Caerphilly East Neighbourhood Care Network Action Plan ... East NCN Action... · Caerphilly East Neighbourhood Care Network Action Plan & Progress Report ... better patient care

Caerphilly East Neighbourhood Care Network Action Plan & Progress Report 2015-16

Complete Started Not Started

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

No Objective Key Partners For Completion

by

Outcome Agreed actions / Progress to Date

RAG Rating

1.1 Smoking

1.1.1 Achieve/work towards the National

Tier 1 target of 5% of smokers make a quit

attempt via smoking cessation services, with at least a 40%

CO validated quit rate at 4 weeks

Supports Caerphilly SIP – Healthier Caerphilly H1, H2, H3, H4 Supports IMTP SCP3

NCN

PHW

Smoking Cessation Wales

Housing

Associations Communities

First

Community Pharmacy

31.03.16 Increased numbers of staff who have access to brief

intervention training

Increased access for patients to staff trained in brief intervention techniques

Patients will be motivated to

make a quit attempt and will receive effective treatment to quit smoking

Progress: 2014-15 Figures for Caerphilly

Patients scheduled to

attend a smoking cessation appointment = 441 (467 initial

assessments undertaken)

Number of treated

smokers = 263

% of patients who quit

at 4-weeks (CO-validated) = 54% (40% target level)

Actions

Develop local communication plan with the Communities

First Smoking Cessation Officers

Increase numbers of

staff who have access to

brief intervention training


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RAG Rating

Review data on uptake

of smoking cessation services and quit rates at NCN meetings

including with non-medical members

Continue to improve

referral rate through

collaborative working

Ensure every practice has appointed a smoking champion

Increase number of

pharmacies offering Level 3 smoking

cessation services

1.1.2 Communities First Staff to offer

Maudsley Smoking Cessation advice to

patients across Caerphilly funded

from NCN monies for 2015-16

See 1.1.1 Supports Caerphilly SIP – Healthier Caerphilly H1, H2, H3

Communities First

NCN

31.03.16 Increase in patients making a quit attempt as service can be

offered on a 1-2-1 basis

Delivery staff will have established relationships with

patients

Provide regular reports to NCN on progress of

Communities First Staff.


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RAG Rating

1.2 Obesity

1.2.1

To address Obesity issues within the NCN

Network through Partnership working

Supports Caerphilly SIP –

Healthier Caerphilly H2, H3, H4

NCN

Social Services/ Communities

First Adult Weight

Management Service

PHW

GAVO

31.03.16 NCN membership and stakeholders will be able to plan

for integrated service provision across the Caerphilly NCN

areas. Families will have access to a

wide range of children and young people’s services,

initiatives and projects addressing obesity issues

Identify baseline data for NCN area regarding

the number of citizens attending services.

Map Level 2 services for

weight management

and refer/recommend – Foodwise, commercial

clubs, NERS, led walks

Increase in the number of citizens attending the services.

Refer routinely to Adult

Weight Management Service

To develop identify existing service

pathways to address childhood obesity needs


by


RAG Rating

1.3 Bowel Screening

1.3.1 Achieve the National

Target of 60%

eligible patients

screened

Supports Caerphilly SIP –

Healthier Caerphilly H2,

H3, H4

NCN

PHW

National Screening

Services

GP Practices

31.03.16 Earlier detection of bowel

cancer with improved chance of

survival

PHW to liaise with

national screening services regarding

providing practices with a list of non-responders

Identify achievements against national target

of 60% and action to achieve

Practices to complete

work according to

protocol

1.4 Public Engagement

1.4.1 To support the work of the ABUHB

Engagement Team in implementing the

Engagement Strategy and seeking /

collecting information on service provision and change from the

wider Gwent resident population.

Supports Caerphilly SIP – Healthier Caerphilly H4, H5

Network Team

NCN

GP Practices

Communities First

GAVO

On-going Formal and informal consultation opportunities for all

residents to influence the development and improvement

of all services (including integrated services) across

ABUHB.

