabling people to keep themselves well and independent for as long as possible.

• Develop the range and quality of services that are provided in the community.

• Ensure services provided by a wide range of health and social care professionals in the community are better co-ordinated to local needs.

• Improve communication and information sharing between different health, social care and voluntary sector professionals.

• Facilitate closer working between community based and hospital services, ensuring that patients receive a smooth and safe transition from hospital services to communitybased services and vice versa.

In order to support the development of the Network Cluster Plan, information has been collated on a wide range of health needs within the City Network area. The summary belowhighlights the key points and this information has been used to inform the development of priorities for the plan.

The 10 Network Cluster practices serve a varied population of 51,372 that has:

• High deprivation levels; with 24,833 (49%) residents living in the most deprived fifth of areas in Wales (see Deprivation Comparison below)

• Large student, asylum seeker and multi-racial/multi-cultural groups

• A large proportion of young parents

• 7,920 patients aged 65+ (16%) and 1,060 aged 85+ (2.2%)

• A 8% obesity rate (ABMU average is 9%)

• The highest percentage of smokers (30%) across Swansea (20%) {GP register data}

• An Incidence rate of 195 per 100,000 population for referrals to drug and alcohol treatment services

• Bowel Screening uptake of 43.4% (Target 60%) – Lowest in Swansea

• Cervical Screening uptake of 70.3% (Target 80%) – Lowest in SwanseaThe highest number of A&E attendances of any network in Swansea

• The second highest rate in Swansea of emergency inpatient admissions

• The highest rate of prescription of anxiolytics and hypnotics, antidepressants, opioid analgesics, tramadol, NSAIDs in Swansea

The Network area is served by:

• 4 General Dental Practices

• 1 Specialist Orthodontic Practice

• 1 Specialist Dental Practice (Sedation and Oral Surgery)

• 15 Pharmacies

• 6 Opticians

• 4 Nursing/Residential Homes

• 10 Schools

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The Network area, together with Penderi network area, forms the geographical area for one of three integrated community hubs within Swansea.

This is the second Network Development Plan for the City Health Network which will build upon progress made in year one. It encompasses a range of priorities identified in PracticeDevelopment Plans and via a multi-agency prioritisation session held at the July Network Board.

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

No Objective Action Key partners For completionby:

Outcome for patients Progress to Date / CurrentPosition

RAG

1a To improve Primaryand Communityservices for FrailElderly/Falls

Ensure continued strong links aremaintained with Chronic Care Nurses

Continue to promote the fallsprevention service.

Continue to distribute Falls Preventionguide.

Hubs

Networks toliaise withCCNs

Ongoing –Quarterly checks.

To improve communitycare and reducenumber of falls

Falls prevention guide has beenproduced and has been deliveredto all practices for patients toprevent and support individualswho are at risk of falling.

1b Support CommunityServices.

Network to act as pilot in supportingdelivery of comprehensive patientdischarge summaries to BonymaenHouse.

NetworkPracticesHealth BoardCommunityServices

Dec 15 Safe and appropriatecare.

Agreement reached withNetwork to support.

1c To improve SexualHealth services forpatients.

To provide specialist services e.g. IUCT,UCD, Implanon with abilities to cross-refer between practices.

Establish who currently provides whatand which practices will be providers.

Network

Network ChairHealth Board

Dec 15 Allow patients to accesscontraception servicesin a local generalpractice.

Services agreed in principle.

LARC spec issued and distributedto practices. Details of claimprocess/structure recentlycirculated.

Practices listed below whoprovide IUCD insertions.

• St Helen’s

• Brunswick

• Kingsway

• Greenhill

• Harbourside

• Cockett

• SA1

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High Street – Implants

1d Smoking Signpost smokers to Public Health Level3 Pharmacy Scheme and support withPublic Health materials.

Public HealthWales &Network

Ongoing Reduction of smokingrates within theNetwork

Practices auditing progress.

1e Substance Misuse Health board to sign off revised versionof draft LESRelaunch once confirmation received.

Need to raise implications of SharedCare worker being withdrawn withBoard.

Network

Health Board

Health BoardCDAT

Apr 15

Oct 15

Improved access tosubstance misuseservices.

In discussion with LMT.