To promote the work of ABUHB & NCN where

possible

To attend events to provide a range of

information relating to e.g. Flu / smoking cessation / Health

initiatives

Feedback findings from Listening Events to NCN and ABUHB

Engagement Teams

Where possible build


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RAG Rating

feedback into actions

for future NCN plans

Work with partners in

Wellbeing Delivery Group to maximise communication and

engagement opportunities

1.5 Influenza

1.5.1

Achieve the national

target of 75% for

immunisation against

influenza

GP Practices

NCN Contractor

Services

DNs

31.03.16 Decrease in hospital admissions

Decrease in morbidity

Progress:

63% achieved in 2014-15 for immunisation against influenza for 65yrs and

older for Caerphilly East NCN

49% achieved in 2014-15 for immunisation against

influenza for 6months to 64yrs for Caerphilly East

NCN

Hold discussions

between practices regarding best practice

Receive regular practice

updates during flu

season

NCN Management Team to agree an approach to deliver the programme

(see 1.6)


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RAG Rating

1.6 NCN Management Team

1.6.1 Establish a

Management Team Structure for Caerphilly East NCN

NCN Lead

NCN Partnership

Teams

Network team

31.03.16 Improved guidance, co-

ordination and development / skills, knowledge and engagement

Implement

NCN/Integrated Management Team

Agree Priorities for 2015/16

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

needs of local patients


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RAG Rating

2.1 Access

2.1.2 Achieve LMC agreed access figures

GP Practices

NCN Lead

31.03.16 Practices to engage with project to optimise access in keeping

with emerging guidance to be agreed with CHC, Health Board and LMC

Practices to monitor performance against

LMC standards

Monitor & report

performance to NCN Lead on a

monthly/quarterly basis

2.1.3 Monitor the

continuation and uptake of My Health Online

Supports Caerphilly SIP – Healthier Caerphilly H5

NCN, Practices 31.03.16 Ease of access to GP services All practices to offer

appointment availability and repeat prescription ordering via MHOL


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RAG Rating

Supports IMTP SCP3

2.2 Workforce

2.2.1

Improve locum

arrangements and ensure that practices

in difficulty have access to NCN salaried support

team to ensure continuity of service

in the short term.

Supports IMTP SCP3

ABUHB

GP Practices

PC&ND

31.03.16 Patients experience shorter

waits for GP appointments and increased patient appointment

capacity Increased access to

appointments, measured through audit

Continuity of services

Support against potential practice fragility

Practices to inform NCN

verbally/in writing if anticipating having

difficulty, and agree to meet with NCN Lead and CD to discuss next

steps

2.2.2 To support relevant

education and development opportunities across

the NCN

NCN Lead 31.03.16 Sharing education sessions

across practices providing up to date enhanced skills to provide better patient care

Utilise the NCN Training Plan

from NCN slippage monies

Develop a process for

Practice and other staff to access training Identify Training

providers and costs

NCN practices and partners apply for relevant funding

0515 Providing for the Future.pdf

2.2.3 To enhance the

delivery of NCN based services, specifically dental,

AMD

CDs NCN Leads

31.03.16 Patients will benefit from the

appointment of Independent Advisors and the value of debate they will bring from

Allocate funding from

NCN budget

Appoint Independent

0715 Strengthening General Practice.pdf


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optometry and

pharmacy. Supports IMPT SCP3

across ALL Primary Care

Services in the development and delivery of NCN Work Programmes.

1 x Dental, Pharmacy,

Optometrist Advisors

2.2.4 Provide Practice Based Social Workers (Pilot)

NCN Lead

Social Services

Identified

practices

31.03.16 Better GP Access

A greater focus on achieving

people’s well-being outcomes through holistic integrated

assessment and co-productive solutions

Increased capacity for GP’s where people can access the

right person, with the right skills and at the right time.

Increased patient safety and the

promotion of carer’s needs

Avoidance of admissions to

hospital through community support via Frailty, increased care at home, innovative co-

productive solutions or access to step up beds

Implement the service within the identified practices so that Social

Workers are integrated and become a member

of the multi-disciplinary team

Progress Three social workers

appointed across Caerphilly, (1 in

Caerphilly East NCN based at Risca Surgery). Feedback to

date extremely positive

Funding allocated from NCN budget

2.2.5 Recruit Primary Care Based Pharmacists

from NCN funding to integrated with NCN

and Partners (Also see 7.2.1) Supports IMTP SCP3

NCN Lead

Pharmacy

NCN Practices

31.03.16 Example outcomes from Welsh Governments Model of Care for

Pharmacy & Meds Management:

Medication review undertaken

Medicines optimisation

releases GP time and works towards GMS contract

Appointment made July/August 2015

Report progress, on

outcomes and impact at NCN meetings

Identify opportunities for Pharmacists to


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targets

Improve patient adherence through co-production

Medication is clinically

appropriate and effective (Polypharmacy)

Reduced hospital admissions through better management of condition and safe use of

medicine Less waiting time as patients

signposted to appropriate service at the start

Good governance around

repeat prescribing Reduction in waste

Provides link for community teams dealing with complex

patients needing advice and support on medication

Nursing Homes: Reduction in

waste and polypharmacy

further develop

appropriate skills

Funding allocated from

NCN budget

2.2.6 Increase access to

Primary Care Community Phlebotomy Service

Supports IMTP SCP3

NCN

Community Nursing

31.03.16 Increased capacity and access

to Primary Care phlebotomy services

Releasing DN time to focus on wound care, vaccinations and

immunisations and other interventions Releasing DN time to support

patients with complex needs who will require greater time

spent with them and/or more

£1.1 Million NCN

funding agreed across NCNs plus funding from £4.4 million for

Phlebotomy Service across Gwent. Work

Programme to be developed and agreed by NCN


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RAG Rating

frequent interventions.

Enabling DNs to undertake specialist training to upskill to

support patients with complex needs eg wound care

Ensuring the core DN workforce has the capacity and skills to

respond to the ever growing demands, thus avoiding the

development of short term or bolt on specialist services.

2.3 Estates

2.3.1 Improve the

management of estate issues, lack of space in buildings,

lack of grants to be able to increase size

of premises Supports IMTP - SCP3

Clinical Lead,

PC & ND

31.05.16 High quality facilities available

to best meet patient need Annual practice reviews and

CHC statutory visit reports demonstrated facilities are to

required standard.

NCN Lead to clarify the

position regarding Caerphilly East estate/premises

development and refurbishment during

practice visits

Primary Care Estates

Strategy will highlight issues for action

Contact Local Authority

Housing Dept staff for

input re expected housing development

plans

2014-15

AMBER


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RAG Rating

2.3.2 To consider accommodation

requirements within primary care in

relation to wider delivery of services Supports IMTP SCP3

NCN 31.03.16 Patients are able to local access services in high quality

premises

NCN to consider wider accommodation needs

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

No Objective Key Partners For

Completion by

Outcome Agreed actions /

Progress to Date

RAG

Rating

3.1 District Nursing


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3.1.1 To maximise the

effectiveness of the District Nursing (DN) workforce by

appointing Community

Phlebotomists.

Practices

Community Division

District Nursing

Team Lead

31.03.16 Patients have improved access

to both DN Team services and to newly established Community Phlebotomy Team services.

See 2.2.6

See 2.2.6

3.2 Health Visiting

3.2.1 To build up relationships between Health Visitors and

practices

NCN, ABUHB Colleagues

31.03.16 Feedback from HVs and Primary Care demonstrates improved communication.

Improved services for patients

Consistency for patients in which members of staff they

see when having a visit from the Health Visiting Service.

Respond to work-streams from Pan Gwent Working Group

Team co-ordinator to

provide performance information for NCN meetings

3.3 Mental Health

3.3.1 To strengthen integration at practice

level between Primary Care and the PMHT

Supports Caerphilly SIP – Healthier Caerphilly H1, H2, H4, H5

Practices, PCMHSS,

Third Sector, Statutory

Services

31.03.16 Reduction in the number of referrals passed between

different teams within Mental Health services, and PMHTs

Clearer care pathways, including transparent, concise access criteria, will be in place

for patients

GP’s to make use of the PCMHSS Flowcharts and increase their use of the

PCMHSS Practitioners for advice/guidance.