Discussion ongoing with UnitDirector and CDAT

1f To support newlydiagnosed diabeticpatients (and thosepre-diabetic patients)in undertaking lifestylechanges which willbenefit their healthand wellbeing

To embed the WeightWatchers/Positive Steps programmeacross the Network

To proactively review the number ofpatients being referred by the practiceto NERS/Weight Watchers

GPsWeightWatchersPositive StepsPHWHB

Oct 15

Quarterly

Better health for thosepatients with chronicdiseases

Improved lifestylechoices leading to a lessmedical model of care

Engage with Public Health/ThirdSector

Maintain links withWeightwatchers Programme toreceive progress reports atregular intervals

1g To improve access tomental health services

To increase mental health nursing input

To provide in house counselling services

To further develop the LMPHSSinformation clinic within the CityNetwork and explore new ways ofworking e.g. Development of MentalHealth focussedNoticeboards/Information Provisionwithin the GP Practices

SCVSHealth BoardGP practices

Dec 15 Improved, timely accessto mental healthservices

Improved access tocounselling services forpatients who need Tier0 support either viapractice or networklevel

Designation of Mental Healthofficer is SCVS

Signposting patients to Tier 0services

Develop service for all practicesto received LMPHSS andattendance and for all practicesto have the opportunity, TW toprovide option paper for all

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practices for visits and bestpractice.

All practices to use counsellingguides developed by SCVS as aresource.

1h Increase uptake ofbowel and cervicalscreening

Continue to raise awareness of boweland cervical screening programme.Advertise via posters and leafletsprovided by cervical screening;including GP practices, communitypharmacists and local authoritybuildings.

Compare actions of best-performingCity practices.

NetworkPracticesCommunityPharmaciesLocalAuthority

Mar 16 Early detection ofcancers. Increasedscreening uptake.

Current screening uptakes of:Bowel Screening 43.4% (Target60%)Cervical Screening 70.3% (Target80%)

1i Increase fluimmunisation uptake

Lower performing practices to workwith PHW

PHWNetworkPracticesCommunityPharmacies

Mar 16 Protect patients at riskand the widerpopulation.

PHW assisting St Helens andNicholl Street to improve uptake.

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Strategic Aim 2: To ensure the sustainability of core GP services and access arrangements that meet the reasonable needs of local patients (WORKFORCE)


Outcome forpatients

Progress to Date / Current Position RAG

2 Ensure that accessarrangements are inplace that meet thereasonable needs oflocal patients

Determine City practices to pilottelephone triage.

Network practices Dec 15 Services developedto reflect local needRelease morecapacity for patientcare.

Discuss further at Oct ’15 meeting.

Use SMS reminder system whenrolled out by NWIS.

NWISNetwork practices

Jan 16 NWIS roll out July 2015.

Continue to review accessarrangements.

Network practiceswith Kingsway aslink.

Quarterly Access more broadly discussed inPLTS 25/3/2015 (in addition totelephone triage)Discuss at future meeting.

Consider staffing/workforcepressures.

Establish Locum Bank.

Speak with Training Practices reretention of GPs.

Network practices Quarterly

Awaiting outcomeof bid

Nov 15

Board to discuss possibility of settingup informal co-operative locumbank to include nursing andreception staff in addition todoctors.

Bid gone to IMTP - Primary CareWorkforce funding.

Review report and action anyrecommendations from Primary CareFoundation to develop accessarrangements.

Network practices Nov 15 PC Foundation – All practices signedup. Analysis and site visits to beundertaken in Sept 15

Address Homelessness Servicecontinuation and improvement.

NetworkHealth Board

Ongoing Service currently operating fromCentral Clinic.

Possibly develop theNetwork as aFederation

Use slippage money to set upadditional PLTS session to discuss.Invite facilitator.

NetworkABMU

Dec 15 Information documents circulated.

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Strategic Aim 3: Planned Care- to ensure that patients needs are met through prudent care pathways, facilitating rapid, accurate diagnosis and management andminimising waste and harms

No Objective Action Key partners Forcompletionby:


RAG

3a To implement a MinorSurgery service

Draw up SLA allowing cross-referral. Health Board,Network

Nov 15 Improved local and user-friendly access to Minorsurgery

Network Chair to e-mailpractices to establishmechanism.

3b To work to removeservice barriers whichimpair treatment forpatients with MentalHealth issues

Need to consider CMHT response. Network/CMHT

Network, HealthBoard

Oct 15 Better more supportivemental health service forpatients

CMHT representatives atDec 14 meeting.Written response to issuesraised circulated forinformation.

3c PMS Plus –RespiratoryPrescribing: to beconsidered on anetwork basis

This is a new initiativewhich will operatewhere opportunitiesarise for specific targetareas to releasesavings throughintegrated workingacross CommunityNetworks and AcuteCare sectors.