Work ongoing regarding best working and sign

posting.

Team co-ordinator to provide performance information for NCN

meetings

Evaluate effectiveness of Primary Care Flowchart for use in practices and

flowchart for CYP via annual audit of GP


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RAG Rating

satisfaction with the

PCMHSS.

WG to fund in full the

proposals from Directors of Primary,

Community and Mental Health for a strategic programme of

pathfinder and pacesetting projects for

primary care - £8m allocated to MH. Feedback on how this

funding will be used in Caerphilly East to be

given to the NCN

3.3.2 To ensure that

patients are seen by the ‘right person in the right place at the

right time’.

Practices,

PCMHSS, Third Sector, Statutory

Services

31.03.16 The usage of CCBT kiosks are

regularly monitored through the gathering of statistical information.

Computerised Cognitive

Behaviour Therapy (CCBT) kiosks are available for patients to

access at a number of accessible sites in the

Borough (telephone support is available)

Enhance the library of

available local resources

for use within primary care.


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RAG Rating

3.3.3 To increase the

uptake of psychological intervention through

the ‘Road to Wellbeing’

programme.

Practices,

PCMHSS, Third Sector, Statutory

Services

31.03.16 300 people to have accessed

Stress Control and ACTivate your Life classes in Caerphilly between September 2015 and

March 2016.

Help to promote the

Stress Control and ACTivate your Life courses offered locally

NCN to receive regular

feedback from service

3.4 Pulmonary Rehabilitation Services

3.4.1 NCN to explore the

feasibility of providing a Pulmonary

Rehabilitation Service in the NCN Network Supports Caerphilly SIP – Healthier Caerphilly H3, H4

ABUHB

Divisional Colleagues,

Thematic Leads

31.03.16

There will be a locally available

Pulmonary Rehabilitation service provision for Patients

within the NCN Network Decreased waiting time from

referral

Decreased travel for patients

NCN to explore the

feasibility of providing a Pulmonary Rehabilitation

Service in the NCN Network

Ongoing re-structuring and development of the

Pulmonary Rehabilitation Service

3.5 Diabetes

3.5.1 To improve diabetes services across the NCN for Patients

Supports Caerphilly SIP – Healthier Caerphilly H1, H3, H4 Supports IMTP SCP5

As above 31.03.16 Improved management of patient diabetic service needs across the NCN

Access to advice from multi-

disciplinary team and implementation of the new diabetes work plan leads to

improved outcomes for patients

Improved access to DSNs via email/telephone for

initiation of injectable therapy

• To implement the Diabetes Integrated Service Model across

the NCN

• To use PH Observatory data as a baseline for

improvement Refer routinely to Adult

Weight Management Service

Consider increasing

Adult Weight

Diabetes Work Plan NCN comms 16 45.ppt


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RAG Rating

Improved access to

Consultants for advice

Improved rapid assessment

of patients who need consultation opinion

Management Service

capacity for specific populations (e.g. Pre-diabetes, pregnant

women)

DSNs to cleanse lists to ensure appropriate patients are managed in

primary and secondary care

Monitor referrals to

diabetes secondary care

per practice

3.6 COPD

3.6.1

Improve Inhaler Technique for patients

Community Pharmacy

NCN

31.03.16 Patients using devices appropriately

To cascade inhaler technique training-

multidisciplinary strategy. NCN funding identified.

Accredited training

provided by WCPPE, pre and post course

learning, plus take away pack of placebo devices.