Each scheme will beindividually designed

To undertake a range of prescribinginitiatives as required to improverespiratory prescribingClose liaison with expanding communityresource and medicines managementteams to facilitate suitable medicinesmanagement arrangements for peoplebeing cared for at home

Close liaison with communitypharmacists undertaking Medicationusage Reviews and Discharge reviews

GP’s within networkssupport fromMedicinesManagement to bedetermined onpractice level

Mar 15 andongoing

Improvement in patientsymptom control

Medicines management toassist all practices incompleting

All practices have agreed toundertake PMS Plus

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and may crossfinancial years. Anypayments will be non-recurrent.

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Strategic Aim 4: To provide high quality, consistent care for patients presenting with urgent care needs and to support the continuous development of services toimprove patient experience, coordination of care and the effectiveness of risk management (UNSCHEDULED CARE)


Outcome forpatients


4a To reduce theinappropriate use ofA&E and GP Out ofOurs

To improve patient education e.g.display posters

Link in with alternative services e.g.AGPU

Analyse emergency admission rateson GP portal in greater detail andconsider where improvements canbe made.

Signpost patients to ensureattendances are appropriateincluding e.g. ”choose well’’ posters

GP OOHA&EMIUHBCommunity Voices

Ongoing Better education onhow to accessservicesappropriately tomeet their needs

ABMU Communication Team hasbecome involved with surgeries andassist in getting correct informationout

“Choose Well” campaign

4b To improveantimicrobialstewardship

Antibiotic audit at all practices. Medicinesmanagement team

Ongoingquarterlymonitoring oftrends

Reduced resistance

Reduced C.Diff

Increasedknowledge andempowerment toself care

Discussed at all annual practiceprescribing visits. Cluster level data tobe shared at forthcoming clustermeeting

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Strategic Aim 5: Improving the delivery of end of life care

No Objective Action Key partners Forcompletion by:

Outcome forpatients


5 Palliative Care-Adopt principles ofend of life care withfocus on continuityof care relating topatients withpalliative conditionin last two weeks oflife.

Develop relationship between Practice/and Secondary Care:

Topic arose following discussion aroundpoor discharge summaries and raisedexpectation of patient.

Network Chair produced a template toaudit summaries. Practices to completeand agree approach to Medical Director.

Network practicesSecondary Care

Ongoingand inQOF15/16

Reduce significantrisks associated withmanaging dischargedpatients withno/inadequateinformation

Lead Clinician in Palliative Careattended July 15 meeting.

PLTS presentation on Discharge -copy of presentation given to eachpractice May 2015, no issues raised.

Discuss audit findings at Novembercluster meeting.

Liaise with lead clinician in palliative careregarding review of makeup of team andservice, including:Feedback of continuity of access to CNs;Feedback on issues with responses tocalls to CNs as they arise;Receive update on way forward forseparate palliative care dischargesummaries from hospital support team;Arrange follow-up session with SueMorgan for March 2016

Secondary CareCNsHealth Board

Mar 16 Improved palliativecare service

Lead Clinician in Palliative Careattended July 15 meeting.

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Strategic Aim 6: Targeting the prevention and early detection of cancers


Outcome forpatients


6a Secondary caredowngrading USCs

Review USC referral downgrades.Network to collate examples on anetwork basis to raise to relevantspecialties.

Have agreed for future to:Remind GPs to complete a USC referral incases of change of bowel habit;Remind GPs to refer as USC on suspicionof cancer rather than awaitinginvestigations and avoid falsereassurance of inappropriateinvestigations.

Network Mar 16 Potential earlieridentification forpatients with cancer

Chair has collated practiceinformation re downgrades.

Concerns confirmed and awaitingavailability of a representative fromsecondary care to discuss with us.Fiona Hughes/Linzi Thomas invitedto Sep ’15 meeting.

6b Address smoking as acause of cancer

PHW and Stop Smoking Wales developinga menu of options to compliment Level 3Pharmacy Scheme.

PHWTobacco ActionGroup

Mar 16 Improved stopsmoking support

Meeting held with TAG/PHW

6c To target theprevention and earlydetection ofdigestive, lung andovarian cancers

Review patients with lung, digestive andovarian cancer in line with ClusterNetwork Development Domain.

Network practices Ongoingand inQOF15/16

Better preventionand earlier detectionof cancers for ourpatients

National Pathway work to bediscussed and undertaken betweenOct 15 and March 16

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Strategic Aim 7: Minimising the risk of poly-pharmacy


Outcome forpatients


7a Polypharmacy Reviews& High Dose SteroidAsthma Reviews

Close liaison with expanding communityresource and medicines managementteams to facilitate suitable medicinesmanagement arrangements for peoplebeing cared for at home e.g.simplification of medication regimes,changes to medicines formulations,arrangements for warfarin etc.

Close liaison with communitypharmacists undertaking Medicationusage Reviews and Discharge reviews.

MedicinesManagement

Network Practices

Network Pharmacist

Ongoingwithin QOF15/16

Reduction inmedicationload/improvedsymptom controletc

leads pp4.ppt

7b Improvement/maintenance against targetprescribing indicators

Can consider and review practice andnetwork data forantibiotics/statins/hypnotics &anxiolytics and discuss howimprovements can be made if required.

MedicinesManagementNetwork PracticesNetwork Pharmacist

Ongoingwithin PMS15/16

Improvement inprescribing qualityto improve healthoutcomes

pms progress march15.ppt

7c Appointment ofClinical Pharmacist

Clinical Pharmacist to be appointed andshared across the Network focussing onpolypharmacy issues particularlyrelating to patients who have beendischarged from hospital or are residingin a care home.

Network PracticesHealth Board

Oct 15 Shared CP wouldreduce medicineswastage, ensurecompliance withmedication andreduce the risk ofdrug contraindications topatients across thenetworkAll patients acrossthe Network willbenefit fromenhanced provision

£54,000 allocated to implement theclinical pharmacist Service across thenetwork.Cluster pharmacist starting 12th

October.

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ensuring positivepatient outcomes

7d To provide accreditedtraining for prescribingclerks

Provide accredited training forprescribing clerks

MedicinesManagement team

Mar 2016 Improved repeatprescribing systems

Training packs in development

7e To ensure appropriateuse of the pharmacistand technicianresources to reducerisks frompolypharmacy

Network and individual practices toagree work agenda for clusterpharmacists. Support provided byexisting medicines management team


Clusterpharmacistavailable byOct 2015

Improved accessfor improvedpharmaceuticalcare

Cluster pharmacist starting 12th

October.

7f To engage in thePrescribingManagement Scheme(PMS) and PMS+respiratory schemes(which containpolypharmacyelements)

Networks to consider role of clusterpharmacists in supporting respiratoryPMS +


PMS 15/16– by Mar16PMS +respiratory– by Nov 16

Improvedmedicinesmanagementincludingpolypharmacy

All practices engaged and makingprogress

7g To progresspolypharmacy issuesidentified in previouscluster network plan

Practices to continue to support thepolypharmacy agenda using clusterpharmacist where appropriate to targetcomplex patients

Practice teams Ongoing Improvedprescribing andmechanisms forpolypharmacyreview

Ongoing

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Strategic Aim 8: Deliver consistent, effective systems of Clinical Governance (Inc. PREMISES)


Outcome forpatients


8a To ensure thatpremises are fit forpurpose withinnetwork

To ensure that risks and opportunities areflagged are identified within the HealthBoard’s Primary and Community Estatesstrategy.

Health Board,Networks, LocalAuthority, Coastal,WG, Shared ServicesPartnership

Ongoing Premises fit forservice provision

Raised in Practice DevelopmentPlans. To address through EstatesStrategy.

8b Ensure robustsystems at practicelevel

Ensure that CGPSAT toolkit,significant event analysis are undertaken,results shared to ensure best practice.

Practices to share SEAs at Networkmeeting to share learning.

Networks/practices Ongoing Safe environment forpatients

Sharing event at each meeting.

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Strategic Aim 9: Other Locality issues


Outcome forpatients


9a To ensure thatimpacts ofpopulation changeare planned for

Scope for population increase – e.g.housing/student developments andinclude mitigating action in future plans,including workforce considerations. Riskparticularly to practices on east of clusterwho are at maximum capacity already

Consider practices collaborating toensure equitable distribution of newpatients

Use this as a focus to discuss/plan howthe network could share services infuture in a federated approach aroundpayroll, recruitment, admin etc.

NetworkHealth Board(through supportiveinformationprovision)

Network

Ongoing Ensuring suitableprovision available.

More cost-effectiveservices able tobetter provide forpatient needs.

Consider ways in which LHB mayhelp

9b INR service –ensuring dosing andprescribing are notseparated

Review of INRservice to ensureincludes NOACs

INR Enhanced Service to becommissioned across practicesORConsideration given to mechanisms tonot separate INR monitoring fromprescribinge.g. use of pharmacists or medicalscientists in community doing dosing &prescribing OR secondary care prescribingas they do monitoring and dosing.

LHBGP practices +/-secondary careservices +/- HBmedicinesmanagement teams

Ongoing Safer servicesthrough notseparating roles ofmonitoring andprescribing – in linewith MHRA

PBMA (Programme Budgeting &Marginal Analysis) exercise ongoingwithin the Health Board, looking atthe AF pathway, with a particularfocus on Anticoagulation ServiceModels. Engagement exercisesundertaken with both GPs andpatients. Currently analysingexisting and suggested servicemodels based on cost and quality.