3.7 Osteoarthritis Knee


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RAG Rating

3.7.1 Improve management

of patients with Supports IMTP SCP5

NCN Lead

NCN

Practices

31.03.16 Osteoarthritis of the Knee

(OAK) education sessions -

scheduled to take place on a

Monday afternoon on a weekly

basis

General Practice been

invited to refer people with newly diagnosed OA knee to an

appropriate course

Improve numbers attending the group – DNA rate currently

below 50%

Monitor referral rates via regular update reports

Receiving referrals from

Physiotherapy, Orthopaedics and GPs

One course already held

at Risca Flying Start

Monitor referrals to MRI

3.8 Sustainable Care Homes Services


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3.8.1 Move toward a more

sustainable service for delivery of care for patients in care

homes

NCN Lead

Practices

31.03.16 Improved care for residential

patients

Support the education

programme for nursing

staff in homes NCN to

support

NCN lead to undertake

data gathering exercise

around care homes

experience of primary

care

Monitor and increase

the uptake of the

enhanced service

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

Key Partners For Completion

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4.1 Urgent Access

4.1.1

Practices to review

performance against

LMC agreed urgent

access figures

GP Practices

31.03.16 Improved patient access to

primary care services

Practices to engage with project

to optimise access in keeping

Practices to monitor performance against LMC standards

Practices to monitor &

No Objective


by


RAG Rating

NCN Lead with emerging guidance to be

agreed with CHC, Health Board

and LMC

report performance to

NCN Lead on a monthly/quarterly basis

Monitor A&E attendances per practice

4.1.2 To improve utilisation

of available data sources to review

activity for the NCN

NCN Lead

Network Team

GP Practices

31.03.16 Informed understanding of

urgent access referrals for NCN patients to secondary care

services

Identify make up of

urgent referrals

Share findings at NCN meetings and instigate remedial action where

appropriate

4.1.3 Appropriate utilisation of WECS Scheme –

Eye Health Examination Wales

(EHEW)

NCN

WECS

31.03.16 Reduction in avoidable referrals/admissions

Education session for NCN with regard to the

WECS services by ABUHB Optom Advisor

Baseline data for

attendance updated by

Optom Lead

No Objective


by


RAG Rating

4.1.4 Appropriate use of

YYF Minor Injuries

Unit

NCN

YYF Minor Injuries Unit

31.03.16 Clarification of MIU services

within YYF Reduction in avoidable

admissions

Hold education session

for NCN with regard to services available

Obtain practice data with regards to

attendance at A&E and YYF MIU

Ensure YYF MIU has details of how to access

emergency/urgent slots in each practice

4.2 Frailty (CRT)

4.2.1 Improve appropriate utilisation of the Frailty Service

Supports IMTP SCP4

NCN, Practices,

CRT Team

31.03.16 Improved access and communication with Frailty and between Frailty and the OOH

Service

Less hand offs between services, and improved communication about the needs

of the individual will result in better quality, more timely care

Increased GP referrals

Reduction in rejection of referrals

Frailty run charts will show improvements

Work proactively to improve communication and working

relationships through regular invitation to

NCN meetings

Monitor referrals to the

frailty service per practice

Gain better understanding of pressures that all

services are working under including OOH

Ensure appropriate use of the SPA contact number by all practices

No Objective


by


RAG Rating

from 01.09.15

4.3 Social Services

4.3.1 To improve communication

between Health Services and Social Services

Supports Caerphilly SIP – Healthier Caerphilly H3, H4

NCN Lead

Network Team Caerphilly

Integrated Partnership

31.03.16 Feedback from GP Practices, Health Visitors,

District/Community Nurses will demonstrate improved communications

Patients will receive seamless

service transition between primary care and social services

Raise any issues with Caerphilly Integrated

Partnership / NCN Management Team

Continuously monitor impact and consider

best ways of working and communication issues at NCN meetings

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


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5.1 Review the delivery of End of Life Care

using the Individual

NCN Leads, Practices, NCN

Support Teams

31.3.16 Better care received by individuals at EoL.

NCN to support Practices to review audit

of patients who have 0815 Gwent Palliative Care Strategy.docx


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RAG Rating

Case Review Audit died to be reflected

upon/inform future care delivery.

5.2 Summarise case

review data, and

any arising issues

and actions

identified, for

sharing with the

network and the

wider health board

NCN Leads, St

Davids Palliative

Care Team,

Practices, NCN

Support Teams

31.03.16 Learning through shared

experience will inform future

care improvements for patients

on the EOL pathway.

Highlight best practice for improvement to be

shared in a multi-professional discussion

0715 EOLC All Gwent Summary.docx

Caer East National Priorities Audit Summary 0315.docm

5.3 Establish a review

cycle, to monitor progress (or

maintenance of high quality), with further submission of

reports to the GP network and wider

health board as appropriate

NCN Leads,

Practices, NCN Support Teams

31.03.16 Improved consistency in

standard of care delivered

Agree of ‘best practice’

in EOLC. Identify and monitorf

areas for improvement so that appropriate education and support

can be delivered

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


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6.1 Review the care of all NCN, NCN 31.03.16 All lung, gastrointestinal and Practices complete Audit


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patients newly

diagnosed between 1 January 2015 to 31 December 2015 with

lung, gastrointestinal and ovarian cancer

Leads,

Practices

ovarian cancer patients will

have their referral information reviewed and o/p appointments / results followed up

Tool and discuss

findings

6.2 Learning and actions to be shared with the

GP network and the wider LHB

NCN, NCN Leads,

Practices

31.03.16 Audit tool to ensure continuous review, reflection and

improvement in processes and care pathways for patients with a diagnosis of cancer.

Practices complete audit and discuss findings


6.3 Identify and include

any relevant actions to be addressed in the Practice Development

Plan

NCN, NCN

Leads, Practices

31.03.16 Improved patient information.

Patients preferred place of death.

Practice by practice NCN

USC cancer data will be collated to provide better informed

demographic data relating to cancers on a

regular basis

6.4 Summarise themes and actions for review with the GP network

and share information with the LHB as

required

NCN, NCN Leads, Practices

31.03.16 Improved patient information. Patients preferred place of

death.

NCNs to share learning with secondary care

National Priority Target Audit Summary Cancer 14-15.docx

6.5 Develop protocols to

ensure Practices refer patients as ‘USC’ rather than ‘Urgent’ if

cancer was suspected and that Practice

based systems should be established to track USCs referred.

NCN Lead Practices

30.09.15. Patients will be referred for

Secondary Care interventions with the appropriate level of urgency and seen accordingly.

Practices to discuss and

agree to use USC notation on suspected

Cancer patient referrals


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Supports IMTP SCP3

6.6 Practices to encourage

patients to attend appointments with the

Bowel Screening Programme. Supports IMTP SCP3

Public Health NCN Lead Practices

31.03.16. Earlier detection of bowel

cancer. Data supports improved survival rates. Patients may receive diagnostic

and procedural interventions quicker than via a non-Screening Programme referral.

PHW to liaise with

national screening

services regarding provision of list of non-responders

Practices to discuss and

agree a process to write to patients who have not attended scheduled

bowel screening appointments

encouraging them to reconsider and do so.

6.7 to ensure referring GPs are informed by Secondary Care

Consultants of downgrades to USC

referrals. Supports IMTP SCP3

PC & ND / AMD Secondary Care Consultants GPs

31.03.16. Improved patient information. Appropriate treatment pathways initiated.

PC & ND / AMD to contact Divisional Leads

to ensure consultants inform referring GPs of

downgrades. Practices to consider

processes to follow up all USC referrals and

subsequent potential downgrades.

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


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7.1 Poly-pharmacy


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7.1.1 Identify and record

numbers and rates for patients aged 85 years or more

receiving 6 or more medications.

NCN, NCN

Leads, Practices

31.03.16 Identify patients at high risk or

harm of either over or under medicating.

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.

7.1.2 Undertake face to face medication

reviews, using the ‘No Tears’ approach

NCN, NCN Leads, Practices

31.03.16 Reduction in unnecessary admissions to hospital.

Identification of further

untreated conditions. Number of MUR Consultations

Using data from the review audit book

appointments for medication reviews of

patients over the age of 85yrs receiving 6 or more medicines.