9c To continue tosupport thedevelopment ofintegrated health

To act as a key stakeholder in informingthe ongoing development of integratedhealth and social care teams deliveringservices for older people.

Social Services,community nursing,third sector, primarycare, domiciliary

March 16andongoing

More effective,timely and co-ordinated healthand social care and

Hub Manager and Lead Nurse

attending all Network meetings.

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and social careservices for olderpeople and youngerdisabled adults inSwansea.

Linking in with network to ensureappropriate and consistent linkages aremade.

Network to inform the review of thesingle point of access (Intake) for theintegrated teams

care, independentcare providers

a better ability tomanage demand.

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Strategic Aim 10: Third Sector/Partnership Working



RAG

10a To further developthe Third Sectorsupport project,increasing the use ofvoluntary sectorservices by the CityNetwork population

Ensure that links are made withvoluntary sector organisationssupporting the agreed network priorityareas where possible.

SCVS to map Third Sector provisionagainst network priorities.

Led byNetworkpracticessupported bySCVS

Mar 16 Improved support andaccess to services.

Practices invited to take part inHealthy Partnership project.

Ensure that up to date information onvoluntary sector services is displayed inGP practices, e.g. information stands,notice boards.

Led byNetworkpracticessupported bySCVS andVoluntarySectororganisations

Mar 16 SCVS liaising with practices.

To extend voluntary sector presencewithin GP practices in the network byincreasing the number of practicesparticipating, Healthy Partnerships andexploring new ways of working jointlysuch as pre bookable appointmentswhere possible.

Network andSCVS

Mar 16 Brunswick and Kingsway ontimetable for third sectorattendance and haveorganisations attend theirpractices.Mayhill promoting via leaflets.

10b To obtain patient andcarer views onnetwork services andpriorities programme

To establish a patient/ carerparticipation group within the networkarea in line with the Community Voicesprogramme

SCVS Oct 15 & Ongoing Responsive servicestaking into accountservice user and carerfeedback.

1 road show and 3 meetingsheld – no attendee at the lasttwo. Engagement with citizenshas been difficult.

SCVS provided practices withflyers for promotion and to

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attach to prescriptions.

SCVS linking with Central Hubmanager for patientinvolvement in patient/carerpanel.

Priority engagement / publicityevent to be held in the GrandTheatre

Further promotion

Support Network to promote apriority within their plan tocitizens.

Further roadshow planned forOctober.

10c Develop Local AreaCoordinator pilot

ABMU to work with LACs to provideclear eligibility criteria for referringpatients.Practices to actively refer patientswhere suitable.ABMU to assist in promotion of LACproject to practices.

Health BoardLACNetworkpractices

Jul 15 andongoing

Improved support LACs now working in Citypractices and making links.

10d Develop closerworking links withCommunities First

Increase the use ofCommunities Firstservices by the CityNetwork population

Ensure up to date information aboutCommunities First is displayed in GPpractices e.g. leaflets and posters

To ensure that practice actively referpatients to Communities First wheresuitable. Activities include learning,physical activity, volunteering andcommunity engagement

CommunitiesFirstNetworkPractices

Ongoing Improved support andaccess to services forthe City Networkpopulation

Referral scheme to be set upand piloted at practice.

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Explore the potential for joint projectswhere patients would benefit from anintegrated approach.

10e Access to CitizensAdvice Bureau withinGeneral Practice

CAB to provide an advice service

resource in the Network GP practices

through the provision of advice workers

for 7 days per week, six of which to be

provided as an outreach to Networks.

The pilot will be fully evaluated at yearend.

Lead GPsHealth BoardCAB

Funding until Mar16. Fullevaluation willthen beundertaken.

Better support forpatients withwelfare/social problemsthat need dedicatedsupport and guidance

Funding has been given to CABto start a pilot and they will bepresent in a City surgery for 1day each week to provideinformation and support topatients.

CAB in Kingsway and SA1.

10f To increase the use ofthe Healthy CityDirectory within thenetwork

To increase the use of the Healthy CityDirectory within the network

NHS DirectHealth BoardSCVSVoluntarySectororganisations

Mar 16 Network populationmore informed onavailable health andwell being servicesleading to increasedusage

To promote the use of theHealthy City Directory withinpractices and to patients

Documents

2015-16 CITY GP Cluster Network Action Plan CITY GP Cluster N… · 2015-16 City Cluster. 2 | P a g e Welcome to the City Health Network Cluster Plan for 2015/16. The City Health