7.1.3 Identify any actions

to be addressed in the Practice

Development Plan

NCN, NCN

Leads, Practices

31.03.16 Poly-pharmacy at NCN

meetings Quarterly information to NCN on

utilisation of notional budget


National Priority Target Audit Summary Polypharmacy 14-15.docx

7.2 Medicines Management


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7.2.1 Appointment of

Primary Care Pharmacists to assist the delivery of safe

and cost effective prescribing to the

NCN population

NCN Lead,

Practices

31.03.16 See 2.2.6 Recruit and appoint

Pharmacists in Primary Care

Agree range of duties expected of appointees

Report and monitor

activities and impact of

appointments to NCN Lead

0715 Pharmacists in Primary Care.docx

7.2.2 To monitor the NCN prescribing budget and delivery of the

Medicines Management Plan

NCN Lead Prescribing

Lead

GP Practices

31.03.16 Efficient use of resources leads to re-investment & more appropriate care

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 priorities for

NCNs to achieve in terms of service

improvement, costs and quality

7.2.3 To review the variation in prescribing compared

NCN Lead GP Practices

31.03.16 Patients and professionals have access to a named Pharmacist in Primary Care

NCNs to work with Primary Care and Networks Division Pharmacy staff to:


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to national guidance

in relation to Diabetes and Respiratory and deliver the NCN

savings target for these work streams

within the three year plan

Pharmacy

Efficient use of resources that can be re-invested more appropriately into patient care

Minimise avoidable harm from

the adverse effects of inhaled steroids

Undertaking the minimum appropriate intervention to

ensure prudent prescribing aligned with NICE Guidance.

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

7.2.5 To provide

consistency in medicines reviews in both Practice and

home visit settings.

NCN Leads Practices

On-going Patients will have a consistent

medicines review in Practice or at home.

Practices to consider

printing out the NOTEARS template for

use on home visits to provide consistency of

reviews. Develop NCN Standard.

For discussion at

NCN Meeting 03/09/15

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


by


RAG Rating

8.1 Clinical Governance

8.1.1 To fully implement the Clinical

Governance Toolkit

NCN

Primary Care & Network Division

GP Practices

31.03.16 Consistency and safety in Practice and NCN wide primary

care services

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 MHOL

How practices respond to urgent and same day requests from Care

Homes, WAST and Hospital Emergency

Depts Actions to foster

greater integration of health and social care

Consideration of how

Third Sector support may be maximised

Map local services to highlight where services are delivered across

practices (e.g. contraceptive services,

minor surgery)


by


RAG Rating

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: Agreed Locality Priority Issues

No Objective Key Partners For

Completion by

Outcome Agreed actions /

Progress to Date

RAG

Rating

9.1 To Improve communication and utilisation of Mental

Health / Mental Wellbeing services in

the Locality

NCN, NCN Lead, Practices, PCMHSS,

ABUHB Divisional

Colleagues

31.03.15 Better referrals and access to services in appropriate timescales

Presentations shared with NCN. Ongoing work regarding PMHT

and signposting

Continued liaison with Communities First and Third Sector


by


RAG Rating

9.2 Establishment of an

NCN Web based solution that provides information for local,

available services for Dementia patients.

PC & ND

Phil Diamond - (Dementia Friendly

Community Lead)

31.03.16 Patients and their families /

carers can access up to date information on services available to them relating to

dementia support.

Implement and

promote Dementia Roadmap

All practices to be encouraged to sign up

for Dementia Friends Training

9.3 Increase awareness of dementia friendly

communities

ABUHB,OAMH,

Social Services,

LA,

NCN

GP Practices

31.03.16 Patients are supported in their communities

Training practice staff as Dementia Friends

Collate the number of

practice staff completed training

9.4 To improve utilisation of available data

sources to review activity for the NCN

NCN Lead, NM, NSO

Practices

31.03.16 Informed understanding of recorded activity for NCN

patients accessing Primary and Secondary Care services

NCN to undertake regular deep dive

analysis of the Caerphilly Core NCN

Performance Report

Identify availability of

other data sources for analysis

Share findings at NCN

meetings and instigate

remedial action where appropriate

Documents

Caerphilly East Neighbourhood Care Network Action Plan ... East NCN Action... · Caerphilly East Neighbourhood Care Network Action Plan & Progress Report ... better patient care